1. Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 12 Emphysema Plate 3. Panlobular emphysema. Inset, Excessive bronchial secretions, a common secondary anatomic alteration of the lungs.

2. Copyright © 2006 by Mosby, Inc. Slide 2 Figure 12–2. Centrilobular emphysema. Abnormal weakening and enlargement of the respiratory bronchioles in the proximal portion of the acinus.

3. Copyright © 2006 by Mosby, Inc. Slide 3 Anatomic Alterations of the Lungs  Permanent enlargement and deterioration of the air spaces distal to the terminal bronchioles  Destruction of pulmonary capillaries  Weakening of the distal airways, primarily the respiratory bronchioles  Bronchospasm (with concomitant bronchitis)  Hyperinflation of alveoli (air-trapping)

4. Copyright © 2006 by Mosby, Inc. Slide 4 Etiology  Cigarette smoking  Genetic predisposition  Alpha 1 protease inhibitor  Occupational exposure to chemical irritants  Exposure to atmospheric pollutants

5. Copyright © 2006 by Mosby, Inc. Slide 5 Overview of the Cardiopulmonary Clinical Manifestations Associated with EMPHYSEMA The following result from the pathophysiologic mechanisms caused by Distal Airway and mechanisms caused by Distal Airway and Alveolar Weakening ( Figure 9-12)—the major anatomic alterations of the lungs associated anatomic alterations of the lungs associated with emphysema (see Figures 12-1 and 12-2). with emphysema (see Figures 12-1 and 12-2).

6. Copyright © 2006 by Mosby, Inc. Slide 6 Figure 9-12. Distal airway and alveolar weakening clinical scenario.

7. Copyright © 2006 by Mosby, Inc. Slide 7 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside Vital signs  Increased respiratory rate  Increased heart rate, cardiac output, blood pressure

8. Copyright © 2006 by Mosby, Inc. Slide 8 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside  Use of accessory muscles of inspiration  Use of accessory muscles of expiration  Pursed-lip breathing  Increased anteroposterior chest diameter (barrel chest)  Cyanosis  Digital clubbing

9. Copyright © 2006 by Mosby, Inc. Slide 9 Clinical Data Obtained at the Patient’s Bedside Peripheral edema and venous distention  Distended neck veins  Pitting edema  Enlarged and tender liver

10. Copyright © 2006 by Mosby, Inc. Slide 10 Distended Neck Veins Figure 2-48. Distended neck veins (arrows).

11. Copyright © 2006 by Mosby, Inc. Slide 11 Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2, London, 1992, Mosby-Wolfe.

12. Copyright © 2006 by Mosby, Inc. Slide 12 Clinical Data Obtained at the Patient’s Bedside  Cough, sputum production, hemoptysis  Chest assessment findings  Hyperresonant percussion notes  Wheezing  Diminished breath sounds  Diminished heart sounds  Decreased tactile and vocal fremitus  Crackles/rhonchi (when accompanied by bronchitis)

13. Copyright © 2006 by Mosby, Inc. Slide 13 Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.

14. Copyright © 2006 by Mosby, Inc. Slide 14 Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive lung diseases, breath sounds progressively diminish.

15. Copyright © 2006 by Mosby, Inc. Slide 15 Clinical Data Obtained from Laboratory Tests and Special Procedures

16. Copyright © 2006 by Mosby, Inc. Slide 16 Pulmonary Function Study Expiratory Maneuver Findings FVCFEV T FEF 25%-75% FEF 200-1200   PEFRMVVFEF 50% FEV 1%  

17. Copyright © 2006 by Mosby, Inc. Slide 17 Pulmonary Function Study Lung Volume and Capacity Findings V T RV FRC TLC V T RV FRC TLC N or    N or  N or    N or  VC IC ERV RV/TLC ratio  N or  N or   VC IC ERV RV/TLC ratio  N or  N or  

18. Copyright © 2006 by Mosby, Inc. Slide 18 Decreased Diffusion Capacity (DL CO )

19. Copyright © 2006 by Mosby, Inc. Slide 19 Arterial Blood Gases Mild to Moderate Emphysema  Acute alveolar hyperventilation with hypoxemia pH Pa CO 2 HCO 3 - Pa O 2    (Slightly) 

20. Copyright © 2006 by Mosby, Inc. Slide 20 Time and Progression of Disease 100 50 30 80 0 0 Pa CO 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa O 2 Disease Onset Pa O 2 or Pa CO 2 Figure 4-2. PaO 2 and PaC0 2 trends during acute alveolar hyperventilation.

