Pulmonary Conditions
Medical and Psychosocial Aspects of
Disability
RCS 6080
Description & Definitions
 Chronic Obstructive Pulmonary Disease
(COPD) is characterized by decreased
expiratory airflow
 Reduction in expiratory airflow has 2
causes:
• Decreased expiratory air flow pressure
(decrease in driving pressure)
• Increased resistance to expiratory air flow
(resulting from narrowing of airways)
Descriptions/Definitions
 Emphysema & chronic bronchitis are often
considered together under the term COPD
because most people with one of these
conditions has the other. Thus most people
with COPD with have both airway & alveolar
disease.
 COPD affects as many as 30,000,000
Americans
 COPD is the 5th leading cause of death
Etiology, Pathophysiology &
Clinical Features
 Several factors are involved in the
pathogenesis of COPD, but smoking is the
most important
• Other factors include occupational exposure
to dust, fumes & air pollution.
 Aside from these factors, the development
and progression of COPD is largely related
to genetic disposition.
Emphysema

Emphysema is an
enlargement of air spaces
caused by destruction of
alveolar walls. Air spaces
greater than one cm are
bullae. This photo shows
apical bullous disease
with relatively little
involvement of the rest of
the lung.
Emphysema

Emphysema can be a result of
obstruction caused by
chronic bronchitis. It occurs
when there is back pressure
on the alveoli. This increased
pressure tends over time to
make their walls break down,
and instead of having lots of
tiny air sacs functioning well,
you end up with large cavities
consisting of alveoli that
have coalesced, and which do
not adequately perform the
task of gas transfer.
Chronic Bronchitis




The lungs essentially comprise lots of
tubes and tubules (called bronchi and
bronchioles) of gradually diminishing
size, which end in little collections of
air sacs called alveoli. It is across the
walls of the alveoli that the gases are
exchanged, oxygen being taken into
the bloodstream and carbon dioxide
passing into the alveoli to be exhaled.
Chronic bronchitis is an inflammation
or irritation of the airways in the lungs
which is associated with:
Scarring or fibrosis of the walls of the
bronchioles making them less pliable
Thickening of their lining causing
narrowing of the airway
Production of excessive quantities of
thick mucus which further plugs the
tubules and compromises breathing
Categories of COPD
 Type A - “Pink Puffer”
• Considered to have predominantly
emphysema
 Type B - “Blue Bloater”
• Considered to have predominantly chronic
bronchitis.
Functional Disabilities

Earliest manifestations of COPD may be relatively
mild, but as time goes on, dyspnea becomes the
most limiting factor
• Years may pass before the degree of dyspnea is severe
enough to limit routine ADLs such as walking.
• As time progresses, activities such as dressing,
bathing, speech and even eating cannot be
accomplished without severe shortness of breath
Functional Disabilities
 Until the disease is extremely advanced,
sedentary activities may be accomplished
without much difficulty.
 Driving may be possible, but walking - even
limited distances - may not be feasible,
particularly is there is an incline or stairs.
Functional Disabilities
 Assessment of a given person’s functional
capabilities may be difficult to determine
based solely on pulmonary function studies
and blood gases.
 Depression, fear, & anxiety are potent factors
that may further exacerbate the person’s
physical limitations.
 Preparation of sedentary occupation is useful
even when COPD is mild because the rate of
progression is variable.
Treatment of COPD
 Many people with COPD might be able to
have some reversibility – through proper
medical management.
 Adequate fluid intake and use of
expectorants are needed to clear the
respiratory tract of secretions.
 Oxygen therapy
Treatment of COPD
 Chest physical therapy and pulmonary
rehabilitation programs are useful to:
• Learn how to expel mucus from respiratory
tract
• Learn breathing exercises and relaxation
techniques (useful in ADLs)
• Do exercise reconditioning that can help
increase endurance & improve work capacity
Psychological Implications
 Counseling often helps the person deal
with the anxiety/stress associated with
diseases that can cause shortness of
breath & limitations of activity.
• Learning to deal effectively with problems &
make satisfactory lifestyle can reduce
feelings of desperation.
Vocational implications
People may have to change employment goals
 The American Thoracic Society:

• Mild impairment – usually not correlated with reduced
ability to perform most jobs.
• Moderate impairment – correlates with a decreased
ability to meet the demands of many jobs
• Severe impairment – pulmonary function is so
impaired that a person cannot meet the demands of
most occupations.
Asthma
 Asthma is considered an inflammatory
disease of the airways
• Reversible airway obstruction
• Bronchial hyper-reactivity
 Frequency, duration, & severity of asthma
attacks varies from person to person.
 Asthma attacks are characterized by
shortness of breath & wheezing.
Asthma






