[os 213] lec 01 approach to a patient with respiratory disease (b)-1

7/17/2019 [OS 213] LEC 01 Approach to a Patient With Respiratory Disease (B)-1

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OS 213: Circulation and RespirationLEC 01: APPROACH TO A PATIENT WITH RESPIRATORY

ISEASEExam #1 | Lenora Fernandez, MD, FPCCP | August 13, 2012

O!T"INE I Lung !tru"ture and Fun"ton

A Lung !tru"tures$ Lung Fun"tons

II P%&so'og" A(norma'tesA )as Ex"%ange Pro('ems$ *t%er Man+estatons

III!tru"ture and Corre'atedPat%o'og&

IC'n"a' A--roa"% to t%ePatentA Com-onents o+ E.a'uaton$ A--roa"%es to C'n"a'

Pro('ems

Common Pu'monar& C'n"a'Presentatons

D&s-neaA Coug%$ /emo-t&ss

APPEDI

I /&-oxemaA Me"%ansms Causng

/&-oxemaII !"o-e *.er.e o+ *! 213

45es-rator& Modu'e6

ote: A 'ot o+ n+ormaton as ta7en out e e-demo'og& o+ res-rator& dsease89gures, ta('es, and n+ormaton +rom t%e $'o"7 A 201 trans8 Dont orr& t%eseere not ds"ussed or -art o+ %dden s'des ;%e& ma& (e +urt%er ds"ussed n ot%er'e"tures t%ere+ore t%e& ere omtted +rom t%s trans

"!N# STR!CT!RE AN $!NCTION

"un% Structure

• Consder %"% -art<s o+ t%e 'ung are a=e"ted todagnose t%e -at%o'og& and to m-'ement s-e"9"t%era-eut" nter.entons

1& Al'eolio Paren"%&ma, ars-a"e o+ t%e 'ungo !ma''est "om-artment %eren gas ex"%ange ta7es

-'a"e2& Air(a)so $ran"%ng s&stem startng +rom t%e mout% and

nose, and n"'udng t%e orop*ar)n+,nasop*ar)n+, trac*ea, as e'' as t%e-rogress.e'& su(d.dng -ronc*i and-ronc*ioles

o Man goa' s to a''o t%e ar to rea"% t%e a'.eo' norder +or gas ex"%ange to o""ur

3& Interstitiu.o Mes%or7 o+ 'ung tssue nters-ersed (eteen

a'.eo'/& 0asculatureo etor7 o+ .esse's n %"% ('ood tra.e's and

t%roug% t, u'tmate'& a"%e.es t%e goa' o+ gasex"%ange and res-raton

& PleuralC*est Wallo !tru"tures outsde o+ t%e 'ungs t%at mo.e as -art o+

(reat%ngo Com-rsed man'& o+ t%e r( "age& Neural Co.ponento Com-rsed o+ t%e "ontro' "enters and ner.es t%at

exer"se neura'>me"%an" "ontro' o+ res-raton

"un% $unctions

#as E+c*an%eo Prmar& +un"ton o+ t%e 'ungo Pro"ess o+ ox&gen and "ar(on doxde mo.ng

(eteen t%e 'ungs and ('oodo *""urs .a d=uson t%roug% t%e one>"e'' t%"7 a''s

o+ t%e a'.eo' and "a-''ares4eta-olic Processeso Cellular Respiration: (& %"% an organsm

o(tans energ& (& rea"tng ox&gen t% g'u"ose tog.e ater, "ar(on doxde and A;P 4energ&6

o An%iotensin5Con'ertin% En6).e 7ACE8: +ound-redomnant'& n t%e "a-''ares o+ t%e 'ung, a''os"on.erson o+ Angotensn I to An%iotensin II t%ata"ts as and endo"rne and -ara"rne %ormone

