1. Respiratory system Romanciuc Lilia Romanciuc Lilia

2. Development of Resp. system : At about 24 days of gestation in the development of human body primordial (primary) lungs are detectable as a bored of gut, within another 4 days the major bronchi are differentiated they undergo rapid growth and at 12 weeks of gestation appear the lobs of the lung tissue. At about 24 days of gestation in the development of human body primordial (primary) lungs are detectable as a bored of gut, within another 4 days the major bronchi are differentiated they undergo rapid growth and at 12 weeks of gestation appear the lobs of the lung tissue. Development of Resp. system : At about 24 days of gestation in the development of human body primordial (primary) lungs are detectable as a bored of gut, within another 4 days the major bronchi are differentiated they undergo rapid growth and at 12 weeks of gestation appear the lobs of the lung tissue. At about 24 days of gestation in the development of human body primordial (primary) lungs are detectable as a bored of gut, within another 4 days the major bronchi are differentiated they undergo rapid growth and at 12 weeks of gestation appear the lobs of the lung tissue.

3. Stages of development : 1. Stage  ”glandular stage”, is completed at 16 weeks of gestation. 2. Stage  “canalicular stage” which takes place between 16-24 weeks of gestation. the airway epithelium and submucosal glands develop and alveoli begin to appear late in this phase. Stages of development : 1. Stage  ”glandular stage”, is completed at 16 weeks of gestation. 2. Stage  “canalicular stage” which takes place between 16-24 weeks of gestation. the airway epithelium and submucosal glands develop and alveoli begin to appear late in this phase.

4. 3. Stage  ”alveolar stage” rapid proliferation of the alveoli, it takes place at about 24 weeks of gestation and continuous in postnatal life.The capillary network develops during the 20 weeks of gestation but these capillaries are not closely associated with alveolar surfaces until 26-28 weeks then alveolar walls became thinner. 3. Stage  ”alveolar stage” rapid proliferation of the alveoli, it takes place at about 24 weeks of gestation and continuous in postnatal life.The capillary network develops during the 20 weeks of gestation but these capillaries are not closely associated with alveolar surfaces until 26-28 weeks then alveolar walls became thinner.

5. The alveolar surface constitutes of 2 types of cells :  Type 1 has very thin cytoplasm and forms the major tissue barrier between air spaces and capillary across which gas diffuses.  Type 2 synthetizes and secretes surfactant ( this is a substance that reduces the alveolar surface tension, thus reduces the pressure to maintain the alveolar volume, surfactant is essential for normal respiration ). The alveolar surface constitutes of 2 types of cells :  Type 1 has very thin cytoplasm and forms the major tissue barrier between air spaces and capillary across which gas diffuses.  Type 2 synthetizes and secretes surfactant ( this is a substance that reduces the alveolar surface tension, thus reduces the pressure to maintain the alveolar volume, surfactant is essential for normal respiration ).

6. During early postnatal life the lungs continue to develop primarily by increased number of alveoli and terminal airways. During early postnatal life the lungs continue to develop primarily by increased number of alveoli and terminal airways. At birth, the normal full term baby has approximately 25 million alveoli. At birth, the normal full term baby has approximately 25 million alveoli. In adulthood this number increases nearly to 300 million. In adulthood this number increases nearly to 300 million. All this alveolar growth take place in the first 8 years, most important period is the first 3-4 years. All this alveolar growth take place in the first 8 years, most important period is the first 3-4 years. During early postnatal life the lungs continue to develop primarily by increased number of alveoli and terminal airways. During early postnatal life the lungs continue to develop primarily by increased number of alveoli and terminal airways. At birth, the normal full term baby has approximately 25 million alveoli. At birth, the normal full term baby has approximately 25 million alveoli. In adulthood this number increases nearly to 300 million. In adulthood this number increases nearly to 300 million. All this alveolar growth take place in the first 8 years, most important period is the first 3-4 years. All this alveolar growth take place in the first 8 years, most important period is the first 3-4 years.

7. The diagnostic evaluation begins with careful and complete history and physical examination. The diagnostic evaluation begins with careful and complete history and physical examination. The signs or symptoms in children with airway disease appear different during sleep. Its necessary to observe the resp. rate, depth and retraction. The signs or symptoms in children with airway disease appear different during sleep. Its necessary to observe the resp. rate, depth and retraction. The child should be quite not crying. The child should be quite not crying. The diagnostic evaluation begins with careful and complete history and physical examination. The diagnostic evaluation begins with careful and complete history and physical examination. The signs or symptoms in children with airway disease appear different during sleep. Its necessary to observe the resp. rate, depth and retraction. The signs or symptoms in children with airway disease appear different during sleep. Its necessary to observe the resp. rate, depth and retraction. The child should be quite not crying. The child should be quite not crying. Evaluation of patient with respiratory disorders :

8. Resp. rate - is an important indicator of resp. system, any factor that affects resp. mechanism is likely to result in more rapid breathing rate, during sleep resp. rate is variable. Resp. rate - is an important indicator of resp. system, any factor that affects resp. mechanism is likely to result in more rapid breathing rate, during sleep resp. rate is variable. AgeResp. rate New born40-60 / min < 1 year30-35 / min < 5 years25 / min < 10 years20 / min > 12 years16-20 / min

9. Tachypnea according to WHO : from 2 weeks - 2 months : considered increase in rate 60 /min or more. from 2 months – 12 months : considered increase in rate 50/min and more. from 1 year – 5 years : considered increase in rate 40/min and more. Tachypnea according to WHO : from 2 weeks - 2 months : considered increase in rate 60 /min or more. from 2 months – 12 months : considered increase in rate 50/min and more. from 1 year – 5 years : considered increase in rate 40/min and more.

