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VII.

PATHOPHYSIOLOGY PLEURAL EFFUSION SECONDARY TO COMMUNITY ACQUIRED PNEUMONIA Theoretically Based

Non-Modifiable Factors: Extremes of Age: The Very Young The Elderly (60 and Above) Race or Ethnicity: Native Americans Native Alaskans Gender: Male Environmental: Inhalation of foreign materials into the lungs

Modifiable Factors: Lifestyle: Smoking and Alcohol abuse Improper diet causing malnutrition Environmental: Exposure to Pathogens: S. Pneumoniae, H. Influenza, Lagionella, P. Aureginosa, other gram (-) rods and viruses Exposure and inhalation of Secondhand smoke and other chemical pollutants Genetics: The immunocompromised or immunosuppressed patients with low neutrophil count Underlying Diseases: HIV/AIDS Diabetes Mellitus Cardiovascular Diseases Respiratory Diseases: Pulmonary tuberculosis and Chronic Obstructive Pulmonary Disease Medication: Drugs that may cause Respiratory Depression: General Anesthetics, Opioids, Sedatives Drugs that may cause Immunosuppresion: Corticosteroids, Chemotherapeutic Drugs Self-medicating with antibiotics that may cause bacterial/viral resistance: Penicillin, Cephalosporins Others:
Depressed Cough Reflex

Legend: Modifiable and Non-Modifiable Risk Factors Clinical Manifestations/Signs and Symptoms

RACE

AGE

GENDER

ENVIRONMENTAL

LIFESTYLE

GENETICS

UNDERLYING DISEASES

MEDICATION

OTHERS

Native Americans and Native Alaskans

Possible depressed cough and glotic reflex

Male

Highest morbidity and mortality rate

More men smoke than women

Exposure to 2nd hand smoke and other chemical pollutants

Exposure to pathogens:
S. Pneumoniae, H. Influenza, Lagionella, P. Aureginosa, other gram (-) rods and viruses

Excessive alcohol intake and smoking

Improper diet causing


malnutrition

The immunocompromised or immunosuppressed patients with low neutrophil count

HIV/ADIS, DM, CVD, COPD, PTB

Impairment of hosts immune defenses Susceptibility to bacterial invasion

Drugs that may cause Respiratory Depression and Immunosuppression:


General Anesthetics, Opioids, Sedatives, Corticosteroids, chemotherapeutic drugs

Selfmedicating with antibiotics that may cause pathogenic resistance

Decreased cough reflex

Inhalation of foreign materials

Alterations in normal flora

Decreased/Disruption of mucocilliary and macrophage activity

Decreased Immune response or immunesuppression

Aspiration of bacteria in lower respiratory tract Bacterial invasion into the lungs and lower respiratory tract (trachea > bronchus > bronchioles > alveoli) Immune response triggered

Inflammatory response

Lymphocytes produce cytokines WBC

Release of chemical mediators (Histamine, Bradykinin, etc.) Vasodilation and capillary permeability Fluid shifting and edema

Stimulate release of prostaglandin Fever Chills

Release of killer T-Cells, macrophages, phagocytes and anti-bodies

Migration to alveoli Killer T-Cells, macrophages, phagocytes and anti-bodies take effect to pathogens

Purulent exudate formation

Crackles Chest pain Cough with purulent yellowish secretions Dyspnea

Filling of WBC in alveoli and the normally air containing space Exudate/Fluid accumulation in alveoli Partial occlusion of bronchi and alveoli Altered ventilation and diffusion

Decrease oxygen level of blood that passes on the lungs Alveolar O2 tension

Venous blood entering pulmonary circulation passes unventilated area

Ventilation and Perfusion mismatch

Poorly oxygenated blood travels to the left side of the heart

Circulating O2 Arterial hypoxemia Hypoxia Altered Tissue Perfusion Oxygen demand

Hypoventilation Cerebral hypoxia CNS Alterations Headache, dizziness, fatigue, lethargy, restlessness, confusion, irritability, loss of appetite, mood swings

Continuous exudates/fluid accumulation

Pallor Cyanosis

Hemoptysis

Alveolar damage

Alveolar collapse

Pulmonary consolidation

Atelectasis

RBC

Hyperventilation

Heart Rate Pulmonary neutrophilia

Difficulty of breathing and shortness of breath

Use of accessory muscles

Respiratory Rate Apoptosis of other phagocytes

Secondary necrosis of other phagocytes Further damage to other lung parenchyma near the affected part

Inflammation
Permeability of pleural capillary membrane

Altered fluid absorption Pale, Yellow, Cloudy Exudate; Protein; WBC; pH


Accumulation of fluid in pleural space

Irritation of pleural surfaces

Non-productive cough

Protein in Pleural fluid or absent tactile fremitus

Oncotic pressure

Dullness in percussion

Further accumulation of exudates in pleural space

Empyema

Chest pain

> 150-200ml

Flattening or inversion of the diaphragm

Thoracic cavity size and lung size

Mediastinal compression

Compromised cardiac output

Dyspnea

Lung tissue compression

Lung expansion

Ventilation-perfusion mismatch

Arterial hypoxemia

Total lung capacity, functional residual capacity, force vital capacity

Gas-exchange capacity

Difficulty in taking deep breaths

Compromised breathing Shallow breaths Hypoxemia Tachypnea Hypoxia Breath sounds on affected area Unmanaged effusion

Lung compliance

Ventilatory restriction

Atelectasis Source: Focus on Pathophysiology by Bullock and Henze pp253-285 & 572-573 Medical-Surgical Nursing by Brunner and Suddarth pp328330 & 574