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Tuesday, January 23, 2007

Lung Diseases Lexicon

Basic Termonology:

1. Pulmonary Toilet: This is a generic term used to describe all the procedures used to flush all the excess sputum out of their lungs. This is generally done on blue bloaters due the fact they have destroyed cilia (see below), and therefore have no means to get all the secretions out. With increased secretions, they have an increased chance of getting pneumonia. To enhance secretion clearance, bronchodilators (like Albuterol) are used to open up the lungs to help release trapped sputum, mucolytics (like Mucomyst) are used to break up phlegm, chest physiotherapy (see below) is also done to help break up the phlegm, along with PEP therapy, flutter therapy, cough and deep breathing exercises, and incentive spirometry. Altogether, these procedures are called the pulmonary toilet.

2. Cilia: These are little hair-like structures that line the respiratory tract from your nose to the bronchioles (air passages in your lungs) that work to bring up secretions/ sputum (see below) from your lungs to your upper airway so you can cough or sneeze it out. These are part of the immune system and are used as a means of keeping the lungs clear of bacteria, viruses and other particles. The lungs, therefore, are generally kept sterile.

3. Secretions: (Sputum) This is part of the immune system. It's your body balling up microscopic particles such as bacteria, viruses, parisites, etc., that are not supposed to be in your lungs. These are brough up to the upper-airway by means of riding up on the cilia.

4. Chest Physiotherapy: A procedure that involves the cupping of the RTs hands and clapping on the back of the patient with the intent purpose of loosening secretions in the lungs so the patient can spit it up. It's often done on patients with thick secretions, such as bronchitis, cystic fibrosis, pneumonia, etc.). It can also be done with electronic purcussers, like these.

5. PEP therapy: This is a device that when you exhale into it vibrations are caused in your lungs thus loosening secretions.

6. Incentive Spirometry: This is a procedure where you place a small mouthpiece into your mouth and inhale slowly and as deep as you can, followed by a breath hold and a cough. The device provides a modicum of resistance to exercise your lungs. It's pretty much used as incentive to get a patient to take deep breaths, which they are not inclined to do after chest or abdominal surgery or following a trauma and broken ribs. Ideally this is more a preventative measure than a treatment, and is not really part of the pulmonary toilet. For COPD patients, it is used as a means to prevent them from getting pneumonia, or to treat pneumonia.

7. Cough and deep breathing exercises: Same as for IS. It is preventative more so than part of the pulmonary toilet. It's not going to help you expectorate anything. Actually, I think this is way better than an IS. While I have had many patients who cannot do the IS, I have never had a patient who can't do simple cough and deep breathing exercises. This is good for COPD patients to do as it helps prevent and treat pneumonia.

8. Hypoxic Drive Theory:  The belief a COPD patient will stop breathing if their oxygen is too high.

9. Hypoxic Drive Hoax:  See hypoxic drive theory.

10. Air trapping: This is air that gets trapped or retained in the lungs due to an obstruction in the air passages (bronchioles) of the lungs that prevents air from getting out. The obstruction can be caused by inflammation and/or spasming of the muscles surrounding the bronchioles (asthma/COPD), or substances such as meconium as in meconium aspiration. This can often lead to an increased A/P diameter of the chest, often called a barrel chest (see below).

11. Bronchospasm: This is where the muscles surrounding the air passages of the lungs (bronchioles) spasm and swell as a result of your bodies response to stimuli in the surrounding atmosphere, such as asthma triggers and COPD triggers. This results in constriction or narrowing of the walls of the bronchioles.

12. Dyspnea: Feeling of air hunger; uncomfortable sensations; feeling you can't get enough air.

13. Barrel chest: A chest that looks rounded and bulging due to air trapping (see above) that is occurring in the lungs. This can be temporary as in asthma, or permanent as in emphysema (end stage COPD).

14. Airway obstruction: This is anything that blocks or obstructs air from getting out of the lungs, or the physiological condition where you are unable to exhale all the air you breathe in. The obstruction can be caused by bronchospasm (see above) or other. It actually results in increased resistance in the lungs due to decreased radius of the bronchioles, causes air trapping, and that ultimately reduces the amount of air inhaled with each breath.

15. Alpha-1 Antitrypson: A glycoprotein that protects lung tissues from enzymes of inflammatory cells, especially elastase, that can break down elastin in the lungs. This ultimately is a breakdown of lung tissue that causes emphysema (COPD).

16. Arterial Blood Gas (ABG):This is a laboratory test that involves a needle to be inserted into your artery, usually the radial artery in your wrist. The test measures the amount of oxygen (PaO2), carbon dioxide (PCO2), and bicarbonate (HCO3) in your blood. It also measures the acidity (pH) of your blood.

