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PART IIPART II
Obstructive Airway DiseasesObstructive Airway Diseases
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Chronic obstructive pulmonary disease.Chronic obstructive pulmonary disease.
Bronchitis, emphysema, and asthma may Bronchitis, emphysema, and asthma may present alone or in combination.present alone or in combination.
AsthmaBronchitis
Emphysema
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Chapter 11 Chapter 11 Chronic BronchitisChronic Bronchitis
Chronic bronchitis. Chronic bronchitis. InsetInset, Weakened distal airways in emphysema, , Weakened distal airways in emphysema, a common secondary anatomic alteration of the lungsa common secondary anatomic alteration of the lungs..
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Anatomic Alterations of the LungsAnatomic Alterations of the Lungs
Chronic inflammation and swelling of the Chronic inflammation and swelling of the peripheral airwaysperipheral airways
Excessive mucus production and Excessive mucus production and accumulationaccumulation
Partial or total mucus pluggingPartial or total mucus plugging
Hyperinflation of alveoli (air-trapping)Hyperinflation of alveoli (air-trapping)
Smooth muscle constriction of bronchial Smooth muscle constriction of bronchial airways (bronchospasm)airways (bronchospasm)
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EtiologyEtiology
Cigarette smokingCigarette smoking
Atmospheric pollutantsAtmospheric pollutants
InfectionInfection
Gastroesophageal reflux diseaseGastroesophageal reflux disease
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Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Associated Clinical Manifestations Associated
with CHRONIC BRONCHITISwith CHRONIC BRONCHITIS
The following clinical manifestations result from The following clinical manifestations result from the pathophysiologic mechanisms caused (or the pathophysiologic mechanisms caused (or activated) by activated) by Excessive Bronchial SecretionsExcessive Bronchial Secretions (see Figure 9-11) and (see Figure 9-11) and BronchospasmBronchospasm (see (see Figure 9-10)—the major anatomic alterations of Figure 9-10)—the major anatomic alterations of the lungs associated with chronic bronchitis the lungs associated with chronic bronchitis (see Figure 11-1).(see Figure 11-1).
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Figure 9-11. Excessive bronchial secretions clinical scenario.Figure 9-11. Excessive bronchial secretions clinical scenario.
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Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).
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Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside
Vital signsVital signs
Increased respiratory rateIncreased respiratory rate
Increased heart rate, cardiac output, blood Increased heart rate, cardiac output, blood pressurepressure
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Clinical Data Obtained at theClinical Data Obtained at the Patient’s Bedside Patient’s Bedside
Use of accessory muscles of inspirationUse of accessory muscles of inspiration
Use of accessory muscles of expirationUse of accessory muscles of expiration
Pursed-lip breathingPursed-lip breathing
Increased anteroposterior chest diameter Increased anteroposterior chest diameter (barrel chest)(barrel chest)
CyanosisCyanosis
Digital clubbingDigital clubbing
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Figure 2-36. Figure 2-36. The way a patient may appear when using the The way a patient may appear when using the pectoralis major muscles for inspiration.pectoralis major muscles for inspiration.
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Figure 2-41. Figure 2-41. A, Schematic illustration of alveolar compression of weakened bronchiolar A, Schematic illustration of alveolar compression of weakened bronchiolar airways during normal expiration in patients with chronic obstructive pulmonary disease airways during normal expiration in patients with chronic obstructive pulmonary disease (e.g., emphysema). B, Effects of pursed-lip breathing. The weakened bronchiolar airways (e.g., emphysema). B, Effects of pursed-lip breathing. The weakened bronchiolar airways
are kept open by the effects of positive pressure created by pursed lips during expiration.are kept open by the effects of positive pressure created by pursed lips during expiration.
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Digital Clubbing
Figure 2-46. Digital clubbing.Figure 2-46. Digital clubbing.
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Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside
Peripheral edema and venous distentionPeripheral edema and venous distention
Distended neck veinsDistended neck veins
Pitting edemaPitting edema
Enlarged and tender liverEnlarged and tender liver
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DistendedDistendedNeck VeinsNeck Veins
Figure 2-48. Distended neck veins (Figure 2-48. Distended neck veins (arrowsarrows).).
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Figure 2-47. Pitting edema. From Bloom A, Ireland J: Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetesColor atlas of diabetes, ed 2,, ed 2,London, 1992, Mosby-Wolfe.London, 1992, Mosby-Wolfe.
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Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside
Cough, sputum production, hemoptysisCough, sputum production, hemoptysis
Chest assessment findingsChest assessment findings Hyperresonant percussion noteHyperresonant percussion note
Diminished breath soundsDiminished breath sounds
Diminished heart soundsDiminished heart sounds
Decreased tactile and vocal fremitusDecreased tactile and vocal fremitus
Crackles/rhonchi/wheezingCrackles/rhonchi/wheezing
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Figure 2-12. Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.Percussion becomes more hyperresonant with alveolar hyperinflation.
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Figure 2-17. Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive As air trapping and alveolar hyperinflation develop in obstructive lung diseases, breath sounds progressively diminish.lung diseases, breath sounds progressively diminish.
