Respiratory A & P
with Med Terms
• Montana Hospital Association
• June 1, 2011 10 am - Noon
• © Irene Mueller, EdD, RHIA
http://media.healthday.com/images/editorial/respiratory.jpg
1
Objectives
• Coding-focused Review of Respiratory
system anatomy and physiology
• Focus on the medical knowledge
requirements of ICD-10-CM/PCS coding
2
ICD-10-CM/PCS Respiratory
• ICD-10-CM
– Chapter 10 – J00-J99
– Chapter 18 – R04-R09
• ICD-10-PCS
– 0B1-0BY
– 090-09W (Sinus = part of Ear, Nose, Sinus)
3
A & P Review
• Functions
• Cells
– Cilia
• Top – Down
• Inside - Out
•
•
•
•
Nose/Sinuses
Pharynx/Larynx
Trachea/Bronchi
Lungs
– Alveolus (Alveoli) – air sac
• Type I - gas transmission
• Type II – surfactant
production
4
Functions of
Respiratory System
• 1st – Ventilation and respiration
– Maintaining life
• Oxygenation of organs, tissues, cells
– Controlled by CNS
• medulla oblongata and pons
• 2nd – Metabolic functions
– Acid-base (pH) balance of the blood
• Coordinated with kidney functions
– Removal of CO2 (Metabolism waste product)
5
Medulla oblongata and Pons
• http://www.britannica.com/bps/mediaview/59842/1/0/0
• Part of Brain stem (hind brain)
• Controls automatic functions that are
necessary for survival
– Breathing, Digestion, Heart rate
6
Ventilation
• Feedback mechanism
• Chemosensory receptors
– Spinal fluid
– Carotid/aortic arteries
– Arterial CO2 tension
– O2 deficiency
• Changes rate of respiration
– Increase
– Decrease
7
Breathing
• http://www.5min.com/Video/Learn-aboutThe-Breathing-Process-117566835
8
Ventilation and Respiration
• Ventilation (Action of chest)
– Inhalation (active)
– Exhalation (passive)
• Respiration, external
– Exchange O2 and CO2 in lungs
• Respiration, internal
– Exchange gases between blood and tissue cells
• Respiration, cellular
– Oxidation, use of O2 to release energy
9
Lung Capacity
Total Lung
Capacity
Vital Lung
Capacity
Tidal volume
6,000 ml = 6
Liters
Inspiratory
Reserve volume
(IRV)
500 ml
3,000 ml
Expiratory reserve
volume (ERV)
1,000 ml
Functional
residual capacity
2,500 ml
4,500 ml
ERV + Residual air
Residual Air
1.500 ml
10
Acid-Base Balance
• Lungs and Kidneys work together
• Hypocapnia -  CO2 in blood
– Can be caused by hyperventilation
= Respiratory Alkalosis
• Hypercapnia -  CO2 in blood
– Lack of O2 in blood
= Respiratory Acidosis
Kidneys adjust bicarbonate (HCO3) in blood
11
Method to change ventilation
• Hyperventilation (anxiety, etc.)
• -  CO2 in blood
• Rebreathing air in bag
– Decreases O2
– Increases CO2
• Feedback to respiratory center
• Quick response to slow breathing
12
Acidosis
• Respiratory Acidosis
– pH < 7.35 (Normal: 7.35 - 7.45)
– CO2 > 45 (Normal: 35 – 45)
• Metabolic Acidosis
– pH < 7.35 (Normal: 7.35 - 7.45)
– HCO3- < 22 (normal: 22 – 26)
13
Alkalosis
• Respiratory Alkalosis
– pH > 7.45 (Normal: 7.35 - 7.45)
– CO2 < 35 (Normal: 35 – 45)
• Metabolic Alkalosis
– pH > 7.45 (Normal: 7.35 - 7.45)
– HCO3- > 26
14
Homeostasis
• Body tries to maintain homeostasis with
the Acid/Base balance using acids and
bases contained within the body
• Each acid and alkaline (base)
counterbalances the other
• Body enzymes cannot work when
acid/base is out of balance
