PHYSIO-ANATOMY OF RESPIRATORY SYSTEM

➢ Respiratory tract
● Divided into the upper (nose to larynx) and lower respiratory tracts (trachea to alveoli)
● Can also be divided into 2 zones, the conducting (nose to bronchioles) & respiratory zones (alveolar duct to alveoli)
➔ Respiratory zone starts at the point where the terminal bronchioles join the respiratory bronchiole.
➢ Pleura
● There are two pleurae in the body: one associated with each lung. They consist of a serous membrane – a layer of simple squamous cells supported
by connective tissue. This simple squamous epithelial layer is also known as the mesothelium.
● Divided into 2 lobes:
➔ Visceral - covers the lungs
★ It extends into the interlobar fissures.
★ It is continuous with the parietal pleura at the hilum of each lung (this is where structures enter and leave the lung).
➔ Parietal - covers the internal surface of the thoracic cavity
● Divisions of the parietal pleura
➔ Mediastinal pleura - Covers the lateral aspect of the mediastinum (the central component of the thoracic cavity, containing a
number of organs).
➔ Cervical pleura - Lines the extension of the pleural cavity into the neck.
➔ Costal pleura - Covers the inner aspect of the ribs, costal cartilages, and intercostal muscles.
➔ Diaphragmatic pleura - Covers the thoracic (superior) surface of the diaphragm.
● Pleural cavity
➔ It is a potential space between the parietal and visceral pleura. It contains a small volume of serous fluid, which has two major functions:
★ Lubrication
★ Surface tension
● Pleural recesses
➔ Spaces in the pleural cavity where the lungs don’t completely refill
➔ 2 pleural recesses:
★ Costodiaphragmatic recess - located between the costal pleurae and the diaphragmatic pleura.
★ Costomediastinal recess - located between the costal pleurae and the mediastinal pleurae, behind the sternum.
➢ Lung parenchyma and lobes
● It is responsible for gas exchange and includes the alveoli, alveolar ducts, and bronchioles.
● The lungs divide into five major lobes: three lobes on the right and two lobes on the left. Each lobe is made up of many small alveoli, which are the
primary site of gas exchange.
 ●
● Each lobe is made up of many small alveoli, which are the primary site of gas exchange. At the alveoli, diffusion of gasses into the arterioles occurs.
➢ Respiratory function
● To extract oxygen from the environment and provide it for aerobic respiration at the cellular level.
● Respiratory tract organs facilitate the process of gas exchange, including the nose, oral cavity, throat, trachea, bronchi, and lungs
➢ Pulmonary function tests
● Spirometry
● Plethysmography
● What is being measured by the PFTs:
➔ Tidal volume - amount of air inhaled or exhaled during normal breathing
➔ Minute volume - total amount of air exhaled per minute
➔ Vital capacity - total air volume exhaled after inhaling as much as you can
➔ Functional residual capacity - air volume left after normal exhalation
➔ Residual volume - total air volume after full exhalation
➔ Total lung capacity - total lung volume when filled with air after inhalation
➔ Forced vital capacity - air volume forcefully exhaled and quickly inhaled as much as you can after.
➔ Forced expiratory volume - air volume exhaled during the 1st 3 seconds of FVC test
➔ Forced expiratory flow - average flow rate during the middle half of FVC test
➔ Peak expiratory flow rate - fastest rate of forced air expiration
Goblet cells Their expanded apical region is occupied by closely packed mucigen granules
Ciliated cells They have microvillous border through which the cilia project into lumen
Brush cells Less abundant than goblet and ciliated cells and have small aggregation of glycogen
Serous cells Has electron-dense apical granules that produce secretion of lower viscosity than that of mucous cells
Basal cells fewer organelles. They are interpreted as a reserve of stem cells capable of differentiating to replace damaged or exfoliated ciliated
and goblet cells
Bronchial Kulchitsky cells Have neuro-endocrine function
Lamina propria - loose, connective tissue between the epithelium and the cartilages in the wall of the trachea and the bronchi. It contains numerous bronchial
submucosal glands whose ducts open onto the surface of the epithelium
Blood Supply: derived mainly from the inferior thyroid arteries
Nerve supply: recurrent branch of the vagus and the sympathetic trunks or chain
Lymphatic drainage: drain into the pretracheal and paratracheal lymph nodes

Right Main Bronchus wider, shorter and more

vertical, one inch long
Gives off the superior lobar
bronchus just before it enters
the hilum of the right lung
On entering the hilum, it divides into a middle and an
inferior lobar bronchus

Left Main Bronchus

narrower, longer and more
horizontal
Divides into a superior and an
inferior lobar bronchus on
entering the hilum of the left
lung

