Respiration Module Programme PDF

Module “Respiration and Circulation”
“RESPIRATION”
Programme
1. General information
Supervisor of the module: assoc.prof. dr. Palmira Leišytė

(palmira.leisyte@lsmuni.lt)
Departments:
Institute of Anatomy
Department of Histology and Embryology
Institute of Physiology and Pharmacology
Department of Biochemistry
Department of Pathological Anatomy
Department of Radiology
Department of Internal Medicine
Department of General Surgery
Department of Environmental and Occupational Medicine
Subjects and Coordinating Teachers:

Anatomy (in charge – assoc. prof.dr. Inga Saburkina );
Human Histology and Embryology (in charge – assoc. prof. dr. Jolita Palubinskienė);
Physiology (in charge - assoc.prof. dr. Alė Laukevičienė);
Pathological Physiology (in charge – assoc.prof. dr.Dalia Akramienė);
Biochemistry (in charge –dr. Irma Martišienė);
Pathological Anatomy (in charge – dr.Milda Kuprytė);
Radiology (in charge – assoc. prof.dr. Laima Dobrovolskienė);
Pharmacology (in charge – dr. Valdas Liukaitis);
Basics of Medical Diagnostics (in charge – assoc.prof. dr. Palmira Leišytė)
General Surgery (in charge – assoc. prof.dr. Saulius Bradulskis);
Environmental and Occupational Medicine (in charge - dr. Rita Raškevičienė);
2. General content of the module
1. Anatomy of bronchi and lungs:

Embryology.
Bronchial tree.
Topography of lungs, lobes, and pleura.
Bronchial and alveolar vessels.
Pulmonary lymphnodes.
Nerves of the respiratory system.
Respiratory muscles.
2. Histology and Embryology of Respiratory system:
Development and developmental defects of the respiratory system.
The structure of the lower airways’ wall (trachea, bronchus and bronchiole).
Histological structure of respiratory part of lungs (alveolar tree and alveoli).
Histology of pleura.
Structural basis of defensive mechanisms, involved in lungs (immunocompetent cells of airways
and pulmonary parenchyma: alveolar macrophages, lymphocytes, neutrophils, eosinophils, mast
cells).
Peculiarities of pulmonary blood vessels structure and blood supply.
3. Physiology and pathophysiology of the respiratory system:

Mechanics of breathing.
Intrapleural and alveolar pressure.
Pulmonary volumes and capacities.
Pulmonary and alveolar ventilation.
Compliance of the lungs and the chest wall.
Alveolar surface tension; airway resistance.
Pulmonary circulation; ventilation-perfusion ratio.
Autoregulation of pulmonary blood flow distribution.
Composition of inspiratory, expiratory, and alveolar air. Partial pressures of gases.
Gas exchange in the lungs.
Transport of oxygen and carbon dioxide by the blood.
Oxygen-hemoglobin dissociation curve.
Neural and humoral (chemical) regulation of respiration.
Vital pulmonary mechanisms: air filtration in the nose, air warming, moistening, cough,
sneezing.
Mucociliary clearance.
Complement system.
Lysozyme.
Lactoferrin.
Antioxidant systems.
Protease inhibitors.
Immune protective pulmonary mechanisms.
4. Biochemistry of the respiratory system:

Biochemical mechanisms of gas exchange.
Base-acid balance alterations in respiratory failure.
5. Pathology of the respiratory system:

Morphology of bronchial pathology: emphysema, chronic bronchitis, asthma,
bronchiectases.
Morphology of pulmonary and pleura pathology: pneumonia, pleuritis.
Tumors of lungs and pleura.
6. Medicines acting on the respiratory system:
Bronchodilators.
Antiinflammatory and antiallergic drugs.
Cough and cold medicines (secretolytics, mucolytics, antitussives).
7. Radiological investigations of lungs:

Fluoroscopy and radiography of the chest.
Computed tomography (CT) of lungs.
Angiography of pulmonary and bronchial arteries.
Lung ventilation and perfusion scintigraphy.
Ultrasonography of lungs.
Magnetic resonance imaging (MRI) of lungs.
8. Clinical cases :
Syndrome of bronchial obstruction.
Pulmonary hypertension, cor pulmonale and pulmonary artery obstruction.
Respiratory failure.
Syndrome of pulmonary restriction.
Pulmonary consolidation.
Syndromes of air and fluid accumulation in the pleural cavity.
9. Environmental and occupational medicine:

Ambient air pollution, sources, components – their impact to respiratory system.
Occupational respiratory diseases caused by exposure to dust.
Pneumoconioses and diseases caused by exposure to asbestos.
Respiratory diseases caused by exposure to organic dust.
Diagnostics and prevention of occupational lung diseases.
3. Aim and objectives of the module
Aim :
To study theory and aquire practical skills on morphology, physiology, biochemistry, pathology,
pathophysiology, pharmacology, clinical examination of respiratory system, respiratory
syndromes; be able to relate the theory with clinical symptoms and syndromes.
Objectives:
1. To study anatomy and function of respiratory system; to know the mechanisms of pulmonary
ventilation, gas exchange; nervous and humoral regulation of breathing, alterations in base-acid
balance.
2. To study pathophysiological mechanisms of changes of respiratory system.
3. To know histology and structural basis of defense mechanisms of respiratory system.
4. To study the medicines acting on the respiratory system.
5. To know pathology of respiratory system, radiological diagnosis.
6. To look into the clinical diagnosis and syndromes of respiratory system; relate clinical skills
and practical knowledge.
4. Tutorials
4.1. Case 1. Dyspnea of an allergic boy.

A 19-year-old student visited his general practitioner‘s office because of attacks of dyspnea,
nonproductive cough, and sneezing early in the morning. He has been suffering from these
complaints for three weeks. One month ago he was ill with allergic conjunctivitis, attended
ophthalmologist‘s office, and antiallergic eye drops were prescribed. In childhood he suffered
from frequent bronchitis and pneumonia, allergic reactions to fish products, chocolate, penicillin.
On examination he looked fair; his respiratory rate was 22 breaths per minute; pulmonary
auscultation revealed diffuse sibilant wheezes over the chest of both sides. His heart rate was 92
beats per minute, and a blood pressure was 140/80 mmHg. The findings of examination of other
systems were normal.
What syndrome do you suppose?
Explain the findings of clinical examination.
Concept of the problem: bronchial obstruction.
Clinical signs: paroxysmal dyspnea, sibilant wheezes.
Aim
To learn anatomy and histology of bronchi; mechanisms of bronchial obstruction,
functional and clinical diagnosis, principles of pharmacotherapy.
Learning objectives and contents
To complete an analysis of this problem the students must know:
1. Anatomy and innervation of bronchi.

Subject –Anatomy
References:
Gray‘s anatomy for students, 2005, p. 140-146, 149
2. Functioning of respiratory muscles (definitions of main and accessory muscles), physiology of

bronchi.
3. Mechanics of breathing, functioning of main and accessory respiratory muscles during
breathing.
4. Compliance of the lungs and the chest wall. Alveolar surface tension. Airway resistance. Work
of breathing.
Subject - Physiology
References:
1. Guyton and Hall Textbook of Medical Physiology /John E. Hall. Philadelphia: Saunders
Elsevier; 2016. Chapter 38, Pulmonary Ventilation. Available from:
https://www.clinicalkey.com/#!/content/book/3-s2.0-B978145577005200038X
2. Ganong’s Review of Medical Physiology. 26ed. McGraw-Hill Education; 2019, Chapter
34, Mechanics of respiration. Available from:
https://accessmedicine.mhmedical.com/content.aspx?bookid=2525&sectionid=20429752
3#1159054947
5. Explanation of bronchial spasm according to static and dynamic volumes, and resistance of
airways; recognition the changes of lung function parameters characteristic to the syndrome of
bronchial obstruction.
6. Respiratory failure: ventilatory failure, gas exchange failure. Disturbances in nasal breathing,
narrowing of larynx and trachea. Mechanisms of cough and sneezing. Mechanism of bronchial
spasm. Disturbances of functioning of bronchi. Expiratory dyspnea.
Subject- Pathological Physiology
References:
Porth CM. Pathophysiology : Concepts of Altered Health States. Lippincott Williams & Wilkins,
7th ed, 2005. p. 694-705
Supplementary readings
Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 713-728
Ado A.D. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453.
7. Histological structure of the bronchial wall, mucociliary clearance.

Subject- Human Histology and Embryology
Department of Human Histology and Embryology
References:
1. Mescher A.L. Junqueira’s Basic Histology: text and atlas. 14th, 13th, 12th ed. New York:
McGraw–Hill Education/Medical, 2016.
Access on internet:
http://accessmedicine.mhmedical.com/book.aspx?bookid=1687
2. Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press, 2002,
p. 228-230.
3. Taschenlehrbuch Histologie. 5 Auflage; R. Luellmann-Rauch. Thieme 2015, p. 369-387.
4. Color Textbook of Histology. Leslie P. Gartner, James L. Hiatt, 2nd ed. Saunders. p. 349-355.
8. Morphological changes of lung and heart vessels in asthma.

Subject- Pathological Anatomy
References:
Robbins and Cotran. Pathologic Basis of Disease. Elsevier Inc, 7th ed, 2005. p. 717-728
9. Action of bronchodilators and inhaled steroids in patients with asthma. Cough and cold
medicines (secretolytics, mucolytics, antitusives).
Subject - Pharmacology
References:
1. Katzung BG, editor. Basic & Clinical Pharmacology. 14th ed.: McGraw-Hill Education /
LANGE medical book, 2018: p. 346-365, 124-130, 139-142, 145, 148-149, 152 . Access on
internet: https://accessmedicine.mhmedical.com/book.aspx?bookid=2249
2. Karen Whalen, editor; Carinda Feild, Rajan Radhakrishnan, collaborating editors.
Lippincott’s Illustrated Reviews: Pharmacology. 7th ed. Philadelphia: Wolters Kluwer, 2019:
p.527-539, 62-90.
Access on internet:
https://meded-lwwhealthlibrary-com.ezproxy.dbazes.lsmuni.lt/book.aspx?bookid=2486
Supplementary readings:
3. Rang and Dale’s Pharmacology. 8th ed. 2016, Elsevier Ltd. Chapter 28: p.342-354.
4. Laurence L. Brunton, Randa Hilal-Dandan, Björn C. Knollmann, editors. Goodman and
Gilman’s The Pharmacological Basis of Therapeutics. 13th ed. New York 2018, McGraw-Hill
Education, chapter 40.
Access on internet: https://accessmedicine.mhmedical.com/book.aspx?bookid=2189#165936917
10. Clinical and functional diagnostics of bronchial obstruction syndrome.

