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Expiratory flow limitation_diseases

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  • 1. (;3,5$725< )/2: /,0,7$,21 ',6($6( SKVLRSDWKRORJ 8EDLGXU 5DKDPDQ 6HQLRU 5HVLGHQW &&0 6*3*,06 /XFNQRZ ,QGLD
  • 2. COPD is a disease of resistance during expiration but with the consequence of restriction during inspiration. Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 3. Pressure Volume relationship of respiratory system Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 4. P-V curve of Lung, Chest wall and Respiratory system Chest wall Lung TLC Vital capacity % 100 Chest wall and Lung ( respiratory system) 75 50 25 FRC RV 0 -20 0 20 Pressure ( cm H2O) Ppl, Pcw, Prs Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 5. Resting Volume of Respiratory system Elastic force of LUNG = Elastic force of CHEST WALL At End Expiration Functional Residual Capacity (FRC) Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 6. Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 7. LUNG VOLUMES 5.0 IRV IC 3.0 VC TV TLC 2.5 ERV 1.25 FRC RV 0 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 8. Pressure, Volume and Flow relationship of Respiratory system Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 9. Relationship between intrathoracic pressures TPP = PA – Ppl PA = Ppl + Pel TPP = (Ppl + Pel) – (Ppl) = Pel TPP = Transpulmonary Pressure PA = Alveolar Pressure Ppl = Pleural Pressure Pel = lung elastic recoil pressure Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 10. Relationship between intrathoracic pressures TAP = Paw – Ppl TAP Paw TPP TAP = Transairway Pressure Paw = airway pressure Ppl = Pleural Pressure Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 11. End expiration 0 TPP = PA – Ppl -5 PA = 0 -5 Ppl = -5 TPP = 0 – (-5) = +5 0 -5 -5 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 12. Beginning of inspiration 0 TPP = PA – Ppl Ppl = -7 -7 -7 +5 = PA – (-7) PA = +5 – 7 = -2 -2 -7 -7 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 13. Mid inspiration 0 -7 -7 -1 -7 -7 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 14. End inspiration 0 TPP = PA – Ppl Ppl = -7 -7 -7 TPP = 0 – (-7) TPP= +7 0 -7 -7 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 15. Beginning of passive expiration 0 TPP = PA – Ppl Ppl = -5 -5 -5 +7 = PA– (-5) PA = +2 +2 -5 -5 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 16. Mid expiration 0 TPP = PA – Ppl PA = +1 -5 -5 TPP = +1– (-5) PA = +6 +1 -5 -5 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 17. End expiration 0 TPP = PA – Ppl PA = 0 -5 -5 TPP = 0– (-5) TPP = +5 0 -5 -5 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 18. In healthy lung during normal tidal respiration Throughout the respiratory cycle TPP and TAP remains positive keeping the alveoli and airways patent Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 19. Beginning of forced expiration 0 +2 +4 TPP = PA – Ppl +6 +8 +10 +10 +10 Ppl = +10 +13 +7 = PA– (+10)) +15 PA = +17 +17 +10 +10 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 20. forced expiration 0 +2 +4 +6 TAP = Paw – Pp +8 +10 +10 TAP = (+10) – ( +10) = 0 +10 +13 Equal Pressure Point ( EPP) +15 Dynamic airway Collapse ( DAC) +17 +10 +10 Expiratory Flow Limitation Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 21. Equal Pressure Point ( EPP) Point in airway where TAP is zero during expiration Dynamic Airway Collapse Point in airway distal to EPP, TAP becomes negative, causing airway to collapse No amount of effort will increase the expiratory flow Expiratory Flow limitation Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 22. Counter balance of Dynamic Airway Collapse First 11 generation of airway ( bronchi) supported by cartilage ring/ plates 12th generation and beyond ( bronchioles) supported by tethering effect of elastic recoil of surrounding lung parenchyma Patency of airways is a function of cartilagenous support in bronchi Lung volume in bronchioles Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 23. Equal Pressure Point Dynamic point As airway resistance increases or Lung volume decreases Moves closer to Alveoli Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 24. FORCED EXPIRATION 0 0 +2 +4 +2 +6 +10 +8 +10 +10 +4 +10 +6 +10 +13 +10 +15 +12 +17 +10 +10 Beginning of forced expiration +10 +10 Mid forced expiration Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 25. Expiratory Flow Limitation can be a manifestation of Airway disease COPD, Asthma Destruction of cartilage of airway Lung parenchyma disease leading to reduced lung volume collapse, lung destruction, pneumonectomy Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 26. IN HEALTHY LUNG During quiet breathing There is no dynamic airway collapse No expiratory flow limitation During forced expiration Small degree of dynamic airway collapse can occur (Upto 40% reduction in cross sectional area of airway) Because of invagination of posterior membrane of tracheo bronchial tree Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 27. Dynamic airway collapse during Coughing Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 28. Flow and Time Relationship Of Respiratory system Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 29. Concept of Closing Volume & Closing Capacity Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 30. Effect of gravity + weight of lung Vertical gradient in Ppl and TTP Dependent alveoli have lesser volume than non dependent alveoli Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 31. PLEURAL PRESSURE AND TPP GRADIENT (At FRC) BODY POSITION TOP OF LUNG BOTTOM OF LUNG Ppl TPP Ppl TPP UPRIGHT -8 8 -2 2 SUPINE -4 4 0 0 PRONE -3.5 3.5 0 0 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 32. P- V curve of Respiratory system at different Lung