Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Alterations of Pulmonary.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Dyspnea  Dyspnea is the subjective sensation of uncomfortable breathing, including breathlessness and increased respiratory effort.  Causes - disturbances of ventilation, gas exchange, or ventilation-perfusion relationships, increased work of breathing or any disease that damages lung tissue (lung parenchyma).

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Dyspnea  Pathophysiology  May be due to a mismatch between sensory and motor input from the respiratory center such that there is more urge to breathe than there is response by the respiratory muscles.  Other causes include stimulation of central and peripheral chemoreceptors, and stimulation of afferent receptors in the lung and chest wall.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Dyspnea  Orthopnea - dyspnea when a person is lying down.  Paroxysmal nocturnal dyspnea (PND) – occurs at night, patients wake up gasping for air and have to sit up or stand to relieve the dyspnea.  Often occurs with pulmonary or cardiac disease with heart failure.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Abnormal breathing patterns  Kussmaul respirations (hyperpnea) - characterized by a slightly increased ventilatory rate, very large tidal volumes, and no expiratory pause.  Occur during strenuous exercise or metabolic acidosis.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Abnormal breathing patterns  Cheyne-Stokes respirations - characterized by alternating periods of rapid, deep breathing and shallow breathing or apnea.  Result from any condition that slows the blood flow to the brain stem, which in turn slows impulses sending information to the respiratory centers; or from neurologic impairment above the brain stem.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Hypoventilation/hyperventilation  Background – ventilation is measured as the minute ventilation rate.  Minute ventilation rate = tidal volume x ventilation rate (in breaths per minute).

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Hypoventilation – inadequate alveolar ventilation in relation to metabolic demands.  Causes - airway obstruction, chest wall restriction, or altered neurologic control of breathing.  Pathophysiology - CO 2 removal does not keep up with CO 2 production and the level of CO 2 in the arterial blood (PaCO 2 ) increases.  Hypercapnia - PaCO 2 more than 44mm Hg  Results in respiratory acidosis.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Hyperventilation - alveolar ventilation exceeding metabolic demands.  Causes - severe anxiety, acute head injury, pain, and in response to conditions that cause insufficient oxygenation of the blood.  Pathophysiology - the lungs remove CO 2 faster than it is produced by cellular metabolism, resulting in decreased PaCO 2.  Hypocapnia - PaCO 2 less than 36mm Hg  Results in a respiratory alkalosis.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Cyanosis  Bluish discoloration of the skin and mucous membranes caused by increasing amounts of deoxygenated hemoglobin.  Causes - decreased arterial oxygenation (low PaO 2 ), pulmonary or cardiac right-to-left shunts, decreased cardiac output, cold environment, or anxiety.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Cyanosis  Central cyanosis - decreased oxygen saturation of hemoglobin in arterial blood; best seen in buccal mucous membranes and lips.  Peripheral cyanosis - slow blood circulation in fingers and toes; best seen in nail beds.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. ACTIVITY 1. A symptom of brain stem impairment is: 1. A symptom of brain stem impairment is: a. Kussmaul respirationsb. Cheyne-Stokes respirations 2. A symptom of metabolic acidosis is: 2. A symptom of metabolic acidosis is: a. Kussmaul respirationsb. Cheyne-Stokes respirations 3. An increase in PaCO 2 could be due to: 3. An increase in PaCO 2 could be due to: a. hyperventilationb. hypoventilation

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Clubbing  Selective bulbous enlargement of the end of a finger or toe.  Associated with diseases that cause chronic hypoxemia, such as lung cancer, bronchiectasis, cystic fibrosis, pulmonary fibrosis, lung abscess, and congenital heart disease.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Cough  Protective reflex that expels secretions and irritants from the lower airways.  Caused by stimulation of irritant receptors, which are located in the upper airways and proximal bronchi (few in the distal bronchi and alveoli).

