Download PBL Int Medicine By Dr Uzma 05-03-2015

Respiratory system module
Asthma
Bronchitis
Flail chest
Slide 1
Copyright © 2006 by Mosby, Inc.
CASE SCENARIO

Slide 2
A 30 YRS OLD MALE NON SMOKER
PRESENTED IN EMERGENCY
DEPARTMENT WITH SEVERE
SHORTNESS OF BREATH FOR LAST 2
DAYS IT HAS WORSENED OVER FEW HRS
TO SUCH AN EXTENT THAT HE HAS TO
COME TO EME DEPARTMENT .HE HAS
REVIOUS HISTORY OF SIMILAR ATTACKS
OF SHORTNESS OF BREATH WITH
WHEEZE ESPECIALLY IN WINTERS USED
TO RELIEVE AFTER TAKING
MEDICATIONS .THERE IS HISTORY OF
NOCTURNAL COUGH ON AN OFF
Copyright © 2006 by Mosby, Inc.

Slide 3
THERE IS NO HISTORY OF ORTHOPNEA
AND PND NO HISTORY OF ANY HEART
PROBLEM NO HISTORY OF ANY
feverCONNECTIVE TISSUE DISEASE OR
KIDNEY DISORDER NO HISTORYOF
KEEPING PETS AT HOME HE HAS LEFT
HIS MEDICATION AND LOST FOLLOW UP
WITH GPE FOR LAST 6 MONTHS
Copyright © 2006 by Mosby, Inc.
Slide 4

WHAT IS THE LIKELY DIAGNOSIS IN THIS
PATIENT?

WHAT PHYSICAL FINDINGS HELP TO
REACH A DIAGNOSIS?

WHAT INVESTIGATIONS SHOULD BE
DONE ?

WHAT ARE MANAGEMENT OPTIONS?
Copyright © 2006 by Mosby, Inc.
What is known about asthma?
Slide 5

Asthma is a common and potentially serious
chronic disease that can be controlled but not
cured

Asthma causes symptoms such as wheezing,
shortness of breath, chest tightness and
cough that vary over time in their occurrence,
frequency and intensity

Symptoms are associated with variable
expiratory airflow,
i.e. difficulty breathing air out of the lungs due
to
GINA 2014
Copyright © 2006 by Mosby, Inc.
What is known about asthma?
Slide 6

Asthma can be effectively treated

When asthma is well-controlled, patients can
GINA 2014

Avoid troublesome symptoms during the day and
night

Need little or no reliever medication

Have productive, physically active lives

Have normal or near-normal lung function

Avoid serious asthma flare-ups (also called
exacerbations, or severe attacks)
Copyright © 2006 by Mosby, Inc.
Definition of asthma
Asthma is a heterogeneous disease, usually characterized
by chronic airway inflammation.
It is defined by the history of respiratory symptoms such as
wheeze, shortness of breath, chest tightness and cough
that vary over time and in intensity, together with variable
expiratory airflow limitation.
NEW!
Slide 7
GINA 2014
Copyright © 2006 by Mosby, Inc.
ASTHMA DEFINITION

Slide 8
“a common chronic disorder of the airways
that is complex and characterized by variable
and recurring symptoms, airflow obstruction,
bronchial hyperresponsiveness, and an
underlying inflammation. The interaction of
these features of asthma determines the
clinical manifestations and severity of asthma
and the response to treatment
Copyright © 2006 by Mosby, Inc.
Diagnosis of asthma


The diagnosis of asthma should be based on:

A history of characteristic symptom patterns

Evidence of variable airflow limitation, from
bronchodilator reversibility testing or other tests
Document evidence for the diagnosis in the
patient’s notes, preferably before starting
controller treatment


Slide 9
GINA 2014
It is often more difficult to confirm the diagnosis
after treatment has been started
Asthma is usually characterized by airway
inflammation and airway
Copyright © 2006 by Mosby, Inc.
NEW!
Slide 10 2014, Box 1-1
GINA
Copyright © 2006 by Mosby, Inc.
© Global Initiative for Asthma
Diagnosis of asthma – symptoms


