CHRONIC BRONCHITIS IN EXACERBATION COR PULMONALE WITH HYPERTENSION

OBJECTIVES
Within 2 hours of Case Presentation, the students will be able to: ‡ Compare the age of onset, clinical manifestations, and pathologic mechanisms of chronic bronchitis and its complications. ‡ Identify risk factors of chronic bronchitis. ‡ Explain the physiology of chronic bronchitis that will lead to its complications. ‡ Describe the significance of complete assessment when caring patients, ‡ Explain & discuss the physiology of Chronic bronchitis and its relationship in the development of cor pulmonale and acute respiratory failure. ‡ Identify the use of the different therapies applied to patients with chronic bronchitis. ‡ Identify and enumerate the nursing plan and action applicable to patients having chronic bronchitis with cor pulmonale and ARF

INTRODUCTION
‡ Bronchitis is one of the top conditions for which patients seek medical care. ‡ Bronchitis is characterized by inflammation of the bronchial tubes (or bronchi), which are the air passages that extend from the trachea into the small airways and alveoli. Triggers may be infectious agents, such as viruses or bacteria, or noninfectious agents, such as smoking or inhalation of chemical pollutants or dust. ‡ Generally, bronchitis is a diagnosis made by exclusion of other conditions such as sinusitis, pharyngitis, tonsillitis, and pneumonia. Types of bronchitis: ‡ Acute bronchitis is manifested by cough and, occasionally, sputum production that last for no more than 3 weeks. Although bronchitis should not be treated with antimicrobials, it is frequently difficult to refrain from prescribing them. Accurate testing and decisionmaking protocols regarding who might benefit from antimicrobial therapy would be useful but are not currently available.

Chronic bronchitis is defined clinically as cough with sputum expectoration for at least 3 months during a period of 2 consecutive years and is is a type of COPD that causes inflammation, or irritation, in the bronchioles of the lungs. The bronchioles connect the trachea, or windpipe, to the lungs. This irritation causes an increased amount of heavy mucus in the lungs that over time, interferes with breathing. The body responds to this mucus by producing a cough in an attempt to clear the airways. But because the mucus is so abundant and thick, it is often difficult for a person with chronic bronchitis to expel it. Additionally, large amounts of thick mucus make the lungs a perfect habitat for bacteria to thrive. So bacterial lung infections among people who have chronic bronchitis are common and frequent.

‡ Chronic bronchitis is associated with hypertrophy of the mucus-producing glands found in the mucosa of large cartilaginous airways. The alveolar epithelium is both the target and the initiator of inflammation in chronic bronchitis. As the disease advances, progressive airflow limitation occurs, usually in association with pathologic changes of emphysema. This condition is called chronic obstructive pulmonary disease (COPD). When a stable patient experiences sudden clinical deterioration with increased sputum volume, sputum purulence, and/or worsening of shortness of breath, this is referred to as an acute exacerbation of chronic bronchitis as long as conditions other than acute tracheobronchitis are ruled out.

Chronic bronchitis may result from a series of attacks of acute bronchitis, or it may evolve gradually because of heavy smoking or inhalation of air contaminated with other pollutants in the environment. When so-called smoker's cough is continual rather than occasional, the mucusproducing layer of the bronchial lining has probably thickened, narrowing the airways to the point where breathing becomes increasingly difficult. With immobilization of the cilia that sweep the air clean of foreign irritants, the bronchial passages become more vulnerable to further infection and the spread of tissue damage.

In order for a diagnosis of chronic bronchitis to be made, you need to have a productive, long-term cough that lasts 3 months out of the year for 2 consecutive years. This differentiates it from acute bronchitis. Unlike acute bronchitis, chronic bronchitis is irreversible and its path is one of frequent recurrences. Chronic bronchitis, like emphysema, is among a group of lung diseases known as chronic obstructive pulmonary disease, or COPD. Like other types of Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis is primarily caused by cigarette smoking, second hand smoke, and air pollution. Additionally, allergies, and infection are known factors that can cause exacerbation of chronic bronchitis. In fact, people who are diagnosed with chronic bronchitis are more likely to develop recurring infections in the lungs.

If a person have a chronic bronchitis, he/she is more likely to develop recurrent respiratory infections. He/she may also develop; Emphysema, Right-sided heart failure or cor pulmonale, pulmonary hypertension, and acute respiratory failure. Cor pulmonale is failure of the right side of the heart brought on by long-term high blood pressure in the pulmonary arteries and right ventricle of the heart. This is one of the complications of chronic bronchitis.

The other complications of chronic bronchitis is acute respiratory failure, it is characterized by a failure of oxygenation or ventilation, or both. Hypoxemia is common to all causes of respiratory failure, whereas PaCO2 may be normal, decreased, or elevated. These abnormalities result from several pathophysiologic processes, including intrapulmonary venoarterial shunt, alveolar hypoventilation, diffusion impairment, and ventilation-perfusion mismatch. According to the American Lung Association, in 2004, approximately 9 million people in the United States were diagnosed with chronic bronchitis. Chronic bronchitis can occur in all ages, but is more likely to affect those over 45 years. Unlike emphysema, chronic bronchitis affects women more than men. In 2004, 2.8 million males were diagnosed with chronic bronchitis compared to 6.3 million women.

DEFINITION OF TERMS
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Acute bronchitis is manifested by cough and, occasionally, sputum production that last for no more than 3 weeks. Chronic bronchitis is defined clinically as cough with sputum expectoration for at least 3 months during a period of 2 consecutive years and is is a type of COPD that causes inflammation, or irritation, in the bronchioles of the lungs. Cor pulmonale is failure of the right side of the heart brought on by long-term high blood pressure in the pulmonary arteries and right ventricle of the heart. Emphysema is a type of COPD that causes a permanent enlargement of the airways in your lungs. Tracheotomy and tracheostomy are surgical procedures on the neck to open a direct airway through an incision in the trachea (the windpipe). Tracheotomy, from the Greek root tom- meaning "to cut," refers to the procedure of cutting into the trachea and is an emergency procedure Tracheostomy, from the root stom- meaning "mouth," refers to the making of a semipermanent or permanent opening, and to the opening itself. Lung transplantation is a surgical procedure in which a patient's diseased lungs are partially or totally replaced by lungs which come from a donor. Lobe transplant is a surgery in which part of a living donor's lung is removed and used to replace part of recipient's diseased lung. Lung reduction surgery: A surgical treatment for patients with advanced emphysema in which 20-35% of the emphysematous lung is removed to allow the remaining tissue to expand more fully and restore some of the patient's breathing capacity. Thoracoscopy is a minimally invasive technique. Three small (approximately 1 inch) incisions are made in each side, between your ribs. Sternotomy (bilateral) An incision is made through the breastbone to expose both lungs.

