U6

Question 1

ATELECTASIS

Answer 1

Atelectasis - the incomplete expansion of a part of the lungs (the alveoli cannot fill with air); caused by –
A blockage of the air passages (bronchus/bronchioles) or
(2) By pressure on the outside of the lung, or
(3) By surfactant failure.

Question 2

ATELECTASIS
READ
S/S
TX

Answer 2

Atelectasis is common soon after surgery or in patients who have limited mobility in the hospital (secretions build up in the lungs due to immobility). Pneumonia may develop quickly after atelectasis starts in the affected part of the lung. In an adult, atelectasis in a small area of the lung is usually not life threatening. The rest of the lung can make up for the collapsed area, bringing in enough oxygen for the body to function. But large areas of atelectasis may be life threatening, especially in a baby or small child, or in someone who has another lung disease or illness. See page 571 of textbook.

S/S – Dyspnea, chest pain or cough.

Tx – Pulmonary Hygiene: Incentive spirometry and TCDB (Have patient “Turn, Cough, and Deep Breath” frequently). These actions are intended to keep the alveoli open and prevent further lung collapse.

Question 3

RISK FACTORS FOR DEVELOPING ATELECTASIS

Answer 3

Risk factors for developing ATELECTASIS include:

~Anesthesia*
~Foreign object in airway (common in children)*
~Lung diseases (inflammation blocks airways)*
~Mucus that plugs the airway*
~Prolonged bed rest w/few changes in position*
~Shallow breathing (i.e., hurts to breathe)*
~Pressure on lungs caused by pleural effusion **
~Tumors that block an airway**

Question 4

ABSORPTION ATELECTASIS

Answer 4

*ABSORPTION Atelectasis: Alveoli CANNOT EXPAND because the airways are blocked and air cannot get into
the air sac, or there is no nitrogen in the air sac to keep it open. Example: Post-Op Atelectasis =
Oxygen (given in general anesthesia) pushes CO2 and Nitrogen gases out of the alveoli.
Oxygen then leaves the alveoli too as it gets absorbed into the capillaries.
No gas is left in the alveoli to keep it open.

Question 5

COMPRESSION ATELECTASIS

Answer 5

COMPRESSION Atelectasis is caused by outside pressure pushing on the alveoli and collapsing it -
such as a space-occupying tumor, or a pocket of pleural effusion.

Question 6

HYPERCAPNIA

Answer 6

Hypercapnia – Too much carbon dioxide in the BLOOD (caused by a problem with ventilation)

Question 7

HYPOXEMIA

Answer 7

Hypoxemia – low oxygen in the BLOOD

Question 8

HYPOXIA

Answer 8

Hypoxia - low oxygen in the TISSUE (caused by a problem with perfusion)

Question 9

1 RANDOM FACTOID

Answer 9

1 RANDOM FACTOID: The first indicator of HYPOXIA is a Change in LOC [level of consciousness] such as Restlessness, confusion, anxiety because low oxygen is registered in the brain FIRST. The brain responds to hypoxemia long before the tissues become hypoxic (in other words, before a major change can be detected by an oximeter, since it measures the level of oxygen in the tissue).

Question 10

2 RANDOM FACTOID

Answer 10

2 RANDOM FACTOID: The primary regulator of respiration is CO2 - not oxygen!

Question 11

PNEUMOTHORAX

Answer 11

Pneumothorax – Air in the Pleural Space. A collapsed lung occurs when air escapes from the lung. The air then fills the space outside of the lung, between the lung and chest wall. This buildup of air puts pressure on the lung, so it cannot expand as much as it normally does when you take a breath. A pneumothorax can be caused by an injury to the lung such as a gunshot or knife wound to the chest, rib fracture, or certain medical procedures.

Question 12

PNEUMOTHORAX
READ

LUNG DISEASES THAT HEIGHTEN RISKS OF PNUEMO

Answer 12

In some cases, a collapsed lung is caused by air blisters (blebs/bulla) that break open, sending air into the space around the lung. This can result from mechanical ventilator is set too high, or without warning to people with weakened alveoli (such as COPD patients). Tall, thin people and smokers are more likely to have a collapsed lung. In some cases, a collapsed lung occurs without any cause. This is called a spontaneous pneumothorax or collapsed lung.

    Lung diseases can also increase the chance of getting a collapsed lung. These include:

Asthma
COPD
Cystic fibrosis
Tuberculosis
Whooping cough

Question 13

PLEURISY

Answer 13

Pleurisy - Inflammation of the lining of the lungs and chest (the pleura) that causes chest pain when taking a breath or coughing. The normally smooth surfaces lining the lung (the pleura) become rough. They rub together with each breath resulting in a rough, grating sound called a friction rub.

