Pulmonary Disease

hello and welcome to part 2 of our pulmonary discussion and this section we're going to talk about pulmonary disease so what specifically is happening with the pathophysiology and what that means to your patient some of the major classifications of diseases that are caused by a pulmonary problem include hypercapnia so hypercapnia is a very high carbon monoxide level so we have a high co2 level this is caused by a problem with ventilation whereas hypoxemia is a condition that occurs because the patient's not getting enough oxygen into the tissue so separate problems here we have a problem with oxygenation versus a problem with our co2 now these are also caused by different etiology hypercapnia a problem with a high co2 is caused by a lack of ventilation where as opposed to hypoxia is caused by the patient having poor perfusion so you see there's a difference here there's a difference between hypercapnia that's ventilation and hypoxia that's going to be a perfusion problem just to differentiate here when we talk about hypoxia and hypoxemia hypoxia means without oxygen doesn't say where it is it could be without oxygen in the alveoli could be without oxygen at the tissue level hypoxemia means a lack of oxygen in the blood so what happens with many of our patients that causes either hypercapnia hypoxemia is acute respiratory failure now acute respiratory failure is simply a clinical observation the patient stopped breathing look at what the words say acute respiratory failure that means we have failure to have respiration in other words the patient's not breathing why that's the thing you want to be able to ask yourself is why did this occur so that we can find out what's going on to that patient and treat it appropriately pulmonary edema is another common condition and this is going to be caused by having excessive fluid in the lungs so one of the situations that was talked about here on the first slide was this ventilation/perfusion mismatch and that's what this diagram is illustrating so let's start up in the very top left corner where it says normal VQ remember VQ is an abbreviation for a ventilation and Q is for perfusion I don't know why it's not VP but we use Q as an abbreviation for perfusion so when you take a look at the upper left-hand corner we have normal ventilation air is moving in and out of the airway and into the alveolus and we have a normal perfusion you see the perfusion around the alveoli in the vasculature move over to the right and you see we have a low vq ventilation - perfusion ratio now you see what's happened is we have impaired ventilation our perfusion remains the same there's nothing wrong with the vasculature the problem in this case is impaired ventilation we have a narrowed airway so maybe the patient's got secretions in the airway maybe this patient has got asthma but we have a narrowed airway which is limiting the amount of oxygen that's getting down to the tissues and that's going to lead to a low ventilation perfusion ratio and to lead to hypoxia okay now notice over on the left lower we have completely blocked ventilation in a collapsed alveolus now we have a very low ventilation perfusion ratio and again hypoxemia will be even more pronounced over in the bottom right hand corner now we have a decrease in perfusion so we have impaired perfusion this could be caused by a pulmonary embolus for example that's decreasing the amount of circulation getting to the alveolus and the end result will still be the same even though ventilation is okay so air is moving in and out of the lungs you see there's no problem in the Airways no problem in the alveolus but there's not as much perfusion around that right alveolus which then is going to lead to hypoxia as well so all of these conditions where there's altered ventilation perfusion lead to hypoxemia forming another of the conditions that was mentioned in our previous slide was pulmonary edema pulmonary edema occurs when we have edema fluid accumulating in the pulmonary system so we have an excess of water and along it's an imbalance between our capillary hydrostatic pressure so this could be caused by having a heart problem where there's too much pressure in the pulmonary vasculature pushing fluid out into the pulmonary system it could also be caused by capillary oncotic pressure capillary oncotic pressure is the difference between the amount of pull we have from the tissues and the amount of pull we have from in the vasculature this is related to solutes versus fluid in the blood so if we have more solutes outside the vasculature it's going to pull fluid out of the masculine air and into the tissues next would be capillary permeability capillary permeability can cause pulmonary edema as well this happens in conditions such as sepsis a loss of surfactant is also going to lead the pulmonary edema and lead to collapse of alveoli leading to a atelectasis most common cause are going to be heart disease ard as toxic injuries so a lot of different things here that could possibly cause patients to develop pulmonary edema what we always want to be looking for in pulmonary edema is asking the question is this fluid that has leaked out so as a serous fluid or is what we're hearing when we see this is that this just secretions that are building up in the alveoli so we'll talk a little bit about how to differentiate those when we talk about the specific problems what kind of symptoms you're going to see in this patient would include dyspnea hypoxia and increased work of breathing so this is a graphic illustration of what we just talked about there we have the different functions that can cause a patient to develop pulmonary edema so starting over on the left hand side over