Pulmonary Pulmonary

RT 210 A&P RT 210 A&P

Unit AUnit A

Upper airwayUpper airway

NoseNose Warms, humidifies and filters gasWarms, humidifies and filters gas External opening-naresExternal opening-nares Conchae-nares to nasal pharynxConchae-nares to nasal pharynx Nasal conchae-turbinates, allows Nasal conchae-turbinates, allows

maximum air surface contactmaximum air surface contact Posterior nose is ciliated Posterior nose is ciliated

pseudostratified columnar epithelium pseudostratified columnar epithelium whose purpose is to filter, humidify and whose purpose is to filter, humidify and warmwarm

Upper airwayUpper airway

Mouth – oral cavityMouth – oral cavity Lined with stratified squamousLined with stratified squamous

Upper airwayUpper airway

PharynxPharynx Extends from base of skull to esophagus (about Extends from base of skull to esophagus (about

5 inches)5 inches) The nasal cavities and mouth to the point The nasal cavities and mouth to the point

where the airway and digestive tract separatewhere the airway and digestive tract separate Three partsThree parts

Nasopharynx (behind the nose)Nasopharynx (behind the nose) Aconchae to uvulaAconchae to uvula Lined with pseudostratified ciliated columnar epitheliumLined with pseudostratified ciliated columnar epithelium Purpose: gas conduction to airways, filters and houses Purpose: gas conduction to airways, filters and houses

adenoids (defense)adenoids (defense)

Upper airwayUpper airway

PharynxPharynx Three parts (con’t)Three parts (con’t)

Oropharynx (behind the mouth)Oropharynx (behind the mouth) Uvula to epiglottisUvula to epiglottis Function: defense, holds tonsils, gas conduction, Function: defense, holds tonsils, gas conduction,

food conduction, filtrationfood conduction, filtration Stratified squamous epitheliumStratified squamous epithelium

Upper airwayUpper airway

PharynxPharynx Three parts (con’t)Three parts (con’t)

Laryngopharynx (below the hyoid bone Laryngopharynx (below the hyoid bone behind the larynx)behind the larynx) Lined with stratified squamous epitheliumLined with stratified squamous epithelium Function: gas and food conductionFunction: gas and food conduction Larynx divides upper and lower airway at the Larynx divides upper and lower airway at the

vocal cordsvocal cords Opening to larynx at the glottisOpening to larynx at the glottis

Lower AirwayLower Airway

LarynxLarynx Functions:Functions:

Conduct gasConduct gas Protect lower airwayProtect lower airway CoughCough SpeechSpeech

Extends from c-3 to c-6Extends from c-3 to c-6

Lower AirwayLower Airway

Larynx (cont)Larynx (cont) Unpaired cartilageUnpaired cartilage

Epiglottis covers the superior larynx Epiglottis covers the superior larynx opening on swallowing, preventing food opening on swallowing, preventing food from entering tracheafrom entering trachea

Thyroid - adam’s appleThyroid - adam’s apple Cricoid - only complete ring of cartilageCricoid - only complete ring of cartilage

Lower AirwayLower Airway

Larynx (cont)Larynx (cont) Paired cartilagePaired cartilage

Arytenoid - allows vocal cord movementArytenoid - allows vocal cord movement Corniculate-supports walls of the larynxCorniculate-supports walls of the larynx Cuneiform-connect epiglottis to the Cuneiform-connect epiglottis to the

arytenoid cartilagearytenoid cartilage

Tracheobronchial TreeTracheobronchial Tree

Functions for air conductionFunctions for air conduction Pseudostratified ciliated columnar Pseudostratified ciliated columnar

epitheliumepithelium Layers (change further down T.B. tree):Layers (change further down T.B. tree):

Cartilaginous layerCartilaginous layer Lamina propria - contains vessels and Lamina propria - contains vessels and

nerves epitheliumnerves epithelium

Tracheobronchial TreeTracheobronchial Tree

Trachea (generation 0)Trachea (generation 0) Approximately 4.5 - 5.5 inches in length, or Approximately 4.5 - 5.5 inches in length, or

10-12 cm10-12 cm Approximately 1 inch in diameter, or 2-2.5 cmApproximately 1 inch in diameter, or 2-2.5 cm 16-20 c-shaped cartilage rings prevent 16-20 c-shaped cartilage rings prevent

collapsecollapse Anterior to esophagusAnterior to esophagus Ciliated pseudostratified columnar epitheliumCiliated pseudostratified columnar epithelium Divides at carina into 2 mainstem bronchusDivides at carina into 2 mainstem bronchus

