Week 3 (parts 1 and 2) Flashcards
WEEK 3 - pt1
pathology symptoms, subjective Ax + auscultation intro
what are the main cardinal signs and symptoms
- Cough
- Sputum
- Dyspnoea
- Wheeze
- Chest pain
what are the other cardinal signs and symptoms
- Tachycardia and Tachypnoea
- Blood in Sputum (haemoptysis)
- Frequent infections
- Cyanosis
- Peripheral Oedema
- Fatigue
- Insomnia
What do OD, BD, TDS, QDS, PRN stand for in terms of drug history
OD – once a day
BD – twice a day
TDS – three times a day
QDS – four times a day
PRN – patient required needs
how many lobes does the right lung have
3 - upper, middle, lower
how many lobes does the left lung have
2 - upper and lower
what are the 4 auscultation points on the right lung
1 - Apex, palpate and mark 2.5cm above medial 1/3 of clavicle
2 - palpate and mark rib 4 (just above and to the right of the nipple)
3 - palpate and mark rib 6 (bra line)
4 - palpate and mark rib 7 (laterally)
what are the 3 auscultation points of the left lung
1 - apex, palpate and mark 2.5cm above medial 1/3 of clavicle
2 - palpate and mark rib 6 (bra line)
3 - palpate and mark rib 7 (laterally)
what are the 4 auscultation points (both sides) on the back
- apices (upper curve of scapula)
- superior lobes (medial curve of scapula)
- Inferior/ lower lobes (slightly lateral and lower to superior lobe point)
- lung bases (lateral and lower to inferior lobe point)
WEEK 3 - pt 2
Pulmonary Pathology notes
What are the 3 classifications of lung disease
- Tissue or vessel affected
- Obstructive or Restrictive Lung Disease
- Other Classifications
What is Tissue or vessel affected lung disease
- Airways: asthma, COPD etc
- Lung tissue: pulmonary fibrosis, sarcoidosis etc
- Lung circulation: Pulmonary embolism, pulmonary hypertension
what is obstructive or restrictive lung disease
- Obstructive: COPD, bronchitis etc
- Restrictive: sarcoidosis, interstitial lung disease etc
what are the other classifications of lung disease
- Acute
- Chronic
- Occupational
what are the 5 cardinal signs of respiratory disease
- Cough
- Sputum
- Dyspnoea (breathlessness)
- Wheeze
- Chest pain
what is COPD (Chronic Obstructive Pulmonary Disease)
’a common preventable and treatable disease, is characterised by persistent air flow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases..’
Progressive lung disease
Airflow obstruction with little or no reversibility
what are the causes of COPD
- Smoking
- Industrial pollutants
- Mining
- Bacterial infection
- Viral infection
- Wood, fires, biomass fuels
- Vehicle exhaust pollution
what is emphysema
Permanent enlargement of the alveoli
Destruction of alveolar walls
Lungs lose their elasticity
Walls of terminal bronchioles and alveoli are destroyed by inflammation
Airway collapse
Air trapping
Enlarged alveoli sacs-dead space
Air trapping
Bronchioles open on inspiration but
collapse on expiration
Air trapped within alveoli
Hyperinflation-barrel chest
Diaphragm flattens
Ventilation capacity decreased
Usually co-exists with chronic bronchitis
Primarily a disease of the alveoli
Caused by smoking or Congenital
what are the accessory muscles of inspiration
Sternocleidomastoid
Scalene (anterior, middle and posterior)
Serratus anterior
Serratus posterior
Pectoralis major
Pectoralis minor
Trapezius
Latissimus dorsi
what are the accessory muscles of expiration
Abdominals
Rectus Abdominis
External Obliques
Internal Oblique
Transversus Abdominis
what is a barreled chest
Enlarged chest
Rounded cross section
Fixed horizontal position of ribs
what happens during emphysema
Alveolar walls disintegrate
Increases resistance in pulmonary circulation
Right ventricle has to work harder
Enlarged right ventricle
Cor pulmonale
what is cor pulmonale
Cor pulmonale is a condition that causes the right side of the heart to enlarge and fail. It’s also known as pulmonary heart disease caused by long term high pressure in the pulmonary arteries of the lungs and right ventricle of the heart
what are the symptoms of Cor Pulmonale
SOB
Syncope
Tachycardia
Chest pain
Foot and ankle swelling
Cyanosis
what are the symptoms of COPD
Cough
Dyspnoea-difficult or laboured breathing
Excessive sputum production
Chest tightness or wheeze
Oedema
Heart Failure
Recurrent chest infections
Hyperinflated lungs
Fatigue
Chest pain/discomfort
risk factors associated with COPD and smoking
smoking history
occupational exposure to harmful fumes, dust or chemicals
exposure to fumes, such as biomass fuels
what is bronchitis
an inflammation of the lining of the bronchial tubes
what is chronic bronchitis
Chronic bronchitis is defined as a cough that occurs every day with sputum production that lasts for at least 3 months, 2 years in a row.
