Professional Documents
Culture Documents
Respiratory
Respiratory
Respiratory
David D. Ralph, MD
New England Journal of Medicine
MEDICAL-SURGICAL
NURSING
Arni A. Magdamo, MD, MHA,
FPCP
University of the Philippines
College of Medicine, College of Nursing
Mechanics of Breathing
Mechanics of Breathing
Mechanics of Breathing
Mechanics of Breathing
IRV
IC
TOTAL
LUNG
CAPACITY
VC
TV
ERV
MAXIMUM
EXPIRATION
FRC
RV
RV
Pulmonary Pressures
Alveolar pressure
Intrapleural pressure
Alveolar surfactant
Pulmonary Pressures
Boyles Law:
During inspiration, the enlargement of
the thoracic cage decreases the
pressure in the alveoli to about 3
mmHg. This negative pressure pulls air
through the respiratory passageways
into the alveoli.
Pulmonary Pressures
Boyles Law:
During expiration, the exact mechanism
and effects occur. Compression of the
thoracic cage around the lungs
increases the alveolar pressure to
approximately +3 mmHg which pushes
the air out of the alveoli into the
atmosphere.
Pulmonary Pressures
Intrapleural Pressures:
Pulmonary Pressures
Surfactant:
Gas Exchange
Gas Exchange
Cardiac output
Erythrocyte count
Exercise
Hematocrit
Control of Respiration
Control of Respiration
Control of Respiration
Diagnosis of Pulmonary
Function
Clinical Assessment
Symptoms of Pulmonary
Disease
Dyspnea
Orthopnea
Dyspnea on recumbency.
Platypnea
Symptoms of Pulmonary
Disease
Persistent cough
Always abnormal
Chronic persistent cough may be caused by
cigarette smoking, asthma, bronchiectasis
or COPD.
May also be caused by drugs, cardiac
disease, occupational agents and
psychogenic factors.
Complications include (1) worsening of
bronchospasm, (2) vomiting, (3) rib
fractures,
(4) urinary incontinence, and (5) syncope.
Symptoms of Pulmonary
Disease
Stridor
Symptoms of Pulmonary
Disease
Wheezing
Hemoptysis
Expectoration of blood.
Often the first indication of serious
bronchopulmonary disease.
Massive hemoptysis: coughing up of more
than 600 ml of blood in 24 hours.
Signs of Pulmonary
Disease
Tachypnea
Bradypnea
Slow breathing.
Hyperpnea
Hyperventilation
Signs of Pulmonary
Disease
Cheyne-Stokes respiration
Signs of Pulmonary
Disease
Biot breathing
Signs of Pulmonary
Disease
Singultus
Signs of Pulmonary
Disease
Scoliosis
Chest wall deformity
Severe fibrothorax
Conditions with unilateral loss of lung volume
Signs of Pulmonary
Disease
Neuromuscular disease
Emphysema
Ankylosis of the spine
Signs of Pulmonary
Disease
Airway obstruction
Intercostal muscle paralysis
Flail deformity of the chest
Signs of Pulmonary
Disease
Pulsus paradoxicus
Signs of Pulmonary
Disease
Cyanosis
Signs of Pulmonary
Disease
Digital clubbing
Signs of Pulmonary
Disease
Signs of Pulmonary
Disease
Wheezes
Rhonchi
Signs of Pulmonary
Disease
Crackles
Signs of Pulmonary
Disease
Fremitus
Bronchophony
Signs of Pulmonary
Disease
Whispered pectoriloquy
Egophony
Signs of Pulmonary
Disease
TYPICAL CHEST EXAMINATION FINDINGS IN SELECTED CLINICAL CONDITIONS
CONDITION
Normal
Consolidatio
n or
Atelectasis
(with patent
airway)
Consolidatio
n or
Atelectasis
(with
blocked
Bronchial
airway)
Asthma
PERCUSSIO
N
FREMITUS
BREATH
SOUNDS
VOICE
TRANSMISSIO
N
Normal
ADVENTITIOU
S SOUNDS
Resonant
Normal
