Symptoms of Bronchiectasis Beyond Cough and Sputum
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In clinical practice, the classic manifestations of bronchiectasis include:
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cough daily mucopurulent sputum production, often lasting months to years. Blood-streaked sputum or hemoptysis resulting from airway damage associated with acute infection.
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What are other less specific symptoms of bronchiectasis?
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dyspnea pleuritic chest pain wheezing fever weakness weight loss.
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What breath sounds are heard with bronchiectasis?
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Crackles- compression of alveoli Rhonchi- moving mucous Wheezes- mucous causing narrowed airways / collapsing airways
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Currently, mortality from bronchiectasis is more often related to __________ than to uncontrolled infection. Life-threatening hemoptysis may also occur but is uncommon.
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progressive respiratory failure and cor pulmonale
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Study from Finland on bronchiectasis suggested mortality rates of
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-28% - greater than asthma, less than COPD
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What are the three types of bronchiectasis?
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- Cylindrical -Cystic or saccular -Varicose
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Explain Cylindrical bronchiectasis
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-involves diffuse mucosal edema, with resultant bronchi that are dilated minimally but have straight, regular outlines
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Explain Cystic or saccular bronchiectasis
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-has ulceration with bronchial neovascularization and a resultant ballooned appearance that may have air-fluid levels
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Explain Varicose bronchiectasis
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-has a bulbous appearance with a dilated bronchus and interspersed sites of relative constriction and, potentially, obstructive scarring.
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obstructive scarring may result in...
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- postobstructive pneumonitis and additional parenchymal damage
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What are the causes of bronchiectasis?
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-necrotizing infections (acquired) -Cystic Fibrosis (congenital) -Bronchial obstruction e.g. bronchial tumor (acquired) -Immunodeficiency states (congenital) -Congenital anatomic defects -Alpha1-antitrypsin deficiency -Autoimmune diseases (congenital)
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What are types of infections that patients with bronchiectasis can get?
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- Klebsiella species, Staphylococcus aureus, Mycobacterium tuberculosis, Mycoplasma pneumoniae
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What is important to note about immunodeficiency states and bronchiectasis?
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-repeated infections in patients who are immunosuppressed (HIV) -Allergic bronchopulmonary aspergillosis -Fungal infection usually seen in immunosuppressed patients -Secondary to mucous plugging
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What is the common immune deficiency disorder patients with rbonchectasis get?
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Hypogammaglobulinemia
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Explain Kartagener's Syndrome
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Triad of problems Bronchiectasis Dextrocardia Paranasal sinusitis Accounts for 20% of all congenital bronchiectasis
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How do you diagnose bronchiectasis?
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Imaging studies, especially high-resolution CT (HRCT) scanning, are the cornerstone for the diagnosis of bronchiectasis.
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What would a PFT look like in a patient with bronchiectasis?
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-Usually obstructive in presentation: Decreases FVC Decreased FEF200-1200 Decreased FEF25%-75% Decreased FEV1/FVC ratio Decreased PEFR MVV
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What would spirometey look like in patients with bronchiectasis?
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Increased-Tidal volume Vt Increased RV Increased FRC Increased RV/TLC ratio Decreased Inspiratory Capacity-IC Decreased Expiratory Reserve Volume ERV Increased/normal TLC
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What is non-pharmacological treatment for bronchiectasis?
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Oxygen for hypoxemia and decrease myocardial work and WOB Bronchial Hygiene Therapy Cough and Deep breathing IS PEP CPT Suctioning
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What is pharmacological treatment for patients with bronchiectasis?
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Mucolytics - Mucomyst Recombinant Human Deoxyribonuclease (DNase, Pulmozyme, Dornase) Antibiotics for infection Bronchodilators- as indicated Sympathomimetics Xanthines Fluids - keep pt hydrated
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What is near drowning?
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Survival longer than 24 hours after asphyxia related to submersion ETOH / Drug ingestion Diving MI Seizures
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What are common problems associated with near drowning?
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Hypoxia Pulmonary edema Hypotension Respiratory and metabolic acidosis
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What are potential complications of near drowning?
