54 Avinash,

Pulmonology
The Respiratory System
Pulmonology is the medical study of the structure and diseases of the respiratory system,
which includes all of the air passages from the nose to the tiny air sacs in the lungs. The lungs
are vital to our existence because they extract oxygen from the atmosphere, transferring
oxygen to blood vessels that then carry it throughout our bodies. Without a steady supply of
oxygen, we can survive for only a few minutes. A pulmonologist is a physician who specializes
in the diagnosis and treatment of diseases and conditions related to the respiratory system.

THE STRUCTURE OF THE RESPIRATORY SYSTEM

The upper part of the respiratory system, including the nasal and oral cavities, pharynx, and
larynx. The current chapter is concerned with the lungs and those structures associated with
them. As depicted in Figure 12-1, the trachea, or windpipe, extends from the lower part of the
larynx to the bronchi and contains 16 to 20 pieces of C-shaped cartilage that provides its rigidity.
The lungs are the primary organs of respiration and are positioned on either side of the thorax.
They are protected by the ribs and sternum (or breastbone).

The thoracic vertebrae are posterior to the lungs. The medial space between the two lungs is
called the mediastinum and contains the heart and thoracic viscera, except for the lungs.
Because the heart is inclined to the left in the mediastinum, the right lung is slightly larger than
the left. Each lung is divided into sections called lobes. The left lung has two lobes while the
right lung has three lobes. As depicted in Figure 12-2, each lung has an oblique (major) fissure.
In addition, the right lung has a horizontal (minor) fissure.

