2. OBSTRUCTIVE PULMONARY
DISORDERS
ā¢ Manifested by increased resistance to airflow
ā¢ Classifications
ā¢ Obstruction from conditions in the wall of the lumen
ā¢ Obstruction resulting from increasing pressure around the
outside of the airway lumen
ā¢ Obstruction of the airway lumen
3. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
Asthma
ā¢ Etiology
ā¢ Airway obstruction that is reversible (not completely in
some patients)
ā¢ Airway inflammation
ā¢ Increased airway responsiveness to a variety of stimuli
4. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Statistics
ā¢ Occurs in 5% to 12% of U.S. population
ā¢ Most common chronic disease of children
ā¢ High-risk populations
ā¢ African Americans
ā¢ Inner-city dwellers
ā¢ Premature/low-birth-weight children
5. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Predisposing factors
ā¢ Genetic for atopy and structural (smaller airways)
ā¢ Chromosomes 5, 11, 14
ā¢ History of hay fever, eczema
ā¢ Family history
ā¢ Positive skin test reactions to allergens
6. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Extrinsic (allergic)
ā¢ 1/3 to Ā½ of asthma cases
ā¢ An IgE-mediated response is common
ā¢ Clinical manifestations
ā¢ Elevated IgE levels
ā¢ Allergic rhinitis
ā¢ Eczema
ā¢ Positive family history of allergy
ā¢ Attacks associated with seasonal, environmental or
occupational exposure
7. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Extrinsic
ā¢ Mechanism of action
ā¢ Immediate phase
ā¢ Initiated by exposure to specific antigen that has previously
sensitized mast cells in airway mucosa
ā¢ Antigen reacts with antibody on surface of mast cell
ā¢ Mast cell releases packets of chemical mediator substances
8. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Extrinsic
ā¢ Mechanism of action
ā¢ Chemical mediators released
ā¢ Histamine
ā¢ Slow-reacting substances of anaphylaxis (leukotrienes)
ā¢ Prostaglandins
ā¢ Bradykinins
ā¢ Eosinophilic chemotactic factor
ā¢ Serotonin
10. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Extrinsic
ā¢ Mechanism of action
ā¢ Normal respiratory epithelium is denuded and replaced by
goblet cells
ā¢ Alterations in epithelial integrity
11. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Extrinsic
ā¢ Mechanism of action
ā¢ Increased microvascular permeability
ā¢ Mucosal edema
ā¢ Inflammatory exudates
ā¢ Bronchoconstriction
ā¢ Leakage
12. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Extrinsic
ā¢ Mechanism of action
ā¢ Late phase
ā¢ Arrival of recruited leukocytes signals initiation
ā¢ More mediator release causes damage to epithelium
13. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Extrinsic
ā¢ Mechanism of action
ā¢ Epithelial damage
ā¢ Hypertrophied smooth muscle
ā¢ Edema
ā¢ Mucous gland hypertrophy
ā¢ Mucus in lumen
14. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Inflammation of airway
ā¢ Causes
ā¢ Acute bronchospasm (bronchoconstriction)
ā¢ Mucosal edema
ā¢ Mucous plug formation
ā¢ Airway wall remodeling
16. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Pathogenesis
ā¢ Immunohistopathologic features
ā¢ Denudation of airway epithelium
ā¢ Collagen deposition beneath the basement membrane
ā¢ Edema
ā¢ Mast cell activation
ā¢ Inflammatory cell infiltration by neutrophils, eosinophils, and
lymphocytes
17. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Common symptoms
ā¢ Wheezing
ā¢ Feeling of tightness of chest
ā¢ Dyspnea
ā¢ Cough (dry or productive)
ā¢ Increased sputum production (thick, tenacious, scant, and
viscid
18. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Symptoms of severe attack
ā¢ Use of accessory muscles of respiration
ā¢ Intercostal retractions
