PULMONARY CONDITIONS

FUNCTIONS OF THE RESPIRATORY SYSTEM

MAJOR SEQUELAE OF PULMOARY DSE OR INJURY

Hypoxemia
• MC condition caused by pulmonary disease or injury.
• deficient oxygenation of arterial blood, may lead to hypoxia,
Hypoxia
• term meaning diminished availability of oxygen to the body
tissues

MOST COMMON SIGNS AND SYMPTOMS OF PULMONARY

DISEASE
• Cough
• Dyspnea
• Abnormal sputum PULMONARY PAIN
• Chest pain • Localized in the substernal or chest region over involved
• Hemoptysis lung fields
• Cyanosis • Referred pain from the pulmonary system is the chest, ribs,
• Digital clubbing upper trapezius, shoulder, medial aspect of the arm, and
• Altered breathing patterns thoracic spine.
• Aggravated by increases with inspiratory movements,
COUGH (laughing, coughing, sneezing, or deep breathing), recumbent
• A persistent dry cough may be caused by a tumor, position.
congestion, or hypersensitive airways (allergies). • Palpation and resisted movements will not reproduce the
• A productive cough with symptoms

DYSPNEA SCALE
• Shortness of breath (SOB)
• usually indicates hypoxemia but can be associated with
emotional states, particularly fear and anxiety.
FACTORS CONTRIBUTING TO DYSPNEA
• Increased work of breathing (WOB)
• Respiratory muscle fatigue
• Increased systemic metabolic demands
• Decreased respiratory reserve capacity.
• Positional changes - orthopnea
Fig. 7-2 Tracheobronchial pain is referred to sites in the neck
or anterior chest at the same levels as the points of irritation
in the air passages. The points of pain are on the same side as
the areas of irritation
PLEURAL IRRITATION/PLEURAL PAIN
• sharp, localized pain that is aggravated by any respiratory
movement.
• pain is alleviated by Auto-splinting
• Referred pain: shoulder, upper trapezius muscle, neck,
lower chest wall, or abdomen.
DIAPHRAGMATIC PLEURAL PAIN
• paralysis of the corresponding half of the diaphragm
(Phrenic & Intercostals)
• sharp pain felt along the costal margins
• sharp pain referred to the upper trapezius muscle and
shoulder on the ipsilateral side of the stimulation

CYANOSIS
• Bluish color of the skin and mucous membranes, depends
on the oxygen saturation of arterial blood and the total
amount of circulating hemoglobin.
• Central cyanosis is best observed as a bluish discoloration
in the oral mucous membranes, and conjunctivae
• Peripheral cyanosis is associated with decreased perfusion
to the extremities, nail beds, lips, and nose
CLUBBING
• Thickening and widening of the terminal phalanges of the
fingers and toes result in a painless
club-like appearance recognized by the loss of the angle
between the nail and the nail bed

WINDOW TEST

ALTERED BREATHING PATTERNS

• Changes in the rate, depth, regularity, and effort of
breathing occur in response to any condition affecting the
pulmonary system
• depending on the neuromuscular or neurologic disease or
trauma
DESCRIPTIONS OF LATERED BREATHING PATTERNS
AND SOUNDS

COPD VS CRPD
TABLE 2.1 THE GLOBAL INITIATIVE FOR CHRONIC
OBSTRUCTIVE LUNG DISEASE (GOLD) CLASSIFICATION

Stage

ACUTE BRONCHITIS
• inflammation of the trachea and bronchi (tracheobronchial
tree) that is self-limiting and of short duration with few
pulmonary signs.
• This condition may result from chemical irritation or may
occur with viral infections
Acute Bronchitis
• Mild fever from 1 to 3 days
• Malaise
• Back and muscle pain CHRONIC BRONCHITIS
• Sore throat • Persistent cough
• Cough with sputum production, followed by wheezing • Sputum production (worse in the morning and evening than
• Possibly laryngitis at midday).
• SOB, prolonged expiration,
CHRONIC BRONCHITIS • Fever and malaise.
• Hallmark: condition of productive cough lasting for at least • Reduced chest expansion,
3 months (usually the winter months) per year for 2 • Wheezing, cyanosis,
consecutive years. • Decreased exercise tolerance may occur
• Characterized by inflammation and scarring of the bronchial • Increased PaCO2.
lining. > obstruct airflow to and from the lungs and increases
mucus production. EMPHYSEMA
Chronic Bronchitis • Defined as an enlargement of the air spaces beyond the
• Persistent cough with production of sputum (worse in the terminal bronchiole, and is associated with a loss of elasticity
morning and evening than at midday) in the distal airways, airway collapse, and gas trapping
• Reduced chest expansion
• Wheezing
• Fever
• Dyspnea (SOB)
• Cyanosis (blue discoloration of skin and mucous
membranes)
• Decreased exercise tolerance

