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What is the precise cause of Kyphoscoliosis ?
  • Precise cause is unknown in 80-85%.
  • Thought to be imbalance of the bilateral skeletal muscle groups
Pathologic conditions known to cause Kyphoscoliosis.
  • Congenital vertebral defects
  • Poliomylitis
  • Cerebral Palsy
  • Spinal muscle atrophy
Kyphoscoliosis Pathophysiology
  • Twisted thorax compresses lungs and impedes alveolar expansin
  • Result is alveolar hypoventilation and atelectasis
  • Chestwall restriction impairs cough and ability to mobilize secretions result is further atelectasis
  • Thoracic contents twist to cause mediastinal shift in same direction as lateral curvature
  • Causes restrictive disease
Kyphoscoliosis Chest Assessment
  • Thoracic deformaties
  • Tacheal shift
  • Increases fremitus
  • Dull percussion note
  • Whispered pectoriloquy
  • BS- Broncial, crackles, rhonci, wheezing
  • PFT- Restrictive pattern
Kyphoscoliosis ABG's

  • Early stages Mild to moderate- Acute alveolar hyperventilation with hypoxemia

  • Advanced stages Chronic ventilatory failure with hypoxemia

Mgt of Kyphoscoliosis
  • Bracing
  • Electrical stimulation
  • Surgery- fuse vertabrae, insert metal rod
  • Mobilization of secretions
  • Hyperinflation techniques
  • Supplemental O2- use w/caution, hypoxemia may be refractory
Describe flail chest
  • Double fractures of three or more adjacent ribs
  • Affected ribs cave in during inspiration
  • Underlying lung tisue compressed and restricted. this leads to atelectasis.
Flail Chest ABG's Mild
  • Increased HR, CO, BP, CVP
  • Decreased PaO2, PaCo2, HCO3
  • Increased pH
Flail Chest ABG's Severe
  • PaO2 Decreased <60
  • PaCO2 Increased >50
  • HCO3 Increased
  • pH Decreased <7.30
With paradoxical chest movement there can be the movement of air from one lung to another. This is called:
  • Pendelluft movement of air
  • Result is venous admixture
  • Restrictive disorder
Define paradoxical movement of the chest.
  • Flails on inspiration
  • Bulges on expiration
  • Increased RR, WOB
  • Decreased lung compliance
  • Stimulation of peripheral chemoreceptors and Type J receptors.
Etiologic classifications of pneumothorax

  • Traumatic

  • Spontaneous

  • Iatrogenic

Pneumothorax management
  • If less than 20% of lung involved may need only bedrest
  • If greater than 20% air should be evacuated
  • Supplemental O2
Chest physical examination for pneumothorax
  • Absent BS
  • Decreased fremitus, voice sounds
  • Increased AP diameter
  • Traceal shift
  • Hyperresonant percussion note
  • Displaced heart sounds
Two types of asthma
  • Extrinsic
  • Intrinsic
Define extrinsic asthma
  • Allergic or atopic
  • Associated w/exposure to specific antigens
  • Hypersensitvity reaction
  • Genetic predisposition
  • Usually seen in children/adults under 30
Define intrinsic asthma
  • Nonalleric/nonatopic
  • Not associated w/exposure to specific antigens
  • No hypersensitivity reaction
  • Chronic bronchitis is frequent complication
  • Usually seen in 4th decade of life with no family history
  • Imbalance of autonomic nervous system thought to play role
Mechanism of bronchoconstriction

With exposure to _____, lymphoid tissue produces ______. These attach to _____ cells. 
  • Antigens
  • Ige molecules
  • Mast
Mechanism of bronchoconstriction

Subsequent exposure causes ______ of mast cells and the release of chemical ________. 
  • Degranulation
  • Mediators
Chemical mediators released during degranulation of mast cells
  • Histamine
  • ECF-A
  • SRS-A
  • Bradykinin
Pathophysiology during asthma attack
  • Hypertrophy of smooth muscle may be 3 times normal
  • Goblet cells increase and submucosal glands enlarge
  • Thick tenacious secretions occlude bronchioles
  • Mucosal edema w/infiltration of eosinophils
  • Cilia are damaged. Basement membrane thickened
  • Airtrapping and hyperinflation develop
What causes drop in blood pressure on inspiration ?
  • Pulsus paradoxus blood pools in lungs due to negative pressure
Chronic bronchitis etiology
  • Exact cause is unknown but important etiological factors have been identified
  • Cigarette smoking
  • Air pollution
  • Infections
Define Reid index
  • Ratio of submucosal gland thickness to bronchial wall thickness
  • Ratio greater than 0.36 indicates bronchitis
Pft findings for bronchitis
  • Obstructive
  • Normal  mild
Pathophysiology of advanced bronchitis
  • Number of cilia decreased
  • Peripheral airways occluded w/mucus plugs
  • V/Q mismatch = hypoxemia
  • Chronic hypoxemia causes increased PVR
  • Increased PVR causes RV hpertrophy
  • If continues = Cor pulmonale
Emphysema etiology
  • Cigarette smoking
  • Inhaled irritants
  • Infections
  • Alpha 1 Protease Inhibitor
Define Alpha 1 Protease deficiency
  • Old WBC in lungs release elastase which destroys elastic tissue
  • Normal 0.2-0.4
  • ZZ homozygous 1-2% of cases
  • Heterozygous mz 10-20% of cases
Advanced Emphysema presentation
  • Chronic ventilatory failure w/hypoxemia
  • Cyanosis
  • Polycythemia
  • Dyspnea
  • Cor Pulmonale
  • Weight loss
Define polycythemia
  • Increased viscosity
  • Increases work of heart
Define panlobular emphysema
  • weakening and enlargement of all air spaces distal to terminal bronchioles.
  • Alpha 1 protease inhibitor deficiency
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