chapter 24 kyphoscoliosis

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Chapter 24Chapter 24

KyphoscoliosisKyphoscoliosis


Figure 24-1. Kyphoscoliosis. Posterior and lateral curvature of the spine causing lung compression. Excessive bronchial secretions (A) and atelectasis (B) are common secondary anatomic alterations of the lungs.

A

B


Kyphoscoliosis is a combination of two thoracic deformities that commonly appear together. Kyphosis is a posterior curvature of the spine

(humpback). In scoliosis the spine is curved to one side—

typically appearing as an S or C shape.

Anatomic Alterations of the LungsAnatomic Alterations of the Lungs


Anatomic Alterations of the Lungs Anatomic Alterations of the Lungs (Cont’d)(Cont’d)

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

Mediastinal shiftMediastinal shift Mucous accumulation throughout the Mucous accumulation throughout the

tracheobronchial treetracheobronchial tree AtelectasisAtelectasis


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

spurts Rarely develops in adults—unless a worsening

condition from childhood Kyphoscoliosis may also develop in adults from a

degenerative joint condition in the spine

EtiologyEtiology


Kyphoscoliosis is commonly associated with the following general conditions: Congential scoliosis

• Problem with the formation of the spine or fused ribs during fetal development

Neuromuscular scoliosis• Problems caused by poor muscle control, muscle

weakness, or paralysis Idiopathic scoliosis

• Scoliosis from a unknown cause (80%-85% of the cases) (80%-85% of the cases)

Etiology (Cont’d)Etiology (Cont’d)


Idiopathic scoliosis is classified as follows: Infantile scoliosis

• The curvature of the spine develops during the first 3 years of life.

Juvenile scoliosis• The curvature occurs between 4 years and the onset of

adolescence. Adolescent scoliosis

• The spine curvature develops after the age of 10.



Risk Factors Include: Sex—Girls are more likely to develop curvature of

the spine than boys. Age—The younger the child is when the diagnosis

is first made, the greater the chance of curve progression.

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



Risk Factors Include: Location—Curves in the middle to lower spine are

less likely to progress than those in the upper spine.

Height—Taller people have a greater chance of curve progression.

Spinal problems at birth—Children with scoliosis at birth (congenital scoliosis) have a greater risk of worsening of the curve.



Scoliosis is diagnosed by means of the patient’s medical history, physical examination, x-ray evaluation, and curve measurement.

DiagnosisDiagnosis


Diagnosis (Cont’d)Diagnosis (Cont’d) Clinically, scoliosis is commonly defined

according to the following factors related to the curvature of the spine: Shape Location Direction Angle


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

Associated with Associated with KyphoscoliosisKyphoscoliosis

The following clinical manifestations result from the The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) pathophysiologic mechanisms caused (or activated) by by

AtelectasisAtelectasis Excessive Airway SecretionsExcessive Airway Secretions


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


The Physical ExaminationThe Physical Examination

Vital signs Increased

• Respiratory rate (tachypnea)• Heart rate (pulse)• Blood pressure

Cyanosis


The Physical Examination, (Cont’d)The Physical Examination, (Cont’d)

Digital clubbing Peripheral edema and venous distention Cough and sputum production


The Physical Examination, (Cont’d)The Physical Examination, (Cont’d)

Chest Assessment Findings Obvious thoracic deformity Tracheal shift Increased tactile and vocal fremitus Dull percussion note Bronchial breath sounds Whispered pectoriloquy Crackles, rhonchi, and wheezing


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

ProceduresProcedures


Pulmonary Function Test FindingsModerate to Severe

(Restrictive Lung Pathophysiology)

Forced Expiratory Flow Rate Findings

FVC FEVT FEV1/FVC ratio FEF25%-75%

N or N or N or

FEF50% FEF200-1200 PEFR MVV

N or N or N or N or


Pulmonary Function Test FindingsModerate to Severe

(Restrictive Lung Pathophysiology)

Lung Volume & Capacity Findings

VT IRV ERV RV VC

N or

IC FRC TLC RV/TLC ratio

N


Arterial Blood GasesArterial Blood Gases(Mild to Moderate Kyphoscoliosis)(Mild to Moderate Kyphoscoliosis)

Acute Alveolar Hyperventilation with Hypoxemia Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis)(Acute Respiratory Alkalosis)

pH PaCOpH PaCO22 HCO HCO33 PaO PaO22

(slightly)(slightly)


PaOPaO22 and PaCO and PaCO22 trends during acute alveolar hyperventilation. trends during acute alveolar hyperventilation.


