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Handbook of Laboratory Activity

Respiratory System
NAME Facu
lty
STUDENT NUMBER
of
Medi
cine
Univ
ersit
as
Padj
adja
ran
3rd
Year
Und
ergr
adua
te
prog
ram
2015
-
2016
TABLE OF CONTENTS

WEEK DATE DEPARTMENT THEME PAGE

I 26,28,30 Oktober 2015 ANATOMY & BIOSEL ANATOMY & EMBRYOLOGY OF NOSE, NASAL
CAVITIES, PARANASAL SINUS, MIDDLE EAR,
AND PHARYNX
II 2,4,6 Nopember 2015 ANATOMY & BIOSEL
ANATOMY & EMBRYOLOGY OF
RESPIRATORY MUSCLES, LUNGS ORGAN,
BRONCHIAL TREE, AND ALVEOLUS

III 9,11,13 Nopember 2015 ANATOMY & BIOSEL HISTOLOGY OF


TONSIL, LARYNX, TRACHEA, BRONCHUS,
RESPIRATORY MUSCLES, LUNGS ORGAN,
BRONCHIAL TREE, AND ALVEOLUS

16,18,20 Nopember PHYSIOLOGY & PHYSICAL LUNG FUNCTION TEST & BREATHING
IV
2015 REHABILITATION TECHNIQUE FOR ASTHMATIC PATIENT

CLINICAL PATHOLOGY CLINICAL PATHOLOGY OF LUNG INFECTION

VI 30 sept, 2 & 4 Des 2015 MICROBIOLOGY MICROBIOLOGY LABORATORY


EXAMINATIONS OF ORGANISM ASSOCIATED
WITH RESPIRATORY TRACT INFECTIONS

PATIENT EDUCATION OF DRUG USED IN


VII 7,9,11 Desember 2015 PHARMACOLOGY
RESPIRATORY DISEASE

VIII 14,16,18 Desember PATHOLOGY ANATOMY PATHOLOGY ANATOMY OF


2015 RESPIRATORY SYSTEM

1 Respiratory System – 3rd Year Undergraduate Program


LABORATORY MANUAL – 1ST WEEK
ANATOMY & EMBRYOLOGY OF NOSE AND NASAL
CAVITIES, PARANASAL SINUS, MIDDLE EAR AND
PHARYNX

Anatomy
GENERAL OBJECTIVE
The students will be able to describe anatomy of upper respiratory system

SPECIFIC OBJECTIVES
After performing laboratory activity, the students should be able to:
1. Describe the anatomy of nose, paranasal sinuses, pharynx, and middle ear.
2. Describe the vascularization, innervations and lymphatic vessels of nose, paranasal sinuses,
pharynx, and middle ear.

SEQUENCE:

1. Collecting the homework ( 5 min)


2. Pretest (10 min)
3. Homework presentation (25 min)
4. Lab activity:
- identification (30 min)
- video
5. Post test (10 min )

RESOURCE PERSON

1. Fifi Veronika, dr
2. Nani M Yazid, drg. M.Kes
3. Fenny Dwiyatnaningrum, dr
4. Putri Halleyana A R., dr

REFERENCE

1. Moore KL and Dalley AF. Clinically Oriented Anatomy. 5th Edition. Lippincott Williams &
Wilkins. 2006 pp 1013 – 1032

NOTE :
Before enter the lab activity, the student must be:

1. Bring anatomy atlas ( 1 for each group)


2. Make flipchart for presentation based on your homework assignment

2 Respiratory System – 3rd Year Undergraduate Program


INTRODUCTION

The upper respiratory system includes the nose, pharynx, and associated structure. The nose is
superior to the hard palate and contains the peripheral organ of smell. According to its
embryological development, it includes the external nose and nasal cavity, which is divided into
right and left cavities by the nasal septum. Posteriorly, the nasal cavity is continuous with the
nasopharynx via the choanae; the soft palate serves as a valve or gate controlling access to and
from the nasal passageway. The bone and mucosa of the lateral walls of this passageway are
perforated by opening of the nasolacrimal ducts, the paranasal sinuses and the pharyngotympanic
tube. Meanwhile, the cavity of middle ear or tympanic cavity is connected anteromedially with the
nasopharynx by the pharyngotympanic tube and posterosuperiorly with the mastoid cells through
the mastoid antrum.

Infection of the middle ear is often secondary to upper respiratory infections.

The larynx is the complex organ of voice production composed by nine cartilages connected by
membranes and ligaments and containing the vocal folds. The trachea, extending from the larynx
into the thorax, terminates inferiorly as it divides into right and left main bronchi. The pharynx is
superior expanded part of the alimentary system posterior to the nasal and oral cavities, extending
inferiorly past the larynx. The pharynx divided into three parts nasopharynx (which has a
respiratory function), oropharynx (posterior to the mouth) and laryngopharynx (posterior to the
larynx). The patine tonsils are collections of lymphoid tissue on each side of the oropharynx in the
interval between the palatine arches.

Taking into consideration all aspects above, it is a prerequisite for the students to learn about
development, topography and normal structure nose, middle ear, paranasal sinuses, larynx,
pharynx, trachea and palatine tonsil to understand the clinical aspects of nose, middle ear and
paranasal sinuses, larynx, pharynx, trachea and palatine tonsil triggered by the case presentation.

HOMEWORK ASSIGNMENT

To be collected to your tutor at the day of lab activity ( please write in separated papers – not
in lab the manual )

A. Please answer these questions in separate paper


1. Describe the air passage in upper respiratory organs!
2. Describe the openings of paranasal sinuses!
3. Describe the vascularization of the nose and nasal cavity!
4. Describe about the pharyngotympanic tube and it’s blockage!
5. Describe the different parts of pharynxs and it’s functional difference!

3 Respiratory System – 3rd Year Undergraduate Program


Lab Activity :
Give the check list √ if you have already

done 1. Identification :

The part of external nose :

- Dorsum :
- Root
- Apex
- N a re s
- Alae
- Vestibule

Skeleton of the external nose is composed of :

- bone
- hyaline cartilage

The cartilaginous part :

- two lateral cartilages, two alar cartilages and one septal cartilage

Nasal Septum :

- Perpendicular plate of the ethmoid bone


- Cribiform plate
- Crista galli
- Vo m e r
- Septal cartilage
Nasal cavity :

- Choanae
- Nasal mucosa
- Respiratory area -
Olfactory area

The boundaries of the nasal cavity :

- Roof :
- Floor :
- Medial wall :
- Lateral walls :

4 Respiratory System – 3rd Year Undergraduate


Program
Features of the nasal cavity :

- The nasal conchae (superior, middle & inferior)


- Sphenoethmoidal recess : -
Ethmoidal infundibulum -
Semilunar hiatus

Vasculature and innervations of the nose :

The arterial supply of the medial and lateral walls of the nasal cavity is from five source :

· Anterior ethmoidal artery (from the ophthalmic artery)


· Posterior ethmoidal artery (from the ophthalmic artery)
· Sphenopalatine artery (from the maxillary artery)
· Greater palatine artery (from the maxillary artery)
· Septal branch of thesuperior labial artery (from the facial artery)
· Submucosal venous plexus
· Anterior and posterior ethmoidal nerves
· Olfactory nerves

Paranasal sinuses

· Frontal sinuses :
o Location :
o Each sinus drains through.....into the
o They are innervated by

· Ethmoidal cells (sinuses)


o Location :
o They are innervated by the............

· Sphenoidal sinuses
o Located :...............
o Sphenoethmoidal recess
o Vascularization and innervate by.......

· Maxillary sinuses
o The arterial suplly is mainly from............
o Innervation is from................

5 Respiratory System – 3rd Year Undergraduate


Program
EMBRYOLOGY
SPECIFIC OBJECTIVES:
After finishing this activity, the student will be able to:
1. Describe the development of nasal cavities
2. Describe the paranasal sinuses.
3. Describe the development of nasopharynx and oropharynx.
4. Describe the development of palatine tonsil.
5. Also describe the development of middle ear.

RESOURCE PERSON
1. Arti Rosaria Dewi, dr, M.Kes
2. Sudradjat Sulaeman, Drs, MS.

REFERENCE
1. T.W. Sadler: Langman’s Medical Embryology, 10thEd. Philadelphia, Lippincott Williams &
Wilkins, 2006, pp. 195-201, 257-283.
2. K.L. Moore, T.V.N. Persaud. The Developing Human: Clinically Oriented Embryology. 7thEd.
Philadelphia, Saunders, 2003, pp. 202-239.

INTRODUCTION

The respiratory system does not carry out its physiological function (of gas exchange) until
after birth. The respiratory tract, diaphragm and lungs do form early in embryonic development.
The respiratory tract is divided anatomically into 2 main parts: 1) upper respiratory tract,
consisting of the nose, nasal cavity and the pharynx; 2) lower respiratory tract consisting of the
larynx, trachea, bronchi and the lungs.

In the head/neck region, the pharynx forms a major arched cavity within the phrayngeal
arches. The lungs go through 4 distinct histological phases of development and in late fetal
development respiratory motions and amniotic fluid are thought to have a role in lung maturation.

Development of the respiratory system is not completed until the last weeks of fetal development,
just before birth. Therefore premature babies have difficulties associated with insufficient
surfactant (end month 6 alveolar cells type 2 appear and begin to secrete surfactant).

Embryology of respiratory system is divided into:

a. Development of the upper respiratory system (nose, nasopharynx, and oropharynx) is


discussed in chapter “Head and Neck” or “The Pharyngeal Apparatus” (Moore & Persaud,
2003; Sadler, 2006): Lab Activity Week-1.

b. Development of the lower respiratory system (larynx, trachea, bronchi, and lungs): Lab
Activity Week-2 and 3.

6 Respiratory System – 3rd Year Undergraduate Program


Developmentally nose and paranasal sinuses are interlinked. They are always considered
together developmentally. Developmentally the various sinuses may follow different calenders,
their orgin is the same.

Development of head and neck along with face, nose and paranasal sinuses takes place
simultaneously in a short window span. At the end of 4th week of development pharyngeal arches,
pharyngeal pouches and primitive gut makes their appearance. This is when the embryo gets its
first identifiable head and face with an orifice in its middle known as the stomodeum.
The stomodeum (primitive mouth) is surrounded by mandibular and maxillary prominences
bilaterally. These prominences are derivatives of first arch. This arch will give rise to all vascular
and neural supply of this area. The stomodeum is limited superiorly by the presence of frontonasal
eminence and inferiorly by the mandibular arch.

