CH. 15
Goodman







Pulmonary (think of anatomical structures)
Pulmonary (from L. pulmonarius “of the lungs,”) is more
inclusive - however respiration is really the end game goal
of the system
Pulmonary system includes the upper airways; lower
airways and alveoli
Pulmonary system allows for external respiration; but only
given internal respiration – in other words, without internal
respiration - external respiration is not possible.
Respiratory (think of a process or a physiological function)
Respiration - gas exchange
Ventilation - air flow that supports (allows) for respiration
◦ RESPIRATION AND VENTILATION





REMEMBER that ventilation is air in/out of
lungs
AND that respiration is gas exchange
WELL… respiration can be divided into
external respiration and internal respiration
EXTERNAL respiration is exchange of O2/CO2
between air and blood
INTERNAL respiration is exchange of O2/CO2
between blood and tissue (metabolic process)
THE PULMONARY SYSTEM
Note: divided into 3 sections:
Upper airways, lower airways
and alveoli

Respiration is a flow of gases; flow is
dependent on pressure gradients; therefore
respiratory flows of particular gases (oxygen,
carbon dioxide) are dependent on partial
pressure gradients; HgB saturation of oxygen
is dependent on the partial pressure of
oxygen in arterial blood as determined by the
oxyhemoglobin dissociation curve:
OXYHEMOGLOBIN DISSOCIATION CURVE
Note: When PaO2 < 60 mmHg, the SpO2 or
SaO2 drops below 90%



What is the oxyhemoglobin dissociation curve
and why is it important?
The Oxyhemoglobin dissociation curve
describes the non-linear tendency for oxygen
to bind to hemoglobin: below a SaO2 of 90%,
small differences in PaO2 result in large
changes in SaO2.
This is the way to describe the causal nature
of the PaO2 on the SaO2

SpO2


SaO2

PaO2



O2 saturation taken
with pulse oximeter
(estimation of
SaO2)
O2 saturation in
arterial blood
Partial pressure of
O2 in arterial blood
NOT SYNONYMOUS!




Hypoxemia is the most common condition
caused by pulmonary disease or injury.
Hypoxemia is deficient oxygenation of
arterial blood.
This may lead to hypoxia; prolonged hypoxia
will cause tissue damage or death.
Hypoxia is a broad term meaning diminished
availability of oxygen to the body tissues.



Hypoxemia- low oxygen levels in the arterial
blood *PaO2 is normally > 95 mm Hg
Hypercarbia - elevated carbon dioxide levels
in the arterial blood (Pa CO2 > 45 mm Hg;
Normally = 40mm Hg)
Respiratory Acidosis - pH < 7.4 with elevated
PaCO2



Pathological conditions of every major organ
system can have secondary effects on the
pulmonary system; pulmonary secondary effects
are typically the life threatening component
of illnesses.
For example - pulmonary complications are the
major cause of death due to just about
every chronic neurological condition; and are the
life threatening complications that arise
following surgery
“Critical care” is typically critical due to the
pulmonary needs


PT assessing signs and symptoms of
pulmonary disease must consider that these
(signs and symptoms) may be secondary
effects and should investigate underlying
etiological factors
EXAMPLE of a PT assessment: Patient
demonstrates a decline in functional mobility
secondary to inability to tolerate low level
activities due to CHF and COPD complicated
by acute exacerbation of these conditions
with diagnosis of pneumonia.




Cough (sign)
dry vs wet
productive vs non productive (does
something come up (or get swallowed)
dry can be a sign of early onset of CHF (low
specificity) - specificity increases if highly
repeatable with physical exertion / fatigue
(i.e. if every time the patient exerts to fatigue
they get a dry cough)


TYPES OF SPUTUM:
Purulent: containing pus; composed of WBCs,
cellular debris, mucus, dead tissue….
◦ Can be greenish-yellow, milky white

Non-purulent: not containing pus

Hemoptysis: coughing/spitting up blood





Dyspnea (SOB) (symptom)
breathlessness - uncomfortable feeling with
breathing
Dyspnea that occurs in recumbant position
(including supine) -> orthopnea
Signs of dyspnea can include tachypnea,
nasal flaring, accessory muscle use
Signs that dyspnea is due to a medical
emergency include: wheezing, cyanosis,
drops in BP, irregular cardiac rhythm





