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Case 6, Features/Symptoms of Tension Pneumothorax, Chronic Emphysema,…

- - - - Oxygen Cascade meaning
        Po2 decreases,
        as it moves from atmosphere moves into tissues
        
        Disruptions further
        
        Decrease Arterial oxygen partial pressure
        .
        
        leads to reduce tissue partial pressure
        
        What 4 events results in decreased Po2?
        
        Humidification from the atmosphere to trachea
        
        Mixing with dead space from airway to alveoli
        (Alveolar Gas Equation)
        
        Moving from alveoli to Pulmonary capillaries
        
        1 more item...
    - - What is the oxygen consumptions by the body?
        
        250ml O2 per minute is the body requirement
        
        What if we only depend on dissolve oxygen?
        .
        1) 250ml oxygen per minute [requirement]
        .
        2) 0.3 ml O2 / 100ml blood [dissolve oxygen conc]
        1 divide 2 = 83.33 litres of blood per min needed if dissolve oxygen was the only source
        Cardiac output is only 5 litres per minute
        
        How to calculate how much oxygen is carried in the blood
        
        Calculate theoretical oxygen capacity
        
        Multiply
        oxygen that binds to one gram of haemoglobin with
        amount of haemoglobin in 100ml of blood
        
        Calculate actual Oxygen Carrying capacity
        
        Multiply
        actual Oxygen Carrying capactiy
        with
        average oxygen saturation
        = oxygen content in arterial blood
        
        Sum them up to form Total Oxygen in Arterial Blood
        
        Minus Total Oxygen in Arterial Blood with
        Total Oxygen in Venous Blood
        
        Get Oxygen Consumption
        
        2 more items...
      - What are the two major forms of oxygen transportation?
        98% oxyhaemoglobin + 2% plasma
    - - Central chemoreceptors
        (brain stem)
        
        Found in
        Dorsal of medulla oblongata
        
        Function
        Sense Co2 and pH level of CSF
        
        Relationship of pH and Co2 in CSF
        pH of CSF drops when high Co2 in blood
        
        How pH drop when high Co2
        
        Co2 cross blood brain barrier into CSF
        
        Co2 dissolve to form H+
        
        more H+ means reduce pH
        
        Triggers Brainstem respiratory center
        
        muscles of breathing
        
        Alveolar ventilation
      - Peripheral chemoreceptors
        
        Function
        sense Co2, o2 and pH of blood
        
        Glomus cells act as chemosensors at
        
        Carotid body
        
        Aortic body
        
        release neurotransmitter
        
        activate under 2 conditions
        
        Low oxygen level
        
        Low pH (High Co2 level in blood)
    - - Minute to minute control of breathing normally
    - - Giving oxygen to patient treatment is called
        
        Oxygen therapy
    - - Condition A
        
        alveolar oxygen level - Constant
        
        carbon dioxide level in blood - increase
        
        1.Stimulate the response of peripheral and central chemoreceptors
        
        Increase in ventilation
      - Condition B
        
        Carbon dioxide level in blood constant
        
        Hypoxemia
        
        Stimulate response of peripheral chemoreceptors (central chemoreceptors not directly involved)
        
        2.Increase in ventilation
      - Condition C
        
        Alveolar oxygen level is low (Hypoxia)
        
        Carbon dioxide level in blood - further increase
        
        Greatly stimulate the response from
        
        negative feedback
        
        Double increase in ventilation
      - Condition D (either 1)
        
        Low pH with Hypoxemia
        
        Low pH with hypercapnia
        
        Low pH with Hypoxemia and Hypercapnia
        .
        
        Metabolic or respiratory acidosis - low pH*
      - Clinical conditions
        Metabolic Acidosis
        
        Body more sensitive to responding Co2
        
        Easily get Hyperventilation
        
        Related to Condition D
        
        Narcotic Drug, Anaesthetic
        and COPD patients
        
        Less sensitive to Co2
        
        Hypoventilation occurs
        
        "Narcotic drugs and anesthetics directly depress the central chemoreceptors,
        .
        in COPD patients, chronic exposure to elevated CO2 leads to a decreased sensitivity of the central chemoreceptors to further changes in CO2
  - - - Factors affecting Airway Resistance
        
        Increase airway diameter = Reduce resistance
        
        Increase lung volume = Reduce resistance
        
        Airflow
        Laminar Flow = Reduce Resistance
        Turbulent Flow = More Resistance
        
        Transition Point = Airway Resistance max at 5th to 8th generation bronchi
        
        Less number of different airways and small diameter
        However, as it goes smaller, because the number of tubes is a lot, so resultant airway resistance is lower
      - Effects of Increase
        muscle tone
        
        Bronchoconstriction
        
        Increase Airway Resistance
        
        Reduce Airflow
        
        From smooth muscle contract
      - Effects of Increase
        Secretions
        
        Hypersecretion of mucus
        
        Partially / Fully obstruct airway
        
        Impaired Mucociliary clearance
        
        Altered airflow pattern
        
        Increase Airway resistance
        
        Laminar Airflow to Turbulent Flow
        
        Accumulate the secretion
    - - 3 types of ANS
        
        parasympathetic - Acetylcholine
        
        Fibers from vagus nerve penetrate lung
        
        stimulate postsynaptic muscarinic M3 receptors
        
        bronchoconstriction
        
        Mucus secretion
        
        Sympathetic - Adrenergic
        
        sympathetic nervous system activated and trigger release of catecholamines from adrenal medulla
        
