Cardiopulmonary disease
Chronic Obstructive Pulmonary Disease
Obstructive lung diseases
Obstructive disease process
Patients have difficulty exhaling all the air from the lungs
Exhaled air comes out more slowly than normal
At the end of full exhalation, an abnormal amount of air may still linger in the lungs
Obstructive lung diseases
The most common causes of obstructive lung disease are:
Chronic Obstructive Pulmonary Disease (COPD), which can have two components:
Bronchitis and Emphysema
Asthma
Bronchiectasis
Cystic Fibrosis
Chronic obstructive pulmonary disease – Definition
When chronic bronchitis and emphysema appear together
Preventable and treatable, but not able to be cured
Characterized by airflow limitation that is not fully reversible
Progressive disease associated with abnormal inflammatory response of the lung to noxious particles or gases
Chronic bronchitis and emphysema can each develop alone; however, they often occur together as one disease complex. COPD refers to two lung diseases, chronic bronchitis and emphysema, which occurs simultaneously. Patients demonstrate a variety of clinical manifestations associated with both disorders and the relative contribution of each respiratory disorder is difficult to acertain.
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COPD – Chronic bronchitis
Anatomic Alterations
Chronic inflammation and swelling of the walls of the peripheral airways
Excessive mucous production and accumulation
Partial or total mucous plugging of the airways
Smooth muscle constriction of the bronchial airways (bronchospasm)
Air trapping and hyperinflation of alveoli (in the later stages)
Chronic Bronchitis
Diagnosed based on symptoms
Cough with excessive sputum for at least three months for two consecutive years
Emphysema
Anatomic Alterations
Permanent enlargement and destruction of the air spaces distal to the terminal bronchioles (alveoli)
Destruction of pulmonary capillaries
Weakening of the distal airways, primarily the respiratory bronchioles
Air trapping and hyperinflation
Emphysema
Diagnosed definitively only by lung biopsy or post-mortem exam
Two types
Centrilobular
Panlobular
Normal anatomy
Acinus: A grouping of alveoli distal to a terminal bronchiole.
Normal Acinus
Centrilobular Emphysema
Centrilobular (centriacinar) emphysema is characterized by enlargement and destruction of the central part of the acinus (the respiratory bronchioles) with the more distal parts (the alveoli) remaining intact.
The respiratory bronchioles enlarge, become confluent, and are then destroyed.
Most common form of emphysema.
Associated with cigarette smoking
Panlobular Emphysema
In panlobular emphysema, the entire acinus is involved.
The normal structure of the alveoli and alveolar ducts are lost along with the loss of pulmonary parenchyma.
Bullae (emphysematous spaces greater than one cm) are often present in this type of emphysema.
Emphysema
Panulobular Emphysema
Panulobular emphysema can also be genetic.
Caused by Alpha 1 Antitrypsin Deficiency
Protein that protects lung elastin from neutrophil elastase
Neutrophil elastase breaks down elastin during an inflammatory response, resulting in destruction of the alveolar walls
Alpha 1 Antitrypsin lab test
Normal range is 200-400 mg/dl
COPD
Precise incidence of COPD is not known.
10-15 million people have chronic bronchitis, emphysema, or a combination of both.
In 2004, the annual cost related to COPD was about $37.2 billion
4th leading cause of death
Since 2000, more women than men have died of COPD
The number one cause of COPD is cigarette smoking.
Mucocillary Escalator is damaged.
Paralyzed
Cilia
Excessive
mucus
Damaged Tissues
& Cells
Mucus
Plugging &
Airway
Obstruction
Infection
Hypoxemia
Cigarette
smoke
COPD Risk factors
Risk factors are related to the total burden of inhaled particles over a person’s lifetime.
Tobacco smoke
Occupational dusts or chemicals
Indoor air pollution (i.e., fuel particles related to cooking and heating in poorly vented dwellings)
Outdoor air pollution (small effect in causing COPD)
Conditions affecting normal lung growth may increase a person’s risk of developing COPD (low birth weight, chronic respiratory infections)
Genetic predisposition (Alpha 1 Antrypsin Deficiency)
COPD Signs and Symptoms
COPD should be considered for any patient over 40 with the following symptoms:
Dyspnea
Chronic cough
Chronic sputum production
History of exposure to risk factors, such as tobacco smoke
Pulmonary Function Testing can be used to help identify COPD.
