Restrictive and Obstructive Lung Flashcards
VO2
Oxygen consumption
Good reflection of O2 demand
(arterial O2 content - venous O2) * cardiac output
OER
O2 extraction ratio
VO2/DO2
OER is normally 23% at rest
Manifestations of respiratory disease
Impaired oxygenation
Impaired CO2 removal
Hypoxemia
Low PaO2 in the blood
Hypoxia
Low oxygen in the tissues
Can also occur due to other conditions that can restrict the oxygen supply to tissues
Anoxia
Absence of oxygen
Signs/symptoms of impaired oxygenation
Cyanosis
Cerebral hypoxia
Cardiac arrhythmia
Pulmonary artery vasoconstriction
Hypercapnia
Increased PCO2
Sx/sy... Increased HR and BP Dizziness Headache Confusion or loss of consciousness Mm twitching and tremor
Hypocapnia
Low PCO2
Sx/sy... Lightheadedness (Cerebral vasoconstriction, decreased blood flow) Fatigue Irritability Inability to concentrate Tingling Impaired consciousness
Pneumotaxic area in pons
Sends inhibitory impulses to the inspiratory area
SHORTENS inhalation
Drop in CO2 will…
Increase pH
Decrease ventilation
Obstruction
Disease of respiratory tract, which produces and obstruction to airFLOW
Restriction
Abnormal reduction in pulmonary ventilation often due to diminished lung expansion
Decreased volume of gas moving in and out
COPD
Lung diseases that result in air trapping in the lungs
Can affect both mechanical fx and gas exchange
Dx made by pulmonary fx test, symptoms, and hx
Pts usually present c hyperinflation, barrel chest, and increased accessory mm use
COPD Pathogenesis
Inflammatory immune response in the lungs usually in response to noxious stimuli
Can also see…
Increased mucus production (impaired clearance)
Inflammation of mucosal lining of bronchi
Mucosal thickening
Bronchospasm (constriction of bronchial walls due to smooth mm spasm)
Decrease in the size of bronchial lumen
HYPERinflated lungs (air gets trapped behind collapsed bronchial walls)
COPD signs
Hypoxemia Hypercapnia Increase production of mucous/impaired mucous clearance Pulmonary HTN Polycythemia (increased RBCs) Cor pulmonale (R side heart failure) Increased resistance to coronary artery Often see productive cough (also can see ineffective cough) Decreased expiratory flow rates (FEV1) Increased residual volume
COPD symptoms
Dyspnea on exertion
Chronic cough
Expectoration of mucus
Wheezing
Types of COPD
Bronchitis Emphysema Asthma Bronchiecstasis Cystic fibrosis
Variability of COPD
Primary cause
Location of obstruction
Reversibility
Common co-existing conditions…
Asthmatic bronchitis
Chronic bronchitis with emphysema
Cystic fibrosis with bronchiecstasis
Bronchitis
Productive cough on MOST days for 3 mos during 2 consecutive years
Bronchitis sx/sy
Chronic cough Morning expectoration Frequent infections Barrel chest May be overweight Cyanotic (blue bloater) Edema due to heart failure
If it gets worse... IV fluids Antibiotics Bronchodilators Steroids O2
Emphysema
Abnormal, irreversible enlargement of airway distal to terminal bronchioles
Alveolar disease
Destructive change in alveolar wall - can see collapse of airway on exhalation
Centriacinar emphysema
Begins in the respiratory bronchioles and spreads peripherally
AKA centrilobular emphysema
Associated c long-standing cigarette smoking
Upper half of the lungs
Panacinar emphysema
Destroys the entire alveolus uniformly
Lower half of the lungs
Generally observed in pts c AAT deficiency
In those that smoke, focal panacinar may accompany centriacinar
Paraseptal emphysema
AKA distal acinar emphysema
Involves distal airway sxs, alveolar ducts, and alveolar sacs
Process localized around the septae of the lungs or pleura
Airflow frequently preserved; however, apical bullae may lead to spontaneous pneumothorax
Giant bullae occasionally cause severe compression of adjacent lung tissue
Hyper-inflated lungs lead to…
Compensatory changes of chest wall
Decreased diaphragmatic excursion
Bullae
Emphysemidus spaces that are bigger than 1 cm in size
Decreased/no participation in gas exchange or diffusion
Increased incidence of pneumothorax
Emphysema sx/sy
Barrel chest Floppy lungs Flat diaphragm "Pink puffer" SOB/DOE Minimal sputum Increased subcostal angle, horizontal ribs Hypertrophied accessory mm*** PLB at rest Often thin Clinically (ausc, xray, etc) PFT