The 2 lobar bronchi on the left and the 3 lobar bronchi on the right, in turn, divide into segmental bronchi.
Histological Features
The bronchi epithelium is not significantly different from that of the trachea, consisting of ciliated columnar epithelium with many goblet cells and submucosal
glands. The glands diminish in number and end at the level of the bronchioles.the potential space between the two pleura and incorporates an intervening
pellicle of fluid that allows close sliding contact between the two layers during all phases of respiration
Pleura
A serous membrane arranged as a closed invaginated sac.
Parietal Pleura Visceral Pleura
Costovertebral pleura
- lines the internal surface of the thoracic wall and the vertebral bodies
Diaphragmatic pleura
- lies on the thoracic muscular surface of the diaphragm
Cervical pleura
- (pleural dome) covers the pulmonary apices
Mediastinal pleura
- Represents the lateral boundary of the mediastinum and forms a continuous coat above the hilum of the lung from the sternum to the vertebral column
- inseparably adherent to the lung over all its surfaces, including those in the fissure, except at the root or hium of the lung and along a line
descending from this, which marks the attachment of the pul
Lung parenchyma & lobes
Each lung is conical, covered with visceral pleura and suspended free in its own pleural cavity, being attached to the mediastinum only
by its roots. The right lung weighs about 625 grams while the left lung weighs about 565 grams.
Each lung has a blunt apex, which projects upward into the neck for about one inch above the clavicle; a concave base that sits on the
diaphragm; a convex costal surface, which corresponds to the concave chest wall; a concave mediastinal surface, which is modeled to the pericardium and
other mediastinal structures.
Right Lung Left Lung
Divided into 3 lobes namely; the upper, middle and lower lobes by the oblique and horizontal fissures
Left LUNG: Divided into 2 lobes; the upper and the lower lobes by the oblique fissure.
● The root of the lung is formed by the structures that enter or leave the lung. It is made up of the bronchi, pulmonary artery and veins, lymph vessels, bronchial
vessels and nerves.
● Each lobar bronchus, which passes to a lobe of the lung, gives off segmental bronchi.
● Each segmental bronchi passes to a structurally and functionally independent unit of a lung lobe called a bronchopulmonary segment.
● On entering a bronchopulmonary segment, each segmental bronchus divides repeatedly.
● The smallest bronchi divides and gives rise to bronchioles.
Bronchopulmonary segments
The bronchopulmonary segments are the anatomic, function and surgical units of the lungs. Each bronchopulmonary segment is structurally and functionally
independent unit of a lung lobe.
Histological Features of the Bronchioles
The bronchioles are less than 1 mm in diameter. They have no cartilage in their walls and are lined with columnar ciliated epithelium.
The submucosa possesses a complete layer of circularly arranged smooth muscle fibers.
Clara Cells and Its Significance
Clara cells are columnar with dome shaped apices that have short, blunt microvilli found in the epithelial lining of bronchioles.
These cells are believed to protect the bronchiolar epithelium by lining it with the secretory product, also these cells degrade toxins in
the inhaled air via cytochrome p-450 enzyme in their smooth endoplasmic reticulum. Some investigations also suggest that clara
cells produced a surfactant-like material that reduces the surface tension of bronchioles and facilitates the maintenance of their
potency. Moreover, clara cells divide to regenerate the bronchiolar epithelium
Histo-physiologic significance of the smooth muscle fiber layer found in the wall of the bronchioles
The muscle is innervated by parasympathetic nerve fibers, and its contraction produces constriction of the lumen of the bronchioles. It
relaxes during inspiration and contracts at the end of expiration.
When contraction is abnormally persistent, as it is during an asthmatic attack, constriction of the bronchioles makes it difficult to empty the lungs during
exhalation.
● Respiratory bronchioles
These bronchioles show delicate outpouching from their walls. Gaseous exchange between blood and the air takes place in the walls of these outpouchings,
hence, the name respiratory bronchioles.
● Alveolar ducts
Alveolar ducts are the terminal branches of the respiratory bronchioles. Each duct leads into tubular passages with numerous thin-walled outpouchings called
alveolar sacs.
● Alveolar sacs
The alveolar sac consists of several alveoli opening into a single chamber.
● Alveoli
Alveoli are the very thin-walled saccular compartments at the termination of the arborescent branching of the bronchioles and the
respiratory bronchioles. Estimates of the number of alveoli in the 2 lungs range from 200 - 500 million. Each alveolus is surrounded by a
rich network of blood capillaries. Gaseous exchange takes place between the air in the alveolar lumen through the alveolar wall into
the blood within the surrounding capillaries. The alveolus is the primary structure and functional unit of the respiratory system.
Respiratory function
Primary role
Main functions of respiration are to provide oxygen to the tissues and remove carbon dioxide. The 4 major components of respiration are
(1) pulmonary ventilation, the inflow and outflow of air between the atmosphere and the lung alveoli;
(2) diffusion of oxygen and carbon dioxide between the alveoli and the blood;
(3) transport of oxygen and carbon dioxide in the blood and body fluids to and from the body’s tissue cells;
(4) regulation of ventilation and other facets of respiration.
Secondary role
● Aid in acid-base balance
● Defend body against inhaled particles
● Acting as filter to prevent clots from entering the systemic circulation
● Regulating various hormonal & humoral concentration by means of the pulmonary capillary endothelium.

MECHANISM OF COUGH

● Both chemical (e.g., capsaicin) and mechanical (e.g., mucus, particulates in air pollution) stimuli can initiate the cough reflex.
● Cationic channels (e.g., transient receptor potential channels) and adenosine triphosphate–activated ion channels (P2X3) function as sensory
neuronal receptors, with signals transmitted centrally via Aδ (mechanosensory) and C fibers (chemosensory).
● Afferent nerve endings richly innervate the pharynx, larynx, and airways to the level of the terminal bronchioles and extend into the lung
parenchyma. They are also located in the external auditory canal (the auricular branch of the vagus nerve, or Arnold’s nerve) and in the esophagus.
● Sensory signals travel via the vagus and superior laryngeal nerves to a region of the brainstem in the nucleus tractus solitarius.
● Integrated neural networks process this input into a conscious sensation referred to as the “urge to cough.”
● The efferent limb of the cough reflex involves a highly orchestrated series of involuntary muscular actions, with the potential for input from cortical
pathways as well, making possible voluntary cough.
● The vocal cords adduct, leading to transient upper-airway occlusion.
● Expiratory muscles contract, generating positive intrathoracic pressures as high as 300 mmHg.
● With sudden release of the laryngeal contraction, rapid expiratory flows are generated, exceeding the normal “envelope” of maximal expiratory flow.
● Bronchial smooth-muscle contraction together with dynamic compression of airways narrows airway lumens and maximizes the velocity of
exhalation.
● The kinetic energy available to dislodge mucus from the inside of airway walls is directly proportional to the square of the velocity of expiratory
airflow.
● A deep breath preceding a cough optimizes the function of the expiratory muscles; a series of repetitive coughs at successively lower lung volumes
sweeps the point of maximal expiratory velocity progressively further into the lung periphery.
● Addendum by doc: Take note of smokers cough due to cilia and epithelium paralyzed already
 PNEUMONIA