Tracheobronchial TreeTracheobronchial Tree

Mainstem Bronchus (generation 1)Mainstem Bronchus (generation 1) RightRight

20-30 degree angle – less acute angle20-30 degree angle – less acute angle Shorter and wider than leftShorter and wider than left

LeftLeft 40-60 degree angle – more acute angle40-60 degree angle – more acute angle Smaller and longer than rightSmaller and longer than right Structurally similar to tracheaStructurally similar to trachea

Tracheobronchial TreeTracheobronchial Tree

Lobar bronchi (generation 2)Lobar bronchi (generation 2) Right mainstem divides into 3 lobar Right mainstem divides into 3 lobar

divisions (accommodates 3 lobes)divisions (accommodates 3 lobes) UpperUpper MiddleMiddle LowerLower

Left mainstem divides into 2 lobar (2 lobes)Left mainstem divides into 2 lobar (2 lobes) UpperUpper LowerLower

Tracheobronchial TreeTracheobronchial Tree

Segmental Bronchi (generation 3) are Segmental Bronchi (generation 3) are named to the segments they representnamed to the segments they represent Right upper lobeRight upper lobe

ApicalApical PosteriorPosterior AnteriorAnterior

Right middle lobeRight middle lobe LateralLateral MedialMedial

Tracheobronchial TreeTracheobronchial Tree

Segmental Bronchi (generation 3) are Segmental Bronchi (generation 3) are named to the segments they representnamed to the segments they represent Right lower lobeRight lower lobe

SuperiorSuperior Medial basalMedial basal Anterior basalAnterior basal Lateral basalLateral basal Posterior basalPosterior basal

Tracheobronchial TreeTracheobronchial Tree Segmental Bronchi (generation 3) are Segmental Bronchi (generation 3) are

named to the segments they representnamed to the segments they represent Left upper lobeLeft upper lobe

Apical-posterior* (upper division)Apical-posterior* (upper division) Anterior (upper div.)Anterior (upper div.) Superior lingula (lower div.)Superior lingula (lower div.) Inferior lingula (lower division)Inferior lingula (lower division)

Left lower lobeLeft lower lobe SuperiorSuperior Anteromedial*(antero basal)Anteromedial*(antero basal) Lateral basalLateral basal Posterior basalPosterior basal **Some authors feel that the left lung should be numbered so Some authors feel that the left lung should be numbered so

that there are eight segments, the apical-posterior is that there are eight segments, the apical-posterior is numbered 1 and anteromedial is numbered 6 numbered 1 and anteromedial is numbered 6

Tracheobronchial TreeTracheobronchial Tree

Subsegmental bronchi (generation #4-Subsegmental bronchi (generation #4-9)9) Diameter from 1-4 mmDiameter from 1-4 mm Tubes greater than 1 mm with connective Tubes greater than 1 mm with connective

tissue are bronchitissue are bronchi Bronchioles (generation # 10-15)Bronchioles (generation # 10-15)

Less than 1 mmLess than 1 mm No connective tissueNo connective tissue Decreasing number of goblet cell/ciliaDecreasing number of goblet cell/cilia Ciliated cuboidal epitheliumCiliated cuboidal epithelium

Tracheobronchial TreeTracheobronchial Tree

Terminal bronchioles (generation# 16)Terminal bronchioles (generation# 16) About 0.5mm in diameterAbout 0.5mm in diameter Cuboidal epithelium to squamous Cuboidal epithelium to squamous

epitheliumepithelium Clara cells may secrete mucous/surfactantClara cells may secrete mucous/surfactant End of conducting airwaysEnd of conducting airways Canals of LambertCanals of Lambert

Parenchyma of the LungParenchyma of the Lung

PurposePurpose Gas exchange between alveolar air/bloodGas exchange between alveolar air/blood called external respirationcalled external respiration

Start at the respiratory bronchiolesStart at the respiratory bronchioles Generation #17-19Generation #17-19 Gas exchange is beginning to occurGas exchange is beginning to occur Some cuboidal but mostly squamousSome cuboidal but mostly squamous

Alveolar Ducts (generation Alveolar Ducts (generation #20-22)#20-22)

Alveoli separated by septal wallsAlveoli separated by septal walls

Alveolar Sacs (generation Alveolar Sacs (generation #23)#23)

