Research Topics: Respiratory Disorder Case Studies

Diagnosis and Treatment of Most Respiratory Disorders

Critically evaluate the relevant importance of histology, cytology and immunohistochemistry in the diagnosis and management of non-malignant diseases of the respiratory tract.   INTRODUCTION             The diagnosis and treatment of most respiratory disorders depend heavily on understanding the basic physiologic principles of respiration and gas exchange. Some respiratory diseases result from inadequate ventilation, whereas others result from abnormalities of diffusion through the pulmonary membrane or abnormal transport in the blood from the lungs to the tissues. The therapy is often entirely different for these diseases, so it is no longer satisfactory simply to make a diagnosis of “respiratory insufficiency” (Guyton & Hall, 2000). In the normal respiratory system, the volume and pattern of ventilation are determined by the neural output from the respiratory center located near the ventrolateral surface of the medulla. This output is influenced by afferent information from several sources, including higher centers in the brain, peripheral chemoreceptors, central chemoreceptors, and neural impulses from moving tendons and joints.             Deviation from the normal range, and consequent respiratory insufficiency, can result from malfunction of the respiratory system at any point in the respiratory pathway. It is important to appreciate this when ordering and interpreting pulmonary function tests. Disturbances of different points can usually be measured specifically when the tests available and the patterns of pathophysiologic disturbances are understood.             Diagnosis and management of pulmonary disorders requires a history, a physical examination, and usually chest x-rays. Pulmonary function testing, arterial blood gas analysis, chemical or microbiologic tests, or special studies (eg, endoscopy, bronchoalveolar lavage, biopsy, radionuclide scanning) may be needed.             Among the most fundamental of all tests of pulmonary performance are determinations of the blood PO2, CO2 and pH. Several simple and rapid methods have been developed to make these measurements within a few minutes, using no more than a few drops of blood (Guyton & Hall, 2000).             Blood pH is measured using a glass of pH electrode of the type used in all chemical laboratories. However, the electrodes used for this purpose are miniaturized. A glass electrode pH meter can also be used to determine blood CO2. The concentration of oxygen in a fluid can be measured by a technique called polarography. Electric current is made to flow between a small negative electrode and the solution (Guyton & Hall, 2000). Non malignant respiratory diseases that will be discussed in this paper will include pulmonary hypertension, asthma, chronic obstructive pulmonary disease (COPD), pneumonia, cystic fibrosis, and allergic pulmonary diseases. The importance of histology, cytology and immunohistochemistry in the diagnosis and management of these non-malignant diseases of the respiratory tract will be discussed.   PULMONARY HYPERTENSION             Primary pulmonary hypertension is a rare disease of unknown etiology, whereas secondary pulmonary hypertension is a complication of many pulmonary, cardiac and extrathoracic conditions. Chronic obstructive pulmonary disease, left ventricular dysfunction and disorders associated with hypoxemia frequently result in pulmonary hypertension. Regardless of the etiology, unrelieved pulmonary hypertension can lead to right-sided heart failure. Signs and symptoms of pulmonary hypertension are often subtle and nonspecific. The diagnosis should be suspected in patients with increasing dyspnea on exertion and a known cause of pulmonary hypertension (Stites, 2001).             All patients with documented pulmonary hypertension should undergo a comprehensive laboratory evaluation to clarify the etiology. The goal is to identify or exclude treatable causes. Initial tests include complete blood count, prothrombin time, partial thromboplastin time, hepatic profile and autoimmune panel (Stites, 2001). HIV testing should be considered in all patients, especially those with a compatible history or risk factors. Treatment of pulmonary hypertension is directed at the underlying etiology. For example, patients with emphysema should be treated with long-term oxygen therapy, bronchodilators and steroids to reduce the pulmonary artery pressure. Afterload reduction and diuretics are part of the therapy in patients with left ventricular dysfunction causing pulmonary venous disease. A patient with mitral valve disease may need valve repair or replacement to reduce the chronically elevated left atrial pressure. A patient with chronic thromboembolic pulmonary hypertension will need to be treated indefinitely with anticoagulation therapy, an inferior vena cava filter and a thromboendarterectomy to open the lumen (Brooke Huffman, 2001).   CHRONIC OBSTRUCTIVE PULMONARY DISEASE             Chronic obstructive pulmonary disease (COPD) is a disease state characterized by the progressive development of airflow limitation that is not fully reversible. The airflow limitation is associated with an abnormal inflammatory response of the lungs to noxious particles or gases (Daryanani, 2004). COPD is an umbrella term for two diseases, chronic bronchitis and emphysema, both of which are characterized by irreversible obstruction to air flow on exhalation. Asthma is another obstructive lung disease; however, it is classified separately from COPD because the person with asthma usually has periods during which air flow returns to normal. While many persons with COPD also have some degree of airway reactivity (or bronchospasm) and are thus said to have an asthmatic component to their disease, their air flow never returns to normal. Both COPD and asthma are also inflammatory processes; however, inflammation in COPD differs markedly from that seen in asthma, with different cells, mediators, and responses to treatment (Locke, 2004). In COPD, definite diagnosis depends on (1) demonstration of physiologic evidence of airways obstruction which persists despite intensive and maximum medical management, and (2) exclusion of any specific disease as a cause of this physiologic abnormality. Individuals with a family history of lung disease and those with an early onset of emphysema should be tested for α1-antitrypsin deficiency to determine the serum levels. Phenotyping should be done if the level is low. The normal phenotype is constituted by the MM genetic pattern. The most common abnormal phenotype associated with α1-antitrypsin deficiency is the ZZ pattern. Persons with the MZ phenotype are carriers of the disease, but do not appear to have an increased risk of developing COPD (Locke, 2004). β-2 agonists, corticosteroids, anticholinergics, and methylxanthines have been the mainstay of COPD therapy. New agents, classes, and combinations of drugs are being developed for the treatment of COPD. In February 2004, tiotropium, a long-acting anticholinergic bronchodilator, was approved by FDA. Three combination products are available: ipratropium/albuterol as a metered-dose inhaler (MDI); ipratropium/albuterol as a solution for inhalation via a nebulizer; and fluticasone/salmeterol, in the 250/50 mcg strength for the treatment of COPD associated with chronic bronchitis (Daryanani, 2004). Phosphodiesterase-4 (PDE4) inhibitors are a newer class of drugs under investigation for the treatment of COPD that may also be available in the near future. With the growing number of pharmacologic options for the treatment of COPD, it is important to use evidence-based clinical data to determine which agents are most beneficial.   