Pulmonary%20Conditions

1
Pulmonary Conditions

• Medical and Psychosocial Aspects of Disability
• RCS 6080

2
Description Definitions

• Chronic Obstructive Pulmonary Disease (COPD) is
  characterized by decreased expiratory airflow
• Reduction in expiratory airflow has 2 causes
• Decreased expiratory air flow pressure (decrease
  in driving pressure)
• Increased resistance to expiratory air flow
  (resulting from narrowing of airways)

3
Descriptions/Definitions

• Emphysema chronic bronchitis are often
  considered together under the term COPD because
  most people with one of these conditions has the
  other. Thus most people with COPD with have both
  airway alveolar disease.
• COPD affects as many as 30,000,000 Americans
• COPD is the 5th leading cause of death

4
Etiology, Pathophysiology Clinical Features

• Several factors are involved in the pathogenesis
  of COPD, but smoking is the most important
• Other factors include occupational exposure to
  dust, fumes air pollution.
• Aside from these factors, the development and
  progression of COPD is largely related to genetic
  disposition.

5
(No Transcript)
6
Emphysema

• Emphysema is an enlargement of air spaces caused
  by destruction of alveolar walls. Air spaces
  greater than one cm are bullae. This photo shows
  apical bullous disease with relatively little
  involvement of the rest of the lung.

7
Emphysema

• Emphysema can be a result of obstruction caused
  by chronic bronchitis. It occurs when there is
  back pressure on the alveoli. This increased
  pressure tends over time to make their walls
  break down, and instead of having lots of tiny
  air sacs functioning well, you end up with large
  cavities consisting of alveoli that have
  coalesced, and which do not adequately perform
  the task of gas transfer.

8
Chronic Bronchitis

• The lungs essentially comprise lots of tubes and
  tubules (called bronchi and bronchioles) of
  gradually diminishing size, which end in little
  collections of air sacs called alveoli. It is
  across the walls of the alveoli that the gases
  are exchanged, oxygen being taken into the
  bloodstream and carbon dioxide passing into the
  alveoli to be exhaled. Chronic bronchitis is an
  inflammation or irritation of the airways in the
  lungs which is associated with
• Scarring or fibrosis of the walls of the
  bronchioles making them less pliable
• Thickening of their lining causing narrowing of
  the airway
• Production of excessive quantities of thick mucus
  which further plugs the tubules and compromises
  breathing

9
Categories of COPD

• Type A - Pink Puffer
• Considered to have predominantly emphysema
• Type B - Blue Bloater
• Considered to have predominantly chronic
  bronchitis.

10
Functional Disabilities

• Earliest manifestations of COPD may be relatively
  mild, but as time goes on, dyspnea becomes the
  most limiting factor
• Years may pass before the degree of dyspnea is
  severe enough to limit routine ADLs such as
  walking.
• As time progresses, activities such as dressing,
  bathing, speech and even eating cannot be
  accomplished without severe shortness of breath

11
Functional Disabilities

• Until the disease is extremely advanced,
  sedentary activities may be accomplished without
  much difficulty.
• Driving may be possible, but walking - even
  limited distances - may not be feasible,
  particularly is there is an incline or stairs.

12
Functional Disabilities

• Assessment of a given persons functional
  capabilities may be difficult to determine based
  solely on pulmonary function studies and blood
  gases.
• Depression, fear, anxiety are potent factors
  that may further exacerbate the persons physical
  limitations.
• Preparation of sedentary occupation is useful
  even when COPD is mild because the rate of
  progression is variable.

13
Treatment of COPD

• Many people with COPD might be able to have some
  reversibility through proper medical
  management.
• Adequate fluid intake and use of expectorants are
  needed to clear the respiratory tract of
  secretions.
• Oxygen therapy

14
Treatment of COPD

• Chest physical therapy and pulmonary
  rehabilitation programs are useful to
• Learn how to expel mucus from respiratory tract
• Learn breathing exercises and relaxation
  techniques (useful in ADLs)
• Do exercise reconditioning that can help increase
  endurance improve work capacity

15
Psychological Implications

• Counseling often helps the person deal with the
  anxiety/stress associated with diseases that can
  cause shortness of breath limitations of
  activity.
• Learning to deal effectively with problems make
  satisfactory lifestyle can reduce feelings of
  desperation.

