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SYSTEM
Dr.Srinath.Chandramani
Anatomy :
The respiratory system can be divided into following anatomical
levels :
Upper respiratory tract
Airway
Parenchyma
Interstitium
Pleura
Mediastinum
Pulmonary vasculature
Diagphragm
Anatomy Ctd
Anatomy Ctd
Mediastinum is the region between the pleural sacs.
It is separated into three compartments.
The anterior mediastinum extends from the sternum anteriorly to the
pericardium and brachiocephalic vessels posteriorly. It contains the
thymus gland, the anterior mediastinal lymph nodes, and the internal
mammary arteries and veins.
Anatomy Ctd
Lymphatic drainage :
Surface anatomy
The apices of both the lungs rise 2-3 cms above the clavicles
The margins of the lung are on 6th ICS in the MCL. 8th rib at the mid
axillary line.
10th rib at the scapular line and the paravertebral line at D10
vertebrae.
The pleural border is 2 spaces lower than corresponding lung margin
i.e. 8th space in MCL, 10th in Mid axillary line and D12 at the scapular
and vertebral line.
Physiology
1.
2.
3.
4.
Symtomatology
Types of cough :
1. Dry cough pleural, ILD and Mediastinal diseases
2. Productive cough Airway and Parenchymal disorders
3. Short cough URTI
4. Brassy cough external tracheal compression
5. Bovine cough Recurrent laryngeal n. palsy
6. Barking Epiglottic lesions/ hysteria.
Nocturnal cough :
PND,Post nasal drip, Chronic bronchitis, asthma, GERD,
Tropical Eosinophilia.
Sputum
Copious Sputum :
Bronchiectasis
Lung Abcess
Necrotising Pneumonia
Alveolar cell carcinoma ( large amount of colourless sputum)
Colour of Sputum
Green
or Yellow Bacterial
Myeloperoxidase
Black Coal miners pneumoconiosis
Rusty Pneumococcal pneumonia
Red currant jelly Klebsiella
Pink frothy Pulmonary edema
Blood stained Kochs
Anchovy sauce Amoebic liver abscess
Hemoptysis
Physical signs
CHEST RADIOGRAPHY
AP vs PA view
Exposure and centralisation
Bony thorax
Cardio-pulmonary ratio
Cardiac shadow
Lung fields
(1) total lung capacity (TLC), the volume of gas contained in the
lungs after a maximal inspiration;
(2) residual volume (RV), the volume of gas remaining in the lungs
at the end of a maximal expiration.
The volume of gas that is exhaled from the lungs in going from TLC
to RV is the vital capacity.
Interpreting PFT
Interpreting PFT
Etiology
PFT - Conclusion
Reversibility
is traditionally defined
as a 15% increase in FEV1 after two
puffs of a B-adrenergic agonist.
PEFR
Test 1
1.
To qualify as a solitary pulmonary nodule in chest X-ray the size should not
exceed....
(A)
3 cm
(B)
6 cm
(C)
8 cm
(D)
9 cm
2.
3.
A 28-years old woman having limited capacity for the last 10 years complains of
shortness of
breath for last one month. Her pulmonary function tests are as follows :
PFT
Observed
Predicted
FVC
2.63
2.82
FEV1
88%
80%
What is the most likely diagnosis in this case
(A) Interstitial lung disease
(B) Pulmonary artery hypertension
(C) Congestive heart failure
(D) Bronchiectasis
Test 1
4.
5.
Test 1
6.
7..
8.
(B)
FEV1 is high
All of the above
Test 1
9.
10.
A patient presents with decreased vital capacity and total lung volume. What is
most probable diagnosis?
(A)
Bronchiectasis
(B)
Sarcoidosis
(C)
Cystic fibrosis
(D)
Asthma
11.
12.
4L
7L
Test 1
13.
The blood gas parameters: pH - 7.58, pCO2 23 mm Hg PO3 300
mm Hg and oxygen saturation 60% are most consistent with.....
(A) Carbon monoxide poisoning
(B) Ventilatory malfunction
(C) Voluntary hyperventilation
(D) Methyl alcohol poisoning
14.
Test 1
15.
16..
Introduction :
Epidemiology :
Bronchial asthma occurs at all ages but predominantly in
early life.
About one-half of cases develop before age 10, and
another third occur before age 40. Elderly onset is
unlikely.
In childhood, there is a 2:1 male/female preponderance,
but the sex ratio equalizes by age 30.
