Pulmonary System I

Functions
 Ventilation: act of moving air in and out of the lungs (boyle’s law)
 Perfusion: pulmonary blood flow
o Greatest perfusion base of the lungs because of gravity
o Normal V/Q ratio: 0.8 (ventilation: V and Perfusion: Q)
𝐹𝐸𝑉1 𝐹𝑜𝑟𝑐𝑒𝑑 𝐸𝑥𝑝𝑖𝑟𝑎𝑡𝑜𝑟𝑦 𝑉𝑜𝑙𝑢𝑚𝑒 𝑖𝑛 1 𝑠𝑒𝑐 𝐴𝑙𝑣𝑒𝑜𝑙𝑎𝑟 𝑉𝑒𝑛𝑡𝑖𝑙𝑎𝑡𝑖𝑜𝑛
= =
𝐹𝑉𝐶 𝐹𝑜𝑟𝑐𝑒𝑑 𝑉𝑖𝑡𝑎𝑙 𝐶𝑎𝑝𝑎𝑐𝑖𝑡𝑦 𝑃𝑢𝑙𝑚𝑜𝑛𝑎𝑟𝑦 𝐵𝑙𝑜𝑜𝑑 𝐹𝑙𝑜𝑤 (𝑎𝑘𝑎 𝐶𝑎𝑟𝑑𝑖𝑎𝑐 𝑂𝑢𝑡𝑝𝑢𝑡)
4𝐿/𝑚𝑖𝑛
= = 0.8
5𝐿/𝑚𝑖𝑛
 Respiration: gaseous exchange
o 2 types
 External Respiration: between alveoli and capillaries
 Internal Respiration: between tissues and capillaries
o Arteries (O2 blood) “Ar” = Red; A-A - “Arteries Away”
o Veins (Un-O2 blood) “Vlu” = Blue; V-V – Veins Valik
 Transport of O2 and CO2
 Diffusion of O2 and CO2
o From higher to lower concentration

I. Upper Respiratory Tract

1. Nose (Nasal Cavity)
a. Large mucosal surface area
b. Function: filters and warms air, humidifies air
c. Vibrissae: hair in nose, filters air
2. Pharynx (Throat)
a. Three types:
i. Naso
1. (same fxn as the nose),
ii. Oro, laryngo
1. (conduits of air)
b. Respiratory & digestive system
3. Larynx (Voice Box)
a. Function: voice or sound production, ensures that air will pass through the trachea
b. Cartilages (9)
i. Thyroid (1)
ii. Cricoid (1)
iii. Arytenoid (2)
iv. Corniculate (2)
v. Cuneiform (2)
vi. Epiglottis (1)
1. Has sphincter function “Guardian of the airways”

II. Lower Respiratory Tract (LRT)

Tracheobronchial Tree (23 Generations)

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Conducting Zone 1. Trachea (windpipe)

2. Main Bronchi
(+) passageway of air 3. Lobar Bronchi
(-) gas exchange 4. Segmental Bronchi
5. Terminal Bronchioles
Respiratory Zone 6. Respiratory Bronchioles
aka Acinus: Functional unit 7. Alveolar ducts
of the Lungs 8. Alveolar sacs
9. Alveoli (Structural unit
(+) Passageway
of the lungs)
(+) gas exchange
10. Capillaries
MC Site of Intubation: Trachea
Emergency Site of Intubation: Pharynx

 2 Zones
o Conducting Zone: only passageway, no gas exchange
o Respiratory Zone: (+) gas exchange
 Functional Unit: acinus
 Structural Unit: alveoli
 (R) Main Bronchus: Common Area for Large Aspirated Objects
o Shorter, Wider, More Vertical in Orientation
 (L) Main Bronchus
o Narrower, larger, more horizontal
 Common Area for Small Aspirated Objects: Lobar Bronchi

III. Lungs
RIGHT LUNG (3) LEFT LUNG (2)
3 Lobes 2 Lobes & Lingula
Horizontal Oblique Fissures Oblique Fissure
Upper, lower
Upper, Middle, Lower
Lingula: tongue shaped upper left lobe