16
Vocational implications

• People may have to change employment goals
• The American Thoracic Society
• Mild impairment usually not correlated with
  reduced ability to perform most jobs.
• Moderate impairment correlates with a decreased
  ability to meet the demands of many jobs
• Severe impairment pulmonary function is so
  impaired that a person cannot meet the demands of
  most occupations.

17
Asthma

• Asthma is considered an inflammatory disease of
  the airways
• Reversible airway obstruction
• Bronchial hyper-reactivity
• Frequency, duration, severity of asthma attacks
  varies from person to person.
• Asthma attacks are characterized by shortness of
  breath wheezing.

18
Asthma

• Mainly a bronchial disease, asthma is
  characterized by features in the following 3
  images
• Mural inflammation (eosinophils, mast cells,
  lymphocytes)
• Wall thickening by edema, hyperemia, fibrosis
• Smooth muscle thickening (arrow)
• Mucous plugs
• Epithelial slough

19
(No Transcript)
20
Pathology of Asthma
Normal Lungs
Asthma
Source What You and Your Family Can Do About
Asthma by the Global Initiative For Asthma
Created and funded by NIH/NHLBI
21
Asthma Prevalence by AgeUnited States 19801996
Under 18
Total
18
Source National Health Interview Survey
12-month prevalence
22
Asthma Prevalence by SexUnited States 19821996
Female
Total
Male
Source National Health Interview Survey
12-month prevalence
23
Asthma Prevalence by RaceUnited States
19821996
Black
White
Source National Health Interview Survey
12-month prevalence
24
Asthma Prevalence by RaceAges 5-34, United
States 19801996
Black, 5-34
White, 5-34
Source National Health Interview Survey
12-month prevalence
25
Age-Adjusted Asthma Mortality Rates by Sex,
United States 19791998
Female
Total
Male
Source Underlying Cause of Death dataset by the
National Center for Health Statistics
Age-adjusted to 2000 U.S. population
26
Age-Adjusted Asthma Mortality Rates by Race,
United States 19791998
60
50
Black
40
Other
30
20
Rate per million
White
10
0
Year
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
Source Underlying Cause of Death dataset by the
National Center for Health Statistics
Age-adjusted to 2000 U.S. population
27
Asthma Mortality Rates by RaceAges 5-34, United
States 19791998
Black
White
Other
Source Underlying Cause of Death dataset by the
National Center for Health Statistics
Unreliable (lt 20 deaths) 19791995
28
Costs of AsthmaUnited States, 19801998Projectio
n for the Year 2000
Source Weiss, et al. 1992 Weiss, et al.
2001
29
Risk Factors for Development of Asthma

• Genetic characteristics
• Environmental exposures
• Contributing factors

30
Risk Factors for Development of AsthmaGenetic
Characteristics

• Atopy
• The bodys predisposition to develop an antibody
  called immunoglobulin E (IgE) in response to
  exposure to environmental allergens
• Can be measured in the blood

31
Clearing the AirCategories for Associations of
Various Elements

• Sufficient evidence of a causal relationship
• Sufficient evidence of an association
• Limited or suggested evidence of an association
• Inadequate or insufficient evidence to determine
  whether an association exists
• Limited or suggestive evidence of no association

32
Clearing the AirIndoor Air Exposures and Asthma
Development

• Biological Agents
• Sufficient evidence of a causal relationship
• House dust mite
• Sufficient evidence of an association
• None found
• Limited or suggestive evidence of an association
• Cockroach (in preschool-aged
  children)
• Respiratory syncytial virus (RSV)

• Chemical Agents
• Sufficient evidence of a causal relationship
• None found
• Sufficient evidence of an association
• Environmental tobacco smoke (in
  preschool-aged children)
• Limited or suggestive evidence of an association
• None found

33
Clearing the AirIndoor Air Exposures and Asthma
Exacerbation

• Biological Agents
• Sufficient evidence of a causal relationship
• Cat
• Cockroach
• House dust mite
• Sufficient evidence of an association
• Dog
• Fungi/Molds
• Rhinovirus
• Limited or Suggestive Evidence of an Association
• Domestic birds
• Chlamydia and Mycoplasma
• pneumoniae
• RSV

• Chemical Agents
• Sufficient evidence of a causal relationship
• Environmental tobacco smoke (in preschool-aged
  children)
• Sufficient evidence of an association
• NO2, NOx (high levels)
• Limited or suggestive evidence of an association
• Environmental tobacco smoke (school-aged, older
  children and adults)
• Formaldehyde
• Fragrances

