Case Management Pulmonary Consideration Objectives

1-9 objective 1

The Right lung has how many lobes

3

How many lobes does the L lung have

2

The diaphragm is known as the ___ to the liver

roof

The kidneys are between which spinal segments

t12-l3; posterior to the liver and stomach

Muscles of inspiration

Diaphragm, externam intercostals, scalenes, pectorals

Muscles of expiration

abdominals, internal intercostals

Inspiration/expiration is passive

expiration

The AP motion of the chest wall is called what?

Pump handle- rise and fall of sternum and rib cage

The frontal plane motion of chest wall is what

Bucket handle- lateral rib cage moves more lateral and rises superiorly

What happens when the pulmonary system ages

Increased stiffness or chest wall and costovertebral joints

Reduced elastic recoil which raises residual volume

Decreased ciliary function and ability to protect airway

Decreased strength and flattening of diaphragm reduces vital capacity, changes in alveoli and capillaries cause reduced diffusion of oxygen and CO2

COPD effects on lung volume/capacity

Expired air is trapped and increased residual vollume

Advanced COPD effects on lung volume/capacity

Increased residual volume, hyperinflation due to increased IRV

Restrictive lung disease lung volume and capacity effects

all volumes decreased

FVC and FEV1 are expressed as what

% of predicted normal value for gender, age, height

How does a patient’s FVC get tested

patient performs a maximal inspiration followed by a maximal expiratory effort

Normal FVC

80-120% expected value

RLD has increased/decreased FVC

decreased

Why does RLD have a decreased FVC

Decreased lung compliance (flexibility), increased work of breathing, decreased ventilatory muscle strength

With RLD, the entire ___ is smaller

TLC

COPD has increased or decreased FVC and why

decreased due to air trapping

What is FEV1

Forced Expiratory Volume in the amount expired in the 1st second of forced exhalation

Normal FEV1

80-120%

RLD and COPD FEV1 values are increased or decreased

both decreased

What is the FVC/FEV1 ratio

The ratio of the amount in one second over the total amount forcefully expired

Normal FEV1/FVC ratio

0.8 or 80%

RLD FEV1/FVC ratio

normal or increased due to decreased vital capacity

COPD FEV1/FVC ratio

Decreased due to air trapping and increased work of breathing

Optimal V:Q ratio

0.8

What is the V:Q ratio and what does it measure

Ratio/balance of activity on both sides of alveolar capillary junction (gas exchange to transport in blood)

V:Q > 0.8 means what

inadequate perfusion

What diagnosis are associated with inadequate perfusion

Pulmonary embolism, pulmonary artery hypertension

V:Q < 0.8 means what

Inadequate ventilation

Diagnosis that indicate inadequate ventilation

Atelectasis

Consolidation

Bronchoconstriction

Mucous plugs (chronic bronchitis)

Alveolar Destruction

What is atelectasis

Airlessness; incomplete expansion of airways/alveoli which results in collapse of airways/alveoli

Causes of atelectasis

Pleural effusion, pneumothorax, pulmonary embolus, bronchoconstriction, mucous plugs, diaphragm paralysis, and other neurological respiratory muscle weakness.

Auscultation of Atelectasis

Absent or diminished breath sounds with crackles

Expected tactile fremitus and percussion with atelectasis

Decreased tactile fremitus; dull percussion

Trachea deviation with atelectatsis

ipsilateral side

What is consolidation

Exudate (secretions) fluid that leaks out of tissue typically due to inflammatory process; they collect in proximal airways and can fill up and solidify alveoli that would otherwise be aerated

Causes of consolidation

Pneumonia, aspiration of fluid, food, upper respiratory secretions, inhalation of noxious chemicals

Auscultation expected with consolidation

Bronchial breath sounds, crackles; transmitted voice sounds increased

Tactile fremitus and percussion expected with consolidation

increased tactile fremitus and dull percussion

What are the 5 obstructive pulmonary diseases

Chronic bronchitis

Emphysema

Asthma

Bronchiectasis

Cystic Fibrosis

Clinical definition chronic bronchitis

Persistent, productive cough on most days of a 3 month period for 2 or more years