EOSINOPHILS
Eosinophils
Contain
They
All
Mast
Special types
Clinical presentation
Episodic
unable to speak
Central cyanosis
Altered sensorium
Bradycardia
Silent chest
Unrecordable peak flow
Severe hypoxemia
High CO2 retention
Low pH.
Steps
Symptoms
Step 1 :
Intermittent
<1 /week
Nocturnal
symptoms
< 2/month
>80% of
predicted but
normal in
between
attacks
>1/week but > 2/month > 80% never
< 1 /day
normal even
during
asymptomatic
period.
> 1/week
Daily
>60% <80% of
attacks.
predicted with
variability > 30%
Functional
impairment
Treatment
Step 2 : Mild
persistent
Step 3 :
Moderate
persistent
Step 4 :
Severe
persistent
PEFR
Continuous
Limited
activity
Frequent
Short-term
Long-term
relief
prevention
none
Inhaled B2
agonist short
acting.
Inhaled B2
Inhaled
agonist short corticosterio
d
acting.
SOS
Inhaled B2
agonist
shortacting.
not to exceed
3-4/day
Inhaled
corticosteroi
d
LABA
< 60% of
Inhaled B2
predicted with
agonist
variability > 30% shortacting.
not to exceed
3-4/day
Inhaled
corticosteroi
d
LABA
Oral steriods
Drugs
BRONCHIECTASIS
BRONCHIECTASIS
BRONCHIECTASIS
BRONCHIECTASIS
An
ABPA
COPD includes :
emphysema, an anatomically defined condition characterized by
irreversible destruction and enlargement of the lung alveoli;
chronic bronchitis, a clinically defined condition with chronic cough
with expectoration for most days for atleast 3 months a year for 2
consecutive years.
small airways disease, a condition in which small bronchioles are
narrowed.
Cigarette Smoking
Airway Responsiveness
Respiratory Infections
Occupational Exposures
Ambient Air Pollution
Passive, or Second-Hand, Smoking Exposure
GENETIC : Alpha-1 Antitrypsin deficiency.
FEATURES
PREDOMINANEMPHYSEMA
PREDOMINANT
BRONCHITIS
AGE OF ONSET
6TH DECADE
5TH DECADE
COUGH
SPUTUM
AFTER
BREATHLESSNESS
SCANTY
INFECTIONS
LESS COMMON
BEFORE
BREATHLESSNESS
COPIOUS,
PURULENT
COMMON
RESPIRATORY DISTRESS
OFTEN TERMINAL
EPISODIC
CXR
HYPERINFLATION
INCREASED BVM
CYANOSIS
TERMINAL
COMMON
PULMONARY
HYPERTENSION
COR PULMONALE
MILD
MODERATE/SEVER
E
EARLY
LATE
COPD
COPD Ctd..
Pneumonia
Pneumonia can be broadly categorized as community-acquired or
hospital-acquired (nosocomial).
Based on pattern of lung involvement they are classified as : Lobar,
Broncho, Interstitial or Miliary.
Etiology of pneumonia :
For pneumonia to occur, a potential pathogen must reach the lower
respiratory tract in sufficient numbers or with sufficient virulence to
overwhelm host defenses.
Possible routes include gross aspiration, microaspiration, aerosolization,
hematogenous spread from a distant infected site, and direct spread
from a contiguous infected site.
By far the most common route for bacterial pneumonia is
microaspiration of oropharyngeal secretions colonized with pathogenic
microorganisms.
Etiological agent : Streptocoocus pyogenes.
Management
Prognosis and clinical grading :
The single most useful clinical sign of the severity of pneumonia is a
respiratory rate of > 30/min in a person without underlying lung
disease.
British Thoracic Society Rule for Definition of Severe CommunityAcquired Pneumonia ( CURB)
Confusion
Urea: _7 mmol/L
Respiratory rate: _30/min
Blood pressure: diastolic _60 mmHg or systolic _90 mmHg
If none of these features is present, the mortality rate is 2.4%; with one
feature, the mortality
rate is 8%; with two, 23%; with three, 33%; and with all four, 83%.
The mortality rate is highest (_50%)for pneumonia due to P.
aeruginosa, followed by the rates for Klebsiella spp., E. coli, S. aureus,
and Acinetobacter spp. (all 30 to 35%).
pneumonia,
formation of abscesses,
vascular invasion with infarction,
cavitation, and
extension to the pleura with empyema or
bronchopleural fistula.
Complications of mechanical ventilation and
supplemental oxygen administration.
