Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 24 Kyphoscoliosis Figure 24-1. Kyphoscoliosis. Posterior and lateral curvature of the spine causing lung

Copyright © 2006 by Mosby, Inc.Slide 1

Chapter 24Chapter 24 Kyphoscoliosis Kyphoscoliosis

Figure 24-1. Kyphoscoliosis. Posterior and lateral curvature of the spine Figure 24-1. Kyphoscoliosis. Posterior and lateral curvature of the spine causing lung compression. Excessive bronchial secretions (A) and atelectasis causing lung compression. Excessive bronchial secretions (A) and atelectasis

(B) are common secondary anatomic alterations of the lungs. (B) are common secondary anatomic alterations of the lungs.

A B


Anatomic Alterations of the LungsAnatomic Alterations of the Lungs

Lung restriction and compression as a result Lung restriction and compression as a result of the thoracic deformityof the thoracic deformity

Mediastinal shiftMediastinal shift

Mucus accumulation throughout the Mucus accumulation throughout the tracheobronchial treetracheobronchial tree

AtelectasisAtelectasis


EtiologyEtiology

Kyphoscoliosis affects about 2% of the Kyphoscoliosis affects about 2% of the people in the United Statespeople in the United States Mostly young children going through growing Mostly young children going through growing

spurtsspurts

Rarely develops in adults—unless a worsening Rarely develops in adults—unless a worsening condition from childhoodcondition from childhood

Kyphoscoliosis may also develop in adults from a Kyphoscoliosis may also develop in adults from a degenerative joint condition in the spinedegenerative joint condition in the spine


EtiologyEtiologyAssociated with the following conditions:Associated with the following conditions: Congenital connective tissue and skeletal disordersCongenital connective tissue and skeletal disorders Hormonal imbalanceHormonal imbalance Neuromuscular disordersNeuromuscular disorders TraumaTrauma Extraspinal contracturesExtraspinal contractures Bone infections involving the vertebraeBone infections involving the vertebrae Metabolic bone disordersMetabolic bone disorders Joint diseaseJoint disease TumorsTumors


EtiologyEtiology

Risk FactorsRisk Factors

Sex—females are 10 times more likely than Sex—females are 10 times more likely than males to develop curvature of the spinemales to develop curvature of the spine

Age—the younger the child is when Age—the younger the child is when diagnosed, the greater the chance of curve diagnosed, the greater the chance of curve progressionprogression

Angle of the curve—the greater the curvature Angle of the curve—the greater the curvature of the spine, the greater the risk that the of the spine, the greater the risk that the curve progression will worsencurve progression will worsen


EtiologyEtiology

Risk FactorsRisk Factors

Location—in girls with lower back curvature, Location—in girls with lower back curvature, the curve is less likely to progress the curve is less likely to progress

Height—taller girls have a greater chance of Height—taller girls have a greater chance of curve progressioncurve progression

Spinal problems at birth—children with Spinal problems at birth—children with scoliosis at birth may experience a rapid scoliosis at birth may experience a rapid curve progressioncurve progression


EtiologyEtiologyClinically, scoliosis is commonly defined according toClinically, scoliosis is commonly defined according tothe following factors:the following factors: ShapeShape

Nonstructural scoliosis—a side-to-side curveNonstructural scoliosis—a side-to-side curve Structural scoliosis—a curvature of the spine associated Structural scoliosis—a curvature of the spine associated

with vertebral rotationwith vertebral rotation LocationLocation

ThoracicThoracic LumbarLumbar ThoracolumbarThoracolumbar

DirectionDirection Left or right curvature of the spineLeft or right curvature of the spine

AngleAngle


Cobb AngleCobb Angle


Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Associated Clinical Manifestations Associated

with KYPHOSCOLIOSISwith KYPHOSCOLIOSIS

The following clinical manifestations result from The following clinical manifestations result from the pathophysiologic mechanisms caused (or the pathophysiologic mechanisms caused (or activated) by activated) by Atelectasis Atelectasis (see Figure 9-7) and (see Figure 9-7) and Excessive Bronchial SecretionsExcessive Bronchial Secretions (see Figure (see Figure 9-11)—the major anatomic alterations of the 9-11)—the major anatomic alterations of the lungs associated with kyphoscoliosis (see lungs associated with kyphoscoliosis (see Figure 24-1). Figure 24-1).


Figure 9-7. Atelectasis clinical scenario.Figure 9-7. Atelectasis clinical scenario.


Figure 9-11. Excessive bronchial secretions clinical scenario. Figure 9-11. Excessive bronchial secretions clinical scenario.


Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside

Vital signsVital signs

Increased respiratory rateIncreased respiratory rate

Increased heart rate, cardiac output, Increased heart rate, cardiac output, blood pressureblood pressure



CyanosisCyanosis

Digital clubbingDigital clubbing

Peripheral edema and venous distentionPeripheral edema and venous distention Distended neck veinsDistended neck veins

Pitting edemaPitting edema

Enlarged and tender liverEnlarged and tender liver

Cough and sputum productionCough and sputum production


Digital Clubbing

Figure 2-46. Digital clubbing.Figure 2-46. Digital clubbing.


DistendedDistendedNeck VeinsNeck Veins

Figure 2-48. Distended neck veins (Figure 2-48. Distended neck veins (arrowsarrows).).


Figure 2-47. Pitting edema. From Bloom A, Ireland J: Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetesColor atlas of diabetes, ed 2,, ed 2,London, 1992, Mosby-Wolfe.London, 1992, Mosby-Wolfe.



Chest assessment findingsChest assessment findings

Obvious thoracic deformityObvious thoracic deformity

Tracheal shiftTracheal shift

Increased tactile and vocal fremitusIncreased tactile and vocal fremitus

Dull percussion noteDull percussion note

Bronchial breath soundsBronchial breath sounds

Whispered pectoriloquyWhispered pectoriloquy

Crackles, rhonchi, and wheezingCrackles, rhonchi, and wheezing


Figure 2-11. Figure 2-11. A short, dull, or flat percussion note is typically produced over areas A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.of alveolar consolidation.


Figure 2-16. Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung Auscultation of bronchial breath sounds over a consolidated lung unit.unit.


Figure 2-19. Figure 2-19. Whispered voice sounds auscultated over a normal lungWhispered voice sounds auscultated over a normal lungare usually faint and unintelligible.are usually faint and unintelligible.


Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special

ProceduresProcedures


Pulmonary Function Study: Pulmonary Function Study: Expiratory Maneuver FindingsExpiratory Maneuver Findings

FVC FEVT FEF25%-75% FEF200-1200

N or N or N

PEFR MVV FEF50% FEV1%

N N or N N or

FVC FEVT FEF25%-75% FEF200-1200

N or N or N

PEFR MVV FEF50% FEV1%

N N or N N or


Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings

VT RV FRC TLC

N or

VC IC ERV RV/TLC%

N

VT RV FRC TLC

N or

VC IC ERV RV/TLC%

N


Arterial Blood GasesArterial Blood Gases

Mild to Moderate KyphoscoliosisMild to Moderate Kyphoscoliosis

Acute alveolar hyperventilation with Acute alveolar hyperventilation with hypoxemiahypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)

pH PaCO2 HCO3- PaO2

(Slightly)


Time and Progression of Disease Time and Progression of Disease

100100

5050

3030

8080

00

PaCO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaO2

Disease OnsetDisease OnsetP

aO2

or

PaC

O2

PaO

2 o

r P

aCO

2

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.


Arterial Blood GasesArterial Blood Gases

Severe KyphoscoliosisSevere Kyphoscoliosis

Chronic ventilatory failure with hypoxemiaChronic ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2

Normal (Significantly)

pH PaCO2 HCO3- PaO2

Normal (Significantly)


Time and Progression of DiseaseTime and Progression of Disease

100100

5050

3030

80

0

PaO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaCO 2

Chronic Ventilatory Failure Chronic Ventilatory FailureDisease OnsetDisease Onset

Point at which disease becomes severe and patient begins to become fatigued

Point at which disease becomes severe and patient begins to become fatigued

Pa0

2 o

r P

aC0 2

Pa0

2 o

r P

aC0 2

Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.


Acute Ventilatory Changes on Acute Ventilatory Changes on Chronic Ventilatory FailureChronic Ventilatory Failure

Acute alveolar hyperventilation on chronic Acute alveolar hyperventilation on chronic ventilatory failureventilatory failure

Acute ventilatory failure on chronic Acute ventilatory failure on chronic ventilatory failure ventilatory failure


Oxygenation IndicesOxygenation Indices

QS/QT DO2 VO2 C(a-v)O2

Normal Normal

O2ER SvO2

QS/QT DO2 VO2 C(a-v)O2

Normal Normal

O2ER SvO2


Hemodynamic Indices Hemodynamic Indices (Severe Kyphoscoliosis)(Severe Kyphoscoliosis)

CVP CVP RAPRAP PAPA PCWPPCWP

NormalNormal

COCO SVSV SVISVI CICI

NormalNormal NormalNormal NormalNormal Normal Normal

RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR

NormalNormal NormalNormal


Laboratory findingsLaboratory findings

Complete blood count (CBC)Complete blood count (CBC) Elevated hemoglobin concentration and Elevated hemoglobin concentration and

hematocrit if the patient is chronically hypoxemichematocrit if the patient is chronically hypoxemic


Radiologic FindingsRadiologic Findings

Chest radiographChest radiograph

Thoracic deformityThoracic deformity

Mediastinal shift Mediastinal shift

Increased lung opacityIncreased lung opacity

Atelectasis in areas of compressed lungsAtelectasis in areas of compressed lungs

Enlarged heart (cor pulmonale)Enlarged heart (cor pulmonale)


Figure 24-2. Severe kyphoscoliosis in a 14-year-old male patient.Figure 24-2. Severe kyphoscoliosis in a 14-year-old male patient.


