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December 2017 Version 2.0

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Respiratory Module - Phase I

Faculty of Medical Sciences

University of Sri Jayewardenepura


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Introduction

Respiratory module in Phase I is designed to facilitate learning of the normal structure /

function relationships of the respiratory system. The main content areas of the module are

covered over a period of 4 weeks during the 1st and 2nd term of the medical curriculum.

The burden of respiratory diseases is high in the world and as a doctor you will come across a

variety of respiratory disorders in your day-to-day practice. A Understanding the structure

and function of the respiratory system is the key to study the normal and diseased states.

Therefore this module is an essential foundation to diagnose and manage respiratory

disorders.

Teaching / learning activities of this module will be in the form of lectures, tutorials,

dissections, practicals, seminars, hospital visits & small group discussions. Interactive

learning modules in the IT laboratory, activities in the Language and Communication

laboratory and practicing clinical skills in the Skills laboratory relevant to the respiratory

system will enhance your own learning process during these four weeks.

The “real life scenarios” are included for you to apply your anatomy and physiology

knowledge to work out signs, symptoms, interpretation of investigations and the management

of few common respiratory conditions. This will give you a taste of the interesting clinical

scenarios you would experience in the future. You are expected to attempt these on your own

at the end of the module.

You are encouraged to engage on active self-learning using the respiratory module hand book

and the list of reading materials as guides.

Best wishes for an enjoyable and a fruitful respiratory module.

Module committee

Dr. Chandimani Undugodage (Chairperson, Department of Physiology)

Dr. Sithara Dissanayake (Convener, Department of Anatomy)

Prof. Savithri Wimalasekara (Department of Physiology)

Prof. Priyadarshika Hettiarachchi (Department of Physiology)

Dr. Harsha Dissanayake (Department of Anatomy)

Dr. S. Shiyanth (Department of Anatomy)

Dr. W. A. N. Y. Silva (Department of Physiology)

Dr U. Senarathne (Department of Biochemistry)


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General Objectives

At the end of the respiratory module, the student should be able to:

1. describe the normal structure and function relationships of respiratory system

2. Apply the basic scientific knowledge in understanding the respiratory adjustments in

health and in disease states.

3. describe the physiological basis of signs and symptoms of altered structure & function

of respiratory system

4. Interpret the results of investigations of respiratory function in the normal and in

disease states.

5. Outline the physiological principles of treatment of common respiratory disorders.


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Main Content Areas

Main Content Area Lectures

(Hours)

Practical/Dissections

No. of (3hrs)

sessions

Tutorials/SGD

No. of (2hrs)

sessions

1. General Structure of Thorax

(Anatomy)

01 03 01

2.Structure of airways / lungs

(Anatomy)

01 01 -

3.Structure of diaphragm

(Anatomy)

01 01 01

4.Embryology of Respiratory

Apparatus (Anatomy)

01 - -

5.Histology of airways / lungs

(Anatomy)

01 01 -

6.Mechanics of Ventilation

(Physiology)

03 - 01

7.Lung volumes and capacities

(Physiology)

01 - -

8.Lung Function Tests

(Physiology)

- 01 -

9.Pulmonary blood flow & its

regulation (Physiology)

02 - -

10.Gas exchange across Alveolar

Capillary Membrane

(Physiology)

01 - -

11.Distribution of Ventilation &

V/Q ratios (Physiology)

01 - 01

12.Gas transport between lungs

& tissues (Physiology)

02 - 01

13.Regulation of respiration

(Physiology)

02 - 01

14.Hypoxia, Apnoea

(Physiology)

1.5 - 01

16.Altered physiology of selected

respiratory diseases

(Physiology)

02 -

01

17.Modified acts of respiration

(Physiology)

- 01 -


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*Structure of Nasal air passages /*Structure & Function of larynx

-will be covered in neuroscience module Real life situations

Real life situation 1: Pneumothorax

Real life situation 2: Acute shortness of breath

Real life situation 3: Chest infection

Main Content Area Lectures

(Hours)

Practical/Dissections

No. of (3hrs)

sessions

Tutorials/SGD

No. of (2hrs)

sessions

18.Principles of O2 therapy

(Physiology)

01

19.Physiological adjustments at

high altitudes, space & diving

(Physiology)