Subject– Basics of Medical Diagnostics
References:
1. Macleods‘ Clinical Examination,14 edition, 5 chapter, 2018, Elsevier.
Access on internet: https://www-clinicalkey-com.ezproxy.dbazes.lsmuni.lt/#!/browse/book/3-s2.0-
C20150047001?indexOverride=GLOBAL
2. Harrison's Principles of Internal Medicine, 20 edition, part 7: chapters 278,279,280.

Access on internet:
https://accessmedicine-mhmedical-com.ezproxy.dbazes.lsmuni.lt/book.aspx?bookID=2129
4.2. Case 2. Dyspnea and pain in the calves.

A 19-year-old man complained having severe breathlessness at rest, which increased during
slight exertion, and episodes of recurrent chest pain with increasing breathlessness. He felt ill
three months ago during his service in the army. After “marching“ the pain in his legs occurred
with running temperature to 38o C . He was admitted to the military hospital, pneumonia was
diagnosed, antibiotics were prescribed. When he became better he was discharged from the
hospital, and returned to the military subunit. Two weeks later the pain in his left calf occurred
again, there was an episode of dyspnea, and after some days fever was detected. The soldier was
hospitalized again in the military hospital. The diagnosis of pneumonia and chronic cor
pulmonale was made.
The young soldier was demobilized. On his way home he suffered from dyspnea, weakness,
palpitation. As soon as his parents saw him, they took him to the hospital.
He suffered from measles and pneumonia in his childhood. The patient was recruited by the
military just after finishing his secondary school. His brother died from seminoma at the age of
16.
The patient‘s apparent state of health was serious. The height 180 cm, weight 70 kg. His breath
rate was 28 breaths per minute, accessory respiratory muscles took part in the breathing. Dilated
and overfilled jugular veins were observed. On auscultation, vesicular breath sound was audible,
adventitious sounds were absent. He had a pulse rate of 105 beats per minute, S2 accentuated,
and an arterial blood pressure 130/80 mmHg. The liver size determined by percussion along the
right midclavicular line was 10 cm. The left calf was thicker as compared to the right one, the
palpation of the left calf revealed tenderness. The Homans‘ sign was positive.
ECG: the strain pattern of right atrium and right ventricle. The chest X-ray examination
(standard posteroanterior view): the branches of pulmonary artery were broad, shortened due to
hypertension, the right branch – 25 mm. V.cava superior and conus pulmonalis were dilated. The
diagnosis was confirmed by pulmoangiography. Systolic blood pressure in pulmonary artery was
80/40 mmHg. A lot of contrast medium filling defects were detected in lobar, segmental,
subsegmental branches of pulmonary artery. During venocavography the floating thrombus was
detected in v.cava inferior. A venous filter was placed in the infrarenal portion of the inferior
vena cava.
Despite the anticoagulant therapy the patient’s state became worse, pulmonary hypertension was
increasing, respiratory failure was progressing and 8 weeks later after hospitalization the patient
died.
The findings of autopsy: v.cava inferior, v.iliaca and deep veins of left leg were obstructed by
thrombi. Thrombi were detected in most of segmental and subsegmental pulmonary arteries.
How do you evaluate the clinical signs?

How do you interpret the laboratory and instrumental examinations?
How do you evaluate the treatment given to this patient?
Concept of the problem: pulmonary hypertension and cor pulmonale.
Clinical signs: breathlessness, tachycardia, asymmetric edema in legs.
Aim
To study etiopathogenesis of pulmonary hypertension, the clinical signs and diagnostics of
acute and chronic cor pulmonale.
1. Anatomy of pulmonary circulation.

Subject - Anatomy
Department – Institute of Anatomy
References:
Gray‘s anatomy for students, 2005, p. 146, 194.
2. Histology of vessels.
Subject – Human Histology
References:
Mescher A.L. Junqueira’s Basic Histology: text and atlas. 14th, 13th, 12th ed. New York:
Internet access: http://accessmedicine.mhmedical.com/book.aspx?bookid=1687
Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press, 2002, p.
143-144.
3. Peculiarities of pulmonary circulation, blood gas transference, dissociation of

oxyhemoglobin, compounds of carbon dioxide in blood.
Department of Physiology and Pharmacology
References:
Elsevier; 2016. Chapter 39, Pulmonary Circulation, Pulmonary Edema, Pleural Fluid.
Available from: https://www.clinicalkey.com/#!/content/book/3-s2.0-
B9781455770052000391
34: Introduction to Pulmonary Structure & Mechanics. Available from:
3
4. Pathogenesis of pulmonary hypertension. Mechanisms and alterations of pulmonary

perfusion. Mismatching of ventilation to perfusion. The role of pathological reflexes.
Subject – Pathological Physiology
References:
Porth C.M. Pathophysiology : Concepts of Altered Health States. Lippincott Williams &
Wilkins, 7th ed, 2005. p. 638-649
Ado A.D. Patologičeskaja fiziologija, Maskva, 2002. p. 427-453
5. Alterations of right heart and lungs in pulmonary hypertension, morphology of

pulmonary embolism, Virchov‘s triad.
Subject – Pathological Anatomy
References:
6. Radiological signs in case of PE and pulmonary hypertension – evaluation of filling

defects of contrast enhancement in CT and MRI.
7. Evaluation criteria of PE comparing lung perfusion scintigrams to lung ventilation
scintigrams and chest radiographs.
Subject - Radiology
References:
1. S.Lange. G. Walsh. Radiology of Chest Diseases. Thieme Medical Publishers, 3rd edition
(2007) ISBN-13: 978-1588904478; p.183-194.
2. H.N. Wagner, Zszabo, J Buchanan Principles of Nuclear Medicine, 1995.p.881-906
www. radiologyeducation.com - teaching files
www.radiologyassistant.nl
8. Clinical diagnostics of pulmonary hypertension and cor pulmonale (acute and chronic).
Subject – Basics of Medical Diagnostics
References:
2. Harrison's Principles of Internal Medicine, 20 edition, 6 part: chapters 273, 277; part 7:
chapter 278.
Access on internet:
4.3. Case 3. A silicate brick-maker‘s tale.

A 73-year-old man presented to the emergency department with a complaint of worsening
breathlessness. He also suffered from cough with mucous sputum production, palpitation,
swelling of legs at the end of the day, persistent boring pain in the right hypochondrium. He has
been ill for 20 years. In the beginning he suffered from cough and sputum production, later
increasing breathlessness on moderate exertion occurred. During the last two years
breathlessness became very strong, increased on slight exertion (during walking in the room);
palpitation, boring pain in the right hypochondrium, swelling of legs occurred. During the last
two weeks he suffered from breathlessness at rest, edema in legs was also increasing.
He was ill with childhood infectious diseases, chronic bronchitis (later chronic obstructive
pulmonary disease was diagnosed), pneumonia, three years ago he experienced intermittent
paroxysmal ischemia of brain. He was a smoker for 40 years: he smoked 20 cigarettes per day.
During the last two years he was ex-smoker. He worked as a silicate brick-maker for 30 years.
Now he is a pensioner. He has no allergy, he is married and has two children. His father died of
lung cancer, mother – of cerebrovascular stroke.
The patient‘s apparent state of health is serious. He is conscious, but his answers to questions are
slow. He is in the active forced sitting position. Cyanosis of the face and lips, accessory
respiratory muscles are seen. His chest is of barrel shape, intercostal spaces are increased. His
breath rate is 36 breaths per minute, epigastrium pulsation is seen. The chest palpation revealed
reduced elasticity. Tactile fremitus is normal. Cardiac beat is palpable. On percussion,
hyperresonance note is audible over both sides of the chest, his heart borders are shifted to both
sides, especially right border. His heart rate (HR) is 110 beats per minute. On auscultation of the
heart, II-IIIº diastolic murmur over the pulmonary artery is audible. He has a blood pressure of
90/60 mmHg. An abdomen is soft, with small tenderness in the right hypochondrium. The liver
size in the right midclavicular line (determined by percussion): 16 cm. Significant edemas in his
legs are seen.
Investigations:
Haematology: Hb 180 g/L, RBCs 6,8x1012/L, WBCs 8,5x109/L, differential WBC count -
segmented neutrophils 70%, lymphocytes 20%, monocytes 6%, eosinophils 4%, basophils -0 %.
ECG: sinus tachycardia, HR 106 beats/min, P “pulmonale” II-III-aVF leads, biphasic P in V1
and V2 leads.
Blood gas examination (blood was taken from a radial artery): pH 7,28, PaCO2 70 mmHg, PaO2
60 mmHg.
Posteroanterior radiographic view: Lung pattern is increased, fibrosis in the basal areas is seen,
on the right side - pleurodiaphragmatic adhesions. The shadow of the heart is shifted to both
sides, but the enlargement of right chambers of the heart predominates.
Ultrasonography of upper abdomen: Liver is markedly enlarged but homogeneous. Gall-bladder
is normal.
What syndromes do you suppose? Why?

How do you interpret the complaints and the findings of physical examination?
How do you estimate the data of laboratory and instrumental examination?
Would you explain radiographic changes?
How do you treat this patient?
Concept of the problem: chronic respiratory failure, chronic cor pulmonale.
Clinical signs: breathlessness, tachycardia, cyanosis, hypoxaemia, hypercapnia.
Aim
To study etiopathogenesis, semiotics, arterial blood gas alterations, clinical diagnostics of
chronic respiratory failure, and chronic cor pulmonale.
1. Anatomy of pulmonary circulation.

Subject - Anatomy
References:
Gray‘s anatomy for students, 2005, p. 146, 194
2. Nervous and humoral regulation of breathing, rhythmicity of breathing, breathing

centers and their activity.
References:
Elsevier; 2016. Chapter 42, Regulation of Respiration. Available from:
https://www.clinicalkey.com/#!/content/book/3-s2.0-B9781455770052000421
36: Regulation of Respiration. Available from:
4
3. Pathogenesis of pulmonary hypertension, development of secondary erythrocytosis.

4. Chronic respiratory failure. Disorders of ventilation, diffusion, perfusion; mechanisms
of these disorders. Hypoxia, types and mechanisms. Alterations of tissue respiration.
References:
Porth C.M. Pathophysiology : Concepts of Altered Health States. Lippincott Williams &
Wilkins, 7th ed, 2005. p. 112-113, 717
1. Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 713-728
2. Ado A.D. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453
5. Morphological changes of the heart in pulmonary hypertension.

References:
6. Radiological signs of chronic pulmonary hypertension: roentgenosemiotic syndromes

of alterations of lung pattern and hiluses.
Subject - Radiology
References:
S.Lange. G. Walsh. Radiology of Chest Diseases. Thieme Medical Publishers, 3rd edition
(2007) ISBN-13: 978-1588904478; p.128-45.
7. Clinical diagnosis of chronic respiratory failure and chronic cor pulmonale.

