Lecture Notes Respiratory Medicine 9th Edition

Visit the link below to download the full version of this book:

https://medipdf.com/product/lecture-notes-respiratory-medicine-9th-edition/

Click Download Now

Respiratory Medicine
Lecture Notes

Stephen J. Bourke
Consultant Physician
Royal Victoria Infirmary
Newcastle upon Tyne;
Honorary Senior Lecturer
Newcastle University

Graham P. Burns
Consultant Physician
Royal Victoria Infirmary
Newcastle upon Tyne;
Honorary Senior Lecturer
Newcastle University

Ninth Edition
This edition first published 2015 © 2015 by John Wiley & Sons, Ltd.

Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex,
PO19 8SQ, UK
Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK
The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
111 River Street, Hoboken, NJ 07030-5774, USA

For details of our global editorial offices, for customer services and for information about how to
apply for permission to reuse the copyright material in this book please see our website at
www.wiley.com/wiley-blackwell

The right of the author to be identified as the author of this work has been asserted in accordance
with the UK 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.

Designations used by companies to distinguish their products are often claimed as trademarks. All
brand names and product names used in this book are trade names, service marks, trademarks or
registered trademarks of their respective owners. The publisher is not associated with any product
or vendor mentioned in this book. It is sold on the understanding that the publisher is not engaged
in rendering professional services. If professional advice or other expert assistance is required, the
services of a competent professional should be sought.

The contents of this work are intended to further general scientific research, understanding, and
discussion only and are not intended and should not be relied upon as recommending or
promoting a specific method, diagnosis, or treatment by health science practitioners for any
particular patient. The publisher and the author make no representations or warranties with respect
to the accuracy or completeness of the contents of this work and specifically disclaim all warranties,
including without limitation any implied warranties of fitness for a particular purpose. In view of
ongoing research, equipment modifications, changes in governmental regulations, and the constant
flow of information relating to the use of medicines, equipment, and devices, the reader is urged to
review and evaluate the information provided in the package insert or instructions for each
medicine, equipment, or device for, among other things, any changes in the instructions or
indication of usage and for added warnings and precautions. Readers should consult with a
specialist where appropriate. The fact that an organization or Website is referred to in this work as a
citation and/or a potential source of further information does not mean that the author or the
publisher endorses the information the organization or Website may provide or recommendations
it may make. Further, readers should be aware that Internet Websites listed in this work may have
changed or disappeared between when this work was written and when it is read. No warranty may
be created or extended by any promotional statements for this work. Neither the publisher nor the
author shall be liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data

Bourke, S. J., author.
Lecture notes. Respiratory medicine / Stephen J. Bourke, Graham P. Burns. – Ninth edition.
p. ; cm.
Respiratory medicine
Includes bibliographical references and index.
ISBN 978-1-118-65232-9 (pbk. : alk. paper)
I. Burns, Graham P., author. II. Title. III. Title: Respiratory medicine.
[DNLM: 1. Respiratory Tract Diseases. WF 140]
RC731
616.2 – dc23
2015006394

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print
may not be available in electronic books.

