Selected Neurological and Respiratory Disorders

Selected Neurological and Respiratory Disorders

Selected Neurological and Respiratory Disorders Neurological Disorders Muscle Paralysis Neural Tube Disorders

Cerebrovascular Accidents (Stroke) Transient Ischemia Attack Aneurysm Muscle Paralysis Flaccid paralysis

Destruction of motor neurons by disease Interruption of reflex arc responsible for muscle tone Muscle deprived of innervation Low muscle tone Peripheral nerve destruction Spastic paralysis

Reflex arc not disturbed Injury to cortical neurons stops voluntary control Muscle retains innervation Increased muscle tone Neural Tube Defects Anencephaly Failure of normal development of brain and cranial cavity Multifactorial inheritance Spina bifida

Diagnosis: amniocentesis and alpha-fetoprotein levels Alpha-fetoprotein leaks from fetal blood into amnionic fluid through open neural tube defect; high levels found in amnionic fluid Occult Meningocele Meningomyelocele Characteristic appearance of anencephalic infant Various types of spina bifida.

Neural Tube Defects A. Thoracic meningomyelocele covered by thin membrane B. Large meningomyelocele associated with neurologic deficit Stroke: Cerebrovascular Accident (1 of 5) Any injury to brain tissue from disturbance of blood supply to brain Types of stroke Cerebral thrombosis: most common; thrombosis of

cerebral artery narrowed by arteriosclerosis Cerebral embolus: occurs less frequently; blockage of cerebral artery by fragment of blood clot from an arteriosclerotic plaque or from heart Cerebral hemorrhage: most serious type of stroke; usually from rupture of a cerebral artery in person with hypertension Stroke: Cerebrovascular Accident (2 of 5) Predisposing Factors 1. Mural thrombus formed on wall of left ventricle

adjacent to a healing myocardial infarction 2. Thrombus formed on rough surface of diseased mitral or aortic valve 3. Small thrombus in left atrium of person with atrial fibrillation Stroke: Cerebrovascular Accident (3 of 5) Ischemic infarct: no blood leaks into brain Hemorrhagic infarct: blood leaks into damaged brain tissue Arteriosclerosis of extracranial arteries Sclerosis of a major artery from aorta that supply

brain Common affected site: carotid artery in neck; arteriosclerotic plaque may narrow lumen and reduce cerebral blood flow Stroke: Cerebrovascular Accident (4 of 5) Diagnosis Cerebral angiogram Carotid endarterectomy Less invasive methods: similar to balloon angioplasty and stent insertion procedures used to treat coronary artery plaques

Stroke: Cerebrovascular Accident (5 of 5) CT scan: can distinguish a cerebral infarct from cerebral hemorrhage Magnetic resonance imaging (MRI): provides similar information and is equally effective Effects of atherosclerosis of carotid artery A. Narrowing of lumen B. Thrombus formation

C. Thrombus dislodged & forms emboli D. Complete occlusion of artery by thrombus Coronal section of brain illustrating large cerebral hemorrhage that has compressed and displaced the cerebral ventricles. Transient Ischemic Attack, TIA Brief episodes of neurologic disfunction From embolization of material from plaque in carotid artery

One-third of patients eventually suffer major stroke Treatment: endarterectomy or medical therapy Cerebral Aneurysm Congenital aneurysm of circle of Willis

Congenital weakness in arterial wall allows lining to protrude Weakness is congenital but aneurysm develops in adult life Rupture causes subarachnoid hemorrhage Hypertension predisposes Treatment: aneurysm occluded surgically Arteriosclerotic aneurysm Cerebral artery dilates and compresses adjacent tissue Rupture uncommon Dissection of vessels from the brain of a person with large congenital cerebral

aneurysm. A cerebral aneurysm (arrow) demonstrated by an angiogram. Undersurface of brain, illustrating subarachnoid hemorrhage secondary to ruptured cerebral aneurysm. Respiratory Disorders Pneumothorax Atelectasis Pneumonia

Tuberculosis Bronchitis Chronic Obstructive Pulmonary Disease (COPD) Emphysema Bronchial Asthma Pneumothorax Pathogenesis/Manifestations Pathogenesis Lung injury or pulmonary disease that allows air to escape into the pleural space Stab wound or penetrating injury to the chest wall