Emphysema tx
Medication O2 Fluids Bronchodilators Surgery (bullectomy, volume reduction)
Asthma
Chronic inflammatory disease of the airways
Characterized by REVERSIBLE obstruction to airflow
Asthma attack is a combination of all these
Increased mucosal edema
Bronchospasm > bronchoconstriction
Secretions
Extrinsic asthma
Begins in childhood
Triggered by allergens
Intrinsic asthma
Begins as adult (usually after age 35) More severe (non-allergic)
Exercise induced asthma
Due to loss of water/heat in lower respiratory system
Status astmaticus
Attack that persists for hours and is unresponsive to medical management
MEDICAL EMERGENCY
Bronchiectasis
Abnormal permanent dilation of bronchi and bronchioles
Trouble c pulmonary hygiene
Frequent infections
Mucopurulent sputum
Permanent dilation can ulcerate and become fibrotic
Bronchiectasis auscultation
Crackles
Wheezes
Pleural rub
Bronchiectasis treatment
P/PD Fluids Abx (as needed) O2 Other meds Encourage to drink lots of water to help keep
Cystic fibrosis
Exocrine gland dysfunction
Respiratory - thick, excessive secretions and poor ciliary fx
GI - pancreatic enzyme deficiency; can digest fat; stress incontinence
Integumentary - increased sweat production
Respiratory cystic fibrosis
Obstructions of small airways ... Develop mucus plugs and destroy cartilagenous support of airways ... Bronchiecstasis
BRONCHIAL HYGIENE IS KEY
CF clinical signs
CXR - flattening of lungs, increased chest expansion PFT Ausc Cough Accessory mm use Clubbing
CF treatment
Pulmonary care Management of pancreatic insufficiency Antibiotics/antifungals Nutritional supplements General exercise
Bronchopulmonary dysplasia (BPD)
One of the most common chronic lung diseases in children (Asthma, CF also)
O2 distress and obstruction within one month of age; abnormal development of lung tissue (scarring/inflammation)
Restrictive dysfunction etiology
Abnormal reduction in pulmonary ventilation - can’t get air in
Not a disease in and of itself, but arises from other disease states in or out of the pulmonary system
Restrictive dysfunction pathogenesis
Compliance (of lung and chest wall)…
Decreased
Stiffer/more difficult to expand
Takes greater pulm pressure to expand the lung to a given volume
Lung volumes and capacities…
Decreased
Most marked decrease in IRV and ERV
Work of breathing…
Pt has to work harder to move air into the lungs
Clinical manifestations of restrictive dysfunction
Tachypnea Hypoxemia Diminished breath sounds Possible adventitious breath sounds Decreased lung volumes Decreased diffusion capacity Cor pulmonale (R heart failure) Dyspnea Cough (dry, non-productive) Emaciation
Medical management of restrictive dysfunction
Supportive…
Supplemental O2
Management of secretions
Nutritional support
Prevention of infection
Corrective…
Treatment specific to injury/dx
Pulmonary fibrosis
Inflammatory process of alveolar wall
Scarring leads to stiffness (decreased compliance)
May be idiopathic (IPF)
Immune response
Genetic
Occupational hazards (coal dust, asbestosis)
Pulmonary fibrosis s/s
Shallow/fast breathers
Pulmonary fibrosis tx
Corticosteroid
Pulmonary prognosis
5-6 years on average
Cause of death respiratory/heart failure related to pulmonary HTN
Pneumonia
Primary pulmonary pathologies in RLD Inflammatory process of the lung Begins from a lower respiratory tract infection 10% of all nosocomial infections CAP HAP VAP Risk factors... medical condition, environmental conditions Dx... xray
Pneumonia s/s
Dyspnea
Fever
Increased WBC
Pneumonia tx
Sputum sample to determine bug
Acute Respiratory Distress Syndrome
AKA acute lung injury
Sudden respiratory failure due to fluid accumulation in alveoli
Fluid leaking from smallest blood vessels in lungs into the alveoli
Can lead to fibrosis
ARDS s/s
SOB Labored/unusually rapid breathing Hypotension Confusion Extreme fatigue Cough Fever Hypoxia May not respond to supplemental O2 Xray - diffuse infiltrates (vessels will look normal in size)
ARDS treatment
Treat the cause Maintain the airway Manage nutrition Manage fluid balances Prevent complications Symptomatic management (pain, infection, etc)
