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OBJECTIVES

1. Describe common diagnostic tests that are used to detect pulmonary disease and adequacy of pulmonary function. (Chap. 36)

2. Name and briefly describe seven cardinal signs and symptoms of respiratory disease. (Chap. 37)

3. Differentiate between restrictive and obstructive patterns of respiratory disease. (pp. 559, 578)

4. Name and briefly describe 3 obstructive conditions (asthma, chronic bronchitis and pulmonary emphysema). (pp. 578-584)

5. Name and briefly describe 4 restrictive conditions (pneumonia, pneumothorax, pleural effusion and kyphoscoliosis). Chap. 39

6. Know all underlined terms and * questions in this handout.

Normal Human Lung - (H 7745) Click here 

Notice the open network of air passages and alveoli and the thin walls of the alveoli.

* What is the advantage of the thin alveolar walls? (pp. 542, 547-548) 

Pulmonary emphysema - (PH 1250) Click here 

Note that the alveoli (air spaces) in this slide are much larger than in the slide of normal lung. The functional efficiency of this lung is much reduced as compared to normal.

* What happens to the alveoli in emphysema? (p. 580, Fig. 38-3)

* Why does this reduce the efficiency of the lung? (pp. 542-543, 547-549)

Chronic pneumonia - (PH 1222) Click here 

Compare the alveoli (air spaces) of this lung with the normal. Notice that they are filled with cells and fluid.

* Why are these cells and fluid present? (pp. 594-596)

* How does this impair respiratory function? (Fig. 39-6, p. 595) 

Bronchogenic Carcinoma - (PH 1240) Click here 

Note that the cancerous neoplasm is invading throughout the lung and replacing normal lung tissue. Note that in many areas the alveolar walls are thickened and many air spaces are filled with cancer cells.

* How does this affect respiratory function? 

Granuloma - Ghon Tubercle (PH 1225) (Fig. 4-13, pp. 55-56) Click here 

Notice that an area of lung tissue has been displaced by a dense spherical mass of necrosis surrounded by a capsule of fibrous connective tissue.

* What type of necrosis is present in this lesion? (Fig. 4-13, pp. 55-56, p. 629)

Compare the dense arrangement of material in the granuloma with the open, air-filled normal lung tissue surrounding it by moving the slide from one area to another.

* What effect does this lesion have on gas exchange in this area? (pp. 56, 629-630)

* With what disease are Ghon tubercles associated? (pp. 56, 629)

Normal Sheep Lung Specimens

Note that the lung tissue is made up mostly of microscopic air spaces. The lung tissue has the consistency of Styrofoam. The large open tubes are normal airways (bronchi and bronchioles) and blood vessels. Refer back to these specimens while observing the abnormal specimens described below.

Panacinar (Panlobular) Emphysema (Fig. 38-3 & 38-4, pp. 580-581)

Notice that the lower normal part of the lung specimen appears to be dense because of the microscopic size of the air spaces. Notice that the upper part of the specimen contains many large open spaces because it is affected by emphysema. It is similar in appearance to a sponge. Compare the normal and diseased areas. Also note the large bullae and blebs in the upper lobe of this lung. Occasionally the blebs may rupture and cause pneumothorax. The black carbon deposits in this lung may be due to smoking or city air pollution and are consistent with the appearance of the average lung.

* How can pneumothorax cause problems? (pp. 591-592)

Neoplasia - Dried lung specimens (pp. 111-114, 623-627)

Compare the 3 specimens of dried lung. The specimen at left is like the specimen of panacinar emphysema described above. Notice that the lower normal part of the specimen appears to be dense because of the microscopic size of the air spaces and that the upper section contains many large open spaces because it is affected by emphysema. Note the many alveoli (air spaces) separated by the thin alveolar walls.

The center specimen contains a single nodule of primary lung cancer. (Although this nodule does not show any gross signs of invasion, it is probably malignant because 90% of primary lung tumors are malignant). Note the differences in color, texture and density between the tumor and the normal tissue. Note also how the neoplasm is pushing aside the surrounding normal tissue.

* What effect would this tumor have on lung function? (Fig. 8-7, p. 114)

The specimen on the right contains multiple nodules of metastatic cancer; the normal lung tissue is almost completely replaced by cancerous tissue. These secondary nodules are composed of cancer cells which metastasized to the lung from some other site such as the breast, kidney or gastrointestinal tract. Though tuberculosis is an entirely different disease, a lung with severe TB would have the same appearance from multiple granulomas (ghon tubercles).

* How do the cancer cells arrive in the lungs? (p. 625)

* How would these cancerous lesions affect lung functioning? Compare these effects with those caused by granulomas from TB.

