Beruflich Dokumente
Kultur Dokumente
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
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
16,18,20 Nopember PHYSIOLOGY & PHYSICAL LUNG FUNCTION TEST & BREATHING
IV
2015 REHABILITATION TECHNIQUE FOR ASTHMATIC PATIENT
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:
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:
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.
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 )
done 1. Identification :
- Dorsum :
- Root
- Apex
- N a re s
- Alae
- Vestibule
- bone
- hyaline cartilage
- two lateral cartilages, two alar cartilages and one septal cartilage
Nasal Septum :
- Choanae
- Nasal mucosa
- Respiratory area -
Olfactory area
- Roof :
- Floor :
- Medial wall :
- Lateral walls :
The arterial supply of the medial and lateral walls of the nasal cavity is from five source :
Paranasal sinuses
· Frontal sinuses :
o Location :
o Each sinus drains through.....into the
o They are innervated by
· 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................
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).
b. Development of the lower respiratory system (larynx, trachea, bronchi, and lungs): Lab
Activity Week-2 and 3.
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
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:
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.
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
LEARNING OBJECTIVES
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,
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.
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.
Fig. 2.3 Development of the lung. A, the canalicular period. B, the terminal sac period.
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.
HISTOLOGY
LEARNING OBJECTIVES:
RESOURCE PERSON
REFERENCES
1. Junqueira, L. Carlos and Carneiro J. Basic Histology Text and Atlas. 10t Edition. Lange
h
HOMEWORK ASSIGNMENT
1. Complete the following histologic figure by naming the pointed parts (13
points).
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.
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.
24
Specimen: IM-7 (Palatine tonsil)
Schematic Drawings Description
44
HISTOLOGY
LEARNING OBJECTIVES
RESOURCE PERSON
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
HOMEWORK ASSIGNMENT
1) Trachea
5
6
1 7
8
3
9
4 10
11
27
Fig. 3.1 Diagram of a portion of the bronchial tree.
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
RESOURCE PERSON
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?
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.
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.
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
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).
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
VI Interfering factor
· 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
VII. INTERPRETATION
· 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 .
24 /0,03 x 40
24/1,2
20/1
increased excretion of H+
decreased of pHCO3-
24/0,03X40
24/1,2
20/1
-* H2CO3 increased
Renal compensation :
increased excretion of H+
complete compensation
· Decreased pH decreased
· Increased HCO3-
If there are any complete compensation in BGA; pH will be changed to the normal value.
- COPD
- Asthma
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.
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
- 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
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
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
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
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
SPECIFIC OBJECTIVE
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
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.
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
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.
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.
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.
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.
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.
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.
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
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
Note : if 1 – 3 AFB/ HPF, repeat exam using new specimen, if still 1 – 3 report as neg, if 4 – 9 report as
pos.
Signature of trainer
GENERAL OBJECTIVE:
Able to design treatment plan according to pharmacokinetic and pharmacodynamics for common
respiratory disease.
SPECIFIC OBJECTIVES:
SEQUENCE:
MATERIAL:
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.
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.
Compare the specific pharmacological properties of each class that impact to specific
clinical application!
GROUP HOMEWORK:
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
Case I (Tuberculosis)
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
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
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
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
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
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
1. NASAL POLYP
Microscopic
2. CHRONIC RHINITIS
.
Clinical appearance/macroscopic
74 Respiratory System – 3rd Year Undergraduate Program
.
Microscopic
4. NASOPHARYNGEAL CARCINOMA
Clinical appearance/macroscopic
1. Emphysema
2. Pneumonia
3. Pulmonary tuberculosis
4. Lung carcinoma
RESOURCE PERSON
REFERENCE
Kumar V, Abbas AK, Fausto N. Robins and Cotran Pathologic Basis of Disease, 8th edition.
LEARNING OBJECTIVE
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
Microscopic
Clinical appearance/macroscopic
Microscopic
79 Respiratory System – 3
rd Year Undergraduate Program
c. PULMONARY TUBERCULOSIS
Clinical appearance/macroscopic
Microscopic
Microscopic
Draw schematic microscopic appearance in these boxes