Clinical Symposium Portfolio

anatomical structures affected by asthma

small and large airways

physiology affected by asthma

• transfer of air in/out of lungs

• effective gas exchange

structural abnormalities associated with asthma

• reversible airflow obstruction

• bronchospasm

physiological abnormalities associated with asthma

• inflammatory disorder of airways

• reduced rate of airflow to and from alveoli→ limits effectiveness of lungs

• greatest reduction in airflow occurs in expiration→ pressure in chest compresses rather than expands airway

• dynamic hyperinflation:

  • air from previous breath remains in lungs when next breath started→ increased volume of air in lungs

prior events causing asthma

• exposure to allergens e.g. pollen, hay, house dust

• exposure to irritants e.g. smoke, pollution

• exercise/cold

• prior eczema/hay fever

• family history of asthma

symptoms of asthma

• wheezing

• coughing

• chest tightness

• shortness of breath

clinical signs of asthma

• wheeze heard with stethoscope on chest

• use of accessory muscles of respiration

• paradoxical pulse→ weaker on inhalation, stronger on exhalation

• over inflation of chest

test results found in asthma

• reduced FEV₁ → reversible

• CXR→ hyper expansion of chest

medical/surgical interventions for asthma

• inhaled short-acting β-2 agonist e.g. salbutamol

• inhaled corticosteroid e.g. beclomethasone

• long acting β-2 agonist e.g. salmeterol

• oral prednisolone (corticosteroid)

• biologics

secondary prevention of asthma

• avoiding triggers

• leukotriene antagonists

anatomical structures affected by COPD

• small and large airways

• alveoli

physiology affected by COPD

• transfer of air in and out of lungs

• efficient gas exchange

structural abnormalities associated with COPD

• narrowing of airways

• enlargement of air spaces distal to terminal bronchioles with destruction of walls→ emphysema

• expansion of chest

physiological abnormalities associated with COPD

• reduced rate of air flow to and from alveoli

• limits effectiveness of lungs

• greatest reduction in air flow when exhaling→ pressure in chest compresses rather than expands airway

• dynamic hyperinflation

prior events that cause COPD

• smoking

• repeated chest infections

• family history

• exposure to dust in workplace

• air pollution

symptoms of COPD

• Dyspnoea (breathlessness)

• wheeze

• clear/coloured phlegm

• breath sounds decreased

• prolonged expiration

clinical signs of COPD

• tachypnoea

• hyper-inflated chest

• wheeze

• breath sounds decreased

• prolonged expiration

test results seen in COPD

• chest x-ray→ hyperinflated lungs

• reduced FEV₁→ not fully reversible

• hypoxia

• hypercapnoea

medical/surgical intervention

• antibiotics for episodes of infective bronchitis

• beta-2-receptor agonists bronchodilator therapy

• anticholinergic bronchodilator therapy

• long acting beta-2 agonists e.g. salmeterol

• inhaled steroids e.g. budesonide

• oral steroid anti inflammation therapy (for bad episodes of wheezing)

• oxygen therapy

secondary prevention of COPD

• not smoking

• oxygen supplement

• not vaping

anatomical structures affected in lung cancer

• all lung tissues

  • particularly bronchi

physiology affected in lung cancer

• transfer of air in and out of lungs

• efficient gas exchange

• protection against infection

structural abnormalities associated with lung cancer

• blockage of bronchi due to intra-luminal growth or extra-luminal compression

• accumulation of pleural fluid compressing lung

physiological abnormalities associated with lung cancer

• limits effectiveness of lungs

• wide range of para-neoplastic (besides cancer) syndromes e.g.:

  • lambert-eaton myasthenic syndrome

  • hypercalcaemia

  • syndrome of inappropriate ADH

  • tumours in apex of lung→ Pancoast tumours:

    • can invade sympathetic nervous system and cause muscle weakness

prior events causing lung cancer

• smoking

• asbestos exposure

symptoms associated with lung cancer

• dyspnoea

• haemoptysis

• chronic coughing

• wheezing

• chest pain

• weight loss

clinical signs of lung cancer

• cachexia (weight loss)

• dysphonia (hoarse voice)

• clubbing of fingernails

• dysphagia (difficulty swallowing)

test results confirming lung cancer

• chest x-ray→ shadow or lung collapse

• CT scan may show a mass, lymphadenopathy, metastasis

• bronchoscopy

• PET showing metabolic activity

• endobronchial ultrasound- lymph node tissue

• biopsy

medical/surgical intervention

• lobectomy, pneumonectomy

• chemotherapy

• radiotherapy

primary and secondary intervention

• cancer has often spread beyond the original site by the time symptoms

• screening to pick up early disease

• common sites of metastasis include brain, bone, liver, pericardium, kidneys

anatomical structures affected by bronchiectasis

small and large airways

physiology affected by bronchiectasis

• transfer of air in and out of lungs

• protection of lungs from infection

• efficient gas exchange

structural abnormalities associated with bronchiectasis

• bronchi dilated, inflamed and easily collapsible→ airflow obstruction and impaired clearance of secretions