DEFINITION & ETIOLOGY CLINICAL MORPHOLOGY & DIFFERENTIAL MANAGEMENT COMPLICATIONS

CLASSIFICATION MANIFESTATIONS DIAGNOSTIC DIAGNOSIS & PROGNOSIS
TESTS

Definition: ● Atypical ● Patient is Morphologic ● The differential Preventive: Complications:

● an infection of the ○ S. pneumoniae frequently febrile Changes: diagnosis includes ● Main preventive ● Respiratory
pulmonary (usually appears or tachycardic Pathology: infectious and measure is failure
parenchyma as diplococci) and may 1. edema with noninfectious vaccination. ● Severely ill
○ H. influenzae experience chills a entities, including: Influenza and patients:
Classification: ○ S.Aureus or sweats proteinaceo ○ acute bronchitis pneumococcal ○ Shock
● CAP: acquired ○ G(-) Bacilli: us exudate ○ exacerbations vaccine are to be ○ Multiorgan
outside the Klebsiella ● Cough may be and often of chronic recommended. failure
hospital before the pneumoniae, P, nonproductive or bacteria in bronchitis ● The influenza ● Exacerbation
admission aeruginosa productive of the alveoli. ○ heart failure vaccine is of comorbid
Lower RTI mucoid, purulent, ○ pulmonary available in an illness
acquired in the ● Typical or blood-tinged 2. Red embolism inactivated or ● Lung abscess
community within ○ Mycoplasma. sputum hepatizatio recombinant form. may occur in
24 pneumoniae n phase. ● During an association with
hours to less than (lacks rigid cell ● If there’s gross influenza aspiration
2 weeks. It wall allowing it hemoptysis, it is outbreak, pneumonia or
-Erythrocytes in the
commonly to alter its size suggestive of unprotected with infection
intra alveolar
presents with: and shape to necrotizing patients at risk caused by CA-
exudate
● acute cough suit its pneumonia (due to from complications MRSA, and
● tachypnea surrounding CA-MRSA should be P.aeruginosa
(RR>20 conditions; 3. gray vaccinated Metastatic infection
breaths/min), “fried-egg” ● Depending on hepatizatio immediately and (brain abscess or
● tachycardia colonies) severity, patient n given endocarditis)
(CR>100/min), ○ Chlamydia. may be able to chemoprophylaxi very unusual and will
● fever pneumoniae speak in full - no new s with either require a high
(T>37.8oC) with at ○ Legionella sentences or be erythrocytes are oseltamivir or degree of
least one species short of breath extravasating, and zanamivir for suspicion and a
abnormal (exposure to air- those already 2 weeks—i.e., detailed workup for
chest finding of: conditioners, ● Pleuritic chest present have been until vaccine- proper
○ diminished building water pain may be lysed and degraded. induced antibody treatment
breath sounds, systems) experienced if - neutrophil is the levels are Lung abscess may
○ rhonchi, ○ Respiratory there’s pleural predominant cell sufficiently high. occur in association
○ crackles or viruses: involvement - fibrin deposition is with aspiration or
wheeze. influenza virus, abundant with infection caused
adenovirus, Physical Exam: - bacteria have by a single CAP
● HAP/nosocomial: metapneumoviru ● Degree of disappeared. pathogen, such as
- successful
 occurs 48 hrs or s, respiratory pulmonary containment of the CA-MRSA, P.
more after syncytial virus, consolidation infection aeruginosa,
admission & is not coronaviruses ● Presence or - improvement in or (rarely) S.
present during absence of gas exchange. pneumoniae.
time of admission In previously healthy significant Aspiration
Infection acquired adult pleural effusion 4. Resolution pneumonia is
in the hospital patients with CAP to ● Increased - macrophage typically a
setting in be Respiratory rate reappears polymicrobial
non-intubated managed as ● Use of accessory as the infection involving
patients. outpatients muscles dominant both aerobes
HAP = higher Streptococcus ● Palpation: reveal cell in the and anaerobes.
frequency of NON- pneumoniae and increased or alveolar Complicated pleural
MDR Haemophilus decreased tactile space effusion
pathogens influenzae are the fremitus - debris of If significant, should
● Due to macro predominant ● Percussion: dull neutrophils, be tapped for
aspiration etiologic agents to flat (reflecting and bacteria diagnostic
● Anaerobes in In patients admitted underlying and fibrin and therapeutic
nasopharyngeal to the ○ consolidated have been purposes.
area gaining hospital lung - dull cleared> as Drain completely if:
access to In addition to S. ○ and pleural fluid has the ● Fluid has a pH of
respiratory tract pneumonia, and H. - flat) inflammator <7
influenza, Gram ● Crackles, y response. ● Glucose level of
● VAP: occur more negative enteric bronchial breath <2.2 mmol/L
than 48 hours bacilli are sounds, and - In VAP, ● Lactate
after patient has important etiologic possibly pleural respiratory dehydrogenase
been intubated & considerations. friction rub may bronchiolitis may concentration of
received ● Enteric Gram be heard precede the >1000 U/L
mechanical negatives ● Severely ill development of a ● Bacteria are seen
ventilator ○ P. aeruginosa patients may have radiologically or cultured
○ S. aureus septic shock and apparent infiltrate. A chest tube is often
Infection acquired in ○ L. pneumophila evidence of required, and
the hospital setting For patients w/ risk organ failure video-assisted
bronchopneumoni
among for thoracoscopy may
a pattern - most
patients with a aspiration be needed
common in
mechanical Consider anaerobes for late treatment or
nosocomial
ventilator. P. aeruginosa difficult cases.
pneumonias
VAP = higher infection ●
frequency of MDR Prolonged use of Prognosis:
pathogens broad-spectrum lobar pattern - ● Depends on the
● Due to micro antibiotic therapy more common in patient’s age,
aspiration (> 7 days within the bacterial CAP. comorbidities,
(secretions through past month) and site of
the sides of the ● With severe treatment
