S&S of Pulmonary Disease

• Dyspnea: subjective sensation of uncomfortable breathing (SOB & difficulty breathing)

• Orthopnea: dyspnea while laying down

• Paroxysmal nocturnal dsypnea (PND): violent attacks of severe SOB and coughing; only occurs at night and awakes person from sleep

  • The emotional is more severe than the physical for patients

• Finger clubbing → hypoxic epithelial tissue compensates and grows new blood vessels

  • 160º → normal finger and nail bed

  • 180º → early clubbing

  • 180º → moderate & advanced clubbing

• Coughing

  • Acute cough → less than 14 days

  • Chronic cough → more than 14 days

• Sputum: should generally be odorless (if putrid = tissue death)

  • Productive cough: coughing up sputum

  • Non-productive cough: no sputum

  • Bloody: hemoptysis

    • Blood-streaked sputum: inflammation, lung cancer in lower airway

    • Pink sputum: sputum evenly mixed with blood from alveoli and or small peripheral bronchi → CHF (pulmonary edema)

    • Massive blood: TB, tumor, abscess, pulmonary embolism

  • Yellow(ish): purulent/pus = bacterial pneumonia

  • Green/greenish: longstanding lung infection = chronic bronchitis

  • Rust colored: TB, pneumococcal pneumonia

Breathing Patterns

• Tachy=fast/rapid

• Brady=slow

• Hypoventilation → Hypercapnia (deep breath)

• Hyperventilation → Hypocapnia (shallow depth)

• Eupnea: normal breathing rate and pattern

• Tachypnea: increased respiratory rate, caused by: fever, anxiety, shock

• Bradypnea: Decreased respiratory rate, caused by: sleep, drugs, metabolic disorders, head injury, stroke

• Apnea: absence of breathing, caused by: death, head injury, stroke

• Hyperpnea: normal rate, but deep respirations, caused by: emotional stress, diabetic ketoacidosis

• Cheyne-Stokes: gradual increases and decreases in respirations with periods of apnea, caused by: NEURO, increasing intracranial pressure, brain stem injury

• Biot’s: rapid deep respirations (gasps) with short pauses between sets, caused by: spinal meningitis, CNS causes, head injury

• Kussmaul’s: tachypnea and hypernea, caused by: renal failure, metabolic acidosis, diabetic ketoacidosis

• Apneustic: prolong inspiratory phase with shortened expiratory phase, caused by: lesion in brain stem

Adventitious Breath Sounds

• Crackles (rales): bronchioectasis, bronchitis, pneumonia, fibrosis, CHF; course vs. fine

  • Discontinuous

• Wheezes: asthma, COPD and airway obstruction

  • Continuous

• Rhonchi: suggests secretions in the large airway

  • Continuous

Pleural Abnormalities

• Pneumothorax → air ends up in thoracic cavity → causes lung collapse

  • Spontaneous (PRIMARY) pneumothorax: just happens, occurs in thin, tall, white, male, smokers at risk

  • Secondary pneumothorax: caused by obvious lung diseases; people with cancer, cysts, infection, inflammation (always pathogenic causes)

  • @@Traumatic pneumothorax: @@

    • Iatrogenic → hospital caused (bronchoscopy most common cause)

    • Blunt vs. penetrating → stab wounds, GSWs, car crash

  • Tension pneumothorax: complication from primary OR secondary pneumothorax; causes the pressure to shift to non-affected side (can cause tracheal deviation, heart compression), ⬆️ in mortality

Lung Diseases

Restrictive Pulmonary Disorder

• Lungs are restricted from fully expanding; troubles inhaling

  • Air has a problem going into the lungs

• Condition: stiffness in the lungs, chest wall, weak muscles, or damaged nerves may cause restriction

Obstructive Pulmonary Disorder

• Hard to exhale all the air in the lungs

  • Air had a problem leaving the lungs, trapped in alveoli

• Damage to the lungs or narrowing of the airways → high amounts of air may still linger in the lungs, ⬆️ in CO2 levels

Types of Restrictive Lung Disorders

• Parenchymal:

  • Atelectasis

  • Fluid (edema, pus, blood)

  • ARDS

  • Trauma

  • Autoimmune

  • Chronic infections

  • Occupational

  • Environmental

• Extra-pulmonary

  • Obesity

  • Scoliosis

• Neuromuscular

  • Myasthenia gravis

  • ALS

Types of Obstructive Lung Disorders

• Airway narrowing and obstruction that is worse with expiration

  • Accessory muscles of expiration required

  • Increased work of breathing

• Dyspnea and wheezing most seen with this disorder

• Asthma, COPD (emphysema & chronic bronchitis)