The frontonasal process inferiorly differentiates into two projections known as “Nasal
Placodes”. These nasal placodes will be ultimately invaded by growing ectoderm and
mesenchyme. These structures later fuse to become the nasal cavity and primitive choana,
separated from the stomodeum by the oronasal membrane. The primitive choana forms the
point of development of posterior pharyngeal wall and the various paranasal sinuses.
The oronasal membrane is fully formed by the end of 5th week of development. It gives rise to the
floor of the nose (palate develops from this membrane).

HOMEWORK ASSIGNMENT

a) ANSWER THE QUESTION


1. EXPLAIN DEVELOPMENT OF NASAL CAVITIES .
2. What are paranasal sinuses? How do they formed?
3. Explain development of nasopharynx and oropharynx.
4. What is palatine tonsil? How does it formed?
5. Explain development of the middle ear.

7 Respiratory System – 3rd Year Undergraduate Program


b) COMPLETE THE FIGURE BY NAMING THE POINTED PARTS OF THE EMBRYO.

Key names for Fig.1A, B,


C. 2 nd Pharyngeal arch
Frontonasal prominence
Mandibular prominence
Maxillary prominence Nasal
placode
Stomadeum

8 Respiratory System – 3rd Year Undergraduate Program


Key names for Fig.2
2nd Pharyngeal arch
1st Pharyngeal arch
3rd Pharyngeal arch
Pharyngeal pouch
Pharyngeal cleft
Laryngeal opening
Spinal cord

9 Respiratory System – 3rd Year Undergraduate Program


Key names for Fig.3A, B, C, and D:
Conchae
Lower lip
Mandible
Maxilla
Medial nasal prominence
Nasal chamber
Nasal pit
Oral cavity
Primary palate
Primitive choana
Secondary palate
Upper lip
10 Respiratory System – 3rd Year Undergraduate Program
Key names for Fig.4A, B:
Nasal chamber
Nasal septum
Palatine shelf
Primary palate

Key names for Fig.5A, B:


Nasal chamber
Nasal septum
Oral cavity
Palatine shelf
Primary palate

11 Respiratory System – 3rd Year Undergraduate Program 2014 - 2015


Fig.6 Development of primitive tympanic cavity, auditory tube,
and auditory ossicles.

Key names for Fig.6A, B:


1st Pharyngeal cleft
Auditory ossicles
Auditory tube
Endolymphatic duct
External auditory meatus
Primitive tympanic cavity
Saccular portion of otic vesicle
Tubotympanic recess Utricular
portion of otic vesicle

12 Respiratory System – 3rd Year Undergraduate Program


LABORATORY MANUAL – 2ND WEEK
ANATOMY AND EMBRYOLOGY OF RESPIRATORY
MUSCLES, LUNGS ORGAN, BRONCHIAL TREE AND
ALVEOLUS

ANATOMY
GENERAL OBJECTIVE
The students will be able to describe the anatomy of Tonsil, Lower Respiratory Tract and
Respiratory muscles

SPECIFIC OBJECTIVES
1. Describe the anatomy of larynx, trachea and bronchus
2. Describe the vascularization, innervations and lymphatic vessels of larynx, trachea
and bronchus
3. Describe the anatomy of Tonsils
4. Describe the anatomy of respiratory muscles, lungs organ, pleura, bronchial tree & alveolus.
5. Describe the vascularization, innervations and lymphatic vessels of respiratory muscles,
pleura bronchial tree and alveolus.

SEQUENCE:

1. Collecting the homework


2. Pretest (5 min)
3. Homework discussion (30 min)
4. Lab activity: observation of anatomical preparation (35 min)
5. Post test (5min)

RESOURCE PERSON
1. Fifi Veronica, dr
2. Gita Tiara D. N., dr.
3. Putri Halleyana A R., dr

REFERENCE
1. Moore KL and Dalley AF. Clinically Oriented Anatomy. 5th Edition. Lippincott Williams &
Wilkins. 2006 pp 93 – 98, 124 – 127.

13Respiratory System – 3rd Year Undergraduate Program


INTRODUCTION

The larynx is a rigid, short passage for air between the pharynx and the trachea. It is the
complex organ of voice production composed by nine cartilages connected by membranes and
ligaments and containing the vocal folds. Its wall is reinforced by hyaline cartilage (in the thyroid,
cricoid, and the inferior arytenoid cartilages) and smaller elastic cartilages (in the epiglottis,
cuneiform, corniculate, and the superior arytenoids cartilages), all connected by ligaments. In
addition to maintaining an open airway, movements of these cartilages by skeleton muscles
participate in sound production during phonation and the epiglottis serves as a valve to prevent
swallowed food or fluid from entering the trachea.
The trachea, extending from the larynx into the thorax, terminates inferiorly as it divides
into right and left main bronchi that enter the lungs at the hilum, along with arteries, veins, and
lymphatic vessels. Each primary bronchus branches repeatedly, with each branch becoming
progressively smaller until it reaches a diameter of about 5 mm.

The respiratory muscles have unique characteristic. Their organized movement make
ventilation of air can be happened. After ventilation, the other steps involved in gas exchange are
perfusion and diffusion. The walls of the alveoli contain a dense network of capillaries bringing
mixed-venous blood from the right heart. Perfusion of blood through these pulmonary capillaries
allows diffusion, and therefore gas exchange, to take place.
The bronchial tree begins at the bifurcation of the trachea, as the right and left primary
bronchi, which arborize (form branches that gradually decrease in size). The bronchial tree is
composed of airways located outside the lungs (the primary bronchi, extrapulmonary bronchi) and
airways located inside the lungs: the intrapulmonary bronchi (secondary and tertiary bronchi),
bronchioles, terminal bronchioles, respiratory bronchioles, alveolar ducts, atria, and alveolar sacs. As
the airways progressively decrease in size, several trends are observed, including a decrease in the
amount of cartilage, and the numbers of glands and goblet cells, and the height of epithelial cells and
an increase in smooth muscle and elastic tissue (with respect to the thickness of the wall).

HOMEWORK ASSIGNMENT

Aswer questions below correctly in separate paper!

1. Describe the vocal folds and it’s role in valsava maneuver!


2. Describe the different types Tonsils and the Waldeyer’s ring!
3. Describe the laryngeal skeleton!
4. Describe the boundaries of trachea!
5. What is the difference between bronchi and bronchioles?
6. What is pleura? Explain!
7. Make a drawing of pulmonary segment and label them!
8. Explain the respiratory muscle!
9. Which vascularization supplies blood to the lung?
10. What causes tightness in asthma?
11. Which part of lobe that mostly affected in TB infection? Why?
12. What is the pathognomonic symptoms for tension pneumothorax? Please explain!

14 Respiratory System – 3rd Year Undergraduate Program


LABORATORY ACTIVITY
A. Identify:
1. Tonsil
o Palatine
o Lingual
o Pharyngeal
o Others
2. Larynx
o Cartilages
 3
si ng u l a r 
3 pa i re d
o Muscle
o Vocal folds
3. Bronchial Tree
o Primary branch
o Secondary branch
o Tertiary branch
o bronchioles
4. Pleura
o Visceral
o Parietal
o Pleural cavity
o Innervation & vascularization
5. Lungs
o Lobes
o Segments
o Hilus
o Innervation
o Vascularization
6. Lymphatic flow

B. Make a drawing of your identification!


15 Respiratory System – 3rd Year Undergraduate Program
EMBRYOLOGY

LEARNING OBJECTIVES

After performing laboratory activity, the students should be able to:

1. Describe the development of larynx, trachea, and bronchus.


2. Describe the development of bronchial tree and lungs.
3. Explain maturation of the
lungs. RESOURCE PERSON

1. Sudradjat Sulaeman, Drs., MS


2. Nursiah Nasution, dr

REFERENCES

1. Sadler, TW. Langman’s Medical Embryology. 10 th Ed, Lippincott Williams & Wilkins. 2006.
pp 197-201.
2. Moore KL and Persaud TVN. The Developing Human: Clinically Oriented Embryology. 7 th
Edition. Saunders. 2003.
3. Junqueira LC and Carneiro J. Basic Histology Text and Atlas. 10 t Edition. Lange Medical
h

Books McGraw-Hill.

INTRODUCTION
When the embryo is approximately 4 weeks old, the respiratory diverticulum (lung bud) appears
as an outgrowth from the ventral wall of the foregut (see Fig. 1A). The location of the bud along the
gut tube is determined by the transcription factor TBX4 expressed in the endoderm of the gut tube
at the site of the respiratory diverticulum. TBX4 induces formation of the bud and the continued
growth and differentiation of the lungs. Hence, epitheliurn of the internal lining of the larynx,
trachea, and bronchi, as well as that of the lungs, is entirely of endodermal origin. The
cartilaginous, muscular, and connective tissue components of the trachea and lungs are derived
from splanchnic mesoderm surrounding the foregut.

Initially the lung bud is in open communication with the foregut (Fig. 1 B). When the diverticulum
expands caudally, however, two longitudinal ridges, the tracheoesophageal ridges, separate it
from the foregut (see Fig. 2A). Subsequently, when these ridges fuse to form the
tracheoesophageal septum, the foregut is divided into a dorsal portion, the esophagus, and a
ventral portion, the trachea and lung buds (Fig. 2B, C). The respiratory primordium maintains its
communication with the pharynx through the laryngeal orifice (Fig. 2D).

The larynx is a rigid, short passage for air between the pharynx and the trachea. It is the complex
organ of voice production composed by nine cartilages connected by membranes and ligaments and
containing the vocal folds. Its wall is reinforced by hyaline cartilage (in the thyroid, cricoid, and the
inferior arytenoid cartilages) and smaller elastic cartilages (in the epiglottis, cuneiform, corniculate,

16 Respiratory System – 3rd Year Undergraduate Program


and the superior arytenoids cartilages), all connected by ligaments. In addition to maintaining an
open airway, movements of these cartilages by skeleton muscles participate in sound production
during phonation and the epiglottis serves as a valve to prevent swallowed food or fluid from
entering the trachea.

