Respiratory system – part 2

Respiratory System – Part 2
• Presented By –
Prof.Dr.R.R.Deshpande
Mobile – 922 68 10 630
04/14/16 Prof.Dr.R.R.Deshpande 1

Lung Function Tests / Pulmonary
Function Tests
• 1) Indications
• To differentiate between obstructive (Asthma & Bronchitis) &
restrictive (Pneumonia, Pleural effusion) Lung diseases
• To study the effect of harmful agents like dust & smoke on
lungs in industrial workers.
• For the fitness test in players or before employment
• In research to study the effect of bronchodilator drugs
(Deriphylline)

Spirometer

Graph of Spirometer

2) Limitations of Lung Function Tests
• These tests require co - operation of the
patient. In comatose & in children, tests
cannot be done.
• Because the lung has large functional reserve,
early detection of the disease is difficult.
• Single test is not useful, multiple tests are
required

2) Limitations of Lung Function Tests
• Findings of the clinical examination must be
co - related with the lung function test report.
• Patho - anatomical diagnosis of the disease
cannot be made (cause & location cannot be
detected).

Classification of LFT
• 1) Static Lung Function Tests
• 2) Dynamic Lung Function Tests

Static Tests
• 1) Tidal volume (TV) = Amount of air taken in
or out during quiet
• respiration. Normal value = 400 - 500 ml
• 2) Inspiratory Reserve volume (IRV) = Amount
of air taken in, by forceful inspiration, over &
above tidal volume.
• Normal value = 2400 - 2800 ml

Static Tests

Static Tests
• 4) Expiratory Reserve Volume (ERV) = Amount of air
given out by forceful expiration over & above Tidal
volume.
• Normal value = 800 - 900 ml
• 5) Residual Volume (RV) = Amount of air, that
remains in lungs at a end of forceful expiration.
Normal Value = 1000 ml

Static Tests

Static Tests
• 7) Vital Capacity (VC) = Amount of air that can
be given out by forceful expiration, after
forceful inspiration.
• VC = IV + IRV + ERV
• Normal value - Adult Indian males = 4 - 5 liters
• Adult Indian females = 3.3 - 4 liters

Physiological Variations
• a) Age = With the age, VC increases up to adulthood.
• b) Height = VC is more in tall person.
• c) Posture = VC is more in standing position.
• d) Gender = VC is less in females because average
height is low.
• e) Exercise & yoga = Increases VC
• f) At High Altitude = VC Increases

Practical Importance of Tests
• 1) Vital capacity is affected in restrictive lung
diseases such as pneumonia & VC is not affected in
obstructive diseases like Asthma.
• 2) VC Test is used in sports people & before joining
particular occupation like Military Services.
• 3) Total Lung Capacity (TLC) - It is VC+ Residual
volume.
• (Normal value = 5 to 6 liters)

Dynamic Lung Tests
• 1) FEV1 - Forced expiratory volume, at the end of 1
second Normal value –
• FEV1 = 85 %
• FEV2 = 97 %
• FEV3 = 100 %
• These values are reduced in obstructive lung disease
(Asthma & Bronchitis)

Dynamic Lung Tests
• 2) Resting Minute Ventilation (RMV)
• Amount of the air ventilated in 1 minute at
rest.
• RMV = Tidal volume x Respiratory Rate
• (Normal value = 8 to 9 lit. /min)

Dynamic Lung Tests
• 3) Maximum Breathing Capacity (MBC) Or
Maximum Voluntary Ventilation (MVV)
• Amount of air which is ventilated by forceful
ventilation in 1 minute. (Normal value = 80 to
100 lit. /min)
• MBC is reduced in both obstructive &
restrictive lung diseases

Dynamic Lung Tests
• 4) Pick Flow Rate (PFR)
• It is the maximum rate at which, air can be
expired out.
• (Normal value = 450 - 500 lit. /min.)
• PFR is measured by ‘Peak Flow Meter’
• PFR is reduced ‘Obstructive lung disease. ’
(Asthma)

Types of dead space
• 1) Functional Residual Capacity (FRC)
• Amount of air remaining in the air passages &
the alveoli, at the end of quiet expiration.
• 2) Residual volume - Amount of air left behind
in the ling at the end of deep expiration (1 to
1.4 lit.)

Types of dead space
• 3) Dead space air - Air left in the bronchial
tree, which does not take part in respiration.