Mainly a bronchial disease,
asthma is characterized by
features in the following 3
images:
Mural inflammation
(eosinophils, mast cells,
lymphocytes)
Wall thickening by edema,
hyperemia, fibrosis
Smooth muscle thickening
(arrow)
Mucous plugs
Epithelial slough
Pathology of Asthma
Normal Lungs
Asthma
Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma
Created and funded by NIH/NHLBI
Asthma Prevalence* by Age
United States: 1980–1996
8
Under 18
Total
6
5
4
18+
3
2
1
19
96
19
94
19
92
19
90
19
88
19
86
19
84
19
82
0
19
80
Prevalence (%)
7
Source: National Health Interview Survey
* 12-month prevalence
Year
Asthma Prevalence* by Sex
United States: 1982–1996
Female
8
Total
6
5
Male
4
3
2
1
19
96
19
94
19
92
19
90
19
88
19
86
19
84
19
82
0
19
80
Prevalence (%)
7
Source: National Health Interview Survey
* 12-month prevalence
Year
Asthma Prevalence* by Race
United States: 1982–1996
8
Black
6
5
White
4
3
2
1
Source: National Health Interview Survey
* 12-month prevalence
19
96
19
94
19
92
19
90
19
88
19
86
19
84
19
82
0
19
80
Prevalence (%)
7
Year
Asthma Prevalence* by Race
9
8
7
6
5
4
3
2
1
0
Black, 5-34
Source: National Health Interview Survey
* 12-month prevalence
19
96
19
94
19
92
19
90
19
88
19
86
19
84
19
82
White, 5-34
19
80
Prevalence (%)
Ages 5-34, United States: 1980–1996
Year
Age-Adjusted* Asthma Mortality Rates
by Sex, United States: 1979–1998
Female
Total
25
Male
20
15
10
5
19
97
19
95
19
93
19
91
19
89
19
87
19
85
19
83
19
81
0
19
79
Rate per million
30
Source: Underlying Cause of Death dataset by the
National Center for Health Statistics
* Age-adjusted to 2000 U.S. population
Year
Age-Adjusted* Asthma Mortality
Rates
by Race, United States: 1979–1998
60
50
Rate per million
40
30
Black
Other
20
10
White
0
Year
Source: Underlying Cause of Death dataset by the
National Center for Health Statistics
* Age-adjusted to 2000 U.S. population
Asthma Mortality Rates by Race
Ages 5-34, United States: 1979–1998
20
Rate per million
Black
15
10
White
Other*
5
Source: Underlying Cause of Death dataset
by the National Center for Health Statistics
* Unreliable (< 20 deaths) 1979–1995
97
19
95
19
93
19
91
19
89
19
87
19
85
19
83
19
81
19
19
79
0
Year
Costs of Asthma
United States, 1980–1998
Projection for the Year 2000
15
Estimated
costs in
billions of
dollars
10
5
0
1980*
1985* 1990** 1994** 1998**
Year
Source: * Weiss, et al. 1992
** Weiss, et al. 2001
2000
Risk Factors
for Development of Asthma
Genetic characteristics
 Environmental exposures
 Contributing factors

Risk Factors for Development of Asthma:
Genetic Characteristics
Atopy


The body’s predisposition to develop an antibody called
immunoglobulin E (IgE) in response to exposure to
environmental allergens
Can be measured in the blood
Clearing the Air
Categories for Associations of Various Elements





Sufficient evidence of a causal relationship
Sufficient evidence of an association
Limited or suggested evidence of an
association
Inadequate or insufficient evidence to
determine whether an association exists
Limited or suggestive evidence of no
association
Clearing the Air
Indoor Air Exposures and Asthma Development
Chemical Agents
Biological Agents

Sufficient evidence of a causal
relationship

• House dust mite

Sufficient evidence of an
association
• None found

• None found

•
Cockroach (in
preschool-aged
children)
Respiratory syncytial
virus (RSV)
Sufficient evidence of an
association
• Environmental tobacco
smoke (in preschoolaged children)
Limited or suggestive evidence
of an association
•
Sufficient evidence of a causal
relationship

Limited or suggestive evidence
of an association
• None found
Clearing the Air
Indoor Air Exposures and Asthma Exacerbation
Biological Agents