The trachea, extending from the larynx into the thorax, terminates inferiorly as it divides into right
and left main bronchi that enter the lungs at the hilum, along with arteries, veins, and lymphatic
vessels. Each primary bronchus branches repeatedly, with each branch becoming progressively
smaller until it reaches a diameter of about 5 mm.

Taking into consideration all aspects above, it is a prerequisite for the students to learn about
development, topography and normal structure, and also pathological aspects of larynx, trachea and
bronchus to understand the clinical aspects of larynx, trachea and bronchus triggered by the case
presentation.

During laboratory activity, the students will be asked to show any anatomical parts, interactive CD
and histopathological preparates. Before activity, the students have to accomplish the homework
assignment first and read the primary references, so that they will be more readily performing
laboratory activity.

Developmently the respiratory system is an outgrowth of the ventral wall of the foregut, and the
epithelium of the larynx, trachea, bronchi, and alveoli originates in the endoderm. The cartilaginous,
muscular, and connective tissue components arise in the mesoderm. In the fourth week of
development, the tracheoesophageal septum seperates the trachea from the foregut, dividing the
foregut into the lung bud anteriorly and the esophagus posteriorly. Contact between the two is
maintained through the larynx, which is formed by tissue of the fourth and sixth pharyngeal arches.
The lung bud develops into two main bronchi: the right forms three secondary bronchi and three
lobes; the left forms two secondary bronchi and two lobes. Faulty partitioning of the foregut by the
tracheoesophageal septum causes esophageal atresias and tracheoesophageal fistulas.

After a pseudoglandular (5-16 weeks) and canalicular (16-26 weeks) phase, cells of the cuboidal
lined bronchioles change into thin, flat cells, type I alveolar epithelial cells, intimately associated
with blood and lymph capillaries. In the seventh month, gas exchange between the blood and air in
the primitive alveoli is possible. Before birth, the lungs are filled with fluid with little protein, some
mucus, and surfactant, which is produced by type II alveolar epithelial cells and which forms a
phospholipid coat on the alveolar membranes. At the beginning of respiration the lung fluid is
resorbed except for the surfactant coat, which prevents the collapse of the alveoli during expiration
by reducing the surface tension at the air-blood capillary interface. Absent or insufficient surfactant
in the premature baby causes respiratory distress syndrome (RDS) because of collapse of the
primitive alveoli (hyaline membrane disease).

Growth of the lungs after birth is primarily due to all increase in the number of respiratory
bronchioles and alveoli and not to an increase in the size of the alveoli. New alveoli are formed
during the first 10 years of postnatal life.

17 Respiratory System – 3rd Year Undergraduate Program


HOMEWORK ASSIGNMENT

1. Embryology
Please complete this figure by naming the pointed parts.
18 Respiratory System – 3rd Year Undergraduate Program
19 Respiratory System – 3rd Year Undergraduate Program
Please complete this figure by naming the pointed parts.
Fig. 2.1 Expansion of the lung buds into the pericardioperitoneal canals.

20 Respiratory System – 3rd Year Undergraduate Program


.

Fig. 2.3 Development of the lung. A, the canalicular period. B, the terminal sac period.

Think first and answer the question correctly and concisely!!

1. What is the derivation of the epithelial lining of the entire respiratory system (from
tracheal epitheliuim to Type I pnemocytes lining alveoli)?
2. What are the derivation of the components of the blood-air barrier in the lung?
3. A common cause of death in the premature infant is respiratory distress syndrome (RDS),
which is also known as hyaline membrane disease. Discribe the RDS!
4. Explain maturation of the lung (periods of development, time periods, and descriptions).

LABORATORY ACTIVITY

Task of Embryology

The students have to discuss about the development of brocnchial tree and lung, and also to
explain maturation of the lungs.

21 Respiratory System – 3rd Year Undergraduate Program


LABORATORY MANUAL – 3RD WEEK
HISTOLOGY PATHOLOGY ANATOMY OF
RESPIRATORY MUSCLES, LUNGS ORGAN, BRONCHIAL
TREE, AND ALVEOLUS

HISTOLOGY
LEARNING OBJECTIVES:

After performing laboratory activity, the student should be able to:


1. Describe the microscopic structure of wall layers of nasal cavities.
2. Describe the microscopic structure of paranasal sinuses.
3. Describe the microscopic structure of wall layers of middle ear and auditory tube.
4. Describe the microscopic structure of tonsils.

RESOURCE PERSON

1. Nursiah Nasution, dr.


2. Sudradjat Sulaeman, Drs., MS.

REFERENCES

1. Junqueira, L. Carlos and Carneiro J. Basic Histology Text and Atlas. 10t Edition. Lange
h

Medical Books McGraw-Hill. pp 349-368.


2. Eroschenko, Victor P. Di Fiore‘s. Atlas of Histology with Functional Correlations. 9th Edition.
Lippincott Williams &Wilkins. Philadelphia. pp 234-248.
3. Paulsen, Douglas F. Basic Histology Examination & Board Review. 2nd Edition. Appleton &
Lange. pp 246-254.

HOMEWORK ASSIGNMENT

1. Complete the following histologic figure by naming the pointed parts (13
points).

22 Respiratory System – 3rd Year Undergraduate Program


3
4
5
1 6

7
8

9
10
11
2

12

13
Fig.1 Respiratory epithelium Key names for Fig.1:
Basal bodies
Basal cells (nuclei)
Basement membrane
Cilia
Columnar cell
Connective tissue
Connective tissue (lamina
propria)
Epithelium
Goblet cell
Migrating lymphocyte
Mucous alveolus
Serous alveolus
Venule

2. Complete the following histologic figure by naming the pointed parts (12
points).

1.

2. 7.

8.
3.
e9.

4. _____
du
5. 10.

11.

6.
12.

Fig.2 Palatine tonsil

23 Respiratory System – 3rd Year Undergraduate


Program
Key names for Fig.2:
Blood vesel in the capsule
Epithelium of crypt (tg. s)
Fundi of crypts
Germinal center
Internodular septum (trabecula)
Lymphatic nodules
Merging nodules
Skeletal muscle fibers
Stratified squamous epithelium
Tonsillar crypts

Think first and answer the question correctly and concisely!


1. Describe the microscopic structure of wall layers of nasal cavity.
2. Describe the microscopic structure of paranasal sinuses.
3. Describe the microscopic structure of wall layers of middle ear and auditory tube.
4. Describe the microscopic structure of tonsils.

LABORATORY ACTIVITY
See the specimen under the microscope and try to make a schematic drawings and write
down the most important description based on the schematic draw.

Specimen: SR-2 (Respiratory epithelium)


Schematic Drawings Description
Respiratory System – 3rd Year
Undergraduate Program

24
Specimen: IM-7 (Palatine tonsil)
Schematic Drawings Description
44
HISTOLOGY

LEARNING OBJECTIVES

After performing laboratory activity, the students should be able


to: 1. Describe the histology of larynx, trachea and bronchus.

RESOURCE PERSON

1. Sudradjat Sulaeman, Drs, MS.


2. Nursiah Nasution, dr.

REFERENCES

1. Sadler, TW. Langman’s Medical Embryology. 10t Ed, Lippincott Williams & Wilkins. 2006.
h

2. Moore KL and Persaud TVN. The Developing Human: Clinically Oriented Embryology.
7th Edition. Saunders. 2003.
3. Junqueira LC and Carneiro J. Basic Histology Text and Atlas. 10t Edition. Lange
h

Medical Books McGraw-Hill.

HOMEWORK ASSIGNMENT

Think first and answer the question correctly and concisely!!

1. Describe structure of interalveolar septum.


2. Describe the blood air barrier.
3. Describe cell alveolar types.
4. Describe the alveolar pores.
5. Describe the pulmonary surfactant.
6. Describe the structure of visceral pleura.
7. Describe the pulmonary blood vessels.

25 Respiratory System – 3rd Year Undergraduate Program


Complete this histological figure by naming the pointed parts.

1) Trachea
5
6
1 7

8
3
9

4 10
11

Respiratory System – 3rd Year Undergraduate Program


26
2) Bronchus (Secondary Bronchus)

27
Fig. 3.1 Diagram of a portion of the bronchial tree.

28 Respiratory System – 3rd Year Undergraduate Program


Fig. 3.2 Three-dimensional schematic diagram of pulmonary alveoli showing the structure of the
interalveolar septum.
29 Respiratory System – 3rd Year Undergraduate Program
Fig. 3.3 Portion of the interalveolar
septum showing the blood-air barrier.

LABORATORY ACTIVITY

Pre-requisites: The students have to do the homework assignment and read the references
as listed in the first page.
During lab activity, 4 sub-groups will be divided into 4 main activities following the
rotation.

Task of Histology

The students have to see the histological and anatomical pathology preparation under the
microscope.
1. Discuss the homework materials in the small group (tutorial group).
2. See the specimen under microscope and try to make a schematic draw and put the
most important description based on the schematic draw.

Speciment No.1:
Schematic Draw Description
Respiratory System – 3rd Year Undergraduate Program

30
0
Speciment No.2:
Schematic Draw Description
Speciment No.3:
Schematic Draw Description
31 Respiratory System – 3rd Year Undergraduate Program
Speciment No.4:
Schematic Draw Description
Speciment No.5:
Schematic Draw Description
32 Respiratory System – 3rd Year Undergraduate
Program
Speciment No.6:
Schematic Draw Description
33 Respiratory System – 3rd Year Undergraduate Program
LABORATORY MANUAL – 4TH WEEK
LUNG FUNCTION TEST

LEARNING OBJECTIVES

After performing laboratory activity, the student should be able to:

1. Know the concept of lung volume and capacities.


2. Know the ventilation process and its pathological process
3. Perform lung function test and interpret the results.

RESOURCE PERSON

1. Reni Farenia, dr.,Mkes.,AIF


2. Dr.med. Setiawan, dr.
3. Yuni S.Lazuardhi, dr.,Mkes

REFERENCES

1. Guyton and Hall. Textbook of Medical Physiology. 11th ed. Elsevier Saunders. 2006. pp 475-
478, 525-530
2. Vitalograph Ltd. Vitalograph Operating Manual. Buckingham, England. pp II-1 – V4
3. Spirometry –Question and Answer, taken from http://www.priory.com/med/spiromet.htm
4. Lung Function Test, taken from http://www.webmd.com/hw/lungdisease/hw5022.asp

HOMEWORK ASSIGNMENT

1. Could you elaborate the principles and procedure of lung function test using spirometer?
2. What kind of parameters can be collected and explanation about that parameters?
3. What kind of respiratory diseases can be diagnoses using this method?
4. What diseases can cause an obstructive lung condition?
5. What diseases can cause a restrictive lung condition?
6. From Lung Function Test what kind of results do you expect either for obstructive and
restrictive lung condition?
7. Could you explain the results you gained in either lung condition?