Study of Respiration
• a) Inspection - Note construction of bony
structures, any deformities, asymmetry or
rickets, muscles, skin, etc.
• Normally movements of chest wall are equal
on both sides from midplane.

Examination of Respiratory system

• b) Palpation - It is done to confirm the findings
of inspection
• c) Percussion (Tapping) - Lung tissue normally
gives resonant note while solid tissue (fibrous)
gives a dull tone.

Percussion

• d) Auscultation - It is done with stethoscope
to hear the normal & abnormal sounds. 3
types of normal sounds are Tracheal sounds at
the root of neck.
• Bronchial sounds in bronchial region.
• Vesicular sounds of lung tissue

Special Study
• X ray chest – PA view
• Screening of chest
• MRI of chest
• Bronchoscopy
• Sputum Examination for AFB
• Pleural Tapping

A few important terms
• Eupnoea - Normal breathing.
• Hyperpnoea - Increase in amplitude of rate of
respiration.
• Dyspnoea - Difficulty in breathing

Note
• 1) In male, breathing is predominantly abdominal &
in females it is thoracic.
• 2) Artificial respiration is needed in some
emergencies like drowning, an electric shock,
operations, greater doses of anesthesia etc,
suffocation due to smoke, Paralysis of respiratory
muscles
• When breathing suddenly stops but heart keeps on
breathing.

2) Respiratory Insufficiency
• 2A) Hypoxia (Less O2) - This is deficiency of O2
at tissue level.
• Types –
• 1) Hypoxic Hypoxia
• 2) Anaemic Hypoxia
• 3) Stagnant Hypoxia
• 4) Histotoxic Hypoxia

1) Hypoxic Hypoxia
• Atmospheric O2 is less (high altitude)
• Ventilation in the lung is improper (Bronchitis &
Asthma) Narrow bronchi.
• Improper diffusion across pulmonary membrane
(pulmonary oedema, fibrosis of lung, T. B.)
• Improper mixing of arterial & venous blood
(congenital atrial septal defect (P. D. A. - Patent
Ductus Arteriosus)

2) Anaemic Hypoxia
• Atmospheric O2 is normal
• Diffusion of O2 is normal but ----
• Hb% is less or defective.
• So O2 is not transported properly. (Severe
anemia or CO2 poisoning)

3) Stagnant hypoxia
• Atmospheric O2 normal,
• Diffusion normal,
• Hb normal but -----
• Circulation is defective.
• So O2 is not transported properly (C.C.F. or
obstruction of arteries due to thrombo
embolism)

4) Histo - toxic hypoxia
• Atmospheric O2 normal,
• diffusion normal,
• Hb normal, circulation is normal but ---
• Cellular mitochondrial enzymes are damaged.
• So O2 cannot be utilized

Effects of Hypoxia
• 1) R. S. - To begin with Respiration is stimulated but
when CO2 is washed out, no further rise in
respiration.
• 2) C. V. S. - To begin with H. R. increases but if
hypoxia persist for longer time, Myocardial
weakening occurs.
• 3) Excretory system - Due to washing of CO2 alkalosis
occurs. Urinary pH becomes alkaline

Effects of Hypoxia
• 4) Why there is polycythemia at high
altitude?
• J. G. cells are stimulated by hypoxia.
Erythropoietin formation increases Bone
marrow is stimulated → R. B. C. count ↑ →
Hb ↑

Effects of Hypoxia
• 5) Digestive System (GIT) --- Nausea &
vomiting occur due to hypoxia of GIT.
• 6) Nervous System - Throbbing headache,
mental concentration becomes less &
irritability increases.

Treatment of Hypoxia
• 1) Treat the basic cause
• 2) O2 therapy is useful in Hypoxic hypoxia &
few cases of anaemic hypoxia.

2B) Asphyxia
• Lack of O2 & excess of CO2 in the body
• Causes –
• 1) Drowning
• 2) Suffocation in the smoke
• 3) Foreign body obstruction in trachea
• 4) Paralysis of respiratory muscles

Pathological stages
of Asphyxia
• 1) 1st stage – Hyperpnea -last for 1 min due to
excess of CO2 & so R. R. increases.
• 2) 2nd stage - Central excitation
• Duration - 2 min. Due to excess of CO2
complete CNS stimulates, H. R., B. P.
increases.

Pathological stages
of Asphyxia
• 3) 3rd stage - Central failure
• Lasts for 3 min. due to lack of O2, irreversible
damage to N. S.
• H. R., B. P., decreases.
• Lastly pupils are dilated & death occurs.