02 -

-

20.Applied anatomy of chest

wall (Anatomy)

01 - 01

21.X rays, CT / MRI scans as

diagnostic aids in respiratory

disorders (Anatomy)

01 01

-


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Respiratory Module - Phase I

A-Essential to know B- Good to know C- Nice to know

1. GENERAL STRUCTURE OF THORAX

Intermediate Objectives Broad Content Areas Activity Duration Department

Describe the general structure of the thoracic cage

Identify the following important bony landmarks:

- Sternal angle

- Sternocostal joints

- Xiphoid process

- Midclavicular point

- Tip of the 9th costal cartilage

Draw the anterior / middle / posterior axillary lines

and mid clavicular line on the chest wall

Surface mark lungs and pleura on the chest wall

Bones, cartilages & joints of

thoracic skeleton

Muscles of respiration

Segmental innervation & blood

supply of thoracic wall

Boundaries & important anatomical

structures of thoracic inlet / outlet

Intercostal space

(A)

Surface marking of the lungs &

pleura

(A)

Démonstrations/

Dissections

Lecture

Tutorial

9 hrs

1 hr

2 hrs

Anatomy

Anatomy

Anatomy


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2. STRUCTURE OF AIRWAYS & LUNGS

3. STRUCTURE OF DIAPHRAGM

Intermediate Objectives Broad Content areas Activity Duration Department

Describe the anatomy of trachea, bronchial tree,

lungs & pleura

Structural anatomy of trachea,

bronchial tree, bronchopulmonary

segments, lungs & pleura

(B)

Dissections/

Demonstration

of prosected

specimens &

models

Lecture

3 hrs

1 hr

Anatomy

Anatomy


Describe the general structure of the diaphragm

Describe the embryological development of the

diaphragm

Outline briefly the developmental anomalies of:

- Tracheoesophageal fistula

- Diaphragmatic hernia

- Hiatus hernia

General structure of diaphragm

(A)

Embryological development of

diaphragm

(C)

Developmental anomalies of

- Tracheoesophageal fistula

- Diaphragmatic hernia

- Hiatus hernia

(B)

Lecture

Dissections

Tutorial

1 hr

3 hrs

2 hrs

Anatomy

Anatomy

Anatomy


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4. EMBRYOLOGY OF RESPIRATORY APPARATUS

5. HISTOLOGY OF AIRWAYS & LUNGS


Describe the normal developmental embryology of

the respiratory apparatus

Normal developmental embryology

of the nasal passages, larynx,

trachea, bronchi, lungs, pleura, &

thoracic cavity

(B)

Lecture

1 hr

Anatomy


Identify & describe the microstructure of upper /

lower respiratory tracts & alveoli

Histology of the upper / lower

respiratory tracts & alveoli

(B)

Lecture

Practical

1 hr

3 hrs

Anatomy

Anatomy


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6. MECHANICS OF VENTILATION


Mechanics of ventilation

Define the terms

- Compliance & airway resistance

List the conditions with altered

- Compliance & airway resistance

Describe the

- Role of surfactant in maintaining alveolar

stability

Name the conditions with surfactant deficiency and

to outline the deranged physiology

Explain

- The term “Work of Breathing”(WOB)

- The effects of respiratory diseases on WOB

Physical / physiological principles of

ventilation

Mechanism of air trapping

(A)

Compliance and its influence on

ventilation of the lungs

(A)

Airway resistance and its influence

on ventilation

Understand the altered physiology

in lung fibrosis, emphysema and

asthma

(A)

Surfactant

- Synthesis

- Physical properties aiding the

reduction of surface tension

- Alveolar stability explained on

the basis of “Law of Laplace”

- Deficiency states and associated

problems

(A)

Factors influencing WOB

Conditions with altered WOB

(A)

Lecture

SGD

3hrs

2 hrs

Physiology

Physiology


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7. LUNG VOLUMES AND CAPACITIES


Enumerate & define the tests used in the

assessment of

- Ventilatory functions

- Gas exchange of the lungs

To identify the volumes & capacities on

- A spirograph

Lung volumes & capacities

Dead space volumes

Usefulness of FEV1 / FVC ratios in

differentiating obstructive from

restrictive airway diseases

Normal flow volume loop

Volume time curve and it’s changes

in obstructive and restrictive airway

diseases

(A)