ā¢ Distant breath sounds with inspiratory wheezing
ā¢ Orthopnea
ā¢ Agitation
ā¢ Tachypnea
ā¢ Tachycardia
19. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Diagnosis
ā¢ Physical findings
ā¢ Cough
ā¢ Wheezing
ā¢ Hyperinflated chest
ā¢ Decreased breath sounds
20. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Diagnosis
ā¢ Radiographic finding
ā¢ Hyperinflation with flattening of the diaphragm
ā¢ Sputum examination
ā¢ Charcot-Leyden crystals (formed from crystallized enzymes
from eosinophilic membranes)
ā¢ Eosinophils
ā¢ Curschmann spirals (mucous casts of bronchioles)
21. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Diagnosis
ā¢ Pulmonary function tests
ā¢ Forced expiratory volumes decrease
ā¢ Peak expiratory flow rate (PEFR)
ā¢ Determines index of airway function
ā¢ FEV1 measured over 1 second
ā¢ FVC
ā¢ Ratio of FEV1/FVC before and after administration of short-acting
bronchodilator
ā¢ Obstruction indicated by FEV1/FVC <75%
23. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Diagnosis
ā¢ ABG
ā¢ Normal during mild attack
ā¢ Respiratory alkalosis and hypoxemia as bronchospasm
increases in intensity
ā¢ PaCO2 elevation
24. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Diagnosis
ā¢ Skin testing
ā¢ Young patients with extrinsic asthma
ā¢ Bronchial provocation testing
ā¢ Test with histamine or methacholine
ā¢ CBC
ā¢ Elevated WBCs
ā¢ Elevated eosinophils
25. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Asthma
ā¢ Treatment
ā¢ Avoid triggers
ā¢ Environmental control
ā¢ Removal of allergens
ā¢ Air purifiers
ā¢ Air conditioners
ā¢ Preventive therapy
ā¢ Desensitization (allergen specific immunotherapy)
29. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Acute Bronchitis
ā¢ Etiology
ā¢ Acute inflammation of the trachea and bronchi
ā¢ Causes
ā¢ Viral
ā¢ Influenza virus A or B
ā¢ Parainfluenza virus
ā¢ Respiratory syncytial virus
ā¢ Coronavirus
ā¢ Rhinovirus
ā¢ Coxsackievirus
ā¢ Adenovirus
30. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Acute Bronchitis
ā¢ Etiology
ā¢ Causes
ā¢ Nonviral
ā¢ Streptococcus pneumoniae
ā¢ Haemophilus influenzae
ā¢ Mycoplasma
ā¢ Moraxella
ā¢ Chlamydia pneumoniae
31. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Acute Bronchitis
ā¢ Etiology
ā¢ Causes
ā¢ Heat
ā¢ Smoke inhalation
ā¢ Inhalation of irritant chemicals
ā¢ Allergic reactions
32. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Acute Bronchitis
ā¢ Pathogenesis
ā¢ Airways become inflamed and narrowed from capillary
dilation
ā¢ Swelling from exudation of fluid
ā¢ Infiltration with inflammatory cells increased mucus
production
ā¢ Loss of ciliary function
ā¢ Loss of portions of the ciliated epithelium
33. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Acute Bronchitis
ā¢ Clinical manifestations
ā¢ Cough (productive or nonproductive)
ā¢ Low-grade fever
ā¢ Substernal chest discomfort
ā¢ Sore throat
ā¢ Postnasal drip
ā¢ Fatigue
34. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Acute Bronchitis
ā¢ Diagnosis
ā¢ Clinical presentation
ā¢ Chest x-ray to distinguish acute bronchitis from
pneumonia
35. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Acute Bronchitis
ā¢ Treatment
ā¢ Antibiotic therapy (bacterial)
ā¢ Codeine-containing medications (for cough)
ā¢ Increase fluid intake
ā¢ Avoid smoke
ā¢ Use a vaporizer in bedroom
36. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Etiology
ā¢ Type B COPD, āblue bloaterā
ā¢ Chronic or recurrent productive cough >3 months >2+
successive years
ā¢ Persistent, irreversible
ā¢ Typical patient is overweight (1:2 male to female ratio)
ā¢ >30-40 years
ā¢ Commonly associated with emphysema
37. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Cause
