Class Work sheet (pathologies) Flashcards
What is COPD
A progressive chronic obstructive pulmonary disease which is an umbrella term for emphysema and chronic bronchitis.
Usually >40yrs
Caused by smoking, dust or environmental factors which cause chronic inflammation
Physiotherapy problems with COPD
- Loss of lung volume
- Increased work of breathing (WOB)
- V/Q missmatch
- Reduced ex tolerance
- secretion retention
COPD
Why does INCREASED SPUTUM PRODUCTION occur
What symptoms does this cause and the PT problem
Why - The irritant (smoking/dust) stimulates the inflammatory response, causing goblet cells to hypertrophy and proliferate = hyper-secretion of mucus
Symptoms - Chronic cough, wet cough, coarse crackles on auscultation and a wheeze if airways blocked.
PT problem - Secretion retention
COPD
Why does STRUCTURAL DAMAGE TO CILIA occur
What symptoms does this cause and the PT problem
Why - Smoking/ irritant initially causes cilia to become paralysed, then cell death and damage occurs, reducing the cilia function and thickening the membrane meaning the cilia cannot beat the increased mucus out and towards the throat = damaged mucociliary escalator
Symptoms - Chronic wet cough, increased respiratory infections, green sputum, crackles and wheeze on auscultation from blocked airways
PT problem - Secretion retention
COPD
Why does the vicious cycle of infection occur
What symptoms does this cause and the PT problem
Why - the lungs become susceptible to repeated acute airway infections due to the abundance of rich mucus in the airways. Bacteria thrive off of the glycoproteins in the sputum.
These constant infections trigger the constant activation of the inflammatory response, causing worsening symptoms for the patient (eg: more sputum and then more infection) , this chronic inflammation of the airways/ bronchi = chronic bronchitis
Symptoms - Dependent on the acute infection ( lung scarring, lung fibrosis, pyrexia, wet cough, crackles/ wheeze)
PT problem - secretion retention and loss of lung volume
COPD
Why does hyperinflation of the lungs occur
What symptoms does this cause and the PT problem
why - Smoking damages the elastic fibres in the lungs so they cannot recoil back after inhalation. This causes the lungs to remain inflated and inhalation if difficult as the lungs are full of stale air = SOB
Emphysema = Alveolar distention creates Boullae and trapped air within the lungs increases FRC
Symptoms - Reduced chest movement, reduced expansion, atypical breathing pattern, increased RR, chest bases on auscultation, type 1/2 resp failure due to poor gas exchange and O2 intake, use of accessory muscles on inhale (scalene and sternocleidomastoid) and exhale (internal intercostals and abdominal muscles), malnutrition, reduced FEV1
PT problem - Increased WOB, V/Q mismatch, Loss of lung volume, decreased ex tolerance
COPD
Why does structural damage to the alveoli occur
What symptoms does this cause and the PT problem
why - Distention to the alveoli, the alveoli are constantly stretched in COPD (hyperinflation) so the alveolar walls become loose/ break down to form large sacs. Also, smoking damages the surfactant in the lung which usually nreduces surface tension to keep the alveoli open. When this is damaged they more likely to collapse
This reduces the surface area and amount of gas exchange
(emphysema)
Symptoms - Increased RR, type 1/2 resp failure, Low Sp02, Low PaO2 (altered ABGs) , hypoxia/ hypoxaemia, reduced breath sounds on auscultation, reduced baseline of SpO2
PT problem - V/Q mismatch, reduced ex tolerance,
ASTHMA
Why does the release of inflammatory mediators occur
What symptoms does this cause and the PT problem
why -
1) hyper reactive airways are exposed to an allergen which is picked up b y dentritic cells which process it and present the allergen to T-helper 2 cells
2) T-helper 2 cells in turn stimulate eosinophils and plasma cells which produce antibody immunoglobulin E (IgE)
3) IgE antibodies bind to mast cells and cause them to degrade and release chemical mediators: histamine, leukotrienes and cytokines = inflammatory cascade
4) This inflammatory response causes damage to the mucosa and gives us the asthma symptoms
Symptoms: Bronchoconstriction as the smooth muscle of the airways spasms and contracts =. wheezing and SOB, can be unable to complete sentences, type 1 resp failure
PT problem - Increased WOB, V/Q mismatch
What is Asthma
Causes
A chronic inflammatory condition which narrows the airways with inflammation and mucus.
