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Respiratory Medicine from Our Teachers and Their Teachers, to Our Students and Their Students LECTURE NOTES on Respiratory Medicine

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Respiratory Medicine from Our Teachers and Their Teachers, to Our Students and Their Students LECTURE NOTES on Respiratory Medicine Respiratory Medicine From our teachers and their teachers, to our students and their students LECTURE NOTES ON Respiratory Medicine S.J. BOURKE MD, FRCPI, FRCP,FCCP,DCH Consultant Physician Royal Victoria Infirmary Newcastle upon Tyne Senior Lecturer in Medicine University of Newcastle upon Tyne Sixth Edition © 1975, 1980, 1985, 1991, 1998, 2003 by Blackwell Publishing Ltd Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5018, USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton South,Victoria 3053,Australia The right of the Author to be identified as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. First published 1975 Second edition 1980 Third edition 1985 Fourth edition 1991 Fifth edition 1998 Sixth edition 2003 Reprinted 2003 Library of Congress Cataloging-in-Publication Data Bourke, S. J. Lecture notes on respiratory medicine / S. J. Bourke. — 6th ed. p. ; cm. Includes bibliographical references and index. ISBN 1-40510-675-1 (alk. paper) 1. Respiratory organs—Diseases—Outlines, syllabi, etc. [DNLM: 1. Respiratory Tract Diseases. WF 140 B8475L 2003] I. Title. RC731 .B69 2003 616.2—dc21 2002015535 ISBN 1-4051-0675-1 A catalogue record for this title is available from the British Library Set in 9/11.5 pt Gill Sans by SNP Best-set Typesetter Ltd., Hong Kong Printed and bound in the United Kingdom by TJ International Ltd,Padstow Commissioning Editor:Vicki Noyes Production Editor: Karen Moore Production Controller: Kate Charman For further information on Blackwell Publishing, visit our website: http://www.blackwellpublishing.com Contents Preface, vi 1 Anatomy and Physiology of the Lungs, 1 2 Symptoms and Signs of Respiratory Disease, 8 3 Pulmonary Function Tests,18 4 Radiology of the Chest, 30 5Upper Respiratory Tract Infections, 40 6 Pneumonia, 45 7Tuberculosis, 55 8 Respiratory Disease in AIDS and Immunocompromised Patients, 65 9Bronchiectasis and Lung Abscess, 73 10 Cystic Fibrosis, 81 11 Asthma, 91 12 Chronic Obstructive Pulmonary Disease, 111 13 Carcinoma of the Lung, 125 14 Interstitial Lung Disease, 136 15 Occupational Lung Disease, 146 16 Pulmonary Vascular Disease, 156 17 Pneumothorax and Pleural Effusion, 165 18 Acute Respiratory Distress Syndrome, 174 19 Sleep-Related Breathing Disorders, 180 20 Lung Transplantation,187 21 Smoking and Smoking Cessation, 191 Index, 197 v Preface It is now more than a quarter of a century since the first edition of Lecture Notes on Respiratory Medicine was written by my predecessor and colleague, Dr Alistair Brewis. It rapidly became a classic textbook which opened the eyes of a generation of students to the special fascinations of the subject such that many were attracted into the specialty.Thus, students became teachers, and continued to learn by teach- ing. Subsequent editions show how respiratory medicine has developed over the years to become such a major specialty in hospitals and in the community, treating a wide range of diseases from cystic fibrosis to lung cancer, asthma to tuberculosis, sleep disorders to occupational lung diseases. In the sixth edition the text has been revised and expanded to provide a concise up-to-date summary of respiratory medicine for undergraduate students and junior doctors preparing for postgraduate examinations. A particular feature of respira- tory medicine in recent years has been the focusing of skills from a variety of disci- plines in providing the best care for patients with respiratory diseases, and this book should be useful to colleagues such as physiotherapists, lung function technicians and respiratory nurse specialists. Some of Dr Alistair Brewis’ original drawings, such as the classic ‘blue bloater’ and ‘pink puffer’, have been retained.The emphasis of Lec- ture Notes on Respiratory Medicine has always been on information which is useful and relevant to everyday clinical medicine, and the sixth edition remains a patient-based book to be read before and after visits to the wards and clinics where clinical medi- cine is learnt and practised. As Lecture Notes on Respiratory Medicine develops over time, we remain grateful to our teachers, and their teachers, and we pass on our evolving knowledge of respiratory medicine to our students, and their students. S.J.Bourke vi CHAPTER 1 Anatomy and Physiology of the Lungs Introduction, 1 Gas exchange and Control of breathing, 5 Bronchial tree, 1 ventilation/perfusion (V/Q) Further reading, 7 Alveolar ventilation, 3 relationships, 4 Lung perfusion, 4 artery to the left atrium without passing Introduction through ventilated alveoli does not contribute