Lung with Abscess (pp. 53-54, Fig 4-10)

Observe the large hole in the lung. Note that the area is surrounded by dense tissue.

* What material filled the abscess before the lung was removed from the body? (p. 53)

* What type of necrosis occurred? (p. 53)

* What is the dense tissue around the abscess?

Fungal Lesions in Lung of Leukemia Patient (pp. 595, 598)

In patients with advanced leukemia (this patient had acute lymphocytic leukemia), there are tremendous numbers of leukemic cells but very few normal lymphocytes. Because of this, these patients are often immunodeficient and are more susceptible to respiratory infections produced by fungi. This patient developed an infection caused by Aspergillus. Note the localized lesions of infection within the lung.

* What type of necrosis is present in these lesions? (Fig. 39-6, p. 595)

1. Normal chest - study this X-ray well before observing the abnormal ones. Note the relative size (volume) of the thoracic cavity, the size and location of the heart, and the black color of the area occupied by the lungs. (Remember that lung tissue is not very dense and therefore does not absorb as much radiation as denser tissues such as the heart and bones).

2. Emphysema - In this X-ray, note that the chest cavity is enlarged, and the diaphragm is flattened (barrel-chested). Note also that the lungs appear very dark as compared with normal, suggesting that the lung tissue is less dense than normal.

* What change seen in emphysema would be responsible for the decreased density of the lung tissue?

3. Spontaneous Pneumothorax - Air has entered the thorax of this patient and it is pushing the left lung away from the wall of the thoracic cavity. The marks on the X-ray point out the surface of the lung which is an inch or so away from the wall.

4. Pleural Effusion - In this lateral radiograph, the pleural effusion appears as a triangle of dense material in the lower portion of the pleural cavity, just above the diaphragm. This effusion is the result of surgery. Notice the metal clips used to close the surgical openings.

5. Hemothorax, as the result of a gunshot wound. In this radiograph, it is possible to see bullet fragments, broken ribs and hemothorax (the presence of blood in the pleural cavity). The functional effects of hemothorax would be similar to those of pneumothorax or pleural effusion.

6. Kyphoscoliosis - This is an anterior view . Notice how misshapen the thoracic cavity is in this patient with severe kyphoscoliosis.

* Radiographs 3,4,5 & 6 all illustrate examples of Restrictive pulmonary disease. Can you briefly describe how each of these produces restrictive lung problems?

7. Congestive Heart Disease with Pulmonary Edema - This person has congestive heart failure - notice the pacemaker. Note the enlarged heart and presence of fluid in the lungs (especially the lower portions).

* How does Congestive Heart Disease result in pulmonary edema? (pp. 496, 554-545, 605)

* What problems are caused by pulmonary edema? (p. 605)

8. Primary Cancer of the Lung - Note the area of dense neoplastic tissue to the left of the heart.

9. Metastatic Cancer in the Lung - Note the patches of dense neoplastic tissue scattered throughout the lung.

BRONCHOGRAM - See pp. 116-119 of radiograph book.

Because the tissues of the trachea and bronchi are soft, they do not show up well on regular radiographs. Note how difficult they are to see in the normal chest film. In a bronchogram, a fine mist of radiopaque particles is sprayed into the air passages (to make them more visible) and then an X-ray is taken. The tube used to spray the mist is still present in the trachea. This technique allows easy viewing of the trachea and bronchi but is stressful and may cause complications. Currently CT scans or MRIs are often used instead of bronchograms.

Chronic Bronchitis

Bronchitis is the medical term for inflammation of the bronchial tubes.

* What is one of the most common causes of chronic bronchitis? (pp. 579-580)

* Describe briefly the signs and symptoms associated with chronic bronchitis. (p. 580).

How would you describe the sputum produced in chronic bronchitis? (p. 578)

Emphysema

Pulmonary emphysema is an anatomic alteration of the lung parenchyma characterized by abnormal enlargement of the alveoli and alveolar ducts and destruction and fusion of alveolar walls. Note that the external surface of the lung has a mottled, red-black color.

Why is this? (see Wall Chart Guide)

Note the blebs or large bubble-like cysts that have been caused by a progressive rupturing of one overstretched air sac into another. Emphysema produces an obstructive pattern of ventilatory function because the patient is unable to effectively empty his/her lungs of air. (pp. 580-582, Figs. 38-3, 38-4)

Cancer in Bronchial Tube

In America, lung cancer is the leading cause of cancer deaths in men. Over 75,000 Americans now die of lung cancer each year. Lung cancer is classified into a number of types based on histologic type; four of these types are categorized as bronchogenic carcinoma and comprise 95% of all lung cancers. (Nox 42-1, p. 624) Smoking plays a leading role in the etiology of lung cancer.