COMPLICATION OF CHRONIC BRONCHITIS

• impaired ciliary function reduces mucous clearance
• increases client susceptibility to infection.
• abnormal ventilation/perfusion (V• /Q• ) ratio
• Cyanosis results from insufficient arterial oxygenation and
• Peripheral edema from right ventricular failure. Pulmonary
vascular resistance caused by inflammation and loss of
capillary beds will contribute to cor pulmonale (right-sided EMPHYSEMA
congestive heart failure). CENTRILOBULAR EMPHYSEMA
• most common type,
• produces destruction in the bronchioles of the upper lung
regions.
• Inflammation develops in the bronchioles,
• but usually the alveolar sac (distal to respiratory
bronchioles) remains intact
• most common type in smokers.
PANLOBULAR EMPHYSEMA
• destroys the air spaces of the entire acinus
• most commonly involves the lower lung.
• common in those with al- antitrypsin deficiency.
PARASEPTAL or PANACINAR EMPHYSEMA
• Destroys the alveoli in the lower lobes of the lungs,
resulting in isolated blebs along the lung
periphery.
• often occurs alongside of centrilobular in chronic smokers.
• likely cause of spontaneous pneumothorax
EMPHYSEMA
• Destruction of elastin protein in the lung that normally
maintains the strength of the alveolar walls which leads to
permanent enlargement of the acini.
• causes narrowing or collapse of the bronchioles so that
inspired air becomes trapped in the lungs
EMPHYSEMA
• Hyperinflation of the lungs
• Permanent overdistention of the air spaces
• Destruction of the walls (septa) between the alveoli
• Pockets of air form between the alveolar spaces
• (blebs) and within the lung parenchyma (bullae).
• Increase ventilatory dead space
• diminishing V" /Q" matching
EMPHYSEMA: CLINICAL MANIFESTATION
• exertional dyspnea progresses to dyspnea at rest.
• Cough is uncommon, with little sputum production.
• Pt is often thin, has tachypnea with prolonged expiration,
and must use accessory muscles for ventilation.
• Barrel chest
BLUE BLOATER
 • Characterized by chronic airway inflammation associated
with airway hyper- responsiveness (hyper-reactivity) resulting
in bronchospasm

ASTHMA: TRIGGERS
• Respiratory infection
• Cigarette smoke
• Pollen, mold, animal hair, feather, dust and insects
• Physical exertion
• Cold air, temp change
• Strong emotions
CATEGORIES OF ASTHMA
• Conventional asthma :
• Extrinsic (allergic) — IGG
• Intrinsic — local inflammatory response
• Occupational asthma — exposed to irritants in work
• Exercise induced asthma

PINK PUFFER BOX 7-2 FACTORS THAT MAY TRIGGER ASTHMA

• Respiratory infections, colds
• Cigarette smoke
• Allergic reactions to pollen, mold, animal dander, feather,
dust, food, insects
• Indoor and outdoor air pollutants, including ozone
• Physical exertion or vigorous exercise
• Exposure to cold air or sudden temperature change
• Excitement or strong emotion, psychologic or emotional
stress
ASTHMA: TRIAD
• Wheezing
• Dyspnea
• Cough
WITH REPEATED EPISODES
• Barrel chest
• Elevated shoulders
• Use of accessory muscles of respiration
• Skin retraction (clavicles, ribs, sternum)
• Facial appearance: flattened malar bones, circles beneath
the eyes, narrow nose, prominent upper teen, nostrils flaring

ASTHMA
COMPLICATION
• Status asthmaticus is a severe, life threatening complication ° Inherited disorder of ion transport (sodium and chloride) in
of asthma. the exocrine glands affecting the hepatic, digestive,
• acute cor pulmonale reproductive and respiratory systems
• severe paradoxic pulse ° Autosomal Recessive - long arm of chromosome 7 (Ch 7p).
• BP drop of more than 10 mm Hg during inspiration ° (+) sweat test: chloride concentration of greater than or
• Pneumothorax can develop. equal to 60 mEq/L
• hypoxemia worsens and acidosis begins. ° (+) Honeycomb Lungs
• Respiratory or cardiac arrest.
CURSCHMANN’S SPIRALS
• Spiral-shaped mucus plug
• Asthma attack is terminated by a cough producing a thick
stringy mucus

