PART II

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

PART IIPART II

Obstructive Airway Obstructive Airway DiseasesDiseases


Asthma

Chronic Bronchitis

Emphysema

Obstructive Lung Diseases

Cystic Fibrosis

Bronchiectasis

The most common obstructive lung diseases


Chapter 11Chapter 11

Chronic Obstructive Pulmonary Chronic Obstructive Pulmonary Disease (COPD) Chronic Bronchitis Disease (COPD) Chronic Bronchitis

and Emphysemaand Emphysema


Figure 11-1. Chronic bronchitis, one of the most common airway diseases.Figure 11-1. Chronic bronchitis, one of the most common airway diseases.


Figure 11-2. Panlobular emphysema. A, Normal alveoli for comparison purposes. B, Panlobular Figure 11-2. Panlobular emphysema. A, Normal alveoli for comparison purposes. B, Panlobular emphysema. C, Excessive bronchial secretions from bronchitis, a common alteration of the emphysema. C, Excessive bronchial secretions from bronchitis, a common alteration of the

lungs.lungs.

A

B

C


Figure 11-3. Centrilobular emphysema. Abnormal weakening and enlargement Figure 11-3. Centrilobular emphysema. Abnormal weakening and enlargement of the respiratory bronchioles in the proximal portion of the acinus. of the respiratory bronchioles in the proximal portion of the acinus.


The American Thoracic Society The American Thoracic Society (ATS)(ATS)

Guidelines for Guidelines for Chronic obstructive pulmonary disease (COPD)Chronic obstructive pulmonary disease (COPD) Chronic bronchitis, Chronic bronchitis, EmphysemaEmphysema


Chronic Obstructive PulmonaryChronic Obstructive Pulmonary DiseaseDisease

Is a preventable and treatable disease state Is a preventable and treatable disease state characterized by airflow limitation that is not characterized by airflow limitation that is not fully reversible. fully reversible.

The airflow limitation is usually progressive The airflow limitation is usually progressive and is associated with an abnormal and is associated with an abnormal inflammatory response of the lungs to inflammatory response of the lungs to noxious particles or gases, primarily caused noxious particles or gases, primarily caused by cigarette smoking. by cigarette smoking.

Although COPD affects the lungs, it also Although COPD affects the lungs, it also produces significant systemic consequences.produces significant systemic consequences.


Chronic BronchitisChronic Bronchitis

Is defined clinically as chronic productive Is defined clinically as chronic productive cough for 3 months in each of 2 successive cough for 3 months in each of 2 successive years in a patient in whom other causes of years in a patient in whom other causes of productive chronic cough have been productive chronic cough have been excluded.excluded.


EmphysemaEmphysema

Is defined pathologically as the presence of Is defined pathologically as the presence of permanent enlargement of the airspaces permanent enlargement of the airspaces distal to the terminal bronchioles, distal to the terminal bronchioles, accompanied by destruction of their walls accompanied by destruction of their walls and without obvious fibrosis. and without obvious fibrosis.


In patients with In patients with COPD:COPD:

Either or both of those conditions may be Either or both of those conditions may be present. present.

However, the relative contribution of each to However, the relative contribution of each to the disease process is often difficult to the disease process is often difficult to discern.”discern.”


Note that the ATS’s definition forNote that the ATS’s definition for

Chronic bronchitisChronic bronchitis is based on the major is based on the major ""clinical manifestationsclinical manifestations" associated with the " associated with the disease. disease.

EmphysemaEmphysema is based on the pathology, or is based on the pathology, or the "the "anatomic alterations of the lung,anatomic alterations of the lung," " associated with the disorder. associated with the disorder.


The The GGlobal Initiative for Chronic lobal Initiative for Chronic OObstructive bstructive LLung ung DDisease (isease (GOLDGOLD) )

provides this working definition:provides this working definition:


Chronic Obstructive Pulmonary Chronic Obstructive Pulmonary Disease (COPD)Disease (COPD) is….. is…..

