Transcript Document
Chapter 12
Emphysema
Plate 3. Panlobular emphysema. Inset, Excessive bronchial secretions,
a common secondary anatomic alteration of the lungs.
Slide 1
Copyright © 2006 by Mosby, Inc.
Figure 12–2. Centrilobular emphysema. Abnormal weakening and enlargement
of the respiratory bronchioles in the proximal portion of the acinus.
Slide 2
Copyright © 2006 by Mosby, Inc.
Anatomic Alterations of the Lungs
Slide 3
Permanent enlargement and deterioration of
the air spaces distal to the terminal
bronchioles
Destruction of pulmonary capillaries
Weakening of the distal airways, primarily the
respiratory bronchioles
Bronchospasm (with concomitant bronchitis)
Hyperinflation of alveoli (air-trapping)
Copyright © 2006 by Mosby, Inc.
Etiology
Cigarette smoking
Genetic predisposition
Slide 4
Alpha1 protease inhibitor
Occupational exposure to chemical irritants
Exposure to atmospheric pollutants
Copyright © 2006 by Mosby, Inc.
Overview of the Cardiopulmonary
Clinical Manifestations Associated
with EMPHYSEMA
The following result from the pathophysiologic
mechanisms caused by Distal Airway and
Alveolar Weakening ( Figure 9-12)—the major
anatomic alterations of the lungs associated
with emphysema (see Figures 12-1 and 12-2).
Slide 5
Copyright © 2006 by Mosby, Inc.
Figure 9-12. Distal airway and alveolar weakening clinical scenario.
Slide 6
Copyright © 2006 by Mosby, Inc.
Clinical Data Obtained at the
Patient’s Bedside
Vital signs
Slide 7
Increased respiratory rate
Increased heart rate, cardiac output,
blood pressure
Copyright © 2006 by Mosby, Inc.
Clinical Data Obtained at the
Patient’s Bedside
Slide 8
Use of accessory muscles of inspiration
Use of accessory muscles of expiration
Pursed-lip breathing
Increased anteroposterior chest diameter
(barrel chest)
Cyanosis
Digital clubbing
Copyright © 2006 by Mosby, Inc.
Clinical Data Obtained at the
Patient’s Bedside
Peripheral edema and venous distention
Slide 9
Distended neck veins
Pitting edema
Enlarged and tender liver
Copyright © 2006 by Mosby, Inc.
Distended
Neck Veins
Figure 2-48. Distended neck veins (arrows).
Slide 10
Copyright © 2006 by Mosby, Inc.
Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2,
London, 1992, Mosby-Wolfe.
Slide 11
Copyright © 2006 by Mosby, Inc.
Clinical Data Obtained at the
Patient’s Bedside
Slide 12
Cough, sputum production, hemoptysis
Chest assessment findings
Hyperresonant percussion notes
Wheezing
Diminished breath sounds
Diminished heart sounds
Decreased tactile and vocal fremitus
Crackles/rhonchi (when accompanied by bronchitis)
Copyright © 2006 by Mosby, Inc.
Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.
Slide 13
Copyright © 2006 by Mosby, Inc.
Slide 14
Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive
lung diseases, breath sounds progressively diminish.
Copyright © 2006 by Mosby, Inc.
Clinical Data Obtained from
Laboratory Tests and Special
Procedures
Slide 15
Copyright © 2006 by Mosby, Inc.
Pulmonary Function Study
Expiratory Maneuver Findings
Slide 16
FVC
FEVT
FEF25%-75%
FEF200-1200
PEFR
MVV
FEF50%
FEV1%
Copyright © 2006 by Mosby, Inc.
Pulmonary Function Study
Lung Volume and Capacity Findings
VT
RV
FRC
N or
IC
ERV
VC
Slide 17
N or
N or
TLC
N or
RV/TLC ratio
Copyright © 2006 by Mosby, Inc.
Decreased Diffusion Capacity
(DLCO)
Slide 18
Copyright © 2006 by Mosby, Inc.
Arterial Blood Gases
Mild to Moderate Emphysema
Slide 19
Acute alveolar hyperventilation with
hypoxemia
pH
PaCO2
HCO3 (Slightly)
PaO2
Copyright © 2006 by Mosby, Inc.
