Lecture 3: Obstructive Respiratory Disease PDF

Obstructive Respiratory Disease Dr. VanWye, PT, DPT, PhD Board-Certified Clinical Specialist in Cardiovascular and Pulmonary Physical Therapy Objectives 7250.4 - Recognize the red flags associated with cardiopulmonary medications and medical conditions. 7250.7 - Explain and document the clini...

Obstructive Respiratory Disease Dr. VanWye, PT, DPT, PhD Board-Certified Clinical Specialist in Cardiovascular and Pulmonary Physical Therapy Objectives 7250.4 - Recognize the red flags associated with cardiopulmonary medications and medical conditions. 7250.7 - Explain and document the clinical significance of therapeutic medical and surgical procedures related to the cardiovascular and pulmonary systems (e.g., CABG, Ablation therapy, stenting, cardiac catheterization, PE treatment, COPD treatment, ventilation, oxygen therapy). 7250.11 - Evaluate a situation in a case scenario in which a patient/client is in cardiac distress and document how to respond effectively to an emergency situation. Let’s start with definitions… Nail Clubbing Chronic hypoxia leads to tissue changes Bulbous soft tissue swelling of the terminal phalanx Cause unknown, possibly due to increased capillary density and connective tissue growth Loss of the normal concave angle between the nail and nail bed  Cyanosis Bluish discoloration of the skin due to tissue hypoxia Peripheral cyanosis (bluish nails) Central cyanosis (bluish lips)  Pallor Paleness Conjunctiva Palate Tongue Nail beds Palmar and plantar surfaces Diaphoresis Excessive, abnormal sweating as a symptom of disease Hemoptysis Coughing up bright red blood vs. Hematemesis, which is vomiting up blood Urgent referral for both  Cachexia A complex syndrome characterized by muscle wasting and significant weight loss, often associated with chronic illness (*more in notes) vs. Sarcopenia, which is age-related, primarily involves loss of muscle mass and strength Breathing Patterns Tachypnea – Increased rate Hyperventilation – Increased rate and volume Bradypnea – Decreased rate Hypoventilation – Decreased rate and volume Breathing Patterns Apnea No breathing Agonal breathing Slow, shallow, irregular respirations Dyspnea Labored or difficult breathing Subjective sensation of uncomfortable breathing aka shortness of breath Breathing Patterns Orthopnea Difficulty breathing while supine, with an easing of breathing with more vertical positioning Common in left-sided heart failure due to fluid backing up into the lungs and decreasing gas exchange Common in respiratory disease Decreased diaphragmatic muscle function Increased airway resistance Breathing Patterns Paradoxical breathing Retraction/indrawing of the abdomen and lateral intercostal spaces during inspiration Normally, during inspiration: The diaphragm causes the abdomen to expand outward The chest expands AP, and the ribs expand laterally This reverses with expiration *Causes Breathing Patterns Cheyne-Stokes Respiration CO2 inspiration Hyperventilation followed by hypoventilation, then apnea, with the cycle repeating Associated with heart failure, kidney failure, and raised intracranial pressure Kussmaul Respirations Type of hyperventilation associated with severe metabolic acidosis, particularly diabetic ketoacidosis, and kidney failure Low Oxygen Hypoxemia Low oxygen in the blood Oxygen saturation (SpO2) Hypoxia Low oxygen in tissues How is Lung Disease Diagnosed? Spirometry There are three related measurements: volume, time, and flow Obstructive vs. Restrictive Respiratory conditions are classified as: Obstructive can'tgetrid of Co2 Reduced airflow Normal or excessive lung volumes Restrictive cannotexpand bearhug Normal airflow Reduced lung volumes  Pulmonary Reduced airflow Conditions – Normal or excessive lung volumes Obstructive The airways are blocked or “obstructed” Obstructive Lung Disease Emphysema (COPD) Big 5 The Chronic Bronchitis (COPD) Bronchiectasis Asthma Cystic Fibrosis (mixed) Obstructive Lung Disease Common Examination Findings Dyspnea Chronic cough Reduced activity tolerance Digital (nail) clubbing Barrel chest Accessory muscle use Tripod position Pursed lip breathing  Barrel Chest Obstructive lung disease results in hyperinflated alveoli Although this is occurring at a micro level, alveoli expansion eventually causes a macro change in the size/volume of the lungs The expansion is enough to cause a visible change to the thorax’s size Accessory Muscle Use At rest, contraction of any muscle other than the diaphragm during inspiration or use of any muscle during