Causes:
- genetics - hypersensitive (eczema)
- Hyper-responsiveness
- Nasal polyps
- dust/ smoke/ mould
- chest infections or URT infection
- pollen/ animal hair
- cold/ weather
- exercise
it is reversible however after chronic asthma, scarring and fibrosis can occur and cause permanent narrowing
during asthma the pt cannot fully exhale before their next breath causing CO2 to build up in the lungs as it’s trapped in the alveoli = severe causes type 2 resp failure
ASTHMA
why does the number of goblet cells increase
What symptoms does this cause and the PT problem
why - The body tries to repair itself and the airways being remodelling. Hyperplasia of Goblet cell in airway epithelium and hypertrophy of submucosal glands cause hyper secretion of mucus and increased blockages in airways.
Symptoms - Chronic cough, wet cough, coarse crackles and wheeze on auscultation
PT problem - secretion retention, likely increased WOB, V/Q mismatch
ASTHMA
Why does the airway narrow/thicken and remodel itself
What symptoms does this cause and the PT problem
Why - Bronchospasm and bronchial wall oedema
Bronchospasm occurs as the inflammatory response causes the smooth muscle cells int he bronchioles to contract which narrows the airways
Bronchial wall oedema occurs becuase the inflammatory response increase capillary permeability to allow inflammatory cells into the area. Therefore fluid and immune cells leak from the bronchiole wall capillaries and accumulate in the bronchial tissue = narrowing/ obstruction
Chronic asthma = as the body tries to repair itself from repeated damage, the epithelial membrane thickens from epithelial grow and proliferate which thickens airways. Scarring and fibrosis occur in the airways, goblet cells undergo hyperplasia and secrete excess mucus which all narrow and obstruct the airways causing irreversible damage to the airways.
Symptoms - decline in lung function in general, SOB, fatigue, wheeze, resp failure and altered ABGs.
PT problem - Increased WOB, reduced ex tolerance, V/Q mismatch, secretion retention
BRONCHIECTASIS
Why is there increased sputum volume
What symptoms does this cause and the PT problem
why - Inflammatory damage to widen the bronchial walls stimulates proliferation of goblet cells, causing hypersecretion of mucus and exacerbating airway obstruction as it pools in the widened areas. The thickened mucus can also contribute to the formation of mucus plugs, which can further obstruct the airways and impair lung function.
the formation of extra thick mucus production to pool in the widened airways.
Symptoms - chronic productive wet cough, crackly, constantly brining up white phlegm, stress incontinence (leak urine from constant cough)
PT problem - secretion retention, V/Q mismatch, probably increased WOB
What is Bronchiectasis
Causes
widening of the airways
Bronchiectasis is an obstructive lung condition where the bronchi become abnormally widened due to an excessive inflammatory response or previous infection such as CF, TB, RA
Pts are less able to clear secretions.
leading to a build-up of excess mucus that can make the lungs more vulnerable to infection, resulting in airway blockage and further breakdown of the airway
overtime the bronchial tissue becomes fibrotic as elastic properties are lost so the bronchi are permanently widened/ damaged
Causes - 40% still unknown cause
- often from another respiratory disease/ infection
- pneumonia / CF
- Rheumatoid Arthrisits
- Chronic asthma
BRONCHIECTASIS
why permanent widening of the airways
What symptoms does this cause and the PT problem
why - The vicious cycle of infection from bacteria in the mucus or from other resp diseases ie CF, causes chronic inflammation and widening of the airways, results in a constant immune response and the release of inflammatory mediators such as neutrophils which over time cause tissue damage and fibrosis = permanent widening
elastin, mus§cle and cartilage breakdown by neutrophils
symptoms - SOB, snoring, finger clubbing, fatigue, anxiety, depression, continuous coughing of green sputum
PT problem - reduced ex tolerance, reduced lung volume
BRONCHIECTASIS
why is there reduced sputum clearance
What symptoms does this cause and the PT problem
Why - cilia become clogged with vast thick mucus and the become damaged. The walls membrane can also thicken and reduce movement of the cilia. This means the cilia cannot beat the mucus up and towards the throat.
mucociliary escalator becomes ineffective and the build up of mucus makes the airways prone to the vicious cycle of infection
Symptoms - chronic wet cough, increased resp infections, white or green sputum if infection , crackles, squeaks and pops on auscultation wheeze,
PT problem - secretion retention, V/Q mismatch, increased WOB, could have loss of lung volume
What is cystic fibrosis
causes
Cystic fibrosis is an inherited condition in which the mucous, salivary and sweat glads produce thick, sticky mucus which clogs up the organs.