Slide 11
GINA 2014
Increased probability that symptoms are due to asthma if:

More than one type of symptom (wheeze, shortness of breath, cough, chest
tightness)

Symptoms often worse at night or in the early morning

Symptoms vary over time and in intensity

Symptoms are triggered by viral infections, exercise, allergen exposure, changes
in weather, laughter, irritants such as car exhaust fumes, smoke, or strong smells
Decreased probability that symptoms are due to asthma if:

Isolated cough with no other respiratory symptoms

Chronic production of sputum

Shortness of breath associated with dizziness, light-headedness or peripheral
tingling

Chest pain

Exercise-induced dyspnea with noisy inspiration (stridor)
Copyright © 2006 by Mosby, Inc.
Diagnosis of asthma – variable
airflow limitation

Confirm presence of airflow limitation



Document that FEV1/FVC is reduced (at least once, when FEV1 is low)
FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and
>0.90 in children
Confirm variation in lung function is greater than in healthy individuals

The greater the variation, or the more times variation is seen, the greater
probability that the diagnosis is asthma
 Excessive bronchodilator reversibility (adults: increase in FEV 1 >12% and
>200mL; children: increase >12% predicted)
 Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring (daily
amplitude x 100/daily mean, averaged)
 Significant increase in FEV1 or PEF after 4 weeks of controller treatment
 If initial testing is negative:
• Repeat when patient is symptomatic, or after withholding bronchodilators
• Refer for additional tests (especially children ≤5 years, or the elderly)
Slide 12
GINA 2014, Box 1-2
Copyright © 2006 by Mosby, Inc.
Typical spirometric tracings
Flow
Volume
Normal
FEV1
Asthma
(after BD)
Normal
Asthma
(before BD)
Asthma
(after BD)
Asthma
(before BD)
1
2
3
4
5
Volume
Time (seconds)
Note: Each FEV1 represents the highest of
three reproducible measurements
Slide 13
GINA 2014
Copyright © 2006 by Mosby, Inc.
© Global Initiative for Asthma
Diagnosis of asthma – physical
examination


Slide 14
GINA 2014
Physical examination in people with asthma

Often normal

The most frequent finding is wheezing on
auscultation, especially on forced expiration
Wheezing is also found in other conditions,
for example:

Respiratory infections

COPD

Upper airway dysfunction

Endobronchial obstruction
Copyright © 2006 by Mosby, Inc.
Step 1 – as-needed inhaled short-acting
beta2-agonist (SABA)
*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
Slide 15
GINA 2014, Box 3-5, Step 1
Copyright © 2006 by Mosby, Inc.
© Global Initiative for Asthma
Step 1 – as-needed inhaled short-acting
beta2-agonist (SABA)
*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
Slide 16
GINA 2014, Box 3-5, Step 1
Copyright © 2006 by Mosby, Inc.
© Global Initiative for Asthma
Step 1 – as-needed reliever inhaler


Slide 17
GINA 2014
Preferred option: as-needed inhaled shortacting beta2-agonist (SABA)

SABAs are highly effective for relief of asthma
symptoms

However …. there is insufficient evidence about
the safety of treating asthma with SABA alone

This option should be reserved for patients with
infrequent symptoms (less than twice a month) of
short duration, and with no risk factors for
exacerbations
Other options

Consider adding regular low dose inhaled
Copyright © 2006 by Mosby, Inc.
Step 2 – low-dose controller + as-needed
inhaled SABA
*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
Slide 18
GINA 2014, Box 3-5, Step 2
Copyright © 2006 by Mosby, Inc.
© Global Initiative for Asthma
Step 2 – Low dose controller + asneeded SABA

Preferred option: regular low dose ICS with as-needed inhaled SABA


Low dose ICS reduces symptoms and reduces risk of exacerbations and
asthma-related hospitalization and death
Other options