A preventable and treatable disease with A preventable and treatable disease with some significant extrapulmonary effects that some significant extrapulmonary effects that may contribute to the severity in individual may contribute to the severity in individual patients. patients.

Its pulmonary component is characterized by Its pulmonary component is characterized by airflow limitation that is not fully reversible. airflow limitation that is not fully reversible.

The airflow limitation is usually progressive The airflow limitation is usually progressive and associated with an abnormal and associated with an abnormal inflammatory response of the lung to noxious inflammatory response of the lung to noxious particles or gases.particles or gases.


The bottom line is this:The bottom line is this:

Even though chronic bronchitis and Even though chronic bronchitis and emphysema can each develop alone, they emphysema can each develop alone, they often occur together as one disease often occur together as one disease complex.complex.

When this happens, the disease entity is When this happens, the disease entity is called called chronic obstructive pulmonary chronic obstructive pulmonary disease (COPD)disease (COPD)..


GOLD Website Address

http://www.goldcopd.org


Anatomic Alterations of the LungsAnatomic Alterations of the LungsAssociated with Chronic BronchitisAssociated with Chronic Bronchitis

Chronic inflammation and swelling of the Chronic inflammation and swelling of the peripheral airwaysperipheral airways

Excessive mucus production and Excessive mucus production and accumulationaccumulation

Partial or total mucus plugging of the airwaysPartial or total mucus plugging of the airways Smooth muscle constriction of bronchial Smooth muscle constriction of bronchial

airways (bronchospasm)airways (bronchospasm) Air trapping and hyperinflation of alveoli—Air trapping and hyperinflation of alveoli—

occasionally in the late stagesoccasionally in the late stages


Anatomic Alterations of the Lungs Anatomic Alterations of the Lungs Associated with EmphysemaAssociated with Emphysema

Permanent enlargement and deterioration of Permanent enlargement and deterioration of the air spaces distal to the terminal the air spaces distal to the terminal bronchiolesbronchioles

Destruction of pulmonary capillariesDestruction of pulmonary capillaries Weakening of the distal airways, primarily the Weakening of the distal airways, primarily the

respiratory bronchiolesrespiratory bronchioles Air trapping and hyperinflation of alveoli (air-Air trapping and hyperinflation of alveoli (air-

trapping)trapping)


EpidemiologyEpidemiology

It is estimated that between 10 and 15 million It is estimated that between 10 and 15 million people in the United States either have people in the United States either have chronic bronchitis, emphysema, or a chronic bronchitis, emphysema, or a combination of both. combination of both.

Most authorities agree that COPD is under-Most authorities agree that COPD is under-diagnosed.diagnosed.


Risk FactorsRisk FactorsAccording to GOLDAccording to GOLD

Tobacco smokeTobacco smoke Occupational dusts and chemicalsOccupational dusts and chemicals Indoor air pollutionIndoor air pollution Outdoor air pollutionOutdoor air pollution Conditions that affect normal lung growthConditions that affect normal lung growth Genetic predispositionGenetic predisposition

Alpha 1-antitrypsin deficiencyAlpha 1-antitrypsin deficiency


Diagnosis of COPDDiagnosis of COPDAccording to GOLDAccording to GOLD

Key Indicators for Considering a COPD Key Indicators for Considering a COPD Diagnosis:Diagnosis: DysypneaDysypnea Chronic coughChronic cough Chronic sputum productionChronic sputum production History of exposure to risk factorsHistory of exposure to risk factors


Pulmonary Function Study in the Pulmonary Function Study in the Diagnosis of COPDDiagnosis of COPD

According to GOLDAccording to GOLD The three main spirometry tests for COPD The three main spirometry tests for COPD

are the :are the : FVCFVC FEVFEV11

FEVFEV11/FVC ratio/FVC ratio


Figure 11-4 Normal spirogram and spirogram typical of patients with mild to moderate chronic obstructive pulmonary disease.


