Chapter 24 Kyphoscoliosis B Figure 24-1. Kyphoscoliosis. Posterior and lateral curvature of the spine causing lung compression. Excessive bronchial secretions (A) and atelectasis (B) are common secondary anatomic alterations of the lungs.

Anatomic Alterations of the Lungs Lung restriction and compression as a result of the thoracic deformity Mediastinal shift Mucus accumulation throughout the tracheobronchial tree Atelectasis

Etiology Kyphoscoliosis affects about 2% of the people in the United States Mostly young children going through growing spurts Rarely develops in adults—unless a worsening condition from childhood Kyphoscoliosis may also develop in adults from a degenerative joint condition in the spine

Etiology Associated with the following conditions: Congenital connective tissue and skeletal disorders Hormonal imbalance Neuromuscular disorders Trauma Extraspinal contractures Bone infections involving the vertebrae Metabolic bone disorders Joint disease Tumors

Etiology Risk Factors Sex—females are 10 times more likely than males to develop curvature of the spine Age—the younger the child is when diagnosed, the greater the chance of curve progression Angle of the curve—the greater the curvature of the spine, the greater the risk that the curve progression will worsen

Etiology Risk Factors Location—in girls with lower back curvature, the curve is less likely to progress Height—taller girls have a greater chance of curve progression Spinal problems at birth—children with scoliosis at birth may experience a rapid curve progression

Etiology Clinically, scoliosis is commonly defined according to the following factors: Shape Nonstructural scoliosis—a side-to-side curve Structural scoliosis—a curvature of the spine associated with vertebral rotation Location Thoracic Lumbar Thoracolumbar Direction Left or right curvature of the spine Angle

Cobb Angle

Overview of the Cardiopulmonary Clinical Manifestations Associated with KYPHOSCOLIOSIS The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Atelectasis (see Figure 9-7) and Excessive Bronchial Secretions (see Figure 9-11)—the major anatomic alterations of the lungs associated with kyphoscoliosis (see Figure 24-1).

Figure 9-7. Atelectasis clinical scenario.   Figure 9-7. Atelectasis clinical scenario.

Figure 9-11. Excessive bronchial secretions clinical scenario.   Figure 9-11. Excessive bronchial secretions clinical scenario.

Clinical Data Obtained at the Patient’s Bedside Vital signs Increased respiratory rate Increased heart rate, cardiac output, blood pressure

Clinical Data Obtained at the Patient’s Bedside Cyanosis Digital clubbing Peripheral edema and venous distention Distended neck veins Pitting edema Enlarged and tender liver Cough and sputum production

Figure 2-46. Digital clubbing.

Figure 2-48. Distended neck veins (arrows).

Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2, London, 1992, Mosby-Wolfe.

Clinical Data Obtained at the Patient’s Bedside Chest assessment findings Obvious thoracic deformity Tracheal shift Increased tactile and vocal fremitus Dull percussion note Bronchial breath sounds Whispered pectoriloquy Crackles, rhonchi, and wheezing

Figure 2-11. A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.

Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung unit.

Figure 2-19. Whispered voice sounds auscultated over a normal lung are usually faint and unintelligible.

Clinical Data Obtained from Laboratory Tests and Special Procedures

Pulmonary Function Study: Expiratory Maneuver Findings FVC FEVT FEF25%-75% FEF200-1200  N or  N or  N PEFR MVV FEF50% FEV1% N N or  N N or 

Pulmonary Function Study: Lung Volume and Capacity Findings VT RV FRC TLC N or     VC IC ERV RV/TLC%    N

Arterial Blood Gases Mild to Moderate Kyphoscoliosis Acute alveolar hyperventilation with hypoxemia pH PaCO2 HCO3- PaO2    (Slightly) 

Alveolar Hyperventilation Time and Progression of Disease Disease Onset Alveolar Hyperventilation 100 90 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors 80 70 60 PaO2 PaO2 or PaCO2 50 40 30 PaCO2 20 10 Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.

