The Power is in Your Hands… · Flu vaccine Pneumovax for pneumococcus Prognosis Usually reversible if treated Untreated: 30% mortality rate; may complicate to meningitis, respiratory

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Respiratory System

Introduction__________

Infectious RespiratoryDisorders

Chronic ObstructivePulmonary Diseases

OtherRespiratoryDisorders

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Respiratory System

Copyright 2009 Walters Kluwers Health l Lippincott Williams & Wilkins

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Respiratory SystemEasiest way to discuss structure of the Respiratory System is to follow aparticle of air through it.

Bronchi

Asymmetrical with right bronchus being bigger, wider andstraighter. Right bronchus leads to three lobes; Leftbronchus is smaller and curves into two lobes. (If a foreignobject is inhales it almost always follows the path of leastresistance to the right side.)

Alveoli

Next section of tubing is bronchioles which subdivide 23 timesto end in microscopic alveoli: grape shaped clusters are liketiny balloons surrounded by blood capillaries. Gaseousexchange occurs between alveoli and capillaries.

Lobes

Have separate segments called lobules lined with mucousmembrane which traps pathogens and other particles.

Smooth tissue lines all of the tubes

Take a Deep Breath

l

Air drawn in the Noseencounters Mucous

Membranes

l

Air enters the Pharynx,

l

then Larynx,

l

then Trachea

l

and then Bronchi

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FunctionAir cycles through the lungs 12-20 times per minutes.

Fresh air contains about 21% oxygen

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Exhaled air contains about 16% oxygen

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Enough surface area in lungs that only 5% of resting energy isneeded to supply the whole body with adequate oxygen

Lungs have no muscletissue to make them fillup or empty; they are

limp-walled sacs. Theyare stretched by pulling

on thorax walls and snapback to original shape on

exhale.

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Infectious Respiratory System Conditions

Acute Bronchitis

Common cold

Influenza

Pneumonia

Sinusitis

Tuberculosis

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Acute Bronchitis

Self-limiting inflammation of bronchial tree; Usually acomplication of cold or flu; Distinguished from chronicbronchitis

Etiology

Irritated bronchi get inflamed: tubes swell, cilia aredamaged, mucus producedLeads to coughing, wheezingMost are complications of cold or flu:Virus can attack bronchial mucosa or bacteria can takeadvantage of a good growth mediumSelf-limiting: lasts about 10 days, then heals (notchronic bronchitis)

Demographics

12 million cases/year 3 million doctor visits

Smokers, workers in pollutedenvironments at risk ; Also, elderly, heartproblems, immunosuppressed

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more Acute Bronchitis

Signs and Symptoms Diagnosis Treatment Massage

Persistent coughStarts dry, becomesproductiveWheezing, congestion,headache, fever,muscle aches, chestpain, fatigueIf fever goes over101ºF (38.3ºC) or ifmucus becomes thickand opaque,pneumonia is possible

Usually clearCan look like sinusitis,pneumonia, asthma

Rest, fluids, warmhumid airAntibiotics only ifidentified as bacterialinfectionBronchodilators/coughsuppressants maysuppress symptoms;don’t speed healing

Circulatory massagecontraindicated foracute infectionMay be appropriateduring recovery

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Common Cold

200 viruses that attack upper respiratory system ; Also calledupper respiratory tract infection (URTI)

Etiology

Rhinoviruses (110 subtypes)CoronavirusesAdenovirusesRespiratory syncytial viruses

___________________________Viruses enter nose: good growth mediumAccess cells in lymphoid tissue of adenoidsIncubation is short: 12 hoursImmune system attacks infected cells; causes mostsymptoms

Does being cold cause cold? Maybe

Demographics

An estimated 1 billion infections/year inthe United States

Children most at risk: 6–10/yearAdults: 2–4/yearElderly: <2/year




more Common Cold

Signs and Symptoms Prevention Treatment Massage

Runny nose, sneezing,sore throat, drycoughing, headache,mild fever

Less than 2weeks

Bacterial infections ofear, larynx, sinusesMay go to lungs:bronchitis, pneumonia

Especially iflungs arecompromised,e.g., chronicobstructivepulmonarydisease(COPD)

Virus can be airborneor picked up by handfrom contaminatedsurfacesPrevent spread bywashing hands,disposing of tissues,staying home whensick

No antibiotics!Rest, fluids, humidifierOver-the-counter(OTC) drugs canreduce symptoms,may increasecommunicabilityVitamin C, Echinacea,lysine, zinc, licoriceroot, hydrotherapy

Safest aftersymptoms havepeakedMay be more severe ifmassage occurs earlyin infectionMay exacerbatesymptoms for a day orso if massage occursduring healing—getpermission!