34 Respiratory System – 3rd Year Undergraduate Program


LABORATORY ACTIVITY

Pre-requisites: The students have to do the homework assignment and read the references as listed
in the first page.

INTRODUCTION

Diagnosis and treatment of most respiratory disorders depend heavily on understanding the basic
physiologic principles of respiration. Some respiratory diseases result from inadequate ventilation.
A simple method for studying pulmonary ventilation is to record the volume movement of air into
and out of the lungs, a process called spirometry.

Principles

Spirometry (meaning the measuring of breath) is the most common of the Pulmonary Function Tests
(PFTs), measuring lung function, specifically the measurement of the amount (volume) and/or speed
(flow) of air that can be inhaled and exhaled. Spirometry is an important tool used for assessing
conditions such as asthma, pulmonary fibrosis, and COPD.

For this test, you breathe into a mouthpiece attached to a recording device. The information
collected by the spirometer may be printed out on a chart called a spirogram.

MATERIAL

1. Spirometer (vitalograph)
2. Recording paper (spirogram)
3. Mouthpiece

PROCEDURE

Preparation

1. Do not use a reliever inhaler for the 4 hours before the test, if possible.

2. Do not take the morning dose of a long acting reliever on the day of the test.

3. Do not take the morning dose of a combination inhaler on the day of the test.

4. No smoking for 24 hours (if possible).

5. No alcohol for 4 hours.

6. No vigorous exercise for 6 hours.

35 Respiratory System – 3rd Year Undergraduate Program


Do not eat heavy meal just before the test, because a full stomach may prevent your
lungs from fully expanding.

7. Wear loose clothing that does not restrict your breathing in any way.

8. If you have dentures, wear them during the test to help you form a tight seal around the
mouthpiece of the spirometer

Spirometry is a very low risk test. However, blowing out hard can increase the pressure in your
chest, abdomen and eye. So, you may be advised not to have spirometry if you have:

· unstable angina.
· had a recent pneumothorax (air trapped beneath the chest wall).
· had a recent heart attack or stroke.
· had recent eye or abdominal surgery.
· coughed up blood recently and the cause is not known.

Implementation

1. The subject applies his/her mouth to the mouthpiece inserted at the end of the breathing
tube.

2. Hold the breathing tube at the near of jaw level

3. Subject takes a maximal inhalation whilst being continually exhorted, persisting almost
until he feels he will burst

4. Then the subject closes his lips around the mouthpiece ensuring that no leak of air occurs,
and exhales into the machine

5. As the subject exhales into the breathing tube, the wedge shape bellows begin to inflate,
displacing a stylus writer on a curved arm and causing it to move down in relation to
exhalation.

6. The correct curve should show a maximal rise at the commencement and should flatten out
to a plateau at the end. A cough, a pause on an inspiratory phase during the examination
will cause an indentation in the curve which makes it unacceptable.

Limitations of test

The maneuver is highly dependent on patient cooperation and effort. Since results are dependent
on patient cooperation, FEV1 and FVC can only be underestimated, never overestimated.

Sources of error: the most usual source of error is a result of not obtaining the full co-operation of
the patient. It may occur that in the case of very severe airway obstruction it is not possible to carry
out spirometry as the effort is too great. If the cooperation is poor, many types of erroneous tracing

36 Respiratory System – 3rd Year Undergraduate Program


may occur. There may be a wide divergence between separate readings and, unless at least two best
tracings correspond fairly closely, it suggests that maximum effort is not being made.

RESULTS

Results are usually given in both raw data (liters, liters per second) and percent predicted - the test
result as a percent of the "predicted values" for the patients of similar characteristics (height, age,
sex, and sometimes race and weight).

37 Respiratory System – 3rd Year Undergraduate Program


LABORATORY MANUAL – 5TH WEEK
BLOOD GASES ANALYSIS SPECIMEN COLLECTION AND
INTERPRETATION
DEPARTMENT OF CLINICAL PATHOLOGY

I.GENERAL OBJECTIVE

At the end of the activity the student will understand and can describe about: specimen collection
and interpretation of Blood Gases Analysis in respiratory disorders; respiratory alkalosis and
respiratory acidosis status.

II. INTRODUCTION

Much useful information can be gained from the Blood Gases Analysis. Arterial blood is
analyzed to assess adequacy of oxygenation, ventilation and acid base status, the Indications for
Blood gases analysis are : 1). to evaluate ventilatory and acid base disturbance and monitor
effectiveness of therapy, 2) to titrate the appropriate oxygen flow rate and 3) to Qualify a patient for
home oxygenation use

Blood gases analysis are use to determine the acid-base balance and/or the respiratory or
metabolic status of the patient, especially in the respiratory system, the blood gases analysis are
useful for determine the respiratory alkalosis or respiratory acidosis status

There are so many interfering factor that could be influenced the result of blood gases
analysis according to the specimen collection

III. Specimen collection of Blood Gases Analysis

1. Unaerobic Collection: to avoid gas exchange


2. Should be performed immediately (within 10 minutes). If it is delayed, the specimen should
be placed in ice water, but still should be assayed within 1 hour.
3. Whole blood samples (using Lithium heparin as the anti-coagulant: 240 Unit/ml)
4. Samples may be obtained from arteries (it is more uniform in composition): radial,
ulnar,brachial, femoral artery

38 Respiratory System – 3rd Year Undergraduate Program


5. If arterial blood cannot be obtained, capillary blood may be used after arterialization
(=Arterialized blood is obtained by warming a limb/heel to 45 0 C, 20 minutes).
6. This method of collection is routinely used when samples are obtained from infants.
7. Heparinized-capillary tubes are used for collecting arterialized blood. Before sealing a small
piece of wire is inserted into the capillary tube.
8. The wire may be moved by a magnet to allow mixing of the blood prior to analysis.

VI Interfering factor

· Delay without cooling > 10 mnt  pH pCO2 pO2 (lactic ac


· Sampling aerobic air contamination  pH pCO2 pO2
· Condition: hyperventilation  pH pCO2 pO2
· Temp: hyperthermia : pH pCO2 pO2
o hypothermia : pH pCO2 pO2

· Capillary blood
· DILUTED with the tissue fluid, caused by squeeze the heel excessively
· CONTAMINATED by the alcohol swab
· Recent smoking increase the carboxyhemoglobin level thereby decreasing the pO2

39 Respiratory System – 3rd Year Undergraduate Program


V. Location of arterial puncture for Blood Gases Analysis

VI. Expected test outcomes

· pH: negative log of the hydrogen ion concentration


· Blood pH in Adult : 7.35 – 7.45
· Blood pH in Child : 7.36 – 7.44
· PCO2: 35 – 45 mmHg
· HCO3: 22 – 28 mEq /L
· PO2 : > 80 mmHg

VII. INTERPRETATION

Test outcome deviations

· Blood gas value outside of the above range can be grouped into two primary and four
underlying disturbances for interpretive basis: as shown in table 1 .

40 Respiratory System – 3rd Year Undergraduate


Program
Table 1

No Ventilatory Disturbance pH PCO2 pHCO3-

1 Respiratory acidosis Decreased Increased Normal


Compensated Normal Increased Increased

2 Respiratory alkalosis Increased Decreased Normal


Compensated Normal Decreased Decreased

3 Metabolic acidosis Decrease Normal Decreased


Compensated d Normal Decrease Decreased
d
4 Metabolic alkalosis Increase Normal Increased
Compensated d Normal Decrease Increased
d

Pathophyisiology of respiratory alkalosis

pH = pKa + log HCO3-/H2CO3

24 /0,03 x 40

24/1,2

20/1

If there any depletion of pCO2  CO2 + H2O  H2CO3

 log HCO3-/H2CO3 increased  > 20/1  pH was increased;

These condition because of hypoventilation.

41 Respiratory System – 3rd Year Undergraduate Program


The renal compensation:

a. decreased reabsorption of HCO3- or


decreased production of HCO3-

b. decreased exchanged of Na+ and H+


decreased reabsorption of Na+

increased excretion of H+

· Renal compensation would result of: decreasing of pH to the normal value


· Laboratory result of BGA in respiratory alkalosis;
increased of pH value

decreased of pHCO3-

· Etiology of respiratory alkalosis; pnemonia

Pathophysiology of Respiratory acidosis:

pH = pKa + log HCO3-/H2CO3

24/0,03X40

24/1,2

20/1

If there are an excess of pCO2 -*CO2 + H2O -*H2CO3

-* H2CO3 increased

-* log HCO2-/H2CO3 decreased


- * < 20/1
-* pH decreased -* asidosis
These condition because of; hyperventilation

Renal compensation :

a. increased reabsorption of HCO3-


increased production of HCO3-

b. increased exchange of Na+ and H+ -* pH increased

increased reabsorption of Na+

increased excretion of H+

42 Respiratory System – 3rd Year Undergraduate


Program
· Renal compensation would result of : log
HCO3-/H2CO3 = 30/1,5 = 20/1

complete compensation

Laboratory result of respiratory acidosis;

· Decreased pH decreased
· Increased HCO3-

If there are any complete compensation in BGA; pH will be changed to the normal value.

Etiologi of respiratory acidosis;

- COPD

- Asthma

- Block air way (tumor)


- Spontaneous lung collaps
- Injury to the chest wall

VIII. CONCLUSION

Blood gases analysis are use to determine the acid-base balance and/or the respiratory or
metabolic status of the patient, espesially in the respiratory system, the blood gases analysis are
useful for determine the respiratory alkalosis or respiratory acidosis status

There are so many interfering factors that could influenced the result of Blood Gases Analysis
according to the specimen collection

REFERENCE

M.K Gaedeke; Laboratory and Diagnostic Test Handbook; Eddison – Wesley Publishing
Company,Inc; 1996 : page 62-7.