Leukotriene receptor antagonists (LTRA) with as-needed SABA
• Less effective than low dose ICS
• May be used for some patients with both asthma and allergic rhinitis, or if patient will not
use ICS

Combination low dose ICS/long-acting beta2-agonist (LABA)
with as-needed SABA
• Reduces symptoms and increases lung function compared with ICS
• More expensive, and does not further reduce exacerbations

Intermittent ICS with as-needed SABA for purely seasonal allergic asthma with
no interval symptoms
• Start ICS immediately symptoms commence, and continue for
4 weeks after pollen season ends
Slide 19
GINA 2014
Copyright © 2006 by Mosby, Inc.
Step 3 – one or two controllers + as-needed
inhaled reliever
*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
Slide 20
GINA 2014, Box 3-5, Step 3
Copyright © 2006 by Mosby, Inc.
© Global Initiative for Asthma
Slide 21
Copyright © 2006 by Mosby, Inc.

Step 3 – one or two controllers + asneeded inhaled reliever
Before considering step-up


Check inhaler technique and adherence, confirm diagnosis
Adults/adolescents: preferred options are either combination low dose ICS/LABA
maintenance with as-needed SABA, OR combination low dose ICS/formoterol
maintenance and reliever regimen*

Adding LABA reduces symptoms and exacerbations and increases FEV 1, while allowing
lower dose of ICS

In at-risk patients, maintenance and reliever regimen significantly reduces exacerbations
with similar level of symptom control and lower ICS doses compared with other regimens

Children 6-11 years: preferred option is medium dose ICS with
as-needed SABA

Other options

Adults/adolescents: Increase ICS dose or add LTRA or theophylline (less effective than
ICS/LABA)

Children 6-11 years – add LABA (similar effect as increasing ICS)
*Approved only for low dose beclometasone/formoterol and low dose
Slide
22
budesonide/formoterol
GINA
2014
Copyright © 2006 by Mosby, Inc.
Step 4 – two or more controllers + as-needed
inhaled reliever
*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
Slide 23
GINA 2014, Box 3-5, Step 4
Copyright © 2006 by Mosby, Inc.
© Global Initiative for Asthma
Step 4 – two or more controllers +
as-needed inhaled reliever

Before considering step-up

Check inhaler technique and adherence

Adults or adolescents: preferred option is
combination low dose ICS/formoterol as
maintenance and reliever regimen*, OR
combination medium dose ICS/LABA with asneeded SABA

Children 6–11 years: preferred option is to
refer for expert advice

Other options (adults or adolescents)
*Approved only for low dose beclometasone/formoterol and low dose
Slide
24
budesonide/formoterol
GINA
2014
Copyright © 2006 by Mosby, Inc.
Step 5 – higher level care and/or add-on
treatment
*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
Slide 25
GINA 2014, Box 3-5, Step 5
Copyright © 2006 by Mosby, Inc.
© Global Initiative for Asthma
Step 5 – higher level care and/or
add-on treatment


Slide 26
GINA 2014
Preferred option is referral for specialist
investigation and consideration of add-on
treatment

If symptoms uncontrolled or exacerbations persist
despite Step 4 treatment, check inhaler technique
and adherence before referring

Add-on omalizumab (anti-IgE) is suggested for
patients with moderate or severe allergic asthma
that is uncontrolled on Step 4 treatment
Other add-on treatment options at Step 5
include:

Sputum-guided treatment: this is available in
Copyright © 2006 by Mosby, Inc.
Low, medium and high dose inhaled
corticosteroids
Adults
and
adolescents
(≥12
years)
Inhaled corticosteroid
Total daily dose (mcg)
Low
Medium
High
Beclometasone dipropionate (CFC)
200–500
>500–1000
>1000
Beclometasone dipropionate (HFA)
100–200
>200–400
>400
Budesonide (DPI)
200–400
>400–800
>800
Ciclesonide (HFA)
80–160
>160–320
>320
Fluticasone propionate (DPI or HFA)
100–250
>250–500
>500
Mometasone furoate
110–220
>220–440
>440
400–1000
>1000–2000
>2000
Triamcinolone acetonide
 This
is not a table of equivalence, but of estimated clinical comparability
 Most
of the clinical benefit from ICS is seen at low doses
 High
doses are arbitrary, but for most ICS are those that, with prolonged use,
are associated with increased risk of systemic side-effects
Slide 27
GINA 2014, Box 3-6 (1/2)
Copyright © 2006 by Mosby, Inc.
Low, medium and high dose inhaled
corticosteroids
Children
6–11
years
Inhaled corticosteroid
Total daily dose (mcg)
Low
Medium
High
Beclometasone dipropionate (CFC)
100–200
>200–400
>400
Beclometasone dipropionate (HFA)
50–100
>100–200
>200
Budesonide (DPI)
100–200
>200–400
>400
Budesonide (nebules)
250–500
>500–1000
>1000
80
>80–160
>160
Fluticasone propionate (DPI)
100–200
>200–400
>400
Fluticasone propionate (HFA)
100–200
>200–500
>500
110
≥220–<440
≥440
400–800
>800–1200
>1200
Ciclesonide (HFA)
Mometasone furoate
Triamcinolone acetonide
Slide 28

This is not a table of equivalence, but of estimated clinical comparability

Most of the clinical benefit from ICS is seen at low doses

High doses are arbitrary, but for most ICS are those that, with prolonged use, are
associated with increased risk of systemic side-effects
GINA 2014, Box 3-6 (2/2)
Copyright © 2006 by Mosby, Inc.
Case scenario
2
Slide 29

A 60 yr old male heavy smoker presented in
pulmonology outdoor with progressive
worsening of shortnes of breath for last one
yr .he also complains or cough wth scanty
sputum .there is no diurnal variation or history
of wheezing .

What can be possible underlying condition
Copyright © 2006 by Mosby, Inc.
Slide 30

On examination patient is of thin built with
B.p 150/90 mmHg pulse 88/min ,afebrile ,rr
22/min.he was clubbed ,and cyanosed .chest
movements limited breath sounds reduced
vocal resonance increased

X-ray chest showed hyperinflated lungs with
tubular heart

FEV1/VC reduced

What can be ndelying lung condition?
Copyright © 2006 by Mosby, Inc.
Emphysema
Bronchitis
Slide 31
Asthma

Chronic obstructive pulmonary disease.

Bronchitis, emphysema, and asthma may
present alone or in combination.
Copyright © 2006 by Mosby, Inc.
Chronic bronchitis. Inset, Weakened distal airways in emphysema,
a common secondary anatomic alteration of the lungs.
Slide 32
Copyright © 2006 by Mosby, Inc.
Anatomic Alterations of the Lungs
Slide 33

Chronic inflammation and swelling of the
peripheral airways

Excessive mucus production and
accumulation

Partial or total mucus plugging

Hyperinflation of alveoli (air-trapping)

Smooth muscle constriction of bronchial
airways (bronchospasm)
Copyright © 2006 by Mosby, Inc.
Etiology
Slide 34

Cigarette smoking

Atmospheric pollutants

Infection

Gastroesophageal reflux disease
Copyright © 2006 by Mosby, Inc.
Overview of the Cardiopulmonary
Clinical Manifestations Associated
with CHRONIC BRONCHITIS
The following clinical manifestations result from
the pathophysiologic mechanisms caused (or
activated) by Excessive Bronchial Secretions
(see Figure 9-11) and Bronchospasm (see
Figure 9-10)—the major anatomic alterations of
the lungs associated with chronic bronchitis
(see Figure 11-1).
Slide 35
Copyright © 2006 by Mosby, Inc.
Figure 9-11. Excessive bronchial secretions clinical scenario.
Slide 36
Copyright © 2006 by Mosby, Inc.
Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).
Slide 37
Copyright © 2006 by Mosby, Inc.
Clinical Data Obtained at the
Patient’s Bedside
Vital signs
Slide 38

