Transcript Chapter 7 Body Systems - Kingwood Application Server

Chapter 14
Bronchiectasis
C
A
B
E
D
Figure 14–1. Bronchiectasis. A, Varicose bronchiectasis. B, Cylindrical bronchiectasis. C,
Saccular bronchiectasis. Also illustrated are excessive bronchial secretions (D) and
atelectasis (E), which are both common anatomic alterations of the lungs in this disease.
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Three Forms of Bronchiectasis
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
Varicose bronchiectasis

Cylindrical bronchiectasis

Saccular bronchiectasis
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Anatomic Alterations of the Lungs
Slide 3

Chronic dilation and distortion of bronchial airways

Excessive production of often foul-smelling sputum

Smooth muscle constriction of bronchial airways

Hyperinflation of alveoli (air-trapping)

Atelectasis, consolidation, and parenchymal fibrosis

Hemorrhage secondary to bronchial arterial erosion
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Etiology


Slide 4
Acquired bronchiectasis

Recurrent pulmonary infection

Bronchial obstruction
Congenital bronchiectasis

Kartagener’s syndrome

Hypogammaglobulinemia

Cystic fibrosis
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Overview of the Cardiopulmonary
Clinical Manifestations Associated
with BRONCHIECTASIS
The following clinical manifestations result from the
pathophysiologic mechanisms caused (or activated)
by Atelectasis (see Figure 9-12), Consolidation
(see Figure 9-8), Bronchospasm (see Figure 9-10),
and Excessive Bronchial Secretions (see Figure
9-11)—the major anatomic alterations of the lungs
associated with bronchiectasis (see Figure 14-1).
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Figure 9-7. Atelectasis clinical scenario.
Slide 6
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Figure 9-8. Alveolar consolidation clinical scenario.
Slide 7
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Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.
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Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).
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Figure 9-11. Excessive bronchial secretions clinical scenario.
Slide 10
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Clinical Data Obtained at the
Patient’s Bedside
Vital signs
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
Increased respiratory rate

Increased heart rate, cardiac output,
blood pressure
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Clinical Data Obtained at the
Patient’s Bedside
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
Use of accessory muscles of inspiration

Use of accessory muscles of expiration

Pursed-lip breathing

Increased anteroposterior chest diameter
(barrel chest)

Cyanosis

Digital clubbing
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Figure 2-36. The way a patient may appear when using the
pectoralis major muscles for inspiration.
Slide 13
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Figure 2-41. A, Schematic illustration of alveolar compression of weakened bronchiolar
airways during normal expiration in patients with chronic obstructive pulmonary disease
(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.
Slide 14
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Digital
Clubbing
Figure 2-46. Digital clubbing.
Slide 15
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Clinical Data Obtained at the
Patient’s Bedside

Slide 16
Peripheral edema and venous distention

Distended neck veins

Pitting edema

Enlarged and tender liver
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Distended
Neck Veins
Figure 2-48. Distended neck veins (arrows).
Slide 17
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Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2,
London, 1992, Mosby-Wolfe.
Slide 18
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
Cough, sputum production, and hemoptysis

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A chronic cough with production of large quantities
of foul-smelling sputum is a hallmark of
bronchiectasis
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Clinical Data Obtained at the
Patient’s Bedside
Chest assessment findings (primarily obstructive)
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Decreased tactile and vocal fremitus
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Hyperresonant percussion note
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Diminished breath sounds

Rhonchi and Wheezing
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Clinical Data Obtained at the
Patient’s Bedside
Chest assessment findings (primarily restrictive)
Slide 21

Increased tactile and vocal fremitus

Bronchial breath sounds
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Crackles

Whispered pectoriloquy

Dull percussion note
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Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.
Slide 22
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Slide 23
Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive
lung diseases, breath sounds progressively diminish.
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Clinical Data Obtained from
Laboratory Tests and Special
Procedures
Slide 24
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Pulmonary Function Study:
Expiratory Maneuver Findings
Primarily Obstructive
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FVC

FEVT

FEF25%-75%

FEF200-1200

PEFR
MVV
FEF50%
FEV1%




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Pulmonary Function Study:
Lung Volume and Capacity Findings
Primarily Obstructive
VT
N or 
VC

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RV
FRC


N or 
ERV
N or 
RV/TLC ratio

IC
N or 
TLC
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Pulmonary Function Study:
Expiratory Maneuver Findings
Primarily Restrictive
FVC