there we have valvular dysfunction some kind of heart problems occurring that's going to cause increased left atrial pressure and it's going to cause too much pressure in the pulmonary capillary bed increasing our hydrostatic pressure and pushing fluid out of the pulmonary capillaries and into the lung tissue we can also have an injury to the capillary endothelium that's in the middle where we have increased capillary permeability now again there's a couple times that this frequently happens in the long Nets with a RDS and with sepsis so we have a movement of fluid and plasma proteins from the capillary out into the interstitial space and that will fill the alveolus and we have pulmonary edema lastly over on the right hand side we can have blockage of our lymphatics which is going to decrease the ability of the lung to be able to remove excess fluid from the interstitial space and that will also build up fluid and cause pulmonary edema pulmonary disease or injury can cause the patient to develop a number of different complications such as aspiration aspiration could be the original thing is causing the pulmonary injury as well but aspiration can be secondary to pulmonary injury on the other hand as well the right lung is more susceptible remember when we looked at the anatomy and physiology we said hey that right bronchus is straighter and shorter than the left one and that leaves the right lung more susceptible to aspiration because if the patient vomits and aspirates particles into the lung well the shorter straighter bronchi is more likely to get the aspirate atelectasis is caused by alveoli that are collapsing alveoli can collapse just because they're not being used for very much like for example a patient in the hospital is not getting up and walking and things like that that patient can develop atelectasis bronchiectasis is an abnormal dilation of the bronchi that can be caused by a variety of different pulmonary conditions atelectasis is a rather common situation that we see in patients in the hospital and it's collapse of certain parts of the lung tissue so there can be two different types of atelectasis that's caused and your patient could be compression which means there's some kind of external pressure on the lung that's causing this to occur so let's say the patient has a pneumothorax the pneumothorax air is pressing in on that area of the lung compressing the lung tissue and then causing the alveoli to collapse the second kind which is the kind that we see far more often is going to be the absorption kind and this happens when we have the removal of air from obstructed or hypo ventilated alveoli and you know basically just someone who's not getting up out of bed at Jude maybe after surgery and things like that the patient's laying in bed and they're not taking deep breaths so what happens is that the alveoli collapse because they're not being expanded and the patient develops atelectasis you some other pulmonary conditions that are of note include bronchiectasis we talked about that before occurs with other diseases and it's caused or the problem that occurs is we have problems with our bronchi we can also have bronchiolitis which is an obstruction I'm sorry an inflammation and possibly obstruction of small Airways kind of like a chronic bronchitis issue that occurs one particular type is called Bo Opie which is a B obliterans bronchiolitis late-stage fibrotic disease can have this occur and what happens is we have a lot of fibrotic damage occurring to the lung so the most often time that I have seen this in my experience both booop and with bronchiolitis is going to be in patients who have long term chronic fibrotic disease of the lungs so patients with cystic fibrosis and things like that abscess formation can occur with pulmonary disease and can pulmonary fibrosis if you recall from our anatomy and physiology the pleura is on the outside of the lung and there's a little space between the pleura and the chest wall called the pleural space that is filled with just a little bit of fluid and that fluid keeps the lung from rubbing up against the chest wall however we can have some problems occur in that pleural space so we can have more fluid accumulating there than should be in there so maybe some edema has formed in that area that's called a pleural effusion if that pleural effusion becomes infected we call it an empyema so in an empyema we have infected pleural effusion fluid we can have a pneumothorax which is the presence of air in the pleural space we can have a hemothorax which is the presence of blood in the pleural space we can have an open pneumothorax which means there's a hole to the outside of the body and we can have a tension pneumothorax where air is starting to build up in the chest wall compressing the lung the heart and maybe even the lung on the opposite side in addition we can have problems with the pleura including chest wall restrictions where we have deformity and maybe for example something like a flail chest that's causing a restriction of our ability to be able to have respiration you some additional definitions of pneumothorax are included here including our open pneumothorax which again means that we have a hole through the chest wall so air is coming in from the outside a tension pneumothorax which means we have air building up pressure building up inside the thorax now when we didn't talk about yet is called a spontaneous pneumothorax in a spontaneous pneumothorax as the name implies it happens spontaneously which means that the patient may be just relaxing on the couch watching TV and put the patient develops pneumothorax okay this happens because there's a little blab or an outpouching on the outside of the lung