Increased respiratory rate

Increased heart rate, cardiac output, blood
pressure
Copyright © 2006 by Mosby, Inc.
Clinical Data Obtained at the
Patient’s Bedside
Slide 39

Use of accessory muscles of inspiration

Use of accessory muscles of expiration

Pursed-lip breathing

Increased anteroposterior chest diameter
(barrel chest)

Cyanosis

Digital clubbing
Copyright © 2006 by Mosby, Inc.
Figure 2-36. The way a patient may appear when using the
pectoralis major muscles for inspiration.
Slide 40
Copyright © 2006 by Mosby, Inc.
Figure 2-41. A, Schematic illustration of alveolar compression of weakened bronchiolar
airways during normal expiration in patients with chronic obstructive pulmonary disease
(e.g., emphysema). B, Effects of pursed-lip breathing. The weakened bronchiolar airways
are kept open by the effects of positive pressure created by pursed lips during expiration.
Slide 41
Copyright © 2006 by Mosby, Inc.
Digital
Clubbing
Figure 2-46. Digital clubbing.
Slide 42
Copyright © 2006 by Mosby, Inc.
Clinical Data Obtained at the
Patient’s Bedside
Peripheral edema and venous distention
Slide 43

Distended neck veins

Pitting edema

Enlarged and tender liver
Copyright © 2006 by Mosby, Inc.
Distended
Neck Veins
Figure 2-48. Distended neck veins (arrows).
Slide 44
Copyright © 2006 by Mosby, Inc.
Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2,
London, 1992, Mosby-Wolfe.
Slide 45
Copyright © 2006 by Mosby, Inc.
Clinical Data Obtained at the
Patient’s Bedside
Slide 46

Cough, sputum production, hemoptysis

Chest assessment findings

Hyperresonant percussion note

Diminished breath sounds

Diminished heart sounds

Decreased tactile and vocal fremitus

Crackles/rhonchi/wheezing
Copyright © 2006 by Mosby, Inc.
Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.
Slide 47
Copyright © 2006 by Mosby, Inc.
Slide 48
Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive
lung diseases, breath sounds progressively diminish.
Copyright © 2006 by Mosby, Inc.
Clinical Data Obtained from
Laboratory Tests and Special
Procedures
Slide 49
Copyright © 2006 by Mosby, Inc.
Pulmonary Function Study:
Expiratory Maneuver Findings
Slide 50
FVC

FEVT

FEF25%-75%

FEF200-1200

PEFR
MVV
FEF50%
FEV1%




Copyright © 2006 by Mosby, Inc.
Pulmonary Function Study:
Lung Volume and Capacity Findings
VT
RV
FRC
N or 


IC
ERV
VC

Slide 51
N or 
N or 
TLC
N or 
RV/TLC ratio

Copyright © 2006 by Mosby, Inc.
Arterial Blood Gases
Mild to Moderate Chronic Bronchitis

Slide 52
Acute alveolar hyperventilation with
hypoxemia
pH
PaCO2


HCO3 (Slightly)
PaO2

Copyright © 2006 by Mosby, Inc.
Time and Progression of Disease
Disease Onset
Alveolar Hyperventilation
100
90
PaO2 or PaCO2
80
Point at which PaO2
declines enough to
stimulate peripheral
oxygen receptors
70
60
PaO2
50
40
30
20
10
0
Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.
Slide 53
Copyright © 2006 by Mosby, Inc.
Arterial Blood Gases
Severe Chronic Bronchitis

Chronic ventilatory failure with hypoxemia
pH
Normal
Slide 54
PaCO2

HCO3(Significantly)
PaO2

Copyright © 2006 by Mosby, Inc.
Time and Progression of Disease
Disease Onset
Alveolar Hyperventilation
Chronic Ventilatory Failure
100
90
Pa02 or PaC02
80
70
Point at which PaO2
declines enough to
stimulate peripheral
oxygen receptors
Point at which disease
becomes severe and patient
begins to become fatigued
60
50
40
30
20
10
0
Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.
Slide 55
Copyright © 2006 by Mosby, Inc.
Acute Ventilatory Changes
Superimposed on Chronic Ventilatory
Failure
Slide 56