ā¢ Cigarette smoking (90%)
ā¢ Repeated airway infections
ā¢ Genetic predisposition
ā¢ Inhalation of physical or chemical irritants
38. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Pathogenesis
ā¢ Chronic inflammation and swelling of the bronchial
mucosa resulting in scarring
ā¢ Elevated IL8 levels recruit neutrophil activation
ā¢ Elevated CD8 T-lymphocytes
ā¢ Extend into surrounding alveoli
ā¢ Prevent proper oxygenation and potentiate airway
obstruction
39. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Pathogenesis
ā¢ Hyperplasia of bronchial mucous gland/goblet cells
ā¢ Increased mucus production
ā¢ Mucus combines with purulent exudate (bronchial plugs) to
form mucous plug
41. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Pathogenesis
ā¢ Increased bronchial wall thickness
ā¢ Resistance increases work of breathing
ā¢ Increased O2 demands
ā¢ Produce ventilation-perfusion mismatch with hypoxemia and
hypercarbia
ā¢ Increases pulmonary artery resistance
43. OBSTRUCTION FROM CONDITIONS
IN THE WALL OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Pathogenesis
ā¢ Pulmonary hypertension
ā¢ Inflammation in bronchial walls with vasoconstriction of
pulmonary blood vessels and pulmonary arteries
ā¢ Right-sided heart failure may occur r/t high pulmonary
resistance
44. OBSTRUCTION CONDITIONS IN
THE WALL FROM OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Clinical manifestations
ā¢ SOB on exertion
ā¢ Excessive sputum
ā¢ Chronic cough (more severe in mornings)
ā¢ Evidence of excess body fluids (edema, hypervolemia)
ā¢ Cyanosis (late sign)
46. OBSTRUCTION CONDITIONS IN
THE WALL FROM OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Diagnosis
ā¢ Chest x-ray
ā¢ Increased bronchial vascular markings
ā¢ Congested lung fields
ā¢ Enlarged horizontal cardiac silhouette
ā¢ Evidence of previous pulmonary infection
47. OBSTRUCTION CONDITIONS IN
THE WALL FROM OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Diagnosis
ā¢ Pulmonary function tests
ā¢ Normal total lung capacity (TLC)
ā¢ Increased residual volume (RV)
ā¢ Decreased FEV1
48. OBSTRUCTION CONDITIONS IN
THE WALL FROM OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Diagnosis
ā¢ Arterial blood gas (ABG)
ā¢ Elevated PaCO2
ā¢ Decreased PO2
ā¢ Develop early in disease process
49. OBSTRUCTION CONDITIONS IN
THE WALL FROM OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Diagnosis
ā¢ ECG
ā¢ Atrial arrhythmias
ā¢ Evidence of right ventricular hypertrophy
ā¢ Secondary polycythemia
ā¢ R/t continuous or nocturnal hypoxemia
50. OBSTRUCTION CONDITIONS IN
THE WALL FROM OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Treatment
ā¢ Medications
ā¢ Inhaled short-acting B2 agonists
ā¢ Inhaled anticholinergic bronchodilators
ā¢ Cough suppressants
ā¢ Antimicrobial agents (bacterial infections)
ā¢ Inhaled/oral corticosteroids
ā¢ Theophylline products
51. OBSTRUCTION CONDITIONS IN
THE WALL FROM OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Treatment
ā¢ Low-dose O2 therapy
ā¢ Patients with PaO2 levels <55 mm Hg
52. OBSTRUCTION CONDITIONS IN
THE WALL FROM OF THE LUMEN
(CONT.)
Chronic Bronchitis
ā¢ Management
ā¢ Smoking cessation
ā¢ Bronchodilator therapy
ā¢ Reduction to exposure of irritants
ā¢ Adequate rest
ā¢ Proper hydration
ā¢ Physical reconditioning
ā¢ Treadmill/stationary bike
ā¢ Alternating rest and exercise
53. OBSTRUCTION RELATED TO LOSS
OF LUNG PARENCHYMA
Emphysema
ā¢ Etiology
ā¢ Type A COPD
ā¢ āPink pufferā
ā¢ Young to middle-age adults <50 years (uncommon)
ā¢ Hereditary low Ī±1-antitrypsin activity in lung
ā¢ >50 years (develops over time)
55. OBSTRUCTION RELATED TO LOSS
OF LUNG PARENCHYMA (CONT.)
