PULMONARY DISEASE PULMONARY FUNCTION AND CONTROL PULMONARY DISEASES PULMONARY INTERVENTION

PULMONARY DISEASE

PULMONARY FUNCTION AND CONTROL PULMONARY DISEASES

PULMONARY INTERVENTION

THE LUNGS

• The right lung is larger than the left lung to accommodate the space taken up by the heart

• There are several lobes on each side.

The right lung has:

• The apical lobe which is oriented totally anterior in the chest wall.

• The upper lobe

• The middle lobe om the right side

• The small lingular lobe which is only on the left side, that lies around the posterior distal aspects of the heart

• The lower lobe

• The basilar lobe that is located totally posteriorly

THE AIRWAYS

Air passes up and down from:

• The mouth or better, because it is warmed and cleansed, the nasal passages.

• Through the larynx and the vocal cords

• Into the trachea, which has rings of fibrocartilage to keep it open, which bifurcates into

• The right and left main stem bronchus

• These narrow to form bronchioles that have a smooth muscle around them in the same way as the arterial wall.

• These branch further into the alveolus which have a capillary bed surrounding it so that blood and alveolar gasses can exchange.

THE LARYNX

INCLUDING MUSCLES AND THEIR INNERVATIONS

• Digastric

• Inferior alveolar nerve and the facial nerve

• ^Stylohyoid

• Facial nerve

• ^Mylohyoid

• inferior alveolar nerve

• Sternothyoid

• Ansa cervicalsis C1-3

• Sternothyoid

• Ansa cervicalsis C1-3

• Thyrohyoid

• Branch of the hypoglossal nerve

• Omohyoid

• Ansa cervicalsis C1 Ansa cervicalsis

THE ALVEOLUS

The alveolus is where the air meets the blood at the distal end of the airways.

This is where the gas exchange and true respiration

VENTILATION

•

Ventilation is the process of

breathing (moving air in and out).

The primary purpose of the lung is to bring air and blood into intimate

contact so that oxygen can be added to the blood and carbon dioxide

removed from it. This is called respiration.

•

There are two phases of the

respiratory cycle, inspiration and expiration^.

This is achieved by two pumping systems:

• One moving a gas (the muscles of respiration and the walls of the plural space).

• The other a liquid (the right and left ventricles of the heart).

• The blood and air are brought together so closely that only approx. 1 mm (10-6 mm.) of tissue (at the alveoli) separates them.

● The volume of the pulmonary capillary circulation is 150 ml, but this is spread out over a surface area of approx. 750 sq. ft. (69.68 sq. m).

● This capillary surface area surrounds 300 million air sacs called alveoli.

● The blood that is low in oxygen but high in carbon dioxide is in contact with the air that is high in oxygen and low in carbon dioxide for less than 1 second.

•

There is a negative pressure in the plural space which keeps the lungs from collapsing. This is called the residual volume

BREATHING

INSPIRATION

• The muscles that provide breathing.

For inspiration it is increasing the thoracic space which lowers the pressure (below atmospheric pressure) in the intra-plural space which causes air to flow into the lungs and expand them to equalize this pressure.

• Normal breathing (tidal breathing) is accomplished most efficiently by the

contraction of the diaphragm.

• Forced inspiration, which consumes considerably more energy, uses the

diaphragm and the accessory muscles.

• For a louder voice, such as yelling and singing loudly the accessory muscles are also used.

EXPIRATION

• Expiration is accomplished by increasing the intra-plural pressure through the relaxation of the diaphragm.

• Forced expiration adds a force generated by the abdominal muscles to decrease the intrathoracic space.

• A cough can be accomplished volitionally but can also be triggered by an irritation from the lining of the bronchioles or

bronchus

•

Tidal expiration is passive and is accomplished by the diaphragm not contracting and recoiling to its normal length.

•

Forced expiration, such as a

cough, is used to clear the airway or

“belting” when singing.

MUSCLES OF INSPIRATION

• ^Diaphragm

• Tidal respiration

• Phrenic nerve From spinal levels C3, C4, C5

• External Intercostal muscles

• Some use in tidal respiration high use in forced

• T1-T12

• Sternocleidomastoid

• Cranial nerve XI, Ventral rami of C2, C3

• Upper Trapezius

• Cranial nerve XI, from the nucleus ambiguum

• Scalene muscles

• Cranial nerve XI from the nucleus ambiguum

• Serratus anterior

• ^{C5 to C7}

• Pectoralis major and Minor C5 to T1

MUSCLES OF EXPIRATION

• Internal Oblique

• External Oblique

• Transverse Oblique

• Nerve roots T9-12

• Rectus Abdominis

• Nerve roots T9-12

NERVE SUPPLY AND CONTROL:

• The lungs are enervated by parasympathetic fibers via the vagus nerve and sympathetic fibers from the anterior and posterior pulmonary plexuses to the smooth muscle in the

walls of the bronchial tree. The sympatric fibers cause contraction of the smooth muscles of the bronchioles

constricting the airways. Parasympathic stimulation cause these muscles to relax thus bronchodilation.