Lecture

1 hr

Physiology


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8. LUNG FUNCTION TESTS (LFT)


Enumerate &define the tests used in the assessment

of

- Ventilatory functions

- Gas exchange of the lungs

To identify the volumes & capacities on

- A spirograph

To calculate the FEV1 / FVC ratio on a vitalograph

To interpret the results of LFT to diagnose

underlying physiological derangement / clinical

abnormality

- Lung volumes & capacities

- PEFR

- Blood gas reports

- FEV1 / FVC ratios

To acquire the skill of using a peak flow meter to

measure & interpret the results of PEFR

Demonstrate and interpret 6- minute walk test

Lung volumes & capacities

Minute ventilation and alveolar

ventilation and dead space

Diffusion capacity of lung (DLCO)

(A)

Usefulness of FEV1 / FVC ratios in

differentiating obstructive from

restrictive airway diseases

(A)

Interpretation of LFT with reference to

the deranged lung functions /

underlying diseases of the lungs

(A)

Interpretation of blood gas report

(A)

Practical

Hospital visit

3 hrs

3hrs

Physiology

Physiology


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9. PULMONARY BLOOD FLOW AND REGULATION

10. GAS EXCHANGE ACROSS THE ALVEOLAR CAPILLARY MEMBRANE (ACM)


Factors governing gas exchange across the Alveolar

Capillary Membrane (ACM)

Physical factors governing gas

exchange across ACM

Characteristics of ACM facilitating

gas exchange

Diffusion capacity of lung (DLCO)

(A)

Lecture

1 hr

Physiology


Characteristics of pulmonary circulation in

comparison to systemic circulation

Distribution of pulmonary blood flow in standing /

recumbent positions

Regulation of pulmonary blood flow

Altered physiology of pulmonary hypertension

Pressure / flow characteristics of

pulmonary circulation

(A)

Factors governing the distribution of

pulmonary blood flow

(A)

Factors affecting pulmonary blood

flow

(A)

Causes of pulmonary hypertension

(A)

Lecture

2 hrs

Physiology


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11. DISTRIBUTION OF VENTILATION & V/Q RATIOS


“Regional variation” in the distribution of ventilation

in standing / recumbent positions

Distribution of ventilation in relation to alveolar

perfusion (V/Q ratios)

Define

- Alveolar-arterial gradient (A-a gradient)

Factors governing the distribution of

ventilation

(A)

V/Q ratios

(A)

Normal, low and high V/Q ratios

(A)

Physiological basis of abnormal A-a

gradients

(A)

Lectures

Tutorial

1 hr

1 hr

Physiology

Physiology


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12. GAS TRANSPORT


Carriage of O2 to the tissues with reference to the

“O2 cascade”

Influence of PaO2 on the affinity of haemoglobin for

O2 (SO2) with reference to Oxygen Haemoglobin

Dissociation Curve (O- HbDC)

Describe the role of RBC & plasma in the transport

of CO2

Methods of O2 transport between

lungs & tissues

(A)

Factors altering the affinity of

haemoglobin for O2and Bohr effect

(A)

Significance of right / left shift of O-

HbDC with reference to O2 transport

(A)

Methods of CO2 transport between

lungs & tissues

Mechanism of release of CO2 at the

pulmonary capillaries

Role of “Haldane effect” on CO2

transport

(A)

Lectures

Tutorial

2 hrs

1 hr

Physiology

Physiology


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13. REGULATION OF RESPIRATION

14. HYPOXIA, APNOEA


Regulatory mechanisms of respiration in health & in

disease states

Role of respiratory center in

controlling respiration

Chemical control of respiration via

chemo-receptors

Non chemical influences on

respiration

Respiratory adjustments in disease

states

(A)

Lecture

SGD

2 hrs

2hrs

Physiology

Physiology


Explain the likely types and causes of hypoxia

Explain the compensatory mechanisms in the body

in hypoxia

Define apnoea

Define hypoxia

Types & causes of hypoxias

(A)

Compensatory mechanisms of acute

& chronic hypoxias

Diffusion of O2 to the tissues

(A)

Types & causes of apnoea

Altered physiology of apnoea

(A)

Lecture

Tutorial

1 1/2hrs

1 hr

Physiology

Physiology


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15. APPLIED ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM

16. ALTERED PHYSIOLOGY OF SELECTED RESPIRATORY DISEASES


Applied anatomy and physiology of respiratory

system

Altered physiology and anatomy of

respiratory system

(A)

Seminar

2 hrs

Physiology

& Anatomy


Explain the pathophysiological basis of Bronchial

Asthma

Briefly outline the principles of management

Respiratory failure

- List the types & likely causes of respiratory

failure

- Artificial ventilation

Describe the

- Effects of deranged respiratory physiology on

blood gas tensions

Interpret a blood gas report in relation to the

- Types of respiratory failure

Types & causes of respiratory failure

Types of artificial ventilation

(A)

Physiological basis of the deranged

blood gases in 2 types of respiratory

failure

(A)

Blood gas analysis based diagnosis of

the type & severity of respiratory

failure

(A)

Lecture

Lecture

SGD

1 hr

1hr

2 hrs

Physiology

Physiology

Physiology


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17. MODIFIED ACTS OF RESPIRATION


Explain the physiological basis of

- Deglutition apnoea

The period of voluntary apnoea following

- Normal breaths

- Hyperventilation

- Re breathing of CO2

- O2 therapy

Signs / symptoms accompanying voluntary

hyperventilation

Mechanisms of deglutition

apnoea

(A)

Factors governing the period of

voluntary apnoea

(A)

Consequences of voluntary

hyperventilation

(A)

Practical

3hrs

Physiology


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18. PRINCIPLES OF O2 THERAPY

19.PHYSIOLOGICAL ADJUSTMENTS AT HIGH ALTITUDES, SPACE & DIVING

20.

APPL


Principles of O2 therapy

Outline the

- Risks associated with O2 therapy

O2 cascade

FiO2

O2delivery devices

Usefulness of O2 therapy in

different types of hypoxias

Physiological basis of “controlled

O2 therapy” in patients with chronic

hypercarbia

(A)

O2 toxicity(causes & effects on the

body)

Hyperbaric O2 therapy

(A)

Lecture

1 hr

Physiology


Describe the

- Physiological adjustments at high

altitudes, Space.

Physiological adjustments derangements in

diving

Acute & chronic changes

(acclimatization) at high altitudes

and space

(A)

Decompression sickness and N2 /

CO2 narcosis in divers

(A)

Lecture

2hrs

Physiology


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20. IED ANATOMY OF CHEST WALL


Outline the causes / mechanisms / effects of

pneumothorax, haemothorax, flail chest

Outline the anatomical considerations in

- The insertion of intercostal tubes

- Intercostal nerve blocks

- Thoracic inlet syndrome

Causes / mechanisms / effects of

pneumothorax, haemothorax, flail

chest

(A)

Anatomical considerations in

- The insertion of intercostal tubes

- Intercostal nerve blocks

- Thoracic inlet syndrome

(B)

Lecture

Tutorial

1 hr

2 hrs

Anatomy

Anatomy


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21. X RAYS, CT / MRI SCANS AS DIAGNOSTIC AIDS IN RESPIRATORY DISORDERS


Identify and comment on the normal

radiological appearances of the following on a

chest x ray

- Borders of the heart

- Trachea, main bronchi & hilar regions,

mediastinum

- Lung fields, lobes & fissures

- Bony skeleton

- Domes of the diaphragm

Identify the following abnormalities on a

chest x ray

- Cardiomegaly

- Tracheal & mediastinal shift

- Pneumothorax, pleural effusion

- Collapse, consolidation of the lung

- Emphysema

- Bony abnormalities

Identify the thoracic structures on scan reports

X rays of the chest

(A)

Cardiomegaly

Tracheal & mediastinal shift

Pneumothorax, pleural effusion

Collapse, consolidation of the lung

Emphysema

Bony abnormalities

(B)

CT / MRI scans of chest

(C)

Lecture

Practical

1 hr

3 hrs

Anatomy

Anatomy


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Real Life Situation-1

Pneumothorax

Topic: Pneumothorax

Scenario:

A previously healthy 55 year old male is admitted to the Accident service-CSTH following a

road traffic accident. He has been knocked down by a three wheeler when he was trying to

cross the road.

On admission he is conscious but complaining of difficulty in breathing and chest tightness.