that bursts it's like a little bubble on the outside of the lung that bursts and causes air to leak into the pleural space so that's a spontaneous pneumothorax spontaneous pneumothoraces will often reoccur so we do have to be careful about them for that reason is that they will often reoccur in our patients for example one patient we had came in she was an 18 year old patient and she was just watching TV with her boyfriend and suddenly developed chest pains shortness of breath she went into the emergency department they found out she had a spontaneous pneumothorax and they had to put a chest tube in a chest tube goes into the pleural space and then allows us to connect up a suction device that will pull that air out of the pleural space but she was just sitting there watching TV not doing anything she didn't have any trauma and it just spontaneously burst this diagram is illustrating a couple different types of pneumothoraces if we started looking at the lung that's pictured on the right side of your screen and you notice the little arrow of air coming out of the lungs air is coming out of the lung going into the pleural space that would be a simple pneumothorax however look at the arrow up toward the top and through the chest wall if we have air entering from outside the patient's body that would be considered an open pneumothorax where air is entering from outside of the body so when you're hearing definitions like open pneumothorax open fracture we need to be thinking about an opening to the outside of the body well we need to get this air out of that patients pleural space and the way they do it as they instill a chest tube so the surgeon will come in and put a chest tube into the patient the chest tube goes between the ribs and into the pleural space so it's actually rather invasive we're going down into the pleural space here with this big tube and that tube is then connected to a suction device so that air will leave the pleural space and re-expand the lung as a result of trauma a patient can develop what's called a flail chest with a flannel chest we have multiple rib fractures occurring so we have two or more ribs that are fractured in two or more places this leads to having an area of the chest wall that is no longer connected to the ribs around it in other words a flail segment of the chest this free-floating section of the ribs and of the chest wall will move paradoxically with the patient's breaths so as the patient breathes in it sucks in as the patient breathes out it pushes out so this diagram illustrates an A and B what our normal respiration would look like so the chest wall expands and it sucks air into the lungs that's a in B the lung the chest wall is becoming smaller the diaphragm is going back up into its more relaxed position okay more of a curved relaxed position and pushing air out of the lungs now look what happens in C here we have a flail segment so there's a segment of ribs that are no longer connected on the right-hand side of the picture so there's a segment of ribs that are no longer connected now when the patient inhales it not only sucks air in from outside but it's sucking air from the bad lung over to the good lung and as the patient exhales it sucked it pushes air not only out but also back to the bad lung and pushes that part of the chest wall out so what we're going to do with this to try to be able to deal with it is we're just going to put some tape over that loose segment of the chest wall to keep the chest wall from moving paradoxically so that the patient can oxygenate better along the same lines there if the chest wall is restricted in any way that can also lead to the patient having problems moving air in and out which could lead to hypoxemia and hypercapnia some of the reasons some of the causes for a patient having chest wall restriction include trauma to the ribs to the muscles a skeletal deformity you know when you have patients who have that barrel chest from COPD they have a skeletal deformity of the chest wall and that can lead to having some chest wall restrictions obesity and neuromuscular diseases compromise chest wall maybe the patient's got a flail chest or some other condition going on so what will happen with any kind of chest wall restriction is will get ventilatory impairment which will increase the work of breathing impair our gas exchange cause dystiny a hypoventilation secretions will start to form because we're getting irritation inflammation long and then hypoxia will then to start to present bronchiolitis is a condition where we have inflammation of the small Airways very common in children could be caused by having a viral infection in children it can occur in adults usually in adults who have chronic bronchitis which is part of our whole COPD mechanism it usually associated with viral infections but can also be associated with inhalation of toxic gases in late-stage fibrotic diseases such as cystic fibrosis we can see bronchiolitis obliterans and i mentioned that earlier this can also happen in late stages of bronchiolitis another couple conditions that I mentioned briefly earlier was abscess formation and cavitation that it can occur in pulmonary disease an abscess is going to be a welling caption alized area that we have fluid that has accumulated now typically we don't call it an abscess until that fluid becomes disturbed in some way maybe it has a lot of white blood cells in it maybe it contains bacteria and bacterial toxins so it may be infected we can have a consolidation consolidation means we have an area of the lung that has become kind of solid usually this is the result of having an inflammatory response and then the flu building up in the lung such as fluid that looks like