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Cough  Acute cough - resolves within 2 to 3 weeks of the onset of illness or resolves with treatment.  Usually the result of upper respiratory infections, allergic rhinitis, acute bronchitis, pneumonia, congestive heart failure, pulmonary embolus, or aspiration.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Cough  Chronic cough - cough that has persisted for more than 3 weeks.  In nonsmokers – results from postnasal drainage syndrome, asthma, or gastroesophageal reflux disease.  In smokers – usually due to chronic bronchitis, and less commonly lung cancer.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Signs and Symptoms of Pulmonary Disease Hemoptysis  Expectoration of bloody mucus  Causes - bronchitis, tuberculosis, abscess, neoplasms, and other conditions that cause hemorrhage from damaged pulmonary vessels. Pain  Chest pain can result from inflamed pleurae, trachea, bronchi, or respiratory muscles.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Hypercapnia  Increased PaCO 2 caused by hypoventilation.  Causes – any disorder that decreases the drive to breathe or results in an inadequate ability to respond to ventilatory stimulation, including drugs that depress the respiratory center, CNS disorders like damage to the medulla or spinal cord, disorders of the muscles of ventilation, thoracic deformities, airway obstruction, or advanced emphysema.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Hypoxemia  Reduced oxygenation of arterial blood (reduced PaO 2 ) caused by respiratory alterations.  General causes – (a) decreased oxygen content of inspired gas, (b) hypoventilation, (c) diffusion abnormality, (d) ventilation-perfusion mismatch, or (e) blood bypassing the lungs.  Diffusion of oxygen from the alveoli into the blood depends on the V/Q ratio and the status of the respiratory membrane.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Ventilation-perfusion (V/Q) abnormalities  V/Q ratio - the balance between the amount of air getting into alveoli (V) and the amount of blood perfusing the capillaries around the alveoli (Q).  An abnormal V/Q ratio is the most common cause of hypoxemia.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Ventilation-perfusion (V/Q) abnormalities  Low V/Q (Shunting) - inadequate ventilation of well-perfused areas of the lung.  Causes decreased systemic PaO 2 and hypoxemia.  Occurs in atelectasis, emphysema, in asthma as a result of bronchoconstriction, and in pulmonary edema and pneumonia when alveoli are filled with fluid.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Ventilation-perfusion (V/Q) abnormalities  High V/Q - Hypoxemia also can be caused by poor perfusion of well-ventilated portions of the lung, resulting in wasted ventilation.  Alveolar dead space - an area where alveoli are ventilated but not perfused.  Usually due to a pulmonary embolus that impairs blood flow to a segment of lung.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Respiratory membrane impairment  Respiratory membrane (alveolocapillary barrier) – composed of the epithelial lining of the alveolus, its basement membrane, and the epithelium of the neighboring capillary.  Diffusion of oxygen is impaired by:  Thickening of respiratory membrane - edema & fibrosis  Reduction in alveolar surface area - emphysema (causes destruction of alveoli)  Hypercapnia is seldom produced because CO 2 diffuses easily across membrane.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Hypoxemia  Circulatory bypass of lungs  Due to intracardiac defects that cause right-to- left shunting or because of intrapulmonary arteriovenous malformations.  Symptoms of hypoxemia - cyanosis, confusion, tachycardia, edema, and decreased renal output, and compensatory hyperventilation.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. ACTIVITY O = causes only hypoxemia B = causes both hypoxemia and hypercapnia 1. Pulmonary edema 1. Pulmonary edema 2. Circulatory bypass of lungs 2. Circulatory bypass of lungs 3. Airway obstruction 3. Airway obstruction 4. Breathing air with a low oxygen content 4. Breathing air with a low oxygen content 5. Drug overdose 5. Drug overdose 6. Thickening of respiratory membrane 6. Thickening of respiratory membrane