• Respiratory system (fast) = acid
• Kidneys (slow) = base
15
Pulmonary Circulation
• Pulmonary arteries
– Carry deoxygenated venous blood from heart
to lungs (Exception to rule)
• Pulmonary capillaries
– Gas exchange occurs (diffusion)
• Pulmonary veins
– Return freshly oxygenated blood to heart
• Bronchial arteries
– Supply O2 and nutrients to lungs
16
Oxygenation
• 95-100% = Normal level of O2
• Red Blood cells carry
– O2 from lungs to tissues
– CO2 from tissues to lungs
• Hypoxemia
– Low O2
– <85%
17
Main vs Accessory Organs
• ACCESSORY Organs
– Diaphragm
– Pleura (visceral and parietal)
– Thorax (Ribs, Intercostal muscles, sternum,
12 vertebrae)
• Mediastinum
– Between lungs
– Heart, great vessals
– Trachea, Esophagus
– Lymph nodes
18
Respiratory Tract (ICD-10)
• UPPER RT
• Nose
– Turbinates
• Sinuses
• Pharynx
– Salivary Glands/Ducts
• Tonsils
• Epiglottis
• Larynx
•
•
•
•
LOWER RT
Bronchi
Bronchioles
Lungs
–
–
–
–
Lobes
Hilum
Alveoli
Surfactant
• Interstitium
– Vocal Cords
• Trachea (usu. LRT)
19
Nose (Rhino-)
http://training.seer.cancer.gov/anatomy/respiratory/passages/nose.html
20
Nose
• Functions
–
–
–
–
–
–
–
Cleansing
Warming
Humidifying
Olfaction (Smell)
Taste
Voice
Lacrimal drainage
– 1st line of immune
system
• Nares (nostrils)
• Nasal Septum
• Turbinates (Conchae)
– Warming/Humidifying
• Cilia
– Hair-like cells
– Sweep away
• Mucus (Igs)
– 1 qt/daily
– immune cells,
antibodies,
antibacterial proteins
21
Sinuses
•
•
•
•
•
All bilateral
Frontal
Ethmoid (Gr: sieve)
Sphenoid (Gr: wedgelike)
Maxillary (L: jaw)
http://american-rhinologic.org/patientinfo.sinusnasalanatomy.phtml
22
Function(s) of Sinuses
Not completely understood, possible functions
include
-Warming/humidification of air
-Regulation of intranasal & serum gas pressures
-Contributing to immune defense
-Increasing mucosal surface area
-Lightening the skull
-Absorbing shock
-Contributing to facial growth
Resonance of voice
23
Pharynx
http://training.seer.cancer.gov/anatomy/respiratory/passages/pharynx.html
24
Pharynx (Gr: throat)
• About 5 inches long
• Functions
– Passageway for air and food/liquids
– Swallowing
– Drainage
• Auditory tubes
• Nose
25
Salivary Glands/Ducts
• Pairs
• Major
– Parotid (near ear, largest, mumps)
– Sublingual
– Submaxillary
• Minor (many)
• Saliva can be aspirated
26
Tonsils (L. tonsilla)
• Function in Respiratory system
– Contain lymphocytes
– Protect against inhaled foreign antigens
• Palatine - both sides of back of throat
• Lingual – base of tongue
• Pharyngeal tonsils, or adenoids –
– high in throat, behind nose
27
Epiglottis (Glottis)
http://www.nlm.nih.gov/medlineplus/ency/imagepages/19595.htm
28
Function of Epiglottis
• A flap of cartilage at the upper part of
larynx - projects into pharynx
• During swallowing, whole larynx rises to
epiglottis, blocking connection to
respiratory tract
• Once food is in esophagus, larynx relaxes
and returns to normal location
29
Normal Swallowing
http://www.radiologyassistant.
nl/en/440bca82f1b77
30
Larynx (Voicebox)
http://training.seer.cancer.gov/anatomy/respiratory/passages/larynx.html
31
Functions of Larynx
• Valve to prevent air escaping lungs, e.g.
