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Pathophysiology of The respiratory system

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Title: Pathophysiology of The respiratory system


1
Pathophysiology of The respiratory system
2
Objectives
  • Classifying different respiratory diseases.
  • Defining the different predisposing factors for
    respiratory diseases.
  • Studying different manifestations of the most
    important respiratory diseases.
  • Studying the social effects of the most common
    respiratory diseases.
  • Studying the main steps of prevention and control
    of the respiratory diseases.

3
These respiratory diseases include
  • Infections such as pneumonia.
  • Obstructive disorders that obstruct airflow into
    and out of the lungs such as asthma, bronchitis
    and emphysema.
  • Restrictive disorders are conditions that limit
    normal expansion of the lungs such as
    pneumothorax, atelectasis, respiratory distress
    syndrome and cystic fibrosis.

4
These respiratory diseases include(cont.)
  • Neoplasms abnormal growth of tissues that can
    be benign or malignant.
  • Inhalation of particles such as noxious gases
    and pollens that can alter the pulmonary
    function.
  • Vascular diseases such as epistaxis, pulmonary
    oedema and pulmonary embolism.

5
HEALTHY HABITS FOR CARING FOR OUR RESPIRATORY
SYSTEM
  • Exercise regularly, this helps to improve the
    circulation of the blood.
  • Eat a well balanced diet.
  • Eat vegetables, especially green vegetables, and
    fruits.
  • Avoid eating too much saturated fats. Use
    beneficial fats and oils.
  • Maintain a healthy weight.
  • Live in a clean environment.

6
HEALTHY HABITS FOR CARING FOR OUR RESPIRATORY
SYSTEM (cont.)
  • Avoid smoking cigarettes and second hand smoke.
    Smoking increases the risk of stroke and coronary
    heart disease.
  • Have a positive outlook in life.
  • Try to reduce stress and tension.
  • Avoid high blood pressure because this can cause
    heart failure and stroke.

7
Respiratory System DiseasesGeneral Outline
  • Infectious diseases
  • Upper
  • URI
  • Croup
  • Epiglottitis
  • Flu (Influenza)
  • Lower
  • Bronchiolitis (RSV)
  • Pneumonia
  • SARS
  • TB
  • Fungal diseases
  • Obstructive lung diseases
  • Cystic fibrosis
  • Cancer
  • Aspiration pneumonia
  • Asthma
  • COPD (chronic obstr. pulm. dis)
  • Emphysema
  • Chronic bronchitis
  • Restrictive lung diseases
  • Chest wall abnormalities
  • Connective tissue abnormalities
  • Pneumoconioses
  • Vascular disorders
  • Pulmonary edema
  • Pulmonary embolism
  • Expansion disorders
  • Atelectasis
  • Pleural effusion
  • Pneumothorax
  • Resp. distress syndrome
  • Infant adult types.

8
Infectious diseases

  • Upper respiratory tract
  • URI
  • Croup
  • Epiglottitis
  • Flu (Influenza)
  • Lower respiratory tract
  • Bronchiolitis (RSV)
  • Pneumonia
  • SARS
  • TB
  • Fungal diseases

9
The Upper Respiratory System
  • Consists of
  • Nose
  • Pharynx (throat)
  • Middle ear
  • Eustachian tubes

10
Upper Respiratory System defense Mechanisms
  • Coarse hairs in the nose filter large particles
    from air entering the respiratory tract.
  • The ciliated mucous membranes of the nose and
    throat trap airborne particles and remove them
    from the body.
  • Lymphoid tissue, tonsils, and adenoids provide
    immunity to certain infections.

11
Microbial Diseases of the Respiratory System
  • Infections of the upper respiratory system are
    the most common type of infection.
  • Pathogens that enter the respiratory system can
    infect other parts of the body.

12
  • Most respiratory tract infections are
    self-limiting.
  • Often caused by bacteria viruses in combination.

13
  • Upper respiratory system

14
The Lower Respiratory System
  • Consists of
  • Larynx
  • Trachea
  • Bronchial tubes
  • Alveoli
  • Pleura

15
Structures of Lower Respiratory System
16
The Lower Respiratory System Defense Mechanisms
  • The ciliary escalator of the lower respiratory
    system helps prevent microorganisms from reaching
    the lungs.
  • The normal microbiota (nasal flora) of the nasal
    cavity and throat can include pathogenic
    microorganisms.
  • Microbes in the lungs can be phagocytozed by
    alveolar macrophages.
  • Respiratory mucus contains IgA antibodies.

17
Mucocilary Escalator
  • The lower respiratory system is usually sterile
    because of the action of the ciliary escalator.
  • Microorganisms hoping to infect the respiratory
    tract are caught in the sticky mucus and moved up
    by the mucociliary escalator.

18
  • General Manifestation of respiratory disease
  • Sneezing reflex response to irritation of upper
    respiratory tract
  • Coughing reflex response to irritation of lower
    respiratory tract
  • Sputum production
  • If yellowish- green ------ infection
  • If rusty ------- blood pus pneumococcal
    pneumonia
  • If bloody (hemoptysis) usually frothy , seen in
    pulm. Edema
  • Also seen in pulm. TB cancer
  • Large amounts foul bronchiectasis
    (suppuration).
  • Thick sticky asthma, cystic fibrosis

19
General Manifestation of respiratory disease
(cont.)
  • Hypoxemia Decreased levels of oxygen in
    arterial blood
  • Hypercapnia Increased levels of CO2 in the
    blood
  • Hypocapnia Decreased levels of CO2 in the blood
  • Hypoxia Decreased levels of oxygen in the
    tissues
  • Dyspnea Difficulty breathing (shortness of
    breath).
  • Tachypnea Rapid rate of breathing

