1. Copyright © 2006 by Mosby, Inc. Slide 1 PART VII Environmental Lung Diseases

2. Copyright © 2006 by Mosby, Inc. Slide 2 Chapter 25 Pneumoconiosis Chapter 25 Pneumoconiosis Figure 25-1. Pneumoconiosis, illustrated here in a case of asbestosis (close-up of one alveolar unit). AF, Asbestos fiber; FIB, fibrosis; M, macrophage. Inset, Cross-section showing fibrotic thickening of the alveolus, a common secondary anatomic alteration of the lungs.

3. Copyright © 2006 by Mosby, Inc. Slide 3 Anatomic Alterations of the Lungs  Destruction of the alveoli and adjacent pulmonary capillaries  Fibrotic thickening of the respiratory bronchioles, alveolar ducts, and alveoli  Cystlike structures (honeycomb appearance)  Fibrocalcific pleural plaques (e.g., asbestosis)  Airway obstruction caused by inflammation and excessive bronchial secretions  Bronchospasm  Bronchogenic carcinoma  Mesothelioma (in asbestosis)

4. Copyright © 2006 by Mosby, Inc. Slide 4 Etiology Etiologic Determinants  Size of inhaled particle  0.3 and 0.5 μm reach the alveoli  Chemical nature of the particle  Concentration of the particle  Length of exposure  The individual’s susceptibility

5. Copyright © 2006 by Mosby, Inc. Slide 5 Etiology Asbestosis  Acoustic products  Automobile undercoating  Brake lining  Cements  Clutch casings  Floor tiles  Fire-fighting suits  Fireproof paints  Insulation  Roofing materials  Ropes  Steam pipe material

6. Copyright © 2006 by Mosby, Inc. Slide 6 Etiology Coal Worker’s Pneumoconiosis  The deposition and accumulation of large amounts of coal dust cause what is know as coal worker’s pneumoconiosis (CWP)  Also called:  Coal miner’s lung  Black lung  Black phthisis  Miner’s phthisis

7. Copyright © 2006 by Mosby, Inc. Slide 7 Etiology Silicosis  Tunneling  Hard-rock mining  Sandblasting  Quarrying  Stonecutting  Foundry work  Ceramics work  Abrasive work  Brick making  Paint making  Polishing  Stone drilling  Well drilling

8. Copyright © 2006 by Mosby, Inc. Slide 8 Etiology Berylliosis  Beryllium is a steel-gray, lightweight metal found in:  Certain plastics and ceramics  Rocket fuels  X-ray

9. Copyright © 2006 by Mosby, Inc. Slide 9 Etiology Other Forms of Pneumoconiosis  Aluminum  Ammunition workers  Baritosis (barium)  Barite millers and miners  Ceramics workers  Kaolinosis (clay)  Brick makers and potters  Ceramics workers  Siderosis (iron)  Welders  Talcosis (certain talcs)  Ceramics workers  Plastic and rubber workers

10. Copyright © 2006 by Mosby, Inc. Slide 10 Overview of the Cardiopulmonary Clinical Manifestations Associated with PNEUMOCONIOSIS The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Increased Alveolar-Capillary membrane (see Figure 9-9), Bronchospasm (see Figure 9-10), and Excessive Bronchial Secretions (see Figure 9-11)—the major anatomic alterations of the lungs associated with chronic bronchitis (see Figure 25-1).

11. Copyright © 2006 by Mosby, Inc. Slide 11 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.

12. Copyright © 2006 by Mosby, Inc. Slide 12 Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).

13. Copyright © 2006 by Mosby, Inc. Slide 13 Figure 9-11. Excessive bronchial secretions clinical scenario.

14. Copyright © 2006 by Mosby, Inc. Slide 14 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside Vital signs  Increased respiratory rate  Increased heart rate, cardiac output, blood pressure

15. Copyright © 2006 by Mosby, Inc. Slide 15 Clinical Data Obtained at the Patient’s Bedside  Cyanosis  Digital clubbing  Peripheral edema and venous distention  Distended neck veins  Pitting edema  Enlarged and tender liver  Cough and sputum production

16. Copyright © 2006 by Mosby, Inc. Slide 16 Digital Clubbing Figure 2-46. Digital clubbing.

17. Copyright © 2006 by Mosby, Inc. Slide 17 Distended Neck Veins Figure 2-48. Distended neck veins (arrows).

18. Copyright © 2006 by Mosby, Inc. Slide 18 Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2, London, 1992, Mosby-Wolfe.

19. Copyright © 2006 by Mosby, Inc. Slide 19 Clinical Data Obtained at the Patient’s Bedside  Chest assessment findings  Increased tactile and vocal fremitus  Dull percussion note  Bronchial breath sounds  Crackles, rhonchi, and wheezing  Pleural friction rub  Whispered pectoriloquy

20. Copyright © 2006 by Mosby, Inc. Slide 20 Figure 2-11. A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.

21. Copyright © 2006 by Mosby, Inc. Slide 21 Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung unit.

22. Copyright © 2006 by Mosby, Inc. Slide 22 Figure 2-19. Whispered voice sounds auscultated over a normal lung are usually faint and unintelligible.