4ucociliar) Clearanceo Der.ed +rom t%e mu"us and "'a 'o"ated on t%e

sur+a"e e-t%e'um o+ t%e res-rator& tra"to Coordnated (eatng o+ t%e "'a mo.es t%e mu"us

o Attem-ts to "orre"t -/ (& "%angng t%e"on"entraton o+ "ar(on doxde and "ar(on" a"dn t%e ('ood

o Meta(o'" a"doss stmu'ates (reat%ng, 'eadng to%&-er.ent'aton, %'e meta(o'" a'7a'oss

su--resses tCou%*o For"e+u' re'ease o+ ar aganst a "'osed g'ottso !er.es +un"ton o+ "'earan"e n t%e ara&s

PHYSIO"O#IC A9NOR4A"ITIES

#as E+c*an%e Pro-le.s

• )A! EC/A)E: ent'aton D=uson Per+uson

• Inade?ua"& n remo.ng "ar(on doxde andre-'ens%ng ox&gen n t%e ('ood

• Most -u'monar& dseases are rooted n gas ex"%ange-ro('ems

o Most "ommon man+estaton8 as gas ex"%ange st%e -rmar& +un"ton o+ t%e 'ungs

o Most "ommon o+ t%e gas ex"%ange -ro('ems:ent'aton -er+uson msmat"% (e"ause a'' "anman+est t% a <@ msmat"% at t%e start

H)po+e.ia

• *x&gen saturaton -elo( ;<

• De"reased -arta' -ressure o+ ox&gen n t%e ('ood

• Ex"'udes de"reased ('ood ox&gen "ontent due toanema and ot%er %emog'o(n de9"en"es

• (Please go to Appendix A for more exhaustivediscussion.)

H)percar-ia 7H)percapnia8

• Ex"ess o+ C*2 n t%e ('ood nd"ated (& an e'e.ated('ood PC*2

•

)enera''& "aused (& %&-o.ent'aton

Causes o= #as E+c*an%e Pro-le.s

0entilation

In.o'.ed stru"tures: Al'eoli 7parenc*).a8, air(a)s,pu.p 7neur.o.uscular pleura, c*est (all8

• )'o(a' /&-o.ent'aton

• A'.eo'ar and Ara& Pat%o'og&

• eura' Contro'a& Central H)po'entilation

PCO2> 0CO2

+ ? 0A

• eurome"%ansm

• Ma& not a'a&s -resent t% %&-oxemao P*2 '' not dro- mmedate'& (e"ause ox&gen s

st'' a('e to d=use eas'& sn"e t%ere s nom-arment

• /a''mar7: PaC*2 s al(a)s increased

• C%emore"e-tors are more senst.e to C*2

• C*2 'e.e's are ndre"t'& "orre'ated t% a'.eo'ar+un"ton

o An& de9"en"& '' 'ead to a 2+ increase in CO2

'e.e's (e"ause o+ t%er str"t re'atons%-, as e'' aseas& -er+uson

• De"rease (ot% PA*2 and Pa*2 so t%e PA*2>Pa*2 gradents norma'

o

I+ g.en su--'ementa' *2, Pa*2 '' n"rease as e'' PAO2> PIO2 @PACO2 $

R



OS 213 "EC ;1: APPROACH TO A PATIENT WITH RESPIRATORY ISEASE

"ondu"tng ara&s, anteror %orn "e'' dseases exPo'o, ner.es to res- mus"'es 4)$!6, m&oneura' un"ton 4m&ast%ena gra.s6, dss o+ res- mus"'es4ex Lou )ergs dsease6, t%ora"" "agea(norma'tes, u--er ara& o(stru"ton

• *(stru"t.e s'ee- a-nea no (reat%ng durng s'ee-,

n s-te o+ a"t.t& o+ res-rator& mus"'es, t%ere sno arGo 4"o''a-se o+ -%ar&ngea' a'', P"7"7ans&ndrome, !ID!6

-& Al'eolar H)po'entilation

• o matter %o mu"% P*2 &ou g.e, &our PC*2 ''a'a&s (e %g

• /a''mar7: PaC*2 s al(a)s increased

• De"rease (ot% PA*2 and Pa*2 so t%e PA*2>Pa*2 gradent s norma'

• Ex: Centra' %&-o.ent'aton, *(stru"t.e s'ee-a-nea 4+un"tona' +a''ng o+ t%e mus"'es6

PCO2> 0CO2

+ ? 0A

& iBusion• In.o'.ed stru"tures: Al'eolocapillar) linin%

interstitiu.