weightlifting
• Prevent foreign substances entering the
lungs, trachea and glottis
• Forcefully expel foreign substances
threatening trachea (coughing)
• Production of sound (non-biological
function) http://www.youtube.com/watch?v=Cxj
_-RGAxWM&NR=1
32
Vocal Cords (Folds)
• True
– Sound
– Lower in larynx
Singing high
note
• False
– Vestibular
– Above true cords
– No sound
Deep
breath
http://etc.usf.edu/clipart/50900/50956/50956_vocal.htm
33
Break Time
Fluid Exchanges
34
Trachea (Gr: trkheia, rough )
•
•
•
•
•
•
4-4.5 inches long
1 inch diameter
15 - 20 C-shaped Rings
Ligaments
Bifurcation
Carina (L: keel)
Clipart courtesy FCIT
http://www.youtube.com/watch?v=3ALJjtNeAb8
35
Functions of Trachea
• Conduit for air
• Conditioning of air
–Warming
–Moistening
–Removal of particulate materials
• Ciliated escalator
36
Bronchial Tree
http://image.wistatutor.com/content/feed/tvcs/lungs4.gif
37
Bronchi (Gr: bronkhos, windpipe)
• Bronchus (sing) (cartilage in walls)
• Primary (main, principal)
End of
conduction
• Secondary (lobar)
– 2 left, 3 right
• Tertiary (segmental)
• Bronchioles
– Bronchioli
– No cartilage
http://medicaldictionary.thefreedictionary.com/_/viewer.aspx?path=dorland&name=bronchiole_terminal.jpg
38
Functions of Bronchi/Bronchioli
• Conduction of air
• Conditioning of air
– Cilia
– Mucus
• Transition to respiration
– Terminal Bronchioli
39
Lung Anatomy
• Right Lung
– Wider, shorter, more
vertical
– 3 lobes
• Superior
• Medial
• Inferior
–
–
–
–
Segments
Lobules
Fissures
Alveoli
• Left Lung
– Smaller
– 2 lobes, to allow space
for heart
• Superior
• Inferior
–
–
–
–
–
Lingula
Segments
Lobules
Fissures
Alveoli
40
Lingula (L: small tongue)
• A tongue-like process or part
• Projection from the lower costal
surface of the upper lobe of the left
lung
• Has its own pleura
• Has its own bronchus
41
Lung Segments
• R lung = 10 Bronchopulmonary segments
• L lung = 8 Bronchopulmonary segments
• Each segment is connected to a tertiary
bronchus
42
Lobules of lungs
• Each lobule has a lymphatic vessel, arteriole,
venule, and a branch from a terminal bronchiole
http://www.tpub.com/content/armymedical/MD0568/MD05680015.htm
43
Fissures of lungs
• Walls of connective tissues separating the
lobes of the lungs
• R lung
– Horizontal fissure
– Oblique fissure
• L lung
– Oblique fissure
44
Alveolus (L: small hollow, pit)
• The lungs hold about 300-400 million
alveoli, each wrapped in capillaries
• Total surface area of 83-107 square yards
• Function
– Gas exchange – external respiration
– Oxygen in alveolus passes across the alveolar
membrane to enter the bloodstream
• 50 of these = thickness of piece of paper
– CO2 & other waste gases pass across the
membrane from blood to air within alveolus
45
Surfactant in Alveoli
• Lowers normal surface tension
• Reducing surface tension prevents
alveoli from collapsing
• Increases the ability of the lung to
stretch; the distensibility of the lung
tissues
46
Interstitium (L: space between)
• Space between cells in a tissue
• Plasma/interstitial fluid exchange easily
through thin capillary walls
• Arteriole
– fluid moves plasma  interstitium
• Venule
– Fluid moves interstitium  plasma
• Small fluid excess  lymph system
47
Other Respiratory Anatomy
• ACCESSORY Organs
– Diaphragm
– Pleura (visceral and parietal)
– Thorax (Ribs, Intercostal muscles)
• Mediastinum
– Between lungs
– Heart, great vessals
– Trachea, Esophagus
– Lymph nodes
48
Diaphragm (G: partition, barrier)
• Dome-shaped
structure that
separates thoracic
and abdominal
cavities
• Major muscle of
respiration
• Innervated by the
Phrenic nerve
http://www.nlm.nih.gov/medlineplus/ency/imagepages/19380.htm
49
Pleura (Gr: rib, side)
• Large, thin (one-cell layer) tissue sheet wraps
around outside of lungs (visceral) and inside chest
cavity (parietal)
• Between pleural layers is very thin space,
normally filled with small amount of fluid (10mL x 2)
• Fluid helps layers of pleura
glide smoothly past each
other as lungs breathe air
in and out
http://www.nlm.nih.gov/medlineplus/pleuraldis
orders.html
50
Pleura/Pleurae
• Pleura for each lung
is separate
• Parietal pleura has
many pain fibers
• Visceral pleura has
no pain fibers
Clipart courtesy FCIT
• Cupola of pleura
– Covers apex of lung
51
Mediastinum
• Interpleural space
• Part of the chest lying between sternum
and spinal column, between the lungs
• Contains heart, large blood vessels,
windpipe (trachea), thymus gland, and
connective tissues
• Roots of lungs
• Has its own pleura
52
Hilum (L: little thing)
• Wedge-shaped
depression on
mediastinal surface of
each lung
• Where bronchus,
blood vessels,
nerves, & lymphatics
enter/leave the viscus
• (Root of lung)
http://147.126.239.16/lumen/meded/radio/curriculum/pulmonary/image2.jpg
53
Thorax (Rib cage)
(L: Latin thorax,
breastplate, chest)
• Between neck and abdomen
• Part of axial skeleton
–Ribs
–Sternum
–Thoracic vertebrae (12)
54
Sternum (G: sternon, breast,
breastbone)
• Manubrium
– (L: handle)
• Body (breastbone)
– Gladiolus
– (L: sm. Sword)
• Xiphoid process
– (G: straight sword)
Clipart courtesy FCIT
http://dicountcostumes.pubks.com/Long-Roman-Sword
55
Costal (L: rib)
• 12 pairs (11, 13)
• True ribs (1st seven)
– Vertebro-sternal
• False ribs (next 5)
– Vertebro-chondral (3)
– Vertebral (floating) (2)
Clipart courtesy FCIT
56
Functions of Ribs
• Protection
• Structure
• Inspiration stage of ventilation
– Bucket Handle motion
• Twisting of upper ribs superiorly.