43 Respiratory System – 3rd Year Undergraduate


Program
PERIPHERAL BLOOD FILM/SMEAR, DIFFERENTIAL
COUNT AND EOSINOPHIL COUNT
DEPARTMENT OF CLINICAL PATHOLOGY

I.OBJECTIVE

At the end of the activity the student will understand and can describe about: differential count
and Eosinophil count.

II. INTRODUCTION

Much useful information can be gained from the microscopic examination of the stained
blood smear. Examination of the Lekocytes and classification of cells into different types is a
differential count. The “diff”, as it is often called, is usually apart of a complete blood count (CBC).
However the “ WBC count and diff” combination is also a common laboratory request. The
differential count can be used to diagnose and monitor the treatment of leukemias, anemias, and
other disease.

The differential procedure involves counting 100-200 WBCs on a stain blood smear and
recording how many of each of the five type of WBCs are seen. Information is also obtained
concerning the RBCs and platelets. The RBCs are evaluated for morphology and hemoglobin content.
The platelets are evaluated for morphology and an estimation of platelet numbers.

III. MEASUREMENT/EXAMINATION

The Eosinophil is the WBC with granules that have an affinity for the eosin portion of the stain.
The nucleus of the eosinophil is usually divided into two or three lobes and stains purple. The
Cytoplasm is pink-tan, but may be difficult to see because it is filled with large red-orange

44 Respiratory System – 3rd Year Undergraduate


Program
(Eosinophilic) granules. Eosinophil are approximately the size of neutrophils, but are much less
numerous.
IV. EQUIPMENT AND REAGENTS

- Gloves
- Hand Disinfectant
- Stain normal blood smears (giemsa)
- Microscope with oil immersion objective
- Immersion oil
- Lens paper and lens cleaner
- Soft tissue or soft paper towel
- Blood cell atlas; drawings of photographs and descriptions of stained blood cells
- Tally counter or differential counter
- Worksheet
- Puncture-proof container for contaminated sharpes
- Surface disinfectant or 10% chlorine bleach solution
V. PROCEDURE

PREPARATION OF THIN BLOOD FILM


THIN BLOOD FILM (BLOOD SMEAR) IS USED TO DO :
1. DIFFERENTIAL COUNTING OF LEUKOCYTE
2.STUDY OF RED CELLS, WITH CELL AND PLATELET MORPHOLOGY
3.DETECTION OF BLOOD PARASITES
4. EXAMINE OF ANOTHER BLOOD DISORDER
MATERIALS:

1. SLIDES (2 PIECES), CLEAN, DRY AND FREE FROM FAT


2. 96% METHANOL
3. STANDARD GIEMSA SOLUTION
4. AQUADEST

1. PRICK THE FINGER

2. TO GET BLOOD
3. COLLECT A DROP OF BLOOD AT ONE END OF FIRST SLIDE
4. PLACE THE EDGE OF 2nd SLIDE (SPREADER) JUST IN
FRONT OF THE DROP OF BLOOD
5. DRAW THE SPREADER BACKWARD UNTIL IT TOUCHES THE
METHOD 5

2 4

1
3

SMEAR OF BLOOD

TA I L HEAD DROP OF
THICK
(THIN) BLOOD
Repirat
6. LET THE BLOOD RUN ALONG THE EDGE OF THE SPREADER
2012 - 2013
7. PUSH SPREADER TO THE OTHER END OF THE SLIDE, WITH
EVALUATION OF THE SMEAR
NOT GOOD

THE FILM IS SATISFACTORY BLOOD DROP IS SMALL

DRY IT BLOOD DROP IS TOO MUCH

GEIMSA STAIN
 FIXATION WITH 96% METHANOL 2 - 3’
 COVER THE SLIDE WITH DILUTED GIEMSA
SLIDE DO NOT FREE OF FAT
STAIN (IN 1 : 10) 20‘
 WASH THE STAIN OFF WITH BUFFER WATER
 TIP THE WATER STAND THE SLIDE IN THE
DRAINING RACK TO DRY

DIFFERENTIAL CELLS (LEUKOCYTE) COUNT


TO DETERMINE THE RELATIVE NUMBER OF
EACH TYPE OF LEUKOCYTE,SPREADING
AREA OF LEUKOCYTE :
- PHERIPHERAL EDGE: THE LARGER LEUKOCYTE
= GRANULOCYTES & MONOCYTES
- CENTRAL OF THE SMEAR = LYMPHOCYTE

METHOD :
TO PERFORM THE DIFFERENTIALCOUNTING
OF LEUKOCYTE MUST BE DONE AS :
MOVE THE SLIDE AS SHOWN IN FIGURE,AND COUNT
EACH LEUKOCYTE SEEN AND RECORD ON : THE
DIFFERENTIAL CELLS COUNTER OR ON A PIECE OF
PAPER UNTIL 100 CELLS
IF ANY NUCLEOTED RBC ARE SEEN ENUMERATED
THEM ON A SEPARATE COUNTER AND NOT TO BE
INCLUDED IN THE 100 CELLS DEFFERENTIAL COUNT
The differential count

1 2 3 4 5 6 7 8 9 10 COUNT NORM
BASOPHILS - - - - - - - - - - - 0–1
EOSINOPHILS I - - - - - - - - II 3 1-3
STAB. II II - - - - - - - - 4 2-6
SEGMENT IIII I IIII IIII II IIII I IIII II IIII IIII I IIII IIII I IIII 58 50 - 70
LYMPHOCITE I II II IIII III IIII IIII IIII IIII III 33 20 - 40
MONOCYTE - I I - - - - - - - 2 2-8
COUNT 10 10 10 10 10 10 10 10 10 10 100

ABNORMAL FINDING :
NORMAL ABNORMAL

1. BASOPHILS 0-1% BASOPHILIA -


2. EOSINOPHIL 1 - 3% EOSINOPHILIA ALLERGIC CONDITION
PARACITIC INVESTATION
SCARLET FEVER
LEUKEMIA
3. STAB CELL 2 - 6% SHIFT TO THE LEFT INFECTION
4. SEGMENT 50 - 70% NEUTROPHILIA APPENDICITIS ACUTE
INTERPRETATIO BACTERIAL INFECTION
N LEUKEMIA
5. LYMPHOCYTE 20 - 40% LYMPHOCYTOSIS VIRAL INFECTION
LEUKEMIA
6. MONOCYTE 2-8% MONOCYTOSIS BRUCELLOSIS
TUBERCULOSIS
LEUKEMIA
VI.
47 Respiratory System – 3rd Year Undergraduate Program 2014 - 2015
VII. CONCLUSION

Jika Eosinophil meningkat menunjang diagnosis asma bronchiale, infeksi parasit dan reaksi
alergi.

Reference

Barbara H.Estridge; Basic Medical Laboratory Techniques; 4th ed. Th 2000; Delmar Thomson
Learning.

ss
48 Respiratory System – 3rd Year Undergraduate Program
LABORATORY MANUAL – 6TH WEEK
MICROBIOLOGY OF RESPIRATORY TRACT INFECTIONS

GENERAL OBJECTIVE

After finishing this activity, the student will be able to:

Understood microbiological examinations to confirm the diagnosis of respiratory tract


infections and pulmonary tuberculosis

SPECIFIC OBJECTIVE

At the end of laboratory practice, the student could:

1. Understood methods of specimen collection and the laboratory examinations to confirm the
diagnosis respiratory tract infections
2. Understood the methods of isolation and identification of bacteria that cause infection in
the respiratory tract
3. Understood microscopic examinations of acid fast bacteria

Upon completion of this course, the student will be able to:

1. List examples of respiratory specimens.


2. Determine acceptability of sputum for culture by evaluating the Gram stain.
3. List organisms which may be considered normal oropharyngeal flora.
4. List common pathogens from each respiratory source.
5. Explain the rationale for selection and use of the primary plating media for each respiratory
specimen.
6. Understand all types of respiratory specimens to appropriate media.
7. Select incubation atmosphere, temperature, and time for each culture.
8. Perform, interpret, and evaluate direct Gram stains of respiratory specimens.
9. Describe colonial morphology and growth characteristics of normal flora and pathogens.
10. Differentiate pathogens from normal flora in respiratory cultures.
11. Correlate direct specimen Gram stains with culture results.
12. Determine appropriate biochemical tests or adjunct procedures required for identification
of significant isolates.
13. Interpretation antibiotic susceptibility tests as required and evaluate their appropriateness
with regard to the treatment
14. Explain the rationale for use of the transtracheal aspiration for collection of respiratory
specimens.
15. Explain the principle of the test(s) used to determine X and V factor requirements of
Haemophilus sp.

49 Respiratory System – 3rd Year Undergraduate Program


Explain the procedure and principle of bacitracin sensitivity testing in the identification of
group A Streptococcus.
16. Correlate culture results with clinical history and presentation.

METHODS
· Presentation
· Demonstration
· Discussion

LABORATORY ACTIVITY

The laboratory examination is an integral part of the Microbiology course. It provides the student an
opportunity to learn basic microbiological techniques, and introduces him/her to a case based
approach to microorganisms related to respiratory tract infection.

Steps in making diagnosis:


· History – what happened before student sees patient
· Clinical signs – changes from normal
· Diagnostic tests – changes from normal
– Direct exam – microscopy
– Culture (grow and identify pathogen)

Infectious disease: diagnostic tests

· Direct – detect infectious agent


– Visualization
– Culture
– Nucleic acid (DNA or RNA)
– Antigens
· Indirect – detect host’s response to infection –
Serological – detect antibody

Direct detection:
o Visualization (Microscopic) - smears from lesions
o Light microscope and simple
stains  Bacteria
 Fungal spores
o Electron microscope
 Viruses
o Quick and easy if positive , negative results not definitive

Visualize bacteria:
– mucosal smears or secretion (nasal, nasopharynx, tonsil) –
sputum and bronchial secretion

50 Respiratory System – 3rd Year Undergraduate


Program
Direct detection:
· Culture and identification
– Growth medium
– Adequate incubations conditions
· Temperature
· Atmosphere (O2, H, N, CO2)
– Biochemical or genetic tests for ID
· Expensive and time-consuming, positive results may be definitive
· Inoculate enrichment or selective media, incubate 24 hours
· Streak on agar plates, incubate 24hrs
· Pick presumptive colonies and restreak for identification

51 Respiratory System – 3rd Year Undergraduate Program


COLLECTING RESPIRATORY SPECIMENS

Seven types of respiratory specimens may be collected for viral and/or bacterial diagnostics:
1) nasopharyngeal wash/aspirates,
2) nasopharyngeal swabs,
3) oropharyngeal swabs,
4) broncheoalveolar lavage,
5) tracheal aspirate,
6) pleural fluid tap, and
7) sputum

Nasopharyngeal wash/aspirates are the specimen of choice for detection of most respiratory viruses
and are the preferred specimen type for children under age 2 years.