20
General Manifestation of respiratory disease
(cont.)
  • Breathing patterns eupnia, labored (dyspnea) ,
    wheezing, stridor
  • Breath sounds normal, rales ( rhonchi,
    crepitations) decreased breath sounds.
  • Cyanosis Bluish discoloration of skin and
    mucous membranes due to poor oxygenation of the
    blood.
  • Hemoptysis Blood in the sputum

21
Patterns of Breathing
  • Apnea temporary cessation of breathing (one or
    more skipped breaths)
  • Dyspnea labored, gasping breathing shortness
    of breath
  • Eupnea normal, relaxed, quiet breathing
  • Hyperpnea increased rate and depth of breathing
    in response to exercise, pain, or other
    conditions
  • Hyperventilation increased pulmonary
    ventilation in excess of metabolic demand
  • Hypoventilation reduced pulmonary ventilation
  • Orthopnea Dyspnea that occurs when a person is
    lying down
  • Respiratory arrest permanent cessation of
    breathing
  • Tachypnea accelerated respiration

22
Respiratory infections
  • Infections of the respiratory tract can occur in
  • The upper respiratory tract.
  • The lower respiratory tract.
  • Both.
  • Organisms capable of infecting respiratory
    structures include
  • bacteria.
  • viruses the majority of upper respiratory tract
    infections are caused by viruses as rhinovirus
    and parainfluenza virus.
  • fungi.

23
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24
Upper respiratory tract Infections
Pharyngitis inflammation of the
pharynx Laryngitis swelling and irritation
(inflammation) of the voice box
(larynx) Tonsillitis inflammation of the
tonsils Sinusitis inflammation of the sinuses
Epiglottitis inflammation of the cartilage that
covers the trachea H. influenzae type b
most threatening
25
Acute Chronic Pharyngitis
  • Inflammation of the pharynx.
  • Most common throat disorder.
  • Acute (viral,streptococcal bacteria, etc).
  • Chronic (allergy, persistent cough, etc).
  • Treatment Varies with etiology.

26
Acute Chronic Laryngitis
  • Inflammation of the larynx vocal cords.
  • Acute viral or bacterial infections, excessive
    use of the voice, inhalational injuries (dust or
    chemicals).
  • Chronic often due to other ENT diseases
    (polyps, sinusitis, allergies, etc).
  • Treatment
  • Varies with etiology.

27
Sinusitis
  • Inflammation of the paranasal sinuses.
  • Acute (infection viral or bacterial).
  • Chronic (often allergic or hyperplastic).
  • Treatment
  • Varies with type.

28
Upper respiratory tract Infections
  • Viral Infections

29
The Common Cold
  • Cause rhinovirus, parainfluenza virus,
    respiratory syncytial virus, adenovirus and
    coronavirus.
  • The disease has seasonal variations in peak
    incidence.
  • Mode of infection through the nasal mucosa and
    the surfaces of the eye via respiratory
    secretions.
  • Manifestations
  • Rhinitis Inflammation of the nasal mucosa
    (discharge).
  • Sinusitis Inflammation of the sinus mucosa
    (headache).
  • Pharyngitis Inflammation of the pharynx (sore
    throat).

30
  • Any one of approximately 200 different viruses
    can cause the common cold Rhinoviruses cause
    about 50 of all colds.
  • Coronaviruses (1520)
  • Symptoms include sneezing, nasal secretions, and
    congestion.

31
Influenza
  • Influenza is a viral infection that can affect
    the upper or lower respiratory tract. It is a
    highly transmissible respiratory pathogen.
  • Because the viral has a high tendency for genetic
    mutation, new variant of the virus are constantly
    arising allover the world. Serious pandemics
    (spread of infection across a large region) of
    influenza are seen every 8 to 10 years as a
    result of this genetic mutation .

32
What is influenza?
  • RNA virus that has three classes
  • Influenza A, the most common.
  • Disease in humans, can cause pandemics
  • Influenza B
  • Inflects humans, less severe than type A
  • Influenza C
  • Infects pigs and humans, generally mild disease

33
Structure of the flu virus
  • RNA virus
  • Outer lipid coat
  • Projections on the outer layer
  • Hemagglutin spikes (H) 16 types
  • Neuraminidase spikes (N) 9 types

34
Influenza virus
35
Spikes
  • Hemagglutinin spikes
  • 500 per virus
  • Allows virus to recognize and attach to body
    cells
  • Antibodies made to these spikes
  • Neuraminidase spikes
  • 100 per virus
  • Help virus separate from infected host cell

36
  • Symptoms of influenza infection
  • Headache, Fever, chills, Muscle aches, Nasal
    discharge, Unproductive cough, Sore throat.
  • Influenza infection can cause acute tissue damage
    and a loss of ciliated cells that protect the
    respiratory passages from other organisms.
  • Can cause co-infection of the respiratory
    passages with bacteria.
  • The virus can infect the tissues of the lung
    itself to cause a viral pneumonia.

37
  • Treatment of influenza mainly symptomatic.
  • Bed rest, fluids, warmth, Antiviral drugs.
  • Influenza vaccine
  • Protects against certain A and B influenza
    strains that are expected to be prevalent in a
    certain year.
  • The vaccine must be updated and administered
    yearly to be effective but will not be effective
    against influenza strains not included in the
    vaccine.
  • The influenza vaccine is particularly indicated
    in elderly people, in individuals weakened by
    other disease and in health-care workers

38
  • Drugs for Treating Influenza
  • Amantidine.
  • Used orally or by aerosol administration
  • Effective only against type A influenza
  • Inhibits viral fusion, assembly and release from
    the infected host cell
  • Neuraminidase inhibitors (Zanamavir,
    Oseltamivir).
  • New drugs that can be used by inhalation
    (Zanamavir) or orally (Oseltamivir)
  • Effective against both type A and B influenza
  • Inhibits the activity of viral neuraminidase
    enzyme that is necessary for spread of the
    influenza virus

39
Influenza Serotypes and epidemic incidence
Type Antigenic Subtype Year Severity
A H3N2 H1N1 H2N2 H3N2 H1N1 1889 1918 1957 1968 1977 Moderate Severe pandemic Severe Moderate Low
B None 1940 Moderate
C None 1947 Very mild
40
Why do I need to get a new flu shot every year?
  • Antigenic drift changes in the structure of the
    spikes that allow the virus to evade the immune
    system. It occurs on an annual basis
  • Antigenic shift major change in the protein of
    the spikes that creates a virus that is new to
    the human population little herd immunity major
    epidemics.