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Thoracotomy technique, an incision is made between your ribs. The incision is approximately 5 to 12 inches long Chest tubes are used for drainage and to monitor air leaking. The upper respiratory system consists of the nostrils (external nares), nasal cavity, nasal vestibule, nasal septum, both hard and soft palate, nasopharynx, pharynx, larynx and trachea. Cellular Respiration This is the cells own respiration. Internal respiration is basically the exchange of gasses between the blood in the capillaries and the body's cells. Mechanical barriers - are the first line of defense against harmful agents. Mechanical barriers include the skin, mucus membranes that line passageways that enter the body. Chemical Barriers - tears, perspiration and saliva work to wash away harmful invaders while digestive juices and enzymes destroy bacteria and other toxins from ingested substances. Phagocytosis - is the ability of certain white blood cells to take in and destroy waste and foreign materials. Natural Killer Cells - are able to distinguish cells with an abnormal cellular membrane such as tumor cells or cells infected with a virus and kill them on contact. Inflammation - is the body's effort to get rid of anything that irritates it. If the inflammation is due to pathogens, the inflammation is referred to as an infection. Fever - boosts the immune system by stimulating phagocytes, increasing metabolism and decreasing the ability of certain organisms to multiply. Dust cells are another name for monocyte derivatives in the lungs that reside on respiratory surfaces and clean off particles such as dust or microorganisms. Alveolar macrophages It is a type of macrophage found in the pulmonary alveolus, near the pneumocytes, but separated from the wall. Circulatory system is responsible for the transport of water and dissolved materials throughout the body, including oxygen, carbon dioxide, nutrients, and waste. Heart is a specialized, four-chambered muscle that maintains the blood flow in the circulatory system. It lies immediately behind the sternum, or breastbone, and between the lungs.

VITAL INFORMATION
Name: Mr. Xbox Room Number: 232-A Age: 61 Gender: Male Civil Status: Married Date of Birth: August 09, 1948 Birthplace: Iligan City Cultural Group: Iliganon Primary Language: Bisaya Religion: Catholic Highest Educational Attainment: 2nd yr. high school Occupation: N/A Usual Health Care Provider: Doctor Reason for Health Contact: For Further Evaluation and Management Date of Confinement: Feb. 15, 2010 Source of History: 30% - chart, 30% - Mr. Xbox, 40% - Mrs. Xbox Attending Physician: Dr. Aniceto Impression/ Final Diagnosis: Acute respiratory failure secondary to COPD in exacerbation cor pulmonale Description of Patient: awake on bed, responsive, coherent, with patent IVF hooked @ right arm, with nasogastrictube , O2 mask connected to an oxygen tank and tracheostomy, restless, with positive SOB, and poor skin turgor.

NURSING HISTORY
A. Chief Complaints/Reason for Visit Difficulty of Breathing (DOB) ³Naglisud jud kaayo siya¶g ginahawa,´ as verbalized by Mrs.Xbox. B. History of Present Illness 10 days prior to admission, patient had an on & off fever which was relived with Paracetamol. There were no chills noted according to his wife. 1 week prior to admission, patient had productive cough with yellowish phlegm. This was associated with (DOB) difficulty of breathing and loss of appetite. The patient did not experience abdominal pain, vomiting and dysuria. Symptoms persisted, hence admitted.

C. History of Past Illness Mr. Xbox, had no allergies with foods, animals and any substances. According to him, he claimed that his immunization was not complete due to his generation of underdeveloped immunizations compared in this present time. In the year 1996, the patient was diagnosed with emphysema with the same chief complaint. On October 23, 2009, the patient was admitted again due to (DOB) difficulty of breathing and cough. Then, he had undergone Tracheotomy on the day after his admission. At that time, he was confined in the Intensive care Unit (ICU) for two weeks. After 2 weeks, he was moved to a private room in Unit IV and was discharged on November 22, 2009. The whole hospitalization was attended by the same physician (Dr. Aniceto) as in the present hospitalization. In addition with His claims, Mr. Xbox is hypertensive for 14 years and is on maintenance with Vascorten, but lately changed into Vasalat. In regards to chronic Illnesses, Mr. Xbox was in lined with a hypertensive genes, both sides of his parents. In addition, he is also in lined with stroke/CVA and paralysis. He was a drinker with unrecalled number of bottles a day but he claimed to be moderate in amount and a smoker with at least 2 packs a day. Before he retired, he undergone a annual physical check-ups such as the whole body or physical exmination from head to foot as sponsored by his company formerly Fluorocement factory, now the holcim where he worked there as a process technician for 19 years, but before the fluorocement occupation, he worked the in La salle construction for 5 years still in the work of cement processing. That time, the same benefit from fluorocement factory, his annual physical examinations are subsidized.

GENOGRAM

GORDONS ASSESSMENT
Hospitalized Client Client·s reason for admission is to have further management of his condition. He has been hospitalized before because of emphysema in the year 1996 and admitted due to DOB and cough and underwent tracheostomy last \Oct. 23, 2009. Patient expected his present hospitalization would help him a lot to recover for he was always being admitted. Nutritional/Metabolic Pattern The client·s appetite is good but the time prior to his admission, he had loss his appetite. His typical meals for a day is eating meat, fish,and egg. Patient is taking Clusivol and Cecon vitamins. He likes sea foods like the ´shellfishµ. Since the start of his condition, he doesn·t go anymore to any fastfoods and restaurant. He doesn·t have discomfort in eating and swallowing. Patient does not have dental problems but is now using dentures. His daily typical fluid intake is 2-3 liters a day. Elimination Pattern The client has a good bowel movement pattern. He defecates everyday. He sometimes experience diarrhea and constipation but does not experience ileostomy. Patient has Foley bag catheter attached, and urine color is clear. Patient has poor skin turgor, has presence of dead skin and atrophy. Patient said that he experiences excess perspiration when he gets out from their house.

