▪ Abnormal respiratory rate/ pattern:

– Tachypnea/ bradypnea

– Hyperpnea/hypopnea/apnea

– Kussmaul respiration – DKA (or any acidosis)

– Cheyne-Stokes respiration

▪ Abnormal sputum

– Can be colored or clear, can increase or decrease in amount and frequency

▪ Hemoptysis:

– Coughing up blood (cancer or TB)

▪ Empyema:

– Pus in the pleural space, not a disease but a manifestation

▪ Hypoventilation

– Leads to Hypercapnia

▪ Hyperventilation

– Hypocapnia

▪ Cyanosis

▪ Clubbing

Disorders of the Respiratory System

Chest Wall Disorders

▪ Disorders that compromise chest wall and restrict respiration

Causes:

▪ Deformities

▪ Musculoskeletal disorders

▪ Immobilization

▪ Obesity

Pathophysiology:

▪ Mechanical restrictions of inspiration and expiration

Clinical manifestations:

▪ Breathing difficulty

▪ Of the underlying condition

Flail Chest

▪ Multiple adjacent ribs are broken in multiple places, separating a segment

Etiology:

▪ Severe trauma, falls

Pathophysiology:

▪ Segment of chest wall moves independently in the opposite direction of the lung’s intention

▪ Due to difference in pressure, flail segment goes in while the rest of the chest is moving out (vice versa) → paradoxical breathing

Clinical manifestations:

▪ Chest pain

▪ Dyspnea

Pneumothorax

▪ Abnormal collection of air in pleural space

Etiology:

▪ Physical trauma

▪ Complication of medical/surgical intervention

Pathophysiology:

▪ Uncoupling of the lung from the chest wall, air interferes with normal respiration

▪ Increased pressure inside > atmospheric pressure,

– Compresses the lung

– Lung collapse (atelectasis)

▪ Pressure displaces the mediastinum and cause cardiopulmonary impairment

▪ Xray: black = air, tissue and fluid = white

Types:

▪ Spontaneous pneumothorax:

– Rupture of a subpleural bleb

▪ Secondary pneumothorax:

– Due to lung pathology, e.g. COPD

▪ Open pneumothorax:

– Stab or bullet wounds

▪ Tension pneumothorax:

– One-way valve allowing air and pressure to increase progressively inside pleural space

o Significant impairment of respiration and/or circulation

Clinical manifestations & diagnosis:

▪ Chest pain, resp. distress

▪ Diminished breath sounds

▪ Hyper-resonant on percussion

▪ X-ray

Pleural Effusion

▪ Excess fluid accumulation in the pleural cavity

Causes/Types

▪ Transudative effusion

– Congestive heart failure

– Liver cirrhosis

– Nephrotic syndrome

▪ Exudative effusion

– Infection

– Malignancy

– Pulmonary embolism, infarction

– Pancreatitis

– Hemothorax

– Trauma

Pathophysiology:

▪ Fluid limits expansion of lungs; impair breathing

▪ Increased hydrostatic pressure

▪ Injuries to the pleural lining

▪ >300 ml = detectable clinical signs

▪ Xray: tissue and fluid = white

Clinical manifestations & diagnosis:

▪ Chest pain (sharp pain worsen by cough or deep breaths)

▪ Impaired chest movement on the affected side

▪ Dullness to percussion over the fluid

▪ Diminished breath sounds on the affected side

▪ Pleural friction rub

▪ X ray confirms condition

Pulmonary Disorders

Restrictive lung diseases

▪ Pulmonary, extra-pulmonary, diseases characterized by restriction of full expansion of lungs

▪ Pathology: reduced lung volume, reduced ventilation/oxygenation, reduced effort in breathing

Main manifestation:

▪ Dyspnea

Common diseases/conditions:

▪ Aspiration

▪ Atelectasis

▪ Pulmonary fibrosis

▪ Inhalation disorders

▪ Pulmonary edema

▪ ARDS

Obstructive lung diseases

▪ Pulmonary diseases characterized by airway obstruction that is worse with expiration

▪ Pathology:

o Inflamed and easily collapsible airways, frequent medical visits/ hospitalizations

Main manifestations:

▪ Cough, dyspnea, and wheezing

Common diseases/conditions:

▪ COPD

▪ Chronic bronchitis/Emphysema

▪ Bronchial Asthma

▪ Bronchiectasis

▪ Sleep breathing disorder (E.g. OSA)

Restrictive Lung disorders

Lung Aspiration

▪ Entry of material from oropharynx or GI into resp. tract

▪ Types of aspirate: pharyngeal secretions, food/drink, gastric content

Etiology:

▪ Medical procedure; during positive pressure ventilation

▪ Meconium aspiration syndrome

Risk factors:

▪ Impaired consciousness (TBI), alcohol or drug overdose, general anesthesia

▪ Tracheal intubation, presence of gastric tube

Pathophysiology:

▪ Depends on particle size, volume, chemical composition of aspirated material, and underlying patient health status

▪ Air way obstruction

▪ Damage of lung tissue (acidity, microbes)

