Dr. isazaehfar

1. Obstructive and Inflammatory Lung Disease Dr. isazaehfar

2. Obstructive and Inflammatory Lung Disease • Emphysema • Chronic Bronchitis • Asthma

3. Chronic Obstructive Pulmonary Disease: COPD Disease of airflow obstruction that is not totally reversible • Chronic Bronchitis • Emphysema

4. New Definition • Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterized by airflow limitation that is not fully reversible. • The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. • Although COPD affects the lungs, it also produces significant systemic consequences.

5. COPD

6. COPD • In COPD, less air flows in and out of the airways because of one or more of the following: • The airways and air sacs lose their elastic quality. • The walls between many of the air sacs are destroyed. • The walls of the airways become thick and inflamed. • The airways make more mucus than usual, which tends to clog them.

7. COPD: Etiology • Cigarette smoking • Recurrent respiratory infection • Alpha 1-antitrypsin deficiency • Aging

8. Chronic Bronchitis • Recurrent or chronic productive cough for a minimum of 3 months for 2 consecutive years. • Risk factors • Cigarette smoke • Air pollution

9. Chronic Bronchitis Pathophysiology • Chronic inflammation • Hypertrophy & hyperplasia of bronchial glands that secrete mucus • Increase number of goblet cells • Cilia are destroyed

10. Chronic Bronchitis Pathophysiology • Narrowing of airway • Starting w/ bronchi  smaller airways • airflow resistance • work of breathing • Hypoventilation & CO2 retention  hypoxemia & hypercapnea

11. Chronic Bronchitis Pathophysiology • Bronchospasm often occurs • End result • Hypoxemia • Hypercapnea • Polycythemia (increase RBCs) • Cyanosis • Cor pulmonale (enlargement of right side of heart)

12. Chronic Bronchitis: Clinical Manifestations • In early stages • Clients may not recognize early symptoms • Symptoms progress slowly • May not be diagnosed until severe episode with a cold or flu • Productive cough • Especially in the morning • Typically referred to as “cigarette cough” • Bronchospasm • Frequent respiratory infections

13. Chronic Bronchitis: Clinical Manifestations • Advanced stages • Dyspnea on exertion Dyspnea at rest • Hypoxemia & hypercapnea • Polycythemia • Cyanosis • Bluish-red skin color • Pulmonary hypertension Cor pulmonale

14. Chronic Bronchitis: Diagnostic Tests • PFTs • FVC:  Forced vital capacity • FEV1:  Forcible exhale in 1 second • FEV1/FVC = <70% • ABGs •  PaCO2 •  PaO2 • CBC •  Hct

15. Emphysema • Abnormal distension of air spaces • Actual cause is unknown • Abnormal permanent enlargement of the airspaces distal to the terminal bronchioles accompanying destruction of the airspaces walls

16. Emphysema: Pathophysiology • Structural changes • Hyperinflation of alveoli • Destruction of alveolar & alveolar-capillary walls • Small airways narrow • Lung elasticity decreases

17. Emphysema: Pathophysiology • Mechanisms of structural change • Obstruction of small bronchioles • Proteolytic enzymes destroy alveolar tissue • Elastin & collagen are destroyed • Support structure is destroyed • “paper bag” lungs

18. Emphysema: Pathophysiology • The end result: • Alveoli lose elastic recoil, then distend, & eventually blow out. • Small airways collapse or narrow • Air trapping • Hyperinflation • Decreased surface area for ventilation

19. Emphysema: Clinical Manifestations • Early stages • Dyspnea • Non productive cough • Diaphragm flattens • A-P diameter increases • “Barrel chest” • Hypoxemia may occur • Increased respiratory rate • Respiratory alkalosis • Prolonged expiratory phase

20. Emphysema: Clinical Manifestations • Later stages • Hypercapnea • Purse-lip breathing • Use of accessory muscles to breathe • Underweight • No appetite & increase breathing workload • Lung sounds diminished

21. Emphysema: Clinical Manifestations

23. COPDSymptoms • Productive cough • Breathlessness • Chest infection • Other symptoms of COPD can be more vague, weight loss, tiredness and ankle swelling.

24. Emphysema: Clinical Manifestations • Pulmonary function •  residual volume,  lung capacity, DECREASED FEV1, vital capacity maybe normal • Arterial blood gases • Normal in moderate disease • May develop respiratory alkalosis • Later: hypercapnia and respiratory acidosis • Chest x-ray • Flattened diaphragm • hyperinflation

25. COPDDiagnostic tests • Symptoms • Physical examination • Sample of sputum • Chest x-ray • High-resolution CT (HRCT scan) • Pulmonary function test (spirometery) • Arterial blood gases test • Pulse oximeter

27. Goals of Treatment: Emphysema & Chronic Bronchitis • Improved ventilation • Remove secretions • Prevent complications • Slow progression of signs & symptoms • Promote patient comfort and participation in treatment

28. Collaborative Care: Emphysema & Chronic Bronchitis • Treat respiratory infection • Monitor spirometry and PEFR • Nutritional support • Fluid intake 3 lit/day • O2 as indicated

29. Collaborative Care: Medications • Anti-inflammatory • Corticosteroids • Bronchodilators • Beta-adrenergic agonist: Proventil • Methylxanthines: Theophylline • Anticholinergics: Atrovent • Mucolytics: Mucomyst • Expectorants: Guaifenisin • Antihistamines: non-drying

30. Collaborative Care: Emphysema & Chronic Bronchitis • Client teaching • Support to stop smoking • Conservation of energy • Breathing exercises • Pursed lip breathing • Diaphragm breathing • Chest physiotherapy • Percussion, vibration • Postural drainage • Self-manage medications • Inhaler & oxygen equipment

31. COPDMedical management • Give antibiotics to treat infection • Give bronchodilators to relieve bronchospasm, reduce airway obstruction, mucosal edema and liquefy secretions. • Chest physiotherapy and postural drainage to improve pulmonary ventilation. • Proper hydration helps to cough up secretions or tracheal suctioning when the patient is unable to cough. • Steroid therapy if the patient fails to respond to more conservative treatment.