Pulmonary Function Study in the Pulmonary Function Study in the Diagnosis of COPD (Cont’d)Diagnosis of COPD (Cont’d)

The presence of COPD is confirmed when The presence of COPD is confirmed when both the FEVboth the FEV11 and FEV and FEV11/FVC ratio are /FVC ratio are

decreaseddecreased


Stages of COPDStages of COPDAccording to GOLDAccording to GOLD

Stage I: Mild COPDStage I: Mild COPD Stage II: Moderate COPDStage II: Moderate COPD Stage III: severe COPDStage III: severe COPD Stage IV: Very severe COPDStage IV: Very severe COPD


Additional Diagnostic Studies of COPDAdditional Diagnostic Studies of COPDAccording to GOLDAccording to GOLD

Bronchodilator reversibility testingBronchodilator reversibility testing Chest x-rayChest x-ray Arterial blood gas measurementArterial blood gas measurement AlphaAlpha11 antitrypsin deficiency screening antitrypsin deficiency screening


Table 11-1 Common Key Distinguishing Features Between Emphysema & Chronic Bronchitis

Clinical Manifestations

Emphysema(Type A: Pink Puffer)

Chronic Bronchitis(Type B: Blue Bloater)

Inspection

Body build Thin Stocky, overweight

Barrel Chest Common—classic sign Normal






Respiratory patternHyperventilation &

marked dyspnea; often occurs at rest

Late stage: diminished respiratory drive & hypoventilation

Diminished respiratory drive

Hypoventilation common, with resultant hypoxia and hypercapnia


Table 11-1 Common Key Distinguishing Features Between Emphysema & Chronic Bronchitis (Cont’d)




Pursed-lip breathing

Common Uncommon

Cough Uncommon Common—classic sign

Sputum Uncommon Common—classic sign

Copious amounts, purulent






Cyanosis Uncommon (reddish skin)

Common

Peripheral edema Uncommon Common Right-heart failure

Neck vein distention

Uncommon Common Right-heart failure






Use of accessory muscles

Common Uncommon






Auscultation Decreased breath

sounds, decreased heart sounds; prolonged expiration

Wheezes, crackles, rhonchi, depending on severity of disease

Percussion Hyperresonance Normal






Laboratory Tests

Hyperresonance Normal

Chest radiograph Hyperinflation, narrow mediastinum, normal or small vertical heart, low flat diagphragm, presence of blebs or bullae

Congested lung fields, densities, increased bronchial vascular markings, enlarged horizontal heart

Polycythemia Uncommon Common






Infections Occasionally Common

Polycythemia Uncommon Common






Pulmonary Function Study

DLCO and DLCO/VA Decreased Often normal

Other

Pulmonary hypertension

Uncommon Common

Cor pulmonale Uncommon Common Right-heart failure


Overview Overview of the Cardiopulmonary Clinical Manifestations of the Cardiopulmonary Clinical Manifestations

Associated with Associated with Chronic Bronchitis and Emphysema (COPD)Chronic Bronchitis and Emphysema (COPD)

The following clinical manifestations result from the The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) pathophysiologic mechanisms caused (or activated) by by

Excessive Bronchial Secretions Bronchospasm Distal Airway and Alveolar Weakening





Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside

Vital Signs Chronic Bronchitis & Emphysema

Heart rate and respiratory rate

Stable patients: normal vital signs Exacerbations: Usually acute

increase in heart rate and respiratory rate (Tachypnea)

Classic sign of hypoxemia


Chest Assessment Findings

Emphysema Chronic Bronchitis

Inspection

General body build Thin, underweight Stocky, overweight

Altered Sensorium—anxiety, irritability

Common—severe stage


Common—during moderate and severe stage


Barrel Chest Yes—classic sign Occasionally

Digital Clubbing Late-Stage Common


Chest Assessment Findings (Cont’d)