34
Medications to Treat Asthma

• Medications come in a variety of forms.
• Two major categories of medications are
• Long-term control
• Quick relief

35
Medications to Treat AsthmaLong-Term Control

• Taken daily, over a long period of time
• Used to reduce inflammation, relax airway
  muscles, and improve symptoms and pulmonary
  function
• Inhaled corticosteroids
• Long-acting beta2-agonists
• Leukotriene modifiers

36
Medications to Treat AsthmaQuick-Relief

• Used in acute asthma episodes
• Generally they are short-acting beta2-agonists

37
Medications to Treat AsthmaHow to Use a Spray
Inhaler
Health-care provider should evaluate inhaler
technique at each visit.
Source What You and Your Family Can Do About
Asthma by the Global Initiative For Asthma
Created and funded by NIH/NHLBI
38
Medications to Treat AsthmaInhalers and Spacers
Spacers can help patients who have difficulty
with technique and can reduce potential side
effects.
Inhalers
Spacers
39
Medications to Treat AsthmaNebulizers

• Uses compressed air machine to deliver medicine
  as a mist
• Good for small children or for severe asthma
  episodes

40
Managing AsthmaAsthma Management Goals

• Control symptoms
• Prevent exacerbation
• Maintain lung function as close to normal as
  possible
• Avoid adverse effects from medications
• Prevent irreversible airway obstruction
• Prevent asthma mortality

41
Managing AsthmaAsthma Management Plan

• Develop with a physician
• Tailor to meet individual needs
• Educate patients and families on all aspects of
  the plan
• Recognizing symptoms
• Medication benefits and side effects
• Proper use of inhalers and peak expiratory
  flow (PEF) meters

42
Managing AsthmaIndications of a Severe Attack

• Breathless at rest
• Hunched forward
• Talking in words rather than sentences
• Agitated
• Peak flow rate is less than 60 of normal

43
Resources

• National Asthma Education and Prevention Program
• http//www.nhlbi.nih.gov/about/naepp/index.htm
• Asthma and Allergy Foundation of America
• http//www.aafa.org
• American Lung Association
• http//www.lungusa.org
• American Academy of Allergy, Asthma, and
  Immunology
• http//www.aaaai.org

44
Resources

• Allergy and Asthma Network, Mothers of
  Asthmatics. Inc.
• http//www.aanma.org/
• American College of Allergy, Asthma, and
  Immunology
• http//allergy.mcg.edu
• American College of Chest Physicians
• http//www.chestnet.org
• American Thoracic Society
• http//www.thoracic.org

45
Cystic Fibrosis

• CF is a hereditary disease that causes some
  glands to produce abnormal secretions that
  results in tissue and organ damage. Lungs and
  digestive tract appear to be affected the most.
• Most common inherited disease leading to a
  shortened life among white people in the US
• 13,300 white infants
• 115,300 black infants
• Rare in Asians
• Found equally in boys and girls

46
Cystic Fibrosis

• Currently, there is no cure for CF, but there are
  many promising new treatments in use and even
  more on the horizon.
• The median life expectancy for a person with CF
  is now 32
• thirty years ago, a CF patient was not expected
  to reach adulthood. Many people even live into
  their fifties and sixties.

47
Cystic Fibrosis

• Cystic fibrosis results when a person inherits
  two defective copies of a particular gene. This
  gene controls the production of a protein that
  regulates the transport of chloride and sodium
  across cell membranes. Worldwide, about 3 of 100
  white people carry one defective copy of the
  gene. About 3 of 10,000 white people inherit two
  defective copies of the gene thus, they develop
  cystic fibrosis. In these people, chloride and
  sodium transport is disrupted and dehydration and
  increased stickiness of secretions occur.

48
The key to Cystic Fibrosis is clogging. The
affected areas of the body are the airways,
liver, pancreas, intestine, and reproductive
tract.
49
CF - Symptoms

• The lungs are normal at birth, but breathing
  problems can develop at any time afterward. Thick
  secretions eventually block the small airways,
  which leads to inflammation and thickening of
  their walls. As larger airways fill with
  secretions, areas of the lung collapse and
  contract (a condition called atelectasis) and the
  lymph nodes enlarge. All these changes make
  breathing increasingly difficult and reduce the
  lungs' ability to transfer oxygen to the blood.
  Respiratory tract infections occur because of
  bacterial growth in the bronchial secretions and
  walls of the airways.