Question 14

PULMONARY EMBOLISM

Answer 14

Pulmonary Embolism (P.E.) – Arteries in the lungs become blocked by a blood clot. This restricts blood flow to a portion of the lung resulting in a “Perfusion Mismatch” (see pg. 1), and ultimately that portion of the lung can die.

Most times, a pulmonary embolism is caused by blood clots that travel from the legs (deep vein thrombosis –DVT) or, rarely, other parts of the body).  Commonly, a DVT breaks off and travels to the lungs after first passing through the right side of the heart and ultimately lodging in pulmonary artery of the lung.

Question 15

PULMONARY EMBOLISM
READ
HIGH RISK

Answer 15

HIGH RISK for a P. E.: Use of birth control pills (causes hypercoagulation), large bone fractures (releases fatty emboli-causing Fat Embolism Syndrome-FES), smoking (vasoconstriction slows blood flow →clot formation), atrial fibrillation (clots form in atria of the heart), Post-operatively [3 – 10 days after] especially orthopedic surgeries.

Symptoms: shortness of breath (S.O.B.), chest pain, s/s of hypoxia, and cough.
DX: V/Q Scan (Nuclear Medicine test) and blood tests (remember “D-Dimer”) and Platelet count.

Question 16

PLEURAL EFFUSION

Answer 16

Pleural Effusion - a buildup of fluid between the ribs and the lungs in the pleural space. Fluid can be serous fluid, pus (empyema), lymph fluid, or blood (hemothorax). This type of fluid collection can be removed (aspirated) with a needle because it is in a cavity of the body. If large enough a pleural effusion can cause a “compression atelectasis” (see pg. 3 of outline).

Question 17

PULMONARY EDEMA

Answer 17

Pulmonary Edema – a buildup of fluid in the interstitial tissue of the lung. Pulmonary edema occurs when the alveoli fill up with excess fluid seeped out of the blood vessels in the lung instead of air.

     This can cause problems with the exchange of gas (oxygen and carbon dioxide), resulting in breathing difficulty and poor oxygenation of blood. Sometimes, this can be referred to as "water in the lungs" when describing the condition to patients. Commonly caused by left sided heart failure (back up of fluid into the lungs) but also can be caused by kidney failure (kidney does not remove excess body fluid); Sepsis (See below under ARDS) or any lung damage that involves inflammation.

Question 18

ARDS

Answer 18

ARDS starts with an Acute lung injury/insult (ALI) of some type (infection/sepsis, trauma, hypoxic event, aspiration of gastric juices/vomit, pulmonary embolism, blood transfusion reaction, etc.) that causes SEVERE LUNG INFLAMMATION - also referred to as SIRS [Systemic Inflammatory Response Syndrome].

 In response to lung injury, the body releases chemical mediators, clotting factors, vasodilating agents, etc. which damage the lung further. In particular the alveoli and surrounding capillary bed is severely damaged and rendered useless.  The lung stops producing surfactant (the oily substance that holds the lung in place in the chest cavity and keeps the alveoli from collapsing inside the lung) which leads to atelectasis.

Question 19

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Answer 19

Chronic obstructive pulmonary disease (COPD) refers to a group of lung diseases that block airflow and make breathing difficult. emphysema and chronic bronchitis are the two most common conditions that make up COPD. Asthma and Cystic Fibrosis fall under this umbrella term of COPD because they involve obstructive pathologies.

Question 20

COPD

READ

Answer 20

Symptoms of COPD often do not appear until significant lung damage has occurred, and they usually worsen over time.

  Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke (or used to smoke). Long-term exposure to other lung irritants—such as air pollution, chemical fumes, or dust—also may contribute to COPD.

In COPD, air flow is impaired because of one or more of the following:

The airways and air sacs lose their elastic quality.
The walls between many of the air sacs are destroyed.
The walls of the airways become thick and inflamed.
The airways make more mucus than usual, which can clog them.

Question 21

ASTHMA

Answer 21

Asthma – (aka, Reactive Airway Disease) is a chronic inflammatory disorder of the airway. Inflammation results from HYPER-RESPONSIVENESS of the airway to any number of airborne irritants from pollen to perfume; exercise, infections, air pollution and anxiety can all trigger an asthma attack.

    All the products of inflammation (chemical mediators such as histamines, bradykinins, and cytokines) go into mass production and over whelm the lungs.  This results in inflammation leading to constricted airways and the characteristic “wheezing” sounds. 

