Patho Ch. 29 Tutoring PDF

CHAPTER 29: ALTERATIONS OF PULMONARY FUNCTION  SIGNS AND SYMPTOMS OF PULMONARY DISEASE Dyspnea (most common): breathing discomfort Orthopnea: dyspnea that occurs when an individual lays flat; seen in heart failure Cough (most common): protective reflex that hel...

CHAPTER 29: ALTERATIONS OF PULMONARY FUNCTION  SIGNS AND SYMPTOMS OF PULMONARY DISEASE Dyspnea (most common): breathing discomfort Orthopnea: dyspnea that occurs when an individual lays flat; seen in heart failure Cough (most common): protective reflex that helps clear the airways when receptors in the bronchioles & alveoli are stimulated Abnormal sputum: changes in the amount, color, and consistency of sputum (always remember a culture!**) Hemoptysis: coughing up of blood or bloody secretions (heme = blood) Empyema: pus in the pleural space of the lungs Abnormal breathing patterns: effort of breathing changes in response to physiologic and pathophysiologic conditions Kussmaul respirations: deep, rapid, and labored breathing (DKA) Cheyne-Stokes respirations: alternating periods of deep and shallow breathing with apnea between; common in pts who are actively dying  SIGNS AND SYMPTOMS CONTINUED Hypoventilation: inadequate alveolar ventilation in relation to metabolic demands (ex. drug overdose) Hyperventilation: alveolar ventilation exceeding metabolic demands; this leads to too much CO2 being expelled Cyanosis: bluish discoloration of the skin and mucous membranes caused by an increased amount of desaturated (or reduced) hemoglobin in the blood; not always present in a deoxygenated state Clubbing: selective bulbous enlargement of the end of a digit; associated with diseases that cause chronic hypoxemia, such as bronchiectasis, cystic fibrosis, pulmonary fibrosis, lung abscess, and congenital heart disease; rarely reversible  What is pus in the pleural space called? Difficulty breathing when lying down is referred to as? QUESTIONS What is the name of respirations that are characterized by increased ventilatory rate and very large tidal volumes?  What is pus in the pleural space called? Empyema Difficulty breathing when lying down is referred to as? Orthopnea QUESTIONS What is the name of respirations that are characterized by increased ventilatory rate and very large tidal volumes? Kussmaul respirations  CONDITIONS CAUSED BY PULMONARY DISEASE OR INJURY Hypercapnia: increased CO2 concentration in the arterial blood (increased PaCO 2) caused by hypoventilation of the alveoli (cause of respiratory acidosis) Drug overdose or sedation Diseases of the medulla (ex. trauma or infection) Abnormalities of the spinal conducting pathways Diseases of the neuromuscular junction or respiratory muscles Thoracic cage abnormalities (ex. injury or deformity) Large airway obstruction Increased work of breathing or physiologic dead space (no perfusion with ventilation) (ex. Emphysema)  C ON D ITION S C A U S E D BY P U L M ON ARY D I S E A S E OR IN JU RY Hypoxemia: reduced oxygenation of arterial blood (reduced PaO2)caused by respiratory alterations Hypoxia (or ischemia): reduced oxygenation of cells in tissues Oxygen delivery to the alveoli- not enough oxygen available in the alveoli to diffuse into the blood Minute ventilation (respiratory rate x tidal volume) Diffusion of oxygen from the alveoli into the blood Balance between alveolar ventilation and perfusion (V/Q mismatch) Diffusion of oxygen across the alveolar capillary barrier (ex. edema or fibrosis of alveolocapillary membrane) Perfusion of the pulmonary system  Figure 29.3, p. 673 in book The amount of air (V) that enters the alveoli and the amount of blood perfusing the capillaries (Q) is the V/Q ratio- normal is 0.8 Abnormal V/Q ration is the most common cause of hypoxemia (low O2 in the blood) Low V/Q: inadequate ventilation of well-perfused areas V E N T I L AT ION / of the lung (about 0.4) called shunting; caused by P E R F U S ION (V/ Q) trouble getting air into the lungs from infection, A