Inspection

Cyanosis Uncommon—often reddish skin

Common

Peripheral edema and venous distention

End-stage emphysema

Common—Because polycythemia & cor pulmonale are common, the following are often seen:

Distended neck veins

Pitting edema Enlarged &

tender liver




Inspection

Use of accessory muscles

Common Especially

during exacerbations

Uncommon End-stage in some

chronic bronchitis

Hoover’s Sign The inward movement of the lower lateral chest wall during each inspiration—indicates severe hyperinflation

Common—Severe Stage

Uncommon




Inspection

Pursed-lip breathing Common Uncommon

Cough Uncommon during mild and moderate stage Some coughing

during severe-stage with infection

Classic sign More severe in the

mornings

Sputum Uncommon Little, mucoid

Common Classic sign;

copious amounts, purulent




Inspection

Palpation of the Chest

Decreased tactile fremitus

Decreased chest expansion

PMI often shifts to the epigastric area

Normal




Inspection

Percussion of the Chest

Hyperresonance Decreased

diaphragmatic excursion

Normal

Auscultation of the Chest

Diminished breath sounds

Prolonged expiration

Diminished heart sounds

Rhonchi Crackles Wheezes


Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special

ProceduresProcedures


Pulmonary Function Test FindingsModerate to Severe Chronic Bronchitis & Emphysema

(Obstructive Lung Pathophysiology)

Forced Expiratory Flow Rate Findings

FVC FEVT FEV1/FVC ratio FEF25%-75

FEF50% FEF200-1200 PEFR MVV


Pulmonary Function Test FindingsModerate to Severe Chronic Bronchitis & Emphysema

(Obstructive Lung Pathophysiology)

Lung Volume & Capacity Findings

VT IRV ERV RV VC

N or N or N or

IC FRC TLC RV/TLC ratio

N or N or N or


Diffusion Capacity (DLCO)Emphysema Chronic Bronchitis

Decreased A decreased DLCO is

a classic diagnostic sign of emphysema

Normal


Arterial Blood GasesChronic Bronchitis & Emphysema

Mild to Moderate StagesAcute Alveolar Hyperventilation with Hypoxemia

(Acute Respiratory Alkalosis)

pH PaC02 HCO3 Pa02

(slightly)


PaOPaO22 and PaCO and PaCO22 trends during acute alveolar hyperventilation. trends during acute alveolar hyperventilation.



Severe StageChronic Ventilatory Failure with Hypoxemia

(Compensated Respiratory Acidosis)

pH PaC02 HCO3 Pa02

N (significantly)


PaOPaO22 and PaCO and PaCO22 trends during acute or chronic ventilatory failure. trends during acute or chronic ventilatory failure.



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.


Oxygenation IndicesChronic Bronchitis and Emphysema

Moderate to Severe Stages

QS/QT D02 V02 C(a-v)02 02ER Sv02

N N


Hemodynamic IndicesChronic Bronchitis and Emphysema

Moderate to Severe Stages

CVP RAP PA PCWP CO SV

N N N

SVI CI RVSWI LVSWI PVR SVR

N N N N


Laboratory Tests and ProceduresTest Emphysema Chronic Bronchitis

Hematocrit & Hemoglobin

Normal—mild moderate stage

Elevated—late stage

Polycythemia common during the early and late stage

Electrolytes(abnormal)

Late stage: Hypochloremia (CL-)

When chronic ventilatory failure is present

Hypernatremia (Na+)

Early & Late stages: Hypochloremia (CL-)

When chronic ventilatory failure is present

Hypernatremia (Na+)


Laboratory Tests and Procedures (Cont’d)

Test Emphysema Chronic Bronchitis

Sputum examination(culture)

Normal Streptococcus pneumoniae

Haemophilus influsenzae

Moraxella catarrhalis


Radiology FindingsTest Chronic Bronchitis

Chest Radiograph

Lungs may be clear if only large bronchi are affected

Occasionally Translucent Depressed or flattened

diaphragms Common

Cor pulmonale

Bronchogram Small spikelike protrusions


Figure 11-5 Chest X-ray film from a patient with chronic bronchitis. Note the translucent (dark) lung fields at the bases, depressed diaphragms, and long and narrow heart.


