1. 1 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 24 Kyphoscoliosis

2. 2 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-1. Kyphoscoliosis. Posterior and lateral curvature of the spine causing lung compression. Excessive bronchial secretions (A) and atelectasis (B) are common secondary anatomic alterations of the lungs. A B

3. 3 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Kyphoscoliosis is a combination of two thoracic deformities that commonly appear together.   Kyphosis is a posterior curvature of the spine (humpback).   In scoliosis the spine is curved to one side— typically appearing as an S or C shape. Anatomic Alterations of the Lungs

4. 4 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Anatomic Alterations of the Lungs (Cont’d)  Lung restriction and compression as a result of the thoracic deformity  Mediastinal shift  Mucous accumulation throughout the tracheobronchial tree  Atelectasis

5. 5 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Kyphoscoliosis affects about 2% of the people in the United States   Mostly young children going through growing spurts   Rarely develops in adults—unless a worsening condition from childhood   Kyphoscoliosis may also develop in adults from a degenerative joint condition in the spine Etiology

6. 6 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Kyphoscoliosis is commonly associated with the following general conditions:   Congential scoliosis Problem with the formation of the spine or fused ribs during fetal development   Neuromuscular scoliosis Problems caused by poor muscle control, muscle weakness, or paralysis   Idiopathic scoliosis (80%-85% of the cases) Scoliosis from a unknown cause (80%-85% of the cases) Etiology (Cont’d)

7. 7 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Idiopathic scoliosis is classified as follows:   Infantile scoliosis The curvature of the spine develops during the first 3 years of life.   Juvenile scoliosis The curvature occurs between 4 years and the onset of adolescence.   Adolescent scoliosis The spine curvature develops after the age of 10. Etiology (Cont’d)

8. 8 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Risk Factors Include:   Sex—Girls are more likely to develop curvature of the spine than boys.   Age—The younger the child is when the diagnosis is first made, the greater the chance of curve progression.   Angle of the curve—The greater the curvature of the spine, the greater the risk that the curve progression will worsen. Etiology (Cont’d)

9. 9 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Risk Factors Include:   Location—Curves in the middle to lower spine are less likely to progress than those in the upper spine.   Height—Taller people have a greater chance of curve progression.   Spinal problems at birth—Children with scoliosis at birth (congenital scoliosis) have a greater risk of worsening of the curve. Etiology (Cont’d)

10. 10 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Scoliosis is diagnosed by means of the patient’s medical history, physical examination, x-ray evaluation, and curve measurement. Diagnosis

11. 11 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnosis (Cont’d)   Clinically, scoliosis is commonly defined according to the following factors related to the curvature of the spine:   Shape   Location   Direction   Angle

12. 12 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

13. 13 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Overview of the Cardiopulmonary Clinical Manifestations Associated with Kyphoscoliosis The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by  Atelectasis  Excessive Airway Secretions

14. 14 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

15. 15 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

16. 16 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained at the Patient’s Bedside

17. 17 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination  Vital signs  Increased Respiratory rate (tachypnea) Heart rate (pulse) Blood pressure  Cyanosis

18. 18 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination, (Cont’d)  Digital clubbing  Peripheral edema and venous distention  Cough and sputum production

19. 19 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination, (Cont’d)  Chest Assessment Findings  Obvious thoracic deformity  Tracheal shift  Increased tactile and vocal fremitus  Dull percussion note  Bronchial breath sounds  Whispered pectoriloquy  Crackles, rhonchi, and wheezing

20. 20 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained from Laboratory Tests and Special Procedures

21. 21 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pulmonary Function Test Findings Moderate to Severe (Restrictive Lung Pathophysiology) Forced Expiratory Flow Rate Findings FVC FEV T FEV 1 /FVC ratio FEF 25%-75%  N or  N or  N or  FEF 50% FEF 200-1200 PEFR MVV N or  N or 

22. 22 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pulmonary Function Test Findings Moderate to Severe (Restrictive Lung Pathophysiology) Lung Volume & Capacity Findings VT IRV ERV RV VC N or      IC FRC TLC RV/TLC ratio    N

23. 23 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases (Mild to Moderate Kyphoscoliosis) Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) pH PaCO 2 HCO 3 PaO 2 pH PaCO 2 HCO 3 PaO 2    (slightly)     (slightly) 

24. 24 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute alveolar hyperventilation.