Layers of the Lung

1. Parietal Pleura (Outermost)
a. Membrane covering the thoracic wall
b. Sensitive to Pain

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2. Visceral Pleura (Innermost)

a. Membrane covering the lungs and its fissures
b. Sensitive to stretch
3. Pleural Space (between the Pleura)
a. Pressure: -4 mmHg
b. + pressure: gunshot wound, pneumothorax
c. Contains Pleural Fluid
i. Lubricates the pleurae
ii. Shock absorber

Cells in the Lungs

 Types I Cells/Pneumocytes: Flat cells lining the alveoli
 Type II Cells/Pneumocytes: synthesizes “Surfactant”
o Reduces the surface tension of lungs to prevent atelectasis (lung collapse)
o (-) Surfactant  RDS (Respiratory Distress Syndrome) or Hyaline Membrane Disease
 *Hering-Breur Reflex (bronchus, bronchioles)
o A stretch/inflation reflex that prevents over inflation of the lungs

IV. Thorax/Thoracic Cage/Rib Cage

A. Boundaries
o Anterior: Sternum “AS”
o Posterior: Thoracic Cage “PTC”
o Lateral: Ribs (12 pairs)
 True ribs (ribs 1-7; connected to sternum by costal cartilages)
 False Ribs (ribs 8-10; articulates 7th rib with costal cartilages)
 Floating Ribs (ribs 11-12; articulates no rib; Rib 11 = T11, Rib 12 = T12)
o Superior: Thoracic Outlet
o Inferior: Diaphragm Muscles
B. Thoracic Cage Mechanisms
o Pump-Handle motion: between sternum & ribs 1-6 (↑ A/P Diameter)
o Bucket-Handle Motion: between ribs 7-10 (↑ Lateral Diameter)
o Caliper Motion: between ribs 8-12 (↑ ICS)
o Piston Action: Diaphragm Muscle (Dome Shaped muscle, moves downward during inspiration, upward
during expiration)

V. Muscles of Respiration [February Board Exam Questions]

I. Relaxed Inspiration
a. Diaphragm Muscle (Primary Muscle of respiration)
b. External Intercostals: ↑ intercostal space, between Rib 1, 2, 3

II. Forced Inspiration

S CM
U pper Trapezius
P ectoralis Major & Minor
A nterior, Middle, Posterior Scalenes (AMS)
S erratus Anterior, Serratus Posterior Superior (APS)

III. Relaxed Expiration

a. No muscle involved d/t elastic recoil of lungs and thorax
IV. Forced Expiration (eg. Coughing)

A bdominals
S erratus Posterior Inferior
I nternal Intercostals (↓ intercostal space)

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VI. Controls of Respiration

Pons and Medulla Oblongata (PM) – Controls of Respiration
Medulla Oblongata (MO) – Automatic Respiratory Center
I. Dorsal Respiratory Group (DRG)
a. Location: Dorsal Medulla (Nucleus Tractus Solitarius)
b. Function: Inspiration (DIN)
c. Inspiratory Ramp signal: 2 sec on, 3 sec off
II. Ventral Respiratory Group (VRG)
a. Location: Ventrolateral Medulla (Nucleus Ambiguus, Retro-ambiguus)
b. Function: Expiration (VEX) & Inspiration
III. Pneumotaxic Center
a. Location: Upper Pons (Nucleus Parabrachialis)
b. Function: limits inspiration by “switching-off” the inspiration ramp signal; controls the rate and depth of
breathing
c. Respiratory Rate: Adult 12-20 cpm
IV. Apneustic Center
a. Location: Lower pons (PULA: Pneumotaxic Upper, Lower Apneustic)
b. Function: prevents “switching-off” the Inspiratory Ramp Signal
V. Chemoreceptors
a. Central
i. Location: Ventral Medulla
ii. Stimulus: ↑ hydrogen ions, results in hyperventilation
b. Peripheral
i. Location: Carotid and Aortic bodies
ii. Stimulus: ↓ PaCO2, ↑PaCO2, Acidosis (↓ pH)
iii. Board Exam: 1st choice AOTA, 2nd Choice↓ PaO2, 3rd Choice ↑PaCO2, 4th choice Acidosis (↓ pH)

VII. Arterial Blood Gas (ABG)

pH 7.35 – 7.45
PaCO2 35-45 mmHg
HCO3 22-26 mEq/L
PaO2 80-100 mmHg
SaO2 95-100%

pH Relations (Sir Lester’s Way)