pus Pasic alee we can have cavitations occurring this occurs in certain types of cancers where we actually have destruction of the lung tissue it becomes necrotic and we have like a hole dug out of the lung where that necrotic area has formed pulmonary fibrosis occurs in people who have situations where they would have an increased amount of connective tissue in other words fibrous tissue it's occurring in a lung and one of the common times are one of the commonly the times when people are probably familiar with is cystic fibrosis and as was mentioned earlier chest wall restrictions and flail chest can also lead the patient to developing problems with their pulmonary disease pulmonary disease can be associated with or even caused by having inhalation disorders so we have an exposure to toxic gases remember these gases are going in the lung so you know we got to breathe our body's telling us breathe breathe breathe and as you breathe in you're breathing in these toxic gases and they can be causing damage to the lung now these things that we're talking about here are things that happen over a long period of time so when we're talking about developing some irritation inflammation - damage to the lung as a result of inhaling silica or asbestos or coal we're talking about conditions that occur over a long period of time and eventually end up looking like COPD we can also have an allergic alveoli tiss where the patient has an allergy a hypersensitivity that causes the alveoli to become inflamed as well so let's talk a little bit about specific pulmonary disorders and what they're going to look like in your patient so one that's very common that we see often in patients in the hospital is called a RDS which is acute respiratory distress syndrome maybe you've already heard of this from some previous experience that you've had what happens in a RDS is we have an overwhelming out-of-control inflammatory response of the lung we have malignant inflammation of the lung we have malignant inflammation of the lungs happen with inflammation we get vasodilation capillary permeability and clotting think about that stuff happening in the lung vasodilation well that might be a good thing we get more perfusion of long but capillary permeability oh that's not going to be good remember capillary permeability can cause edema formation and when we get edema that's caused by capillary permeability that edema can be thick and can include things like proteins and cells and all that kind of stuff so that could be a real bad situation all right that's not good and then the third part was clotting remember so we get clotting occurring clotting is going to cause millions of tiny little pulmonary emboli in along coupled up with that edema that's forming we're going to get a lot of lung destruction occurring here as a result of having a RDS so symptom wise we could anticipate the patient's going to develop initially hyperventilation with respiratory alkalosis now that's an initial early sign the patient's breathing faster at this point in time we don't have the edema formation you don't have a lot of symptoms so it doesn't make a lot of sense you're looking at this thinking hmm I wonder what's going on at this patient that the patient is breathing so fast and having the respiratory alkalosis we can also have dyspnea and hypoxemia occurring as the disease progresses and as the alveoli become more affected we're not going to be able to get oxygen across that alveolar capillary membrane and the patient will develop hypoxemia the body's response to hypoxemia is to cause the patient to breathe faster therefore we get dissed Miam eventually we will develop a metabolic acidosis this is related to some of the changes that are occurring out in the tissue as a result of hypoxemia initially though we'll get a respiratory acidosis that's caused by the direct lung injury itself further hypoxemia more hypotension decreased cardiac output and death can result from a RDS so how on earth are we going to know that this patient could have a RDS well we look at the physical examination remember we're looking for somebody who's going to be developing that capillary permeability and clotting in the lung and we're going to be looking for the risk factors that could cause a RDS anything that causes systemic inflammation such as sepsis or any other kind of trauma or infection that's occurring in the body that could be causing an overwhelming inflammation in the lung so we look for a physical examination we can check our blood gases to look for either that early sign which is respiratory alkalosis or the later sign which is respiratory acidosis followed by metabolic acidosis and then we're going to give the patient's supportive therapy there's no real treatment for I already asked we just have to support the patient long enough until the body recovers on it own so this slide here is showing some of the different mechanisms that are occurring in ard asks we have that indirect or direct lung injury going down the left side is causing the injury to the alveolus and damaging some of the cells decreasing surfactant atelectasis starts to form and then we're going to end up with respiratory failure over in the middle we have capillary endothelial injury which causes capillary permeability and more fluid forming in the lung because of first of all a release of inflammatory cytokines we get vasoconstriction in the lung which will further worsen the hypoxemia we have now the lungs response to hypoxia is to cause vasoconstriction as well so all this vasoconstriction is really going to cause problems for the patient's oxygenation way over on the far right side it talks about releasing our growth factors and this is what's going