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Cerebral anoxia Tubular necrosis ---- acute renal failure Disseminated intravascular coagulation (DIC)
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What is DIC?
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-Disseminated Intravascular Coagulation
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What are symptoms of DIC?
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-diffuse bleeding or clotting, elevations in PT and PTT and a decreasing platelet count. Thrombin activation stimulates plasmin-mediated thrombolysis. Fibrin split products are formed in this process With concurrent clotting and fibrinolysis, clotting factors, fibrinogen and platelets are rapidly consumed. Bleeding occurs if consumption exceeds production. Results from continuous activation of the clotting mechanism. Such stimulation is frequently found in cases of vascular damage or sepsis
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What are the two categories of near-drowning?
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Wet: near drowning with aspiration Dry:near-drowning without aspiration
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Wet drowning accounts for _____ of all drowning
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-85-90% Aspirate submersion fluid or vomitus
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Explain freshwater aspiration In wet drowning
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Hypotonic and rapidly absorbed in the blood Destroys pulmonary surfactant Atelectasis Alveolar flood Pulmonary edema
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Explain saltwater aspiration In wet drowning
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Hypertonic When aspirated, leads to a rapid shift of water and plasma proteins from circulation into alveoli Atelectasis occurs as fluid washes out the surfactant
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In wet drowning, Intravascular depletion results from
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Hypoxia --- anoxia Altering membrane permeability Loss of plasma proteins
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In wet drowning, what are possible aspirated contaminants
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Chemicals, Algae,Bacteria, Sand Add to obstruction and can increased pace of asphyxiation Pneumonic process common Chemical pneumonitis a/w gastric aspiration
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Explain dry drowning
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Lack of aspirate from laryngospasm Water irritant Fear/pain can also bring this about Not as common
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What are other phenomena that can occur with submersion (occur & lead to aspiration)?
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-Immersion syndrome Sudden immersion in cold water triggers hyperventilation Increases the risk of swallowing or aspirating large amounts of cold water Vagally stimulated bradycardia---- loss of consciousness -Hyperventilation syndrome Divers hyperventilate to increase their breath-hold time Drive to breath is impaired from low CO2 levels Oxygen consumption continues If drive to breath does not resume before low levels of oxygen develop, hypoxia can lead to seizures, dysrrhythmia or death
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What is hypothermia?
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-drop in core temperature to 33 C (91.4 F) or less -Muscle activity and vital functions cease -V fib at 28 C(82 F)
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What are the benchmarks of hypothermia?
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86-95 - confusion/lethargy 86 - cardiac irritability 82 -V fib common 81 -anuria/50% mortality 80 - coma/fixed pupils 75 - respiratory arrest/heat production stops 60 -asystole common
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CNS more tolerant of ________ because the rate of cerebral oxygen consumption is halved for each 10 C (18 F) drop in core temperature
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- hypothermic conditions
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Complete neurological recovery is possible even after _____ of asystolic cardiac resuscitation
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- 1 hour
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Respiratory drive decreases in ______ with temperature
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- parallel -respiratory acidosis seen
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What are blood related issues in regards to hypothermia?
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- Hypothermia induced diuresis - hemoconcentration and sluggish movement of blood DVT risk Left shift of ODC- (O2 Dissociation Curve) Tissue oxygenation
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What are rewarming methods?
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Remove cold/wet clothing and replace with dry/warm May be all that is necessary if temp is > 91 CP bypass & mediastinal lavage are fast but impractical Peritoneal lavage can increase temp 4 C per hour & is easily done Heated humidification (increase temp up to 46 ) raises core by about 1 C/hour Warm gastric lavage is helpful, but not relied on solely
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What are two important things to keep in mind about rewarming?
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Should be done quickly when cardiac instability exists and temperature is < 85 F Patient's must be warmed to at least 32 C ( 85-90 F) before death is declared
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What are ABGS for patients who have nearly drowned?