CYSTIC FIBROSIS
IN EARLY OR UNDIAGNOSED STAGES
BRONCHIECTASIS
• Persistent coughing and wheezing
• Progressive condition with irreversible destruction and
• Recurrent pneumonia
dilation of airways.
• Excessive appetite but poor weight gain
• Abnormal and permanent dilation of the bronchi and
• Salty skin/sweat
bronchioles develops when the supporting structures
• Bulky, foul-smelling stools (undigested fats caused by a Tack
(bronchial walls) are weakened by chronic inflammatory
of amylase and tryptase enzymes)
changes associated with secondary infection
IN OLDER CHILD AND YOUNG ADULT
• Infertility
• Nasal polyps
• Periostitis
• Glucose intolerance
PULMONARY INVOLVEMENT IN CYSTIC FIBROSIS
• Tachypnea (very rapid breathing)
• Sustained chronic cough with mucus production and
vomiting
• Barrel chest (caused by trapped air)
• Use of accessory muscles for respiration and intercostal
retraction
• Cyanosis and digital clubbing
BRONCHIECTASIS: CLINICAL MANIFESTATION • Exertional dyspnea with decreased exercise tolerance
• Chronic “wet” cough with copious foul-smelling secretions; Further complications include:
generally worse in the morning after the individual has been • Pneumothorax
recumbent for a length of time • Hemoptysis
• Hemoptysis (bloody sputum) • Right-sided heart failure secondary to pulmonary
• Occasional wheezing sounds hypertension
• Dyspnea CYSTIC FIBROSIS: HONEYCOMB LUNGS
• Sinusitis (inflammation of one or more paranasal sinuses)
• Weight loss
• Anemia
• Malaise
• Recurrent fever and chills
• Fatigue

CYSTIC FIBROSIS RESPIRATORY DSE SUMMARY OF DIFFERENCES

CRPD ATELECTASIS
RESTRICTED LUNG DISEASE • Collapsed or airless alveolar unit due to hypoventilation
• a group of diseases with differing etiologies that result in secondary to pain (LUNG COLLAPSE)
difficulty expanding the lungs and a reduction in lung • Most common cause is post-surgical atelectasis
volumes.
1. Diseases of the alveolar parenchyma and/or the pleura
2. Changes in the chest wall
3. an alteration in the neuromuscular apparatus of the thorax
PULMONARY FIBROSIS
• AKA “interstitial lung disease”
• Epithelial damage leads to progressive scarring (fibrosis) of
the lungs, predominantly fibroblasts and small blood vessels
that progressively remove and replace normal tissue
• Honeycombing/ Honeycomb Lungs
• Usually caused by asbestos inflammation (pneumoconiosis)
PLEURAL INJURY
• Pneumothorax PULMONARY EDEMA
• Air in the pleural space, usually through lacerated visceral • Seepage of fluid in pulmonary vascular system into the
pleura, from a rib fracture (traumatic pneumothorax) or interstitial spaces
ruptured bullae (spontaneous pneumothorax) • Cough with pink, frothy secretions
• Hemothorax
• Blood in the pleural space due to a laceration of parietal
pleura

PLEURAL INJURY/ PNEUMOTHORAX PNEUMONIA

• Inflammation of the lungs • Shoulder pain that is aggravated by supine positioning; pain
• Causes: that is worse when lying down and improves when sitting up
• Aspiration of fluids, food or vomitus or leaning forward
• Inhalation of chemicals, dust, smoke or gas • Shoulder or chest (thorax) pain that subsides with
• Bacterial or viral infection autosplinting
• Pneumocystis Carinii Pneumonia (PCP) • For the client with asthma: Signs of asthma or bronchial
• Most opportunistic infection and most common life activity during exercise.
threatening conditions in persons who suffer from aids • Weak and rapid pulse accompanied by fall in blood pressure
(pneumothorax).
RISK FACTOR • Presence of associated signs and symptoms such as
• Age: very young, very old persistent cough, dyspnea (rest or exertional), or
• Have not received a pneumococcal vaccination constitutional symptoms
• Smoking
• Air pollution BOX 1-3 CONSTITUTIONAL SYMPTOMS
• Upper respiratory infection (URI) Fever
• Altered consciousness: alcoholism, head injury, seizure Diaphoresis (unexplained perspiration)
disorder, drug overdose, general anesthesia Sweats (can occur anytime night or day)
• Endotracheal intubation, nasogastric tube Nausea
• Recent chest surgery Vomiting
• Prolonged immobility Diarrhea
• Immunosuppressive therapy Pallor
• Nonfunctional immune system: acquired immunodeficiency Dizzinness/syncope (fainting)
syndrome (AIDS) Fatigue
• Prolonged exposure to virulent organisms Weight loss
• Malnutrition, dehydration
• Chronic diseases: diabetes mellitus, heart disease, chronic
lung disease, renal disease, cancer
• Prolonged debilitating disease
• Inhalation of noxious substances
• Aspiration of oral/gastric material (food or fluid), foreign
materials (e.g., Petroleum products)

PNEUMONIA
• Sudden and sharp pleuritic chest pain that is aggravated by
chest movement
• Shoulder pain
• Hacking, productive cough (rust-colored or green, purulent
sputum)
• Dyspnea
• Tachypnea (rapid respirations associated with fever or
pneumonia) accompanied by decreased chest excursion on
the affected side
• Cyanosis
• Headache
• Fever and chills
• Generalized aches and myalgia that may extend to the
thighs and calves
• Knees may be painful and swollen
• Fatigue
• Confusion in older adult or increased confusion in client
with dementia or Alzheimer's disease

GUIDELINES FOR PHYSICIAN REFERRAL

• Shoulder pain aggravated by respiratory movements;