RESPIRATORY DISEASES

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RESPIRATORY DISEASES

Hypoxemia/Hypercapnia

• Hypoxemia =/= hypoxia

– Hypoxia = decr’d oxygen at tissues

– Hypoxemia = low PaO

2

• V/Q

– Ratio ventilation rate(V) compared to perfusion rate(Q) of blood through lung capillaries at alveoli

– Normal (healthy) ratio = 0.8

• Pa

CO2

dependent on V ventilation rate)

A

(alveolar

– If CO

2 removal =/= CO increase

2 prod'n, Pa

CO2 will

– If decr’d V

A

(hypoventilation) incr’d Pa

(hypercapnia)

CO2

• Ventilation not adequate to meet metabolic demands (cells producing more CO can get rid of)

2 than lungs

• If CO

2 removed faster than produced, Pa will decrease

CO2

– If incr’d V

A

(hyperventilation), decr’d Pa

(hypocapnia)

CO2

• Ventilation exceeds metabolic demands

– Occurs with

• Anxiety

• Head injury

• Insufficient O

2 faster?) in blood (Why would you now breathe

– Remember acid/base imbalances: what happens to acid/base balance if you breathe too little? What compound is increased in the blood? Why is this bad?

What would your body do to compensate?

So, with respect to V/Q Ratio:

• If V/Q < 0.8, body has “wasted perfusion”

(physiologic shunt)

– Blood “shunted” past alveoli w/out adequate gas exchange

– Due to impaired ventilation

– PaO2 decr’d

– PaCO2 incr’d

– Shunting - alveolar spaces nonfunctional

• If extreme physiologic shunt (if alveoli collapsed, edematous, filled w/ exudates), get extreme V/Q mismatch (V=0)

• Can cause:

– Severe hypoxemia

– Administration oxygen does not correct

• If V/Q > 0.8, called dead-space disease

– Q = 0 (again, extreme V/Q mismatch; now due to no perfusion)

– Ventilation not effected physiologically, BUT see incr’d work of breathing

• Also hypercapnia, hypoxemia

• Clinical - variable response

– Hypoxemia if Pa

O2

= 40-50 mm Hg

• Impairment of

– Brain – headache, confusion,    unconsciousness

– Heart – tachycardia, dysrhythmias, incr’d bp

– Hypercapnia

• CNS depressed (headache    coma)

• Body fluids become acidotic

Pathologies

vent’n/ perfusion imbalance

• Heart disease

– Incr’d pressures in lung vasculature (pulmonary hypertension)

• W/ valve disorders, CHF, etc.

•  pulmonary arteriosclerosis

 decr

’ d blood volume at lung (hypoperfusion)

– So decr’d Q and V/Q mismatch

• Note: not the same as incr’d perfusion

• Actually, more similar to ischemia to lung tissues

• Pulmonary embolism  hypoperfusion

– Material in pulmonary circulation  “plugged” vessel

– Thromboembolism most common

• Often w/ thrombi from lower extremities

– Same risk factors as w/ systemic thromboembolism

(smoking, hyperlipidemia, hypertension, etc.)

– Most common cause of acute pulmonary disease in US

• ½ deaths occur w/in 2 hrs of embolism in pulmonary circulation

– Pathophysiology

• V/Q mismatch (decr’d Q)  incr’d Pa

CO2 and decr’d Pa

O2

• Also pulmonary hypertension may result (Why?) and/or decr’d CO

• Pulmonary embolism – cont’d

– Clinical – severity varies

• Massive

–  shock, chest pain, tachypnea, tachycardia

• With lung infarct, see pleural pain, pleural effusion, dyspnea

– What does the term infarct mean?

– Treatment

• Prevention

– Eliminate risks associated w/ thrombus formation (stop smoking, etc.)

• Anticoagulants

– Prevent clot formation

• Pulmonary edema

– Excess fluid in lung, so decr’d ventilation

– Lung usually kept “dry” by 3 mechanisms:

1) lymph drainage

2) capillary exchange

3) surfactant lining the alveoli

– Predisposing factors to pulmonary edema related to 3

• Heart disease

– LV failure  incr’d pressures in L heart  incr’d pressures in respiratory (gas exchange) capillaries

– Fluid gets forced out of capillaries  alveoli and between lung cells

– So decr’d gas exchange ability and decr’d lung compliance

– Lymph drainage compensates for awhile

• Capillary injury

– Injury incr’s capillary permeability  fluid forced more easily out of capillaries into alveoli and between cells (as above)

– Decr’s compliance and gas exchange

– Injury to cap’s may be due to chemical, physical lung injury

• Obstruction of lymph system

– If lymph vessels or nodes blocked  little/no drainage of ISF

(so builds up between lung cells and into alveoli)

