Term
Disorders of inflation
restrictive disease
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Definition
pleural effusion
pneumothorax
atelctasis |
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Term
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Definition
- Increased capillary hydrostatic pressure
transudative CHF
- Increased capillary permeability
exudative infection: increased protein, yellow fluid
- Decreased collidal osmotic pressure
liver failure, nephrotic syndrome, malnutrition
-empyema: infection of pleural space- pus, green fluid
- chylothorax: tumor, trauma - obstruction to lymph flow, white, milky
- hemothorax: trauma, vessel rupture- blood, red fluid |
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Term
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Definition
- decrease lung expansion on affecte side
- "" lung volume
- "" tactile fremitus
-"" breath sounds
- shift of mediastinal contents toward unaffected side
- pain
-dyspnea (shortness of breath)
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Term
Pathophsiology of pleural effussion
1 fluid formation faster than fluid removal
2 if inflammatory (infection)
3 physical signs |
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Definition
Clinical links of pleural effusion
1. restriction of ventilation, dyspnea
2. fever, wbc, pleuritic pain
3. dullness to percussion, decreased tactile fremitus, dminished breath sounds on side of effusion |
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Term
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Definition
- bleb rupture in otherwise healthy: unknown cause.greater pressure gradients from top to bottom of lung in tall individ
- typically apical
- tall boys/men 10-30 yo
- bleb as part of lung disease: ongoing dz causes trapping of gas and destruction of lung tissue - most often from emphysema: asthma, cancer, tuberculosis, cystic fibrosis
- catamenial pneumo-associated w/ menstrual periods. |
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Term
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Definition
-Intrapleural pressure> atmospheric
- life threatening
- air into BUT NOT OUT OF pleural space -> compression of unaffected lung, and vascular structures. Eventual C-V collapse - pulseless |
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Term
| Pneumothorax Diagnosis and Rx |
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Definition
- symptom analysis
- chest x ray, CT scan
- ABG
- small pneumos may resolve as air is reabsorbed
- large may require chest tube or emergency decompression w/ large bore needle |
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Term
Atelectasis:
"imperfect" (incomplete) expansion |
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Definition
- primary: seen in newborns
- secondary (acquired) caused by:airway obstruction, pleural effusion, ^ recoil of lung (dec surfactant)
- mucus plug or retained secretions -> obstruction - controbuting factors: anesthesia, narcotics, pain, immobility, hypoventilaion
- compression atelectasis: pleura compresses lung - effusion, tumor |
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Term
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Definition
- tachypnea - fast breathing
- tachycardia - fast heart rate
- dyspnea - external muscles are retracting
- cyanosis
- external intercostal retractions
- fever
-diminished breath sounds and chest expansion on affected side |
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Term
Ateletasis:
pathophysiology |
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Definition
- inflammation from retained secretions
- mucus plug obstruction w/ absorption of dep alveoli
- collapse of lung
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Term
Atelectasis:
clinical links |
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Definition
- collapse of that portion of lung
- decreased chest expansion, dyspnea, tachypnea, tachycardia, hypoxemia, intercostal retractions
- diminshed breathe sounds, hypoxemia
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Term
| Diagnosis and Rx of Atelectasis |
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Definition
- symptoms analysis
- chest x-ray
- rx aimed at specific cause:
- turn/cough/deep breath (TCDB): dep. lung has better V and Q and put "bad" lung down by increasing its perfusion
- adequate pain control
- mobility in be or w/ ambulation OOB
- incentive spirometry (ISB)
- adequate fluid intake
- bronchoscopy: if atelectatic area large enough
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Term
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Definition
- aggressive, locally invasive and very metastic
- from epithelial lining of bronchi
- further divide into 2 categories:
- Non-small cell lung cancer (NSCLC): squamous cell (25-40%), adenocarcinoma (25-40%), large cell (10-15)
- Small cell lung cancer (20%) (SCLC)
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Term
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Definition
- most common in men
- close correlation w/ smoking
- usual origin in central bronchi
- more amenable to early detection w/ sputum exam
- central spread to major bronchi and hilar lymph nodes w/ later metastasis outside of thorax (compared to other lung Ca) |
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Term
| lung cancer: manifestations |
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Definition
- insidious development: - symptoms similar to smoking/bronchitis -anorexia and weight loss
- involvement of lung: cough, SOB, wheezing, hemoptysis, retrosternal pain, effusion