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Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special
ProceduresProcedures
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Pulmonary Function Study: Pulmonary Function Study: Expiratory Maneuver FindingsExpiratory Maneuver Findings
FVCFVC FEVFEVTT FEFFEF25%-75%25%-75% FEFFEF200-1200200-1200
PEFRPEFR MVVMVV FEFFEF50%50% FEVFEV1%1%
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Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings
VVTT RV FRC TLC RV FRC TLC
N or N or N or N or
VCVC IC ERV RV/TLC ratio IC ERV RV/TLC ratio
N or N or
N or N or
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Arterial Blood GasesArterial Blood Gases
Mild to Moderate Chronic BronchitisMild to Moderate Chronic Bronchitis
Acute alveolar hyperventilation with Acute alveolar hyperventilation with hypoxemiahypoxemia
pH PaCO2 HCO3- PaO2
(Slightly)
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Time and Progression of Disease Time and Progression of Disease
100100
5050
3030
8080
00
PaCO2
1010
2020
4040
Alveolar HyperventilationAlveolar Hyperventilation
6060
7070
9090 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
PaO2
Disease OnsetDisease OnsetP
aO2
or
PaC
O2
PaO
2 o
r P
aCO
2
Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.
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Arterial Blood GasesArterial Blood Gases
Severe Chronic BronchitisSevere Chronic Bronchitis
Chronic ventilatory failure with hypoxemiaChronic ventilatory failure with hypoxemia
pH PapH PaCOCO22 HCO HCO33-- Pa PaOO2 2
Normal Normal (Significantly)(Significantly)
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Time and Progression of DiseaseTime and Progression of Disease
100100
5050
3030
80
0
PaO2
1010
2020
4040
Alveolar HyperventilationAlveolar Hyperventilation
6060
7070
9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
PaCO 2
Chronic Ventilatory Failure Chronic Ventilatory FailureDisease OnsetDisease Onset
Point at which disease becomes severe and patient begins to become fatigued
Point at which disease becomes severe and patient begins to become fatigued
Pa0
2 o
r P
aC0 2
Pa0
2 o
r P
aC0 2
Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.
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Acute Ventilatory Changes Acute Ventilatory Changes Superimposed on Chronic Ventilatory Superimposed on Chronic Ventilatory
FailureFailure
Acute alveolar hyperventilation on chronic Acute alveolar hyperventilation on chronic ventilatory failureventilatory failure
Acute ventilatory failure on chronic Acute ventilatory failure on chronic ventilatory failureventilatory failure
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Oxygenation IndicesOxygenation Indices
QQSS/Q/QTTDDOO22 VVOO22 C(a-v)C(a-v)OO22
NormalNormal NormalNormal
OO22ERER SvSvOO22
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Hemodynamic Indices Hemodynamic Indices (Severe Chronic Bronchitis)(Severe Chronic Bronchitis)
CVP CVP RAPRAP PAPA PCWPPCWP
NormalNormal
COCO SVSV SVISVI CICI
NormalNormal NormalNormal NormalNormal Normal Normal
RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR
NormalNormal NormalNormal
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Abnormal Laboratory Tests and Abnormal Laboratory Tests and ProceduresProcedures
Hematology Hematology Increased hematocrit and hemoglobinIncreased hematocrit and hemoglobin
Electrolytes Electrolytes Hypochloremia (chronic ventilatory failure)Hypochloremia (chronic ventilatory failure) Increased bicarbonate (chronic ventilatory failure)Increased bicarbonate (chronic ventilatory failure)
Sputum examinationSputum examination Increased white blood cellsIncreased white blood cells Streptococcus pneumoniaeStreptococcus pneumoniae Haemophilus influenzaeHaemophilus influenzae Moraxella catarrhalisMoraxella catarrhalis
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Radiologic FindingsRadiologic Findings
Chest radiographChest radiograph
Translucent (dark) lung fieldsTranslucent (dark) lung fields
Depressed or flattened diaphragmsDepressed or flattened diaphragms
Long and narrow heartLong and narrow heart
Enlarged heartEnlarged heart
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Figure 11-2. Chest X-ray film of a patient with chronic bronchitis. Note the translucent (dark) lung fields, depressed diaphragms, and long and narrow heart.
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Radiologic FindingsRadiologic Findings
BronchogramBronchogram
Small spikelike protrusionsSmall spikelike protrusions
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Figure 11-3. Chronic bronchitis. Bronchogram with localized view of left hilum. Rounded collections of contrast lie adjacent to bronchial walls and are particularly well seen below the left main stem bronchus (arrow) in this film. They are caused by contrast in dilated mucous gland ducts. (From Armstrong P, Wilson AG, Dee P: Imaging of diseases of the chest, St. Louis, 1990, Mosby.)
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General Management of General Management of Chronic BronchitisChronic Bronchitis
Patient and family educationPatient and family education
Behavioral managementBehavioral management Avoidance of smoking and inhaled irritantsAvoidance of smoking and inhaled irritants
Avoidance of infectionsAvoidance of infections
Respiratory care treatment protocolsRespiratory care treatment protocols Oxygen therapy protocolOxygen therapy protocol
Bronchopulmonary hygiene therapy protocolBronchopulmonary hygiene therapy protocol
Aerosolized medication protocolAerosolized medication protocol
Mechanical ventilation protocolMechanical ventilation protocol
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Global Initiative for Chronic
Obstructive
Lung
Disease
GOLD StandardsGOLD Standards
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Figure 11-4. Acute exacerbation of COPD (AECOPD): Guideline algorithm (ACCP/ACP-ASIM). CXR, Chest X-ray; NPPV, noninvasive positive pressure ventilation; PEFR, peak expiratory flow rate; URI, upper respiratory infection. (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)
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Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)
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Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)
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Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)
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Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)
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Figure 11-4. Acute exacerbation of COPD (AECOPD): Guideline algorithm (ACCP/ACP-ASIM). CXR, Chest X-ray; NPPV, noninvasive positive pressure ventilation; PEFR, peak expiratory flow rate; URI, upper respiratory infection. (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)
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Classroom DiscussionClassroom DiscussionCase Study: Chronic BronchitisCase Study: Chronic Bronchitis
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