Wk 7: Obstructive Pulmonary Disorders

Anatomy of the Respiratory System

• Obtain oxygen from the atmospheric air.

• Transports air throughout respiratory track → alveoli (air sacs)\, where gas exchange takes place) → diffuses oxygen into blood → carries oxygen to all cells

• Ventilation: O2 process, inspiration (inhaling) and expiration (exhaling)

• inspiration: o2 → alveoli → o2 → co2

• expiration: o2 expelled from body

• respiration (used w ventilation): cellular level exchange of o2 and co2

Major Muscles of Respiration

• Diaphragm: major muscle of breathing, controlled by phrenic nerve, located in neck (C3-C5), needs ventilatory support if neck injured, C1 injury: fatal

• Intercostals

• Abdominals

• Trapezius

• Sternocleidomastoid

• all muscles used if pt has trouble breathing, using accessory muscle = respiratory distress

Posterior Auscultation

• Take a deep breathe

• Auscultate lung fields (anterior, lateral, posterior, upper/lower lobes)

• Lower lobe: fluid is stagnate (crackles if fluid present)

• Short acting Beta 2 agonist (SABA) and bronchodilator

• pt who is in acute distress (breathing, ↓ RR, ↑ O2%)

• Albuterol (Proventil): dilate constricted bronchi, relaxes muscle/airway to make air flow easier to lungs, ↓ constriction

• S/S: tachycardia, tremors, anxiety

• Desaturation: pt is wheezing, <95% O2

• Bronchi: 2 main air passages where air flows through trachea

• Bronchioles: deliver air to alveoli

Normal Gravitational Effects

• Left lower lobe pneumonia

• Healthy lung down better perfusion

• Fluid goes where gravity goes

• pt laying= posterior lung recieves perfusion / anterior lung does ventilation

Bacterial Pneumonia

• Excess fluid in lungs, inflammation in interstitial spaces, alveoli, bronchi

• Caused by bacteria, viruses, fungus

• Noninfectious causes: inhalation, aspiration, vomitus

• Extreme fatigue

• Weakness

• Wheezing, Shortness of breath

• Coughing caused by bronchi fluid and receptors of trachea

• Sputum production, yellow, blood tinged (inflammatory)

• Fever (WBCs fighting the pathogens, hypothalamus is responsible for temperature control, >10000= infectious)

Pneumonia (Additional Symptoms)

• Hypoxemia (LACK OF OXYGENATION IN THE BLOOD)

• Dyspnea (DIFFICULTY BREATHING)

• Apnea (no breathing at all)

• Tachypnea

• Orthopnea (difficulty sleeping flat → needs elevation)

Treatment for Bacteria Pneumonia

• Broad spectrum Antibiotic

• Levofloxacin (Levaquin 750 mg x 5 days)

• QVar (Beclomethasone Dipropionate) 2 puffs Twice a day, Once every 12 hours

• ↓ inflammation, cough

• usage of both suppress immune system

• rinse mouth after use to reduce overgrowth of candida albicans (white patches on tongue)

Asthma

• More the 26 million people affected across all age groups in the United States (Allergy and Asthma Foundation of America, 2024)

• Approximately 8% adults & 6.5% children affected in the United States (Allergy and Asthma Foundation of America, 2024)

• Airflow resistance, long-term, acute attack, causes periods of airway obstruction from bronchospasms

• Bronchospasms: tightening of muscles surrouding airways, mucus/secretion/edeme involved

Pathophysiology & Symptoms of Asthma

• Bronchoconstriction: tighting of muscles surrounding airway

• Inflammation: irritation of airway

• Both cause narrowing of airways leading to →

• Sputum Production

• Wheezing

• Chest tightness

• Coughing

• ↑ Mast cells trigger as well

Asthma Triggers

• Pollen (trees, grass)

• Dust mites

• Mold

• Pet dander

• Exercise-induced asthma (take SABA albuterol)

• Allergies (shellfish, nuts)

• Drugs (penicillin)

Clinical Manifestations and Goals

Clinical Manifestations During an Attack

• Bronchoconstriction

• Release of mast cells (fight pathogens) mucus secretion, mucosal edema
• WBCs release → mast cells activate → release chemical mediators → complicate inflammatory process → ↑ bronchoconstriction, blood flow, fluid

• Ineffective airway clearance, mucus secretion, mucosal edema

• airway swelling, dyspnea, hypercapnia (CO2 retention), ↑ work of breathing, hypoxemia (↓ O2 saturation)

Goals

• Identify and minimize exposure to allergens

• Medication adherence (Inhaled corticosteroids, bronchodilators)

• Monitor lung function with with peak flow meters

Parasympathetic system

• Mat cell responds to allergens

• Body responds chemical mediators (histamines, cytokines)

• Stimulates parasympathetic system (resting and digesting)

• Stimulatation cause bronchoconstriction, decreased oxygenation to the pt

Oxygen Delivery Devices

• Non-rebreather Mask:

• pt exhales through side ports

• can experience CO2 toxcity, • used for additional/high level of O2 (1005)

• has hypoxemia or respiratory distress

• Simple mask: 10 liters (60% O2), needed for pt of bronchospasms/bronchoconstriction, gas exchange is impaired

• Venturi Mask

• high flow O2 therapy, provides expiratory flow (FIO2)