    The inflammation makes the airways swollen and very sensitive. The airways tend to react strongly to certain inhaled substances. When the airways react, the muscles around them tighten. Narrowed airways reduces air flow into the lungs. Swelling also can worsen, making the airways even narrower. Cells in the airways might make more mucus than usual. The mucus produced is sticky and thick which can further narrow the airways. This chain reaction can result in asthma symptoms. Symptoms can happen each time the airways are inflammed

Question 22

EMPHYSEMA

Answer 22

Emphysema – PERMANENT damage to the lung as a result of the inflammatory process. Abnormal [and permanent] enlargement of the airways accompanied by destruction of alveolar walls without obvious fibrosis. The lungs lose their ability to recoil after each respiration.

     The characteristic sign of emphysema is the anatomical change in the patient’s chest from oval to round (“barrel chest”) as a result of the body trying to adjust for the extra work of breathing (WOB). 

    Patients with COPD live with persistently elevated CO2 levels and therefore do not respond to high PCO2 to stimulate respirations.  Instead, they breathe only in response to low oxygen levels.  Therefore, if too much oxygen is given to someone with COPD, it removes theirrespiratory drive and causes respiratory arrest.  (Also see “Causes of Hemoptysis” on the last page for more info about Emphysema).

Question 23

BRONCHITIS

Answer 23

Bronchitis is a respiratory disease in which the mucus membrane in the lungs’ bronchial passages becomes inflamed. As the irritated membrane swells and grows thicker, it narrows or shuts off the tiny airways in the lungs, resulting in coughing spells that may be accompanied by phlegm and breathlessness. The disease comes in two forms: ACUTE (lasting from one to three weeks) and CHRONIC (lasting at least 3 months of the year for two years in a row). People with asthma or emphysema may also have asthmatic bronchitis, inflammation of the lining of the bronchial tubes.

Acute bronchitis may be responsible for the hacking cough and phlegm production that sometime accompany an upper respiratory infection. In most cases, the infection is viral in origin, but sometimes it’s caused by bacteria. The mucus membrane should return to normal after resolution of the initial lung infection, which usually lasts for several days.

Question 24

CHRONIC BRONCHITIS

Answer 24

Chronic Bronchitis - chronic hyper-secretion of thick mucus (thicker than normal) and productive cough that lasts for at least 3 months of the year and for at least 2 consecutive years. Chronic Bronchitis is a serious long-term disorder that often requires regular medical treatment. It is caused by inspired irritants that increase mucus production and the size & number of mucous glands along with damage to cilia that prevents movement of mucous out of the bronchus. Chronic Bronchitis is considered a COPD due to its obstructive nature, and in fact is usually present in emphysema patients.

     Smoking (inhaled personally or second hand) is a common cause of bronchitis.  Cigarette smoking damages the cilia (tiny hair-like structures in the lungs) that are responsible for brushing out debris, irritants, and excess mucus. Smoking damage to the cilia prevent them from functioning properly, thus increasing chances of developing chronic bronchitis. Once clogged with mucus, the lungs are then vulnerable to viral and bacterial infections, which over time distort and permanently damage the lungs' airways. This permanent condition is called COPD.

Question 25

CYSTIC FIBROSIS

Answer 25

Cystic Fibrosis– Autosomal recessive gene abnormality causing multisystem disease. Thickening of the connective tissue leads to fibrosis (nonfunctioning tissue). Exocrine or mucus-producing glands secrete abnormally thick mucus because of defective epithelial ion transport. In the lungs, thick secretions obstruct the bronchioles and predispose the lungs to chronic infections. Secretions are like “rubber cement”!

C.F Pathophysiology – impaired chloride and sodium reabsorption. Impaired chloride movement alters vascular osmolarity and triggers sodium to shift fromthe secreting cells on glands and mucous membranes to the vascular space.

       Because sodium is leaving the tissue, water follows which leads to dehydration of the tissue.  As a result, the mucous in the lungs, pancreas and biliary ducts gets very thick (and obstructs normal processes).

Question 26

LUNG CANCER

Answer 26

Lung Cancer
Bronchogenic carcinoma (cancer originating in the lining of the bronchi) is a less common cause of hemoptysis than bronchitis or bronchiectasis, but is an important one. About 7 percent of patients with bronchogenic cancer are initially diagnosed because of hemoptysis. About 20 percent of patients with bronchogenic cancer experience hemoptysis at some point. The bleeding results from:

Necrosis of the tumor (death of the cells that make up the tumor)
The rupture of small blood vessels in the area
A tumor invading one of the pulmonary blood vessels → major hemorrhage can result

Massive bleeding can occur if the tumor erodes into one of the large pulmonary vessels. Hemoptysis can also result from metastatic cancer to the lungs (especially breast, kidney, colon, and esophageal metastases). The cancer causes bleeding in much the same way that bronchogenic carcinoma causes bleeding.