41
Croup
  • Inflammation of the upper airways (the subglottic
    area)
  • Viral etiology
  • Winter illness
  • Usually in infants up to 3 YOA
  • S/S barking (seal-like) cough, worse when supine
  • Treatment humidified air, cool air

42
Infectious Mononucleosis
  • Acute viral infection
  • Usually adolescents young adults
  • Sore throat, fever, enlarged cervical LN
  • Etiology Epstein-Barr virus (EBV)
  • Disease episodes of the above symptoms,
    fatigue, splenomegaly, often 6-8 week course.
  • Treatment pain fever relief, steroids in some
    cases.

43
Upper respiratory tract Infections
  • Bacterial Infections

44
Streptococcal throat inection
45
Streptococcal pharyngitis
  • Streptococcus pyogenes
  • Beta hemolysis on blood agar from throat swab
  • Sore throat, fever, swelling of tonsils and neck
  • Sensitive to Penicillin

46
  • Also called strep throat
  • Streptococcus pyogenes
  • Gram positive cocci chains
  • Resistant to phagocytosis
  • Streptokinases lyse clots
  • Streptolysins are cytotoxic
  • Diagnosis by enzyme immunoassay (EIA) tests (have
    replaced latex agglutination tests)

Characterized by lack of cough
47
Scarlet Fever
  • Streptococcus pyogenes
  • Pharyngitis
  • Erythrogenic toxin produced by lysogenized S.
    pyogenes
  • Symptoms include a red rash (sandpaper), high
    fever, and a red, enlarged tongue.

48
Acute Tonsillitis
  • Tonsillar inflammation
  • Acute or chronic
  • Most common infection
  • Strep pyogenes, Staphylococcus aureus
  • S/S sore throat, hoarseness, fever, dysphagia
  • Treatment antibiotics

49
Otitis Media
  • Middle ear infection
  • Common in young children
  • Bacteria enter the middle ear from the oropharynx
    via the short internal auditory tube
  • Painful swelling of ear drum

50
  • Various bacteria cause the condition, mainly
    Streptococcus and Staphylococcus.
  • Children generally outgrow the condition.
  • Amoxicillin is used but this treatment is
    currently being phased out to limit resistance.

51
Diphtheria
  • Corynebacterium diphtheriae Gram-positive rods
  • Diphtheria toxin produced by lysogenized C.
    diphtheriae.
  • A membrane, containing fibrin and dead human and
    bacterial cells, forms in the throat and can
    block the passage of air.

52
Diphtheria membrane
  • Fibrin, tissue, bacterial cells

53
  • Still common in developing countries where
    immunizations aren't given routinely.
  • Up to 40 to 50 of those who don't get treated
    can die.
  • The exotoxin inhibits protein synthesis, and
    heart, kidney, or nerve damage may result.
  • Prevented by DTaP vaccine.
  • Diphtheria toxoid.

54
  • Symptoms includes fever, sore throat, malaise,
    swelling of the neck and tough grayish membrane
    forms in the throat from the infection
  • Cutaneous diphtheria (esp. in persons gt30 yrs).
    It is infected skin wound leads to slow-healing
    ulcer.
  • Treated by erythromycin or penicillin

55
Lower Respiratory Tract Infection
56
Lower respiratory tract Infections
  • The respiratory tract is protected by a number of
    very effective defense mechanisms designed to
    keep infectious organisms and particulates from
    reaching the lungs .
  • For an organism to reach the lower respiratory
    tract, the organism must be particularly virulent
    and present in very large number or the host
    defense barriers must be weakened.

57
  • Lower respiratory system
  • Contains the larynx, trachea, bronchial tubes,
    and lungs

58
  • Factor that might weaken the respiratory defense
    barriers
  • Cigarette smoking, which can paralyze the cilia
    lining the cells of the respiratory passages and
    impair removal of secretions, particles and
    microorganisms.
  • The presence of a respiratory pathogen such as
    the cold or influenza virus .

59
  • Defenses of the Respiratory System
  • Moist, mucus-covered surfaces Trap particles
    and organisms
  • Cell surface IgA, lysosomes
  • Ciliated epithelium Clears trapped particles
    and organisms from airway passages
  • Cough reflex and epiglottis Prevents aspiration
    of particles and irritants into lower airways
  • Pulmonary macrophages Phagocytize foreign
    particles and organisms in the alveolar spaces

60
Lower Respirator Tract Infection
  • Bacteria, viruses, and fungi cause
  • Bronchitis
  • Bronchiolitis
  • Pneumonia

61
Lower respiratory tract Infections
  • Bacterial Infections

62
  • Pneumonia
  • Pneumonia is a condition that involves
    inflammation of lower lung structures such as the
    alveoli or interstitial spaces.
  • It may be caused by bacteria such as Pneumococci
  • The prevalence and severity of pneumonia have
    been heightened in recent years due to the
    emergence of HIV as well as antibiotic
    resistance.
  • There tend to be distinct organisms that cause
    pneumonia in the hospital setting vs. the
    community setting.

63
Predisposing Factors
  • Individuals Most at Risk for Pneumonia
  • Elderly
  • Those with viral infection
  • Chronically ill
  • AIDS or immunosuppressed patients
  • Smokers
  • Patients with chronic respiratory disease e.g.
    bronchial asthma.