B N OR M AL I T I E S asthma, or trauma Very low V/Q: (about 0.2) is typically from atelectasis, which is the collapse of lung tissue that blocks ventilation High V/Q: (about 1.0) the most common cause of this is a pulmonary embolus, which stops the flow of blood to the lungs  VENTIL ATION/ PERFUSION V = air (ventilation) Q = blood/blood flow (perfusion) Normal V/Q - 0.8 (8/10) Shunting/Low V/Q - poor ventilation (4/10) - asthma; plenty of blood flow Very low V/Q - very poor ventilation (2/10) - atelectasis/alveolar collapse High V/Q - perfusion is limited (blood clot  Pneumonia ARDS (Acute Respiratory Distress Syndrome) Atelectasis: collapsed lung or alveolar tissue Pulmonary edema: increase of fluid in the COMMON lungs REASONS Pulmonary embolism: blood clot in the lung FOR FAILURE TO blocking that stops blood flow OXYGENATE Interstitial fibrosis: like a callous on alveoli Pneumothorax: presence of air or gas in the pleural space caused by a rupture in the visceral pleura (surrounding the lungs) or the parietal pleura and chest wall; this destroys the negative pressure; may be primary (spontaneous), secondary (trauma), or iatrogenic (needle aspiration)  CNS depression due to drug overdose COPD Flail chest: fracture of multiple ribs consecutively resulting in instability of a portion of the chest wall, causing paradoxical movement of the chest with COMMON breathing; the lung collapses in that space REASONS on inspiration, and expands to fill in on FOR FAILURE TO expiration VENTIL ATE ALS: degeneration of neurons Guillian-Barre syndrome Multiple sclerosis: breakdown in mylenation Myasthenia gravis Spinal cord injury  FLAIL CHEST A) normal B) ​normal lung on lung inspiration on expirati on D) unstable C) ​area of lung portion lining flattens inflates during outward inspiration during expiration  COMMON ARDS REASONS Asthma FOR COMBINED FAILURE COPD  Define the terms: Shunt QUESTIONS Dead space A low ventilation-perfusion (V/Q) ratio of the lung will result in?  Define the terms: Shunt- lack of oxygen-rich air getting to the capillaries surrounding the alveoli (atelectasis) Dead space- lack of blood reaching the QUESTIONS alveolar membrane to receive oxygen from the lungs (PE) A low ventilation-perfusion (V/Q) ratio of the lung will result in? not enough oxygen getting to the blood surrounding the alveoli  Of the following which is at the highest risk for developing a PE? 21-year-old male with hemophilia 28-year-old woman who is 6 months QUESTIONS postpartum 36-year-old woman with a history of alcohol abuse who had a gastric ulcer 72-year-old male recovering from hip replacement surgery  Of the following which is at the highest risk for developing a PE? 21-year-old male with hemophilia 28-year-old woman who is 6 months QUESTIONS postpartum 36-year-old woman with a history of alcohol abuse who had a gastric ulcer 72-year-old male recovering from hip replacement surgery  Which of the following assessment findings would be expected in a patient with a pulmonary embolism (PE)? Chest pain QUESTIONS Tachycardia Tachypnea Fever Hemoptysis  Which of the following assessment findings would be expected in a patient with a pulmonary embolism (PE)? Chest pain Tachycardia QUESTIONS Tachypnea Fever (less common) Hemoptysis (less common)  PLEURAL ABNORMALITIES Pneumothorax: air or gas in the pleural space caused by a rupture of the pleura and chest wall; destroys negative pressure in the pleural space and disrupting elastic recoil Open: air is drawn into the pleural space during inspiration and forced back out during Closed – the air is trapped expiration inside Tension: site acts as a one-way valve, permitting air to enter during inspiration, but not exit during expiration (most serious)** Open – the air moves with Spontaneous: unexpected; rupture of blebs on inspiration and expiration; the visceral pleura; usually healthy 20 to 40- only partial lung collapse year-olds (typically men) **Insert a chest tube!!!