Copyright © 2006 by Mosby, Inc. Slide 1 Respiratory system module AsthmaBronchitis Flail chest

Copyright © 2006 by Mosby, Inc.Slide 1

Respiratory system moduleRespiratory system module

Asthma Asthma

BronchitisBronchitis

Flail chest Flail chest


CASE SCENARIOCASE SCENARIO

A 30 YRS OLD MALE NON SMOKER A 30 YRS OLD MALE NON SMOKER PRESENTED IN EMERGENCY DEPARTMENT PRESENTED IN EMERGENCY DEPARTMENT WITH SEVERE SHORTNESS OF BREATH WITH SEVERE SHORTNESS OF BREATH FOR LAST 2 DAYS IT HAS WORSENED OVER FOR LAST 2 DAYS IT HAS WORSENED OVER FEW HRS TO SUCH AN EXTENT THAT HE FEW HRS TO SUCH AN EXTENT THAT HE HAS TO COME TO EME DEPARTMENT .HE HAS TO COME TO EME DEPARTMENT .HE HAS REVIOUS HISTORY OF SIMILAR HAS REVIOUS HISTORY OF SIMILAR ATTACKS OF SHORTNESS OF BREATH ATTACKS OF SHORTNESS OF BREATH WITH WHEEZE ESPECIALLY IN WINTERS WITH WHEEZE ESPECIALLY IN WINTERS USED TO RELIEVE AFTER TAKING USED TO RELIEVE AFTER TAKING MEDICATIONS .THERE IS HISTORY OF MEDICATIONS .THERE IS HISTORY OF NOCTURNAL COUGH ON AN OFFNOCTURNAL COUGH ON AN OFF


THERE IS NO HISTORY OF ORTHOPNEA AND PND THERE IS NO HISTORY OF ORTHOPNEA AND PND NO HISTORY OF ANY HEART PROBLEM NO HISTORY NO HISTORY OF ANY HEART PROBLEM NO HISTORY OF ANY feverCONNECTIVE TISSUE DISEASE OR OF ANY feverCONNECTIVE TISSUE DISEASE OR KIDNEY DISORDER NO HISTORYOF KEEPING PETS KIDNEY DISORDER NO HISTORYOF KEEPING PETS AT HOME HE HAS LEFT HIS MEDICATION AND LOST AT HOME HE HAS LEFT HIS MEDICATION AND LOST FOLLOW UP WITH GPE FOR LAST 6 MONTHS FOLLOW UP WITH GPE FOR LAST 6 MONTHS


WHAT IS THE LIKELY DIAGNOSIS IN THIS WHAT IS THE LIKELY DIAGNOSIS IN THIS PATIENT?PATIENT?

WHAT PHYSICAL FINDINGS HELP TO WHAT PHYSICAL FINDINGS HELP TO REACH A DIAGNOSIS?REACH A DIAGNOSIS?

WHAT INVESTIGATIONS SHOULD BE WHAT INVESTIGATIONS SHOULD BE DONE ?DONE ?

WHAT ARE MANAGEMENT OPTIONS?WHAT ARE MANAGEMENT OPTIONS?


Asthma is a common and potentially serious chronic disease Asthma is a common and potentially serious chronic disease that can be controlled but not curedthat can be controlled but not cured

Asthma causes symptoms such as wheezing, shortness of Asthma causes symptoms such as wheezing, shortness of breath, chest tightness and cough that vary over time in their breath, chest tightness and cough that vary over time in their occurrence, frequency and intensityoccurrence, frequency and intensity

Symptoms are associated with variable expiratory airflow, Symptoms are associated with variable expiratory airflow, i.e. difficulty breathing air out of the lungs due to i.e. difficulty breathing air out of the lungs due to Bronchoconstriction (airway narrowing)Bronchoconstriction (airway narrowing)

Airway wall thickeningAirway wall thickening

Increased mucusIncreased mucus

Symptoms may be triggered or worsened by factors such as Symptoms may be triggered or worsened by factors such as viral infections, allergens, tobacco smoke, exercise and stressviral infections, allergens, tobacco smoke, exercise and stress

What is known about asthma?What is known about asthma?

GINA 2014


Asthma can be effectively treatedAsthma can be effectively treated

When asthma is well-controlled, patients canWhen asthma is well-controlled, patients can Avoid troublesome symptoms during the day and Avoid troublesome symptoms during the day and

nightnight

Need little or no reliever medicationNeed little or no reliever medication

Have productive, physically active livesHave productive, physically active lives

Have normal or near-normal lung functionHave normal or near-normal lung function

Avoid serious asthma flare-ups (also called Avoid serious asthma flare-ups (also called exacerbations, or severe attacks)exacerbations, or severe attacks)

What is known about asthma?What is known about asthma?

