Lecture 1 - Pulmonary Disease - Signs and Symptoms Notes | Knowt (2024)

Five Stations of Pulmonary Disease

• Airway Problems (ABCs)

  • Asthma

  • Bronchiectasis

  • COPD

• Alveolar Problems

  • Pneumonia

  • CHF

• Interstitial Problems

  • Pulmonary Fibrosis

• Pleural Problems

  • Effusion

  • Pleural Metastatic Disease

  • Thickened Pleura

• Chest Wall Problems

  • Paralyzed Diaphragm

  • Neuromuscular Disease

    • Polio, Muscular Dystrophy, Amyotopic, Lateral Sclerosis, Lambert-Eaton, Myasthenia Gravis

  • Respiratory Depression

    • Opiate Overdose

  • Obesity

  • Kyphoscoliosis

Airway Problems

• Air flow obstruction

  • Starts BELOW the vocal cords

• Landmark: pt will feel that they cannot breathe OUT

Presenting Complaints…

• Asthma

  • Dyspnea / Cough: YES, dry cough

  • Increased Sputum: Only during exacerbation

  • Hemoptysis: Rare

  • Breath Sounds: Expiratory wheezing

• COPD

  • Dyspnea / Cough: YES

  • Increased Sputum: Only during exacerbation

  • Hemoptysis: May occur during acute bronchitis

  • Breath Sounds: Expiratory wheezing

• Bronchiectasis

  • Dyspnea / Cough: YES, with increased sputum

  • Increased Sputum: Most patients report copius sputum

    • No increase or decrease during exacerbation

  • Hemoptysis: Massive hemoptysis can occur

  • Breath Sounds: Expiratory wheezing + Crackles

CXR

• May be “normal” OR…

  • Hyper-inflated lung fields or advanced bronchiectasis

    • Due to inability to exhale —> AIR TRAPPING

      • FLATTENED DIAPHRAGM

  • Complications like pneumomediastinum, pneumothorax, or associated pneumonia

Presenting Complaints Cont…

• ABG —> Low PaO2

  • Present with HYPERVENTILATION —> lowers PaCO2

• Asthma

  • High PaCO2, presenting with HYPOVENTILATION / HYPERCARBIA

  • Sign of RESPIRATORY FAILURE —> possible intubation

    • Bad prognosis

  • Inhaled steroids + bronchodilators (Beta2 agonists)

• COPD / Bronchiectasis

  • High PaCO2 —> advanced disease and poor prognosis

    • Severe COPD —> COR PULMONALE

  • COPD: bronchodilators + muscarinic receptor (m3 receptor blockers) anticholinergics + inhaled steroids

  • Bronchiectasis: inhaled steroids + bronchodilators (+ antibiotics)

• Hypoxemia improves on supplemental oxygenation

  • Improved V/Q mismatch

Time and Progression of Disease

• Disease Onset:

  • PaO2 decreases

  • PaCO2 remains

• Alveolar Hyperventilation:

  • Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

  • PaO2 less severe decrease

  • PaCO2 decreases

• Chronic Ventilatory Failure:

  • Point at which disease becomes severe and patient begins to become fatigued

  • PaO2 drastically decreases

  • PaCO2 drastically increases

Alveolar Disorders

• Pus —> Pneumonia

• Water —> CHF [cardiogenic pulmonary edema]

• Blood —> Hemoptysis

• CXR is ALWAYS ABNORMAL

  • Density of white increases —> severity of lung disease worsens

    See Also

    Understanding Common Lab Values in Pulmonary Acute Care: A Primer for Occupational Therapists - MedBridge BlogDeep Vein Thrombosis | UCSF Department of Surgery

Presenting Complaints…

• CHF [cardiogenic pulmonary edema]

  • Dyspnea / Cough: PND / Orthopnea, Dry cough, Pink frothy sputum

  • Examination: B/L coarse crackles, LVS3

  • Fever: NO

  • Investigation: CXR / ECHO

  • Treatment: Ace inhibitors, diuretics, beta blockers, arrhythmia management, surgery

• Pneumonia

  • Dyspnea / Cough: Dyspnea, Productive cough, Rust colored sputum

  • Examination: Crackles, Whispered pectoriloquy

  • Fever: YES

  • Investigation: CXR

  • Treatment: Early and appropriate antibiotics

• Hemoptysis

  • Dyspnea / Cough: Dyspnea + Hemoptysis

  • Examination: Depends on the cause of hemoptysis

  • Fever: Depends on the cause of hemoptysis

  • Investigation: CXR, CT scan of chest, Bronchography, Bronchoscopy

  • Treatment: Control bleeding + treat underlying cause

• ABG —> Low PaO2

  • Present with HYPERVENTILATION —> lowers PaCO2

• Hypoxemia improves on supplemental oxygenation

  • Improved V/Q mismatch

• High PaCO2 [hypercarbia]