Clusters of 15-20 alveoliClusters of 15-20 alveoli Walls are other alveoliWalls are other alveoli

AlveoliAlveoli

Air spaces that contain capillary wallsAir spaces that contain capillary walls Approximately 300-600 million totalApproximately 300-600 million total Simple squamous epitheliumSimple squamous epithelium Alveolar communication – pores of Alveolar communication – pores of

Kohn (collateral ventilation)Kohn (collateral ventilation)

Three types of alveolar cellsThree types of alveolar cells

Type IType I Squamous epithelium – thin and flatSquamous epithelium – thin and flat 95% of alveolar cells95% of alveolar cells Allows gas diffusionAllows gas diffusion

Type II (Clara Cells)Type II (Clara Cells) High metabolic rateHigh metabolic rate Produce surfactantProduce surfactant

Type IIIType III Pneumocystic macrophagesPneumocystic macrophages Ingest and eliminates foreign bodiesIngest and eliminates foreign bodies

The LungThe Lung

LocationLocation In thoraxIn thorax Surrounds heart in mediastinumSurrounds heart in mediastinum Superior to the diaphragmSuperior to the diaphragm Surrounded by pleura in the thoraxSurrounded by pleura in the thorax

Parietal pleura - on the thoraxParietal pleura - on the thorax Visceral pleura - on the lungVisceral pleura - on the lung Small potential space between the two Small potential space between the two

filled with small amount of serous fluid filled with small amount of serous fluid which decreases friction which decreases friction

StructureStructure

Upper lungUpper lung Apices – apexApices – apex Extends 1-2 inches above clavicleExtends 1-2 inches above clavicle Root or hilum is attachment of mainstem Root or hilum is attachment of mainstem

bronchus and arteriesbronchus and arteries

BaseBase Shape is concave due to diaphragmShape is concave due to diaphragm Right side is higher than the left due to the Right side is higher than the left due to the

liverliver

StructureStructure

Bony thoraxBony thorax Surrounds and protects the lungSurrounds and protects the lung Aids in ventilation Aids in ventilation

SternumSternum 18 cm long18 cm long PartsParts

Manubrium - superior portionManubrium - superior portion Body or Gladiolus - middle portionBody or Gladiolus - middle portion Xiphoid process – inferior portionXiphoid process – inferior portion

Notch above is the suprasternal notchNotch above is the suprasternal notch Trachea is palpable behind itTrachea is palpable behind it

StructureStructure

Sternum (cont)Sternum (cont) Junction of manubrium and body is the Junction of manubrium and body is the

Angle of LouisAngle of Louis The point of tracheal bifurcation (carina)The point of tracheal bifurcation (carina)

True ribsTrue ribs Pairs 1-7Pairs 1-7 Connect directly to the sternumConnect directly to the sternum

False ribsFalse ribs Pairs 8-10Pairs 8-10 Connect to the sternum indirectly via the costal Connect to the sternum indirectly via the costal

cartilagecartilage

StructureStructure

Sternum (cont)Sternum (cont) Floating ribsFloating ribs

Pairs 11 and 12Pairs 11 and 12 No attachment to sternum or other ribsNo attachment to sternum or other ribs May also be called false ribsMay also be called false ribs

StructureStructure

MediastinumMediastinum HeartHeart Great vesselsGreat vessels TracheaTrachea EsophagusEsophagus Thymus glandThymus gland Lymphatic structuresLymphatic structures NervesNerves ThymusThymus

Mucus Production and Mucus Production and Movement Movement

Goblet CellsGoblet Cells In the surface of the tracheobronchial treeIn the surface of the tracheobronchial tree Secrete mucusSecrete mucus

Submucosal GlandsSubmucosal Glands Below the lamina propriaBelow the lamina propria Secrete mucus & bronchial secretionsSecrete mucus & bronchial secretions

Mucus CompositionMucus Composition 95% water95% water 2% glyco protein2% glyco protein 1 % carbohydrate1 % carbohydrate

Mucus Production and Mucus Production and Movement Movement

Mucus Composition (cont)Mucus Composition (cont) Traces of lipid, debris, DNA, and foreign bodiesTraces of lipid, debris, DNA, and foreign bodies 100 – 150 ml produced daily100 – 150 ml produced daily Traps foreign bodiesTraps foreign bodies

