INTERNAL MEDICINE: APPROACH TO THE PATIENT WITH RESPIRATORY DISEASE

DIAGNOSTIC PROCEDURES IN RESPIRATORY DISEASE

Rommel N. Tipones, MD, FPCP, FPCCP
* The other parts of the respiratory system are the ribs, skeleton, chestwall,
Overview of the Anatomy and Physiology of the Respiratory System 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
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lung 3. What comprises the anterior part is the upper lobe (majority), middle
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lobe and lower lobe (little). In the skeleton, the upper lobe ends in the 4 th rib,
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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
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 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
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

Glands PHYSIOLOGY OF RESPIRATION

submucosa of the bronchi Functions of the Respiratory System
secrete water, mucins into the lumen
release modulated by neurotransmitters/
inflammatory mediators 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 What the System Needs
smooth muscle cells - tone Adequate provision of fresh air to the alveoli (VENTILATION)
mast cells - immune function Adequate circulation (PERFUSION)
Adequate movement of gas between alveoli and pulmonary capillaries
Terminal Airways (DIFFUSION)
partially ciliated low cuboidal Appropriate contact between alveolar gas and pulmonary capillary
interspersed with Clara cells blood (VENTILATION-PERFUSION matching)

Clara Cells Every Breath You Take

source of apoproteins Repeated 12 to 16 times per minute
synthesis, storage and secretion of lipids, proteins and Has a tidal volume of 500 mL
glycoproteins Has a portion (30%) which does not reach the alveoli (anatomic dead
progenitors of ciliated cells. goblet cells, and new Clara cells 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 During inspiration, as these muscles contract, the thorax expands.
The macrophage acts as phagocytic defense vs infection. Intrathoracic pressure decreases, drawing air into the tracheobronchial
The adult respiratory system contains approximately 300 million alveoli. tree into the alveoli and expanding the lungs. Gas exchange takes place
The surface area of the alveolo-capillary membrane available for 02-C02 in the alveoli.
exchange is approximately 70-85m2. After inspiratory effort stops, the expiratory phase begins. The chest
wall and the lungs recoil, the diaphragm relaxes and rises passively, air
Terminal Respiratory Unit flows outward and the chest and abdomen return to their resting
alveolar ducts (100) positions.
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
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 History of Symptoms
Common
Dyspnea/ Shortness of breath
Cough
Less common
Hemoptysis
Chest pain/ Pleurisy

How long have you been short?

Acute Subacute Chronic

Airways Exacerbation of airways COPD

Lung parenchyma disease CILD
Pleural space Slow infection or Chronic cardiac
Pulmonary inflammation disease
vasculature Neuromuscular disease
Chronic cardiac disease
PHYSIOLOGY OF RESPIRATION
During inspiration, air enters the upper airway, travels through the Cough
lower airways until it reaches the alveoli. Each alveolus is surrounded by May indicate the presence of lung disease
multiple capillaries. Sputum often suggests airway disease
During systole, deoxygenated blood returning from the bodys cells is Chronic cough
pumped from the right ventricle through the arterial pulmonary Asthma
circulation to the alveolar capillaries. CO2 diffuses from the capillary Chronic Obstructive Pulmonary Disease
blood across alveolo-capillary membrane and enters the alveolar air. Gastroesophageal Reflux Disease
Simultaneously, O2 from inspired atm. air in the alveolus crosses the Postnasal drip
alveolar capillary membrane and enters the pulmonary capillary blood. Pulmonary Tuberculosis
During expiration, CO2 is exhaled from the lungs. Oxygenated blood
travels to the left side of the heart and is pumped from the ventricle Hemoptysis
into the arterial circulation to the cells of the body, where cellular
respiration occurs. Inflammatory
bronchitis
bronchiectasis
Airways
cystic fibrosis
Neoplastic
tumors

Localized
pneumonia
lung abscess
Lung Parenchyma
tuberculosis
aspergillosis
Diffuse
RESPIRATORY FAILURE
Inability of the lung to meet the metabolic demands of the body. Pulmonary thromboembolic disease
Vasculature
Failure of tissue oxygenation and/or Arteriovenous malformations
Failure of CO2 homeostasis
Clinical definition: Chest Pain
PaO2 <60 mmHg while breathing air, or pleuritic
PaCO2 >50 mmHg. 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

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 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
These photos show the presence of hydrothorax. The lateral decubitus view
Clubbing
(photo on the right) confirms the diagnosis. Note the presence of a meniscus
Extrapulmonary findings
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
Diagnostic Procedures in Respiratory Disease linear radioopaque structure adjacent to the air is
Imaging studies the lung itself.
Techniques for acquiring specimens
Direct visualization
Pulmonary function testing
Ancillary procedures