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Acute respiratory failure  Respiratory failure is defined as inadequate gas exchange such that PaO 2 ≤50mm Hg or PaCO 2 ≥50mm Hg with pH ≤7.25.  Can result from direct injury to the lungs, airways, or chest wall or indirectly because of injury to another body system, such as the brain or spinal cord.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Acute respiratory failure  Hypercapnic failure - result of inadequate alveolar ventilation; requires ventilatory support.  Hypoxemic failure - result of inadequate exchange of oxygen between the alveoli and the capillaries; requires supplemental oxygen therapy.  Often a combined hypercapnic and hypoxemic respiratory failure occurs.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Acute respiratory failure  Potential complication of any major surgical procedure, especially those that involve the central nervous system, thorax, or upper abdomen.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Pulmonary edema  Excess water in the lungs.  Causes - disturbances of capillary hydrostatic pressure, capillary oncotic pressure, or capillary permeability. Commonly results from:  Left heart failure - increases the hydrostatic pressure in the pulmonary circulation.  Systemic infection - increases capillary permeability due to inflammatory cytokines.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Pulmonary edema  Clinical manifestations - dyspnea, hypoxemia, and increased work of breathing; inspiratory crackles (rales) and dullness to percussion over the lung bases. In severe edema, pink frothy sputum is expectorated and PaCO 2 increases.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Aspiration  Passage of fluid and solid particles into the lungs.  Tends to occur in people whose normal swallowing mechanism and cough reflex are impaired.  Aspiration of large food particles or foreign bodies can obstruct a bronchus, resulting in bronchial inflammation and collapse of airways distal to the obstruction.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Aspiration  Aspiration of acidic gastric fluid may cause severe pneumonitis (lung inflammation) which could progress to pneumonia.  Clinical manifestations - sudden onset of choking, cough, vomiting, dyspnea, and wheezing.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Atelectasis  Collapse of lung tissue.  Compression atelectasis - caused by external pressure exerted by tumor, fluid, or air in pleural space or by abdominal distention pressing on a portion of lung, causing alveoli to collapse.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Atelectasis  Absorption atelectasis - results from removal of air from obstructed or hypoventilated alveoli or from inhalation of concentrated oxygen or anesthetic agents.  Clinical manifestations - include dyspnea, cough, fever, and leukocytosis.  Atelectasis tends to occur after surgery.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Pleural Abnormalities Pneumothorax - accumulation of air or gas in the pleural space.  Caused by a spontaneous rupture of weakened areas of a pleura, or it can be secondary to pleural damage caused by disease, trauma, or mechanical ventilation.  Open pneumothorax - air is drawn in and out of pleural cavity through the rupture during breathing, so the lung will only partially inflate.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Pleural Abnormalities  Tension pneumothorax – the site of pleural rupture acts as a one-way valve, permitting air to enter on inspiration but preventing its escape by closing up during expiration, so pressure builds up in the pleural space.  Air pressure in the pleural space pushes against the lung, causing compression atelectasis, and against the mediastinum, compressing and displacing the heart and great vessels.  Life threatening medical emergency.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Pleural Abnormalities Pleural effusion  Presence of fluid in the pleural space.  Results from migration of fluids and other blood components through the walls of intact capillaries bordering the pleura or from blockage or injury that causes lymphatic vessels to drain into the pleural space.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Pleural Abnormalities Pleural effusion  Transudative effusion – watery fluid.  Exudative effusion – contains high concentration of white blood cells and plasma proteins.  Hemothorax – blood in pleural space.  Chylothorax – chlye in pleural space.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Pleural Abnormalities Pleural effusion  Empyema (infected pleural effusion) – fluid contaminated with pus from an infection.  Develops when pulmonary lymphatics become blocked, leading to an outpouring of contaminated lymphatic fluid into the pleural space.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Conditions Caused by Pulmonary Disease or Injury Pleural Abnormalities Pleurisy (pleuritis)  Inflammation of the pleura.  Usually results from an infection of the adjacent lung tissue, but could be caused by thoracic trauma or an invading tumor.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Pulmonary Disorders Restrictive Lung Diseases  Characterized by decreased compliance of lung tissue and resultant increased work of breathing.  Commonly affect the alveolocapillary membrane and cause decreased diffusion of oxygen from the alveoli into the blood resulting in hypoxemia.  Includes pulmonary edema, atelectasis and pneumothorax, as well as the following.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Restrictive Lung Diseases Pulmonary fibrosis  Excessive amount of fibrous or connective tissue in the lung, which diminishes lung compliance and diffusing capacity of alveolocapillary membrane.  May be idiopathic or caused by diseases such as infections, ARDS, autoimmune disorders or inhalation of harmful substances.  Diffuse pulmonary fibrosis has a poor prognosis.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Restrictive Lung Diseases Pneumoconiosis  Any change in the lung caused by inhalation of inorganic dust particles.  Often occurs after years of exposure to the offending dust, with progressive fibrosis of lung tissue.  Causes – most commonly from inhalation of silica, asbestos, and coal (others are less common).