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 20
Copyright © 2006 by Mosby, Inc.
Arterial Blood Gases
Severe Emphysema
Chronic ventilatory failure with hypoxemia
pH
Normal
Slide 21
PaCO2
HCO3(Significantly)
PaO2
Copyright © 2006 by Mosby, Inc.
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 22
Copyright © 2006 by Mosby, Inc.
Acute Ventilatory Changes Superimposed
on Chronic Ventilatory Failure
Slide 23
Acute alveolar hyperventilation on chronic
ventilatory failure
Acute ventilatory failure on chronic ventilatory
failure
Copyright © 2006 by Mosby, Inc.
Oxygenation Indices
QS/QT
O2ER
Slide 24
DO2
VO2
C(a-v)O2
Normal
Normal
SvO2
Copyright © 2006 by Mosby, Inc.
Hemodynamic Indices
(Severe Emphysema)
Slide 25
CVP
RAP
PA
PCWP
Normal
CO
SV
SVI
CI
Normal
Normal
Normal
Normal
RVSWI
LVSWI
PVR
SVR
Normal
Normal
Copyright © 2006 by Mosby, Inc.
Abnormal Laboratory Tests
and Procedures
Hematology
Increased hematocrit and hemoglobin
Electrolytes
Hypochloremia (chronic ventilatory failure)
Sputum examination
Slide 26
Streptococcus pneumoniae
Haemophilus influenzae
Copyright © 2006 by Mosby, Inc.
Radiologic Findings
Chest radiograph
Slide 27
Translucent (dark) lung fields
Depressed or flattened diaphragms
Long and narrow heart
Enlarged heart
Increased retrosternal air space
(lateral radiograph)
Copyright © 2006 by Mosby, Inc.
Figure 12-3. Chest X-ray of a patient with emphysema. The heart often appears long
and narrow as a result of being drawn downward by the descending diaphragm.
Slide 28
Copyright © 2006 by Mosby, Inc.
Figure 12–4. Emphysema. Lateral chest radiograph demonstrates a characteristically large
retrosternal radiolucency with increased separation of the aorta and sternum measuring 4.6 cm, 3 cm
below the angle of Louis and extending down to within 3 cm of the diaphragm anteriorly. Both
costophrenic angles are obtuse, and both hemidiaphragms are flat. (From Armstrong P et al, editors:
Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
Copyright © 2006 by Mosby, Inc.
Slide 29
Slide 30
Copyright © 2006 by Mosby, Inc.
General Management of
Emphysema
Slide 31
Patient and family education
Behavioral management
Avoidance of smoking and inhaled irritants
Avoidance of infections
Proper nutrition instruction
Copyright © 2006 by Mosby, Inc.
GOLD Standards
Global Initiative for Chronic
Obstructive
Lung
Disease
Slide 32
Copyright © 2006 by Mosby, Inc.
Slide 33
Figure 11-4. From GUIDELINES Pocketcard: Managing chronic obstructive pulmonary
disease, Baltimore, 2004, Version 4.0, International Guidelines Center. (From
GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease.
Copyright © 2006 by Mosby, Inc.
Baltimore, 2004, Version 4.0, International Guidelines Center.)
Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic
Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International
Guidelines Center.)
Slide 34
Copyright © 2006 by Mosby, Inc.
Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic
Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International
Guidelines Center.)
Slide 35
Copyright © 2006 by Mosby, Inc.
Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic
Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International
Guidelines Center.)
Slide 36
Copyright © 2006 by Mosby, Inc.
Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic
Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International
Guidelines Center.)
Slide 37
Copyright © 2006 by Mosby, Inc.
General Management of
Emphysema
Respiratory care treatment protocols
Slide 38
Oxygen therapy protocol
Bronchopulmonary hygiene therapy protocol
Aerosolized medication protocol
Mechanical ventilation protocol
Copyright © 2006 by Mosby, Inc.
Additional Treatment Considerations
for Emphysema
Slide 39
Antibiotics
Inoculations against influenza and pneumonia
Alpha1 antitrypsin therapy
Lung volume reduction surgery
Lung transplantation
Copyright © 2006 by Mosby, Inc.
Classroom Discussion
Case Study: Emphysema
Slide 40
Copyright © 2006 by Mosby, Inc.