Pulmonary Disorders 1

what is an obstructive disease?

difficulty exhaling all of the air within the lungs leading to hyperaeration. (exhaling) (Air gets stuck in the lungs, and they cannot push it out)

***Most are

what is a restrictive disease?

difficulty fully expanding lungs with air (Trouble getting air in)

(inhalation)

obstructive and restrictive diseases share ____________.

the same presenting symptoms

Common Causes of

OBSTRUCTIVE Lung

Disease

Alpha1 – Antitrypsin Deficiency

Asthma

Bronchiectasis

Chronic Obstructive Pulmonary

Disease (COPD)

Cystic Fibrosis

Common Causes of RESTRICTIVE

Lung Disease: Pathology of the Chest wall

Kyphosis

Morbid obesity

Scoliosis

Common Causes of RESTRICTIVE

Lung Disease: Adverse medication reactions

Methotrexate

Nitrofurantoin

Common Causes of RESTRICTIVE

Lung Disease: Interstitial Lung disease

Asbestosis

Sarcoidosis

Idiopathic pulmonary fibrosis

Hypersensitivity pneumonitis

Common Causes of RESTRICTIVE

Lung Disease: Neuromuscular disorders

Amyotrophic lateral sclerosis

(ALS)

Guillain-Barre syndrome

Muscular dystrophy

Myasthenia gravis

what is dyspnea?

difficult breathing or shortness of breath (SOB)

can dyspnea be acute or chronic?

YES

what are the 3 main categories of dyspnea?

- respiratory system dyspnea (asthma, COPD, pneumonia)

- cardiovascular system dyspnea (CHF, CAD)

-other (acid/base imbalance)

How Patients Describe Dyspnea

• Short of breath

• Unpleasant breathing

• Labored, difficult or heavy breathing

• Uncomfortable sensation when breathing

• Awareness of breathing

• Unable to get enough air

• Breathlessness

• Air hunger

• Choking

• Suffocation

what is used to determine the degree of dyspnea a patient is experiencing?

MRC dyspnea scale Grade (1-5)

Grade 1

Not troubled by breathlessness EXCEPT on

strenuous exercise

Grade 2

Short of breath when hurrying on a level or when

walking up a slight incline

Grade 3

Walks slower than most people on the level; stops

after a mile +, or stops after 15min walking at own

pace

Grade 4

Stops for breath after walking 100 yards or after a few

min on level ground

Grade 5

Too breathless to leave the house, or breathless when dressing/undressing

What are common causes of acute dyspnea?

Respiratory System

• Bronchospasm

• Pulmonary embolism

• Pneumothorax

• Pulmonary infections

• Upper airway obstruction

Cardiovascular System

• Acute myocardial infarction

• Heart failure

• Cardiac tamponade

Causes of Chronic/Recurrent Dyspnea

Upper airway

Chest/Abdominal wall

Pulmonary

Cardiac

Neuromuscular disease

Toxic/Metabolic Conditions

What causes chronic/recurrent dyspnea?

MANY things, primarily chronic lung infections

What must you investigate in Dyspnea?

Investigate the temporal pattern, severity,

associated Sx, qualitative description, &

exposures

What classifies as need for emergent evaluation of dyspnea?

- tachycardia

- tachypnea

- pulse ox <90%

- inability to speak in full sentences

what is used to evaluate both chronic and acute dyspnea?

bloodwork and imaging

what is orthopnea?

A variation of dyspnea

the sensation of breathlessness in the supine (flat) position, relieved by sitting or standing

what is the common complaint of patients that experience orthopnea?

"I began sleeping with extra pillows at night, but now it is better for me to sleep in my recliner"

Causes of Orthopnea

Fera of anxiety

URTI

Pleural effusion

Ascites

Pulmonary Edema

Severe Pneumonia

Obesity/Sleep Apnea

COPD

Hypothyroidism and Hyperthyroidism

Bilateral Diaphragmatic paralysis

what is paroxysmal nocturnal dyspnea?

a sensation of SOB that awakens the patient, often after 1-2 hours of sleep

• Patient may state they have to take a step outside to get air

What causes Paroxysmal Nocturnal Dyspnea

From fluid build up in the lungs and trouble with oxidation

• Ischaemic heart disease

• Aortic valve disease

• hypertension

• cardiomyopathy

• Atrial fibrillation

• Mitral valve disease

• Atrial tumors

What is the mechanism of Paroxysmal nocturnal dyspnea?