10. Hyperpnea – increased depth of respiration. appears with fever, acidosis, pulm. disease or extreme anxiety. Hyperpnea – increased depth of respiration. appears with fever, acidosis, pulm. disease or extreme anxiety. Hyperpnea without signs of resp. distress should suggest nonpulmonary etiology, example : acidosis. Hyperpnea without signs of resp. distress should suggest nonpulmonary etiology, example : acidosis. When the degree of effort is increased because of airway obstruction. When the degree of effort is increased because of airway obstruction. The intrathoracic pressure may be more negative than usual and intercostal retraction can be observed.. The intrathoracic pressure may be more negative than usual and intercostal retraction can be observed.. Hyperpnea – increased depth of respiration. appears with fever, acidosis, pulm. disease or extreme anxiety. Hyperpnea – increased depth of respiration. appears with fever, acidosis, pulm. disease or extreme anxiety. Hyperpnea without signs of resp. distress should suggest nonpulmonary etiology, example : acidosis. Hyperpnea without signs of resp. distress should suggest nonpulmonary etiology, example : acidosis. When the degree of effort is increased because of airway obstruction. When the degree of effort is increased because of airway obstruction. The intrathoracic pressure may be more negative than usual and intercostal retraction can be observed.. The intrathoracic pressure may be more negative than usual and intercostal retraction can be observed..

11. Granting - forced expiration against partially closed glottis should suggest hypoxia, atelectasis, pneumonia and pulm. Edema. Sounds of breathing : Stridor – usually heard on inspiration, is a harsh sound which emanates from the upper airway and is due to partially obstructed extra-thoracic airway. Wheezing - produced by partially obstruction of the lower airway and is heard during expiration. Wheezing maybe harsh and low pitch or high pitch and musical. Granting - forced expiration against partially closed glottis should suggest hypoxia, atelectasis, pneumonia and pulm. Edema. Sounds of breathing : Stridor – usually heard on inspiration, is a harsh sound which emanates from the upper airway and is due to partially obstructed extra-thoracic airway. Wheezing - produced by partially obstruction of the lower airway and is heard during expiration. Wheezing maybe harsh and low pitch or high pitch and musical.

12.  The secretion in the airway may result in wheezing but more commonly they resulting in irregular sounds called ronchi.  The fluid or secretions in the alveolar spaces or in terminal airways may produce a sound that is characteristic of crumpling cellophane.  This sound may disappear after a few deep respiration or a cough, but it‘s persistence suggest pulm. edema or pneumonitis.  The secretion in the airway may result in wheezing but more commonly they resulting in irregular sounds called ronchi.  The fluid or secretions in the alveolar spaces or in terminal airways may produce a sound that is characteristic of crumpling cellophane.  This sound may disappear after a few deep respiration or a cough, but it‘s persistence suggest pulm. edema or pneumonitis.

13.  The quality of breath sounds maybe bronchial normally heard upon the trachea, the inspiration and expiration, clearly auscultate.  More peripheral breath sounds are vesicular with a greater proportion in inspiration.  Bronchial breath sounds in the periphery of the lungs suggest consolidation or pleural effusion.  This physical sign when combined with inspection of trachea or cardiac deviation, chest wall, motion, percussion, vocal fremitus and the presence or absence of breath sounds help to identify the intrathoracic pathology.  The quality of breath sounds maybe bronchial normally heard upon the trachea, the inspiration and expiration, clearly auscultate.  More peripheral breath sounds are vesicular with a greater proportion in inspiration.  Bronchial breath sounds in the periphery of the lungs suggest consolidation or pleural effusion.  This physical sign when combined with inspection of trachea or cardiac deviation, chest wall, motion, percussion, vocal fremitus and the presence or absence of breath sounds help to identify the intrathoracic pathology.

14. Finger clubbing – is a sign of chronic pulm. disease but also appears in cardiac pathologies, example : cyanotic congenital heart disease, teratology of Fallot, biliary cirrhosis, celiac disease, chronic active hepatitis. distal phalangeal diameter (DPD), interphalangeal diameter (IPD),

15. Breath sounds – the normal breath sounds has been classified into 3 categories according to intensity, pitch and relative duration of respiratory phases ( inspiration : expiration phases ). Vesicular breath sounds – are soft and low pitched, they are heard from inspiration continue without pause into expiration and then fade away. about 1/3 of the way through expiration. Bronchial breath sounds – are louder and higher in pitch, there is a short silent period between inspiratory and expiratory sounds, and expiratory sound last longer than inspiratory. Breath sounds – the normal breath sounds has been classified into 3 categories according to intensity, pitch and relative duration of respiratory phases ( inspiration : expiration phases ). Vesicular breath sounds – are soft and low pitched, they are heard from inspiration continue without pause into expiration and then fade away. about 1/3 of the way through expiration. Bronchial breath sounds – are louder and higher in pitch, there is a short silent period between inspiratory and expiratory sounds, and expiratory sound last longer than inspiratory.