• A'.eo>"a-''ar& Mem(rane Hun"ton

• NOT a si%niDcant .ec*anis. (e"ause norma''ung %as 'ots o+ d=uson tme n reser.e4"a-''ar& ('ood *2 rea"%es t%at o+ a'.eo'ar gasa+ter 1<3 on'& o+ tota' "onta"t tme o+ 5$Cs t%a'.eo>"a-''ar& mem(rane 4 o+ a se"6

• B%at -%&so'og" state "ou'd exaggerate%&-oxema n d=uson m-arment (& 'essenng"onta"t tme o+ 5$C t% a'.eo>"a-''ar&mem(raneJ EERCISE 7principle o= e+ercisetests8

• Bt% s%ortened transt tme,&ou "an e'"t%&-oxema

& Per=usion

• as"u'ar !&stem" Dseases, eg H)pertension

o C'oggng o+ .as"u'ature -re.ents ('ood +rom-assng t%roug% "a-''ares and +rom (engade?uate'& -er+used

& 0entilation5Per=usion 4is.atc*

• Measurement used to assess t%e eK"en"& andade?ua"& o+ t%e to mat"%ng .ara('es

• ;%e extent to %"% t%e ar t%at rea"%es t%e 'ungss a('e to ox&genate t%e ('ood Gong t%roug%t%e 'ungs

• Most "ommon msmat"% n.o'.ng a'' -arts o+ t%e

'ung• ent'aton ('ood Go are msmat"%ed n .arous

regons o+ t%e 'ung > o.era'' gas ex"%ange(e"omes neK"ent

• orma' 'ung de"reasng <@ raton +rom a-ex to(ase

• PaC*2 usua''& not n"reased n m'd "ases (ut as<@ msmat"% (e"omes more se.ere, eK"en"&

n gas trans+er .er& mu"% "om-romsed, PaC*2n"reases a'so

• orma' PaC*2 3N>O3

• PaC*2 s not t%at mu"% a=e"ted t% <@msmat"% (e"ause unts t% %g% <@ ratos.er& e+e"t.e at e'mnatng C*2 (ut t%e& %a.e

'tt'e ad.antage o.er norma' unts n ta7ng u-*2 (e"ause o+ t%e s%a-e o+ t%e *2 dsso"aton"ur.e 4a'most Gat at t%e to-6

• M*!; "ommon me"%ansm o+ %&-oxema

• 5es-ons('e +or most o+ %&-oxema n C*PD,nterstta' 'ung dsease and -u'monar&em(o'sm

• Bdens PA*2>Pa*2 gradentS*untin%

• ero -er+uson<.ent'aton

enous ('ood e=e"t.e'& (&-assng ox&genaton att%e a'.eo'ar>"a-''ar& 'e.e', and ('ood remansdesaturated

CARIAC 0S& P!"4ONARY SH!NT• Carda" !%unt > 5g%t to 'e+t s%unts n "arda"

dseases 4rg%t sde o+ %eart to 'e+t sde o+ %eart6

• Pu'monar& !%unt > Pu'monar& artera' ('ood 4mxed.enous ('ood6 remanng unox&genated 4des-te-assng t%roug% -u'monar& "a-''ares6 admxngt% -u'monar& .enous ('ood

OHA, ?AT, 4I#O !PC4 2;1 9: I,Ba'ang a-anta&

2 o=




• Caused (& 2 genera' -u'monar& "ondtons 4<o"arda" "auses61 $'o"7 n -u'monar& "r"u'aton Q $'o"7 n

-er+uson

em(o'us, se.ere -neumona, C/F2 $'o"7 n t%e a'.eo'ar "om-artment Q $'o"7n .ent'aton

+oregn (od&, Adu't 5es-rator& Dstress!&ndrome 4A5D!6

• /a''mar7: e.en t% Gus%ng t% ox&gen, no-er+uson o""urs

o /&-oxema s re+ra"tor& to su--'ementa'*2(e"ause t%e ox&gen s not a('e to Rrea"%('ood at "a-''ar& 'e.e'

