Lesson 1, Topic 1
In Progress

Chronic Respiratory Diseases

April 11, 2024

Learning Objective: Examine chronic respiratory diseases and disorders, including the signs, symptoms, etiology, diagnostic procedures, and treatments.
      A chronic disease, disorder, or syndrome that lasts longer than 6 months. Some chronic diseases last a lifetime. The following sections examine common chronic respiratory diseases.

Allergic Rhinitis
Learning Objective: Describe allergic rhinitis, including the signs, symptoms, etiology, diagnostic procedures, and treatments.
      When a person is allergic to dust, animal dander, pollen, or foods, allergic rhinitis can occur. When the reaction is due to a pollen allergy, the person is said to have hay fever, seasonal allergies, or allergic rhinitis.
The cause of allergic rhinitis can be traced to an allergen that triggers an allergy in a person. When the allergen is breathed in, histamines in the body cause allergy symptoms to occur. Allergic rhinitis can cause the following:
               • Itchy nose, mouth, eyes, and throat
               • Problems smelling and runny nose
               • Sneezing and watery eyes
      Later symptoms may include nasal congestion, coughing, decreased sense of smell, and sore throat. Patients can also have dark circles and puffiness under the eyes. Fatigue and headaches are also common.
      The provider will perform a physical exam and ask about the patient’s allergy history. Allergy testing, a complete blood count (CBC), and other allergy-related tests (e.g., the IgE radioallergosorbent test [RAST] test) may be done. Treatment consists of avoiding the allergen or reducing exposure. A nasal wash may be recommended to remove mucus from the nose. Medications, such as antihistamines, decongestants, and corticosteroids, may also be ordered. Depending on the severity, the provider may also refer the patient to an allergy department for evaluation. Allergy shots (immunotherapy) are sometimes recommended.

FIGURE 26.4  Inflammation and bronchospasm.

FIGURE 26.5  A pulse oximeter is used for oxygen saturation measurement.

Asthma
Learning Objective: Describe asthma, including the signs, symptoms, etiology, diagnostic procedures, and treatments.
      Asthma is a chronic disease that affects the airway. Bronchospasms and airway swelling narrow the passageway. The mucus in the lungs clogs the airway (FIGURE 26.4). Getting air into and out of the lungs becomes harder. The frequency of asthma episodes can vary. Severe asthma attacks are life-threatening and require immediate emergency care.
      Many different things can trigger an asthma episode:
                • Allergens including foods (e.g., tree nuts), medications, and environmental substances, such as pollen, mold spores, pet dander, tobacco smoke, dust mites, cockroaches, wood smoke, and latex
                • Environmental causes, such as chemical gases or fumes, dust, high humidity, and cold, dry air
                • Strong emotional states
                • Strenuous physical exercise
      Asthma symptoms can vary in type and frequency. Typical symptoms include shortness of breath, chest tightness or pain, coughing or wheezing attacks, and early morning or nighttime coughing.
The provider may order peak flow monitoring, pulse oximetry (also called oxygen saturation measurement), and spirometry tests for diagnostic testing (FIGURE 26.5). Peak flow monitoring measures the amount of air exhaled. Peak flow monitoring can be used with at-home management of asthma. The provider can set up an asthma action plan to accompany the peak flow readings (TABLE 26.1).
TABLE 26.1

      Treatment for asthma is based on the severity of the disease. Asthma medications can be taken orally or inhaled. Inhaled medications are usually taken via a metered-dose inhaler with a spacer or a nebulizer. Long-term control medications are usually taken daily and may include inhaled corticosteroids, leukotriene modifiers, long-acting beta-agonists, and combination inhalers. Quick-relief medications are usually taken during the asthma episode because they provide rapid, short-term relief. Quick-relief medications include short-acting beta agonists supplied by metered-dose inhalers (MDIs), such as albuterol and levalbuterol. If the quick-relief medications do not reduce the episode, immediate emergency care is required.


Chronic Obstructive Pulmonary Disease
Learning Objective: Discuss chronic obstructive pulmonary disease, including the signs, symptoms, etiology, diagnostic procedures, and treatments.
      According to the Centers for Disease Control and Prevention (CDC), more than 16 million Americans have COPD and more than 150,000 Americans die of COPD each year. This condition is both treatable and preventable. COPD develops slowly, making it hard for the affected person to breathe. It includes two conditions:

FIGURE 26.6  Finger clubbing. The nail is enlarged and curved. From Ball J, et al: Seidel’s guide to physical examination, ed 9, St. Louis, 2019, Mosby.