References:
2. Harrison's Principles of Internal Medicine, 20 edition, part 7: chapters 278,279, 286.

Access on internet:
8. Pneumoconioses, their classification, pathogenesis, the main clinical features,
diagnostic and prevention.
Subject – Environmental and Occupational medicine

References:
1. Balmes JR. Occupational Lung Diseases in: LaDou J, Harrison RJ, editors. Current
occupational & environmental medicine. 5th ed. New York : McGraw Hill Education, 2014.
Prieiga per internetą:
https://accessmedicine.mhmedical.com/content.aspx?bookid=1186&sectionid=66481685 911 p.
2. Occupational lung diseases. Prieiga per internetą: https://www.thoracic.org/patients/patient-
resources/breathing-in-america/resources/chapter-13-occupational-lung-diseases.pdf
3. Madan I, Cullinan P. Respiratory disorders in: Snashall D, Patel D, editors. ABC of
occupational and environmental medicine. Chichester, West Sussex : Wiley, 2012, p 63-67.
4. WHO Air quality and health website: http://www.euro.who.int/en/health-topics/environment-
and-health/air-quality
4.4. Case 4. A roofer with increasing breathlessness.

A 52-year-old roofer sought a medical advice: he complained of increasing breathlessness on
exertion, cough, mucous sputum production. For the whole year he suffered from nonpurulent
productive cough accompanied by increasing breathlessness during moderate physical exercise
(going upstairs to the 2nd floor).
He suffered from acute bronchitis and pneumonia in the past, an operation due to appendicitis
was performed on him. He is a roofer for 30 years. He slated roofs for more than 20 years. He
has been smoking 10-15 cigarettes per day for 20 years.
The patient‘s apparent state of health is fair. His breath rate is 26 breaths per minute. A barrel
shaped chest is seen. Elasticity of the chest is decreased. Percussion of the chest revealed
hyperresonance. Vesicular breath sounds and fine crackles in basilar areas were detected during
auscultation of the lungs. The general practitioner has sent the patient to the pulmonologist.
Laboratory and instrumental investigations:
Peripheral blood examination: Hb 145 g/L; RBCs 5,1x1012/L; WBCs 8,1x109/L, differential
white blood cell count is normal; CRP 68 mg/L.
Chest X-ray examination: small reticulonodular changes in both lungs with predominating
changes over the right lung. Here and there pulmonary tissue resembles″honeycomb″.
Spirometry:
1. Vital capacity (VC) 3,8 L (64 % of predicted)
2. The forced vital capacity (FVC) 3,6 L (61 % of predicted)
3. The forced expiratory volume in 1 second (FEV1) 3,2 L (76 % of predicted)
4. FEV1/VC (Tiffeneau index) 85%, FEV1/FVC 89% .
Arterial blood gas analysis: PaO2 59 mmHg, PaCO2 44 mmHg, pH 7,35

Examination of bronchoalveolar lavage:
Cellularity 30x104/ml (Norm 10-20x104/ml)
Macrophages 67% (Norm 80-90%)
Neutrophils 10% (Norm < 2%)
Lymphocytes 23% (Norm 7-15%).
Transbronchial biopsy of pulmonary tissue: Pulmonary fibrosis. Asbestos bodies were revealed
after dyeing it by Prusse.
Which syndrome do you suppose?

Interpret the findings of clinical and laboratory examination.
Explain the detected disorders.
Concept of the problem: pulmonary restriction.
Clinical signs: exertional dyspnea, dry cough.
Aim
To learn pathophysiology, functional and clinical diagnosis of restriction syndrome, gas
diffusion mechanisms, pathology of alveolitis, mechanisms of development of fibrosis.
To complete analysis of this problem the students must know:
1. Gas diffusion and gas exchange mechanisms, regulation of acid-base balance.

Subject - Biochemistry
References:
1. M. Lieberman, A. Peet. Marks’ basic medical biochemistry: a clinical approach, 5th ed,
Wolters Kluwer, 2018, p. 53 - 55, 109 - 114.
2. J. Baggot. Gas transport and pH regulation in book MD. Devlin Textbook of biochemistry
with clinical correlations. Wiley-Liss; 4th ed, 1997, p. 1025 – 1052.
WJ Marshal, SK Bangert. Clinical chemistry, 5th ed Mosby, 2004, p. 41-61.
2. Histological structure of alveoli, relationship to pulmonary volumes, ventilation

mechanisms in norm and in pulmonary fibrosis (syndrome of restriction).
Subject - Human Histology
References:
1. Mescher A.L. Junqueira’s Basic Histology: text and atlas. 14th, 13th, 12th ed. New
York: McGraw–Hill Education/Medical, 2016.
Access on Internet: http://accessmedicine.mhmedical.com/book.aspx?bookid=1687
2. Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University
Press, 2002, p. 230-234.
1. Taschenlehrbuch Histologie. 5 Auflage; R. Luellmann-Rauch. Thieme 2015, p. 369-
387.
2. Color Textbook of Histology. Leslie P. Gartner, James L. Hiatt, 2nd ed. Saunders. p.
356-36
3. Gas exchange in the lungs; inspiratory, expiratory and alveolar air composition (partial
presures of gases), pulmonary ventilation parameters, pulmonary volumes and capacities.
Dead space and alveolar ventilation. Ventilation and blood flow (ventilation/perfusion
ratio).
References:
Guyton and Hall Textbook of Medical Physiology /John E. Hall. Philadelphia: Saunders
Elsevier; 2016. Chapter 40, Principles of Gas Exchange; Diffusion of Oxygen and Carbon
Dioxide Through the Respiratory Membrane. Available from:
https://www.clinicalkey.com/#!/content/book/3-s2.0-B9781455770052000408
4. Pathophysiology of hypoxia and hypercapnia in pulmonary fibrosis.

5. Mechanisms of cough and sputum production. Alterations of lung function. Restrictive
ventilatory pattern. Alveolar ventilation disorder, asphyxia.
References:
7th ed, 2005. p. 647-657
1. Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 676-682
6. Etiology, pathology of interstitial lung diseases, the role of alveolar macrophages, the
genesis of pulmonary fibrosis.
References:
Robbins and Cotran. Pathologic Basis of Disease. Elsevier Inc, 7th ed, 2005. p. 728-741.
7. Diseases caused by exposure to asbestos: pathogenesis, the main clinical features,

diagnostic and prevention.
Subject – Environmental and Occupational Medicine
References:
8. Radiological signs of alveolitis and pulmonary fibrosis: roentgenosemiotic syndromes of

alterations of lung pattern, hiluses and dissemination.
Subject - Radiology
References:
(2007) ISBN-13: 978-1588904478; p.222-24, 324-31.
9. Clinical and functional diagnosis of pulmonary restriction syndrome.

References:
2. Harrison's Principles of Internal Medicine, 20 edition, part 7: chapters 278,279, 283.

Access on internet:
4.5. Case 5. An acute illness of a wood-cutter

A 48-year-old wood-cutter complains of fever up to 39,5ºC, sweating, right-sided chest pain,
cough with rusty sputum, moderate breathlessness. Three days ago he suddenly got ill after lying
for some hours on a cold and wet ground (after abundant alcohol consumption). He thought that
he had caught a cold, and that is why he didn‘t visit his general practitioner. An ambulance was
called when breathlessness and rusty sputum production occurred.
In the past he suffered from children infections, grippe, pneumonia, prostatitis. He is a smoker:
he smokes 20 cigarettes daily. He uses alcohol 2-3 times per week. He is married, and has two
children.
The patient‘s apparent state of health is serious. Flushed face. He is in the forced active right
lateral decubitus position, broken into a sweat, with a herpetic rash around his lips. His body
temperature is 39,5ºC. His breath rate is 30 breaths per minute. Asymmetric respiration is seen:
the right side of the chest follows the left one. Elasticity of the chest is normal, tactile fremitus is
stronger on the right side of the chest. Percussion along l.axillaris anterior, media, posterior and
l.scapularis in the right side of the chest – below 4th rib - revealed dullness. On auscultation of
right chest, bronchial breath sound is audible, bronchophony is present. He has a regular pulse of
120 beats per minute and a blood pressure of 90/50 mmHg. Palpation of the abdomen revealed
tenderness below the right hypochondrium.
Investigations were performed urgently:
Haematology: Hb 130 g/L, RBCs 4,1x1012/L, platelets 180x109/L, WBCs 22,5x109/L;
differential WBC count: segmented neutrophils 80%, lymphocytes 12%, monocytes 8%; CRP
195 mg/L.
Cytologic examination of sputum: a lot of RBCs, WBCs.
Gram stain of sputum: Gram+ diplococci.
Chest radiograph: On the right inferior area the confluent infiltration is evident, slight right-
sided pleural effusion is possible.
What syndrome do you suppose? Indicate the diagnostic criteria.

What is the cause of tachycardia and reduced blood pressure?
How do you interpret the examinations of peripheral blood and sputum?
How would you explain the radiographic changes?
What treatments do you consider?
Concept of the problem: pulmonary consolidation.
Clinical signs: breathlessness, cough, fever, sputum production.
Aim
To study etiopathogenesis, semiotics, morphological, clinical, radiographic signs of
pulmonary consolidation.
1. Anatomy of the lung lobes.

Subject - Anatomy
References:
Gray‘s anatomy for students, 2005, p. 140-146
2. Histological structure of the lung tissue.

Subject – Human Histology
References:
1. Mescher A.L. Junqueira’s Basic Histology: text and atlas. 14th, 13th, 12th ed. New
York: McGraw–Hill Education/Medical, 2016.
Access on Internet: http://accessmedicine.mhmedical.com/book.aspx?bookid=1687
2.Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press,
2002, p. 228-233.
3. Formation of intrapleural pressure, the physiological role.

References:
Elsevier; 2016. Chapter 38, Pulmonary Ventilation. Available from:
https://www.clinicalkey.com/#!/content/book/3-s2.0-B978145577005200038X
2. Ganong’s Review of Medical Physiology. 26ed. McGraw-Hill Education; 2019, Chapter 34:
Mechanics of Respiration. Available from:
https://accessmedicine.mhmedical.com/content.aspx?bookid=2525&sectionid=204297523#1159
054947
4. Pathogenesis of pneumonia, changes of peripheral blood in inflammation. Disorder of

alveolar function. Disorders of ventilation, diffusion, perfusion, mechanisms of those
disorders.
5. Dyspnea, mechanism of dyspnea.
References:
7th ed, 2005. p. 647-655
1. Robbins and Cotran. Pathologic Basis of Disease. Elsevier Inc, 7th ed, 2005. p. 713-728
6. Pathology of pulmonary consolidation.