• I+ &ou g.e 100S, F*2, Pa*2 does not m-ro.esgn9"ant'& (e"ause e.en sma'' amounts o+ s%unted ('ood 4t% .er& 'o *2 "ontent orunsaturated ('ood6 admxed t% e''

ox&genated ('ood at t%e end"a-''ar& 'e.e' ''"ause a 'arge +a'' n Pa*2

Ot*er .ani=estations

• Mu"o"'ar& "'earan"e a(norma'tes

• Dre"t 'o"a' man+estatons

• !&stem" man+estatons

CO44ON P!"4ONARY A9NOR4A"ITIESCORRE"ATES

Ta-le 1& Structural Related to #as E+c*an%e Pro-le.s

Structure #as E+c*an%e Pro-le.s

Al'eoli ent'aton A(norma't&

Air(a)s ent'aton A(norma't&

Interstitiu. D=uson A(norma't&0asculature D=uson A(norma't&, Per+uson

A(norma't&

PleuralC*est Wall ent'aton A(norma't&

Neuro.ec*Control

ent'aton A(norma't&

TA'' stru"tures a(o.e ma& %a.e <@ A(norma't&

Ta-le 2& Co..on and Representati'e Pul.onar)iseases Accordin% to Structural In'ol'e.ent"!N#PART

CO44ON PATHO"O#Y ISEASESYNRO4E

Al'eoli A'.eo'ar 9''ng, mu"us or ('oodU

ent'aton m-arment,

5estr"t.e 4de"reased e'ast"re"o'6U

ent'aton<-er+usonmsmat"%

U!%untng n se.ere "ases

U/&-oxemaD&s-nea

In"reased se"retonsCoug%

!%untng : re+ra"tor&%&-oxema

Pneumona,Congest.e /ear

Fa'ure,

/emo-t&ss,Adu't 5es-rator&Dstress !&ndrom

Air(a)s Constr"ton or damage o+ ara&s

Uent'aton m-arment!tmu'aton o+ mu"us

-rodu"tonAir trappin% 4man

me"%ansm +or neK"en"&8d&s-nea n C*PD6

D=uson m-arment nem-%&sema

Uent'aton<-er+uson

msmat"%U

/&-oxemaD&s-neaCoug%

P%&s"a' e.den"e o+ ara&

4%eezng6"onstr"ton and ar tra--ng

$ron"%a' Ast%maC%ron" *(stru"t.Pu'monar& Dseas

4C*PD6,$ron"%e"tass

Interstitiu.

;%"7enng or n9'tratono+ ntersttum8 nGammaton

UD=uson m-arment

ent'aton m-arment4restr"t.e6

!tmu'aton o+ nterstta' Hre"e-tors

Uent'aton<-er+uson

msmat"%U

D&s-nea, ta"%&-nea/&-oxema

V Coug%Pau"t& o+ -%&s"a' exam

9ndngs4dete"ta('e on'& (e"ause o+

d&s-nea or xra&6

WInterstta' LungDseaseXIdo-at%"

Pu'monar& F(ros

0ascular $'o"7ng o+ ('ood .esse's4em(o'6

asos-asm or t%"7enng o+ .as"u'ar a''s

Pu'monar&/&-ertenson,

Pu'monar&Em(o'sm


3 o=




UPer+uson m-armentD=uson m-arment

<@ msmat"%U

!%untng n se.ere "asesPu'monar& artera'

%&-ertenson Y5g%t sded %eart +a'ureCor -u'mona'e

UD&s-nea

/&-oxema!gns o+

rg%t sded %eart +a'ure!%untng: re+ra"tor&

%&-oxema

Notes: most commonmechanism to increase pulmonar

vasospasm hpoxemia!ow "#P$ patientsend up with cor pulmonale

%reatment: &ong term#' therap preventsremodelling andcorrection of thehpoxmemia

Pleurac*est(all

F''ng u- o+ -'eura' s-a"e4Gud, ('ood, ar6

Loss o+ -%&so'og" negat.e-ressure n -'eura' s-a"e

!t=enng<"o''a-se<a(norma'mo.ement o+ "%est a''<r(

"ageU

ent'aton m-arment4restr"t.e6

ent'aton<-er+usonmsmat"%

UIn"reased t%ora"" -ressure Y

De"reased .enous ('oodreturn

UD&s-nea

/&-oxemaP%&s"a' sgns o+ Gud<ar n

'ung!&stem" %&-otenson

P'eura' e=uson,/&drot%orax,/emot%orax,

Pneumot%orax

Neuro.ec*anical

controlo=

'entilationor

P!4Ppro-le.