Figure 11-6. Chronic bronchitis. Bronchogram with localized view of left hilum. Rounded collections of contrast lie adjacent to bronchial walls and are particularly well demonstrated below the left main stem bronchus (arrow) in this film. They are caused by contrast in dilated mucous gland ducts. (From Hansel DM, Armstrong P, Lynch DA, McAdams HP, eds: Imaging of the diseases of the chest, ed 4, St Louis, 2005, Mosby.)


Radiology Findings (Cont’d)Test Emphysema

Chest RadiographCommon Translucent Depressed or flattened diaphragms Long & narrow heart Increased retrosternal air spaceOccasionally cor pulmonale


Figure 11-7. Figure 11-7. Chest X-ray film of a patient with emphysema. The heart often appears Chest X-ray film of a patient with emphysema. The heart often appears long and narrow as a result of being drawn downward by the descending diaphragm.long and narrow as a result of being drawn downward by the descending diaphragm.


Figure 11-8. Emphysema. Lateral chest radiograph demonstrates a characteristically large Figure 11-8. Emphysema. Lateral chest radiograph demonstrates a characteristically large retrosternal radiolucency with increased separation of the aorta and sternum measuring 4.6 cm, 3 retrosternal radiolucency with increased separation of the aorta and sternum measuring 4.6 cm, 3 cm below the angle of Louis and extending down to within 3 cm of the diaphragm anteriorly. Both cm below the angle of Louis and extending down to within 3 cm of the diaphragm anteriorly. Both costophrenic angles are obtuse, and both hemidiaphragms are flat.costophrenic angles are obtuse, and both hemidiaphragms are flat.


Figure 11-9. Figure 11-9. Cor pulmonale. Cor pulmonale. A,A, A 50-year-old man with chronic airflow obstruction. Lungs are large in A 50-year-old man with chronic airflow obstruction. Lungs are large in volume, the diaphragm is flat, and vascular attenuation is evident at the right apex. These features suggest volume, the diaphragm is flat, and vascular attenuation is evident at the right apex. These features suggest emphysema, and this diagnosis was supported by a low carbon monoxide diffusion capacity. Lung emphysema, and this diagnosis was supported by a low carbon monoxide diffusion capacity. Lung “markings” are increased peripherally, particularly in the left midzone. “markings” are increased peripherally, particularly in the left midzone. B,B, The patient became chronically The patient became chronically hypoxic and, with respiratory infections, hypercapnic. One of these episodes was associated with cor hypoxic and, with respiratory infections, hypercapnic. One of these episodes was associated with cor pulmonale when the patient became edematous, and the heart and hilar and pulmonary parenchymal pulmonale when the patient became edematous, and the heart and hilar and pulmonary parenchymal vessels became enlarged. The emphysematous right upper zone shows fewer vascular markings and is vessels became enlarged. The emphysematous right upper zone shows fewer vascular markings and is relatively transradient. The diaphragm is less depressed and more curved than before. (From Hansell DM, relatively transradient. The diaphragm is less depressed and more curved than before. (From Hansell DM, Armstrong P, Lynch DA, McAdams HP, eds: Armstrong P, Lynch DA, McAdams HP, eds: Imaging of the diseases of the chest,Imaging of the diseases of the chest, ed 4, St Louis, 2005, ed 4, St Louis, 2005, Mosby.)Mosby.)


