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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.