References:
Robbins and Cotran. Pathologic Basis of Disease. Elsevier Inc, 7th ed, 2005.
7. Radiological signs of lung infiltration: syndromes of local opacity of lung field, round
opacity, ring-shaped opacity and dissemination.
Subject - Radiology
References:
(2007) ISBN-13: 978-1588904478; p.64-109.
8. The changes of sound transmission in consolidation. Clinical signs of pulmonary

consolidation, semiotics.
References:
2. Harrison's Principles of Internal Medicine, 20 edition, part 7: chapter 278; part 5: chapter
121.
Access on internet:
9. Cough and cold medicines (secretolytics, mucolytics, antitussives): pharmacodynamics

and pharmacokinetics.
Subject - Pharmacology
References:
p.527-539. Access on internet:
https://meded-lwwhealthlibrary-com.ezproxy.dbazes.lsmuni.lt/book.aspx?bookid=2486
LANGE medical book, 2018: p. 570,. Access on internet:
https://accessmedicine.mhmedical.com/book.aspx?bookid=2249
.
3. Rang and Dale’s Pharmacology. 8th ed. 2016, Elsevier Ltd. Chapter 28: p.353.
4.6. Case 6A. A brick-layer‘s case.

A 46-year-old brick-layer with previously good health complains of fever up to 38ºC, right–sided
chest pain, that is increasing during the deep inspiration. Two weeks ago he fell down to the right
side in the building site. Some days later the pain in the right side occurred. This pain increased
during the deep inspiration. He was running a temperature up to 38ºC, exertional dyspnea
developed. He used analgetics. His health state became worse and he refered to his doctor for
medical advice.
In the past he suffered from pneumonia, prostatitis. He is a smoker. He smokes 20 cigerettes per
day. His father died of lung cancer at the age of 58. His mother is still alive.
The patient‘s apparent state of health is fair. Active forced lateral decubitus position is seen: he
lies on the right side. During breathing the right side of the chest follows the left one. His breath
rate is 22 breaths per minute. The findings of palpation: elasticity of the chest is normal, tactile
fremitus is weaker on the right side. Percussion along l. medioclavicularis, l.axillaris anterior,
media, posterior, and l. scapularis revealed dullness below right fourth rib. Auscultation of this
place detected the absence of breath sounds. His heart rate is 90 beats per minute, a blood
pressure is 120/80 mmHg. The liver size, determined by percussion on the right midclavicular
line - 10 cm. The abdomen on palpation is soft, without tenderness. The liver and the spleen are
nonpalpable. Edema in legs is absent.
Laboratory and instrumental investigations:
Haematology: Hb 140 g/L; RBCs 4,2x1012/L; WBCs 8,2x109/L; differential WBC count –
neutrophils 72%, lymphocytes - 20%, monocytes - 8%.
The chest radiographs (anteroposterior and lateral views): On the right side, below the 4th rib a
dense uniform opacification with oblique fluid line is evident, mediastinum is displaced to the
left.
Which syndrome and why do you suspect?

How do you interpret the findings of peripheral blood examination?
How do you explain the radiographic changes?
How can you help the patient?
What findings of pleural fluid examination do you expect?
4.6. Case 6B. Urgent help is required.

A 74-year-age retired man complains of acute dyspnea and the pain in the right chest that
occurred suddenly on getting up after endoscopic procedure. The patient was treated in the
department of gastroenterology because of peptic ulcer in the duodenum. After the treatment the
controlling fibroesophagogastroduodenoscopy procedure was performed. The conclusion of
fibroesophagogastroduodenoscopy was made: the ulcer was healed up, the procedure passed
without complications.
Past medical history: pneumonia, chronic bronchitis, five years ago – myocardial infarction. He
is a smoker for 40 years: he smokes 20 cigarettes per day. He is married and has two children.
His parents are dead: his mother died of brain stroke, and his father – of myocardial infarction.
The patient‘s apparent state of health is serious. Active forced sitting position. Cyanosis of the
face and lips is seen. His breath rate is 39 breaths per minute. During breathing the right chest
follows the left one. Tactile fremitus is absent over the right chest. There is tympany to
percussion over the right chest wall. Breath sounds and voice sounds are absent over the same
area on auscultation. His heart rate is 120 beats per minute, and a blood pressure is 80/40 mmHg.
The radiographic examination of the chest was performed urgently:
The posteroanterior radiographic view of the chest: Air in the right pleural cavity, the
mediastinum is displaced to the left.
What syndrome is it? Why?

What are the pathogenesis and semiotics of this syndrome?
Is the complication associated with the performed procedure? Do you consider it a jatrogenic
one?
How do you interpret the findings of physical and radiographic examination?
What help are you going to give urgently?
Concept of the problem: fluid in pleural cavity, air in pleural cavity.

Clinical signs: pain in the chest, dullness to percussion, tympany to percussion.
Aim
To study etiopathogenesis, morphology, clinical signs of fluid and air accumulation in
pleural cavity.
To complete analysis of this problem the students must know:
1. Anatomy of pleura.
Subject –Anatomy
References:
Gray‘s anatomy for students, 2005, p. 136-140
2. Histology of pleura.
Subject - Histology
References:
1.Mescher A.L. Junqueira’s Basic Histology: text and atlas. 14th, 13th, 12th ed. New York:
Access on internet: http://accessmedicine.mhmedical.com/book.aspx?bookid=1687
2. Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press, 2002,
p. 234.
3. Mechanisms of pneumothorax, their role in the development of pneumothorax.

References:
Ado AD. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453.
4. Pathogenesis of air accumulation in pleural cavity.

5. Pathogenesis of fluid accumulation in pleural cavity.
6. Disorders of function of pleura.
7. Pneumothorax: etiology, pathogenesis, alterations of organism functions.
8. Hydrothorax: etiology, pathogenesis, alterations of organism functions.
References:
Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 766-770.
9. Fluid accumulation in pleural cavity: etiology, morphological changes, cytological

examination of pleural fluid.
References:
Robbins and Cotran. Pathologic Basis of Disease. Elsevier Inc, 7th ed, 2005.
10. Radiological signs of pleural effusion: roentgenosemiotic syndromes of total and local
opacification.
11. Ultrasonography of pleural effusion and evaluation of fluid volume.
12. Radiological signs of air in pleural cavity: roentgenosemiotic syndrome of brightening of
lung field.
Subject - Radiology
References:
(2007) ISBN-13: 978-1588904478; p.183-194.
13. The clinical diagnosis of fluid accumulation in pleural cavity.

14. The clinical diagnosis of air accumulation in pleural cavity; the changes of sound
transmission; the principles of treatment.
References:
1. Macleods‘ Clinical Examination,14 edition, Elsevier, 2018 (5th chapter).
2. Harrison's Principles of Internal Medicine, 20 edition, part 7: chapters 278, 288; part 24:
chapter 2.
Access on internet:
5. Lectures
5.1. Anatomy of the respiratory system

In charge – assoc.prof. dr.Inga Saburkina.
Description: anatomy of bronchial tree and lungs.
5.2. Histology of the respiratory system

In charge - assoc.prof. dr. Jolita Palubinskienė
Description: Histology of airways and of the lungs. Structural basis of the defense mechanisms
in the respiratory system, mucociliary clearance. The structure of pleura. The structure of
pulmonary blood vessels. Development of airways and lungs, and their malformations.
5.3. Physiology of the respiratory system

In charge - assoc.prof. dr. Alė Laukevičienė
Description: Mechanics of external respiration, types of respiration; formation of intrapleural
pressure; alveolar pressure; lung volumes and capacities, pulmonary and alveolar ventilation;
pressure-volume relationship (compliance), alveolar surface tension. Pulmonary circulation;
ventilation/perfusion ratio; composition of inspiratory, expiratory, and alveolar air. Oxygen
transport; carbon dioxide transport. Nervous and humoral (chemical) regulation of respiration.
Rhythmicity of respiration. Respiratory centers and their activity.
5.4. Pathological physiology of the respiratory system

In charge – assoc.prof. Dalia Akramienė
Description: Etiology, pathogenesis of external respiratory failure, alterations of organism
functions. Etiology, pathogenesis of disorders of ventilation, diffusion, perfusion. Etiology,
pathogenesis of alterations of airways and lung functions. Sneezing, cough, sputum production;
causes, alterations of organism functions. Dyspnea, causes and types. Asphyxia, etiology,
pathogenesis, stages. Bronchial spasm, etiology, pathogenesis, alterations of organism functions.
Pneumothorax, hydrothorax, etiology, pathogenesis, alterations of organism functions.
Comprehension of internal respiration, etiology, pathogenesis, alterations of organism functions.
5.5. Pathological anatomy of the respiratory system

In charge –prof.habil.dr. Vaiva Lesauskaitė
Description: The most common dysplasias of the respiratory system. Pulmonary endoinfections:
bronchitis, bronchopneumonia, lobar pneumonia. Morphology of chronic obstructive pulmonary
diseases (chronic bronchitis, pulmonary emphysema, asthma, bronchiectases) and restrictive
diseases (pneumoconioses). Secondary pulmonary hypertension and cor pulmonale syndrome.
Lung tumors. Pathological anatomy of smoking.
5.6. Radiology of the respiratory system

In charge – assoc.prof.dr. Laima Dobrovolskienė, dr. Eglė Bakučionytė
Description: Radiological methods of the investigation of the respiratory system: fluoroscopy
and radiography of the chest, computed tomography (CT), magnetic resonance imaging (MRI),
ultrasonography, lung ventilation and perfusion scintigraphy. Radiological topographic anatomy
of the chest, methods of investigation, interpretation of pathological symptoms.
5.7. Gas exchange and molecular mechanisms of gas transfer

In charge – dr.Irma Martišienė
Description: Molecular mechanisms of oxygen transfer in human organism. Oxygen carriers in
blood and tissues. Hemoglobin structure, types, allosteric effects, factors that influence oxygen
transfer. Molecular mechanisms of carbon dioxide transfer. Types and causes of
hemoglobinopathies.
5.8. Medicines acting on the respiratory system

In charge – dr.Vygandas Barsys
Description: Studies of medicines acting on the respiratory system.
5.9. Understanding clinical examination. Thrombosis of deep veins. Pulmonary
thromboembolism. Pulmonary hypertension
In charge –assoc.prof.dr.Eglė Kalinauskienė
Description: The main clinical symptoms, laboratory and instrumental examinations in deep
vein thrombosis, pulmonary embolism, pulmonary hypertension.
5.10. The sources of air pollution, the components of air pollution, their impact
on health, the means of prevention
In charge – assoc.prof. dr. Rūta Ustinavičienė
Description: The assessment of air pollution. The main sources of air pollution: transport,
industry and energetics enterprises, their contribution to the pollution of the environment. The
main components of air pollution (sulphur oxides, nitrogen oxides, dust, hydrocarbons,
cancerogenic substances), their physical and chemical properties, the impact on health. The
prevention of environmental air pollution: organizational and legislation means, air cleaning in
industry and energetics.
5.11. Clinical diagnostics of pathology of the respiratory system

