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Pulmonary
Disorders
Bill Buron, PhD, RNC, GNP/FNP-BC
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Signs and Symptoms of
Pulmonary Disease
Dyspnea- subjective sensation of uncomfortable breathing
Dyspnea on exertion Orthopnea- dyspnea when a person is lying
down
Paroxysmal nocturnal dyspnea
Abnormal breathing patterns Kussmaul respirations- hyperpnea
Cheyne-Stokes respirations
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Signs and Symptoms of
Pulmonary Disease
Hypoventilation
Hypercapnia
Hyperventilation
Hypocapnia
Cough- acute vs chronic
Hemoptysis
Pain
Pleural friction rub
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Signs and Symptoms of
Pulmonary Disease
Cyanosis
Clubbing
Abnormal sputum
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Oxygen Transport to the Tissues
Ventilation
Distribution
Perfusion
Exchange at the blood-gas barrier
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Ventilation-Perfusion
Relationships Nomenclature
Va= gas flow (usually inliters/minute)
Q= blood flow (usually in ml /
minute)
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Perfusion
In upright position, gravity causes
less blood flow to reach the higher,
upper lobes than the lower lobes
Upper alveoli receive moderate
ventilation with decreased or littleblood flow, creating a high Va/Q ratio
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Perfusion
Lower alveoli receive moderately
increased ventilation and greatly
increased blood flow, creating a lower Va/Q ratio
Va/Q ratios decrease from top tobottom
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Perfusion
Blood flow to lungs changes with
exercise and position
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Va/Q Mismatching
Abnormal
distribution of
ventilation andperfusion
Most common
cause of
hypoxemia
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Va/Q Mismatch
Hypoxia caused by
Inadequate ventilation
of well-perfused areas
of lung causes a lowV/Q
Poor perfusion of well-
ventilated areas
causes a high V/Qcalled alveloar dead
space
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Acute Respiratory Failure
Inadequate gas exchange
PaO2 < 50 mmHg
PaCO2 > 50 mmHg
pH < 7.25
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Pulmonary Edema
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Pulmonary Edema Clinical
Manifestations
Dyspnea
Hypoxemia
Increased work of breathing
Inspiratory crackles
Dullness to percussion over lung bases
Frothy sputum (late sign)
PaCO2 increases
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Aspiration
Passage of fluid and/or
solid particles into the
lungs Patients at high risk
CNS abnormalities
Decreased LOC
Altered cough/swallowingmechanism
Children
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Aspiration Clinical Manifestations
Sudden onset of choking, cough
Vomiting
Dyspnea
Wheezing
Development of a chemical pneumonitis
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Restrictive Patterns of
Respiratory Disease Characterized by increased stiffness
of the lungs or thorax or both
Due to decreased compliance and
reduction in all lung volumes
Causes decrease in:
Total lung capacity
Vital capacity
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Restrictive Patterns of
Respiratory Disease Increased WOB
Rapid, shallow breathing noted
Alveolar hypoventilation
Inability to maintain normal blood gas
tensions
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Classification of Restrictive
Patterns of Respiratory Disease: Diseases of the pleura and lung
parenchyma
Extra pulmonary Disorders
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Diseases of the Pleura and Lung
Parenchyma Atelectasis:
“imperfect
expansion”Involvescollapse of a
previouslyexpandedalveoli.
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Diseases of the Pleura and Lung
Parenchyma Compression atelectasis:
compression of lung tissue from a
source outside the alveoli.
Pneumothorax/hemothorax
Pleural effusionTumors within the thorax
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Diseases of the Pleura and Lung
Parenchyma Absorption atelectasis: Obstruction of the airway
prevents air from entering the alveoli distal tothe obstruction. Absorption of gas form the
alveoli, causing the lung to collapse.
Intrinsic causes- most common isretention of secretions or exudates
Extrinsic pressure on a bronchuscommonly results form neoplasm, lymphnode enlargement, aneurysm, or scar formation
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Obstruction Atelectasis
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Obstructive Atelectasis
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Pathogenesis of Atelectasis
Collateral ventilation- air can pass form one lung
acinus to another by other than the normal
airways. Small pores, called the pores of Kohn, between
the alveoli provide a path for collateral
ventilation to help prevent atelectasis
Prolonged atelectasis may lead to replacementof lung tissue with fibrous tissue.