When laying:

• Fluid redistributed into lungs

• Rise in left atrial pressure and fall in PaO2 during sleep

• Increased venous return to the heart

• Reabsorption of fluid from tissues into plasma around the legs

Features of Paroxysmal Nocturnal Dyspnea

Dyspnea

Cough

Frothy sputum

Pallor

Sweating

Tachycardia

Crackles

what is the most common presenting symptom in patients of all ages in the primary care setting?

COUGH

what can persistent and excessive cough lead to?

- It can impair quality of life

- vomiting

- muscle pain

- rib fractures

- urinary incontinence (bc of pressure changes)

- fatigue

- syncope

- depression

what is an acute cough?

less than 3 weeks (infectious)

what is a subacute cough?

3-8 weeks (noninfectious, cardiac, medication)

what is a chronic cough?

more than 8 weeks

what is a productive cough?

cough with sputum (WET)

• Cold

• Flu

• Lung infection

• Cystic fibrosis

• COPD

• Acute bronchitis

• Bronchiectasis

What is a nonproductive cough?

dry cough

• Asthma

• Cold

• GERD

• Sleep apnea

• Vocal cord Dysfunction

• Allergies

• COVID

what could potentially lead to a nonproductive cough?

tight airways that cannot get mucous all the way up

what are common causes of acute cough?

URI

what are common causes of subacute cough?

- post-infection

- upper airway cough syndrome

what are common causes of chronic cough?

- asthma

- COPD

- Interstitial lung disease

- CHF

- GERD

what is hemoptysis?

coughing up blood or blood-stained mucus from the lower respiratory tract

what are common things to be question for a productive cough?

- color

- consistency

- amount

- timing

- presence of blood

When assessing a patient, how do you assess a cough?

• Frequency

• Dry vs productive

• Treatment attempted at home (over the counter medications, asthma inhaler)

• Productive- ask about sputum

• If severe or chronic- ask about the development of complications

Clinical Characteristics: Dry vs productive

• Subjective but does help

• Productive usually implies mucous/sputum production, but

“tight mucus” can present as dry cough

Chest pain can be caused by what?

pulmonary, cardiovascular, gastrointestinal, musculoskeletal, dermatologic, and neuropsychiatric disorders

what are "can't miss" causes of chest pain?

- acute coronary syndrome

- aortic dissection

- pulmonary embolism

- tension pneumothorax

- esophageal rupture/perf

- cardiac tamponade

- specific arrhythmias

Cardiac tamponade

Fluid in heart and cannot pump

what is pleuritic chest pain?

sudden and intense sharp, stabbing, or burning chest pain when inhaling and exhaling associated with inflammation of the parietal pleura

Elephant in chest sign

Metaphor for cardiac chest pain

what is the pleura?

the outer lining of the lung

Pleuritic Chest Pain is Exacerbated when…

laughing, coughing, deep breathing & sneezing

Associated symptoms in Pleuritic Chest Pain

dyspnea, cough, PND, fever

what are common causes of pleuritic chest pain?

- respiratory viruses

- pneumonia

- pneumothorax

- pulmonary embolism

what is a pleural effusion?

collection of fluid between the parietal and visceral pleura that is considered a manifestation of disease but rarely idiopathic

What is pleural effusion is a manifestation of what

manifestation of disease although rarely may be idiopathic

what fluid types can be apart of a pleural effusion?

transudative, exudative, purulent

how does a pleural effusion clinically present?

- asymptomatic

- dyspnea

- cough, pleuritic chest pain

- PE shows fluid

(Symptoms as it continues)

COMMON Causes of Pleural Effusion

• Heart failure

• Bacterial pneumonia

• Pulmonary embolism

• Malignancy

• Viral respiratory diseases

how is a pleural effusion diagnosed?

• Chest x-ray (Air is black, fluid is white)

• Thoracentesis (Needle btw ribs and draw fluid out)

- Can be diagnostic or therapeutic (diagnosis and treat)

- Fluid analysis (gross & microscopic) (Makes the patient feel better)

how is a pleural effusion treated?

- treat underlying cause

- thoracentesis for severe symptoms

what scale is used to rate perceived exertion of the pulmonary system?

Borg scale

Borg Scale

(1-10)

10- Maximum effort (feels impossible to keep going, completely out of breathe, unable to talk)

9 - Very hard activity (very difficult to maintain exercise intensity)

7/8 - Vigorous Activity (Borderline uncomfortable)

4-6 - Moderate activity (breathing heavy)

2-3 - Light Activity (Can maintain for hours)

1 - Very light activity (Hardly any exertion)

How is an examination of the pulmonary system?

