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OBSTRUCTIVE: list some

Bronchopulmonary Dysplasia (sounds familiar)• Cystic Fibrosis, muscous
• Asthma, the airways get smaller
• Bronchitis → Bronchiectasis, inflammation of the airways
• Emphysema, is ptherwise known as COPD, chronic OBSTRUCTIVE Pulmonary Disease.

1

Obstructive Pulmonary Disease is?

Respiratory tract diseases that produce an
obstruction to air flow which can
ultimately affect the mechanical function andgas exchange of the lungs
We cannot get the gas out.

2

Risk Factors for obstructive lung disease...

• Age: (Prematurity, Elderly) All the extreme ages have this problem. Premes do not have enough surfactant. Replace it.
• Immunocompromise
• Environmental Factors
• Smoking Most direct link to emphyzema.
• Genetics Always consider this.
• Restricted Thoracic Movement We are getting less gas in

3

Smoking is involved in obstructive lung disease by...

Produces a low level chronic inflammation in the lungs
Increased phagocytes, neutrophils, and
alveolar macrophages all contribute to the
breakdown of elastin in the alveoli
Destroys the action of cilia
The mucuciliary escalator, they get lowered so
then the materials do not come out, and so there is obstruction of the passageway of the air.

4

Hypoxia is ________________. It canresult from:

inadequate oxygenation...
Pulmonary Disease with impaired diffusion• V-Q mismatching: shunting
• Inadequate O2 transport Sickle cell anemia.
• Inadequate tissue oxygenation

5

Hypoventilation can be caused by...

Respiratory center depression
Neural conduction interference
Respiratory muscle disease
Restriction of the thorax
Restriction of lung excursion
How far the lung tissue can move,mthe lung tissue compliance, it cannot move as much, it will affect the compliance.

6

Hyperventilation can be caused by...

Anxiety
Lesion of CNS
Medications/ Hormones
Increased Metabolism
Hypoxia/ CO2 retention (short term)Acidosis
Hypotension
Pain

7

BPD: Chronic lung disease of

early infancy

8

Presentation of bronchiopulmonary displasia

O2 dependency beyond 1 mos., and vent support

9

Infants at risk for BPD include those with:

Prematurity
Meconium aspiration The baby inhales the placentaand waste material.
Persistent fetal circulation (name 2 examples)
TETROLOGY OF FALLOT ASD OR PFO, THEY have a dysatructure but it is not so bad. PDA.

10

BRONCHOPULMONARY DYSPLASIA AKA

Pulmonary Fibroplasia and ventilator lung

11

BRONCHOPULMONARY DYSPLASIA
• Occurs more in

LBW babies who rec’d highflow O2 for 5 d or longer

12

Do LBW infants recover from oxygen induced BPD?

Many infants recover and improve over timehowever severe BPD correlates highly with
developmental delays

13

BPD: Pathology

Stage 1: Hyaline membrane disease caused by
decreased surfactant
Stage 2: Tissue granulation, obliterating bronchitisStage 3: Emphysematous changes (distended
terminal airways and open alveoli)(hyperinflation) Stage 4: Subepithelial fibrosis, right ventricular hypertrophy. The lung have lost compkiance and excursion. And it will cause right venticular hypertrophy, to be able to push against its afterload better. Cor pulmonary.
Babies who have emphyzema, like, in the alveoli, the alveoli loose their elasticity, because we are pushing in that air with the ventilator and it will cause ehhsematous changes. Hyperinflation is related to emphyzema.

14

BPD: Clinical Features
Infants will present with:

Tachypnea
Cyanosis
Bronchiolitis or Pneumonia
May require a tracheostomy

15

Cystic Fibrosis Pathology

Accumulation of hyper viscous secretions
leads to progressive obstruction of mucoussecreting exocrine glands, preventing
delivery to target organs
Organs most affected: lungs, pancreas,
reproductive system, sinuses, and sweat
glands

16

Cystic Fibrosis Impairments

1) Dysfunctional Cl channel epithelial
function causes abnormal concentrations ofNa and Cl
2) Blocked exocrine gland function
3) Increased susceptibility to chronic
endobronchial colonization

Bacterial infection.