Cyanosis (sign)
bluish discoloration due to a lack of oxygen
Can be due to low oxygen in the blood (Hct
and/or SpO2); or due to oxygen delivery
(blood flow)
Blood flow problems can be local (vascular
issues) or systemic (low cardiac output)



Clubbing (sign)
Thickening and widening
of terminal phalanges of
fingers and toes –
painless
Tend to be caused by
conditions of prolonged
interference of tissue
perfusion - common in
Cystic Fibrosis, COPD,
lung cancer,
bronchiectasis,
pulmonary fibrosis,
congenital heart disease





Altered breathing patterns (signs)
1. Accessory muscle dependence
2. Cheyne-stokes respiration - cycles of deep to
shallow breathing with periods of apnea
then starting the cycle over again - common with
brain damage and severe heart failure
3. Thoracic paradox - inward movement of
thorax during inspiration (thoracic ms paralysis;
rib fracture)
4. Abdominal paradox - inward movement of
abdomen during inspiration (diaphragm
paralysis)




Sounds (signs)
Wheezes - high pitched sounds due to difficulty
with airflow
Stridor – high-pitched wheeze that occurs with
significant upper airway obstruction ; *medical
emergency ; can be heard without a stethoscope
Fine Crackles (Rales)- “static electricity” sound
with inspiration associated with mucous,
edema or atelectasis
Course crackles (Rhonchi) - course sound deep in
lungs associated with loose mucous,
lots of edema
Aging and the Pulmonary
 Aging results in declines in: ventilation,
respiration and pulmonary defenses to infectious
processes and environmental pollutants
 Ventilation: *declines with age in FVC, FEV1, Peak
Flow; *increases with age in RV and FRC.
 These changes are mostly due to age related
changes in lung tissue (reduced elasticity, less
wall structure -> airways collapse and trap air);
as well as in musculoskeletal changes of the
thorax and breathing muscles.


Respiration: decreases in ventilation /
perfusion matching (related to increases in
RV and FRC); decreases in diffusion due to
decreased alveolar surface area; net result:
increase in Ve/VO2 and Ve/VCO2 with aging
(i.e. need to ventilate more air in a minute to
consume1 L of O2, or expire 1 L CO2)
Normal Ve/VO2 = 22-26; can increase to
26-28 without being diagnosed with
pulmonary disease

Pulmonary defenses: reduced because of less
ventilation (impacts coughing and general
mucociliary clearance); and also less specific
mucociliary clearance due to less cilia
activity
**Most adults attain maximal lung function (as
measured by FEV1) during their early twenties,
but with increasing age, especially after age 55
years, there is an overall decrease in the
functional ability of the lungs to move air in and
out. This decline peaks by age 75 years, to about
70% of our maximum.
Lung Volumes
*Refer to this when reviewing age
related changes in the pulmonary
system.







Intra vs. Extra Pulmonary
Intra : starts with the lung tissue itself interstitium (parenchyma) or airways
Extra : starts with non lung tissue - such as the
pleura, pleural space, chest wall (ROM or
strength)
Obstructive vs. Restrictive
Restrictive : primarily (originates as) difficulty
getting air INTO the lungs
Obstructive : primarily (originates as) difficulty
getting air OUT OF the lungs





Acute vs. Chronic
Acute: short term, generally reversible
Chronic: long term, generally irreversible
Can be used to describe the entire disease, or
just a component
For example - Asthma is a chronic condition,
long term and generally irreversible; but
airway obstruction associated with asthma is
acute - comes on suddenly, is short term
and is generally reversible




A. Pneumonia (acute, intrapulmonary, restrictive): inflammation
affecting the parenchyma of the lungs; caused by infection,
inhalation of toxic chemicals, aspiration of food, liquid or
vomitus
B. Pneumocystis Carinii Pneumonia (acute, intrapulmonary,
restrictive): progressive, almost fatal pneumonia ; origin of
organism is unknown
C. Pulmonary Tuberculosis (TB) (chronic, intrapulmonary,
restrictive): infectious, inflammatory systemic disease that
affects the lung. May disseminate to affect the lymph nodes and
other organs
D. Lung abscess (acute, intrapulmonary, restrictive): localized
accumulation of purulent exudate within the lung; usually
develops as a complication of pneumonia


