1

Lung diseases


Respiratory and Lung diseases
H
2
Lung diseases
COPD
Pneumonia 1
2
3 ARDS
3
Lung diseases
Pneumonia 1
4
Lung diseases
Pneumonia
Def.: infection of the lung tissue


Cause: Pneumonia results from bacterial settlement of the normally sterile
lower respiratory tract.
Germs can arrive in principle on the following way into the respiratory tract:
aspiration of secretions from the oropharynx
inhalation of germs with the inhaled gas
with the bloodstream from other settled regions


5
Lung diseases
Diagnosis: coughing
fever >38C
leucocytosis
increased secretion production
pulmonale infitrates

in the case of a ventilated patient these symptoms are caused by other reasons
the diagnosis should rely therefor on being present further criteria

positive micro-biological findings in the tracheal secretion
auscultation state
festering tracheal secretion
Pneumonia
6
Lung diseases
Therapy: mucolytic and antitussive drugs
febrifugal drugs - antipyretic
antibacterial drugs - antibiotics
respiratory exercises - breathing trainer

in complicated cases: ventilation
Complications: ARDS / ALI
Pneumonia
7
Lung diseases
Pneumonia: - but now ventilated


Problems: *decreased mucociliary clearence
*risk of atelectasis
*decreased oxygenation
*decreased CO
2
-removal because of increased shunt

Consequences: *ventilation should improve the oxygenation and eliminate CO
2


8
Lung diseases
Pneumonia: Case report
boy in the age of 11 years
dry coughing for 2 weeks
subfebrile temperatures till light fever
<39C

X-ray of the Chest - first day at the hospital

Diagnosis: mycoplasm pneumonia
9
Lung diseases
Pneumonia: Case report
boy in the age of 11 years
dry coughing for 2 weeks
subfebrile temperatures till light fever
<39C

Diagnosis: mycoplasm pneumonia

same patient after a two weeks treatment
with an antibiotic ( Erythromycin )
1
0
Lung diseases
COPD 2
1
1
Lung diseases
COPD
Def.: COPD an abbreviation for Chronic Obstructive Pulmonary Disease
long term inflammatory disease of the bronchus and the lung with an
obstruction of the airways
a group of several diseases
> chronic obstructive bronchitis
> bronchial asthma
> lung emphysema
Cause: cigarette smoking
air pollution
exposure to particulate matter and gases
Leads to a chronic obstruction of the airways. The result is an extended
expiration time - no complete exhalation possible because of the increased
resistance of the airways - leads to an INTRINSIC PEEP.
1
2
Lung diseases
COPD
Diagnosis: Spirometry is measuring the volume exhaled forcefully in 1
second (FEV
1
) following a deep inspiration, and
the forced vital capacity

Chest X-ray / CT detecting emphysema

Arterial blood gas is showing a compensated respiratory
acidosis

Endoscopy (see below)





Trachea
normal state
Chronic bronchitis
with tram-lines
1
3
Lung diseases
COPD
Therapy: cessation smoking - will slow the rate of decline in lung function

bronchodilators - will relax the airways and are use in the symp-
tomatic treatment

corticosteroids - inhaled, have no effect on the inflammatory
response in COPD
- no evidence that they reduce long-term decline
in lung function

Complications: exacerbation
ARDS / ALI
Influenza vaccination is recommended for the prevention of acute exacerbation
of COPD during the winter months.
1
4
Lung diseases
COPD
thorax a.p.
normal state
thorax a.p.
bullous (blistered) emphysema
with over distended areas
1
5
Lung diseases
COPD: - but now ventilated

Problems: *increased inspiratory and expiratory resistance
*increased work of breathing because of the resistance - muscle fatigue
*over distended areas - physiological intrinsic PEEP
*decreased oxygenation
*decreased CO
2
- removal because of the increased resistance
*compensated respiratory acidosis
*drive of breathing by decreased p
a
O
2
instead of increased p
a
CO
2