tube) underlying (inpatient or
The greatest bronchopulmonary outpatient)
difference between disease (COPD, ● Young patients
VAP and bronchiectasis), without
HCAP/HAP is the ● Malnutrition Diagnostic Tests: Pharmacologic: comorbidity do
return to ● Chronic use of well and usually
dependence on steroid therapy Clinical Diagnosis LOW-RISK CAP recover fully after
expectorated (<7.5 mg/day) • compatible ● empiric tx w/o 2 weeks
sputum for a Staph infection history comorbidities: ● Older patients
microbiological suspected amoxicillin 1 g and with comorbid
diagnosis of VAP, ● with lung 3x/day/clarithromy conditions take
which is further abscesses, o cough, sputum several weeks
cin 500mg
complicated by ● pneumatoceles, production, fever longer to fully
2x/day/azithromyci
frequent colonization ● pyothorax and dyspnea recover
n 500mg once a
by pathogens in day ● Overall mortality
patients • new infiltrate on for outpatient
with HAP or HCAP. chest radiography group is <5%
Both MDR and non- ● w/ comorbidity: ● Inpatient, overall
MDR bacterial Etiologic Diagnosis Beta-lactam- Co- mortality ranges
pathogens, • Gram’s stain and amoxiclav from 12-40%,
some fungal and culture of sputum (amoxicillin/clavula depending on the
viral pathogens, may - ensure suitability of nate 500 mg/125 category of the
cause a specimen for mg three times patient and
VAP. culture daily, OR process of care
= sputum ● amoxicillin/ like the timely
● HCAP: introduced sample must clavulanate 875 administration of
to encompass have >25 mg/125 mg twice appropriate
cases caused by neutrophils daily) antibiotics
MDR associated and <10 OR Prognosis
with HAP squamous ● Cefuroxime ● Fever and
epithelial 500mg, twice daily leukocytosis usually
Represents a cells per ● PLUS OR MINUS resolve within 2–4
transition between low-power (+/-) days in
classic CAP field ● Macrolide- otherwise healthy
and typical HAP. - can identify S. Clarithromycin patients with CAP,
Several studies pneumoniae, S. 500mg, twice daily but physical findings
showed increased aureus, and gram- OR may persist longer.
incidence of negative bacteria ● Azithromycin ● Chest radiographic
MDR pathogens, 500mg once daily abnormalities are
particularly MRSA, - For patients OR slowest to resolve
in HCAP. admitted to the ICU ● Doxycycline (4–12 weeks).
Factors responsible and intubated 100mg, twice daily ● Young patients
for this include: =deep-suction w/o comorbidity
● Development and aspirate or MODERATE RISK: recover after ~2
widespread use of bronchoalveolar ● Non-pseudomonal weeks.
potent lavage sample has Beta-lactam ● The overall
oral antibiotics, a high yield on antibiotic mortality rate for the
● Earlier transfer of culture ● Ampicillin- outpatient group is
patient out of acute- sulbactam 1.5–3 g <5%.
care - greatest benefit of every 6 h ● For patients
hospitals to their staining and OR requiring
homes or various culturing respiratory ● Cefotaxime 1–2 g hospitalization, the
lower secretions is to alert every 8 h overall mortality
acuity facilities, the physician to OR rate ranges from 2 to
● Increased use of unexpected and/or ● Ceftriaxone 1–2 g 40%
outpatient IV resistant daily Failure to Improve
antibiotic pathogens and to PLUS Day 3 - assess the
therapy, permit appropriate ● MACROLIDE- patient for response
● General aging of modification of AZITHROMYCIN to therapy. If slow
the population therapy 500MG response
● More extensive - recommended only DAILY/CLARITHR to therapy, possible
immunomodulatory for hospitalized CAP OMYCIN 500 MG reasons include:
therapies. patients esp. with 2X A DAY 1) Wrong or other dx
severe cases or 2) Drug resistance
those with risks of 3) Sequestered
MRSA or P. focus (ex. Lung
aeruginosa abscess that needs
infection HIGH RISK: draining)
● FIRST LINE 4) Wrong drug/
• Blood cultures THERAPY dose/ administration
Non-pseudomonal 5) Unsuspected
Beta-lactam pathogen
o Low yield and
antibiotic 6) Nosocomial
lack of significant
- Ampicillin- superinfection
impact on
sulbactam
outcome, not
1.5–3 g IV
considered de
every 6 h
rigueur for all
OR
hospitalized CAP
- Cefotaxime
patients
1–2 g IV
every 8 h
o high-risk patients OR
should have blood - Ceftriaxone
cultured 1–2 g IV
▪ daily
neutropenia PLUS
secondary - Macrolide
to Azithromycin 500
pneumonia mg PO/IV daily
 ▪ asplenia OR
▪ Erythromycin 500
complement mg PO every 6
deficiencies hours
▪ chronic OR
liver disease Clarithromycin 500
▪ severe mg PO twice daily
CAP ALTERNATIVE
▪ at risk of THERAPY
MRSA or P. Non-pseudomonal
aeruginosa Beta-lactam
infection antibiotic
PLUS
Urine Antigen test Respiratory
o Legionella fluoroquinolone*
pneumophila test Levofloxacin 750 mg
PO/IV daily
OR
- detects only
Moxifloxacin 400 mg
serogroup 1 (most
PO/IV daily
CA cases of
* given as 1 hour IV
Legionnaires’ dse in
infusion
US)
* to add table from
harrison for test
- severe cases and purposes* iask daw
in situations where sa test
relevant
epidemiologic Non Pharmacologic:
factors
are present ● Adjunctive
measures
o Pneumococcal ○ Adequate
urine antigen test hydration
○ Oxygen therapy
▪ reserved for severe for hypoxemia
cases ○ Vasopressor
treatment
Polymerase Chain ○ Assisted
Reaction ventilation when
o amplify a necessary
microorganism’s ○ Glucocorticoid
DNA or RNA s NOT
o PCR of RECOMMENDE
nasopharyngeal D FOR CAP
swabs except in
▪ standard patients with
for diagnosis refractory septic
of shock
respiratory
viral ● Failure to
infection improve
○ Reevaluated at
o detect the nucleic day 3 or sooner
acid of Legionella if the condition is
species, M. worsening
pneumoniae, C. ○ In all cases of
pneumoniae, and delayed
mycobacteria response or
worsening
• Serology condition, the
patient must be
o fourfold rise in carefully
specific IgM reassess
antibody titer
between acute- and
convalescent- phase
serum samples

