Introduction to Respiratory System

Components

Lining Epithelium

Lung Defense

Nose & Oropharynx:

Formidable barrier to inhaled particulates.
Anatomical structure Nasal hairs Nasal mucosa Secretory Ig A

Conducting airways:
Mucociliary clearance Cough Minor mechanisms are
Dichotomous branching of airways BALT

Alveolar spaces:
Airways distal to major bronchi are probably sterile. Non-immunological Immunological
Nonspecific. Specific.

Symptoms

Cough
Cough is an explosive expiration which provides a means of clearing the tracheobronchial tree of secretions & foreign bodies Vital host defense mechanism

Pathophysiology:
Cough has two major functions To prevent foreign material from entering the lower respiratory tract To clear foreign material & excessive secretions from the lower respiratory tract

 Tidal inspiration glottic closure increase in intrathoracic pressure violent exhalation at increased flow rates Afferent pathway- cough receptors in trachea, pharynx, larynx & bronchi- fifth, ninth & tenth cranial nerves Efferent pathway- tenth nerve and spinal accessory nerve.

Classification Dry & Productive

Acute, sub-acute & Chronic

Types of cough
Hacking pharyngitis, laryngitis Barking cough- hysterical Brassy aortic aneurysm, mediastinal tumour Bovine cough- recurrent laryngeal nerve palsy Staccato whooping cough- pertusiss Spluttering Cough after meals- TOF, hiatus hernia, GERD Nocturnal cough- Asthma, pulmonary odema, post nasal drip

Causes
Infections & Inflammation:
Acute laryngitis, tracheitis, bronchitis, pharyngitis Chronic bronchitis, bronchiectasis, lung abscess, tuberculosis, bronchial asthma, ILD & pneumonia

Causes (contd.)
Mechanical stimuli
Inhalation of particulate matter e.g. dust Pressure or tension on the air passages
Interstitial lung disease (ILD) Pulmonary edema

Compression of air passages

Extramural - Thyroid pathologies Intramural- Foreign body inhalation

Causes (contd.)
Chemical stimuli & Thermal stimuli:
Inhalation of irritant gases, including cigarette smoke & chemical fumes & inhalation of very hot or cold air

Extra pulmonary cause: mitral stenosis, LV

failure, aortic aneurysms, mediastinal nodes & growths. Diseases of the pleura, diaphragm & oesophagus

Evaluation
History
Type Duration Variation Drug history Associated symptoms

Examination

Investigations
X-ray Chest X-ray PNS Spirometry before & after bronchodilators or methacholine inhalation challenge Modified barium esophagography, gastroscopy or 24 hours esophageal pH monitoringv Flexible bronchoscopy Chest CT Noninvasive cardiac studies

Complications
Arterial hypotension Brady/ tachyarrhythmias Rib fractures Cough syncope

Treatment
Antitussive therapy
Specific Non specific
(Codeine/ dextromethorphan 15mg qid) Demulcents Local anesthetics

Protussive therapy
Expectorants e.g. Iodides, Guaifenesin, Ammonium chloride Mucolytics e.g. Acetylcysteine

Haemoptysis

Coughing up of blood is termed haemoptysis Haemoptysis more than 400 ml- Massive haemoptysis Bleed may be arterial, venous or capillary

Causes
Inflammatory
Bronchitis TB Bronchiectasis Aspergilloma

Neoplastic Other
Pulmonary thromboembolism Mitral stenosis PPH, AV malformation Idiopathic pulmonary hemosiderosis Pulmonary vasculitis Hemorrhagic diathesis including anticoagulant therapy Upper respiratory cause

Investigations
Differentiate from haematemesis Grouping , cross matching & Complete haemogram Bleeding & clotting parameters XRC Bronchoscopy CT chest Pulmonary or bronchial arteriography

Treatment
Treat the underlying disorder Calm the patient / Sedation / Complete bed rest Blood transfusion Prevent aspiration by lateral positioning Bronchoscopy BAE Surgery

Dyspnea
Greek- dys meaning painful, difficult & pneuma meaning breath Subjective awareness of ones own breathing

Mechanisms
Poorly understood Increased central respiratory drive secondary to hypoxia, hypercapnia or other afferent input Augmented respiratory effort to overcome mechanical constraints or weakness Altered central perception Lengthtension inappropriateness

Causes
Acute to hyper acute:
Acute severe asthma LVF Pneumothorax FB aspiration Pulmonary thromboembolism Acute exacerbation of COPD

Causes (contd.)
Sub acute chronic:
COPD ILD Asthma Pneumonia Neuromuscular disease Kyphoscoliosis Pleural effusion

Causes (based on physiologic categories)

Mechanical interference with ventilation
Obstruction to air flow (central or peripheral)
Asthma, Emphysema, Bronchitis, Endobronchial tumor & foreign body

Resistance to expansion of the lungs (stiff lungs)

Interstitial fibrosis of any cause, LVF

Resistance to expansion of the chest wall or diaphragm

Pleural effusion, Pneumothorax, Pleural thickening, Kyphoscoliosis, Obesity, Abdominal mass (e.g. tumor, pregnancy)

Causes (contd.)
Disorders of neuro muscular pathway
Prior poliomyelitis Neuromuscular disease Gullian barre syndrome Tetanus Muscular dystroiphy Stroke Depression of CNS drive

Evaluation
History
Type at rest / on exertion, associated wheeze, paroxysmal episodes Aggravating or precipitating factors Seasonal, diurnal variation Associated symptoms- cardiac, abdominal, upper respiratory

Examination
RS CVS

Investigations
Routine laboratory
Anemia, ESR, Chemistry, XRC, ECG.

Special studies
PFT Imaging techniques- CT Cardiac evaluation- Echocardiography Esophageal examination or pH monitoring Sleep studies Psychologic assessment

Treatment
Treat the underlying cause Non specific
Oxygen therapy Drugs Exercise Nutrition

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