64
Types of pneumonia
  • Community acquired pneumonia (CAP)
  • Aspiration pneumonia
  • Hospital
  • Hospital acquired pneumonia (HAP)
  • Ventilator associated pneumonia (VAP)
  • Healthcare associated pneumonia (HCAP)

65
Potential Pathogens
  • Typical
  • Streptococcus pneumoniae (Pneumococci).
  • Hemophilus influenzae
  • Mycobacterium catarrhalis
  • Klebsiella pneumoniae
  • Atypical
  • Chlamydia pneumoniae
  • Legionella pneumophila
  • Mycoplasma pneumoniae.

66
Other Potential Pathogens
  • Viruses
  • Fungi
  • Less Common pathogens
  • N. meningitidis
  • Chlamydia psittaci
  • B. anthracis
  • Y. pestis

67
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68
Other classification of pneumonia
  • A second classification scheme for pneumonia is
    based on the specific structures of the lung that
    the organisms infect and includes typical and
    atypical pneumonia.
  • 1-Typical pneumonia
  • Usually bacterial in origin.
  • Organisms replicate in the spaces of the
    alveoli.
  • Manifestations
  • Inflammation and fluid accumulation are seen in
    the alveoli.
  • White cell infiltration and exudation can been
    seen on chest radiographs.
  • High fever, chest pain, chills, and malaise are
    present.
  • Purulent sputum is present.
  • Some degree of hypoxemia is present.

69
  • 2- Atypical pneumonia
  • Usually viral in origin.
  • Organisms replicate in the spaces around the
    alveoli.
  • Manifestations
  • Milder symptoms than typical pneumonia.
  • Lack of white cell infiltration in alveoli.
  • Lack of fluid accumulation in the alveoli.
  • Not usually evident on radiographs.
  • May make the patient susceptible to bacterial
    pneumonia.

70
  • 3- Opportunistic organisms
  • A number of organisms can cause severe
    respiratory infections and pneumonia in patients
    with immunocompromisation (eg. HIV virus or as a
    result of immune suppressive therapy).
  • These organisms include mycobacteria, fungus
    (Histoplasma) and fungi (Pneumocystis carinii).
    They rarely affect healthy people.
  • Treatment of these organisms requires specific
    drug therapy.

71
  • Treatment of pneumonia
  • Antibiotics if bacterial in origin. The
    health-care provider should consider the
    possibility that antibiotic-resistant organisms
    are present. Other causative agent are treated
    accordingly(eg . Antiviral, antifungal and anti
    protozoal).
  • Oxygen therapy for hypoxemia.
  • A vaccine for pneumococcal pneumonia is
    currently available and highly effective. This
    vaccine should be considered in high-risk
    individuals.

72
Pertussis (Whooping Cough)
  • Bordetella pertussis
  • Gram-negative coccobacillus.
  • Encapsulated.
  • Aerosal Transmission from human to human.

73
  • Pathogenesis
  • Tracheal cytotoxin of cell wall damaged ciliated
    cells
  • Pertussis toxin
  • Prevented by DTaP vaccine (acellular Pertussis
    cell fragments)

74
  • Clinical picture of Pertussis.
  • Stage 1 Catarrhal stage, like common cold.
  • Stage 2 Paroxysmal stageviolent coughing
    sieges.
  • Stage 3 Convalescence stage.

75
Mycoplasma pneumonia
  • Atypical pneumonia caused by the bacteria
    Mycoplasma pneumoniae
  • Bacteria has no cell wall
  • More common in young adults (under 40) and
    children
  • Symptoms are low grade fever, cough, headache
    that may last for several weeks
  • Treated with erythromycin and tetracycline

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Tuberculosis
  • Lung infection caused by the acid-fast bacteria
    Mycobacterium tuberculosis.
  • Acquired by inhalation
  • Strong immune system often will prevent the
    bacteria from causing infection
  • Weak immune system or poor general health can
    lead to infection and possibly death

78
Mycobacterium tuberculosis
79
Types of Mycobacteria
  • M. bovis lt1 U.S. cases not transmitted from
    human to human usually affect the bones or
    lymphatic system.
  • M. avium-intracellulare complex infects people
    with late-stage HIV infection.
  • - The mycolic acids of the cell wall are an
    important factor in the pathogenicity.

80
  • - Mycolic acids also gives it resistance to
    drying and disinfectants.
  • - Lesions formed by M. tuberculosis are called
    tubercles dead macrophages and bacteria form the
    caseous lesion that might calcify and appear in
    an X-ray image as a Ghons complex.

81
Ghons complex
82
Pathogenesis of TB
  • Bacteria are ingested by lung macrophages but are
    not killed.
  • Bacteria multiply inside the macrophages.
  • Infected macrophages are isolated in the lungs in
    lesions called tubercles.
  • The tubercles can rupture and release bacteria
    into the body to cause systemic disease and
    infection to others.
  • Symptoms include weight loss, coughing blood,
    loss of vigor, wasting and death.

83
The Pathogenesis of Tuberculosis
84
The Pathogenesis of Tuberculosis
85
The Pathogenesis of Tuberculosis
86
The Pathogenesis of Tuberculosis
87
The Pathogenesis of Tuberculosis
88
Diagnosis of Tuberculosis
  • Tuberculin skin test screening
  • Positive reaction means current or previous
    infection
  • Followed by X-ray or CT exam, acid-fast staining
    of sputum, culturing of bacteria and PCR TEST for
    TB.

89
TB Testing
  • Tuberculin skin test is used to screen for the
    disease
  • Test results
  • if you have had TB
  • if you have been exposed but never had active
    TB
  • if you have been vaccinated
  • - never had or been exposed to the disease

90
A Positive Tuberculin Skin Test
  • A positive tuberculin skin test can indicate
    either an active case of TB, prior infection, or
    vaccination and immunity to the disease.