- effects of local and distant spread: - mediastinum, esophagus, pleural effusion and - brain, bone, liver metastasis
- paraneoplastic (caused by or resulting from the presence of cancer in the body but not the physical presence of cancerous tissue in the part or organ affected) manifestions: hypercalcemia, ACTH, SIADH, neuropathies, coagulopathies and Mostly w/ SCLCs
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Term
lung cancer:
pathophysiology |
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Definition
- most arise from bronchial epithelial cells exposed to cigarette smoke
- lung tumor symptoms from endobronhial obstructions, pleural dz, metastases, endocrine abnromalities ... most asymptomatic until late
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Term
lung cancer:
clincial links |
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Definition
- cessation is biggest step to prevention. Risk returns to normal 5 yrs after cessation
- screening controversial but high risk (> 40 pack years, airway obstruction, COPD symptoms) should receieve yearly sputum cytology and chest x-rays
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Term
| Obstructive Pulmonary disease |
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Definition
- limited expiratory function
- either more force is needed to expire a given volume of air or emptying of lungs is slowe or both
- asthma - reversible until stages
- chronic obstructive pulmonary disease (COPD): chronic bronchitis, emphysema, almost 100% due to smoking or environmental exposure to smoke/dust
-cystic fibrosis |
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Term
| general pathopysiology of obstructive dz |
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Definition
smooth muscle of lower respiratory tree
- innervated by parasympathetic via vagus to constrict
- have beta-2 receptors for dilation
- responsive to inflammatory mediators (from mast cells) producing
-bronchial constriction and antigen-antibody reaction. |
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Term
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Definition
- inflammatory dz due to allergies
- episodic cases, airway inflammation is present when asymptomatic
- inflamatory proces sensitizes airways become hypersentistive to "triggers" which produce episodic periods of bronchospasm
- biochemical, autonomic, immunologic, infectious, endocrine, and psychologic factors. |
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Term
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Definition
-based on severity of symptoms
- degree of activity limitation
- nighttime awakenings
- use of beta agonists for symptom control pulmonary fxn test (PFTs)
- use of FEV1 or PEFR for home monitoring. |
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Term
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Definition
- mast cell ativation produces chemical mediators and infiltration of inflammatory cells such as eosinophils
- chemical mediators produce inflammation with airway swelling, airflow limitation and bronchospasm
- episodic bronchospasm can be triggered by antigens (more in the youth) or nonspeific "triggers" (adults), like cold air, emotional stress, etc.
- bronchoconstriction w/n minutes of exposure to trigger w/ resolution w/n short time
- second episode or late asthmatic response possible, espeically w/ antigenic trigger |
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Term
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Definition
- eliminate triggers and/or allergens
- reverse inflammation
- reverse bronchospasm
- anyone w/ more than a rare bronchospastic episode needs anti-inflammatory drug |
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Term
| Inhaled drug routes for asthma treatment |
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Definition
MDI small, handheld
Deliver measured dose 1 or 2 puffs
with 1 minute between puffs
Need hand breath coordination
Even with “good” technique only ~10% gets to lungs
Spacers help with getting drug to lungs and NOT in oropharynx
really important for inhaled glucocorticoids |
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Term
| Nebulizers for asthma treatment |
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Definition
Machine converts drug to a fine particle mist
Inhaled through mask or mouthpiece
Takes longer to administer but usually more effective for some patients
Mostly seen in hospital, but some portable devices for home-use available |
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Term
asthma
Reverse inflammation: Anti-inflammatory drugs |
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Definition
Glucocorticoids
Inhaled
Oral
Cromolyn and Nedocromil
Leukotriene modifiers |
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Term
asthma
Reverse inflammation: Glucocorticoids |
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Definition
Inhaled, PO or IV
Work by
suppressing inflammatory response and bronchial hyperreactivity
Decrease airway mucus production
Increase number of bronchial beta2 receptors and beta2 responsiveness
Most often used for prophylaxis
Dosing by fixed schedule
Inhaled
First line Rx
Daily dosing
Oral reserved for severe asthma
Concern with more systemic effects of glucocorticoids |
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Term
| glucocorticoids: adverse effects |
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Definition
Inhaled
Oropharyngeal candidiasis and dysphonia
Both of these concerns are minimized with oral care and spacer use.