In patients with severe damage, tissue repair may
lead to fibrosis with various anatomical distributions,
such as organizing pneumonia, bronchiolitis
obliterans, and pleural adhesions.
TEST 2
17.
All of the following statements regarding mast cells are true except...
(A)
(B)
(C)
(D)
18.
19.
(B)
(D)
Monocytes
Mast cells
TEST 2
20.
21.
22.
TEST 2
23.
24.
25.
TEST 2
26.
Zileuton is...
(A) 5 lipo oxygenase inhibitor
(B) TX A2 inhibitor
(C) Leukotriene receptor antagonist
(D) Lymphocyte inhibitor
27.
28.
All of the following are useful for treating acute bronchial asthma in
children except....
(A) 100% oxygen
(B) Hydrocortisone infusion
(C) IV aminophylline
(D) Sodium chromoglycate inhalation
ILD
Among
PATHOGENESIS
Inciting agent
Interstitial edema
ARDS
Clinical features :
Sudden onset pulmonary infiltrates with hypoxemia and extreme VQ
mismatch.
Tachypnoea, Dysnoea, Diffuse crackles/rhonchi
Rapid respiratory failure requiring ventilation.
Severe hypoxemia poorly responding to oxygen
High peak airway pressure.
Treatment ;
Hypersensitivity pneumonitis
Hypersensitivity pneumonitis
Disease
Antigen
Source of Antigen
Idiopathic
ABPA
CYSTIC FIBROSIS
Cystic fibrosis is an autosomal recessive genetic disorder.
Incidence in whites >> blacks >> Asians
Etiology : Caused by a defect in the cystic fibrosis
transmembrane receptor (CFTR) protein which results in
defective ion transport in the exocrine gland.
In the lungs, abnormal sodium and chloride transport causes
thick, poorly cleared mucous, resulting in chronic bacterial
colonization and recurrent infections.
Chronic inflammation impairs lung function, eventually resulting
in respiratory failure.
Thickened secretion in the pancreas result in retention of
pancreatic enzymes with eventual destruction of the pancreas
and steatorrhea.
Cystic Fibrosis
Clinical features :
1. Pulmonary : a. chronic cough b. purulent sputum
c. wheezing
d. chronic sinusitis e. recurrent pneumonia
f. Pneumothorax g. clubbing
h. Nasal polyps
i. hemoptysis
Commonest Infective agent is Pseudomonas followed by S.Pyogenes.
2. Gastrointestinal : a. pancreatic insufficiency (90%)
b. Protein/Fat malabsorption
c. Diabetes mellitus (10%)
d. Obstruction/Intususception
e. Biliary stasis
3. Reproductive : a. Sterility in males (95%) and 20% in females.
Cystic Fibrosis
Chilhood presentation : Meconium ileus, recurrent LRTI, cachexia.
Adult presentation is chronic/recurrent sinusitis.
Diagnosis :
Clinical symptoms plus sweat chloride >80mEq in adults.
Treatment :
Antibiotics inhaled during exacerbation and chronic use.
Mobilisation of chest secretions : Physiotherapy, inhaled
bronchodilators.
Nutritional therapy : increased fat diet, vitamins.
Control of airway inflammation : vaccination and steroids
Gene therapy for definitive cure.
Lung transplant has relatively good results.
Prognosis :
Median survival >30 years. Respiratory failure is cause of death in most
cases.
LUNG CANCER
Types :
Cancer of the respiratory epithelium (bronchogenic)
Non-Small cell lung cancer (NSCLC) : 70% of lung cancers, spreads to
regional lymph nodes.
Squamous (30%) : central mass in upper lobes, slow growth, late
metastasis
Adenocarcinoma (30%) : peripheral mass, slow growth, early
metastasis
Large cell (10%) : peripheral mass, early metastasis and early
cavitation.
Small-cell lung cancer (SCLC) : Rapid growth and very early,
widespread mets (70%)
Rare types : Carcinoid, Broncho-alveolar (in non-smokers)
Etiology :
Smoking 90%
Others : Asbestos, pollutants.
Lung Cancer
Clinical features :
Pulmonary : cough, hemoptysis, dysnoea, post-obstructive
pneumonia, effusion
SVC syndrome : Face and neck edema due to superior vena
cava obstruction
Pancoast tumour : Apical tumour leading to Horners
syndrome and arm/shoulder pain due to brachial plexus
involvement.