A. Collecting specimens from the upper respiratory tract


1. Nasopharyngeal wash/aspirate
Have the patient sit with head tilted slightly backward. Instil 2 ml-3 ml of physiological saline into
the rubber bulb and flush into one nostril. Collect the specimens from the other nostril in sterile
vials

2. Nasopharyngeal or oropharyngeal swabs


The figure on the above shows the way a child should be held when an NP swab as well as NP wash is
to be collected. Have an adult sit with the child on his/her lap with one arm around the child’s upper
body, one arm holding across the forehead to stabilize the head, and the legs and knees stabilizing
the child’s lower body.

52 Respiratory System – 3rd Year Undergraduate Program


NP swab collection is a clinical procedure and should therefore be performed by trained health-care
workers. A specifically designed swab with a flexible wire shaft and a small calcium alginate tip
should be used; calcium alginate is inert and nontoxic to Neisseria and other sensitive bacteria.

Use sterile dacron or rayon swabs with plastic shafts for viruses Do not use calcium alginate swabs
or swabs with wooden sticks, as they may contain substances that inactivate some viruses and
inhibit PCR testing.

3. Ear, Nose, Sinus Culture.


Sterile specimens (eg, sinus aspirates or tympanocentesis fluid), collected by invasive procedures,
should be submitted as sterile body fluid cultures. If the amount of material aspirated is small, it may
be advisable to inject it into an anaerobic transport or absorb it onto the swab of the bacterial swab
collection kit and use the bacterial transport.

B. Collecting specimens from the lower respiratory tract


1. Broncheoalveolar lavage, tracheal aspirate, pleural fluid tap

2. Sputum
Educate the patient about the difference between sputum and oral secretions. Have the patient rinse
the mouth with water and then expectorate deep cough sputum directly into a sterile screw-cap
sputum collection cup or sterile dry container.

53 Respiratory System – 3rd Year Undergraduate Program


CULTURE OF ORGANISMS

Nasopharyngeal culture
A nasopharyngeal culture is used to identify pathogenic (disease causing) organisms present in the
nasal cavity that may cause upper respiratory tract symptoms.

Purpose
Some organisms that cause upper respiratory infections are carried primarily in the nasopharynx, or
back of the nose. The person carrying these pathogenic bacteria may have no symptoms, but can still
infect others with the pathogen and resulting illness. The most serious of these organisms is
Neisseriea meningitidis, which causes meningitis or blood stream infection in infants. By culturing a
sample from the nasopharynx, the physician can identify this organism, and others, in the
asymptomatic carrier. The procedure can also be used as a substitute for a throat culture in infants,
the elderly patient, the debilitated patient, or in cases where a throat culture is difficult to obtain.

Precautions
The person taking the specimen should wear gloves, to prevent spreading infectious organisms. The
patient should not be taking antibiotics, as this may influence the test results.

Description
The patient should cough before collection of the specimen. Then, as the patient tilts his or her head
backwards, the caregiver will inspect the back of the throat using a penlight and tongue depressor. A
swab on a flexible wire is inserted into the nostril, back to the nasal cavity and upper part of the
throat. The swab is rotated quickly and then removed. Next, the swab is placed into a sterile tube
with culture fluid in it for transport to the microbiology laboratory. To prevent contamination, the
swab should not touch the patient's tongue or side of the nostrils.
When the sample reaches the lab, the swab will be spread onto an agar plate and the agar plate
incubated for 24-48 hours, to allow organisms present to grow. These organisms will be identified
and any pathogenic organisms may also be tested for susceptibility to specific antibiotics. This
allows the treating physician to determine which antibiotics will be effective.

Alternative Procedures
In most cases of upper respiratory tract infections, a throat culture is more appropriate than a
nasopharyngeal culture. However, the nasopharyngeal culture should be used in cases where throat
cultures are difficult to obtain or to detect the carrier states of Harmophilus influenzae and
meningococcal disease.

Preparation
The procedure should be described to the patient, as there is a slight discomfort associated with the
procedure. Other than that, no special preparation is necessary.

Aftercare
None

Risks
There is little to no risk involved in a nasopharyngeal culture.

54 Respiratory System – 3rd Year Undergraduate Program


Normal results
Bacteria that normally grow in the nose cavity will be identified by a nasopharyngeal culture. These
include nonhemolytic streptococci, alpha-hemolytic streptococci, some Neisseria species, and some
types of staphylococci.

Abnormal results
Pathogenic organisms that might be identified by this culture include
· Group A beta-hemolytic streptococci
· Bordetella pertussis, the causative agent of whooping cough
· Corynebacterium diptheriae, the causative agent of diptheria (will be discuss in tropical
medicaine system)
· Staphylococcus aureus, the causative agent of many Staphylococcal infections.
Additional bacteria are abnormal if they are found in large amounts. These include
· Haemophilus influenzae, a causative agent for certain types of meningitis and chronic
pulmonary disease.
· Streptococcus pneumoniae, a causative agent of pneumonia
· Candida albicans, the causative agent of thrush.

55 Respiratory System – 3rd Year Undergraduate Program


LABORATORY EXAMINATIONS

I. Microscopic examination of sputum specimen


A. Gram stain
1. Grading acceptability (samples with normal flora)
2. Less than 25 squamous epithelial cells/l00x field
3. For bacteriology only
4. Aid in culture work-up for all specimens

B. Acid-fast stain: Ziehl-Neelsen, Kinyoun, Auramine-Rhodamine

C. Direct wet mount


1. KOH
2. Lactophenol Cotton Blue
3. Yeast, fungi, and parasites

II. Inoculation and incubation


A. Blood agar, chocolate agar, and MacConkey agar
B. Anaerobic blood agar for suitable specimens on request

Topic for discussion:


1. Isolation, identification Staphylococcus aureus
2. Isolation, identification Streptococcus pneumoniae
3. Isolation, identification Klebsiella pneumonia, Haemophilis influenza, and other gram
negative bacteria associated with RTI
56 Respiratory System – 3rd Year Undergraduate Program
Haemophilus influenzae

H. influenzae appears as large, flat, colorless-to-grey opaque colonies on chocolate agar. No hemolysis
or discoloration of the medium is apparent. Encapsulated strains appear more mucoidal than non-
encapsulated strains, which appear as compact greyish colonies. Gram staining will yield small, gram-
negative bacilli or coccobacilli.

V (hemin) and X (nicotinamideadenine dinucleotide, NAD) factor for differentiation

57 Respiratory System – 3rd Year Undergraduate Program


S. pneumoniae
S. pneumoniae appears as small, greyish, moist (sometimes mucoid), watery colonies with a greenish
zone of α-hemolysis surrounding them on blood agar. The degree of mucoidness of S. pneumoniae
colonies is dependent on the freshness of the medium and the incubation atmosphere. Some serotypes
appear more mucoid than others, and the fresher the medium, the more mucoid the cultures appear.

58 Respiratory System – 3rd Year Undergraduate Program


C. diphtheriae
A. Specimen collection, direct stain, and inoculation
B. Nasopharyngeal or throat swab
C. Routine plates plus chocolate tellurite, Loeffler's agar
D. Toxin assay on all C. diphtheriae isolates: ELEK plate

Legionella pneumophila
A. Deep specimens avoid normal flora
B. Buffered charcoal yeast extract media
C. Direct FA

Mycoplasma
A. Some species are normal flora
B. Mycoplasma pneumoniae strict pathogen PPLO
C. Cell wall deficient organisms
D. Special media fried egg colonies

59 Respiratory System – 3rd Year Undergraduate Program


Yeast and fungi
A. Candida albicans
B. Special media for fungus cultures
1. Sabourauds
2. Mycosel etc.
3. Blood agar

C. Nocardia and Actinomyces


1. Gram positive pleomorphic
2. Nocardia may be acid-fast
3. Actinomyces-some anaerobic
D. Aspergillus sp.

Bordetella pertussis
A. Cultured from nasopharyngeal
B. Infection of bronchial tree can be interstitial pneumonia
C. Bordet-Gengou agar
1. moist chamber for 7 days
2. silver (mercury) drop colonies
D. Direct FA on specimen or suspect colonies

Viruses
Coronavirus, Rhinovirus, Respiratory synctitial virus, parainfluenzae virus, influenzae virus and
adenovirus, etc. Many respiratory transmission or initial onset-later tissue tropic

Mycobacteria sp.
A. Specimen collection
1. Any respiratory site deep
2. gastric aspirates
3. biopsy from other organs
4. skin
5. No 24 hour urines or sputum (too much overgrowth)
B. Processing
1. digestion of samples from non-sterile body sites
2. break-up mucus
3. kill other organisms
C. Lowenstein-Jensen, Middlebrook formulas
D. Biochemical identification and susceptibility testing
E. PCR testing to speed up results - still need live organism for susceptibility
60 Respiratory System – 3rd Year Undergraduate Program

Staining Methods
The best known and distinctive property of the genus, Mycobacteria, depends upon their lipid-rich cell
walls which are relatively impermeable to various basic dyes unless the dyes are combined with
phenol. Once stained the cells resist decolorization with acidified organic solvents and are therefore
called ACID FAST. Although the ability to retain arylmethane dyes such as carbol fuchsin and
auramine-rhodamine after washing with alcohol or weak acids is a primary feature of this genus it is
not entirely unique to the genus. Other bacteria which contain mycolic acids, such as Nocardia, can
also exhibit this feature. The exact method by which the stain is retained is unclear but it is thought
that some of the stain becomes trapped within the cell and some forms a complex with the mycolic
acids. This is supported by the finding that shorter chain mycolic acids or mycobacterial cells with
disrupted cell walls stain weakly acid-fast.
Ziehl-Neelsen Staining Procedure