– Pump handle movement, when the handle
(sternum) is moved anteriorly
57
Other Respiratory Muscles
• External and internal intercostal
muscles elevate ribs
• Increase anterior-posterior diameter
of the thoracic cavity
58
Secondary Respiration Muscles
• Breathing may need to be assisted by other
muscles
• Include parasternal, scalene,
sternocleidomastoid, trapezius, and
pectoralis muscles
• Do NOT function during normal ventilation
• Sometimes needed in certain respiratory
disorders
59
External
Obliques
Expiratory
Abdominals
http://spinalcolumnblog.com/2009/12/11/a-sigh-of-relief/
60
Homework
61
1. Which feature is found only in
the left lung?
Cardiac notch
Horizontal fissure
Oblique fissure
Superior lobar bronchus
Three lobes
62
2. Which part of the left lung might
partially fill the costomediastinal
recess in full inspiration?
Apex
Cupola
Hilum
Lingula
Middle lobe
63
3. The oblique fissure of the right lung
separates which structures?
Lower lobe from lingula
Lower lobe from upper lobe only
Lower lobe from both upper &
middle lobes
Lower lobe from middle lobe only
Upper from middle lobe
•
64
4. A 4-year-old girl is coughing, and mother
states she was playing with some beads
and had apparently aspirated one. Where
would it most likely be?
Apicoposterior segmental bronchus of
L lung
Left main bronchus
Lingular segment of left lung
Right main bronchus
Terminal bronchiole of right lung, lower
lobe
65
5. Which statement is true about the right lung?
It is slightly smaller than the left lung
It has a lingular segmental bronchus
It occupies the rightmost portion of
mediastinum
Its upper lobar bronchus lies behind and
above the right pulmonary artery
It has the right phrenic nerve passing
posterior to the lung root
66
6. A 10-y-o boy had a tonsillectomy. At home he lay
supine in bed for 2 weeks, developing a fever, chest
pain, & cough. He returned to the hospital and was
diagnosed w/R lung pneumonia due to aspiration
during tonsillectomy. In which broncho-pulmonary
segment of the lung would fluid (pus) most likely
accumulate by the force of gravity?
Anterior basal segment--inferior lobe
Anterior segment--superior lobe
Lateral segment--middle lobe
Superior segment--inferior lobe
Superior lingual segment--lingula
67
7. You are observing a doctor perform a
bronchoscopy. As he passes the scope down
the trachea, a cartilagenous structure is seen
separating the R and L main stem bronchi. He
asks what it is called. You reply that it really
does look like a ship's keel and that it is called
the
Carina
Cricoid cartilage
Costal cartilage
Pulmonary ligament
Tracheal ring
68
8. Because of its angle with the trachea
and size of the main bronchus, a
bronchoscope would pass more
readily into which lung?
Left
Right
69
9. How do the lungs stay inflated?
– Each lung is ribbed with cartilage to
prevent collapse on exhalation
– The lungs are tethered to the ribcage
with a network of connective tissue
– The lungs rely on a vacuum within the
chest, maintained by the diaphragm
70
10. Our breathing is controlled by the part of
the brain called the
cerebrum
medulla oblongata
spinal cord
71
11. Which of these structures has NO
cartilage around it?