Adrenal suppression and bone loss with long-term/high-dose Rx
Be careful switching from oral to inhaled (need supplemental po)
Slow growth in children/adolescents
Oral
Adrenal suppression, osteoporosis, hyperglycemia, gastric irritation and/or ulceration, Cushings syndrome |
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Term
| Anti-inflammatory drugs: Cromolyn & Nedocromil |
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Definition
First line chronic asthma prophylaxis (can also be used for allergic rhinitis)
Prevent exercise-induced bronchospasm
Suppresses inflammation by stabilizing cytoplasmic membrane of mast cells
Slow onset – prophylaxis only*
Not bronchodilator*
Inhaled administration
No systemic effects
Few adverse effects—cough, bronchospasm |
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Term
| Anti-inflammatory drugs: Leukotriene Modifiers: montelukast (Singulair), zafirlukast (Accolate |
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Definition
Suppress leukotrienes which promote bronchospasm
Decrease inflammation, reduce edema, reduce mucus production, reduce bronchoconstriction
Prophylaxis only - NOT used to abort acute attack
Liver metabolism
Watch liver S&S |
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Term
| Bronchodilators: Beta2 adrenergic agonists |
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Definition
Selective beta 2 receptor activation
Bronchodilation to relieve bronchospasm
Suppress histamine release
Increase ciliary motility*
Inhaled - short acting – “rescue inhalers”
PRN to prevent or relieve breakthrough symptoms
May be nebulized in acute severe attack
Inhaled - long acting or PO
Fixed schedule dosing
NOT USED FOR ACUTE ATTACKS |
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Term
| Beta2 adrenergic agonists: Adverse effects |
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Definition
Inhaled:
Tachycardia
Angina
Tremor
Oral:
Tremor (lower dose can help)
Some activation of beta1 (heart) angina, tachydysrhythmias
Increased risk of death associated with heavy Beta2 use |
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Term
| Bronchodilations: Methylxanthines |
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Definition
Theophylline - rarely used any more
relaxes bronchial smooth muscle
Given PO and rarely IV
Less effective than beta 2 agonists but with longer duration
Narrow therapeutic range—careful dosing
Therapeutic drug levels 10-20 mcg/ml
Hepatic metabolism – many drug interactions
Adverse reactions: nausea, vomiting, diarrhea, insomnia, restlessness, dysrhythmias, seizures
Stop drug, induce vomiting, activated charcoal, cathartic |
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Term
| Bronchochodilators: Anticholinergics |
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Definition
Ipratropium & tiotropium—muscarinc antagonists
Block muscarinic receptors for bronchodilation
Approved for bronchoconstriction associated with COPD but used off-label for asthma
Work best with exercise and allergen induced asthma
less effective than beta2 agonists
Additive effects with beta2 agonists
Ipratropium + albuterol = Combivent |
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Term
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Definition
Advair Diskus
Inhaled glucocorticoid and long-acting beta2 agonist
Maintenance of asthma in adults and children
Need to pay attention to dose of both meds
Not for an acute attack |
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Term
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Definition
Bronchospasm not reversed with usual measures >>> Work of breathing 5-10Xs normal
Severe air trapping >>> paradoxical pulse and pneumothorax
Silent chest (no audible air movement) and PaCO2 >70mm Hg
DEATH
pulse strength even changes from inspiration and expiratoin |
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Term
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Definition
Genetic cause
Allergen or irritating stimuli
Mast cells release inflammatory mediators produce constriction, edema, sputum
Eosinophils & neuropeptides casue late asthmatic response
Inflammatory mediators, neuropeptides, & immune responses lead to epithelial desquamation and chronic inflammation
V/Q mismatch and hypoxemia with hypocapnia early with later work of breathing increases, hypercapnia and sudden respiratory failure |
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Term
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Definition
Family history, allergic history
History of exposure
Management must include antiinflammatories and bronchodilators
Recurrent symptoms 4-8 hours later-must continue to monitor
Antiinflammatories MUST be used accurately & chronically
Arterial blood gases should be monitored,; oximetry alone is not sufficient |
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Term
| chronic bronchitis: manifestations |
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Definition
Decreased exercise tolerance
Wheezing
Shortness of breath
Usually a productive cough
Decreased FEV1 by spirometry
Copious sputum production
Frequent pulmonary infection
FVC and FEV1 more reduced
FRC and residual volume increased with obstruction and air trapping
Airway obstruction >>> decreased alveolar ventilation and increased PaCO2
Hypoxia >>> polycythemia and cyanosis
Hypoxia further leads to pulmonary HTN and cor pulmonale |
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Term
| Chronic Bronchitis: Eval and Rx |
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Definition
Diagnosis:
Chest x-ray, PFTs and ABGs
Rx: Prevention and when that fails…
Stop exposure to toxins
Bronchodilators
Expectorants
Chest PT
Nutritional counseling
Prophylactic antibiotics??