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93
Incidence of TB
  • 20,000 new cases in the US each year
  • Incidence decreasing in the US
  • Estimated 1/3 of the world population is infected
  • 10-12 million deaths per year from TB
  • Antibiotic resistant strains are emerging

94
Treatment
  • Long term antibiotic therapy with antibiotic such
    as isoniazid, rifampin, and pyrazinamide
  • Vaccination with the BCG vaccine
  • Vaccine effectiveness is questionable used in
    much of the world except the US

95
Pleurisy/ Pleuritis
  • Inflamation of parietal visceral pleura.
  • May be primary or secondary.
  • Etiology
  • Infection, SLE, traumatic, etc.
  • S/S Pleuritic or sharp chest pain.
  • Treatment pain relief and treatment of
    underlying cause.

96
Lung Abscess
  • Area of necrotic purulent lung
  • More common in dependent areas of lungs and in
    right lung
  • May be caused by pneumonias or by spread of
    infection by blood from other areas of the body
  • Testing treatment Often seen on CXR,
    antibiotics possible excision

97
Legionnaires Disease(Legionella Pneumonia)
  • Pneumonia caused by bacteria
  • Legionella pneumophilia.
  • Named for 1976 outbreak at an American Legion
    convention
  • Severity varies
  • S/S nonproductive cough at first, then grayish
    sputum
  • Treatment antibiotics

98
Lower respiratory tract Infections
  • Fungal Infections

99
Fungal Infections
  • Fungal spores are easily inhaled they may
    germinate in the lower respiratory tract.
  • The incidence of fungal diseases has been
    increased in recent years.
  • The mycoses can be treated with amphotericin B.

100
Coccidiodomycosis
  • Fungal disease of the lungs
  • Coccidiodes immitis
  • Endemic to the desert southwest
  • Causes either no symptoms or mild symptoms,
    including chest pain, fever, coughing, and weight
    loss
  • Immune suppressed individuals may develop a TB
    like disease that can become systemic
  • Amphotericin B is used to treat the condition

101
Histoplasmosis
  • Histoplasma capsulatum, dimorphic fungus
  • Bird droppings provide nutrients, especially
    nitrogen, to the fungus
  • Symptoms similar to tuberculosis (identify by
    microscopic exam of sputa serologic tests)

102
Obstructive lung diseases
  • Cystic fibrosis
  • Cancer
  • Aspiration pneumonia
  • COPD (chronic obstr. pulm. dis)
  • - Emphysema
  • - Chronic bronchitis
  • - Bronchial asthma
  • - bronchiectasis

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104
Bronchial Asthma
  • Asthma is a condition characterized by reversible
    bronchospasm and chronic inflammation of airway
    passages.
  • The incidence of asthma has been steadily
    increasing in recent years.
  • Although the exact etiology is still uncertain,
    there appears to be a definite genetic
    predisposition to the development of asthma.

105
Pathogenesis of bronchial ashma.
  • A key component of asthma appears to be airway
    hyper reactivity in affected individuals.
    Exposure to certain triggers can induce marked
    bronchospasm and airway inflammation in
    susceptible patients.
  • Patients with asthma appear to produce large
    amounts of the antibody IgE that attach to the
    mast cells present in many tissues.

106
  • Exposure to a trigger such as pollen will result
    in the allergen-binding mast cell-bound IgE,
    which in turn causes the release of inflammatory
    mediators such as Histamine , Leukotrienes and
    Eosinophilic Chemotactic factor.
  • The response of a patient with asthma to these
    triggers can be divided into an early phase and
    a late phase.

107
  • Some Potential Asthma Triggers
  • Allergens Pollen, pet dander, fungi, dust
    mites.
  • Cold air.
  • Pollutants.
  • Cigarette smoke.
  • Strong emotions.
  • Exercise.
  • Respiratory tract infections.

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  • Early phase of asthma
  • The early phase of asthma is characterized by
  • marked constriction of bronchial airways
    (bronchospasm)
  • edema of the airways
  • production of excess mucus.
  • The bronchospasm that occurs may be the result
    of the increased release of certain inflammatory
    mediators such as histamine, prostaglandins and
    bradykinin that, in the early stages of asthmatic
    response, promote bronchoconstriction rather than
    inflammation.

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  • Early phase of asthma

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  • Late phase of asthma
  • The late phase of asthma can occur several hours
    after the initial onset of symptoms and manifests
    mainly as an inflammatory response.
  • The primary mediators of inflammation during the
    asthmatic response are the white blood cells
    Eosinophils that stimulate mast cell
    degranulation and release substances that attract
    other white cells to the area.

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  • Subsequent infiltration of the airway tissues
    with white blood cells such as Neutrophils and
    lymphocytes also contributes to the overall
    inflammatory response of the late phase of asthma.

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Clinical Classification of Asthma
  • Mild intermittent Attacks occur 2 times per
    week or less
  • Mild persistent Attacks occur more than 2 times
    per week
  • Moderate persistent Attacks occur daily or
    almost daily and are severe enough to affect
    activity
  • Severe persistent Attacks are very frequent and
    persist for a long period of time attacks
    severely limit activity

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  • Manifestations of asthma
  • Coughing, wheezing
  • Difficulty breathing
  • Rapid, shallow breathing
  • Increased respiratory rate
  • Excess mucus production
  • Significant anxiety

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  • Staging of the Severity of an Acute Asthma Attack
  • Stage I (mild)
  • Mild Dyspnea
  • Diffuse wheezing
  • Adequate air exchange
  • Stage II (moderate)
  • Respiratory distress at rest
  • Marked wheezing
  • Stage III (severe)
  • Marked respiratory distress
  • Cyanosis
  • Marked wheezing or absence of breath sounds
  • Stage IV (respiratory failure)
  • Severe respiratory distress, lethargy, confusion,
    prominent pulsus paradoxus

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  • Possible complications of asthma can include
  • 1- Severe acute Asthma (status asthmatics), which
    is a life-threatening condition of prolonged
    bronchospasm that is often not responsive to drug
    therapy.
  • 2- Respiratory failure marked hypoxemia and
    acidosis might occur.