What happens to the secretory cells with chronic bronchitis

Hypertrophy and results in increased secretions and mucous plugs causing crackles

Color of sputum for chronic bronchitis

Clear to white

How does chronic bronchitis typically presetnt

like cor pulmonale; overweight, cyanotic, edematous

COPD is the ___ ___

blue bloater

What does COPD show on radiograph

Radiopaque infiltrates

Auscultation of chronic bronchitis

Normal breath sounds but crackles and wheezes

Tactile fremitus and percussion sounds with chronic bronchitis

Decreased tactile fremitus, more reasonant percussion sounds from air trapping

Treatment for Chronic bronchitis

bronchodialator, inhaled corticosteroids, supplemental O2, pulmonary rehab

What is emphysema

Irreversible destruction of airways distal to bronchiole causing air trapping and lung hyperinflation

Emphysema PFTs

Increased residual volume

Emphysema is aka the ___ ___

pink puffer

T/F emphysema has increased lung compliance which causes parenchyma to expand to fill increased AP diameter of thoracic cage

true

Emphysema on a radiograph

Hyperinflated lungs and flattened diaphragm

Tactile fremitus and percussion with emphysema

decreased tactile fremitus; more reasonant percussion

Auscultation with emphysema

Decreased or diminished/distant; possible expiratory wheeze or crackles

S/S of emphysema

Hypoxemia, hypercapnia, increased non-productive cough

Emphysema treatment

Bronchodilator, inhaled corticosteroids, supplemental O2, pulmonary rehab, bullectomy, lung volume reduction surgery, lung transplant

Asthma definition

Reversible and episodic manner that causes e and traps air which produces wheezing and tachypnea

What muscles are obvious with asthma

accessory muscle use and intercostal retractions

What is status asthmaticus

no air can be inhaled or exhaled and can cause respiratory failure requiring ventilation; medical emergency

Exercise induced asthma can manifest how long after a submaximal exercise session is terminated

6-8

Triggers for asthma

NSAIDS, beta-blockers, ACE inhibitors, dry cold air, air pollution, mold, food, animal dander

Diagnosing asthma

an increased in FEV1 of 15% or more with a bronchodialating machine

Why would a asthma patient have increased overall airway resistence and noisier breath sounds?

Due to irritation and rawness from previous episodes

Auscultation during asthma episode

Decreased/diminished/distance; bilateral high pitched expiratory wheeze with possible inspiratory wheeze

Treatment of asthma

Avoid triggers, short acting rescue bronchodilator, inhaled corticosteroid, leukotriene modifier, chromone, long acting bronchodilator, aerobic conditioning, relaxing techniques, dyspnea positions

What is cystic fibrosis

Hereditary disease of several systems involving secretory glands causing excessive very thick lung secretions that often become septic

CF signs/symptoms

Sputum, cough, dyspnea, accessory muscle use, cyanosis, susceptible to infection

Later stafe CF signs

Hemoptysis, digital clubbing, hemoxemia and hypercapnia, cor pulmonale secondary to pulmonary hypertension

Mean survival of CF patients

37 years

Auscultation of cf patients

expiratory wheeze

Treatment for CF patients

Airway clearance,, exercise, postural education

Bronchiectasis definition

permanent dilation of a local segment of bronchus that collects or traps secretions which often become septic and purulent

Why does bronchiectasis occur

Manifests later in life due to childhood episodes of severe pneumonia, measles, pertussis, adenovirus infection, CF, RA, lupus, emphysema

Auscultation with bronchiectasis

Normal breath sounds with localized crackles

Treatment of bronchiectasis

Antibiotics if acute, inhaled corticosteroids, mucolytics, pulmonary rehab, surgical resection