Emphysema             In the degenerative and potentially fatal pulmonary disease called emphysema, the lungs lose their elasticity as a result of disruption of elastic tissue and the walls between the alveoli break down so that the alveoli are replaced by large air sacs.             The most common cause of emphysema is excessive cigarette smoking. The smoke causes an increase in the number of pulmonary alveolar macrophages, and these macrophages release a chemical substance that attracts leukocytes to the lungs. The leukocytes in turn release proteases including elastase, which attacks the elastic tissue in the lungs. At the same time, α1-antitrypsin, a plasma protein that normally inactivates elastase and other proteases, is itself inhibited (Ganong, 2001). The α1-antitrypsin is inactivated by oxygen radicals, and these are released by the leukocytes. The final result which can be seen in biochemical and histological tests is a protease-antiprotease imbalance with increased destruction of lung tissue.   Chronic Bronchitis             Chronic bronchitis is an inflammatory condition clinically defined as a chronic cough that exists for 3 months of the year for 2 consecutive years. While the diagnosis of bronchitis is based on clinical criteria, distinctive pathologic features of the airways are associated with the hypersecretion of mucus (Locke, 2004). Again, as in emphysema, certain proteases are involved. In chronic bronchitis, these proteases are potent stimulants of mucus secretion as the size and number of mucus-secreting goblet cells in the airway epithelium increase. Mucosal inflammation is characterized by edema, which further narrows the airways. These inflammatory airway changes occur secondary to chronic stimulation from irritants such as cigarette smoke. The presence of thick and tenacious mucus in the airways also promotes adherence of bacteria, which can reproduce rapidly in this environment. Impaired ciliary function, caused by cigarette smoking, further compromises the lung’s defense mechanisms and increases the patient’s susceptibility to infection (Locke, 2004).   ASTHMA             Asthma is characterized by episodic or chronic wheezing, cough, and a feeling of tightness in the chest as a result of bronchoconstriction. Three abnormalities are present: airway obstruction that is at least partially reversible, airway inflammation, and airway hyper-responsiveness to a variety of stimuli. A link to allergy has long been recognized, and plasma IgE levels are often elevated as found out in biochemical tests. The sputum in a patient with uncomplicated asthma is highly distinctive. Grossly, it is tenacious, rubbery and whitish. In the presence of infection, particularly in adults, the sputum may be yellowish. Examination of the blood and the sputum of a patient with asthma commonly shows eosinophilia regardless of whether allergic factors can be shown to have an etiologic role in the disease. Blood eosinophilia > 250 to 400 cells/cu mm is the rule; in many asthmatics, the degree of the eosinophilia may correlate with the severity of the asthma. The extent to which blood eosinophilia can be suppressed with corticosteroids has been used as an index of the therapeutic efficacy of these agents. Proteins released from eosinophils in the inflammatory reaction may damage the airway epithelium and contribute to the hyper-responsiveness. Leukotrienes are released from eosinophils and mast cells, and leukotrienes cause bronchoconstriction. Numerous other amines, neuropeptides, chemokines, and interleukins have effects on bronchial smooth muscle or produce inflammation, and they may be involved in asthma (Ganong, 2001).             Many eosinophils are found histologically, frequently arranged in sheets; large numbers of histiocytes and polymorphonuclear leukocytes are also present. Eosinophilic granules from disrupted cells may be seen throughout the sputum smear. Elongated dipyramidal crystals (Charcot-Leyden) originating from eosinophils are commonly found. When infection is present, and particularly when there is a bronchotic element, polymorphonuclear leukocytes and bacteria predominate. In uncomplicated asthma, sputum cultures rarely reveal pathogenic bacteria.             In the treatment of asthma, inhibitors of leukotriene synthesis such as zilueton and CysLT1 receptor blockers such as montelukast are found to be effective. β-Adrenergic receptors mediate bronchodilation, and treatment with inhaled β-Adrenergic agonists is a standard therapy for asthma.   PNEUMONIA             In diagnosing lower respiratory tract infections, histology and immunohistochemistry are important. Most of the clinical manifestations of the various pneumonias overlap. Some investigators demonstrated that chest radiography is not helpful for differentiating bacterial from nonbacterial pneumonia. Therefore, microbiologic means should be used to identify the causative agent in pneumonia (Thomson, 1991). Identification of the causative agent and knowledge of its antimicrobial susceptibility are important in determining the approach to treatment. Consequently, gram stain and culture of lower respiratory secretions should be performed.             Immunologic diagnosis of community-acquired pneumonia in adults can be attempted using methods that detect bacterial antigen in tissue fluids and microorganism-specific antibody (IgM or IgG) in serum. Detection of Haemophilus influenzae and Streptococcus pneumoniae antigens has been evaluated using counter-immunoelectrophoresis, latex agglutination, coagglutination and enzyme immunoassay (Thomson, 1991). The following tests can help with diagnosis and treatment of pneumonia: (1) Chest X-ray, indicated for anyone with suspected pneumonia to aid diagnosis, gain insight into the cause and severity of pneumonia, detect associated lung diseases, and assess the patient’s response to treatment. (2) Blood work, including complete blood cell count and differential; serum creatinine, urea nitrogen, glucose, electrolyte, bilirubin, and liver enzyme levels; possibly HIV status; Sao^sub 2^ levels; and blood cultures. (3) Sputum tests, including Gram’s stain, culture and sensitivity, and possibly tuberculosis and Legionella testing. Negative results help confirm the presence of viral pneumonia. (4) Thoracentesis with culture and stain, pH, white blood cell count and differential, and possibly cytologic testing (Schultz, 2002).  