Productive Diseases

Question 1

Definition of pneumonia

Answer 1

Pneumonia is an inflammatory condition of the lung leading abnormal alveolar filling with consolidation and exudation
Pneumonia is sometimes referred to as a O2 diffusion disorder

Question 2

Pathology of pneumonia

Answer 2

During pulmonary infection, acute inflammation results in the migration of neutrophils out of capillaries and into airspaces (alveoli), these cells phagocytose and release antimicrobial enzymes and inhibitors which leads to more inflammation and oedema.

Question 3

4 stages of pneumonia

Answer 3

Congestion (inflammatory phase) - first 24 hours; Characterised by vascular engorgement, intra-alveolar fluid, & numerous bacteria; the lung is heavy, boggy & red

Red Hepatisation (red, liver-like consistency alveoli) - 2-3 days; In this stage, 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

Grey Hepatisation (grey, liver-like consistency alveoli) - 4-6 days; This stage is characterised by progressive disintegration of red blood cells and the persistence of a fibrin exudate

Resolution (PTs most actively involved) - >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

Question 4

Causes of pneumonia

Answer 4

1. Bacteria – Streptococcus Pneumonia, Haemophilus Influenza type b (Hib)
2. Virus – e.g. respiratory syncytial
3. Fungi
4. Parasites
5. Chemical
6. Aspiration – food, drink, stomach acids (vomit)
7. Inhalation (smoke, burns)

Question 5

Classification of pneumonia

Answer 5

Community Acquired Pneumonia (CAP) – acquired in community setting

Hospital Acquired Pneumonia (HAP) – acquired within 48 hours or more of admission and patient were not incubating a CAP

Healthcare Associated Pneumonia (HCAP) – acquired from patients being nursed within 90 days of being treated with antibiotics for something else, e.g. wound

Ventilator Associated Pneumonia (VAP) – occurs 48-72 hours post intubation

Question 6

Medical Diagnosis of pneumonia

Answer 6

Pneumonia is diagnosed using a clinical prediction rule which uses the following 5 markers compared to a CXR to determine the likelihood of pneumonia being a diagnosis:

1. Temperature > 37.8o (100oF)
2. HR > 100 bpm
3. Crackles
4. Increased (bronchial) or decreased (absent) breath sounds
5. Absence of asthma - if they do have asthma they may have high HR from steroid use, may have altered auscultation findings

Check CXR for pulmonary infiltrates (collapse or consolidation) and compare to 5 markers to give a predictive value of the likelihood the diagnosis is pneumonia:
5 findings = 84 – 91% probability
4 findings = 58 – 85%
3 findings = 35 – 51%
2 findings = 14 – 24%
1 finding = 5 – 9%
0 findings = 2 – 3%

Question 7

Other diagnostic tests of pneumonia

Answer 7

If Pneumonia is suspected other tests will be used to make a final diagnosis.

1. CXR
2. CT scan
3. Blood test
4. Sputum culture – resolution phase
5. Pleural fluid culture – invasive
6. Bronchoscopy – invasive

Question 8

Signs and Symptoms of pneumonia

Answer 8

Some symptoms relate to inflammation and others relate to lack of O2 as it is a diffusion disorder

Common symptoms:

1. Fever
2. Malaise
3. Muscle ache/fatigue
4. Coughing (productive and non-productive) - depending on stage
5. Tactile Fremitus on palpation - depending on stage
6. Dyspnoea
7. Pleuritic or chest pain
8. Loss of Appetite
9. Rapid Heartbeat

Less common symptoms:

1. Coughing up of Blood
2. Fatigue
3. Nausea/Vomiting
4. Diarrhoea
5. Wheezing
6. Confusion - very severe relating to lack of O2 diffusion

Question 9

General management of pneumonia

Answer 9

1. Antibiotics /Anti-Fungal medication = Treatment of source of problem
2. Oxygen support as O2 diffusion disorder
3. Hydration - IV fluids = Often loss of appetite, high temperature leads to dehydration
4. Rest as body needs time to concentrate on fighting infection, plus do not want to increase O2 demand
5. Analgesics = any chest pain or general aches
6. Cough suppressant medication = occasionally in non-productive stages pts have a very irritable cough
7. Fever-reducing medication - paracetamol = control any rise in temperature to ensure enzymes working at correct temperature
8. Vaccination - prevention for pneumonia but also associated diseases like flu

Question 10

Physiotherapy treatment of pneumonia

Answer 10

Care needed, especially in early stages, as it may increase oxygen consumption & demand, or cause bronchospasm