o fallen out of favor

because of the time
required to obtain a
final result for the
convalescent-phase
sample and the
difficulty of
interpretation

• Biomarkers
o CRP and PCT

▪ Increased
in presence
of
inflammator
y response
esp.
bacterial
 pathogens

o should not be used

alone but, in
conjunction with
findings from the
history, physical
examination,
radiography, and
laboratory tests

APPROACH TO PATIENTS WITH RESPIRATORY SYMPTOMS DURING COVID-19 PANDEMIC

SIGNS & SYMPTOMS LAB TESTS

➢ Symptoms include cough, fever, myalgia, headache,
dyspnea, sore throat, and gastrointestinal symptoms of
nausea, vomiting, or diarrhea.
➢ Sudden onset of dysgeusia and anosmia (loss of taste and
smell) which typically resolves in weeks to months.
➢ immunofluorescence assays)
Lab Tests for influenza-like illnesses or pneumonia:
● CDC:
○ molecular assays (including rapid molecular assays, reverse
transcription polymerase chain reaction (RT-PCR)
○ other nucleic acid amplification tests
○ antigen detection tests (including rapid influenza diagnostic tests and
○ Viral culture
○ Chest xray

Gold standard for diagnosing COVID 19:

● Medscape: reverse-transcriptase polymerase chain reaction (RT-PCR)

NORMAL PRODUCTION AND REMOVAL OF FLUID IN THE PLEURAL SPACE

● Pleural fluid accumulates when pleural fluid formation exceeds pleural fluid absorption.
● Normally, fluid enters the pleural space from the capillaries in the parietal pleura and is removed via the lymphatics in the parietal pleura.
● Fluid also can enter the pleural length from the interstitial spaces of the lung via the visceral pleura or from the peritoneal cavity via small holes in the
diaphragm.
● The lymphatics have the capacity to absorb 20 times more fluid than is formed normally.
● Accordingly, a pleural effusion may develop when there is:
○ excess pleural fluid formation (from the interstitial spaces of the lung, the parietal pleura, or the peritoneal cavity) or
 ○ decreased fluid removal by the lymphatics

PLEURAL EFFUSION

DEFINITION & CLASSIFICATION & CLINICAL DIAGNOSTIC TESTS MANAGEMENT COMPLICATIONS &
MECHANISM EXAMPLES MANIFESTATIONS PROGNOSIS

Definition: Transudative Pleural Medscape: Pharmacologic: (MSD Complications:

● A pleural effusion is Effusion: This type of ● The clinical CBC will usually show MANUALS) ● Lung scarring
present when there is pleural effusion typically manifestations of mild anemia and ● Pleuritic pain can ● Pneumothorax as a
an excess quantity of occurs due to systemic pleural effusion are leukocytosis. usually be managed complication of
factors that alter the variable and often are with nonsteroidal anti- thoracentesis
fluid in the pleural
balance of fluid related to the inflammatory drugs ● Empyema
space. Free pleural fluid may
formation and underlying disease (NSAIDs) or other oral ● Sepsis (blood
be seen by a lateral
reabsorption in the process analgesics infection) sometimes
decubitus radiograph
pleural space. It often ● The most commonly leads to death
(affected side down),
results from conditions associated symptoms ultrasound, or CT scan
Mechanism: such as congestive are progressive Non Pharmacologic: Prognosis:
of the chest.
● Pleural fluid heart failure or liver dyspnea, cough, and ● The effusion itself ● depends on the cause
accumulates when cirrhosis. pleuritic chest pain generally does not of the pleural effusion
● Chest pain, usually a Radiographically, finding require treatment if it ● benign effusions can
pleural fluid formation absence of fluid shift
Example: Heart failure- sharp pain that is is asymptomatic be cured, but if the
exceeds pleural fluid with a change in
related pleural effusion, worse with cough or because many cause is a
absorption. position (i.e lateral effusions resorb malignancy, the
cirrhosis-related pleural deep breaths
○ Interstitial spaces effusion. decubitus) may indicate spontaneously when prognosis is very poor.
of the lung via the a loculated empyema. the underlying ● Another feature of
visceral pleura Exudative Pleural disorder is treated pleural effusions is
○ Peritoneal cavity Effusion: Exudative o Chest UTZ ● Therapeutic recurrence which can
via small holes in effusions occur due to • Determine whether thoracentesis also occur with
increased permeability effusion is transudative ○ usually around 1 to benign disorders like
the diaphragm
of pleural membranes, or exudative 1.5 L in a single lupus, uremia, and
○ Decreased fluid treatment and it is rheumatoid arthritis.
usually resulting from
removal by inflammation or sufficient for many ● If the pleural effusion
lymphatics infection. They are often o Transudative pleural symptomatic is not drained, it can
○ Parietal pleura associated with ● Asbestos - effusion effusions and can lead to dyspnea and
Excess fl uid conditions such as causes - systemic factors that be repeated for even empyema.
pneumonia, malignancy influence the formation effusions that ● Development of a
accumulates in pleural
tuberculosis, or ● Pulmonary and absorption of reaccumulate. malignant pleural
space embolism - pleural fluid are altered
pulmonary embolism. ○ There are no limits effusion is associated
▪ Lung expansion limited commonly - left ventricular failure on the amount of with a very poor
→ impaired Example: Pneumonia- caused by DVT; and cirrhosis fluid that can be prognosis, with
ventilation virchow’s triad; removed median survival of 4
Origin related pleural effusion, commonly due o Exudative pleural ○ Removal of fluid can months and mean
▪ Hydrothorax (serous fl tuberculosis-related to pulmonary effusion be continued until survival of less than
pleural effusion. embolism; early - local factors that the effusion is 1 year.
uid), hemothorax
ambulation is influence the formation drained or the ● The most common
(blood), urinothorax important; and absorption of patient develops associated
Hemothorax: This is a
(urine), chylothorax/ type of pleural effusion dangle legs if pleural fluid are altered chest tightness, malignancy in men is
lymphatic effusion characterized by the cannot walk - bacterial pneumonia, chest pain, or lung cancer.
(chyle), pyothorax (pus, accumulation of blood in malignancy, viral severe coughing. ● The most common
AKA empyema) the pleural cavity, infection, and SURGERY associated
Pathophysiology usually due to trauma or pulmonary embolism ▪ Therapeutic aspiration malignancy in women
injury to the chest wall ▪ Insertion of intercostal is breast cancer.
▪ Transudative pleural
or lungs. > It is imperative to do a drain ● Median survival
effusion diagnostic ▪ Repeated effusions ranges from 3-12
▫ Pressure driven fi Example: Trauma- thoracentesis. ▫ Surgical pleurodesis: months, depending on
ltration: ↑ hydrostatic related hemothorax, obliteration the malignancy.
pressure/↓ oncotic ruptured blood vessel in -Tests on pleural fluid of pleural space; ● Effusions from
pressure → force the chest. • description of the prevents fl uid cancers that are more
imbalance, fl uid appearance of the fluid, accumulation responsive to
Chylothorax: glucose level, differential TREATMENT OTHER chemotherapy, such
extravasation → fl uid
Chylothorax occurs cell count, microbiologic INTERVENTIONS as lymphoma or
leaks across intact studies, and cytology ▪ Supplemental oxygen breast cancer, are
when lymphatic fluid
capillary membranes (chyle) accumulates in ▪ Repeated effusions more likely to be
▫ Alteration in Starling the pleural cavity due to The pleural fluid (PF) is ▫ Chemical pleurodesis: associated with
forces leakage or obstruction of defined as an exudate if obliteration prolonged survival,
▪ Exudative pleural the thoracic duct. It can any one of the following of pleural space; compared with those
effusion result from trauma, criteria (Light’s criteria) prevents fl uid from lung cancer or
malignancy, or certain are met: accumulation (talc, mesothelioma.
▫ Local infl ammatory
medical procedures. 1. PF/serum protein bleomycin,
processes → leaky ratio > 0.5 tetracycline/doxycycline)
capillaries Example: Thoracic duct 2. PF/serum LDH ratio > ▪ Pleural catheter
CAUSES injury during surgery, 0.6 ▫ User-operated daily
▪ Transudative lymphoma-related 3. PF LDH > 2/3 of the draining
▫ Congestive heart chylothorax. upper normal limit of ▪ Treat underlying cause
serum LDH
failure, liver cirrhosis,
Empyema: Empyema is Chest X-ray
severe ▪ Fluid occupies space
a pleural effusion
hypoalbuminemia, between visceral,
characterized by the
nephrotic presence of pus in the parietal pleural
syndrome, acute pleural cavity, usually ▪ Area of whiteness on
atelectasis, myxedema, resulting from a bacterial standard
peritoneal dialysis, infection such as posteroanterior (PA)
pneumonia or lung chest X-ray
Meigs syndrome,
▪ Blunted costophrenic
obstructive uropathy,
end-stage renal abscess. angles
disease ▪ Greater density than
▪ Exudative Example: Bacterial rest of lung →
pneumonia complicated gravitates towards
▫ Infection, malignancy,
by empyema. dependent regions
trauma, ▫ ↑ fl uid on upright X-ray
pulmonary infarction, Malignant Pleural or lateral
pulmonary Effusion: This type of decubitus X-ray
embolism, autoimmune effusion occurs when Lung ultrasound
processes, cancer cells invade the ▪ Confi rms presence of
pancreatitis, ruptured pleural space, leading to effusion and detects
fluid accumulation. It is pleural fl uid septations
esophagus
commonly associated
with lung cancer, breast LAB RESULTS
cancer, or metastatic Thoracentesis
cancers. ▪ Needle inserted
through chest wall, 5th–
Example: Lung cancer- 8th intercostal space,
related malignant pleural midaxillary line →
effusion, breast cancer- pleural space →
related malignant pleural withdraw fl uid
effusion. ▪ Trial diuresis for three
days in heart failure
before thoracentesis
▪ Effusion analysis
▫ Amylase: pancreatitis,
esophageal
perforation, malignancy
▫ Blood: traumatic,
malignancy,
pulmonary embolism
with infarction,
tuberculosis
▫ Cholesterol: chylous
(lymphatic fl uid) vs.
chyliform effusion
(chyle-like fl uid from
chronic disease)
▫ Cytology: malignancy,
infection (reactive
effusion)
▫ Differential cell count:
lymphocytic
effusion in tuberculosis,
cancer,
lymphoma
▫ Glucose (low):
rheumatoid arthritis,
tuberculosis, empyema,
malignancy
▫ Microscopy, culture:
microorganisms
▫ ↓ pH: empyema,
tuberculosis,
mesothelioma
▫ Protein, LDH:
transudative/exudative
Rheumatoid factor,
antinuclear
antibody, complement:
collagen
vascular disease
▫ Triglycerides:
chylothorax from
thoracic duct leakage
(trauma, cancer,
lymphoma)
OTHER DIAGNOSTICS
▪ Medical history
Clinical examination
▪ ↑ fl uid on affected side
▫ ↓ chest expansion
▫ Stony dullness to
percussion
▫ Diminished breath
sounds
▫ ↓ vocal resonance,
fremitus
▫ Tracheal deviation
away from effusion
▪ If lung compressed
above effusion
▫ Bronchial breathing,
egophony
Light’s criteria
▪ Classifi cation of
transudative/exudative
effusion
▪ Transudative
▫ Difference between
albumin in blood,
pleural fl uid > 1.2g/dL
▪ Exudative
▫ Ratio of pleural fl uid
protein to serum
protein > 0.5
▫ Ratio of pleural fl uid
LDH to serum LDH
> 0.6
▫ Pleural fl uid LDH >
0.6, ⅔ times lab
specifi c upper limit for
serum
 PNEUMOTHORAX