23. Copyright © 2006 by Mosby, Inc. Slide 23 Clinical Data Obtained from Laboratory Tests and Special Procedures

24. Copyright © 2006 by Mosby, Inc. Slide 24 Pulmonary Function Study: Expiratory Maneuver Findings FVC FEV T FEF 25%-75% FEF 200-1200     PEFR MVV FEF 50% FEV 1%    N  FVC FEV T FEF 25%-75% FEF 200-1200     PEFR MVV FEF 50% FEV 1%    N 

25. Copyright © 2006 by Mosby, Inc. Slide 25 Pulmonary Function Study: Lung Volume and Capacity Findings V T RV FRC TLC     VC IC ERV RV/TLC%    N or  V T RV FRC TLC     VC IC ERV RV/TLC%    N or 

26. Copyright © 2006 by Mosby, Inc. Slide 26 Decreased Diffusion Capacity (DL CO )

27. Copyright © 2006 by Mosby, Inc. Slide 27 Arterial Blood Gases Mild to Moderate Pneumoconiosis  Acute alveolar hyperventilation with hypoxemia pH PaCO 2 HCO 3 - PaO 2    (Slightly)  pH PaCO 2 HCO 3 - PaO 2    (Slightly) 

28. Copyright © 2006 by Mosby, Inc. Slide 28 Time and Progression of Disease 100 50 30 80 0 0 Pa CO 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa O 2 Disease Onset Pa O 2 or Pa CO 2 Figure 4-2. Pa O 2 and Pa CO 2 trends during acute alveolar hyperventilation.

29. Copyright © 2006 by Mosby, Inc. Slide 29 Arterial Blood Gases Severe Pneumoconiosis with Extensive Fibrosis  Chronic ventilatory failure with hypoxemia pH PaCO 2 HCO 3 - PaO 2 Normal   (Significantly)  pH PaCO 2 HCO 3 - PaO 2 Normal   (Significantly) 

30. Copyright © 2006 by Mosby, Inc. Slide 30 Time and Progression of Disease 100 50 30 80 0 Pa O 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa CO 2 Chronic Ventilatory Failure Disease Onset Point at which disease becomes severe and patient begins to become fatigued Pa 0 2 or Pa C0 2 Figure 4-7. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.

31. Copyright © 2006 by Mosby, Inc. Slide 31 Acute Ventilatory Changes Superimposed on Chronic Ventilatory Failure  Acute alveolar hyperventilation on chronic ventilatory failure  Acute ventilatory failure on chronic ventilatory failure

32. Copyright © 2006 by Mosby, Inc. Slide 32 Oxygenation Indices Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal Normal O 2 ER Sv O 2   Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal Normal O 2 ER Sv O 2  

33. Copyright © 2006 by Mosby, Inc. Slide 33 Hemodynamic Indices (Severe Pneumoconiosis) CVP RAPPAPCWP  Normal COSVSVICI NormalNormalNormalNormal RVSWILVSWIPVRSVR  Normal  Normal

34. Copyright © 2006 by Mosby, Inc. Slide 34 Laboratory Findings  Complete blood count (CBC)  Elevated hemoglobin concentration and hematocrit if the patient is chronically hypoxemic

35. Copyright © 2006 by Mosby, Inc. Slide 35 Radiologic Findings Chest radiograph  Small rounded opacities scattered throughout the lung  Irregularly shaped opacities  Irregular cardiac and diaphragmatic borders  Pleural plaques  Honeycomb appearance

36. Copyright © 2006 by Mosby, Inc. Slide 36 Figure 25-2. Chest X-ray of a patient with asbestosis.

37. Copyright © 2006 by Mosby, Inc. Slide 37 Figure 25-3, Calcified pleural plaques on the superior border of the diaphragm (arrows) in a patient with asbestosis. Thickening of the pleural margins also is seen along the lower lateral borders of the chest. A, Anteroposterior view. B, Lateral view.

38. Copyright © 2006 by Mosby, Inc. Slide 38 General Management of Pneumoconiosis  Control of occupational diseases is the responsibility of the:  Worker  Management  Community health department  State and federal governments  Prevention is the key  After the disease is established, it has no effective cure

39. Copyright © 2006 by Mosby, Inc. Slide 39 General Management of Pneumoconiosis  Respiratory care treatment protocols  Oxygen therapy protocol  Bronchopulmonary hygiene therapy protocol  Aerosolized medication protocol  Hyperinflation therapy protocol

40. Copyright © 2006 by Mosby, Inc. Slide 40 Classroom Discussion Case Study: Pneumoconiosis