The goal of empiric therapy is to choose a regimen that will be effective against the most likely pathogen. When rapid diagnostic techniques are not available, therapy should be started based on the knowledge of the susceptibility pattern of the common respiratory pathogens in the community. A reasonable attempt should be made to obtain a Gram stain of respiratory secretions before antimicrobial therapy is started (Thomson, 1991).             With the aid of the Gram stain results, the physician can initiate treatment based on a suspected pathogen. When gram-positive cocci in chains or pairs are found as the predominant organism, S. pneumoniae is the most likely causative organism. When the smear indicates gram-positive cocci in clusters, staphylococcal infection must be considered. The finding of gram-negative coccobacilli in the smear is compatible with H. influenzae. Gram-negative diplococci suggest M. catarrhalis, and gram-negative rods are indicative of Enterobacteriaceae, Pseudomonas and anaerobic organisms. When mixed gram-positive and gram-negative organisms are seen, aspiration of oral flora should be suspected (Thomson, 1991).   CYSTIC FIBROSIS             Cystic fibrosis is another condition that leads to repeated pulmonary infections and progressive, eventually fatal destruction of the lungs. In this congenital recessive disorder, a Cl- channel in the apical membrane of airway epithelial cells is not activated in a normal fashion by cyclic adenosine monophosphate (cAMP).             Histologically, the gene that is abnormal in cystic fibrosis is located in the long arm of chromosome 7. This gene encodes a Cl- channel called the cystic fibrosis transmembrane conductance regulator (CFTR) (Ganong, 2001). Functional abnormalities in the CFTR protein result in a paucity of salt and water in secretions from epithelial cells. Consequently, airway secretions are tenacious and difficult to clear, leading to airway obstruction and subsequent bacterial infection. Recurrent bacterial infections and subsequent inflammation damage the lungs and account for much of the irreversible pulmonary disease in patients with cystic fibrosis (Worth, 1996). Sweat testing (using pilocarpine iontophoresis) is a standard quantitative test in the diagnosis of cystic fibrosis. A chloride level greater than 60 mEq per L is a positive test. False-negative and false-positive results are rare, but they do occur. A positive sweat test in combination with typical pulmonary manifestations, pancreatic malabsorption or a history of cystic fibrosis in the immediate family is considered diagnostic (Worth, 1996). Similarly, eosinophilia and elevated serum Ige levels lend confirmatory evidence but cannot establish the diagnosis. This test is usually performed at age 1 to 2 weeks when cystic fibrosis is suspected at birth, but can be done at any age. A complete microbiological assessment of expectorated sputum, including antibiotic susceptibility testing, should be performed at least on an annual basis, and preferably on a quarterly basis. Oropharyngeal swab cultures, which are commonly obtained from children who do not produce sputum, have not been fully studied in adults. Multiply-resistant Gram-negative organisms, such as Burkholderia cepacia, Stenotrophomonas maltophilia, and Achromobacter xylosoxidans, are found in up to one third of adults with cystic fibrosis (David, 2004).             ALLERGIC PULMONARY DISEASES             Hypersensitivity (allergic) diseases of the lungs include hypersensitivity pneumonitis (extrinsic allergic alveolitis), allergic bronchopulmonary aspergillosis, and many drug reactions. Other eosinophilic pneumonias and the pulmonary granulomatoses are of suspected allergic origin.              Most data suggest that Th1 responses are required for viral clearance but Th1 cytokines such as interferon-[gamma] can also enhance the inflammatory response. Allergic airway responses are characterized by Th2 cytokines, increased production of total and allergen-specific IgE, tissue eosinophilia, and elevated exhaled nitric oxide (NO) in the lower airway, and are thought to be ineffective against viral infection and perhaps even detrimental (Varner, 2002).             Inhaled corticosteroids are the primary treatment for rhinitis and are thought to suppress Th2-like inflammation but not Th1 responses. Yet, nondiscriminate suppression of Th2 responses leads to a reduction in eosinophils, anti-inflammatory Th2 cytokines, and exhaled NO, and thus may enhance susceptibility to or severity of viral infection. Indeed, inhaled steroids are less effective against viral-induced wheezing than other triggers of asthma exacerbations and increase adverse sequelae of viral infection, such as otitis media in children, when used in the upper airway (Varner, 2002).   SUMMARIZATION/CONCLUSION             There are already significant advancements in the diagnosis and management of non-malignant diseases of the respiratory tract. These advancements are in the field of histology, cytology and immunohistochemistry.             Most non-malignant diseases of the respiratory tract can be diagnosed using cell and tissue specimens of respiratory organs. Cytological and histological examinations would be helpful in diagnosing these diseases. Diseases usually show abnormal patterns and characteristics in cell and tissue cultures that will be examined.             Histology, cytology and immunohistochemistry can help in confirming diseases, as sometimes chest X-rays and other procedures are not totally exact in diagnosing non-malignant diseases of the respiratory tract.               REFERENCES   Brooke Huffman, G. 2001, Pulmonary Hypertension: Diagnosis and Treatment, American Family Physician. Daryanani, A.A. 2004, Treatment Options for the Management of Chronic Obstructive Pulmonary Disease, Formulary. David, R. 2004, Cystic Fibrosis Adult Care: Consensus Conference Report, Chest. Ganong, W. 2001, Review of Medical Physiology 20th Edition, McGraw-Hill, USA. Gargiulo, R.F. 2000, Postobstructive Pulmonary Edema, American Family Physician. Guyton, A. and Hall, J. 2000, Textbook of Medical Physiology 10th Edition, Harcourt Asia Pte Ltd, Singapore. Locke, D.L. 2004, Update on Chronic Obstructive Pulmonary Disease, MedSurg Nursing. Schultz, T.R. 2002, Pinpointing a Diagnosis, Nursing. Stites, S.W. 2001, Diagnosis and Treatment of Pulmonary Hypertension. American Family Physician. Thomson, R.B. 1991, Ambulatory Management of Lower Respiratory Tract Infections, American Family Physician. Varner, A.E. 2002, The Increase in Allergic Respiratory Disease: Survival of the Fittest? Chest. Credit:ivythesis.typepad.com

Diagnosis and Treatment of Most Respiratory Disorders

Critically evaluate the relevant importance of histology, cytology and immunohistochemistry in the diagnosis and management of non-malign...