EXERCISE AND ACTIVITY PATTERN Client is having exercised at home but not regularly. His typical exercise is walking. He has his walking exercise once or twice a day for 3-5minutes. He said that he easily gets tired and have difficulty of breathing in performing his exercise or other activity. Patient experienced DOB (dyspnea and wheezing), and has productive cough, fatigue, and weakness. His leisure activity is playing his X-Box. Patient is smoking since he was 15y/o and stopped in the year 1996. He can consume 2or more packs daily. SLEEP AND REST PATTERN Patient sleeps usually by 8:00 pm when at home, and wakes up at 6 or7:00am. He also takes naps but just for some time. And if he does, he naps for 30minutes or sleeps for 1 hour during day time. He feels ready and rested after asleep. He has aid to help him sleep. That is his X-Box, which he will use before sleeping. Pt. can·t remember his dreams or nightmares, but sometimes experience insomnia. COGNITIVE/PERCEPTUAL PATTERN After the occurrence of client·s condition, he doesn·t do anymore eye check-up. Since 2008, no eye check-up happened. In addition, he only wears eyeglasses when he reads and does not use contact lenses. Patient experiences blurring of vision on his right eye only, and the left eye is clear. About his ability to feel pain, temperature changes, he doesn·t have problems with it. He can also distinguish object by touch, can smell well, and also has good ability of taste.

SELF -PERCEPTION PATTERN Patient feels inferior about his condition because he thinks he is useless for he can t do things accordingly. He feels also anxious thinking what would happen next. ROLE-RELATIONSHIP PATTERN Patient lives with his wife, his youngest son, and a stay-out helper. His present family structure is nuclear. Patient turns for help directly to his family. his wife and children. Family members don t depend on the patient. Each of his children has own source of income. His family is very much supportive to him. SEXUALITY AND REPRODUCTIVE PATTERN Patient doesn t perform testicular examination but doesn t also have any complaints of prostate problems. He doesn t have infections or any reproductive tract infections. Patient has 6 children. VALUE AND BELIEF PATTERN Patient doesn t have regular church goings or visits. They just go to church if they are not busy. He also said that he doesn t pray always. He just said that 1 prayer is enough as long as it comes from the heart. But he does believe in God. That s his belief. Patient considers health as his most important thing aside from his family. He really believes of the saying that health is wealth. He values that saying so much.

2ND DAY

NUTRITIONAL/METABOLIC PATTERN

Patient¶s appetite is good. He eats well and can consume all foods served to him. Patient has decreased fluid intakes. ELIMINATION PATTERN Patient has not defecated during this day. Still with foley bag catheter attached, and complained of pain at his reproductive site during urination. EXERCISE AND ACTIVITY PATTERN Patient moves his upper and lower extremities slowly and alternately. Patient still experienced DOB but less fatigue and weakness. 3RD DAY NUTRITIONAL/METABOLIC PATTERN Patient eats very well. He has good appetite. He can drink, and eat solid foods through mouth. Has increased fluid intake. ELIMINATION PATTERN Patient¶s foley bag catheter is terminated and is using a diaper but has not yet defecated. NGT is terminated also. Discharges from tracheostomy mask is less. Patient has presence of pitting edema grade 1 noted at the left foot and rashes noted on the left and right arm. EXERCISE AND ACTIVITY PATTERN Patient moves his upper and lower extremities more frequently. Patient experienced SOB and DOB but less, patient talks and responds more to student nurses/nurses. (Patient is discharged)

PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS

DIAGNOSTIC TESTS

NORMAL ANATOMY AND PHYSIOLOGY
Respiratory System We often complete the daily tasks of living without thinking about the respiratory system. We breathe in and out and take for granted one of our most vital organ systems. The respiratory system provides the oxygen necessary to sustain life. It consists of both upper and lower respiratory tracts. It is divided into two functions: conducting and respiration. Function The function of the respiratory system is to give us a surface area for exchanging gases between the air and our circulating blood. It moves that air to and from the surfaces of the lungs while it protects the lungs from dehydration, temperature changes and unwelcome pathogens. It also plays a part in making sounds such as talking, singing, other nonverbal sounds and works with the central nervous system for the ability to smell.

Upper Respiratory Anatomy The upper respiratory system consists of the nostrils (external nares), nasal cavity, nasal vestibule, nasal septum, both hard and soft palate, nasopharynx, pharynx, larynx and trachea. Within the nostrils, course hairs protect us from dust, insects and sand. The hard palate serves to separate the oral and nasal cavities. There is a protective mucous membrane that lines the naval cavities and other parts of the respiratory tract. It is secreted over the exposed surfaces and then the cilia sweep that mucus and any microorganisms or debris to the pharynx, so it is swallowed and then destroyed in stomach acid. Lower Respiratory Anatomy The trachea branches off into what is known as the bronchi (more commonly called bronchial tubes). These two main bronchi have branches forming the bronchial tree. Where it enters the lung, there are then secondary bronchi. In each lung, the secondary bronchi divide into tertiary bronchi and in turn these divide repeatedly into smaller bronchioles. The bronchioles control the ratio of resistance to airflow and distribution of air in our lungs. The bronchioles open into the alveolar ducts. Alveolar sacs are at the end of the ducts. These sacs are chambers that are connected to several individual alveoli, which make up the exchange surface of the lungs.

The Lungs The human respiratory system has two lungs, which contain lobes separated by deep fissures. Surprisingly, the right lung has three lobes while the left one has only two lobes. The lungs are made up of elastic fibers that give it the ability to handle large changes in air volume. The pleural cavity is where the lungs are located. The diaphragm is the muscle that makes up the floor of the thoracic cavity and plays a major role in the pressure and volume of air moving in and out of the lungs. Significance Our lungs filter and deliver oxygen that is necessary for healthy red blood cells. It is important that we keep the respiratory tract healthy through proper rest, hydration, diet and exercise.

