1. Copyright © 2006 by Mosby, Inc. Slide 1 Obstructive Airway Diseases

2. Copyright © 2006 by Mosby, Inc. Slide 2  Chronic obstructive pulmonary disease.  Bronchitis, emphysema, and asthma may present alone or in combination. AsthmaBronchitis Emphysema

3. Copyright © 2006 by Mosby, Inc. Slide 3 Chapter 11 Chronic Bronchitis Chapter 11 Chronic Bronchitis Chronic bronchitis. Inset, Weakened distal airways in emphysema, a common secondary anatomic alteration of the lungs.

4. Copyright © 2006 by Mosby, Inc. Slide 4 Anatomic Alterations of the Lungs  Chronic inflammation and swelling of the peripheral airways  Excessive mucus production and accumulation  Partial or total mucus plugging  Hyperinflation of alveoli (air-trapping)  Smooth muscle constriction of bronchial airways (bronchospasm)

5. Copyright © 2006 by Mosby, Inc. Slide 5 Etiology  Cigarette smoking  Atmospheric pollutants  Infection  Gastroesophageal reflux disease

6. Copyright © 2006 by Mosby, Inc. Slide 6 Overview of the Cardiopulmonary Clinical Manifestations Associated with CHRONIC BRONCHITIS The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Excessive Bronchial Secretions (see Figure 9-11) and Bronchospasm (see Figure 9-10)—the major anatomic alterations of the lungs associated with chronic bronchitis (see Figure 11-1).

7. Copyright © 2006 by Mosby, Inc. Slide 7 Figure 9-11. Excessive bronchial secretions clinical scenario.

8. Copyright © 2006 by Mosby, Inc. Slide 8 Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).

9. Copyright © 2006 by Mosby, Inc. Slide 9 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

10. Copyright © 2006 by Mosby, Inc. Slide 10 Clinical Data Obtained at the Patient’s Bedside  Use of accessory muscles of inspiration  Use of accessory muscles of expiration  Pursed-lip breathing  Increased anteroposterior chest diameter (barrel chest)  Cyanosis  Digital clubbing

11. Copyright © 2006 by Mosby, Inc. Slide 11 Figure 2-36. The way a patient may appear when using the pectoralis major muscles for inspiration.

12. Copyright © 2006 by Mosby, Inc. Slide 12 Figure 2-41. A, Schematic illustration of alveolar compression of weakened bronchiolar airways during normal expiration in patients with chronic obstructive pulmonary disease (e.g., emphysema). B, Effects of pursed-lip breathing. The weakened bronchiolar airways are kept open by the effects of positive pressure created by pursed lips during expiration.

13. Copyright © 2006 by Mosby, Inc. Slide 13 Digital Clubbing Figure 2-46. Digital clubbing.

14. Copyright © 2006 by Mosby, Inc. Slide 14 Clinical Data Obtained at the Patient’s Bedside Peripheral edema and venous distention  Distended neck veins  Pitting edema  Enlarged and tender liver

15. Copyright © 2006 by Mosby, Inc. Slide 15 Distended Neck Veins Figure 2-48. Distended neck veins (arrows).

16. Copyright © 2006 by Mosby, Inc. Slide 16 Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2, London, 1992, Mosby-Wolfe.

17. Copyright © 2006 by Mosby, Inc. Slide 17 Clinical Data Obtained at the Patient’s Bedside  Cough, sputum production, hemoptysis  Chest assessment findings  Hyperresonant percussion note  Diminished breath sounds  Diminished heart sounds  Decreased tactile and vocal fremitus  Crackles/rhonchi/wheezing

18. Copyright © 2006 by Mosby, Inc. Slide 18 Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.

19. Copyright © 2006 by Mosby, Inc. Slide 19 Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive lung diseases, breath sounds progressively diminish.

20. Copyright © 2006 by Mosby, Inc. Slide 20 Clinical Data Obtained from Laboratory Tests and Special Procedures

21. Copyright © 2006 by Mosby, Inc. Slide 21 Pulmonary Function Study: Expiratory Maneuver Findings FVCFEV T FEF 25%-75% FEF 200-1200   PEFRMVVFEF 50% FEV 1%  

22. Copyright © 2006 by Mosby, Inc. Slide 22 Pulmonary Function Study: Lung Volume and Capacity Findings V T RV FRC TLC V T RV FRC TLC N or    N or  N or    N or  VC IC ERV RV/TLC ratio  N or  N or   VC IC ERV RV/TLC ratio  N or  N or  

