Dynamic Central Airway Obstruction: Tracheomalacia, Tracheobronchomalacia, An...Bassel Ericsoussi, MD
Dynamic Central Airway Obstruction: Tracheomalacia, Tracheobronchomalacia, And Excessive Dynamic Airway Collapse: Classification, Diagnosis, and Treatment
Pulmonary function tests (PFT) are series of tests that measure lung function and aid in the management of patients with respiratory disease.
They are performed using standardized equipment and can be used for diagnosis, prognostication, management and follow-up of patients with pulmonary pathology.
Although PFT may not identify the exact pathology, it broadly classifies respiratory disorders as either obstructive or restrictive. In this session , the role of PFT in the measurement of lung mechanics and diagnosis of various diseases will be discussed in detail.
Various types of Pulmonary function tests, physiology , how to do spirometry, how to interpret, precautions while doing it, newer pfts : described in this ppt.
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
2. What Are PFTs?
• Series of maneuvers designed to
measure lung size and function
• Elements of the test:
– Spirometry – dynamic flows and volumes
– Static lung volumes
– Gas transfer
4. What does the test measure?
• Flow and volume during maximal inspiration
and forced expiration - spirometry
• Total lung volumes
• Surface area of gas exchange
• Respiratory muscle function
• Cardiopulmonary function during exercise
8. Pulmonary Function Testing:
Spirometry
• Simplest measurement:
– Measure how fast/how long you can blow
• Maneuver:
– Deep breath (to TLC)
– Forced exhalation (to RV)
– Measure volume and time
– Calculate flow
TLC
RV
10. A given patient
can never get out
of the envelope of
the flow-volume
loop
•WHY?
Dynamic airway
collapse
Pulmonary Function Testing:
Spirometry
TLC RV
25. Algorithm for Spirometry Interpretation
FEV1/FVC ratio < lower limits of normal (LLN)?
Obstruction
Yes
Bronchodilator response?
Obstruction
No response to BD
No
Obstruction
With significant response to BD
Yes
Adapted from www.clevelandclinicmeded.com/diseasemanagement/pulmonary/pft/pft.htm
Grade severity by the FEV1
26. What is the Lower Limit of Normal?
5%
1.645 SD
27. Algorithm for Spirometry Interpretation
FEV1/FVC ratio < lower limits of normal (LLN)?
Obstruction
Yes
Bronchodilator response?
Obstruction
No response to BD
No
Obstruction
With significant response to BD
Yes
Adapted from www.clevelandclinicmeded.com/diseasemanagement/pulmonary/pft/pft.htm
Grade severity by the FEV1
No
28. Algorithm for Spirometry Interpretation
FEV1/FVC ratio < lower limits of normal (LLN)?
Normal
No
Suggests Restriction
Ye
s
Adapted from www.clevelandclinicmeded.com/diseasemanagement/pulmonary/pft/pft.htm
Is FVC < LLN?
No
29. Algorithm for Spirometry Interpretation
FEV1/FVC ratio < lower limits of normal (LLN)?
Possible Mixed
Process
Yes
Obstruction
Yes
Bronchodilator response?
Obstruction
No response to BD
No
Obstruction
With significant response to BD
Yes
Is FVC < LLN?
Isolated Obstruction
No
30. Severity of impairment as determined
by spirometry:
Normal > LLN
Mild 70-80% predicted
Moderate 60-69%
Moderate-Severe 50-59%
Severe 34-49%
Very Severe < 34%
31. Case #1
• Obstructive or Restrictive
Process?
Obstructive
• What is the severity?
