Pathophysiology Flashcards
What is pneumonia?
An inflammatory condition of the lung leading to abnormal alveolar filling with consolidation & exudation
Who does pneumonia affect?
Affects youngest and oldest most
Single largest infectious cause for death in children
What is the pathology of pneumonia?
An infection, chemical or aspiration irritant
During pulmonary infection, acute inflammation results in the migration of neutrophils out of capillaries into airspaces (alveoli), these cells phagocytose & release antimicrobial enzymes & inhibitors -> more inflammation and oedema
What are the 4 stages of pneumonia?
Congestion
Red hepatisation
Grey hepatisation
Resolution
What is the congestion stage of pneumonia?
The first 24 hours
Characterised by vascular engorgement, intra-alveolar fluid & numerous bacteria
The lung is heavy, boggy and red
What is the red hepatisation stage of pneumonia?
2-3 days
Massive exudation develops, with red blood cells, leukocytes & fibrin filling the alveolar spaces
The affected area appears red, firm & airless, with a liver like consistency
What is the grey hepatisation stage of pneumonia?
4-6 days
Progressive disintegration of red blood cells and the persistence of a fibrin exudate
What is the resolution stage of pneumonia?
> 6 days
The consolidated exudate within the alveolar spaces undergoes progressive digestion to produce debris that is later reabsorbed, ingested by macrophages or coughed up
What are the causes of pneumonia?
Bacteria Fungi Virus Parasites Chemical Aspiration Inhalation
What are the classifications of pneumonia?
Community Acquired Pneumonia (CAP)
Health Care Associated Pneumonia (HCAP)
Hospital Acquired Pneumonia (HAP)
Ventilator Associated Pneumonia (VAP)
What are the causes of CAP?
Strep pneumonia/staphylococcus aureus 25% Virus 10% Mycoplasma 6% H influenza 5% Legionella 3% Unknown cause 37%
What are the causes of HAP
MRSA 15% Pseudomonas Aeruginosa 14% MSSA 9% Kiebsiella pneumonia 3% Other gram negative rods 9% Unknown cause 37%
Common symptoms of pneumonia
Fever Malaise Muscle ache/fatigue Coughing (productive & non-productive) Tactile fremitus on palpation Dyspnoea Pleuritic or chest pain Loss of appetite Rapid heartbeat
Less common symptoms of pneumonia
Coughing up blood Fatigue Nausea/vomiting Diarrhoea Wheezing Confusion
What are the complications of pneumonia?
Lung abscess
Pleural effusions
Empyema (infection/puss inbetween pleural cavity)
Septic shock
What is the medical diagnosis for pneumonia?
Temperature> 37.8 degrees HR > 100bpm Crackles Decreased breath sounds or bronchial breath sounds Absence of asthma
What is the clinical prediction rate of pneumonia?
5 findings = 84-91% 4 findings = 58-85% 3 findings = 35-51% 2 findings = 14-24% 1 finding = 5-9% 0 findings = 2-3% With a chest x ray
What are the other diagnostic tests for pneumonia?
CXR CT scan Blood test Sputum culture Pleural fluid culture Bronchoscopy
What is the general management for pneumonia?
Antibiotics/Anti-fungal medication Oxygen support Hydration - IV fluids Rest Analgesics Cough-suppressant medication Fever-reducing medication Prevention through vaccination programmes
What is the physiotherapist treatment for pneumonia?
Care needed as may increase oxygen consumption and demand or cause a bronchospasm
Treat the clinical signs and symptoms
Non-productive - positioning V/Q, mobilising or no intervention
Productive - sputum clearance techniques including positioning, breathing exercises, adjuncts etc
What is bronchiectasis?
Permanent abnormal dilation in one or more of the lungs Bronchi
Extra mucus is secreted and pools in the areas of the airways that are dilated making the person more prone to infection
It has similar symptoms to COPD but doesn’t always show as airflow obstruction
What is the epidemiology of bronchiectasis?