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Influenza

Viral infection of respiratory tract: different from viruses thatcause colds

Etiology

Virus gains access (airborne or via hands)Invade mucus-producing cells in respiratory tractImmune system kills infected cells, making mostsymptomsIncubation 2–3 days; communicable before symptomsappearPeak of communicability about day 4; continues throughrecovery

____________________________Type A: most virulent, associated with epidemics,pandemicsType B, C: stable, less severeType A infects other animals (birds, pigs, etc); mutateseasily

Demographics

5–20% population has flu 1/year

Children more at risk thanadults

For young, elderly,immunocompromised, can be dangerous

200,000 hospitalizations36,000 deaths/year




more Influenza

Signs and Symptoms Complications Treatment Massage

Looks like a bad cold

Respiratoryirritation,high fever 3or moredaysMuscle,joint pain

May last 2 weeksNo such thing asstomach flu

Acute bronchitis,pneumonia

No antibioticsRest, liquidsOTC drugs may controlsymptoms, don’tshorten durationAntiviral medications

Amantadine,rimantadine,Tamiflu,Relenza

Flu vaccine: madeseveral months aheadto predict active virus;must be updated yearly

Circulatory work iscontraindicated whileacuteMay exacerbatesymptoms duringrecovery: askpermission!May be contagiousduring recovery

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Pneumonia

Inflammation of the lungs, usually due to an infectious agent

Etiology

Alveoli fill with pus, mucus, other fluidDiffusion of gases is impossible; person drownsMay affect pleura: pleurisy is scarring of pleural layersInfection of pleural fluid: empyema

CausesMay be more than one at a time Viruses

About half of casesFlu, syncytial viruses most commonShort-lived, not serious for most

Bacteria

Staphylococci or streptococci get fromthroat to lungs; toxins initiate inflammatoryresponseCould also be tuberculosis, legionellaEdema in alveoliResponsive to antibiotics

Mycoplasma

Smallest living infectious agentsTiny bacteria: responsive to antibioticsWalking pneumonia

Fungi

Several species are endemic to certainareasPCP: Pneumocystis carinii pneumonia inimmunosuppressed people

DemographicsOpportunistic infection: takes advantageof weak immune system

Combines with flu to benumber 7 cause of death inthe United States3 million to 5 millioncases/year, 500,000+hospitalizations, 60,000deaths



Forms of pneumoniaPrimary pneumonia: rare attack directly on lungs Secondary pneumonia: more common, complication ofother problems; may be classified by location Bronchopneumonia: patchy pattern all over the lungs Lobar pneumonia: Restricted to one lobe; may spreadto whole lung Double pneumonia: affects both lungs

Source of the infectious agentCommunity acquired pneumoniaNosocomial, or hospital-acquired, pneumonia




more Pneumonia

Signs andSymptoms Diagnosis Treatment Massage

Vary with agent,virulence, health ofpatientCoughing, high fever,chills, sweating,delirium, chest pain,cyanosis, thicksputum, shortness ofbreath, muscle aches,pleurisySudden or gradualonset; looks like flu butgets progressivelyworse

Clinical examinationand description ofsymptomsViral, bacterial oftenhave fast onsetMycobacterium hasslower onset, lesssevere symptomsRadiography,computed tomography(CT), arterial blood gasstudy

Depends on type

Antibioticsfor bacteria,mycoplasma

Humidifier, fluids, rest,oxygenSurgery to drain pleuralspace if necessary

PreventionFlu vaccinePneumovax forpneumococcus

PrognosisUsually reversible iftreatedUntreated: 30%mortality rate; maycomplicate tomeningitis, respiratoryfailure, blood poisoningFibrosis, scar tissuemay accumulate

Raises riskof futureinfections

Contraindicated forcirculatory massagewhile acutePost acute stage canbenefit frompercussive massageon back, chest

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Sinusitis

Inflammation of mucous membranes in nose,sinuses ; Can be from infection or allergies