                • Emphysema: Thinning and eventual destruction of the alveoli. This usually accompanies chronic bronchitis.
                • Chronic bronchitis: Inflammation of the bronchial tubes, excessive production of mucus, and diminished activity of the cilia.
      The main cause of COPD is smoking tobacco. Other causes include secondhand smoke, air pollution, dust, and chemical fumes. COPD can also be caused by an alpha-1 antitrypsin (AAT) deficiency.
      The symptoms of COPD often appear after damage has already been done to the lungs. With chronic bronchitis, a long-term, daily productive cough is seen. Additional symptoms of COPD include shortness of breath, chest tightness, breathlessness, wheezing, cyanosis of the lips and nail beds, and clubbing (FIGURE 26.6). The patient may experience a lack of energy and fatigue. Frequent respiratory infections are common.
      Typical diagnostic tests include lung function tests (i.e., spirometry and pulse oximetry), chest x-rays, and chest computed tomography (CT) scan. An arterial blood gas test may be done to identify the severity of COPD. Because there is no cure for COPD, the goal of treatment is to slow the disease progression. Patients typically use bronchodilators and a bronchodilator-corticosteroid combination to reduce the inflammation. Patients may use low-level oxygen therapy. Adequate nutrition, vaccinations, and smoking cessation are also important in the treatment plan. With severe COPD, surgical options may be considered, such as lung volume reduction surgery (removal of damaged lung tissue) and lung transplantation.

Alpha-1 Antitrypsin Deficiency
      Alpha-1 antitrypsin (AAT) deficiency is a rare inherited disorder that can increase a person’s risk of developing lung and liver disease. The onset of lung disease occurs at a younger age than normal (around 30 to 41 years of age).
      AAT is a protein in the blood and lungs. It protects the lungs from chronic obstructive pulmonary disease (COPD). Sometimes a person may not make enough of this protein, or the AAT that is made is abnormal. Genetic testing is available to determine a person’s risk. There is no cure for AAT deficiency, although the lung disease can be managed.

Smoking and Smokeless Tobacco
Tobacco smoke contains more than 7000 chemicals. Of these, 250 are harmful, and at least 69 can cause cancer. It is estimated that 1 in 5 deaths are related to smoking. According to the Centers for Disease Control and Prevention (CDC), smokers are more likely to develop heart disease, lung cancer, and strokes. Smoking can cause the following effects:
                • Respiratory system: Pneumonia, chronic obstructive pulmonary disease (COPD), tuberculosis, asthma, and cancer of the trachea, bronchus, and lung
                • Nervous system: Stroke
                • Cardiovascular system: Aortic aneurysm, early abdominal aortic atherosclerosis in young adults, coronary heart disease, atherosclerotic peripheral vascular disease, and acute myeloid leukemia
                • Sensory system: Blindness, cataracts, and age-related macular degeneration
                • Digestive system: Orofacial clefts (congenital defect from maternal smoking) and periodontitis; oropharynx, larynx, esophagus, stomach, liver, and colorectal cancers
                • Endocrine system: Type 2 diabetes mellitus and pancreatic cancer
                • Musculoskeletal system: Hip fractures and rheumatoid arthritis
                • Urinary system: Cancer of the bladder, kidney, and ureters
                • Immune system: Immune function issues
                • Reproductive system: In females, reproductive effects (e.g., reduced fertility), ectopic pregnancy, and cervical cancer; in males, erectile dysfunction
      Passive or secondhand smoke, which stays in the air and can be breathed in by others, causes lung cancer, strokes, low-birth-weight babies, and heart disease. Exposure to secondhand smoke increases a person’s risk for lung cancer by 20%. Children exposed to secondhand smoke have an increased risk of sudden infant death syndrome (SIDS), ear infections, bronchitis, pneumonia, colds, and asthma. Secondhand smoke causes more than 53,000 deaths a year in the United States.
      Thirdhand smoke is the residue or chemicals from the smoke that gets on skin, clothing, furniture, carpets, and so on. This can be harmful to little children and animals that spend time on the floor. Besides breathing in the residue, these chemicals can be ingested. They can transfer from the carpet, clothing, and so on to hands and then into the person’s mouth.
      The CDC reports that at least 28 cancer-causing chemicals have been found in smokeless tobacco (e.g., chew and dip). Smokeless tobacco can cause cancer of the mouth, pancreas, and esophagus.
      E-cigarettes, which are used for vaping, are also considered tobacco products because they usually contain nicotine. E-cigarettes (also called e-cigs, vape pens, mods, or e-hookahs) are battery-operated devices that heat liquids to form an aerosol, which is then inhaled. The liquids typically contain nicotine, flavorings, and other additives. E-cigs can also be used for marijuana and other drugs. An e-cig may look like a cigarette, pipe, whiteout, marker, lipstick, pen, or USB (flash) drive. Compared to cigarettes, e-cigs are safer, but they still can be harmful. The aerosol can contain nicotine, heavy metals (e.g., lead), volatile organic compounds, and cancer-causing substances. One example of a health risk comes from diacetyl, which is found in many e-cigarette flavors. It has been known to cause bronchiolitis obliterans, commonly called “popcorn lung.” Diacetyl was an ingredient in microwave popcorn and food flavorings until it was linked to hundreds of cases of bronchiolitis obliterans. Like COPD, this disease can cause wheezing, persistent cough, shortness of breath, and death. The alveoli become scarred, and the airway becomes narrowed.
      According to the CDC, the advantages of giving up the use of tobacco products include the following:
                • Blood pressure and heart rate begin to return to normal.
                • Within a few hours, carbon monoxide levels in the blood decline.
                • Within a few weeks, circulation improves, and abnormal respiratory symptoms (e.g., cough, wheezing) decrease.
                • One year after quitting, the cardiovascular risks decrease sharply.
                • Two to 5 years after quitting, the risk for stroke returns to a nonsmoker’s level.
                • Five years after quitting, the risk of cancer of the esophagus, bladder, throat, and mouth is cut in half.
                • Ten years after quitting, the lung cancer risk decreases by 50%.
      Local resources and prescriptive medications are available to assist people who want to quit using these products. Websites (e.g., https://smokefree.gov) and quit lines are also available (e.g., National Cancer Institute Smoking Quitline: 1-877-44U-QUIT).