• The diaphragm is enervated by the phrenic nerve that

leaves the spinal cord at the C3 level. The diaphragm is the

major muscle of inspiration.

BLOOD VESSELS:

• The bronchial arteries and veins circulate blood to the bronchial tree. This is where a pulmonary embolus affects the patient by blocking of a bronchial artery.

• The pulmonary arteries and veins circulate the blood involved in gas exchange. This is where congestive heart failure (due to a decrease in the pumping force from the heart ventricles) affects the patient. Right side heart failure decreases the blood flow into the bronchial artery and left side heart failure congests the

bronchial veins.

TESTS AND MEASURES

• VITAL SIGNS

• ^PALPATION

• AUSCULTATION

• PULMONARY FUNCTION TESTING

VITAL SIGNS

•

Rate of ventilation

•

Blood pressure

•

^{Heart rate}

•

^O₂ ^Saturation

DEPTH OF VENTILATION

This value changes first when a patient is stressed Use palpation to assess:

Diaphragm is assessed by palpation of abdomen

External intercostal muscles assessed by palpation of the ribs Other assessor muscles are assessed by palpation of their muscle bellies

Spirometry

`Uses a spirometer to show the volume of air exhaled/inhaled

in a measured amount of time

Resting heart rate

Age or fitness level Beats per minute (bpm)

Babies to age 1: 100––160

Children age 1 to 10: 60––140

Children age 10+ and adults: 60––100

Well-conditioned athletes: 40––60

RATE OF VENTILATION

• This can be measured by:

• ^Inspection

• Mechanical band across

the chest

RPE Scale: The scale goes from 6 to 20.

Borg Scale 10 Level

6 0 Nothing

7 Very, very light 0.5 Very, very weak (nothing) 8

9 Very light 2 Weak, (light)

10

11 Light

12 3 Moderate

13 Somewhat hard 4 Somewhat hard

14

15 Hard 5 Strong

16

17 Very hard 7 Very strong

18

19 Very, very hard

20 10 Very, very strong (almost maximal)

ARTERIAL BLOOD GASSES

Arterial Blood Gases (at sea level and breathing room air)

Partial pressure of oxygen (PaO₂): 70––100 millimeters of mercury (mm Hg)

Partial pressure of carbon dioxide (PaCO₂):

35––45 mm Hg

pH: 7.35––7.45

Bicarbonate (HCO₃): 22-26 mill equivalents per liter (mEq/L)

Oxygen content (O₂CT): 15––23%

Oxygen saturation (O₂Sat): 98%

PALPATION AND OTHER FINDINGS

•

Percussion

• Thumping over a specific lobe of the lung

• ^{Feel is:}

• Hyper-resonant

• ^Normal

• Non-resonant

•

Vocal Fremitus

• Vibration present

• Vibration not present

•

^{Skin color}

• ^Pale

• ^Cyanotic

AUSCULTATION

• Listen over a lobe of the lung

• ^Sounds

• ^Rhonchi

• ^Rales

• ^Wheezing

PULMONARY FUNCTION TESTING

• TV - Tidal volume The volume of gas inhaled/exhaled at rest Abnormalities Indicates Disease

• IRV- Inspiratory reserve volume The maximal inhalation - tidal inhalation

• IC - Inspiratory capacity (IRV+TV) The total amount of air that can be inspired

• ERV - Expiratory reserve volume The maximal amount of air that a patient can exhale after a maximal inhalation

• RV - Residual volume The air that a patient cannot exhale. This is measured by a volume dilution method

• IC - Inspiratory capacity (IRV+TV) The total amount of air that can be inspired

• TLC - Total lung capacity (IRV+TV+ERV+RV) The total volume of air

• TLC - Total lung capacity (IRV+TV+ERV+RV) The total volume of air

• FRC - Functional reserve capacity (ERV+RV) The total amount of air that is available for expiration

• VC - Vital capacity (IRV+TV+ERV) The total volume of air that is inhaled and exhaled during a maximal effort

Sputum Analysis

Term Description

Fetid Foul smelling, typical of anaerobic infection; typically occurs with

bronchiectasis, lung abscess, or cystic fibrosis. This is when the sputum is accumulated within the lung over a period of time.