Vesicular
Dull
Increased
Bronchial
Bronchophony
, whispered
pectoriloquy,
egophony
Crackles
Dull
Decrease
d
Decreased
Decreased
Absent
Resonant
Normal
Vesicular
Normal
Wheezing
Absent
Signs of Pulmonary
Disease
TYPICAL CHEST EXAMINATION FINDINGS IN SELECTED CLINICAL CONDITIONS
CONDITION
PERCUSSION
FREMITUS
BREATH
SOUNDS
Interstitial
Lung
Disease
Emphysema
Resonant
Normal
Vesicular
Hyperresona
nt
Decrease
d
Hyperresona
nt
Dull
Pneumothor
ax
Pleural
effusion
VOICE
TRANSMISSIO
N
Normal
ADVENTITIOU
S SOUNDS
Decrease
d
Decreased
Absent or
wheezing
Decrease
d
Decrease
d
Decreased
Absent
Decrease
d
Decrease
d
Decreased
Absent or
pleural
friction rub
Crackles
Diagnosis of Pulmonary
Function
Laboratory Assessment
Routine Radiography
Routine Radiography
Chest Radiography
Chest Radiography
Ultrasonography
Computed Tomography
Computed Tomography
Computed Tomography
Magnetic Resonance
Imaging
Indications:
Relative contraindications:
Spirometry
IRV
IC
TOTAL
LUNG
CAPACITY
VC
TV
ERV
MAXIMUM
EXPIRATION
FRC
RV
RV
Biologic Specimen
Collection
Sputum collection
Biologic Specimen
Collection
Thoracentesis
Biologic Specimen
Collection
Bronchoscopy
Biologic Specimen
Collection
Bronchoscopy
Biologic Specimen
Collection
Thoracotomy
Biologic Specimen
Collection
Diseases of the
Respiratory System
Nose, Paranasal Sinuses and
Larynx
Influenza
Influenza:
Clinical Manifestations
Influenza:
Clinical Manifestations
Reyes syndrome
Myositis, rhabdomyolysis and myoglobinuria
Encephalitis, transverse myelitis
Guillain-Barr syndrome
Influenza: Treatment
Antivirals:
Amantadine (Influenza A)
Rimantadine (Influenza B)
Ribavirin (Influenza A and B)
Influenza: Treatment
Prophylaxis:
Viral Rhinitis
Viral Rhinitis
Viral Rhinitis:
Clinical Manifestations
Headache
Nasal congestion
Water rhinorrhea
Sneezing
Scratchy throat
General malaise and occasionally fever
Viral Rhinitis:
Clinical Manifestations
Signs:
Viral Rhinitis:
Clinical Manifestations
Complications:
Clinical Manifestations:
Rhinorrhea
Low-grade fever
Mild systemic symptoms
Cough and wheezing
25-40% with lower respiratory tract
involvement
Treatment:
Treatment:
Clinical Manifestations:
Rhinitis
Pharyngoconjunctival fever (bilateral
conjunctivitis, low-grade fever, rhinitis, sore
throat and cervical lymphadenopathy)
In adults, the most frequent syndrome is the
acute respiratory disease seen in military
recruits, with prominent sore throat, fever
on the second or third day of illness, cough,
coryza and regional lymphadenopathy.
Typical Pathogens:
Streptococcus pneumoniae
Other streptococci
Haemophilus influenzae
Staphylococcus aureus
Moraxella catarrhalis
Imaging:
Transillumination
Caldwell view (frontal)
Waters view (maxillary)
Lateral view (sphenoid)
Submentovertical view (ethmoid)
CT scan for recurrent sinusitis
MRI if malignancy in suspected
Uncomplicated:
Outpatient management
Oral decongestants and nasal decongestant
sprays
Appropriate oral antibiotics for at least two
weeks
* Amoxicillin provides better sinus
penetration than ampicillin.
Complicated:
Complications:
Allergic Rhinitis
Allergic Rhinitis
Hay fever
Symptoms mimic that of viral rhinitis
but more persistent and show seasonal
variation.