16. Bronchovesicular sounds - are intermitted (stop temporarily), inspiratory and expiratory sounds are equal in length and silent period may and may not be present. The difference in pitch and intensity are often more easily detected during expiration.If bronchovesicular or bronchial breath sound are heard suspect that air field lung has been replaced with fluid or solid ( fibrosis ). Bronchovesicular sounds - are intermitted (stop temporarily), inspiratory and expiratory sounds are equal in length and silent period may and may not be present. The difference in pitch and intensity are often more easily detected during expiration.If bronchovesicular or bronchial breath sound are heard suspect that air field lung has been replaced with fluid or solid ( fibrosis ).

17.  The breath sounds are usually louder in the lower posterior lung field and may also vary from area to area, it is necessary to ask the patient to breath more deeply. It is necessary to listen for pitch, intensity and duration of inspiration and expiration sounds.  Vesicular breath sounds – distributed normally over the chest wall. The breath sound maybe decreased when the air flow is decreased in obstructed lung disease, muscular weakness or when transmission of sounds is poor ( pneumothorax, pleural effusion, emphysema )  The breath sounds are usually louder in the lower posterior lung field and may also vary from area to area, it is necessary to ask the patient to breath more deeply. It is necessary to listen for pitch, intensity and duration of inspiration and expiration sounds.  Vesicular breath sounds – distributed normally over the chest wall. The breath sound maybe decreased when the air flow is decreased in obstructed lung disease, muscular weakness or when transmission of sounds is poor ( pneumothorax, pleural effusion, emphysema )

19. Continues crackles – are intermitted, not musical and very brief may be simulated of rolling of hair lock near to ears. Crackles are divided onto 2 sub-groups : 1- fine : soft, high pitch and very brief. 2- coarse : louder, lower in pitch and not so brief. It is necessary to note the number of this (few / many) timing or location on the chest wall, it is helpful to note if they change the position or after coughing. In some normal people crackles that have no pathological sounds that heard in the lung basis anterior after maximum expiration, crackles depend on portion of the lungs. Additional Sounds

20. Continues sounds – it is longer than crackles, that doesn’t necessary persist through resp. cycle, the musical quality distinguish them from breath sounds. 2 subgroups are differentiated by pitch : 1-Wheezing relatively high pitch. 2-Ronchi relatively low pitch.

21.  The continues sounds are suggest that one or more airways are narrowed almost to the point of closure.  This closure maybe local or generalized from bronchospasm, accumulated bronchus secretion or edema.  It is necessary to make differentiation if this accumulating bronchial secretion or bronchial mucus.

22. 1. Inspection : observe color of the skin, shape of the fingers nails, position of the trachea, evidence of resp. distress, rate, rhythm and depth of breathing, deformities or asymmetry, abnormal retraction of the intercostal spaces during inspiration ( retraction is more frequent in the lower intercostal spaces ) in severe asthma, COPD, upper airway obstruction. observe the participation of resp. movement, symmetrically or unilateral. unilateral participation suggest pleuritis, hydrothorax. Technique of examinations

23. 2. Palpation : a- identification of tender areas. b-assessment of observable abnormalities example : tumors, masses, inflammatory tubules. c-assessment of resp. elasticity. d-vocal fremitus – the causes of unilateral delay in chest elasticity in chronic fibrotic disease of the underlying lung or pleura, pleural effusion, lobar pneumonia. Fremitus decreased or absent when the voice is soft or when the transmission of vibrations from the larynx to the surface of the chest is decreased.

24. The causes are COPD, fibrosis, pleural effusion, pneumothorax.The fremitus increased when the transmission sound is increased, example : lobar pneumonia consolidation. It is necessary to describe, to realize the areas of increased or decreased fremitus. Fremitus is typically more prominent in the interscapular area than in the lower lungs fields and is often more prominent in the right side than in the left, it is disappears below the diaphragm.

25. 3. Percussion : Topographic – to determine the lower and upper borders of the lung. Comparative – symmetrical to determine changes in sound ( percussion of the anterior, lateral chest and comparing both sides ). symmetrically dullness replacing the resonance appears in fluid or solid tissue replaces. hyperresonance – emphysema.

26. 4. Auscultation : its necessary to listen the chest anterior laterally as the patient breath with open mouth and more deeply than normal. compare, listen breath sounds, noting intensity identifying various from normal. vesicular breath sounds is louder on upper than in another lung fields. bronchovesicular breath sound maybe heard over the lung airways more frequent on right, its is necessary to describe the location how many sounds and according to the time of resp. cycle.