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 Avinash, 55

The right and left bronchi extend from the trachea to the lungs. Once the bronchi enter the
lungs, they divide into smaller and smaller branches, creating the appearance of an upside-down
tree with the trachea being its trunk. In fact, this structure is referred to as the tracheobronchial
tree. The smallest branches are called bronchioles. At the end of the bronchioles are tiny air
sacs called alveoli. Networks of tiny blood vessels called capillaries surround these alveoli.
These capillary beds obtain oxygen from the alveoli and, in return, transfer carbon dioxide to the
alveoli. It is this exchange of oxygen for carbon dioxide that allows our bodies to obtain oxygen
needed for survival and to get rid of carbon dioxide as a waste product.
Each lung is contained within its own pleural sac that is formed from a serous membrane called
the pleura. The visceral pleura lines the outer surface of each lung. The parietal pleura lines
the outer wall of the pleural cavity and separates the rib cage and the superior surface of the
diaphragm from the pleural cavity. Between these two pleurae, the pleural cavity is created. It is
the space lubricated by pleural fluid, allowing the lungs to move freely within the rib cage
during breathing.
The process of moving air in and out of the lungs is referred to as breathing or ventilation.
During breathing, air enters the body through either the mouth or the nose. Air then passes into
the pharynx, through the trachea, and into the tracheobronchial tree. Normally, breathing occurs
about 14 to 20 times a minute. It is an automatic function of which we are normally unaware.
However, if our breathing becomes labored due to exertion or an abnormal respiratory condition,
we may become conscious of our breathing. In addition, we can control our breathing when
necessary, such as during swimming. Breathing consists of two distinct phases: the inspiratory
phase and the expiratory phase. During inspiration, the diaphragm, a large
musculomembranous structure between the thoracic and abdominal cavities, contracts, pushing
the abdominal cavity downward and allowing the muscles in the thorax to expand. As the thorax
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expands, its internal pressure is reduced. This causes the lungs to expand and air to be drawn
into the tracheobronchial tree. When the inspiratory phase stops, the lungs and chest wall relax
and the diaphragm slowly rises.
This produces expiration, the phase during which air is pushed out of the nose or mouth.
Respiration can be divided into two processes: external and internal. During external respiration,
oxygen and carbon dioxide are exchanged between the person and the air in the environment.
Internal respiration refers to the exchange of oxygen and carbon dioxide at the cellular level. The
body uses oxygen and releases carbon dioxide.
EXAMINING THE RESPIRATORY SYSTEM
When examining the respiratory system, the examiner begins by inquiring about respiratory
problems such as dyspnea (shortness of breath), asthma, bronchitis, general chest pain,
pneumonia, and tuberculosis. In addition, questions are asked about any personal habits, such as
smoking, that can lead to respiratory problems. Medical professionals typically state a patient’s
smoking history in terms of average number of packs smoked per day times the number of years
of smoking. For example, an individual who smoked 1-1/2 packs of cigarettes a day for 20 years
would have a 30- pack-year smoking history (1-1/2 x 20 = 30).
The patient is also asked about occupational or environmental exposure to pollution. If coughing
is present, the examiner should ask if the coughing began suddenly or developed gradually and
whether it causes chest or throat pain. Determining what factors elicit coughing can help in
determining its cause. For example, if coughing occurs following a change in posture, the
coughing can be indicative of tuberculosis, a tumor, or lung abscess while coughing that occurs
during exercise is often a symptom of asthma.
The patient should also be questioned about sputum production. Sputum consists of mucus and
other purulent matter that is expectorated from the airways and is a symptom of a variety of
respiratory conditions and diseases. The examiner observes chest movement during inspiration
and expiration and counts the respirations per minute. A normal resting adult breathes
approximately 14 to 20 times a minute, and the breaths are regular and barely audible. The
examiner listens for irregular or abnormal sounds such as wheezing. Wheezing is the act of
producing musical sounds during breathing and is usually caused by a narrowed air passage,
such as a bronchus or the trachea. The examiner inspects for a condition referred to as
“clubbing” of the fingers, in which the ends of the fingers (particularly the nailbeds) are round
and bulbous. Clubbed fingers can be a sign of several conditions, including chronic hypoxia
(below normal levels of oxygen in the body) or lung cancer.
The exterior nose and oral and nasal cavities should be inspected for any abnormalities. The
examiner also inspects for signs of cyanosis. Cyanosis is a bluish or purplish discoloration of the
skin and mucous membranes indicating insufficient oxygenation of the blood. The examiner
palpates the chest wall to check for deformities or a lack of symmetry between the two sides. In
addition, the examiner palpates the chest for fremitus, the vibrations of the thorax that can be
felt during breathing.
The examiner percusses the chest wall to determine the content of the lungs. The sound
produced during percussion is an indicator of the density of the part percussed. The examiner
performs percussion by placing one hand, with the fingers outstretched, on the chest wall of the
patient. The middle finger of the examiner’s other hand is then used to briskly strike the first
joint of the middle finger of the extended hand. In healthy lungs, percussing the upper back will
generate a clear note. The tone is duller in lungs that are filled with fluid. A dull sound is
produced when percussing over the ribs and sternum. The best method of assessing airflow
through the tracheobronchial tree is auscultation. Auscultation refers to listening to sounds in
various parts of the body, including the heart, lungs, and abdomen, for diagnostic purposes. A
stethoscope is used to listen to sounds made by the trachea, bronchi, and lungs. The stethoscope
has two hollow tubes with earpieces on one end and a bellshaped structure that helps in
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amplifying sounds on the other end. As people age, the chest wall becomes stiffer, the
muscles may become weaker and the lungs become less active. Older patients are more likely to
experience dyspnea during exercise. The ability of the lungs to fill with air is referred to as
compliance. As people age, the lungs tend to become less compliant.
DISEASES AND CONDITIONS OF THE RESPIRATORY SYSTEM
Chronic obstructive pulmonary disease (COPD), sometimes called chronic obstructive lung
disease (COLD), refers to any disease that is characterized by permanent or temporary bronchial
narrowing. Such conditions include asthma, chronic bronchitis, and emphysema. COPD is
generally progressive, leading to greater and greater obstruction of the airways. It is the fourth
leading cause of death in the US. Risk factors include smoking and air pollution.
One important type of lung disease is pneumonia, which is an acute infection of the lung tissue,
including the air spaces within the alveoli. The alveoli typically fill with pus or other materials
that are byproducts of inflammation. Pneumonia may affect an entire lobe, a portion of a lobe, or
the alveoli next to the bronchi. It is the sixth leading cause of death in the US today. The most
common cause of pneumonia is bacteria, including Streptococcus pneumoniae and
Staphylococcus aureus. Pneumonia may be caused by a virus, particularly in infants and
children.
In addition, pneumonia may be caused by fungi such as Pneumocystis carinii. Pneumocystis
carinii pneumonia (PCP) is most commonly seen in individuals infected by human
immunodeficiency virus (HIV).