Precise incidence is uncertain
Female > male
Average age of 66
What is the pathology of bronchiectasis?
Impaired mucociliary clearance leads to accumulation of secretions
Accumulation of secretions leads to infection by bacteria
Infection by bacteria leads to increased mucus production, increased impaired ciliary performance, increased inflammatory response
Excessive inflammatory response causes tissue damage
Tissue damage eventually produces dilated bronchi including loss of cilliated epithelium and impaired mucocillary clearance
VISCOUS CYCLE
What are the causes of bronchiectasis?
Idiopathic Infection (usually in childhood) Cystic fibrosis Immunodeficiency Cillary dysfunction Allergic brochopulmonary aspergillosis (ABPA) Inflammatory conditions Aspiration/obstruction
What are the clinical features of bronchiectasis?
Virtually all patients have cough & sputum production
75% dyspnoea & wheeze
50% chest pain
1/3 have signs of chronic sinusitis & nasal polyps
Recurrent exacerbations are common
Approx. 50% patients experience experience haemoptysis (very rarely life threatening)
What is the diagnosis of bronchiectasis?
Chest X-ray
High resolution computed tomography (HRCT)
Bloods & sputum microbiology
Pulmonary function tests
What are the types of bronchiectasis?
Saccular - occurs in large bronchi that become large and balloon like
Cylindrical - involves medium sized bronchi which usually are symmetrically dilated
Varicose - constrictions and dilations deform the bronchi
They can be localised or widespread
What are the symptoms of acute exacerbation?
Change in sputum production Increased dyspnoea Increased cough Temperature > 38 degrees Increased wheezing Malaise, fatigue, lethargy or decreased exercise tolerance Reduced pulmonary function X-ray changes consistent with a new pulmonary process Changes in chest sounds
What is the treatment and management for bronchiectasis?
Physiotherapy IV/oral/rebulised antibiotics Bronchodilators Steroids Nasal sprays All & pneumococcal vaccinations Surgery
What is the prognosis of bronchiectasis?
Prognosis for hospital treated patients is better than COPD but poorer than asthma
Associated disease has an effect on prognosis
What is COPD?
Characterised by airflow obstruction
- progressive in severity
- not fully reversible
- doesn’t change markedly over several months
- umbrella term for chronic bronchitis, emphysema and chronic asthma
What are the three diseases under COPD?
Emphysema
Chronic bronchitis
Asthma
What is normal airway clearance?
Airways are lined with cells which produce mucus and tiny hairs (cilia) which continually beat
Mucus traps dust particles and bacteria
The cilia move the mucus along until it reaches the throat and we swallow it or cough
Defence mechanism
What can go wrong in airway clearance in COPD?
Excess mucus is produced Mucus is thicker and stickier The cilia are unable to beat Smoking paralyses the cilia This means: - dust and bacteria stay trapped in the airways - mucus build up & provides warm, moist environment for bacteria to grow - infections can develop
What is bronchitis?
Chronic disease of the lungs where bronchi become inflamed
The inflammation causes more mucus to be produced which narrows the airways & makes breathing more difficult
What does bronchitis cause?
Increased sputum production - over production of mucus in airways which becomes difficult to clear
Wheezing is very common (especially after coughing) due to inflamed airways narrowing for short periods of time which reduces the amount of air entering the lungs
Inflamed airways
Airways narrower with less space for sputum to get through
May feel tired, unwell and unable to cough
What’s emphysema?
A condition where the alveoli of the lungs become inflamed and lose their natural elasticity
The alveoli over expand and lose their ability to fill up and contract properly
As air fills up in these sacs some rupture and become one sac reducing surface area for gas exchange
When breathe out the trapped air cannot be released and breathing becomes more and more difficult
What’s asthma?
An episodic increase in airway obstruction caused by various stimuli resulting in increased airway resisted
Common disease in UK - approx 5 million people suffer with it
Often reversible airway disease but it can become chronic with some fixed airway damage and therefore comes under COPD umbrella
Inflammation & Bronchoconstriction
What are the symptoms of asthma?