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Restrictive Lung Diseases Pneumoconiosis  Pathophysiology – deposition of these materials in the lungs leads to chronic inflammation with scarring of the alveolocapillary membrane leading to pulmonary fibrosis.  Dust deposits are permanent and lead to progressive pulmonary deterioration.  Clinical manifestations - cough, chronic sputum production, dyspnea, decreased lung volumes, and hypoxemia.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Restrictive Lung Diseases Acute respiratory distress syndrome (ARDS)  A fulminant form of respiratory failure that results from acute lung inflammation, diffuse injury to the alveolocapillary membrane, and hyaline membrane formation in the alveoli.  Often occurs as a complication of sepsis and multiple trauma; but also with many other disorders including pneumonia, burns, aspiration, pancreatitis, inhalation of smoke or noxious gases, oxygen toxicity and disseminated intravascular coagulation.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Restrictive Lung Diseases Acute respiratory distress syndrome (ARDS)  Pathophysiology:  An insult to the body damages the alveolocapillary membrane, resulting in the systemic release of high levels of inflammatory cytokines (especially TNF-alpha and IL-1).  Inflammation causes breakdown of the alveolar- capillary barrier, thus flooding the alveoli with protein-rich exudate and cells, causing edema and development of a hyaline membrane.  Hyaline membrane - thick, gel-like layer that forms when protein deposits in the alveoli.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Restrictive Lung Diseases Acute respiratory distress syndrome (ARDS)  Pathophysiology (cont.):  Inflammation is complicated by loss of surfactant, causing atelectasis, and by vasoconstriction of the alveolar capillaries and pulmonary thrombus formation.  The resultant V/Q mismatch is usually very severe, and the associated hypoxemia is not responsive to administration of supplemental oxygen.  As the lungs become stiffer (decreasing lung compliance) due to fluid and atelectasis, hypoventilation and hypercapnia follow.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Restrictive Lung Diseases Acute respiratory distress syndrome (ARDS)  Clinical manifestations - dyspnea; rapid, shallow breathing; inspiratory crackles; respiratory alkalosis; decreased lung compliance; hypoxemia unresponsive to oxygen therapy (refractory hypoxemia); and diffuse alveolar infiltrates on radiographs, without evidence of cardiac disease.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Restrictive Lung Diseases Acute respiratory distress syndrome (ARDS)  Patients frequently present with the symptoms of the original insult, followed in 24 to 48 hours by increasing dyspnea. This may progress to complete respiratory failure and death.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. ACTIVITY Why is ARDS considered a restrictive lung disease rather than obstructive?

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Obstructive Lung Diseases  Characterized by airway obstruction that is worse with expiration.  During inspiration airways stretch to allow air in.  During expiration excess mucus or loss of lung elasticity causes airways to collapse, trapping air in the alveoli.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Obstructive Lung Diseases  Patients exhibit dyspnea, and wheezing that is worse with expiration, with increased work of breathing, V/Q mismatching, and a decreased forced expiratory volume in one second (FEV1).  Trapping of air in alveoli can cause less CO 2 to be exhaled, resulting in hypercapnia.  The major obstructive lung diseases are asthma, chronic bronchitis, and emphysema.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Obstructive Lung Diseases Asthma  Asthma is a chronic inflammatory disorder of the airways.  Results from a type 1 hypersensitivity immune response involving the activity of lymphocytes, IgE, mast cells, and eosinophils.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Obstructive Lung Diseases   Asthma: an animation   http://www.youtube.com/watch?v=7EDo9pUYv PE http://www.youtube.com/watch?v=7EDo9pUYv PE   Advance to 1:00.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Obstructive Lung Diseases Asthma  Occurs in individuals with a genetic predisposition to certain environmental antigens (allergens) so that high levels of interleukin-4 (IL-4) and IgE are produced.  This causes the airways to be hyperresponsive to allergens, with excessive mast cell degranulation, and resulting mucus secretion, bronchoconstriction, and pulmonary edema.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Obstructive Lung Diseases Asthma  Clinical manifestations during attacks - tripod positioning, use of accessory muscles, tachypnea, tachycardia, expiratory wheezing/prolonged expiratory phase, increased pulsus paradoxus (a decrease in systolic blood pressure during inspiration of more than 10mm Hg).