Cause:
Both parents must have the defective CFTR gene on chromosome 7 which is responsible for the transport of salt and water in/out of cells.
CYSTIC FIBROSIS
why is there increased thickness of sputum
What symptoms does this cause and the PT problem
the CFTR gene responsible for salt and water transport is defective. Therefore the mucus produced is dehydrated, saltier and thicker.
symptoms - Chronic cough, wet cough, coarse crackles on auscultation, wheeze
PT problem - secretion retention, liekly increased WOB
CYSTIC FIBROSIS
why is the mucociliary transport impaired
What symptoms does this cause and the PT problem
why - The mucus is so thick and sticky the cilia are unable to move it and beat the mucus up and towards the throat.
Symptoms - Chronic cough, coarse crackles, wheeze, anxiety, fatigue, depression, SOBOE (on exertion)
PT problem - Secretion retention, likely increased WOB as well
CYSTIC FIBROSIS
why is there a viscous cycle of infection in CF
What symptoms does this cause and the PT problem
why - The CFTR gene defects disrupts the salt and water transport between cells. Meaning that the mucus is thicker and rich in glycoprotein for bacteria to live off. And the mucus cannot be cleared so bacteria will enter lungs rich with mucus.
Symptoms - Depends on the infection: scarring, fibrotic lungs, pyrexia, wet cough, crackles, wheeze
PT problem - Reduced lung volume, reduced ex tolerance
CYSTIC FIBROSIS
Why is there permanent lung damage (lung fibrosis)
What symptoms does this cause and the PT problem
why - With the repeated infections in the lungs, over time the lungs become damaged, scar and become fibrotic.
Symptoms - SOBOE, low SpO2, low PaO2, altered ABGs, hypoxaemia, cyanosis (if Caucasian)
spontaneous pneumothorax is common at end stage CF
PT problem - reduced lung volume, reduced ex tolerance, V/Q mismatch,
CYSTIC FIBROSIS
Why do people have low BMIs
What symptoms does this cause and the PT problem
why - With the altered salt and water transport within cells, juices in the digestive system are also thickened and food/ nutrients are not absorbed as well
Symptoms - have to take creon in their food (mix of digestive enzymes), poor compliance with physio, depression
PT problem - reduced ex tolerance
PNEUMONIA vs LRTI
Think of pneumonia as being a whole lobe of consolidation
whereas
Remember pneumonia has 4 different stages – the signs and symptoms will depend on the stage the patient is going through
LRTI is more widespread and is more like a typical ‘chest infection’ like bronchitis
PNEUMONIA / LTRI
why is pyrexia a symptom
What symptoms does this cause and the PT problem
Why - The immune system also raises the body’s temperature as a way to kill off the invading microorganisms, as many bacteria and viruses cannot survive at higher temperatures. Causing fever symptoms to appear. eg. rise in temperature
symptoms - unwell, feverish, faint, low bp, high HR, dizzy, signs of sepsis
PT problem - reduced ex tolerance
What is pneumonia
Inflammation of the alveoli in one or both lungs which causes consolidation and the alveoli to be filled with sputum, bacteria and white blood cells. There are 4 stages.
Caused by:
- Bacterial infection (streptococcus)
- viral infection (influenza/ covid)
- A fungal infection
- aspiration of food, liquid, vomit or other substances in the lungs causing inflammation/ infection
- underlying medical conditions or other respiratory conditions (COPD)
What is a LRTI
Lower respiratory tract infection is an infection that affects the lungs and the airways below the larynx. So the bronchi, bronchioles, alveoli.
