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Alternation of Respiratory function (Restrictive Pulmonary Disorders…
Alternation of
Respiratory function
Lung Volumes and Capacities
解剖生理
Upper Airway
Lower Airway
呼吸控制的相互作用機制
Pulmonary Blood Flow
Distribution of blood flow (perfusion) is uneven and is affected by body position and exercise.
When a person is upright, blood flow is decreased in the upper regions of the lungs (apices), when compared to the lower regions (bases).
When a person assumes the supine position, blood flow to the posterior dependent portion of the lung is higher than to the anterior lung, although the redistribution of blood flow is less dramatic than that seen in the upright lung.
The effect of gravity on the lung has led to the concept of lung zones.
Obstructive Pulmonary Disorders
Asthma
• Asthma is a lung disease characterized by (a)airway obstruction that is reversible (but not completely in some patients); (b) airway inflammation
• asthma is defined by paroxysms of diffuse wheezing, dyspnea
• asthma is thought to involve inflammation of the airways.
• Most cases of asthma can be triggered both by allergens
Treatment
• Environmental control、removal of allergens
• The patient should also be taught preventive therapy in regard to smoking cessation and avoidance of passive smoke, aerosols, and odors.
• obstructive disorders is similar and focuses on decreasing inflammation and bronchoconstriction,
• Chronic Bronchitis
• Pathologic changes in the airway include chronic inflammation and swelling of the bronchial mucosa resulting in scarring,
• Inflammation appears to predominantly be the result of neutrophil activity.
• CD8 Tlymphocyte levels are also elevated
Treatment
• goals are to (1) block the progression of the disease, (2) return the patient to optimal respiratory function, and (3) return the patient to usual activities of daily living.
• Pharmacologic treatment involves the use of inhaled short-acting β2 agonists and inhaled anticholinergic bronchodilators, cough suppressants, and antimicrobial agents for infections.
• Inhaled or oral corticosteroids may also be used in the treatment of some patients for acute exacerbations.
• Low-dose oxygen therapy
• Smoking cessation
Emphysema
• also referred to as type A COPD or the “pink puffer”
• defined pathologically by destructive changes of the alveolar walls and abnormal enlargement of the distal air sacs.
• Emphysema is frequently associated with chronic bronchitis.
• The etiologies of emphysema include smoking, air pollution, certain occupations (e.g., welding, mining, and working with or near asbestos), and α1-antitrypsin deficiency (1%).
• Age>50years
• Cigarette smoking in excess of 70 pack-years is highly predictive of COPD.
Diagnosis
• patient’s history and physical findings, pulmonary function tests, chest radiographs, arterial blood gases, and electrocardiogram.
• Changes seen on pulmonary function tests include an increased functional residual capacity, increased RV, increased TLC, decreased FEV1, and decreased FVC.
• increased anteroposterior chest diameter (barrel chest) are also common findings.
• Weight loss occurs because of anorexia and lack of energy to eat.
Restrictive Pulmonary Disorders
Diffuse Interstitial Lung Disease
• Pathogenesis of the disease is not well understood, but is possibly related to an immune reaction that usually begins with injury to the alveolar epithelial or capillary endothelial cells.
• Pathophysiologic changes may include interstitial and alveolar wall thickening and increased collagen bundles in the interstitium (Figure 23-1)
• Lung tissue becomes infiltrated by lymphocytes, macrophages, and plasma cells.
Diagnosis
• CXR:honeycomb appearance
• HRCT
• bronchoalveolar lavage
• lung biopsy
• transbronchial biopsy
• gallium-67 scanning
• pulmonary function tests : decreased vital capacity, reduced total lung capacity, and decreased diffusing capacity
Treatment
• avoid tobacco
• antiinflammatory and immunosuppressive agents
• Oxygen therapy is needed in patients with hypoxemia
• Lung transplantation
Hypersensitivity Pneumonitis
•classified as a restrictive and occupational disease
•Numerous inhaled organic agents are responsible for the inflammatory process.