General Management of General Management of KyphoscoliosisKyphoscoliosis

Braces (25 – 45 degree curvature)Braces (25 – 45 degree curvature) Milwaukee braceMilwaukee brace

Charleston braceCharleston brace

Boston braceBoston brace

Wilmington braceWilmington brace

Thoracolumbosacral orthosis Thoracolumbosacral orthosis

Surgery (40 – 50 degree curvature)Surgery (40 – 50 degree curvature) Posterior spinal fusion and instrumentationPosterior spinal fusion and instrumentation

Anterior spinal fusionAnterior spinal fusion



Other approachesOther approaches

Electrical stimulationElectrical stimulation

Chiropractic manipulationChiropractic manipulation

Exercise to treat scoliosisExercise to treat scoliosis



Respiratory care treatment protocolsRespiratory care treatment protocols

Oxygen therapy protocolOxygen therapy protocol

Bronchopulmonary hygiene therapy protocolBronchopulmonary hygiene therapy protocol

Hyperinflation therapy protocolHyperinflation therapy protocol

Nocturnal mechanical ventilationNocturnal mechanical ventilation






Chest CuirassChest Cuirass


Ankylosing SpondylitisAnkylosing Spondylitis

Rheumatologic disease affects spine and Rheumatologic disease affects spine and thoracic cagethoracic cage

Dramatically decreases thoracic cage Dramatically decreases thoracic cage compliancecompliance


ReviewReview A posterior curvature of the spine is called?A posterior curvature of the spine is called?

KyphosisKyphosis

A lateral curvature of the spine is called?A lateral curvature of the spine is called? ScoliosisScoliosis

Kyphoscoliosis affects approximately what Kyphoscoliosis affects approximately what percentage of the U.S. population?percentage of the U.S. population? 2%2%

What is the most common form of idopathic What is the most common form of idopathic kyphoscoliosis?kyphoscoliosis? Adolescent ScoliosisAdolescent Scoliosis


What is a nonstructural scoliosis?What is a nonstructural scoliosis? A side-to-side curve that results from a cause A side-to-side curve that results from a cause

other than the spine (poor posture, pain)other than the spine (poor posture, pain)

What is a structural scoliosis?What is a structural scoliosis? Curvature associated with vertebral rotationCurvature associated with vertebral rotation


True / FalseTrue / False Kyphoscoliosis is classified as an obstructive Kyphoscoliosis is classified as an obstructive

disorder.disorder. FalseFalse

Girl are 10 times more likely to develop Girl are 10 times more likely to develop curvature of the spine than boys.curvature of the spine than boys. True True

Kyphoscoloiosis causes the patient’s PEFR to Kyphoscoloiosis causes the patient’s PEFR to increase.increase. FalseFalse


Classroom DiscussionClassroom DiscussionCase Study: KyphoscoliosisCase Study: Kyphoscoliosis


What was the patient’s P(A-a)OWhat was the patient’s P(A-a)O2?2?

Do we have enough information to calculate ODo we have enough information to calculate O22 content?content?


Expected Effect of Acute Changes in Expected Effect of Acute Changes in PaCOPaCO22 on Arterial pH on Arterial pH

PaCO2 Change pH Change

Decrease 1 mm Hg10 mm Hg

Increase 0.01 0.10

Increase 1 mm Hg10 mm Hg

Decrease 0.006 0.06

Expected pH when measured PaCO2 < 40 mm Hg Expected pH = 7.40 + (40 – measured PaCO2)0.01

Expected pH when measured PaCO2 > 40 mm Hg Expected pH = 7.40 - (measured PaCO2 - 40)0.006


Effect of Acute Changes in PaCO2 Effect of Acute Changes in PaCO2 on Bicarbonateon Bicarbonate

Increase in PaCOIncrease in PaCO22

Plasma HCOPlasma HCO33- - increases by 1 mEg/L for every 10 increases by 1 mEg/L for every 10

mm Hg PaCOmm Hg PaCO2 2 > 40 mm Hg> 40 mm Hg

Decrease in PaCODecrease in PaCO22

Plasma HCOPlasma HCO33- - decreases by 2 mEg/L for every 10 decreases by 2 mEg/L for every 10

mm Hg PaCOmm Hg PaCO2 2 < 40 mm Hg< 40 mm Hg

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Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 24 Kyphoscoliosis Figure 24-1. Kyphoscoliosis. Posterior and lateral curvature of the spine causing lung