32. COPD classification based on spirometry SPIROMETRY is not to substitute for clinical judgment in the evaluation of the severity of disease in individual patients.

33. Management based on GOLD Post-bronchodilatorFEV1(% predicted)

34. COPDPreventive measures • To prevent irritation and infection of the airways, instruct the patient to: • Avoid exposure to cigarette, pipe, and cigar smoke as well as to dusts and powders. • Avoid use of aerosol sprays. • Stay indoors when the pollen count is high. • Stay indoors when temperature and humidity are both high

35. COPDPreventive measures (cont…) • Use air conditioning to help decrease pollutants and control temperature • Avoid exposure to persons known to have colds or other respiratory tract infection • Avoid enclosed, crowded areas during cold and flu season. • Obtain immunization against influenza and streptococcal pneumonia.

36. COPDPreventive measures (cont…) • To ensure prompt, effective treatment of a developing respiratory infection, instruct the patient to do the following:- • Report any change in sputum color character, increased tightness of the chest, increased dyspnea, or fatigue. • Call the physician if ordered antibiotics do not relieve symptoms within 24 hours.

37. Asthma • Reversible inflammation & obstruction • Intermittent attacks • Sudden onset • Varies from person to person • Severity can vary from shortness of breath to death

38. Difference between COPD and Asthma • In COPD there is permanent damage to the airways. The narrowed airways are fixed, and so symptoms are chronic (persistent). Treatment to open up the airways, is therefore limited. • In asthma there is inflammation in the airways which makes the muscles in the airways constrict. This causes the airways to narrow. The symptoms tend to come and go, and vary in severity from time to time. Treatment to reduce inflammation and to open up the airways usually works well. • COPD is more likely than asthma to cause a chronic (ongoing) cough with sputum.

39. Difference between COPD and asthma (cont…) • Night time waking with breathlessness or wheeze is common in asthma and uncommon in COPD. • COPD is rare before the age of 35 whilst asthma is common in under-35.

40. Asthma • Triggers • Allergens • Exercise • Respiratory infections • Drugs and food additives • Nose and sinus problems • GERD • Emotional stress

41. Asthma: Pathophysiology • Swelling of mucus membranes (edema) • Spasm of smooth muscle in bronchioles • Increased airway resistance • Increased mucus gland secretion

42. Asthma: Pathophysiology • Early phase response: 30 – 60 minutes • Allergen or irritant activates mast cells • Inflammatory mediators are released • histamine, bradykinin, leukotrienes, prostaglandins, platelet-activating-factor, chemotactic factors, cytokines • Intense inflammation occurs • Bronchial smooth muscle constricts • Increased vasodilation and permeability • Epithelial damage • Bronchospasm • Increased mucus secretion • Edema

43. Asthma: Pathophysiology • Late phase response: 5 – 6 hours • Characterized by inflammation • Eosinophils and neutrophils infiltrate • Mediators are released mast cells release histamine and additional mediators • Self-perpetuating cycle • Lymphocytes and monocytes invade as well • Future attacks may be worse because of increased airway reactivity that results from late phase response • Individual becomes hyperresponsive to specific allergens and non-specific irritants such as cold air and dust • Specific triggers can be difficult to identify and less stimulation is required to produce a reaction

44. Asthma: Early Clinical Manifestations • Expiratory & inspiratory wheezing • Dry or moist non-productive cough • Chest tightness • Dyspnea • Anxious &Agitated • Prolonged expiratory phase • Increased respiratory & heart rate • Decreased PEFR

45. Asthma: Early Clinical Manifestations • Wheezing • Chest tightness • Dyspnea • Cough • Prolonged expiratory phase [1:3 or 1:4]

46. Asthma: Severe Clinical Manifestations • Hypoxia • Confusion • Increased heart rate & blood pressure • Respiratory rate up to 40/minute & pursed lip breathing • Use of accessory muscles • Diaphoresis & pallor • Cyanotic nail beds • Flaring nostrils

47. Endotracheal Intubation

48. Classifications of Asthma • Mild intermittent • Mild persistent • Moderate persistent • Severe persistent

49. Asthma: Diagnostic Tests • Pulmonary Function Tests • FEV1 decreased • Increase of 12% - 15% after bronchodilator indicative of asthma • PEFR decreased • Symptomatic patient • eosinophils > 5% of total WBC • Increased serum IgE • Chest x-ray shows hyperinflation • ABGs • Early: respiratory alkalosis, PaO2 normal or near-normal • severe: respiratory acidosis, increased PaCO2,

50. Asthma: Collaborative Care • Mild intermittent • Avoid triggers • Premedicate before exercising • May not need daily medication • Mild persistent asthma • Avoid triggers • Premedicate before exercising • Low-dose inhaled corticosteroids