Transcript Obstructive Diseases - Respiratory Therapy Files

Chronic Obstructive
Pulmonary Disease
•
ystic Fibrosis
•
ronchitis – Chronic
•
sthma
•
ronchiectasis
•
mphysema
Chronic Obstructive
Pulmonary Disease
• Smoking
• #1 cause of COPD
• Increased mucous production
• Inhibition of mucociliary clearance
• Toxicity of inhaled gases and particulates
• Bronchospasm
• Decrease in macrophage activity
• Disruption of the alveolar wall and capillary endothelium
Epidemiology
• Some 16 Million Americans are affected
• COPD is the 3rd leading cause of death in the U.S.
• COPD causes millions of hospital admissions per year
• Total health expenditure of $32.1 Billion in 2000
• Most common form of COPD is Chronic Bronchitis
Risk Factors for COPD
1. Cigarette smoking/passive smoking
2. Pollution
3. Occupational exposure to dust and fumes
4. Recurrent lung infections
5. Hereditary factors
6. Allergies
7. Socioeconomic factors
8. Alcohol ingestion
9. Age
General Manifestations of
COPD
1. Small airways ( < 2mm) are most susceptible to airway obstruction in COPD
2. Diagnosed by Pulmonary Function Testing, clinical signs and symptoms
3. Early to middle manifestations of COPD include:
I. Changes in pulmonary function testing
II. Shortness of breath with exertion
III. Changes in CXR
IV. Increases in sputum production
V. Cough
VI. Recurrent pulmonary infections
VII. Wheezing
4. Late manifestations of COPD include:
I. Accessory muscle usage
II. Edema from Cor Pulmonale
III. Mental status changes from chronic hypoxia/hypercapnea
IV. Clubbing of fingers
V. Barrel Chest or Increased A-P Diameter
What is Emphysema?
 Loss of elastic recoil
 This loss of recoil leads to
an increased compliance
and inability to expel gas
out of the alveoli
 Leading to trapped air in
the lung
 Alveoli cluster together
forming “bullae”
What is Emphysema Cont…
 Damage occurs to the tiny airways in the lungs called
bronchioles. Bronchioles are joined to alveoli, tiny
grape-like clusters of sacs in the lungs where oxygen
from the air is exchanged for carbon dioxide from the
body. The elastic properties of the lung reside in the
tissue around the alveoli
 Because the lungs lose elasticity they become less
able to retract
 This prevents the alveoli from deflating completely,
and the person has difficulty exhaling.
Emphysema Cont…
• Hence, the next breath is started with more air in the lungs.
• The trapped "old" air takes up space, so the alveoli are unable
to fill with enough fresh air to supply the body with needed
oxygen.
Pulmonary Emphysema
• Centrilobular emphysema
• Abnormal weakening and
enlargement of the respiratory
bronchioles in the proximal
portion of the acinus
• Primary changes occur in upper
lobes
• High correlation with smoking
Pulmonary Emphysema
• Bullous emphysema
• Changes seen at
both respiratory
bronchiole and
alveolar levels
• Prominent bullae
formation (air
spaces greater
than 1 cm in
diameter)
Emphysema
 Typically, symptoms of emphysema appear only
after 30 to 50 percent of lung tissue is lost.
 Emphysema rates are highest for men age 65 and
older.
 More people in the Midwest have emphysema
than in any other region in the country.
 Emphysema is an irreversible disease that can be
slowed but not reversed or stopped.
Accessory muscle use
Causes
• Generally, lungs become damaged because of
reactions to irritants entering the airways and
alveoli. Researchers continue to investigate the
factors that may make some people more
susceptible to emphysema than others. But
there are some clear causes for emphysema:
• Cigarette smoking
• Alpha-1 antitrypsin deficiency
Causes
 Cigarette smoking is the major cause of emphysema. When exposed
to cigarette smoke, the air sacs of the lungs produce defensive cells,
called macrophages, which "eat" the inhaled particles. But
macrophages are stimulated to release materials which can destroy
the proteins that let the lungs expand and contract, called elastin
and collagen .
 Cigarette smoke also damages the cilia, tiny hair-like projections in
the bronchi that "sweep" foreign bodies and bacteria out of the
lungs
Other Cause
Alpha-1 Antitrypsin Deficiency
• People who a deficiency of a protein called alpha-1 antitrypsin
(AAT) are at a higher risk of developing severe emphysema.
Alpha-1 antitrypsin deficiency (AAT deficiency) is an inherited
condition and occurs in varying degrees
AAT
• AAT is thought to protect against some of the
damage caused by macrophages. In AAT
deficiency-related emphysema, the walls of the
bronchial tubes and the alveoli are both
damaged, often leading to severe disease.
• About 2 out of every 1,000 people have an
alpha-1 antitrypsin deficiency. People who
smoke and have AAT deficiency are almost
certain to develop emphysema.
Symptoms
The first sign of emphysema is shortness of breath during
exertion. Eventually, this shortness of breath occurs while at
rest
As the disease progresses, the following symptoms which are
related to one of the other major lung diseases also caused
by smoking - bronchitis - may occur:
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Difficulty breathing (dyspnea)
Coughing (with or without sputum)
Wheezing (this can also be caused by emphysema itself)
Excess mucus production
A bluish tint to the skin (cyanosis)
Hypoxemia
Tachycardia
Polytcythemia (increased hemoglobin levels)
More Symptoms
• Clubbed fingers (chronic hypoxia)
• Right Heart Failure
• Stained yellow fingers, teeth
Diagnosis
History And Physical Examination
 Smoking history (calculate pack years, # packs smoked times #
years smoked)
 Working environment- Breathing in any harmful chemicals?
