1. 1 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Topic Of Presentation Kyphoscoliosis By DR S. B. SULEHRIA Assistant Professor East Medical Ward KEMU/Mayo hospital

2. 2 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. CASE SCENARIO  A 70 years old healthy looking Caucasian female presented with complaints of  progressive loss of standing balance, severe back pain and buttock pain, and moderate neurogenic claudication.

3. 3 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Kyphoscoliosis is a combination of two thoracic deformities that commonly appear together.  Kyphosis is a posterior curvature of the spine (humpback).  In scoliosis the spine is curved to one side— typically appearing as an S or C shape. DEFINITION

4. 4 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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. A B

5. 5 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. ETIOLOGY

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8. 8  Idiopathic scoliosis is classified as follows:  Infantile scoliosis The curvature of the spine develops during the first 3 years of life.  Juvenile scoliosis The curvature occurs between 4 years and the onset of adolescence.  Adolescent scoliosis The spine curvature develops after the age of 10. Etiology (Cont’d)

9. 9 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Risk Factors Include:  Sex—Girls are more likely to develop curvature of the spine than boys.  Age—The younger the child is when the diagnosis is first made, 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 (Cont’d)

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18. 18 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnosis  Scoliosis is diagnosed by means of the patient’s medical history, physical examination, x-ray evaluation, and curve measurement.

19. 19 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnosis (Cont’d)  Clinically, scoliosis is commonly defined according to the following factors related to the curvature of the spine:  Shape  Location  Direction  Angle

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23. 23 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. MANIFESTATIONS  Lung restriction and compression as a result of the thoracic deformity  Mediastinal shift  Mucous accumulation throughout the tracheobronchial tree  Atelectasis

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26. 26 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination  Vital signs  Increased Respiratory rate (tachypnea) Heart rate (pulse) Blood pressure  Cyanosis

27. 27 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination, (Cont’d)  Digital clubbing  Peripheral edema and venous distention  Cough and sputum production

28. 28 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination, (Cont’d)  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

29. 29 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained from Laboratory Tests and Special Procedures

30. 30 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pulmonary Function Test Findings Moderate to Severe (Restrictive Lung Pathophysiology) Forced Expiratory Flow Rate Findings FVC FEV T FEV 1 /FVC ratio FEF 25%-75%  N or  N or  N or  FEF 50% FEF 200-1200 PEFR MVV N or  N or 

31. 31 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pulmonary Function Test Findings Moderate to Severe (Restrictive Lung Pathophysiology) Lung Volume & Capacity Findings VT IRV ERV RV VC N or      IC FRC TLC RV/TLC ratio    N

32. 32 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases (Mild to Moderate Kyphoscoliosis) Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) pH PaCO 2 HCO 3 PaO 2 pH PaCO 2 HCO 3 PaO 2    (slightly)     (slightly) 

33. 33 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute alveolar hyperventilation.

34. 34 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases (Severe Kyphoscoliosis) Chronic Ventilatory Failure with Hypoxemia (Compensated Respiratory Acidosis) pH PaCO 2 HCO 3 PaO 2 pH PaCO 2 HCO 3 PaO 2   (Significantly)  N   (Significantly) 

35. 35 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.

36. 36 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases Acute Ventilatory Changes Superimposed On Chronic Ventilatory Failure  Because acute ventilatory changes are frequently seen in patients with chronic ventilatory failure, the respiratory care practitioner must be familiar with and alert for the following:  Acute alveolar hyperventilation superimposed on chronic ventilatory failure  Acute ventilatory failure (acute hypoventilation) superimposed on chronic ventialtory failure.

37. 37 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Oxygenation Indices (Moderate to Severe Kyphoscoliosis) Q S /Q T DO 2 VO 2 C(a-v)O 2 O 2 ER SvO 2 Q S /Q T DO 2 VO 2 C(a-v)O 2 O 2 ER SvO 2   N      N   

38. 38 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Hemodynamic Indices Moderate to Severe Kyphoscoliosis CVP RAP PA PCWP CO SV CVP RAP PA PCWP CO SV    N N N    N N N SVI CI RVSWI LVSWI PVR SVR SVI CI RVSWI LVSWI PVR SVR N N  N  N N N  N  N

39. 39 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Laboratory Findings  Severe and/or Late Stage Kyphoscoliosis  If the patient is chronically hypoxemic Increased hematocrit and hemoglobin (polycythemia) Hypochloremia (Cl - ) Hypernatremia (Na + )

40. 40 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Radiologic Findings  Chest Radiograph  Blunting t horacic deformity  Mediastinal shift  Increased lung opacity  Atelectasis in areas of compressed (atelectatic) lungs  Enlarged heart (cor pulmonale)

41. 41 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Severe kyphoscoliosis in a 14-year-old male patient. Figure 24-3. Severe kyphoscoliosis in a 14-year-old male patient.

42. 42 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. MANAGEMENT

43. 43 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. General Management of Scoliosis   The treatment of scoliosis largely depends on the cause of the scoliosis, the size and location of the curve, and how much more growing the patient is expected to do.   In most cases of scoliosis (less than 20 degrees), the degree of abnormal spine curvature is relatively small and requires only observation to ensure that the curve does not worsen.   Observation is usually recommended in patients with a spine curvature of less than 20 degrees.

44. 44 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   In young children who are still growing, observation checkups are usually scheduled in 3- to 6-month intervals.   When the curve is determined to be progressing to a more serious degree (above 25 to 30 degrees in a child who is still growing), the following treatments options are available: General Management of Scoliosis (Cont’d)

45. 45 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Braces   Boston brace   Charleston bending brace   Milwaukee brace General Management of Scoliosis (Cont’d)

46. 46 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-4 Common types of braces for scoliosis. A, Boston back brace (also called a thoraco-lumbro- sacral-orthosis [TLSO], a low-profile brace, or an underarm brace). Typically used for curves in the lumbar (low-back) or thoracolumbar sections of the spine. B, Charleston bending brace (also known as a part-time brace). C, Milwaukee brace (also called cervicothoracolumbosacral orthosis [CTLSO]) is used for high thoracic (mid-back) curves.

47. 47 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Surgery   Spinal fusion   Rod Instrumentation General Management of Scoliosis (Cont’d)

48. 48 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-5 Radiograph of patient with scoliosis treated with a Harrington rod.

49. 49 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Other Approaches   Some physicians may try electrical stimulation of muscles, chiropractic manipulation, and exercise to treat scoliosis.   There is no evidence that any of these procedures will stop the progression of spine curvature. General Management of Scoliosis (Cont’d)

50. 50 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Other Approaches (Cont’d)   Exercise, however, may improve the patient’s overall health and well-being.   Prophylactic deep breathing and coughing (DB&C) exercises are also taught. Their long-term effect is debatable. General Management of Scoliosis (Cont’d)

51. 51 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Respiratory Care Treatment Protocols   Oxygen Therapy Protocol   Bronchopulmonary Hygiene Therapy Protocol   Lung Expansion Therapy Protocol

52. 52 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.