17. Bronchiole: It's the first airway branch that no longer contain cartilage. These branch out and lead to the alveoli.

18. Broncho constriction: This is when the bronchioles narrow due to airway obstruction or bronchospasm.

26. Bronchoscopy: This is a procedure where a scope is inserted into your mouth and down to your lungs where the doctor can see what is going on in your lungs. The doctor may also be able to do biopsies of tissue, and help remove excessive secretions, and wash out your lungs (bronchiolar lavage).

27. Chronic: This means that it is permanant; will not go away

28. Cyanosis: This is a blue discoloration of the skin as a result of lack of oxygen to that area. There are two types of cyanosis: Central Cyanosis: Cyanosis of the core of the body. This is the more severe type, and means tissues of your body are not getting adequate amounts of oxygen, including vital organs such as heart, lungs, and kidneys. Acrocyanosis: This is cyanosis of the tips of fingers, lips and toes. This means that your body is constricting vessels in the periphery so oxygen gets to vital organs.

29. Nebulizer: It is a device that allows respiratory medicine to get to the patient in the form of a mist. It is often used for chronic lung patients. A nebulizer is a small cup with a mouthpiece that is connected to a small air compressor. Other names are updraft and aerosol and neb.

30. Expectorate: This means spitting up secretions. Getting all that junk out of your lungs.

31. Inhaler: This is a device that is hand held and often called a metered dose inhaler (MDI). It is easily portable, fits in your purse or pocket, and is simple to use.

32. Metered Dose Inhaler: See inhaler above.

33. Updraft: See nebulizer above

34. Aerosol: See nebulizer above

34. Edema: This is when fluid builds up abnormally inside the body, and is usually the result of kidney or heart failure. Abnormal build-up of fluid under the skin or among cavities of the body.

35. Pulmonary Edema: An abnormal buildup of fluid in the lungs, usually due to heart failure.

36. Artery: These are the vessels in the body that transport freshly oxygenated blood from the lungs to the various tissues of the body.

37. Vein: These are the vessels in the body that transport deoxygenated blood from the tissues to the lungs.

38. Hypertension: This is high blood pressure. Generally, this is a blood pressure that is constantly 140/90 or greater (normal bp is 120/80). Although what is considered normal or hypertension may vary from patient to patient

39. Hypoxia: This is a lack of oxygen to the tissues.

40. Hypoxemia: This is lack of oxygen to the blood.

41. Hypoxic Hypoxemia: This is lack of oxygen to the blood and tissues.

42. Inflammation: Swelling.

43. BiPAP: This is a machine that requires a mask to be placed over the nose or mouth, and a flow of air assists the patient with his inhalations (IPAP) and another flow of air prevents complete exhalation (EPAP, CPAP) to keep the upper airway from collapsing (treats sleep apnea), and the alveoli from collapsing.

44. CPAP: This is where a flow of air on exhalation prevents your alveoli from collapsing. It actually works like a balloon, where if you prevent your alveoli from completely collapsing it is easier to open the alveoli upon the next inhalation. It can also work to prevent the upper airway from collapsing, and thus treats sleep apnea. This also helps to keep your oxygen levels (SpO2 and PO2) from dropping while you are wearing it (usually while sleeping).

45. Mechanical Ventilation: This is a machine that is sometimes required to breath for a patient when he or she is unable to breath on his own. Sometimes, during the course of some diseases, the lungs (heart and pulmonary), the lungs need to be rested a few days so they can recover, and this is the machine that is used.

46. Mucus: It is a slippery secretion that is produced by goblet cells that line your respiratory tract.

47. Oxygen: It is a gas that is in the air we breath that usually measures about 21% in the atmospheric air. During certain diseases, the % of oxygen (called the fraction of inspired oxygen or FiO2) is increased to meat the oxygen needs of the body. Using various devices, the FiO2 can be as high as 100% if needed. Oxygen is needed for normal metabolic processes to occur within the cells of our body.

48. Carbon Dionoxide: This ia a gas in the air we breath, although it is in low amounts. It is a biproduct of cellular metabolism and is exhaled from the lungs to the air. Certain disease processes may make is so CO2 builds up in the body.

49. Secretions: This is mucus that is expectorated.

50. Wheezing: This is the high pitched musical sound that is caused when the bronchiols of the lungs are narrowed, either from the inside (asthma, COPD) or from the outside (pulmonary edema).

51. Crackles: This is a sharp popping sound of the alveoli opening or fluid in the lungs. It usually sounds like when you remove velcro from a surface. If it is on inspiration is is usually referred to as fine crackles, and this is usually indicative of collapsed alveoli opening. If it is on inspiration and expiration, this is referred to as coarse crackles, and is usually indicative of fluid in the lungs (pulmonary edema). Coarse crackles are also known as rhales.

