Chapter 12

Emphysema

Slide 1

Plate3.Panlobularemphysema.Inset,Excessivebronchialsecretions,
acommonsecondaryanatomicalterationofthelungs .

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Slide 2

Figure122.Centrilobularemphysema.Abnormalweakeningandenlargement
oftherespiratorybronchiolesintheproximalportionoftheacinus. Copyright 2006 by Mosby, Inc.

Anatomic Alterations of the Lungs

Slide 3

Permanent enlargement and deterioration of

the air spaces distal to the terminal
bronchioles

Destruction of pulmonary capillaries

Weakening of the distal airways, primarily the

respiratory bronchioles

Bronchospasm (with concomitant bronchitis)

Hyperinflation of alveoli (air-trapping)

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Etiology

Cigarette smoking

Genetic predisposition

Slide 4

Alpha1 protease inhibitor

Occupational exposure to chemical irritants

Exposure to atmospheric pollutants

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Overview of the Cardiopulmonary

Clinical Manifestations Associated
with EMPHYSEMA
The following result from the pathophysiologic
mechanisms caused by DistalAirwayand
AlveolarWeakening ( Figure 9-12)the major
anatomic alterations of the lungs associated
with emphysema (see Figures 12-1 and 12-2).

Slide 5

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Figure9-12.Distalairwayandalveolarweakeningclinicalscenario.
Slide 6

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Clinical Data Obtained at the

Patients Bedside
Vital signs

Slide 7

Increased respiratory rate

Increased heart rate, cardiac output,

blood pressure

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Clinical Data Obtained at the

Patients Bedside

Slide 8

Use of accessory muscles of inspiration

Use of accessory muscles of expiration

Pursed-lip breathing

Increased anteroposterior chest diameter

(barrel chest)

Cyanosis

Digital clubbing

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Clinical Data Obtained at the

Patients Bedside
Peripheral edema and venous distention

Slide 9

Distended neck veins

Pitting edema

Enlarged and tender liver

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Distended
NeckVeins

Figure2-48.Distendedneckveins(arrows).
Slide 10

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Figure2-47.Pittingedema.FromBloomA,IrelandJ: Color atlas of diabetes,ed2,

London,1992,Mosby-Wolfe.
Slide 11

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Clinical Data Obtained at the

Patients Bedside

Slide 12

Cough, sputum production, hemoptysis

Chest assessment findings

Hyperresonant percussion notes

Wheezing

Diminished breath sounds

Diminished heart sounds

Decreased tactile and vocal fremitus

Crackles/rhonchi (when accompanied by bronchitis)

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Figure2-12.Percussionbecomesmorehyperresonantwithalveolarhyperinflation.
Slide 13

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Slide 14

Figure2-17.Asairtrappingandalveolarhyperinflationdevelopinobstructive
lungdiseases,breathsoundsprogressivelydiminish.
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Clinical Data Obtained from

Laboratory Tests and Special
Procedures

Slide 15

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Pulmonary Function Study

Expiratory Maneuver Findings

FVC

FEVT

FEF25%-75%

FEF200-1200

PEFR

MVV

FEF50%

FEV1%

Slide 16

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Pulmonary Function Study

Lung Volume and Capacity Findings
VTRVFRCTLC
Nor Nor

VCICERVRV/TLCratio
Nor
Nor
Slide 17

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Decreased Diffusion Capacity

(DLCO)

Slide 18

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Arterial Blood Gases

MildtoModerateEmphysema

Acute alveolar hyperventilation with

hypoxemia

pHPaCO2HCO3-PaO2
(Slightly)

Slide 19

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TimeandProgressionofDisease
DiseaseOnset

AlveolarHyperventilation

100
90

PaO2orPaCO2

80

Point at which PaO22

declines enough to
stimulate peripheral
oxygen receptors

70
60

PaO2

50
40
30
20

PaC
O

10
0

Figure4-2.PaO2andPaC02trendsduringacutealveolarhyperventilation.
Slide 20

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Arterial Blood Gases

SevereEmphysema

Chronic ventilatory failure with hypoxemia

pHPaCO2HCO3-PaO2
Normal (Significantly)

Slide 21

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TimeandProgressionofDisease
DiseaseOnset