The major cause of chronic bronchitis is cigarette smoking; other causes are bronchial irritants, usually inhaled repeatedly by the affected person
Over 90% of patients with chronic bronchitis have a history of smoking
The lining of the bronchial tubes repeatedly becomes irritated and inflamed.
The continuous irritation and swelling can damage the airways and cause a buildup of sticky mucus, making it difficult for air to move through the lungs.
This leads to breathing difficulties that gradually get worse.
The inflammation can also damage the cilia
When the cilia don’t work properly, the airways often become a breeding ground for bacterial and viral infections.
Infections typically trigger the initial irritation and swelling that lead to acute bronchitis.
Chronic production of excessive mucus
Lower respiratory airways becomme inflammed and fibrosed causing airway obstruction
Gaseous exchange is impaired
Frequent chest infections
More mucus doesn’t lead to disability
The subsequent fibrosis and inflammation does as it progresses to larger airways
what effect does short term smoking have on the cilia
- In acute (short term) cases of exposure to smoke, coughing is induced and cilial beating increases to clear the smoke out of the lungs.
what effect does long term smoking have on the cilia
- In long term exposure, smokers’ cilia beat slower than normal, and continue to slow down the longer the person smokes.
what is alpha 1 anti-trypsin deficiency
a rare, inherited condition, which can cause lung and liver problems
lack a protective enzyme inhibitor called alpha-1-antitrypsin
more vulnerable to the effects of inhaling smoke or other toxic materials like dust, fumes or chemicals.
More likely to develop chronic obstructive pulmonary disease (COPD).
why do you perform spirometry on diagnosis
At diagnosis
To reconsider the diagnosis, for people who show an exceptionally good response to treatment
To monitor disease progression
when is diagnosis of COPD confrimed in terms of post-bronchodilator
FEV1/FVC < 0.7 (i.e. <70%) &
FEV1 < 80% of predicted
FEV1 = forced expiratory volume in 1 second
FVC = forced vital capacity
what are the stages of the GOLD (2008) and NICE (2010) grades 1-4 (severity of airflow obstruction)
1- mild, below 80% predicted for post bronchodilator FEV, 0.7 PB FEV
2- moderate, 50-79% predicted % for PB FEV,
3- severe, 30-49% PB FEV predicted
4- very severe, <30% PB FEV
what further investigations could patients have on diagnosis
A chest x-ray
A full blood count (FBC) to identify anaemia or polycythaemia
Body mass index (BMI) calculated
Additional investigations may include:
Sputum culture
Home peak flow measurements (to exclude asthma if doubt remains)
Electrocardiogram (ECG)
Echocardiogram
CT thorax
Serum alpha-1 antitrypsin
what is the BODE index used for prognosis
Assessment of the prognosis of COPD
BMI
Airflow Obstruction (FEV₁ % predicted)
Dyspnoea (MRC dyspnoea scale)
Exercise capacity (6 minute walk test)
Approx. 4 year survival rate
0-2 points 80%
3-4 points 67%
5-6 points 57%
7-10 points 18%
what are the differences between COPD and asthma
smoker/ ex-smoker - Nearly all/possibly
Symptoms under 35
- Rare/ often
Chronic productive cough
-common/uncommon
breathlessness
- persistent and aggressive/ variable
night-time waking with breathlessness
- uncommon/ common
Significant varying of symptoms
- uncommon/ common
why do airflow obstructions occur
Airflow obstruction due to a combination of damage to the airways and also to lung parenchyma (e.g. alveoli)
The damage is the result of chronic inflammation that differs to that seen in asthma
Significant airflow obstruction may be present before the individual is aware of it
what are the main symptoms of COPD
cough, sputum, dyspnoea, wheeze, chest pains, swollen ankles, haemoptysis, weight loss/ anorexia, muscle weakness and wasting
