INTERNAL MEDICINE: APPROACH TO THE PATIENT WITH RESPIRATORY DISEASE

DIAGNOSTIC PROCEDURES IN RESPIRATORY DISEASE

Rommel N. Tipones, MD, FPCP, FPCCP
Overview of the Anatomy and Physiology of the Respiratory System

060911

* The other parts of the respiratory system are the ribs, skeleton, chestwall,
the muscles surrounding the chestwall, and the backbone.
*Surface anatomy helpful in conducting the physical exam to localize the
problem.
*The top is the anterior view. The right lung contains 3 lobes while the left
lung 3. What comprises the anterior part is the upper lobe (majority), middle
lobe and lower lobe (little). In the skeleton, the upper lobe ends in the 4 th rib,
nipple area.
*Below is the posterior view. On the right lobe, middle lobe is NOT seen.
*Majority is lower lobe on both sides.
*Beside is the reflection in the skeleton.

Larynx trachea bronchus bronchioles intrapulmonary bronchioles

lungs terminal bronchioles alveolar ducts alveoli

*The lung weighs 1 kg.

*2.5 L left in the lung after expiration
Intrapulmonary Airways
bronchi
membranous bronchioles
respiratory bronchioles/gas exchange ducts
Anatomic Dead Space
upper extrapulmonary airways
cartilaginous intrapulmonary airways

1. CONDUCTING SYSTEM: from nasal cavity and pharynx (upper airways)

down to the larynx, trachea, main bronchi, down to distal bronchioles
(lower airways).

2. GAS-EXCHANGING

SYSTEM: 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.

*Dead space part of the respiratory system not participating in the gas
exchange
*Increase in dead space decrease portion for gas exchange;
increase work of breathing; impairment of gas exchange
Respiratory bronchiole-Alveolar duct system
* Not 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 Resistance
mostly in upper airways and bronchi
minimal airway diameter at the terminal bronchioles (0.5 mm)
large airways maintain partial constriction due to bronchomotor tone
*Resistance to the passage of air - common in respiratory problems; mostly
in the upper airways or bronchi
*Alveoli - viable; like a balloon; less resistance
*Bronchomotor tone brought about by the
smooth muscles wrap
around the airways
Cilia

*Upper lobe ends at the 4th rib

Transcribed by: KC

 half of the epithelial cells at all airway generations

down to the bronchioles
6 um long, 0.3 um wide
9 +2 axonemal structure/ motile
move the superficial liquid lining layer toward the
pharynx
*Cross section of the cilia
*Moves unidirectionally to propel the mucus
out of the respiratory tract cough

Glands
submucosa of the bronchi
secrete water, mucins into the lumen
release modulated by neurotransmitters/
inflammatory mediators

intracellular lamellar bodies

internalize and recycle surfactant lipids and proteins
Type I Cells
large, flattened
accounts for 90 to 95% of the alveolar surface area of the peripheral
lung
provide a large, thin cellular barrier for gas exchange
Air Space Macrophages and Lymphatics
superficial plexus of lymphatics
deep plexus of lymphatics
regional pulmonary lymph nodes
extrapulmonary lymph nodes around the primary bronchia and trachea
PHYSIOLOGY OF RESPIRATION
Functions of the Respiratory System
Diffusion of O2 and CO2

Goblet 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
Terminal Airways
partially ciliated low cuboidal
interspersed with Clara cells
Clara Cells
source of apoproteins
synthesis, storage and secretion of lipids, proteins and
glycoproteins
progenitors of ciliated cells. goblet cells, and new Clara cells

What the System Needs

Adequate provision of fresh air to the alveoli (VENTILATION)
Adequate circulation (PERFUSION)
Adequate movement of gas between alveoli and pulmonary capillaries
(DIFFUSION)
Appropriate contact between alveolar gas and pulmonary capillary
blood (VENTILATION-PERFUSION matching)
Every Breath You Take
Repeated 12 to 16 times per minute
Has a tidal volume of 500 mL
Has a portion (30%) which does not reach the alveoli (anatomic dead
space)
Has the remaining 70% reaching the alveolar zone

Bronchial Circulation
arteries from the aorta or upper intercostal arteries (hilum)
blood supply to the trachea, bronchi, pulmonary vessels, visceral pleura
venous blood drain into the azygos or hemiazygos veins, pulmonary
venules
* The pulmonary artery from the heart carries deoxygenated blood to the
lungs
The terminal bronchioles divide into 2-5 alveolar ducts, each of which
consists of 10-16 alveoli.
Alveoli has 3 cell types:
Type I - lining cell accounts for 95% of the alveolar surface area
Type II cell produces surfactant, a mixture of phospholipids, which
maintains alveolar stability
The macrophage acts as phagocytic defense vs infection.
The adult respiratory system contains approximately 300 million alveoli.
The surface area of the alveolo-capillary membrane available for 02-C02
exchange is approximately 70-85m2.
Terminal Respiratory Unit
alveolar ducts (100)
alveoli (2000)
150,000 units
0.02 ml
acinus (10 12 TRUs)
Type II Cells
small, cuboidal
outnumber type I cells (15% vs 8%)
synthesis, secretion and repair
Transcribed by: KC

During inspiration, as these muscles contract, the thorax expands.