TABLE 12-1 Pulmonary Diseases and Conditions

Condition or Description
Disease
adult respiratory Acute respiratory failure that appears following pulmonary injury,
distress syndrome such as direct chest trauma, sepsis, or inhalation of toxic gas.
(ARDS) Hypoxemia, respiratory distress, and pulmonary edema are some of
the signs.
anoxia Complete or nearly complete absence of oxygen from the blood
and/or tissue.
anthracosis A type of lung disease caused by the long-term inhalation of coal dust
during coal mining. A type of pneumoconiosis. Also called coal
workers pneumoconiosis or black lung disease.
asbestosis A type of lung disease caused by the long-term inhalation of asbestos
dust. A type of pneumoconiosis.
asphyxia An inadequate exchange of oxygen and carbon dioxide.
asthma Inflammation and constriction of the airway over a relatively short
period of time that can be caused by a reaction to a stimulus such as
an allergen or exercise. Asthma is usually reversible.
atelectasis An absence of air from all or part of the lungs which can lead to a
collapsed lung. It can be acute (for example, when there is bronchial
obstruction due to a foreign object) or chronic (such as obstruction by
a tumor).
bradypnea Breathing that is slower than normal.
bronchiectasis Chronic dilation of bronchi or bronchioles as a result of an obstruction
or an inflammatory disease. Symptoms include coughing and spitting
up mucus.
bronchitis Inflammation of the bronchi.
Bronchogenic Cancer that originates in a bronchus. The most common type of lung
carcinoma cancer. Its primary cause is tobacco smoking.
Cheyne-Stokes Abnormal breathing characterized by periods of deep breathing

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respiration (hyperpnea) followed by periods of no breathing (apnea).
chronic bronchitis Bronchitis that lasts at least 3 months. It can be a symptom of lung
cancer, tuberculosis, or chronic heart failure.
chronic obstructive A general term used for diseases that cause the bronchi to be either
pulmonary permanently or temporarily narrowed.
disease(COPD)
clubbing of the fingers A physical finding in which the ends of the fingers are enlarged,
round, and bulbous. The angle of the nailbed also changes. It can be a
sign of several conditions, including chronic hypoxia and lung cancer.
cough A sudden, explosive forcing of air out of the airways. Its primary
purpose is to clear sputum and other materials from the airways.
crackles Abnormal breath sounds heard on auscultation of the chest that are
brief, sharp, and nonmusical.
croup Any acute respiratory condition in children and infants that is
characterized by rough breathing and a hoarse cough.
cyanosis A bluish or purplish discoloration of the skin and mucous membranes
due to inadequate oxygenation of the blood cells.
cystic fibrosis A disease in which the secretions of the exocrine glands are thick,
causing obstruction of various passageways in the respiratory and
digestive systems It is an inherited disease in which symptoms
typically first appear during childhood.
dyspnea An unpleasant sensation of shortness of breath along with a subjective
feeling of not being able to breathe normally. It can occur with
diseases of the heart or lungs. It also can occur in healthy individuals
during strenuous exertion or when at high altitudes.
edema An accumulation of excessive amounts of fluid in cells, tissues, or in a
body cavity.
egophony A term used to describe an abnormal vocal sound, similar to the
bleating of a goat.
emphysema Abnormal and permanent enlargement of the alveoli with destruction
of the alveolar walls. Characterized by use of the accessory muscles
for breathing and pursed lips.
empyema Pus in a body cavity. This term is most commonly used to refer to pus
in a pleural cavity (pyothorax).
hemoptysis The act of spitting blood.
hyaline membrane A condition in premature newborns caused by deficient pulmonary
disease (HMD) surfactant, the substance required for the lungs to expand, leading to
respiratory distress. Also called respiratory distress syndrome.
hypercapnia An abnormally excessive amount of carbon dioxide in the arterial
blood.
hyperpnea Rapid deep breathing that can be brought on by exertion, anxiety, or
certain abnormal medical conditions.
hypoxemia Below-normal oxygenation of the arterial blood. Hypoxemia is not as
severe as anoxia.
hypoxia A below-normal level of oxygen in arterial blood, tissues, or inspired
gases. Hypoxia is not as severe as anoxia.
Legionnaire disease A serious form of bacterial pneumonia caused by Legionella
pneumophila.
malignant A cancerous growth of the pleural lining.
mesothelioma
orthopnea The situation in which breathing is easier in an upright position and
becomes more difficult when lying flat.