In charge - assoc.prof. dr.Palmira Leišytė
Description: Clinical examination of the respiratory system:the main complaints and their
characteristics, the main risk factors of respiratory diseases, findings of inspection, palpation,
percussion, auscultation. Examination of sputum. Thoracentesis. Laboratory examination of
pleural fluid. Transudate versus exudate. Clinical meanings of abnormal findings.
5.12. Functional diagnostics of pathology of the respiratory system

In charge - assoc.prof.dr. Palmira Leišytė
Description: Examination of lung function in clinical practice: introduction to the main
methods used in clinical practice (spirometry, bronchodilator test, bronchoprovocation test,
PEF-metry, bodyplethysmography, gas diffusion examination). Spirometry: the main functional
parameters, normal and pathological values, interpretation, obstructive and restrictive patterns of
impaired ventilation . Arterial blood gas examination: the main parameters, interpretation.
Pulsoxymetry.
5.13. Syndromes of respiratory pathology

In charge - assoc.prof.dr. Palmira Leišytė
Description: Clinical-structural, clinical- functional syndromes of the respiratory system
affection: pulmonary consolidation, lung cavity, air in pleural cavity, fluid in pleural cavity,
increased lung aireness , bronchial irritation syndrome, obstruction syndrome, restriction
syndrome, respiratory failure. Underlying causes, symptoms and signs.
6. Practicals
6.1. Anatomy of the respiratory tract
Subject: Anatomy
In charge – assoc. prof. dr. Inga Saburkina
Aim: to learn the anatomy of the respiratory tract.

Tasks:
1. To study the structure, topography, innervation, vascularization and clinically applied
anatomy of the external nose and nasal cavity.
2. To study the structure, topography, innervation, vascularisation and clinically applied
anatomy of the larynx.
anatomy of the trachea.
anatomy of the bronchial tree, respiratory bronchioles and acinus.
Expected results:
Students should be able to describe the bones of the nasal cavity, in particular the major features
of the lateral wall of the nasal cavity. Describe the arteries that supply the lateral wall and nasal
septum in relation to epistaxis. Name the paranasal sinuses. Describe their relationship to the
nasal cavity and their sites of drainage through its lateral wall. Explain their innervation in
relation to referred pain. Describe the hyoid bone, cartilages of the larynx and their junctions.
Describe the intrinsic and extrinsic laryngeal muscles responsible for closing the laryngeal inlet
and controlling vocal cord position and tension. Explain how these muscles function during
phonation, laryngeal closure. Describe the origin, course and functions of the motor and sensory
nerve supply of the larynx and the functional consequences of their injury. Describe the position
and anatomy of the thyroid gland and significance of the course of the laryngeal nerves. Explain
the structure of the bronchial tree.
Work description:
1. Dissection of the nasal cavity. Review the bony anatomy of the nasal cavity, both
external and internal parts including the nasal, lacrimal bones, maxilla, palatine,
sphenoid, ethmoid bones, inferior nasal concha and vomer. Review the cartilaginous
anatomy of the nasal cavity including the septal, lateral, greater and lesser alar cartilages.
Review the paranasal sinuses and their entrances into the nasal cavity. In the hemisection
identify vestibule, respiratory region, superior, middle and inferior meatuses,
sphenoethmoidal recess, and olfactory region. Flip the middle concha anteriorly up to
expose the semilunar hiatus and flip inferior concha to see the nasolacrimal duct ostium.
Locate the entrances of six paranasal sinuses. Probe the superior mucosa of the nasal
cavity to identify the olfactory region near the cribriform plate. Probe the foramen
sphenopalatinum to locate the nasopalatine nerve (from V2) and sphenopalatine artery
from maxillary artery). Do expect variations from one individual to another. Do not try to
find everything on each side. One side may be damaged after hemisection.
2. Dissection of the larynx. Review the sceletal and cartilage structure of the larynx and find
the thyrohyoid and cricothyroid membrane. Locate the hyoid bone, thyroid, cricoid
cartilages and epiglottis using the hemisected head and neck. Uncover the cricothyroid
muscle on the external surface anteriorly of the larynx with the external branch of the
superior laryngeal nerve (Fig. 1). Identify ventricle with false (vestibular) and true vocal
cords. Expose the cricoarytenoid posterior muscle located on the external surface
posteriorly (key muscle – primary abductor). Find the arytenoid cartilages and note the
interarytenoid muscle between them. Peel mocosa below vocal cords to expose the
thyroarytenoid and vocalis muscles. Located the recurrent laryngeal nerve (key nerve for
all muscles, excepted cricothyroid) in the tracheoesophageal groove. Place the laryngeal
halves together to study the aditus, vestibule, ventricle and glottis.
3. Dissection of trachea and bronchi. First cut both clavicles in the middle third and without
removing the manubrium simply rotate the piece up to access the superior mediastinum.
Carefully clean and mobilize the great vessels and preserve the vagus, phrenic and
recurrent laryngeal nerves. Clean the brachiocephalic veins, major branches of the aortic
arch, primary bronchi and trachea.
4. To dissect the bronchial tree up to the segmental bronchi.
5. To study theoretically the pattern of the blood supply of the nasal cavity and to draw the
scheme illustrating the arterial blood supply of the nasal cavity.
Fig. 1. The most frequent variation of the superior laryngeal nerve.
Review questions:
1. Arteries of nasal cavity.

2. Venous anastomosis between in the external nose oftalmic vein that drains into cavernous
sinus and angular vein that drains into facial vein.
3. The ways of the spread of infections from the nasal cavity.
4. Sites of the drainage of paranasal sinuses into the meatus of the nasal cavity.
5. Innervation of larynx and injury of laryngeal nerves during thyroidectomy.
6. Muscles of larynx.
7. Anatomical relationships of trachea those are important for the tracheostomy.
8. Eparteric and hyparteric bronchi (definition and examples).
9. Terminal bronchioles.
References:
Moore K. L., Dalley A. F. and Agur A. M. R. Clinically oriented anatomy 6th Edition. (2010)
Lippincott Williams & Wilkins, Philadelphia, Baltimore, New York, London, Buenos Aires,
Hong Kong, Sydney, Tokyo. P.
Electronical access of this book:
http://meded.lwwhealthlibrary.com/book.aspx?bookid=2212
6. 2. Anatomy of the lungs, pleura, pulmonary trunk, pulmonary veins and muscles of
respiration
Subject: Anatomy
In charge – assoc. prof. dr.Inga Saburkina
Aim: to learn the anatomy of the lungs and pleura.
Tasks:

anatomy of the lungs.
anatomy of the pleura.
Expected results:
Students should be able to explain the sceletotopy (relation to the skeleton) of the lungs and
pleura. Describe the clinical significance of the bronchopulmonary segments. Describe the blood
supply, innervation and venous and lymphatic drainage of the lungs. Describe the topographical
relations of the main bronchi, pulmonary arteries and veins within the lung hilum. Describe the
structure and clinical significance of the pleural recessuses. Demonstrate the surface markings of
the heart and great vessels, the margins of the pleura and the lobes and fissures of the lungs and
explain their clinical relevance. Identify the major anatomical features of the right heart and
explain their functional signicicance. Demonstrate the position and site of the auscultation of the
valve of pulmony trunk. Describe the origins, courses and relationships of the brachiocephalic
veins, inferior and superior venae cavae. Describe the origin, course and distribution of the vagus
and phrenic nerves. Describe the anatomy of the intercostal muscles. Describe a neurovascular
bundle in a typical intercostal space. Explain the movements involved in normal, vigorous and
forced ventilation and describe the muscles responsible for these movements.
Work description:
1. To mark the anterior, posterior and inferior borders of the lungs in the sceleton.
2. To draw the borders of the bronchopulmonary segments in the lung model (Fig. 2).
3. To mark the anterior, posterior and inferior borders of the pleura in the sceleton.
4. To open the thoracic cavity. The cadaver is laid on its back. Jugular fossa, clavicles and
sternal angle are viewed and palpated; second ribs are palpated next to the sternal angle.
This angle coincides with the lower part of a body of T4 vertebra. At this level trachea
bifurcates, and there is also an upper edge of pericardial sac and the beginning and the
end of aortic arch. Nipple of the breast (in man) indicates the fourth intercostal space.
Intercostal spaces and costal arches are palpated. The first incision of the skin is made in
direction from top to bottom starting from the jugular notch and ending at the navel. A
second incision is made slightly higher than the jugular notch and square to the first
incision. A third incision is also square to the first one and is made along the lower edge
of costal arch. Skin is prepared in direction going from mid line to the sides. Fascia is
prepared starting from m. pectoralis major. Then reflect pectoralis major, pectoralis
minor and serratus anterior muscles from the ribs. Make butterfly cuts and remove ribs by
special instruments. Identify the intercostal muscles, the intercostal neurovascular
bundles, fascias and internal thoracic vessels.
5. To dissect the organs of the thoracic cage. Locate, mobilize and preserve the phrenic and
vagus nerve at the root of the lung. Observe the region of the hilum, push away the
anterior border of the lung and observe the mediastinum. Push pericardium to the side
and find the phrenic nerve and pericardiacophrenic artery and vein. Separate this nerve.
Dissect the vagus nerve that is located behind the root of the lung. Remove the lymph
node from the hilum. |On the left side the left vagus nerve makes a loop around the aorta.
Cut the pulmonary vessels and primary bronchi at the root of each lung and remove lung.
6. To study the relationships of the arteries to the bronchi in each hilum of the lung. In the
left lung, the artery is above bronchus, in the right – below and in front. Note, that right
principal bronchus is eparteric (above the pulmonary artery), while the left principal
bronchus – hiparteric (below the pulmonary artery).
7. To observe the lobes of the lungs.
8. To study theoretically variations in the lobes of the lung.
9. To insert fingers into the costodiaphragmatic and costomediastinal recesses.
10. To observe the pulmonary ligament – the duplicature of the parietal pleura surrounding
the root of the lung extends downwards from the hilum in a fold called the pulmonary
ligament. The lower end of this is sometimes referred to as the inferior pulmonary
ligament. At the lower edge of each lung the pleural layers come into contact with each
other and terminate in a free curved edge. The pulmonary ligaments serve to hold the
lower part of the lungs in position.
11. In the cadaver, demonstrate the surface markings of the heart and great vessels, the
margins of the pleura and the lobes and fissures of the lungs and explain their clinical
relevance.
12. Identify the major anatomical features of the right heart and explain their functional
signicicance. In the sceleton, demonstrate the position and site of the auscultation of the
valve of pulmony trunk (repeat the anatomy of the module of circulation).
13. Describe the origins, courses and relationships of the brachiocephalic veins, inferior and
superior venae cavae (repeat the anatomy of the module of circulation).
14. Describe the origin, course and distribution of the vagus and phrenic nerves (repeat the
material of first course).
15. Describe the anatomy of the intercostal muscles. Describe a neurovascular bundle in a
typical intercostal space. Explain the movements involved in normal, vigorous and forced
ventilation and describe the muscles responsible for these movements (repeat the
anatomy of the module of locomotion).
16. To study theoretically the pattern of the blood supply of the lungs and to draw the scheme
illustrating the intraorganic blood supply of the lungs.
17. To study theoretically the lymph drainage from the lunds and to draw the scheme
illustrating the lymph drainage.
Fig. 2 The bronchopulmonary segments
Review questions:
1. Sceletotopy of lungs.
2. Topographical relation of the pulmonary artery, pulmonary veins and principal bronchus
in the hilum of lungs. Structure of the roots of the lungs.
3. Pulmonary ligament.
4. Organotopy of the lungs.
5. Blood supply of lungs.
6. Lymph drainage of lungs.
7. Costodiaphragmatic recess.
8. Sceletotopy of pleura.
9. Determine the site of the auscultation of the valve of pulmony trunk.
10. Describe the muscles responsible for the normal, vigorous and forced ventilation.
References:
1. Moore K. L., Dalley A. F. and Agur A. M. R. Clinically oriented anatomy 6th Edition.
(2010) Lippincott Williams & Wilkins, Philadelphia, Baltimore, New York, London,
Buenos Aires, Hong Kong, Sydney, Tokyo.
Electronical access of this book:
http://meded.lwwhealthlibrary.com/book.aspx?bookid=2212
6.3. Histology of trachea, bronchi, bronchioles. Histophysiology of blood vessels.