Gas Exchange There are a total of five parts in gas exchange and these are as follows: Breathing Breathing consists of two phases, inspiration and expiration. During inspiration, the diaphragm and the intercostal muscles contract. The diaphragm moves downwards increasing the volume of the thoracic (chest) cavity, and the intercostal muscles pull the ribs up expanding the rib cage and further increasing this volume. This increase of volume lowers the air pressure in the alveoli to below atmospheric pressure. Because air always flows from a region of high pressure to a region of lower pressure, it rushes in through the respiratory tract and into the alveoli. This is called negative pressure breathing, changing the pressure inside athelings relative to the pressure of the outside atmosphere. In contrast to inspiration, during expiration the diaphragm and intercostal muscles relax. This returns the thoracic cavity to its original volume, increasing the air pressure in the lungs, and forcing the air out.

External Respiration When a breath is taken, air passes in through the nostrils, through the nasal passages, into the pharynx, through the larynx, down the trachea, into one of the main bronchi, then into smaller bronchial tubules, through even smaller bronchioles, and into a microscopic air sac called an alveolus. It is here that external respiration occurs. Simply put, it is the exchange of oxygen and carbon dioxide between the air and the blood in the lungs. Blood enters the lungs via the pulmonary arteries. It then proceeds through arterioles and into the alveolar capillaries. Oxygen and carbon dioxide are exchanged between blood and the air. This blood then flows out of the alveolar capillaries, through venoules, and back to the heart via the pulmonary veins. For an explanation as to why gasses are exchanged here, this is from Dalton·s law of partial pressure - the pressure that one component of a mixture of gases would exert if it were alone in a container. Gas Transport If 100mL of plasma is exposed to an atmosphere with a pO2 of 100mm Hg, only 0.3mL of oxygen would be absorbed. However, if 100mL of blood is exposed to the same atmosphere, about 19mL of oxygen would be absorbed. This is due to the presence of hemoglobin, the main means of oxygen transport in the body. The respiratory pigment hemoglobin is made up of an iron-containing porphyron, haem, combined with the protein globin. Each iron atom in haem is attached to four pyrole groups by covalent bonds. A fifth covalent bond of the iron is attached to the globin part of the molecule and the sixth covalent bond is available for combination with oxygen. There are four iron atoms in each hemoglobin molecule and therefore four heam groups.

Oxygen Transport - In the loading and unloading of oxygen, there is cooperation between these four haem groups. When oxygen binds to one of the groups, the others change shape slightly and their attraction to oxygen increases. The loading of the first oxygen, results in the rapid loading of the next three (forming oxyhaemoglobin). At the other end, when one group unloads its oxygen, the other three rapidly unload as their groups change shape again having less attraction for oxygen. This method of cooperative binding and release can be seen in the dissociation curve for hemoglobin. Over the range of oxygen concentrations where the curve has a steep slope, the slightest change in concentration will cause hemoglobin to load or unload a substantial amount of oxygen. Notice that the steep part of the curve corresponds to the range of oxygen concentrations found in the tissues. When the cells in a particular location begin to work harder, e.g. during exercise, oxygen concentration dips in that location, as the oxygen is used in cellular respiration. Because of the cooperation between the haem groups, this slight change in concentration is enough to cause a large increase in the amount of oxygen unloaded. As with all proteins, hemoglobin·s shape shift is sensitive to a variety of environmental conditions. A drop in pH lowers the attraction of hemoglobin to oxygen, an effect known as the Bohr shift. Because carbon dioxide reacts with water to produce carbonic acid, an active tissue will lower the pH of its surroundings and encourage hemoglobin to give up extra oxygen, to be used in cellular respiration. Hemoglobin a notable molecule for its ability to transport oxygen·s from regions of supply to regions of demand.

Carbon Dioxide Transport - Out of the carbon dioxide released from respiring cells, 7% dissolves into the plasma, 23% binds 23% to the multiple amino groups of hemoglobin (Caroxyhaemoglobin), and 70% is carried as bicarbonate Caroxyhaemoglobin), 70% ions. ions. Carbon dioxide created by respiring cells diffuses into the blood plasma and then into the red blood cells, where most of it is converted to bicarbonate ions. It first reacts with ions. water forming carbonic acid, which then breaks down into H+ and CO3-. Most of the hydrogen ions that are produced attach to hemoglobin or other proteins. proteins. Internal Respiration The body tissues need the oxygen and have to get rid of the carbon dioxide, so the blood carried throughout the body exchanges oxygen and carbon dioxide with the body's tissues. tissues. Internal respiration is basically the exchange of gasses between the blood in the capillaries and the body's cells. cells. Cellular Respiration This is the cells own respiration... respiration...

Immune System (Alveolar Macrophages) So let·s discuss first about the lymphatic system; all body tissues live in a system; liquid environment, both in the cells and surrounding them. During them. cellular metabolism, waste products, including carbon dioxide and other substances are routed back through the blood stream to be eliminated. eliminated. In addition to the elimination provided for by the circulatory system, a second pathway for the removal of tissue fluids from the body is achieved though the lymph system. system. The function of the lymph system is to remove excess tissue fluids that do not return through the circulatory system. In addition, the lymph system system. is responsible for absorbing protein from this fluid and returning it to the blood. blood. Like the circulatory system, the lymphatic system is made up of a series of capillaries and lymphatic vessels. Unlike the circulatory system, the vessels. lymph system does not have a heart to propel lymph (tissue fluids that have entered the lymphatic system) through the system. The movement system. of lymph is based upon either the volume of fluid within the lymph vessel or by mechanical means, i.e. through movement of the skeletal muscles, where the muscles compress the lymphatic vessels and drive the
lymph forward.