Etiology

Cilia in sinuses break down in response toinfection, pollutants

CausesNoninfectious sinusitis: allergic rhinitis:sinuses are inflamed without infection; mayincrease risk of infectionInfectious sinusitis:Acute (complication of viral infection, lasts6–8 weeks)Chronic (less severe, longer-lastingsymptoms)

Infectious agentsViruses and bacteria: cold, flu,Streptococcus pneumoniae,Haemophilus influenzae, bacteriafreed by dental workFungi and bacteria: Colonies offungi may create growth mediumfor bacteria as well

Other causes of infectious sinusitis

Structural problems: Deviatedseptum, nasal polypsEnvironmental irritants: cigarettesmoke, indoor and outdoorpollutants, cocaine, other irritantsOther conditions: severe cavities,asthma

Demographics37 million infections/year in the United States


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more Sinusitis

Signs and Symptoms Treatment Massage

Depends on causeSevere headache, worse withbending overLocal pain, edemaFever, chills with acuteinfectionSore throat, coughing(postnasal drip)Mucus clear with allergies;streaked or opaque withinfection

Humid air, fluids, saline wash ofsinusesDrugs: antibiotics for bacterialinfection; short-termdecongestants; steroid spraySurgery to correct structuralanomalies

Indicated for allergies if client iscomfortable on table (mayrequire some adjustment inposition or duration)Circulatory massage iscontraindicated for acute,untreated infection

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Tuberculosis

Tubercle = bump ; TB is a bacterial infection leading topus-filled bumps in lungs and other areas

Etiology

Airborne bacterium: Mycobacterium tuberculosisSpore gives it environmental resistanceUsually takes prolonged, repeated exposure tospread; can go more quickly

ProgressionTwo phases

Primary phase

Inhaled bacteria travel to alveoli, engulfed bymacrophages (doesn’t work)Set up small colonyBody builds protective wall around them: tubercleThis is exposure—not active disease; stays stablefor 90%

Secondary phase

Bacteria escape capsule and spread through lungto other tissuesScarring, pleurisyHappens to about 10% of infected, usually withinfirst yearInside large capsules tissue is infected, dead

Risk Factors

Long-term exposure to a person with activediseaseTravelers to areas with high infection ratesMost likely to → active infection if poor, unhealthy,drug user, alcoholic, HIV+

HIV and tuberculosis

DemographicsWorldwide:

2 billion people exposed8 million new infections/year9 million develop infection in activeform2 million to 3 million deaths/year:>AIDS + malaria + all tropicaldiseases combined

United States

10 million to 15 million exposed14,000 in active formMostly in poor, indigent, limitedaccess to health care




Coinfection with HIV and TB increases risk of TBbecoming activeHIV+ can interfere with accurate diagnosisWorldwide one-third who are HIV+ are also TB+




more Tuberculosis


Primary phase: may besilent or look like mildfluActive phase: fever,sweating, weight loss,exhaustion, chest pain,shortness of breath

Cough withphlegm thatmaybecomebloodyOtherorgans:bone pain,hematuria,CNSsymptoms

Within weeks ofexposure a skin test ispositive

Coinfectionwith HIVcan altertestVaccinationwith bacilleCalmette-Guérin(BCG) canalter test

Harder to catch activeinfection: looks likecold, flu, pneumonia,fungal infections oflungs

Previously: sanatoriaNow: antibiotics (INH =isoniazid)

6–12months,severalsideeffects,especiallywith alcohol

Low compliance leadsto drug-resistant TB

Drug-Resistant TBMDR-TB$250,000 to treat; 18–24 months ofmedications; samemortality as untreatedregular TB; spreads asMDR-TBWorldwide: 1% haveMDR-TB; 47 statesand DC in the UnitedStatesXDR-TBVirtually no treatmentworks74 deaths in the UnitedStates since 1993Most common in theformer Soviet Union,Asia, in HIV+ in SouthAfrica

Safe if infection islatent2 weeks of antibiotictreatment cutscommunicability risk tonear 0Contraindicated withactive infection



Chronic Obstructive Pulmonary Diseases

Asthma

Chronic bronchitis

Emphysema




Asthma

Sympathetic/parasympathetic swing in bronchioles ; Triggered by irritant, stress ; Sometimes classifiedas COPD; doesn’t usually cause irreversible lungdamage