GINA 2014


Asthma is a heterogeneous disease, usually characterized Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. by chronic airway inflammation.

It is defined by the history of respiratory symptoms such as It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable that vary over time and in intensity, together with variable expiratory airflow limitation.expiratory airflow limitation.

Definition of asthmaDefinition of asthma

NEW!

GINA 2014


ASTHMA DEFINITIONASTHMA DEFINITION

“a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and an underlying inflammation. The interaction of these features of asthma determines the clinical manifestations and severity of asthma and the response to treatment


The diagnosis of asthma should be based on:The diagnosis of asthma should be based on: A history of characteristic symptom patterns A history of characteristic symptom patterns

Evidence of variable airflow limitation, from bronchodilator Evidence of variable airflow limitation, from bronchodilator reversibility testing or other tests reversibility testing or other tests

Document evidence for the diagnosis in the patient’s Document evidence for the diagnosis in the patient’s notes, preferably before starting controller treatmentnotes, preferably before starting controller treatment It is often more difficult to confirm the diagnosis after It is often more difficult to confirm the diagnosis after

treatment has been startedtreatment has been started

Asthma is usually characterized by airway Asthma is usually characterized by airway inflammation and airway hyperresponsiveness, but inflammation and airway hyperresponsiveness, but these are not necessary or sufficient to make the these are not necessary or sufficient to make the diagnosis of asthma.diagnosis of asthma.

Diagnosis of asthmaDiagnosis of asthma

GINA 2014

Copyright © 2006 by Mosby, Inc.Slide 10GINA 2014, Box 1-1 © Global Initiative for Asthma

NEW!


IncreasedIncreased probability that symptoms are due to asthma if: probability that symptoms are due to asthma if: More than one type of symptom (wheeze, shortness of breath, cough, chest More than one type of symptom (wheeze, shortness of breath, cough, chest

tightness)tightness)

Symptoms often worse at night or in the early morningSymptoms often worse at night or in the early morning

Symptoms vary over time and in intensitySymptoms vary over time and in intensity

Symptoms are triggered by viral infections, exercise, allergen exposure, Symptoms are triggered by viral infections, exercise, allergen exposure, changes in weather, laughter, irritants such as car exhaust fumes, smoke, or changes in weather, laughter, irritants such as car exhaust fumes, smoke, or strong smellsstrong smells

DecreasedDecreased probability that symptoms are due to asthma if: probability that symptoms are due to asthma if: Isolated cough with no other respiratory symptomsIsolated cough with no other respiratory symptoms

Chronic production of sputumChronic production of sputum

Shortness of breath associated with dizziness, light-headedness or peripheral Shortness of breath associated with dizziness, light-headedness or peripheral tinglingtingling

Chest painChest pain

Exercise-induced dyspnea with noisy inspiration (stridor)Exercise-induced dyspnea with noisy inspiration (stridor)

Diagnosis of asthma – symptomsDiagnosis of asthma – symptoms

GINA 2014


Confirm presence of airflow limitationConfirm presence of airflow limitation Document that FEVDocument that FEV11/FVC is reduced (at least once, when FEV/FVC is reduced (at least once, when FEV11 is low) is low) FEVFEV11/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and / FVC ratio is normally >0.75 – 0.80 in healthy adults, and

>0.90 in children>0.90 in children Confirm variation in lung function is greater than in healthy individualsConfirm variation in lung function is greater than in healthy individuals

The greater the variation, or the more times variation is seen, the greater The greater the variation, or the more times variation is seen, the greater probability that the diagnosis is asthmaprobability that the diagnosis is asthma

Excessive bronchodilator reversibility (adults: increase in FEVExcessive bronchodilator reversibility (adults: increase in FEV11 >12% and >12% and >200mL; children: increase >12% predicted)>200mL; children: increase >12% predicted)

Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring (daily Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring (daily amplitude x 100/daily mean, averaged)amplitude x 100/daily mean, averaged)

Significant increase in FEVSignificant increase in FEV11 or PEF after 4 weeks of controller treatment or PEF after 4 weeks of controller treatment If initial testing is negative:If initial testing is negative:

• Repeat when patient is symptomatic, or after withholding bronchodilatorsRepeat when patient is symptomatic, or after withholding bronchodilators

• Refer for additional tests (especially children ≤5 years, or the elderly)Refer for additional tests (especially children ≤5 years, or the elderly)

Diagnosis of asthma – variable Diagnosis of asthma – variable airflow limitationairflow limitation

GINA 2014, Box 1-2

Copyright © 2006 by Mosby, Inc.Slide 13 © Global Initiative for Asthma

Time (seconds)

Volume

Note: Each FEV1 represents the highest of three reproducible measurements

Typical spirometric tracingsTypical spirometric tracings

FEV1

1 2 3 4 5

Normal

Asthma (after BD)

