approach to the patient with respiratory disease

7/26/2019 Approach to the Patient With Respiratory Disease

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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

approach to the patient with respiratory disease

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