Etiology

Hyperreactive bronchioles

Chronic inflammation, waiting fortriggerDilation (sympathetic) followed byconstriction (parasympathetic)Membranes swell, secreteexcessive mucus

Breathing, especially exhalation, becomeslaboredTriggers: pet allergens, cockroach waste,cigarette smoke, dust mites, viral infections,breathing cold dry air, exercise

Mild, intermittent asthmaEpisodes < twice/week; little impact on activity

Mild, persistent asthma>Once/week; up to 1/day; impacts activity

Moderate, persistent asthma

At least 1/day, plus nighttime episodes1+/week

Severe, persistent asthmaEpisodes most days and nights; activityseverely limited

Demographics20 million in United States; 9 million < 18 years old12.7 million doctor visits; 2 million emergencydepartment visits, 5,000 deaths/yearStatistics continue to climb; up 160% between 1980-1994Highest among African Americans


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more Asthma


Dyspnea, wheezing,coughingHardest to expel airBronchial asthma: tightbronchioles withexcess mucusExercise induced: withexertionSilent: no transition,just sudden shortnessof breathCough variant:coughing is onlysymptomDuring episode: panicsymptoms, cyanosis

Rule out other lungdisordersSpirometry

Manage exposure tostimuliRecognize warningsigns of attackShort term: beta-agonist inhalersLong term: inhaled ororal steroidsAllergy shots

Contraindicated duringepisode; otherwise canbe helpful for breathingefficiencyBe careful abouttriggers in massagesetting: essential oils,hyperallergenic oil,perfume, etc.

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Chronic Bronchitis

Part of COPD ; Long-term irritation of the bronchi andbronchioles, with or without infection ; Progressive andirreversible ; Precursor to emphysema

Etiology

Long-term irritation to bronchial tubes

Inflammation: destruction of cilia, elastin andovergrowth of mucus-producing cells

Increased resistance to air movement in lungsDamage becomes permanentWith increasing resistanceHeart works harderRed blood cell production increases (blood becomesthicker)Acidosis → vasoconstriction in pulmonary arteriesRight-sided heart failure, edema in extremities

Demographics9 million people in the United States

Men > womenWhites > other groups

Leading risk factor is smoking

Others: occupational irritants,air pollution, history ofrespiratory infections




more Chronic Bronchitis


Slow onsetCough followsrespiratory infection,lingers

Producesthick, clearsputum forweeks to 3monthsRepeatsseveraltimes within2 years

Frequent throatclearingShortness of breathgets worseVulnerable torespiratory infections,pneumoniaCyanosis

ComplicationsHigh risk of infection,heart failure

Patient history,examination,pulmonary functiontestsChest radiography, CTto rule out otherdamage

Aggressively treatinfectionsVaccinate for flu,pneumococcusLimit progression ofdamage, quit smoking,avoid polluted airBronchodilators withanti-inflammatories forbest function

May be indicated ifcirculatory system isstrongClients in advancedstage may not toleratelaying flat, strongchallenges tocirculatory systemAdjust for positioning

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Emphysema

Part of COPD ; Blown up, inflated

Etiology

Normal exhalation is passive: elastin in alveoliand bronchioles pulls lungs back to neutral300 million alveoli in lungs, each with capillarybed for gaseous exchange, coated with alpha-1antitrypsin (AAT)With chronic exposure to irritants

AAT doesn’t work to protect alveoliElastin degenerates; lungs don’treboundAlveoli fuse into bullaeReduces surface area for gasexchangeMore effort to breathe, to exhaleRespiration rate slows → acidosis,high carbon dioxide, spasm ofpulmonary arteriesRight-sided heart failure: can’t pumpadequate blood through resistantpulmonary circuitRespiratory/circulatory collapse

Demographics3.6 million people in the United States

Most have smoked 20/day, 20years+

Other irritants: coal dust, quarries, grain dust,etc.