• obstructive lung disease

prior events resulting in bronchiectasis

• usually result of prior infection:

  • bacterial pneumonia

  • measles

• immunodeficiencies

• other acquired causes e.g. TB, connective tissue diseases, allergic bronchopulmonary aspergillosis, foreign body aspiration

• other congenital causes→ ciliary dyskinesia, alpha-1-antitrypsin deficiency

symptoms experienced in bronchiectasis

• dyspnoea

• halitosis (bad breath)

• chronic sputum production→ often yellow/green

• repeated chest infections

clinical signs of bronchiectasis

• coarse crepitations heard with stethoscope

• hypoxaemia

• hypercapnia

abnormal test results seen in bronchiectasis

• high-res CT scan findings show dilated airways with ring shadows

• ‘signet ring sign’ on CT

• obstructive pattern on spirometry

• abnormal blood gas→ low oxygen high CO₂

medical/surgical interventions for bronchiectasis

• controlling infections and bronchial secretions

• relieving airway obstructions

• prompt antibiotic therapy for pulmonary exacerbations

• nebulised antibiotics e.g. colomycin

• maintain body weight with nutritional support

• small number of cases→ physiotherapy such as postural drainage

primary and secondary prevention of bronchiectasis

• children should be immunised against measles, pertussis and respiratory infections

• adult vaccination especially against pneumonia and influenza

• avoiding smoking

anatomical structures affected by cystic fibrosis

• airway epithelial cells that line respiratory tract

• multi-system disorder e.g. lungs, sweat glands, pancreas and bowel

physiology affected by cystic fibrosis

• transfer of air in and out of lungs

• efficient gas exchange

• protection of lungs from infection

structural abnormalities associated with cystic fibrosis

• males usually infertile due to congenital absence of vans deferens

• dysregulation of hydration of sweat, digestion, airways and mucus

• development of bronchiectasis

• loss of islets of langerhans cells→ caused cystic fibrosis related diabetes

physiological abnormalities associated with cystic fibrosis

• ciliated airway epithelial cells in the patient have a mutated protein

  • leads to airway dehydration and abnormally viscous mucus production

• affects entire body

• progressive disability and early death

prior events causing cystic fibrosis

• family history

• symptoms often appear in infancy

symptoms experienced in cystic fibrosis

• coughing, sputum, pyrexia

• shortness of breath

• chronic lung infection

• repeated chest exacerbations

• abnormal bowel motions

clinical signs of cystic fibrosis

• salty skin

• poor growth

• poor weight gain

• poor absorption of nutrients through GIT including fat soluble vitamins

• haemoptysis

• finger clubbing/cyanosis

abnormal test results associated with cystic fibrosis

• before/at birth through genetic screening

• sweat test in early childhood

• obstructive lung function

• sputum cultures positive for staphylococcus, haemophilus and pseudomonas aeruginosa

• abnormal pancreatic function

• azoospermia

• hypoxia

medical/surgical intervention

• specialist multidisciplinary centres

• physiotherapy/nutrition

• treat chronic and acute infections

• CFTR modulators

• lung transplantation

primary and secondary intervention for cystic fibrosis

• antenatal genetic counselling of parents

• partial cure for 90% of patients

• proactive treatment of airway infection

• encouragement of good nutrition and an active lifesyle

anatomical structures affected by pneumonia

• parenchyma of the lung

• bronchial tree often involved

physiology affected by pneumonia

• alveoli

physiological abnormalities associated with pneumonia

• inflammatory condition of the lung

  • includes inflammation of alveoli and bronchi

• most commonly bacterial bronchopneumonia

• chemical and physical injury to the lungs

• alveoli fills with fluid→ stops oxygen from reaching blood

prior events leading to pneumonia

• vomiting when semi-conscious and with unprotected airway can lead to aspirational pneumonia

• viral flu

symptoms experiences in pneumonia

• productive cough

• fever/rigors/chills

• unilateral chest pain aggravated by breathing→ ‘sharp stabbing’

• difficulty breathing

• headache/confusion

clinical signs of pneumonia

• high temperature

• green/brown sputum

• tachypnoea

• tachycardia

• hypotension

• hypoxia

• bronchial breathing and crackles heard with a stethescope

abnormal test results associated with pneumonia

• chest x-ray showing consolidation

• blood/sputum culture

• atypical pneumonias

medical/ surgical intervention associated with pneumonia

• oxygen

• fluids→ intravenous if low blood pressure

• bacterial pneumonia treated with antibiotics

• assisted ventilation required in severe cases

primary and secondary intervention associated with pneumonia

• leading cause of death among the young, old and chronically ill

• vaccination available for pneumococcal pneumonia and flu

anatomical structures affected by pneumothorax

• ‘anatomical space’ between lungs and chest wall (pleural cavity)