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Clinical Manifestations
Dyspnea
Tachycardia
Cough
Fever
Decreased chest wall expansion Hypoxemia
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Diagnostic
Blood gases show hypoxemia,
hypercapnia, and a decreased pH
Chest film
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Infectious Diseases
Bacterial
pneumonia-
characterizedby an intra-
alveolar
suppurativeexudates with
consolidation
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Pneumococcal pneumonia
(streptococcus pneumonia) Common bacterial infection of the
lung, responsible for 30-80% of
community-acquired pneumonia
Malnutrition, alcoholism and aging
are risk factors
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Pneumococcal pneumonia
(streptococcus pneumonia) Pathogenesis: an acute inflammatory response
leads to consolidation (leukocytes and fibrin) of the involved area
Clinical manifestations- sudden onset of symptoms
Fever
Cough Pleuritic chest pain
Production of rusty-colored or blood-streakedsputum
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Viral or Mycoplasma Pneumonia
Characterized by an interstitial
inflammation with accumulation of an
infiltrate in the alveolar walls,although, the alveolar spaces
themselves are free of exudate and
there is no consolidation
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Viral or Mycoplasma Pneumonia
Mycoplasmal pneumonia is a self -
limiting disease that is a common
cause of respiratory tract infections
Viral pneumonia is usually mild and
self-limiting in adults but may be
rapidly proliferative and be fatal in
children (usually under the age of 2)
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Mycobacterium Tuberculosis
Causes patchy distribution of
granulomas, which undergo caseous
necrosis with the development of cavities
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Tuberculosis Granuloma
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Advanced Tuberculosis
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Tuberculosis
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Pneumonias
Nosocomial infections- acquired within the
hospital
More likely to be gram-negativebacteria or Staphylococcus aureus
and less likely to be caused by
pneurmococci or mycoplasma
Community based infections
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Aspiration Pneumonia
Inhalation of gastric contents, food,
water, or blood into the
tracheobronchial system.
Pneumonia results when the
material is propelled into the alveolar
system. Chemical irritation form the
aspirant leads to bronchospasm,necrosis, and fibrosis of airways.
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Aspiration Pneumonia
Clinical manifestations
Abrupt signs of bronchospasm
Dyspnea
Tachycardia
TachypneaCyanosis
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Pneumocystis Pneumonia
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Traumatic Injuries of the Chest
Wall Simple rib fracture
Fracture of several ribs (flail chest,
fluid chest)
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Pleura Disorders
Pneumothorax- Air in the pleural
space form an opening in the chest
wall (through parietal pleura) or formthe lungs (through the visceral pleura)
Spontaneous Pneumothorax
Tension Pneumothorax
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Pneumothorax Clinical
Manifestations Dyspnea
Chest pain
Tracheal deviation with a mediastinalshift toward the unaffected side
Unequal chest expansion
Reduced breath sounds on theaffected side
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Pneumothroax
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Pneumothorax
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Pneumothorax
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Pleural Disorders
Pleural Effusion: The accumulation
of excess fluid in the pleural cavity,
resulting from trauma or disease
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Related terminology
Transudate: accumulation of fluid due to arise in pulmonary venous pressure,hypoproteinemia, or pressure form atumor on the vena cava
Hydrothorax- accumulation of pleuraltransudate
Empyema- effusion contains purulentmaterial
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Related terminology
Fibrothorax- fibrous fusion of the
lung and chest wall
Hemothorax- frank blood in the
pleural fluid (trauma)
Exudate-fluid that has a higher specific gravity and protein content
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Respiratory Diseases Caused by
Exposure to Organic and Inorganic Dust
Silicosis-An industrial disease (seenin masons, potters, sandblasters)
resulting form inhalation of silicondioxide
Coal Workers’ Pneumonconiosis
(black lung disease) Asbestosis
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Asbestosis
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Structural Restriction of Thoracic
Excursion Skeletal deformities
Compression may decrease lung
volume and cause atelectasis
Compliance and total lung capacity are
reduced
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Structural Restriction of Thoracic
Excursion Pulmonary vascular bed is reduced,
causing increased work of ventilation,alveolar hypoventilation, and hypoxemia
Kyposcoliosis
Pectus Excavtum (funnel chest
Pectus Carinatum (pigeon chest) Picwickian syndrome
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Obstructive Patterns of
Respiratory Disease Acute Obstructive Airway Disease
Acute bronchitis
Asthma Chronic Obstructive Airway Disease
Bronchiectasis
Cystic fibrosis Chronic bronchitis
Pulmonary emphysema
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Acute Bronchitis
Caused by infection and inhalants
Inflammation of mucosal lining of tracheobronchial tree
Characterized by:
Increased secretions of mucus
Bronchial swelling
Dysfunction of cilia leading to increased resistance to
expiratory airflow
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Clinical Manifestations of Acute
Bronchitis Recent history of upper respiratory infection
Chronic lung disease
Smoking
Exposure to respiratory irritants
Mucoid- viral
Mucopurulent- bacterial
Mucopurulent productive congestion Fever below 101oF
Wheezing
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Asthma
Episodic disorder characterized by recurrentparoxysm of wheezing and dyspnea notattributable to other diseases
Initiated by release of chemical mediators in anIgE mast cell interaction
Results in increased bronchial secretion,mucosal swelling and bronchospasm
Classified as
Extrinsic
Intrinsic
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Clinical Manifestations of Asthma
History of childhood asthma/or positive family history
Inhalation of irritants
Respiratory infection
Psychogenic factors Tightness in chest
Dyspnea
Fatigue due to increased WOB
Tachypnea/ may have pulsus paradoxus Expiratory wheezing progressing to inspiratory and
expiratory wheezing
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Status Asthmaticus
Severe episode of asthma that isrefractory to therapy
Life-threatening event with increasingmortality rates
Onset of respiratory failure may besignaled by cyanosis, decreased
wheezing with progressive hypoventilationand decreased levels of consciousness
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Chronic Obstructive Pulmonary
Disease Bronchiectasis
Cystic fibrosis
Chronic bronchitis.