Breathlessness
Wheeze
Tightness in chest
Why are the airways sensitive in asthma?
Become irritated, inflamed and narrow
Reduced airflow through the airways
What are the causes of COPD?
Cigarette smoking (90%) significant smoking history - 20 pack years or more
Occupational exposure - coal miners
Alpha-1 Antitrypsin deficiency
Social deprivation
What the diagnosis for COPD?
Detailed patient history Clinical signs - breathlessness on exertion - cough - increased sputum - risk factors - rule our other causes Spirometry - diagnosis - categorise severity - monitor progression Chest x-ray
What’s the classification for COPD?
Early disease
Moderate disease
Severe disease
What is the early disease classification for COPD?
Often few symptoms
- morning cough (smokers cough)
- chest infections in winter
- breathlessness when exercising vigorously
Clinical examination may be normal although spirometry may be reduced
What is the moderate disease classification of COPD?
Range of respiratory symptoms - cough - wheeze - SOB with moderate exertion Clinical examination may reveal wheeze, barrel chest, flattened diaphragm on CXR
What is the severe disease classification of COPD?
Severe symptoms
- cyanosis
- weight loss
- raised JVP (jugular venous pressure)
- peripheral oedema
What is the treatment for COPD?
Smoking cessation
- 4x more likely to quit with help, advice & nicotine replacement
- stop smoking services are widely available in the community
- stopping smoking will help to slow the progression of the disease
- we can refer as physios any time
What’s the medication for COPD?
Inhalers
Steroids & antibiotics
Mucolytics
Flu & pneumonia vaccines
Pulmonary rehabilitation for COPD ?
Exercise Education Self management Diet Lifestyle modification Will help reduce admissions & aid recovery time post exacerbation
What is pulmonary fibrosis?
Restrictive disease caused by inflammation and scarring of the lungs
Progressive condition where the scarring and inflammation build up (build up called fibrosis)
Can be known as ctyptogenic fibrosing alveolitis or usual interstitial pneumonia
Results in reduced gas exchange
What are the causes of pulmonary fibrosis?
Men, older people more likely
Causes unknown (idiopathic)
?smoking
?occupational exposure - dust from wood, metal, textile or stone
?infection & some viruses such as herpes & Hep C
Some link to people with GORD (gastro-oesophageal reflux disease) which causes heart burn
In a few cases can be a genetic link
What are the symptoms of pulmonary fibrosis?
Main symptom - breathlessness, severe in most
In some symptoms gradually worsen and in others progress quickly
No cure - almost 1/2 don’t live for more than 3 years after diagnosis
Constant cough
Feeling tired all the time
Clubbing of fingers and toes
It’s not infectious
What’s the diagnosis of pulmonary fibrosis?
Detailed patient history Clinical signs - breathlessness at rest & exertion - persistent cough - clubbing Spirometry Bronchoscopy - look at lung tissue Chest x-ray - followed by a CT
What’s the treatment for pulmonary fibrosis?
Not generally treated with inhalers
Oxygen therapy
Pulmonary rehab to manage breathlessness, maintain & improve exercise tolerance
Medications such as sedatives & morphine for help with breathlessness
Treatment for heartburn & blocked nose that may be making the symptoms worse
Lung transplant - very rare
What are the medications for pulmonary fibrosis?
Pirfenidone (Esbriet)
- mild to moderate IPF
- capsule that is thought to slow down the inflammation and build up of scar
Nintedanib
- originally used in lung cancer patients
- reduces the rate at which the lungs become scarred & helps reduce ‘flare ups’
What is the pulmonary rehab for pulmonary fibrosis?
Exercise Education Self management Diet Lifestyle modifications Help with management of breathlessness & exercise tolerance
How can pulmonary fibrosis patients help themselves?