1. Treat the clinical signs and symptoms = SOB, preventing overusing accessory muscles - relaxed breathing
2. Non-productive phases – positioning V/Q for O2 diffusion, mobilising or no intervention
3. Productive phase – Sputum clearance techniques including positioning, breathing exercises, adjuncts etc

Question 11

Definition of Bronchiectasis

Answer 11

Bronchiectasis is the 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 does not always show as airflow obstruction. It does not therefore come under the term COPD.
Chronic progressive disease where more recurrent exacerbations worsens prognosis

Question 12

Pathogenesis of Bronchiectasis

Answer 12

The cyclical process by which the disease occurs is:

1. Impaired mucociliary clearance leads to accumulation of secretions
2. Accumulation of secretions leads to infection by bacteria
3. Infection by bacteria leads to increased mucus production which in turn further impairs ciliary performance which in turn leads to increased inflammatory response
4. Excessive inflammatory response causes tissue damage
5. Tissue damage eventually produces dilated bronchi including loss of ciliated epithelium and impaired mucociliary clearance permanently

BACK TO STEP ONE – VISCIOUS CYCLE

Question 13

Causes of Bronchiecstasis

Answer 13

Bronchiectasis is thought to be caused by:

1. Idiopathic in nature – unknown cause mainly
2. Infection (usually in childhood)
3. Cystic fibrosis link
4. Immunodeficiency
5. Ciliary dysfunction
6. ?Allergic bronchopulmonary aspergillosis (ABPA) - fungal infection difficult to get rid off; prolonged use of certain inhaled medication may cause fungal infections
7. Inflammatory conditions – chronic can cause fibrotic changes causing loss of shape
8. Aspiration/obstruction

Question 14

Clinical features of Bronchiectasis

Answer 14

Patients will present with the following symptoms:

1. Virtually all patients have a cough and chronic sputum production – permanently wet cough
2. 75% dyspnoea and wheeze
3. 50% chest pain – from chronic cough = muscular pain; may be another cardiac issue
4. 1/3 sign of chronic sinusitis (blocked noses) & nasal polyps (growths in nasal cavities) – thus patients are mouth breathers which is dry air breathed in causing worser cough
5. Recurrent exacerbations are common
6. Approx. 50% patients experience haemoptysis (very rarely life threatening in this population)

Question 15

Medical Diagnosis of Bronchiectasis

Answer 15

If bronchiectasis is suspected other diagnostic tools will be used to confirm it.

1. Chest x-ray - consolidation
2. High resolution Computer Tomography (HRCT) scan – loss of structure, heavy mucus formation
3. Blood and sputum microbiology – blood = infective marker; sputum culture = causative organism
4. Pulmonary function tests – indication if it is obstructive or not

Question 16

Types of bronchiectasis

Answer 16

1. Saccular (occurs in large bronchi that become large & balloon-like)
2. Cylindrical (involves medium sized bronchi which usually are symmetrically dilated)
3. Varicose (constrictions & dilations deform the bronchi)

Any may be lobar or widespread

Question 17

Symptoms of acute exacerbation of bronchiectasis

Answer 17

Pts will know their chests and what is normal or abnormal for them where signs are:

1. Change in sputum production
2. Increased dyspnoea
3. Increased cough
4. Temperature >38.0˚C
5. Increased wheezing
6. Malaise, fatigue, lethargy or reduced exercise tolerance
7. Reduced pulmonary function - not often used; may be used to check after treatment to assess if pt disease is progressively worsening
8. X-ray changes consistent with a new pulmonary process (CXR with new changes to previous CXR)
9. Changes in chest sounds

Any 4 symptoms = acute exacerbation

Question 18

Medical management of bronchiectasis

Answer 18

IV/oral/nebulised antibiotics
Bronchodilators -inflammation and loss of wall shape
Steroids - inflammation
Nasal sprays - nasal sinusitis
Flu & pneumoccocal vaccinations - prevent complications
Surgery - worst case scenario and for complications; transplants (rare)

Question 19

Physiotherapy treatment for bronchiectasis

Answer 19

Actively involved in long-term management as it is a progressive disease
Treating acute exacerbation symptoms - sputum, SOB, wheezing

Question 20

Definition of Cystic Fibrosis

Answer 20

CF is an inherited autosomal recessive disease (genetic). There is a gene mutation causing a 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 Cystic Fibrosis Transmembrane Regulating (CFTR) protein. This defect leads to a compromise in ion transport which impairs the transport of Cl ions, and also affects levels of Na and water within the cell. It affects several organs causing ducts to become obstructed with mucus leading to inflammation and replacement of damaged cells with connective tissue (scarring).