Intrathoracic pressure decreases, drawing air into the tracheobronchial
tree into the alveoli and expanding the lungs. Gas exchange takes place
in the alveoli.
After inspiratory effort stops, the expiratory phase begins. The chest
wall and the lungs recoil, the diaphragm relaxes and rises passively, air
flows outward and the chest and abdomen return to their resting
positions.

History of Symptoms
Common
Dyspnea/ Shortness of breath
Cough
Less common
Hemoptysis
Chest pain/ Pleurisy
How long have you been short?
Acute
Airways
Lung parenchyma
Pleural space
Pulmonary
vasculature
PHYSIOLOGY OF RESPIRATION
During inspiration, air enters the upper airway, travels through the
lower airways until it reaches the alveoli. Each alveolus is surrounded by
multiple capillaries.
During systole, deoxygenated blood returning from the bodys cells is
pumped from the right ventricle through the arterial pulmonary
circulation to the alveolar capillaries. CO2 diffuses from the capillary
blood across alveolo-capillary membrane and enters the alveolar air.
Simultaneously, O2 from inspired atm. air in the alveolus crosses the
alveolar capillary membrane and enters the pulmonary capillary blood.
During expiration, CO2 is exhaled from the lungs. Oxygenated 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.

Exacerbation of airways
disease
Slow infection or
inflammation
Neuromuscular disease
Chronic cardiac disease

Chronic
COPD
CILD
Chronic cardiac
disease

Cough
May indicate the presence of lung disease
Sputum often suggests airway disease
Chronic cough
Asthma
Chronic Obstructive Pulmonary Disease
Gastroesophageal Reflux Disease
Postnasal drip
Pulmonary Tuberculosis
Hemoptysis

Airways

Lung Parenchyma

RESPIRATORY FAILURE
Inability of the lung to meet the metabolic demands of the body.
Failure of tissue oxygenation and/or
Failure of CO2 homeostasis
Clinical definition:
PaO2 <60 mmHg while breathing air, or
PaCO2 >50 mmHg.

Subacute

Vasculature

Inflammatory
bronchitis
bronchiectasis
cystic fibrosis
Neoplastic
tumors
Localized
pneumonia
lung abscess
tuberculosis
aspergillosis
Diffuse
Pulmonary thromboembolic disease
Arteriovenous malformations

Chest Pain
pleuritic
accentuated by respiratory motion
neoplasms/inflammation involving pleura
parenchymal disorders extending to the pleura
Additional Historic Information/Risk Factors
smoking
inhaled agents
coexisting illness
AIDS
previous treatments
family history
Physical Examination
inspection
palpation
percussion
auscultation
extrapulmonary manifestations

APPROACH TO THE PATIENT WITH RESPIRATORY DISEASE

Patients with Respiratory Disease

Transcribed by: KC

The photo on the left shows pneumonia of the left hemithorax while the
photo on the right shows pleural effusion that seeps into the fissures of the
lungs

The photo on the left shows consolidationof pneumonia due to the irregular
margins while the photo on the right shows a pulmonary tumor due to its
distinct and smooth margin and shape.

Physical Examination
Meticulous
Enlarged lymphnodes
Mentation
Signs pointing to smoking
Clubbing
Extrapulmonary findings

These photos show the presence of hydrothorax. The lateral decubitus view
(photo on the right) confirms the diagnosis. Note the presence of a meniscus
on the left photo.

DIAGNOSTIC MODALITIES IN PULMONOLOGY

This photo shows atelectasis. The arrow points to

the presence of air inside the pleural cavity. The
linear radioopaque structure adjacent to the air is
the lung itself.

Diagnostic Procedures in Respiratory Disease

Imaging studies
Techniques for acquiring specimens
Direct visualization
Pulmonary function testing
Ancillary procedures
Routine Radiography
Posteroanterior and Lateral
Lateral decubitus
Apicolordotic
Anteroposterior
BaSICC Approach to Radiography
Background
Survey
Identify
Compare
Conclude
COMPARISON OF CHEST X-RAY FINDINGS IN ATELECTASIS, PNEUMONIA, &
PLEURAL EFFUSION
ATELECTASIS
margins sharply defined & linear
tends to occur at outer third of lung
areas of lung adjacent to atelectatic regions may be hyperlucent
tends to respect lobar & segmental boundaries
PNEUMONIA
margins indistinct unless disease strictly lobar or segmental
distribution tends to be patchy rather than linear
PLEURAL EFFUSION
increases opacity of involved hemithorax; at bases
often layers when placed on decubitus position
may mimic pleural thickening

The photo from the left shows lobar consolidation indicative of pneumonia.
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.
Computed Tomography (CT Scan)
Cross-sectional images
Better tissue density
Accurate size
Hilar and mediastinal disease
Pulmonary nodule assessment
High-resolution CT Scan
*Provides an accurate view due to its ability to
provide high resolution images and allows for cross
sectional imaging.