Emphysema
ā¢ Etiology
ā¢ Causes
ā¢ Smoking >70 pack/year
ā¢ Air pollution
ā¢ Certain occupations (mining, welding, working with or near
asbestos)
ā¢ Ī±1-Antitrypsin deficiency
56. OBSTRUCTION RELATED TO LOSS
OF LUNG PARENCHYMA (CONT.)
Emphysema
ā¢ Etiology
ā¢ Smoking causes alveolar damage
ā¢ Inflammation in lung tissue leading to release of proteolytic
enzymes
ā¢ Inactivates Ī±1-antitrypsin (protects lung parenchyma)
58. OBSTRUCTION RELATED TO LOSS
OF LUNG PARENCHYMA (CONT.)
Emphysema
ā¢ Pathogenesis
ā¢ Release of proteolytic enzymes from inflammatory cells
(neutrophils, macrophages) leading to alveolar damage
ā¢ Reduction in pulmonary capillary bed
ā¢ Exchange of O2 and CO2 between alveolar and capillary
blood impaired
60. OBSTRUCTION RELATED TO LOSS
OF LUNG PARENCHYMA (CONT.)
Emphysema
ā¢ Pathogenesis
ā¢ Loss of elastic tissue in lung
ā¢ Results in decrease in size of smaller bronchioles
ā¢ Results in loss of radial traction (holds airway open)
64. OBSTRUCTION RELATED TO LOSS
OF LUNG PARENCHYMA (CONT.)
Emphysema
ā¢ Clinical manifestations
ā¢ Progressive, exertional dyspnea
ā¢ Increased SOB for past 3-4 years
ā¢ Thin
ā¢ R/t increased caloric expenditure and decreased ability to
consume adequate calories
ā¢ Use of accessory muscles
ā¢ Pursed-lip breathing
ā¢ Cough (minimal or absent)
66. OBSTRUCTION RELATED TO LOSS
OF LUNG PARENCHYMA (CONT.)
Emphysema
ā¢ Diagnosis
ā¢ Patient history and physical finding
ā¢ Thin, wasted individual hunched forward
ā¢ Barrel chest
ā¢ Digital clubbing
ā¢ Decreased breath sounds, lack of crackles and rhonchi with
prolonged expiration
ā¢ Decreased heart sounds
ā¢ Decreased diaphragmatic excursion
67. OBSTRUCTION RELATED TO LOSS
OF LUNG PARENCHYMA (CONT.)
Emphysema
ā¢ Diagnosis
ā¢ Pulmonary function tests (PFTs)
ā¢ Increased functional residual capacity
ā¢ Increased RV
ā¢ Increased TLC
ā¢ Decreased FEV
ā¢ Decreased FVC
68. OBSTRUCTION RELATED TO LOSS
OF LUNG PARENCHYMA (CONT.)
Emphysema
ā¢ Diagnosis
ā¢ Chest x-ray
ā¢ Hyperventilation
ā¢ Low, flat diaphragm
ā¢ Presence of blebs or bullae
ā¢ Narrow mediastinum
ā¢ Normal or small āverticalā heart
69. OBSTRUCTION RELATED TO LOSS
OF LUNG PARENCHYMA (CONT.)
Emphysema
ā¢ Diagnosis
ā¢ ABG
ā¢ Mild increase in PaO2
ā¢ Normal PaCO2 (elevated in late stages)
ā¢ ECG
ā¢ Normal, show tall P waves
ā¢ Sinus tachycardia
ā¢ Supraventricular arrhythmias
ā¢ Ventricular irregularities
70. OBSTRUCTION RELATED TO LOSS
OF LUNG PARENCHYMA (CONT.)
