Approach to the Patient With Respiratory Disease

#N"&RNA. '&#C#N&( APPROAC* "O "*& PA"#&N" /#"* R&SP#RA"OR% #S&AS& #A$NOS"#C PROC&!R&S #N R&SP#RA" R&SP#RA"OR% OR% #S&AS& Rommel N0 "ipones ' 2PCP 2PCCP Overview of the Anatomy and Physiology of the Respiratory System   0   6   0  9   1   1

* 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 " th rib, 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 skeleton

Larynx  trachea   bronchus   bronchioles bronchioles  intrapulmonary bronchioles bronchioles  lungs  terminal bronchioles  alveolar ducts  alveoli

*The lung weighs / kg *01 L – left in the lung after expiration

 #ntrap+lmonary Airways  bronchi  membranous bronchioles  respiratory bronchioles/gas 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 exchange3 increase work of breathing3 impairment of gas exchange exchange

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$ $AS-&)C*AN$#N$

S%S"&'( S%S"&'( terminal bronchioles, alveolar ducts and

alveoli. *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

 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  spac space e wher where e fres fresh h air air vent ventil ilat atio ion n ente enters rs duri during ng 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 *Bronch Bronchomo omotor tor tone tone brou brough ghtt abou aboutt by the the smoo smooth th musc muscle less wrap wrap around the airways

 Cilia

*!pper lobe ends at the " th rib  Transcribed  Transcribed by: KC

1



  

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

 

intracellular lamellar bodies internalie 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 O 4 and CO4

$olet 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

/hat the System Needs  *de%uate provision of fresh air to the alveoli (3456*75)  *de%uate circulation (849:75)  *de%uate movement of gas between alveoli and pulmonary capillaries (;99:75)  *ppropriate contact between alveolar gas and pulmonary capillary blood (3456*75&849:75 matching) &very 3reath %o+ "a5e  epeated 12 to 1! times per minute  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 linear P.&!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 from the left shows lobar consolidation indicative of  pneumoni a The photo on the middle shows prominent vascular markings with findings of  bronchiectasis while the last photo shows the presence of cavitation indicative of tuberculosis Comp+ted "omography of having lung disease  o assess preoperative ris>  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##

?

Maya natin Nto. 6et?s con%uer this year. 

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 Capaci ty - 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 