Cystic Fibrosis
Learning Objective: Describe cystic fibrosis, including the signs, symptoms, etiology, diagnostic procedures, and treatments.
      Cystic fibrosis (CF) is a life-threatening, congenital disease. Mucus builds up in the lungs, pancreas, and other organs. The mucus blocks the airways and increases the risk of infections. In the pancreas, the mucus interrupts the release of digestive enzymes used to break down food.
      More than 30,000 people in the United States have cystic fibrosis. The majority of people with CF are diagnosed by age 2. All states require newborn screening tests for cystic fibrosis. With improvements in treatments, people with CF can live, work, and play with a much greater quality of life than in the past.
      CF is a genetic disease. Each parent gives one copy of a specific gene to the child. As a result, the child gets two copies of a specific gene. If one of the copies is defective, the person will be a carrier of that disease. If both copies are defective, the person will have the disease. CF can cause the following conditions:
                • Higher than normal levels of salt in the sweat and electrolyte imbalances
                • A persistent cough that produces a thick, sticky sputum
                • Breathlessness, shortness of breath, wheezing, and frequent lung infections
                • Poor growth and weight gain
                • Intestinal blockage, severe constipation, and foul-smelling, greasy stools
One of the following tests can be done to diagnose CF:
                • Two positive sweat tests (the tests must be performed on different days)
                • Genetic testing, to detect two defective genes (for CF), and one positive sweat test
There is no cure for CF. Treatment centers on reducing the complications and symptoms. Treatment can include the following:

                • Antibiotics for lung infections and anti-inflammatory medications can reduce the swelling in the lungs.
                • Bronchodilators and mucus-thinning medication can help clear the lungs of mucus.
                • Oral pancreatic enzymes are used to help with digestion.
                • Chest physical therapy, vest therapy (vibrating vest), and O2 therapy can be initiated.
                • Surgical options for CF complications include lung transplantation and bowel surgery for obstructions.

Sleep Apnea
Learning Objective: Discuss sleep apnea, including the signs, symptoms, etiology, diagnostic procedures, and treatments.
      Sleep apnea occurs when a person stops breathing, or the breathing becomes very shallow. Breathing pauses may last a few seconds to minutes and can occur 30 or more times an hour. The cause of sleep apnea depends on the type:
                • Obstructive sleep apnea (OSA): The most common type of sleep apnea; it causes breathing to pause during sleep. OSA results from a blockage or narrowing of the airway when the throat muscles relax. It can be caused by excessive weight, a thicker neck circumference, a narrowed airway, smoking, and nasal congestion. Males are twice as likely to have it, and age increases the risk.
                • Central sleep apnea: The breathing repeatedly stops during sleep. The brain temporarily stops sending signals to the muscles that control breathing. This condition can be caused by brainstem injuries (including infections and stroke), congestive heart disease, and narcotic analgesics.
                • Complex sleep apnea syndrome: Occurs when a person has both obstructive and central sleep apnea.
The most common signs and symptoms of these conditions include loud snoring, breathing cessation during sleep, dry mouth, sore throat, morning headache, difficulty staying asleep, excessive daytime sleepiness, irritability, and attention problems.
      After an examination, the provider may refer the patient to a sleep specialist or order a sleep study. Treatments may include weight loss or stopping the use of alcohol or medications that may be causing the condition. Continuous positive airway pressure (CPAP) therapy is the most common treatment for OSA (FIGURE 26.7). It uses mild air pressure to keep the airway open.