SYNDROMES of bronchial obstruction emphysema respiratory failure

SYNDROMES of bronchial obstruction, emphysema, respiratory failure

Syndrome of the bronchial obstruction is a complex of symptoms that develops due to limitation of air passing through narrowed airway or increasing of resistance against air flow during ventilation

CAUSES ORGANIC (cause the irreversible obstruction) – – endobronchial tumor foreign bodies exobronchial tumor compressed by an enlarged lymph nodes – compressed by an aneurysm of the aorta – compressed by an scars of bronchi FUNCTIONAL (cause the reversible obstruction) – bronchus smooth muscles contraction, – hyper- and dyscrinia, – oedema of bronchial mucous membrane

Diseases with bronchial obstruction bronchial asthma, COPD, pneumonia with obstructive syndrome, bronchiectasis, cystic fibrosis.

Symptoms of bronchial obstruction Shortness of breath – difficulty during expiration from light dyspnea to severe asthma attack. Cough is mostly dry, episodic, morning or nocturnal. Feeling of compression in a thorax Wheezes as a noisy whistling sound when breathing with difficulty

Wheezes Are caused by air passing through narrowed airways and heard at a distance from the patient. They are symptoms of – acute bronchial asthma, – asthma attack, – sometimes COPD

General inspection Position in bed : sitting upright and leans on the edge of the table or chair with hands for mobilizing accessory respiratory muscles. The skin. central cyanosis: – skin is blue and grey, – localization - face, neck, upper half of chest; – warm – Cyanosis ↓ after inhalations of oxygen during 5 -10 minutes.

Local inspection of the chest Static – Chest shape is normal – Symmetrical Dynamic – – Respiratory rate is normal or tachypnea Mixed type of breathing Rhythmical Both halves of the chest participate equally in the act of respiration – Participation of the accessory muscles in breath – Prolonged exhalation

Palpation of the chest Pleural points are painless elasticity↓ Vocal resonance is symmetrical, diminished Intercostals' intervals are moderate resistibility on the symmetrical areas of the chest

Percussion of the chest Tympanic lung sound The upper and lower border of the lung, the lung border mobility are not changed

AUSCULTATION Main sound - rough vesicular breathing with prolonged expiration. Adventitious sounds – different intensity diffuse wheezes.

Obstructive disorder Spirometry: Severity of obstruction: – FEV 1<80% from predicted Mild - 70%≤FEV 1<80% value Moderate -50%≤FEV 1<70% – ↓ PEF, FEF 25 -75% Severe - FEV 1<50% from predicted value. – FVC normal – FEV 1/FVC<70%,

Reversibility test Check FEV 1 or PEF in 15 min after inhalation 400 mcg of salbutamol ↑FEV 1 or/and ↑ PEF more then 12% and more then 200 ml from initial value – reversible obstruction

Sputum examination: mucous, white, clear with eosinophiles in microscopy. Pulse oximetry - O 2 saturation diminishes less than 90% if patient with obstruction has respiratory failure. X-ray examination – hyperinflation or evidence of localized abnormality simulating wheeze, e. g. adenoma. Fibreoptic bronchoscopy – its main use to exclude an obstructive airway tumor

SYNDROME of INCEASED AIRINESS of the LUNGS Emphysema - pathological condition of irreversible destruction of alveolar elastic fibres with enlargement of the airspaces distal to the terminal bronchioles and ventilation perfusion disorders

CAUSES There is primary (due to congenital α 1 -antitrypsin deficiency and other pathology of connective tissue) There is secondary: – COPD, – occupation (musician, glassblower), – senility.

SYMPTOMS Dyspnoe (shortness of breath) during inhalation. Patient notes decreased exercise tolerance Rare dry cough.

Local inspection of the chest Static – – Barrel (emphysemic) shape of chest symmetrycal The respiratory rate is normal or tachypnea The respiration can be rhythmical Dynamic – normal respiratory rate or tachypnea – rhythmical – Both halves of the chest participate equally in breathing – Participation of the accessory muscles

Palpation of the chest Painless pleural point Vocal resonance is diminished on the symmetrical areas of the chest Chest is rigid (resistence)

Percussion of the chest Comparative percussion: bandbox sound Topographic percussion: – lower borders of the lungs descend down – apexes of lungs lift up – There is dimension of lower lung border excursion.

AUSCULTATION Weakened vesicular breathing on the symmetrical areas of the chest of the case: – diminishing of elasticity of alveolar walls.

Instrumental methods Spirometry – mixed pattern of disorder: : – ↓ VC, ↓ FVC and ↓ FEV 1, ↓ PEF – Total lung capacity and residual volume ↑ X-ray examination – hyperinflated lung fields with attenuation of peripheral vasculature – “black lung sign”, flattened diaphragms, more horizontal ribs, may see bullae, especially in the lung apices.

SYNDROM OF RESPIRATORY FAILURE - It is a pathological state in the case of gas exchange is inadequate, resulting in hypoxia.