Treatment of Asphyxia
• 1) Treat the cause
• 2) First Aid - CPR - Cardio pulmonary
Resiscitation.
• 3) Emergency - Tracheostomy & 100% O2 is
given.

2C) Dyspnoea (Breathlessness)
• 1) Dysponea = Difficulty in breathing
• 2) Hyperopnea = Double the normal
respiration
• 3) Dysponea = when R. R. becomes 3 to 4
times more than normal, the patient starts
feeling breathless.

Causes of Dyspnoea
• 1) Respiratory causes - Bronchial asthma,
Acute bronchitis, pneumonia etc.
• 2) Cardio vascular problems - C.C.F. =
congestive card
• 3) Metabolic causes - Uremia, Diabetic
Ketoacidosis
• 4) Blood diseases - Severe Anemiaiac failure,
I.H.D.

Grades of Dyspnoea
• 1) Grade I = Dyspnoea after accustomed
exertion.
• 2) Grade II = Dyspnoea after climbing up
• 3) Grade III = Dyspnoea after walking on flat
surface
• 4) Grade IV = Dyspnoea at rest

3) Artificial Respiration
• In the event of accidental drowning, electric
shock, artificial respiration may be given as
first aid, treatment.

1) Mouth to mouth breathing
• a) The patient is laid flat on the back on the
table or on ground, higher than that on which
rescuer stands
• Under the patient’s shoulders some soft
Towel or pillow is placed so that the patient’s
head falls well back.

• Standing or kneeling opposite to the patient’s
head, the rescuer presses with one hand on
the crown of the patient’s head gently so that
the head is fully extended.
• Other hand is placed on the patient’s jaw so
that the jaw is drawn well forward.

• b) Breathing in deeply the rescuer’s mouth is
placed over the patient’s mouth whilst
pinching the patient’s nose to block the nasal
orifice.
• The rescuer breaths out forcibly into the
patient’s lungs. When the patient is a child or
baby the rescuer should breath delicately.

• c) The patient expires passively & the jaw is
kept drawn well forward so that the patient’s
air passage is always kept patent

• In this method, which in fact is very simple; the
doctor takes a deep breath and exhales that air in
the patient’s mouth.
• This process is repeated for 10-12 times per min.
• This method was somewhat neglected in recent past
because of the misconception that the air exhaled by
the Doctor into the patient’s mouth is not
appropriate for the patient.

• But medically, this proposition is wrong, as
• Exhaled air also contains sufficient amount of
Oxygen which certainly helps the patient.
• Also, the carbon di oxide exhaled by the
Doctor assists in exciting the respiratory
center of the patient.

2) Sharpey Shaffer’s Method

Artificial Respiration – Chin Lift

Artificial Respiration

• a) Lying casualty’s face downwards ( Prone position)
with head turned to one side arms bent & forehead
resting on his hands with neck extended
• kneeling to one side of casualty’s hips facing his
head & placing hands flat on the small of the
casualty’s back just above the top of the pelvic
bones, thumbs almost touched each other in the
midline, fingers being spread over the loins &
pointing towards the ground.

• b) Seating on heals & swinging body slowly
forward from knees being kept arms straight
& hands in place all the time only applying
gentle pressure by the body weight.
• Forcing air out of the lungs (expiration) to be
maintained this position for 2 sec. counting 1,
2.

• c) Relaxing the pressure by swinging quietly &
gradually backwards on to heals allowing
inspiration & counting 3, 4, 5 in 3 sec.
• Before swinging forwards again to first
movement being kept arms straight & hands
in place all the time

3) Holger - Nielsen Method
• The subject is placed in the prone position with the
arms abducted at the shoulders & elbows remaining
flexed.
• The face is turned to one side & rests on the hands.
• The mouth is cleaned (by wiping the mucus, fluid
etc.) The operator kneels down in front of the
subject facing towards the head. 2 hands are placed
on the 2 side of the chest.

• With the thumbs & fingers spread apart. Then the
operator puts his body weight leaning forwards upon
the subject’s back.
• This compresses the chest & helps in expiration.
• The operator then makes himself straight & at the
same time draws the subject’s arms forwards by
holding them above the elbows.
• This helps in natural inspiration. This process is
repeated about 10 - 12 times a min.

• a) Rocking forwards quietly with arms straight &
applying light pressure to back by weight of the
upper part of body only counting for 2 sec. 1, 2
(Expiration).
• b) Rocking back with arms straight releasing pressure
gradually & sliding hands to elbows of casualty
counting 3 for 1 sec.
• c) Raising & pulling casualty’s arms until tension
being felt for 2 sec. counting 4, 5 causing inspiration.

4) Hospital Management
• Artificial Respiration
• Respiration is a vital sign.
• Inadequate airway is the main cause for the
death.
• WHO has mentioned that 50 to 60% deaths
occur due to improper ventilation.
• So airway management & ventilation is
important.

Causes of breathlessness –
In conscious patient
• 1) Foreign body obstruction.
• 2) Aspiration of food or any other secretion in
the respiratory tract. (eg. Fast eating habits).

Symptoms
• i) Deep breathing
• ii) Difficulty in expiration (Grasping)

Symptoms

Symptoms
• During inspiration trachea dilates & during
expiration trachea recoil.
• Foreign body sticks to the mucous.
• Due to the irritation of mucosa - secretion
increases - so obstruction also increases.

Symptoms
• a) In upper air way obstruction patient express the
chocking by holding his hand around the throat. -
Universal sign.
• b) The doctor must see the important sign Cyanosis
• 2 types of Cyanosis
• I) Central Cyanosis - Tip of the tongue become bluish.
II) Peripheral Cyanosis - Tip of the finger become
bluish.

Cyanosis

Treatment
• 1) Patient has to be sited in relax position. Lift
up the neck, put the left hand on the chest &
do the stumping (stroke by the pump) at the
neck.
• 2) Or patient can be asked to lie down & do
the chest physiotherapy. Extend the neck
(Head lift, chin tilt position) Tapping is done
from lower lobe to upper lobe of the lungs on
both the side.

Treatment
• 3) Hot fomentation can be given.
• 4) Mostly with this efforts, airway opens.
These are primary efforts.
• If needed.
• Injection Atropine IV 0.6 mg (It reduces the
mucous secretion)
• Bronchodilators are given. For eg.
• ‘Inj. Deriphylline’ 1 ampoule.

Treatment
• 5) Advise - Bronchoscopy = Planned bronchoscopy or
Emergency bronchoscopy
• Note - Foreign body can be hydroscopic or non -
hygroscopic
• Basic principle about foreign body removal is to push
the F. B. from down to the upper side. If the foreign
body sticks, lung infection chances are more. So, it is
necessary to start higher antibiotics.

If the patient is unconscious
• 2 important features indicate the dyspnoea.
• 1) Aphonia 2) Absence of cough reflex / Gag
reflex
• Causes
• 1) Status asthmaticus 2) Foreign body in the
air - way

If the patient is unconscious
• In unconscious patient first treat the symptoms &
then ask the patient.
• In emergency like shock gasping respiration,
peripheral & central cyanosis - 3 parameters are
observed.
• Rate of the respiration (14 - 18 / min.)
• Regularity & rhythm (observe the chest expansion)
• Efforts to take breathing.

To activate the
Respiratory Centers
• Mouth to mouth breathing is very important
(Head low position, Head lift & chin tilt
position, Pinching of the nose & then mouth
to mouth breathing).
• In the patients of HIV or Hepatitis in spite of
mouth to mouth breathing the patient is
directly taken on the ventilator

To activate the
Respiratory Centers
• If the air way is not open, endotracheal
intubation is done. 2 types of endotracheal
tubes are available nasal & oral. Size No. is 2.
5 up to 8. For endotracheal intubation direct
laryngoscope is also use. Endotracheal tube is
connected to ‘Ambu bag’. During the
procedure observe the chest expansion &
check the air entry by stethoscope

To activate the
Respiratory Centers
• After 48 hours if the patient is not out,
tracheostomy is done. Number of
tracheostomy tube is decided according to
age.
• Tracheostomy tube is of 2 types, metal &
plastic. Vertical incision is taken on the
trachea & with proper sterilization care the
tube is introduced with stirrer.

To activate the
Respiratory Centers
• After observing PO2 by pulse oxymeter, the
decision of O2 administration is taken.
• Tracheostomy care - 1) daily dressing 2)
antibiotic coverage

Prof.Dr.R.R.Deshpande
• Sharing of Knowledge
• FOR
• Propagating Ayurved
04/14/16 82Prof.Dr.R.R.Deshpande

Respiratory system – part 2

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