– primary bronchus
– secondary bronchus
– terminal bronchiole
– larynx
– trachea
72
12. If a person's vital capacity is 4000mL,
and her expiratory reserve volume is
1000mL and her inspiratory reserve
volume is 2500mL, then her tidal volume is
– 3500mL
– 3000mL
– 1500mL
– 1000mL
– 500mL
73
13. A segment of lung tissue that is bounded
by connective tissue partitions and
supplied by a single bronchiole is called
– a lobe.
– an alveolar sac.
– an alveolar duct.
– a lobule.
74
14. The mucous membrane lining the nasal
cavity and upper pharynx has a protective
function that relates to which of the
following organ systems?
– nervous system
– endocrine system
– lymphoid system
– integumentary system
75
15. Activity of which of the following organ
systems generates carbon dioxide?
– muscular system
– nervous system
– skeletal system
– endocrine system
76
General Resources
• Frazier, M. S. & Drzymkowski, J. W. Essentials of Human
Diseases and Conditions, 4th ed., Saunders, 2009
• Gray, H. Anatomy of the Human Body. 1918.
– http://www.bartleby.com/107/
• Neighbors, M. & Tennehill-Jones, R. Human Diseases,
Thomson Learning, 2000.
• Scott, A. S. & Fong, E. Body Structures and Functions, 11th
ed., Delmar, 2009
• Respiratory Glossary.
– http://www.rnceus.com/resp/respgloss.html#accessory
• The Free Dictionary (includes audio pronunciation).
– http://www.thefreedictionary.com/
• A free online Talking Dictionary of English Pronunciation
– http://www.howjsay.com/
Respiratory A& P Resources
• GetBodySmart. A Review of the Structures and
Functions of the Respiratory System.
– http://getbodysmart.com/ap/respiratorysystem
/menu/menu.html
• Jenson, M. Anatomy and Physiology Learning
Modules. University of Minnesota.
– http://msjensen.cehd.umn.edu/default.asp
• Nasal Physiology.
– http://emedicine.medscape.com/article/874771-overview#a1
78
Respiratory A & P Resources
• National Cancer Institute. Introduction to the
Respiratory System. SEER Training Modules
– http://training.seer.cancer.gov/anatomy/respir
atory/
• Norman, W. Pleural cavity and lungs.
– http://home.comcast.net/~wnor/thoraxlesson2.htm
• Physiology of the Nose. UC San Diego Health
System.
– http://health.ucsd.edu/specialties/surgery/otolaryngology/nasal/p
hysiology.htm
79
Respiratory A & P Resources
• Pokorski, P. L. Respiratory System (PPT)
– www.umd.umich.edu/casl/natsci/bio/B100W06/Respi
ratory%20System.ppt
• Respiratory Assessment: Adult and Child by
RnCeus.com. Interactive tutorial.
– http://www.rnceus.com/course_frame.asp?exam_id=2
6&directory=resp
80
Quiz Resources
• Grass, J. Quizzes. Human Anatomy and
Physiology
– http://lrn.org/Content/Quizzes/Quizlist.html
• Practice Quiz - Superior Mediastinum & Lungs.
University of Michigan Medical School
– http://anatomy.med.umich.edu/cardiovascular_system/su
p_med_questions.html
• Respiratory System Multiple Choice Quizzes.
GetBodySmart.com
– http://www.getbodysmart.com/ap/respiratorysystem/quizz
es/multiplechoice/menu/menu.html
• Web Anatomy. Quizzes.
– http://msjensen.cehd.umn.edu/webanatomy/
81
Video/Audio Resources
• Bronchial Tree Model – Larynx, Trachea,
Bronchi (Videos).
– Dr. Robert Droual, Modesto Jr. College
– http://www.youtube.com/results?search_type=
&search_query=Bronchial%20Tree%20Model
• MedlinePlus. Breathing (anatomy video).
– http://www.nlm.nih.gov/medlineplus/ency/anat
omyvideos/000018.htm
82
ICD 10 CM
• 2011 release of ICD 10 CM
– http://www.cdc.gov/nchs/icd/icd10cm.htm
– Preface [PDF - 93 KB]
– ICD-10-CM Guidelines [PDF - 494 KB]
– ICD-10-CM PDF Format
– ICD-10-CM XML Format
– ICD-10-CM 2010 to 2011 Addenda
– ICD-10-CM List of codes and Descriptions
– General Equivalence Mapping Files
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ilemten@gmail.com
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