        Circulating catecholamines binds to Beta-2 Receptors
        
        Smooth Muscle relaxation causes bronchodilation
        
        Take note:
        no secretion of mucus here
        
        Non-adrenergic non-cholinergic (NANC)
        Eg: Bradykinin, Nitric Oxide , Substance P
        ( All are vasodilators )
    - - Anticholinergic Drugs (Anti-parasympathetic)
        Known as "Anti-muscarinic drugs"
        
        Blocks the postsynaptic muscarinic
        M3 Receptors
        
        Bronchodilation effect
        
        Decrease secretion
        
        A drug which causes bronchodilation + neither anticholinergic nor adrenergic drug + inhibit bronchocontriction
        Theophyline inhibits PDE which breaks down cAMP which stimulate Bronchodilation
        
        2 drugs which blocks only M3 muscarinic Receptors (Specific)
        Ipratropium and tiotropium
        
        All of these either inhibits the para-sympathetic and stimulate sympathetic nervous system
        
        Treat COPD and Asthma which has bronchoconstriction and increase airflow resistance
        
        1 drug which blocks all M1-M5 receptors
        (Non-specific)
        Atropine
      - Adrenergic drugs
        Known as "Sympathomimetic/adrenoceptor agonists
        "
        
        Pro-sympathetic basically
        
        Stimulate Beta 2 receptors in the lungs
        
        Increase cAMP
        
        Increase smooth muscle relaxation
        
        Bronchodilation
        
        2 drug Beta-2 Agonist (Specific)
        Salbutamol and terbutaline
        
        This can also stabilises mass cells and and prevent histamine release which cause bronchoconstriction
        
        1 drug A and B-adrenergic receptors (non-specific)
        Adrenaline
  - - - Medulla
        
        Dorsal Respiratory Group
        
        Ventral Respiratory Group
      - Pons
- - - - 1. Pleural Effusions
        Fluid
        
        Two main categories of pleural effusion
        
        Transudate Pleural effusion
        (low protein)
        
        Pathophysiology
        
        Fluid leaks from blood vessels but protein does not
        .
        
        Increase hydrostatic pressure
        
        Reduce oncotic pressure
        
        4 common Causes
        
        Heart Failure
        
        Hypoalbuminemia
        
        Cirrhosis
        
        Nephrotic syndrome
        .
        Primarily Organ Failure
        
        3 more items...
        
        Diagnostic Factor for Transudate Pleural Effusion
        
        Light's Criteria
        Pleural fluid protein / serum protein ratio less than 0.5
        
        Pleural Fluid LDH
        
        Pleural / Serum LDH ratio
        < 0.6
        LDH = Lactate dehydrogenase
        
        Exudate Pleural effusion
        (High Protein)
        
        Pathophysiology
        
        Inflammation leads to increase permeability
        .
        
        Increase protein and fluid leaks out from blood vessels
        
        2 common causes
        
        Para-pneumonic effusion
        
        Malignancy (lung for man, breast for woman )
        
        Large + unilateral pleural effusion due to
        malignancy commonly
        Either Infections or Malignancies
        
        2 more items...
        
        Diagnostic Factor for Exudate Pleural Effusion
        
        Light's Criteria
        
        Pleural fluid protein / serum protein ratio more than 0.5
        
        Pleural Fluid LDH
        
        Pleural / Serum LDH ratio
        > 0.6
        LDH = Lactate dehydrogenase
      - 2. Pneumothorax
        Air
        
        4 Types
        
        Primary Spontaneous
        
        Causes by rupture of bleb/bullae
        
        Occurs in healthy ppl
        (Tall Thin Men)
        
        Secondary Spontaneous
        
        From underlying conditions
        (rupture of bulla in COPD)
        
        Traumatic
        
        Iatrogenic
        i not L
        
        From Medical procedure
        
        Trauma
        
        Penetrating chest trauma
        (Stab Wound)
        
        Tension Pneumothorax
        
        3 mechanism
        
        Open Pneumothorax
        
        Pleural Pressure = ATM
        
        Lung Collapse
        
        Lung no re-expand until repair by occlusive dressing
        
        Close Pneumothorax
        
        During Inspiration, air flows into pleural space through a leak
        
        Leak sealed , trapped air reabsorbed
        
        Lungs slowly re-expand as air reabsorbed
        
        Leak not sealed, tension pneumothorax
        
        During Expiration, tear acts as one way valve.
        
        Air cannot escape from pleural space
        
        1 more item...
        