Asthma (before BD)

Volume

Normal

Asthma (after BD)

Asthma (before BD)

GINA 2014


Physical examination in people with asthmaPhysical examination in people with asthma Often normalOften normal

The most frequent finding is wheezing on auscultation, especially on The most frequent finding is wheezing on auscultation, especially on forced expirationforced expiration

Wheezing is also found in other conditions, for example:Wheezing is also found in other conditions, for example: Respiratory infectionsRespiratory infections

COPDCOPD

Upper airway dysfunctionUpper airway dysfunction

Endobronchial obstruction Endobronchial obstruction

Inhaled foreign bodyInhaled foreign body

Wheezing may be absent during severe asthma Wheezing may be absent during severe asthma exacerbations (‘silent chest’)exacerbations (‘silent chest’)

Diagnosis of asthma – physical Diagnosis of asthma – physical examinationexamination

GINA 2014


Step 1 – as-needed inhaled short-acting Step 1 – as-needed inhaled short-acting betabeta22-agonist (SABA) -agonist (SABA)

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

GINA 2014, Box 3-5, Step 1


Step 1 – as-needed inhaled short-acting Step 1 – as-needed inhaled short-acting betabeta22-agonist (SABA) -agonist (SABA)




Preferred option: as-needed inhaled short-acting Preferred option: as-needed inhaled short-acting betabeta22-agonist (SABA)-agonist (SABA) SABAs are highly effective for relief of asthma symptomsSABAs are highly effective for relief of asthma symptoms

However …. there is insufficient evidence about the However …. there is insufficient evidence about the safety of treating asthma with SABA alonesafety of treating asthma with SABA alone

This option should be reserved for patients with This option should be reserved for patients with infrequent symptoms (less than twice a month) of short infrequent symptoms (less than twice a month) of short duration, and with no risk factors for exacerbationsduration, and with no risk factors for exacerbations

Other optionsOther options Consider adding regular low dose inhaled corticosteroid Consider adding regular low dose inhaled corticosteroid

(ICS) for patients at risk of exacerbations (ICS) for patients at risk of exacerbations

Step 1 – as-needed reliever inhalerStep 1 – as-needed reliever inhaler

GINA 2014


Step 2 – low-dose controller + as-needed Step 2 – low-dose controller + as-needed inhaled SABAinhaled SABA




Preferred option: regular low dose ICS with as-needed inhaled SABAPreferred option: regular low dose ICS with as-needed inhaled SABA Low dose ICS reduces symptoms and reduces risk of exacerbations and Low dose ICS reduces symptoms and reduces risk of exacerbations and

asthma-related hospitalization and deathasthma-related hospitalization and death

Other optionsOther options Leukotriene receptor antagonists (LTRA) with as-needed SABALeukotriene receptor antagonists (LTRA) with as-needed SABA

• Less effective than low dose ICSLess effective than low dose ICS

• May be used for some patients with both asthma and allergic rhinitis, or if patient will not May be used for some patients with both asthma and allergic rhinitis, or if patient will not use ICS use ICS

Combination low dose ICS/long-acting beta2-agonist (LABA) Combination low dose ICS/long-acting beta2-agonist (LABA) with as-needed SABAwith as-needed SABA

• Reduces symptoms and increases lung function compared with ICSReduces symptoms and increases lung function compared with ICS

• More expensive, and does not further reduce exacerbationsMore expensive, and does not further reduce exacerbations

Intermittent ICS with as-needed SABA for purely seasonal allergic asthma with Intermittent ICS with as-needed SABA for purely seasonal allergic asthma with no interval symptomsno interval symptoms

• Start ICS immediately symptoms commence, and continue for Start ICS immediately symptoms commence, and continue for 4 weeks after pollen season ends4 weeks after pollen season ends

Step 2 – Low dose controller + as-Step 2 – Low dose controller + as-needed SABAneeded SABA

GINA 2014


Step 3 – one or two controllers + as-needed Step 3 – one or two controllers + as-needed inhaled relieverinhaled reliever





Before considering step-upBefore considering step-up Check inhaler technique and adherence, confirm diagnosisCheck inhaler technique and adherence, confirm diagnosis

Adults/adolescents: preferred options are either combination low dose ICS/LABA Adults/adolescents: preferred options are either combination low dose ICS/LABA maintenance with as-needed SABA, OR combination low dose ICS/formoterol maintenance with as-needed SABA, OR combination low dose ICS/formoterol maintenance and reliever regimen*maintenance and reliever regimen*