to cause a chronic pulmonary insufficiency at least the possibility which in a patient with acute lung injury or a RDS in our surgical patients we can have a post-operative respiratory failure and this occurs as a result of at elective system anja possibly pulmonary edema or pulmonary emboli atelectasis can occur because during surgery the patient is not taking deep breaths if they're on a ventilator the ventilator doesn't give them deep breaths it just helps them to ventilate normally so this is why it's so important after the patient's had surgery to have them do the deep breathing pneumonia can occur - as a result of not having the deep breaths and secretions starting to form in the lungs so again we want to have that deep breathing we want to do some free turning and early ambulation so that we're moving the patient around that's going to help to mobilize secretions pulmonary edema could form so we want to be careful if patient has heart failure or any kind of cardiac condition and pulmonary emboli so this is why again it's important to get the patient up and ambulating get them moving so that we're able to prevent those blood clots from forming into legs so our prevention strategies now these things that are listed here are called pulmonary hygiene so you may see this in other documents that you get somewhere along your nursing career and listed as being pulmonary hygiene frequent turning deep breathing early ambulation air humidification and incentive spirometry you so as you may have imagined by looking at the previous slide asthma has this allergic basis to it yeah it's an inflammatory condition that occurs in the Airways but it's caused by an underlying at allergy that's occurring in the patient so this underlying allergy is what's stimulating the patient to develop this hyperactivity of the Airways now the patient doesn't have to come in contact with an allergen to have an asthma attack this patient may be just inhaling you know a perfume or something like that and have an asthma attack okay it doesn't mean they're allergic to perfume it just means that that particular thing now when they're inhaling it happen to cause irritation to already irritated bronchi and cause them to have an asthma attack in asthma we get wheezing dis Mia and tachypnea so wheezing usually starts on expiration first remember the chest wall including the Airways are smaller during expiration and bigger during inspiration how we can try to assess the patient who has asthma is using a peak flow meter this will help us to be able to determine how much air the patient is able to move in and out we can give the patient oral corticosteroids and inhaled beta-agonists and anti-inflammatories in order to try to control their asthma so again a lot of stuff going on here when a patient has an asthma attack you can see all the different immune mediators and allergic mediators that are going to town here in the early asthmatic response there can also be what's called a late asthmatic response as well so the person comes in contact with the allergen and then eight hours later 24 hours later has an allergic as a asthmatic response so that's not necessarily always going to happen right at the time but it could happen much later with these late asthmatic response as well don't get real involved in looking at all the details of this just understand that there is a both/and allergic and an inflammatory processes going on here in asthma and we can have both an early and/or a late response in our patient now I want to be clear about differentiating COPD chronic obstructive pulmonary disease from asthma COPD is a different condition this is a chronic inflammatory condition caused by inhaling irritants over a long period of time in chronic bronchitis the patient has chronic mucus production and this is defined as having a chronic productive cough to last for at least three months of the year and for at least two consecutive years so you get pneumonia one year or bronchitis one year and you're coughing for three months that does not mean you have chronic bronchitis now if that happens two years in a row then they might start to analyze they might start to I do some studies to try and find out if you have chronic bronchitis but that's the underlying definition here of what it takes in order to be able to say hey this person's got chronic bronchitis what happens is that we have inhaled irritants for example cigarette smoke that increases mucus production and the size of the number of mucus glands producing more mucus and lung the mucus is thicker than normal which causes problems in getting it back out of the lung so we're going to have to probably use bronchodilators expectorants expectorant sour medications that draw fluid into that mucus to make it thinner so hopefully it will mobilize better and chest physical therapy may be used to treat chest physical therapy is using vibration and percussion in order to break up those secretions so they will mobilize upward this is an interesting picture of what happens when air is moving past secretions that happen to be forming in those small alveolar ducts so you see here we have just a little mucus plug occurring here and we have air moving in and out of the one on the left not great but then during expiration you see because again during inspiration they always get bigger during expiration the Airways get smaller so they get smaller with the picture on the right and then that mucus plug there is starting to block the airway and the air is getting trapped in the alveolus now this is what happens in patients with COPD that causes them to have these big hyper expanded lungs COPD contains another possible diagnosis including emphysema so COPD is kind of our general heading chronic obstructive pulmonary disease for problems chronic arms that are occurring to the lung as a result of having chronic inflammation and irritation one so one of those would be chronic bronchitis where we have too much mucus production the second one would be emphysema where we have the permanent damage occurring to the lung permanent damage occurring to the lung as a result of this chronic inflammation so these are just a couple slides here showing you alveoli we have the nice little round alveoli then we have the really big distended ones there that are occurring in patients who have emphysema so to help differentiate here a little bit more we have this diagram where the patient is let's say smoking for example or maybe there's air pollution in the air and that's causing inflammation of the Airways this then starts to cause a couple different problems occurring in the lung continuous bronchial irritation and inflammation which causes bronchitis chronic bronchitis and increased protease activity which starts to cause the destruction of elastin elastin is part of our connective tissue and along which then leads to destruction along tissue we get the overinflation of the lungs and that's emphysema both of these things together or separately the patient may only be diagnosed with emphysema but may also have mucous production a patient may be diagnosed with chronic bronchitis but also have long destruction so these things go hand-in-hand and together they cause airway obstruction and air trapping loss of surface area in the lung for gas exchange which means that we're going to have hypoxemia and hypercapnia we can also develop a cough dyspnea and cor pulmonale which is another name for right-sided heart failure pneumonia is a condition that occurs when we have an infection of the lung here are some common different types of pneumonia that we can see in patients but one of the things that often occurs is that we have a community acquired pneumonia somebody comes into the hospital and they say hey I've gotta pneumonia they're admitted from the emergency department with pneumonia that's community-acquired pneumonia they got it out there in the community got it home now somebody else can also be in the hospital they had surgery and now they developed pneumonia that's a hospital-acquired pneumonia we want to be careful with those because a hospital-acquired pneumonia is something we gave to them so we want to be sure that we are doing good hand-washing and so on so that our patients are not developing pneumonia in the hospital you we talked in another section about necrosis and maybe you recall from them from that section that caseous necrosis is one of the conditions that can happen with tuberculosis so tuberculosis is a bacterial infection of the lung and it's going to be airborne transmission and hopefully we're trying to control this in our communities in the United States we're trying to keep this down however there has been a little bit of a recurrence of TB that has been kind of floating around and that's probably because people have not been getting tested and we're not treating it appropriately to to keep it out of the population so take a few moments here and look at all the signs and symptoms you may see with tuberculosis but we get that progressive fatigue the malaise the anorexia weight loss the main thing is just this chronic productive cough so chronic cough cough cough cough cough oftentimes with some blood in the cough may be a low-grade temperature maybe some chest pain but that's basically what we see is that cough cough cough and then the patient comes in to have the chest x-ray we say oh wow look there's TB on the chest x-ray unfortunately the treatment for tuberculosis is not fun it lasts from 6 to 12 months this is a difficult infection to get rid of so the patient's going to be on antibiotics and oftentimes these antibiotics are kind of difficult on the liver for example and can lead to other kinds of social restrictions on the patient while the patient's taking the antibiotic well cute bronchitis can happen to an acute bronchitis the patient has an infection or inflammation in the Airways or bronchi so in the wintertime and cold climates while you see a lot of bronchitis because the patient is inhaling or maybe the patient had a viral illness and they had an upper respiratory tract infection and now this is just kind of settled on down into the bronchi you know you sleep at night and when you're sleeping oftentimes drainage from the sinuses will go down it gets down in the trachea goes down on the bronchi and can set up shop there as an infection so acute bronchitis you're going to see similar kind of symptoms that we see with pneumonia where the patient is going to have maybe some chest pain coughing especially with a productive cough maybe a little bit of a low-grade or maybe a little bit of a fever with this you know and that's the kind of symptoms we typically see so usually it's going to be treated with an antibiotic you so this may describe it a little bit better for you here we have one of those conditions occurring venous stasis vassal injury or we have hypercoagulability which is causing you thrombus to form the thrombus dislodges it breaks free goes back through the central circulation back to the pulmonary circulation and causes occlusion this leads to all of the symptoms that we see associated with a pulmonary embolisms you might want to pause the video here for a moment so you can take a look at the symptoms that are caused by RPE and in more of a goofy way this shows the symptoms that are caused by a PE so we have patient here and have the risk factors listed down there at the bottom in mobility obesity and deep vein thrombosis is DBT post-operative patients you know so a lot of our different types of things are listed there now over on the right hand side at the sill in that same box it talks about our venous stasis our end until your injury and alterations and coagulation so then you see we have that clot going back up through the venous pathway getting stuck in the lung some of the treatments we may use would be thrombolytic therapy some of the symptoms we may see include tachypnea hypoxemia dis mia tachycardia maybe even hemoptysis where we have blood in the sputum and in our blood gasses anticipate seeing a low co2 at least initially a low po2 and an increase in our pH so we have a respiratory alkalosis associated with hypoxemia you pulmonary hypertension can be classified as either being arterial or venous depending upon which side of the pulmonary vasculature is involved now remember when we're talking about the pulmonary system we're talking about the arterial end being the unex to native blood coming to the lung versus the venous end being the oxygenated blood coming to the heart so on the arterial system that might be caused by pulmonary hypertension from a respiratory disease pulmonary hypertension caused by thrombotic an embolic disease is also arterial whereas if it's a disease caused by a patient having a cardiac condition that would be pulmonary venous hypertension you now in this slide is showing the process by which somebody with COPD can end up developing pulmonary artery vasoconstriction which leads to increased pulmonary artery pressure which causes the patient to develop chronic pulmonary hypertension and that chronic pulmonary hypertension then causes the person to develop right heart failure now I mentioned this earlier but cor pulmonale is another name for right heart failure so the patient has a right heart failure you're going to see this is an older term for right heart failure you can see this may be listed in some patients charts where it says cor pulmonale in general now you're going to hear people talk about right heart failure and you're probably going to see that listed in the patient's chart so just know that those terms are kind of interchangeable now again we're talking about the right side of the heart we're not talking about the left side we're talking about the right side of the heart so the right side of the heart is going to back up into the systemic circulation that's where we're going to see the problems with the right side of the heart with cor pulmonale so just keep that in mind when you're thinking about right-sided versus left side one of the most common symptoms we see with right-sided failure is going to be edema and you see in the picture here at showing the dependent edema of the patients feet and legs in most cases edema and signs of right-sided heart failure are not caused by independent heart failure right on the right side but of left-sided failure that is backed up through the right side so rather than it being independent right-sided failure because the right side rarely fails by itself instead it's probably bilateral failure well in addition to those problems we talked about so far we can also have a number of different cancers of the respiratory tract starting all the way up from the top with lip cancer lip cancer of course it is going to be very common in people who smoke so any kind of smoking is going to increase the risk there along with laryngeal cancer any kind of smoking is going to increase the risk smoking and drinking alcohol increases the risk of both of these types of cancer from forming and this is showing a picture a very dramatic picture of what a lift cancer would look like a patient usually is Glenda Sh end up going to the hospital sooner when the lesion is smaller than that but that's obviously a very large lesion that has occurred on the patient's lip laryngeal cancer occurs when we have cancer occurring somewhere in the lenox and this can cause a lot of problems first of all can cause problems with the patient's ability to be able to breathe but secondly it can also cause problems with the patient's ability to be able to speak and laryngeal cancer may involve the may involve or require the the use of surgery in order to be able to remove it well guess what is the most common cause for lung cancer you probably already guessed it's cigarette smoking right heavy smokers of 20 times greater risk of developing lung cancers than non-smokers you know and there's other risk factors in other parts of the country coal dust for example or heavy pollution those are also risk factors for people to develop lung cancer as well so if you've got somebody who lives in an area of high pollution and smoke or a person who works in a coal mine and smokes boy they've got a lot of environmental risk factors here for lung cancer and not uncommon to see people in their 40s and 50s dying of lung cancer because of all of that damage it's occurring to the lung lung cancer is going to be divided out into three main categories non-small-cell lung cancer and this includes squamous cell carcinoma and not a--not carcinomas large cell carcinoma which is a none differentiate kind of cancer and then a small cell carcinoma so we have three major categories here with the subdivision of the squamous cell carcinoma and aDNA carcinomas under the small cell or now as we previously discussed with cancer their evaluation and treatment options for a patient who has cancer include the TNM classification system of tumor knowned involvement and metastasis so we can look at that to determine how involved or how progressed this particular cancer is and then decide upon the appropriate or surgery or appropriate treatment with