Spontaneous generally in young healthy persons Manifestations Chest pain Shortness of breath Air in pleural cavity Tension pneumothorax Tension Pneumothorax Development of a higher than atmospheric pressure in the pleural cavity creating a tension Can accompany any type of pneumothorax Upon inhalation air enters pleural space due to

drop in intrapleural pressure On exhalation air gets trapped due to the edges of the tear compressing as a result of the increased intrapleural pressure thus the pressure in the intrapleural space is getting greater and greater Heart and Mediastinal structures shifted away from pneumothorax Atelectasis An incomplete expansion of the lung, a collapse of a part of the lung There are two types

1. Obstructive atelectasis: complete bronchial obstruction by Mucous secretions, tumor, foreign object Resulting in collapse of the part of the lung supplied by the blocked bronchus Can also develop as a postoperative complication, where because of the pain, the patient does not cough or breathe deeply, accumulating mucous secretions Atelectasis 2. Compression atelectasis

External compression on the lung Fluid, air, or blood in the pleural cavity, reducing its volume and preventing lung expansion Pneumonia An inflammation of the lung The exudate spreads unimpeded through the lung Filling the alveoli The affected portions of the lung become relatively solid (consolidation) At times, the exudate reaches the pleural surface

Pneumonia Classification Classification 1. Etiology: most important because it serves as a guide for treatment Bacteria, chlamydia, mycoplasmas, rickettsiae, viruses, fungi 2. Anatomic distribution of the inflammatory processdescribes what part of the lung is involved Lobar: entire lung (bacteria, neutrophil infiltration) Bronchopneumonia (bacteria, neutrophil

infiltration): parts of one or more lobes adjacent to the bronchi bronchopulmonary segments Pneumonia Classification Interstitial pneumonia or primary atypical pneumonia (virus or mycoplasma; lymphocyte, monocyte, and plasma cell infiltration): alveolar septa affected 3. Predisposing factors that lead to its development Any condition associated with poor lung ventilation and retention of bronchial secretions

Postoperative atelectasis and secondary bacterial infection Aspiration Obstruction Clinical features of pneumonia Manifestations of systemic infection Feeling ill Elevated temperature Increased white blood cell count Manifestations of lung inflammation

Cough Purulent sputum Pain on respiration if involves pleura Shortness of breath Tuberculosis

It is a special type of pneumonia caused by Mycobacterium tuberculosis an acid fast bacteria Because the tubercle bacillus has a capsule composed of waxes and fatty substances, it is more resistant to destruction than others thick cell wall As a result of this organisms resistance monocytes accumulate around the bacteria many fuse with the bacteria attempting phagocytosis but the fusion produces a large multinucleated giant cell. Lymphocytes and plasma cells surround the area followed by fibrous tissue proliferation. The central portion becomes necrotic thus a granuloma is

formed. TB is termed a granulomatous disease. Manifestations Course of infection Acquired from organisms inhaled in airborne droplets Organisms lodge within pulmonary alveoli where they proceed to multiply Initially the organisms do not elicit a marked inflammatory reaction because they do not produce any toxins or destructive enzymes Macrophage phagocytose the bacteria but are unable to destroy them they may even carry the organisms to other parts of the lung and into regional lymph nodes. After several weeks cell-mediated immunity develops

Sensitized T- cytotoxic lymphocytes attract and activate macrophages the activated macrophages attack and destroy many of the organisms forming the characteristic granulomas formed In the majority of cases the person is unaware they have been infected no symptoms Infection arrested in majority of cases Outcome depends Number of organisms inhaled State of bodys defenses May heal by scarring or progress to cavitation

Sometimes the granuloma is large enough to be seen on X-ray but most of the times it is too small The positive skin test reveals the infection Cell-mediated immunity generally controls the infection The healed granuloma may contain small numbers of viable organisms and the infection may become reactivated when the immune system drops In some individuals the primary infection does not respond favorably to the immune system fight The granuloma may extend into a nearby bronchus and necrotic inflammatory tissue is discharged into it A cavity may form