Stop smoking
Have early flu jab
Have pneumococcal vaccination
Avoid people with chest infections and colds
Stay as fit and active as you can
Eat a healthy balanced diet
Get in touch with the British lung foundation for further support and guidance
What is cystic fibrosis?
An inherited autosomal recessive disease that’s the result of a gene mutation (single gene defect on chromosome 7)
Chromosome 7 is responsible for encoding the cystic fibrosis membrane conductance regulator - a transmembrane protein involved in ion transport called the CF Transmembrane Regulating (CTFR) protein
This defect leads to a compromise in ion transport - it impairs transport of chloride ions and also affects levels of sodium and water in the cell
It affects several organs causing ducts to become obstructed with mucus -> inflammation & replacement of damaged cells with connective tissue (scarring)
What does the CFTR protein do?
It’s a channel protein that controls the flow of water & chloride ions between membranes
When the structure is changed the passage of molecules & ions is blocked
The most common pathology of CF
There are over 1500 mutations of the CTFR gene that produce different variations of the CTFR protein
What does a defect in the CFTR result in?
Respiratory disease - abnormally conc. fluid in lungs leads to viscous secretions in airways, mucus isn’t cleared predisposing pts to infection
High sodium sweat - chloride ions not absorbed prevents sodium absorption
Pancreatic insufficiency - abnormal ion transport leads to dehydration of pancreatic secretions - leads to stagnation in pancreatic duct
Biliary disease - reduced water mvt in lumen, concentrated bile damages wall
Infertility - males due to absence of vas deferens prevents transport of sperm
Cirrhosis of liver - abnormality in ion transport
Gastrointestinal disease - intraluminal water deficiency problem w bowel mvt
What is the diagnosis for CF?
Genetic testing - simple mouthwash or blood test
Heal prick test
Sweat test - collecting small amount of sweat from arm or leg
What are the symptoms of CF at birth?
Roughly 10% babies born with a serious bowel obstruction (meconium ileus) - thick black substance that is normally passed out within a day or 2
In babies with CF it’s too thick to be passed through so causes a blockage in the bowels and surgery is normally needed to clear
Some babies will show signs of jaundice which are yellowing of the skin, eyes & mucus membrane
What are common symptoms of CF in the lungs?
Persistent cough Coughing fits Inflammation in the lungs - wheezing, SOB, difficulties breathing Recurring chest & lung infections Cross infection Impaired diaphragm from enlarged liver
What are the common symptoms of CF in the digestive system?
Large, smelly stools
Malnutrition, poor weight gain, stunted growth
What are other symptoms of CF?
Diabetes
Sinusitis
Nasal polyps (fleshy swellings that grow from the lining of nose or sinuses)
Arthritis
Osteoporosis
Infertility
Liver failure (tiny bile ducts get blocked by mucus)
Urinalysis incontinence
Delayed puberty
Msk system
- inspiratory muscle atrophy
- weakness/atrophy in anti-gravity muscles such as gastrocnemius
- kyphosis of the spine resulting in neck & back pain
What treatments are there for CF?
Medication Physiotherapy Dietary advice Education Exercise Lung transplant psychological support
What medications are there for CF?
Bronchodilators Hypertonic saline nebs Antibiotics Mucolytic (DNAse) Steroids Routine vaccinations Digestive enzymes (creon)
What physiotherapy is used for CF?
Postural drainage? Percussion, vibs/shakes Active cycle of breathing technique Autogenic drainage Adjuncts Mobilisation/exercise Suction (ITU)
What’s the prognosis of CF?
No cure or prevention
Currently about 1/2 of people with CF will live past the age of 40 (some to 47)
Lung complications are normally the cause of death in CF patients
Specific quality of life depends of specific protein mutation (1500 types) and environmental & developmental factors
What is cardiovascular disease?
General term for conditions affecting the heart and blood vessels
It is also associated with damage to the arteries of the brain, kidneys and eyes
What are the types of CVD?