A. pH inversely related to PaCO2 (Respiratory [lungs])
o Alkalosis ↑ pH = ↓ PaCO2
o Acidosis ↓ pH = ↑ PaCO2
B. pH directly related to HCO3 (Metabolic [kidneys])
o Alkalosis ↑ pH = ↑ HCO3
o Acidosis ↓ pH = ↓ HCO3

Uncompensated Abnormal pH One Gas is Normal

Resp. Alkalosis ↑ ↓ N
Resp. Acidosis ↓ ↑ N
Metab. Alkalosis ↑ N ↑
Metab. Acidosis ↓ N ↓

Partially Compensated All Are Abnormal

Resp. Alkalosis ↑ ↓ *RC ↓
Resp. Acidosis ↓ ↑ *RC ↑
Metab. Alkalosis ↑ ↑ ↑ *RC
Metab. Acidosis ↓ ↓ ↓ *RC

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Fully Compensated Normal pH Abnormal Gases

Resp. Alkalosis N ↓ ↓
Resp. Acidosis N ↑ ↑
Metab. Alkalosis N ↑ ↑
Metab. Acidosis N ↓ ↓
Normal pH = 7.40

RC = Root Cause (typically higher value/lowest value)

Signs and Symptoms

Condition Signs/Symptoms Abbrev Caused By
Resp. Dizziness, Early Tetany, Numbness, Tingling,
DENTS Hyperventilation
Alkalosis Syncope
Resp. Early: Headache, Anxiety, Restlessness, Dyspnea HARDy
Hypoventilation
Acidosis Late: Disorientation (PBEQ), Somnolence, Coma DiSC
Metab. Weakness, Early Tetany, Mental Dullness, ↑ W-E-Men-
Vomiting
Alkalosis DTRs, Muscle Twitching ↑-Muscle
Metab. Nausea, Lethargy, Coma
Acidosis (+) Kussmal breathing NaLoCo Diarrhea
(↑ rate, ↑ depth, metabolic/ketoacidosis)

Buffer System (Sir Jungie’s Way)

Alkalosis Acidosis
“Mother” pH: 7.35-7.45 ↑ ↓
Respiratory PaCO2: 35-45 mmHg ↓ ↑
Metabolic HCO3: 22-26 mEq/L ↑ ↓
1. Compensation: “Yes or no”
a. Is the pH normal?
b. Is there opposing factors?
2. Legend
a. If there are “2 Yes” -> Fully compensated
b. If there is “1 Yes” -> Partially Compensated
c. If there is “2 No” -> Uncompensated
d. The value that copies pH, it is the term

VIII. Pulmonary Volumes & Capacities

TLC (6000mL) VC (4500mL) IC (3500mL) IRV (3000mL)
IRV+TV+ER+RV IRV+TV+ERV IRV+TV TV (500mL)
IC+FRC IV+ERV FRC (2500mL) ERV (1000mL)
VC+RV RV (1500mL) ERV+RV RV (1500mL)

Yo-Mi (1st Part)

IC (Three 500 IRV (3K)
VC (Four 500
[hundred]) TV (500)
TLC (6K) [hundred])
ERV (1K)
FRC (Two 500)
RV (One 500) RV (One-Five)
Chorus
IRV
VC IC (Paused)
TV
TLC
& ERV
FRC &
RV RV

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These are the Pulmonary Volumes N’ Capacities

IRV
VC IC (Paused)
TV
TLC
& ERV
FRC Pati
RV RV

 Tidal Volume (TV – 500mL)

o Amount of air inspired or expired with each normal breath
 Inspiratory Reserve Volume (IRV – 3000mL)
o Amount of air that can still be inspired in after a normal/resting inspiration
 Expiratory Reserve Volume (ERV – 1000mL)
o Amount of air that can still be expired after a normal/resting expiration
 Residual Volume (RV – 1500mL)
o Amount of air left inside the lungs after a forceful/maximal expiration
 Inspiratory Capacity (IC – 3500mL)
o Amount of air that can be maximally inspired in after a normal/resting expiration
 Functional Residual Capacity (FRC – 2500mL)
o Amount of air left inside the lungs after a normal/resting expiration
 Vital Capacity (VC – 4500ml)
o Amount of air that can be maximally expired after a maximal inspiration
 Total Lung Capacity (TLC – 6000mL)
o Amount of air that can be contained inside the lungs after a forceful/maximal inspiration