        Tension Pneumothorax
        
        Presentation of Pneumothorax
        
        Unilateral pleuritic pain
        
        Increasing Breathlessness
        
        Possible cyanosis
        
        Bluish discoloration in limbs and lips due to hypoxemia
        
        Examination of Pneumothorax
        
        Reduced Chest Expansion
        
        Reduce or absent in breath sounds
        
        Hyper-resonance or percussion
        
        Louder, Lower pitched and longer duration
        like drum on empty box
        
        Chest X-Ray
        
        Collapsed lungs
        Can't see air(black) in colour in normal lung place
        
        Treatment for Pneumothorax
        
        Chest Drain
        
        Insert pipe into pleural space to drain air & fluid
        
        Needle Thoracostomy ( Emergency )
        
        At 2nd intercostal space , Mid-Clavicular line
        Gush of air confirms diagnosis
      - 4. Empyema
        Pus
        
        cause of Empyema
        
        microorganisms gain entry into the pleural cavity
        
        What are the 4 bacteria that causes empyema?
        
        Streptococcus pneumoniae
        
        Streptococcus aureus
        
        E.Coli
        
        Myobacterium Tubercolosis
        
        4 methods that microorganism gain entry
        
        Alveoli - Seen in Pneumonia
        
        Blood
        
        Mediastinum
        
        Abdominal Infection passing through diaphragm
        
        Directly from environment due to trauma
        
        Symptoms of Empyema
        
        Breathlessness
        
        Pleuritic chest pain
        
        Sharp stabbing, which increases when inspiration
        From inflammation and friction against the pleural surface
        
        Examination of Empyema
        
        Inspection
        
        restricted movement of the chest wall on the same side (ipsilateral)
        
        Percussion
        
        Dullness means filled with fluid / pus
        
        Hyper-resonance means filled with air
        
        Auscultation
        
        Diminished breathe sound / inaudible
      - 3. Haemothorax
        Blood
        
        Cause of Haemothorax
        
        Traumatic
        
        Penetrating chest trauma
        
        Blunt chest trauma
        
        Complications from heart/lung surgery
        
        Spontaneous
      - 5. Pleural neoplasm
        
        3 types of Pleural neoplasm
        
        Metastatic
        (most common)
        
        From Lung/Breast
        
        Means metastasis ; spread from original site
        
        Benign
        
        Pleural lipoma
        
        Affects the visceral pleura
        Pleural Lipoma: Made up of fat cells.
        Pleural Fibroma: Made up of fibrous tissue.
        
        Lungs has
        
        Parietal pleural
        
        Pleural cavity
        
        Visceral pleural
        
        Pleural fibroma
        
        Malignant
        
        Mesothelioma
        
        Affects both visceral and parietal pleura
        Mesothelioma : Made up of mesothelial cells
        
        Cause of mesothelioma?
        From asbestos
        
        How long is the latent period?
        25 to 40 years
        
        Symptoms
        
        breathlessness
        
        Pleural Effusion
        
        Progressive / Dull chest Pain
        
        Palpable chest wall mass
        
        Tumours big enought are palpable
        
        Weight loss , Fatigue , fever
        
        Finger Clubbing (related to asbestosis)
        
        Asbestosis
        
        Causes fibrosis and inflammation
        
        Scarring makes it difficult for lung expand
        
        Leads to hypoxemia
  - - - Obstruction of pulmonary arteries by a substance that originated elsewhere
        
        Solid, liquid or gas
    - - Most CommonCause?
        
        Deep vein Thrombosis (DVT)
      - Deep Vein Thrombosis (DVT) + pulmonary embolism
        
        Forms Venous thromboembolism
    - - Presentation of Deep Vein Thrombosis?
        
        50% of patients asymptomatic
        
        50% of patients symptomatic
        3 Symptoms :
        
        swelling
        
        redness
        
        pain of the affected leg
- - - - inhibit antiprotease due to increase free radicals
        
        Mechanism 2 :
        Protease-antiprotease imbalance
      - Mechanism 1 :
        Oxidative Stress
    - - Neutrophills migrate to alveoli and accumulate with macrophages
        
        Release protease (neutrophil elastase)
        
        degrade elastic tissues
        
        tissue damage
        
        congenital deficiency of a1-anti trypsin
- - - - Young man with pneumothorax
- - - - Squamous metaplasia
        
        Hyperplasia and hypertrophy of mucus glands
- - - - Inflammation and fibrosis
        
        narrowing of the airways
      - Hyperplasia of goblet cells
      - Hyperplasia/ hypertrophy of mucous gland
        
        mucus hypersecretion
        
        Chronic airway obstruction
  - - - 1. Persistent cough and productive of copious sputum
    - - Dyspoea on exertion
        
        COPD is characterized by increase cholinergic tone and parasympathetic activity which causes bronchoconstriction
    - - Hypercapnia, hypoxemia, mild cyanosis (Blue Bloater), digital clubbing
- - - - Auscultation
        
        a. Breathe sounds reduced or absent
        b. vocal resonance reduced or absent
        
        Chest X-Ray
        
        a. Shows costophrenic angle blunting
- - - - Compensation
        .
        
        Renal compensation takes time
        
        Cannot stop oxygen therapy anymore as worsen hypoxemia, patient die or high-risk coma
        
        Solution
        .
        
        Low oxygen therapy to be use
        
        Make sure respiratory acidosis no develop
        
        Long-term oxygen therapy might be needed