Causes:
- many different causes of pathogens, bacteria or fungi
- can be mild or severe and treatment depends on the symptoms
- can be a common chest infection treated with antibiotics
PNEUMONIA/ LRTI
why is there lung exudate
What symptoms does this cause and the PT problem
Why - The inflammatory response to the invading pathogen causes the alveoli to inflame. During inflammation, blood vessels in the affected area become more permeable, allowing immune cells and other components of the blood to enter the area and fight off the infection or repair the damage. However, this increased permeability can also allow fluid to leak out of the blood vessels and into the surrounding tissue and fill alveoli with exudate/pus (fluid, mostly dead white blood cells, and other debris)
Symptoms - wet crackles (fluid filled in tissue as well as alveoli), chest pain, fatigue
PT problem - secretion retention, V/Q mismatch, increased WOB
PNEUMONIA
why is there consolidation in the lungs
What symptoms does this cause and the PT problem
why - Consolidation occurs because of the exudate formed in the alveoli. During pneumonia, the lungs fill with white blood cells and fibrin as part of the immune response to the infection because the blood vessels become more permeable allowing excess immune cells and also fluid to leak through and this accumulation cells and fluid instead of air causes consolidation.
Capillary congestion = When the capillaries are congested, it means that there is an increase in blood flow and a build-up of red blood cells within the alveolar capillary network. The lungs will be very heavy and red as the capillaries in the alveolar walls become congested = impaired gas exchange
symptoms = Bronchial breathing in early stages of pneumonia (listening through consolidated alveoli), coarse crackles, coughing, SOB, wheeze
PT problem - secretion retention, V/Q mismatch, increased WOB
PNEUMONIA/ LRTI
why is there sometimes and oxygen requirement
What symptoms does this cause and the PT problem
why - Hypoxaemia can occur due to all the symptoms
- reduced gas exchange (capillary consolidation, exudate in lungs/ alveoli, consolidation)
- mucus plugs/ reduced ventilation
Also respiratory failure (type 1 or 2)
Symptoms
- SOBAR (SOB at rest)
- low SpO2, low PaO2 (altered ABGs)
- hypoxaemia/ cyanosis (depending)
PT problem - V/Q mismatch, increased WOB
Stage 1 of pneumonia
Congestion (within 24hrs)
- inflammation of alveolar walls
- blood vessels dilate
- increased vascular engorgement (overfilling of blood vessel)
- lungs become heavy and congested
Stage 2 of pneumonia
Red Hepatisation (2-4 days)
- excessive fluid and inflammatory exudate enters the alveoli
- RBCs, neutrophils and fibrin enter the lungs to fight infection = causes redness
- Cellular exudates containing neutrophils, lymphocytes and fibrin replaces the alveolar air
- air is driven out Alveolar capillaries are engorged with blood
- Fibrinous exudates fill the alveoli
Stage 3 of pneumonia
Grey hepatisation (4 days)
- RBCs disintegrate giving lungs greyish colour
- the lobe is solid, dry and airless
- The pressure of the exudates in the alveoli causes compression of the capillaries = avascular
= consolidation
Stage 4 of pneumonia
Resolution (8-9 days without antibitotics)
- A large number of macrophages enter the alveolar spaces to undergo phagocytosis of the bacteria
- alveolar clear through expectoration
What is pulmonary fibrosis
Pulmonary fibrosis is a progressive and irreversible lung disease. Where chronic inflammation, damage or an irritant (eg: environmental toxin, smoking, or autoimmune disease) causes the lung tissue to be replaced fibrotic tissue
causing scarring and thickening of lungs and alveolar walls over time
Damages pulmonary-capilllary bed
results in patchy areas of V/Q matching and reduced gas exchange
decreased lung compliance (ability to stretch)
= leading to difficulty breathing and reduced oxygen levels in the body as the fibrotic layer reduces lung compliance (elastic recoil) and ability for gas exchange to occur through thickness.
Symptoms of Pulmonary fibrosis
shortness of breath,
a dry cough
feeling tired
weight loss/ loss of appetite (malnurished)
nail clubbing
loss of lung volume
V/Q mismatch
Why are COPD pts more susceptible to airway collapse
- The EPP in COPD pts is more distal where there is no cartilaginous rings to keep the airways patent. Therefore, the contriction which occurs at EPP may cause a collapse (CAUTION) to reduce FET
- smoking damages surfactant in the lungs which usually decreases surface tension and ensures alveoli do not collapse.