Frothy Pink-tinged, foamy, thin sputum associated with pulmonary edema

This is a thin fluid. The plasma leaks through the alveolar walls from the blood stream into the airways. The membrane of some of the alveoli rupture spilling blood and

causing the pink tinge.

Hemoptysis Expectoration of blood or bloody sputum; amount may range from blood streaked to massive hemorrhage and is present in a variety of pathologies.

The blood is from the rupture of the vascular supply of the airways.

Mucoid White or clear, and indicates inflammation without infection. This is not generally

associated with broncho-pulmonary infection but is present with chronic cough (acute or chronic bronchitis, cystic fibrosis) and with asthma.

Mucopurulent Mixture of mucoid sputum and pus, yellow to pale green, and is a mixture of white blood cells and necrotic bacteria. It is associated with infection.

Purulent Pus, yellow or greenish sputum, often copious and thick. This is associated with common with acute and chronic infection.

Rusty Descriptive of the color of sputum; classic for pneumococcal pneumonia (also called prune juice) The color is from the lung expelling necrotic cells.

Tenacious Thick, sticky sputum. This is from a lack of secretion of sputum and is the primary cause of cystic fibrosis.

PATHOLOGY OF THE PULMONARY SYSTEM

ASTHMA

CONGESTIVE OBSTRUCTIVE PULMONARY DISEASE (COPD) PNEUMONIA

OTHER

ASTHMA

•

Asthma is a long-term (chronic) disease of the respiratory system that affects the bronchial tubes, which carry air to the lungs. Asthma involves:

•

Long-term inflammation in the bronchial tubes. Medication can control inflammation and help the person have fewer periods when breathing can become suddenly difficult (asthma episodes or attacks). If inflammation is not controlled, asthma can lead to changes in the bronchial tubes that cannot be reversed. Overreaction (hyper-responsiveness) of the

bronchial tubes to some substances (triggers).

•

Long-term inflammation in the bronchial tubes makes the tubes more likely to overreact to triggers, resulting in sudden difficulty breathing. Avoiding triggers helps control

inflammation in the bronchial tubes.

•

Sudden periods of difficult breathing (asthma episodes or attacks). The overreaction of the bronchial tubes to triggers causes sudden narrowing and blockage of the tubes, making it difficult for the person to breathe. Asthma episodes sometimes clear up on their own, but usually medication is needed

CONGESTIVE OBSTRUCTIVE PULMONARY DISEASE (COPD)

•

COPD most often is caused by chronic bronchitis and/or emphysema.

Although a person sometimes can have either chronic bronchitis or emphysema, they usually has a mixture of the symptoms of both diseases. COPD develops chronically before shortness of breath becomes enough of a problem that a person notices difficulty breathing. For this reason, COPD usually is

considered a disease of older adults and is most commonly diagnosed in the geriatric population. Damage to the airways and lungs cannot be reversed once it has occurred. Quitting smoking is the only way to slow the lung

damage from COPD.

CHRONIC BRONCHITIS

•

Chronic bronchitis sometimes is caused by long-term (chronic) irritation of the lungs. Frequent lung infections, especially in a person who smokes, may lead to more rapid development of chronic bronchitis than might occur otherwise.

Symptoms of chronic bronchitis:

•

Produces too much mucus (sputum) in the bronchial tubes. This mucus builds up and occludes the airways, deceasing ventilation.

•

Usually has a cough that brings up mucus from the lungs (a productive cough).

•

Often will have inflammation and leave scarring in the larger airways. This can further narrow the airways, making it hard to breathe.

•

Medications are only partially effective in making breathing easier for

people with chronic bronchitis. This differs from asthma, in which medications often make breathing dramatically better.

EMPHYSEMA

The disease can lead to a decrease of oxygen in the blood in two ways. In emphysema, the parts of the lungs where oxygen moves into the blood, alveoli are destroyed. Once alveoli are destroyed, they cannot be replaced thus

creating an increasing dead space.

• The small airways (bronchioles) in the lungs will tend to close off during exhalation, trapping stagnant air inside the alveoli.

• COPD is sometimes called chronic obstructive lung disease

(COLD) or chronic airflow obstruction (CAO).