Coronary heart disease (CHD)
Cerebral vascular accidents (CVA)& Transient ischaemic attacks (TIA)
Peripheral vascular disease (PVD)
Aortic disease
What is coronary heart disease?
Sometimes called Ischaemic heart disease or coronary artery disease
A disease where the coronary arteries are blocked or narrowed
Includes:
Angina
Myocardial infarction
Heart failure
What are the risk factors of CHD?
Age Gender Social deprivation Smoking Diet Exercise Alcohol Psychosocial well being Blood pressure Cholesterol Obesity Diabetes Ethnicity Family history
What are the symptoms of CHD?
- Only appear when a coronary artery is 70-75% occluded
Pain, discomfort, pressure, tightness, numbness or burning sensation in chest, arms, shoulders, back, upper abdomen or jaw
Dizziness
SOB
fatigue or weakness
Nausea or vomiting
Indigestion or heartburn
Sweating or clammy skin
Rapid heart rate
Palpations
Swollen ankles or legs feeling of something being wrong
What is angina?
Chest pain due to inadequate supply of oxygen to the heart muscle
Tends to be transient
What are the types of angina?
Stable - happens at predictable times e.g. stress or exercise
Unstable - happens when no particular demand is being placed on the heart
Variant - when a coronary artery goes into spasm
Microvascular - affects the very smallest of the vessels
What is treatment for angina?
Medications - nitrates, anticoagulants
Lifestyle changes
Surgery - angioplasty, CABG
What is a myocardial infarction?
When the blood supplying the oxygen to the heart is severely reduced or cut off
The result is ischaemia of the heart muscle and scar formation
What is the diagnosis of MI?
Cardiac enzymes - troponin - appears after 3-6 hours - peaks 24-48 hours - lasts 7-10 days - creating kinase ECG - ST elevation - inversion of T wave - enlarged Q wave
What are the symptoms of MI?
Sweating or cold, clammy skin
Feeling out of breath
Feeling dizzy or like you’re going to pass out
Pain, tingling or discomfort in other parts of the upper body, including the arms, back, neck, jaw or stomach
Pain, pressure or discomfort in chest
Nausea, vomiting, burping or heartburn
A fast or uneven heartbeat
What is the prognosis for MI?
Depends on site of infarction and degree of damage Sudden death Arrhythmias Heart failure Cardiogenic shock Thrombus formation Rupture
What is the treatment for MI?
Depends on severity of symptoms
Drugs - beta-blockers & vasodilators
Cardiac catheterisation/angiography, PTCA, stents, laser, drilling
CABG
Physiotherapy involvement in cardiac rehab and preoperative care
What is the physiotherapy for MI?
MI rehab - in patient - outpatient CABG surgery - range from critical care -> discharge - post discharge rehab
What is heart failure?
The heart is unable to adequately pump the blood around the body usually because the heart has become too stiff or weak
What are the causes of heart failure?
Common cause is MI Other causes: HTN (particularly pulmonary) Cardiomyopathy Damaged valves Arrhythmias Congenital conditions Viral infections Chemotherapy Excessive alcohol Anaemia Thyroid disease
What are the symptoms of heart failure?
SOB on exertion +/- at rest
Swollen feet, ankles, stomach & lower back
Fatigue or feeling weak
What are the treatments of heart failure?
No cure or treatments so aim to control symptoms
Diuretics
Some patients benefit from a pacemaker or an implantable cardioverter defibrillator (ICD) to help improve the pumping action of the heart
What are the causes of heart valve disease?
Congenital HD Rheumatic fever Cardiomyopathy MI Endocarditis Aging
What are the symptoms of heart valve disease?
SOB
Ankle/feet swelling
Fatigue
How does a diseased/damaged valve affect the flow of blood?
If the valve doesn’t open fully -> obstruct or restrict flow of blood = stenosis or narrowing
If the valve doesn’t close properly -> blood leaking backwards = valve incompetence or regurgitation or leaky valve
What are other common cardiac problems?