1. Flame slides to heat fix


2. Flood the entire slide with Carbol Fuchsin
Ensure enough stain is added to keep the slides covered throughout the entire staining step.
3. Using a Bunsen burner, heat the slides slowly until they are steaming. Maintain steaming for 5
minutes by using low or intermittent heat (i.e. by occasionally passing the flame from the
Bunsen burner over the slides)
Caution: Using too much flame or heat can cause the slide to break.
4. Rinse the slide with water.
5. Flood the slide with 3% acid-alcohol and allow to decolorize for 5 minutes.
Throughout the 5 minutes, continue to flood the slides with 3% acid-alcohol until the slides are clear of
stain visible to the naked eye.
6. Rinse the slide thoroughly with water and then drain any excess from the slides.
7. Flood the slide with the counterstain, Methylene Blue. Keep the counterstain on the slides for 1
minute
8. Rinse the slide thoroughly with
water. Morphological Characteristics

61 Respiratory System – 3rd Year Undergraduate Program


2014 - 2015
It is critical to learn the morphological characteristics of mycobacteria since they are not the only
objects that can stain as acid-fast in a smear. Debris, some species of Nocardia, and some bacterial
and fungal spores can also stain acid-fast.
· Acid-fast bacilli range from 1 to 10 µm in length and 0.2 to 0.6 µm in width.
· They typically appear as slender, rod-shaped bacilli, but they may appear curved or bent.
· Individual bacteria may display heavily stained area reffered to as beads and areas of
alternating stain producing a banded appearance.
· Some mycobacteria other than M. tuberculosis may appear pleomorphic, ranging in
appearance from long slender rods to coccoid forms, with more uniform distribution of
staining properties.
Method of Examination
Ziehl-Neelsen stained smears should be examined with a 54x or 100x oil immersion* objective;
fluorochrome stained smears with a 20x or 40x dry objective.
Regardless of which type of stain is being observed, each
slide must be thoroughly examined for the presence or
absence of acid-fast bacilli. It is recommended that a
minimum of 100 fields be examined before a smear is
reported as negative. To achieve this, you should adopt a
procedure that ensures that a representative area of the
smear is reviewed. Three passes along the long axis of the
slide or nine passes along the short axis of the slide should
provide an ample area for reading and eliminate the
possibility of reading the same area more than once.

Reporting Results of Acid-Fast Bacilli Smears


When examining a slide that contains AFB, only observe enough fields to obtain a representative
average of AFB present. Count each AFB that is not touching another AFB as one, and because a
clump represents one colony-forming unit, count clumps of AFB also as one.
There are several methods for the reporting of numbers of AFB seen in a smear. Interpretation of AFB
according to IUATLD (International Union against Tuberculous Lung Disease) when reporting fuchsin-
stained smears observed at 1000x is:

Number of AFB seen Report

Not found in 100 HPF Negative


1 – 9 / 100 HPF the number of bacteria
10 – 99 / 100 HPF + or +1
1 – 10 / 1 HPF ++ or +2

> 10 / 1 HPF +++ or +3

Note : if 1 – 3 AFB/ HPF, repeat exam using new specimen, if still 1 – 3 report as neg, if 4 – 9 report as
pos.

Reexamine the smear.


Make several more smears from the specimen, stain, and examine.
Report the questionable findings to the Doctor and ask that further specimens be submitted.

62 Respiratory System – 3rd Year Undergraduate Program


Reports should state:
1. If acid-fast bacilli were seen or not seen.
2. If acid-fast bacilli were seen, state the number of AFB seen.
3. Since tubercle bacilli can not be microscopically distinguished from nontuberculous
mycobacteria by smear examination, do not report species. A positive report should only state
that "acid-fast bacilli were seen".
4. State the method by which the smear was examined (i.e. Fluorescent Microscopy or
Ziehl-Neelsen stain).
Examples:
Negative report Positive report
3+ acid-fast bacilli were seen by
Acid-fast bacilli were not seen by
auramine-rhodamine and Ziehl-Neelsen
fluorescent microscopy.
stain.

63 Respiratory System – 3rd Year Undergraduate Program


DRAW THE RESULT OF YOUR ACTIVITY

Signature of trainer

64 Respiratory System – 3rd Year Undergraduate Program


LABORATORY MANUAL – 7TH WEEK

PATIENT EDUCATION OF DRUG USED IN RESPIRATORY


DISEASES

GENERAL OBJECTIVE:

Able to design treatment plan according to pharmacokinetic and pharmacodynamics for common
respiratory disease.

SPECIFIC OBJECTIVES:

- Able to make good and rational prescription


- Able to inform patient about the drug used and its side effects for improving the patient
compliance.

SEQUENCE:

Explaining general steps during activity, including:

1. Introduction: explaining the aims of lab activity 20 minutes


2. Pre-test 10 minutes
3. Lab activity (role play) 45 minutes
4. Discussion I (prescription) 25 minutes
5. Discussion II (pharmacological properties) 40 minutes
6. Post-test 10 minutes

MATERIAL:

- Manual laboratory activity -


List of drugs
- Sample of drugs
- Role play room (skills lab) -
Scenario
METHOD:

This learning activity will be conducted using role play methods. The activity begins with short
introduction about the activity objectives and the mechanism of role play. The allotted time for this
activity is 3x50 minutes.

Every laboratory instructor facilitates maximal 10 students.

LEARNING METHOD:

Role play method is used in this laboratory activity. Each group is divided into 3 subgroups. Each
subgroup will be given a different clinical scenario from the case tuberculosis, asthma and
rhinosinusitis. After the role play, each group should discussed the problems by assist of the
instructors.

The students evaluate using multiple choice question and OSOCA that is integrated with assessment
in the block; but the formative assessment can be done to evaluates students’ understanding on
basic science and evaluate the activity.

INTRODUCTION

This activity is intended to impress the students and motivate them to deeply learn clinical
application of drugs used in asthma, Tuberculosis, and other drugs used in respiratory disease, like
decongestant, antitussives, mucolytic and expectorant.

Before activity, the students have to accomplish the homework assignment first, read the primary
references, so that they will be more readily in performing laboratory activity.

65 Respiratory System – 3rd Year Undergraduate Program


INDIVIDUAL HOMEWORK ASSIGNMENT:
To be collected to your tutor

1. Explain etiology and pathogenesis of asthma!


2. Describe the classification of drugs used in asthma!
3. Describe advantage and disadvantage each of drugs used in asthma disease.
4. What is the definition of below and mention each 2 examples :
· Decongestant
· Antitussives
· Mucolytic
· Expectorant
5. Explain advantage and disadvantage each of drugs used in respiratory disease, especially as
decongestant, antitussives, mucolytic and expectorant.
6. Describe the classification of macrolides antibiotics! Compare the
specific spectrum activity and indication of each class!

Compare the specific pharmacological properties of each class that impact to specific
clinical application!

Compare the advantages and disadvantages of each class!

7. List antituberculosis classification!


8. What is the mechanism of action of ethambutol?
9. Why Ethambutol contraindicated in children?
10. List antituberculosis drugs reach a significant concentration in CSF!
11. Mention antituberculosis drug should be administered with pyridoxine concomitantly! Explain
it!
12. Explain pharmacological properties of antituberculosis!

GROUP HOMEWORK:

1. Each group should be divided into 3 subgroups


2. Prepare the role play scenario based on table 1. Each role play consists of a doctor and a patient.
3. Try to understand the case setting and its problems
4. The doctor should try to give appropriate education to the patient according to the medication
that is used.

REFERENCES

1. Katzung, B.G. et al. Antimycobacterial Drugs in Basic and Clinical Pharmacology 11th
edition. Singapore: McGraw-Hill Companies. 2009
2. Pedoman Nasional Penanggulangan Tuberkulosis, 2Ed. Depkes RI. 2007. Free download at
http://www.tbindonesia.or.id/pdf/BPN 2007.pdf

66 Respiratory System – 3rd Year Undergraduate Program


3. WHO. Treatment of tuberculosis: guidelines – 4th ed. 108-110, 2009. Free
download: http://whqlibdoc.who.int/publications/2010/9789241547833 eng.pdf
4. Katzung, B.G. et al. Adrenoceptor Agonists & Sympathomimetic Drugs in Basic and
Clinical Pharmacology 11th edition. Singapore: McGraw-Hill Companies. 2009
5. Rubin BK. Mucolytics, expectorants, and mucokinetic medications. Respir Care. 2007
Jul;52(7):859-65
6. Katzung, B.G. et al. Drugs Used in Asthma in Basic and Clinical Pharmacology 11th edition.
Singapore: McGraw-Hill Companies. 2009
7. Katzung, B.G. et al. Tetracyclines, Macrolides, Clindamycin, Chloramphenicol,
Streptogramins, & Oxazolidinones in Basic and Clinical Pharmacology 11th edition.
Singapore: McGraw-Hill Companies. 2009
8. Katzung, B.G. et al. Rational Prescribing & Prescription Writing in Basic and
Clinical Pharmacology 11th edition. Singapore: McGraw-Hill Companies. 2009.
9. Guide to Good Prescribing- A practical manual. WHO. 1995. Free download
at http://apps.who.int/medicinedocs/pdf/whozip23e/whozip23e.pdf

67 Respiratory System – 3rd Year Undergraduate Program


Case Synopsis

Case I (Tuberculosis)

CODE Case setting Learning objectives:

C1.1 A-32-years old man was fail in getting drive license patient education of TB treatment
because he could not pass Ishihara blind test. He is an and side effect of ethambutol
angkot driver. He was having diagnosed as pulmonary
tuberculosis, he was currently in therapy 4th weeks of 2nd prescription of 2nd category TB
category. initial phase

- Make prescription pyridoxine role on TB treatment


- What information needed to be given to the
pharmacological properties of
patient regarding his failure in color blind test
- How if he had renal insufficiency, what is your antituberculosis
plan?
C1.2 A-10-years old boy, 20kg, had been diagnosed by lung patient education of TB treatment
tuberculosis by a pediatrician and regularly took anti & drop out criteria
tuberculosis since 3 month ago. Her doctor asked her
to continue the medication in the primary health care. prescription of 2nd category TB
continue phase for pediatric
· What information needed to be given to
the patient regarding his condition pyridoxine role on TB treatment
· What is your plan
pharmacological properties of
· Make the prescription
antituberculosis

C1.3 A woman, 25-year old, came to PUSKESMAS with patient education of TB treatment
hemaptoe. She said that she had been diagnosed and rifampisin side effects
lung tuberculosis few months before her pregnancy.
prescription of 2nd category TB
One week ago, she delivered a healthy baby. She said initial phase
that she had 1 month of continuation phase therapy
using R and H before she stopped her treatment by pyridoxine role on TB treatment
herself because of her pregnancy. pharmacological properties of
antituberculosis
· What information needed to be given to
the patient regarding his condition
· What is your plan for her son
· Give information to the patient about the
breast feeding while taking the medicine
· Make the prescription
· How if he had renal insufficiency, what is your
plan?
C1.4 A man, 47-year old, was diagnosed by extra Pulmonary patient education of TB treatment
Tuberculosis. He was in the end of initial phase of TB and side effect of pyrazinamide
treatment. Although he felt improvement of TBC clinical

68 Respiratory System – 3rd Year Undergraduate Program


symptoms, he had complaint of his feet thumb since prescription of 2nd category TB
3 days ago. His thumb became swelled and painful. initial phase
He felt these similar symptoms at 5 years ago.
pyridoxine role on TB treatment
His uric acid was 8,9 mg/dl.
pharmacological properties of
· What information needed to be given antituberculosis
to the patient regarding his condition
· What is your plan for his complaint
· Make the prescription
· How if he had liver dysfunction, what is your
plan?