– moderate
• 45 y/o man complaining of
cough and dyspnea for
months. Smoked 10 pack-
yrs
32. Case #1 Spirometry
• Bronchodilator response:
– Spirometry repeated after inhaled beta-agonists
– “Significant” with a 12% and a 200ml
improvement in FEV-1 or FVC
BD response = obstructive defect but doesn’t equal
asthma
No response does not mean adequate Rx
33. Case #1 Spirometry with BD
challenge
Pre-BD
%
Pred
Post-
BD
%
Pred
%
Chang
e
FEV1 1.33 60% 1.89 80% 42%
FVC 2.61 95% 2.97 108% 14%
FEV1
/FVC
50% 64%
34. Case #2
• 64 y/o man referred for
shortness of breath on
exertion
Suggests restrictive process
- good start
- smooth contour
- effort/reproducibility
35. Spirometry interpretation
• Obstruction:
– Diagnosis: FEV1/FVC < LLN
– Severity: degree of reduction in FEV1
• Restriction:
– Defined as TLC <80%
– “can be inferred” if
• FEV1/FVC normal or increased and
• FVC < LLN
If FEV1/FVC is reduced,
can’t diagnose restriction
based on FVC
38. How to measure static lung
volumes
• Gas dilution techniques:
Introduce known
amount of a gas
TLC
VC
RV
39. Static lung volumes
• Gas dilution techniques:
Give it time to
diffuse throughout
the lung TLC
VC
RV
40. Static lung volumes
• Gas dilution techniques:
Measure concentration
of the gas in the
exhaled sample
TLC
VC
RV
41. Static lung volumes
• Gas dilution techniques:
– Easy to do
– Extra equipment cheap
– Only measures volume of
areas in free communication
with the mouth
TLC
VC
RVbulla
42. Static lung volumes
• Body plethysmography
Patient makes panting
movements against a
closed mouth shutter
43. Static lung volumes
• Body plethysmography
Measure pressure at
the mouth and in the box
Use Boyle’s law to
calculate the
intra-thoracic volume
44. Case #2
• 64 y/o man referred for
shortness of breath on
exertion
Restrictive process
49. Gas transfer
Introduce known
(and small) amount of
carbon monoxide
Most will get into
Blood and bind Hb
Measure amount of
exhaled CO
alveolus
CO
capillary
51. Gas transfer
• Reduced DLCO
– Fewer alveoli
•
•
– Fewer working alveoli
•
•
– Not enough blood
•
•
• Increased DLCO
52. Gas transfer
• Reduced DLCO
– Fewer alveoli
• Lobectomy
• Pleural effusion
– Fewer working alveoli
• Emphysema
• IPF
– Not enough blood
• Anemia
• Vasculitis
• Pulmonary Hypertension
• Increased DLCO
53. Gas transfer
• Reduced DLCO
– Fewer alveoli
• Lobectomy
• Pleural effusion
– Fewer working alveoli
• Emphysema
• IPF
– Not enough blood
• Anemia
• Vasculitis
• Pulmonary
Hypertension
• Increased DLCO
– Too much blood
– Faster transit of blood
54. Gas transfer
• Reduced DLCO
– Fewer alveoli
• Lobectomy
• Pleural effusion
– Fewer working alveoli
• Emphysema
• IPF
– Not enough blood
• Anemia
• Vasculitis
• Pulmonary
Hypertension
• Increased DLCO
– Too much blood
• Polycythemia
• Alveolar hemorrhage
– Faster transit of blood
• High cardiac output
• L -> R shunt
55. Case #3
• 62 y/o woman referred for
shortness of breath
Obstructive Defect
- very severe
????
- good start
- smooth contour
- effort/reproducibility
56. Case #3
• 62 y/o woman referred for
shortness of breath
Severe obstruction
Hyperexpansion and air-trapping
Moderately reduced DLCO
- good start
- smooth contour
- effort/reproducibility
57. Case #4
• 53 y/o woman with chest
tightness
• FVC 5.08 103%pred
FEV-1 2.66 74%pred
FEV-1/FVC 52% 72%
Uninterpretable study
0 1 2 3 4 5 6 7
time
58. Case #5:
• 32 y/o LVN with poorly-controlled
asthma on chronic steroids.
• Admitted to Zale-Lipshy University
Hospital with a diagnosis of status
asthmaticus.
• Physical exam: Retractions, audible
wheezing, and respiratory distress.
62. Vocal Cord Dysfunction:
• Mimicker of asthma
• Predominantly seen in women
• Conversion disorder
– History of physical or sexual abuse
– Pre-existing psychiatric illness
• Diagnosis:
– Flow-volume loops
– Direct laryngoscopy
• Treatment:
– Heli-Ox
– Speech therapy and psychotherapy
– ?Self-hypnosis and bio-feedback self-regulation
training
63. Vocal Cord Paralysis
• Most common cause of
extra-thoracic airflow
obstruction
• Due to trauma or a
laryngeal or intrathoracic
tumor
• Speech might be
preserved
• Acute treatment with Heli-
Ox or emergency
tracheostomy
64. Diseases of the larynx and trachea:
The Flow-Volume loop
St. John RC. Journal of General Internal Medicine 1993; 8:564-572
and Cherniack RM. Pulmonary Function Testing 1992, 209-230.
65. Case #6
• 38 y/o man with a
“wheeze”
FVC 3.66 103%pred
FEV-1 2.30 83%pred
FEV-1/FVC 63% 78%
Fixed large airway obstruction
