signs and symptoms of severe pulmonary emphysema · elastin and collagen are destroyed air goes...
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Signs and Symptoms of Severe Pulmonary
Emphysema
Saroglou MariaMD,MSc, PhDPulmonologist
Concultant G.N. Drama
EmphysemaDescription
Abnormal permanent enlargement of the
air space distal to the terminal bronchioles
Accompanied by destruction of bronchioles
Etiology
Cigarette smoking
Genetic predisposition
➢ Alpha1 protease inhibitor
Occupational exposure to chemical irritants
Exposure to atmospheric pollutants
Figure 9-12. Distal airway and alveolar weakening clinical scenario.
Anatomic Alterations of the Lungs (1)
Permanent enlargement and deterioration
of the air spaces distal to the terminal
bronchioles
Destruction of pulmonary capillaries
Weakening of the distal airways, primarily
the respiratory bronchioles
Anatomic Alterations of the Lungs(2)
Bronchospasm (with concomitant
bronchitis)
Hyperinflation of alveoli (air-trapping)
Emphysema Pathophysiology
➢ Two types:
Centrilobular (central part
of lobule)
▪ Most common
Panlobular (destruction of
whole lobule)
▪ Usually associated with AAT
deficiency
Emphysema Pathophysiology
Structural changes are:
➢ Hyperinflation of alveoli
➢ Destruction of alveolar capillary walls
➢ Narrowed, tortuous small airways
➢ Loss of lung elasticity
Emphysema Pathophysiology
➢ Small bronchioles become obstructed as a result of
Mucus
Smooth muscle spasm
Inflammatory process
Collapse of bronchiolar walls
Emphysema Pathophysiology
➢ Recurrent infections production/stimulation
of neutrophils and macrophages release
proteolytic enzymes alveolar destruction
inflammation, exudate, and edema
Emphysema Pathophysiology
➢ Elastin and collagen are destroyed
➢ Air goes into the lungs but is unable to come out on its own and remains in the lung
Causes bronchioles to collapse
Emphysema Pathophysiology
➢ Trapped air hyperinflation and overdistention
➢ As more alveoli coalesce, blebs and bullae may develop
➢ Destruction of alveolar walls and capillaries reduced surface area for O2 diffusion
Emphysema Pathophysiology
➢ Compensation is done by increasing respiratory rate to increase alveolar ventilation
➢ Hypoxemia usually develops late in disease
Clinical Data Obtained from
Laboratory Testsand Special Procedures
Pulmonary Function Study Expiratory Maneuver Findings
FVC FEV1 FEF25%-75% FEF200-1200
PEFR MVV FEF50% FEV1%
Pulmonary Function Study Lung Volume and Capacity Findings
VT RV FRC TLC
N or N or
VC IC ERV RV/TLC ratio
N or N or
Decreased Diffusion Capacity
(DLCO)
Arterial Blood Gases
Mild to Moderate Emphysema
Acute alveolar hyperventilation with
hypoxemia
pH PaCO2 HCO3- PaO2
(Slightly)
Time and Progression of Disease
100
50
30
80
0
10
20
40
Alveolar Hyperventilation
60
70
90 Point at which PaO2
declines enough to
stimulate peripheral
oxygen receptors
PaO2
Disease OnsetP
aO
2o
r P
aC
O2
Figure 4-2. PaO2 and PaC02 trends during acute alveolar hyperventilation.
Arterial Blood Gases
Severe Emphysema
Chronic ventilatory failure with hypoxemia
pH PaCO2 HCO3- PaO2
Normal (Significantly)
Time and Progression of Disease
100
50
30
80
0
10
20
40
Alveolar Hyperventilation
60
70
90
Point at which PaO2
declines enough to
stimulate peripheral
oxygen receptors
Chronic Ventilatory FailureDisease Onset
Point at which disease
becomes severe and patient
begins to become fatigued
Pa
02
or
Pa
C0
2
Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.
Clinical Data Obtained at the Patient’s Bedside
Peripheral edema and venous distention
Distended neck veins
Pitting edema
Enlarged and tender liver
DistendedNeck Veins
Figure 2-48. Distended neck veins (arrows).
Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2,
London, 1992, Mosby-Wolfe.
Clinical Data Obtained at the Patient’s Bedside
Cough, sputum production, hemoptysis
Chest assessment findings
➢ Hyperresonant percussion notes
➢ Wheezing
Clinical Data Obtained at the Patient’s Bedside
➢ Diminished breath sounds
➢ Diminished heart sounds
➢ Decreased tactile and vocal fremitus
➢ Crackles/rhonchi (when accompanied by bronchitis)
Clinical Data Obtained at the Patient’s Bedside
Use of accessory muscles of inspiration
Use of accessory muscles of expiration
Pursed-lip breathing
Clinical Data Obtained at the Patient’s Bedside
Increased anteroposterior chest diameter
(barrel chest)
Cyanosis
Digital clubbing
Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.
Abnormal Laboratory Testsand Procedures
Hematology
Increased hematocrit and hemoglobin
Electrolytes
Hypochloremia (chronic ventilatory failure)
Sputum examination
Streptococcus pneumoniae
Haemophilus influenzae
Radiologic Findings
Chest radiograph
Translucent (dark) lung fields
Depressed or flattened
diaphragms
Radiologic Findings
Long and narrow heart
Enlarged heart
Increased retrosternal air space
(lateral radiograph)
Figure 12-3. Chest X-ray of a patient with emphysema. The heart often appears long
and narrow as a result of being drawn downward by the descending diaphragm.
Figure 12–4. Emphysema. Lateral chest radiograph demonstrates a characteristically large
retrosternal radiolucency with increased separation of the aorta and sternum measuring 4.6 cm, 3 cm
below the angle of Louis and extending down to within 3 cm of the diaphragm anteriorly. Both
costophrenic angles are obtuse, and both hemidiaphragms are flat. (From Armstrong P et al, editors:
Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
Clinical Data Obtained at the Patient’s Bedside
Vital signs
Increased respiratory rate
Increased heart rate, cardiac
output, blood pressure
EmphysemaClinical Manifestations
➢ Dyspnea
Progresses in severity
Patient will first complain of dyspnea
on exertion and progress to rest
Emphysema Clinical Manifestations
➢ Minimal coughing with no to small
amounts of sputum
➢ Overdistention of alveoli causes
diaphragm to flatten and AP diameter to
increase
Emphysema Clinical Manifestations
➢ Patient becomes chest breather, relying
on accessory muscles
Ribs become fixed in inspiratory
position
EmphysemaClinical Manifestations
➢ Patient is underweight (despite adequate
calorie intake)