Subject: Human Histology and Embryology
In charge – assoc.prof.dr. Jolita Palubinskienė
Histological structure of trachea, bronchus and bronchiole. Histophysiology of pulmonary blood

vessels and of muscular vein of lower extremity.
Histological slides:
1. Trachea (H-E, azan);
2. Lungs (H-E, azan);
3. Vein of muscular type (H-E).
4. Lungs (azan)
1. Using medium magnification find mucosa, submucosa layer, C-shaped hyaline cartilage and
adventitia in the preparation of cross-sectioned trachea. Find columnar ciliated epithelial cells,
goblet cells, basal cells and intermediate cells using the highest magnification, and make a
drawing. Pay attention to a rather thick basement membrane. Find and draw serous glands in the
submucosa layer. Bundles of smooth muscle (m. trachealis) connect the ends of the cartilage,
which constitutes the supportive structure. Some of the glands can be found outside of the
muscle. The outer layer is adventitia. Pay attention to the rich vascular network, which is well
defined in the submucosa in the longitudinal section of the trachea.
2.Find bronchus in the H-E stained preparation of lungs, inspect it under the highest
magnification and draw: mucosa with respiratory epithelium (pseudostratified columnar ciliated
epithelium), the layer of smooth muscle cells, submucosa layer with serous or mixed bronchial
glands, hyaline cartilage rings and plates, and tunica adventitia. In some slides bronchus-
associated lymphoid tissue may be observed: lymphatic follicles with multiple lymphocytes just
under the epithelium, especially near the branching points of bronchial tree. The bronchiole’s
wall is devoid of glands and cartilage plates, it has a prominent muscular layer between the
mucosa and the adventitia, epithelium is simple columnar with longitudinal folds due to
contraction of muscular layer.
3.Muscular vein. Evaluate the form of the muscular type vein lumen using the lowest
magnification. Using the highest magnification find endothelial cells in tunica intima, smooth
muscle cells and collagen fibers in the tunica media which runs into tunica adventitia without
clear border. Remember the functional and structural peculiarities of tunica intima and the
endothelial cells.
4.In the azan stained section of lungs find a large bronchus and a blood vessel in its
neighborhood. It is a branch of pulmonary artery with multiple elastic lamina in the tunica
media. Elastic fibers are unstained, collagen fibers stain blue, smooth muscle cells are red.
Branches of the bronchial arteries are of much smaller diameter and are found in the adventitia of
the wall of bronchus. Tributaries of pulmonary veins are usually away from larger bronchi,
somewhere between the lobules. Make a drawing of pulmonary vessels and remember the
peculiarities of pulmonary circulation.
References:
http://www.usuhs.mil/pat/surg_path/nlhist/lung.html
6.4. Histology of pleura and pulmonary parenchyma

Subject: Human Histology and Embryology
In charge – assoc.prof.dr. Jolita Palubinskienė
Histological slides: Lungs (H-E, Rezorcin-fuchsin)

1.Find the natural border of the hematoxylin-eosin stained preparation of the lungs. It is the
pleura. With large objective lens you may see one layer of squamous cells with elongated nuclei.
That is mesothelium. A translucent space just under the epithelium is the layer of elastic fibers,
which are unstained using this staining method. The layer of the collagen fibers is stained in
rose-red, there may be found small tributaries of pulmonary veins.
2.Using medium magnification find respiratory bronchioles, alveolar ducts, sacs and alveoli.
Using the highest magnification find type I pneumocytes with flattened nuclei and type II
pneumocytes with round nuclei and transparent cytoplasm.
3.Rezorcin-fuchsin stains elastic fibers in dark red or purple. Determine them with the help of the
highest magnification in the pleura and in the interstitium of the alveolar septa. Alveolar
macrophages may be observed in the alveolar spaces. Make a drawing of the air-blood barrier.
References:
6.5. Physiology of respiratory system

Subject: Physiology
In charge – assoc.prof.dr. Alė Laukevičienė
Description:
Respiratory Air Flow and Volume
Theoretical background
Gas exchange between air and blood occurs in the alveolar air sacs. The efficiency of gas exchange is
dependent on ventilation; cyclical breathing movements alternately inflate and deflate the alveolar air
sacs. Inspiration provides the alveoli with some fresh atmospheric air and expiration removes some of the
stale air, which has reduced oxygen and increased carbon dioxide concentrations.
Many important aspects of lung function can be determined by measuring airflow and the corresponding
changes in lung volume. The airflow can be measured directly with a pneumotachometer.
The PowerLab pneumotachometer.
The flow head contains a fine mesh. Air breathed through the mesh gives rise to a small pressure
difference proportional to flow rate. Two small plastic tubes transmit this pressure difference to the
Spirometer Pod, where a transducer converts the pressure signal into a changing voltage that is recorded
by the PowerLab and displayed in LabTutor. The volume, V, is then calculated as the integral of flow:
This integration represents a summation over time; the volume traces that you will see in LabTutor during
the experiment are obtained by adding successive sampled values of the flow signal and scaling the sum
appropriately. The integral is initialized to zero every time a recording is started.
A complication in the volume measurement is caused by the difference in air temperature between the
Spirometer Pod (at ambient temperature) and the air exhaled from the lungs (at body temperature). The
volume of gas expands with warming, therefore the air volume expired from the lungs will be slightly
greater than that inspired. Thus a volume trace, as calculated by integration of flow, drifts in the
expiratory direction. To reduce the drift, the flow has to be integrated separately during inspiration and
expiration, with the inspiratory volume being corrected by a factor related to the BTPS factor (body
temperature, atmospheric pressure, saturated with water vapor). The LabTutor software makes this
correction.
Lung volumes and capacities.

Spirometry allows many components of pulmonary function to be visualized, measured and calculated.
Respiration consists of repeated cycles of inspiration followed by expiration. During the respiratory cycle,
a specific volume of air is drawn into and then expired from the lungs; this volume is the Tidal Volume
(VT). In normal ventilation, the rate of breathing (breaths/minute or BPM) is approximately 15 respiratory
cycles per minute. This value varies with the level of activity. The product of BPM and VT is the Expired
Minute Volume, the amount of air exhaled in one minute of breathing. This parameter also changes
according to the level of activity.
Note that the volume of air remaining in the lungs after a full expiration, residual volume (RV), cannot be
measured by spirometry as a volunteer is unable to exhale any further. Other common lung volumes and
capacities are shown in the table below.
Lung volumes and capacities

Laboratory exercise
In this laboratory, you will be introduced to spirometry as a technique for recording respiratory variables
and you will analyze a recording to derive respiratory parameters. You will examine lung volumes and
capacities, as well as the basic tests of pulmonary function and simulate an airway obstruction.
Learning Objectives
By the end of today's laboratory you will be able to:

• Explain the principles of spirometry and how integration of the flow signal gives a volume.
• Relate your recorded lung volumes and capacities, to those of a typical person of the same gender,
height and age.
• Perform pulmonary function tests, describe the common measurements made from them (PIF, PEF,
FVC and FEV1) and relate these measurements to those of a typical person of the same gender, height
and age.
• Describe the effect of airway obstruction on PIF, PEF, FVC and FEV1.
References:
Pathophysiology; Lee-Ellen C. Copstead and J.L. Banasik, 5th ed. Saunders Elsevier 2013. p.
476-482, 487-489.
6.6. Obstructive airway diseases and tumors .
Subject: Pathological Anatomy
In charge: prof.habil.dr. Dalia Pangonytė
Analysis of macro-, histological preparations, and electron micrographs. Students learn the
morphologic changes in chronic bronchitis, pulmonary emphysema, and asthma, their
complications (pulmonary hypertension, cor pulmonale), and causes of death.
Smoking induced morphologic changes; the role of smoking for developement of respiratory
diseases. Morphology of pneumoconiosis. Classification of lung tumors, complications and
causes of death.
Obstructive emphysema and pneumosclerosis. Electron micrograph (x 15000).
Find out obliteration of alveolar capillaries by collagen and elastic fibres.
Regeneratio epithelii bronchi (metaplasii). Histological slide (H+E). Find section of bronchus
where normal ciliated columnar epithelial cells were replaced by metaplastic stratified squamous
epithelium.
Carcinoma epidermoide (planocellulare) – cornescens. Histological slides (H+E). Find the
site where the basement membrane of the stratified squamous epithelium is penetrated by
atypical cells with invasion to the underlying connective tissue. At greater depth, the tumor cells
are keratinized forming keratinous pearls. Note the multitude of immune cells.
References:
Pathologic Basis of Disease/Eds I. L. Robbins, R.S. Cotran. 7 th edition 2005, p. 717-728, 743-
745,757-766.
6.7. Endoinfections of the respiratory system and pathology of the pleura