Adding LABA reduces symptoms and exacerbations and increases FEVAdding LABA reduces symptoms and exacerbations and increases FEV11, while allowing , while allowing

lower dose of ICSlower dose of ICS

In at-risk patients, maintenance and reliever regimen significantly reduces exacerbations In at-risk patients, maintenance and reliever regimen significantly reduces exacerbations with similar level of symptom control and lower ICS doses compared with other regimenswith similar level of symptom control and lower ICS doses compared with other regimens

Children 6-11 years: preferred option is medium dose ICS with Children 6-11 years: preferred option is medium dose ICS with as-needed SABAas-needed SABA

Other optionsOther options Adults/adolescents: Increase ICS dose or add LTRA or theophylline (less effective than Adults/adolescents: Increase ICS dose or add LTRA or theophylline (less effective than

ICS/LABA)ICS/LABA)

Children 6-11 years – add LABA (similar effect as increasing ICS)Children 6-11 years – add LABA (similar effect as increasing ICS)

Step 3 – one or two controllers + as-Step 3 – one or two controllers + as-needed inhaled relieverneeded inhaled reliever

*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterolGINA 2014


Step 4 – two or more controllers + as-needed Step 4 – two or more controllers + as-needed inhaled relieverinhaled reliever




Before considering step-upBefore considering step-up Check inhaler technique and adherenceCheck inhaler technique and adherence

Adults or adolescents: preferred option is combination low dose Adults or adolescents: preferred option is combination low dose ICS/formoterol as maintenance and reliever regimen*, ORICS/formoterol as maintenance and reliever regimen*, ORcombination medium dose ICS/LABA with as-needed SABAcombination medium dose ICS/LABA with as-needed SABA

Children 6–11 years: preferred option is to refer for expert Children 6–11 years: preferred option is to refer for expert adviceadvice

Other options (adults or adolescents)Other options (adults or adolescents) Trial of high dose combination ICS/LABA, but little extra benefit and Trial of high dose combination ICS/LABA, but little extra benefit and

increased risk of side-effectsincreased risk of side-effects

Increase dosing frequency (for budesonide-containing inhalers)Increase dosing frequency (for budesonide-containing inhalers)

Add-on LTRA or low dose theophyllineAdd-on LTRA or low dose theophylline

Step 4 – two or more controllers + Step 4 – two or more controllers + as-needed inhaled relieveras-needed inhaled reliever

GINA 2014

*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol


Step 5 – higher level care and/or add-on Step 5 – higher level care and/or add-on treatmenttreatment




Preferred option is referral for specialist investigation and Preferred option is referral for specialist investigation and consideration of add-on treatmentconsideration of add-on treatment If symptoms uncontrolled or exacerbations persist despite Step 4 If symptoms uncontrolled or exacerbations persist despite Step 4

treatment, check inhaler technique and adherence before referringtreatment, check inhaler technique and adherence before referring

Add-on omalizumab (anti-IgE) is suggested for patients with moderate Add-on omalizumab (anti-IgE) is suggested for patients with moderate or severe allergic asthma that is uncontrolled on Step 4 treatmentor severe allergic asthma that is uncontrolled on Step 4 treatment

Other add-on treatment options at Step 5 include:Other add-on treatment options at Step 5 include: Sputum-guided treatment: this is available in specialized centers; Sputum-guided treatment: this is available in specialized centers;

reduces exacerbations and/or corticosteroid dosereduces exacerbations and/or corticosteroid dose

Add-on low dose oral corticosteroids (≤7.5mg/day prednisone Add-on low dose oral corticosteroids (≤7.5mg/day prednisone equivalent): this may benefit some patients, but has significant equivalent): this may benefit some patients, but has significant systemic side-effects. Assess and monitor for osteoporosissystemic side-effects. Assess and monitor for osteoporosis

See Severe Asthma Guidelines (Chung et al, ERJ 2014) for more See Severe Asthma Guidelines (Chung et al, ERJ 2014) for more detaildetail

Step 5 – higher level care and/or Step 5 – higher level care and/or add-on treatmentadd-on treatment

GINA 2014


Low, medium and high dose inhaled Low, medium and high dose inhaled corticosteroids corticosteroids

Adults and adolescents (≥12 years)Adults and adolescents (≥12 years)

This is not a table of equivalence, but of estimated clinical comparabilityThis is not a table of equivalence, but of estimated clinical comparability

Most of the clinical benefit from ICS is seen at low dosesMost of the clinical benefit from ICS is seen at low doses

High doses are arbitrary, but for most ICS are those that, with prolonged use, High doses are arbitrary, but for most ICS are those that, with prolonged use, are associated with increased risk of systemic side-effectsare associated with increased risk of systemic side-effects

Inhaled corticosteroid Total daily dose (mcg)Low Medium High

Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000

Beclometasone dipropionate (HFA) 100–200 >200–400 >400

Budesonide (DPI) 200–400 >400–800 >800

Ciclesonide (HFA) 80–160 >160–320 >320

Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500

Mometasone furoate 110–220 >220–440 >440

Triamcinolone acetonide 400–1000 >1000–2000 >2000

GINA 2014, Box 3-6 (1/2)