Symptoms:
Watery rhinorrhea
Eye irritation, pruritus, erythema and
tearing
Signs:
Allergic Rhinitis:
Treatment
Epistaxis
Epistaxis
Treatment:
Acute Laryngitis
Viral
Bacterial (Moraxella catarrhalis,
Haemophilus influenzae)
Treatment:
Diseases of the
Respiratory System
Diseases of the Airways
Diseases of the
Respiratory System
Obstructive Airway Diseases
Asthma
Asthma
Variants:
Exercise-induced asthma
Triad asthma
Cardiac asthma
Asthmatic bronchitis
Drug-induced asthma
Asthma
Asthma
Pathogenesis:
Allergenic
Pharmacologic
Environmental, occupational
Infectious
Emotional
Activity-related
Asthma
Episodic wheezing
Chest tightness
Dyspnea and cough
Tachycardia and tachypnea with prolonged
expiation
Ominous signs: fatigue, pulsus paradoxicus,
diaphoresis, inaudible breath sounds with
diminished wheezing, inability to maintain
recumbency, and cyanosis
Asthma
Laboratory Findings:
Asthma
Asthma
Asthma
Asthma
Asthma
Complications:
Exhaustion
Dehydration
Airway infection
Cor pulmonale
Tussive syncope
Pneumothorax (rare)
Asthma
Prevention:
Asthma: Classifications
Mild asthma:
Asthma: Classifications
Moderate asthma:
Asthma: Classifications
Severe asthma:
Continuous symptoms
Frequent exacerbations
Limitations of physical activities
Frequent nocturnal symptoms
Requirement for frequent emergency care
PEFR less than 60% of predicted, with
variability of 20-30% on treatment, and
greater than 50% on severe exacerbations
Prolonged asthma refractory to conventional
modes of therapy (status asthmaticus)
Asthma: Treatment
Asthma: Treatment
Asthma: Treatment
Asthma: Treatment
Status asthmaticus:
Asthma: Prognosis
Chronic Obstructive
Pulmonary Disease (COPD)
Chronic Bronchitis
Emphysema
Chronic Obstructive
Pulmonary Disease (COPD)
EMPHYSEMA VS CHRONIC BRONCHITIS
EMPHYSEMA
HISTORY
After age 50
CHRONIC
BRONCHITIS
After age 35
Progressive,
constant, severe
Intermittent, mild to
moderate
Cough
Absent or mild
Persistent, severe
Sputum production
Absent or mild
Copious
Sputum
appearance
Clear, mucoid
Mucopurulent or
purulent
Other features
Weight loss
pink puffer
Airway infections,
right heart failure,
obesity
blue bloater
Onset of
symptoms
Dyspnea
Chronic Obstructive
Pulmonary Disease (COPD)
EMPHYSEMA VS CHRONIC BRONCHITIS
EMPHYSEMA
PHYSICAL
EXAMINATION
Thin, wasted
CHRONIC
BRONCHITIS
Stocky, obese
Central cyanosis
Absent
Present
Plethora
Absent
Present
Hypertrophied
Unremarkable
Increased
Normal
Hyperresonant
Normal
Diminished breath
sounds
Wheezes, rhonchi
Body habitus
Accessory
respiratory
muscles
Anteroposterior
chest diameter
Percussion note
Auscultation
Chronic Obstructive
Pulmonary Disease (COPD)
EMPHYSEMA VS CHRONIC BRONCHITIS
EMPHYSEMA
CHEST X-RAY
CHRONIC
BRONCHITIS
Absent
Bullae, blebs
Present
Overall
appearance
Decreased
markings in the
periphery
Present
Dirty lungs
Normal or small,
vertical
Large, horizontal
Low, flat
Normal, rounded
Hyperinflation
Heart size
Hemidiaphragms
Absent
Chronic Obstructive
Pulmonary Disease (COPD)
EMPHYSEMA VS CHRONIC BRONCHITIS
EMPHYSEMA
LABORATORY
INDICES
Hematocrit
Normal
ECG
Normal
CHRONIC
BRONCHITIS
Increased
Absent, mild
RAD, RVH, P
pulmonale
Moderate, severe
Hypercapnia
Absent
Moderate, severe
Respiratory
acidosis
Total lung capacity
Absent
Present
Increased
Normal
Static lung
compliance
Increased
Normal
Diffusing capacity
Decreased
Normal
Hypoxemia
Chronic Obstructive
Pulmonary Disease (COPD)
Causes:
Cigarette smoking
Air pollution
Airway infection
Familial factors
Allergies
Chronic Obstructive
Pulmonary Disease (COPD)
Laboratory findings:
Secondary polycythemia
Presence of microorganisms in the sputum
Spirometry shows obstructive pattern
Hyperinflation on radiographs
Chronic Obstructive
Pulmonary Disease (COPD)
Complications:
Chronic Obstructive
Pulmonary Disease (COPD)
Prevention:
Smoking cessation
Early treatment of airway infections
Vaccination against pneumococcal
pneumonia and influenza.