*What is the name of the carcinogen found in cigarette (and cigar) smoke)? (p. 623)

* What are the signs and symptoms (name 6) associated with bronchogenic carcinoma? (p. 625)

* What diagnostic tests (name 5) confirm lung cancer? (pp. 625-626)

Pulmonary Infarction

Pulmonary infarction occurs when an embolus, usually a blood clot which breaks free from its attachment site in a vein of the lower limbs, circulates through the blood stream and the right side of the heart to become lodged in the main pulmonary artery or one of its branches. Pulmonary infarction is the term used to describe a local focus of necrosis resulting from vascular obstruction.

* Identify 3 basic factors believed to be related to the development of venous thrombosis and subsequent embolism. (p. 603)

* Several diseases and activities increase one's risk of developing a thrombus. Name at least three. (pp. 603-604)

Large infarctions or multiple infarctions of the lung are often fatal.

Abscess of the Lung

An abscess is a localized area of infection filled with bacteria and pus. Most lung abscesses are the result of pneumonia or obstruction from foreign bodies. Early symptoms are fever, coughing, sweating, chills and chest pain. The abscess must be surgically drained and antibiotic therapy must be aggressive.

Tuberculosis Infection in Lymph Nodes - See Wall Chart Guide for description.

Asthma (with mucous plugs in airways) (Fig. 38-2, p. 579)

Airway obstruction found in the medium-sized bronchi and bronchioles characterizes asthma. Bronchospasms, mucosal edema and hypersecretion of viscous mucus should be noted.

*Identify 4 types of treatment for asthma. (p. 579)

Pleurisy (with Pleural Effusion) (p. 691, Fig. 39-4)

Pleurisy refers to an inflammation of the pleura, the membrane lining and covering the lungs. Most instances of pleurisy represent an extension of infection from within the lungs, but it may also result from bacteria or viruses spread via the bloodstream. It may accompany pneumonia or injuries to the chest. A pleural effusion (the presence of excess fluid in the pleural cavity) often accompanies pleurisy. Pain on breathing is the primary symptom of pleurisy. Pain relievers and antibiotics are the therapies of choice.

Fractured Ribs (p. 590, Fig. 39-3)

Fractured ribs may damage or irritate the underlying lung. In the case of multiple rib fractures resulting from a crushing chest injury, a flail chest may result. A flail chest is an example of a restrictive pattern of respiratory disease.

* What is a flail chest? (p. 590)

* Describe the paradoxical breathing associated with a flail chest. (Fig. 39-3, p. 590)

Atelectasis of Emphysematous Lung

Atelectasis refers to a collapsed, airless segment of lung.

* Distinguish between absorption atelectasis and compression atelectasis. (pp. 592-594)

* Which is most common? (p. 594).

Pneumonia - Bronchopneumonia and Lobar Pneumonia

* Distinguish between broncho- and lobar pneumonia. (p. 595)

* Name the organism responsible for about 75% of the bacterial pneumonias. (p. 595)

First, view the Normal test results (Example A). Note (1) the Patient Information indicating occupation, exposure to dust, history of smoking, respiratory signs and symptoms, and health history. Then note (2) Predicted and Patient values for the test results. This normal person had values at or above the predicted values for a person of this age, sex, height and weight. Next, notice (3) the graph of expiratory and inspiratory flow rates. The portion of the graph above the line represents expiration and that below the line represents inspiration. The Ns on the graph indicate points through which the patient line on the graph should pass. Since this person's lines were outside of the N points, his respiration is better than expected. The most important line is the Expiratory flow rate line. This example is better than expected and shows the normal pattern of expiration. There is a relatively rapid rate of expiration at the beginning of forced expiration, followed by a gradually diminishing rate as the lungs empty. Next (4) note the summary graph. The black dot indicates that patient's overall result. It is above (better than) the normal cut-off for normal ventilation. Finally (5) note the diagnosis indicating no disease present.

Compare the other patient results with the normal example. The PtbBD values were for tests performed after administration of a bronchodilator. (VC = vital capacity, IC = inspiratory capacity, ERV = expiratory reserve capacity and FEV = forced expiratory capacity). (see pp. 559-565, and  especially Table 36-1, p. 560 for more information)

Which patients had normal or better than normal results?

What conditions caused the abnormal results in the other patients?

8Copyright 2001 - Augustine G. DiGiovanna - All rights reserved.