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hypoxemia with metabolic or respiratory acidosis common
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What does 3 indicate on the GCS-Glascow coma scale
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- brain death
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What are Favorable Prognostic Factors in cold water near drowning
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Younger Less submersion time Water temp colder (70 degrees F) Cleaner the water, the better No other serious injuries Less struggle Good CPR technique Deliberate vs accidental
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What should treatment for near drowning involve? When should it begin?
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-should begin onsite with BLS and transport ABC No Heimlich w/o FBO (foreign body obstruction) In ER Oxygen for desired sat or PaO2 CPAP Intubation/PEEP may hyperventilate to manage ICP elevation is head injury present (ICP=intracranial pressure) ICP may also be elevated from cerebral swelling secondary to anoxia CXR ABG Management of hypothermia if applicable Careful fluid administration if needed Inotropic agents possible. (Increase heart force of contractions)
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______ is the leading cause of cancer death in both men and women
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- lung cancer
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What is the 5 year survival rate for lung cancer?
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-17%
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What are the next most common cancers? What is their survival rate?
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-colorectal, breast, prostate - > 65% survival rate for these
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What are the survival rates better for the other most common cancers?
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-Better survival rate due to good screening methods for these cancers
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Is there good screening for lung cancer?
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- no. screening is poor
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What is the biggest risk factor for lung cancer?
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- smoking
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________ and smoking increase risk above 50%
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- Asbestos
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Women smoking causing lung CA increased with ______
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- women's rights
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Genetic abnormalities take about ______ to develop towards lung CA
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- 30 years
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_____-% of lung cancer is in smokers or former smokers
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- 85
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____% of lung CA patients are asymptomatic
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- 25
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Major method to determine type of lung CA is
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- BRONCHOSCOPY or TRANSTHORACIC NEEDLE BIOPSY
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Other diagnostic methods for lung cancer include
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- CXR, CTscan, physical exam
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Bronchogenic carcinoma - 2 types:
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-small cell - 20% -non small-cell - 75% -other types - 5%
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Non small-cell lung CA divided into 3 subtypes:
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-adenocarcinomas, squamous cell, large-cell
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Adeno means
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- gland
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explain some facts about adenocarcinomas
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-more common in women -metastasize early. -ASSOCIATED with non-smokers -unknown why non-smokers get lung CA
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4 areas for spreading (metastasizing) -
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1-brain 2- bone 3- liver 4- adrenal glands(above the kidneys). These spread by moving through the blood - hematogenous
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4 stages of NON SMALL CELL Lung CA
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stage I least invasive, stage IV - worst stage I - 1 site in 1 lung only stage II - primary site and movement to the hilar lymph nodes stage III - A - spread to mediastinal nodes on same side B - spread to mediastinal nodes on opposite side Stage IV - CA spread outside the chest
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TNM Classification system
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T - for tumor 1 - 4 N - for nodal 1, 2, 3 M - Metastasis 0, 1
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How often each stage occur vs recovery rate
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Stage I - 10% 80% Stage II - 20% 50% Stage III - 30% 30% Stage IV - 40% - seen most often 1 or 2%
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To find the Stage of the CANCER:
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1- CXR can be seen if >3cm 2 - CT with contrast 3 - MRI 4 - PET - Positive Emission Tomography - body's use of sugar and how sugar is taken up is shown on a PET. 90% effective to "stage" Cancer.
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Survival rate of stage III
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- - 35-40%
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Best scenario to cure lung cancer-
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Stage I or II non small-cell with surgery - 3 to 4 times more likely to recur
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Do not perform surgery when CA is.....
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- outside the chest
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Radiation and chemotherapy help to slow cancer, combination is used in...
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- stage III NON-SMALL CELL
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Stage IV non small cell is ______ care,
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-palliative care - often at request of the patient and family
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What are some facts from the lecture about small cell cancer?
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-Dr. Lamberti has never seen small cell CA in a non smoker -No surgery for small cell. Cells are everywhere and can not get them all. -Often presents with metastasis. -1- limited - found only in 1 lung - 5 year survival rate
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What is the primary treatment for small cell lung cancer
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-chemotherapy is primary treatment - High response rate to chemotherapy - up to 70% - unfortunately there is a high likelihood of recurrence. This level is achieved when CA can not be found on CT scan in over 4-6 months.