volumes VERTICAL GRANIDIENT FRC Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 33. P- V curve of Respiratory system at different Lung volumes VERTICAL GRANIDIENT TLC RV Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 34. IN HEALTHY LUNG During forced expiration Dynamic airway collapse occurs starting from dependent lung regions Critical volume of lung during expiration to prevent dynamic airway collapse CLOSING CAPACITY Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 35. CLOSING CAPACITY 5.0 TLC In healthy lung 44 years CC= FRC in supine position 3.0 2.5 1.25 CC 66 years CC = FRC in upright position FRC CC RV Smoking, ageing, obesity, supine position Increases CC 0 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 36. Effect of PEEP on CLOSING CAPACITY 5.0 TLC PEEP 3.0 CC 2.5 FRC 1.25 RV 0 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 37. TIME CONSTANT length of time required to fill or empty lung units Function of Alveoli = compliance Airway= resistance TC = C R 1 TC = 63% of lung unit fill/ empty 3 TC = 95% “ “ “ 5 TC = 99% “ “ “ Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 38. normal TC ↓ Decreased compliance TC ↑ Increased resistance Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 39. Obstructive Airway Disease Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 40. Increased Airway Resistance dynamic airway collapse Expiratory Flow Limitation Air Trapping Increased End Expiratory Lung Volume ( EELV) DYNAMIC HYPERINFLATION (DHI) Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 41. v FRC T DHI is probably an adaptive response to overcome DAC Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 42. Initially DHI Increases elastic recoil of lung ---- opens airway---- improves expiratory flow But Comes At price Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 43. P-V CURVE OF RESPIRATORY SYSTEM Healthy lung- tidal ventilation V TLC IRV IC TV FRC ERV RV P Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 44. P-V CURVE OF RESPIRATORY SYSTEM Healthy lung - exercise V TLC IRV IC TV FRV ERV RV P Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 45. P-V CURVE OF RESPIRATORY SYSTEM Chronic obstructive airway disease- tidal breathing V TLC IRV IC TV EELV RV P Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 46. P-V CURVE OF RESPIRATORY SYSTEM Chronic obstructive airway disease- exacerbation V TLC IRV IC EELV EELV RV P Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 47. EFFECT ON GAS EXCHANGE Increased EELV More Zone I and II formation Increased dead space V/Q mismatch Increased minute ventilation requirement Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 48. EFFECT ON DYNAMIC MECHANICS Displacement of respiratory system towards upper flatter portion of P-V curve P- Altered geometry of the chest wall Flattened and lowered diaphragm, more horizontal rib cage Respiratory muscles operating at higher lung volumes Increased elastic loading of inspiratory muscles at end expiration Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 49. EFFECT ON DYNAMIC MECHANICS Before starting inspiratory flow must overcome this increased elastic load Effort required to generate tidal volume is more than the muscle can generate at that lung volume Expiratory muscles axis of contraction is altered paradoxical indrawing of lower ribs– hoover sign ribs– •Decreased ventilatory capacity •Functional muscle weakness and fatigue •Increased WOB Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 50. EFFECT ON HEMODYNAMICS Increased EELV Increased ventilatory drive Increased TPP More negative pleural pressure ↓ preload and ↑ afterload of RV ↑ RV preload in face of ↑ RV afterload Series ventriclular interdependence Parallel ventricular interdependence ↓ LV stroke volume LV filing compromised Hypotension LV dysfunction and failure Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 51. EFFECT ON PATIENT Increased ventilatory drive Increased WOB anxiety Neuromechanical discoupling VQ mismatch Worsening hemodynamics Neural drive= Increased RR = decreased expiratory time Expiratory flow limitation = need for increased expiratory time dyspnoea Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 52. forced expiration ( obstructive airway disease) 0 0 +3 +4 +4 +2 +4 +4 +4 +5 +2 +4 +5 +6 +4 +6 +4 +4 +4 Pursed lip breathing PEEP Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 53. MANAGEMENT GOAL Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 54. CORRECTION OF GAS EXCHANGE REDUCTION OF WOB CORRECTION OF LUNG MECHANICS TREATMENT OF BASELINE DISEASE Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 55. CORRECTION OF LUNG MECHANICS Prevention of DHI Reduce airway resistance Treatment of disease PPV PEEP •Easy Inspiratory flow •Prevention of DAC PPV Adequate expiratory time Neuro muscular recoupling sedation,anti anxiety Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 56. Positive Pressure Ventilation Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 57. PEEP For easy inspiration +7 o -11 +10 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India -4 +10
  • 58. Beginning of inspiration 0 TPP = PA – Ppl Ppl = -7 -7 -7 +5 = PA – (-7) PA = +5 – 7 = -2 +10 -7 -7 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 59. PEEP For easy expiration +3 +4 +4 +4 +5 +6 +4 +4 PEEP Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 60. Setting total cycle time Flow rise cycling Calculation of expiratory time Calculation of TCT Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  • 61. the difficulty lies, not in new ideas, but escaping old ones, which ramify, for those brought up with them, as most of us have been, into every corner of our minds. - John Maynard Keynes Thank you Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India

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