Chapter 27: Pulmonology

Pulmonology- study of the respiratory system. COPD (Chronic Obstructive Pulmonary Disease)- a disease characterized by a decreased ability of the lungs to perform the function of ventilation. Process of Gas Exchange Ventilation- the mechanical process of moving air in and out of the lungs. Diffusion- the movement of molecules through a membrane from an area of greater concentration to an area of lesser concentration. Perfusion- the circulation of blood through the capillaries. o Lung perfusion is dependent on 3 conditions Adequate blood volume Intact pulmonary capillaries Efficient pumping of blood by the heart Hemoglobin (Hb)- the transport protein that carries O2 in the blood. Oxygen dissociation curve- as fully oxygen-bound hemoglobin begins to release oxygen, it more readily sheds additional oxygen. Basically, the more Hb the more O2 can be transported. Changes in body temperature, blood pH, and the PCO2 can all alter the Oxygen dissociation curve. Bohr effect- phenomenon in which a decrease in PCO2/acidity causes an increase in the quantity of O2 that binds w/ the hemoglobin and, conversely, an increase in PCO2/acidity causes the hemoglobin to give up a greater quantity of O2. CO2 is transported from the cells to the lungs in one of three ways. 1. as bicarbonate ion- is predominantly what CO2 is converted to 2. bound to the globin portion of the hemoglobin molecule 3. dissolved in plasma (measured as PCO2) Respiration- the exchange of gases between a living organism and its environment. Pathophysiology Disruption in Ventilation o Upper and Lower Respiratory Tract Obstruction o Chest Wall & Diaphragm Pneumothorax- a collection of air in the pleural space, causing a loss of the negative-pressure that binds the lung to the chest wall. Hemothorax- a collection of blood in the pleural space. Flail chest- one or more ribs fractured in two or more places, creating an unattached rib segment. o Nervous System- certain abnormal respiratory patterns are produced by specific brain injury or illness. Kussmauls respirations- deep, slow or rapid, gasping breathing. Associated w/ diabetic ketoacidosis Cheyne-Stokes respirations- progressively deeper, faster breathing alternating gradually w/shallow, slower breathing, indicating brain stem injury.

Biots respirations- irregular pattern of rate and depth w/ sudden, periodic episodes of apnea, indicating increased ICP. Central neurogenic hyperventilation- deep, rapid respirations, indicating increased ICP. Agonal respirations- shallow, slow or infrequent breathing, indicating brain anoxia. Disruption in Diffusion- any disruption in diffusion can cause Hypoxia o Hypoxia- state in which insufficient O2 s available to meet the O2 requirements of the cells. Disruption in Perfusion- any state that reduces the normal circulating blood volume, such as trauma, hemorrhage, dehydration, shock or other causes of Hypovolemia, will limit normal perfusion or the lungs. o Pulmonary shunting- when an area of lung tissue is appropriately ventilated but no capillary perfusion occurs, available O2 is not moved into the circulatory system. Assessment of the Respiratory System Scene Size Up1. Is the Scene Safe to approach the patient? 2. Are there visual clues that might provide information regarding the patients medical complaint? Initial Assessment o General impression Position?- tripod, usually respiratory distress will be upright Color ?1. Pallor- paleness 2. Diaphoresis- sweatiness 3. Cyanosis- bluish discoloration of the skin due to an increase in reduced hemoglobin in the blood. The condition is directly related to poor ventilation. Mental status- AVPU Ability to speak- possibly can only speak 1-2 word sentences Respiratory effort4. Nasal flaring- excessive widening of the nares w/respiration 5. Accessory muscle- use indicates significant breathing effort. 6. Pursed lips 7. Tracheal tugging- retraction of the tissues of the neck due to airway obstruction or Dyspnea. o Airway- Principals to assessing the airway Noisy breathing nearly always means partial airway obstruction Obstructed breathing is not always noisy The brain can survive only a few minutes in asphyxia.

8. Asphyxia- a decrease in the amount of O2 & an increase in the amount of CO2 as a result of some interference w/respiration. Artificial respiration is useless if the airway is blocked. A patent airway is useless if the patient is apneic. If you note airway obstruction, fix it immediately. o Breathing- suggested signs of possible life-threatening respiratory problems in adults. 1) Alterations in mental status 2) Severe central cyanosis 3) Absent breath sounds 4) Audible Stridor 5) 1-2 word Dyspnea 6) Tachycardia 130bpm 7) Pallor and diaphoresis 8) Accessory muscle use during labored breathing Focused History & Physical Examination o History SAMPLE OPQRST ? Orthopnea- Dyspnea while lying supine ? Paroxysmal Nocturnal Dyspnea- short attacks of Dyspnea that occur at night and interrupt sleep. ? Hemoptysis- expectoration of blood from the respiratory tree. o Physical Examination Head Neck Chest Inspection Palpation o Crepitus- crackling sounds o Subcutaneous Emphysema- presence of air in the subcutaneous tissue. o Tactile fremitus- vibratory tremors felt through the chest by palpation. o Tracheal deviation- any position of the trachea other that midline Percussion Auscultation o Snoring- partial obstruction of upper airway by tongue o Stridor- associated w/laryngeal edema or constriction o Wheezing- associated w/bronchiolar constriction