Mucus BlanketMucus Blanket Continuous blanket of mucus over the Continuous blanket of mucus over the

tracheobronchial treetracheobronchial tree LayersLayers

Sol layerSol layer * Near the tissue* Near the tissue

* Is more liquid* Is more liquid Gel layerGel layer

* Near air* Near air * Is more thick* Is more thick

Mucus Production and Mucus Production and Movement Movement

Layers (cont)Layers (cont) CiliaCilia

* Hair-like projections* Hair-like projections

* Extend into the sol layer * Extend into the sol layer Mucociliary escalatorMucociliary escalator

* Formed by mucus blanket * Formed by mucus blanket and ciliaand cilia

* Cilia move in a wave like * Cilia move in a wave like fashionfashion

* Moves mucus upward at * Moves mucus upward at 2cm per minute 2cm per minute toward the mouth toward the mouth

* Means to remove the * Means to remove the mucus from the lungmucus from the lung

Mucus Production and Mucus Production and Movement Movement

SputumSputum Mucus, saliva and nasal secretionsMucus, saliva and nasal secretions Mobilized and expelled by coughMobilized and expelled by cough

Alveolar Fluid Alveolar Fluid

SurfactantSurfactant Detergent-like phospholipidDetergent-like phospholipid Decreases surface tensionDecreases surface tension Prevents alveolar collapsePrevents alveolar collapse Continuously produced, secreted, and Continuously produced, secreted, and

eliminatedeliminated

Muscles of VentilationMuscles of Ventilation

DiaphragmDiaphragm Separates thorax and abdomenSeparates thorax and abdomen Muscular hemi-diaphragmsMuscular hemi-diaphragms Normally dome-shapedNormally dome-shaped Right side higher than left due to liverRight side higher than left due to liver Flatten on inspirationFlatten on inspiration Phrenic nerve stimulatesPhrenic nerve stimulates Major muscle of ventilationMajor muscle of ventilation Normal diaphragmatic excursion is 1.5cm Normal diaphragmatic excursion is 1.5cm

during quiet breathingduring quiet breathing May increase to 6-10cm during labored May increase to 6-10cm during labored

ventilationventilation

Muscles of VentilationMuscles of Ventilation

Intercostal MusclesIntercostal Muscles Between ribsBetween ribs 2 layers2 layers

Internal - helps with exhalationInternal - helps with exhalation External - helps with inhalationExternal - helps with inhalation

T- 1 to T- 11 innervationT- 1 to T- 11 innervation External-contraction pulls ribs up and outExternal-contraction pulls ribs up and out

Increases anterior-posterior chest diameter Increases anterior-posterior chest diameter for inspirationfor inspiration

Internal-contraction pulls ribs down and in Internal-contraction pulls ribs down and in for forced expiration for forced expiration

Muscles of VentilationMuscles of Ventilation

Accessory MusclesAccessory Muscles Elevate and stabilize chest for labored Elevate and stabilize chest for labored

breathingbreathing Neck and shoulder musclesNeck and shoulder muscles

ScaleneScalene SternocleidomastoidSternocleidomastoid TrapeziumTrapezium PectoralisPectoralis

Muscles of VentilationMuscles of Ventilation

Expiratory MusclesExpiratory Muscles Normally passiveNormally passive Muscles of forced exhalationMuscles of forced exhalation

External obliqueExternal oblique Rectus abdominusRectus abdominus Internal obliqueInternal oblique Transverse abdominusTransverse abdominus

Types of BreathingTypes of Breathing

EupneaEupnea Normal breathingNormal breathing 12-20 breaths per minute12-20 breaths per minute

Hyperventilation: Rapid and/or deep Hyperventilation: Rapid and/or deep breathingbreathing

Hypoventilation: Slow and/or shallow Hypoventilation: Slow and/or shallow breathingbreathing

Dyspnea: Labored or difficult breathingDyspnea: Labored or difficult breathing Apnea: No breathing occursApnea: No breathing occurs

Types of BreathingTypes of Breathing

Biot’s BreathingBiot’s Breathing Several short breaths followed by long, Several short breaths followed by long,

irregular periods of apneairregular periods of apnea Caused by brain damage and increased ICPCaused by brain damage and increased ICP

Cheyne-Stokes BreathingCheyne-Stokes Breathing Increasing and decreasing depth and rate Increasing and decreasing depth and rate

of respirations followed by periods of of respirations followed by periods of apneaapnea