 A physical examination will include an examination of your
chest and breathing patterns; prolonged expiratory times
 Nasal flaring, accessory muscle usage (due to loss of
diaphragm recoil from air trapping)
Diagnosis Continued
X-Ray and/or CT of the Chest
 Chest x-rays are a very useful tool to evaluate anatomy of
the lung. In emphysema, there is evidence of increased
air in the chest and destruction of some of the lung
tissue. Bronchitis can be suspected on a chest x-ray by
presence of thickening of the tissue around the large
airways (bronchi). Chest x-rays are also useful as
screening for lung cancer and heart disease.
 Computerized axial tomography or CAT scans indicate
lung anatomy in greater detail. In some cases, this
information is needed to fully evaluate lung disease.
• Cat scan of chest
• Air Trapping,
flattened diaphragm
Pulmonary Function Testing
Spirometry measures breathing capacity. A common measure
of breathing capacity is the forced expiratory volume in one
second (FEV1), or the amount of air that can be forced out of
the lungs in one second. This is a common way to determine
the amount of airway obstruction.
Pulmonary Function Testing
• Spirometry and body plethysmography be
repeated after administration of an inhaled
bronchodilator
• This test will help your physician determine if
there is an asthmatic component present
• Lung Volumes measures the amount of air in the
lungs. This increases markedly in emphysema.
Arterial Blood Gas
• Patient’s with emphysema have chronic CO2 retention due to
the inability to expel gas. Their blood reflects higher levels of
CO2 than normal people; CO2 is acidic in nature
• Over time their body compensates for this higher CO2 by
creating more buffer in the blood in the form of Bicarb from
the Kidney
Treatment
• There is no cure for emphysema. The goal of treatment is to
slow the development of disabling symptoms. The most
important step to take is to stop smoking.
• Treatments for emphysema caused by smoking include
medication, breathing retraining, and surgery.
• People with inherited emphysema due to alpha-1 antitrypsin
deficiency can receive alpha 1-proteinase inhibitor (A1PI),
which slows lung tissue destruction.
Breathing Techniques
Diaphragmatic Breathing
• The diaphragm is a major muscle used in breathing and is located beneath
the lowest two ribs. At rest, the diaphragm muscle is bell shaped. During
inspiration, it lowers and flattens out.
• Optimizing the use of the diaphragm is beneficial because it pulls air into
the lower lobes of the lungs where more gas exchange takes place. Not
only is the diaphragm the most efficient of all respiratory muscles, but
using it tends to be very relaxing and calming.
• Along with our diaphragm, we use intercostal and abdominal muscles in
the work of breathing. The intercostals (muscles between the ribs) pull to
lift the rib cage up and out. This causes the lungs to open in all directions
and air can be pulled down the airways. To exhale, the muscles that have
been pulling relax and air is forced out.
Medications Used
Medications To Treat Emphysema
 Emphysema cannot be cured and, except for oxygen,
does not reverse with any medication. However,
emphysema is frequently associated with bronchitis and
asthma and the symptoms associated with these
processes often can be alleviated with medication (hence,
you can see the value of pulmonary function and other
tests designed to discover if there is asthmatic
component present:
 Bronchodilator medication
 Corticosteroids
 Supplemental oxygen
Bronchodilator Medication
• Bronchodilator medication may be prescribed for airway
tightness. Bronchodilators react similar to norepinephrine
through the sympathetic nervous system
• The most commonly prescribed bronchodilators are beta2
agonists , the anti-cholinergic drug ipatropium bromide, and
theophylline
• Anti-cholinergics block musacaric receptors which normally
respond to acetylcholine and cause bronchoconstriction
Corticosteroids
• The potent anti-inflammatory medications known as corticosteroids
- commonly called steroids - may be used to help lessen the
inflammation that often accompanies emphysema. These may be
taken by mouth or inhaled.
Therapy at Each Stage of COPD
Oxygen
• Due to the chronic state of increased CO2 in the blood
(hypercapnia), the patient has adapted a breathing regulation
in the brain that responds to changes in O2 and not CO2 like
most people
• If you give a patient with COPD more than 30% oxygen they
will slow their breathing
• Give low flow oxygen at 2 LPM by NC
• Or high flow with venturi mask at 22-30%
Lung Reduction
 A surgical procedure called lung reduction may improve
symptoms for people with certain types of emphysema.
During the procedure, part of the lung is cut out, giving
healthy lung tissue more room to expand.
 Lung reduction may eliminate the need for supplemental
oxygen and make it much easier for the person to
breathe. Early studies show that it reduces the volume of
the over-inflated lungs. This improves the ability of the
lung and chest wall to spring back during exhalation. This
more-elastic lung appears to
be the biggest reason that emphysema sufferers
experience relief.
Conclusion
 Emphysema is a chronic disease that takes years to
progress; usually as a result of heavy cigarette smoking
but also can be caused by inherited Alpha-1 antitrypsin
deficiency
 It destroys the stability of the alveoli and bronchioles
leaving them over compliant
 This leads to air trapping and an accumulation of CO2 and
decrease in O2
 The air trapping leads to dyspnea
 Diagnose with symptoms, ABG, CXR, PFT and history
 Treatment consists of stop smoking, medications and lung
reduction surgery or transplant