Copd signs and symptoms
Pulmonary Function Testing can be used to help identify COPD.
FEV1: How much air a patient can blow out in one second.
Source: http://www.mspulmonary.com/services/pulmonary-function-tests/
COPD Signs and symptoms
Other signs and symptoms are:
Increased Respiratory Rate
Prolonged expiratory time
Hoover’s Sign: Inward Movement of the lower ribs during inspiration
Accessory Muscle Usage
Tripod Positioning
Barrel Chest
Pursed-Lip Breathing
Diminished Breath Sounds, Inspiratory Crackles, Expiratory Wheezing
Digital Clubbing
Hemoptysis
Stages of copd
Stage 1: Mild COPD – Mild airflow limitation as seen on PFT’s. Symptoms may be so mild that the patient may not recognize abnormal lung function. FEV 1 is greater than 80% of the predicted value.
Stages of copd
Stage 2: Moderate COPD – Worsening airflow limitation as seen on PFT’s. The patient often complains of shortness of breath upon exertion.
Patients usually will seek medical attention at this stage.
FEV 1 is between 50-80% of predicted
Stages of copd
Stage 3: Severe COPD. Further worsening of airflow limitation.
Symptoms impact a patient’s quality of life
FEV 1 is between 30-49% of predicted
Stages of copd
Stage 4: Very Severe COPD: Severe airflow limitation. Chronic ventilatory failure. Quality of life is very impaired. Exacerbations may be life-threatening. FEV 1 is less than 30% of predicted.
Diagnostic Studies for copd
Chest X-ray – cannot definitively diagnose COPD, but can be used to rule out additional diagnoses such as TB or pneumonia.
Hyperinflation
Flattened hemidiaphragms
“Tram Tracks”: parallel, linear white shows that result from thickening of the airways. Seen in severe cases of chronic bronchitis
Right Heart Enlargement
Diagnostic Studies for copd
Arterial Blood Gas Measurement. This should be performed if ventilatory failure or right-sided heart failure is suspected.
Definition of ventilatory failure: PaO2 is < 60 mmHg and the PaCO2 > 50 mmHg with breathing room air
Bronchodilator reversibility testing to rule out asthma
Diagnostic studies for copd
Alpha-1 Antitrypsin Deficiency Screening
Source: http://www.ruleitout.org/patient/rule-it-out/order-free-test-kit.html
Pink Puffer vs. blue bloater
A patient with emphysema is sometimes referred to as a “pink puffer.”
Derived from a reddish complexion and pursed-lip breathing.
What causes this?
Progressive destruction of the distal airways and pulmonary capillaries
This destruction leads to reduced pulmonary blood flow throughout the lungs (an increased ventilation/perfusion ratio)(The ratio of the amount of air reaching the alveoli compared to the amount of blood reaching the alveoli).
To compensate for an increased V/Q ratio, the patient hyperventilates.
The increased RR works to maintain a relatively normal arterial oxygenation level, and causes a ruddy or flushed skin complexion.
During the end stage of emphysema, the patient’s oxygen status decreases and the carbon dioxide level increases
So, a patient with a rapid RR and a red complexion is called a pink puffer.
Source: http://rightatrium.tumblr.com/image/43568301576
Pink puffer vs. Blue bloater
A patient with chronic bronchitis is sometimes referred to as a “blue bloater.”
Derived from cyanosis
What causes this?
Pulmonary capillaries are not damaged.
Patent responds to increased airway obstruction by decreasing ventilation and increasing cardiac output-hypoventilation
Leads to decreased V/Q ratio, which in turn leads to a decreased oxygen level in the blood and an increased CO2 level in the blood
The respiratory drive is depressed in patients with chronic ventilatory failure
The reduced arterial oxygenation levels and polycythemia cause cyanosis
Source: http://media-cache-ak0.pinimg.com/originals/54/51/04/5451047206a300734b0221348397aa1b.jpg
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