Emphysema
ā¢ Treatment
ā¢ O2 therapy
ā¢ Medications
ā¢ Inhaled short-acting B2 agonists
ā¢ Inhaled anticholinergic bronchodilators
ā¢ Cough suppressants
ā¢ Antimicrobial agents (infections)
ā¢ Inhaled/oral corticosteroids
ā¢ Theophylline products
71. OBSTRUCTION OF AIRWAY LUMEN
Bronchiectasis
ā¢ Etiology
ā¢ Dilation of bronchial wall
ā¢ Obstructive and suppurative (pus-forming) disorder
ā¢ Increased risk in children
ā¢ Acquired
ā¢ Rare
ā¢ Congenital
ā¢ 50% associated with cystic fibrosis
72. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Bronchiectasis
ā¢ Classifications
ā¢ According to bronchial shape
ā¢ Saccular
ā¢ Cavity-like dilatations
ā¢ Cylindrical
ā¢ Fusiform
ā¢ Combination of saccular and cylindrical
74. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Bronchiectasis
ā¢ Pathogenesis
ā¢ Recurrent infection and infection of bronchial walls leads
to persistent dilation
ā¢ Inflammation results in destruction of walls
ā¢ Destructive process leads to loss of ciliated epithelium
ā¢ Transforms to squamous cell and pus formation
ā¢ Leads to obstruction
83. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Bronchiolitis
ā¢ Widespread inflammation of bronchioles due to
infectious agents
ā¢ Occasionally related to allergic reactions
ā¢ Occurs winter to spring
ā¢ Children <2 years
ā¢ Adults
ā¢ Smoking, toxic fumes, immunosuppression
84. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Bronchiolitis
ā¢ Common organisms
ā¢ Viral
ā¢ RSV, influenzavirus (A, B, C)
ā¢ Bacterial
ā¢ H. influenzae, pneumococci, hemolytic streptococci,
mycoplasma, chlamydia, Pneumocystis jiroveci
85. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Bronchiolitis
ā¢ Pathogenesis
ā¢ Proliferation and necrosis of bronchiolar epithelium
ā¢ Production of thick, tenacious mucus
ā¢ Airway obstruction
ā¢ Atelectasis
ā¢ Hyperinflation
86. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Bronchiolitis
ā¢ Pathogenesis
ā¢ Possible mechanisms of airway obstruction
ā¢ Development of inflammatory exudate
ā¢ Release of chemical mediators
ā¢ Inflammation
ā¢ Goblet cell metaplasia
ā¢ Increased bronchial muscle mass
87. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Bronchiolitis
ā¢ Clinical manifestations
ā¢ Severity and course range from mild-fatal
ā¢ Wheezing r/t bronchospasm
ā¢ Crackles
ā¢ Decreased breath sounds
ā¢ Retractions
ā¢ Increased sputum
ā¢ Dyspnea
ā¢ Tachypnea
ā¢ Low-grade fever
88. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Bronchiolitis
ā¢ Diagnosis
ā¢ Elevated WBC
ā¢ Chest x-ray
ā¢ Enlarged air sacs, interstitial infiltrates, atelectasis, severe
hyperinflation
ā¢ PFT
ā¢ Severe obstruction to airflow
ā¢ Nasal swab
90. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Cystic Fibrosis
ā¢ Etiology
ā¢ Autosomal recessive disorder of exocrine glands
ā¢ Dysfunction of CFTR gene (60%-75% of patients)
ā¢ 1:2000-3000 Caucasian births
ā¢ >18 years (35%)
ā¢ Affects pancreas, intestinal tract, sweat glands, lungs,
infertility (male)
ā¢ Classified as Airflow or suppurative (pus-forming)
91. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Cystic Fibrosis
ā¢ Clinical manifestations
ā¢ History of cough in young adult or child
ā¢ Thick, tenacious sputum
ā¢ Recurrent pulmonary infections
ā¢ Recurrent episodes of bronchitis
92. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Cystic Fibrosis
ā¢ Clinical manifestations
ā¢ Physical findings
ā¢ Digital clubbing (late)
ā¢ Dyspnea, tachypnea
ā¢ Sternal retractions
ā¢ Unequal breath sounds
ā¢ Moist basilar crackles and rhonchi
ā¢ Barrel chest hyperresonant to percussion
93. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Cystic Fibrosis
ā¢ Clinical manifestations
ā¢ Nutritional assessment
ā¢ Depleted fat stores
ā¢ Steatorrhea (fatty stools)
ā¢ Anorexia
ā¢ Decreased growth rate in children (wt, ht, head circ)
ā¢ Decreased mid-arm indices
96. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Cystic Fibrosis
ā¢ Treatment
ā¢ Postural drainage and chest physiotherapy (priority)
ā¢ Medications
ā¢ Bronchodilators
ā¢ High dose antibiotics (bacterial infections)
