Cardiopulm - Obstructive Disease Management

The upper respiratory tract consists of

- Nasal cavities

- Pharynx

- Larynx

The function of the upper respiratory tract includes

- Provide open airway

- Routes food and air appropriately

- Voice production

- Ventilation

The lower respiratory tract consists of

- Trachea

- Bronchi

- Bronchioles

- Alveoli

The function of the lower respiratory tract includes

- Conducts air from upper tract to lungs

- Perform gas exchange

What is the purpose of cilia

They move secretions up and out of the lungs/respiratory tract

Alveoli communicate with each other through

Kohn's pores

Alveoli communicate with bronchioles via

Lambert's canals

During exhalation, surfactant will

Decrease surface tension of alveoli as their size decreases

During inhalation, surfactant will

Increase surface tension as their size increases

Surfactant stabilizes the alveolar cell membrane, which prevents

Collapse

Surfactant helps to improve _, decreasing the work of breathing

Lung compliance

Inspiratory muscles include

- Diaphragm

- Intercostals

Acessory inspiratory muscles include

- SCM

- Scalenes

- SA

- Pec maj/min

- Upper trap

- ES

- Lats

Expiratory muscles include

- RA

- Obliques

- Intercostal

What are the mechanics of inhalation

Active contraction of the diaphragm and external intercostals causes thoracic and lung expansion, creating a negative intrapleural pressure that causes air flow into the lungs

What are the mechanics of exhalation

Passive relaxation of inspiratory muscles along with the elastic recoil of the lungs causes alveolar pressure to rise, leading to air flowing out of the lungs

Gas exchange takes place by

Diffusion across the extremely thin aleveolar-capillary membrane

Oxygen delivery at rest is _ demand

3-4 times

Co2 that is diffused across the alveolar membrane is eliminated by the

Respiratory system

Impaired breathing mechanics includes

- Ineffective breathing pattern

- Impaired lung expansion

- Impaired chest mobility

- Ventilatory muscle weakness

COPD is a catch all term that describes both

Emphysema and chronic bronchitis

General characteristics of COPD includes

- Inflammation of bronchial walls

- Chronic inflammation that leads to narrowing of small airways

- Destruction of lung parenchyma, resulting in a loss of lung tissue elasticity

- Permanent damage of alveoli walls

COPD results in

Poor gas exchange, air trapping, and hyperinflated lungs

COPD generally results in increased usage of

Accessory muscles and altered breathing mechanics

Patients with COPD are prone to

Recurrent respiratory infections

The "pink puffer" presentation generally consists of

- Increasing SOB for the last 3-4 years

- Barrel chest

- Cugh may be productive (generally nonproductive)

- Increased work of breathing to maintain normal oygenation

Emphysema is characterized by

Enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of alveolar walls

What are the key s/s of emphysema

- Typically has tripod position

- Increased use of accessory muscles

- Decreased breath sounds with prolonged expiratory phase

The destruction of alveoli from emphysema causes a massive

Loss of surface area of gas exchange as the disease progresses

Most common causes of of emphysema includes

Smoking and environmental exposure

Alveoli destruction from emphysema is most typically marked in

Apex of the lungs and spreads down as disease progresses

Alpha1-antritrypsin deficiency can (rarely) cause emphysema that sees destruction more in the

Lower lobe

Repeated airway inflammation from emphysema causes

Progressive lung tissue destruction

The disruption of elastic fiber network from airway inflammation causes

Premature closure of airways that results in air trapping, increasing residual volume

A loss of lung parenchyma and vascular beds as a result of emphysema accelerates

HTN

Barrel chest is seen in patients with emphysema due to

Air trapping that increases residual volume and hyperinflated lungs

A bullae on a chest x ray is

Abnormal air spaces when disease is moderately advanced

Bullae (left lung)

Emphysema presentation consists of

- increased Co2 retention

- minimal cyanosis

- pursed lip breathing

- dyspnea

- hyperresonance on chest percussion

- orthopneic

- barrel chest

- exertional dyspnea

- prolonged expiratory time

- short jerky speaking

- anxious

- accessory muscle breathing

- thin appearance

Why would emphysema patients speak with short jerky sentences

They are likely unable to maintain oxygen output during normal speaking

The "blue bloater" chronic bronchitis patient typically presents with

- Year round productive cough

- SOB and DOE worsening with progressively limited exercise tolerance

- Acute exacerbations with purulent sputum becoming more common

- Stocky build with puffy complexion and some cyanosis

- Adventitious sounds during auscultations

- JVD and peripheral edema

Cough from chronic bronchitis begins

Slowly with an insidious onset and becomes chronic

What is the effect of chronic bronchitis on exercise tolerance

Decreases steadily until the individual has essentially no reserve

Chronic bronchitis is characterized by

Idiopathic chronic cough with excessive mucus production

Chronic bronchitis results from

Long term irritation of the tracheobronchial tree

Diagnosis of chronic bronchitis requires

Productive cough on most days for 3 months during 2 consecutive years

Chronic bronchitis is caused by repeated exposure to any inhaled irritants such as