What is emphysema
characterised by the break down in alveolar walls which causes
- dilation of the distal airways (alveoli)
- destruction of the pulmonary capillary bed
- reduction in elasticity of the lungs
- decreased surface area for gas exchange (boulle) = air trapping
- hyper inflation and ventilation
Subjective Questions help anagram
HOW DO PEOPLE ONLY PAY FOR A SMALL SMOKE
H - history of present condition
D - Drug history
P - past medical history
O - occupation
P - physiotherapy, past? goals? Own way of managing chest?
F - family, support
A - allergies (pets?)
S - social history? environment, support ADLs, mobility
S - smoking/ sputum history, same? how long/many, Want to stop? coughing? breathless?
Respiratory failure
Acute, chronic, acute on chronic
Type 1
- when the bodies respiratory system cannot deliver sufficient O2 into the blood to meet the demand
- PaO2 <8 , PaCO2 normal/ low
- can occur in healthy individuals with infection or obstructed lungs
= cardiac shunt or v/q mismatch
Mixed resp failure
When type 1 turns into type 2 (at the end of severe type 1)
Type 2
- when the bodies respiratory system cannot supply suffiencent levels of O2 into the blood to meet the demand but also fails to remove enough CO2 out of the blood.
- PaO2 < 8, PaCO2 > 6
- can be due to CNS drive issue
- thoracic wall abnormalities
- fatigue or exhaustion of muscles to breath
- patients can become desensitised to high levels of CO2 in th eblood which normally is the drive more people to breath and therefore rely on low levels of O2 in the blood to stimulate breathing (DO NOT PUT INTO HYPOXIC DRIVE as levels usually 88-92%) = COPD
Treating type 1 and type 2 resp failure
Type 1
- Nasal Canula = 1-5L
- Face mask = 6-10L
Severe type 1 - NIV
- CPAP: continuous positive airway pressure delivered into the lungs during inspiration and expiration to improve ventilation and keep the airways open with a higher pressure then atmospheric pressure)
- it also helps the patient breath can reduces the risk of resp muscle fatigue
Type 2 -NIV
- HFNC = up to 60L which can be humidified and heated,
- BIPAP: bi level positive airway pressure, high levels during inspiration to improve oxygenation, volume and ensure airways/ alveoli remain open. Then a lower pressure during exhalation to allow CO2 elimination
- it also reduces the work of breathing for patients to avoid resp muscle fatigue and need to be invasively ventilated
PPC
pneumonia/ LRTI
- Caused from increased bacteria/ infections in hospital (HAP)
- invasive ventilation into sterile environment
- decreased mucociliary escalator as cilia put to sleep and resp muscle (diaphragm and intercostals) don’t function properly so cannot clear sputum = infection
- Aspired pneumonia from vomit or food after surgery
Symptoms
chest pain, fatigue, malaise, hypoxia, altered ABGs, crackles, green sputum, cough, malaise, wheeze
PPC
Atelectasis
Obstructive or non-obstructive
non-obstructive = outside pressures on lungs such as surgen moving heart or pressing on lung or abdominal contents or pneumothorax
Obstructive = mucus plus (decrease MCE)
O2 therapy = the high concentration of O2 washes out the air in the lungs and is readily absorbed into the blood and leaves the alveolar without sufficient air = collapse
Symptoms
reduced breath sounds
increased RR
increased HR
low PaO2
chest pain
Risk of PPC
. obesity
. smoking
. long surgery
. lung condition (asthma, COPD, bronchiectasis)
. difficulties swallowing
PPC
positioning
- long supine lie causes abdominal contents to push onto lungs, flattens diaphragm and reduce LV/ FRC
- muscle weakness due to lack of use and bed rest
symptoms
increased RR
fatigue
Increased HR
SOB
decreased breath sounds
chest pain
PPC
Anestesia
- Cilia/ diaphragm and intercostal muscles go to sleep so they cannot clear secretions (deceased MCE)
- anaesthesia reduces cough reflex
Laparotomy or laparoscopy
Laparotomy = large incision, a quicker operation right down the center = more pulmonsy complications = higher risk of PPC
Laparoscopy = smaller incision, longer but less risk of PPC