what happens in lung areas with chronic under-ventilation
there is a local shutdown of vessels which forces blood to the better ventilated regions
This is achieved by the pulmonary blood vessels vasoconstricting therefore increasing pulmonary vascular resistance
what does pulmonary vascular resistance over a long period of time have as a consequence
Re-modelling of the pulmonary circulation and hypertrophy of the small pulmonary arteries
Narrower, thicker and more muscular pulmonary arteries provide higher resistance to blood flow, this = pulmonary hypertension
what is cor pulmonale
alteration in the structure and function of the R ventricle
Dilation and hypertrophy of the right ventricle in response to diseases of the pulmonary vasculature and/or lung parenchyma (pulmonary heart disease)
Chronic obstructive lung disease and chronic bronchitis are responsible for approx. 50% of cases of cor pulmonale in the developed countries
Aka right sided heart failure
what is pulmonary hypertension
↑ afterload on the right ventricle
Right ventricle hypertrophy
↓R ventricular ejection fraction (pump failure)
Back pressure into venous circulation
↑ pressure at venous end of capillary bed
Interrupts normal capillary dynamics
Peripheral oedema
what is peripheral oedema
Palpable swelling produced by the expansion of interstitial tissue
Starling’s law tells us that forces dictate the movement of fluid between the capillary and the interstitial space
↑ pressure at venous end of capillary bed = increased capillary hydrostatic pressure = net efflux of fluid into the interstitial tissue
what is exacerbation of COPD
an acute worsening of respiratory symptoms that result in additional therapy
how is exacerbation of COPD classified
Mild – treated with short acting bronchodilators (SABD) only
Moderate – treated with SABDs plus antibiotics and/or oral corticosteroids
Severe – patient requires hospitalisation or visits to the emergency department. Severe exacerbations may also be associated with acute respiratory failure
COPD patients experience 1-4 exacerbations per year
what are the symptoms of exacerbation of COPD
Dyspnoea (84%)
Fatigue (81%)
Cold symptoms e.g. runny nose (59%)
Sputum colour changes (53%)
Sputum volume changes (47%)
Cough (44%) (Costi et al., 2006)
what causes exacerbation
Viral – most common cause (especially rhinovirus) associated with more symptoms and slower recovery
Bacterial infections – less common however airways of COPD patients often colonised with bacteria which can lead to secondary bacterial infection (up to 60% of cases)
Environmental pollution
1/3 of severe exacerbations have unknown cause
what are the symptoms of both infective and non-infective exacerbation of COPD
Increased dyspnoea
Upper airway symptoms (eg, colds and sore throats)
Increased wheeze and chest tightness
Fatigue and reduced ex tolerance
Marked respiratory distress with dyspnoea and tachypnoea
Possibly acute confusion, increased cyanosis, peripheral oedema
Respiratory failure - may develop
what is infective exacerbation of COPD
Added symptoms of infective exacerbation only:
Increased cough
Increased sputum purulence (change in colour and viscocity)
Increased sputum volume
Pyrexia (fever)
what is the process of exacerbation
Exposure to trigger (viral, bacterial or environmental) causes worsening airway inflammation
Increased inflammation = increased airway oedema and mucus hypersecretion
Also have worsening:
airway obstruction
dynamic hyperinflation
dyspnoea
cough
Increased WOB
Sometimes leads to respiratory failure
what are the long term effects of exacerbation
Inflammatory cascade that occurs during acute exacerbation thought to contribute to structural lung damage responsible for the progression of COPD over time
Exacerbations associated with:
A more rapid decline in lung function
Sustained reduction in health related QOL
Increased risk of future exacerbation