Atelectasis

• RESTRICTIVE

• Loss of lung volume due to the collapse of alveoli

Pathogenesis:

• Absorptions (obstructive) → can develop pneumonia → the reason why patients have to get up and walk after surgery → spirometer also reduces risk

• Non-obstructive → loss of contact between visceral and parietal pleura; surfectant impairment (adhesive)

  • Compression (fluid, air, mass, bed-ridden)

  • Contraction (smokers, fibrosis, infection, pneumoconiosis)

ARDS

• RESTRICTIVE

• Acute respiratory distress syndrome

• Most severe form of acute lung injury; highest mortality rate (impacts both alveoli & blood vessels/ alveolocapillary membrane)

Development

Acute lung injury (to blood vessels) → endothelial cell damage → activation of neutrophils/macrophages/platelets → release of inflammatory cytokines → increase aveolocapillary permeability w/edema → V/Q mismatch (shunt) & hypoxemia → ==acute respiratory failure ==

**Acute lung injury (to alveoli)**→ epithelial cell damage → type II pneumocyte damage → decreased surfectant → alveoli collapse → atelectasis and decreased lung compliance → decreased tidal volume & hypercapnia (muscles tire out) → ==acute respiratory failure ==

Manifestations

• Dyspnea & hypoxemia (O2 sats drop)

• Pulmonary edema

• Increased work of breathing → hyperventilation and respir. alkalosis

• Bilateral infiltrates on chest x-ray

• Respiratory failure, decreased cardiac output, hypotension, death

Diagnosis & Care

• Have to treat accordingly = supportive care

• Hx of lung injury

• Physical exam (won’t really show)

• Analysis of ABGs

• Radiologic exam

• No exact Tx… only support

  • COVID → give antibiotics

  • Smoke inhalation → O2 treatment

  • Chemical inhalation → no Tx, have the let the chemicals absorb into the body before Tx can even be considered to treat

Asthma

• OBSTRUCTIVE

• Reversible airflow obstruction

• LOCATION: Small bronchi, bronchioles

• Typer I hypersensitivity reaction

• Most common chronic disease in children

• NO KNOWN CAUSE (genetic vs. environmental)

Pathogenesis

1. Allergen or irritant exposure

2. Mast cell degranulation and release of mediators → bind to receptors

3. Mediator effects:

   1. Mucus production → mucus plug

   2. Vascular leak → cell edema

   3. Airway smooth muscle constriction → bronchoconstriction

   4. Neutrophil activiation → release of serotonin, histamine, and heparin

• Trifecta of Asthma: a,b,c only

• All have one thing shared: air is trapped in the alveoli and can’t get out (can get air in but not out)

Manifestations

• Cough

• Wheezing

  • Expiratory only = mild & moderate

  • Expiratory & inspiratory = SEVERE

• SOB, tachypnea

• Nasal flaring

• Use of accessory muscles

• Exercise intolerance → seen in adult population (cool weather can cause bronchospasms)

Diagnosis

• Clinical, doesn’t require $ testing

• ABGs

• Pulse Ox.

• Chest radiography

  • ABGs and Pulse Ox. determine severity

Management

• Corticosteroids → decreases inflammatory response (edemas, mucus plugs, etc.)

• Beta agonist: albuterol → inhaled, smooth muscle relaxation

• Anti-cholinergic: ipratropium → relaxes muscle

• Phosphodiesterase enzyme inhibitor: theophylline (xanthine) → vasodilation

• Mast cell stabilizer: cromolyn sodium → for those who go outside and exercise

• Leukotrine receptor antagonist: Zafirulkast → blocks inflammatory response

• Monoclonal antibodies: omalizumab

• Combination drugs → steroids, agonists/cholinergic drugs mixed together

How many attacks = how many drugs the patient will take

Classification of Asthmas

COPD

• OBSTRUCTIVE

• Chronic obstructive pulmonary disease

• Umbrella term for other disease (chronic bronchitis & emphysema)

• Not fully reversible, but can be managed

• MOST COMMON CHRONIC LUNG DISEASE IN THE WORLD

• Risk Factors:

  • Tobacco smoke → vaping popular in US, smoking still popular in Europe/Asia

  • Air pollution → highly populated cities with smog/pollution

  • Genetics

Chronic Bronchitis

• ^^BLUE BLOATERS ^^

• Hypersecretion of mucus and chronic productive cough that lasts for at least 3 consecutive months of the year and for at least 2 consecutive years

• LOCATION: Bronchi

• Hx of smoking

• Living in urban areas, “dirty air”

• 3rd leading cause of death in the US

• Greater than 40 years old

• ^^Overweight, cyanotic, elevated Hgb’s, peripheral edemas, rhonchi and wheezing ^^

  • Frequent infections, common CHF, large amounts of purulent pus coughed up

Emphysema

• PINK PUFFERS

• Abnormal, permanent dilation of gas-exchange airways accompanied by the destruction of alveolar walls (elastic septum) without obvious fibrosis

• LOCATION: Alveoli

• Disease of the air spaces

• Loss of elastic recoil

• @@Barrel chested, pursed lips, older and thin, severe dyspnea, quiet chest @@

  • Little sputum, late CHF

• Caused by smoking or inherited deficit of alpha 1-antitrypsin

  • Trypsin digests elastic fibers, antitrypsin prevents it from digesting the elastic fibers, appears like a history of smoking; this deficit is seen in younger patients only ; loses the ability to protect elastic fibers

Diagnosis

• Spirometry

• ERB measured for COPD

  • IRB & ERB = functional vital capacity

• Pulmonary function test = baseline

• ABGs → checks for pH of blood, PO2, PCO2, HCO3-

• Serum chemistries

• Alpha-1-antitrypsin levels → ALWAYS DO THIS (young vs. old patients)

• Sputum evaluation → bacteria → inflammation/infection → antibiotics to treat

Treatment & Management

• ==In truth, some patients just won’t make the changes and won’t care about their health ==

• Improvement of functional status, symptoms, and quality of life

• Preventing recurrences

• NO Tx available to improve lung function, other than lung transplants

• O2 therapy when appropriate

• Smoking cessation may reduce mortality

Pneumonia

• Any infection of the lung tissue (parenchyma); alveoli filled with fluid & pus

• Typical pneumonia: fever (high, 101.5), cough (productive), rigor (chills); lobar pneumonia & bronchopneumonia

• Atypical pneumonia: fever (low, <100), cough (non-productive); “walking pneumonia (PAP)”

Community Acquired Pneumonia

• Clinical setting = community (walking into hospital/doctor’s office)

• Non-hospitalized or previous ambulatory patient

• Bronchial breath sounds and crackles on auscultation; fever, cough, sputum production, rigors, pleuritic chest pain, dyspnea, tachycardia

• TYPICAL:

  • S. pneumonia, H. influenza, Legionella

    • S. pneumonia is most common and most fatal

• ==ATYPICAL: ==

  • Mycoplasma, Chlamydia

    • Virus

      • Respiratory syncytial virus → children

      • Para-influenza → children

      • Influenza A & B → older population

      • Adenovirus → military barracks

Nosocomial Pneumonia

• Gram - rods

• MRSA

• Alcoholics, bed-ridden, stroke, unconscious

• ==Ventilators = highest chance to develop nosocomial infections (pseudomonas aerugionsa) ==

• Asplenic patients

• Chronic

• Necrotizing

• Immunocompromised (HIV, cancer therapy)

Pulmonary Tuberculosis

• Caused by an acid-fast bacillus, mycobacterium tuberculosis (AIRBORNE)

  • Living in crowded conditions

  • Immunodeficiency

  • Malnutrition & alcoholism → seen in the homeless

  • War

  • Chronic disease

• Pathogenesis → tubercule/granuloma formation → caseous necrosis

Clinical Presentation (for chronic infectious disease)

• Cough w/blood

• Weight loss/anorexia

• Fever (low grade, 100-100.5)

• ==NIGHT SWEATS = distinctive sign of active infection ==

• Hemoptysis

• Chest pain

• Fatigue

Active Infections

• Acid-fast sputum smear test (when + = active TB)

  • Early morning, 3 consecutive days of collecting

• Chest radiography → shows active TB

• Drug susceptibility testing

• Tx depends

Diagnostics

• Blood test: IGRAs

  • $

  • Single patient visit

  • CDC recommended

• Tuberculin skin test: TST

  • Recorded 2-3 days after 1st administration

• HIV serology test → HIV & TB go hand in hand, so always good to check if HIV is +