Caused by CHF, decreased blood flow to Caused by CHF, decreased blood flow to respiratory center, and brain damagerespiratory center, and brain damage

Types of BreathingTypes of Breathing

Kussmaul BreathingKussmaul Breathing Deep gasping type of respirationDeep gasping type of respiration Caused by diabetic acidosisCaused by diabetic acidosis

Tachypnea: Respiratory rate >20 bpmTachypnea: Respiratory rate >20 bpm Bradypnea: Respiratory rate < 12Bradypnea: Respiratory rate < 12

Regulation of BreathingRegulation of Breathing

Medullary Respiratory CenterMedullary Respiratory Center Medulla is lowest part of brain stemMedulla is lowest part of brain stem Contains widely dispersed respiratory Contains widely dispersed respiratory

neuronsneurons Dorsal Respiratory GroupsDorsal Respiratory Groups

Mainly inspiratory neurons Mainly inspiratory neurons Send impulses to diaphragm and external Send impulses to diaphragm and external

intercostals musclesintercostals muscles

Regulation of BreathingRegulation of Breathing

Ventral Respiratory GroupsVentral Respiratory Groups Inspiratory neuronsInspiratory neurons

Abduct vocal cordsAbduct vocal cords Increase diameter of glottisIncrease diameter of glottis Innervate diaphragm and external Innervate diaphragm and external

intercostalsintercostals Expiratory neuronsExpiratory neurons

Send impulses to internal intercostals and Send impulses to internal intercostals and abdominal expiratory musclesabdominal expiratory muscles

Regulation of BreathingRegulation of Breathing Pontine Respiratory CentersPontine Respiratory Centers

Pons is located above the medulla on the Pons is located above the medulla on the brain stembrain stem

Apneustic centerApneustic center Sends signals to promote a prolonged, Sends signals to promote a prolonged,

unrestrained inspirationunrestrained inspiration Vagal and pneumotaxic center impulses hold Vagal and pneumotaxic center impulses hold

the stimulatory effect in checkthe stimulatory effect in check Pneumotaxic centerPneumotaxic center

Controls inspiratory timeControls inspiratory time Strong signals increase respiratory rateStrong signals increase respiratory rate Weak signals prolong inspiration and increase Weak signals prolong inspiration and increase

tidal volumestidal volumes

Reflex Control of BreathingReflex Control of Breathing

Hering-Breuer Inflation ReflexHering-Breuer Inflation Reflex Stretch receptors located in smooth Stretch receptors located in smooth

muscle of large and small airwaysmuscle of large and small airways When stimulated they send a signal via When stimulated they send a signal via

vagus nerve to the medullary center to vagus nerve to the medullary center to stop further inspirationstop further inspiration

In adults it is activated at a tidal volume of In adults it is activated at a tidal volume of about 800 to 1000 mlabout 800 to 1000 ml

CoughCough One of the most common symptoms One of the most common symptoms

associated with lung diseaseassociated with lung disease Powerful protective mechanism for the Powerful protective mechanism for the

lung and airwayslung and airways Caused by mechanical, chemical, Caused by mechanical, chemical,

inflammatory, or thermal stimulation of inflammatory, or thermal stimulation of the cough receptorsthe cough receptors

Made up of three phasesMade up of three phases Inspiratory phaseInspiratory phase Compression phaseCompression phase Expulsion phaseExpulsion phase

CoughCough

Causes and Clinical PresentationCauses and Clinical Presentation Acute cough most often associated with Acute cough most often associated with

viral infection of the upper airwayviral infection of the upper airway Chronic cough often associated with Chronic cough often associated with

postnasal drip, asthma, COPD, postnasal drip, asthma, COPD, gastroesophageal reflux, and left gastroesophageal reflux, and left ventricular failureventricular failure

CoughCough

DescriptionsDescriptions The type of cough present should be The type of cough present should be

documented using commonly accepted documented using commonly accepted adjectives.adjectives. Productive—mucus is produced with the coughProductive—mucus is produced with the cough Effective—a strong coughEffective—a strong cough Weak—ineffectiveWeak—ineffective Dry—no secretions presentDry—no secretions present Chronic productive—patient produces phlegm Chronic productive—patient produces phlegm

most days for at least 3 weeksmost days for at least 3 weeks

Sputum ProductionSputum Production

Sputum is the mucus expelled from the Sputum is the mucus expelled from the tracheobronchial tree that has been tracheobronchial tree that has been contaminated by the mouth.contaminated by the mouth.