that surgery chemotherapy radiation therapy etc an upper respiratory problem that includes the epiglottis is called acute epiglottitis this is a bacterial infection that has caused the patient to have severe rapidly progressive life-threatening kind of a condition because the epiglottis is up there in the upper airway and as that becomes swollen and enlarged it can block the patient's airway in the patient can have problems breathing symptoms include a high fever sore throat an inspiratory stridor now a Strider is a different sound than a wheeze wheeze is a high-pitched musical sound on inspiration a Strider is heard primarily ah I said that backwards a wheeze is a high-pitched musical sound on expiration a Strider is primarily heard on inspiration it's a high-pitched sound it sounds like a squeak on inspiration it's caused by the upper airway and this is us this is a real emergent kind of a condition because we could have blockage of the airway then the patient couldn't breathe so this diagram here is illustrating some of the different conditions that are occurring there causing the patient of developable colitis and then the treatment and the symptoms that we see in our patients who have epiglottitis although this is usually associated with children epiglottitis does also happen in adults this interesting picture here is illustrating what kind of sounds were going to hear in different parts of the airway when it's way up there in the nasal pharynx we're going to have snoring occuring when we move down into the voice area so down here into the learning's now we're going to have an inspiratory stridor so that's where we hear the inspiratory stridor we get down a little bit further now into the trachea on the bronchi now we're going to hear an expert Ori Strider or maybe even wheezing so remain concern here is that the patient's going to have this inflammation edema occurring in the upper airway causing upper airway obstruction leading to increased resistance to airflow leading to collapse of the upper airway and respiratory failure you so the symptoms we hear this loud snore excessive daytime sleepiness you see because the person with sleep apnea doesn't really get a good sound sleep even though it seems like it from all that snoring it seemed like wow they are really out of it here but they're never really getting down into that deep sleep what happens is that this this airway obstruction that occurs is going to wake this person up hundreds of times an hour so maybe even more frequently than once a minute the patient's going to wake up and the patient never gets into that really deep sleep now they're not waking up and you know open your eyes and everything else but there what's going to happen instead is that they're just kind of going through these upper levels of sleep and never getting a deep sleep and that's what causes the excessive daytime sleepiness because the patient doesn't get into the deep sleep so treatment wise we're going to always start with the non-surgical stuff change the sleep position do all the mechanical stuff get the head of the bed up decrease their weight so if we can get them to lose weight we may use CPAP machines and things like that we're not going to go into the surgical options until we have exhausted all the non-surgical treatments now even though we have differentiated this out and separated this out into respiratory distress syndrome of the newborn so this is the same condition we see in a RDS the mechanism is different but the destruction and the results are the same this is also known as hyaline membrane disease because what happens is the patient does not have an adequate amount of surfactant being produced and that's what's causing the inflammation and irritation lung that causes the respiratory distress syndrome another condition that I have mentioned previously when we talked about bronchiolitis was this cystic fibrosis okay so it's an autosomal recessive recessive multi-system disease and what ends up happening is the patient will develop thickening so they're going to develop thickening of the connective tissue and along which causes fibrosis and then they're also going to have a thickening of the mucus so mucus starts this abnormally thick mucus starts to become stuck in the airways and cause a lot of difficulty with the patient's breathing the chronic inflammation is going to lead to hyperplasia of the goblet cells so that's going to cost even more secretion formation and more difficulty with moving those secretions so this diagram here is showing that we have this underlying defect it's occurring with cystic fibrosis causing the D dehydrated mucus impaired mucus clearance etc and leading all the way down to the patient developing bronchiectasis as a result of all of the problems occurring with the mucus and with our inflammation and connective tissue damage over on the right hand side is showing some of the symptoms involved with cystic fibrosis our chronic cough recurrent upper respiratory infections that thick sticky mucus and chronic hypoxemia then over on the left hand side some of our treatments unfortunately a lot of the treatments that are used or medications that are going to decrease the immune response to try and decrease inflammation and that's going to cause the person to have the risk of having more infections and more problems well I want to thank you for joining me for part two which is pulmonary disease this is David Woodruff and until next time bye now

Channel: David Woodruff

Views: 27,637

Rating: 4.7714286 out of 5

Keywords: Nursing education, nursing, nursing student, Pathophysiology, Respiratory, Pulmonary

Id: t7L81o4El5c

Length: 53min 48sec (3228 seconds)

Published: Tue Jun 04 2013