 Volumes: ITER
o Spirometer
 Cannot measure: RV, FRC, TLC
o Body Plethysmography: TLC
o Helium/Nitrogen Wash-out: FRC, RV
 COPD: volumes ↑
 Restrictive Lung Disease: volumes ↓

IX. O2-Hgb Dissociation Curve “Sa Hgb, Apat-Dapat-Dapat-Apat”

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Shift to the Right

1. ↑ Hydrogen Ions or ↓ pH
2. ↑ CO2
3. ↑ temperature
4. ↑ 2,3 DPG (Phosphoglycerate)
5. Exercise

“↑ HaCOT 23-Ex”

Shift to the Left (Only ↓ PaO2)

1. ↓ Hydrogen Ions or ↑ pH
2. ↓ CO2
3. ↑ Fetal Hgb

X. Bohr Effect “Bo-Co2 (Buko)”

↑ Binding of CO2 with Hgb
↓
Will displace O2
↓
Will promote O2 Transport

XI. Haldane Effect “Hal-O2 (Halo-Halo)”

↑ Binding of O2 with Hgb
↓
Will displace CO2
↓
Will promote CO2 Transport

XII. Pulmonary Assessment

 Inspection
 Auscultation
 Palpation
 Percussion
 “InAus PaPer”

I. Inspection
Chest Deformity
 Barrel Chest (2:2) AP/L Chest Ratio


 Pectus Carinatum (Pigeon Chest) (Prominent Sternum)
 Pectus Excavation (Funnel Chest)
 Normal Anterior/Posterior, Lateral (AP/L) Chest Ratio – 1:2

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Chest Symmetric Expansion

1. Upper Lobes
a. PT: Front of Px
b. Thumb: Sternal Notch
c. Fingers: Above clavicles
2. Right Middle Lobe/Lingula
a. PT: Front of Px
b. Thumb: Xiphoid Process
c. Finger: Lateral Ribs
3. Lower Lobes
a. PT: Behind the Px
b. Thumb: Lower Thoracic Spines
c. Fingers: Lateral Ribs

II. Auscultation
 Stethoscope

 Normal Breath Sounds

1. Vesicular: soft, low pitched sound
2. Bronchial: loud, hollow/tubular, high pitched sound
3. Bronchovesicular: softer than bronchial
 Abnormal/Adventitious Breath Sounds
1. Crackles (Rales): fine discontinued sounds
 Ex. Hair Rubbing next to the ear or popping/fizzing soda
 (+) Secretions/water
2. Wheezes: continuous high pitched sounds heard on exhalation
 Ex. Asthma
3. Stridor: somewhat like muscle breath sounds d/t obstruction of pharynx, larynx, or trachea
4. Rhonchi: somewhat-like snoring d/t (+) secretions
 Abnormal Breathing Patterns
1. Dyspnea: rapid rate, shallow depth, irregular rhythm
2. Tachpnea: fast rate, shallow depth, irregular rhythm
3. Bradypena: slow rate, normal to shallow depth, regular rhythm
4. Hyperventilation: fast, ↑ depth, regular rhythm
5. Apnea: absence of ventilation in expiration
6. Apneusis: absence of ventilation in inspiration
7. Cheyne Stokes (waxing & wailing): alternating ↑ & ↓ depth, apnea, regular rhythm
8. Biot’s: slow rate, shallow depth, periods of apnea, somewhat irregular rhythm
 Voice Transmission Test
1. Egophony
 Normal – “ee”
 Abnormal – “aa” (d/t pneumonia, consolidation, pleural effusion)
2. Bronchophony “99” (PBEQ)
 Normal: ↓ volume from apex to base

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 Abnormal: constant volume from apex to base

3. Whisper Pectoriloquy
 Normal: Whispered “1-2-3”
 Abnormal: Loud “1-2-3”

III. Palpation
 Tactile Fremitus
o Using ulnar border of hand on ICS
o Patient says “99”
o Normal Vibrations: Normal/Air-Filled Lungs
o ↓ Vibrations: hyper-inflated lungs (emphysema)
o ↑ Vibrations: hypo-inflated lungs

IV. Percussion
 Using the middle fingers to tap the ICS
 Normal Response: Normal/Air-filled Lungs
 Hyper-resonance: Hyperinflated lungs
 Hypo-resonance: hypoinflated lungs (Lung Collapse)
 Dull: (+) secretions