Cover image: iStockphoto © sankalpmaya

Set in 8.5/11pt, UtopiaStd by Laserwords Private Limited, Chennai, India

1 2015
To Dr R.A.L. Brewis
Contents
Preface, ix
About the Companion Website, xi

7 Tuberculosis, 86
Part 1 Structure and function, 1 8 Bronchiectasis and lung abscess, 97
9 Cystic fibrosis, 107
1 Anatomy and physiology of the lungs, 3
10 Asthma, 120
11 Chronic obstructive pulmonary disease, 139
12 Carcinoma of the lung, 156
Part 2 History taking, examination
and investigations, 17 13 Interstitial lung disease, 170
14 Occupational lung disease, 182
2 History taking and examination, 19
15 Pulmonary vascular disease, 194
3 Pulmonary function tests, 32
16 Pneumothorax and pleural effusion, 206
4 Radiology of the chest, 48
17 Acute respiratory distress syndrome, 219
18 Ventilatory failure and sleep-related breathing
disorders, 226
Part 3 Respiratory diseases, 59 19 Lung transplantation, 235
5 Upper respiratory tract infections and influenza, 61
6 Pneumonia, 69 Index, 243
Preface
It is now 40 years since the first edition of Lecture cancer, COPD to pneumonia, asthma to tuberculosis,
Notes: Respiratory Medicine was written by our sleep disorders to occupational lung diseases.
predecessor and colleague, Dr Alistair Brewis. In the ninth edition, the text has been revised and
Alistair Brewis, who sadly died in 2014, was inspi- expanded to provide a concise up-to-date summary
rational to generations of students and doctors. He of respiratory medicine for undergraduate students
was something of a polymath. As consultant in the and junior doctors preparing for postgraduate
Royal Victoria Infirmary, Newcastle, he was a very examinations. A particular feature of respiratory
highly regarded physician. With a natural ability to medicine in recent years has been multidisciplinary
communicate, his calm, friendly chats with patients team work, utilising the skills from a variety of dis-
were remarkably insightful, putting them at ease as ciplines to provide the best care for patients with
he pieced together the clinical jigsaw. As a teacher, respiratory diseases. This book should be useful to
he had the ability to make almost any topic seem sur- colleagues such as physiotherapists, lung-function
prisingly understandable. Over the years, he inspired physiologists and respiratory nurse specialists. The
many to take up careers in respiratory medicine. Alis- emphasis of Lecture Notes: Respiratory Medicine
tair was also an accomplished artist. He illustrated has always been on information that is useful and
the first edition of Lecture Notes with sketches and relevant to everyday clinical medicine, and the
diagrams that both amused and genuinely facilitated ninth edition remains a patient-based book to be
understanding; many have been retained in this read before and after visits to the wards and clinics
ninth edition. As a mentor, he was a reliable source of where clinical medicine is learnt and practised. As
sage advice, a wise man who understood the human Lecture Notes: Respiratory Medicine develops over
condition. time, we remain grateful to our teachers and their
From its first edition, Lectures Notes: Respiratory teachers, and we pass on our evolving knowledge
Medicine was a classic textbook, opening the eyes of respiratory medicine to our students and their
of generations of students to the special fascina- students.
tions of the subject. Subsequent editions map the
developments in this very broad-ranging specialty, S.J. Bourke
dealing with diseases from cystic fibrosis to lung G.P. Burns
About the Companion
Website
This book is accompanied by a companion website:

www.lecturenoteseries.com/Respiratory

The website includes:

• Interactive multiple choice questions

• PDFs of figures from the book
• PDFs of key points from the book
• PDFs of web links from the book
 Part 1
Structure and
function
 1
Anatomy and physiology
of the lungs
The anatomy and physiology of the respiratory system walls are referred to as bronchioles. Respiratory
are designed in such a way as to bring air from the bronchioles are peripheral bronchioles with alveoli
atmosphere and blood from the circulation into close in their walls. Bronchioles immediately proximal
proximity across the alveolar capillary membrane. to alveoli are known as terminal bronchioles. In
This facilitates the exchange of oxygen and carbon the bronchi, smooth muscle is arranged in a spiral
dioxide between the blood and the outside world. fashion internal to the cartilaginous plates. The
muscle coat becomes more complete distally as the
cartilaginous plates become more fragmentary.
The epithelial lining is ciliated and includes goblet
A brief revision cells. The cilia beat with a whip-like action, and waves
of contraction pass in an organised fashion from cell
of clinically relevant to cell so that material trapped in the sticky mucus
anatomy layer above the cilia is moved upwards and out of
the lung. This mucociliary escalator is an important
part of the lung’s defences. Larger bronchi also have
Bronchial tree and alveoli acinar mucus-secreting glands in the submucosa,
The trachea has cartilaginous horseshoe-shaped which are hypertrophied in chronic bronchitis.
‘rings’ supporting its anterior and lateral walls. The Alveoli are about 0.1–0.2 mm in diameter and are
posterior wall is flaccid and bulges forward during lined by a thin layer of cells, of which there are two
coughing. This results in narrowing of the lumen, types: type I pneumocytes have flattened processes
which increases the shearing force from the moving that extend to cover most of the internal surface of the
air on the mucus lying on the tracheal walls. alveoli; type II pneumocytes are less numerous and
The trachea divides into the right and left main contain lamellated structures, which are concerned
bronchi at the level of the sternal angle (angle of with the production of surfactant (Fig. 1.3). There
Louis). The left main bronchus is longer than the is a potential space between the alveolar cells and
right and leaves the trachea at a more abrupt angle. the capillary basement membrane, which is only
The right main bronchus is more directly in line with apparent in disease states, when it may contain fluid,
the trachea, so that inhaled material tends to enter fibrous tissue or a cellular infiltrate.
the right lung more readily than the left.
The main bronchi divide into lobar bronchi Lung perfusion
(upper, middle and lower on the right; upper and
lower on the left) and then segmental bronchi, as The lungs receive a blood supply from both the pul-
shown in Fig. 1.1. The position of the lungs in relation monary and the systemic circulations.
to external landmarks is shown in Fig. 1.2. Bronchi The pulmonary artery arises from the right ventri-
are airways with cartilage in their walls, and there are cle and divides into left and right pulmonary arteries,
about 10 divisions of bronchi beyond the tracheal which further divide into branches accompanying
bifurcation. Smaller airways without cartilage in their the bronchial tree. The pulmonary capillary network