Sufficient evidence of a causal
relationship
•
•
•


Dog
Fungi/Molds
Rhinovirus
Limited or Suggestive Evidence of an
Association
•
•
•

Cat
Cockroach
House dust mite
Sufficient evidence of an association
•
•
•
Chemical Agents
Domestic birds
Chlamydia and Mycoplasma
pneumoniae
RSV
Sufficient evidence of a causal
relationship
• Environmental tobacco
smoke (in preschool-aged
children)

Sufficient evidence of an
association
•

NO2, NOx (high levels)
Limited or suggestive evidence of
an association
•
Environmental tobacco
smoke (school-aged, older
children and adults)
• Formaldehyde
• Fragrances
Medications to Treat Asthma


Medications come in a variety of forms.
Two major categories of medications are:
• Long-term control
• Quick relief
Medications to Treat Asthma:
Long-Term Control
 Taken daily, over a long period of time
 Used to reduce inflammation, relax
airway muscles, and improve symptoms
and pulmonary function
• Inhaled corticosteroids
• Long-acting beta2-agonists
• Leukotriene modifiers
Medications to Treat Asthma:
Quick-Relief
 Used in acute
asthma episodes
 Generally they are
short-acting beta2agonists
Medications to Treat Asthma:
How to Use a Spray Inhaler
Health-care provider
should evaluate
inhaler technique at
each visit.
Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma
Created and funded by NIH/NHLBI
Medications to Treat Asthma:
Inhalers and Spacers
Spacers can
help patients
who have
difficulty with
technique and
can reduce
potential side
effects.
Inhalers
Spacers
Medications to Treat Asthma:
Nebulizers


Uses compressed air
machine to deliver
medicine as a mist
Good for small
children or for severe
asthma episodes
Managing Asthma:
Asthma Management Goals
 Control symptoms
 Prevent exacerbation
 Maintain lung function as close to normal
as possible
 Avoid adverse effects from medications
 Prevent irreversible airway obstruction
 Prevent asthma mortality
Managing Asthma:
Asthma Management Plan
 Develop with a physician
 Tailor to meet individual needs
 Educate patients and families on all
aspects of the plan
 Recognizing symptoms
 Medication benefits and side
effects
 Proper use of inhalers and peak
expiratory flow (PEF) meters
Managing Asthma:
Indications of a Severe Attack
 Breathless at rest
 Hunched forward
 Talking in words rather than sentences
 Agitated
 Peak flow rate is less than 60% of normal
Resources




National Asthma Education and Prevention Program
• http://www.nhlbi.nih.gov/about/naepp/index.htm
Asthma and Allergy Foundation of America
• http://www.aafa.org
American Lung Association
• http://www.lungusa.org
American Academy of Allergy, Asthma, and Immunology
• http://www.aaaai.org
Resources




Allergy and Asthma Network, Mothers of Asthmatics. Inc.
• http://www.aanma.org/
American College of Allergy, Asthma, and Immunology
• http://allergy.mcg.edu
American College of Chest Physicians
• http://www.chestnet.org
American Thoracic Society
• http://www.thoracic.org
Cystic Fibrosis
CF is a hereditary disease that causes some
glands to produce abnormal secretions that
results in tissue and organ damage. Lungs and
digestive tract appear to be affected the most.
 Most common inherited disease leading to a
shortened life among white people in the US

•
•
•
•
1:3,300 white infants
1:15,300 black infants
Rare in Asians
Found equally in boys and girls
Cystic Fibrosis
 Currently,
there is no cure for CF, but there
are many promising new treatments in use
and even more on the horizon.
 The median life expectancy for a person
with CF is now 32
• thirty years ago, a CF patient was not expected
to reach adulthood. Many people even live into
their fifties and sixties.
Cystic Fibrosis

Cystic fibrosis results when a
person inherits two defective
copies of a particular gene. This
gene controls the production of a
protein that regulates the
transport of chloride and sodium
across cell membranes.
Worldwide, about 3 of 100 white
people carry one defective copy of
the gene. About 3 of 10,000 white
people inherit two defective
copies of the gene; thus, they
develop cystic fibrosis. In these
people, chloride and sodium
transport is disrupted and
dehydration and increased
stickiness of secretions occur.
The key to Cystic Fibrosis is
clogging.
The affected areas of the
body are the airways, liver,
pancreas, intestine, and
reproductive tract.
CF - Symptoms