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What is SIRS?
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-systemic inflammatory response syndrome - A clinical response arising from a non-specific insult, including 2 or more of these: 1. Temp >38C 90bpm 3. RR > 20bpm 4. WBC >12,000 or 10% immature neutrophils
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What is sepsis?
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-SIRS with a confirmed or presumed infectious process -Sepsis includes an over response of the body-the SIRS part and infection - the sepsis part
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What is severe sepsis?
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-sepsis with 1 or more organs failing: -CV, Renal, Respiratory, Hepatic, Hematology, CNS, unexplained metabolic acidosis
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What is refractory septic shock?
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-cardiovascular refractory hypotension need for high IV infusion rates of norepinephrine and dopamine to maintain a MAP above 60mmHg
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What is septic shock?
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-severe sepsis and a MAP less than 65mmHg after volume (crystalloids-normal saline) is given and low infusion rates of norepinephrine and dopamine
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The PP Venn diagram shows SIRS outside of the infection circle as SIRS is _____
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- the body's inflammatory response and may not be due to infection
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Identification of the patient with sepsis - these are early signs:
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- Tachycardia -normal BP -increased cardiac output -low CVP pressures and decreased SVR. Other signs are: low urinary output, Jaundice (liver), mental psychosis, coagulation problems -hematology.
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What is treatment for sepsis?
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- includes washing out or draining of infection, antibiotics to kill the organism. Sepsis still has a high mortality rate even with newer antibiotics and excellent ICU care. --75% of patients with sepsis are mechanically ventilated-use LOW TIDAL VOLUMES --70% of patients with sepsis need vasopressor drugs as well as fluid volume therapy (IV fluids) in order to maintain cardiovascular stability. Keep MAP <65mmHg --- Blood transfusions for low Sv02 - below 70%
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True or False: Sepsis is common in all ICU's. Severe sepsis is also common- 10% of all ICU pts
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-True
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All sepsis is not diagnosed with a positive blood culture. In fact, only ____ of pts with severe sepsis have a positive blood culture.
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- 1/3
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The _______ of sepsis is complex and still needing further research.
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- pathology
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What is NNT?
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- Number of patients needed to be treated before 1 patient is saved- used in research to see if treatment is effective.
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What is important t know about lactate levels and sepsis?
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- should be taken in suspected sepsis -Patients with critical illness can be considered to have normal lactate concentrations if less than 2 mmol/L. -The normal blood lactate concentration in unstressed patients is 0.5-1 mmol/L.
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What is qSOFA?
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- qSOFA - Sequential Organ Failure Assessment- low score is better. -1 - Respiratory - RR>22 -2 - Neurological - GCS <15 -3 - Cardiovascular - SPB < 100mmHg
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Clinical Criteria for Septic shock includes:
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-After fluid resuscitation: The patient needs: -1. Vasopressors to maintain a MAP > 65mmHg -2. Lactate level > 2mmol/L
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What is treatment for severe sepsis?
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- 02, ventilation with low volumes, CVP line, A-line, Sedation, IV Fluid, Norepinephrine, Transfusions to increase Hb, Dopamine (Inotropes) to increase heart contractions to maintain Cardiac output.
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What is the issue with neuromuscular diseases?
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- An impairment in the communication of the impulse to the muscle -Eventually effects the respiratory muscles -Mechanical dysfunction results -Hypoventilation -Atelectasis -Impair cough/secretion clearance
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What are examples of neuromuscular diseases?
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- Muscular Dystrophies -Botulism -Myasthenia Gravis -Guillain-Barre -Spinal Cord Diseases
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C3, C4, C5 - Injury to these affect the diaphragm. Innervation. What does the inability to use the diaphragm do?
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-Inability to use the diaphragm to breathe results in atelectasis, Vt, and increased pulmonary infections
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What is Scoliosis?
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- curve of spine in a lateral plane - may be managed surgically
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What is Kyphoid?
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-curve of spine as a bump or hump
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what is Kyphoidscoliosis?