The immune system is part of our general body defenses against disease. disease. It functions by recognizing viruses and bacteria and converting that information into hormones that activate the immune process. process. This response can be both specific, where the body responds only to certain agents and no others as well as nonspecific, where the body works to defend itself any harmful agent that enters the body. body. Immunity is the ability of an individual to resist or overcome the effects of a particular disease or other harmful agent. Immunity, agent. however, is a selective process, with one being immune to one disease and not necessarily another. Immunity can be either another. inborn, which is due to inherited factors, or acquired. Acquired acquired. immunity develops during one's lifetime as they encounter various harmful agents and successfully fight them off. off. Acquired immunity is easily seen in the case that we only get the chicken pox once as a child, even though we may be exposed to them on a number of occasions. occasions.

Activity of the alveolar macrophage is relatively high, because they are located at one of the major boundaries between the body and the outside world. world. Dust cells are another name for monocyte derivatives in the lungs that reside on respiratory surfaces and clean off particles such as dust or microorganisms. microorganisms. Alveolar macrophages are frequently seen to contain granules of exogenous material such as particulate carbon that they have picked up from respiratory surfaces. Such black granules may be especially surfaces. common in smoker's lungs or long-term city dwellers. The air we longdwellers. breathe often contains more than the oxygen our bodies need for living. living. Often that air may contain particles or organisms which threaten our health and well-being. The respiratory pathway is a prime site for well-being. exposure to pathogens and toxic substances. The respiratory tree, substances. comprising the larynx, trachea, and bronchioles, is lined by ciliated epithelia cells that are continually exposed to harmful matter. When matter. these insidious agents infiltrate our superficial barriers, the immune systems of our bodies respond in an orchestrated defense involving a litany of specialized cells which target the threat, neutralize it, and clean up the remnants of the battle. battle.

Circulating System Anatomy and Physiology The circulatory system is responsible for the transport of water and dissolved materials throughout the body, including oxygen, carbon dioxide, nutrients, and waste. waste. The circulatory system transports oxygen from the lungs and nutrients from the digestive tract to every cell in the body, allowing for the continuation of cell metabolism. The circulatory system also transports the waste products of cell metabolism. metabolism to the lungs and kidneys where they can be expelled from the body. body. Without this important function toxic substances would quickly build up in the body. body. The human circulatory system is organized into two major circulations. Each has its circulations. own pump with both pumps being incorporated into a single organ³the heart. The organ³ heart. two sides of the human heart are separated by partitions, the interatrial septum and the interventricular septum. Both septa are complete so that the two sides are septum. anatomically and functionally separate pumping units. The right side of the heart units. pumps blood through the pulmonary circulation (the lungs) while the left side of the heart pumps blood through the systemic circulation (the body). body).

The Heart The human heart is a specialized, four-chambered muscle that maintains the fourblood flow in the circulatory system. It lies immediately behind the sternum, or system. breastbone, and between the lungs. The apex, or bottom of the heart, is tilted lungs. to the left side. At rest, the heart pumps about 59 cc (2 oz) of blood per beat side. and 5 l (5 qt) per minute. During exercise it pumps 120-220 cc (4-7.3 oz) of minute. 120blood per beat and 20-30 l (21-32 qt) per minute. The adult human heart is 2021minute. about the size of a fist and weighs about 250-350 gm (9 oz). 250oz). The human heart begins beating early in fetal life and continues regular beating throughout the life span of the individual. If the heart stops beating for more individual. than 3 or 4 minutes permanent brain damage may occur. Blood flow to the occur. heart muscle itself also depends on the continued beating of the heart and if this flow is stopped for more than a few minutes, as in a heart attack, the heart muscle may be damaged to such a great extent that it may be irreversibly stopped. stopped. The heart is made up of two muscle masses. One of these forms the two atria (the masses. upper chambers) of the heart, and the other forms the two ventricles (the lower chambers). chambers). Both atria contract or relax at the same time, as do both ventricles. ventricles.

The Pulmonary Circulation From the right atrium the blood passes to the right ventricle through the tricuspid valve, which consists of three flaps (or cusps) of tissue. The tricuspid valve remains open tissue. during diastole, or ventricular filling. When the ventricle filling. contracts, the valve closes, sealing the opening and preventing backflow into the right atrium. Five cords atrium. attached to small muscles, called papillary muscles, on the ventricles' inner surface prevent the valves' flaps from being forced backward. backward. From the right ventricle blood is pumped through the pulmonary or semilunar valve, which has three halfhalfmoonmoon-shaped flaps, into the pulmonary artery. This valve artery. prevents backflow from the artery into the right ventricle. ventricle. From the pulmonary artery blood is pumped to the lungs where it releases carbon dioxide and picks up oxygen. oxygen.

Blood Flow The Systemic Circulation From the lungs, the blood is returned to the heart through pulmonary veins, two from each lung. From the pulmonary veins the blood enters lung. the left atrium and then passes through the mitral valve to the left ventricle. ventricle. As the ventricles contract, the mitral valve prevents backflow of blood into the left atrium, and blood is driven through the aortic valve into the aorta, the major artery that supplies blood to the entire body. body. The aortic valve, like the pulmonary valve, has a semilunar shape. shape. The aorta has many branches, which carry the blood to various parts of the body. body. Each of these branches in turn has branches, and these branches divide, and so on until there are literally millions of small blood vessels. vessels. The smallest of these on the arterial side of the circulation are called arterioles. arterioles. They contain a great deal of smooth muscle, and because of their ability to constrict or dilate, they play a major role in regulating blood flow through the tissues. tissues.

The Blood The blood transports life-supporting food and oxygen to every cell lifeof the body and removes their waste products. It also helps to products. maintain body temperature, transports hormones, and fights infections. infections. The brain cells in particular are very dependent on a constant supply of oxygen. If the circulation to the brain is oxygen. stopped, death shortly follows. follows. Blood has two main constituents. The cells, or corpuscles, constituents. comprise about 45 percent, and the liquid portion, or plasma, in which the cells are suspended comprises 55 percent. The blood percent. cells comprise three main types: red blood cells, or types: erythrocytes; erythrocytes; white blood cells, or leukocytes, which in turn are of many different types; and platelets, or thrombocytes. Each types; thrombocytes. type of cell has its own individual functions in the body. The body. plasma is a complex colorless solution, about 90 percent water, that carries different ions and molecules including proteins, enzymes, hormones, nutrients, waste materials such as urea, and fibrinogen, the protein that aids in clotting. clotting.