ā¢ Influenza vaccine
ā¢ Heart-lung or lung transplant
97. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Cystic Fibrosis
ā¢ Treatment
ā¢ Nutritional therapy
ā¢ Unrestricted fat consumption
ā¢ 30% of caloric intake
ā¢ High protein
ā¢ Vitamin supplements
ā¢ Pancreatic enzymes
ā¢ Intake of 150% normal caloric intake
98. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Acute Tracheobronchial Obstruction
ā¢ Etiology
ā¢ Causes
ā¢ Aspiration of foreign body (most often in left lung)
ā¢ Malpositioned endotracheal tube
ā¢ Laryngospasm
ā¢ Epiglottitis
ā¢ Trauma
ā¢ Swelling (smoke inhalation)
ā¢ Postsurgical blood clot
ā¢ Compression of bronchus/trache (tumor, enlarged lymph
nodes
99. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Acute Tracheobronchial Obstruction
ā¢ Clinical manifestations
ā¢ Partial obstruction
ā¢ Stridor
ā¢ Sternal and intercostal retractions
ā¢ Wheezing
ā¢ Nasal flaring
ā¢ Tachypnea, dyspnea
ā¢ Tachycardia
ā¢ Use of accessory muscles
100. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Acute Tracheobronchial Obstruction
ā¢ Clinical manifestations
ā¢ Complete obstruction
ā¢ No air movement heard with auscultation (complete
obstruction)
ā¢ Inability to talk
ā¢ Tachycardia
ā¢ Cyanosis
ā¢ Rapid progression to unconsciousness
101. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Acute Tracheobronchial Obstruction
ā¢ Diagnosis
ā¢ Based on clinical features
ā¢ ABG
ā¢ Hypoxemia, hypercarbia
ā¢ Chest x-ray
ā¢ Location of obstruction
102. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Acute Tracheobronchial Obstruction
ā¢ Treatment
ā¢ Open obstructed airway as soon as possible
ā¢ Heimlich to expel foreign body
ā¢ Suction
ā¢ Emergency tracheostomy (obstruction in subglottic region
or above)
103. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Epiglottitis
ā¢ Etiology
ā¢ Rapidly, progressive cellulitis of epiglottis and adjacent
soft tissues
ā¢ Subtype of croup
ā¢ Children 2 to 4 years
ā¢ Common organisms
ā¢ Pneumococci, streptococci, staphylococci
104. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Epiglottitis
ā¢ Pathogenesis
ā¢ Infecting agent localizes in epiglottis and pharyngeal
structures
ā¢ Causes rapid and potentially fatal inflammation
ā¢ Swelling
ā¢ Airway obstruction
105. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Epiglottitis
ā¢ Clinical manifestations
ā¢ Drooling
ā¢ Dysphagia, dysphonia
ā¢ Rapid onset of fever
ā¢ Inspiratory stridor and retractions
ā¢ Oropharynx edematous and cherry red
ā¢ Child sits in āsniffing dogā position
ā¢ Provides best airway patency
106. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Epiglottitis
ā¢ Diagnosis
ā¢ Direct or fiberoptic visualization of epiglottis
ā¢ Lateral neck x-ray
ā¢ Classic āthumbprint signā
ā¢ CBC
ā¢ Leukocytosis with shift to left
107. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Epiglottitis
ā¢ Treatment
ā¢ True medical emergency
ā¢ May necessitate intubation
ā¢ Antibiotic therapy
ā¢ Preventative
ā¢ Hib vaccine
108. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Croup Syndrome
ā¢ Etiology
ā¢ A number of acute, viral inflammatory diseases of larynx,
trachea, and bronchi
ā¢ Laryngotracheobronchitis (viral croup)
ā¢ Epiglottitis
ā¢ Bacterial tracheitis
ā¢ Occurs in fall and early winter
ā¢ Children 6 months to 3 years
109. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Croup Syndrome
ā¢ Etiology
ā¢ Causes
ā¢ Parainfluenza virus type 2 and 3
ā¢ RSV
ā¢ Influenzavirus
ā¢ Adenovirus
ā¢ Mycoplasma pneumoniae
110. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Croup Syndrome
ā¢ Pathogenesis
ā¢ Viral agent of subglottic area
ā¢ Infectious agent causes inflammation along entire airway
ā¢ Leads to edema in subglottic area
111. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Croup Syndrome
ā¢ Clinical manifestations
ā¢ History of upper respiratory infection or cold
ā¢ Barking cough with stridor
ā¢ Low-grade fever (may be absent)
ā¢ Severe cases
ā¢ Stridor at rest
ā¢ Retractions
ā¢ Cyanosis
112. OBSTRUCTION OF AIRWAY LUMEN
(CONT.)