Routine Radiography
Posteroanterior and Lateral
Lateral decubitus
Apicolordotic
Anteroposterior

BaSICC Approach to Radiography The photo from the left shows lobar consolidation indicative of pneumonia.
Background The photo on the middle shows prominent vascular markings with findings of
Survey bronchiectasis while the last photo shows the presence of cavitation
Identify indicative of tuberculosis.
Compare Computed Tomography (CT Scan)
Conclude Cross-sectional images
Better tissue density
COMPARISON OF CHEST X-RAY FINDINGS IN ATELECTASIS, PNEUMONIA, & Accurate size
PLEURAL EFFUSION Hilar and mediastinal disease
ATELECTASIS Pulmonary nodule assessment
margins sharply defined & linear
tends to occur at outer third of lung
areas of lung adjacent to atelectatic regions may be hyperlucent High-resolution CT Scan
tends to respect lobar & segmental boundaries
PNEUMONIA *Provides an accurate view due to its ability to
margins indistinct unless disease strictly lobar or segmental provide high resolution images and allows for cross
distribution tends to be patchy rather than linear sectional imaging.
PLEURAL EFFUSION
increases opacity of involved hemithorax; at bases
often layers when placed on decubitus position
may mimic pleural thickening 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

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 Ventilation-perfusion scanning Remove abnormal endobronchial tissue
Albumin macroaggregates labeled with technenium 99 Perform difficult intubation
Inhaled radiolabeled xenon gas
Blood Gases
assessment of oxygenation capacity
assessment of oxygen pressure to guide therapy
Positron Emission Tomographic Scanning (PET scan) assessment of respiratory adequacy
Identify malignant lesions assessment of acid-base balance
Increased uptake and metabolism of glucose
F-fluoro-2-deoxyglucose (FDG)

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 Normal Arterial Blood Gas Values
pH : 7.35 7.45
Obtaining Biologic Specimens pO2: 80 100 mmHg
Sputum Collection pCO2: 35 45 mmHg
Percutaneous needle aspiration HCO3: 22 26 meq/L
Thoracentesis SaO2: 97 100% (SAT)
Bronchoscopy
VATS - Video-Assisted Thoracoscopic Surgery Contraindications for Arterial Puncture
Thoracotomy Anticoagulant therapy
Mediastinoscopy/Mediastinotomy History of a clotting disorder (haemophilia)
History of arterial spasms following previous punctures
Sputum Collection Severe peripheral vascular disease
Spontaneous expectoration Abnormal or infectious skin processes at or near the puncture sites
Sputum induction Arterial grafts
Adequate specimen: PMNs > 25/LPF; SECs < 10/LPF
Grams staining and culture Pulse Oximetry
Mycobacteria or fungi Alternative method to assess oxygenation
Viruses Calculates oxygen saturation (not PaO2 )
Pneumocystis carinii An arterial PO2 of 60 mmHg corresponds to an SaO2 = 90%
Cytologic staining Spirometry
Polymerase chain reaction amplification
DNA probes

Bronchoscopy
Rigid/flexible
Oral/nasal Measures rate at which lung volume is changing as a function of time
Washing during breathing maneuvers
Brushing Simply put: measures lung volume and airflow from fully inflated lungs
Biopsy
Bronchoalveolar lavage Indications for Spirometry
Transbronchial biopsy To evaluate symptoms, signs or abnormal laboratory tests
To measure the effect of disease on pulmonary function
Endobronchial Pathology on Bronchoscopy To screen persons at risk of having lung disease
Tumors To assess preoperative risk
Granulomas To assess prognosis
Sites of bleeding To assess health status before enrollment in strenuous physical activity
Bronchitis programs
Foreign bodies
Treatment Need for Spirometry
Laser therapy Essential in separating obstructive from restrictive lung diseases
Cryotherapy Necessary to judge response to therapy
Electrocautery Necessary in plotting the course and prognosis of many lung diseases
Stent placement Surrogate marker for risks of other common life-threatening illnesses,
e.g. lung cancer
Therapeutic Uses of Bronchoscopy Predictive of mortality
Remove retained secretions/mucus plugs Petty, T, Simple Spirometry for Frontline Practitioners, 1998
Remove foreign bodies
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 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 Website:
http://www.aafp.org/afp/2004/0301/p1107.html
Dr. Tipones Power Point
Last years handouts
KCs Notes

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
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