Transcript Obstructive_Lung_Disease_slides

OBSTRUCTIVE AND RESTRICTIVE
LUNG DISEASE
JED WOLPAW MD, M.ED
OUTLINE
• OBSTRUCTIVE DISEASE
• UPPER AIRWAY
• EXTRATHORACIC
• INTRATHORACIC
• LOWER AIRWAY/PARENCHYMAL
• RESTRICTIVE DISEASE
• NEUROLOGIC
• MUSKULOSKELETAL
• PARENCHYMAL
• PLEURAL AND MEDIASTINAL
• OTHER
OBSTRUCTIVE DISEASE:
UPPER AIRWAY
UPPER AIRWAY
• FROM MOUTH
TO LOWER
TRACHEA
INTRA VS EXTRATHORACIC
• WHICH LESION LIMITS INSPIRATORY FLOW THE MOST?
• A: VARIABLE UPPER AIRWAY EXTRATHORACIC OBSTRUCTION
• B: VARIABLE UPPER AIRWAY INTRATHORACIC OBSTRUCTION
• C: COPD
• D: ASTHMA
INTRA VS EXTRATHORACIC
• WHICH LESION LIMITS INSPIRATORY FLOW THE MOST?
• A: VARIABLE UPPER AIRWAY EXTRATHORACIC
OBSTRUCTION
• B: VARIABLE UPPER AIRWAY INTRATHORACIC OBSTRUCTION
• C: COPD
• D: ASTHMA
INTRA VS EXTRA THORACIC
HOW TO READ A FLOW VOLUME LOOP
Where is:
-Flow?
-Volume?
-Inspiration?
-Expiration?
Where is:
-Total Lung Capacity?
-End Exhilation (residual volume)?
HOW TO READ A FLOW/VOLUME LOOP
NAME THAT OBSTRUCTION
INTRATHORACIC VERSUS EXTRATHORACIC
VOLUME IS THE SAME, FLOW IS LIMITED
LESIONS AT THE THORACIC INLET
Starts intrathoracic
Shifts to extrathoracic
FEF50%/FIF50%
• FORCED EXPIRATORY FLOW AT 50% VITAL CAPACITY/FORCED INSPIRATORY FLOW AT 50% VC
• EXTRATHORACIC: INCREASED TO AVERAGE 2.2 FROM NORMAL 1
• INTRATHORACIC: DECREASED TO AVERAGE 0.32 FROM NORMAL 1
• FIXED OBSTRUCTION: AROUND 1
CAUSES OF UPPER AIRWAY OBSTRUCTION:
INTRA OR EXTRATHORACIC DEPENDING ON LOCATION
• CONGENITAL: TRACHEOMALACIA (UPPER), LARYNGOMALACIA, VOCAL CORD ABNORMALITIES,
VASCULAR RINGS, LARYNGEAL WEBS, SCOLIOSIS (CAN COMPRESS TRACHEA)
• INFECTIOUS: EPIGLOTTITIS, PERITONSILLAR ABSCESS, RETROPHARYNGEAL ABSCESS, LUDWIG’S
ANGINA, DIPTHERIA, CROUP
• TUMORS
• TRAUMA: NECK HEMATOMA, FRACTURE, BURNS
• FOREIGN BODY
• SOFT TISSUE: OSA, NERVE PALSIES
OBSTRUCTIVE DISEASE:
LOWER AIRWAY/PARENCHYMAL
LOWER AIRWAY/PARENCHYMAL OBSTRUCTIVE DISEASES
• ASTHMA
• EMPHYSEMA
• BRONCHITIS
• CF: BRONCHIECTASIS
• MEDIASTINAL MASSES
MECHANISMS
• OFFICIALLY THESE ARE NO LONGER SEPARATED AND ARE ALL COPD (IF ASTHMA ISN’T
COMPLETELY REVERSIBLE
• ASTHMA: THICKENED/TIGHTENED AIRWAY SMOOTH MUSCLE AND EXCESS MUCOUS
• CD4+ CELLS, T LYMPHOCYTES, EOSINOPHILS, IL-4 AND IL-5
• EMPHYSEMA: DILATION/DESTRUCTION OF AIRWAY DISTAL TO TERMINAL BRONCHIOLE
(ACINUS)
• CD8+ T-LYMPHOCYTES, NEUTROPHILS, AND CD68+ MONOCYTES/MACROPHAGES
• CHRONIC BRONCHITIS: EXCESS MUCOUS, AIRWAY THICKENING
• CD8+ T-LYMPHOCYTES, NEUTROPHILS, AND CD68+ MONOCYTES/MACROPHAGES
COPD/ASTHMA/BRONCHITIS OVERLAP
ACINUS
LOOPS
SPIROMETRY
• FVC: FORCED VITAL CAPACITY
• FEV1: FORCED EXPIRATORY VOLUME
• FEV1/FVC: RATIO OF THESE TWO
• FEF 25-75%: FORCED EXPIRATORY FLOW FROM 25-75% OF VITAL CAPACITY
• THOUGHT TO BE EFFORT INDEPENDENT