TYPES OF RESPIRATORY FAILURE Type I is defined as hypoxia (Pa. O 2<50 mm. Hg) with a normal or low Pa. CO 2. It is caused primarily by ventilation/perfusion mismated. Causes: – – – pneumonia pulmonary oedema pulmonary embolism asthma emphysema fibrosing alveolitis

TYPES OF RESPIRATORY FAILURE Type II is defined as hypoxia (Pa. O 2<50 mm. Hg) with hypercapnia (Pa. CO 2>45 mm. Hg). This is caused by alveolar hypoventilation, with or without ventilation/perfusion mismated. Causes: – Pulmonary diseases: asthma, COPD, pneumonia, pulmonary fibrosis, obstructive sleep apnoea; – Reduced respiratory drive: sedative drugs, central nervous system tumor, or trauma; – Neuromuscular diseases: cervical cord lesion, diaphragmatic paralysis, poliomyelitis, myasthenia gravis. – Thoracic wall diseases: flail chest, kyphoscoliosis

SYMPTOMS OF RESPIRATORY FAILURE Main complaint is dyspnea inspiratory conditioned hypoxia Secondary complaints – headache, palpitation conditioned hypercapnia

Visual examination General: – restlessness; agitation; confusion conditioned hypoxia – confusion, drowsiness, coma conditioned hypercapnia – diffuse cyanosis conditioned hypoxia, – tremor/flap conditioned hypercapnia. Local inspection: – tachypnea, – auxiliary muscles take part in breathing.

Investigation includes arterial blood gas analysis ↓ Pa. O 2 < 70 mm Hg (normal range of Pa. O 2 is 70 -100 mm Hg) ↑ Pa. CO 2 > 45 mm Hg (normal range of 35 -45 mm Hg), ↑ p. H > 7, 45 (normal range of 7, 35 -7, 40).

Pulse oximetry is a quick noninvasive estimation of O 2 saturation (Sp. O 2) of Hb in arterial blood Sp. O 2 normal range is 95 -99% If Sp. O 2 < 90% - patient needs oxygen therapy due to severe hypoxemia

Bronchial asthma Is a chronic inflammatory disease of the airways resulting in airflow obstruction secondary to airway edema, increased mucus production, bronchospasm and infiltration of the airway with leukocytes (eosinophils, lymphocytes and neutrophiles). It is usually reversible either spontaneously or with treatment. It may be allergic and non-allergic and genetic burden.

Triggers of bronchial asthma physical loading, viral infection, influencing of allergens, smoking, fluctuation of external temperature, strong emotional experiencing, action of chemical aerosols, taking some medicines.

Clinical presentation Episodic dyspnoea Wheezing Cough dry and nocturnal or morning or episodic as asthma attack equivalent Episodic chest tightness Signs of reversible bronchial obstructive syndrome

Classification of bronchial asthma I step – Intermittent symptoms rare than 1 a week and night symptoms less than 1 -2 a week (PEF, FEV 1> 80%) II step – mild persistent - symptoms rare than 1 a day and night symptoms less than 1 -2 a week (PEF, FEV 1> 80%) III step – moderate persistent – daily symptoms and night symptoms 1 a week (PEF, FEV 1 80 -60%) IV step – severe persistent – continua day symptoms and frequent night symptoms (PEF, FEV 1<60%)

Complications of bronchial asthma Severe exacerbation of bronchial asthma Acute and chronic cor pulmonale Secondary pulmonary hypertension Respiratory failure Spontaneous pneumothorax Emphysema of lungs

Chronic obstructive pulmonary disease (COPD) a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

Risk factors smoking, occupational dust and chemicals, air pollution, chronic recurrent respiratory infections, hereditary α-1 antitrypsin deficiency

Syndromes of COPD Bronchial obstruction Emphysema Respiratory failure

Symptoms of COPD Cough is productive or dry, slowly progressive dyspnoe with difficulty during expiration, wheeze, decreased exercise tolerance.

SYNDROM OF BRONCIAL OBSTRUCTION-“Blue bloaters” Auscultation: weakened rigided vesicular breathing with prolonged expiration, wheeze. Spirometry: FEV 1, FEV 1/FCV, PEF, FEF 25 -75% is reduced less than 80% for FEV 1, PEF 70% for FEV 1/FCV, and 60% for FEF 25 -75% from predicted value. Reversibility test is performed for patient with obstruction and allow to establish level of its reversibility. Obstruction is reversible if diminished index of spirograme (FEV 1, PEF) increase to 12% from initial value.

SYNDROM OF INCEASED AIRINESS OF LUNGS – Pink puffers” Static examination: the form of the chest – emphysemic Palpation of the chest: Resistance of the intercostal spaces is decreased on the symmetrical areas of the chest, vocal resonance is diminished on the symmetrical areas of the chest, chest not elastic - tightness (rigid) Percussion of the chest: comparative percussion: low tympanic due to increased filling with air and decreased elastic tension of the lung tissue (bandbox). Topographic percussion: lower borders of the lungs descend down, apexes of lungs lift up, there is dimension of lower lung border excursion. Auscultation: weakened vesicular breathing on the symmetrical areas of the chest

SYNDROM OF INCEASED AIRINESS OF LUNGS - “Pink puffers” Spirometry – mixed pattern of disorder: reduced VC, FVC and total lung capacity and residual volume are increased. X-ray examination – hyperinflated lung fields with attenuation of peripheral vasculature – “black lung sign”, flattened diaphragms