– Again  decr’d compliance and gas exchange

– Clinical

• Dyspnea, hypoxemia, incr’d work of breathing

– Treatment

• Depends on cause

Obstructive Respiratory Diseases

•  incr’d resistance to air flow and decr’d vent’n

• Due to obstruction

– In lumen of airway (ex: incr’d secretions w/ asthma)

– In airway wall (ex: inflamm’n at bronchial epithelium w/ asthma, chronic bronchitis)

– In structures surrounding smooth muscle (ex: contraction bronchial smooth muscle w/ asthma)

• Most common obstructive diseases: chronic bronchitis, emphysema, asthma

– Difficult expiration

Chronic bronchitis

• Inflammation of bronchi

• Most common obstructive disease

• Caused by

– Irritants (dominant – cigarette smoke)

– Also infection

• Chronic bronchitis leads to:

– Increased mucus secretion

– AND thickening of mucus

– AND thickening of bronchial mucosa layer (w/ hypertrophy & hyperplasia of bronchial epithelium)

• Body’s compensations for chronic irritation

– Tries to guard cells that make up airways from irritation

– Get diffuse obstruction

– Lung defense mechanisms compromised

• Cilia impaired

• Thickened mucus can’t get rid of invaders

– Find incr’d acute respiratory infections

– Pathophysiology

• Airways collapse w/ expiration

• V/Q mismatch

• Pa

CO2 incr’d (hypercapnia); hypoxemia

– Clinical

• Wheezing, shortness of breath

• Exercise tolerance decr’d

• Productive cough (sputum coughed up)

• Incr’d risk respiratory infections

– Treatment

• Prevention -STOP SMOKING

• Bronchodilators open lumen

• Expectorants decr mucus thickness

Emphysema

•  destruction of alveolar walls, so decr’d elastic recoil of alveoli

– Causes decr’d ability to expire

– Note: obstruction not due to physical substance causing blockage; rather obstruction to gas exchange, air movement due to change in lung tissue

• Genetic predisposition

• Pathophysiology

– Destruction of alveolar septa (shared cell membr between

2 alveoli)

– Large air spaces develop (bullae)

– Airways enlarge

• Clinical

– Dyspnea on exertion developing to dyspnea at rest

• No cough; little sputum (REMEMBER: no incr’d mucus)

• Tachypnea (incr’d rate of breathing)

– Treatment - as per chronic bronchitis

• Together, chronic bronchitis + emphysema =

Chronic Obstructive Pulmonary Disease

(COPD) or Chronic Airway Obstruction (CAO)

Asthma

• Inflammatory disease

• Reversible

– Unlike chronic bronchitis + emphysema

• Bronchospasm + mucus hypersecretion

+ swelling w/ inflamm’n

– Bronchospasm = prolonged contraction bronchial smooth muscle

Obstruction of air flow

• Due to:

– Hyperactive immune response to allergens

• Prod incr’d amounts of IgE

• Bind mast cells in airways

•  Much histamine released

•  Hyperactivated immune, inflammatory responses

• Also, bronchospasm, incr’d mucus and edema w/ incr’d capillary permeability

• Due to (cont’d)

– Neural dysfunction with dysfunctional autonomic nervous system response

• Disrupted or hyperactive irritant receptors (?)

•  Bronchospasm, perhaps also due to mast cell involvement (so all histamine effects noted above)

• Common in children

– Approx 50% of all asthma cases

– Remission common (as adults) when asthma begins in childhood

• Pathophysiology

– Vascular congestion, edema

–  Formation of thick mucus  impaired ciliary function

–  Incr’d work of breathing

– Hyperventilation

• Clinical

– Wheezing, nonproductive cough, tachycardia, mucus formation

• Treatment

– Eliminate cause of attack

– Drugs to reverse bronchospasm

Restrictive respiratory disease

(extrapulmonary)

• Lung tissue is normal, other disorders affect ventilation

• Chest wall restrictions

– Work of breathing incr’s and ventilation decr’s

•  Hypoventilation, hypercapnia, hypoxemia

• Impaired lung defenses

– “Stagnant” air (doesn’t move out of body as it should)

– If contains microbes or invaders, incr’d risk of infecting airways -- more time to grow, replicate

– Due to

• Chest wall deformities

• Fat overlaying chest muscles in very obese patients

• Neuromuscular diseases (ex: polio, muscular dystrophy, others)

– Dyspnea

– Patients more susceptible to lower resp tract infections

– Over time, can  respiratory failure

• Intrinsic restrictions –

– Acute or chronic

– Chronic

• Chronic Intrinsic Restrictive Lung Disease (CIRLD)

– Excessive fibrous/connective tissue deposits in lung

»  Lung injury  scar tissue formation

»  Lung stiffness, so compliance decr’s

– Due to:

» Irritant inhalation, infection, autoimmune dysfunction

– Leads to

» Decr’d ventilation (harder to breathe)

» Hypoxemia

» V/Q mismatch

– Acute restrictions

• ARDS - Adult Respiratory Distress Syndrome

– Due to injury to lung

» Direct: inhaling toxic gases, trauma

» Indirect: systemic disorder  incr’d chemical mediators of infection (thromboxanes, etc.)