  • RESPIRATORY FAILURE —> possible intubation

Congestive Heart Failure

• Systolic, Diastolic, Valvular Disease

• Alveolar edema occurs

  • Manifests as dyspnea + frothy blood stained sputum + B/L basal crepitations

  • Advanced: Crepitations (rales) extends throughout the lung fields

• Lung Field Abnormalities

  • Enlarged heart shadow

  • Cephalization

  • Kerley B lines

  • B/L pleural effusion

  • Pulmonary interstitial edema

  • Pulmonary alveolar edema

  • Consolidation

  • AIR BRONCHOGRAM —> SIGN OF ALVEOLAR DISEASE

Pathogens of the Respiratory System

• Strep. pneumoniae

• Haemophilus influenzae

• Moraxella catarrhalis

• Mycoplasma pneumoniae

Hemoptysis

• Expectoration of blood

  • Range from blood-streaking of sputum to the presence of gross blood in the absence of any accompanying sputum

• Can lead to airway obstruction

  • Massive hemoptysis —> Bronchiectasis, TB, Lung cancer

• Bronchial arteries are generally the source

• Most sensitive Dx —> Chest CT Scan

  • Bronchoscopy if CT is neg

• Causes: BATTLE CAMP

  • Bronchitis, Bronchiectasis

  • Aspergilloma

  • Tumor

  • Tuberculosis

  • Lung Abscess

  • Emboli

  • Coagulopathy, Medications [anticoagulation related]

  • Autoimmune Disorders, Arterial Venous Malformation (AVM), Alveolar Hemorrhage

  • Mitral Stenosis

  • Pneumonia

• Management:

  • Maintain of airway patency

  • Localize the source of the bleeding

    • CT Scan or Bronchoscopy

  • Control the hemorrhage

    • Bronchoscopy, Bronchial Artery Embolization / Surgery

• Bronchial Embolization Complications:

  • Spinal cord ischemia / infarction (artery of Adamkiewicz)

    • Supplies majority of the perfusion to the lower thorax and upper lumbar areas of the spine

    • Damage leads to Anterior Spinal Cord Syndrome

      • Loss of power [Paraplegia]

      • Decrease in pain and sensation below lesion

      • Impaired bowel and bladder function

  • Ischemia / infarction of aortic tributaries, leg vessels, renal, bowel

Interstitial Problems

• Fibrosis-Interstitial Lung Disease

• Pulmonary Vascular Problem

  • Pulmonary Embolism

  • Pulmonary Hypertension

What is the Interstitial Space?

• A ‘potential space’

• Disruption leads to type I respiratory failure

• Interstitial lung disease (ILD) involves not only interstitial space BUT also the alveoli, bronchioles, and blood vessels

  • Gas exchange does NOT occur

Interstitial Lung Disease (ILD)

• Early ILD:

  • CXR may be normal

  • Ground Glass

• CXR Changes:

  • Reticulonodular shadowing

  • Loss of volume

  • Widespread / bilateral

  • Honey Combing

• DX: ILD with CT

• Known Etiology:

  • Connective tissue disease

  • Drugs

  • Occupational exposures

Presenting Complaints

• Pulmonary Fibrosis:

  • Dyspnea / Cough: Dyspnea, Dry cough

  • Examination: Late inspiratory crackles

  • CXR: Early - clear; Later - reticulonodular shadow

  • Investigation: High res CT scan, Lung biopsy

• Pulmonary Embolism:

  • Dyspnea / Cough: Acute dyspnea, Pleuritic chest pain

  • Examination: Tachypnea, Tachycardia, Normal breath sounds

  • CXR: Clear

  • Investigation: CT Angio

• Pulmonary HTN:

  • Dyspnea / Cough: Chronic dyspnea

  • Examination: No crackles, Tricuspid regurgitation, Murmur, Ascites, Pedal edema

  • CXR: Clear, except for cardiomegaly

  • Investigation: ECHO - screening, Right heart catheter for confirmation

• ABG —> Low PaO2

  • Present with HYPERVENTILATION —> lowers PaCO2

• Interstitial Lung Disease:

  • Hypoxemia improves on supplemental oxygenation

    • Improved V/Q mismatch

  • Pts on PFT restrictive lung disorders

  • Treatment: Steroids, Immunosuppressive agents, Lung transplantation, Pirfenidone (Esbriet), Nintedanib (Ofev)

• Massive Pulmonary Embolism:

  • Hypoxemia may NOT improve on supplemental oxygenation

  • Treatment: Anticoagulation

• Pulmonary HTN:

  • Treatment: Diuretic, Pulmonary vasodilator therapy, treat underlying cause

• CXR may be ‘normal’

Pleural Problems

• Fluid —> Pleural Effusion

• Air —> Pneumothorax

• Tumor —> Mesothelioma

• CXR: NO AIR BRONCHOGRAM

Presenting Complaints

• Pleural Effusion:

  • Dyspnea / Cough: Dyspnea, Dry Cough

  • Examination: Dull on percussion, Absent breath sounds

  • CXR: Fluid shows whitish appearance

  • Investigation: Thoracentesis

• Pneumothorax:

  • Dyspnea / Cough: Acute dyspnea, Pleuritic chest pain

  • Examination: Hyperresonant on percussion, Absent breath sounds

  • CXR: Absent lung markings

  • Investigation: CXR

• Mesothelioma:

  • Dyspnea / Cough: Dyspnea, Pleuritic chest pain, Weight loss

  • Examination: Dull on percussion, Absent breath sounds

  • CXR: Appears like pleural effusion

  • Investigation: Chest CT scan, Pleura biopsy for Dx

• ABG —> Low PaO2

  • Present with HYPERVENTILATION —> lowers PaCO2

• Interstitial Lung Disease:

  • Hypoxemia improves on supplemental oxygenation

    • Improved V/Q mismatch

• Massive Pleural Effusion:

  • Hypoxemia may NOT improve on supplemental oxygenation

  • Treat underlying cause; Drainage of pleural fluid

  • Pleural Thickening:

    • A complication of longstanding pleural effusion results in fibrotic pleura, which splints the lung and prevents its expansion

    • B/L disease may cause restrictive lung disease, which may require decortication

• Pneumothorax:

  • Under water seal chest tube drainage

• Mesothelioma:

  • Chemotherapy

Pneumothorax

• Primary

• Secondary:

  • > 60 y/o, structural lung disease (COPD, ILD, bronchiectasis)

• Traumatic

• Tension

• Signs / Symptoms: chest pain on affected side

  • Dyspnea

  • Cough

  • Tachypnea

  • Abnormal respiratory movements

• Dx: CXR taken on respiration

  • Increased translucency

  • Mediastinal shift to UNAFFECTED side in tension

  • Depressed diaphragm

  • Lung collapse

  • Atelectasis

• Management:

  • Small: < 15% of thoracic volume

    • Observation and O2 for 6 hours and discharge if no enlargement

  • Large: > 15% of thoracic volume OR pts with respiratory distress

    • Pleural drainage

• Treatment:

  • Observation with O2 (< 15% and no symptoms)

  • Needle aspiration

  • Chest tube

  • Thoracoscopy / Surgery / Pleurodesis

Primary Spontaneous Pneumothorax

• Ruptured subpleural blebs or bullae at apices, otherwise normal lung

• Peak age early 20s, Male, 40% recurrence rate

• Blebs related to congenital abnormalities, inflammation, and smoking

• Primary Spontaneous Pneumothorax:

  • Small —> observation and O2

  • If lung does not expand or pneumothorax reoccurs, small bore chest tube

  • If recurrent pneumothorax, thoracoscopy and stapling of blebs

Malignant Mesothelioma

• Tumor of mesothelial cells in pleura, occasionally found in peritoneum/other organs

• Majority Hx of Asbestos Exposure

• Weight loss, Chest pain, Recurrent Pleural Effusions, SOB

• Dx: histology from pleural biopsy

• Rx: Symptomatic —> RT and chemo

• Prognosis: Poor, < 2 yrs

Chest Wall Problems

• Resulting in poor ventilation

• Muscular problems

• Diaphragm

• Neuromuscular Junction

  • Myasthenia Gravis, Lambert-Eaton Syndrome, Gentamicin Toxicity

• Neuropathy

  • Guillain-Barre Syndrome

• Motor Nerve

  • Amyotrophic Lateral Sclerosis (ALS)

• Spinal cord trauma

• Syringomyelia

• Syringobulbia

• Brain stem disorders

• Encephalopathy - opiates or sedative overdose

Diseases of the Chest Wall

• Deformity of thoracic cage such as kyphoscoliosis and ankylosing spondylitis

• Scoliosis: lateral curvature of spine

• Kyphosis: posterior curvature of spine

• External dyspnea, rapid shallow breathing

• Hypoxemia, hypercapnia, and cor-pulmonale supervene

• PFTs: Restrictive ventilatory defect with normal diffusion

• Cause of Death: respiratory failure or intracurrent pulmonary infection

• Treatment: Treat underlying cause and non-invasive [BIPAP] or invasive chronic ventilation

Neuromuscular Disorders

• Diseases affecting muscles of respiration or their nerve supply

• Poliomyelitis, Guillain-Barre syndrome, ALS, Myasthenia Gravis, Muscular Dystrophies

  • All lead to dyspnea and respiratory failure

• PFTs: Reduced FVC, TLC, FEV1

• Progress monitored by FVC and blood gasses

• Maximal inspiratory and expiratory pressures are reduced

• Treatment: Treat underlying cause and non-invasive [BIPAP] or invasive chronic ventilation

Presenting Complaints

• ABG —> High PaCO2

  • Present with HYPOVENTILATION —> lowers PaO2

• Hypoxemia will NOT improve on supplemental oxygenation

  • Improved V/Q mismatch

• Treatment: Treat underlying cause and non-invasive [BIPAP] or invasive chronic ventilation

• CXR: Kyphosis or scoliosis, elevated diaphragms

• PFTs: Restrictive ventilatory disorders with normal diffusion