17

Pancreatic Dysfunction

Viscous secretions begin to obstruct
pancreas in utero with periductal
inflammation and fibrosis
Maldigestion of protein = greasy, bulky, foulsmelling stools

18

Pulmonary Dysfunction

Obstruction of small airways
Air trapping and atelectasis
Progressive airway obstruction
Decreased gas exchange Shunting because the alveoli arefull of mucus.
Opportunistic bacteria, inflammation,
bronchiectasis, and irreversible airway
damage
Bronchii change shape.

19

Presentation of CF

Patients are likely to present with: Persistent Cough, because rhey have increased mucous, Recurrent Pneumonia, because the mucous allows for the bacteria to grow, Excessive Appetite/Poor
Weight Gain, because they cannot dogest the food proper so the nutrients are lost, Salty Skin/Sweat, they just sweat more Na Cl,Bulky, Foul Smelling
Stools, because the food is really just passed out and the bacteria inside the guts eat it and make it smelly, Infertility, because of blocking if the ducts, Nasal Polyps, Chronic Wheeze, because the passageways are pblocked with mucous,
Glucose Intolerance, Tachypnea, because they do not get enough oxygen they will breath faster to get their oxygen,Cyanosis/Digital
Clubbing, they just are not getting enough oxygen, Exertional Dyspnea, because they have low ventilation and respiration they will get tired with alomost any work, Pneumothorax, The air pressure, dueto the atlectasis changes, and they get bigger and it pulls the lung away from the wall., Hemoptysis, they will bleed in their lungs due to all the pbstruction, Right Sided Heart Failure, because the righht side has to overcome the pressure of the lungs so it will push harder and cause it that the right ventricle will fail.

20

Meds for CF...

There is one medicstion for one type, but all of this is from management, tominimize the recurrent infection.

21

Genetic Counseling

Controversial

Screening for prospective parents to
determine presence of gene

Genetic testing of the fetus to determine presence of the disease

22

Medical Tests for Diagnosis for CF

Sweat Test: Quantitative pilocarpine iontophoresis.Measures Cl levels in sweat.
Nasal PD: Potential difference of electrical charge
across the mucous membrane of the nose. Nl –5 to –30 mV, CF –40 to –80 mV
Stool Analysis: Find malabsorption ↑ fat in stool 
(>7% is abnl with CF see 20% - 30%)

23

Sputum Cultures• May be positive for:

Strep
Pseudomonas
Burkholderia Cepacia (nosocomial)
Haemophilus Influenza
Klebsiella

24

CXR
Findings are ________ early on in the disease process
Later, X-rays demonstrate streaky, white
bands across the lung fields.

negative

25

Obstructive Components will see what in the PFT?

Air trapping, Increased RV and FRC, IncreasedPaCO2

26

Restrictive Components will see what in the PFT?

Restrictedair flow, Decreased TLC, VC

27

CPT Assessment, looks for?

Auscultation - Rales/sonorous wheezes, because of mucous deposits
Increased A/P diameter (Barrel Chest), they keep their chest full so that they can breath in more
Chronic, productive cough, because of the mucous
Accessory muscle use to breath in harder since it is blocked,
SCM, SCALEMNES, TRAPS, SERRATUS ANTERRIOR, PEC MINOR,
AND EXTERNAL INTERCOSTALS.

28

CPT Treatment

Postural Drainage Place in position tommake the material come from the distal area tot he center to bring it out.
FET (forced expiration technique) (huffing) as
effective as 2-3 CPT treatments/day.
ACB (Active cycle breathing) uses FET in
conjunction with thoracic exp. exercises
PEP (positive expiratory pressure) demonstrated to improve exercise tolerance and secretion clearancewhen paired with FET.
AD (Autogenic draining)(uses segmental breathing) Huffing is like steaming a minorr, it is more energy conservative than just
coughing.

29

CPT Treatment what equipement are used for CF?