» (Biochem’s similar to prostaglandins; patients either release in too high concentrations, or lung cells too sensitive to them)

– Pathophysiology:

» Acute lung inflammation 

» Severe pulmonary edema

»  Diffuse alveolo-capillary injury

»  Severe pulmonary edema, hemorrhage

– Pathophysiology – cont’d

» Get decr’d compliance, decr’d alveolar ventilation, incr’d pulmonary vasoconstriction

» Fibrosis within 7 days of injury  ARDS

– Clinical

» Rapid, shallow breathing

» Marked dyspnea

» Hypoxemia unrelieved by oxygen administration

» Fatal in ~ 70% of cases

– Treatment

» Mechanical vent’n to incr available oxygen

» Sedation to decr oxygen consumption

» Increase C.O., give diuretics to relieve edema

Lung Infections

• When lung defenses decreased

• Pneumonia

– By bacteria or virus

• Common bacteria = strep pneumoniae

• Causes ~70% of all pneumonia

– Pathophysiology

• Pathogens multiply in lung

– Overall, due to decr’d immune response in lung

• Toxins released from microbes

• Bronchial mucosa becomes damaged

– Pathophysiology – cont’d

• Inflammation/edema results

• Exudate found in alveoli

• V/Q mismatch (decreased V)

– Clinical

• Infection  chills/fever/malaise

• Chest edema  cough, pleural pain

• Dyspnea

– Treatment

• Antibiotics – for bacterial infection

• Mechanical ventilation

Atelectasis = collapse of lung

(alveoli)

• Two types

– Compression

• External pressure pushes air out of alveoli

– Alveoli can’t re-expand (because of increased pressure still on lung)

– Absorption

• Occurs w/ obstruction, when no expiration/inspiration

• “Old” air absorbed from alveolus over time, not replaced

– So alveoli collapse

• Seen post-operatively

– Anesthetics cause incr’d mucus production  obstruction

– Clinical

• Dyspnea, cough, fever

Pleura, pleural space affected

• Pleural effusion = fluid (blood, lymph) in pleural space

– Can cause collapse of lung tissue

• Due to incr’d pressure of fluid pressing on alveoli

• Hemothorax = bleeding into pleural space

• Empyema = infected pleural effusion

– Seen w/ lymph blockage

• Pneumothorax = air/gas in pleural space

– Negative pressure in pleural space destroyed

• Pressure differential nec for proper pressures, recoil

– Due to trauma, secondary to thoracic surgery

Lung Cancers

• Bronchogenic carcinoma

– Malignant tumors of mucous membranes

– Larger bronchi

– ~90% of all primary lung cancers

– Epidemic in U.S.

• ~200,000 new cases per year

• Most common of all primary tumors; most frequent cause of cancer death

– Most common cause of bronchogenic carcinoma:

• Cigarette smoking

– Heavy smokers ~25X greater risk than nonsmokers

• Other causes

– Environmental, occupational (breathing in noxious/traumatizing agents, such as asbestos)

• Classification by histological type; each type treated differently

– Non-Small Cell Lung Cancer

• Treated surgically

• Squamous cell carcinoma – most common

– Centrally located

– Remains localized

– Metastasis relatively late

– Associated w/ smoking

– Non-small cell cancers – cont’d

• Adenocarcinoma

– Tumors arise in periphery of lung

– Most common in women

– One type = bronchioalveolar cell carcinoma

» Slow growing

» Weak association w/ cigarette smoking

» Low survival rate

» Asymptomatic w/ early metastasis

– Small Cell Lung Cancer

• Treatment by chemotherapy, radiation

• Strongest association w/ cigarette smoking

• 20-25% of all bronchogenic carcinomas

• Oat cell carcinoma

– Cells compressed

– Rapid growth, early metastasis

– Poor prognosis (<5% alive in 2 yrs)

• Stages common to epithelial cancers

• Irritation  hyperplasia, metaplasia, neoplasia, etc.

• Clinical signs/symptoms

– Coughing, hemoptysis (coughing up blood), dyspnea, chest/pleural pain, atelectasis, hoarseness

• Metastasis mostly through lymphatic system

– Commonly  adrenals, liver, brain, bone marrow

• Treatment depends on tumor type, site

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