Arterial Blood Gases Severe Kyphoscoliosis Chronic ventilatory failure with hypoxemia pH PaCO2 HCO3- PaO2 Normal   (Significantly) 

Alveolar Hyperventilation Chronic Ventilatory Failure Time and Progression of Disease Disease Onset Alveolar Hyperventilation Chronic Ventilatory Failure 100 Point at which disease becomes severe and patient begins to become fatigued 90 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors 80 70 PaCO2 Pa02 or PaC02 60 50 40 30 PaO2 20 10 Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.

Acute Ventilatory Changes on Chronic Ventilatory Failure Acute alveolar hyperventilation on chronic ventilatory failure Acute ventilatory failure on chronic ventilatory failure

Oxygenation Indices QS/QT DO2 VO2 C(a-v)O2   Normal Normal O2ER SvO2  

Hemodynamic Indices (Severe Kyphoscoliosis) CVP RAP PA PCWP    Normal CO SV SVI CI Normal Normal Normal Normal RVSWI LVSWI PVR SVR  Normal  Normal

Laboratory findings Complete blood count (CBC) Elevated hemoglobin concentration and hematocrit if the patient is chronically hypoxemic

Radiologic Findings Chest radiograph Thoracic deformity Mediastinal shift Increased lung opacity Atelectasis in areas of compressed lungs Enlarged heart (cor pulmonale)

Figure 24-2. Severe kyphoscoliosis in a 14-year-old male patient.

General Management of Kyphoscoliosis Braces (25 – 45 degree curvature) Milwaukee brace Charleston brace Boston brace Wilmington brace Thoracolumbosacral orthosis Surgery (40 – 50 degree curvature) Posterior spinal fusion and instrumentation Anterior spinal fusion

General Management of Kyphoscoliosis Other approaches Electrical stimulation Chiropractic manipulation Exercise to treat scoliosis

General Management of Kyphoscoliosis Respiratory care treatment protocols Oxygen therapy protocol Bronchopulmonary hygiene therapy protocol Hyperinflation therapy protocol Nocturnal mechanical ventilation

Chest Cuirass

Ankylosing Spondylitis Rheumatologic disease affects spine and thoracic cage Dramatically decreases thoracic cage compliance

Review A posterior curvature of the spine is called? Kyphosis A lateral curvature of the spine is called? Scoliosis Kyphoscoliosis affects approximately what percentage of the U.S. population? 2% What is the most common form of idopathic kyphoscoliosis? Adolescent Scoliosis

What is a nonstructural scoliosis? A side-to-side curve that results from a cause other than the spine (poor posture, pain) What is a structural scoliosis? Curvature associated with vertebral rotation

True / False Kyphoscoliosis is classified as an obstructive disorder. Girl are 10 times more likely to develop curvature of the spine than boys. True Kyphoscoloiosis causes the patient’s PEFR to increase.

Classroom Discussion Case Study: Kyphoscoliosis

What was the patient’s P(A-a)O2? Do we have enough information to calculate O2 content?

Expected Effect of Acute Changes in PaCO2 on Arterial pH PaCO2 Change pH Change Decrease 1 mm Hg 10 mm Hg Increase 0.01 0.10 0.006 0.06 Expected pH when measured PaCO2 < 40 mm Hg Expected pH = 7.40 + (40 – measured PaCO2)0.01 Expected pH when measured PaCO2 > 40 mm Hg Expected pH = 7.40 - (measured PaCO2 - 40)0.006

Effect of Acute Changes in PaCO2 on Bicarbonate Increase in PaCO2 Plasma HCO3- increases by 1 mEg/L for every 10 mm Hg PaCO2 > 40 mm Hg Decrease in PaCO2 Plasma HCO3- decreases by 2 mEg/L for every 10 mm Hg PaCO2 < 40 mm Hg