25. 25 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases (Severe Kyphoscoliosis) Chronic Ventilatory Failure with Hypoxemia (Compensated Respiratory Acidosis) pH PaCO 2 HCO 3 PaO 2 pH PaCO 2 HCO 3 PaO 2   (Significantly)  N   (Significantly) 

26. 26 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.

27. 27 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases Acute Ventilatory Changes Superimposed On Chronic Ventilatory Failure  Because acute ventilatory changes are frequently seen in patients with chronic ventilatory failure, the respiratory care practitioner must be familiar with and alert for the following:  Acute alveolar hyperventilation superimposed on chronic ventilatory failure  Acute ventilatory failure (acute hypoventilation) superimposed on chronic ventialtory failure.

28. 28 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Oxygenation Indices (Moderate to Severe Kyphoscoliosis) Q S /Q T DO 2 VO 2 C(a-v)O 2 O 2 ER SvO 2 Q S /Q T DO 2 VO 2 C(a-v)O 2 O 2 ER SvO 2   N      N   

29. 29 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Hemodynamic Indices Moderate to Severe Kyphoscoliosis CVP RAP PA PCWP CO SV CVP RAP PA PCWP CO SV    N N N    N N N SVI CI RVSWI LVSWI PVR SVR SVI CI RVSWI LVSWI PVR SVR N N  N  N N N  N  N

30. 30 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Laboratory Findings  Severe and/or Late Stage Kyphoscoliosis  If the patient is chronically hypoxemic Increased hematocrit and hemoglobin (polycythemia) Hypochloremia (Cl - ) Hypernatremia (Na + )

31. 31 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Radiologic Findings  Chest Radiograph  Blunting t horacic deformity  Mediastinal shift  Increased lung opacity  Atelectasis in areas of compressed (atelectatic) lungs  Enlarged heart (cor pulmonale)

32. 32 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Severe kyphoscoliosis in a 14-year-old male patient. Figure 24-3. Severe kyphoscoliosis in a 14-year-old male patient.

33. 33 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. General Management of Scoliosis   The treatment of scoliosis largely depends on the cause of the scoliosis, the size and location of the curve, and how much more growing the patient is expected to do.   In most cases of scoliosis (less than 20 degrees), the degree of abnormal spine curvature is relatively small and requires only observation to ensure that the curve does not worsen.   Observation is usually recommended in patients with a spine curvature of less than 20 degrees.

34. 34 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   In young children who are still growing, observation checkups are usually scheduled in 3- to 6-month intervals.   When the curve is determined to be progressing to a more serious degree (above 25 to 30 degrees in a child who is still growing), the following treatments options are available: General Management of Scoliosis (Cont’d)

35. 35 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Braces   Boston brace   Charleston bending brace   Milwaukee brace General Management of Scoliosis (Cont’d)

36. 36 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-4 Common types of braces for scoliosis. A, Boston back brace (also called a thoraco-lumbro- sacral-orthosis [TLSO], a low-profile brace, or an underarm brace). Typically used for curves in the lumbar (low-back) or thoracolumbar sections of the spine. B, Charleston bending brace (also known as a part-time brace). C, Milwaukee brace (also called cervicothoracolumbosacral orthosis [CTLSO]) is used for high thoracic (mid-back) curves.

37. 37 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Surgery   Spinal fusion   Rod Instrumentation General Management of Scoliosis (Cont’d)

38. 38 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-5 Radiograph of patient with scoliosis treated with a Harrington rod.

39. 39 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Other Approaches   Some physicians may try electrical stimulation of muscles, chiropractic manipulation, and exercise to treat scoliosis.   There is no evidence that any of these procedures will stop the progression of spine curvature. General Management of Scoliosis (Cont’d)

40. 40 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Other Approaches (Cont’d)   Exercise, however, may improve the patient’s overall health and well-being.   Prophylactic deep breathing and coughing (DB&C) exercises are also taught. Their long-term effect is debatable. General Management of Scoliosis (Cont’d)

41. 41 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Respiratory Care Treatment Protocols   Oxygen Therapy Protocol   Bronchopulmonary Hygiene Therapy Protocol   Lung Expansion Therapy Protocol