Chronic Obstructive
Pulmonary Disease (COPD)
Treatment:
Ipratropium bromide
Maintenance therapy with oral theophylline
Oral corticosteroids
Aerosol therapy
Chest physiotherapy
Treatment of complications
Home oxygen therapy
Bronchiectasis
Chronic cough
Copious sputum production, often purulent
Hemoptysis
Recurrent pneumonia
Bronchiectasis
Signs:
Laboratory findings:
Bronchiectasis
Treatment:
Antibiotics
Daily chest physiotherapy with postural
drainage and chest percussion
Inhaled bronchodilators
Surgical resection
Diagnostic and therapeutic bronchoscopy
Complications:
Cor pulmonale
Amyloidosis
Visceral abscesses at distant sites like the
brain
Diseases of the
Respiratory System
Lower Respiratory Tract
Infections
Community-Acquired
Pneumonia
Community-Acquired
Pneumonia:
Pathophysiology
Community-Acquired
Pneumonia:
Pathophysiology
Community-Acquired
Pneumonia
Laboratory findings:
Leukocytosis
Patchy infiltrates on chest radiographs
Atypical pneumonia clinico-radiographic
dissonance; often caused by Mycoplasma or
Chlamydia pneumoniae; less striking
symptoms and physical findings with nonpurulent sputum production and absence of
leukocytosis despite significant infiltrates on
chest radiography; OR severe symptoms in
the absence of significant radiographic
findings
Community-Acquired
Pneumonia
Community-Acquired
Pneumonia:
Community-Acquired
Pneumonia: Management
Prevention:
Pneumococcal vaccine
Influenza vaccine
Community-Acquired
Pneumonia: Management
Streptococcus pneumoniae
Mycoplasma pneumoniae
Respiratory viruses
Chlamydia pneumoniae
Haemophilus influenzae
Legionella
Staphylococcus aureus
Mycobacterium tuberculosis
Community-Acquired
Pneumonia: Management
Streptococcus pneumoniae
Respiratory viruses
Haemophilus influenzae
Moraxella catarrhalis
Streptococcus pneumoniae
Haemophilus influenzae
Legionella
Staphylococcus aureus
Chlamydia pneumoniae
Community-Acquired
Pneumonia: Management
Treatment:
Hospital-Acquired
Pneumonia
Essentials of Diagnosis:
Hospital-Acquired
Pneumonia
Pseudomonas aeruginosa
Staphylococcus aureus
Enterobacter sp.
Klebsiella pneumoniae
Escherichia coli
Treatment:
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Pathogenesis:
Pulmonary Tuberculosis
Pathogenesis (contd):
Pulmonary Tuberculosis
Laboratory findings:
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Pulmonary Tuberculosis
PTB Classifications:
Pulmonary Tuberculosis:
Treatment
Pulmonary Tuberculosis:
Treatment
Pulmonary Tuberculosis:
Treatment
Palawan
Mountain Province and Benguet
Pulmonary Tuberculosis:
Treatment
Pulmonary Tuberculosis:
Treatment
Pulmonary Tuberculosis:
Treatment
Preventive therapy:
Diseases of the
Respiratory System
Bronchogenic Carcinoma
Bronchogenic Carcinoma
Suspected etiologies:
Cigarette smoking
Ionizing radiation
Asbestos
Heavy metals
Industrial agents
Lung scars
Air pollution
Genetic predisposition
Bronchogenic Carcinoma
Bronchogenic Carcinoma
Initial Symptoms:
Cough
Weight loss
Dyspnea
Chest pain
Hemoptysis
Change in the patterns of the symptoms
Bronchogenic Carcinoma
Bronchogenic Carcinoma
PARANEOPLASTIC SYNDROMES IN LUNG CANCER
CLASSIFICATION
ENDOCRINE AND
METABOLIC
SYNDROME
Cushings syndrome
Small cell
SIADH
Small cell
Hypercalcemia
Squamous cell
Gynecomastia
Large cell
CONNECTIVE TISSUE
AND OSSEOUS
NEUROMUSCULAR
Peripheral neuropathy
Small cell
Subacute cerebellar
degeneration
Myasthenia (Eaton-Lambert
syndrome)
Small cell
Dermatomyositis
All
Small cell