Magnetic Resonance Imaging (MRI)

relies on energy generated by tissue when
placed in strong magnetic field
MRI resolution limited to 3-4 mm
susceptible to motion
superior in studying blood vessels & different
soft tissues especially at hila & mediastinum
Scintigraphic Imaging
Radioactive isotopes

Transcribed by: KC

 Ventilation-perfusion scanning
Albumin macroaggregates labeled with
Inhaled radiolabeled xenon gas

technenium 99

Positron Emission Tomographic Scanning (PET scan)

Identify malignant lesions
Increased uptake and metabolism of glucose
F-fluoro-2-deoxyglucose (FDG)

Remove abnormal endobronchial tissue

Perform difficult intubation
Blood Gases
assessment of oxygenation capacity
assessment of oxygen pressure to guide therapy
assessment of respiratory adequacy
assessment of acid-base balance

Pulmonary Angiography
Pulmonary artery
Pulmonary embolism
filling defect
cutoff
Pulmonary AVMs
Arterial invasion by neoplasm
Being replaced by CT Angiography
Ultrasound
uses sonar
limited use; doesnt pass through bone or air-filled
spaces
used to quantify pleural effusion and to guide
percutaneous needle aspiration of accessible
masses/fluid
Obtaining Biologic Specimens
Sputum Collection
Percutaneous needle aspiration
Thoracentesis
Bronchoscopy
VATS - Video-Assisted Thoracoscopic Surgery
Thoracotomy
Mediastinoscopy/Mediastinotomy
Sputum Collection

Spontaneous expectoration
Sputum induction
Adequate specimen: PMNs > 25/LPF; SECs < 10/LPF
Grams staining and culture
Mycobacteria or fungi
Viruses
Pneumocystis carinii
Cytologic staining
Polymerase chain reaction amplification
DNA probes

Bronchoscopy
Rigid/flexible
Oral/nasal
Washing
Brushing
Biopsy
Bronchoalveolar lavage
Transbronchial biopsy
Endobronchial Pathology on Bronchoscopy
Tumors
Granulomas
Sites of bleeding
Bronchitis
Foreign bodies
Treatment
Laser therapy
Cryotherapy
Electrocautery
Stent placement
Therapeutic Uses of Bronchoscopy
Remove retained secretions/mucus plugs
Remove foreign bodies
Transcribed by: KC

Normal Arterial Blood Gas Values

pH :
7.35 7.45
pO2:
80 100 mmHg
pCO2:
35 45 mmHg
HCO3:
22 26 meq/L
SaO2:
97 100% (SAT)
Contraindications for Arterial Puncture
Anticoagulant therapy
History of a clotting disorder (haemophilia)
History of arterial spasms following previous punctures
Severe peripheral vascular disease
Abnormal or infectious skin processes at or near the puncture sites
Arterial grafts
Pulse Oximetry
Alternative method to assess oxygenation
Calculates oxygen saturation (not PaO2 )
An arterial PO2 of 60 mmHg corresponds to an SaO2 = 90%
Spirometry

Measures rate at which lung volume is changing as a function of time

during breathing maneuvers
Simply put: measures lung volume and airflow from fully inflated lungs
Indications for Spirometry
To evaluate symptoms, signs or abnormal laboratory tests
To measure the effect of disease on pulmonary function
To screen persons at risk of having lung disease
To assess preoperative risk
To assess prognosis
To assess health status before enrollment in strenuous physical activity
programs
Need for Spirometry
Essential in separating obstructive from restrictive lung diseases
Necessary to judge response to therapy
Necessary in plotting the course and prognosis of many lung diseases
Surrogate marker for risks of other common life-threatening illnesses,
e.g. lung cancer
Predictive of mortality
Petty, T, Simple Spirometry for Frontline Practitioners, 1998

Kaya natin to. Lets conquer this year.

Spirometry and the Lung Volumes and Subdivisions

* 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
Functional Residual Capacity - the volume of air in the lungs at resting
end-expiration
Total Lung Capacity - the volume of air in the lungs at maximal inflation
Helium dilution method
Helium is diluted by gas present in lungs
Very little helium is absorbed into the pulmonary circulation
May underestimate the actual volume
Body plethysmography
Patients sits in sealed body box
Closed mouthpiece
Measures pressure changes
Graphical Representations of Spirometry
Classic Spirogram: Volume-Time Curve
What does spirometry measure?

1. Measurement of Volume
FVC
FEV1
FEV1/FVC

2. Measurement of Air Flow

PEFR/ Peak Flow/MEF
FEF25-75, FEF50, FEF75
Inspiratory counterparts
MVV

Parameters are expressed as actual values and their % predicted

References:
American
Family
Physician
http://www.aafp.org/afp/2004/0301/p1107.html
Dr. Tipones Power Point
Last years handouts
KCs Notes

Website:

END OF TRANS

First trans ko ito for the year. At medyo nakakalokang gawin kasi bakasyon
mode pa talaga ang utak ko. Lol. Paki-note na lang yung link na nilagay ko kasi
maganda yung article about spirometry dun.
Transcribed by: KC