D&s+un"ton o+ neura'<me"%an"a' "ontro' o+

(reat%ngU

/&-o.ent'atonent'aton m-arment

45estr"t.e6U

D&s-nea/&-oxema

/&-er"ar(a 4un?ue +ora'.eo'ar %&-o.ent'aton: C!

res-onds to t%e "entra'"%emore"e-tors +or

"om-ensator& me"%ansms6!<! o+ -rmar& neuro'og"

-ro('em

*(stru"t.e !'ee-A-nea,Centra'

/&-o.ent'aton

Common "'n"a' -resentaton: ALL MAIFE!;BI;/ C*Z)/ AD D[!PEA

$ro. 2;1A @ not discussed

Patterns O= Air(a) O-struction: Passi'e EBects

Patterns of Airwa #struction

• Certan -at%o'oges a=e"t t%e ara&s 'eadng to n"reasn arGo resstan"e:o Fg A: P%'egm ('o"7ng t%e 'umen, eg -neumonao Fg $: ;%"7enng o+ ara& a'', eg C*PD 4"%ron

(ron"%ts -redomnant6o Fg C: Loss o+ a'.eo'ar atta"%ments, eg C*PD

4em-%&sema -redomnant6Patterns O= Air(a) O-struction: Acti'e EBects

• A"t.e "%ange n ara& dameter s "ommon'& due tosmoot% mus"'e "ontra"ton 4(ron"%o"onstr"ton6

• Furt%er, + t%e ara&s are nGamed t%en mu"us-rodu"ton and mu"osa' edema '' a'so a"t.e'& narrot%e ara&s

TA9"E 3: Air(a) S.oot* 4uscle Tone Responds To 4an)Sti.uli

Sti.ulus Contraction Rela+ation

Neural C%o'nerg" Adrenerg" 4$eta2

Neuro*u.oral

A"et&'"%o'ne ore-ne-%rne

C*e.ical /stamne, Leu7otrenes Prostag'andn E

P*)sical !mo7e, Co'd ar, !*2

C"INICA" APPROACH TO THE PATIENT

Co.ponents o= E'aluation

1& Histor)2& P*)sical E+a.ination

• A good %stor& and -%&s"a' exam s t%e (estdagnost" too'o N0>\0S o+ t%e dagnoss "an (e arr.ed at

t% ust t%ese3& C*est 5Ra) 7in .ost cases8

• Esta('s% t%e need +or su(se?uent testng,n"'udng -u'monar& +un"ton testng, A$)ana'&ss, (ron"%os"o-&, C; s"an and ot%ermagng moda'tes

• Pu'monar& -at%o'og& s sus-e"ted (&o C'n"a' -resentaton> -u'monar& sgns and

s&m-tomso A(norma'tes seen on "%est x>ra&

Ta-le /& Studies on relati'e contri-utions o= H+, PE

and "a-s4OA"IT

Y Ha.pton, et

alSandl

erPeters

on

Histor) \2S ]S N]S

PE ^S 1NS 12S

"a-s ^S 23S 11S

Approac*es to Clinical Pro-le.s


/ o=




isease59ased Pat*op*)siolo%ic Approac*

$i%ure 2& Process o= t*e Pat*op*)siolo%icApproac*

$i%ure 3& Pat*op*)siolo%ic approac* to pul.onar)diseases

Clinical Approac*

$i%ure /& Process o= t*e Clinical Approac*

Etio5P*)siolo%ic Approac* 7not discussed8

$i%ure & Etio5p*)siolo%ic approac* al%orit*.applied to lun% diseases

CO44ON P!"4ONARY C"INICA"PRESENTATIONS

Most o+ t%e -u'monar& dseases man+est t%:Cou%* and )spnea

D=erent -arts o+ t%e res-rator& s&stem are .er&"'ose'&>re'ated to one anot*er suc* t*at apul.onar) disease .a) in'ol'e diBerentparts at a ti.e