• boundaries are visceral and parietal pleura

normal physiology of pleura

• contains thin film of serous fluid to allow lubrication of lung against chest wall

• contains vacuum to assist process of inspiration/lung expansion

structural abnormalities associated with pneumonia

• collection of air/gas in pleural cavity of chest between lung and chest wall

• causes collapse of lung

physiological abnormalities associated with pneumothorax

• impaired mechanics of ventilation

• reduction of blood oxygen if severe

prior events leading to pneumothorax

• primary→ without prior known lung disease

• secondary→ COPD, physical trauma to chest

experienced symptoms of a pneumothorax

• determined by size of air leak and speed by which it occurs

• chest pain on same side as pneumothorax in most cases

• shortness of breath

clinical signs associated with pneumothorax

• deviated trachea

• stethoscope reduced sounds

• hypoxia

• tension pneumothorax:

  • hypotension

  • progressing to cardiac arrest

abnormal test results seen in pneumothorax

• chest x-ray shows air between lungs and chest wall at apex

• CT scan in milder forms

medical/surgical intervention for pneumothorax

• small and spontaneous→ often resolve themselves

• larger/more symptoms:

  • aspirated with syringe

  • chest drain

primary and secondary prevention of pneumothorax

• pleurodesis (sticking lung to chest wall) used if there is significant risk

• avoid significant changes in atmospheric pressure e.g. aeroplanes

anatomical structures affected by type-1 respiratory failure

• upper airway, trachea, bronchial tree, alveoli, pleural space, chest wall, diaphragm

• brain and central respiratory control

normal reference values of blood gases

• PaO₂→ 10.0-13.3 kPa

• PaCO₂→ 4.7-6.0 kPa

structural abnormalities associated with type 1 respiratory failure

• any significant obstruction of upper airway/trachea/bronchial tree/alveoli

• fluid, blood or air in pleural space

• weakness/damage to chest wall/diaphragm

• damage to brain and central respiratory control by trauma or sedation by drugs

physiological abnormalities associated with type-1 respiratory failure

• absence of hypercapnia

• inadequate gas exchange by respiratory system

• arterial oxygen levels cannot be maintained within normal range

• hypoxaemia

prior events leading to type 1 respiratory failure

• ventilation/perfusion mismatch

  • volume of air flowing in and out of lungs not matched with flow of blood to the lungs

  • e.g. pulmonary embolus

  • pneumonia

symptoms experienced in type 1 respiratory failure

• dyspnoea

clinical signs of type 1 respiratory failure

• hypoxia

• tachypnoea

abnormal test results observed in type 1 respiratory failure

• P_aO₂ decreased (<8.0kPa)

• P_aCO₂ normal or low (<6.0kPa)

• pH normal or decreased

medical/surgical intervention required for type 1 respiratory failure

• identify and treat underlying cause

• oxygen

primary and secondary prevention of type-1 respiratory failure

• prevent causes e.g. pulmonary oedema, pulmonary embolus

anatomical structures affected by type 2 respiratory failure

• upper airway/trachea/bronchial tree/ pleural space/ chest wall/ diaphragm

• brain and central respiratory control

structural abnormalities associated with type-2 respiratory failure

• any significant obstruction of upper airways/ trachea/ bronchial tree/ alveoli

• fluid, blood, air in pleural space

• weakness/ damage to chest wall/ diaphragm

• damage to brain and central respiratory control by trauma or sedation by drugs

physiological abnormalities associated with type 2 respiratory failure

• hypercapnia

• inadequate ventilation of respiratory system

• arterial oxygen and/or carbon dioxide levels cannot be maintained within their normal ranges

• hypoxaemia

prior events leading to type 2 respiratory failure

• reduced breathing effort

• decrease in area of lung available for gas exchange

symptoms experienced in type 2 respiratory failure

• dyspnoea

clinical signs associated with type 2 respiratory failure

• hypoxia

• tachypnoea

abnormal test results associated with type 2 respiratory failure

• decreased PaO₂ (<10 kPa)

• increased PaCO₂ (>6 kPa)

• decreased pH→ respiratory acidosis

medical/surgical intervention for type 2 respiratory failure

• identify and treat underlying cause

• low flow oxygen ( high flow can reduce respiratory drive and cause reduced ventilation with CO₂ increase)

• ventilatory support may be required

primary and secondary prevention of type 2 respiratory failure

• if failure due to overdose of sedative e.g. morphine/heroin, appropriate antidote should be given