AlveolarHyperventilation

ChronicVentilatoryFailure

100
90

Pa02orPaC02

80
70
60

Point at which PaO22

declines enough to
stimulate peripheral
oxygen receptors

Point at which disease

becomes severe and patient
begins to become fatigued

O2
C
a

50
40
30

Pa
O

20
10
0
Figure4-7.PaO2andPaCO2trendsduringacuteorchronicventilatoryfailure.
Slide 22

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Acute Ventilatory Changes Superimposed

on Chronic Ventilatory Failure

Slide 23

Acute alveolar hyperventilation on chronic

ventilatory failure

Acute ventilatory failure on chronic ventilatory

failure

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Oxygenation Indices

QS/QTDO2

O2ER

Slide 24

VO2

C(a-v)O2

Normal

Normal

SvO2

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Hemodynamic Indices
(Severe Emphysema)

Slide 25

CVP

RAP

PA

PCWP

Normal

CO

SV

SVI

CI

Normal

Normal

Normal

Normal

RVSWI

LVSWI

PVR

SVR

Normal

Normal

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Abnormal Laboratory Tests

and Procedures
Hematology

Increased hematocrit and hemoglobin

Electrolytes

Hypochloremia (chronic ventilatory failure)

Sputum examination

Slide 26

Streptococcus pneumoniae

Haemophilus influenzae
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Radiologic Findings
Chest radiograph

Slide 27

Translucent (dark) lung fields

Depressed or flattened diaphragms

Long and narrow heart

Enlarged heart

Increased retrosternal air space

(lateral radiograph)

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Figure12-3.ChestX-rayofapatientwithemphysema.Theheartoftenappearslong
andnarrowasaresultofbeingdrawndownwardbythedescendingdiaphragm.
Slide 28

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Figure124.Emphysema.Lateralchestradiographdemonstratesacharacteristicallylarge
retrosternalradiolucencywithincreasedseparationoftheaortaandsternummeasuring4.6cm,3
cmbelowtheangleofLouisandextendingdowntowithin3cmofthediaphragmanteriorly.Both
costophrenicanglesareobtuse,andbothhemidiaphragmsareflat.(FromArmstrongPetal,editors:
Imaging of diseases of the chest,ed2,St.Louis,1995,Mosby.)
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Slide 29

Slide 30

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General Management of
Emphysema

Slide 31

Patient and family education

Behavioral management

Avoidance of smoking and inhaled irritants

Avoidance of infections

Proper nutrition instruction

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GOLD Standards

GlobalInitiativeforChronic
Obstructive
Lung
Disease

Slide 32

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Slide 33

Figure11-4.FromGUIDELINESPocketcard:Managing chronic obstructive pulmonary

disease,Baltimore,2004,Version4.0,InternationalGuidelinesCenter.(From
GUIDELINESPocketcard:ManagingChronicObstructivePulmonaryDisease.
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Baltimore,2004,Version4.0,InternationalGuidelinesCenter.)

Figure11-4.(Close-ups).(FromGUIDELINESPocketcard:ManagingChronic
ObstructivePulmonaryDisease.Baltimore,2004,Version4.0,International
GuidelinesCenter.)
Slide 34

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Figure11-4.(Close-ups).(FromGUIDELINESPocketcard:ManagingChronic
ObstructivePulmonaryDisease.Baltimore,2004,Version4.0,International
GuidelinesCenter.)
Slide 35

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Figure11-4.(Close-ups).(FromGUIDELINESPocketcard:ManagingChronic
ObstructivePulmonaryDisease.Baltimore,2004,Version4.0,International
GuidelinesCenter.)
Slide 36

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Figure11-4.(Close-ups).(FromGUIDELINESPocketcard:ManagingChronic
ObstructivePulmonaryDisease.Baltimore,2004,Version4.0,International
GuidelinesCenter.)
Slide 37

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General Management of
Emphysema
Respiratory care treatment protocols

Slide 38

Oxygen therapy protocol

Bronchopulmonary hygiene therapy protocol

Aerosolized medication protocol

Mechanical ventilation protocol

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Additional Treatment Considerations

for Emphysema

Slide 39

Antibiotics

Inoculations against influenza and pneumonia

Alpha1 antitrypsin therapy

Lung volume reduction surgery

Lung transplantation

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Classroom Discussion

Case Study: Emphysema

Slide 40

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