Clinical manifestations:

▪ Range from no effect, to pneumonia, to death within minutes from asphyxiation

Inhalation Disorders

▪ Entry of a substance with air inhalation into resp. tract

Types and Causes:

▪ Toxic gases: e.g. CO, SO2

▪ Pneumoconiosis (occupational lung disease)

– Silica

– Asbestos

– Coal

Pathophysiology & clinical manifestations:

▪ Depend on dose inhaled, particle size, underlying patients’ health status

Atelectasis

▪ Lung collapse resulting in reduced or absent gas exchange

▪ May affect part or all of one lung

▪ It can be a disease, or it can be caused by a disease

Etiology and Pathophysiology:

▪ Post-surgical (most common cause)

▪ Airway block (foreign body, mucus plug, tumor, lymph node, tubercle)

▪ Poor surfactant

Clinical manifestations:

▪ Breathing difficulty (rapid and shallow)

▪ Low oxygen saturation

▪ Cyanosis

▪ Pleural effusion (transudate type)

Pulmonary Fibrosis

▪ Scarring of lung tissue (alveoli)

Etiology:

▪ Idiopathic

▪ Inhalation, e.g. asbestos

▪ Inflammation, e.g. pneumonitis

▪ Autoimmune, e.g. SLE

Pathophysiology:

▪ Replacement of normal lung parenchyma with fibrous tissue

▪ Reduction of lung compliance

▪ Defective perfusion

Clinical manifestations & evaluation:

▪ Progressive dyspnea with exertion

▪ X-ray to show fibrosis

Pulmonary Edema

▪ Fluid inside the lungs

Etiology and diseases associated with lung edema:

▪ Left side valvular dysfunction

▪ Left ventricular failure

▪ Injury to capillary endothelium

▪ Blockage of lymphatic vessel

Pathophysiology:

▪ Increase in atrial pressures

▪ Increase in capillary permeability

▪ Accumulation of fluid in interstitial space

▪ Increased pulmonary capillary hydrostatic pressure

Clinical manifestations:

▪ Dyspnea, orthopnea, PND

▪ Cough (pink, frothy sputum)

▪ Excessive sweating, anxiety, pale skin

▪ Anxious

Acute Respiratory Distress Syndrome (ARDS)

▪ Fulminant form of respiratory failure characterized by diffuse alveolo-capillary injury

Causes:

▪ Sepsis (main reason)

▪ Multiple trauma

▪ Pneumonia

▪ Near drowning

▪ Drug overdose

Pathophysiology:

▪ Injury to the pulmonary capillary endothelium

▪ Pulmonary edema

▪ Inflammation and platelet activation

▪ Surfactant inactivation/loss

Clinical manifestations & diagnosis:

▪ Dyspnea and hypoxemia

▪ Hypoventilation, increased Pco2

▪ Respiratory acidosis

▪ Hypotension

Obstructive Lung disorders

Bronchial Asthma

▪ The number 1 respiratory disease

▪ Acute/chronic inflammatory/immune disorder of the airways

Etiology:

▪ Complex environmental and genetic factors

Pathophysiology:

▪ Children and adults

▪ Hyper-responsive airways

▪ Bronchospasm, inflammation, vascular congestion, increased mucous secretion

▪ IgE mediated degranulation of mast cells

▪ May lead to status asthmaticus

Precipitating factors:

▪ Allergens, drugs, others

Clinical manifestations/ diagnosis:

▪ *Expiratory wheezing, dyspnea, tachypnea, cough

▪ Spirometry, family history, symptoms, etc.

*Seen everywhere in the world. The terminal airways are blocked from mucus and inflammation of the wall. This is an inflammatory disorder that is IgE mediated from mast cell degeneration. The smooth muscle wall responds quickly to antigen in exposed air. This disease can be acute or chronic and can run in a family. Status asthmaticus = severe acute asthmatic attack.

Chronic Bronchitis

▪ Chronic inflammatory response within bronchi:

– Hyper-secretion of mucus, chronic productive cough at least 3 months/year & at least 2 consecutive years

Cause:

▪ Smoking (main reason)

▪ Air pollution

▪ Long term exposure to irritants (occupation related)

▪ Genetic factors

Pathophysiology:

▪ Constant irritation will mucus production, size & number of mucous glands

▪ Mucus is thicker than normal

▪ Secondary bacterial infection adds to this inflammatory state

Clinical manifestations & evaluation:

▪ Chronic, worsening productive cough

▪ Diffuse, bilateral wheezes & rhonchi

▪ Spirometry can measure the amount of airflow obstruction

▪ Usually complicated by emphysema

▪ Colored sputum = secondary bacterial infection

Bronchiectasis

▪ Permanent enlargement of bronchioles most commonly secondary to infection.

– “ectasis” = dilation. You lose wall elasticity

Etiology:

▪ Cystic fibrosis (50%), COPD

▪ Infection; pneumonia, tuberculosis

▪ Immune disorders

Pathophysiology:

▪ Chronic inflammation

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