Pulmonary emphysema
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Bronchiectasis
Disease of bronchi and broncioles
Associated with chronic infection and inflammation
Irreversible dilation of bronchial tree
Clinical manifestations Childhood onset
Initiating event- pneumonia or bronchitis
Cough
Symptoms of infection Production of large amounts of mucopurulent sputum
Occasional hemoptysis
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Cystic fibrosis
Hereditary disorder affecting children
Disorder affects sweat glands, bronchi, pancreas, and
mucous-secreting glands of small intestine
Clinical manifestations related to inability to handle largequantities of viscous material
Chronic cough
Persistent lung infections-especially Pseudomonas
aeruginosa and Staphylococcus aureus
Cor pulmonale
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Chronic Bronchitis
Chronic bronchial inflammation withprogressive increase in productive coughand dyspnea
Bronchial mucosa becomes thick and rigiddue to vasodilatation, congestion andedema
Excessive secretion of mucous Narrowing of the passageways
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Clinical Manifestations of Chronic
Bronchitis Cigarette smoking
Generally overweight
Cough
Recurrent chest infections
Marked cyanosis and edema
Clinical Manifestations of
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Clinical Manifestations of
Chronic Bronchitis
Lungs
Mild hyperinflations
Marked hypercapnia
Severe hypoxemia Wheezes
Resonant percussion
Heart
Jugular venous distention Cardiac enlargement
Liver engorgement
Peripheral edema
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Pulmonary Emphysema
Chronic pulmonary disease
May be classified with chronic bronchitis
Characterized by permanent enlargementof the acinus
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Clinical Manifestations of
Pulmonary Emphysema Cigarette smoking
Exposure to chemical irritants or air pollution
Chronic respiratory infections
Exert ional dyspnea
Cough with small sputum production
Wheezing or tightness of chest
Tachypnea at rest or with mild exertion Flushed
Purse lipped breathing
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Clinical Manifestations of
Pulmonary Emphysema Decreased PaO2 in late stage
Chronic increase in PaCO2
Increased RV
Prolonged FEV1
Acute Respiratory Distress
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Acute Respiratory Distress
Syndrome
Acute lung inflammation
Diffuse alveolocapillary injury
Non cardiac pulmonary edema
Adult Respiratory Distress
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Adult Respiratory Distress
Syndrome (ARDS)
Manifests within 72 hours following the
predisposing insult
Characterized by noncardiogenicpulmonary edema, collapsed and fluid-
filled alveoli and severe hypoxemia
Incidence – 200,000-250,000 cases/year Mortality 40-90%
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ARDS Risk Factors
Shock
Sepsis
Hypothermia/hyperthermia
Drug overdose
DIC
Massive transfusion Cardiopulmonary
bypass
Eclampsia
Burns
Pancreatitis Severe nonthoracic
trauma
Pneumonia
Inhalation therapy
Aspiration
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ARDS
Change in lung compliance
Decreased in ARDS and lungs become “stiff”
Increased accumulation of secretions andmediator-induced bronchoconstriction
Radiographic Changes
Increasing alveolar atelectasis, consolidation Development of air bronchograms
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Assessment of ARDS
Tachypnea
Dyspnea
Tachycardia
Lung crackles
Refractory hypoxia
Hypercarbia- (LATE SIGN!!)
Intrapulmonary shunt
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ARDS Management
Oxygenation and ventilation
Mechanical ventilation
Small tidal volumes (<10 ml/kg) to minimize airway pressures
Extracorporeal lung assist
Positioning- prone positioning being explored
Pharmacological therapy
Corticosteroids
Antibiotic therapy
Bronchodilators
Exogenous surfactant replacement
Nitric oxide
Antioxidants
Nutritional Support
Patients require 35-45 Kcal/kg/day
TPN