Analysis of macro-, histological preparations, and electron micrographs. Students learn the
pathogenesis of endoinfections (acute bronchitis, bronchopneumonia, lobar pneumonia), their
morphology, complications, and causes of death.
Migration of neutrophil through capillary . Electron micrograph (x20 000, 12 000). Draw
three steps of extravasation of leucocytes: 1. Margination of leucocytes in the lumen of capillary;
2.Transmigration across the endothelium. 3. Migration in interstitial tissues.
Bronchitis purulenta et bronchopneumonia (seu pneumonia focalis. Histological slide
(H+E). Find the purulent exudate and the desquamated epithelial cells in the lumen of the
bronchus. There are pulmonary alveoli in the vicinity filled with a purulent exudate. Notice that
those alveoli free of exudate are enlarged (a compensatory mechanism). There is hyperaemia in
the lung.
Pneumonia lobaris (crouposa). Histological slide (H+E). Pay attention that all alveoli are filled
by fibrinous exudate and neutrophils. There are and some red blood cells in alveoli.
References:
Pathologic Basis of Disease/Eds I. L. Robbins, R.S. Cotran. 7 th edition 2005, p. 747-756, 766-
769.
6.8. Medicines acting on the respiratory system
Subject:Pharmacology
In charge – dr.Valdas Liukaitis
Selective, nonselective and indirect-acting adrenergic agonists, methylxanthines, antileukotriene

drugs: pharmacodynamics, therapeutic indications, adverse effects, overdose, antidotes.
Medicines that increase the adrenoreceptor sensitivity to adrenergic agonists. Mechanisms of
drug-resistance.
References:
LANGE medical book, 2018: p. 336, 346-365, 124-130, 139-155. Access on internet:
https://accessmedicine.mhmedical.com/book.aspx?bookid=2249
p.527-539, 62-90.
3. Rang and Dale’s Pharmacology. 8th ed. 2016, Elsevier Ltd. Chapter 28: p.342-354.
6.9. Thrombosis of deep veins. Pulmonary embolism. Pulmonary hypertension

Subject: Basics of Medical Diagnostics
In charge – prof.dr. Eglė Kalinauskienė
Description:
Introduction course with clinical signs and diagnostic principles of deep vein thrombosis,
pulmonary thromboembolism, pulmonary hypertension.
References:
Macleods‘ Clinical Examination,14 edition, 5 chapter, 2018, Elsevier.
Harrison's Principles of Internal Medicine, 20 edition, part 6: chapters 273, 277.
Access on internet:
6.10. Clinical diagnostics of respiratory system disorders

In charge – assoc.prof.dr. Palmira Leišytė
Description:
The students are taught history-taking from the patient: asking the main complaints of
respiratory diseases and their characteristics, the main risk factors of respiratory diseases; the
students are introduced to physical examination of the patient with respiratory diseases:
techniques of inspection, palpation, percussion, auscultation. Demonstration of normal and
abnormal findings.
References:
Macleods‘ Clinical Examination,14 edition, 5 chapter, 2018, Elsevier.
Harrison's Principles of Internal Medicine, 20 edition, part 7:chapter 278.
Access on internet:
6.11. Functional diagnostics of respiratory disorders

Description:
Interpretation of spirometry findings: the main spirometric parameters, normal and pathological
values, getting skills in diagnostics of obstructive and restrictive patterns of impaired
ventilation. Practise in arterial blood gas examination: interpretation of the main parameters,
diagnostics of respiratory failure. Pulsoxymetry. Sputum and pleural fluid examination. Clinical
meanings of abnormal findings. Transudate versus exudate. Technique of thoracentesis.
References:
2. Harrison's Principles of Internal Medicine, 20 edition , part 7: chapter 279; part 24:
chapter 2.
Access on internet:
Pellegrino R., Viegi G., Brusasco V. et al. Interpretative strategies for lung function tests. Eur
Respir J 2005; 26: 948-968.
6.12. Syndromes of respiratory disorders

Description:
The main clinical-structural syndromes of the respiratory system: pulmonary consolidation,
cavity in the lung, increased airiness of the lung, fluid and air accumulation in the pleural
cavity, bronchial irritation syndrome. The main functional syndromes: bronchial obstruction
syndrome, pulmonary restriction syndrome, respiratory failure. Underlying causes, symptoms
and signs. Principles of diagnostics.
References:
Access on internet: https://www-clinicalkey-com.ezproxy.dbazes.lsmuni.lt/#!/browse/book/3-
s2.0-C20150047001?indexOverride=GLOBAL
2. Harrison's Principles of Internal Medicine, 20 edition, part 7: chapters 282, 286, 288.
Access on internet:
6.13. Radiology of the respiratory system (1)

Subject: Radiology
In charge - assoc.prof.dr. Nemira Jurkienė / assoc.prof. dr.Laima Dobrovolskienė
Topographic anatomy of the chest radiographs. Cross-sectional anatomy of CT and MRI of the
chest. Methods of evaluation. Radiological signs of pulmonary embolism (PE) and pulmonary
hypertension, Evaluation criteria for pulmonary scintigrams. Radiological signs of chronic
pulmonary hypertension – roentgenosemiotic syndromes of alterations of lung pattern and
hyluses.
References:
(2007) ISBN-13: 978-1588904478; p.183-194.
1. Atlas of Radiologic Anatomy. Ed. A. N. Taylor.1994
2. Principles of chest roentgenology. Ed. L.R.Goodman.1999.
3. Wagner HN, Szabo Z, Buchanan JW. Principles of nuclear medicine. 2nd ed. Philadelphia:
W.B. Saunders Company; 1995. p. 881–906
4. www. radiologyassistant.nl.

Subject: Radiology
In charge - assoc.prof. dr.Laima Dobrovolskienė
Radiological signs of alveolitis and pulmonary fibrosis: roentgenosemiotic syndromes of

alterations of lung pattern, hiluses and dissemination. Radiological signs of lung infiltration:
syndromes of local opacity of lung field, round opacity, ring-shaped opacity, and dissemination.
References:
1. Basevičius, S. Lukoševičius, L. Dobrovolskienė ir kt. “Radiologijos pagrindai”, Kaunas
2013, p.137-142, p. 255-259.
(2007) ISBN-13: 978-1588904478; p.183-194.
3. www.radiologyassistan.nl
4. www.radiologyeducation.com

Subject: Radiology
In charge - assoc.prof. dr.Laima Dobrovolskienė
Radiological signs of pleural effusion: roentgenosemiotic syndromes of total and local

opacification. Radiological signs of air in pleural cavity: roentgenosemiotic syndrome of
brightening of lung field. Ultrasonography of pleural effusion, evaluation of fluid volume.
References:
1. Basevičius, S. Lukoševičius, L. Dobrovolskienė ir kt. “Radiologijos pagrindai”, Kaunas
2013, p.203-5 p.214- 34, p. 255-259, p.301-4.
(2007) ISBN-13: 978-1588904478; p.183-194
1. Atlas of Radiologic Anatomy. Ed. A. N. Taylor.1994
2. www.radiologyassistan.nl
3. www.radiologyeducation.com
7. Seminars
7.1. Biochemistry of respiration and gas transport
Subject: Biochemistry
In charge – dr.Irma Martišienė
1. Buffer systems in blood, extracellular fluids and cells.

2. Components and mechanism of action of bicarbonate buffer.
3. Compensatory mechanisms of acid-base balance: respiratory acidosis and alkalosis and
metabolic acidosis and alkalosis.
4. Evaluation of acid base balance disturbances.
5. Nonphysiological ligands and oxidators; their effect on Hb function.
6. Hemoglobinopathies; types, molecular origin and consequences.
References:
1.Devlin Textbook of biochemistry with clinical correlations. Wiley-Liss; 4th ed, 1997,
p. 1025-1052.
2. M. Lieberman, A. Peet. Marks’ basic medical biochemistry: a clinical approach, 5th ed,
Wolters Kluwer, 2018, p. 53 - 55.
WJ Marshal, SK Bangert. Clinical chemistry, 5th ed Mosby, 2004, p. 41-61.
7.2. Environmental dust pollution, classification, physical and chemical properties.

Pneumoconioses
Subject: Environmental and Occupational Medicine
In charge – dr. Rita Raškevičienė
Classification of dust (organic, inorganic). Characteristics that influence the effect of inhaled
particles: the size, shape, chemical properties, fibrogenic and antigenic properties. Occupations
and jobs associated with the dust exposure.
Pneumoconioses, their classification, etiology, symptoms and signs. Silicosis, silicatoses,
asbestosis, coal workers’ pneumoconiosis, their diagnostic.
Respiratory diseases caused by exposure to organic dust. Occupational asthma, hypersensitivity
pneumonitis: etiology, symptoms and signs.
Prevention of occupational respiratory diseases.
References:
8. Module final examination programme

1. Anatomy
1. Anatomy of the nose. Arteries of the nasal cavity. Venous anastomosis between oftalmic and
angular veins in the external nose. The ways of the spread of infections from the nasal cavity.
2. Paranasal sinuses and their drainage into the nasal cavity.
3. Anatomy of the larynx. Muscles of the larynx. Innervation of larynx and injury of laryngeal
nerves during thyroidectomy.
4. Anatomy and anatomical relationships of the trachea.
5. The structure, blood supply, lymph drainage and innervation of the bronchial tree. Eparteric
and hyparteric bronchi. Terminal bronchioles.
6. The surfaces, borders, fissures, lobes, segments, lobules, hilum, root and ligaments of the
lungs.
7. The blood supply, lymph drainage and innervation of the lungs.
8. The topographical relations of the lungs in relation to the skeleton and neighboring organs.
9. Topographical relation of the pulmonary artery, pulmonary veins and principal bronchus in
the hilum of lungs.
10. The structure, blood supply, lymph drainage and innervation of the pleura. Pleural cavity.
Sceletotopy of the pleura. Recesses of pleura.
11. The anatomy of the pulmonary trunk, pulmonary arteries and veins.
12. The principal and accessory respiratory muscles and their functions.
2. Histology and Embryology

