Unit 3

Pathophysiology

Pulmonary Edema

Abnormal accumulation of fluid from pulmonary vascular system into lung parenchyma

Anatomical Changes of Pulmonary Edema

1. Interstitial Edema

2. Alveolar Flooding

3. Increased Surface Tension of Alveolar Fluids

4. Alveolar Shrinkage and Atelectasis

5. Frothy White/Pink Secretions

Cardiogenic Pulmonary Edema

Occurs when left ventricle is unable to pump out sufficient amount of blood during ventricular contraction

Noncardiogenic Pulmonary Edema

Develops due to damage to the lungs

What causes cardiogenic pulmonary edema?

1. CHF and Other Heart Diseases

2. Congenital Heart Defects

3. Excessive Fluid Administration

4. Pulmonary Emboli

5. Renal Failure

How do you diagnose cardiogenic pulmonary edema?

Echocardiogram

LVEF = < 40% may confirm heart failure

What are possible causes of noncardiogenic pulmonary edema?

1. Increased Capillary Permeability

2. Lymphatic Insufficiency

3. Decreased Intrapleural Pressure

4. High-Altitude

5. Decreased Oncotic Pressure

Examples of Decreased Oncotic Pressure

Severe Malnutrition

Over Transfusion of Hypotonic IV Fluids

Abnormal Labs Found with Pulmonary Edema

1. Low Potassium

2. Low Sodium

3. Low Chloride

4. Elevated BNP ——> Cardiac Indicator

X-Rays Findings of Cardiogenic Pulmonary Edema

1. Enlarged Heart - Cardiomegaly

2. ‘Bat’s Wing’ or ‘Butterfly’ Patterns

3. Pleural Effusion

4. Kerley A and B Lines

X-Ray Findings of Noncardiogenic Pulmonary Edema

1. Granular / Ground Glass Appearance

2. Reticulograndular or Honeycombing

3. Bilateral Fluffy Opacities with a Predominantly Central Position in the Chest

Management of Cardiogenic Pulmonary Edema

1. Initial Management

2. Therapeutic Intervention

   1. Preload Reduction

   2. Afterload Reduction

   3. Treatment of Reduced Cardiac Contractility

   4. Other Agents

Management of Noncardiogenic Pulmonary Edema

Largely Supportive (i.e. adequate oxygenation and ventilation)

No Specific Treatment, except for Specific Infections or High Altitude

Pleural Effusion

Fluid that accumulates in pleural space

Restrictive Disorder

Shunt

Empyema

When fluid in the pleural space is infected

Hydrostatic Pressure

Mainly a function of the arterial circulation

Creates the ‘push’ pressure on the walls of the vessels

Oncotic Pressure

Reflects largely the protein concentration in the blood and lymphatic vessels

Creates the ‘pull’ pressure to pull fluid into the vessels

Transudative Pleural Effusions

Develops when fluid from the pulmonary capillaries moves into pleural space

1. Thin

2. Watery

3. Contains Few Blood Cells

4. Contains Little Protein

5. High Hydrostatic Pressure

Exudative Pleural Effusions

Develops when pleural surfaces are diseases

1. High Protein Content

2. High Cellular Debris

3. Lymphatic System is Not Working Properly

4. Usually Caused by Infection or Cancer

5. High Oncotic Pressure

Causes of Transudative Pleural Effusions

1. CHF - Most Commom

2. Pulmonary Embolism

3. Peritoneal Dialysis

4. Nephrotic Syndrome

5. Hepatic Hydrothorax

Causes of Exudative Pleural Effusions

1. Empyema

2. Fungal Diseases

3. TB

4. Pneumonia

5. Cancer

Signs and Symptoms of Pleural Effusions

Tachypnea, Tachycardia, Increased BP, Chest Pain, Dry Nonproductive Cough, Dyspnea, Decreased Chest Expansion, Cyanosis, Chest Pressure when Effusions is about 500-1500mL, Tracheal Shift Away from Affected Side, Dull Percussion Note, Pleural Friction Rub (Occasionally), Decreased Tactile and Vocal Fremitus

ABG’s of Mild Pleural Effusion

High pH

Low PaCO2

Low PaO2

Normal HCO3

ABG’s of Moderate/Severe Pleural Effusion

Low pH

High PaCO2

Low PaO2

Normal HCO3

General Treatment of Pleural Effusions

Best Way to Resolve Pleural Effusion is to Treat Underlying Cause.