21. Copyright © 2006 by Mosby, Inc. Slide 21 Arterial Blood Gases Severe Emphysema  Chronic ventilatory failure with hypoxemia pH Pa CO 2 HCO 3 - Pa O 2 Normal   (Significantly)  Normal   (Significantly) 

22. Copyright © 2006 by Mosby, Inc. Slide 22 Time and Progression of Disease 100 50 30 80 0 Pa O 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa CO 2 Chronic Ventilatory Failure Disease Onset Point at which disease becomes severe and patient begins to become fatigued Pa 0 2 or Pa C0 2 Figure 4-7. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.

23. Copyright © 2006 by Mosby, Inc. Slide 23 Acute Ventilatory Changes Superimposed on Chronic Ventilatory Failure  Acute alveolar hyperventilation on chronic ventilatory failure  Acute ventilatory failure on chronic ventilatory failure

24. Copyright © 2006 by Mosby, Inc. Slide 24 Oxygenation Indices Q S /Q T D O 2 V O 2 C(a-v) O 2  NormalNormal O 2 ERSv O 2 

25. Copyright © 2006 by Mosby, Inc. Slide 25 Hemodynamic Indices (Severe Emphysema) CVP RAPPAPCWP  Normal COSVSVICI NormalNormalNormalNormal RVSWILVSWIPVRSVR  Normal  Normal

26. Copyright © 2006 by Mosby, Inc. Slide 26 Abnormal Laboratory Tests and Procedures Hematology  Increased hematocrit and hemoglobin Electrolytes  Hypochloremia (chronic ventilatory failure) Sputum examination  Streptococcus pneumoniae  Haemophilus influenzae

27. Copyright © 2006 by Mosby, Inc. Slide 27 Radiologic Findings Chest radiograph  Translucent (dark) lung fields  Depressed or flattened diaphragms  Long and narrow heart  Enlarged heart  Increased retrosternal air space (lateral radiograph)

28. Copyright © 2006 by Mosby, Inc. Slide 28 Figure 12-3. Chest X-ray of a patient with emphysema. The heart often appears long and narrow as a result of being drawn downward by the descending diaphragm.

29. Copyright © 2006 by Mosby, Inc. Slide 29 Figure 12–4. Emphysema. Lateral chest radiograph demonstrates a characteristically large retrosternal radiolucency with increased separation of the aorta and sternum measuring 4.6 cm, 3 cm below the angle of Louis and extending down to within 3 cm of the diaphragm anteriorly. Both costophrenic angles are obtuse, and both hemidiaphragms are flat. (From Armstrong P et al, editors: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

30. Copyright © 2006 by Mosby, Inc. Slide 30

31. Copyright © 2006 by Mosby, Inc. Slide 31 General Management of Emphysema  Patient and family education  Behavioral management  Avoidance of smoking and inhaled irritants  Avoidance of infections  Proper nutrition instruction

32. Copyright © 2006 by Mosby, Inc. Slide 32 G lobal Initiative for Chronic O bstructive L ung D isease GOLD Standards

33. Copyright © 2006 by Mosby, Inc. Slide 33 Figure 11-4. From GUIDELINES Pocketcard: Managing chronic obstructive pulmonary disease, Baltimore, 2004, Version 4.0, International Guidelines Center. (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)

34. Copyright © 2006 by Mosby, Inc. Slide 34 Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)

35. Copyright © 2006 by Mosby, Inc. Slide 35 Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)

36. Copyright © 2006 by Mosby, Inc. Slide 36 Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)

37. Copyright © 2006 by Mosby, Inc. Slide 37 Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)

38. Copyright © 2006 by Mosby, Inc. Slide 38 General Management of Emphysema Respiratory care treatment protocols  Oxygen therapy protocol  Bronchopulmonary hygiene therapy protocol  Aerosolized medication protocol  Mechanical ventilation protocol

39. Copyright © 2006 by Mosby, Inc. Slide 39 Additional Treatment Considerations for Emphysema  Antibiotics  Inoculations against influenza and pneumonia  Alpha 1 antitrypsin therapy  Lung volume reduction surgery  Lung transplantation

40. Copyright © 2006 by Mosby, Inc. Slide 40 Classroom Discussion Case Study: Emphysema