Arterial Blood GasesArterial Blood Gases(Severe Kyphoscoliosis)(Severe Kyphoscoliosis)

Chronic Ventilatory Failure with Hypoxemia Chronic Ventilatory Failure with Hypoxemia (Compensated Respiratory Acidosis)(Compensated Respiratory Acidosis)

pH PaCOpH PaCO22 HCO HCO33 PaO PaO22

N (Significantly) (Significantly)


PaOPaO22 and PaCO and PaCO22 trends during acute or chronic ventilatory failure. trends during acute or chronic ventilatory failure.


Arterial Blood GasesArterial Blood GasesAcute Ventilatory Changes Superimposed Acute Ventilatory Changes Superimposed

OnOnChronic Ventilatory FailureChronic Ventilatory Failure

Because acute ventilatory changes are frequently seen in patients with chronic ventilatory failure, the respiratory care practitioner must be familiar with and alert for the following: Acute alveolar hyperventilation superimposed on chronic

ventilatory failure Acute ventilatory failure (acute hypoventilation)

superimposed on chronic ventialtory failure.


Oxygenation IndicesOxygenation Indices(Moderate to Severe Kyphoscoliosis)(Moderate to Severe Kyphoscoliosis)

QQSS/Q/QT T DO DO22 VO VO22 C(a-v)O C(a-v)O22 O O22ER SvOER SvO22

N N


Hemodynamic IndicesHemodynamic IndicesModerate to Severe KyphoscoliosisModerate to Severe Kyphoscoliosis

CVP RAP PA PCWP CO SVCVP RAP PA PCWP CO SV N N N N N N

SVI CI RVSWI LVSWI PVR SVRSVI CI RVSWI LVSWI PVR SVR

N N N N NN NN


Laboratory FindingsLaboratory Findings

Severe and/or Late Stage Kyphoscoliosis If the patient is chronically hypoxemic

• Increased hematocrit and hemoglobin (polycythemia)• Hypochloremia (Cl-)• Hypernatremia (Na+)


Radiologic FindingsRadiologic Findings

Chest Radiograph Blunting thoracic deformity Mediastinal shift Increased lung opacity Atelectasis in areas of compressed (atelectatic) lungs Enlarged heart (cor pulmonale)


Figure 24-3. Severe kyphoscoliosis in a 14-year-old male patient.Severe kyphoscoliosis in a 14-year-old male patient.


General Management of ScoliosisGeneral Management of Scoliosis

The treatment of scoliosis largely depends on the cause of the scoliosis, the size and location of the curve, and how much more growing the patient is expected to do.

In most cases of scoliosis (less than 20 degrees), the degree of abnormal spine curvature is relatively small and requires only observation to ensure that the curve does not worsen.

Observation is usually recommended in patients with a spine curvature of less than 20 degrees.


In young children who are still growing, observation checkups are usually scheduled in 3- to 6-month intervals.

When the curve is determined to be progressing to a more serious degree (above 25 to 30 degrees in a child who is still growing), the following treatments options are available:

General Management of Scoliosis General Management of Scoliosis (Cont’d)(Cont’d)


Braces Boston brace Charleston bending brace Milwaukee brace



Figure 24-4 Common types of braces for scoliosis. A, Boston back brace (also called a thoraco-lumbro-sacral-orthosis [TLSO], a low-profile brace, or an underarm brace). Typically used for curves in the lumbar (low-back) or thoracolumbar sections of the spine. B, Charleston bending brace (also known as a part-time brace). C, Milwaukee brace (also called cervicothoracolumbosacral orthosis [CTLSO]) is used for high thoracic (mid-back) curves.


Surgery Spinal fusion Rod Instrumentation



Figure 24-5 Radiograph of patient with scoliosis treated with a Harrington rod.


Other Approaches Some physicians may try electrical stimulation of

muscles, chiropractic manipulation, and exercise to treat scoliosis.

There is no evidence that any of these procedures will stop the progression of spine curvature.



Other Approaches (Cont’d) Exercise, however, may improve the patient’s

overall health and well-being. Prophylactic deep breathing and coughing (DB&C)

exercises are also taught. • Their long-term effect is debatable.



Respiratory Care Treatment Respiratory Care Treatment ProtocolsProtocols

Oxygen Therapy Protocol Bronchopulmonary Hygiene Therapy Protocol Lung Expansion Therapy Protocol

chapter 24 kyphoscoliosis

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