Horners syndrome : Miosis, Ptosis and anhidrosis
Hoarseness : due to recurrent laryngeal nerve palsy
Extra-thorasic :Anorexia, cachexia, fever, adenopathy and
night sweats
Para-neoplastic syndrome(15%) : SIADH, Eaton-Lambert
syndrome, Trosseaus syndrome (hypercoagulability), Ectopic
PTH leading to hypercalcemia.
Lung Cancer
Treatment :
NSCLC : Resection + Chemotherapy. Radiation is
palliative.
SCLC : Responds well to chemotherapy. Radiation +/Smoking cessation reduces risk of recurrence.
Prognosis :
NSCLC : Resection effective at stage 1 and 2. But few
are diagnosed at this stage.
SCLC : 80-90% respond to chemotherapy. But problem is
of 90% relapse.
Pancoast Syndrome
Pancoast
The
PNEUMOTHORAX
Pneumothorax is the presence of gas in the pleural space.
Types :
A spontaneous pneumothorax is one that occurs without antecedent
trauma.
A primary spontaneous pneumothorax occurs in the absence of underlying
lung disease,
a secondary spontaneous pneumothorax occurs in presence of underlying
disease.
Primary Spontaneous Pneumothorax Primary spontaneous pneumothoraces
are usually due to rupture of apical pleural blebs, small cystic spaces that
lie within or immediately under the visceral pleura. Primary spontaneous
pneumothoraces occur almost exclusively in smokers, which suggests that
these patients have subclinical lung disease.
Approximately one-half of patients with an initial primary spontaneous
pneumothorax will have a recurrence. The initial recommended treatment
for primary spontaneous pneumothorax is simple aspiration. If the lung does
not expand with aspiration, or if the patient has a recurrent pneumothorax,
thoracoscopy with stapling of blebs and pleural abrasion is indicated.
Thoracoscopy or thoracotomy with pleural abrasion is almost 100%
successful in preventing recurrences.
PNEUMOTHORAX
Pneumothorax
VENTILATION DISORDERS
Definition
OBESITY-HYPOVENTILATION SYNDROME
As a result, the functional residual capacity (i.e., endexpiratory lung volume) is reduced, particularly in the
recumbent posture.
Hypoventilation syndrome
Clinical features;
Loud snoring, restlessness during sleep.
Breath cessation while sleeping
Obesity
Daytime fatigue. Somnolence ,morning sluggishness
Cognitive impairment
Headaches
Impotence
Personality changes
Diagnosis : Polysomnography is diagnostic : include
EEG,ECG,SpO2, airflow and respiratory effort. Positive test has
10 apneac spells per hour lasting at least 10seconds each.
Treatment :
Avoid alcohol and sedatives
Lose weight
Oral dental prosthesis
Nasal septoplasty if DNS present
Uvulopalatopharyngoplasty
CPAP
Pulmonary Circulation
PHYSIOLOGY OF PULMONARY CIRCULATION
The pulmonary vasculature handles the entire output of right
ventricle, i.e. 5 L/min
The normal mean pulmonary artery pressure is 15 mmHg, as
compared to 95 mmHg for the normal mean aortic pressure.
Regional blood flow in the lung is dependent on vascular geometry
and on hydrostatic forces. In an upright person, perfusion is least at
the apex of the lung and greatest at the base.
When cardiac output increases, as occurs during exercise, the
pulmonary vasculature is capable of recruiting previously
unperfused vessels and distending underperfused vessels, thus
responding to the increase in flow with a decrease in pulmonary
vascular resistance.
In consequence, the increase in mean pulmonary arterial pressure
(PAP), even with a three- to fourfold increase in cardiac output, is
small.
PULMONARY HYPERTENSION
Classification :
Primary pulmonary hypertension : No identifiable cause but patients may have
increased systemic vasoconstrictors (endothelin-1, Thromboxane A2) and
decreased vasodilators.
Clinical features :
PULMONARY HYPERTENSION
Diagnosis :
Treatment :
PULMONARY HYPERTENSION
Prognosis
Primary
pulmonary hypertension :
usually diagnosed late.
Poor prognosis. Mean survival <3 years
after diagnosis.
Death from RV failure or arrhythmia,.
Secondary
pulmonary hypertension :
depends on underlying disease.