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  • 3- Pneumothorax is also a possible consequence
    as a result of lung pressure increases that can
    result from the extreme difficulty involved in
    expiration during a prolonged asthma attack.

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  • Treatment of asthma
  • The treatment regimen for asthma is based on the
    frequency and severity of the asthma attacks
  • 1. Avoidance of triggers, and allergens. Improved
    ventilation of the living spaces, use of air
    conditioning.
  • 2. Bronchodilators (eg albuterol, terbutaline)
    Short acting ß-Adrenergic receptor activators.
    May be administered as needed in the form of a
    nebulizer solution using a metered dispenser or
    may be given subcutaneously. These drugs block
    bronchoconstriction but do not prevent the
    inflammatory response.

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  • 3.Xanthine drugs (example theophylline)
  • Cause bronchodilation and also inhibit the late
    phase of asthma.
  • These drugs are often used orally as second-line
    agents in combination with other asthma therapies
    such as steroids.
  • Drug like theophylline can have significant
    central nervous system, cardiovascular and
    gastrointestinal side effects that limit their
    overall usefulness.

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  • 4. Cromolyn sodium
  • Anti-inflammatory agent that blocks both the
    early and late phase of asthma. The mechanism of
    action is unclear but may involve mast cell
    function or responsiveness to allergens.
  • 5. Anti-inflammatory drugs (corticosteroids)
  • Used orally or by inhalation to blunt the
    inflammatory response of asthma.

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  • The most significant unwanted effects occur with
    long-term oral use of corticosteroids and may
    include immunosuppression , increased
    susceptibility to infection, osteoporosis and
    effects on other hormones such as the
    glucocorticoids.
  • 6. Leukotrienes modifiers (example Zafirlukast)
  • New class of agents that blocks the synthesis of
    the key inflammatory mediators, leukotrienes.

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Bronchitis
  • Bronchitis is an obstructive respiratory disease
    that may occur in both acute and chronic forms.
  • Acute bronchitis Inflammation of the bronchial
    passages most commonly caused by infection with
    bacteria or viruses.
  • Acute bronchitis is generally a self-limiting
    condition in healthy individuals but can have
    much more severe consequences in individuals who
    are weakened with other illness or who are
    immunocompromised.
  • Symptoms of acute bronchitis often include
    productive cough, Dyspnea and possible fever.

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  • Chronic bronchitis Chronic bronchitis is a
    chronic obstructive pulmonary disease that is
    most frequently associated with cigarette smoking
    (approximately 90 of cases).
  • Chronic bronchitis may also be caused by
    prolonged exposure to inhaled particulates such
    as coal dust or other pollutants.
  • Chronic bronchitis sufferers are often referred
    to as blue bloaters as a result of the cyanosis
    and peripheral edema that is often present.

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  • The disease is characterized by excess mucus
    production (purulent) in the lower respiratory
    tract. This mucus accumulation can impair
    function of the ciliated epithelium and lining of
    the respiratory tract and prevent the clearing of
    debris and organisms. As a result, patients with
    chronic bronchitis often suffer repeated bouts of
    acute respiratory infection.
  • Dyspnea, hypoxia, cyanosis and Symptoms of cor
    pulmonale.
  • Fluid accumulation (edema) in later stages

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  • Treatment of chronic bronchitis
  • 1. Cessation of smoking or exposure to irritants.
  • 2. Bronchodilators to open airway passages.
  • 3. Expectorants to loosen mucus.
  • 4. Anti - inflammatory to relieve airway
    inflammation and reduce mucus secretion.
  • 5. Prophylactic antibiotics for respiratory
    infections.
  • 6. Oxygen therapy.

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  • Bronchiectasis
  • It is a condition that results from prolonged
    injury or inflammation of respiratory airways and
    bronchioles.
  • It is characterized by abnormal dilation of the
    bronchus or bronchi. It is most frequently
    associated with chronic respiratory disease,
    infections, cystic fibrosis, tumor growth or
    exposure to respiratory toxins.
  • The major manifestations of bronchiectasis are
    impaired ventilation of the alveoli, chronic
    inflammation and possible fibrosis of the areas.

127
Emphysema
  • Emphysema is a respiratory disease that is
    characterized by destruction of the elastic wall
    of alveolar air sacs causing their permanent
    enlargement and damage.

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  • Well over 95 of all patients with emphysema were
    chronic cigarette smokers. Although the exact
    etiology of emphysema is still uncertain,
  • Chronic exposure to cigarette smoke causes
    chronic inflammation of the alveolar airways,
    which results in infiltration by lymphocytes and
    macrophages.
  • Excess release of protease enzymes such as
    trypsin from lung tissues and leukocytes can
    digest and destroy the elastic walls of the
    alveoli.

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  • Bullous emphysema Large subpleural
    bullae

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  • Levels of a protective enzyme a-1-antitrypsin
    have been shown to be lacking in certain
    individuals who are chronic cigarette smokers.
    This enzyme inactivates destructive protease
    enzymes (trypsin) in lung tissue.
  • In fact, a rare form of emphysema occurs in
    individuals who are not cigarette smokers but who
    have a genetic lack of a-1-antitrypsin.

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  • Manifestations are caused by Loss of alveolar
    (lung) elasticity and a decrease in the overall
    surface area for gas exchange within the lungs.
  • Manifestations include the following
  • - Tachypnea (increased respiratory rate) Because
    that is effective in maintaining arterial blood
    gases, one does not usually see hypoxia or
    cyanosis until the end stages of the disease.
  • - Barrel chest from prolonged expiration.
  • - Lack of purulent sputum.
  • - Possible long-term consequences, including cor
    pulmonale , respiratory failure.