DEFINITION & CLASSIFICATION CLINICAL DIAGNOSTIC TESTS MANAGEMENT COMPLICATIONS &

CAUSES MANIFESTATIONS PROGNOSIS

Definition: Primary Spontaneous 1.**Sudden, Sharp ● Patients present with Pharmacologic: Complications:
● Pneumothorax is the Pneumothorax Chest Pain**: One of acute dyspnea ● Simple aspiration
presence of gas in the ● usually due to rupture the hallmark ● Physical exam: ● Supplemental oxygen
pleural space. of apical pleural blebs, symptoms of ○ chest lag on the or aspiration
●A spontaneous small cystic spaces pneumothorax is affected side (traumatic
pneumothorax is one that lie within or sudden, sharp chest ○ hyperresonance on pneumothorax)
that occurs without immediately under the pain, often described percussion ● Sclerosing agents
antecedent trauma to visceral pleura as stabbing or tearing ○ decreased or such as doxycycline © AMBOSS
the thorax. ● occur almost in nature. The pain absent breath when inducing (none in TG/book)
●A primary exclusively in smokers may worsen with deep sounds on the pleurodesis
spontaneous = subclinical lung breathing (pleuritic affected side (secondary Pneumomediastinum is
pneumothorax occurs disease chest pain) or ● There could also be pneumothorax) defined as air present in
in the absence of ● 50% will have a movement. shifting of the ● Analgesics (for pain) the mediastinum and
underlying lung recurrence mediastinum on the less frequently referred
disease ● The initial 2.**Shortness of Breath contralateral side to as mediastinal
●a secondary recommended (Dyspnea)**: As air ● Chest x ray: emphysema.
pneumothorax occurs treatment for primary accumulates in the confirms the Pneumomediastinum
in its presence spontaneous pleural space, it can presence of develops when air
●A traumatic pneumothorax is compress the lung, pneumothorax which extravasates from within
pneumothorax results simple aspiration leading to a decrease will show lucency the airways, lungs, or
from penetrating or ● If the lung does not in lung volume and beyond a visible esophagus and migrates
nonpenetrating chest expand with aspiration impairing breathing. pleural line which into the mediastinal
injuries. or if the patient has a This can result in will outline the space.
●A tension recurrent varying degrees of adjacent atelectatic
pneumothorax is a pneumothorax, shortness of breath, lung
pneumothorax in thoracoscopy with ranging from mild to Chest X-ray/CT scan
which the pressure in stapling of blebs and severe, depending on ▪ Identifi es atypical
the pleural space is pleural abrasion is the size of the collections of gas,
positive throughout indicated pneumothorax. changes in lung
the respiratory cycle. ● Thoracoscopy or markings, presence of
Abnormal collection of thoracotomy with 3.**Tachypnea**: Rapid mediastinal shift and/or
air in pleural cavity pleural abrasion is breathing (tachypnea) tracheal deviation;
▪ Air enters through successful in is a common finding in lucent/dark lung fi eld,
damage to chest wall/ preventing pneumothorax due to deep sulcus sign (a
lung/gas-producing recurrences the body's deep costophrenic
microorganisms compensatory angle)
▫ Positive pressure in Secondary mechanism to Ultrasound
pleural space if air Pneumothorax maintain adequate ▪ Reverberation echoes
● enters → lung ● Mostly due to chronic oxygenation despite of the pleural line,
partial/complete obstructive pulmonary reduced lung function. absence of lung sliding
collapse disease at the pleural line
● Pneumothorax in 4.**Cyanosis**: In
Causes: patients with lung severe cases of Non Pharmacologic: Prognosis:
● primary spontaneous disease is more life- pneumothorax where ● Primary spontaneous (none in TG/book)
pneumothorax = due threatening than it is in there is significant pneumothorax
to rupture of apical normal individuals → lung collapse and ➔ Thoracoscopy with - traumatic
pleural blebs d/t lack of pulmonary impaired gas stapling of blebs pneumothorax is
● secondary reserve exchange, cyanosis and pleural excellent if there are no
pneumothorax = due ● Nearly all should be (bluish discoloration of abrasion other life-threatening
to COPD, but treated with tube the skin) may occur ● Secondary injuries;
pneumothoraxes have thoracostomy due to inadequate pneumothorax - spontaneous
been reported with ● Tx: thoracoscopy or oxygenation of the ➔ Tube thoracostomy pneumothorax, the
virtually every lung thoracotomy with the blood. ● Traumatic prognosis depends on
disease stapling of blebs and pneumothorax the underlying cause
● traumatic pleural abrasion 5.**Hypoxemia**: ➔ Tube thoracostomy and method of
pneumothorax results ● If the patient is not a Pneumothorax can ● Iatrogenic treatment.
= can result from both good operative lead to decreased pneumothorax - iatrogenic
