Thoracic Cage Deformites, Obesity

Thoracic cage deformities

Respiratory impairment within thoracic cage deformities is due to a combination of factors

1. Elastic WOB is increased due to stiff thoracic cage

2. Diaphragm and other muscles of ventilation are at a

mechanical disadvantage from abnormal geometry

3. Lung volumes are reduced, and lung growth can be limited

in children

Manifests as: sleep disordered breathing (sleep hypoventilation) and progresses to daytime hypercapnia and pulmonary hypertension if untreated

Scoliosis

spine is curved to one side, typically appearing as an S or C
shape (lateral curvature)

Kyphosis

posterior curvature (convex) of spine occurring in the thoracic

and sacral regions (“humpback/hunchback”)

Kyphoscoliosis

Combination of both these thoracic deformities

• In severe cases, the deformity can compress the lungs &

restrict alveolar expansion → hypoventilation & atelectasis

• Impaired ability to cough & mobilize secretions

Kyphoscoliosis alteration

• Lung restriction/

compression

• Mucous accumulation

• Atelectasis

• Cor Pulmonale

CXR

Mediastinal shift in the same direction as the lateral curvature

increase density of compressed areas

kyphoscoliosis etiology

Affects 1 -2% of population - mostly young children

may present from birth due to congenital or

neuromuscular abnormalities including

Spina Bifida & Muscular

Dystrophy

• However, the majority (80 – 85%) of cases have no known cause

Risk factors Kyphoscoliosis

Gender – female more than male

Age – the younger the child is when first diagnosed, the greater the chance of curve progression

Angle of the curve – the greater the curvature of the spine, the greater the chance that the curve progression will worsen

Location – curves in the middle to lower spine are less likely to progress than those in the upper spine

Height – taller people have a greater chance of curve progression

Spinal problems at birth – children with congenital scoliosis have a greater risk for worsening of the curve

Kyphoscoliosis management

Braces

Surgery

Other Approaches

braces

during growth years to limit curve progression in

idiopathic deformities

Surgery

performed to correct severe deformity (> 40 – 50

degrees) and prevent further curvature

• Spinal fusion

• Rod instrumentation

Other approaches

• Electrical stimulation of muscles for strength

• Chest physio for secretions

• Broncho-dilators, antibiotics, anti-inflammatories as needed

• Adequate oxygenation as always

Ankylosing Spondylitis (AS)

• A systemic rheumatic disease that affects the spine and thoracic cage

• Chronic joint inflammation ultimately leads to fusion of the vertebral bodies and ribs

Typically leading to severe kyphosis and a dramatic decrease in thoracic cage compliance

in severe cases of AS, complete fusion and ridgity of the spine can occur .. what is the percentage of patients develop parenchymal lung disease

10% form PLD at apical fibrocystic changes that can decrease gas exchange and

provide location for chronic infection (especially fungal)

Clinical findings of AS

Extraparenchymal Restriction → decrease chest expansion & VC

Treatment AS

• Ant-inflammatory

• Analgesics

• Exercise programs in early stages to promote range of motion

Pectus Excavatum

• Congenital chest wall deformity, producing a concave or caved-in appearance in the anterior chest wall

• Most common type of congenital chest wall abnormality

• occurs in estimated 1 in 300-400 births (M:F 3:1)

Pectus Carinatum

• spectrum of protrusion abnormalities of the anterior chest wall (Pigeon Chest)

• moderate to severe cases to the chest wall is rigid held outward position

  • respirations are inefficient and need to use accessory muscles for respirations rather than normal chest muscles during strenuous exercise Respirations

Obesity

progressive chronic disease that is characterized by abnormal or excessive fat accumulation that may impair health

Overweight is classified as BMI over___ and over __ is obese

25, 30

BMI

ratio of weight to height (kg/m²)

• normal weight (BMIs 18.5 to 24.9)

• overweight (BMIs 25 to 29.9)

• obese (BMI 30 and over)

• Class I (30.0 – 34.9)

• Class II (35.0 – 39.9)

• Class III (≥ 40.0)

waist circumference

provides an indicator of abdominal fat.

• WC at or above 102 cm (40 in.) for men, and 88 cm (35 in.) for women, is

associated with an increased risk of developing health problems

Subcutaneous fat

• Located in the fatty tissue just beneath the skin

• Behaves like the fat elsewhere in the body

Visceral fat

• Located around the internal organs

• Cells release free fatty acids into the liver, heart, and other organs

• local immune responses in visceral adipose tissue →

chronic systemic inflammation

health-related conditions

Type 2 diabetes

HTN

Cardiovascular disease

Undernutrition

Dyslipidemia

Osteoporosis

Hypertension

Infertility

OSA

Gallbladder disease

Certain cancers ( prostate.breast, colon, endometrial)

Determinants of Obesity

Social determinants: socioeconomic status/poverty.

For adults, education is a strong determinant; for children, household income plays a major role.

Age of Onset

increase size and number of adipose cells in obese children

Genetics

2 – 8 x higher for a person with a family history as opposed to a person with no family history of obesity

Endocrine Disorders – (e.g., hypothyroidism, polycystic ovarian syndrome, Cushing's syndrome )

Respiratory patho

Asthma

Obesity has been identified as a major risk factor for the

development of asthma

tends to not response well for treatment particularly controller medication

One possible explanation is that obesity causes chronic inflammation throughout the body, including the lungs.

• Adipose tissue secretes a large number of proinflammatory cytokines and factors modulating immune function

Obesity hypoventilation Syndrome (OHS)

a combination of obesity, a body mass index greater than

or equal to 30kg/m² with awake chronic hypercapnia (PaCO₂ >45mm Hg) & sleep-disordered breathing

Chronic daytime alveolar hypoventilation

arises from a complex interaction between sleep-disordered breathing, decrease respiratory drive, and obesity-related respiratory impairment (decrease ERV & compliance)

Central chemosensitivity is lost, impairing their ventilatory response to hypoxemia and hypercapnia

is associated with significant morbidity and mortality

~ 90% of patients with OHS also have OSA

Clinical manifestation

Dyspnea

• Cyanosis

• ­­­­increase HR

• HTN (Pulmonary & Systemic)

• Pitting pedal edema (Cor Pulmonale)

• Peripheral vascular disease (emboli/stroke)

• increase surgical risk and postoperative complications

Lab findings with Class 3 obesity

• PFT: Extra parenchymal Restriction

• ABG: Chronic hypoventilation and hypoxia

• Lipid panel: Hyperlipidemia, high triglycerides

• Blood Work: ^Hct, ^ Hgb, (secondary polycythemia---

chronic Decrease O2)

• increase lipoproteins

• CXR: Wide chest wall, elevated diaphragm, enlarged heart

Treatment - Behavioural and psychological interventions

• Cognitive Behavioural Therapy (CBT)

• Medical Nutrition Therapy

• Physical Activity

pharmacological treatments

regulating appetite, metabolism, cravings

surgical interventions

• Gastric Bypass – reduces stomach size and reroutes digestion

• Sleeve Gastrectomy – removes a portion of the stomach, limiting food intake and

affecting hunger hormones

• Duodenal switch – alters digestion to limit calorie absorption (more extensive

procedure)

Respiratory management

• Bronchodilators and steroids as needed

• Oxygen as needed

• CPAP or BiPAP as needed for OSA