Disease of the pulmonary system impacts all other parts of the body

• Therefore we can see manifestations of pulmonary disease in many places throughout physical exam

Assessment of the pulmonary system:

• General Inspection

• Vital Signs

• Skin/Hair/Nails

• HEENT exam (nasal flaring when breathing heavy)

• Chest, Lungs, Cardiovascular exam (Never examine one without the other)

• How they are positioned (Sitting in a tripod position (calluses on thighs)

Lung Exam

• Inspection

• Palpation

• Percussion

• Auscultation

what is inspection during a lung exam?

chest/spine deformities, accessory muscle use (using other areas of the body to help breathe), retractions

what is palpation during a lung exam?

tenderness, symmetry of chest expansion

what is percussion during a lung exam?

assessment of density of underlying lung tissue

what is auscultation during a lung exam?

assessing normal and abnormal breath sounds - stridor, wheezes, crackles,

rhonchi

what is stridor?

high-pitched loud tracheal wheeze

what causes stridor?

upper airway obstruction (larynx and up)

what are wheezes?

muscial, can be heard on both inspiration and expiration, high-pitched

what causes wheezing?

constriction of airways

what are crackles? (fine-medium-coarse)

short, explosive, non-musical sound heard most commonly on inspiration and sometimes on expiration and can be high, medium, or low pitched

what causes crackles?

fluid in the lungs

what is ronchi?

low-pitched, snoring sound that clears/improves with a cough

what causes ronchi?

secretions in the airway

Out of the sounds, which are discontinuous and continuous?

Crackles - discontinuous

Wheezes, Ronchi - continuous

what is pulse oximetry?

estimation of the saturation of hemoglobin by oxygen

what is normal oxygen saturation?

more than 95% (should be 100%, trouble in the brain if it is too low).

what is bad oxygen saturation?

less than 90%

what is spirometry?

• Measures the FEV1 (forced expiratory volume in 1 second) and FVC (forced vital capacity) and determine ratio

• Identifies obstructive (breathing air out) or restrictive process (breathing in air)

Ratios of FEV/FVC

FEV1 - The amount of air pushed out in the first second of a hard breath

FVC - The total amount of air blown out during the entire breath.

FEV/FVC ratio FVC Pattern

Normal Normal Normal

Normal Decreased Restrictive

Decreased Normal Obstructive defect

Decreased Decreased Mixed

what are other pulmonary imaging and studies?

- chest XR

- CT/MRI

- pulmonary angiogram (blood vessels feeding the lungs if there is something blocking it)

- ventilation-perfusion scan (tests how well the lung can disperse out and if the blood is getting to the ends of the lung)

- ultrasound

- arterial blood gas (the arteries are under such pressure, provides a pH)

- polysomnography (sleep study)

What is utilized if needed more knowledge for diagnosis?

Bloodwork, imaging, other diagnostic studies

ex. EKG if myocardial infarction is suspected. CBC if infectious cause is suspected

what is a thoracentesis?

image-guidance to diagnose and remove air or fluid in the pleural space

what is a chest tube?

a device used to continuously remove air or fluid from the pleural space to re-inflate the lungs

what is a trans-thoracic needle biopsy?

uses a needle to biopsy a mass in the lung. Interior of the lung

Pleural Biopsy

USe sa special needle t obtain a piece of the parietal pleura for study

what is a bronchoscopy?

device used to visualize the tracheobronchial tree. inside the airway

what is a thoracoscopy?

minimally invasive procedure using a lighted scope with a video camera to visualize the pleural space. surface of tissue

what is a thoracotomy?

surgical procedure entering the chest space, usually between the ribs or through the sternum, to treat a lung disease

what are common pharmacologic treatment modalities for pulmonary conditions?

- antibiotics

- corticosteroids

- bronchodilators

- “allergy medications” (antihistamines/immunotherapy)

- decongestants : for mucus

- cough suppressants : will not help break up the mucus

- mucolytics : thick mucus that decongestants cannot break

Other lifestyle of treatment modalities

• Weight loss

• Aerobic exercise

• Allergen avoidance

• Postural Drainage

Classification of upper respiratory and lower respiratory tracts

Upper:

Nasal cavity

Pharynx: Nasopharynx, oropharynx, Laryngopharynx

Larynx

trachea

Left and right primary bronchi

Lower:

Right pleural cavity

Left pleural cavity

Bronchioles

Mediastinum

Diaphragm

Pleural space

What are the demographics for airway foreign bodies?

most commonly young children (<3yoa) and older children and adults

what are the common factors for young children to acquire a foreign body?

- behavioral risk factors

- anatomical risk factors (bronchi sits horizontally)

what are common factors for older children and adults to acquire an airway foreign body?

- neurological disorders

- Loss of consciousness

- alcohol/substance abuse