penetrating and candidate → oxygen levels in the ➔ Tube thoracostomy pneumothorax - good
nonpenetrating chest pleurodesis by the blood (hypoxemia), prognosis
trauma intrapleural injection of especially in larger or
● tension pneumothorax a sclerosing agent tension Pleurodesis/ © NIH.gov
= occurs during such as doxycycline pneumothoraces, pleurectomy ▪
mechanical ventilation which can further Repeated
or resuscitative efforts Traumatic contribute to pneumothoraces
Pneumothorax symptoms such as Tension
● result from both confusion, pneumothorax: needle
penetrating and restlessness, or chest
nonpenetrating chest altered mental status. decompression
trauma ▪ AKA needle
● treated with tube 6.**Diminished or thoracostomy
thoracostomy unless Absent Breath ▪ Emergency procedure
very small Sounds**: Upon ▪ Not defi nitive,
● If a auscultation (listening improves
hemopneumothorax is with a stethoscope) of cardiopulmonary
present, one chest the chest, diminished Function
tube should be placed or absent breath ▪ Large bore intravenous
in the superior part of sounds may be noted catheter needle
the hemithorax to over the affected area inserted into pleural
evacuate the air and of the lung due to space
another should be decreased air ▫ Midclavicular line:
placed in the inferior movement. second/third
part of the hemithorax intercostal space
 to remove the blood 7.**Tension ▫ Anterior/mid axillary
● Iatrogenic Pneumothorax line: fi fth intercostal
pneumothorax is Features**: In cases space
becoming more of tension ▫ Listen for air escaping
common pneumothorax, which ▫ Remove needle, leave
○ The leading causes is a medical catheter in place
are transthoracic emergency, additional ▪ May cause injury,
needle aspiration, signs and symptoms reserve for
thoracentesis, and may include tracheal ▫ Mechanism of injury
the insertion of deviation away from suggestive of
central intravenous the affected side, pneumothorax
catheters. distended neck veins ▫ Clinical signs of
○ managed with (jugular venous respiratory distress,
supplemental distention), and persistently low oxygen
oxygen or hemodynamic saturation
aspiration, instability (e.g., despite supplemental
○ if unsuccessful → hypotension, oxygen
tube thoracostomy tachycardia). ▫ Hemodynamic
instability
Sharp chest pain (one- ▫ Prolonged transport
Tension sided) time
Pneumothorax ▪ Dyspnea OTHER
● usually occurs during ▪ Tachycardia INTERVENTIONS
mechanical ventilation ▪ Cyanosis ▪ Supplemental oxygen
or resuscitative efforts ▪ Hypercapnia → ▫ Improves rate of
● The positive pleural confusion, coma pneumothorax
pressure is life- ▪ Diminished/absence of reabsorption
threatening both breath sounds ▪ Small pneumothoraces
because ventilation is (affected side) may resolve
severely compromised ▪ Hyperresonance to spontaneously
and because the percussion ▪ If wound present,
positive pressure is ▪ ↓ vocal, tactile fremitus cover with dressing
transmitted to the ▪ Trachea displaced ▫ Dressing secured on
mediastinum, → result away from affected side three sides to
in decreased venous ▪ Tension pneumothorax create “vent dressing”
return to the heart & ▫ ↓ blood pressure ▪ Chest tube (connected
reduced cardiac ▫ ↓ oxygen saturation to water-seal
output ▫ Epigastric pain drainage system)
● Difficulty in ventilation ▫ Displaced apex beat ▫ Inserted into “safe
during resuscitation or ▫ Distended neck veins triangle,” damage to
high peak inspiratory internal organs avoided
pressures during ▫ Horizontal line, nipple
mechanical ventilation to lateral
suggest the diagnosis chest well; between
● Diagnosis is made by latissimus dorsi,
physical examination pectoralis major
showing an enlarged
hemithorax with no
breath sounds,
hyperresonance to
percussion, and shift
of the mediastinum
to the contralateral
side.
● must be treated as a
medical emergency
● A large-bore needle
should be inserted into
the pleural space
through the second
anterior intercostal
space → If large
amounts of gas
escape from the
needle after insertion
→ the diagnosis is
confirmed
● The needle should be
left in place until a
thoracostomy tube
can be inserted

Primary pneumothorax
▪ No clear cause/no
preexisting lung disease
▫ Secondary to ruptured
blebs (small sacs
of air on lung surface)
Secondary
pneumothorax
▪ Occurs with existing
lung disease
Tension
pneumothorax
▪ One-way valve formed
by damaged tissue
→ air enters, can’t
escape → intrathoracic
pressure builds up →
impaired cardiac,
respiratory function
Traumatic
pneumothorax
▪ Follows physical
trauma to chest (e.g.
blast
injury); result of medical
procedure (e.g.
iatrogenic
pneumothorax)
RISK FACTORS
▪ Smoking, chronic
obstructive pulmonary
disease (COPD),
asthma, tuberculosis
▪ More common in
individuals who are
biologically male
▪ Changes in
atmospheric pressure
▪ Family history of
pneumothoraces