• Nasal cannula: if pt is not in acute distress, 1-6 liters, >6 lead to muscosal irritation → nose bleed)

Drug Therapy

Anticholinergics - Ipratropium (Atrovent)

• used for COPD, block cholinergic receptors

• prevents binding of substances of constriction/secretion, ↓ both

• clears up secretions, dilate vessels, clears airway

Leukotriene receptor antagonists - Montelukast (Singular)

• inhibits action/release of leukotriene

• ↓ bronchoconstriction, inflammation

Beta2 Agonists - Albuterol (Proventil)

Methylxanthines - Theophylline (Elixophyllin)

• smooth muscle relaxation, dilate constricted bronchioles

Corticosteroids -Fluticasone (Flovent), Prednisone (Deltasone)

• prevent inflammation, blocks release of mast cells

Mast Cell stabilizers - Cromolyn (Intal)

• stabilize membrane of mast cells

• prevents the release of inflammatory substances

Chronic Obstructive Pulmonary Disease (COPD)

• Inflammation and airway obstruction Emphysema and chronic bronchitis coexist together

• Flare-ups, sputum production, coughing, wheezing

• Lung infection

• decreased elasticity (ability for lung to return to normal position after exhale)

• narrowing of airways, destruction of aveoli

• no cure but treatable with drugs and lifestyle changes

Chronic Bronchitis

• Years of smoking → inflammation

• Goblet cells multiple → produce thick mucus

• Damages cilia, bacteria enters lung tissue

• Causes: smoking, infection, environmental pollutants, inhalation chemical irritants

Blue Bloater Characteristics

• Chronic Hypoxemia leads to cyanosis

• Chronic Hypercapnia (High carbon dioxide levels in the blood)

• Overweight or bloated appearance due to fluid retention

• Cough with sputum Production

Clinical Manifestations Chronic Bronchitis

• Bronchial edema: excess secretions

• Airway obstruction: air trapping

• Production cough: 3 months

• Recurring ep: 2 consecutive years

• Causes mucosal lining to increase/thicken, tightening of airway

Chronic cough

dyspnea

Bronchospasm

Frequent infections

Immediate Therapy

Beta 2 agonist - Bronchodilator

Metaproterenol (Alupent) - SABA

• for pt w/ exacerbation

• given w/ anticholinergic

• relaxes bronchiole smooth muscle

• relieving bronchospam

• administer x4 a day, inhale x2

• Anticholinergic - Bronchodilator

• Ipratropium Bromide (Atrovent)

• blocks cholinergic receptor, block acetylcholine, inhibits vagus nerve → bronchiole smooth muscle relax → allow bronchi to dilate → improves gas exchange

• blocks signal of goblet cells → ↓ in mucus production

Additional Therapy

• Methylxanthine bronchodilator

• Theophylline (Elixophyllin)

• Only for continued therapy after pt is stabilized (not for emergencies)

• Relax smooth muscles through affects certain enzymes (phosphodiesterase (PDE) enzymes)

• PDE break down substances AMP and GMP → smooth muscle constrict

• Inhibits PDE → relax bronchiole, smooth muscle, bronchodilation

• Smoker needs higher levels of drug, loading dose

• Long acting beta 2 agonist (LABA)

• Never used in an acute attack/emergency

• Takes 30 mins to work, for maintenence

• SABA decrease chances of acute attack

• Salmeterol (Serevent)

Emphysema

• Destruction of Alpha 1 Anti-trysin if pt is young (inherited genetic disorder)

• Smoking → inflammation of lung tissue → initiates release of proteolytic enzymes → damage alveoli tissue

• inactivate alpha 1 antitrysin

• Air pollution

• Welding

• Mining

Clinical Manifestations

• Refer to as pink puffer

• Pursed lip breathing

(effort to get air out of lungs)

continued + pressure → prevents alveoli collapsing

• Barrel chest (ribcage extends outward b/c excess air)

• Accessory muscle use

• Thin looking due to poor nutrition (anorexic)

• Cough may or may not be present

Emphysema

• Destruction of Alpha 1 Anti-trysin (protects lungs from injury)

• Destruction of the alveoli

• Leads to airway instability

• Emphysema and Chronic Bronchitis have the following in common

• Airway Obstruction

• Airway Trapping (lung lose elastic recall ability)

• Dyspnea

• Frequent infections

Treating Emphysema

Bronchodilators -Albuterol (Proventil) & Ipratropium Bromide (Atrovent)

• clear mucus out of lungs, prevent bronchospasm

Mucolytics -Acetylcysteine (Mucomyst)

• decrease thickness of secretion

Antibiotics

• treat respiratory tract infections

Oxygen - Low concentration

• giving too much O2 reduces stimulus to breathe (stop breathing)

• decrease CO2

• Pt w/ COPD are less sensitive to high CO2 levels, reduces CO2 levels from their lungs

Corticosteroids

• decrease inflammation

Pulmonary Rehabilitation (helps with dyspnea, covered by insurance)

• Education

• General exercise training

• Breathing, retraining

• Outcome Assessment

• Nutritional advice

• Psychological support

Chemical mediators (histamines, cytokines)

↑ capillary permeability (inside capillary moves out to the tissue → mucosal edema) → affects ability to breathe

Chronic bronchitis and emphysema

• obstructed airway

• airway trapping

• difficulty in breathing

• persistent infections