Critically evaluate the relevant importance of histology, cytology and immunohistchemistry in the diagnosis and management of non-malignant diseases of the respiratory tract

Critically evaluate the relevant importance of histology, cytology and immunohistochemistry in the diagnosis and management of non-malignant diseases of the respiratory tract.   INTRODUCTION             The diagnosis and treatment of most respiratory disorders depend heavily on understanding the basic physiologic principles of respiration and gas exchange. Some respiratory diseases result from inadequate ventilation, whereas others result from abnormalities of diffusion through the pulmonary membrane or abnormal transport in the blood from the lungs to the tissues. The therapy is often entirely different for these diseases, so it is no longer satisfactory simply to make a diagnosis of “respiratory insufficiency” (Guyton & Hall, 2000). In the normal respiratory system, the volume and pattern of ventilation are determined by the neural output from the respiratory center located near the ventrolateral surface of the medulla. This output is influenced by afferent information from several sources, including higher centers in the brain, peripheral chemoreceptors, central chemoreceptors, and neural impulses from moving tendons and joints.             Deviation from the normal range, and consequent respiratory insufficiency, can result from malfunction of the respiratory system at any point in the respiratory pathway. It is important to appreciate this when ordering and interpreting pulmonary function tests. Disturbances of different points can usually be measured specifically when the tests available and the patterns of pathophysiologic disturbances are understood.             Diagnosis and management of pulmonary disorders requires a history, a physical examination, and usually chest x-rays. Pulmonary function testing, arterial blood gas analysis, chemical or microbiologic tests, or special studies (eg, endoscopy, bronchoalveolar lavage, biopsy, radionuclide scanning) may be needed.             Among the most fundamental of all tests of pulmonary performance are determinations of the blood PO2, CO2 and pH. Several simple and rapid methods have been developed to make these measurements within a few minutes, using no more than a few drops of blood (Guyton & Hall, 2000).             Blood pH is measured using a glass of pH electrode of the type used in all chemical laboratories. However, the electrodes used for this purpose are miniaturized. A glass electrode pH meter can also be used to determine blood CO2. The concentration of oxygen in a fluid can be measured by a technique called polarography. Electric current is made to flow between a small negative electrode and the solution (Guyton & Hall, 2000). Non malignant respiratory diseases that will be discussed in this paper will include pulmonary hypertension, asthma, chronic obstructive pulmonary disease (COPD), pneumonia, cystic fibrosis, and allergic pulmonary diseases. The importance of histology, cytology and immunohistochemistry in the diagnosis and management of these non-malignant diseases of the respiratory tract will be discussed.   PULMONARY HYPERTENSION             Primary pulmonary hypertension is a rare disease of unknown etiology, whereas secondary pulmonary hypertension is a complication of many pulmonary, cardiac and extrathoracic conditions. Chronic obstructive pulmonary disease, left ventricular dysfunction and disorders associated with hypoxemia frequently result in pulmonary hypertension. Regardless of the etiology, unrelieved pulmonary hypertension can lead to right-sided heart failure. Signs and symptoms of pulmonary hypertension are often subtle and nonspecific. The diagnosis should be suspected in patients with increasing dyspnea on exertion and a known cause of pulmonary hypertension (Stites, 2001).             All patients with documented pulmonary hypertension should undergo a comprehensive laboratory evaluation to clarify the etiology. The goal is to identify or exclude treatable causes. Initial tests include complete blood count, prothrombin time, partial thromboplastin time, hepatic profile and autoimmune panel (Stites, 2001). HIV testing should be considered in all patients, especially those with a compatible history or risk factors. Treatment of pulmonary hypertension is directed at the underlying etiology. For example, patients with emphysema should be treated with long-term oxygen therapy, bronchodilators and steroids to reduce the pulmonary artery pressure. Afterload reduction and diuretics are part of the therapy in patients with left ventricular dysfunction causing pulmonary venous disease. A patient with mitral valve disease may need valve repair or replacement to reduce the chronically elevated left atrial pressure. A patient with chronic thromboembolic pulmonary hypertension will need to be treated indefinitely with anticoagulation therapy, an inferior vena cava filter and a thromboendarterectomy to open the lumen (Brooke Huffman, 2001).   CHRONIC OBSTRUCTIVE PULMONARY DISEASE             Chronic obstructive pulmonary disease (COPD) is a disease state characterized by the progressive development of airflow limitation that is not fully reversible. The airflow limitation is associated with an abnormal inflammatory response of the lungs to noxious particles or gases (Daryanani, 2004). COPD is an umbrella term for two diseases, chronic bronchitis and emphysema, both of which are characterized by irreversible obstruction to air flow on exhalation. Asthma is another obstructive lung disease; however, it is classified separately from COPD because the person with asthma usually has periods during which air flow returns to normal. While many persons with COPD also have some degree of airway reactivity (or bronchospasm) and are thus said to have an asthmatic component to their disease, their air flow never returns to normal. Both COPD and asthma are also inflammatory processes; however, inflammation in COPD differs markedly from that seen in asthma, with different cells, mediators, and responses to treatment (Locke, 2004). In COPD, definite diagnosis depends on (1) demonstration of physiologic evidence of airways obstruction which persists despite intensive and maximum medical management, and (2) exclusion of any specific disease as a cause of this physiologic abnormality. Individuals with a family history of lung disease and those with an early onset of emphysema should be tested for α1-antitrypsin deficiency to determine the serum levels. Phenotyping should be done if the level is low. The normal phenotype is constituted by the MM genetic pattern. The most common abnormal phenotype associated with