expiration Expiration at rest is normally a passive process Respiratory disease increases ventilatory demands and requires the recruitment of additional muscles to meet the demands Thus, accessory muscles that are normally inactive under normal ventilatory conditions are recruited for inspiration and expiration  Tripod Position Leaning forward, hands on an object (in this case, the thighs) Facilities use of accessory muscles to assist with ventilation IgE  nations Inspire through the nose 0b Pursed Lip Pucker or "purse" the lips Exhale out of the mouth Breathing Positive expiratory in the lungs, splinting airways open and preventing collapse Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease (COPD) is a combination disease of emphysema and chronic bronchitis Onset is 45-65 years (~50 years) First sign = dyspnea Chronic cough emerges Chronic Obstructive Pulmonary Disease Etiology and Pathophysiology Cigarette smoking is the most common cause Smoke inhalation results in an inflammatory process that damages lung tissue Pollution, fumes, dust Genetic Chronic Obstructive Pulmonary Disease Although patients with COPD commonly present with a combination disease of emphysema and chronic bronchitis, we will discuss them separately for learning purposes. Also, testing may reveal that a patient’s disease fits more of an emphysema pattern vs. a chronic bronchitis pattern.  COPD – Airway obstruction (flow issue) Emphysema Enlarged & destroyed airspaces distal to terminal bronchioles Inducting dead anatomical space COPD – Emphysema alveoli Etiology and Pathophysiology Smoking, pollution, fumes, and dust cause an inflammatory response with increased neutrophil activity Neutrophils release elastase as part of their normal immune function Elastase breaks down elastin Loss of elastin results in alveoli hyperinflation and loss of surface area for gas exchange  exchange affectgas COPD – Emphysema Etiology and Pathophysiology cont. Alpha-1-antitrypsin is a protein that prevents immune system overactivity, such as excessive elastase action Deficiency in alpha-1- antitrypsin results in increased elastase activity COPD – Emphysema Beyond the common examination findings, the unique features of emphysema include: Dry cough Cachexia (shown) This patient exhibits: Pursed lip breathing Barrel chest Tripod position COPD – Chronic Bronchitis sputum production Definition Airway obstruction (flow issue) Narrowing of the bronchi and bronchioles due to excessive sputum production, inflammation, and edema Chronic, productive cough for at least 3 months in each of 2 consecutive years COPD – Chronic Bronchitis Bronchi Bronchioles Etiology and Pathophysiology Most common cause is chronic inflammation from smoking Can occur due to pollution, fumes, or dust Beyond the common examination findings, the unique features of chronic bronchitis include: Chronic, productive (wet) cough: a significant amount of sputum production compared to emphysema  COPD – Chronic with Bronchitis Strong tie Heart rishta Less likely to have a cachectic appearance More likely to experience weight gain due to peripheral edema and ascites Edema results from pulmonary hypertension and subsequent right-sided heart failure We will discuss pulmonary hypertension and right-sided heart failure in another lecture Asthma Definition Acute exacerbations of airflow limitation and hyper- responsiveness Due to chronic inflammation and chronic airway changes Etiology and Pathophysiology Genetic: Atopic asthma is the most common form Atopy = genetic tendency to develop allergic diseases such as rhinitis, asthma, and atopic dermatitis (eczema) Allergic Reactions and Asthma Some substances, which are otherwise benign, result in an immune system response because the body recognizes the allergen as dangerous or an irritant Hypersensitivity reaction to an allergen What aspect of the nervous system drives our immune reaction? parasympathetic Consider: individuals with asthma may experience severe bronchoconstriction with potential hypotension and syncope Allergic Reactions and Asthma Bronchoconstriction and hypotension Histamine release Airway obstruction via smooth muscle contraction, bronchial secretion, and airway mucosal edema Arteriolar vasodilation (↓ BP) Bradykinin release Arteriolar vasodilation (↓ BP) via nitric oxide urinedefication Increase in SLUD saliva lacrimation What do individuals with “allergies” complain of? Asthma Risk Factors Besides genetic atopy, other risk factors for asthma include: Obesity Smoking, Pollution Occupational risk factors (chemicals, dust, allergens) Chronic stress and trauma  Asthma Risk Factors Too many or too few upper respiratory infections Hygiene hypothesis Cleanliness and antibiotics have prevented infections that previously provided a protective effect Exposure to allergens in the first year of life, such as pets or growing up on a farm, is believed to it decrease the risk of asthma Asthma Triggers Smoke, pollution Dust, pests, mold Pollen, pets, dander Cleaners, disinfectants Artificial odors, body sprays, air fresheners Food Cool or dry air: dry mucosa becomes inflamed & swollen Stress & emotions (causes ↑ inflammation)  Asthma Triggers Exercise Exercise-induced asthma (EIA) or bronchospasm (EIB) Rapid ventilation acts as an irritant: Drying of the airway mucosa Particles and toxins enter at a high flow rate Asthma Beyond the common examination findings, the unique features of asthma include: Bronchospasms Wheezing Chest tightness/pain Hypoxia Bronchiectasis Definition Irreversible, abnormal dilation of bronchi and bronchioles Etiology and Pathophysiology Recurrent inflammation and infection destroy bronchial mucosa with tissue collapse distal to area  Bronchiectasis Beyond the common examination findings, the unique features of bronchiectasis include: Chronic, productive cough Foul-smelling sputum Hemoptysis Signs of hypoxia: clubbing, pallor, cyanosis Fatigue and weight loss Cystic Fibrosis Genetic: autosomal recessive inherited disease Systemic disease affecting all exocrine glands resulting in abnormal mucus production *Affects the lungs, pancreas, liver, kidneys, digestive tract, and reproductive organs Chronic inflammation, and chronic infections, including the lungs Cystic Fibrosis Affect on the lungs Thick, viscous secretions, and mucus plugs, which obstruct bronchiole ducts, and decrease gas exchange Bronchiectasis, fibrosis, and scarring Cystic Fibrosis Beyond the common examination findings, the unique features of cystic fibrosis include: Chronic, productive cough Foul-smelling sputum Hemoptysis Signs of hypoxia: clubbing, pallor, cyanosis Fatigue and weight loss Medical Interventions Surgery A patient has just undergone a procedure to remove an air pocket from the lung that has resulted from several years of chronic obstructive pulmonary disease. What is the term for this type of procedure? Bullectomy Lobectomy Pneumonectomy Sleeve lobectomy Medications Cystic Fibrosis Pharmacology Large amount of DNA in secretions (glue-like) Medications: Mucolytics Recombinant DNase therapy Aerosol prep (for inhalation via nebulizer) enzyme that can degrade/breakup DNA Administer 30-60 minutes prior to PT intervention Expectorants, bronchodilators, glucocorticoids Anti-microbial agents to treat chronic infections Obstructive Disease Pharmacology Relievers Controllers Inhaled short-acting Inhaled long-acting beta-2 agonists beta-2 agonists (LABA) (SABA) Inhaled long-acting Inhaled short-acting anticholinergics anticholinergics Combination drugs Preventers Inhaled glucocorticoids *Mast cell stabilizers Supplemental Oxygen Nasal cannula Flow up to ___ 6 L/min FiO2 up to 44% High flow options (up to 100% FiO2) High flow nasal cannula Reservoir cannula Simple face mask Non-rebreather mask Venturi system References Accessory Muscle - an overview | ScienceDirect Topics. Published 2018. Accessed October 24, 2022. https://www.sciencedirect.com/topics/veterinary-science-and- veterinary-medicine/accessory-muscle CDC. Learn what could be triggering your asthma attacks. Centers for Disease Control and Prevention. Published August 21, 2020. Accessed October 24, 2022. https://www.cdc.gov/asthma/triggers.html Comberiati P, Di Cicco ME, D’Elios S, Peroni DG. How Much Asthma Is Atopic in Children? Front Pediatr. 2017;5:122. doi:10.3389/fped.2017.00122 Gea J, Agustí A, Roca J. Pathophysiology of muscle dysfunction in COPD. J Appl Physiol. 2013;114(9):1222-1234. doi:10.1152/japplphysiol.00981.2012 References Hillegass E. Essentials of Cardiopulmonary Physical Therapy. 5th edition. Elsevier; 2022. Huether SE, McCance KL. Understanding Pathophysiology. 6th ed. Elsevier; 2017. Reid WD, Chung F, Hill K. Cardiopulmonary Physical Therapy: Management and Case Studies. 2nd ed. SLACK; 2014. Toskala E, Kennedy DW. Asthma risk factors. Int Forum Allergy Rhinol. 2015;5(Suppl 1):S11-S16. doi:10.1002/alr.21557 Vanfleteren LEGW, Spruit MA, Groenen M, et al. Clusters of Comorbidities Based on Validated Objective Measurements and Systemic Inflammation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2013;187(7):728-735. doi:10.1164/rccm.201209-1665OC