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Comparison of Symptoms for Chronic Bronchitis
and Emphysema
Chronic bronchitis Emphysema
Mild Dyspnea Dyspnea that may be severe
Productive cough Dry or no cough
Cyanosis common Cyanosis rare
Respiratory infection common Infrequent infections
Onset usually after 40 years of age Onset usually after 50 years of age
History of cigarette smoking History of cigarette smoking
Cor pulmonale common Cor pulmonale in terminal stages
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Pneumothorax
  • Pneumothorax is the entry of air into the pleural
    cavity in which the lungs reside.
  • In order for normal lung expansion to occur,
    there must be a negative pressure within the
    pleural cavity with respect to atmospheric
    pressure outside the pleural cavity. The inside
    of the pleural cavity is essentially a vacuum and
    when air enters the pleural cavity the negative
    pressure is lost and the lungs collapse.
  • Because each lung sits in a separate pleural
    cavity, pneumothorax of one plural cavity will
    not cause collapse of the other lung.

135
Types of pneumothorax
  • 1. Open or communicating pneumothorax
  • Usually involves a traumatic chest wound.
  • Air enters the pleural cavity from the
    atmosphere.
  • The lung collapses due to equilibration of
    pressure within the pleural cavity with
    atmospheric pressure.

2. Closed or spontaneous pneumothorax Occurs
when air leaks from the lungs into the pleural
cavity. May be caused by lung cancer, rupture,
pulmonary disease. The increased plural
pressure prevents lung expansion during
inspiration and the lung remains collapsed.
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3. Tension pneumothorax A condition in which
there is a one-way movement of air into but not
out of the pleural cavity. May involve a hole
or wound to the pleural cavity that allows air to
enter and the lung to collapse. Upon expiration,
the hole or opening closes, which prevents the
movement of air back out of the pleural cavity.
A life-threatening condition because pressure in
the pleural cavity continues to increase and may
result in further lung compression or compression
of large blood vessels in the thorax or the
heart.
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  • Manifestations of pneumothorax
  • Tachypnea, Dyspnea
  • Chest pain
  • Possible compression of thoracic blood vessels
    and heart, especially with tension pneumothorax
  • Treatment of pneumothorax
  • Removal of air from the pleural cavity with a
    needle or chest tube
  • Repair of trauma and closure of opening into
    pleural cavity

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Restrictive Pulmonary Disorders
  • Abnormalities of chest wall which limits lung
    expansion
  • - Kyphosis
  • - Scoliosis
  • - Polio
  • - Atelectasis
  • - Muscular dystrophy
  • Disease affecting lung tissue that provides
    supporting framework
  • - Occupational diseases (pneumoconioses)
  • - Idiopathic pulmonary fibrosis (autoimmune
    disease)
  • - Pulmonary edema
  • - Acute respiratory distress syndrome (ARDS)

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Atelectasis
  • Atelectasis is a condition in which there is
    incomplete expansion of lung tissues due to
    blockage of the airways or compression of the
    alveolar sacs.
  • Types of atelectasis
  • 1. Absorption atelectasis
  • Results when the bronchial passages are blocked
    with mucus, tumors or edema
  • May occur with conditions such as chronic
    bronchitis or cystic fibrosis in which there is
    the accumulation of excess mucus in the
    respiratory passages
  • 2. Compression atelectasis
  • Occurs when lung tissue is compressed
    externally by air, blood, fluids or a tumor

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  • Manifestations of atelectasis
  • Dyspnea, cough.
  • Reduced gas exchange.
  • Shunting of blood to areas of the lungs that
    are inflated. The ventilation perfusion coupling
    ability of the lungs will help ensure that blood
    is directed to areas of the lungs where gas
    exchange can still occur.
  • Treatment of atelectasis
  • Removal of airway blockage
  • Removal of air, blood, fluids, tumors, etc.
    that are compressing lung
  • tissues

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  • Pneumoconiosis
  • Def occupational diseases from inhaling
    inorganic dust particles
  • over a long time period (10 years
    or greater)
  • Pathophysiology
  • Get inflammation fibrosis
  • This destroys the connective tissue framework of
    lungs
  • Lung compliance is lost
  • Of all the causes, asbestosis is worst
  • Also gives one pleural fibrosis lung cancer
  • Sx
  • First to appear is dyspnea on exertion
  • Eventually get pulmonary hypertension

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  • Types
  • Anthracosis black lung disease from coal dust
    (carbon)
  • Asbestosis from asbestos fibers, most common
    form
  • Berylliosis from beryllium dust
    (semiconductors)
  • Silicosis from silica dust (quartz dust) e.g.
    stone quarries

Asbestos bodies in lung
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Adult respiratory distress syndrome (ARDS)
  • ARDS is a syndrome associated with destruction of
    alveolar membranes
  • and their related capillaries. It may occur as a
    result of direct injury to the lungs or as a
    result of dramatic decreases in blood flow to the
    lung (shock lung) .

148
Possible Causes of ARDS
  • Septicemia, uremia
  • Trauma
  • Near drowning
  • Inhalation of toxic gases or agents
  • Aspiration of gastric contents
  • Widespread pneumonia
  • Drug overdose
  • Systemic shock

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Manifestations of ARDS
  • Dyspnea, tachypnea.
  • Hypoxemia CO2 is significantly more water
    soluble than O2 and can still be eliminated from
    the lungs via diffusion as a result blood levels
    of oxygen are more affected by ARDS than CO2.
    Hypocapnia may result.
  • Infiltration of lung tissues with immune cells
    that release inflammatory mediators.
  • Accumulation of fluids in alveoli and around
    alveolar spaces.
  • Changes in blood pH due to altered blood levels
    of CO2.
  • Pulmonary fibrosis.
  • Respiratory failure.