Clinical manifestations:
Sudden and sharp
pleuritic chest pain,
hacking productive
cough, rust colored or
green purulent
sputum, dyspnea,
tachypnea, decreased
chest excursion on
affected side, cyanosis,
HA, fatigue, fever and
chills and generalized
aches and myalgias

PT treatment can assist
with DB and coughing/
pulmonary hygiene,
airway clearance, early
ambulation



A. Chronic Obstructive Pulmonary Disease (COPD):
chronic airflow limitation that is not completely
reversible
B. Chronic Bronchitis (major underlying disease of
COPD): clinically defined as a condition of
productive cough lasting at least 3 months per year
for 2 consecutive years
C. Emphysema (major underlying disease of COPD):
pathologic accumulation of air is tissue (lung
tissue) such that the lungs lose their elasticity and
there is “air trapping”




D. Asthma (chronic disease, acute airway obstruction):
inflammation and increased smooth muscle reaction of the
airways to various stimuli. It is a chronic condition with acute
exacerbations.
E. Bronchiectasis (chronic, intrapulmonary, obstructive):
progressive form of obstructive lung disease characterized by
irreversible destruction and dilation or airways generally
associated with chronic bacterial infections
F. Bronchiolitis (chronic, intrapulmonary, obstructive): refers to
several morphologically distinct pathological conditions of the
small airways; was once classified as a chronic pneumonia
G. Sleep-Disordered Breathing (chronic with acute airway
obstruction): collection of syndromes characterized by breathing
abnormalities during sleep that result in intermittently disrupted
gas exchange and in sleep interruption


Airflow limitation in
COPD is usually
progressive and
associated with an
abnormal
inflammatory
response to
noxious particles or
gases
Confirmed with
spirometry testing

Patients with COPD
typically have a
combination of
chronic bronchitis,
emphysema and
small airway
obstruction




A. Pulmonary fibrosis
B. Systemic Sclerosis Lung Disease
C. Chest Wall Trauma or Lung Injury
**Note that pneumonia (PNA) and tuberculosis
(TB) are also restrictive lung diseases.
**This major category describes conditions that
lead to reduced lung volume and decreased lung
compliance
**PFT >>decreased TLC



A. Pneumoconiosis
B. Hypersensitivity Pneumonitis
C. Noxious gases, fumes and smoke inhalation
**Occupational diseases can be divided into 3 major
categories: Conditions from inhalation of:
1. inorganic dusts (example from iron ore, coal)
2. organic dusts (molds, fungal spores, wood dust, coffee
beans, bird feathers)
3. fumes, gases and smoke inhalation

**The pathologic characteristics are common and include:
involvement of the lung parenchyma with a fibrotic
response

Surviving (24 hours or longer) the
physiological effects of hypoxemia and
acidosis that result from submersion in fluid



A. Cystic Fibrosis (obstructive and restrictive,
chronic, intrapulmonary)
**CF is an inherited disorder of the exocrine
glands affecting the hepatic, digestive, male
reproductive and respiratory systems
**The basic genetic defect predisposes to
chronic bacterial airway infections; almost all
will develop obstructive lung disease and
progressive loss of lung function







A. Atelectasis
B. Pulmonary Edema
C. Acute Respiratory Distress Syndrome
D. Post operative respiratory failure
E. Sarcoidosis
F. Lung Cancer
**Conditions affecting the lung parenchyma
(lung tissue)





A. Pulmonary Embolism & Infarction
B. Pulmonary Hypertension
C. Cor pulmonale
D. Collagen Vascular Disease
**Conditions that involve the lungs and the
vascular system




A. Pneumothorax
B. Pleurisy
C. Pleural Effusion
**Conditions involving pathology in the
pleural area of the lungs (pleura of the lung
describes the covering of the lung and is
comprised of visceral and parietal pleura with
a space in between which contains fluid)
Lung Volumes
*Use as a reference
Resources: Acute Care Handbook for Physical Therapists. Paz
and West, 4th ed. 2014.
www.dailymail.co.uk
Goodman Ch. 15
Andrea C. Mendes PT, DPT
Sean M. Collins PT, ScD