Low, medium and high dose inhaled Low, medium and high dose inhaled corticosteroidscorticosteroids

Children 6–11 yearsChildren 6–11 years

This is not a table of equivalence, but of estimated clinical comparabilityThis is not a table of equivalence, but of estimated clinical comparability

Most of the clinical benefit from ICS is seen at low dosesMost of the clinical benefit from ICS is seen at low doses

High doses are arbitrary, but for most ICS are those that, with prolonged use, are High doses are arbitrary, but for most ICS are those that, with prolonged use, are associated with increased risk of systemic side-effectsassociated with increased risk of systemic side-effects

Inhaled corticosteroid Total daily dose (mcg)Low Medium High

Beclometasone dipropionate (CFC) 100–200 >200–400 >400

Beclometasone dipropionate (HFA) 50–100 >100–200 >200

Budesonide (DPI) 100–200 >200–400 >400

Budesonide (nebules) 250–500 >500–1000 >1000

Ciclesonide (HFA) 80 >80–160 >160

Fluticasone propionate (DPI) 100–200 >200–400 >400

Fluticasone propionate (HFA) 100–200 >200–500 >500

Mometasone furoate 110 ≥220–<440 ≥440

Triamcinolone acetonide 400–800 >800–1200 >1200

GINA 2014, Box 3-6 (2/2)


Case scenarioCase scenario 2 2

A 60 yr old male heavy smoker presented in A 60 yr old male heavy smoker presented in pulmonology outdoor with progressive pulmonology outdoor with progressive worsening of shortnes of breath for last one worsening of shortnes of breath for last one yr .he also complains or cough wth scanty yr .he also complains or cough wth scanty sputum .there is no diurnal variation or history sputum .there is no diurnal variation or history of wheezing .of wheezing .

What can be possible underlying conditionWhat can be possible underlying condition


On examination patient is of thin built with On examination patient is of thin built with B.p 150/90 mmHg pulse 88/min ,afebrile ,rr B.p 150/90 mmHg pulse 88/min ,afebrile ,rr 22/min.he was clubbed ,and cyanosed .chest 22/min.he was clubbed ,and cyanosed .chest movements limited breath sounds reduced movements limited breath sounds reduced vocal resonance increased vocal resonance increased

X-ray chest showed hyperinflated lungs with X-ray chest showed hyperinflated lungs with tubular hearttubular heart

FEV1/VC reduced FEV1/VC reduced

What can be ndelying lung condition?What can be ndelying lung condition?


Chronic obstructive pulmonary disease.Chronic obstructive pulmonary disease.

Bronchitis, emphysema, and asthma may Bronchitis, emphysema, and asthma may present alone or in combination.present alone or in combination.

AsthmaBronchitis

Emphysema


Chronic bronchitis. Chronic bronchitis. InsetInset, Weakened distal airways in emphysema, , Weakened distal airways in emphysema, a common secondary anatomic alteration of the lungsa common secondary anatomic alteration of the lungs..


Anatomic Alterations of the LungsAnatomic Alterations of the Lungs

Chronic inflammation and swelling of the Chronic inflammation and swelling of the peripheral airwaysperipheral airways

Excessive mucus production and Excessive mucus production and accumulationaccumulation

Partial or total mucus pluggingPartial or total mucus plugging

Hyperinflation of alveoli (air-trapping)Hyperinflation of alveoli (air-trapping)

Smooth muscle constriction of bronchial Smooth muscle constriction of bronchial airways (bronchospasm)airways (bronchospasm)


EtiologyEtiology

Cigarette smokingCigarette smoking

Atmospheric pollutantsAtmospheric pollutants

InfectionInfection

Gastroesophageal reflux diseaseGastroesophageal reflux disease


Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Associated Clinical Manifestations Associated

with CHRONIC BRONCHITISwith CHRONIC BRONCHITIS

The following clinical manifestations result from The following clinical manifestations result from the pathophysiologic mechanisms caused (or the pathophysiologic mechanisms caused (or activated) by activated) by Excessive Bronchial SecretionsExcessive Bronchial Secretions (see Figure 9-11) and (see Figure 9-11) and BronchospasmBronchospasm (see (see Figure 9-10)—the major anatomic alterations of Figure 9-10)—the major anatomic alterations of the lungs associated with chronic bronchitis the lungs associated with chronic bronchitis (see Figure 11-1).(see Figure 11-1).


Figure 9-11. Excessive bronchial secretions clinical scenario.Figure 9-11. Excessive bronchial secretions clinical scenario.


Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).


Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside

Vital signsVital signs

Increased respiratory rateIncreased respiratory rate

Increased heart rate, cardiac output, blood Increased heart rate, cardiac output, blood pressurepressure


Clinical Data Obtained at theClinical Data Obtained at the Patient’s Bedside Patient’s Bedside

Use of accessory muscles of inspirationUse of accessory muscles of inspiration

Use of accessory muscles of expirationUse of accessory muscles of expiration

Pursed-lip breathingPursed-lip breathing

Increased anteroposterior chest diameter Increased anteroposterior chest diameter (barrel chest)(barrel chest)

CyanosisCyanosis

Digital clubbingDigital clubbing


Figure 2-36. Figure 2-36. The way a patient may appear when using the The way a patient may appear when using the pectoralis major muscles for inspiration.pectoralis major muscles for inspiration.


Figure 2-41. Figure 2-41. A, Schematic illustration of alveolar compression of weakened bronchiolar A, Schematic illustration of alveolar compression of weakened bronchiolar airways during normal expiration in patients with chronic obstructive pulmonary disease airways during normal expiration in patients with chronic obstructive pulmonary disease (e.g., emphysema). B, Effects of pursed-lip breathing. The weakened bronchiolar airways (e.g., emphysema). B, Effects of pursed-lip breathing. The weakened bronchiolar airways

are kept open by the effects of positive pressure created by pursed lips during expiration.are kept open by the effects of positive pressure created by pursed lips during expiration.


Digital Clubbing

Figure 2-46. Digital clubbing.Figure 2-46. Digital clubbing.



Peripheral edema and venous distentionPeripheral edema and venous distention

Distended neck veinsDistended neck veins

Pitting edemaPitting edema

Enlarged and tender liverEnlarged and tender liver


DistendedDistendedNeck VeinsNeck Veins

Figure 2-48. Distended neck veins (Figure 2-48. Distended neck veins (arrowsarrows).).


Figure 2-47. Pitting edema. From Bloom A, Ireland J: Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetesColor atlas of diabetes, ed 2,, ed 2,London, 1992, Mosby-Wolfe.London, 1992, Mosby-Wolfe.



Cough, sputum production, hemoptysisCough, sputum production, hemoptysis

Chest assessment findingsChest assessment findings Hyperresonant percussion noteHyperresonant percussion note

Diminished breath soundsDiminished breath sounds

Diminished heart soundsDiminished heart sounds

Decreased tactile and vocal fremitusDecreased tactile and vocal fremitus

Crackles/rhonchi/wheezingCrackles/rhonchi/wheezing


Figure 2-12. Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.Percussion becomes more hyperresonant with alveolar hyperinflation.


Figure 2-17. Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive As air trapping and alveolar hyperinflation develop in obstructive lung diseases, breath sounds progressively diminish.lung diseases, breath sounds progressively diminish.


Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special

ProceduresProcedures


Pulmonary Function Study: Pulmonary Function Study: Expiratory Maneuver FindingsExpiratory Maneuver Findings

FVCFVC FEVFEVTT FEFFEF25%-75%25%-75% FEFFEF200-1200200-1200

PEFRPEFR MVVMVV FEFFEF50%50% FEVFEV1%1%


Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings

VVTT RV FRC TLC RV FRC TLC

N or N or N or N or

VCVC IC ERV RV/TLC ratio IC ERV RV/TLC ratio

N or N or

N or N or


Arterial Blood GasesArterial Blood Gases

Mild to Moderate Chronic BronchitisMild to Moderate Chronic Bronchitis

Acute alveolar hyperventilation with Acute alveolar hyperventilation with hypoxemiahypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)


Time and Progression of Disease Time and Progression of Disease

100100

5050

3030

8080

00

PaCO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaO2

Disease OnsetDisease OnsetP

aO2

or

PaC

O2

PaO

2 o

r P

aCO

2

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.


Arterial Blood GasesArterial Blood Gases

Severe Chronic BronchitisSevere Chronic Bronchitis

Chronic ventilatory failure with hypoxemiaChronic ventilatory failure with hypoxemia

pH PapH PaCOCO22 HCO HCO33-- Pa PaOO2 2

Normal Normal (Significantly)(Significantly)


Time and Progression of DiseaseTime and Progression of Disease

100100

5050

3030

80

0

PaO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaCO 2

Chronic Ventilatory Failure Chronic Ventilatory FailureDisease OnsetDisease Onset

Point at which disease becomes severe and patient begins to become fatigued

Point at which disease becomes severe and patient begins to become fatigued

Pa0

2 o

r P

aC0 2

Pa0

2 o

r P

aC0 2

Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.