Congenital heart disease
Rhythm issues - AF, Atrial flutter, Arrythmia, AV heart blocks, bundle branch blocks
Sudden death - Brugada syndrome, sudden arrhythmic death syndrome (SADS)
Aortic disease - aneurysm, dissection, stenosis
Out of hospital cardiac arrest (OHCA)
What are the different cardiac operations?
CABG valve repair/replacement heart transplant heart lung transplant repair of congenital heart defects - neonatal, paediatric, adolescents & adults
What’s a coronary artery bypass graft (CABG)?
Surgical procedure used to treat coronary heart disease
Involves bypassing a blocked portion of a coronary artery using another piece of blood vessel
Can be single or multiple arteries
What are the common graft sites for a CABG?
Saphenous vein
Radial artery
Left internal thoracic (mammary) artery - LITA
Right internal thoracic (mammary) artery - RITA
Right gastroepiploic artery
Inferior epigastric artery
What are the complications of a CABG?
Perioperative MI Bleeding 2-5% require reopening Low cardiac output Atrial fibrillation - 40% Lower lobe collapse (L) Restrictive lung deficit Chest infection/pneumonia Other infection Late graft stenosis Non union of sternum Keloid scarring (overgrown scar surrounded by collagen Vasoplegic syndrome Pericardial tamponade Pulmonary oedema/pleural effusion Pneumothorax/haemothorax Renal impairment/failure Wound infection Neurological - CVA 1-5% psychosis Grafts only last 8-15 years Chronic pain at incision sites
What is the physiotherapy management for CABG?
Uncomplicated cardiac surgery Techniques such as - secretion clearance - decrease WOB - increase lung volume Advice regarding early mobilisation Stair climbing day 3/4 post op Discharge home 4/5 days post op Rehab programme 2 weeks post op Advice re ADL & progressive exercise Should be walking approx 3 miles in 4/52
What are the special considerations of CABG?
Complications may lead to prolonged ITU stay
May require ‘high tech’ support which can limit physio treatments
Do not tolerate head down positions
Teach how to support sternum
- if problem w/ sternum may hear & feel clicking
May need postural correction/shoulder exercises
Mood change/depression common in post op recovery period
What are the causes of heart valve disease?
Congenital heart disease Rheumatic fever Cardiomyopathy MI Endocarditis Aging
What are the types of valve replacement?
Mechanical -long lasting 15-25 years - require long term anticoagulants - made of pyrolytic carbon Tissue - sometimes called bioprosthetic - created from animal donors valves or other animal tissue - lasts 10-20 years Donor - least common - lasts 10-20 years Ross procedure - the aortic valve is replaced with the pulmonary valve which is subsequently replaced as well TAVI/TAVR - transcatheter aortic valve implantation or replacement
What are the complications of a valve replacement?
Stroke Clotting Arrhythmia Valve becomes damaged/worn out Chest infection/pneumonia Other infection Pulmonary oedema/pleural effusion Pneumothorax/haemothorax Renal impairment/failure Wound infection Chronic pain at incision sites Keloid scarring Pericardial tamponade non union of sternum
What is a heart transplantation?
Has to be from a heart beating donor Needed: - in severe CHD - cardiomyopathy - congenital heart disease
What are the complications of transplantation?
Immune system recognising transplanted heart as foreign and attacking it (rejection)
Donated heart failing to work properly (graft failure)
Narrowing of the arteries supplying the heart (cardiac allograft vasculopathy)
Side effects from the immunosuppressant medications such as an increased vulnerability to infections, weight gain & kidney problems
Plus the complications on CABG & valve surgery
What’s the life expectancy after a transplantation?
80-90 in every 100 will live at least a year
70-75 at least 5 years
50 at least 10 years
Some people have survived more than 25 years after
What’s the life after transplantation?
Regular follow-up appointments Immunosuppressants for life Exercise Diet Pregnancy