Flutter device Give resistance, to bring up the materials.
Inflatable therapy vest
Trunk Mobility/Postural Education
Exercise encouragement
Mucolytics

30

CF Nutrition

Balanced diet - high calorie
Enzyme supplementation for fat and proteindigestion
May require supplemental nutrition at night by NG or IV (hydration essential for
adequate expectoration of secretions)

31

CF Abx

Controversial
Tolerance to antibiotics

32

Steroids to decrease inflammation

.

33

Lung Transplant Criteria

Severe pulmonary disease with marked
hypoxemia
Increase in the frequency of hospitalizationsIncreased antibiotic resistance
No other significant vital organ disease
History of medical compliance
Acceptable psychological profile
Complicated by fact many recipients are
adolescents
May tend to skip follow up rx in order to fitin better c peers

We want someone that is at the end of their alternative treatments, who is fit for the transplant, who will keep to follow ups, and who is sound of mind.

34

Lung Transplant P/O

Basicaly it is P/O.

Immunological suppression post op

Risk of rejection these two are true by all operations.

Pts may be colonized c infectious agents (esp in
sinuses) that can infect new lungs, by CF there could have been a culture present before the operation.

Unique challenges (only organ transplant that comes intocontact with the outside world)
A really stressed organ, because it is exposed to the outside world.

35

First drug: for CF...

Kalydeco approved Jan 2012, counters mutation present in 4% CF cases,cost: $294,000 yr

36

Asthma is...

Episodic in nature
• Acute episodes alternate with symptom freeperiods
• Chronic inflammatory disease
• Airways narrow in response to a stimulus

37

ASTHMA: Acute Attack

↑ mucosal edema, ↑ secretions, 
hyperactive airways (bronchospasm)
Loud audible wheezes, rales and rhonchi Can be a life threatening event

38

Status Asthmaticus:

severe asthmatic attack thatdoes not respond adequately to usual therapy and may require hospitalization

Emergency, they are not
responding to treatment.

39

ASTHMA: Acute Attack• Acute episodes can be triggered by:

• Allergens
• Infection
• Environmental Stress (esp cold)
Emotional Stress

• EXERCISE

40

Exercise Induced Bronchospasm

Caused by loss of heat and water from the
lungs during exercise due to hyperventilation
of dry cool air
• It is estimated that 80% to 90% of people with asthma have EIB
• Many patients only have bronchospasm with
exercise

41

Asthma Meds
• Long term asthma control medications

Inhaled corticosteroids Low dose, mild, suppose to go to the lung.
• Long acting beta agonists (LABAs)
• Theophylline (taken in pill form)
• Leukotriene modifiers (↓ immune response)• Combination drugs (corticosteroids + LABAs)

42

Asthma Meds
• Quick relief (rescue) medications

Short acting beta agonists– Commonly albuterol
Anticholinergics (Ipratropium) (blocks
acetylcholine, more often rx for COPD thanasthma)
• Oral corticosteroids (for severe attacks
(prednisone) )
Vitals can allow us to see if the person is able to go and do the job.

43

Bronchial Thermoplasty

Using bronchoscope, lungs are heated to 149 degrees F
• 3 stage procedure (3 weeks in between)
• Costs $20,000
• Sig ↓ in ER visits and lost work
• Some insurances now covering
• NYT Article by Anahad O’Connor 9/4/12

44

Bronchitis

Hypertrophy of the mucous glands and increase in goblet cells
Loss of ciliary action
Thickening of bronchial wall
Obstruction, inflammation, ↑ secretions
Thick, tenacious, mucopurulent secretionsStrong, hard to get rid of.
Mucous that is like a pearl

45

Chronic Bronchitis Early stage:

10 -100ml of sputum
expectorated in the AM

Later stage:
Prolonged phase of expiration
Coarse rales, rhonchi, and wheezes

46

Chronic Bronchitis Chronic productive....

cough with morningexpectoration

47

Why is hydration important for thise who are asthmatic?

So that the mucous could be more watery and come out easier.