**  PLEURAL EFFUSION The presence of fluid in the pleural space; most small amounts will resolve on their own and may remain undetected; presence confirmed by chest x-ray and thoracentesis (needle aspiration) Transudative: watery fluid Exudative: high concentration of WBC and plasma proteins Hemothorax: blood Empyema: pus (infected pleural effusion)  R E S T R I C T I V E LU N G D I S E A S E S D I F F I C U LT Y G E T T I N G A I R I N T O T H E L U N G S ; L O W E R C O M P L I A N C E A N D M O R E E F F O R T T O E X P A N D LUNGS Aspiration: passage of fluid and solid particles into the lung; usually when swallowing and cough reflex are impaired by CNS or PNS Right lower lobe is more susceptible due to the branching angle of the bronchial tubes Atelectasis: collapse of lung tissue Compression: external pressure exerted by tumor, fluid, or air Obstructive: obstructed or hypoventilated alveoli; air is gradually absorbed out of alveoli and into blood Surfactant impairment: decreased production or inactivation of surfactant; often due to premature birth, severe lung injury (aspiration, ARDS, anesthesia) Bronchiectasis: persistent abnormal dilation of the bronchi; associated with systemic disorders such as rheumatologic disease, IBD, and immunodeficiency syndromes (AIDS); primary symptoms is a chronic productive cough  Restrictive lung diseases are QUESTIONS characterized by what?  Restrictive lung diseases are characterized by what? QUESTIONS Difficulty getting air into the lungs Decreased compliance (more effort to expand the lungs)  R E S T R I C T I V E LU N G D I S E A S E S D I F F I C U LT Y G E T T I N G A I R I N T O T H E L U N G S ; L O W E R C O M P L I A N C E A N D M O R E E F F O R T T O E X P A N D LUNGS Bronchiolitis: diffuse, inflammatory obstruction of the small airways (common in children) Pulmonary fibrosis: excessive amount of fibrous or connective tissue in the lung; can be idiopathic or caused by scar tissue after a pulmonary disease (ARDS, inhalational injury), autoimmune disorders (RA, progressive system sclerosis, sarcoidosis), or irradiation; marked loss of compliance Inhalation disorders: exposure to toxic substances; caused by dust particles, asbestos, and coal are common; AKA Coal Miners Disease; also hypersensitivity pneumonitis  R E S T R I C T I V E LU N G D I S E A S E S A C U T E LU N G I N J U RY ( A L I ) A C U T E R E S P I RAT O RY D I S T R E S S S Y N D R O M E ( A R D S ) Acute lung inflammation and diffuse alveolocapillary injury Diagnosed by a history of lung injury, exam, blood gasses, CXR Injury and edema to the alveolocapillary membrane (becomes permeable, so fluid seeps in) Three phases: Exudative (within 72 hours) damage to the endothelial cells of the pulmonary capillaries and epithelial cells of the alveoli causes an inflammatory reaction that results in increased capillary membrane permeability; fluids, proteins, and blood leak from capillary bed into the pulmonary interstitium and into the alveoli; lower compliance, decrease in tidal volume and hypercapnia; acute respiratory failure Proliferative (within 4-21 days) a diffusion barrier for oxygen exchange is formed resulting in progressive hypoxemia Fibrotic (within 14-21 days) remodeling and fibrosis of the lung tissue; may cause long- term respiratory compromise  R E S T R I C T I V E LU N G D I S E A S E S A C U T E LU N G I N J U RY ( A L I ) A C U T E R E S P I RAT O RY D I S T R E S S S Y N D R O M E ( A R D S ) Manifestations Dyspnea Hypoxemia Hyperventilation/Hypoventilation Poor tissue perfusion Respiratory failure, poor cardiac output, hypotension, death Supportive therapy: focused on maintaining adequate oxygenation and ventilation while preventing infection; often mechanical ventilation GOAL IS OXYGENATION!  