Phlegm is the term used to describe Phlegm is the term used to describe mucus strictly from the mucus strictly from the tracheobronchial tree.tracheobronchial tree.

Sputum ProductionSputum Production Causes and DescriptionsCauses and Descriptions

Caused by inflammation of the mucus secreting Caused by inflammation of the mucus secreting glands that line the airwaysglands that line the airways

Inflammation occurs with infection, cigarette Inflammation occurs with infection, cigarette smoke, and allergies.smoke, and allergies.

Sputum should be described as to the color, Sputum should be described as to the color, consistency, quantity, time of day, odor, and consistency, quantity, time of day, odor, and presence of blood.presence of blood.

Thick but clear sputum is consistent with Thick but clear sputum is consistent with dehydration.dehydration.

Pink frothy sputum is consistent with pulmonary Pink frothy sputum is consistent with pulmonary edema.edema.

Thick, purulent (pus-containing) sputum is Thick, purulent (pus-containing) sputum is consistent with infection.consistent with infection.

HemoptysisHemoptysis

CausesCauses Persistent strong coughingPersistent strong coughing Acute infectionAcute infection Bronchogenic carcinomaBronchogenic carcinoma Cardiovascular diseaseCardiovascular disease TraumaTrauma Anticoagulant therapyAnticoagulant therapy

HemoptysisHemoptysis

DescriptionsDescriptions Streaky hemoptysis refers to blood-tinged Streaky hemoptysis refers to blood-tinged

sputum.sputum. Massive hemoptysis refers to more than Massive hemoptysis refers to more than

400 ml of blood in 3 hours or 600 ml in 24 400 ml of blood in 3 hours or 600 ml in 24 hours. It is consistent with trauma, lung hours. It is consistent with trauma, lung cancer, tuberculosis, and bronchiectasis. It cancer, tuberculosis, and bronchiectasis. It also is more common in patients on also is more common in patients on anticoagulant therapyanticoagulant therapy

HemoptysisHemoptysis

Hemoptysis versus HematemesisHemoptysis versus Hematemesis Determining if the blood is from the lung Determining if the blood is from the lung

versus the stomach is important.versus the stomach is important. Blood from the lung is often associated Blood from the lung is often associated

with pulmonary symptoms.with pulmonary symptoms. Blood from the stomach is associated with Blood from the stomach is associated with

GI symptoms (see Table 3-4 CARC p. 33)GI symptoms (see Table 3-4 CARC p. 33)

Shortness of Breath Shortness of Breath (Dyspnea)(Dyspnea)

Dyspnea is a common symptom of Dyspnea is a common symptom of patients with lung or cardiac problems.patients with lung or cardiac problems.

Subjectiveness of DyspneaSubjectiveness of Dyspnea Dyspnea is a subjective complaint that Dyspnea is a subjective complaint that

varies with pathologic and psychological varies with pathologic and psychological variables.variables.

The degree of dyspnea may not correlate The degree of dyspnea may not correlate with objective measures of impairment.with objective measures of impairment.

Dyspnea should always be investigated Dyspnea should always be investigated even if initial tests are normal.even if initial tests are normal.

Shortness of Breath Shortness of Breath (Dyspnea)(Dyspnea)

Dyspnea Scoring SystemDyspnea Scoring System A variety of scoring systems have developed A variety of scoring systems have developed

to help quantify dyspnea at a single point in to help quantify dyspnea at a single point in time to help track changes with treatment.time to help track changes with treatment.

The visual analog scales use a straight line The visual analog scales use a straight line 10 cm long. The patient marks a dash on the 10 cm long. The patient marks a dash on the line consistent with the level of dyspnea line consistent with the level of dyspnea currently experienced.currently experienced.

The Modified Borg Scale uses a 0 to 10 The Modified Borg Scale uses a 0 to 10 scale.scale.

Many other tools are also available. Each has Many other tools are also available. Each has its own advantages and disadvantages.its own advantages and disadvantages.

Shortness of Breath Shortness of Breath (Dyspnea)(Dyspnea)

Causes, Types, and Clinical Presentation of Causes, Types, and Clinical Presentation of DyspneaDyspnea

Dyspnea tends to occur when the patient Dyspnea tends to occur when the patient experiences increased WOB, increased drive to experiences increased WOB, increased drive to breathe, and/or decreased ventilatory capacity.breathe, and/or decreased ventilatory capacity.