Steroids
Low flow O2 |
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Term
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Definition
Abnormal permanent enlargement of gas exchange airways (acini) accompanied by destruction of alveolar walls without obvious fibrosis
Obstruction from changes in lung tissues rather than mucus production and inflammation
Major mechanism of air flow limitation is lost of elastic recoil |
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Term
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Definition
1-2% of all cases linked to inherited deficiency of enzyme alpha1-antitrypsin
This enzyme is responsible for inhibition of proteolytic enzymes
Deficiency (therefore more proteolytic enzymes) suggested in occurrence of emphysema before age 40 and in non-smokers who develop the disease |
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Term
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Definition
Smoking increases accumulation of neutrophils within lung parenchyma
Neutrophils release proteolytic enzymes damaging respiratory bronchioles and alveolar wall
Smoking also produces dysfunction of endogenous protease inhibitors such as alpha1-antitrypsin |
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Term
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Definition
Destruction of alveolar septa >>> elimination of portions of pulmonary capillary bed >>> increased volume of air in acinus
Difficult expiration from loss of elastic recoil
Hyperinflated alveoli >>> large air spaces (bullae) and air spaces >>> decreased caliber of bronchioles
DOE(Dyspnea on Exertion) progressing to marked dyspnea at rest
No cough and little sputum production (unless combined with bronchitis)
Thin appearance with tachypnea
Prolonged expiration & use of accessory muscles—(which ones??)
Increased A:P diameter of chest
Hyperresonant sound with percussion
Leans forward supported by arms |
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Term
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Definition
Chest x-ray
Diaphragm flattened and lung fields translucent
Marked and persistent over distention of lungs
PFTs for prognosis
Decreases FVC and FEV1
Increase in FRC, RV, TLC
Disease course prolonged with increasing dyspnea and intermittent infection
Cor pulmonale |
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Term
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Definition
Bronchial mucosa and elastin damage causes expiratory airway obstruction from loss of airway elasticity &/or increased mucous production
Expiratory obstruction, air trapping, uneven ventilation cause decreased minute ventilation, V/Q mismatch
Chronic hypercapnia results in hypoxic ventilatory drive
Bronchoconstriction/
inflammation minor components to COPD |
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Term
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Definition
Patients present with dyspnea, prolonged expiration & wheezing
Hypercapnia and hypoxemia common in COPD
O2 therapy vital must be cautiously used.
Pharmocotherapy less effective—balance against side effects |
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Term
| Restrictive Lung Diseases |
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Definition
Trouble with inspiration
Can’t get enough air in
Result in stiff/noncompliant lungs
Occupational lung diseases
Some chemotherapy
Radiation
Gas and fume inhalation (ammonia, sulfur dioxide) |
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Term
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Definition
Excessive amount of fibrous or connective tissue in the lung
Causes a marked loss of lung compliance.
Lung becomes stiff and difficult to ventilate
Diffusing capacity of aveolocapillary membrane decreases causing hypoxemia
Causes include inhaling small particulate matter
Pneumoconiosis – coal miner’s lung
Silicosis – inhalation of silica dust – quarrying, road building, sand blasting, stone cutting
Asbestosis
Also caused by chronic inflammation
rheumatoid arthritis, lupus, sarcoidosis |
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Term
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Definition
Multisystem granulomatous disorder
Exaggerated cellular immune response
Typical pattern is:
Younger than 40 years
More common among African-Americans and whites in SE US
?? antigens cause T-cell activation in genetically predisposed
Frequently remits, leaving the person with scarred lungs that may or may not cause symptoms |
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Term
| Pathogenesis of restrictive disease |
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Definition
Alveolar injury
Inflammation
Inflammatory and immune cells damage lung
Result in fibrous scaring
Leading to dyspnea & tachypnea without wheezing or signs of obstruction
Easier to breathe shallowly and fast than deeper and more slowly |
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Term
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Definition
^ Pulmonary venous pressure
^ Pulmonary blood flow
Congenital
^ Pulmonary vascular resistance
Pulmonary vascular obstruction (PE), hypoxemia causing pulmonary vasoconstriction
Cor pulmonale = R heart failure due to Pulm HTN |
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Term
| ARDS—Acute Respiratory Distress Syndrome |
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Definition
Diffuse injury to alveolar capillary membrane
Primary problem: basement membrane injury
Direct causes
Pulmonary trauma, aspiration, drowning, pneumonia
Indirect causes
Multiple blood transfusions, septic shock, burns, CP bypass |
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Term
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Definition
Lungs fail to oxygenate blood and eliminate CO2
PO2 of < 50 mmHg and/or PCO2 of > 50 mmHg
Causes
Impaired ventilation
Impaired diffusion
Impaired matching |
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