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Obstructive Lung Diseases Asthma  Status asthmaticus - acute exacerbation of asthma that does not respond to standard treatments of bronchodilators and steroids. The resulting hypoxemia and respiratory acidosis can be life-threatening if not reversed rapidly.  Asthma staging is based on clinical severity from mild intermittent to severe persistent and is used to determine therapy.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Chronic Obstructive Pulmonary Disease  Syndrome that includes emphysema and chronic bronchitis.  Characterized by airflow limitation that is not fully reversible, is usually progressive, and is associated with an abnormal inflammatory response of the lung to noxious particles or gases.  Primarily caused by cigarette smoke, though genetic susceptibilities also have been identified.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Chronic Obstructive Pulmonary Disease   How chronic obstructive pulmonary disease develops   http://www.youtube.com/watch?v=2wF1cs ksp-Q&feature=related http://www.youtube.com/watch?v=2wF1cs ksp-Q&feature=related

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. 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.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Chronic Obstructive Pulmonary Disease Chronic bronchitis  Pathophysiology:  Inhalation of irritants causes inflammation and hyperplasia of the mucus-producing goblet cells of the bronchial epithelium and hypertrophy of smooth muscle.  Accumulated mucus facilitates growth of bacteria, which further contributes to airway inflammation, bronchospasm, and eventual scarring.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Chronic Obstructive Pulmonary Disease Chronic bronchitis  Pathophysiology:  Narrowed airways cause V/Q mismatching and expiratory airway obstruction with air trapping, resulting in hypoxemia and hypercapnia.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Chronic Obstructive Pulmonary Disease Chronic bronchitis  Accumulations of thick mucus make patient at risk for recurrent pulmonary infections.  Clinical manifestations - productive cough of purulent sputum (earliest symptom), dyspnea, prolonged expiratory phase, wheezing, cyanosis, and edema.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Chronic Obstructive Pulmonary Disease Chronic bronchitis  Treatment – bronchodilators, expectorants, and chest physical therapy; during acute attacks antibiotics, steroids and mechanical ventilation may be required.  If patient stops smoking, progression can be halted.  Prevention through smoking cessation is best option since damage is irreversible.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Chronic Obstructive Pulmonary Disease Emphysema  Abnormal permanent enlargement of the gas-exchange airways accompanied by destruction of alveolar walls without obvious fibrosis.  Airflow limitation occurs due to loss of elastic recoil.  Major cause is cigarette smoking.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Chronic Obstructive Pulmonary Disease Emphysema  Primary emphysema (1-3% of cases) is linked to an inherited deficiency of the enzyme alpha 1-antitrypsin, which normally inhibits the action of many proteolytic enzymes in the lungs.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Chronic Obstructive Pulmonary Disease Emphysema  Pathophysiology:  Inhaled irritants cause an imbalance between lung proteases (that break down lung tissue, like elastin) and antiproteases (that preserve lung tissue, like alpha 1-antitrypsin) so that the alveoli and bronchial walls are destroyed.  Alveolar destruction causes decreased surface area for gas exchange, leading to hypoxemia.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Chronic Obstructive Pulmonary Disease Emphysema  Pathophysiology:  Bronchial wall damage causes loss of elastic recoil, leading to expiratory airway collapse, air trapping, hypoventilation, and hypercapnia.  Air trapping causes hyperinflation of lungs and increased residual lung volume, with much energy expended on breathing, and eventually increased thoracic diameter.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Chronic Obstructive Pulmonary Disease Emphysema  Clinical manifestations – severe dyspnea, nonproductive cough, weight loss, barrel chest, prolonged expiratory phase, and wheezing.  Treatment - smoking cessation, bronchodilators, nutrition, breathing retraining, relaxation exercises, anti- inflammatory medications, and antibiotics for acute infections.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. ACTIVITY a. Asthma b. Chronic bronchitis c. Emphysema 1. Involves a hypersensitivity reaction. 1. Involves a hypersensitivity reaction. 2. Involves destruction of alveolar septa. 2. Involves destruction of alveolar septa. 3. Involves hyperplasia and hypertrophy of cells in airways. 3. Involves hyperplasia and hypertrophy of cells in airways. 4. Productive cough 4. Productive cough 5. Barrel chest 5. Barrel chest 6. Systemic edema 6. Systemic edema