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-combination of kyphoid and scholosis
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All neuromuscular diseases lead to a typical clinical course that involves:
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-Ineffective cough -Recurrent pulmonary infections -Ventilatory insufficiency in advanced states -Leading cause of death- Chronic respiratory failure with pulmonary sepsis
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What are some common clinical symptoms of neuromuscular disorders?
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- Fatigue -Poor sleep quality -DOE -Weak cough -Type of muscular disorder determines the pattern and severity of respiratory weakness -Chronic headache -Lethargy -Somnolence -Respiratory infections
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What is FVC important for neuromuscular disease?
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-is the single most important measurement for following the natural history of a disease or response to treatment. -It also closely reflects the degree of general pulmonary function and appears to offer an accurate prognostic index
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Name some options for non-invasive care for neuromuscular disorders?
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-Chest cuirass - inflates lungs by negative pressure - worn around chest -IPPB - to increase FRC -BIPAP - currently chosen mode of ventilation - often just at nite -Tracheostomy if patient agrees
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What is the definition of muscular dystrophies
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-group of hereditary conditions characterized by progressive degeneration of the striated muscles, resulting in severe weakness
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What is Duchenne's?
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-X linked recessive in women -Most common -Deficiency of the muscle protein Dystrophin -Symptom: onset of weakness early on in the proximal muscles. Unable to walk by teen years; life expectancy 20's Ventilatory support NOC recurrent resp infections
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What is Myotonic?
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Progressive muscular weakness Difficulty in relaxing contracted muscles early development of cataracts, testicular atrophy and frontal baldness
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What are some things we learned in class about dystrophies in general?
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-respiratory muscle involvement -swallowing & aspiration -reduced lung volumes -Respiratory failure is typically the cause of death
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Explain Botulism
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-Food poisoning from absorption of the toxin Clostridium botulinum -Muscle paralysis results from the toxin acting at the nerve endings preventing the release of Ach. -Rapid ventilatory failure results
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Polio
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vaccine has declined incidence of disease
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ALS-- Amyotrophic lateral sclerosis
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- progressive neurodegenerative disorder of both upper and lower neurons
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MS
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unknown etiology- demyelinating disease of the CNS-young adults (20's)
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Traumatic injury
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-C4: quadriplegia with diaphragm intact -above C4, loss of diaphragm
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What is Myasthenia Gravis?
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-A chronic, progressive autoimmune disorder that manifests itself as weakness and abnormal tiring of the involved muscles. -The degree of severity ranges from mild, to moderate to severe (acute fulminating) -Respiratory muscle involvement is seen in the moderate to severe forms.
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What is the etiology of MG?
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-Current theory holds that there are antibodies present which disrupt the chemical transmission of Ach at the neuromuscular junction by Blocking the Ach from the muscle receptor sites Increasing the rate of Ach breakdown Destruction of the receptor sites
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Drug Actions and MG
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- Mestinon is a cholinesterase Inhibitor. Allows ACH to cross membrane -Disease - lack of ACH site so low ACH -DRUG- Binds to Cholinesterase sites Allows build up of ACH
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MG and Drug Activity
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- A lack of ACH - is a worsened disease state -Mestinon binds to cholinesterase receptor sites allowing ACH to cross the neuromuscular junction. This allows a muscular contraction to occur. -Too much drug will bind all the Cholinesterase receptors so as ACH crosses the junction a contraction will not occur. Need a balance between disease state and Mestinon. Tensilon test - judge whether disease is worse or too much drug. Tensilon is short-acting (5 minutes).
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What are the drugs of choice for MG? What class are they?
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-Drugs of choice- Neostigmine (Prostigmine) Pyridostigmine (Mestinon) Edrophonium (Tensilon)-short acting -These are Cholinergic agents Inhibit cholinesterase in the post synaptic nerve ending Results in build up of ACH for muscular contraction to occur
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What are common triggers for MG?
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- Triggers of the disease include emotional stress, physical stress, infection, exposure to extreme temperatures and pregnancy, certain drugs*
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Dignosis of MG
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Clinical history-drooping eyelids, weak facial muscles Tensilon testing EMG- electromyogram Antibody levels