- Cigarette smoke

- Air pollution

- Smoke from fires

- Inhalants as recreational drugs

Chronic irritation of airways provokes what inflammatory responses

- Mucosal edema

- Hypersecretion of mucus

- Destruction of cilia

Irritation of airways causes what in bronchitis patients

Bronchoconstriction

Excessive sputum production and increased secretion retention leads to what in bronchitis patients

Decreased ventilation

Chronic bronchitis patients may present with _ on a chest x ray

Cardiomegaly

Why does the heart enlarge with bronchitis patients

The heart hypertrophies in an attempt to compensate for decreased oxygen levels

The blue bloater chronic bronchitis patient typically presents with

- Airway flow problem

- Dusky to cyanotic color

- Recurrent cough and increased sputum production

- Hypoxia

- Hypercapnia (increased pCo2)

- Respiratory acidosis

- Increased Hgb

- Increased respiratory rate

- Exertional dyspnea

- Digital clubbing

- Cardiac enlargement

- Accessory muscle breathing

- R sided heart failure

The usage of a _ confirms airflow obstruction

Spirometer pre/post bronchodilator

In patients with COPD there is decreased air flow rates with increased expiratory time due to

Decreased elastic recoil of the lung

COPD patients take longer to

Get air OUT due to airway obstruction

Gold classification is based on

FEV1 and in patients with a FEV1/FVC <0.7

Gold classification 1 for COPD is

- Mild

- FEV1 >/= 80% predicted

Gold classification 2 for COPD is

- Moderate

- FEV1 >/= 50% but <80%

Gold classification 3 for COPD is

- Severe

- FEV1 >30% but <50%

Gold classification 4 for COPD is

- Very severe

- FEV1< 30%

A FEV1 <65% predicted is diagnosic for

Chronic airway obstruction

Other obstructive diseases include

- Bronchiectasis

- Cystic fibrosis

- Asthma

Bronchiectasis is caused by

Permanently damaged, widened, thicken bronchi

Bronchiecstasis is characterized by

Mucus build up that results in frequent infections and blockages

Asthma is

A chronic inflammatory condition characterized by hyperresponsiveness of the airways to various stimuli, leading to widespread narrowing of the airways

Unlike COPD, asthma is

A reversible airway obstruction

Asthma s/s includes

- Frequently begins in childhood but can occur at any age

- Often a family history

- Recurrent and sudden coughing attacks chest tightness, and difficulty breathing

- Tachypnea

- Thick, tenacious sputum

- Distant breath sounds

- Adventitious breath sounds

Status asthmaticus is

A severe asthma attack that does not respond to the usual use of bronchodilators

Status asthmaticus leads to

- Bronchospasm

- Airway inflammation

- Mucus plugging

- Difficulty breathing

- Co2 retention

- Hypoxemia

If a patient is having status asthmaticus, they need

IMMEDIATE MEDICAL ATTENTION

What are the s/s of status athmaticus

- Persistent SOB

- Breathlessness even when laying down - may need to sit or stand

- Chest tightness

- Cyanosis

- Agitation

- Confusion

- Inability to concentrate

- Hunched shoulders and strained abs/accessory muscles

The pathophysiology of asthma sees

Hypertrophy of airway smooth muscles that contracts during an attack, causing bronchoconstriction

Extrinsic asthma is cuased by

Exposure to exogenous allergens

Extrinsic asthma typically affects

Children

Intrinsic asthma is caused by

Precipitated non-immune mechanisms

Intrinsic asthsma irritants includes

- Chemical irritants

- Weather

- Respiratory infections

- Drugs

- Emotional stress

Occupational asthma is a result of

Toxic exposure to various substances in the workplace

Exercise induced asthma is generally due to

Loss of heat and moisture in the airway that leads to contraction of bronchial smooth muscle without inflammation

Most inhalers for asthma use what medication

Albuterol

Albuterol is a

Short acting rescue inhaler

What type of medication of albuterol

Sympathomimetic beta 2 agonist

Parasympatholytic medications include

- ipratropium (short acting)

- tiotropium (long acting)

Parasympatholytics are usually administered as

Aerosol or dry powder inhalation

Parasympatholytics work to

Prevent bronchoconstriction

How does albuterol work

It causes bronchodilation

Physical therapy management for COPD patients aims to

Provide non invasive interventions that can reverse or mitigate insults to O2 transport and delay/eliminate the need for medical intervention

Increased vibrations of voice sounds indicates

Consolidation

Decreased vibrations of voice sounds indicates

- Pleural effusion

- Pneumothorax

What are the different kinds of voice sounds with COPD

- Bronchophony

- Egophony

- Whispered pectoriloquy

Bronchophony is characterized by

Increased vocal transmission heard in the presence of increased lung density

Fremitus in a patient with bronchophony will be

Louder and clearer with consolidation

What does bronchophoy indicate

Retained secretions

Egophony is characterized by

Increased intensity of voice heard in the lungs with a nasal or bleating quality

If your patient with egophony says "e--" it would sound like

"A--"

In whispered pectroiloquy, a patient whispering will sound

More distinct and clear due to lung consolidation

Whispered pextoriloquy is useful for identifying

Smaller or patchy areas of consolidation

Patients with COPD generally have _ affected more than _

Proximal UE; Distal UE

Aerobic activity for patients with COPD is ideally

High intensity

What kind of resistance training can reduce RPE and breathlessness

Upper body