The adjectives patients use to describe their The adjectives patients use to describe their dyspnea may correlate with the underlying dyspnea may correlate with the underlying pathology. For example, patients with CHF tend to pathology. For example, patients with CHF tend to feel the sensation of “suffocation.” Asthmatics often feel the sensation of “suffocation.” Asthmatics often describe dyspnea by saying they have “tightness in describe dyspnea by saying they have “tightness in their chest.”their chest.”

Acute dyspnea is associated with acute illnesses Acute dyspnea is associated with acute illnesses such as asthma, pneumonia, pneumothorax, etc.such as asthma, pneumonia, pneumothorax, etc.

Chronic dyspnea is almost always progressive. It is Chronic dyspnea is almost always progressive. It is most often seen in patients with COPD and CHF.most often seen in patients with COPD and CHF.

Shortness of Breath Shortness of Breath (Dyspnea)(Dyspnea)

DescriptionsDescriptions Paroxysmal nocturnal dyspnea (PND) is often seen Paroxysmal nocturnal dyspnea (PND) is often seen

in CHF patients. It is associated with the collection in CHF patients. It is associated with the collection of fluid in the lung during sleep.of fluid in the lung during sleep.

Orthopnea is also associated with CHF.Orthopnea is also associated with CHF. Trepopnea (dyspnea while lying on one side) is less Trepopnea (dyspnea while lying on one side) is less

common but is seen in patients with unilateral common but is seen in patients with unilateral disorders.disorders.

Platypnea (dyspnea in the upright position) is not Platypnea (dyspnea in the upright position) is not common but implies a disorder is present that common but implies a disorder is present that causes increased shunting of blood from right to causes increased shunting of blood from right to left when the upright position is assumed.left when the upright position is assumed.

Egan defines trepopnea & platypnea differently from above with both being in Egan defines trepopnea & platypnea differently from above with both being in the upright position, and platypnea being relieved by the patient lying the upright position, and platypnea being relieved by the patient lying

downdown

Chest PainChest Pain

Chest pain is the cardinal symptom of Chest pain is the cardinal symptom of heart disease.heart disease.

Chest pain may be seen in patients Chest pain may be seen in patients with lung disease when the pleural with lung disease when the pleural lining is abnormal.lining is abnormal.

Classic chest pain associated with Classic chest pain associated with heart disease is known as angina, and heart disease is known as angina, and it signals a medical emergency.it signals a medical emergency.

Chest PainChest Pain Pulmonary Causes of Chest PainPulmonary Causes of Chest Pain

Pain associated with lung disease is most Pain associated with lung disease is most often the result of pleural inflammation.often the result of pleural inflammation.

Pneumonia and pulmonary infarction may Pneumonia and pulmonary infarction may cause pleural pain.cause pleural pain.

DescriptionsDescriptions Chest pain from heart disease is often described Chest pain from heart disease is often described

as aching, squeezing, pressing, or viselike. It as aching, squeezing, pressing, or viselike. It often increases with exercise.often increases with exercise.

Patients with pleuritic chest pain may be leaning Patients with pleuritic chest pain may be leaning toward one side and describe the pain as toward one side and describe the pain as stabbing or burning. They state the pain stabbing or burning. They state the pain increases with deep breathing.increases with deep breathing.

Dizziness and Fainting Dizziness and Fainting (Syncope)(Syncope)

Syncope is a temporary loss of Syncope is a temporary loss of consciousness due to reduced blood consciousness due to reduced blood flow and oxygen to the brain.flow and oxygen to the brain.

Syncope is caused by a large variety of Syncope is caused by a large variety of disorders from something as simple as disorders from something as simple as dehydration to serious cerebral dehydration to serious cerebral thrombosis.thrombosis.

Patients with lung disease who cough Patients with lung disease who cough very forcefully may experience syncope.very forcefully may experience syncope.

Dizziness and Fainting Dizziness and Fainting (Syncope)(Syncope)

DescriptionsDescriptions Some patients experience syncope when Some patients experience syncope when

they suddenly stand up. This is often they suddenly stand up. This is often associated with orthostatic hypotension.associated with orthostatic hypotension.

Cough syncope occurs with severe Cough syncope occurs with severe coughing and is the result of reduced coughing and is the result of reduced venous return due to high intrathoracic venous return due to high intrathoracic pressures.pressures.