*high risk of infections and atelectasis due the ventilation


Consequences: *avoid intubation - ideal patient for noninvasive ventilation first
*avoid application of oxygen - drive of breathing is lacking
*ventilation should improve the oxygenation and eliminate CO
2

*ventilation could increase the intrinsic PEEP
*avoid high gas flows




1
6
Lung diseases
COPD: - but now ventilated

normal state
COPD
prolonged expiration
1
7
Lung diseases
COPD: Case report
male, age of 56 years
strong smoker round about 65 cigarettes per day
allergic asthma for 40 years
acute decline of respiratory complaints
fever >39,0C
acute dyspnoea, cyanosis
oxygen mask with 15 l/min
thorax a.p. emphysema

Blood gas analysis: pH 7,28
p
a
CO
2
68 mmHg
p
a
O
2
55 mmHg
BE +8 mmol/l
HCO
3
-
31,2 mmol/l
S
a
O
2
82 %

Diagnosis: acute exacerbation of a long term COPD
with a no compensated respiratory acidosis
1
8
Lung diseases
3 ARDS
1
9
Lung diseases
ARDS
Def.: ARDS an abbreviation for Acute Respiratory Distress Syndrome


Cause: pulmonary and non pulmonary infections are the reasons of an ARDS

risk factors:
infection: e.g. pneumonia
trauma: e.g. lung contusion (car accident)
metabolic reasons: e.g. acute renal failure
drugs: e.g. narcotic intoxication
inhalation trauma: e.g. aspiration, oxygen
others: e.g. pulmonary embolism
complication in blood transfusion
2
0
Lung diseases
Diagnosis: acute occurrence ( car accident, aspiration... )
disturbed oxygenation
p
a
O
2
< 50 mmHg at F
i
O
2
= 0,6
p
a
O
2
/ F
i
O
2
< 200 mmHg
increased alveolar - arterial oxygen difference ( AaDO
2
)
atelectasis
dyspnoea, tachypnoea, cyanosis
decreased lung compliance
bilateral infiltrates due the increased permeability of the blood vessels

ARDS
2
1
Lung diseases
Ventilation
ARDS

Abx
Steroids
Nutrition
Mobilization
Prone Rx
Wet vs
Dry

Support
MSOF

IHD vs
CRRT
EPO
Tfx
Intensivist
Run
Team
Rounds
Vasc
access Sedation
protocol
Medical
Paralytics
Tidal Vol
RR
PEEP
Vol mode
Press mode
Recruitment
FiO2
Open Breath
Weaning
2
2
Lung diseases
ARDS: - but now ventilated

Problems: *decreased compliance because of e.g. interstitial lung edema
*decreased oxygenation and CO
2
- elimination due the prolonged
diffusion distance because of the infection
*increased inspiratory and expiratory resistance
*high risk of atelectasis because of a wet lung - decreased FRC
*ARDS based on multi organ failure as reaction of the lung
*course in stages: from dyspnoea until irreversible fatigue



Consequences: *ventilation should improve the oxygenation and eliminate CO
2

*find the balance between F
i
O
2
, I:E-ratio, PEEP
*lung protective ventilation


*ventilation could increase the intrinsic PEEP
*treatment of an ARDS includes several other therapy options
e.g. positioning, nutrition, renal replacement therapy




2
3
Lung diseases
ARDS: - but now ventilated

normal state
ARDS
expiratory flow not zero
small tidal volume
2
4
Lung diseases
ARDS: Case report
female, age of 38 years
car accident with thorax contusion
no further diagnosis
observation for 3 days at a surgical ICU
day 3: acute respiratory failure, dyspnoea, hypoxia
fever >39,0C , renal failure
thorax a.p. day 1: without significant shadowing
day 2: white lung, ventilated

Blood gas analysis: F
i
O
2
1,0
pH 7,33
p
a
CO
2
78 mmHg
p
a
O
2
51 mmHg
BE +2 mmol/l
HCO
3
-
24,2 mmol/l
S
a
O
2
95 %



p
a
O
2
/ F
i
O
2
= 78 mmHg Diagnosis: seriously ARDS