Acute alveolar hyperventilation on chronic
ventilatory failure

Acute ventilatory failure on chronic
ventilatory failure
Copyright © 2006 by Mosby, Inc.
Abnormal Laboratory Tests and
Procedures

Hematology
Increased hematocrit and hemoglobin

Electrolytes

Slide 57

Hypochloremia (chronic ventilatory failure)

Increased bicarbonate (chronic ventilatory failure)
Sputum examination

Increased white blood cells

Streptococcus pneumoniae

Haemophilus influenzae

Moraxella catarrhalis
Copyright © 2006 by Mosby, Inc.
Radiologic Findings
Chest radiograph
Slide 58

Translucent (dark) lung fields

Depressed or flattened diaphragms

Long and narrow heart

Enlarged heart
Copyright © 2006 by Mosby, Inc.
Figure 11-2. Chest X-ray film of a patient with chronic bronchitis. Note the translucent (dark)
lung fields, depressed diaphragms, and long and narrow heart.
Slide 59
Copyright © 2006 by Mosby, Inc.
Radiologic Findings
Bronchogram

Slide 60
Small spikelike protrusions
Copyright © 2006 by Mosby, Inc.
Figure 11-3. Chronic bronchitis. Bronchogram with localized view of left hilum. Rounded
collections of contrast lie adjacent to bronchial walls and are particularly well seen below
the left main stem bronchus (arrow) in this film. They are caused by contrast in dilated
mucous gland ducts. (From Armstrong P, Wilson AG, Dee P: Imaging of diseases of the
chest, St. Louis, 1990, Mosby.)
Slide 61
Copyright © 2006 by Mosby, Inc.
General Management of
Chronic Bronchitis

Patient and family education

Behavioral management

Slide 62

Avoidance of smoking and inhaled irritants

Avoidance of infections
Respiratory care treatment protocols

Oxygen therapy protocol

Bronchopulmonary hygiene therapy protocol

Aerosolized medication protocol

Mechanical ventilation protocol
Copyright © 2006 by Mosby, Inc.
GOLD Standards
Global Initiative for Chronic
Obstructive
Lung
Disease
Slide 63
Copyright © 2006 by Mosby, Inc.
Figure 11-4. Acute exacerbation of COPD (AECOPD): Guideline algorithm (ACCP/ACP-ASIM). CXR,
Chest X-ray; NPPV, noninvasive positive pressure ventilation; PEFR, peak expiratory flow rate;
URI, upper respiratory infection. (From GUIDELINES Pocketcard: Managing Chronic Obstructive
Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)
Slide 64
Copyright © 2006 by Mosby, Inc.
Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic
Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International
Guidelines Center.)
Slide 65
Copyright © 2006 by Mosby, Inc.
Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic
Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International
Guidelines Center.)
Slide 66
Copyright © 2006 by Mosby, Inc.
Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic
Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International
Guidelines Center.)
Slide 67
Copyright © 2006 by Mosby, Inc.
Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic
Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International
Guidelines Center.)
Slide 68
Copyright © 2006 by Mosby, Inc.
Figure 11-4. Acute exacerbation of COPD (AECOPD): Guideline algorithm (ACCP/ACP-ASIM). CXR,
Chest X-ray; NPPV, noninvasive positive pressure ventilation; PEFR, peak expiratory flow rate; URI,
upper respiratory infection. (From GUIDELINES Pocketcard: Managing Chronic Obstructive
Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)
Slide 69
Copyright © 2006 by Mosby, Inc.
FLAIL CHEST
Slide 70
Copyright © 2006 by Mosby, Inc.
A 22 yr old male presented in emergency
department with history of road traffic trauma to
chest he was ishirt of breath and was in severe
pain
What are possibilities?
Slide 71
Copyright © 2006 by Mosby, Inc.
Slide 72

On examination patient was tachycadic and
tachypnic cyanosed his chest wall moves in
duing inspiration at certain points and out
during expiration