Question 21

Prevalence of CF

Answer 21

Being an autosomal recessive disease means two carriers of this gene have a 1-in-4 chance of having an affected baby and a 1-in-2 chance that their baby will be a carrier

Question 22

Pathology/effects of defect in CFTR

Answer 22

The defect in the CFTR protein results in problems with many different body systems

1. Respiratory disease – abnormally concentrated fluid in the lungs leads to viscous secretions in the airways, due to dehydrated airways mucus is not cleared, predisposing patients to disease and recurrent infection and ultimately scarring of lungs (fibrosis)
2. High sodium sweat – chloride ions not absorbed leading to prevention of sodium absorption so low salt in blood thus low recognition of dehydration (thirst) increasing risk of dehydration
3. Pancreatic insufficiency – production of enzymes is normal but abnormal ion transport leads to dehydration of pancreatic secretions, and therefore leads to stagnation in pancreatic duct. Can cause diabetes in later life
4. Biliary disease – abnormal ion transport reduces water movement in the lumen resulting in concentrated bile which can damage walls of lumen
5. Infertility – Male CF patients (98%) are often infertile due to absence of vas deferens – tube transporting sperm from the testes to the urethra; female CF patients may have impaired fertility due to thicker cervical mucus
6. Cirrhosis of the liver – due to abnormality in ion transport causing higher concentrated secretions which can lead to scarring of the liver
7. Gastrointestinal disease – dehydration leads to intraluminal water deficiency which causes problems with bowel movement, i.e. constipation

Question 23

Medical diagnosis of CF

Answer 23

1. Genetic/Carrier testing – If someone has a history of CF in their family, a partner with CF, or a child with the condition, they may choose to get carrier testing. A simple mouthwash or blood test can determine if someone is a carrier of the faulty gene that causes cystic fibrosis. Carrier testing is often done for people who are thinking of starting a family and have a relative with cystic fibrosis.
2. Heel Prick test – Since 2003 in Scotland and 2007 in the rest of the UK, all babies born have been screened for CF using the heel prick test. This is when a pin prick is used to extract small amount of blood. As a result most children are diagnosed with CF shortly after birth
3. Sweat test – If a baby is suspected of having cystic fibrosis, a sweat test may be performed as part of the follow up to the screening process. In people with CF there is a problem in the transport of chloride across cell membranes, which results in higher concentrations of chloride (as salt) in the sweat. The sweat test measures this concentration, and is done by collecting a small amount of sweat from the arm or leg

Question 24

Symptoms of CF

Answer 24

Common symptoms involve the respiratory and digestive systems:
Lungs:
1.Persistent cough
2.Coughing fits
3.Inflammation in the lungs: wheezing, shortness of breath, difficulties breathing (particularly after exercise)
4.Recurring chest and lung infections - due to the continual build-up of thick mucus in lungs becoming a breeding ground for bacteria
5.Cross infection - through close personal contact or coughing near them; more likely to pick up infection from each other than environment; bacteria can become resistant to antibiotic treatment thus CF pts are kept away from each other (isolative disease)
6.Impaired diaphragm from enlarged liver

Digestive system:

1. Large smelly stools - digestive enzymes not being produced properly thus food not adequately digested so excess fat and protein in stool
2. Malnutrition/poor weight gain/stunted growth (delayed puberty if severe) - due to mucus blocking pancreatic ducts so insufficient food digesting enzymes reach intestines to help break down food

Question 25

Medical management for CF

Answer 25

Individualised and depends on pts main symptoms but commonly uses a cocktail of medication to help with respiratory symptoms:
Medication:
1. Bronchodilators 2. Hypertonic Saline nebs
3. Antibiotics
4. Mucolytic (DNAse) - to break down secretions to make loose enough to cough out
5. Steroids
6. Routine vaccinations - prevention of flu/pneumonia as high risk group
7. Digestive enzymes (Creon) - to aid in absorption of needed nutrients

Dietary advice
Education - compliance of treatment regimes
Exercise
Psychological support - as often difficult as isolating disease
Lung transplant - for some pts however disease still present and while new lungs do not develop condition they require special care; post-transplantation pts required to continue medication and treatment regime for other effects from CF, i.e. digestive system

Question 26

Physiotherapy treatment for CF

Answer 26

mainly for chest clearance techniques

1. PD - postural drainage
2. Percussion, vibs/shakes
3. ACBT
4. AD
5. Adjuncts
6. Mobilisation/exercise
7. Suction (ITU)
8. Breathing exercises
9. General exercises