Alterations of Pulmonary Function Chapter 26

Signs and Symptoms of Pulmonary Disease Dyspnea Subjective sensation of uncomfortable breathing Orthopnea Dyspnea when a person is lying down Paroxysmal nocturnal dyspnea (PND)

Signs and Symptoms of Pulmonary Disease Abnormal breathing patterns Kussmaul respirations (hyperpnea) Cheyne-Stokes respirations

Signs and Symptoms of Pulmonary Disease Hypoventilation Hypercapnia Hyperventilation Hypocapnia Cough Acute cough Chronic cough Hemoptysis

Signs and Symptoms of Pulmonary Disease Cyanosis Pain Clubbing Abnormal sputum

Clubbing

Conditions Caused by Pulmonary Disease or Injury Hypercapnia Hypoxemia Hypoxemia versus hypoxia Ventilation-perfusion abnormalities Shunting Acute respiratory failure Pulmonary edema Excess water in the lungs

Ventilation-Perfusion

Pulmonary Edema

Conditions Caused by Pulmonary Disease or Injury Aspiration Passage of fluid and solid particles into the lungs Atelectasis Compression atelectasis Absorption atelectasis Bronchiectasis Persistent abnormal dilation of the bronchi

Compression Atelectasis Squeeze

Absorption Atelectasis

Conditions Caused by Pulmonary Disease or Injury Bronchiolitis Inflammatory obstruction of the small airways Most common in children Occurs in adults with chronic bronchitis, in association with a viral infection, or with inhalation of toxic gases

Conditions Caused by Pulmonary Disease or Injury Bronchiolitis obliterans Late-stage fibrotic disease of the airways Can occur with all causes of bronchiolitis

Pleural Abnormalities Pneumothorax Open pneumothorax Tension pneumothorax Spontaneous pneumothorax Secondary pneumothorax

Pneumothorax

Tension Pneumothorax One way valve

Pleural Abnormalities Pleural effusion Transudative effusion Exudative effusion Hemothorax Empyema Infected pleural effusion Chylothorax

Pleural Effusion Pleural space

Hemothorax Blood

Conditions Caused by Pulmonary Disease or Injury Abscess formation and cavitation Abscess Consolidation Cavitation Pulmonary fibrosis Excessive amount of fibrous or connective tissue in the lung

Conditions Caused by Pulmonary Disease or Injury Chest wall restriction Compromised chest wall Deformation, immobilization, and/or obesity Flail chest Instability of a portion of the chest wall

Flail Chest

Conditions Caused by Pulmonary Disease or Injury Inhalation disorders Exposure to toxic gases Pneumoconiosis Silica Asbestos Coal Allergic alveolitis Extrinsic allergic alveolitis (hypersensitivity pneumonitis)

Pulmonary Disorders Acute respiratory distress syndrome (ARDS) Fulminant form of respiratory failure characterized by acute lung inflammation and diffuse alveolocapillary injury Injury to the pulmonary capillary endothelium Inflammation and platelet activation Surfactant inactivation Atelectasis

Pulmonary Disorders Acute respiratory distress syndrome (ARDS) Manifestations Hyperventilation Respiratory alkalosis Dyspnea and hypoxemia Metabolic acidosis Hypoventilation Respiratory acidosis Further hypoxemia Hypotension, decreased cardiac output, death

Pulmonary Disorders Acute respiratory distress syndrome (ARDS) Evaluation and treatment Physical examination, blood gases, and radiologic examination Supportive therapy with oxygenation and ventilation and prevention of infection Surfactant to improve compliance

Pulmonary Disorders Postoperative respiratory failure Atelectasis Pneumonia Pulmonary edema Pulmonary emboli Prevention Frequent turning, deep breathing, early ambulation, air humidification, and incentive spirometry

Obstructive Pulmonary Disease Airway obstruction that is worse with expiration Common signs and symptoms Dyspnea and wheezing Common obstructive disorders Asthma Emphysema Chronic bronchitis

Asthma “Chronic inflammatory disorder of the airways” Inflammation results from hyperresponsiveness of the airways Can lead to obstruction and status asthmaticus

Asthma

Asthma Symptoms include expiratory wheezing, dyspnea, and tachypnea Peak flow meters, oral corticosteroids, inhaled beta-agonists, and anti-inflammatories used to treat

Bronchial Thermoplasty The Wall STREET Journal-health November 1, 2010

Abscess Formation & Cavitation Kle bsiella or Staphylococcus- aspiration Abscess-suppuration & destruction Consolidation-fluid, pus, & bacteria with necrosis to form communication with a bronchus Cavitation- abscess empties into the bronchus with a cavity