V. Tracheal/Mediastinal Shifting
Contralateral Shifting
Compressive Atelectasis
Pleural Effusion
Pneumothorax
Hemothorax
“Hinulax”
Ipsilateral Shifting
Obstructive Atelectasis
Pneumonectomy
Lobectomy
Segmental Resection

VI. Colors of Sputum

 100 mL/day
 Best time to collect sputum, early morning
 In the lungs – secretions, outside of lungs – sputum

Clear Normal
Red (+) Blood
Rust (+) Pneumonia
Pink (+) Pulmonary Edema
Yellow Infection
Green Pus
Purple Neoplasm (Lung Cancer)
Flecked (Dark) Carbon Particles

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Pulmonary System II
Cases and Conditions
I. Chronic Obstructive Pulmonary Disease vs Chronic Restrictive Pulmonary Disease
Condition COPD CRPD
Chief Problem Problem with expiration Problem with inspiration
Etiology (+) Air trapping Due to ↓ lung or chest wall compliance
Affected Lung Volumes & ↑ RV ↓ VC
Capacities ↑ FRC ↓ IRV
↑ TLC ↓ TLC
V/Q Ratio < 0.8 > 0.8
Response to Bronchodilators (+) Response (-) response
Examples - Emphysema (most chronic) d/t alterations of
- Chronic Bronchitis 1. Lung Parenchyma & Pleura
- Asthma 2. Chest Wall
- Bronchiectasis 3. Neuromuscular Apparatus
- Cystic Fibrosis

II. Emphysema vs Chronic Bronchitis

Emphysema Chronic Bronchitis
Definition Over-distension of air spaces distal to the terminal Chronic, productive cough of at least 3 months
bronchioles with destruction of alveolar septa for 2 consecutive years
Cause Smoking = ↑ proteolytic enzymes
 Destroys Alveolar Sacs Smoking, pollution, occupational hazard
 ↓ Alpha-1 Antitrypsin
AKA Pink Puffer (Emphysema) Blue Bloater (Bronchitis)
Age +⁄− 60 y/o +⁄− 50 y/o
*Elderly (Elderly) * Conting Bata (Chronic Bronchitis)
Dyspnea Severe Mild
Cough Less Prominent More Prominent
Dyspnea before cough Cough before dyspnea
Sputum Scanty, Mucoid Copious, Purulent
*Evaporated Milk *Condensed Milk
Bronchial
Less Frequent More Frequent
Infection
Body Often overweight, obese
Usually Asthenic with weight loss
Build *Chubby na blue
*Payat
*Cyanotic na baboy
X-Ray  Hyper-inflated lungs  (N) Sized lungs
 Small Heart  (R) Ventricular hypertrophy
 Diaphragm: low & flat  (N) Shaped Diaphragm
 +⁄− bullae (pockets of air)  (+) Dirty lung appearance
Cor
Rare, except at the late stages More prominent
Pulmonale
Other PE (+) Barrel Chest Cyanotic
Findings (+) Use of accessory muscles of respiration (+) peripheral edema

III. Asthma
Definition
Hypersensitivity of bronchial smooth muscle due to various stimuli resulting to widespread bronchoconstriction

Age
50% <10 years old, Male > Female (2:1)

After 30 y/o Male = Female (1:1)

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Triggering Factors (PBEQ)

 Extrinsic
o Inhalant Allergens (Pollen, Dust)
o Food (Chocolate, Milk, Nuts, seafood, chicken, eggs, tomato)
o Animal Hair
o Feathers
o Pollution
o Climate Change
o Drug (Aspirin)
o Irritant Inhalants
 Intrinsic
o Upper Respiratory Tract Infections
o Emotional Stress
o Psychological Stress
o Exercise
o Fatigue

Status Asthmaticus
 Severe form of asthma
 Persists from days to weeks
 Px requires Mechanical Ventilator
 Fatal

Signs and Symptoms

 Triad: Coughing, Wheezing, Dyspnea (CWD) (PBEQ)
 (+) Tachypnea
 (+) Use of accessory muscles of respiration
 Asthma Attack= is terminated by a cough producing a thick, stringy mucus (Kurshmann’s Spirals)