α1-antitrypsin deficiency is the ZZ pattern. Persons with the MZ phenotype are carriers of the disease, but do not appear to have an increased risk of developing COPD (Locke, 2004). β-2 agonists, corticosteroids, anticholinergics, and methylxanthines have been the mainstay of COPD therapy. New agents, classes, and combinations of drugs are being developed for the treatment of COPD. In February 2004, tiotropium, a long-acting anticholinergic bronchodilator, was approved by FDA. Three combination products are available: ipratropium/albuterol as a metered-dose inhaler (MDI); ipratropium/albuterol as a solution for inhalation via a nebulizer; and fluticasone/salmeterol, in the 250/50 mcg strength for the treatment of COPD associated with chronic bronchitis (Daryanani, 2004). Phosphodiesterase-4 (PDE4) inhibitors are a newer class of drugs under investigation for the treatment of COPD that may also be available in the near future. With the growing number of pharmacologic options for the treatment of COPD, it is important to use evidence-based clinical data to determine which agents are most beneficial.   Emphysema             In the degenerative and potentially fatal pulmonary disease called emphysema, the lungs lose their elasticity as a result of disruption of elastic tissue and the walls between the alveoli break down so that the alveoli are replaced by large air sacs.             The most common cause of emphysema is excessive cigarette smoking. The smoke causes an increase in the number of pulmonary alveolar macrophages, and these macrophages release a chemical substance that attracts leukocytes to the lungs. The leukocytes in turn release proteases including elastase, which attacks the elastic tissue in the lungs. At the same time, α1-antitrypsin, a plasma protein that normally inactivates elastase and other proteases, is itself inhibited (Ganong, 2001). The α1-antitrypsin is inactivated by oxygen radicals, and these are released by the leukocytes. The final result which can be seen in biochemical and histological tests is a protease-antiprotease imbalance with increased destruction of lung tissue.   Chronic Bronchitis             Chronic bronchitis is an inflammatory condition clinically defined as a chronic cough that exists for 3 months of the year for 2 consecutive years. While the diagnosis of bronchitis is based on clinical criteria, distinctive pathologic features of the airways are associated with the hypersecretion of mucus (Locke, 2004). Again, as in emphysema, certain proteases are involved. In chronic bronchitis, these proteases are potent stimulants of mucus secretion as the size and number of mucus-secreting goblet cells in the airway epithelium increase. Mucosal inflammation is characterized by edema, which further narrows the airways. These inflammatory airway changes occur secondary to chronic stimulation from irritants such as cigarette smoke. The presence of thick and tenacious mucus in the airways also promotes adherence of bacteria, which can reproduce rapidly in this environment. Impaired ciliary function, caused by cigarette smoking, further compromises the lung’s defense mechanisms and increases the patient’s susceptibility to infection (Locke, 2004).   ASTHMA             Asthma is characterized by episodic or chronic wheezing, cough, and a feeling of tightness in the chest as a result of bronchoconstriction. Three abnormalities are present: airway obstruction that is at least partially reversible, airway inflammation, and airway hyper-responsiveness to a variety of stimuli. A link to allergy has long been recognized, and plasma IgE levels are often elevated as found out in biochemical tests. The sputum in a patient with uncomplicated asthma is highly distinctive. Grossly, it is tenacious, rubbery and whitish. In the presence of infection, particularly in adults, the sputum may be yellowish. Examination of the blood and the sputum of a patient with asthma commonly shows eosinophilia regardless of whether allergic factors can be shown to have an etiologic role in the disease. Blood eosinophilia > 250 to 400 cells/cu mm is the rule; in many asthmatics, the degree of the eosinophilia may correlate with the severity of the asthma. The extent to which blood eosinophilia can be suppressed with corticosteroids has been used as an index of the therapeutic efficacy of these agents. Proteins released from eosinophils in the inflammatory reaction may damage the airway epithelium and contribute to the hyper-responsiveness. Leukotrienes are released from eosinophils and mast cells, and leukotrienes cause bronchoconstriction. Numerous other amines, neuropeptides, chemokines, and interleukins have effects on bronchial smooth muscle or produce inflammation, and they may be involved in asthma (Ganong, 2001).             Many eosinophils are found histologically, frequently arranged in sheets; large numbers of histiocytes and polymorphonuclear leukocytes are also present. Eosinophilic granules from disrupted cells may be seen throughout the sputum smear. Elongated dipyramidal crystals (Charcot-Leyden) originating from eosinophils are commonly found. When infection is present, and particularly when there is a bronchotic element, polymorphonuclear leukocytes and bacteria predominate. In uncomplicated asthma, sputum cultures rarely reveal pathogenic bacteria.             In the treatment of asthma, inhibitors of leukotriene synthesis such as zilueton and CysLT1 receptor blockers such as montelukast are found to be effective. β-Adrenergic receptors mediate bronchodilation, and treatment with inhaled β-Adrenergic agonists is a standard therapy for asthma.   PNEUMONIA             In diagnosing lower respiratory tract infections, histology and immunohistochemistry are important. Most of the clinical manifestations of the various pneumonias overlap. Some investigators demonstrated that chest radiography is not helpful for differentiating bacterial from nonbacterial pneumonia. Therefore, microbiologic means should be used to identify the causative agent in pneumonia (Thomson, 1991). Identification of the causative agent and knowledge of its antimicrobial susceptibility are important in determining the approach to treatment. Consequently, gram stain and culture of lower respiratory secretions should be performed.             