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Respiratory Tract Infections Pneumonia  Acute infection of the lung that is caused by bacteria, viruses, fungi, or parasites.  Risk factors - anything that compromises normal respiratory defense mechanisms, such as age, smoking, compromised immune system, malnutrition, mechanical ventilation, and immobilization.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Respiratory Tract Infections Categories of Pneumonia  Community Acquired Pneumonia (CAP)–most commonly caused by viruses (e.g., influenza) or by bacteria (e.g., Streptococcus pneumoniae, Mycoplasma pneumoniae).  Nosocomial– acquired in hospital, often due to a dangerous organism that is difficult to treat (e.g., Pseudomonas aeruginosa).  Immunocompromised Individuals– often due to opportunistic infections by the fungus Pneumoncystis jiroveci (P. carinii) or by the cytomegalovirus.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Respiratory Tract Infections Pneumonia  Pathophysiology:  Organisms enter the respiratory tract, often by aspiration of infected oral secretions.  These organisms overwhelm the alveolar macrophages and set off an intense immunologic and inflammatory response.  Inflammatory cytokines, white blood cells, and edema fluid flood the alveoli and bronchi.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Respiratory Tract Infections Pneumonia  Pathophysiology:  Exudates and fibrin are deposited in alveoli and interfere with gas exchange.  Ventilation/perfusion (V/Q) mismatching occurs with resultant hypoxemia.  The infection may spread to the bloodstream (bacteremia and sepsis), pleura (empyema), or other organs (e.g., meningitis).

