Pulmonary Diseases

1. Pulmonary Diseases

2. Pulmonary Diseases & Disorders • Pulmonary Disease & Conditions may result from: • Infectious causes • Non-Infectious causes • Adversely affect one or more of the following • Ventilation • Diffusion • Perfusion

3. Pulmonary Diseases & Disorders • The Respiratory Emergency may stem from dysfunction or disease of (examples only): • Control System • Hyperventilation • Central Respiratory Depression • CVA • Thoracic Bellows • Chest/Diaphragm Trauma • Pickwickian Syndrome • Guillian-Barre Syndrome • Myasthenia Gravis • COPD

4. Pulmonary Diseases & Disorders • The Respiratory Emergency may affect the upper or lower airways • Upper Airway Obstruction • Tongue • Foreign Body Aspiration • Angioneurotic Edema • Maxillofacial, Larnygotracheal Trauma • Croup • Epiglottitis

5. Respiratory Emergencies: Causes • Lower Airway Obstruction • Emphysema • Chronic Bronchitis • Asthma • Cystic Fibrosis

6. Pulmonary Diseases & Disorders • The Respiratory Emergency may stem from Gas Exchange Surface Abnormalities • Cardiogenic Pulmonary Edema • Non-cardiogenic Pulmonary Edema • Pneumonia • Toxic Gas Inhalation • Pulmonary Embolism • Drowning

7. Pulmonary Diseases & Disorders Problems with the Gas Exchange Surface

8. Pulmonary Edema

9. Pulmonary Edema: Pathophysiology A pathophysiologic condition, not a disease Fluid in and around alveoli Interferes with gas exchange Increases work of breathing Two Types Cardiogenic (high pressure) Non-Cardiogenic (high permeability)

10. Pulmonary Edema • High Pressure (cardiogenic) • AMI • Chronic HTN • Myocarditis • High Permeability (non-cardiogenic) • Poor perfusion, Shock, Hypoxemia • High Altitude, Drowning • Inhalation of pulmonary irritants

11. Cardiogenic Pulmonary Edema: Etiology Left ventricular failure Valvular heart disease Stenosis Insufficiency Hypertensive crisis (high afterload) Volume overload Increased Pressure in Pulmonary Vascular Bed

12. Pulmonary Edema • High Permeability • Disrupted alveolar-capillary membrane • Membrane allows fluid to leak into the interstitial space • Widened interstitial space impairs diffusion

13. Non-Cardiogenic Pulmonary Edema: Etiology Toxic inhalation Near drowning Liver disease Nutritional deficiencies Lymphomas High altitude pulmonary edema Adult respiratory distress syndrome Increased Permeability of Alveolar-Capillary Walls

14. Pulmonary Edema: Signs &Symptoms Dyspnea on exertion Paroxysmal nocturnal dyspnea Orthopnea Noisy, labored breathing Restlessness, anxiety Productive cough (frothy sputum) Rales, wheezing Tachypnea Tachycardia

15. Management of Non-Cardiogenic Pulmonary Edema • Position • Oxygen • PPV / Intubation • CPAP • PEEP • IV Access; Minimal fluid administration • Treat the underlying cause • Diuretics usually not helpful; May be harmful • Transport

16. Adult Respiratory Distress Syndrome AKA: Non-cardiogenic pulmonary edema A complication of: Severe Trauma / Shock Severe infection / Sepsis Bypass Surgery Multiple blood transfusions Drug overdose Aspiration Decreased compliance Hypoxemia

17. Pneumonia

18. Pneumonia • Fifth leading cause of death in US/Canada • Group of Specific infections • Risk factors • Cigarette smoking • Exposure to cold • Extremes of age • young • old

19. Pneumonia • Inflammation of the bronchioles and alveoli • Products of inflammation (secretions, pus) add to respiration difficulty • Gas exchange is impaired • Work of breathing increases • May lead to • Atelectasis • Sepsis • VQ Mismatch • Hypoxemia

20. Pneumonia: Etiology Viral Bacterial Fungi Protozoa (pneumocystis) Aspiration

21. Presentation of Pneumonia • Shortness of breath, Dyspnea • Fever, chills • Pleuritic Chest Pain, Tachycardia • Cough • Green/brown sputum • May have crackles, rhonchi or wheezing in peripheral lung fields • Consolidation • Egophony

22. Management of Pneumonia • Treatment mostly based upon symptoms • Oxygen • Rarely is intubation required • IV Access & Rehydration • B2 agonists may be useful • Antibiotics (e.g. Rocephin) • Antipyretics

23. Pneumonia: Management MD follow-up for labs, cultures & Rx Transport considerations Elderly have significant co-morbidity Young have difficulty with oral medications ED vs PMD office/clinic Transport in position of comfort Would an anticholinergic like Atrovent be useful in managing pneumonia?