Immunologic diagnosis of community-acquired pneumonia in adults can be attempted using methods that detect bacterial antigen in tissue fluids and microorganism-specific antibody (IgM or IgG) in serum. Detection of Haemophilus influenzae and Streptococcus pneumoniae antigens has been evaluated using counter-immunoelectrophoresis, latex agglutination, coagglutination and enzyme immunoassay (Thomson, 1991). The following tests can help with diagnosis and treatment of pneumonia: (1) Chest X-ray, indicated for anyone with suspected pneumonia to aid diagnosis, gain insight into the cause and severity of pneumonia, detect associated lung diseases, and assess the patient’s response to treatment. (2) Blood work, including complete blood cell count and differential; serum creatinine, urea nitrogen, glucose, electrolyte, bilirubin, and liver enzyme levels; possibly HIV status; Sao^sub 2^ levels; and blood cultures. (3) Sputum tests, including Gram’s stain, culture and sensitivity, and possibly tuberculosis and Legionella testing. Negative results help confirm the presence of viral pneumonia. (4) Thoracentesis with culture and stain, pH, white blood cell count and differential, and possibly cytologic testing (Schultz, 2002).  The goal of empiric therapy is to choose a regimen that will be effective against the most likely pathogen. When rapid diagnostic techniques are not available, therapy should be started based on the knowledge of the susceptibility pattern of the common respiratory pathogens in the community. A reasonable attempt should be made to obtain a Gram stain of respiratory secretions before antimicrobial therapy is started (Thomson, 1991).             With the aid of the Gram stain results, the physician can initiate treatment based on a suspected pathogen. When gram-positive cocci in chains or pairs are found as the predominant organism, S. pneumoniae is the most likely causative organism. When the smear indicates gram-positive cocci in clusters, staphylococcal infection must be considered. The finding of gram-negative coccobacilli in the smear is compatible with H. influenzae. Gram-negative diplococci suggest M. catarrhalis, and gram-negative rods are indicative of Enterobacteriaceae, Pseudomonas and anaerobic organisms. When mixed gram-positive and gram-negative organisms are seen, aspiration of oral flora should be suspected (Thomson, 1991).   CYSTIC FIBROSIS             Cystic fibrosis is another condition that leads to repeated pulmonary infections and progressive, eventually fatal destruction of the lungs. In this congenital recessive disorder, a Cl- channel in the apical membrane of airway epithelial cells is not activated in a normal fashion by cyclic adenosine monophosphate (cAMP).             Histologically, the gene that is abnormal in cystic fibrosis is located in the long arm of chromosome 7. This gene encodes a Cl- channel called the cystic fibrosis transmembrane conductance regulator (CFTR) (Ganong, 2001). Functional abnormalities in the CFTR protein result in a paucity of salt and water in secretions from epithelial cells. Consequently, airway secretions are tenacious and difficult to clear, leading to airway obstruction and subsequent bacterial infection. Recurrent bacterial infections and subsequent inflammation damage the lungs and account for much of the irreversible pulmonary disease in patients with cystic fibrosis (Worth, 1996). Sweat testing (using pilocarpine iontophoresis) is a standard quantitative test in the diagnosis of cystic fibrosis. A chloride level greater than 60 mEq per L is a positive test. False-negative and false-positive results are rare, but they do occur. A positive sweat test in combination with typical pulmonary manifestations, pancreatic malabsorption or a history of cystic fibrosis in the immediate family is considered diagnostic (Worth, 1996). Similarly, eosinophilia and elevated serum Ige levels lend confirmatory evidence but cannot establish the diagnosis. This test is usually performed at age 1 to 2 weeks when cystic fibrosis is suspected at birth, but can be done at any age. A complete microbiological assessment of expectorated sputum, including antibiotic susceptibility testing, should be performed at least on an annual basis, and preferably on a quarterly basis. Oropharyngeal swab cultures, which are commonly obtained from children who do not produce sputum, have not been fully studied in adults. Multiply-resistant Gram-negative organisms, such as Burkholderia cepacia, Stenotrophomonas maltophilia, and Achromobacter xylosoxidans, are found in up to one third of adults with cystic fibrosis (David, 2004).             ALLERGIC PULMONARY DISEASES             Hypersensitivity (allergic) diseases of the lungs include hypersensitivity pneumonitis (extrinsic allergic alveolitis), allergic bronchopulmonary aspergillosis, and many drug reactions. Other eosinophilic pneumonias and the pulmonary granulomatoses are of suspected allergic origin.              Most data suggest that Th1 responses are required for viral clearance but Th1 cytokines such as interferon-[gamma] can also enhance the inflammatory response. Allergic airway responses are characterized by Th2 cytokines, increased production of total and allergen-specific IgE, tissue eosinophilia, and elevated exhaled nitric oxide (NO) in the lower airway, and are thought to be ineffective against viral infection and perhaps even detrimental (Varner, 2002).             Inhaled corticosteroids are the primary treatment for rhinitis and are thought to suppress Th2-like inflammation but not Th1 responses. Yet, nondiscriminate suppression of Th2 responses leads to a reduction in eosinophils, anti-inflammatory Th2 cytokines, and exhaled NO, and thus may enhance susceptibility to or severity of viral infection. Indeed, inhaled steroids are less effective against viral-induced wheezing than other triggers of asthma exacerbations and increase adverse sequelae of viral infection, such as otitis media in children, when used in the upper airway (Varner, 2002).   SUMMARIZATION/CONCLUSION             There are already significant advancements in the diagnosis and management of non-malignant diseases of the respiratory tract. These advancements are in the field of histology, cytology and immunohistochemistry.             Most non-malignant diseases of the respiratory tract can be diagnosed using cell and tissue specimens of respiratory organs. Cytological and histological examinations would be helpful in diagnosing these diseases. Diseases usually show abnormal patterns and characteristics in cell and tissue cultures that will be examined.             Histology, cytology and immunohistochemistry can help in confirming diseases, as sometimes chest X-rays and other procedures are not totally exact in diagnosing non-malignant diseases of the respiratory tract. Credit:ivythesis.typepad.com

Critically evaluate the relevant importance of histology, cytology and immunohistchemistry in the diagnosis and management of non-malignant diseases of the respiratory tract

Critically evaluate the relevant importance of histology, cytology and immunohistochemistry in the diagnosis and management of non-malign...