R E S T R I C T I V E LU N G D I S E A S E S A C U T E LU N G I N J U RY ( A L I ) A C U T E R E S P I RAT O RY D I S T R E S S S Y N D R O M E ( A R D S ) ARDS Positioning Frequent position changes with the “good lung down” Head of bed elevated 30 degrees Prone positioning Improves gas exchange ARDS Causes (slide 22) Aspiration, inhalation injury, sepsis, embolism, pneumonia, trauma  What is the goal of nursing care for a patient who has ARDS? What position is often used for an ARDS QUESTIONS patient? The nurse is concerned a patient may be developing ARDS due to their initial presentation of symptoms including?  What is the goal of nursing care for a patient who has ARDS? Identify early, get them a high concentration of oxygen; get them off the vent using PEEP and inverse i/e ratio What position is often used for an ARDS QUESTIONS patient? Prone The nurse is concerned a patient may be developing ARDS due to their initial presentation of symptoms including? Dyspnea, cyanotic skin color, rails, patch infiltrate  O B S T R U C T I V E LU N G D I S E A S E S I M PA I R E D V E N T I L AT I O N A N D OX Y G E N AT I O N Airway obstruction that is worse with expiration Common signs and symptoms Dyspnea and wheezing Common obstructive disorders Asthma COPD Emphysema Chronic bronchitis  O B S T R U C T I V E LU N G D I S E A S E S I M PA I R E D V E N T I L AT I O N A N D OX Y G E N AT I O N Asthma - chronic airway inflammation; antigen initiates both an innate and adaptive immune response in sensitized individuals Very common in children! Manifestations Wheezing on exhalation- high pitched wheeze in upper lobes during auscultation SOB Chest constriction Tachycardia/tachypnea Excessive accessory muscle use  O B S T R U C T I V E LU N G D I S E A S E S I M PA I R E D V E N T I L AT I O N A N D OX Y G E N AT I O N Asthma Treatment Avoidance of allergens and irritants Low-dose corticosteroids and short-acting beta-agonist inhalers Anti-inflammatory medications used in more severe cases Immunotherapy  O B S T R U C T I V E LU N G D I S E A S E S I M PA I R E D V E N T I L AT I O N A N D OX Y G E N AT I O N Chronic Obstructive Pulmonary Disease (COPD) Persistent airflow limitation; progressive; most common lung disease in the world and 4th leading cause of death worldwide Combination of chronic emphysema and bronchitis Risk factors: Tobacco smoke Occupational dusts/chemicals (vapors, irritants, and fumes) Air pollution (indoor and outdoor) Other factors that affect lung growth during fetal development and childhood (low birth weight, respiratory tract infections)  O B S T R U C T I V E LU N G D I S E A S E S I M PA I R E D V E N T I L AT I O N A N D OX Y G E N AT I O N Chronic bronchitis Hypersecretion of mucus and chronic productive cough lasting for at least 3 months of the year for at least 2 consecutive years Inspired irritants increase mucus production and the size and number of mucous glands Mucus produced is thick Cilia is gone or ineffective and unable to clear mucus Treatment Prevention is key: stop smoking to halt disease progression Bronchodilators, mucolytics, antioxidants, and anti-inflammatory drugs Physical therapy; deep breathing and postural drainage Acute exacerbation- antibiotics and corticosteroids; may need mechanical ventilation  O B S T R U C T I V E LU N G D I S E A S E S I M PA I R E D V E N T I L AT I O N A N D OX Y G E N AT I O N Chronic bronchitis Manifestations productive cough Dyspnea Wheezing Prolonged expiration Cyanosis Chronic hypoventilation Polycythemia Cor pulmonale  O B S T R U C T I V E LU N G D I S E A S E S I M PA I R E D V E N T I L AT I O N A N D OX Y G E N AT I O N Emphysema Abnormal and permanent enlargement of the gas-exchange airways accompanied by destruction of alveolar walls without obvious fibrosis Primary emphysema (1%-3% of cases) linked to an inherited deficiency of alpha 1-antitrypsin, which helps to prevent the breakdown of lung tissue Loss of elastic recoil causes air trapping in the lungs causing hyperexpansion of the chest (barrel chest); increased work breathing People tend to purse their lips to help get air in  O B S T R U C T I V E LU N G D I S E A S E S I M PA I R E D V E N T I L AT I O N A N D OX Y G E N AT I O N Emphysema Manifestations Dyspnea Wheezing Barrel chest Prolonged expiration  What causes the increase in the anterior- QUESTIONS posterior diameter in the chest in emphysema?  