52. Rhonchi: It's the coarse rattling sound like snoring, usually on expiration. It's caused because of secretions in the airways. It is also often referred to as coarse lung sounds.

53. Rhales: See crackles above. It's usually indicative of fluid in the lungs, such as pulmonary edema.

54. Wet lungs: This is where fluid builds up in the lungs due to kidney or heart failure. It often sounds like coarse crackle or rhales upon auscultation.

55. Alveoli: The tiny balloon-like sacs at the end of the pulmonary branches where gas exchange occurs. Each alveolar comes into contact with arterioles where freshly oxygenated blood exits the alveoli and lands in the blood where it attaches to hemoglobin and is taken to the tissues. At the same time, carbon dioxide leaves the blood and enters the alveoli, where it is ultimately exhaled.

56. Pulmonary Function Test: This is a breathing test where you perform a variety of breathing tests to help a doctor diagnose various lung diseases, or the course of a lung disease.

57. Pooping out: This is what happens when a disease causes you to work really hard to breath. Ultimately your lungs will be unable to get rid of CO2 adequately, your lung muscles will ware out, and you will become extremely tired. Usually the next course of action is for medical personel to assist you in some way with your breathing, either with a BiPAP or Mechanical Ventilation.

58. Fingernail clubbing:

59. Do not resuscitate (DNR): This is when the patient incorporates into his advanced directives that he does not want any heroic measures used to restart his heart if it stops.

60. Full Code: This means medical personnel will do whatever possible to restart a heart that stops.

61. Second hand smoke: This is smoke that is inhaled second-hand.

62. Third hand smoke: This is smoke residue that is left on clothing or furniture.

63.  Exaggeration of COPD:  When the patient is faking because their family members taking care of them are tired and need a break.  So it may be assumed that 100% of exaggeration of COPD patients do not come from nursing homes or assisted care living centers.

64.  Exaggeration of Asthma:  When the patient is faking because he is stressed and in need of a break from his family.  He loves it when he comes to the hospital he receives special attention and sympathy, and gets waited on hand and foot.

The medicine:

1. Bronchodilator: Also called beta-adrenergic medicine. These are medicines that are breathed in either through an inhaler or through a breathing treatment. Once the medicine is in the air passages of your lungs they attach to beta adrenergic receptors on the muscles in this area and work to relax these muscles and prevent them from spasming. Bronchodilators, therefore, treat bronchospasm. Examples include Albuterol and Xopenex.

2. Beta Adrenergic: These are your medicines that attach to beta adrenergic receptors in your lungs, and ultimiately cause the lung muscles to relax, making it easier to breath. When the beta adrenergic receptors are stimulated, this results in bronchodilation.

3. Rescue inhaler: See beta adrenergic. Some examples include Albuterol and Ventolin.

4. Long-Acting Beta Adrenergic (LABA): See beta adrenergic. These differ from rescue inhalers in that they are long acting, usually preventing bronchospasm for 12-24 hours. These are generally referred to as preventative medicines.

5. Corticosteroid: They are produced by the adrenal cortex and have a variety of responsibilities, including regulating inflammation.

6. Mucolytic: This is a medicine that you inhale via a nebulizer that breaks up secretions (thins them) so it is easier to expectorate them. A common one prescribed is Mucomyst, and it smells like rotton eggs. Another one used often for CF patients is

7. Diuretic: This is a medicine that triggers your body to eliminate fluid, and increases your bodies ability to get rid of excess fluid. Examples of diuretics are bumex and lasix.

8. Leukotriene Blocker: These are medicines (like Singulair) that block leukotrienes, which are resonsible for causing bronchospasm as a result of the allergic response when you are exposed to your asthma triggers.

9. Antibiotics: A substance that kills bacteria.

10. Anti-Cholinergic: It is a medicine that blocks the cholinergic response that causes bronchospasm.

The Diseases:

1. Bronchitis:  Inflammation of the bronchial tubes.  It can either be acute or chronic.

2.  Chronic bronchitis:  Permanent loss of lung clearance devices (such as cilia) and excessive mucus production that has no way to be expectorated.  Results in a chronic cough and frequent lung infections.  It's one component of COPD.

2. Emphysema: Loss of lung tissue.  It's one component of COPD.  It can either be acute (asthma) or chronic (COPD).

3. Chronic Obstructive Pulmonary Disease (COPD):  Diseases that cause chronic obstruction of the air passages of the lungs that may be partially reversible.

4. Asthma:  An autoimmune disorder caused by various environmental and genetic factors that results in chronic inflammation of the air passages of the lungs, and therefore oversensitization to a variety of asthma triggers.