Croup Syndrome
ā¢ Diagnosis
ā¢ Clinical signs and symptoms
ā¢ Lateral neck films
ā¢ Subglottic narrowing and normal epiglottis
ā¢ Laryngoscopy
ā¢ Confirm presence or rule out epiglottitis
114. DIAGNOSTIC TESTS
Pulmonary Function Testing (PFT)
ā¢ Demonstrates obstruction of airflow in lungs
ā¢ Spirometry
ā¢ Determines severity and diagnosis of COPD
ā¢ Patient inhales deeply and exhales as quickly as possible
until maximal air is exhaled
115. DIAGNOSTIC TESTS (CONT.)
Pulmonary Function Testing (PFT)
ā¢ Spirometry
ā¢ Forced vital capacity
ā¢ Total volume of air exhaled
ā¢ Time required for exhaling the air is also measured
ā¢ Forced expiratory volume in 1 second
ā¢ Volume exhaled in 1st second is reliable and index of
obstructive airway disease
117. DIAGNOSTIC TESTS (CONT.)
Pulmonary Function Testing (PFT)
ā¢ Spirometry
ā¢ Airflow obstruction
ā¢ FEV1/FVC ratio >75%
ā¢ No significant obstruction
ā¢ FEV1/FVC ratio between 60% and 70%
ā¢ Mild obstruction
ā¢ FEV1/FVC ratio 50% to 60%
ā¢ Moderate obstruction
ā¢ FEV1/FVC ratio <50%
ā¢ Severe obstruction
120. DIAGNOSTIC TESTS (CONT.)
Spirometry
ā¢ Diffusion capacity
ā¢ Measures ability of alveolar gases to diffuse into capillary
blood
ā¢ Valuable for determining fibrosis or destruction of
membrane
121. DIAGNOSTIC TESTS (CONT.)
Spirometry
ā¢ Total lung capacity
ā¢ Normal RV/TLC 30% to 35%
ā¢ Breathing mixtures of inert gas (helium)
ā¢ Volume composed of FVC and RV (residual volume
ā¢ Volume voluntarily exhaled all of the air from lungs
ā¢ ABG
ā¢ Assesses oxygenation and acid-base status
123. DIAGNOSTIC TESTS (CONT.)
Spirometry
ā¢ Diagnosis of obstructive disorder
ā¢ Decreased FEV1
ā¢ Low FEV1/FVC ratio (<70%)
ā¢ Improvement in FEV1 after use of bronchodilator
(asthma)
ā¢ Increased residual volume
ā¢ Increased functional residual capacity
124. DIAGNOSTIC TESTS (CONT.)
Bronchial Provocation Tests
ā¢ Induction of bronchospasm by inhalation of
various agents
ā¢ Series of ventilations administered
ā¢ Identify hyper-reactive airways and identify source of
bronchospasm
ā¢ Done only with emergency support services
ā¢ Hyperactivity = fall >20%