IV. Bronchiectasis
Definition
 Permanent dilation of bronchi/bronchioles d/t recurrent pulmonary infections
 Obstruction distal to exudation, dilatation proximal to obstruction

Most Commonly Affected

 Terminal Bronchioles

2 Types
1. Saccular (Cystic): from large, proximal bronchi down to the 4th generation
2. Cylindrical (Fusiform): from 6th to 10th generations

Signs and Symptoms

 Hemoptysis
 Dyspnea
 Fever
 Coughing

V. Cystic Fibrosis (Mucoviscidosis)

Definition
Widespread abnormalities of exocrine glands

B ronchial Mucus Glands

Triad

E xocrine Cells of Pancreas

S weat Glands
*(+) defect of long-arm of chromosome #7 (the long arm is q: the short arm is p)

Signs and Symptoms

 (+) productive cough leads to too much secretions leads to i(+) bronchial infections

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 Weight Loss (malabsorption – inability of body to breakdown food)

 ↑ NaCl in sweat (sweat test)

X-Ray
(+) honeycomb lungs

Chronic Restrictive Pulmonary Disease

I. Interstitial Pulmonary Fibrosis
 Aka: Hamman-Rich Disease
 Idiopathic
 Associated with smoking, family history, collagen disease
 Cardinal Sign: progressive dyspnea
 Death in 5-6 years after the dx

II. Pneumonia (Intra-alveolar Infection)

3 Types
A. Bacterial (Streptococcal; Most common)
B. Viral
C. Aspiration (ex. CVA, ALS; (-) Gag Reflex)

Signs and Symptoms

 Fever
 Chills
 Cough
 Chest Pain

III. Atelectasis (Lung Collapse)

2 Types
Primary (Compressive) Secondary (Obstructive)
Ex. Pleural Effusion: too
much pleural fluid  lung
collapse
Give px Incentive Spirometry to help px breath

S/Sx:
 ↑ vibration
 Hyporesonance
 Asymmetric Expansion
 Dyspnea

IV. Tuberculosis (TB)

Etiology
Mycobacterium Tuberculae

Incubation Period
2-10 weeks

Maximally Infectious
First 2 weeks
(isolate px in a Negative-P° room, bacteria have trouble traveling through air)

Treatment
3-12 months, average 6 months

Primary Complex (TB of Children)

Infected Active TB Adult transmits TB to Child

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S/Sx
Hallmark: HEMOPTYSIS
Cough
Fever
Wt. Loss
Enlargement of Lymph Nodes

Drugs (RIPES)
R ifampicin
I soniazid
P yrazinamide
E thambutol
S treptomycin

V. Pulmonary Edema
H2O in the alveoli due to unequal capillary P
Associated with Left sided heart failure, MI, Mitral Valve disease, Stenosis
S/Sx
(+) Crackles/rales
Nonproductive cough
Sputum: pink & frothy
Fever
Dyspnea

VI. Pulmonary Embolism

Definition
Lodging of large/small particles into the pulmonary venous circulation

Most Common Cause

Deep Vein Thrombosis

Other Causes
C lotting Disorder
O ral Contraceptives
V enous stasis
A ir (Trauma)

Prevention
Ankle Pumps

Positive Pulmonary Embolism Treatment

Immobilization

Signs and Symptoms

 Sudden Acute Pain
 Cough
 Dyspnea

VII. Pleuritis & Pleural Effusion

Pleuritis: inflammation of pleura
Pleural Effusion: excessive accumulation of pleural fluid
S/Sx
 Sharp/Dull Pain
 Doorstop Breathing
 Dyspnea
 Coughing

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 (+) Pleural Rub/Friction

Pleural Tube (P-Tube) Insertion

8th-9th ICS

VIII. Pneumothorax
Air/Gas leaking inside the pleural space

S/Sx
Sudden, Sharp Pain
Doorstop Breathing
Dyspnea
Cough

Pleural Tube (P-Tube) Insertion

2nd to 3rd ICS

IX. Severe Acute Respiratory Syndrome (SARS)

Caused By
Corona Virus

S/Sx
Fever or ↑ in temperature
Sore Throat
Dry Cough
Myalgia
Lethargy

Etiology
Direct transmission within the past 10 days

Code
“K”