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paroxysmal nocturnal An abnormal shortness of breath that occurs during the night, causing
dyspnea the patient to wake up gasping for air. It may be indicative of
cardiovascular disease.
pleural effusion Increased amount of fluid in the pleural cavity.
pleural rub A rubbing sound caused by friction of the pleura when inflamed. Also
called pleural friction.
pleurisy An inflammation of the pleura that usually causes stabbing chest pain
and pleural effusion. Also called pleuritis.
pleurodynia Pain in the tendinous attachments of thoracic muscles. Also referred
to as pleuralgia.
pneumoconiosis An occupational lung disease causing inflammation of the lungs due
to the inhalation of dust particles.
pneumomelanosis Blackening of lung tissue due to the inhalation of coal dust.
pneumonia An acute inflammation of the lung tissue, including the air spaces
within the alveoli. The alveoli typically fill with pus or other materials
as a result of inflammation. Pneumonia can be caused by inhalation of
chemicals; trauma; or bacterial, viral, or fungal infections.
pneumonocele The protrusion of a portion of the lung through an opening in the
chest wall. Also referred to as pleurocele or pneumocele.
pneumothorax The presence of air or gas in the pleural cavity.
pulmonary abscess A collection of pus in the lungs as an end product of the destruction of
lung tissue.
pulmonary edema Excess fluid and swelling in the alveoli and bronchioles.
pulmonary embolism A sudden dislodging of a blood clot in the pulmonary artery (the
(PE) artery that supplies blood to the lungs), causing obstruction of blood
to the lung tissue.
pyothorax Pus in a pleural cavity.
rale An added sound heard on auscultation of breath sounds.
rhonchus (pl. rhonchi) Musically pitched sounds in addition to the normal sounds heard
during inspiration or expiration.
silicosis An occupational lung disease caused by the inhalation of small silica
particles, such as those found in coal, copper, silver, and gold mining.
A type of pneumoconiosis.
stridor An abnormal, high-pitched breath sound, predominantly heard on
inspiration. It can be heard without a stethoscope. Stridor sounds like
the wind blowing.
tachypnea Breathing that is more rapid and more shallow than normal.
tuberculosis (TB) An infectious disease typically characterized by coughing, weight
loss, chest pain, and spitting up blood. It is caused by Mycobacterium
tuberculosis.
wheeze Abnormal breath sounds that are longer than crackles and may have a
whistling, puffing, or hissing quality.

COMMON DIAGNOSTIC TESTS AND PROCEDURES

Chest x-rays are frequently used in the diagnosis of lung conditions, particularly with infectious
conditions. A radiograph allows the physician to determine those areas of the lungs that have
been affected. Various types of endoscopic procedures are also used to examine the airways.
Table 12-2 lists a number of common tests.
TABLE 12-2 Common Diagnostic Tests and Procedures in Pulmonology
Test Description
acid-fast stain Use of an acid-fast stain on a slide preparation prior to microscopic
examination to aid in the diagnosis of conditions such as
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tuberculosis.
arterial blood gas (ABG) A measurement of the partial pressures of O2 and CO2 levels in
analysis arterial blood.
biopsy of lung tissue A specimen of lung tissue is collected, usually during bronchoscopy,
and sent to the lab to be microscopically examined to establish a
diagnosis. Biopsies are commonly used to diagnose malignant
growths.
bronchoalveolar lavage A bronchoscope is inserted through the mouth or nose. A
(BAL) fluoroscope may be used to guide the bronchoscope to the part of the
lung to be examined. A saline solution is used to irrigate the
pulmonary passages and the washings are then suctioned out and
sent to the laboratory for analysis. This test is used to diagnose
certain types of pneumonia and lung cancer.
bronchoscopy An endoscope is inserted through the nose or mouth, passed through
the trachea and into the lungs, allowing for visual examination of the
tracheobronchial tree. Lung secretions and/or tissue may also be
collected for laboratory analysis.
chest radiography Images of the chest are recorded for diagnostic purposes using x-
rays and film.
CT scan of the chest A computer-generated reconstruction of the chest is created from a
series of x-ray images taken as cross-sections of the chest.
Giemsa stain A Giemsa stain is used on a slide preparation prior to microscopic
examination to aid in the diagnosis of conditions such as pulmonary
hemorrhage, bacterial infection, and pneumonia.
Gram stain A Gram stain is used on a slide preparation prior to microscopic
examination to aid in the identification of specific types of bacteria.
mediastinoscopy Endoscopic examination of the mediastinum. It requires an incision
above the breastbone and allows for the removal of tissue samples
for biopsy via an endoscope.
pulmonary function tests A group of tests used to measure respiratory functions including the
(PFTs) volume of air the lungs can take in, the volume of air the lungs can
hold, and the volume of air the lungs can exhale. A spirometer is
used to measure the amount of air moved and the rate of its
movement. Some test measurements are made during regular
breathing while others require forced inspiration and/or expiration.
These tests are useful in diagnosing a variety of lung conditions such
as bronchitis, asthma, and emphysema.
pulmonary This test has two components: the ventilation (V) scan and the
ventilation/perfusion perfusion (Q) scan. In the ventilation scan, the individual inhales
scan (V/Q scan) radioactive gas while the lungs are being scanned. This process
allows the examiner to view the ventilation (breathing) process. In
the perfusion scan a radioactive substance is injected into a vein so
that the flow of blood through the lungs can be viewed via a
specialized scanner.
pulse oximetry An electronic device is placed on the patient’s finger to measure
oxygen saturation in the blood.
spirometry The quantity of air entering the lungs and the rate of its movement
over a period of time are measured. The instrument used is a
spirometer.
sputum culture A sputum specimen is sent to a lab where tests are performed to
identify the presence of certain cell types or infectious agents. These
results can aid in diagnosing and determining the proper course of
treatment for such conditions as pneumonia, bronchitis, tuberculosis,
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and lung abscesses.
sweat test The level of chloride in the sweat is measured. It is used in the
diagnosis of cystic fibrosis and in determining the type of treatment
required.
thoracentesis The pleura is punctured with a needle and fluid (pleural effusion) is
aspirated for analysis. Thoracentesis can also be a therapeutic
procedure.
thoracoscopy Endoscopic examination of the pleural space. It is primarily used to
diagnose pleural disease. Also known as pleuroscopy.