Sample Respiratory Case Study ASTHMA IN CHILDREN

ASTHMA IN CHILDREN             A. Description of Disease:  Textbook Manifestations Asthma is a serious and potentially life-threatening illness affecting many children. It is characterized by episodic or chronic wheezing, cough, and a feeling of tightness in the chest as a result of bronchoconstriction. Its morbidity and mortality are increasing, and its fundamental cause is still unknown despite intensive research. A child who is frequently coughing or has respiratory infections should be evaluated for asthma. Additionally, a child who coughs after running or crying may also have asthma. Recurrent night cough is common, as asthma is often worse at night (American Lung Association, 2006).   B. Possible Etiology/Epidemiology As mentioned, the basic cause of the lung abnormality in asthma is not yet known. However, three abnormalities are present in asthma: airway obstruction that is at least partially reversible, airway inflammation, and airway hyperresponsiveness to a variety of stimuli. Episodes of asthma often are triggered by some condition or stimulus. Common triggers of asthma are exercise, infections, allergy, irritants, and weather.   C. Implications on growth and development Asthma is one of the most pervasive chronic illnesses in the United States, and it disproportionately affects children from low-income, urban, and/or ethnic minority backgrounds. Pediatric research has provided evidence that children who have been diagnosed with asthma experience compromises in psychological, behavioral, and social. The results from one study of urban children indicate young kids with asthma often exhibit behavioral problems, and that in many cases, children with persistent asthma may struggle in more than one area of behavior (KidsHealth, 2006). However, some studies also have found that children with asthma fare as well as their healthy peers in terms of psychosocial functioning (Mitchell, 2005).   D. Pertinent normal and abnormal lab data and diagnostic tests with significance for nursing care Chest x-ray: May reveal hyperinflation of lungs, flattened diaphragm, normal findings during periods of remission. Pulmonary function tests: Done to determine cause of dyspnea, whether functional abnormality is obstructive or restrictive, to estimate degree of dysfunction and to evaluate effects of therapy. Exercise pulmonary function studies may also be done to evaluate activity tolerance in those with known pulmonary impairment/progression of disease. Arterial blood gases (ABGs): Determined degree and severity of disease process, e.g., most often PaO2 is decreased, PaCO2 is often decreased, pH normal or acidotic, and mild respiratory alkalosis secondary to hyperventilation in asthma. Lung scan: Perfusion/ventilation studies may be done to differentiate between the various pulmonary diseases. Complete blood count and differential: Increased eosinophils in asthma. Sputum culture: Determines presence of infection, identifies pathogen. Cytologic examination: Rules out underlying malignancy or allergic disorder. Electrocardiogram (ECG): Right axis deviation and peaked P waves in severe asthma. Exercise, ECG, stress test: Helps in assessing degree of pulmonary dysfunction, evaluating effectiveness of bronchodilator therapy, planning/evaluating exercise program. Children with congenital malformations of the vascular system and of the gastrointestinal and respiratory tracts may present with wheezing. The presence of other congenital malformations, special attention to cases in which symptoms begin before age 1 year, x-ray studies, and a high index of suspicion will lead to a diagnosis of congenital malformation as a cause of wheezing. Foreign-body obstruction must be considered, particularly in children with unilateral wheezing or sudden onset of wheezing with no prior history of respiratory symptoms. Opaque foreign bodies are readily visible on x-ray. Non-opaque foreign bodies are more of a problem, but the diagnosis can be reestablished by a history of sudden onset of cough and wheezing in a previously well child, combined with asymmetric diaphragmatic movement on inspiratory and expiratory chest x-rays. Viral infections of the upper respiratory tract involving the epiglottis, glottis, and subglottis generally cause signs and symptoms of croup (inspiratory stridor, high-pitched cough, and hoarseness) that are distinct from the lower airways signs and symptoms of asthma.   E. Management             Nursing priorities include (a) maintain airway patency, (b) assist with measures to facilitate gas exchange, (c) enhance nutritional intake, (d) prevent complications and slow the progression of asthma, and (e) provide information about disease process of asthma and the prognosis and treatment regimen.             An important component of any intervention model designed to mitigate the impact of asthma on inner city children is the ability to efficiently and reliably identify children who are likely to have poorly controlled asthma. Ideally, this process would identify children with previously diagnosed asthma who are not receiving adequate therapy as well as children with undiagnosed asthma. Schools have received increasing attention as strategic sites for this process. School-based case identification methods that have been tested include parental surveys and exercise challenge procedures (Hanley-Lopez, 2004).             A holistic approach to the nursing care of children is required and involvement of the family is essential. The role of the children’s nurse is multifaceted and continually evolving. It includes being the carer, health educator and health promoter, the researcher, empowerer and the advocate. Children’s nurses must harness their power and influence: by working collaboratively with policymakers, other clinicians and service users, they can strive to give children the priority they deserve. Policy developments, the shift in care from hospital to the community and the recognition given to family centred care mean that children’s nurses must increasingly address the wider issues that influence child health and family wellbeing (Ross, 2003).             Discharge goals include (a) ventilation/oxygenation adequate to meet self-care needs, (b) nutritional intake meeting caloric needs, (c) the infection treated or prevented, (d) disease process or prognosis and therapeutic regimen understood, and (e) plan in place to meet needs after discharge.   F. Prognosis             Children with asthma have acute episodes when the air passages in their lungs get narrower as a result f different triggers. Because of this, their breathing becomes more difficult. These problems are caused by an oversensitivity of the lungs and airways.             The allergic reaction that occurs in asthma is believed to occur in the following way: the child forms abnormally large amounts of IgE antibodies, and these antibodies cause allergic reactions when they react with the specific antigens that have caused them to develop in the first place. When the child breathes in pollen to which he or she is sensitive, the pollen reacts with the antibodies that are attached to mast cells and causes them to release several different substances. The combined effects of all these factors are to produce (1) localized edema in the walls of the small bronchioles, as well as secretion of thick mucus into the bronchiolar lumens, and (2) spasm of the bronchiolar smooth muscle (Guyton & Hall, 2000).   G. Health promotion activities, teaching/learning and discharge needs.             Given the age of the child, he or she could have deficient knowledge regarding condition, treatment, self-care and discharge needs. This learning need is usually due to lack of information/unfamiliarity with information resources, information misinterpretation, and lack of recall/cognitive limitation (Doenges et al, 2002), the last of which could be applicable to the child. The parents or the guardian of the child should therefore be present along with the child during health promotion activities and teaching/learning and discharge needs.             