23. Copyright © 2006 by Mosby, Inc. Slide 23 Arterial Blood Gases Mild to Moderate Chronic Bronchitis  Acute alveolar hyperventilation with hypoxemia pH Pa CO 2 HCO 3 - Pa O 2    (Slightly) 

24. Copyright © 2006 by Mosby, Inc. Slide 24 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.

25. Copyright © 2006 by Mosby, Inc. Slide 25 Arterial Blood Gases Severe Chronic Bronchitis  Chronic ventilatory failure with hypoxemia pH Pa CO 2 HCO 3 - Pa O 2 Normal   (Significantly)  Normal   (Significantly) 

26. Copyright © 2006 by Mosby, Inc. Slide 26 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.

27. Copyright © 2006 by Mosby, Inc. Slide 27 Acute Ventilatory Changes Superimposed on Chronic Ventilatory Failure  Acute alveolar hyperventilation on chronic ventilatory failure  Acute ventilatory failure on chronic ventilatory failure

28. Copyright © 2006 by Mosby, Inc. Slide 28 Oxygenation Indices Q S /Q T D O 2 V O 2 C(a-v) O 2   NormalNormal   NormalNormal O 2 ERSv O 2  

29. Copyright © 2006 by Mosby, Inc. Slide 29 Hemodynamic Indices (Severe Chronic Bronchitis) CVP RAPPAPCWP  Normal COSVSVICI NormalNormalNormalNormal RVSWILVSWIPVRSVR  Normal  Normal

30. Copyright © 2006 by Mosby, Inc. Slide 30 Abnormal Laboratory Tests and Procedures  Hematology Increased hematocrit and hemoglobin  Electrolytes  Hypochloremia (chronic ventilatory failure)  Increased bicarbonate (chronic ventilatory failure)  Sputum examination  Increased white blood cells  Streptococcus pneumoniae  Haemophilus influenzae  Moraxella catarrhalis

31. Copyright © 2006 by Mosby, Inc. Slide 31 Radiologic Findings Chest radiograph  Translucent (dark) lung fields  Depressed or flattened diaphragms  Long and narrow heart  Enlarged heart

32. Copyright © 2006 by Mosby, Inc. Slide 32 Figure 11-2. Chest X-ray film of a patient with chronic bronchitis. Note the translucent (dark) lung fields, depressed diaphragms, and long and narrow heart.

33. Copyright © 2006 by Mosby, Inc. Slide 33 Radiologic Findings Bronchogram  Small spikelike protrusions

34. Copyright © 2006 by Mosby, Inc. Slide 34 Figure 11-3. Chronic bronchitis. Bronchogram with localized view of left hilum. Rounded collections of contrast lie adjacent to bronchial walls and are particularly well seen below the left main stem bronchus (arrow) in this film. They are caused by contrast in dilated mucous gland ducts. (From Armstrong P, Wilson AG, Dee P: Imaging of diseases of the chest, St. Louis, 1990, Mosby.)

35. Copyright © 2006 by Mosby, Inc. Slide 35 General Management of Chronic Bronchitis  Patient and family education  Behavioral management  Avoidance of smoking and inhaled irritants  Avoidance of infections  Respiratory care treatment protocols  Oxygen therapy protocol  Bronchopulmonary hygiene therapy protocol  Aerosolized medication protocol  Mechanical ventilation protocol

36. Copyright © 2006 by Mosby, Inc. Slide 36 G lobal Initiative for Chronic O bstructive L ung D isease GOLD Standards

37. Copyright © 2006 by Mosby, Inc. Slide 37 Figure 11-4. Acute exacerbation of COPD (AECOPD): Guideline algorithm (ACCP/ACP-ASIM). CXR, Chest X-ray; NPPV, noninvasive positive pressure ventilation; PEFR, peak expiratory flow rate; URI, upper respiratory infection. (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)

38. Copyright © 2006 by Mosby, Inc. Slide 38 Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)

39. Copyright © 2006 by Mosby, Inc. Slide 39 Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)

40. Copyright © 2006 by Mosby, Inc. Slide 40 Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)

41. Copyright © 2006 by Mosby, Inc. Slide 41 Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)

42. Copyright © 2006 by Mosby, Inc. Slide 42 Figure 11-4. Acute exacerbation of COPD (AECOPD): Guideline algorithm (ACCP/ACP-ASIM). CXR, Chest X-ray; NPPV, noninvasive positive pressure ventilation; PEFR, peak expiratory flow rate; URI, upper respiratory infection. (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)

43. Copyright © 2006 by Mosby, Inc. Slide 43 Classroom Discussion Case Study: Chronic Bronchitis