1. Thoracentesis

2. Appropriate Antibiotic

3. Chest Tube in Severe Cases

Specific Treatment for Transudative Pleural Effusion

1. Lower BP

2. Diuretics

3. Give Proteins

Specific Treatment for Exudative Pleural Effusion

1. Test for Bacteria and Give Antibiotics

2. Cytologic Exam to Identify Cancer

2 Disorders of COPD

1. Emphysema

2. Chronic Bronchitis

Chronic Bronchitis

Chronic Productive Cough for 3 Months in each of 2 Successive Years in a Patient in Whom Other Causes of Productive Chronic Cough Have Been Excluded

Emphysema

The Presence of Permanent Enlargement of the Air Spaces Distal to the Terminal Bronchioles, Accompanied by Destruction of Bronchiole Walls and Without Obvious Fibrosis

Structures Affected by Chronic Bronchitis

Conducting Airways Especially the Bronchi

Structures Affected by Emphysema

Alveoli

Dysfunction Caused by Chronic Bronchitis

1. Smooth Muscle Constriction

2. Mucus Plugging

3. Hyperinflated Alveoli

4. Enlarged Submucosal Glands

5. Mucus Accumulation

6. Epithelial Inflammation

Why are Patients Who Have Chronic Bronchitis Called Blue Bloaters?

1. Cyanosis

2. Overweight

3. Fluid Retention

Why are Patients Who Have Emphysema Called Pick Puffers?

1. Flushed Skin

2. ‘Puffing’ from Pursed-Lip Breathing

2 Types of Emphsema

1. Panacinar (Panlobular)

2. Centriacinar (Centrilobular)

Panacinar (Panlobular) Emphysema

Abnormal Weakening and Enlargement of ALL Alveoli Distal to the Terminal Bronchioles

Centriacinar (Centrilobular) Emphysema

Involves the Respiratory Bronchioles Proximal (Central) Portion of the Acinus

Most Common Form of Emphysema

Acinus

A region of the lung supplied with air from one of the terminal bronchioles

Emphysema Percussion Sound

Hperresonnant due to Air Trapping

Polycythemia

High Levels of RBCs

Common in Patients with Chronic Bronchitis

Genetic Disorder that Causes Early Onset of Emphysema/COPD

Alpha-1 Antitrypsin Deficiency (ATT1)

Alpha-1 Antitrypsin Deficiency (AAT1)

Protease Inhibitor

Without it Patient Experiences Damaged Airways

Normal Range: 150 - 350mg

Spirometry Test for Diagnosing COPD

Post-Bronchodilator FEV1/FVC

For Diagnosis Patient must Score Less than 70%

Normal Range is Greater Than or Equal to 70%

Score on mMRC to be Considered High-Risk for Severe COPD Exacerbations

Score > 2 is High-Risk

Score on CAT to be Considered High-Risk for Severe COPD Exacerbations

Score > 10 is High Risk

SpO2 Goals for COPD Patients

Target is 88% - 92%

Symptoms of Cor Pulmonale

1. Enlarged Heart

2. Right-Sided Heart Failure

3. Swollen Ankles and Legs

4. Distended Neck Veins

Gold 1 Standard for COPD - Mild

FEV1 ≥ 80% Predicted

Gold 2 Standard for COPD - Moderate

50% ≤ FEV1 < 80% Predicted

Gold 3 Standard for COPD - Severe

30% ≤ FEV1 < 50% Predicted

Gold 4 Standard for COPD - Very Severe

FEV1 < 30% Predicted

Cystic Fibrosis

Progressive Genetic Disease that can Affect Lungs, Pancreas, Liver, and Sweat Glands

What Causes CF?