• MVV: MAXIMUM VOLUNTARY EXPIRATION (HOW MUCH CAN ONE INHALE AND EXHALE IN 1
MINUTE)
SPIROMETRY
DLCO (DIFFUSION CAPACITY FOR CARBON
MONOXIDE)
• MEASURES THE ABILITY OF THE LUNGS TO TRANSFER O2 TO THE BLOOD
• OBSTRUCTIVE DISEASE
• CORRELATES WITH DEGREE OF EMPHYSEMA
• SMOKERS WITH AIRWAY OBSTRUCTION BUT NORMAL DLCO HAVE BRONCHITIS BUT NOT
EMPHYSEMA
• ASTHMATICS HAVE NORMAL OR HIGH DLCO
• CYSTIC FIBROSIS: NORMAL UNTIL VERY LATE IN DISEASE
CYSTIC FIBROSIS
• MUTATION IN CFTR LEADING TO INABILITY TO TRANSPORT CHLORIDE AND SODIUM
• AUTOSOMAL RECESSIVE
• MULTIPLE ORGAN SYSTEMS EFFECTED, WE WILL FOCUS ON RESPIRATORY
• LIFE EXPECTANCY AVERAGE 39 YEARS
WHAT IS BRONCHIECTASIS
• A: CHRONIC AIRWAY INFECTION
• B: RECURRENT PNEUMONIA IN CYSTIC FIBROSIS
• C: DILATION OF AIRWAYS DUE TO WALL DESTRUCTION
• D: BEING THE SUBJECT OF EXCESS BRONCHOSCOPIES
WHAT IS BRONCHIECTASIS
• A: CHRONIC AIRWAY INFECTION
• B: RECURRENT PNEUMONIA IN CYSTIC FIBROSIS
•C: DILATION OF AIRWAYS DUE TO WALL
DESTRUCTION
• D: BEING THE SUBJECT OF EXCESS BRONCHOSCOPIES
CF: BRONCHIECTASIS
• INABILITY TO TRANSPORT CL- AND NA+ EFFECTIVELY LEADS TO THICKENED SECRETIONS
• LEADS TO COLONIZATION W ORGANISMS
• LEADS TO MASSIVE INFLAMMATION FROM NEUTROPHIL DEGRANULATION
• LEADS TO DESTRUCTION OF BRONCHUS WALLDILATION OF AIRWAYS
• LEADS TO MORE MUCOUS
• LEADS TO MORE INFECTION
BRONCHIECTASIS
CF: WHY PSEUDOMONAS?
• INCREASED O2 UTILIZATION BY LUNG EPITHELIAL CELLS CAUSES LOCAL HYPOXIA
• THIS CAUSES PSEUDOMONAS TO GAIN THE ABILITY TO MAKE BIOFILMS
• ALMOST IMPOSSIBLE TO ERADICATE AT THAT POINT
MEDIASTINAL MASSES
• ANTERIOR, MIDDLE AND POSTERIOR MEDIASTINUM
• FOR AIRWAY COMPROMISE MOST SIGNIFICANT IS ANTERIOR
• MOST COMMON: TERRIBLE T’S
• TERATOMA
• THYMOMA
• THYROID TISSUE
• “TERRIBLE LYMPHOMA”
WHAT IS THE SAFEST WAY TO INDUCE A PATIENT
WITH AN ANTERIOR MEDIASTINAL MASS
COMPRESSING THE AIRWAY?
• A: RSI WITH SUX AND ETOMIDATE
• B: ASLEEP FIBER
• C: AWAKE FIBER WITH SURGEON STANDING BY READY TO PERFORM TRACHEOSTOMY
• D: AWAKE FIBER AFTER CANNULATING GROIN VESSELS FOR ECMO
WHAT IS THE SAFEST WAY TO INDUCE A PATIENT
WITH AN ANTERIOR MEDIASTINAL MASS
COMPRESSING THE AIRWAY?
• A: RSI WITH SUX AND ETOMIDATE
• B: ASLEEP FIBER
• C: AWAKE FIBER WITH SURGEON STANDING BY READY TO PERFORM TRACHEOSTOMY
• D: AWAKE FIBER AFTER CANNULATING GROIN VESSELS
FOR ECMO
MEDIASTINAL MASS CXR
MEDIASTINAL MASS
• CAN CAUSE BOTH OBSTRUCTIVE (COMPRESSING TRACHEA) OR RESTRICTIVE (REDUCING
COMPLIANCE OF LUNGS) PATHOLOGY
• CAN COMPRESS:
• AIRWAYS
• VESSELS (SVC)
• HEART
MEDIASTINAL MASS
• PREPARATION
• GROIN LINE IN CASE OF SVC OBSTRUCTION
• AWAKE INTUBATION WITH SPONTANEOUS VENTILATION IN CASE OF AIRWAY OBSTRUCTION
• AVOID NEUROMUSCULAR BLOCKADE IF POSSIBLE
• IF IMAGING/SYMPTOMS VERY CONCERNING CANNULATE FOR ECMO/BYPASS FIRST
• CRICHOTHYROTOMY WILL NOT HELP HERE
ALL THE LOOPS