Respiratory Medicine Lecture Notes, Ninth Edition. Stephen J. Bourke and Graham P. Burns.
© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd.
Companion Website: www.lecturenoteseries.com/Respiratory
4 Anatomy and physiology of the lungs

Right lung Left lung

Apical
Apical
Posterior
UL Posterior
Anterior UL
Anterior
Superior
LING
Lateral Inferior
ML Apical
Medial Apical Lateral basal
lower
lower LL
Lateral basal Posterior basal Figure 1.1 Diagram of
LL Medial basal bronchopulmonary segments. LING,
Posterior basal Anterior basal
Anterior basal lingula; LL, lower lobe; ML, middle
lobe; UL, upper lobe.

Clavicle

4th Thoracic
spine RUL
Level of
RUL angle of
LUL Louis
RML
RML
RLL 6th Costal
RLL LLL cartilage
Lower edge 8th Rib
of lung
Lower limit 10th Rib
Lower limit of pleura of pleura
Lower edge
of lung
(a) (b) Mid-axillary line

Figure 1.2 Surface anatomy. (a) Anterior view of the lungs. (b) Lateral view of the right side of the chest at resting
end-expiratory position. LLL, left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RML, right middle lobe;
RUL, right upper lobe.

in the alveolar walls is very dense and provides a very of the airways down to the level of the respiratory
large surface area for gas exchange. The pulmonary bronchiole. Most of the blood drains into radicles
venules drain laterally to the periphery of lung lob- of the pulmonary vein, contributing a small amount
ules and then pass centrally into the interlobular and of desaturated blood, which accounts for part of the
intersegmental septa, ultimately joining together to ‘physiological shunt’ (blood passing through the
form the four main pulmonary veins, which empty lungs without being oxygenated) observed in normal
into the left atrium. individuals. The bronchial arteries may undergo
Several small bronchial arteries usually arise from hypertrophy when there is chronic pulmonary
the descending aorta and travel in the outer layers of inflammation, and major haemoptysis in diseases
the bronchi and bronchioles, supplying the tissues such as bronchiectasis or aspergilloma usually arises
 Anatomy and physiology of the lungs 5
Lamellar
inclusion
bodies
Alveolus
Ib Figure 1.3 Structure of the alveolar
Ib wall as revealed by electron
Ia microscopy. Ia, type I pneumocyte;
II Ib, flattened extension of type I
pneumocyte covering most of the
IS internal surface of the alveolus; II,
IS type II pneumocyte with lamellar
inclusion bodies, which are probably
RBC the site of surfactant formation; IS,
interstitial space; RBC, red blood
Nucleus of corpuscle. Pneumocytes and
Capillary Ib
endothelial endothelial cells rest upon thin
endothelium
cell continuous basement membranes,
which are not shown.

from the bronchial rather than the pulmonary arteries The muscles that drive the pump
and may be treated by therapeutic bronchial artery
embolisation. The pulmonary circulation normally Inspiration requires muscular work. The diaphragm
offers a much lower resistance and operates at a lower is the principal muscle of inspiration. At the end of
an expiration, the diaphragm sits in a high, domed
perfusion pressure than the systemic circulation. The
position in the thorax (Fig. 1.4). To inspire, the strong
pulmonary capillaries may be compressed as they
muscular sheet contracts, stiffens and tends to push
pass through the alveolar walls if alveolar pressure
rises above capillary pressure.

Inspiration

Physiology
The core business of the lungs is to bring oxygen into
the body and to take carbon dioxide out.
This is brought about by a process best considered
in two steps:

1 Ventilation. The movement of air in and out of the

lungs (between the outside world and the alveoli).
2 Gas exchange. The exchange of oxygen and carbon
dioxide between the airspace of the alveoli and the
blood.
(a) (b)
This process continues throughout life, largely
unconsciously, coordinated by a centre in the brain Figure 1.4 Effect of diaphragmatic contraction.
stem. The factors that regulate the process, ‘the Diagram of the ribcage, abdominal cavity and
control of breathing’, will also be considered here. diaphragm showing the position at the end of resting
expiration (a). As the diaphragm contracts, it pushes the
abdominal contents down (the abdominal wall moves
Ventilation outwards) and reduces pressure within the thorax,
To understand this process, we need to consider the which ‘sucks’ air in through the mouth (inspiration). (b)
As the diaphragm shortens and descends, it also
muscles that ‘drive the pump’ and the resistive forces
stiffens. The diaphragm meets a variable degree of
they have to overcome. These forces include the inher- resistance to downward discursion, which forces the
ent elastic property of the lungs and the resistance to lower ribs to move up and outward to accommodate its
airflow through the bronchi (airway resistance). new position.