Acute Ventilatory Changes Acute Ventilatory Changes Superimposed on Chronic Ventilatory Superimposed on Chronic Ventilatory

FailureFailure

Acute alveolar hyperventilation on chronic Acute alveolar hyperventilation on chronic ventilatory failureventilatory failure

Acute ventilatory failure on chronic Acute ventilatory failure on chronic ventilatory failureventilatory failure


Abnormal Laboratory Tests and Abnormal Laboratory Tests and ProceduresProcedures

Hematology Hematology Increased hematocrit and hemoglobinIncreased hematocrit and hemoglobin

Electrolytes Electrolytes Hypochloremia (chronic ventilatory failure)Hypochloremia (chronic ventilatory failure) Increased bicarbonate (chronic ventilatory failure)Increased bicarbonate (chronic ventilatory failure)

Sputum examinationSputum examination Increased white blood cellsIncreased white blood cells Streptococcus pneumoniaeStreptococcus pneumoniae Haemophilus influenzaeHaemophilus influenzae Moraxella catarrhalisMoraxella catarrhalis


Radiologic FindingsRadiologic Findings

Chest radiographChest radiograph

Translucent (dark) lung fieldsTranslucent (dark) lung fields

Depressed or flattened diaphragmsDepressed or flattened diaphragms

Long and narrow heartLong and narrow heart

Enlarged heartEnlarged heart


Figure 11-2. Chest X-ray film of a patient with chronic bronchitis. Note the translucent (dark) lung fields, depressed diaphragms, and long and narrow heart.


Radiologic FindingsRadiologic Findings

BronchogramBronchogram

Small spikelike protrusionsSmall spikelike protrusions


Figure 11-3. Chronic bronchitis. Bronchogram with localized view of left hilum. Rounded collections of contrast lie adjacent to bronchial walls and are particularly well seen below the left main stem bronchus (arrow) in this film. They are caused by contrast in dilated mucous gland ducts. (From Armstrong P, Wilson AG, Dee P: Imaging of diseases of the chest, St. Louis, 1990, Mosby.)


General Management of General Management of Chronic BronchitisChronic Bronchitis

Patient and family educationPatient and family education

Behavioral managementBehavioral management Avoidance of smoking and inhaled irritantsAvoidance of smoking and inhaled irritants

Avoidance of infectionsAvoidance of infections

Respiratory care treatment protocolsRespiratory care treatment protocols Oxygen therapy protocolOxygen therapy protocol

Bronchopulmonary hygiene therapy protocolBronchopulmonary hygiene therapy protocol

Aerosolized medication protocolAerosolized medication protocol

Mechanical ventilation protocolMechanical ventilation protocol


Global Initiative for Chronic

Obstructive

Lung

Disease

GOLD StandardsGOLD Standards


Figure 11-4. Acute exacerbation of COPD (AECOPD): Guideline algorithm (ACCP/ACP-ASIM). CXR, Chest X-ray; NPPV, noninvasive positive pressure ventilation; PEFR, peak expiratory flow rate; URI, upper respiratory infection. (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)


Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)








Figure 11-4. Acute exacerbation of COPD (AECOPD): Guideline algorithm (ACCP/ACP-ASIM). CXR, Chest X-ray; NPPV, noninvasive positive pressure ventilation; PEFR, peak expiratory flow rate; URI, upper respiratory infection. (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)


FLAIL CHESTFLAIL CHEST


A 22 yr old male presented in emergency A 22 yr old male presented in emergency department with history of road traffic trauma to department with history of road traffic trauma to chest he was ishirt of breath and was in severe chest he was ishirt of breath and was in severe painpain

What are possibilities?What are possibilities?


On examination patient was tachycadic and On examination patient was tachycadic and tachypnic cyanosed his chest wall moves in tachypnic cyanosed his chest wall moves in duing inspiration at certain points and out duing inspiration at certain points and out during expirationduring expiration

These findings suggest what?These findings suggest what?


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AnatomyAnatomy


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Overview of Chest InjuriesOverview of Chest Injuries

Can be life-threateningCan be life-threatening

May result in damage to either theMay result in damage to either the heart or the lung heart or the lung and cause severe internaland cause severe internal bleedingbleeding

Rib cage fractures may result in serious injury toRib cage fractures may result in serious injury to vital vital organsorgans

Deep, Deep, open open wounds allow air to enter the chestwounds allow air to enter the chest cavitycavity

ClosedClosed wounds usually involve injury to wounds usually involve injury to the ribs and the ribs and possibly underlying structurespossibly underlying structures


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Signs of Chest InjuriesSigns of Chest Injuries

An obvious chest woundAn obvious chest wound

Impaired breathingImpaired breathing

Irregular –Irregular – or lack ofor lack of – chest expansion– chest expansion

Coughing-up of bloodCoughing-up of blood

ShockShock

Subcutaneous emphysema: crackling Subcutaneous emphysema: crackling sensationsensation