Red Blood Cells The red blood cells are tiny, round, biconcave disks, averaging about 7.5 microns (0.003 in) in diameter. A normal-sized man has about 5 l diameter. normal(5.3 qt) of blood in his body, containing more than 25 trillion red cells. cells. Because the normal life span of red cells in the circulation is only about 120 days, more than 200 billion cells are normally destroyed each day by the spleen and must be replaced. Red blood cells, as replaced. well as most white cells and platelets, are made by the bone marrow. marrow. The main function of the red blood cells is to transport oxygen from the lungs to the tissues and to transport carbon dioxide, one of the chief waste products, it to the lungs for release from the body. body. The substance in the red blood cells that is largely responsible for their ability to carry oxygen and carbon dioxide is hemoglobin, the material that gives the cells their red color. It is a protein complex color. comprising many linked amino acids, and occupies almost the entire volume of a red blood cell. Essential to its structure and function is cell. the mineral iron. iron.

White Blood Cells The leukocytes, or white blood cells, are of three types; granulocytes, lymphocytes, and types; monocytes. monocytes. All are involved in defending the body against foreign organisms. organisms. There are three types of granulocytes: neutrophils, eosinophils, and basophils, with granulocytes: neutrophils, eosinophils, basophils, neutrophils the most abundant. Neutrophils seek out bacteria and phagocytize, or abundant. phagocytize, engulf, them. them. The lymphocytes' chief function is to migrate into the connective tissue and build antibodies against bacteria and viruses. Leukocytes are almost colorless, viruses. considerably larger than red cells, have a nucleus, and are much less numerous; only numerous; one or two exist for every 1,000 red cells. The number increases in the presence of cells. infection. infection. Monocytes, Monocytes, representing only 4 to 8 percent of white cells, attack organisms not destroyed by granulocytes and leukocytes. leukocytes. The granulocytes, accounting for about 70 percent of all white blood cells, are formed in the bone marrow. The lymphocytes on the other hand are produced primarily by the marrow. lymphoid tissues of the body³the spleen and lymph nodes. They are usually smaller body³ nodes. than the granulocytes. Monocytes are believed to originate from lymphocytes. Just as granulocytes. lymphocytes. the oxygen-carrying function of red cells is necessary for our survival, so are normal oxygennumbers of leukocytes, which protect us against infection. infection.

Platelets Platelets, or thrombocytes, are much smaller than the red blood cells. They are round or thrombocytes, cells. biconcave disks and are normally about 30 to 40 times more numerous than the white blood cells. The platelets' primary function is to stop bleeding. When tissue is cells. bleeding. damaged, the platelets aggregate in clumps to obstruct blood flow. flow. Plasma The plasma is more than 90 percent water and contains a large number of substances, many essential to life. Its major solute is a mixture of proteins. The most abundant life. proteins. plasma protein is albumin. The globulins are even larger protein molecules than albumin. albumin and are of many chemical structures and functions. The antibodies, produced functions. by lymphocytes, are globulins and are carried throughout the body, where many of them fight bacteria and viruses. viruses. An important function of plasma is to transport nutrients to the tissues. Glucose, for tissues. example, absorbed from the intestines, constitutes a major source of body energy. energy. Some of the plasma proteins and fats, or lipids, are also used by the tissues for cell growth and energy. Minerals essential to body function, although present only in trace energy. amounts, are other important elements of the plasma. The calcium ion, for example, is plasma. essential to the building of bone, as is phosphorus. Calcium is also essential to the phosphorus. clotting of blood. Copper is another necessary component of the plasma. blood. plasma.

PATHOPHYSIOLOGY

NCP HEP DISCHARGE PLAN

SURGICAL MANAGEMENT Treatment Surgical Management Surgical Management for Chronic Bronchitis in exacerbation pulmonale with hypertension are depending upon the extent of the problem involved and the complications that arises, with regards to certain individuals such surgeries may be ordered either for relief of complication or for the intervention for the disease itself. Tracheotomy Tracheotomy and tracheostomy are surgical procedures on the neck to open a direct airway through an incision in the trachea (the windpipe). windpipe). They are performed by emergency physicians, and physicians, surgeons. surgeons. Both surgical and percutaneous techniques are now widely used. While tracheostomy may have possibly been portrayed on ancient Egyptian tablets, the first correct description of the tracheotomy operation for patients who are suffocating was described by Ibn Zuhr in the 12th century, and the currently used surgical tracheostomy technique was described in 1909 by Dr. Chevalier Jackson of Pittsburgh, Pennsylvania. Pittsburgh, Pennsylvania.

Uses of tracheotomy The conditions in which a tracheotomy may be used are: Acute setting - maxillofacial injuries, large tumors of the head and neck, congenital cyst, tumors, e.g. branchial cyst, acute inflammation of head and neck, and Chronic / elective setting - when there is need for long term mechanical ventilation and tracheal toilet, e.g. comatose patients, surgery to the head and neck. In emergency settings, in the context of failed endotracheal intubation or where intubation is contraindicated, cricothyroidotomy or mini-tracheostomy may be miniperformed in preference to a tracheostomy. tracheostomy. Tracheotomy procedure Curvilinear skin incision along relaxed skin tension lines (RSTL) between sternal notch and cricoid cartilage. cartilage. Midline vertical incision dividing strap muscles. muscles. Division of thyroid isthmus between ligatures. ligatures. Elevation of cricoid with cricoid hook. flap, Placement of tracheal incision. An inferior based flap, or Björk flap, (through second and third tracheal rings) is commonly used. The flap is then sutured to the inferior skin rings) margin. Alternatives include a vertical tracheal incision (pediatric) or excision of an (pediatric) ellipse of anterior tracheal wall. Insert tracheostomy tube (with concomitant withdrawal of endotracheal tube), inflate cuff, secure with tape around neck or stay sutures. Connect ventilator tubing. It is also possible to make a simple vertical incision between tracheal rings (typically 2nd and 3rd) for the incision. Rear end flaps may produce more intratracheal granulation tissue at the site of the incisions, making it less favorable to some surgeons.