to gas exchange, thereby forming a physiological The essential function of the lungs is the ex- shunt. change of oxygen and carbon dioxide be- tween the blood and the atmosphere.This takes place by a process of molecular diffusion across the alveolar capillary membrane which Bronchial tree has a surface area of about 60m2.The anatomy and physiology of the respiratory system are de- The trachea has cartilaginous horseshoe- signed in such a way as to bring air from the at- shaped ‘rings’ supporting its anterior and lateral mosphere and blood from the circulation into walls. The posterior wall is flaccid and bulges close contact across the alveolar capillary mem- forward during coughing. The trachea divides brane. Contraction of the diaphragm and inter- into the right and left main bronchi at the level of costal muscles results in expansion of the chest the sternal angle (angle of Louis).The left main and a fall in intrathoracic pressure which draws bronchus is longer than the right and leaves the atmospheric air containing 21% oxygen into the trachea at a more abrupt angle.The right main lungs. Ventilation of the alveoli depends upon bronchus is more directly in line with the tra- the size of each breath (tidal volume), respira- chea so that inhaled material tends to enter the tory rate, resistance of the airways to airflow, right lung more readily than the left. The main and compliance (distensibility) of the lungs. bronchi divide into lobar bronchi (upper, mid- About a quarter of the air breathed in remains in dle and lower on the right; upper and lower on the conducting airways and is not available for the left) and then segmental bronchi as gas exchange: this is referred to as the anatomi- shown in Fig. 1.1.The position of the lungs in re- cal deadspace. The lungs are perfused by al- lation to external landmarks is shown in Fig. 1.2. most all the cardiac output from the right Bronchi are airways with cartilage in their ventricle.There is a complex and dynamic inter- walls, and there are about 10 divisions of play between ventilation and perfusion in main- bronchi beyond the tracheal bifurcation. taining gas exchange in health, and derangement Smaller airways without cartilage in their walls of these parameters is a key pathophysiological are referred to as bronchioles. Respiratory feature of respiratory disease. Ventilation of bronchioles are peripheral bronchioles with alveoli which are not perfused increases dead- alveoli in their walls. Bronchioles immediately space, and blood passing from the pulmonary proximal to alveoli are known as terminal 1 2 Chapter 1: Anatomy of the Lungs BRONCHOPULMONARY SEGMENTS Right lung Left lung Apical Apical Posterior UL Posterior Anterior UL Anterior Superior LING Inferior Lateral ML Apical Medial Apical Lateral basal lower lower LL Lateral basal Posterior basal Fig. 1.1 Diagram of LL Medial basal Posterior basal Anterior basal bronchopulmonary segments. Anterior basal LING, lingula; LL, lower lobe; ML, middle lobe; UL, upper lobe. SURFACE ANATOMY OF THE LUNGS Clavicle 4th Thoracic spine RUL RUL Level of LUL angle of Louis RML RML RLL 6th Costal RLL LLL cartilage 8th Rib Lower edge of lung 10th Rib Lower limit Lower edge Lower limit of pleura of pleura of lung Mid-axillary line (a) (b) Fig. 1.2 Surface anatomy.(a) Anterior view of the bronchioles. In the bronchi, smooth muscle is lungs. (b) Lateral view of the right side of chest at arranged in a spiral fashion internal to the carti- resting end-expiratory position. LLL, left lower laginous plates.The muscle coat becomes more lobe; LUL, left upper lobe; RLL, right lower lobe; complete distally as the cartilaginous plates be- RML, right middle lobe; RUL, right upper lobe. come more fragmentary.The epithelial lining is ciliated and includes goblet cells. The cilia beat with a whip-like action, and waves of contrac- tion pass in an organised fashion from cell to cell Alveolar ventilation 3 STRUCTURE OF ALVEOLAR WALL Fig. 1.3 Structure of the Lamellar alveolar wall as revealed by inclusion electron microscopy.Ia, type I bodies Alveolus pneumocyte; Ib, flattened Ib extension of type I pneumocyte Ib covering most of the internal Ia surface of the alveolus; II, type II II pneumocyte with lamellar IS inclusion bodies which are IS probably the site of surfactant formation; IS, interstitial space; RBC RBC, red blood corpuscle. Pneumocytes and endothelial Capillary Nucleus of cells rest upon thin continuous Ib endothelium endothelial basement membranes which cell are not shown. so that material trapped in the sticky mucus respiratory muscles gradually relax their force layer above the cilia is moved upwards and out of contraction. About 8L of air are drawn into of the lung. This mucociliary escalator is an the lungs each minute at rest but not all this air important part of the lung’s defences. Larger reaches the alveoli.
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