1. The structure of wall of trachea.
2. The structure of wall of bronchus.
3. The structure of wall of bronchioles.
4. Histophysiology of lower airway mucosa.
5. Differences between bronchus and bronchiole wall structure.
6. The structures and cells which participate in defense against foreign substances in airways
and alveoli.
7. The structure of pulmonary acinus.
8. The structure of air-blood barrier.
9. The structure and function of the pleura.
10. The development of lungs and pleura.
3. Physiology
1. The mechanics of pulmonary ventilation. Intrapleural and alveolar pressure changes during
the breathing cycle.
2. Lung volumes and capacities.
3. Pulmonary ventilation, dead space and alveolar ventilation.
4. Pulmonary circulation and ventilation/perfusion ratio. Autoregulation of pulmonary blood
flow.
5. Composition of inspired, expired, and alveolar air. Gas exchange in the lungs.
6. Oxygen transport by the blood. Oxyhemoglobin dissociation curve.
7. Carbon dioxide transport by the blood.
8. Neural regulation of respiration. Respiratory centers and their activity.
9. Central and peripheral chemical regulation of respiration.
4. Pathological physiology
1. Etiology, pathogenesis and changes of body functions during the changes of ventilation.
2. Etiology and pathogenesis of the disorders of gas diffusion and blood perfusion in the lungs.
3. Dyspnea: causes and types. Bronchial spasm, its etiology and pathogenesis, changes of body
functions.
4. Respiratory failure: types, etiology, pathogenesis and changes of body functions.
5. Hypoxia, types, pathogenesis and compensatory mechanisms of the body. Hyperoxia, its
etiology, positive and negative effects on body functions.
5. Pathological anatomy
1. General characteristic of chronic obstructive lung diseases. Pulmonary emphysema, its
pathogenesis, morphological forms, complications and causes of death.
2. Chronic bronchitis and bronchiectasis, its pathogenesis, morphology, complications and
causes of death.
3. Bronchial asthma, its pathogenesis, morphology, complications and causes of death.
4. Hypertension of the minor ratio (pulmonary) blood circulation: causative factors,
pathogenetic mechanisms, morphology and causes of death (cor-pulmonale syndrome).
5. Causes and mechanisms of pulmonary endoinfections, its classification.
Bronchopneumonia: etiology, pathogenesis, morphology, causes of death.
6. Lobar pneumonia: etiology, pathogenesis, stages and morphology, complications and
causes of death.
7. Essence of the neoplastic growth, peculiarities of neoplastic cells, microstructure of tumors.
8. Causative factors of tumors development. Characteristics of benign and malignant tumors.
Macroscopical forms of tumor growing and pathways of spreading.
9. Preneoplastic processes, its morphology and significance for tumor development.
10. Principles of the tumors classification. Lung carcinoma: localization, macroscopical and
microscopical forms, complications, causes of death.
11. Morphology of pleural pathology, complications, causes of death.
12. Smoking induced pathology of lung and other organs.
6. Radiology
1. Radiological diagnostic modalities, techniques and principles.
2.The algorithm of radiological diagnosis of the respiratory system. The scheme for evaluation of
radiological images
3. Chest x-ray, tomography and its types, rentgenoanatomy and indications, evaluation of
radiological images.
4. Computer tomography (CT) of the chest, cross-sectional anatomy and indications, evaluation
criteria of radiological images.
5.Ultrasonography of pleural cavity and thoracic wall, method of investigation and application,
evaluation and signs of radiological images.
6.Magnetic resonance imaging (MRI): the principle of the method, cross-sectional anatomy of
the chest, fields of application, evaluation and signs of radiological images.
7.Classification of contrast media, fields, ways and methods of application.
8.Angiographic investigations of pulmonary arteries, evaluation and signs of radiological
images, an investigation technique, contraindication.
9.Pulmonary ventilation and perfusion scintigraphy (V/Q scan); radiopharmaceuticals, their dose
calculation, patient preparation, scan procedure, indications and contraindications.
10.Differential diagnosis of opacity and infiltration of lung field, evaluation and signs of
radiological images.
11. Differential diagnosis of brightening of lung field, evaluation and signs of radiological
images. Pneumothorax, hydropneumothorax.
12. Radiological investigations in case of sharp chest pain, radiological detection of pulmonary
bleeding, evaluation and signs of radiological images.
13.Evaluation criteria for lung perfusion and ventilation scintigrams.
14.Evaluation criteria of PE comparing lung perfusion scintigrams with ventilation scintigrams
and chest radiographs.
7. Biochemistry
1. Structure of hemoglobin and myoglobin; describe protein and nonprotein parts. Types and
composition of hemoglobins.
2. Molecular mechanisms of O2 binding and transport to tissues. Allosteric effectors of Hb;
binding and physiological role. Bohr effect.
3. Scheme of CO2 transport from tissues to the lungs.
4. Hemoglobinopathies; types and molecular origin; examples of anomalous Hb. Why these
Hbs can not supply organism with oxygen?
5. Molecular basis of action and capacity of bicarbonate buffer. Respiratory acidosis and
alkalosis.
8. Pharmacology
1. Adrenergic bronchodilators: a) classification including common names, b) mechanism of
action, c) effects, d) differences in use method.
2. Selective beta adrenergic agonists: a) common names, b) mechanism of action, c) effects,
d) indications, e) advantages and disadvantages of inhalations vs. systemic administration,
f) undesirable effects.
3. M cholinergic bronchodilators: a) common names, b) mechanism of action, c) effects,
d) indications, e) route of administration, f) undesirable effects.
4. Methylxantine bronchodilators: a) common names, b) mechanism of action, c) effects,
d) indications, e) route of administration, f) undesirable effects.
5. Cough and cold medicines: a) common ingredients, b) mechanism of action, c) effects,
d) choice.
6. Anti-inflammatory / anti-allergic agents used in the treatment of asthma: a) classification
including common names, b) mechanism of action, c) effects, d) advantages and disadvantages
of inhalations vs. systemic administration, e) undesirable effects.
9. Basics of Medical Diagnostics

1. Complaints of patients with respiratory diseases.
2. Thoracentesis, technique of performance. Examination of pleural fluid, pathological
meanings.
3. Examination of sputum: macroscopic, microscopical, bacteriological examination,
pathological findings, their clinical meanings.
4. Spirometry: flow-volume curve (norm and pathology).
5. Spirometry: time-volume curve (norm and pathology).
6. Main indices of arterial blood gas analysis: normal and pathological values.
7. Pulmonary consolidation syndrome, main clinical signs, clinical meanings.
8. Syndrome of cavity in the lung, main clinical signs, clinical meanings.
9. Syndrome of increased airiness in the lung, main clinical signs, clinical meanings.
10. Syndrome of air accumulation in the pleural cavity, main clinical signs, clinical meanings.
11. Syndrome of fluid accumulation in the pleural cavity, main clinical signs, clinical meanings.
12. Syndrome of airway irritation, the main clinical signs, clinical meanings.
13. Syndrome of bronchial obstruction, the main clinical signs, functional changes, clinical
meanings.
14. Syndrome of pulmonary restriction, the main clinical signs, functional changes, clinical
meanings.
15. Respiratory failure, the clinical sings, functional changes, classification (types and grades),
causes.
16. Understanding of deep vein thrombosis: causes, clinical signs, principles of diagnosis,
relationship with pulmonary embolism.
17. Understanding of pulmonary embolism: causes, clinical signs, principles of diagnosis,
relationship with thrombosis of deep veins.
18. Understanding of primary and secondary pulmonary hypertension: causes, clinical signs,
principles of diagnosis.
10. Environmental and Occupational Medicine

1. Sources of environmental air pollution, their characteristics.
2. The main components of environmental air pollution, their impact on health.
3. The prevention of environmental air pollution on individual and population levels.
4. Dust in the work environment: main characteristics and health effects.
5. Occupational respiratory diseases caused by exposure to inorganic dust. Pneumoconioses
and diseases caused by exposure to asbestos: pathogenesis, symptoms and signs.
6. Respiratory diseases caused by exposure to organic dust. Occupational asthma,
hypersensitivity pneumonitis: etiology, pathogenesis, symptoms and signs.
7. Diagnostic and prevention of occupational respiratory diseases.

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Module “Respiration and Circulation”

Supervisor of the module: assoc.prof. dr. Palmira Leišytė

Subjects and Coordinating Teachers:

2. General content of the module

1. Anatomy of bronchi and lungs:

3. Physiology and pathophysiology of the respiratory system:

4. Biochemistry of the respiratory system:

5. Pathology of the respiratory system:

7. Radiological investigations of lungs:

9. Environmental and occupational medicine:

3. Aim and objectives of the module

4.1. Case 1. Dyspnea of an allergic boy.

Concept of the problem: bronchial obstruction.

Clinical signs: paroxysmal dyspnea, sibilant wheezes.

Learning objectives and contents

To complete an analysis of this problem the students must know:

1. Anatomy and innervation of bronchi.

2. Functioning of respiratory muscles (definitions of main and accessory muscles), physiology of

7. Histological structure of the bronchial wall, mucociliary clearance.

8. Morphological changes of lung and heart vessels in asthma.

10. Clinical and functional diagnostics of bronchial obstruction syndrome.

2. Harrison's Principles of Internal Medicine, 20 edition, part 7: chapters 278,279,280.

4.2. Case 2. Dyspnea and pain in the calves.

How do you evaluate the clinical signs?

Concept of the problem: pulmonary hypertension and cor pulmonale.

Clinical signs: breathlessness, tachycardia, asymmetric edema in legs.

Learning objectives and contents

To complete an analysis of this problem the students must know:

1. Anatomy of pulmonary circulation.

3. Peculiarities of pulmonary circulation, blood gas transference, dissociation of

4. Pathogenesis of pulmonary hypertension. Mechanisms and alterations of pulmonary

5. Alterations of right heart and lungs in pulmonary hypertension, morphology of

6. Radiological signs in case of PE and pulmonary hypertension – evaluation of filling

4.3. Case 3. A silicate brick-maker‘s tale.

What syndromes do you suppose? Why?

Concept of the problem: chronic respiratory failure, chronic cor pulmonale.

Clinical signs: breathlessness, tachycardia, cyanosis, hypoxaemia, hypercapnia.

Learning objectives and contents

To complete an analysis of this problem the students must know:

1. Anatomy of pulmonary circulation.

2. Nervous and humoral regulation of breathing, rhythmicity of breathing, breathing

3. Pathogenesis of pulmonary hypertension, development of secondary erythrocytosis.

5. Morphological changes of the heart in pulmonary hypertension.

6. Radiological signs of chronic pulmonary hypertension: roentgenosemiotic syndromes

7. Clinical diagnosis of chronic respiratory failure and chronic cor pulmonale.

2. Harrison's Principles of Internal Medicine, 20 edition, part 7: chapters 278,279, 286.

Subject – Environmental and Occupational medicine

4.4. Case 4. A roofer with increasing breathlessness.

Laboratory and instrumental investigations:

Arterial blood gas analysis: PaO2 59 mmHg, PaCO2 44 mmHg, pH 7,35

Which syndrome do you suppose?

Concept of the problem: pulmonary restriction.

Clinical signs: exertional dyspnea, dry cough.

Learning objectives and contents

To complete analysis of this problem the students must know:

1. Gas diffusion and gas exchange mechanisms, regulation of acid-base balance.

2. Histological structure of alveoli, relationship to pulmonary volumes, ventilation

4. Pathophysiology of hypoxia and hypercapnia in pulmonary fibrosis.

7. Diseases caused by exposure to asbestos: pathogenesis, the main clinical features,