o Crackles (Rales)- associated w/ fluid in the smaller bronchioles o Rhonchi- associated w/inflammation, mucus, or fluid in the bronchioles o Pleural Friction Rub- sounds like dried pieces of leather rubbing together; occurs when the pleura becomes inflamed, as in pleurisy. Extremities o Vital Signs Blood Pressure Pulsus paradoxus- a drop in the systolic blood pressure of 10mmHg or more w/each respiratory cycle. It is associated w/COPD and Cardiac Tamponade. Diagnostic Testing Pulse Oximetry Peak Flow Capnometry- normal 35-45% PCO2 Management of Respiratory Disorders Management Principals 1. Airway is the 1st Priority 2. Always Provide O2 to Patients w/respiratory distress or possible hypoxia o Never withhold O2 from a patient suspected of suffering hypoxia. Specific Respiratory Diseases Upper-Airway Obstruction o Causes Tongue- most common cause of Airway obstruction Foreign matter Trauma Burns Allergic reactions Infection o Management Conscious Adult- Hymlick Maneuver (5 Abdominal thrusts) Unconscious Adult- Head-tilt chin-lift, jaw-thrust, or modified jaw-thrust to attempt to open the airway. Then Abdominal thrusts. ARDS (Adult Respiratory Distress Syndrome)- form of pulmonary edema that is caused by fluid accumulating in the interstitial space within the lungs. o Causes Drowning Seizure activity or hypoventilation High altitude exposure Toxins related to septic shock o Management

Use positive pressure ventilation to support and ARDS patient who demonstrates signs of respiratory failure. BVM, ETT, C-PAP Obstructive Lung Diseaseo COPD (Chronic Obstructive Pulmonary Disease) Emphysema (Pink Puffers)- destruction of the alveolar walls distal to the terminal bronchioles. The Alveolar walls grow thick and scar due to the damage of external influences (i.e. Cigarette smoke, toxins). Cigarette smoking is the major factor contributing to emphysema in our society. Patient is barrel chested and breaths backward by trying to hold air in the lungs to keep air passages open. Chronic Bronchitis (Blue Bloaters)- is a build up of mucus in the lungs plugs the airways and obstructs airflow and gas exchange. o Asthma- is a chronic inflammatory disorder of the airways. Triggers or Inducers initiate the inflammatory reaction causing a narrowing of the bronchioles (bronchospasm) and obstruction of the airway. Intrinsic triggers predominantly affect children Extrinsic triggers predominantly affect adults Common Signs of Asthma Dyspnea Wheezing Cough Asthma Management Goals: Correct hypoxia Reverse bronchospasm Reduce inflammation Upper Respiratory Infection (URI)- an interference w/air movement through the upper airway. o The best defense against spread of upper respiratory infection is common practices such as good hand washing and covering the mouth during coughing and sneezing. o Viruses are responsible for a vast majority of URIs, and bacteria also produce infection as well. o 30% of URIs are Strep Throat from the bacteria Group A streptococcus. Pneumonia- acute infection of the lung, including alveolar spaces and interstitial tissue. Lung Cancer (Neoplasm)- is the leading cause of cancer-related death in the US in both & . Toxic Inhalation- of toxic substances into the respiratory tract can cause pain, inflammation, or destruction of the pulmonary tissue. o Products that can result in the formation of corrosive acids or alkalis Ammonia (ammonium hydroxide) Nitrogen oxide (nitric acid) Sulfur dioxide (sulfurous acid)

Sulfur trioxide (sulfuric acid) Chlorine (hydrochloric acid) Carbon Monoxide (CO) Inhalation- CO is an odorless, tasteless, colorless gas produced from the incomplete burning of fossil fuels and other coarboncontaining compounds. o CO has an affinity for hemoglobin 200 times that of O2. Pulmonary Embolism- is a blood clot (thrombus), air or fat embolism or some other particle that lodges in a pulmonary artery, effectively blocking blood flow through that vessel. Spontaneous Pneumothorax- a Pneumothorax that occurs spontaneously, in the absence of blunt or penetrating trauma. Hyperventilation Syndrome- is characterized by rapid breathing, chest pains, numbness, and other symptoms usually associated w/anxiety or a situational reaction. o Popedal spasm- cramping of the muscles of the feet and hands CNS (Central Nervous System) Dysfunction- due to head trauma, stroke, brain tumors, & various drugs. Dysfunction of the Spinal Cord, Nerves, or Respiratory Muscles- numerous disorders can interfere w/ respiratory function; including spinal cord trauma, polio, ALS or Lou Gehrigs Disease, viral infections, and myasthenia gravis.