The lungs are normal at birth, but breathing problems can
develop at any time afterward. Thick secretions
eventually block the small airways, which leads to
inflammation and thickening of their walls. As larger
airways fill with secretions, areas of the lung collapse
and contract (a condition called atelectasis) and the
lymph nodes enlarge. All these changes make breathing
increasingly difficult and reduce the lungs' ability to
transfer oxygen to the blood. Respiratory tract infections
occur because of bacterial growth in the bronchial
secretions and walls of the airways.
CF – Symptoms (cont)


The blockage of pancreatic ducts and intestinal glands
leads to digestive problems, including poor absorption of
fats, proteins, and vitamins. This, in turn, can lead to
nutritional deficiencies, and slower than expected
growth. Some people may have episodes of intestinal
obstruction when abnormal stool contents block the
bowel.
About 15 to 20% of newborns who have cystic fibrosis
have meconium ileus, a serious obstruction of the small
intestine
CF - Symptoms

About half the children with cystic fibrosis are first taken
to the doctor because of frequent coughing, wheezing,
and respiratory tract infections. Coughing, the most
noticeable symptom, is often accompanied by gagging,
vomiting, and disturbed sleep. As the disease progresses,
the chest becomes barrel-shaped, and insufficient
oxygen may make the fingers clubbed and the nail beds
bluish. Polyps may form in the nose. The sinuses may fill
with thick secretions, leading to chronic or recurrent
sinus infections.
CF - Symptoms

When a child or adult with cystic fibrosis sweats
excessively in hot weather or because of a fever,
dehydration may result because of the increased
loss of salt and water. A parent may notice the
formation of salt crystals or even a salty taste on
the child's skin.
 Adolescents often have slowed growth, delayed
puberty, and declining physical endurance. As the
disease progresses, lung infection becomes a
major problem. Recurrent bronchitis and
pneumonia gradually destroy the lungs.
CF - Complications
 About 15% of adults with cystic fibrosis
develop insulin-dependent diabetes
because the scarred pancreas can no
longer produce enough insulin. The
blockage of bile ducts by thick secretions
can lead to inflammation of the liver and
eventually to scarring of the liver
(cirrhosis) in about 5% of adults with cystic
fibrosis
CF – Complications (cont)


People with cystic fibrosis often have impaired
reproductive function. Almost all men have a low sperm
count (which makes them sterile) because one of the
ducts of the testis (the vas deferens) has developed
abnormally and blocks the passage of sperm. In women,
cervical secretions are too thick, causing decreased
fertility. Otherwise, sexual function is not affected.
Women with cystic fibrosis have a higher likelihood of
complications during pregnancy (such as developing a
lung infection or diabetes), but many women with cystic
fibrosis have given birth.
Other complications may include arthritis, kidney stones,
and inflammation of the blood vessels (vasculitis).
CF - Treatment






Advances in antibiotic therapy, nutritional support, and chest
physiotherapy have markedly increased survival in people with
CF
Heart-lung transplantation has been applied to people with CF
5-year survival rates has reached more than 50% in some
centers
People with CF require daily chest physiotherapy to loosen
secretions and prevent stagnation and secondary infections
Antibiotics are essential in treating infection, often given
intravenously
Nutritional support can also be given intravenously in people
who are malnourished
CF – Voc & Psych Implications




People with CF have excellent educational success and
are typically productive individuals
The counselor will have to work with employers to provide
the support mechanisms that will allow the person to
remain in the workplace
This may include the provision of time for chest
physiotherapy or antibiotic treatment during the workday
The work environment must be reviewed to ensure the
absence of irritants that might exacerbate the disease
CF – Voc & Psych Implications



Supplemental oxygen may be necessary to allow the
person the continue to be productive and ambulatory
Psychological outcome in people with CF appears to
depend on factors such as altered physical appearance,
loneliness, and family strife that the person may attribute
to his or her illness
The counselor can also work with the person's family to
improve support at home that will allow the person to
increase social and vocational activities
References
American Thoracic Society (www.thoracic.org)
American Lung Association (www.lungusa.org)
American Lung Association of Florida (www.lungfla.org)
American Association of Cardiovascular and Pulmonary
Rehabilitation (www.aacvpr.org)
Asthma and Allergy Foundation of America (www.aafa.org)
Allergy and Asthma Network (www.aanma.org)
COPD-Support, Inc. (www.copd-support.com)
Cystic Fibrosis Foundation (www.cff.org)
Cystic Fibrosis Research, Inc. (www.cfri.org)
Cystic Fibrosis Resources (www.cysticfibrosis.com)