• ;%e 'ung s t%e organ t%at s .ost e+posed tot*e en'iron.ent, and t%e 'ung "ommon'&ser.es as t%e route o+ entr& to dseases t%at"ou'd a=e"t ot%er organs

• ;%e res-rator& s&stem as a %o'e s nextr"a('&'n7ed to t%e circulator), neurolo%ic andi..une s)ste.s, and dseases o+ t%eses&stems "ou'd %a.e -u'monar& man+estatonsas e'', ust as -u'monar& dseases "ou'd %a.enon>-u'monar& sgns and s&m-toms

$i%ure & ia%nosis o= Pul.onar) isease -)Clinical Clues

%ransers’ Note: %he following were lifted from '*+, trans.(Notdiscussed during the lecture)

)spnea

• Zn-'easant or un"om+orta('e (reat%ngo It %as mu't-'e "om-onents, and s des"r(ed

d=erent'& de-endng on t%e "ause

•

/as mu't-'e "arda", -u'monar&, as e'' as ot%ers&stem>re'ated "auses8 more o+ten t%an not, moret%an one me"%ansm under'es t%e sensaton

Cou%*

• Ex-'os.e ex-rator& maneu.er t%at s reGex.e'& orde'(erate'& ntended to "'ear t%e ara&s

• orma' res-onse to t%e -resen"e o+ mu"us and ot%er+oregn matera' n t%e ara&so Persstent "oug%ng, %oe.er, genera''& nd"ates

rrtaton o+ t%e -u'monar& ara&s

• t% most "ommon s&m-tom -rom-tng -atents to .stt%er -%&s"an

He.opt)sis

• Coug%ng u- o+ ('ood +rom t%e res-rator& tra"t

• $'ood n %emo-t&ss genera''& arses +rom t%e (ron"%a"r"u'atono Ex"e-t %en -u'monar& arteres are damaged (&

trauma, (& eroson (& a granu'omatous o"a'"9ed '&m-% node or tumor, or, rare'&, (&-u'monar& artera' "at%eterzaton, or %en"a-''ares are a=e"ted (& nGammaton

• $'ood>strea7ed s-utum s "ommon n man& mnor


o=




res-rator& ''nesses, su"% as Z5I and (ron"%ts

• Mass.e %emo-t&ssQ ;;." o+ ('ood n 2O %ours

APPENI(%ransers’ Note: -n the PowerPoint the /owchart was shownut the information aout hpoxemia was not)

HYPOE4IA• Ind"ates gas ex"%ange a(norma't&

O2 content > 1&3/ + FH-G + saturation ;&;;31 + PO2

• Measure -arta' -ressures o+ *2 and C*2 nartera' ('ood 4artera' ('ood gas determnaton6

• A--roxmate: measure *2 saturaton n artera'('ood (& oxmetr&

• Measure a'.eo'ar>artera' *2 d=eren"e 4PA*2 Pa*26 or a'.eo'ar>artera' *2 gradent

• /e'-s determne me"%ansm o+ %&-oxema

• From a'.eo'ar gas e?uaton,

PAO2 > $iO2 + 7P9 @ PH2O8 @PaCO2RPAO2 > 1; 51&2 + PaCO2

$i%ure & H)po+e.ia $lo( C*art

SCOPE O0ER0IEW O$ OS213•$rdge 'n7ng (as" 7no'edge on norma' and

a(norma' as-e"ts o+ t%e res-rator& s&stem toa"tua' ex-osure to -u'monar& -ro('ems n anam(u'ator& settng

•*.era'' a--roa"%: dsease>(ased (ut t% "ommon

-u'monar& "'n"a' "om-'ants as um->o= -onts

$i%ure & Concept 4ap o= Pul.onolo%) ____________________________________________________________________________________________

_________

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[os 213] lec 01 approach to a patient with respiratory disease (b)-1

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