Risks nerves. During the procedure, there is a risk of damaging the recurrent laryngeal nerves. These cords. nerves control the vocal cords. If one of the nerves is damaged a patient will probably have a problem with his/her voice; if both of the nerves are damaged, the patient will lose his/her speech. This risk of nerve damage is the reason emergency tracheotomies are performed higher up, in the larynx and why tracheotomies have to be done in hospital under anesthetic. Professor Stephen Hawking lost his speech due to a pneumonia. tracheotomy after contracting pneumonia. Moreover, if the recurrent laryngeal nerve is damaged, the patient will have trouble controlling the flow of air through the rima glottidis, thus ultimately leading to inhibited glottidis, breathing or suffocation. Other Surgeries available include Lung transplants and lung reduction surgery are used only rarely to treat chronic bronchitis. Only those people with severe lung disease that has not improved with drug treatment are considered for surgical procedures. In lung reduction surgery, a large portion of the severely damaged lung tissue is removed. The extra room in the chest allows air to move more easily into and out of the healthy lung tissue that remains. Many people who undergo this surgery report that it improves their quality of life, sometimes enabling them to return to a moderately active life without continuous oxygen therapy. However, the surgery has serious risks; mortality (death) rates can be as high as 15%, and complication rates are even higher. With lung transplant surgery, a person with severe chronic bronchitis is given a healthy lung from a person who has recently died. This surgery is rarely recommended for chronic bronchitis. Complications from the drugs needed to keep the body from rejecting the new lung are high, and the 5-year survival rate is only 50%. 5-

Lung transplantation ‡ Lung transplantation is a surgical procedure in which a patient's diseased lungs are partially or totally replaced by lungs which come from a donor. While lung transplants carry certain associated risks, they can also extend life expectancy and enhance the quality of life for end-stage pulmonary patients. endTypes of lung transplant Lobe ‡ A lobe transplant is a surgery in which part of a living donor's lung is removed and used to replace part of recipient's diseased lung. This procedure usually involves the donation of lobes from two different people, thus replacing a single lung in the recipient. Donors who have been properly screened should be able to maintain a normal quality of life despite the reduction in lung volume. ‡ Single-lung Single‡ Many patients can be helped by the transplantation of a single healthy lung. The donated lung typically comes from a donor who has been pronounced brain-dead. brain-dead.

‡ Double-lung DoubleCertain patients may require both lungs to be replaced. This is especially the case for people with cystic fibrosis, due fibrosis, to the bacterial colonisation commonly found within such patients' lungs; if only one lung were transplanted, bacteria in the native lung could potentially infect the newly transplanted organ. ‡ Heart-lung HeartSome respiratory patients may also have severe cardiac disease which in of itself would necessitate a heart transplant. These patients can be treated by a surgery in which both lungs and the heart are replaced by organs from a donor or donors. A particularly involved example of this has been termed a "domino transplant" in the media. First performed in 1987, this type of transplant typically involves the transplantation of a heart and lungs into recipient A, whose own healthy heart is removed and transplanted

Procedure ‡ While the precise details of surgery will depend on the exact type of transplant, there are many steps which are common to all of these procedures. Prior to operating on the recipient, the transplant surgeon inspects the donor lung(s) for signs of damage or disease. If the lung or lungs are approved, then the recipient is connected to an IV line and various monitoring equipment, including pulse oximetry. oximetry. The patient will be given general anesthesia, anesthesia, and a machine will breathe for him or her. ‡ It takes about one hour for the pre-operative preparation preof the patient. A single lung transplant takes about four to eight hours, while a double lung transplant takes about six to twelve hours to complete. A history of prior chest surgery may complicate the procedure and require

PostPost-operative care ‡ Immediately following the surgery, the patient is placed in an intensive care unit for monitoring, normally for a period of a few days. The patient is put on a days. ventilator to assist breathing. Nutritional needs are generally met via total breathing. parenteral nutrition, although in some cases a nasogastric tube is sufficient for nutrition, feeding. feeding. Chest tubes are put in so that excess fluids may be removed. Because removed. used. the patient is confined to bed, a urinary catheter is used. IV lines are used in the neck and arm for monitoring and giving medications. After a few days, medications. barring any complications, the patient may be transferred to a general inpatient ward for further recovery. The average hospital stay following a lung transplant recovery. is generally one to three weeks, though complications may require a longer period of time. After this stage, patients are typically required to attend time. rehabilitation gym for approximately 3 months to regain fitness. Light weights, fitness. exercise bike, treadmill, stretches and more are all a part of the rehabilitation programme. programme. ‡ There may be a number of side effects following the surgery. Because certain surgery. nerve connections to the lungs are cut during the procedure, transplant recipients cannot feel the urge to cough or feel when their new lungs are becoming congested. They must therefore make conscious efforts to take congested. deep breaths and cough in order to clear secretions from the lungs. Their heart lungs. rate responds less quickly to exertion due to the cutting of the vagus nerve that would normally help regulate it. They may also notice a change in their it. voice due to potential damage to the nerves that coordinate the vocal cords.

Risks ‡ As with any surgical procedure, there are risks of bleeding and infection. The newly transplanted lung itself may fail to properly heal and function. Because a large portion of the patient's body has been exposed to the outside air, sepsis is a possibility, so antibiotics will be given to try to prevent that. ‡ Transplant rejection is a primary concern, both immediately after the surgery and continuing throughout the patient's life. Because the transplanted lung or lungs come from another person, the recipient's immune system will "see" it as an invader and attempt to neutralize it. Transplant rejection is a serious condition and must be treated as soon as possible. Signs of rejection: ‡ fever; ‡ flu-like symptoms, including chills, dizziness, nausea, general feeling of fluillness, night sweats; ‡ increased difficulty in breathing; ‡ worsening pulmonary test results; ‡ increased chest pain or tenderness; ‡ increase or decrease in body weight of more than 2 kilograms in a 24'hour period.