Global Initiative for Chronic

Obstructive

Lung

Disease

GOLD StandardsGOLD Standards(Excerpts)(Excerpts)


Components of Care: A COPD Management Program

The goals of COPD management include: Relieve symptoms Prevent disease progression Improve exercise tolerance Improve health status Prevent and treat complications Prevent and treat exacerbations Reduce mortality Prevent or minimize side effects from treatment


A COPD Management Program with Four Components

Assess and Monitor Disease Reduce Risk Factors Manage Stable COPD Manage Exacerbations


Component 1: Assess and Monitor Disease

Exposure to risk factors, including intensity and duration

Past medical history, including asthma, allergy, sinusitis or nasal polyps, respiratory infections in childhood, and other respiratory diseases

Family history of COPD or other chronic respiratory disease

Pattern of symptom development History of exacerbations or previous hospitalizations

for respiratory disorder.


Component 1: Assess and Monitor Disease (Cont’d)

Presence of comorbidities, such as obesity, heart disease, malignancies, osteoporosis, and musculoskeletal disorders, which may also contribute to restriction of activity.

Appropriateness of current medical treatments.


Component 1: Assess and Monitor Disease (Cont’d)

Impact of disease on patient’s life, including limitation of activity; missed work and economic impact; effect on family routines; and feelings of depression or anxiety.

Social and family support available to the patient. Possibilities for reducing risk factors, especially

smoking cessation.


Component 2: Reduce Risk Factors

Counseling to quit smoking Pharmacotherapy Smoking prevention Occupational exposures Indoor and outdoor air pollution


Table 11-2: Strategy to Help a Patient Quit Smoking, excerpts

Ask—Systematically identify all tobacco users at every visit.

Advise—Strongly urge all tobacco users to quit. Assess—Determine willingness to make a quit

attempt. Assist—Aid the patient in quitting. Arrange—Schedule follow-up contact.


Component 3: Manage Stable COPD, excerpts

Management of stable COPD should be guided by the following general principles:

Determine disease severity Implement a stepwise treatment plan that reflects

this assessment of disease severity Choose treatments according to national and

cultural preferences, the patient’s skills and preferences, and local availability of medications


Component 3: Manage Stable COPD excerpts (Cont’d)

Patient education


Component 3: Manage Stable COPD Table 11-3 excerpts

Pharmacologic treatments (Table 11-3 excerpts) β2-agnoists

Short-acting Fenoterol Levalbuterol Salbutamol Terbutaline


Component 3: Manage Stable COPD Table 11-3 excerpts (Cont’d)

Long-acting Formoterol Saleterol

Anticholinergics Short-acting

Ipratropium bromide Oxitropium bromide

Long-acting Tiotropium



Combination short-acting β2-agonists plus anticholinergic in one inhaler Fenoterol/Ipratropium Oxitropium bromide



Methylxanthines Aminophylline Theophylline



Inhaled glucocorticosteroids Beclomethasone Budesonide Flutcasone Triamcinolone



Combination long-acting β2-agonists plus glucocorticosteroids in one inhaler Formoterol/Budesonide Salmeterol/Fluticasone



Systemic glucocorticosteroids Prednisone Methyl-prednisolone


Component 3: Manage Stable COPD excerpts (Cont’d)

Glucocorticosteroids Vaccines Antibiotics Mucolytic Antitussives Non-pharmacologic treatment Rehabilitation Oxygen therapy Surgical treatment


Figure 11-10 Chronic obstructive lung disease (COPD) management.Figure 11-10 Chronic obstructive lung disease (COPD) management.


Component 4: Manage Exacerbation

Exacerbation of COPD is defined as an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal-day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD


Additional Treatment Considerations for Emphysema

Alpha1 antitrypsin therapy Lung volume reduction surgery Lung transplantation


Classroom DiscussionClassroom Discussion

Case Study 1: Chronic BronchitisCase Study 1: Chronic Bronchitis


Classroom DiscussionClassroom Discussion

Case Study 2: EmphysemaCase Study 2: Emphysema


Classroom Discussion

Case Study 3: COPD

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PART II