He is haemodynamically stable but on examination of the chest, trachea is shifted to left side

and there are no breath sounds on the right side. His X-ray of the chest shows darkening and

absent lung shadow on the right side and trachea appears to be shifted to left. On air SpO2 is

95%.

- What are the features to favour pneumothorax?

- Discuss the pathophysiological basis of pneumothorax, tension pneumothorax, and

open pneumothorax.

- What is a chest drain?

- What is the physiological basis of a chest drain?

- How do you insert a chest drain?

- What are the complications of a chest drain?

- How do you manage a chest drain in the ward?

- Explain the terms – Haemothorax, Flail chest.


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Acute shortness of breath

Topic: Sudden SOB

Scenario 2.1:

A 25 year old girl is admitted with shortness of breath and noisy breathing. This was

preceded by cough and fever for few days. She has been treated several times in the past for

episodes of cough and wheezing but was never on regular medication. She is allergic to

pineapple and gives a history of eczema. She also has runny nose and itchy eyes on most days

and there is a pet cat at home.

- What are the features favouring asthma?

- What is the pathophysiological basis for the wheeze?

- What medication can be used for acute treatment and why?

- What is the long term treatment?

- She undergoes a spirometry. Interpret the result

Predicted Pre bronchodilator Post bronchodilator

FEV1 3.27 2.34 (72%) 2.90 (89%)

FVC 3.81 3.45 (90%) 3.78 (99%)

FEV1/FVC 86% 68% 77%

- What are the precipitating factors for asthma in this patient?

Scenario 2.2:

A 65 year old heavy smoker with a 20 pack year history is admitted with shortness of breath

and wheezing. This was preceded by a history of cough and fever for 3 days. He has been

having similar episodes in the past two years resulting in repeated hospital admissions despite

being on regular inhalers.

He does not give a history of atopy and there is no family history of bronchial asthma. His

diagnosis card states he has chronic obstructive pulmonary disease (COPD).

- Based on the history what are the features that suggest COPD as opposed to asthma?

- What is the pathophysiological basis for shortness of breath?

- What features will you expect to see in examination and why?

- What medication will you use in the acute episode and why?


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Chest infection

Topic: Chest infection

Scenario:

A 68 year old patient complains of a cough with yellow coloured sputum. On the third day he

experiences fever and a dull ache on the right lower chest. He feels breathless at rest.

- Based on the history, what is the likely diagnosis?

- What examination findings will you expect to find and why?

- How will you investigate?

- Interpret his arterial blood gas analysis.

pH 7.21

PO2 53 mmHg

PCO2 72 mmHg

HCO3 28 mEq/L

SaO2 81%

FiO2 0.21


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Recommended Reading

Note- Students are expected to read the latest edition

Anatomy

Cunningham’s Manual of Practical Anatomy by G. J. Romanes

Volume 1 Upper & Lower limbs

Volume 11 Thorax& Abdomen

Volume 111 Head, Neck & Brain

Clinical Anatomy - Applied Anatomy for students and Junior Doctors by Harold Ellis

Vishy Mahadevan

Grant’s Atlas of Anatomy by Anne M.R.Agur and Arthur F. Dalley

Last’s Anatomy by R. M. H. Mc Minn

Biochemistry

Lippincott’s illustrated reviews by Pamela C. Champe and Richard A. Harvey

Physiology

Ganong’s Review of Medical Physiology by Kim E. Barrett, Susan M. Barman, Scott

Boitano and Heddwen L. Brooks

Pathophysiology of Disease: An Introduction to Clinical Medicine by Gary D.

Hammer and Stephen J. McPhee

Guyton and Hall Textbook of Medical Physiology by John E. Hall

Hutchison's Clinical Methods by Michael Glynn and William M. Drake

Kumar & Clark’s Clinical Medicine by Parveen Kumar & Michael Clark

Davidson’s Principles & Practice of Medicine by Edwards Bouchier, Haslett Chilvers

Physiological principles of Medicine series, Respiratory Physiology by John

Widdicombe & Andrew Davies

https://www.amazon.com/s/ref=dp_byline_sr_book_1?ie=UTF8&text=John+E.+Hall+PhD&search-alias=books&field-author=John+E.+Hall+PhD&sort=relevancerank

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