5. Pulmonary Fibrosis:

6. Bronchiectasis

7. Pneumonia:  Inflammation of the lung parynchema.

8. Pneumothorax:  Collapsed lung

9. Pleural Effusion:  Fluid in the pleural sac that takes up space in the lung and makes it difficult to breathe.

10. Congested Heart Failure (CHF):  A.K.A. Cardiac Asthma. It's when the left ventricle of the heart becomes weakened as a result of being overworked.  Fluid backs up into the lungs and causes increased intrapulmonary pressures that squeeze air passages and causes a cardiac wheeze.

11. Pulmonary Hypertension:  It's the result of some obstruction in the lungs causing the right heart to work extra hard to pump blood through the lungs.

12. Hypertrophy:  It's an enlargement of a muscle caused by overworking that muscle.

13. Atrial Fibrilation:  An abnormal heart rythm that is a common feature of end stage lung disease.

14. End Stage Lung Disease:  When the right heart starts to poop out after years of working extra hard to pump blood through diseased lungs.  It's usually a combination of a lung disease and heart failure.

15. Anxiety:  A common result of stress from not being able to breathe.  It can be either acute or chronic.

16. Kidney Failure:

17. Sepsis:

18. Cor Pulmonale:  See right heart failure.   Right heart becomes enlarged and weak after years of working extra hard to pump blood through diseased lungs.  It's a product of end stage lung disease.  May also lead to left heart failure and pulmonary edema.

19. Depression:

20. Thrush:  It's what happens when inhaled steroids wipe out normal flora in your mouth is wiped out (usually by inhaled steroids) creating an environment for fungus to flourish.  It usually results in a white, spotty and painful tongue.

21.  Heart Failure:  See CHF and right heart failure

22.  Right heart failure:  See cor pulmonale

23.  Pulmonary edema:  It's when fluid backs up in the lungs.


Types of COPDers:  

1.  Modest COPDer:


Happy: About 80% of COPDers fit this category. These patients tend to be among the most pleasant of all patients, more so because they are professional patients with a chronic illness and have accepted it. They rarely ask, "Why me?" Happy COPDers generally are of two types: they are either talkative or phlegmatic.

Talkative: About 80% of Happy COPDers are talkative. Some of the best conversations I've ever had with a patient have been with a talkative COPDer. Before their "time is up" they want to share as much of their experiences and knowledge as possible.

When you give a treatment to one of these patients they might not let you leave. They will talk openly about their illness and family life. By the time the patient is discharged you will have a pretty good idea of what kind of a person he was, and what kind of a life he led, prior to getting sick. Usually they are very interesting and intelligent.

If you are talking with a COPD patient, and the patient starts describing an event thatoccurred in 1945, he is probably a talkative COPDer.

Phlegmatic: About 20% of Happy COPDers are phlegmatic. Whatever you want to do, they don't care. They talk little and have very pleasant and modest dispositions. The majority tend to be men.

If you walk into the room and find the patient has his feet up on the end table while watching TV, you know he is a phlegmatic

If you walk into the room and find the patient is moderately labored and still appears cool and calm, he is most probably a phlegmatic.

Melancholy: About 20% of COPDers fall into this category. They love to be waited on hand and foot. These patients have not accepted that they are sick, and have a tendency to be unpleasant
and very bossy.

When this patient wants a drink, she will say something blunt like, "Drink!" or, "Gimme a drink." Many might pretend they are incapable of lifting the glass so you have to do it for them. If you hear the words like please or thank you, you are probably not dealing with a melancholy COPDer.

Exaggerated: Would you believe it if I told you that a certain percentage of patients actually WANT to be in the hospital. The exact percentage is unknown, but it is estimated to be around 20%, and includes both Happy and Grumpy COPDers.

What happens here is that family members are tired and need a break, so the patient feigns his symptoms to get admitted.

If you need to give a series of Duoneb treatments in ER, but once the patient is on the floor she declines a treatment because she wants to sleep, then you should think exaggeration.

If she is lying in low fowlers and appears to be in no respiratory distress when you walk into the room, but as soon as you grab your stethoscope you hear an audible forced expiratory wheeze, you should think exaggeration.

If she is so bored the day after her admission that she is assisting her elderly room mate walk to the bathroom, then you should think exaggeration.

There are two different types of exaggeration of COPD. When emphysema and chronicbronchitis patients are faking it, the diagnosis is generally exaggeration of COPD. Faking asthma patients are referred to as exaggeration of asthma.

It is important that exaggeration of COPD not be confused with exaggeration of asthma. The differences may not be easily identified once the patient is in the hospital, but must be obtained through questioning, or it may simply be assumed.

Now, I know your science teacher told you not to assume, because when you assume you make an A-S-S out of U and ME. But in this rare instance, it is often necessary in order to make a proper diagnosis of the type of COPDer.

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