48

Bronchiectasis is?

Permanent abnormal dilation and distortion ofbronchi caused by destruction of the elastic and
muscular components of the bronchial walls

Describes an anatomic abnormality
NOT a single disease
Many different diseases can lead to bronchiectasis.

Like ling term bronchitis.

49

Bronchiectasis Commonly caused by:

Necrotizing infections of the trachea and bronchial
tubes
Necrotizing PNA (remember, recurrent infections are typically seen in chronic bronchitis and CF)
TB
Pertussis Wooping cough, bad for kids, can kill a baby, by an adult, it looks like a cold, a baby, they can go into respiratory distress. The vaccine works but does not last.

50

Bronchiectasis
Other causes:

Chronic gastroesophageal reflux and aspiration
Foreign body aspiration
Lung diseases that upset the pressure balance thatkeeps the lungs open (Sarcoidosis, Interstitial Fibrosis)
TB
Smoke or other inhalation injury
Immotile cilia syndrome

Again anything that will keep the airways open and lead to permanent structural changes.

51

Bronchiectasis: Clinical Features
Patients will present with:

Cough, copious
mucopurulent sputum, fetid breath, recurrentpulmonary infections

52

Bronchiectasis is Frequently seen in conjunction with?

Cystic Fibrosis
Immotile Cilia Syndrome
Kartagener’s Syndrome [which consists of
bronchiectasis, sinusitis, situs inversus (heart on the right side)]

53

Emphysema is?

Anatomical changes in the lungs
characterized by hyperinflation especially at the alveolar level

54

Bronchiectosis vs. Emphysema

The brinchi is at the bronchi and the emphysema is att he alveoli

55

Blebs are?

(balloon like stretched out alveoli)
when stressed can cause a pneumothorax

56

Obstructive Pulmonary Disease name me five things that can cause this...

Bronchopulmonary Dysplasia
Cystic Fibrosis
• Asthma
• Bronchitis → Bronchiectasis
• Emphysema

57

Fremitus is?

Vibration
• Produced by voice or presence of secretions inairways
• Transmitted to chest wall
Piut the dorsim of your hand on the person and ask to breath or listen to their speech.

Thats all that it is, just vibration, but depending on the amount and location different amounts and types of vibration will ensue at different parts of the chest wall.

58

Abnormal Findings• Increased Fremitus indicates

presence ofsecretions or consolidation

59

Decreased Fremitus indicates

presence of air or fluid in the pleural space

60

Postural Drainage

• Align segmental bronchi with gravity

• Collect secretions centrally

• Cough/expectorate to remove secretions

• Can supplement with P & V

61

Postural Drainage Contraindications

• ICP > 20 mmHg
• Unstabilized head/neck injury
• Active hemorrhage
• Hemoptysis
• Empyema
• Bronchopleural fistula
• Pulmonary edema assoc with CHF

62

Contraindications Tredelenburg

• Neuro dx: Cerebral aneurysm, ICF drain,
coma, recent CVA, uncontrolled sz
• ↑ ICP contraindicated
• Uncontrolled HTN
• Distended abdomen
• Post esophageal procedures
• Cardiovascularly unstable: Acute MI,
pulmonary HTN, arrhythmias

63

Percussion

Cuped hand to clap them over on 5he person.

• Loosens secretions
• Use cupped hand
• Should sound hollow
• Percuss only over ribs
• Percuss for at least one minute

64

Vibration

• Gentler than percussion
• Uses flat hand
• Always go “down and in”
Coordinate with exhale

65

Contraindications for percusion and vibration

• Pneumothorax
• Platelets < 50,000
• Cardiovascularly unstable pt
• Over rib fx or lesion
• Osteoporosis, CA mets, prolonged steroid use• Over sx incisions/sternotomy
• Over recent graft, burn or wound
• When blood too thin (↑ INR, etc.) • Hemoptysis
• Undrained empyema
• Subcutaneous emphysema
• PE
• Flail chest
• Awaiting R/O for MI
• Acute TB
• Severe pain
• Recent spinal fusion