Pulmonary function tests are widely administered to determine the capabilities and capacity of
the respiratory system. Static measurements such as volumes and dynamic measurements such
as flows provide clues as to the quality of ventilation, gas exchange, and lung mechanics.
Spirometry is a measurement method that uses an instrument called a spirometer to measure the
amount of air and the rate of its movement into or out of the lungs over a period of time. The
results of these tests are specified using pulmonary-respiratory terminology. This terminology
and the corresponding abbreviations are shown in Table 12-3. Note that the second column of
this table shows how each abbreviation should be transcribed.
TABLE 12-3 Pulmonary Function Testing
Abbreviation Transcribe Term
As
DLCO DLCO diffusing capacity for carbon monoxide specified in mL/min
per mmHg
ERV ERV expiratory reserve volume
FEF FEF forced expiratory flow
FEF25-75% FEF25-75% mean forced expiratory flow during the middle half of forced
vital capacity
FEV FEV forced expiratory volume
FEV1 FEV1 forced expiratory volume in 1 second, specified in liters
FEV1%FVC FEV1%FVC forced expiratory volume in 1 second, as a percentage of
FVC
FRC FRC functional residual capacity
FVC FVC forced vital capacity
FVL FVL flow volume loop
IC IC inspiratory capacity
IRV IRV inspiratory reserve volume
MEP MEP maximal expiratory pressure (cm H2O)
MIP MIP maximal inspiratory pressure (cm H2O)
MVV MVV maximal voluntary ventilation
PaCO2 PaCO2 partial pressure of arterial carbon dioxide (mmHg)
PAO2 PAO2 partial pressure of oxygen in the alveoli (mmHg)
PaO2 PaO2 partial pressure of arterial oxygen (mmHg)
Pb Pb barometric pressure (mmHg)
PCO2 PCO2 partial pressure of carbon dioxide (mmHg)
PEF PEF peak expiratory flow (L/min)
PO2 PO2 partial pressure of oxygen (mmHg)
Q Q perfusion (L/min)
Raw Raw airway resistance
TLC TLC total lung capacity
VC VC vital capacity
VDS VDS dead space volume
VT VT tidal volume