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Treatment of ARDS
  • Oxygen therapy
  • Anti-inflammatory drugs
  • Diuretics to reduce edema
  • Correction of acidbase balance

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Respiratory distress syndrome of the newborn
  • The etiology of newborn respiratory distress
    syndrome differs considerably from that of the
    adult disorder.
  • Respiratory distress in the newborn is most
    commonly caused by a lack of surfactant in the
    lungs.
  • Pulmonary surfactant is a mixture of lipids and
    proteins produced by Type II cells of the
    alveoli.
  • A thin layer of surfactant covers the surfaces of
    the alveoli and provides surface tension that
    prevents the thin-walled alveoli from collapsing.

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  • Surfactant also moistens the alveolar surfaces to
    facilitate gas exchange.
  • Respiratory distress syndrome of the newborn
    occurs most commonly in infants who are born
    prematurely and whose lungs have not developed to
    the point where they are producing adequate
    surfactant.
  • Clinical manifestations become evident
    immediately at birth and can be rapidly fatal if
    not treated.

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Manifestations
  • Rapid, shallow breathing
  • Lung collapse
  • Lung inflammation and damage
  • Hypoxemia
  • Nasal flaring, grunting upon inspiration

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Treatment
  • 1- Delay or prevention of premature delivery of
    infant if possible.
  • Treatment of premature newborn with synthetic
    surfactant delivered directly into the lower
    respiratory tract. Exogenous surfactant will need
    to be supplied until the infants lungs have
    matured to the point where they are producing
    their own surfactant.

155
  • Mechanical ventilation.
  • Injection of cortisol in the mother prior to
    delivery may significantly reduce the incidence
    of respiratory distress syndrome in premature
    infants.
  • Cortisol has also been shown to stimulate
    activity of Type II cells.

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  • Vascular disorders

157
  • Pulmonary edema
  • Pathophysiology
  • Fluid collection (edema) in all lung tissues
  • Affects gas exchange
  • Affects lung expansion
  • Key pulmonary capillary pressure increases
    fluid moves into alveoli
  • Capillaries rupture get bloody sputum
    (hemoptysis)
  • True medical emergency
  • Etiology
  • Left sided heart failure
  • Hypoproteinemia
  • Inhalation of toxic gases
  • Lymphatic blockage (e.g. from tumor)

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  • Pulmonary Emboli
  • def clot of foreign matter that occludes artery
    in pulmonary system
  • Size of embolus general health of patient
    determine degree of damage and amount of symptoms
  • see next slide for pathophysiology
  • etiol
  • determined by composition of emboli
  • thrombus (most common) , air, fat, bacteria,
    tissue
  • risk increased by CHF, lung disease, stasis with
    varicosities
  • 90 originate from deep veins (primarily in leg)
  • Old age large bone fractures give fat emboli

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  • Sx
  • generally apprehension, cough, chest pain, fever
  • if severe ------ dyspnea, tachypnea, hemoptysis
  • if massive ----- shock death
  • Dx imaging, blood gases
  • Tx
  • maintain adequate ventilation via O2
    anticoagulants
  • ? Thrombolytic drugs
  • Prevention via early ambulation, TED Stockings

161
Pathophysiology of pulmonary embolus
162
  • Lung Cancer
  • leading cause of cancer deaths in both men
    woman in US
  • 4 cell types
  • Oat Cell (2) Squammous Cell (3)
    AdenoCa (4) large cell
  • Pathophysiology
  • Most arise from bronchi or bronchioles

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  • Squamous cell from large bronchi at hilus of lung
  • Slow growing late metastasis
  • Adenocarcinoma (bronchoalveolar)
  • Found in periphery
  • Present frequently with pleural effusion
  • Moderate growth rate
  • Oat cell (small cell)
  • Found centrally near large bronchus
  • Fast growing early metastasis
  • Large cell (undifferentiated)
  • Rapid growth early metastasis
  • Found in periphery thus get pleural effusion

164
  • Effects from lung cancer
  • Obstruction
  • Inflammation
  • Pleural effusion
  • Paraneoplastic syndrome
  • The tumor cells secrete hormone-like substances
  • ADH ACTH
  • Squamous cell lung cancer

165
Squamous cell cancer
Oat cell cancer
Adenocarcinoma
Large cell cancer
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Respiratory Failure
  • Respiratory failure is a condition that results
    when the lungs are no longer able to oxygenate
    the blood sufficiently or remove CO2 from it.
  • It may occur as
  • the end result of chronic respiratory diseases,
    or it may be an acute event caused by factors
    such as neumothorax or Opioid drug overdose

168
Manifestations of respiratory failure
  • Hypoxemia.
  • Hypercapnia
  • Cyanosis, possible but not always present.
  • Central nervous system symptoms Slurred
    speech, confusion, impaired motor function
  • Altered blood pH
  • Initial tachycardia and increased cardiac
    output followed by bradycardia and decreased
    cardiac output

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Causes of Respiratory Failure
  • B) Chronic
  • Emphysema
  • Interstitial lung diseases
  • Cystic fibrosis
  • Spinal cord or brain injury
  • Congestive heart failure
  • Neuromuscular disorders Muscular dystrophy,
    myasthenia gravis, amyotrophic lateral sclerosis
  • Pulmonary emboli
  • Diffuse pneumonia
  • Pulmonary edema
  • A) Acute
  • Pneumothorax
  • Drug overdose (opioids, sedatives)
  • Pleural effusion Accumulation of fluids in the
    pleural cavity
  • Airway obstruction
  • Status asthmaticus
  • Inhalation of toxins or noxious gases.

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  • Treatment of respiratory failure
  • Bronchodilators
  • Correction of blood pH
  • Oxygen therapy
  • Mechanical ventilation

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Respiratory Pathophysiology243 RTS
  • Prepared by
  • Dr. Taghrid M. Abdallah.
  • Dr.Taghrid_at_Inaya.edu.sa
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