What causes the increase in the anterior- posterior diameter in the chest in QUESTIONS emphysema? Enlarged alveoli are trapping air in the lungs leading to the barrel appearance  RESPIRATORY TRACT INFECTIONS Acute bronchitis Acute infection or inflammation of the airways or bronchi Usually caused by viruses Manifestations NO chest infilatrates (like pneumonia) Fever Cough Chills Malaise Chest pain from coughing  RESPIRATORY TRACT INFECTIONS Pneumonia Infection of the lower respiratory tract caused by a pathogen; may be healthcare acquired (HCAP) or community acquired (CAP) Pneumococcal is most common and lethal with an intense inflammatory response; may come from being on a ventilator Usually preceded by a viral upper respiratory infection Commonly affects the aging population Diagnosis: hx and physical exam (tachypnea, tachycardia, crackles, bronchial breath sounds, findings of pleural effusion; WBC count elevated; CXR)  RESPIRATORY TRACT INFECTIONS Pneumonia Avoid aspiration (raise HOB, endotracheal suctioning); isolate infected individuals; vaccinate older population Establish adequate ventilation and oxygenation Hydration and good pulmonary hygiene (deep coughing and breathing, chest physiotherapy) Antibiotics for bacterial pneumonia; may require antifungals or antivirals depending on type  What is another term for pus in the pleural QUESTIONS space as a symptom of pneumonia?  What is another term for pus in the pleural QUESTIONS space as a symptom of pneumonia? Empyema  TUBERCULOSIS Infection caused by Mycobacterium tuberculosis; usually infects the lungs Highly contagious and airborne; can result in a latent TB infection Bacteria may become lodged in lymph and initiate an immune response Test via skin (TB skin test) Abscesses can destroy lymph tissue and result in cavitation when abscesses empty into the bronchi Treated with antibiotics  P U L M O N A RY VA S C U L A R D I S O R D E R S : P U L M O N A RY E M B O LU S Thrombus: stationary clot Emboli: traveling clot through the blood Thromboemboli: a thrombus that dislodged and traveled Occlusion of a part of the pulmonary vascular bed by a thrombus, embolus, tissue fragment, lipids, or an air bubble Commonly arise from deep veins in the legs; watch after surgery!!! - ambulation* Virchow triad: venous stasis, hypercoagulability, and injuries to the endothelial cells that line the vessels  P U L M O N A RY VA S C U L A R D I S O R D E R S : P U L M O N A RY A RT E RY H Y P E RT E N S I O N Mean pulmonary artery pressure 5-10 mmHG above normal or above 20 mmHg Diseases of the respiratory system and hypoxemia are more common causes May not be detected until it is quite severe Fatigue Chest discomfort Tachypnea Dyspnea (particularly with exercise) Peripheral edema, JVD, accentuation of the pulmonary component of the second heart sound  P U L M O N A RY VA S C U L A R D I S O R D E R S : C O R P U L M O N A L E Pulmonary heart disease; right ventricular enlargement Develops as PAH exerts chronic pressure overload in the rt ventricle causing increased work in the rt ventricle, resulting in hypertrophy; eventually leads to failure of the ventricle Goal of treatment is to reduce the workload of the rt ventricle by lowering pulmonary artery pressure  MALIGNANCIES OF THE RESPIRATORY TRACT Lung (bronchogenic) Most common cause is cigarette smoking Heavy smokers have a 20-times greater chance of developing lung cancer than non-smokers Smoking related to cancers of the larynx, oral cavity, esophagus, and urinary bladder Also may be caused by environmental or occupational risk factors Clinical manifestations are in Table 29.3 on p. 692 Non-small cell is most common Squamous cell carcinoma Adenocarcinoma Large cell carcinoma Small cell- from neuroendocrine tissue