Bronchogenic Carcinoma
PARANEOPLASTIC SYNDROMES IN LUNG CANCER
CLASSIFICATION
CARDIOVASCULAR
HEMATOLOGIC
CUTANEOUS
SYNDROME
Thrombophlebitis
Adenocarcinoma
Nonbacterial verrucous
(marantic) endocarditis
Adenocarcinoma
Anemia
All
Disseminated intravascular
coagulation
All
Eosinophilia
All
Thrombocytosis
All
Acanthosis nigricans
All
All
Bronchogenic Carcinoma
Laboratory findings:
Treatment:
Surgery
Chemotherapy
Radiotherapy
Combination therapy
Immunomodulation
Bronchogenic Carcinoma
Prognosis:
Diseases of the
Respiratory System
Ventilation and Perfusion
Disorders
Pulmonary
Thromboembolism
Pulmonary
Thromboembolism
Venous stasis
Venous endothelial injury
Hypercoagulability
Oral contraceptives
Cancer
Protein C or S deficiency
Antithrombin III deficiency
Pulmonary
Thromboembolism
Pulmonary
Thromboembolism
Symptoms:
Pulmonary
Thromboembolism
Signs:
Tachypnea (92%)
Crackles (58%)
Accentuated split second heart sound (53%)
Tachycardia (44%)
Fever > 37.8C (43%)
Phlebitis (32%)
Diaphoresis (36%)
Edema (24%)
Murmur (23%)
Cyanosis (19%)
Pulmonary
Thromboembolism
Laboratory findings:
Chest radiography
Lung scanning
Venous thrombosis studies
Pulmonary angiography
Pulmonary
Thromboembolism
Prevention:
Critically important
Identification of those at risk
Prophylaxis
Treatment:
Anticoagulation
Thrombolytic therapy
Inferior vena cava filter
Pulmonary
Thromboembolism
Prognosis:
Clinical Findings:
Treatment:
Prognosis:
HYDROCARBONS
OZONE
SOURCES
ADVERSE EFFECTS
Automobile exhaust;
gas stoves and
heaters; woodburning stoves;
kerosene
space
Automobile
exhaust,
heaters
cigarette smoke
Automobile exhaust,
high altitude aircraft
cabins
Cough, substernal
discomfort,
bronchoconstriction,
decreased exercise
performance, respiratory
tract irritation
Lung cancer
SOURCES
Power plants,
smelters, oil
refineries, kerosene
space heaters
ADVERSE EFFECTS
Exacerbation of asthma
and chronic obstructive
pulmonary disease,
respiratory tract irritation,
hospitalization may be
necessary, and death may
occur in severe exposure
Pulmonary Aspiration
Syndromes
Caf coronary
Pulmonary Aspiration
Syndromes
Disorders of Ventilation
Obesity-hypoventilation syndrome
(Pickwickian syndrome)
Sleep-related breathing disorders
Obstructive sleep apnea
Hyperventilation syndrome
Clinical Findings:
Tracheal intubation
Hypoxemia
Upper airway obstruction
Impaired airway protection
Poor handling of secretions
Facilitation of mechanical ventilation
Mechanical ventilation
Apnea
Acute hypercapnia
Severe hypoxemia
Progressive patient fatigue
Nutritional support
Maintenance of fluid and electrolyte balance
Psychological and emotional support
Skin care to avoid decubitus ulcers
Meticulous avoidance of nosocomial
infections
Prevention of stress ulcers
Pleural Effusion
Essentials of Diagnosis:
Pleural Effusion
Classifications:
Transudative effusion
Pleural Effusion:
Approach to Management
PLEURAL EFFUSION
Yes
No
EXUDATE
TRANSUDATE
Pleural Effusion:
Approach to Management
EXUDATE
Further diagnostic procedures
Amylase elevated
Consider: esophageal rupture,
Pancreatic pleural effusion
Malignancy
NO DIAGNOSIS
Pleural Effusion:
Approach to Management
NO DIAGNOSIS
Negative
Needle biopsy of
pleura
Negative
Negative
PPD
No: Consider
Thoracoscopy or
Open pleural biopsy
Positive:
Treat for PE
SYMPTOMS IMPROVING
Positive: Treat
for TB
Yes
Observe
Pleural Effusion
Treatment:
Pneumothorax
Types:
Spontaneous
Traumatic
Essentials of diagnosis:
Pneumothorax
Treatment: