approach to the patient with respiratory disease
TRANSCRIPT
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Overview of the Anatomy and Physiology of the Respiratory System
Larynx trachea bronchus bronchioles intrapulmonary bronchioles
lungs terminal bronchioles alveolar ducts alveoli
1.CON!C"#N$ S%S"&'( from nasal cavity and pharynx (upper airways)down to the larynx, trachea, main bronchi, down to distal bronchioles
(lower airways).
2.$AS-&)C*AN$#N$ S%S"&'( terminal bronchioles, alveolar ducts andalveoli.
*Conducting system to conduct the passage of air to the alveoli
*The anatomy is important because when the patient complains to you with
respiratory disorder, you can think of a problem in the conducting system or
the gas-exchanging system
*!pper lobe ends at the " thrib
* The other parts of the respiratory system are the ribs, skeleton, chestwall,
the muscles surrounding the chestwall, and the backbone
*#urface anatomy helpful in conducting the physical exam to locali$e the
problem
*The top is the anterior view The right lung contains % lobes while the left
lung % &hat comprises the anterior part is the upper lobe 'ma(ority), middle
lobe and lower lobe 'little) n the skeleton, the upper lobe ends in the " thrib,
nipple area
*+elow is the posterior view n the right lobe, middle lobe is T seen
*.a(ority is lower lobe on both sides
*+eside is the reflection in the skeleton
*The lung weighs / kg
*01 L left in the lung after expiration
#ntrap+lmonary Airways
bronchi
membranous bronchioles
respiratory bronchioles/gas exchange ducts
Anatomi, ead Spa,e
upper extrapulmonary airways
cartilaginous intrapulmonary airways
*2ead space part of the respiratory system not participating in the gas
exchange
*ncrease in dead space decrease portion for gas exchange
increase work of breathing3 impairment of gas exchange
Respiratory ron,hiole-Alveolar d+,t system
*ot part of the anatomic dead space
do not contribute to the anatomic dead space
one third of the alveolar volume
space where fresh air ventilation enters during
inspiration
Airway Resistan,e
mostly in upper airways and bronchi
minimal airway diameter at the terminal bronchioles (0. mm)
large airways maintain partial constriction due to bronchomotor tone
*Resistance to the passage of air- common in respiratory problems3 mostly
in the upper airways or bronchi
*Alveoli- viable3 like a balloon3 less resistance
*Bronchomotor tone -
brought about by the
smooth muscles wrap
around the airways
Cilia
Transcribed by: KC
#N"&RNA. 'C#N&( APPROAC* "O "*& PA"#&N" /#"* R&SP#RA"OR% #S&AS&
#A$NOS"#C PROC&!R&S #N R&SP#RA"OR% #S&AS&
Rommel N0 "ipones ' 2PCP 2PCCP
1
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half of the epithelial cells at all airway generations
down to the bronchioles
! um long, 0." um wide
# $2 axonemal structure/ motile
move the superficial li%uid lining layer toward the
pharynx
*Cross section of the cilia
*.oves unidirectionally to propel the mucus
out of the respiratory tract cough
$lands
submucosa of the bronchi
secrete water, mucins into the lumen
release modulated by neurotransmitters/
inflammatory mediators
$olet Cells
mucin&secreting epithelial cells
decrease peripherally
disappear at the terminal bronchioles
Other Cells in the Airways
basal cells lymphocytes - immune function
smooth muscle cells & tone
mast cells & immune function
"erminal Airways
partially ciliated low cuboidal
interspersed with 'lara cells
Clara Cells
source of apoproteins
synthesis, storage and secretion of lipids, proteins and
glycoproteins
progenitors of ciliated cells. goblet cells, and new 'lara cells
3ron,hial Cir,+lation
arteries from the aorta or upper intercostal arteries (hilum) blood supply to the trachea, bronchi, pulmonary vessels, visceral pleura
venous blood drain into the aygos or hemiaygos veins, pulmonary
venules
* The pulmonary artery from the heart carries deoxygenatedblood to the
lungs
he terminal bronchioles divide into 2& alveolar ducts, each of which
consists of 10&1! alveoli.
*lveoli has " cell types+
ype & lining cell accounts for #- of the alveolar surface area
ype cell produces surfactant, a mixture of phospholipids, which
maintains alveolar stability
he macrophage acts as phagocytic defense vs infection.
he adult respiratory system contains approximately "00 million alveoli.
he surface area of the alveolo&capillary membrane available for 02&'02
exchange is approximately 0&m2.
"erminal Respiratory !nit
alveolar ducts (100)
alveoli (2000)
10,000 units
0.02 ml
acinus (10 12 s)
"ype ## Cells
small, cuboidal
outnumber type cells (1- vs -)
synthesis, secretion and repair
intracellular lamellar bodies
internalie and recycle surfactant lipids and proteins
"ype # Cells
large, flattened
accounts for #0 to #- of the alveolar surface area of the peripheral
lung
provide a large, thin cellular barrier for gas exchange
Air Spa,e 'a,rophages and .ymphati,s
superficial plexus of lymphatics
deep plexus of lymphatics
regional pulmonary lymph nodes
extrapulmonary lymph nodes around the primary bronchia and trachea
P*%S#O.O$% O2 R&SP#RA"#ON
2+n,tions of the Respiratory System
iff+sion of O4 and CO4
/hat the System Needs
*de%uate provision of fresh air to the alveoli (3456*75)
*de%uate circulation (849:75)
*de%uate movement of gas between alveoli and pulmonary capillaries
(;99:75)
*ppropriate contact between alveolar gas and pulmonary capillary
blood (3456*75&849:75 matching)
&very 3reath %o+ "a5e
epeated 12 to 1! times per minute
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P*%S#O.O$% O2 R&SP#RA"#ON
;uring inspiration, air enters the upper airway, travels through the
lower airways until it reaches the alveoli. 4ach alveolus is surrounded by
multiple capillaries.
;uring systole, deoxygenated blood returning from the body?s cells is
pumped from the right ventricle through the arterial pulmonary
circulation to the alveolar capillaries. '72 diffuses from the capillary
blood across alveolo&capillary membrane and enters the alveolar air.
:imultaneously, 72 from inspired atm. air in the alveolus crosses the
alveolar capillary membrane and enters the pulmonary capillary blood.
;uring expiration, '72 is exhaled from the lungs. 7xygenated blood
travels to the left side of the heart and is pumped from the ventricle
into the arterial circulation to the cells of the body, where cellular
respiration occurs.
R&SP#RA"OR% 2A#.!R&
@nability of the lung to meet the metabolic demands of the body.A
9ailure of tissue oxygenation and/or
9ailure of '72 homeostasis
'linical definition+
8a72B!0 mming
inhaled agents
coexisting illness
*;:
previous treatments family history
Physi,al &9amination
inspection
palpation
percussion
auscultation
extrapulmonary manifestations
Transcribed by: KC :
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Physi,al &9amination
Deticulous
4nlarged lymphnodes
Dentation
:igns pointing to smo>ing
'lubbing
4xtrapulmonary findings
#A$NOS"#C 'OA.#"#&S #N P!.'ONO.O$%
iagnosti, Pro,ed+res in Respiratory isease
maging studies
echni%ues for ac%uiring specimens
;irect visualiation
8ulmonary function testing
*ncillary procedures
Ro+tine Radiography
8osteroanterior and 6ateral
6ateral decubitus
*picolordotic
*nteroposterior
3aS#CC Approa,h to Radiography Eac>ground
:urvey
dentify
'ompare
'onclude
CO'PAR#SON O2 C*&S" )-RA% 2#N#N$S #N A"&.&C"AS#S PN&!'ON#A ;
P.&!RA. &22!S#ON
A"&.&C"AS#S
margins sharply defined F linear
tends to occur at outer third of lung
areas of lung adGacent to atelectatic regions may be hyperlucent
tends to respect lobar F segmental boundaries
PN&!'ON#A
margins indistinct unless disease strictly lobar or segmental
distribution tends to be patchy rather than linearP.&!RA. &22!S#ON
increases opacity of involved hemithoraxH at bases
often layers when placed on decubitus position
may mimic pleural thic>ening
The photo on the left showspneumoniaof the left hemithorax while the
photo on the right showspleural effusionthat seeps into the fissures of the
lungs
The photo on the left shows consolidationofpneumonia due to the irregularmargins while the photo on the right shows a pulmonary tumordue to its
distinct and smooth margin and shape
These photos show the presence of hydrothorax The lateral decubitus view
'photo on the right) confirms the diagnosis ote the presence of a meniscus
on the left photo
This photo shows atelectasis The arrow points to
the presence of air inside the pleural cavity The
linear radioopa4ue structure ad(acent to the air is
the lung itself
The photo from the left shows lobar consolidation indicative of pneumonia
The photo on the middle shows prominent vascular markings with findings of
bronchiectasiswhile the last photo shows the presence of cavitation
indicative of tuberculosis
Comp+ted "omography
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3entilation&perfusion scanning
*lbumin macroaggregates labeled with technenium ##
nhaled radiolabeled xenon gas
Positron &mission "omographi, S,anning
o assess prognosis
o assess health status before enrollment in strenuous physical activity
programs
Need for Spirometry
4ssential in separating obstructive from restrictive lung diseases
5ecessary to Gudge response to therapy
5ecessary in plotting the course and prognosis of many lung diseases
:urrogate mar>er for ris>s of other common life&threatening illnesses
e.g. lung cancer
8redictive of mortality
8etty, , :imple :pirometry for 9rontline 8ractitioners, 1##
Transcribed by: KC ?
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Spirometry and the .+ng 7ol+mes and S+divisions
*Respiratory Volumes Tidal Volume - the volume of air inhaled or exhaled during each
respiratory cycle
Inspiratory Reserve Volume- the maximal volume of air inhaled from
end-inspiration
Expiratory Reserve Volume- the maximal volume of air exhaled from
end-expiration
Residual Volume - the volume of air remaining in the lungs after a
maximal exhalation
*Respiratory Capacities
Vital Capacity - the largest volume measured on complete exhalation
after full inspiration
Inspiratory Capacity- the maximal volume of air that can be inhaled
from the resting expiratory level
unctional Residual Capacity- the volume of air in the lungs at resting
end-expiration Total !ung Capacity- the volume of air in the lungs at maximal inflation