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Closed Chest InjuriesClosed Chest Injuries

Rib fractureRib fracture

Flail chestFlail chest

PneumothoraxPneumothorax


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Rib FractureRib Fracture

Rib fractures are almost always the result of Rib fractures are almost always the result of trauma (a blow) to the rib cagetrauma (a blow) to the rib cage

Signs and SymptomsSigns and Symptoms leaning toward the injured side leaning toward the injured side

if the rib has punctured a lung, air can escape into the if the rib has punctured a lung, air can escape into the tissues of the chest wall creating a crackling sensation tissues of the chest wall creating a crackling sensation (- Subcutaneous Emphysema)(- Subcutaneous Emphysema)

unwillingness to take a deep breathunwillingness to take a deep breath

complaining of local pain and tendernesscomplaining of local pain and tenderness

pain when moving the rib cage when breathing or pain when moving the rib cage when breathing or coughingcoughing


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Rib FractureRib Fracture

TreatmentTreatment Give oxygenGive oxygen

Make the patient as comfortable as possibleMake the patient as comfortable as possible

Activate EMS and treat as Load and GoActivate EMS and treat as Load and Go

Transport patientTransport patient in the position of maximum comfort on the injured in the position of maximum comfort on the injured

sideside


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Flail ChestFlail Chest

Several adjacent ribs fractured in more than Several adjacent ribs fractured in more than one place can produce a loose section of the one place can produce a loose section of the chest wallchest wall

The flail section moves inward when the The flail section moves inward when the patient breathes in, and outward when the patient breathes in, and outward when the patient breathes outpatient breathes out

This phenomenon is known as paradoxical This phenomenon is known as paradoxical movementmovement


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Signs and symptomsSigns and symptoms shortness of breathshortness of breath

swelling over the injury siteswelling over the injury site

shockshock

muscle splinting of the injury sitemuscle splinting of the injury site

severe pain on inhalation/exhalationsevere pain on inhalation/exhalation

possible paradoxical movementpossible paradoxical movement


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TreatmentTreatment Give oxygen as soon as possibleGive oxygen as soon as possible

Be prepared to give ARBe prepared to give AR

Help the patient get in a comfortable position and Help the patient get in a comfortable position and transport to medical aidtransport to medical aid

Continue to monitor vital signsContinue to monitor vital signs

Unless there is substantial bleeding, do not apply Unless there is substantial bleeding, do not apply bulky padding or dressingsbulky padding or dressings


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Use of Dressings on a Flail ChestUse of Dressings on a Flail Chest

Only consider taped-on pad as a treatment in the following Only consider taped-on pad as a treatment in the following cases:cases: if there is likely to be a prolonged time before evacuation and access if there is likely to be a prolonged time before evacuation and access

to medical care to medical care

if the patient has fatigued their chest musclesif the patient has fatigued their chest muscles

To apply dressingsTo apply dressings Press the segment inward with your gloved hand to stabilize itPress the segment inward with your gloved hand to stabilize it

Splint in the inward position with a pillow, large bulky dressing, or Splint in the inward position with a pillow, large bulky dressing, or folded blanket or parkafolded blanket or parka

Secure this thoroughly in place with tapeSecure this thoroughly in place with tape

Be prepared to help breathing with ARBe prepared to help breathing with AR

Do not hold in place with bandages encircling the chest. This would Do not hold in place with bandages encircling the chest. This would further impair the patient’s breathing effortfurther impair the patient’s breathing effort


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IIs a condition that results froms a condition that results from air entering the air entering the interpleural space. The air in theinterpleural space. The air in the interpleural interpleural space compresses the lung andspace compresses the lung and prevents prevents normal breathing.normal breathing.

There are two types of pneumothorax:There are two types of pneumothorax: Tension pneumothoraxTension pneumothorax

Spontaneous pneumothoraxSpontaneous pneumothorax


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Signs and symptomsSigns and symptoms reduction of normal respiratory movements on the reduction of normal respiratory movements on the

affected sideaffected side

a fall in blood pressurea fall in blood pressure

weak and rapid pulseweak and rapid pulse

a sudden sharp chest paina sudden sharp chest pain


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Treatment for Tension PneumothoraxTreatment for Tension Pneumothorax Give oxygenGive oxygen

Activate EMS and treat as Load and GoActivate EMS and treat as Load and Go

Continue to monitor vital signsContinue to monitor vital signs

Treatment for Spontaneous PneumothoraxTreatment for Spontaneous Pneumothorax Give oxygenGive oxygen

Transport to medical aidTransport to medical aid

The patient may prefer to be transported sitting up.The patient may prefer to be transported sitting up.

Documents

Copyright © 2006 by Mosby, Inc. Slide 1 Respiratory system module AsthmaBronchitis Flail chest