<5% have genetic problem: lackingalpha-1 antitrypsin


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Other Respiratory Disorders

Cystic Fibrosis

Lung Cancer




Cystic Fibrosis

Autosomal recessive genetic disorder ;Causes production of thick, viscousexocrine secretions ; Respiratory tract anddigestive, integumentary, reproductivesystem

Etiology

Genetic mutations → transmembraneconductance regulator gene (CFTR) isaltered so that cell membranes can’tconduct chlorideLeads to thick, sticky secretions

Respiratory system:Mucus is thick, gluey, difficult todislodgeGrowth medium for infections; chronicinflammationAlso, growth of nasal polyps, chronicrhinitis

Digestive systemGastrointestinal (GI) tract andaccessory organsBabies may be born with intestinalobstruction: intestines don’t move wellPoor absorption → failure to thriveAbnormal production of bile →splenomegaly, gallstones, portalhypertensionAbnormal pancreatic secretions →pancreatitis, peptic ulcers

Integumentary systemThick, salty sweatRisk of heat stroke, salt depletion

DemographicsCF is the most common lethal inherited disease of whites

1:3,000 births in the United States12 million may have gene (many don’t know)30,000 people in the United States have CF

Life expectancy is improving: patients who make it throughchildhood make it to about 35

40% of patients > 18 years




Reproductive systemMen usually sterile: epididymis can’tsecrete normally or incomplete vasdeferensWomen usually have normal reprotract, successful pregnancies




more Cystic Fibrosis


Vary, depending onsystemRespiratory symptomsare most common: dryor productive cough,dyspnea, wheezing,chest pain, cyanosis,clubbing of fingers

Skin test to analyze forabnormal sweatLook for defect inCFTR geneLook for changes inupper respiratory tract

ComplicationsRelated to the exocrinegland dysfunction ofthe affected system (Chronic intractablebacterial infection;bronchiectasis,resistance in thepulmonary circuit,pnuemothorax, risk ofright-sided heart failureCirrhosis, gallstones,duodenal ulcers,intestinal obstructionwith or without rectalprolapse, risk ofpancreatitis ordiabetes from adamaged pancreas,and vitamin andmineral deficienciesfrom poor absorptionHeat stroke, saltdepletionSterility in men

Minimize symptoms,complicationsBreak up congestion inlungs, breathingexercisesSupplement enzymes,vitaminsBronchodilators,mucolytics, antibioticsto fight infection, anti-inflammatoriesSurgery: lungtransplant

Guided by health,resilience of clientTherapy on lungs caninclude massage

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Lung Cancer

Growth of malignant cells in the lungs

Etiology

85–90% related to tobacco exposureOther factors: radon, asbestos, uranium, arsenic, airpollution, other carcinogensOrderly pattern of death and repair in epithelial cells oflungs is disruptedAbnormal cells accumulate in patchesLots of circulatory and lymph vessels allow cells totravel before a significant tumor forms

Mediastinal lymph nodes, liver, bone, skin,adrenal glands, brain

Types of lung cancerSmall cell lung cancer (SCLC):

Also called oat cell carcinoma15–25% of all lung cancersGrows fast, spreads quickly, usuallyinoperable

Non–small cell lung cancer

75–85% of all lung cancersIncludes squamous cell carcinoma,adenocarcinoma, large cell carcinoma,others (Fig. 7.7)Grow more slowly than SCLC, still hard todetect early

Other types of lung malignancies

Carcinoid tumors, adenoid cystic carcinoma,sarcomas, mesothelioma

Risk FactorsSmokingExposure to asbestos, coal miners, toxic chemicals

Demographics180,000 new diagnoses/year160,000 deaths/yearNumber 1 cause of death by cancer(more deaths from breast and colorectaland prostate cancers)



15,000 deaths/year in people who never smoked

Exposure to other cigarette smoke, geneticpredisposition




more Lung Cancer


No early signsSmoker’s cough,bloodstained phlegm,chest pain, wheezing,and possibly shortnessof breathTumor may putpressure on otherstructures: brachialplexus, vena cavaesophagus, larynx,phrenic nerve

Radiography, CT, MRISputum analysis isinconsistentNo accurate,noninvasive earlydetection methodsUsually metastasizesbefore detection

Surgery, radiation,chemotherapyPhotodynamic therapymay become practical;other biologicaltherapies indevelopment

Useful to deal withchallenges of cancertreatment; respectlimitations of client andrisks associated withtreatment protocols

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The Power is in Your Hands… · Flu vaccine Pneumovax for pneumococcus Prognosis Usually reversible if treated Untreated: 30% mortality rate; may complicate to meningitis, respiratory

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