Mutations of the CFTR Gene Causes to Become Dysfunctional

Creates an Inability to Transport Sodium and Chloride Across Epithelial Surfaces

Most Common Defect of CF

ΔF508

Gating Defect (Class III) of CF

Channel Doesn’t Open

Conductance Defect (Class IV) of CF

Channel is Open, but Chloride Doesn’t Move Effectively

Common Gram Negative Bacteria Found in CF Patients

1. Pseudomonas Aeruginosa

2. Burkholderia Cepacia Complex (Most Dangerous)

Common Gram Positive Bacteria Found in CF Patients

1. Staphylococcus Aureus

Immunoreactive Trypsin (IRT)

Test Performed on All Newborns on Birth

Detection of Atleast 1 CF Mutation is Considered a Positive Screen for CF

Most Reliable Test in Diagnosing CF?

Sweat Chloride Test

x > 60 mmol/L

Nonallergic / Nonatopic / Intrinsic Asthma

Onset Seen in Adults After Age 40

Not Related to Hypersensitivity to Antigens

Does Not Respond Well to ICS Therapy

Causes / Irritants of Intrinsic Asthma

1. Cold Air

2. Infections

3. Emotional Stress

4. Exercise

5. Dust

6. Drugs

7. Smoke

Allergic / Atopic / Extrinsic Asthma

Typically Appears in Childhood

Sputum Contains Eosinophils

Is Considered Type 1 (Immediate Hypersensitivity Reaction)

Elevated IgE Levels

Common Vital Signs of Asthma Exacerbation

1. Tachypnea

2. Tachycardia

3. Hypertension

4. Pulsus Paradoxus

Bronchial Provocation Test

Most Often Using Inhaled Methacholine to Provoke Bronchospasm in a Controlled Environment

Atopy

Genetic Disposition to Develop Allergic Diseases

Associated with Overproduction of IgE to Specific Antigen

FeNO

Fractional Concentration of Nitric Oxide

Increased Levels are Caused by Airway Inflammation

Normal Range:

1. Adult: < 25 ppb

2. Children = < 20ppb

What is Prescribed for High FeNO Levels?

Inhaled Corticosteroids (ICS)

Bronchial / Airway Remodeling

1. Inflammation Leading to Fibrosis

2. Damaged Cilia

3. Basement Membrane of Mucosa Becomes Thick and Stiffened

Symptoms of Asthma

1. Chronic Airway Inflammation

2. Wheeze

3. SOB

4. Chest Tightness

5. Cough

Another Name for Refractory Asthma Exacerbation

Status Asmaticus

Reliver / Rescue Medications for Asthma

Taken as Needed (PRN)

1. SABAs: Albuterol, Levalbuterol

2. Bronchodilator Agents: Epinephrine, Racemic Epinephrine

Controller Medications for Asthma

Taken on a Regular Basis

1. Inhaled Corticosteroids

2. Leukotriene Inhibitors: Montelukast

3. ICS + LABA

4. LAMA (-ium)

2 Oral Corticosteroids Given for Asthma Exacerbations

1. Methylprednisolone

2. Hydrocortisone

3 Oral or IV Medications Given for SEVERE Asthma Exacerbations

1. Prednisone

2. Prednisolone

3. Dexamethasone

Non Respiratory Manifestations of CF

1. Pancreatic Insufficiency / Pancreatitis

2. Liver Dysfunction / Failure

3. Failure to Thrive / Nutrient Deficiency

4. Nasal Polyps

5. Intestinal Obstruction

Breathing Techniques for Lung Expansion and Airway Clearance

1. Cycle Breathing

2. Huff Cough

Mucolytics Used for Airway Clearance in CF Patients

1. Pulmozyme / Dornase Alpha

2. Inhaled Hypertonic Saline (7%)

3. Mucomyst

Medications Given to Aid in Function of CFTR

1. Ivacaftor

2. Lumacaftor

3. Trifakta

Inhaled Antibiotics Given to CF Patients

1. Tobramycin

2. Aztreonam

3. Amikacin

4. Colistin