24. Pulmonary Embolism

25. Pulmonary Embolism • ~ 50,000 deaths / year/ US • ~5% of all sudden deaths • <10% of all PE result in death

26. Pulmonary Embolism: Pathophysiology Something moving with flow of blood passes through right heart into pulmonary circulation It reaches an area too narrow to pass through and lodges there Part of pulmonary circulation is blocked Blood: Does not pass alveoli Does not exchange gases

27. Pulmonary Embolism (PE) • A disorder of perfusion • Combination of factors increase probability of occurrence • Hypercoagulability • Platelet aggregation • Deep vein stasis • Embolus usually originates in lower extremities or pelvis

28. Pulmonary Embolism (PE) • Risk factors • Venostasis or DVT • Recent surgery or trauma • Long bone fractures (lower) • Oral contraceptives • Pregnancy • Smoking • Cancer

29. Pulmonary Embolism: Etiology Most Common Cause = Blood Clots Vessel Wall Injury Virchow’sTriad Hypercoagulability Venous Stasis

30. Other causes Air Amniotic fluid Fat particles (long bone fracture) Particulates from substance abuse Venous catheter Pulmonary Embolism: Etiology

31. Pulmonary Embolism: Signs & Symptoms Small Emboli Rapid Onset Dyspnea Tachycardia Tachypnea Fever Episodic = Showers Evidence or history of thrombophlebitis Consider early when no other cardiorespiratory diagnosis fits

32. Larger Emboli Small Emboli S/S plus: Pleuritic pain Pleural rub Coughing Wheezing Hemoptysis (rare) Pulmonary Embolism: Signs & Symptoms

33. Very Large Emboli Preceded by S/S of Small & Larger Emboli plus: Central chest pain Distended neck veins Acute right heart failure Shock Cardiac arrest Pulmonary Embolism: Signs & Symptoms

34. Pulmonary Embolism: Signs & Symptoms There are NO assessment findings specific to pulmonary embolism

35. Management based on severity of Sx/Sx Airway & Breathing High concentration O2 Consider assisting ventilations Early Intubation Circulation IV, 2 lg bore sites Fluid bolus then TKO; Titrate to BP ~ 90 mm Hg Monitor ECG Rapid transport Pulmonary Embolism: Management

36. PE Management • Thrombolytics • Aspirin & Heparin (questionable if any benefit) • Rapid transport to appropriate facility • Embolectomy or thrombolytics at hospital (rarely effective in severe cases due to time delay) • Poor prognosis when cardiac arrest follows

37. If the patient is alive when you get to them, that embolus isn’t going to kill them. Pulmonary Embolism But the next one they throw might!

38. Pleurisy • Inflammation of pleura caused by a friction rub • layers of pleura rubbing together • Commonly associated with other respiratory disease

39. Presentation of Pleurisy • Sharp, sudden and intermittent chest pain with related dyspnea • Possibly referred to shoulder • May  or  with respiration • Pleural “friction rub” may be audible” • May have effusion or be dry

40. Pleurisy • Management • Based upon severity of presentation • Mostly supportive

41. Pulmonary Diseases & Disorders Problems with Airway Obstructions

42. Obstructive Airway Diseases

43. Obstructive Airway Disease • Asthma • Emphysema • Chronic Bronchitis

44. Obstructive Airway Diseases • Asthma experienced by ~ 4 - 5 % of Canadian population • Mortality rate increasing • Factors leading to Obstructive Airway Diseases • Smoking • Exposure to environmental agents • Genetic predisposition • How does this differ from “COPD”?

45. Obstructive Airway Disease • Exacerbation Factors • Intrinsic • Stress (especially in adults) • URI • Exercise • Extrinsic • Cigarette Smoke • Allergens • Drugs • Occupational hazards

46. Obstructive Airway Disease • General Pathophysiology • Specific pathophysiology varies by disease • Obstruction in bronchioles • Smooth muscle spasm (beta) • Mucous accumulation • Inflammation • Obstruction may be reversible or irreversible

47. Obstructive Airway Disease • General Pathophysiology • Obstruction results in air trapping • Bronchioles usually dilate on inspiration • Dilation allows air to enter even in presence of “obstruction” • Bronchioles tend to constrict on expiration • Air becomes trapped distal to obstruction

48. Lower Airway Disease

49. Chronic Obstructive Pulmonary Disease Emphysema Chronic Bronchitis (Rarely Asthma may result in COPD)

50. COPD: Epidemiology • Most common chronic lung disease • 4th leading cause of death • many deaths annually