Carcinoma
80-90% of lung cancers are caused by tobacco
Leading cause of cancer deaths
Small cell vs non-small cell
Carcinoma tx
Surgery
Radiation
Chemotherapy
Pleural effusion s/s
SOB Pleuritic pain Dry cough Non-productive Poor chest expansion Pleural run heard during ausc
Pleural effusion dx
Chest xray or US
V/Q mismatch
Fluid aspiration
Pleural effusion tx
Thoracocentesis or chest tube
Transudative vs exudative fluid
Exudative - infectious
Sarcoidosis
MULTISYSTEM disease with presence of noncaseating epithelioid granulomas
Autoimmune disease that results in fibrosis
Kidneys, heart, CNS, GI system, skin, eyes
Might hear crackles
Clubbing
SOB
Decreased exercise tolerance
Chronic steroids
Proximal steroidal myopathy
Non-productive cough
Chest p! c exercise due to attempt to increase TV
Tx - chemotherapy
Bronchiolitis obliterans (BO)
BOOP - with Organizing Pneumonia
Fibrotic lung dx of smaller airways with necrosis of the respiratory epithelium
Infants by RSV (respiratory synctial virus)
Adults by toxic fumes or other infections
After a bone marrow transplant
Pts present as COPD pts, but more restrictive/mixed in nature
Progressive dyspnea on exertion
Developing cough
Wheezes and crackles, especially with more of an obstructive pattern
Tx - supplemental O2, antivirals, antibiotics, corticosteroids, bronchodilators
Atelecstasis
Incomplete expansion (or collapse) of lung
Can result from…
Secretion retention
Compression of the lung
S/s
Decreased chest wall movement Absent or diminished breath sounds Fast breathing Fever if related to infection Increased density in involved area
DO2
O2 delivery
Arterial oxygen content * cardiac output
Pneumothorax
PTX
Presence of air in pleural cavity
Signs/symptoms vary based on size and other pulmonary dysfx
S/s…
Severe disease
Pleuritic chest pain
Hyperresonant percussion
Decreased fremitus
PTX tx
Types of pneumothorax (PTX)
Primary - spontaneous Secondary - COPD underlying disease Iatrogenic - MD causes it Traumatic - GSW, stab wound Tension - when air enters pleural space, but can't escape; can compromise venous return
PRIMARY pulm pathologies in RLD
Pulmonary fibrosis Pneumonia Acute Respiratory Distress Syndrome (ARDS) Carcinoma Pulmonary effusion Sarcoidosis Bronchitis Obliterans (BO) Atelectasis PTX
SECONDARY pulm pathologies in RLD
Pulmonary edema Pulmonary embolism Neurological conditions - SCI, ALS, GBS, MG, MD, CVA Ankylosing spondylitis Lupus (SLE) Obesity Pregnancy Scoliosis Trauma Oxygen toxicity
Pulmonary edema
Increased fluid in the lung (alveoli), often due to ventricular failure (especially L)
Can be a medical emergency
S/s…
Dyspnea Fast breathing Restless/uncomfortable Crackles (wetter breath sound) Cyanosis Clubbing Ventilator use if severe enough
Tx…
Treat the cause Diuretics Vasodilators Steroids Supplemental O2
Pulmonary embolism
10% mortality rate
Blood clot lodges in pulmonary artery (location determines severity)
S/s…
Acute sign of SOB Sweating Chest pain Wheezing possible Irregular pulse Light headedness Could come from DVT (prox worse than distal)
Tx…
Early mobilization for prevention
Meds - anti-coagulation, thrombolytic drug, surgery
CVA?
Hemidiaphragm
Ankylosing spondylitis
Spines are getting fused and they are all hunched over
Obesity
Decreased chest wall compliance and increased O2 demand, higher resting diaphragm, closure of small airways and alveoli at bases
Leads to V/Q mismatch
Obesity hypoventilation syndrome
Can’t take a deep enough breath bc of how much soft tissue they have
Increased O2 demand
O2 toxicity
High concentrations can cause interstitial lung disease, alveolar edema, and hemorrhage with atelectasis
Need to keep FiO2
TB
Restrictive disease
Mycobacterium Tuberculosis
PREVENTION first line of tx (universal precautions, respiratory isolation)
Airborne
Incubation period = 2-12 weeks
PPD + 6-8 weeks
S/s…
Unproductive cough Fever Night sweats Weight loss Dyspnea Crackles Xray abnormal c fluffy shadows, atelectasis, enlarged lymph nodes, cavitations in upper lobes, lung scarring
Tx…
Medication (rifambpin and isoniazid (INH)) for several mos
Respiratory isolation
