An ex coal minor is becoming increasingly breathless when he goes to the shops or plays with his grandchildren
Mr Grantham is a 74 year old gentleman who complains of increasing shortness of breath over the preceeding 3 months. He has a 'smokers cough' which is dry and non-productive. He finds that he can no longer run around and play with his grandchildren.
His past medical history includes asthma for which he has a salbutamol and a beclomethasone inhaler. No other regular medications and no allergies.
He worked in a coal mine for 30 years until it was closed down. Since then he has helped his son keep books at his small garage business. Despite advice to the contrary he continues to smoke 15 cigarettes a day with a 30 pack year history. he lives with his wife in a small bungalow and has no trouble with mobility.
Pneumonia is an acute infection, associated with fever, productive cough (in majority of cases) and signs of being systemically unwell. Mr Grantham has had a progressive shortness of breath, a dry cough and no indication yet of any acute systemic symptoms.
Pneumonia is an infection of the lung interstitium (the area which is normally filled with air). An infection irritates the lung causing an inflammatory response. This results in migration of inflammatory cells such as neutrophils into air spaces. These cells release toxins to kill the intruder which subsequent results inflammatory exudate flowing from the tissue into the air spaces. When the air space is filled with fluid and inflammatory cells, no gas reaches the alveolar walls for oxygen transfer. The severity is therefore partially determined on the amount of lung affected. The more lung affected the less surface for oxygen transfer.
We divide pneumonia into two types depending on the location within the lungs; Lobar and Bronchopneumonia.
[diagram of lobar vs bronchopneumonia]
Spreading from alveoli to alveoli via small interconnecting channels until a whole lobe is filled with consolidation.
Infection originates in interstitium of bronchioles and spreads into alveoli from here.
COPD is a chronic, progressive airway obstructiove disease with no reversibility (it has limited improvement with bronchodilators) usually caused by smoking.
"PINK PUFFER" emphysema
Thin patient breathing rapidly through pursed lips.
The patient is trying to make up for the reduced area for oxygen transfer, in order to do this the person breathes more rapidly (increased respiratory rate). They purse their lips in order to maintain a high pressure within their lungs, which holds open their alveoli open ( which would otherwise collapse). This requires lots of energy to maintain and therefore these patients are often very thin. Although it is a lot of effort these patients maintain their oxygen levels and therefore remain pink.
"BLUE BLOATER" Chronic bronchitis
Cyanosed barrel chested individual.
The patient has lots of obstruction due to the mucus and therefore finds it difficult to breath out. This results in the chest becoming gradually more expanded like a balloon that keeps getting bigger. Due to the poor exchange of old air for new, very little fresh air reaches the alveoli for gas transfer and therefore less oxygen is exchanged. This results in a cyanosis, and is why the patient has a blue tinge.
General inspection: Patient appears to have a plethoric face (very red) and is comfortable at rest. BMI 30.
Obs:
Respiratory examination: Mouth is cyanoised. On inspection chest is barrel shaped, with reduced expansion. On percussion there are some areas of hyperresonance, others normal. On auscultation there are quiet breath sounds.
Bullae are areas of alveolar distention due to the damaged tissue in emphysema ( like balloons instead of small grapes). The increased in percussion resonants is due to less dense tissue below your hands.
The cause of COPD in 99% of cases is smoking cigarettes. If a person has over 20 pack years (20 cigarettes per day for 20 years or the equivalent) they are at extremely high risk of getting COPD.
Coal mining such as was Mr Grantham’s Job can contribute to COPD and accelerate the decline in lung function that may be seen.
Asthma is reversible and COPD is not reversible. The damage in COPD is caused by long term exposure to airborne toxins and can not be undone. This is a chronic inflammation.
Whereas asthma is an acute inflammation in response to a trigger, if you remove the trigger and treat with medication you can reverse this reaction.
Pneumonia is an infection of the lung interstitium (the area which is normally filled with air). An infection irritates the lung causing an inflammatory response. This results in migration of inflammatory cells such as neutrophils into air spaces. These cells release toxins to kill the intruder which subsequent results inflammatory exudate flowing from the tissue into the air spaces. When the air space is filled with fluid and inflammatory cells, no gas reaches the alveolar walls for oxygen transfer. The severity is therefore partially determined on the amount of lung affected. The more lung affected the less surface for oxygen transfer.
We divide pneumonia into two types depending on the location within the lungs; Lobar and Bronchopneumonia.
[diagram of lobar vs bronchopneumonia]
Spreading from alveoli to alveoli via small interconnecting channels until a whole lobe is filled with consolidation.
Infection originates in interstitium of bronchioles and spreads into alveoli from here.
Patient treated for ACS.
Wow! You made it all the way to the end. These are the objectives you will have picked up along the way.