-
obstructive pulmonary disorders
manifested by increased resistance to airflow
-
classifications of obstructive pulmonary disorders
- obstruction from conditions in the wall of the lumen
- obstruction resulting from increasing pressure around the outside of the airway lumen
- obstruction of the airway lumen
-
Asthma
[etiology]
- airway obstruction that is reversible (not completely in some patients)
- airway inflammation
- increased airway responsiveness to a variety of stimuli
-
Asthma
[predisposing factors]
- genetic for atopy and structural (smaller airways) - chromosomes 5, 11, 14
- history of hay fever, eczema
- fam. history
- positive skin test reactions to allergens
-
Asthma
[extrinsic - allergic]
IgE mediated response - common
-
Asthma
[clinical manifestations]
- elevated IgE lvls
- allergic rhinitis
- eczema
- positive fam history of allergy
- attacks associated with seasonal, environment, or occupational exposure
-
Asthma
extrinsic - mechanism of action - immediate phase
- initiated by exposure to specific antigen that has previously sensitized mast cells in airway mucosa
- antigen reacts with antibody on surface of mast cell
- mast cell releases packets of chemical mediator substances
-
Asthma - Extrinsic
Mechanism of action
What are the chemical mediators released?
- histamine
- slow-reacting substances of anaphylaxis (leukotrienes)
- prostaglandins
- bradykinins
- eosinophilic chemotactic factor
- serotonin
-
Asthma
extrinsic - mechanism of action
- normal respiratory epithelium is denuded and replaced by goblet cells
- alterations in epithelial integrity
-
Asthma - Extrinsic
mechanism of action
What increased microvascular permeability
- mucosal edema
- inflammatory exudates
- bronchoconstriction
- leakage
-
Asthma
[causes]
- Acute bronchospasm (bronchoconstriction)
- mucosal edema
- mucous plug formation
- airway wall remodeling
-
Asthma
[common symptoms]
- wheezing
- feeling of tightness of chest
- dyspnea
- cough (dry/productive)
- increased sputum production (thick, tenacious, scant, and viscid)
-
Asthma
[symptoms of severe attack]
- use of accessory muscles of respiration
- intercostal retractions
- distant breath sounds w/ inspiratory wheezing
- orthopnea
- agitation
- tachypnea
- tachycardia
-
Asthma
[diagnosis]
- physical findings:
- cough
- wheezing
- hyperinflated chest
- decreased breath sounds
radiographic finding: hyperinflation with flattening of the diaphragm
- sputum exam:
- charcot-leyden crystals (formed from crystallized enzymes fr. eosinophilic membranes)
- Eosinophils
- Curschmann spirals (mucous casts of bronchioles)
- ABG:
- normal during mild attack
- respiratory alkalosis and hypoxemia as bronchospasm increases in intensity
- PaCO2 elevation
-
Asthma
[Treatment]
- avoid triggers
- environmental control
- preventive therapy
- desensitization (allergen specific immunotherapy)
- Meds:
- O2 therapy
- small-volume nebulizers
- B2 agonists
- Corticosteroids
- leukotriene modifiers
- mast cell inhibitors
-
Acute bronchitis
[etiology]
acute inflammation of trachea and bronchi
- viral: influenza virus A/B
- parainfluenza virus
- respiratory syncytial virus
- coronavirus
- rhinovirus
- coxsackievirus
- adenovirus
- Nonviral:
- strept. pneumoniae
- haemophilus influenzae
- Mycoplasma
- moraxella
- chlamydia pneumoniae
- Causes:
- heat/burn
- smoke inhalation
- inhalation of irritant chemicals
- allergic reactions
-
Acute bronchitis
[pathogenesis]
- Airways become inflamed and narrowed from capillary dilation
- swelling from exudation of fluid
- infiltration with inflammatory cells increased mucus production
- loss of ciliary function
- loss of portions of ciliated epithelium
-
Acute bronchitis
[clinical manifestations]
- cough (productive/nonproductive)
- low grade fever
- substernal chest discomfort
- sore throat
- postnasal drip
- fatigue
-
Acute bronchitis
[diagnosis]
- clinical presentation
- chest xray to distinguish acute bronchitis from pneumonia (typically an acute bronchitis will have a normal CXR)
-
Acute bronchitis
[treatment]
- antibiotic therapy (bacterial)
- codeine - containing meds (for cough)
- increase fluid intake
- avoid smoke
- use a vaporizer in bedroom
-
Chronic Bronchitis
[etiology]
- Type B COPD 'blue bloater'
- Chronic/recurrent productive cough >3 mos >2+ yrs
- persistent, irreversible
- typical pt is overweight
- 30-40 yrs
- commonly assoc. w/ emphysema
-
Chronic Bronchitis
[cause]
- cigarette smoking
- repeated airway infections
- genetic predisposition
- inhalation of physical or chemical irritants
-
Chronic Bronchitis
[pathogenesis]
- chronic inflammation and swelling of the bronchial mucosa resulting in scarring
- hyperplasia of bronchial mucous gland/goblet cells (^mucus production)
- increased bronchial wall thickness
- pulmonary hypertension
-
Chronic inflammation and swelling of the bronchial mucosa resulting in scarring means what?
[Chronic Bronchitis]
- elevated IL8 levels recruit neutrophil activation
- elevated CD8 T lymphocytes
- extend into surrounding alveoli
- prevent proper oxygenation andp otentiate airway obstruction
-
Hyperplasia of bronchial mucous gland/goblet cells means ... [chronic bronchitis]
- increased mucus production
- mucus combines with purulent exudate (bronchial plugs) to form mucous plug
-
increased bronchial wall thickness means.. [chronic bronchitis]
- resistance increases work of breathing
- increased O2 demands
- produce ventilation-perfusion mismatch with hypoxemia and hypercarbia (increases pulmonary artery resistance)
-
Pulmonary hypertension means... [chronic bronchitis]
- inflammation in bronchial walls with vasoconstriction of pulmonary blood vessels and pulmonary arteries
- R-sided heart failure may occur r/t high pulmonary resistance
-
Chronic bronchitis
[Clinical manifestations]
- SOB on exertion
- excessive sputum
- chronic cough (more severe in mornings)
- evidence of excess body fluids (edema, hypervolemia)
- Cyanosis (late sign)
-
Chronic Bronchitis
[Diagnosis]
- Chest xray:
- increased bronchial vascular markings
- congested lung fields
- enlarged horizontal cardiac silhouette
- evidence of previous pulmonary infection
- PFT:
- normal total lung capacity (TLC)
- increased residual volume (RV)
- decreased FEV1
- ABG:
- Elevated PaCO2
- Decreased PO2
- Develop early in disease process
-
Chronic Bronchitis
[Treatment]
- Meds:
- inhaled short-acting B2 agonists
- inhaled anticholinergic bronchodilators
- cough suppressants
- antimicrobial agents (bacterial infections)
- inhaled/oral corticosteroids
- theophylline products
- low-dose O2 therapy for patients with PaO2 levels <55mmHg
-
Chronic Bronchitis
[management]
- stop smoking
- bronchodilator therapy
- reduction to exposure of irritants
- adequate rest
- proper hydration
- physical reconditioning
-
Emphysema
[Etiology]
- Type A COPD
- "pink puffer"
- young to middle age adults <50yrs (uncommon)
- ----Hereditary low α1-antitrypsin activity in lung
- >50 yrs (develops over time)
- Smoking >70 pack/year
- Air pollution
- certain occupations
- α1-Antitrypsin deficiency
smoking causes alveolar damage
-
Smoking causes alveolar damage
[What happens]
- inflammation in lung tissue leading to release of proteolytic enzymes
- inactivates α1-antitrypsin (protects lung parenchyma)
-
Emphysema
[Pathogenesis]
- Loss of elastic tissue in lung
- ---results in decrease in size of smaller bronchioles
- ---results in loss of radial traction (holds airway open)
-
Emphysema
[clinical manifestations]
- Progressive, exertional dyspnea
- increased SOB for past 3-4 yrs
- Thin (r/t increased caloric expenditure and decreased ability to consume adequate calories)
- use of accessory muscles
- pursed-lip breathing
- cough (minimal or absent)
-
Emphysema
[diagnosis]
- patient history and physical finding
- -thin,wasted individual hunched forward
- barrel chest
- digital clubbing
- decreased breath sounds, lack of crackles and bronchi with prolonged expiration
- decreased heart sounds
- decreased diaphragmatic excursion
- chest xray
- hyperventilation
- low, flat diaphragm
- presence of blebs or bullae
- narrow mediastinum
- normal/small 'vertical' heart
-
Emphysema
[treatment]
- O2 therapy
- meds:
- -inhaled short-acting B2 agonists
- -inhaled anticholinergic bronchodilators
- cough suppressants
- antimicrobial agents (infections)
- inhaled/oral corticosteroids
- theophylline products
-
Cystic fibrosis
[etiology]
- Autosomal recessive disorder of exocrine glands (dysfunction of CFTR gene)
- affects pancreas, intestinal tract, sweat glands, lungs, infertility (male)
-
Cystic Fibrosis
[clinical manifestations]
- history of cough in young adult/child
- thick, tenacious sputum
- recurrent pulmonary infections/episodes of bronchitis
- physical findings:
- digital clubbing
- dyspnea, tachypnea
- sternal retractions
- unequal breath sounds
- moist basilar crackle and rhonchi
- barrel chest hyperresonant to percussion
- Nutritional assessment:
- Depleted fat stores
- steatorrhea (fatty stools)
- anorexia
- decreased growth rate in children (wt, ht, head circ)
- decreased mid-arm indices
-
Cystic fibrosis
[treatment]
- postural drainage and chest physiotherapy
- meds:
- ---bronchodilators
- ---high dose antibiotics (bacterial infections)
- ---influenza vaccine
- heart lung or lung transplant
- Nutritional therapy:
- ---unrestricted fat consumption
- ---high protein
- ---vitamin supplements
- ---pancreatic enzymes
- ---intake of 150% normal caloric intake
-
Acute Tracheobronchial obstruction
[etiology]
- aspiration of foreigh body (L lung)
- malpositioned endotracheal tube
- laryngospasm
- Epiglottitis
- Trauma
- swelling (smoke inhalation)
- postsurgical blood clot
- compression of bronchus/trache (tumor, enlarged lymph nodes
-
Acute Tracheobronchial obstruction
[clinical obstruction]
partial obstruction
- stridor
- sternal and intercostal retractions
- wheezing
- nasal flaring
- tachypnea, dyspnea
- Tachycardia
- Use of accessory muscles
-
Acute tracheobronchial obstruction
[clinical manifestations]
complete obstruction (emergency)
- no air movement w/ auscultation
- inability to talk
- tachycardia
- cyanosis
- rapid progression to unconsciousness
-
Acute tracheobronchial obstruction
[treatment]
- open obstructed airway asap
- Heimlich
- Emergency tracheostomy
-
Epiglottitis
[Etiology]
- Rapidly, progressive cellulitis of epiglottis and adjacent soft tissues
- subtype of croup
- children 2-4 yrs
- Common organisms (Pneumococci, Streptococci, staphylococci)
-
Epiglottitis
[pathogenesis]
- infecting agent localizes in epiglottis and pharyngeal structures
- causes rapid and potentially fatal inflammation (Swelling and airway obstruction)
-
Epiglottitis
[clinical manifestations]
- drooling
- dysphagia, dysphonia
- rapid onset of fever
- inspiratory stridor and retractions
- oropharynx edematous and cherry red
- child sits in 'sniffing dog' position (provides best airway patency)
-
Epiglottitis
[treatment]
- true medical emergency
- may necessitate intubation
- antibiotic therapy
- preventative (Hib vaccine)
-
Croup Syndrome
[etiology]
- number of acute, viral inflammatory disease of larynx, trachea, and bronchi
- --laryngotracheobronchitis
- --epiglottitis
- --bacterial tracheitis
- Causes:
- parainfluenza virus type 2 and 3
- RSV
- influenzavirus
- Adenovirus
- Mycoplasma pneumoniae
-
Croup syndrome
[pathogenesis]
- viral agent of subglottic area
- infectious agent causes inflammation along entire airway
- leads to edema in subglottic area
-
Croup syndrome
[clinical manifestations]
- history of upper respiratory infection or cold
- barking cough with stridor
- low grade fever (may be absent)
- Severe cases: stridor at rest, retractions, cyanosis
-
Croup syndrome
[treatment]
- mist therapy
- oral hydration
- avoidance of stimulation
- O2 therapy, pulse oximetry (hospitalized)
- nebulized epinephrine (relieves airway obstruction)
- endotracheal intubation (respiratory failure)
|
|