FEVT
N or 
FEF25%-75%
N or 
FEF200-1200
N
PEFR
MVV
FEF50%
FEV1%
N
Slide 27
N or 
N
N or 
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Pulmonary Function Study:
Lung Volume and Capacity Findings
Primarily Restrictive
VT
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RV
FRC
TLC
N or 



VC

IC

ERV

RV/TLC ratio
N
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Arterial Blood Gases
Mild to Moderate Bronchiectasis

pH

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Acute alveolar hyperventilation with
hypoxemia
PaCO2

HCO3 (Slightly)
PaO2

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Time and Progression of Disease
Disease Onset
Alveolar Hyperventilation
100
90
PaO2 or PaCO2
80
Point at which PaO2
declines enough to
stimulate peripheral
oxygen receptors
70
60
PaO2
50
40
30
20
10
0
Figure 4-2. PaO2 and PaC02 trends during acute alveolar hyperventilation.
Slide 30
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Arterial Blood Gases
Severe Bronchiectasis

Chronic ventilatory failure with hypoxemia
pH
Normal
Slide 31
PaCO2

HCO3PaO2
 (Significantly) 
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Time and Progression of Disease
Disease Onset
Alveolar Hyperventilation
Chronic Ventilatory Failure
100
90
Pa02 or PaC02
80
70
Point at which PaO2
declines enough to
stimulate peripheral
oxygen receptors
Point at which disease
becomes severe and patient
begins to become fatigued
60
50
40
30
20
10
0
Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.
Slide 32
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Acute Ventilatory Changes on
Chronic Ventilatory Failure
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Acute alveolar hyperventilation on chronic
ventilatory failure

Acute ventilatory failure on chronic ventilatory
failure
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Oxygenation Indices
QS/QT
DO2
VO2


Normal
O2ER

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C(a-v)O2
Normal
SvO2

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Hemodynamic Indices
(Severe Chronic Bronchiectasis)
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CVP
RAP
PA
PCWP



Normal
CO
SV
SVI
CI
Normal
Normal
Normal
Normal
RVSWI
LVSWI
PVR
SVR

Normal

Normal
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Abnormal Laboratory Tests
and Procedures
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Hematology
(Increased hematocrit and hemoglobin)
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Sputum examination

Streptococcus pneumoniae

Haemophilus influenzae
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Pseudomonas aeruginosa

Anaerobic organisms
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Radiologic Findings

Slide 37
Chest radiograph
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Translucent (dark) lung fields
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Depressed or flattened diaphragm
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Long and narrow heart
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Enlarged heart

Bronchogram

CT scan
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Figure 14-2. Cylindrical bronchiectasis. Left posterior oblique projection of a left bronchogram
showing cylindrical bronchiectasis affecting the whole of the lower lobe except for the superior
segment. Few side branches fill. Basal airways are crowded together, indicating volume loss of
the lower lobe, a common finding in bronchiectasis. (From Armstrong P et al: Imaging of
diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
Slide 38
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Figure 14-3. Saccular bronchiectasis. Right lateral bronchogram showing
saccular bronchiectasis affecting mainly the lower lobe and posterior
segment of the upper lobe. (From Armstrong P et al: Imaging of diseases of
the chest, ed 2, St. Louis, 1995, Mosby.)
Slide 39
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Figure 14-4. Varicose bronchiectasis. Left posterior oblique projection of left
bronchogram in a patient with the ciliary dyskinesia syndrome. All basal
bronchi are affected by varicose bronchiectasis. (From Armstrong P et al:
Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
Slide 40
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Figure 14-5. Bronchiectasis. High-resolution thin-section (1.5-mm) computed tomographic
(HRCT) scan showing numerous oval and rounded ring opacities in the left lower lobe. The
right lung appears normal. The fact that the airways tend to be arranged in a linear fashion
and have walls of more than hairline thickness helps distinguish these bronchiectatic
airways from cysts or bullae. (From Armstrong P, Wilson AG, Dee P: Imaging of diseases
of the chest, St. Louis, 1990, Mosby.)
Slide 41
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General Management of
Bronchiectasis
General treatment includes:
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Controlling pulmonary infections

Controlling airway secretions

Preventing complications
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General Management of
Bronchiectasis
Respiratory care treatment protocols
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Oxygen therapy protocol
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Bronchopulmonary hygiene therapy protocol
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Hyperinflation therapy protocol
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Aerosolized medication protocol

Mechanical ventilation protocol
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General Management of
Bronchiectasis
Other medications commonly prescribed
by the physician
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Xanthines

Expectorants

Antibiotics
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Classroom Discussion
Case Study: Bronchiectasis
Slide 45
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