MERS-CoV – Middle East Respiratory Syndrome – Corona Virus

- MERS-CoV Animal: Camel

X. Bronchogenic Carcinoma (Lung Cancer)

3 Types (SOS)
a. Small Cell (Most Fatal)
b. Oat Cell
c. Squamous Cell (Most Common)

Signs and Symptoms

 Initially: Fever
 (+) Hemoptysis
 Fatigue
 Unexplainable Weight Loss
 Hoarseness

Pulmonary Rehabilitation
I. Postural Drainage (Bronchial Drainage/Chest PT)
2 Goals
1. To prevent accumulation of secretions
2. To remove secretions already there

Duration
20 – 30 minutes, Kisner; 45 minutes O’Sullivan, not more than 45-60 minutes

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Positions
 Use of Tilt Table
 Trendelenburg/T-Position: head down, feet up
o CI for recent cranial surgery bc ↑ ICP
 Reverse T-Position: feet down, head up
Manual Techniques (3-5 minutes)
1. Percussion
2. Vibration
3. Shaking

Do Not Percuss Over

 Bony prominence
 Breast Tissue
 Chest Pain
 Thoracic Surgery

Lung Map
Right Lung Left Lung
10 Segments 8 Segments
Apical
Apical Posterior
Upper Lobes Post Anterior
Anterior Superior Lingular
Inferior Lingular
Lateral
Middle Lobe NONE
Medial
Superior (Apical) Superior (Apical)
Anterior Basal Anterior Basal
Lower Lobes Posterior Basal Posterior Basal
Lateral Basal Lateral Basal
Medial Basal Medial Basal

I. Upper Lobes
Segment Patient Position Percussion Memory Technique
Anterior Apical Sitting, leaning backward Below clavicles
Apical: Sitting
Posterior Apical Sitting, Leaning forward Above scapulae
Male: nipple area
Anterior Supine, bed flat
Female: just above breast
1/4th turn from prone on (R) side
The Only Lobe for
Left Posterior Reverse T-Position (30°-45°) (L) Scapula
Reverse T-Position
18-20 inch head elevation (large pillows)
Right Posterior 1/4th Turn from prone (L) side, bed flat (R) Scapula

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 Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation

II. Middle Lobe/Lingula

Segment Position Percussion Technique
1/4th turn from supine on (L) side
Middle Lobe T-Position (15°-30°) Below (R) Nipple
12-16 inch foot/feet elevation The only T-Position that
1/4th turn from supine on (R) side is 15°-30°
Lingula T-Position (15°-30°) Below (L) Nipple
12-16 inch foot/feet elevation

III. Lower Lobes

Segment Position Percussion
Anterior Supine; T-Position (30°-45°) Anterior Lower Ribs
Posterior Prone; T-Position (30°-45°) Posterior Lower Ribs
Left Lateral (R) Sidelying; T-Position (30°-45°) Left Lateral Lower Ribs
Right Lateral (L) Sidelying; T-Position (30°-45°) Right Lateral Lower Ribs
Superior Prone, bed flat below the Scapulae

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 Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation

IV. Breathing Exercises (2-3 reps)

2-3 reps to prevent hyperventilation

1. Diaphragmatic Breathing
a. Improves ventilation
2. Pursed Lip Breathing
a. For patients with dyspnea, shortness of breath, asthma
b. ↑ intrabronchial P°
c. Creates (+) P°
3. Segmental Breathing
a. For patients with atelectasis, pneumonia
b. Apply resistance to lobe with lung collapse
4. Glossopharyngeal Breathing
a. Aka Frog Breathing
b. For patients with high level SCI, post-polio syndrome
c. 8-10 gulps/gasps of air
5. Sustained Maximum Inspiration (SMI)
a. Used pre-operatively to prevent atelectasis

V. Mediastinal Breathing
CONTRALATERAL IPSILATERAL
Compressive Atelectasis Obstructive Atelectasis
Pleural Effusion Pneumonectomy
Pneumothorax Lobectomy
Hemothorax Segmental Resection

VI. Coughing
 “Double Cough”
o 1st Cough: to remove secretion
o 2nd Cough: to clear the airways
o Effective up to 7th Generation (Alveolar Ducts)
o For SCI px: press 5lbs of pressure on px abdomen to help
 “Endotracheal Suctioning”
o Duration 10-15 sec
o Effective up to 3rd generation (Lobar Bronchi)
 “Tracheal Tickle/Stimulation”
o For infants and unconscious patients

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