-
Pores of Kohn
mixes air between alveoli sacs
-
Number of alveoli in in the adult lung
300 million
-
Type I alveolar cells
- makes up most of the surface area of the alveoli
- does not divide
-
Type II alveolar cells
secrete 5% of surfactant
-
Inspiration uses
external intercostals
-
expiration involves
internal intercostals contract
-
volume of air moved with each breath
Tidal volume
-
volume of air left in the lungs after maximal expiration
Residule volume
-
volume of air remaining in the lungs at the end of expiration (sum of RV and ERV)
functional residual capacity
-
measures pulmonary function. Pt breathes out as hard as they can.
spirometry
-
maximum amount of air that can be rapidly and forecully exhaled from the lungs after full inspiration
forced vital capacity (FVC)
-
volume of air expired in the first second of FVC
forced expiratory volume (FEV1)
-
volume of air expired in the first second expressed as a percentage of the FVC
FEV1/FVC ratio
-
Arterial blood gases
- PO2 >80 mmHg
- PCO2 35-45 mmHg
- usually taken from the femeral artery
-
amount of oxygen bound and dissolved oxygen in the blood
- normal 97-100%
- goal for COPD pt. >92%
-
Restrictive lung disease
lungs cannot expand the way they should
-
Obstructive lung disease
tumor, clot or other space occupying lesion
-
Diagnosis of Asthma
- must have 3 of the following:
- airflow obstruction
- ronchial hyper-responsiveness
- underlying inflammation
-
americans that had an asthma attack in 2005
22.2 million
-
adults with asthma diagnosis
400,000
-
children with asthma diagnosis
111,000
-
ED visits related to asthma in 2005
30,000
-
hospital days related to asthma care
25,000
-
Extrinsic (atopic) asthma
- induced by exposure to an allergen
- developes in 10-20 minutes of exposure
- early and late phase reactions
-
Early phase reaction
- antigen binds IgE receptor on mast cell
- cytokines attract other inflammatory cells cause bronchoconstricion leading to bronchospasm
- increased mucus and edema in the lungs
-
Late phase
- recruited cells drive the response (4-8 hrs later)
- airway epithelial cells also release eotaxin (recruits eosinophils)
- epithelial cell injury and bronchoconstricion
- increased airway responsiveness = prolonged asthma symptoms
-
Intrinsic Asthma triggers
- respiratory tract infections
- excercise, stress, laughter
- Aspirin, NSAIDS, B Blockers
-
Clinical presentation of asthma
- cough, wheezing, dyspnea
- chest tightness
- tachypnea & tachycardia
- hypoxemia
-
Used for short term monitoring of asthma control. Based on pt. personal best value.
- peak flow meter
- used when standing up
-
>80% peak flow zone
- no asthma symptoms
- take meds as usual
-
50-80% peak flow zone
- use short acting beta 2 agonist
- check about changing or increasing dose
-
<50% peak flow zone
- short acting inhaled beta 2 agonist
- emergency medical alert
-
best peak exp flow is 550 L/min. peak flow is now 300 L/min. what zone is this?
yellow
-
Symptoms of Mild Intermittent asthma occur
< 2 days/week
-
nighttime awakenings with mild intermittent asthma
< 2x/month
-
Beta-agonist use for mild intermittent asthma
< 2d/week
-
Interference with activity with mild intermittent asthma
none
-
Lung function with mild intermittent asthma
FEV1 normal between exacerbations
-
symptoms with mild persistent asthma
> 2 days/week, not daily
-
Nighttime awakenings with mild persistent asthma
3-4x/month
-
Beta-agonist use with mild persistent asthma
>2d/week but not daily
-
interference with activity with mild persistent asthma
minor limitation
-
Lung function with mild persistent asthma
- FEV1 > 80% predicted
- FEV1/FVC normal
-
Symptoms of moderate persistent asthma
daily
-
nighttime awakenings with moderate persistent asthma
> 1x/week, not nightly
-
Beta agonist use with moderate persistent asthma
daily
-
moderate persistent asthma interference with activity
some limitation
-
Lung function with moderate persistent asthma
- FEV1 >60% but >80%
- ratio reduced by 5%
-
Symptoms with severe persistent asthma
throughout the day
-
nighttime awakenings with severe persistent asthma
often nightly
-
beta agonist used in severe persistent asthma
several times per day
-
severe persistent asthma interference with activity
extreme limitation
-
lung function with severe persistent asthma
fev1 < 60% predicted
-
Asthma goals (6)
- 1. prevent symptoms
- 2. decrease use of SABA (2 days/week)
- 3. maintain normal pulmonary function
- 4. maintain normal activity
- 5. meet care expectations
- 6. optimal therapy with minimal expectations
-
risk factors for asthma related death
- history of severe exacerbations
- > 2 hospitalizations for asthma in the past year
- > 3 ED visits for asthma in the past year
- using > 2 SABA per month
- current oral steroid use
- low socioeconomic status
-
cough for 3 month in each of two successive years in a patient in whom other causes of chronic cough have been excluded.
chronic bronchitis
-
abnormal permanent enlargement of airspaces distal to the terminal bronchioles accompanied by destruction of their walls.
emphysema
-
4th leading cause of death in america claiming the lives of 123,000 in 2004
COPD
-
approximately ____ COPD cases caused by smoking
80-85%
-
Asthma as compared to COPD
- mostly reversible/intermittent
- associated with allergies
- CD4
-
COPD compared to asthma
- Not reversible
- gets progressively worse
- neutrophils involved
- CD8 and macrophages
-
Hereditary component of COPD
- alpha 1 antitrypsin
- protective enzymes against protease
-
Chemotactic factors of COPD
- attracts neutrophils and CD8 cells
- Leukotriene B4
- Interleukin-8
-
Proinflammatory cytokines in COPD
- Tumor necrosis factor alpha
- Interleukin-6
-
Growth factors in COPD
- fibrosis of small airways
- Transforming growth factor beta
-
ventilation and perfusion in COPD
- perfusion without ventilation
- ventilation without perfusion
-
Consequences of smoking
- more neutrophils and macrophages in alveoli
- increased release of elastase from neutrophils
- oxidants and free radicles inhibit alpha 1 antitrypsin
-
increased inflammation in the alveoli results in
decreased air out
-
hyperinflation of the alveoli results in
decreased air in
-
Dysfunction of alveoli results in
- hypoxemia
- pulmonary vasoconstriction
- hypercapnia (high CO2 in the blood)
-
Pink puffers
- use of accessory muscles
- pursed lip breathing
- tripod position
- barrel chest
- prolonged expiration
-
Blue bloaters
- cyanosis
- right sided heart failure
- fluid retention
- prolonged expiration
-
Grade 1 COPD
no breathlessness except during strenuos exercise
-
grade 2 COPD
short of breath when hurrying or walking up a slight hill
-
grade 3 COPD
walks slower than people of same age or has to stop when walking at own pace due to breathlessness
-
grade 4 COPD
stops for breath after walking for a few minutes on level ground
-
grade 5 copd
too breathless to leave the house or breathless when dressing or undressing
-
Stage 1 Mild COPD
- ratio < 70%
- FEV1 > 80% predicted
-
Stage 2 Moderate COPD
- ratio < 70%
- FEV1 between 50 and 80 %
-
Stage 3 Severe COPD
- ratio < 70%
- FEV1 30 and 50%
-
Stage 4 Very Severe COPD
- ratio <70%
- FEV1 < 30%
- predicted <50%
-
3 cardinal symptoms of COPD exacerbation
- increased dyspnea
- increased sputum purulence
- increased sputum volume
-
mild exacerbation
1 symptom
-
moderate exacerbation
2 symptoms
-
3 symptoms
severe exacerbation
-
Utilize antibiotics when?
two or more cardinal symptoms
-
Goal for oxygen therapy
90-29%
-
cor pulmonale
- right handed heart failure
- increased resistance to flow in the pulmonary artery
-
clinical manifestation of cor pulmonale
- RV hypertrophy
- Peripheral edema
- SOB
- Decreased exercise tolerance
-
Polycythemia Vera
- Kidneys sense chronic hypoxemia which results in increased erythropoietin = more RBCs produced
- increased risk of blood clots
-
Oxygen therapy indicated in patients
- with O2 saturation < 88% and
- polycythemia, pulmonary HTN or signs of right sided heart failure.
-
Oxygen therapy must be used....
at least 15 hrs/day for mortality benefit
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