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Respiratory Tract Infections Pneumonia  Clinical manifestations- fever, usually a productive cough, and dyspnea; infiltrates on chest X-ray; leukocytosis.  Treatment – antibiotics for bacterial pneumonia; supportive care for viral pneumonia.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Respiratory Tract Infections Tuberculosis  An infection caused by Mycobacterium tuberculosis that usually affects the lungs but may invade other body systems.  In the U.S. most active cases are in AIDS patients and other immunocompromised individuals.  Transmitted from person to person in airborne droplets.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Respiratory Tract Infections Tuberculosis  Pathophysiology:  Microorganisms lodge in the lung periphery, usually in the upper lobe.  Bacilli multiply and cause nonspecific pneumonitis (lung inflammation).  Bacilli are engulfed by macrophages and neutrophils which seal off the colonies of bacilli to prevent spread, forming a granulomatous lesion called a tubercle.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Respiratory Tract Infections Tuberculosis  Pathophysiology:  Once the bacilli are isolated in tubercles and immunity develops, tuberculosis may remain dormant for life.  If the immune system is impaired, or if live bacilli escape into the bronchi, active disease occurs and may spread through the blood and lymphatics to other organs.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Respiratory Tract Infections Tuberculosis  Clinical Manifestations  Latent tuberculosis is asymptomatic.  Active tuberculosis - fever, night sweats, dyspnea, productive cough (sometimes with hemoptysis, i.e. blood in sputum), and weight loss.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Respiratory Tract Infections Tuberculosis  Usually diagnosed by a positive tuberculin skin test (PPD), sputum culture, and chest radiographs.  Treatment - antibiotic therapy (6- to 9-month course of treatment)  Multidrug resistant strains of TB are arising which are very difficult to control.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Respiratory Tract Infections Severe Acute Respiratory Syndrome (SARS)  A severe pneumonia that affected more than 300 people in China in 2002- 2003 and spread rapidly around the world.  Caused by a strain of coronavirus.  Fatality rate was 4% to 6%.  Spread mainly by inhalation of droplet nuclei, or by contact with infected respiratory excretions.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Respiratory Tract Infections Severe Acute Respiratory Syndrome (SARS)  Clinical manifestations - high fever, body aches, dry cough, and dyspnea.  Treatment - mainly supportive, although several antivirals are being tested.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. 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 most commonly arise from the deep veins in the legs or pelvis.  Thromboembolism – specifically due to a portion of a clot that has broken off into the bloodstream.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Pulmonary Vascular Disease Pulmonary embolism (cont.)  Risk factors – anything that promotes blood clotting, immobility, trauma and fractures of the head, spine, legs and pelvis; incidence increases with age.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Pulmonary Vascular Disease Pulmonary embolism  Pathophysiology:  An embolus, often from a deep leg vein, breaks off and travels through the venous circulation.  It travels through the right heart and lodges in the pulmonary arterial circulation, blocking flow into the affected portion of the lungs.  This causes immediate V/Q mismatch, hypoxemia, and pulmonary hypertension.  Hypoxemia interferes with surfactant production, resulting in collapse of alveoli.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Pulmonary Vascular Disease Pulmonary embolism  Pathophysiology:  Small emboli often do not cause lung infarction.  Larger emboli often cause some infarction of lung tissue with associated hypoxic vasoconstriction, atelectasis, and loss of functional lung tissue.  Very large emboli cause massive occlusion, resulting in cardiogenic shock and death.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Pulmonary Vascular Disease Pulmonary embolism  Initial symptoms are typically sudden onset of dyspnea, pleuritic chest pain and hemoptysis.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Pulmonary Vascular Disease Pulmonary hypertension  Mean pulmonary artery pressure 5 to 10 mm Hg above normal or above 20 mm Hg.  Primary pulmonary hypertension - rare idiopathic disorder involving the precapillary pulmonary arteries; due to hereditary factors in some cases.  Decreased endogenous vasodilators, increased vasoconstrictors, and vascular remodeling combine to cause vasoconstriction and fibrotic changes in the vessel walls.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Pulmonary Vascular Disease Pulmonary hypertension  Secondary pulmonary hypertension - results from diseases of the respiratory system that cause hypoxemia and are characterized by pulmonary arteriolar vasoconstriction and arterial remodeling.  Most commonly due to chronic pulmonary disease.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Pulmonary Vascular Disease Pulmonary hypertension  Pathophysiology:  Narrowing of the vessels increases resistance to pulmonary artery inflow to the lungs.  Pulmonary artery pressures rise, creating significant afterload to the right ventricle.  This results in right ventricular hypertrophy that usually progresses to right heart failure, which is called cor pulmonale.  Pressures then back up into the systemic venous circulation.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Pulmonary Vascular Disease Cor pulmonale  Right ventricular enlargement caused by chronic pulmonary hypertension.  Progresses to right ventricular failure if the pulmonary hypertension is not reversed.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Lung Cancer  Most common cause of cancer death in the United States.  Commonly caused by cigarette smoking.  Heavy smokers have a 20 times’ greater chance of developing lung cancer than nonsmokers.  Other environmental factors can also contribute, such as asbestos and radiation exposure.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Lung Cancer Bronchogenic carcinomas - primary lung cancers arising from the bronchi. Two major types:  Non–small cell lung carcinoma - 75-85% of lung cancers; different types have different characteristics, but in general these are slower growing and slower to metastasize than small cell tumors.  Small cell lung carcinoma - rarer; grow and metastasize rapidly. Very poor prognosis.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Lung Cancer  Lung cancers most frequently metastasize to the brain, bone marrow, and liver.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Alterations of Pulmonary.

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Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Alterations of Pulmonary.

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