Swelling of the Ankles Swelling of the Ankles (Dependent Edema)(Dependent Edema)

Patients with chronic hypoxemia often Patients with chronic hypoxemia often develop right heart failure.develop right heart failure.

Right heart failure leads to reduced venous Right heart failure leads to reduced venous return and increased hydrostatic pressure in return and increased hydrostatic pressure in the peripheral venous blood vessels especially the peripheral venous blood vessels especially in the dependent tissues (e.g., ankles).in the dependent tissues (e.g., ankles).

Ankle edema thus can be a sign of chronic Ankle edema thus can be a sign of chronic lung disease.lung disease.

Ankle edema may also simply be a sign of Ankle edema may also simply be a sign of heart disease not associated with lung diseaseheart disease not associated with lung disease

Swelling of the Ankles Swelling of the Ankles (Dependent Edema)(Dependent Edema)

DescriptionsDescriptions Pitting edema is present when the Pitting edema is present when the

edematous tissue is pressed inward and it edematous tissue is pressed inward and it does not return to its normal position does not return to its normal position immediately.immediately.

Fever, Chills, and Night Fever, Chills, and Night SweatsSweats

DescriptionsDescriptions Sustained fever is a continuously elevated Sustained fever is a continuously elevated

fever that varies little during a 24-hour period.fever that varies little during a 24-hour period. Remittent fever is continuously elevated but Remittent fever is continuously elevated but

has larger variations and spikes in a 24-hour has larger variations and spikes in a 24-hour period.period.

Intermittent fever refers to spikes in body Intermittent fever refers to spikes in body temperature cycling with periods of normal or temperature cycling with periods of normal or subnormal temperatures.subnormal temperatures.

Fever is a concern because it may signal Fever is a concern because it may signal infection and it increases oxygen infection and it increases oxygen consumption.consumption.

Fever, Chills, and Night Fever, Chills, and Night SweatsSweats

Fever with Pulmonary DisordersFever with Pulmonary Disorders PneumoniaPneumonia Lung abscessLung abscess TuberculosisTuberculosis EmpyemaEmpyema A lack of fever does not rule out infection.A lack of fever does not rule out infection.

Headache, Altered Mental Headache, Altered Mental Status, and Personality Status, and Personality

ChangesChanges Lung disease can lead to headache when Lung disease can lead to headache when

chronic hypoxemia or hypercarbia is present.chronic hypoxemia or hypercarbia is present. Sudden changes in personality are common Sudden changes in personality are common

in patients with chronic lung disease and may in patients with chronic lung disease and may be due to hypoxia, medications, or be due to hypoxia, medications, or psychologic issues.psychologic issues.

RTs must be sensitive to personality changes RTs must be sensitive to personality changes because they may be indicative of acute lung because they may be indicative of acute lung problems in the patient with chronic lung problems in the patient with chronic lung diseasedisease

SnoringSnoring Incidence and CausesIncidence and Causes

Snoring occurs in about 5% to 10% of children and Snoring occurs in about 5% to 10% of children and 10% to 30% of adults.10% to 30% of adults.

Snoring is caused by excessive narrowing of the Snoring is caused by excessive narrowing of the upper airway with breathing during sleep. The upper airway with breathing during sleep. The airway narrowing increases with inspiration and airway narrowing increases with inspiration and lessens during exhalation.lessens during exhalation.

Obesity is the most common cause of obstructive Obesity is the most common cause of obstructive sleep apnea.sleep apnea.

Enlarged tonsils, a large tongue, a short thick neck, Enlarged tonsils, a large tongue, a short thick neck, and nasal obstruction may contribute to the upper and nasal obstruction may contribute to the upper airway narrowing during sleep.airway narrowing during sleep.

Alcohol and sleeping medications can also make Alcohol and sleeping medications can also make snoring worsesnoring worse

SnoringSnoring

Clinical PresentationClinical Presentation Patients with obstructive sleep apnea Patients with obstructive sleep apnea

always snore during sleep.always snore during sleep. OSA patients will complain of excessive OSA patients will complain of excessive

daytime sleepiness because their sleep daytime sleepiness because their sleep continuity is abnormal.continuity is abnormal.

OSA patients may also complain of poor OSA patients may also complain of poor concentration skills, bedwetting, concentration skills, bedwetting, impotence, high blood pressure, and other impotence, high blood pressure, and other complaintscomplaints