These findings suggest what?
Copyright © 2006 by Mosby, Inc.
Anatomy
73
Slide 73
Copyright © 2006 by Mosby, Inc.
Overview of Chest Injuries

Can be life-threatening

May result in damage to either the heart or the lung
and cause severe internal bleeding

Rib cage fractures may result in serious injury to vital
organs

Deep, open wounds allow air to enter the chest
cavity

Closed wounds usually involve injury to the ribs and
possibly underlying structures
74
Slide 74
Copyright © 2006 by Mosby, Inc.
Signs of Chest Injuries

An obvious chest wound

Impaired breathing

Irregular – or lack of – chest expansion

Coughing-up of blood

Shock

Subcutaneous emphysema: crackling
sensation
75
Slide 75
Copyright © 2006 by Mosby, Inc.
Closed Chest Injuries

Rib fracture

Flail chest

Pneumothorax
76
Slide 76
Copyright © 2006 by Mosby, Inc.
Rib Fracture
Slide 77

Rib fractures are almost always the result of
trauma (a blow) to the rib cage

Signs and Symptoms

leaning toward the injured side

if the rib has punctured a lung, air can escape into
the tissues of the chest wall creating a crackling
sensation (- Subcutaneous Emphysema)

unwillingness to take a deep breath

complaining of local pain and tenderness

pain when moving the rib cage when breathing
or
77
coughing
Copyright © 2006 by Mosby, Inc.
Rib Fracture


Treatment

Give oxygen

Make the patient as comfortable as possible

Activate EMS and treat as Load and Go
Transport patient

in the position of maximum comfort on the injured
side
78
Slide 78
Copyright © 2006 by Mosby, Inc.
Flail Chest

Several adjacent ribs fractured in more than
one place can produce a loose section of the
chest wall

The flail section moves inward when the
patient breathes in, and outward when the
patient breathes out

This phenomenon is known as paradoxical
movement
79
Slide 79
Copyright © 2006 by Mosby, Inc.
Flail Chest

Signs and symptoms

shortness of breath

swelling over the injury site

shock

muscle splinting of the injury site

severe pain on inhalation/exhalation

possible paradoxical movement
80
Slide 80
Copyright © 2006 by Mosby, Inc.
Flail Chest

Treatment

Give oxygen as soon as possible

Be prepared to give AR

Help the patient get in a comfortable position and
transport to medical aid

Continue to monitor vital signs

Unless there is substantial bleeding, do not apply
bulky padding or dressings
81
Slide 81
Copyright © 2006 by Mosby, Inc.
Use of Dressings on a Flail Chest


Slide 82
Only consider taped-on pad as a treatment in the
following cases:

if there is likely to be a prolonged time before evacuation and
access to medical care

if the patient has fatigued their chest muscles
To apply dressings

Press the segment inward with your gloved hand to stabilize
it

Splint in the inward position with a pillow, large bulky
dressing, or folded blanket or parka

Secure this thoroughly in place with tape

Be prepared to help breathing with AR

Copyright © 2006 by Mosby, Inc.
Do not hold in place with bandages encircling the chest.
This
82
Pneumothorax

Is a condition that results from air entering the
interpleural space. The air in the interpleural
space compresses the lung and prevents
normal breathing.

There are two types of pneumothorax:

Tension pneumothorax

Spontaneous pneumothorax
83
Slide 83
Copyright © 2006 by Mosby, Inc.
Pneumothorax

Signs and symptoms

reduction of normal respiratory movements on the
affected side

a fall in blood pressure

weak and rapid pulse

a sudden sharp chest pain
84
Slide 84
Copyright © 2006 by Mosby, Inc.
Pneumothorax


Slide 85
Treatment for Tension Pneumothorax

Give oxygen

Activate EMS and treat as Load and Go

Continue to monitor vital signs
Treatment for Spontaneous Pneumothorax

Give oxygen

Transport to medical aid

The patient may prefer to be transported sitting up.
85
Copyright © 2006 by Mosby, Inc.