1. Chapter 24 KyphoscoliosisB
Figure 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.

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. Cobb Angle

9. 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).

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

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

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

13. 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

14. Figure 2-46. Digital clubbing.

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

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

17. 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

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

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

20. Figure Whispered voice sounds auscultated over a normal lung are usually faint and unintelligible.

21. Clinical Data Obtained from Laboratory Tests and Special Procedures

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

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

24. Arterial Blood Gases Mild to Moderate Kyphoscoliosis
Acute alveolar hyperventilation with hypoxemia
pH PaCO HCO PaO2
   (Slightly) 

25. 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.

26. Arterial Blood Gases Severe Kyphoscoliosis
Chronic ventilatory failure with hypoxemia
pH PaCO HCO PaO2
Normal   (Significantly) 

27. 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 PaO2 and PaCO2 trends during acute or chronic ventilatory failure.

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

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

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

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

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

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

34. 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

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

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

41. Chest Cuirass

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

43. 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

44. 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

45. 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.

46. Classroom Discussion Case Study: Kyphoscoliosis

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

48. 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 = (40 – measured PaCO2)0.01
Expected pH when measured PaCO2 > 40 mm Hg
Expected pH = (measured PaCO2 - 40)0.006

49. 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