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METHODS OF ESTABLISHING AN AIRWAY AND MECHANICAL VENTILATION

When a patient is without an adequate airway, damage can occur to vital organs within minutes,
and medical professionals must act quickly to re-establish airflow to the lungs. If a patient is
unable to effectively clear secretions from his or her airway and the airway becomes blocked,
oropharyngeal suctioning may be adequate to open it. A flexible catheter with a number of holes
along the sides of its distal end is inserted through the mouth and into the pharynx. A vacuum is
used to remove the secretions through the catheter. In an emergency situation, a manual
resuscitation bag and mask can be used to temporarily provide ventilation. The mask fits tightly
over the patient’s face.
The bag is then pumped manually to force air into the lungs. An esophageal obturator airway
may be passed through the mouth, creating a passageway to the larynx. The semi-rigid
esophageal obturator is inserted through the mouth, blocking the esophagus. This allows air to
be forced into the trachea. Either mouth-to-mouth resuscitation or a bag and mask can then be
used to force air into the lungs. If the upper airway is obstructed, a tracheotomy
(cricothyrotomy) may be performed. This procedure involves inserting a large needle, catheter,
or similar hollow device into the trachea. Air may then be forced into the trachea through the
opening.
Endotracheal intubation replaces emergency measures when circumstances permit. Endotracheal
intubation allows for full control of the airway and can be done through either the nose or the
mouth. If a patient is unable to maintain adequate oxygenation through unassisted breathing,
mechanical ventilation may be instituted. Mechanical ventilation provides a constant supply of
oxygen to the lungs, permits all aspects of the breathing process to be controlled, and allows
time for other therapies to take effect. A mechanical ventilator is an electronic device that
creates pressure on the airways and forces air into the lungs in a cyclic fashion, in an attempt to
mimic normal breathing. Controls on the ventilator allow the operator to control cycling time,
the volume of air and percentage of oxygen in the air forced into the lungs, and many other
factors. When being placed on a ventilator, the patient is intubated, and hoses are then attached
to allow air to be carried between the ventilator and the patient. Terms used with mechanical
ventilation are listed in Table 12-4.
TABLE 12-4 Mechanical Ventilation Terminology
Term Description Abbreviation
assist-control Automatically forces a patient to inspire if the AC ventilation
ventilation patient has not inspired naturally after a set interval
of time.
assisted ventilation Manually or mechanically assists a patient to inspire
by applying intermittent positive airway pressure
(pressure greater than that of the atmosphere); the
patient is attempting to breath.
bilevel positive airway Provides positive airway pressure that varies about BiPAP
pressure two levels.
continuous positive Continually maintains airway pressure at greater CPAP, C-PAP
airway pressure than atmospheric level throughout the respiratory
cycle by using a face mask.
controlled mechanical Mechanically forces a patient to inspire by applying CMV
ventilation intermittent positive airway pressure; no breathing
effort is required by the patient.
controlled ventilation Mechanically or manually forces a patient to inspire
by applying intermittent positive airway pressure; no
breathing effort is required by the patient.
high-frequency Mechanically forces exchange of gas(es) by rapidly HFV
ventilation pulsing small amounts of gas(es) into the lungs.

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intermittent mandatory Mechanically forces a patient to inspire by applying IMV
ventilation intermittent positive airway pressure at preset
intervals to increase the intake volume of gas(es).
manual ventilation Forces gas(es) into a patient’s airway by using an
air-filled bag that is manually compressed on an
intermittent basis.
positive end-expiratory Creates positive airway pressure at the end of PEEP
pressure exhalation by mechanically impeding exhalation.
positive pressure Forces a patient to inspire by applying intermittent PPV
ventilation positive airway pressure.
pressure-controlled Mechanically forces a patient to inspire by applying PCV
ventilation, pressure intermittent positive airway pressure in such a way
control ventilation that the maximum pressure is regulated by the
equipment.
pressure support Mechanically assists a patient to inspire by PSV
ventilation progressively changing airway pressure up to a fixed
maximum level with each respiratory cycle; the
patient is attempting to breath.
synchronized Synchronizes intermittent mandatory ventilation SIMV
intermittent mandatory with the patient’s own breathing.
ventilation