69 Respiratory System – 3rd Year Undergraduate Program


Case II (ASTHMA or COPD)

CODE Case setting Learning objectives:

C2.1 a 66-year-old man with COPD who is presenting to the Develop an appropriate
family medicine clinic today to have a 1-month follow-up medication regimen for a
appointment from his last hospital admission for an patient with COPD based on
acute exacerbation of COPD. This last COPD exacerbation disease severity.
is the second hospital admission in the last 6 months
related to TJ’s COPD instability. Evaluate the role of inhaled
and/or oral corticosteroids
After TJ’s hospitalization, his discharge COPD regimen in the management of COPD.
was changed to include tiotropium, 1 inhalation daily in
addition to salmeterol 50 mcg, 1 inhalation Q 12 h, and Educate patients on the proper
an albuterol MDI as needed. TJ had pulmonary function use of inhaled medications and
tests (PFTs) while he was in the hospital 1 month ago but determine which patients may
has yet to have them reassessed after the change in his benefit from spacers and/or
COPD regimen. He wants to start taking prednisone every holding chambers.
day because he believes this would prevent him from
being readmitted to the hospital.

C2.2 a 8-year-old boy, 18 kg, who presents to the emergency patient education of asthma
department with a 3-day history of cough and congestion. treatment and the potential side
He had had asthma since 4 years old. He did have a fever 3 effect
days prior to admission, and he was given ibuprofen. The
educate the patient how to use
previous night before admission, he seemed to be gasping
for air and during the day today, he had had an increased inhalation medication
work of breathing. pharmacological properties of
After he had gotten better, the doctor give him 2 asthma treatment
inhalation of 160 μg inhaled Budesonide plus 4.5
prescription of asthma
μg Formoterol fumarate as a LABA twice a day.
treatment

C2.3 a 28-year-old man who presents to the ED for an acute Formulate a patient-specific
visit due to shortness of breath. He reports feeling therapeutic plan (including
especially short of breath since awakening this morning. drugs, route of administration,
He states that he has been using her albuterol every hour and appropriate monitoring
for the past 6 hours and that it doesn’t seem to be parameters) for management of
helping. His peak flows have been running between 180 a patient with chronic asthma.
L/min and 200 L/min today (personal best = 400 L/min).
Develop a self-management
In addition to her albuterol MDI, which he uses PRN, he
action plan for improving
also has a fluticasone MDI, which she uses “most days of
the week.” He reports having to use her albuterol inhaler control of asthma.
approximately 3–4 times per week over the past 2
months, but over the past week she admits to using

70 Respiratory System – 3rd Year Undergraduate Program


albuterol almost daily. He reports being awakened by a
cough three times over the past month. He states he
especially becomes short of breath when he exercises;
although he admits that her shortness of breath is not
always brought on by exercise and sometimes occurs when
he is not actively exercising. He indicates that her morning
peak flows have been running around 300 L/min
(personal best = 400 L/min) over the past several weeks.

71 Respiratory System – 3rd Year Undergraduate Program


Case II (Rhinosinusitis or pharingitis)
CODE Case setting Learning objectives:

C3.1 a-30 years old woman works as secretary at oil company Patient education for taking
was diagnosed pharyngitis and was given Claritomycin, macrolid, ibuprofen and
ibuprofen and ambroxol. ambroxol

1. What information needed to be given to Good prescription for macrolid,


the patient her medications ibuprofen and ambroxol based
2. Make the prescription! on their pharmacological
3. What is your plan if the patient having properties
renal insufficiency
4. What is your plan if the patient having liver Apply the pharmacological
Insufficiency properties of macrolid,
ibuprofen and ambroxol on
organ dysfunction

C3.2 a-10-year old boy, 25 kg, came with runny nose with Patient education for taking
greenish discharge since 3 days. Since 7 days ago, he had macrolid, GG and
been having nasal discharge and blockage. He also had pseudoephedrine
history of repeated cold. Because of his penicillin allergic
history, the doctor gave him Erythromycin, GG and Good prescription for macrolid,
pseudoephedrine. GG and pseudoephedrine based
on their pharmacological
1. What information needed to be given to properties
the patient her medications
2. What is your plan if the mother said that he could Rational antibiotic used in
not take tablets? respiratory diseases
3. Make the prescription!
4. Before she left your room, she said that
patient’s brother, 12 years old, 30 kg, had also
nasal discharge and fever. She wanted you to
write another prescription for his son.

ss

MANUAL – 8TH WEEK


PATHOLOGY ANATOMY OF TONSIL,
LARYNX, TRACHEA, AND BRONCHUS

PATHOLOGY
TOPICS :
1. Nasal polyp
2. Chronic rhinitis
3. Inverted papilloma
4. Nasopharyngeal carcinoma

RESOURCE PERSON
1. Hasrayati Agustina, dr., SpPA, M.Kes
2. Hermin Aminah dr, SpPA

REFERENCE
Kumar V, Abbas AK, Fausto N. Robins and Cotran Pathologic Basis of Disease, 8 th edition.
Elsevier Inc, Philadelphia, 2010.

LEARNING OBJECTIVE
After completing the lab activity, the students should be able to :
1. Understand the pathogenesis of chronic rhinitis
2. Describe the histopathologic appearance of chronic rhinitis
3. Understand the pathogenesis of nasal polyp
4. Describe the histopathologic appearance of nasal polyp
5. Understand the pathogenesis of inverted papilloma
6. Describe the histopathologic appearance of inverted papilloma
7. Understand the pathogenesis of nasopharyngeal carcinoma
8. Describe the histopathologic appearance of nasopharyngeal carcinoma

PRE-REQUISITES:
The students have to do the homework and read the references as listed in the first page.

HOMEWORK
A. Fill in the blank box under each picture with microscopic or clinical/macroscopic
appearance for each cases
B. Answer these questions correctly

72 Respiratory System – 3rd Year Undergraduate


Program
1. Explain the pathogenesis of chronic rhinitis !
2. Explain the pathogenesis of nasal polyp
3. Explain the pathogenesis of inverted papilloma
4. Explain the pathogenesis of nasopharyngeal carcinoma

1. NASAL POLYP

. Clinical appearance / macroscopic

Microscopic
2. CHRONIC RHINITIS
.

Clinical appearance/ macroscopic

73 Respiratory System – 3rd Year Undergraduate Program


Microscopic
3. NASAL INVERTED PAPILLOMA

Clinical appearance/macroscopic
74 Respiratory System – 3rd Year Undergraduate Program
.
Microscopic

4. NASOPHARYNGEAL CARCINOMA

Clinical appearance/macroscopic

75 Respiratory System – 3rd Year Undergraduate Program


Microscopic

Draw schematic microscopic appearance in these boxes


76 Respiratory System – 3rd Year Undergraduate Program
PATHOLOGY
TOPICS :

1. Emphysema
2. Pneumonia
3. Pulmonary tuberculosis
4. Lung carcinoma

RESOURCE PERSON

1. Hasrayati Agustina, dr., SpPA, M.Kes


2. Hermin Aminah dr, SpPA

REFERENCE

Kumar V, Abbas AK, Fausto N. Robins and Cotran Pathologic Basis of Disease, 8th edition.

Elsevier Inc, Philadelphia, 2010.

LEARNING OBJECTIVE

After completing the lab activity, the students should be able to :

1. Understand the pathogenesis of emphysema


2. Describe the histopathologic appearance of emphysema
3. Understand the pathogenesis of pneumonia
4. Describe the histopathologic appearance of pneumonia
5. Understand the pathogenesis of pulmonary tuberculosis
6. Describe the histopathologic appearance of pulmonary tuberculosis
7. Understand the pathogenesis of lung carcinoma
8. Describe the histopathologic appearance of lung carcinoma

PRE-REQUISITES:

The students have to do the homework and read the references as listed in the first page.

HOMEWORK

A. Fill in the blank box under each picture with microscopic or clinical/macroscopic
appearance for each cases
B. Answer these questions correctly
1. Explain the pathogenesis of emphysema !
2. Explain the pathogenesis of pneumonia
3. Explain the pathogenesis of pulmonary tuberculosis
4. Explain the pathogenesis of lung carcinoma
77 Respiratory System – 3rd Year Undergraduate Program
a. EMPHYSEMA

Clinical appearance/ Macroscopic

Microscopic

78 Respiratory System – 3rd Year Undergraduate Program


b. PNEUMONIA

Clinical appearance/macroscopic

Microscopic

79 Respiratory System – 3
rd Year Undergraduate Program
c. PULMONARY TUBERCULOSIS

Clinical appearance/macroscopic

Microscopic

80 Respiratory System – 3rd Year Undergraduate Program


d. LUNG CARCINOMA

Clinical appearance/ macroscopic

Microscopic
Draw schematic microscopic appearance in these boxes

81 Respiratory System – 3rd Year Undergraduate


Program

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