50
CF Symptoms (cont)

• The blockage of pancreatic ducts and intestinal
  glands leads to digestive problems, including
  poor absorption of fats, proteins, and vitamins.
  This, in turn, can lead to nutritional
  deficiencies, and slower than expected growth.
  Some people may have episodes of intestinal
  obstruction when abnormal stool contents block
  the bowel.
• About 15 to 20 of newborns who have cystic
  fibrosis have meconium ileus, a serious
  obstruction of the small intestine

51
CF - Symptoms

• About half the children with cystic fibrosis are
  first taken to the doctor because of frequent
  coughing, wheezing, and respiratory tract
  infections. Coughing, the most noticeable
  symptom, is often accompanied by gagging,
  vomiting, and disturbed sleep. As the disease
  progresses, the chest becomes barrel-shaped, and
  insufficient oxygen may make the fingers clubbed
  and the nail beds bluish. Polyps may form in the
  nose. The sinuses may fill with thick secretions,
  leading to chronic or recurrent sinus infections.

52
CF - Symptoms

• When a child or adult with cystic fibrosis sweats
  excessively in hot weather or because of a fever,
  dehydration may result because of the increased
  loss of salt and water. A parent may notice the
  formation of salt crystals or even a salty taste
  on the child's skin.
• Adolescents often have slowed growth, delayed
  puberty, and declining physical endurance. As the
  disease progresses, lung infection becomes a
  major problem. Recurrent bronchitis and pneumonia
  gradually destroy the lungs.

53
CF - Complications

• About 15 of adults with cystic fibrosis develop
  insulin-dependent diabetes because the scarred
  pancreas can no longer produce enough insulin.
  The blockage of bile ducts by thick secretions
  can lead to inflammation of the liver and
  eventually to scarring of the liver (cirrhosis)
  in about 5 of adults with cystic fibrosis

54
CF Complications (cont)

• People with cystic fibrosis often have impaired
  reproductive function. Almost all men have a low
  sperm count (which makes them sterile) because
  one of the ducts of the testis (the vas deferens)
  has developed abnormally and blocks the passage
  of sperm. In women, cervical secretions are too
  thick, causing decreased fertility. Otherwise,
  sexual function is not affected. Women with
  cystic fibrosis have a higher likelihood of
  complications during pregnancy (such as
  developing a lung infection or diabetes), but
  many women with cystic fibrosis have given birth.
• Other complications may include arthritis, kidney
  stones, and inflammation of the blood vessels
  (vasculitis).

55
CF - Treatment

• Advances in antibiotic therapy, nutritional
  support, and chest physiotherapy have markedly
  increased survival in people with CF
• Heart-lung transplantation has been applied to
  people with CF
• 5-year survival rates has reached more than 50
  in some centers
• People with CF require daily chest physiotherapy
  to loosen secretions and prevent stagnation and
  secondary infections
• Antibiotics are essential in treating infection,
  often given intravenously
• Nutritional support can also be given
  intravenously in people who are malnourished

56
CF Voc Psych Implications

• People with CF have excellent educational success
  and are typically productive individuals
• The counselor will have to work with employers to
  provide the support mechanisms that will allow
  the person to remain in the workplace
• This may include the provision of time for chest
  physiotherapy or antibiotic treatment during the
  workday
• The work environment must be reviewed to ensure
  the absence of irritants that might exacerbate
  the disease

57
CF Voc Psych Implications

• Supplemental oxygen may be necessary to allow the
  person the continue to be productive and
  ambulatory
• Psychological outcome in people with CF appears
  to depend on factors such as altered physical
  appearance, loneliness, and family strife that
  the person may attribute to his or her illness
• The counselor can also work with the person's
  family to improve support at home that will allow
  the person to increase social and vocational
  activities

58
References

• American Thoracic Society
  (www.thoracic.org) American Lung Association
  (www.lungusa.org) American Lung Association of
  Florida (www.lungfla.org) American Association
  of Cardiovascular and Pulmonary Rehabilitation
  (www.aacvpr.org) Asthma and Allergy Foundation
  of America (www.aafa.org) Allergy and Asthma
  Network (www.aanma.org) COPD-Support, Inc.
  (www.copd-support.com) Cystic Fibrosis
  Foundation (www.cff.org) Cystic Fibrosis
  Research, Inc. (www.cfri.org) Cystic Fibrosis
  Resources (www.cysticfibrosis.com)