Diagnosis
• the acute/subacute phase: CXR(bilateral pulmonary infiltrates or increased bronchial markings)
• In the chronic phase: CXR(diffuse reticulonodular infiltrates and fibrosis)
• increased white blood cell count and a decreased PaO2
• Elevations in erythrocyte sedimentation rate and the level of C-reactive protein
• Pulmonary function tests : decreased lung volumes, diffusing capacity, and static compliance.
Treatment
•This may require a change in environment or occupation.
•Oral corticosteroids may be used to decrease the inflammatory process
Occupational Lung Diseases
(1) migrating to small airways to use the mucociliary escalator; (2) engulfing dust and exiting through the lymph and/or blood system; (3) passing through bronchial walls, depositing dust particles in extraalveolar tissue; or (4) destroying the particle (silica).
Clinical manifestations
• Pneumoconioses
• As pneumoconioses progress, patients present with a progressive, productive cough and dyspnea, especially with exercise.
• weakness and fatigue
Treatment
• corticosteroids, inhaled bronchodilators, oxygen therapy, and respiratory treatments (intermittent positive-pressure ventilation, postural drainage, and deep breathing exercises)
Acute(Adult) Respiratory Distress Syndrome
• ARDS involve: (1) injury to the alveoli from a wide variety of disorders, (2) changes in alveolar diameter, (3) injury to the pulmonary circulation, and (4) disruptions in oxygen transport and utilization.
• Common findings in this type of injury include (1) severe hypoxemia caused by intrapulmonary shunting of blood; (2) a decrease in lung compliance; (3) a decrease in FRC; (4) diffuse, fluffy alveolar infiltrates on the chest radiograph; and (5) noncardiogenic pulmonary edema.
Clinical manifestations
• low blood volume state (“shock” state) 1 or 2 days before the onset of respiratory failure.
• sudden marked respiratory distress.
• increase in pulse rate, dyspnea, and a low PaO2.
• crackles and rhonchi
• accessory muscles to breathe and demonstrating intercostal and sternal retractions.
Treatment
• maintaining fluid and electrolyte balance
• use of a volume ventilator utilizing pressure support and positive end-expiratory pressure (PEEP).
Pneumothorax
• Spontaneous pneumothorax (SP) is characterized by the accumulation of air in the pleural space.
• occurring mainly in tall, thin men between ages 20 and 40 years
• SP is 6 times more common in men than women.
Diagnosis
• Spontaneous pneumothorax (SP) is characterized by the accumulation of air in the pleural space.
• occurring mainly in tall, thin men between ages 20 and 40 years
• SP is 6 times more common in men than women.
Treatment
• Smoking cessation should be advised.
• If the lung collapse is less than 15% to 25%, the patient may or may not be hospitalized.
• Chemical pleurodesis may be indicated for patients with recurrent spontaneous pneumothorax to promote adhesion of the visceral pleura to the parietal pleura to prevent further ruptures.
• Approximately 25% of patients with primary pneumothorax will have a recurrence within 2 years.
Pleural Effusion
• The five major types of pleural effusion are: (1) transudates, (2) exudates, (3) empyema attributable to infection in the pleural space, (4) hemothorax or hemorrhagic pleural effusions, and (5) chylothorax or lymphatic pleural effusions.
• Transudates are frequently associated with severe heart failure or other edematous states.
• Exudates are malignancies, infections (especially pneumonia), pulmonary embolism, sarcoidosis, post–myocardial infarction syndrome, and pancreatic disease.
Clinical manifestations
• Small effusions may be asymptomatic (which is common) in patients with less than 300 ml of fluid in the pleural cavity.
• dyspnea, pleuritic pain that is sharp and worsens with inspiration, dry cough, decreased chest wall movement, absence of breath sounds, dullness to percussion, and decreased tactile fremitus over the affected area.
• Dullness
Treatment
• Closed chest tube drainage
• thoracentesis is indicated
Lung Volumes and Capacities