Chronic Obstructive Pulmonary Disease Chronic bronchitis Hypersecretion of mucus and chronic productive cough that lasts for at least 3 months of the year and for at least 2 consecutive years Inspired irritants increase mucus production and the size and number of mucous glands

Chronic Obstructive Pulmonary Disease Chronic bronchitis The mucus is thicker than normal Bronchodilators, expectorants, and chest physical therapy used to treat

Bronchitis

Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease Emphysema Abnormal permanent enlargement of the gas-exchange airways accompanied by destruction of alveolar walls without obvious fibrosis Loss of elastic recoil Centriacinar emphysema Panacinar emphysema

Emphysema

Emphysema

Emphysema ULL

Chronic Obstructive Pulmonary Disease

Obstructive Pulmonary Disease

Respiratory Tract Infections Pneumonia Community-acquired pneumonia (CAP) Streptococcus pneumoniae Hospital-acquired (nosocomial) pneumonia Ventilation – Associated Pneumonia (VAP)-p 695 Immunocompromised pneumonia (HIV/Trsnsplants) See page 695-common microorganisms

Pneumococcal Pneumonia Lobar

Brittany Murphy Died : Community acquired pneumonia

Respiratory Tract Infections Tuberculosis* Mycobacterium tuberculosis Acid-fast bacillus Airborne transmission Tubercle formation Caseous necrosis Positive tuberculin skin test (PPD) *known for 15,000 years 1.4 million RIP 2006

Tuberculosis Cavitary

Respiratory Tract Infections Acute bronchitis Acute infection or inflammation of the airways or bronchi Commonly follows a viral illness Acute bronchitis causes similar symptoms to pneumonia but does not demonstrate pulmonary consolidation and chest infiltrates

Pulmonary Vascular Disease Pulmonary embolism Occlusion of a portion of the pulmonary vascular bed by a thrombus, embolus, tissue fragment, lipids, or an air bubble Pulmonary emboli commonly arise from the deep veins in the thigh Virchow triad Venous stasis, hypercoagulability, and injuries to the endothelial cells that line the vessels

Pulmonary Embolism

Pulmonary Vascular Disease Pulmonary hypertension Mean pulmonary artery pressure > 25 mm Hg

Pulmonary Vascular Disease Pulmonary hypertension Classifications Pulmonary arterial hypertension: ?, inherited, drugs, toxins Pulmonary venous hypertension-CHF-left Pulmonary hypertension due to a respiratory disease or hypoxemia-COPD Pulmonary hypertension due to thrombotic or embolic disease-PE Pulmonary hypertension due to diseases of the pulmonary vasculature

Pulmonary Vascular Disease Primary pulmonary hypertension Idiopathic Women age 20-40 years Endothelial dysfunction vasoconstrictors (THX) Cor pulmonale

Pulmonary Hypertension & cor pulmonale

Cor Pulmonale Pulmonary heart disease Right ventricular enlargement Secondary to pulmonary hypertension Pulmonary hypertension creates chronic pressure overload in the right ventricle with hypertrophy and dilation

Cancer Lip cancer ( < men, 3,000/yr) Most common form Exophytic Stages Laryngeal cancer (2-3% of cancers, 12,000/yr; tobacco + EtOH; HPV) Forms Carcinoma of the true vocal cords (most common) Supraglottic Subglottic

Lip Cancer

Laryngeal Cancer

Lung Cancer Bronchogenic carcinomas Most common cause is cigarette smoking (80-90%)- >30 carcinogens Heavy smokers have a 20 times’ greater chance of developing lung cancer than nonsmokers Smoking is related to cancers of the larynx, oral cavity, esophagus, and urinary bladder

Lung Cancer

Lung Cancer Environmental or occupational risk factors are also associated with lung cancer

Lung Cancer Non–small cell lung cancer(80%) 1. Squamous cell carcinoma (30%) 2. Adenocarcinoma(35-40%) 3. Large cell carcinoma (10-15%) (undifferentiated) Neuroendocrine Tumors 1.Small cell lung cancer-paraneoplastic syndrome See Table 26-3

Squamous Cell Carcinoma “Couhg”

Adenocarcinoma Glands Pleural effusion

Large Cell Carcinoma Anaplastic Pain ,couhg hemoptysis

Small Cell (oat cell) Cough, pain, hemoptysis

Dana Reeves-Nonsmokers “different genetic mutations” Nov 2010

Lung Cancer TNM classification Evaluation and treatment Tumor Nodal involvement Metastasis Surgery, chemotherapy, and radiation