‡ In order to prevent transplant rejection and subsequent damage to the new drugs. lung or lungs, patients must take a regimen of immunosuppressive drugs. Patients will normally have to take a combination of these medicines in order to combat the risk of rejection. This is a lifelong commitment, and must be strictly adhered to. The immunosuppressive regimen is begun just before or cyclosporine, after surgery. Usually the regimen includes cyclosporine, azathioprine and corticosteroids, corticosteroids, but as episodes of rejection may reoccur throughout a patient's life, the exact choices and dosages of immunosuppressants may have to be modified over time. Sometimes tacrolimus is given instead of azathioprine. cyclosporine and mycophenolate mofetil instead of azathioprine. ‡ The immunosuppressants that are needed to prevent organ rejection also introduce some risks. By lowering the body's ability to mount an immune reaction, these medicines also increase the chances of infection. Antibiotics may be prescribed in order to treat or prevent such infections. Certain sidemedications may also have nephrotoxic or other potentially harmful sideeffects. Other medications may also be prescribed in order to help alleviate these side effects. There is also the risk that a patient may have an allergic reaction to the medications. Close follow-up care is required in order to followbalance the benefits of these drugs versus their potential risks

Chronic rejection, meaning repeated bouts of rejection symptoms beyond the first year after the transplant surgery, occurs in approximately 50% of patients. Such chronic rejection presents itself as bronchiolitis obliterans, or less frequently, obliterans, atherosclerosis. atherosclerosis. Lung reduction surgery ‡ Lung reduction surgery: A surgical treatment for patients with 20advanced emphysema in which 20-35% of the emphysematous lung is removed to allow the remaining tissue to expand more fully and restore some of the patient's breathing capacity. Also called lung-volume reduction surgery, or LVRS. lung‡ When this surgery is successful, there is improvement in lung life. function, exercise capacity, and the quality of life. However, the surgical mortality rate is appreciable (4 to 15%, according to the particular study). In a meticulous study, the National Emphysema Treatment Trial Research Group found that lung reduction surgery is detrimental to patients with the most severe emphysema -- those with severe injury to blood vessels of the lung and those with empysema distributed uniformly throughout their lungs. Surgery for emphysema is not for everyone. everyone

Risks ‡ There are many risks involved with lung reduction surgery. Lung reduction surgery has a higher risk than heart surgery. This is because the candidates have poor lung function and are generally older. ‡ The death rate of this surgery is about 6 to 10 percent nationwide. This is one of the highest risk procedures performed electively. Complications ‡ Air leakage-- this is the most common complication. Air leakage occurs when leakage-air leaks from the lung tissue, coming from the suture line, into the chest cavity. If the air volume becomes too great, the pressure could collapse the lung tissue. One or more chest tubes are placed during surgery to monitor the air leakage and prevent the collapse of the lung tissue. Over 50% of patients have some degree of air leak. ‡ Pneumonia (19%) or infection (1-5%) is common in emphysema patients, (1especially when they have a history of recurrent bouts. ‡ Stroke (less than 1%) ‡ Bleeding (2-5%) (2‡ Heart attack (1%) ‡ Death which results from a worsening of one of the above complications causing a combination of problems which ultimately lead to death (6-10%) (6-

Surgical Techniques ‡ Thoracoscopy (unilateral or bilateral) Thoracoscopy is a minimally invasive technique. Three small (approximately 1 inch) incisions are made in each side, between your ribs. A video-scope is placed videothrough one of the incisions. This scope allows the surgeon to see your lungs. A stapler and grasper are inserted in the other incisions. These are used to cut away the most damaged areas of the lung. The stapler will reseal the remaining lung. Sutures that will eventually dissolve close the incisions. This technique can be used to operate on either one or both lungs and allows assesment and resection of any part of the lungs.

Sternotomy (bilateral) ‡ An incision is made through the breastbone to expose both lungs. Both lungs are reduced at the same sitting in this procedure, one after the other. The chest bone is wired together and the skin is closed. This is the most invasive technique, used when thoracocopy is not appropriate. This approach is usually used only for upper lobe disease. Thoracotomy (unilateral or one sided) ‡ For the Thoracotomy technique, an incision is made between your ribs. The incision is approximately 5 to 12 inches long. Your ribs are separated, not broken, and your lungs are seen. Only one lung is reduced with this procedure. Your muscle and skin closed by sutures. Thoracotomy is often used when the surgeon is unable to see the lung clearly through the thoracoscope or when

Chest Tubes ‡ Chest tubes are used for drainage and to monitor air leaking. These are placed at the time of surgery. The chest tube is hooked up to a container and water chamber. The chest tube will remain in until the drainage stops and there is no air leaking. Occasionally, chest tubes are left in after discharge from the hospital and are removed in a subsequent office visit. Pain Control ‡ Operations create pain. We make every effort to minimize your discomfort through IV medications and epidural catheters. An epidural catheter is a very small tube placed in your back at the time of surgery. Pain medication is infused through the catheter that will bathe the spinal cord and prevent pain. You will feel discomfort from the chest tube, but the pain will be managed through the catheter. You will be asked frequently about your pain. Please be honest about your pain. It is very important for the pain to be under control because taking deep breaths and moving are essential for quick recovery

PROGNOSIS
The prognosis of chronic bronchitis in exacerbation is poor. The 1-year mortality rate 1for patients with the disease can be as high as 46%. Many of the patients subsequent hospitalized hospitalized for AECB require subsequent readmissions because of persistent symptoms and often experience a temporary decrease in their functional abilities. emporary Overall, AECB contributes significantly to the morbidity and the diminished quality of life experienced by people with COPD. The prognosis for cor pulmonale is poor, particularly because it occurs late in the process of serious disease. The prognosis for secondary pulmonary hypertension is poor. The prognosis of this disease has an especially broad range, because it can be caused by such a wide variety of underlying conditions. If doctors are able to treat the condition that is producing pulmonary hypertension, which in the case of our patient is chronic bronchitis, then the right ventricle may recover. The heart can become stronger and the symptoms of pulmonary hypertension can be relieved.

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