SYMPTOMS OF MILD OR MODERATE CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

• A productive cough, which often brings up a large amount of sputum from the lungs

• Difficulty breathing or shortness of breath

• Tiring easily from exercise or daily activities

• Difficulty sleeping (a person may wake up feeling short of breath or coughing)

• Early symptoms of COPD often are overlooked or blamed on

getting older.

SYMPTOMS OF SEVERE COPD (THE BLUE BLOATER)

• Blue skin color (cyanosis), especially in the lips, fingers, and toes

• Peripheral edema and ascites

• Inability to do any activity without severe shortness of breath

• Weight loss due to increased caloric consumption and decreased appetite

• Confusion (due to cerebral anoxia)

POSSIBLE COMPLICATIONS OF COPD

These may include:

• Breathing suddenly becoming more difficult (COPD exacerbation).

• Lung infections.

• Depression.

• Weight loss. (Late in the course of the disease)

• Heart failure affecting the right side of the heart (cor pulmonale).

•(End stage) Collapsed lung (pneumothorax).

CYSTIC FIBROSIS

•

Cystic fibrosis is an inherited (genetic) disease that affects certain glands in the body (the mucous glands in the bronchial tubes, sweat glands, digestive glands, and sexual organs).

•

It causes tenacious mucus to form in the airways and lungs, leading to

breathing problems. Children with cystic fibrosis almost always have breathing problems and have frequent lung infections.

•

It can also interfere with normal digestion of food and can affect the function of the sweat glands and reproductive organs. Children with cystic fibrosis may have problems absorbing nutrients from their intestines and may have persistent diarrhea or blockages in their intestines.

•

The symptoms of cystic fibrosis may be present at birth or may develop weeks, months, or years later.

PULMONARY EMBOLISM

Symptoms of a pulmonary embolus include:

• Sudden, sharp chest pain.

• Shortness of breath.

• Chest pain that worsens with deep breathing or coughing.

• Coughing up blood.

• Rapid heart rate.

• ^Sweating.

• ^Anxiety.

This mimics a heart attack, it is separated by the lack of breath sounds over

the lobes involved

PNEUMOTHORAX

•

Pneumothorax is a buildup of air in the space (pleural space) between the lung and the chest wall, leading to a collapsed lung. Large amounts of air in this space can prevent the lung from expanding properly when the person tries to breathe in. As the air builds up in this space, the pressure against the lung makes the lung begin to collapse. The portion of the lung that is collapsed cannot

function correctly, leading to shortness of breath and chest pain

•

Symptoms of pneumothorax often include:

•

Shortness of breath, which may be mild to severe, depending on how much of the lung is collapsed.

•

Sudden, severe, and sharp chest pain on the same side as the collapsed lung.

•

Symptoms may become worse with changes in altitude (for instance, flying in an airplane or going underground).

PNEUMONIA

•

Pneumonia is an inflammation of the lungs most often caused by infection with bacteria or a virus. Pneumonia can make it hard to breathe and to get enough oxygen into the bloodstream. Symptoms often begin suddenly and may follow an upper respiratory infection, such as influenza (flu) or a cold. Common symptoms of pneumonia include:

• Fever of 100 °F (37.78 °C) to 106 °F (41.11 °C).

• Shaking chills.

• Cough that often produces colored mucus (sputum) from the lungs. Sputum may be rust- colored or green or tinged with blood. Older adults may have only a slight cough and no sputum.

• Rapid, often shallow breathing.

• Chest wall pain, often made worse by coughing or deep breathing.

• Fatigue and feelings of weakness (malaise).

•

Symptoms of viral pneumonia are often less severe than those of bacterial pneumonia and may come on more slowly.

SLEEP APNEA

• Sleep apnea is a sleep disorder in which a person regularly stops breathing during sleep for 10 seconds or longer. (An occasional stop in breathing is normal.)

• Apnea episodes can happen from as few as 5 times per hour to as many as 50 times an hour.

• Sleep apnea is usually caused by a blockage (obstruction) in the nose or mouth that obstructs airflow during sleep.

• It is most common in overweight, middle-aged men, but it can

affect people of any age, including children.

TUBERCULOSIS TB

• This is a bacterial infection of the lungs

•

There are antibiotic resistant forms

•

Respiratory Isolation for at least two weeks after an antibiotic proves effective

•

Patient and equipment may not leave the negative pressure room until they are no longer infected

•

Bones may be involved as a primary source

•

IV drug use population is most common

•

May also have HIV and Hepatitis B or C