If the person gets reactivation of the bacteria (becomes active) and they have cavitation (into bronchus) their sputum can be infectious to others Most cases of active TB do not result from the initial infection but rather by a reactivation however some are due to a reinfection (new case) How does reactivation occur- it is due to a drop in the immune system action as a result of AIDS, other debilitating diseases, treatment with corticosteroids, treatment with

immunosuppressive therapy Extrapulmonary tuberculosis Result of hematogenous spread of tubercle bacilli thus a secondary infection Sites Kidneys Bone Uterus Fallopian tubes Sometimes the secondary infection may progress even though the pulmonary infection has healed leading to an

active extrapulmonary TB without clinically apparent pulmonary TB Tuberculosis Diagnosis Skin test (Mantoux): a positive test reveals recent infection chest x-ray: when the granuloma is large enough to be detected or see pulmonary infiltrates sputum culture acid fast bacteria The tuberculosis skin test (also known as the tuberculin test

or PPD test) is a test used to determine if someone has developed an immune response to the bacterium that causes tuberculosis (TB). This response can occur if someone currently has TB, if they were exposed to it in the past, or if they received the BCG vaccine against TB (which is not performed in the U.S.). The tuberculin skin test is based on the fact that infection with M. tuberculosis produces a delayed-type hypersensitivity skin reaction to certain components of the bacterium. Tuberculosis Treatment

Cell-mediated immunity generally controls the infection The healed granulomas, however, may contain small numbers of viable organisms, and the infection may become reactivated Not all primary infections respond as favorably If a large number of organisms are inhaled or if the host is compromised (bodys defenses are inadequate), the inflammation will progress, causing more destruction of lung tissue Tuberculosis

People who have active progressive tuberculosis with a tuberculous cavity can infect others because they can discharge large numbers of tubercle bacilli in the sputum Treatment Antibiotics and Chemotherapeutic agents Drug-resistant tuberculosis treatment More prolonged Results less satisfactory Drugs recommended Following conversion of a negative into positive skin test reaction

Patients with inactive tuberculosis who have increased risk Bronchitis An inflammation of the tracheobronchial mucosa Acute bronchitis Common and self-limiting Chronic bronchitis often associated with emphysema in COPD Secondary to chronic irritation by smoking or atmospheric pollution

Bronchiectasis Walls weakened by inflammation and dilate Distended bronchi retain secretions Chronic cough Production of large amounts of purulent sputum Diagnosed with bronchogram A specialized X-ray which consists of taking films after instilling a radiopaque oil into the trachea and bronchi. The oil covers the mucosa of the bronchi, and the abnormal bronchi can be recognized as dilated Only effective treatment is surgical resection of affected

segments of lung Upper Respiratory System From nose and mouth down to Lungs (includes nose, mouth, pharynx, larynx, and trachea Lower Respiratory System Mainstem bronchus to Alveoli Upper Airway From nose and mouth to and inclusive of larynx (voice box) Lower Airway Trachea down to alveoli Chronic Obstructive Pulmonary Disease

Emphysema and chronic bronchitis occur together so frequently that they are usually considered a single entity, designated COPD Emphysema is characterized by loss of elasticity (increased pulmonary compliance) of the lung tissue caused by destruction of structures feeding the alveoli Chronic bronchitis Secondary to chronic

irritation by smoking or atmospheric pollution Clinical manifestations Dyspnea Cyanosis

Emphysema The air spaces distal to the terminal bronchioles are enlarged and their walls are destroyed The normally fine alveolar structure of the lung is destroyed The large cystic air spaces form throughout the lung The destructive process usually begins in the upper lobes but eventually may affect all lobes Once emphysema has developed, the damaged lungs cannot be restored to normal

Bronchial Asthma Spasmodic contraction of smooth muscles in the walls of the smaller bronchi and bronchioles It causes shortness of breath and wheezing respiration Exerts a greater effect on expiration than on inspiration Attacks are precipitated by allergens: inhalation of dust, pollens, animal dander, or other allergens Treated with drugs such as epinephrine or theophylline that relax bronchospasms and block the release of mediators from mast cells

Bronchial Asthma Pathogenesis Spasmodic contraction of smooth muscles in walls of smaller bronchi and bronchioles Associated with increased secretions from bronchial mucous glands Clinical manifestations Shortness of breath Wheezing respirations Air flow impeded more on expiration than on inspiration

Air trapped in lungs Lungs become overinflated Attacks precipitated by allergens Interact with mast cells coated with IgE antibody Release chemical mediators that induce bronchospasm Treatment Drugs that relax bronchospasm Epinephrine Theophylline

Drugs that block release of mediators from mast cells

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