PULMONARY THROMBOEMBOLISM
PULMONARY THROMBOEMBOLISM
CLINICAL MANIFESTATIONS :
PTE
DIFFERENTIAL
Acute
DIAGNOSIS :
PTE
Wells Diagnostic Scoring System for Suspected PE
Clinical signs and symptoms of DVT
An alternative diagnosis is less likely than PE
Heart rate _100 beats/min
Immobilization or surgery in the previous 4 weeks
Previous DVT/PE
Hemoptysis
Malignancy (on treatment, treated in the past 6 months)
3.0
3.0
1.5
1.5
1.5
1.0
1.0
Progressive right heart failure is the usual cause of death from PE.
PTE
DIAGNOSIS:
Treatment :
Patients with massive PE present with systemic arterial hypotension and
usually have anatomically widespread thromboembolism.
Primary therapy with thrombolysis or embolectomy offers the greatest
chance of survival.
PTE
PTE
PREVENTION
Prophylaxis against PE is of paramount importance because
venous- thromboembolism is difficult to detect and poses an
excessive medical and economic burden.
Mechanical and pharmacologic measures often succeed in
preventing this complication. Patients at high risk can receive a
combination of mechanical and pharmacologic modalities.
Graduated compression stockings and pneumatic
compression devices may complement mini-dose
unfractionated heparin (5000 units subcutaneously twice or
preferably three times daily), low-molecular- weight heparin, a
pentasaccharide or warfarin administration.
Patients who have undergone total hip replacement, total
knee replacement, or cancer surgery will benefit from
extended pharmacologic prophylaxis for a total of 4 to 6
weeks, especially with low-molecular-weight heparin.
TEST 3
29.
30.
Cryptostroma corticale
Asperigullus
Thermophilic actinomycetes
Grain dust
TEST 3
31.
32.
33.
Allergic bronchopulmonary aspergilosis is related to sarcoidosis
involving the lung by which cell type?
(A)
Macrophage
(B)
Plasma cell
(C)
Eosinophil
(D)
Type-II pneumocyte
TEST 3
34.
35.
36.
TEST 3
37.
38.
39.
TEST 3
40.
41.
42.
The following modes of ventilation may be used for weaning off patients from
mechanical ventilation except.....
(A)
Controlled Mechanical Ventilation (CMV)
(B)
Synchronized Intermittent Mandatory Ventilation (SIMV)
(C)
Pressure Support Ventilation (PSV)
(D)
Assist Control Ventilation (ACV)
TEST 3
43.
44.
45.
TEST 3
46.
47.
Ultra structural abnormalities reported in defectivedilia immotile cilia
syndrome
are....
(A)
Dynein in arm deficiency
(B)
Absence of radial spokes
(C)
Absence of central microtubule
(D)
All of the above
48.
TEST 3
49.
In cystic fibrosis the most common organism which causes infection is....
(A)
(C)
Pseudomonas
Klebsiella
(B)
(D)
Staphylococcus
Streptococcus
50.
In cystic fibrosis, pseudomonas aeroginosa is most common organism.
The next
common is.....
(A)
Streptococci
(B)
Klebsiella
(C)
Pneumococci
(D)
Staphylococcus aureus
51.
A mother kissing her baby finds that the baby's skin is salty, the
diagnosis is.....
(A)
Fanconi syndrome
(B)
Thalassemia
(C)
Cystic fibrosis
(D)
Niemann pick disease
TEST 3
52.
53.
The complication least likely to occur in a case of chronic
bronchitis is....
(A)
Pulmonary hypertension
(B)
Pneumothorax
(C)
Emphysema
(D)
Amyloidosis
TEST 3
54.
55.
56.
Vitamin B12
Steroids
TEST 3
57..
58.
is.....
(A)
(B)
(C)
(D)
59.
S1Q3T3 pattern
P. pulmonale
Sinus tachycardia
Right axis deviation
TEST 3
60.
The most definitive method of diagnosing pulmonary
embolism is.....
(A)
Pulmonary ateriography
(B)
Radioisotope perfusion pulmonary
scintigraphy
(C)
EKG
(D)
Venography
61.
TEST 3
62.
Malignancy
Oesophageal rupture
(B)
(D)
Pancreatitis
All
63.
64.
TEST 3
65.
A patient with spontaneous pneumothorax involving more than 50% of
hemithorax is best treated with....
(A)
Needle aspiration
(B)
Closed drainage by tube in underwater
seal
(C)
Let spontaneous remission occurs
(D)
Open thoracotomy
66
67.
TEST 3
67..
68..
69.
Sleep apnea is defined as a temporary pause in breathing during
sleep at least....
(A)
40 seconds
(B)
30 seconds
(C)
20 seconds
(D)
10 seconds
TEST 3
70.
71.
72..
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