PHARMACOLOGY
Several classifications of drugs are widely used in pulmonology. Diseases such as bacterial
pneumonia, Legionnaire disease, and tuberculosis are treated with specialized antibiotics.
Bronchodilators are widely used in conditions such as asthma where the bronchi constrict,
reducing airflow. They are typically administered by inhalation.
TABLE 12-5 Classifications of Pulmonary Drugs
Classification Usage Examples
antibiotic Treatment of bacterial pneumonia such as azithromycin, dirithromycin,
Legionnaire disease. Some of the drugs levofloxacin, rifampin
are also used in the treatment of
tuberculosis.
antitubercular Treatment of tuberculosis. ciprofloxacin, cycloserine,
ethambutol, isoniazid,
rifampin, rifapentine,
streptomycin
bronchodilator Treatment of asthma, emphysema, COPD, albuterol, aminophylline,
and bronchospasm induced by exercise. bitolterol, budesonide,
These drugs work by relaxing the muscles epinephrine, ipratropium,
surrounding the bronchi, allowing for isoproterenol, metaproterenol,
increased airflow. Bronchodilators may be pirbuterol, salmeterol,
given through an inhaler, orally, or terbutaline, theophylline
intravenously.
corticosteroid Reduction of the inflammation and tissue beclomethasone,
swelling associated with COPD. dexamethasone, flunisolide,
triamcinolone
leukotriene Treatment and prophylaxis of asthma and cromolyn, zafirlukast, zileuton
receptor bronchospasm. These drugs block the
antagonist action of leukotriene, which can cause
edema and constriction of the bronchi
during allergic reactions.

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THERAPEUTIC PROCEDURES
Some of the surgical procedures performed on the lungs are highly invasive, requiring cutting
into the chest wall (thoracotomy). Because of the obvious risks involved in these types of
procedures, physicians attempt to use less invasive procedures when possible. Invasive
procedures, however, may be necessary in the treatment of bronchogenic carcinoma, the most
common type of lung cancer. A lobectomy or pneumonectomy may be performed to remove
diseased lung tissue. Radiation therapy and/or chemotherapy may also be used. Several types of
pulmonary procedures are listed in Table 12-7.

TABLE 12-7 Therapeutic Procedures Used in Pulmonology

Procedure Description
bronchoplasty Surgical repair or modification of a bronchus.
cricothyrotomy Establishment of a temporary airway by surgically creating an opening into
the larynx. This opening is usually intended to be temporary. A large needle
or needle catheter is inserted into the airway so that air can be supplied to the
lungs. This procedure is safer to perform in an emergency situation than a
tracheostomy.
laryngectomy Partial or total surgical removal of the larynx, most commonly performed as
a cancer treatment.
lobectomy Excision of a lobe of any organ. When the term is used alone, it usually
refers to the excision of a lobe of a lung.
lung transplant Surgical replacement of one or both lungs with the healthy lungs of a donor.
The lungs typically come from a brain-dead donor who is on life support. In
some instances, a portion of a lung may be transplanted from a living donor.
Lung transplants are performed only on individuals with severe, life-
threatening lung disease.
pleurectomy Excision of the pleura.
pneumonectomy Excision of a lung. Also called pulmonectomy.
thoracentesis Surgical puncture and drainage of the pleural cavity. This procedure can be
done for diagnostic purposes or to relieve inadequate respiration that can
occur with excessive pleural fluid. Also called thoracocentesis.
thoracotomy Surgical incision of the chest wall. This procedure is sometimes done for
diagnostic purposes and also is performed during a lobectomy or
pneumonectomy.
tracheostomy Surgical creation of an airway into the trachea so that air can enter the lungs.
A tracheostomy is more risky for the patient than a cricothyrotomy.
Therefore, it is best performed in a controlled ICU or operating room
environment. Also called a tracheotomy.
tube Surgical creation of an opening in the chest wall to allow for drainage. This
thoracostomy procedure is used to treat conditions such as pneumothorax.

Abbreviations*
Abbreviation Meaning
A&P auscultation and percussion
ABG arterial blood gas(es)
AP anterior posterior
ARDS adult respiratory distress syndrome
BAL bronchoalveolar lavage
BOOP bronchiolitis obliterans with organizing pneumonia
CO carbon monoxide

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CO2 carbon dioxide
COLD chronic obstructive lung disease
COPD chronic obstructive pulmonary disease
CPR cardiopulmonary resuscitation
CXR chest x-ray (chest radiograph)
DNR do not resuscitate
HMD hyaline membrane disease
IPPB intermittent positive-pressure breathing
IRDS infant respiratory distress syndrome
PA posterior anterior
PCP Pneumocystis carinii pneumonia
PE pulmonary embolism
PFT pulmonary function test
RD respiratory disease
RDS respiratory distress syndrome
SOB shortness of breath
TB Tuberculosis
* Abbreviations used in pulmonary function testing are listed in Table 12-3. Abbreviations used
in mechanical ventilation terminology are listed in Table 12-4.

For internal use only