The desired outcomes for these activities are to (a) verbalize understanding of condition/disease process and treatment, (b) identify relationship of current signs/symptoms to the disease process and correlate these with causative factors, and (c) initiate necessary lifestyle changes and participate in treatment regimen. The health promotion activities and teaching of disease process and other needs is outlined below: 		Nursing Actions/Interventions 		Rationale Explain or 		reinforce explanations of individual disease process. The child as well 		as the parents or guardian are encouraged to ask questions. Decreases anxiety 		and can lead to improved participation in treatment plan. Instruct or 		reinforce rationale for breathing exercises, coughing effectively, and 		general conditioning exercises. Specific breathing 		exercises can strengthen the muscles of respiration, help minimize 		collapse of small airways, and provide the child with means to control 		dyspnea. General conditioning exercises increase activity tolerance, 		muscle strength, and sense of well being. Stress importance 		of oral care/dental hygiene. Decreases 		bacterial growth in the mouth, which can lead to pulmonary infections. Discuss importance 		of avoiding people with active respiratory infections. Stress the need 		for routine influenza/pneumococcal vaccinations. Decreases exposure 		to and incidence of acquired acute respiratory infections. Discuss individual 		factors that may trigger or aggravate condition like excessively dry 		air, wind, environmental temperature extremes, pollen, tobacco smoke, 		aerosol sprays, air pollution. Parents/guardians should be encouraged to 		explore ways to control these factors in and around the home, school or 		any environment which the child stays. These 		environmental factors can induce/aggravate bronchial irritation, leading 		to increased secretion production and airway blockage. Provide 		information about activity limitations and alternating activities with 		rest periods to prevent fatigue. Having this 		knowledge can enable parents of the child to make informed 		choices/decisions to reduce dyspnea, maximize activity level, perform 		most desired activities and prevent complications for the child. Upon discharge, 		discuss importance of medical follow-up care, periodic chest x-rays, and 		sputum cultures. Monitoring disease 		process allows for alterations in therapeutic regimen to meet changing 		needs and may help prevent complications. Instruct asthmatic 		patient in use of peak flow meter, as appropriate. Peak flow level 		can drop before the patient exhibits any signs/symptoms of asthma during 		the “first time” after exposure to trigger. Regular use of the peak flow 		meter may reduce the severity of the attack because of the earlier 		intervention. Provide 		information and encourage participation in support groups, e.g., 		American Lung Association, public health department. The child and the 		parents or guardian may experience anxiety, depression, and other 		reactions as they deal with asthma that will have an impact on their 		lifestyle. Support groups and/or home visits may be desired or needed to 		provide assistance, emotional support, and respite care. Refer for 		evaluation of home care if indicated. Provide a detailed plan of care 		and baseline physical assessment to home care nurse as needed on 		discharge from acute care. Provides for 		continuity of care. may help reduce frequency of rehospitalization. Discuss 		respiratory medications, side effects, adverse reactions. The child may be 		on several respiratory drugs that have similar side effects and 		potential drug interactions. It is important that the parents or the 		guardian of the child understand the difference between nuisance side 		effects and untoward or adverse side effects.     Website research   URL: http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=22691             This website is maintained by the American Lung Association, an organization whose mission is to prevent lung disease and promote lung health. The American Lung Association exists outside the internet and is the oldest voluntary health organization in the United States. The association is geared on fighting lung disease in all forms, most especially asthma, tobacco control, and environmental health. A section on Asthma and Children is in the website which has been used as a reference for this paper. The site is appropriate for everyone who is concerned about their lung health and would like to know more about lung problems. Health care professionals and ordinary individuals concerned about lung health can use the site. The information provided in the website are useful, relevant and reliable. The facts presented agree with some which are found in textbooks and journals. This site can be trusted since this is maintained by a reputable health organization and is likely to be more impartial and trustworthy than one privately developed. However, the site presents a disclosure that all information contained in their website is not a substitute for medical advice or treatment, and they recommend consultation with a health care professional or a doctor. There was no specific date as to when the site has been updated but the year printed on the page is 2006.     URL: http://www.nlm.nih.gov/medlineplus/asthmainchildren.html             The name of the website is Medline Plus and is maintained by the U.S. government, specifically the U.S. National Library of Medicine and the National Institutes of Health. Regarding asthma, it contains links to other websites including that of the American Lung Association. The site provides health information regarding almost any kind of health issue, most are linked to other websites. Everyone could make use of the site, not just those who have children with asthma or lung problems. Although a section is dedicated to children with asthma, there are also other pages for adults with asthma. The website could be trusted that it provides useful and reliable information based on the fact that this is maintained by the government and includes information taken from other reliable websites. The site is last updated on November 3, 2006.   URL: http://kidshealth.org/research/asthma_behavioral.html             This is a link taken from the Medline Plus website and contains an article entitled “Behavioral Problems Often Present in Children with Asthma,” which is a review of a study. This website is called Kids Health for Parents. From the name of the website alone, one can tell that this site has parents of little children as its target audience. Aside from asthma, the website offers information regarding other health concerns of children. The information used in the article is reliable and useful since it is taken from a published study in the Pediatrics journal. The article mentioned has been reviewed in February 2006, suggesting that the website could be recently updated.   URL: http://pediatrics.about.com/cs/conditions/a/asthma.htm             This site, about.com, is a commercial organization offering information about virtually everything, not only about health concerns. The target audience of this site is everyone who wishes to know something about any topic. If one wishes to know about asthma, one could just click the link provided that would bring one to the page about asthma. A topic about Asthma in Children, created on November 20, 2003, is provided in one of its pages. The writer of this article is a doctor named Vincent Iannelli. Compared to the previous websites that have been mentioned, this one still contains information that is useful but less reliable.   URL: http://www.umm.edu/pediatric-info/asthma.htm             This is an educational institution website of the University of Maryland Medical Center. It provides various resources regarding medical issues, among them children’s health. The page on asthma in children was last reviewed on May 14, 2003 by a University of Maryland Medicine expert. Compared to commercial organizations, educational institutions can be more trusted regarding the content of their site. The target audience of this website could be medicine students and other health care professionals, but is not strictly limited only to them. Everyone could access the website and do research regarding issues in medicine. Credit:ivythesis.typepad.com

Sample Respiratory Case Study ASTHMA IN CHILDREN

ASTHMA IN CHILDREN A. Description of Disease: Textbook Manifestations Asthma is a serious and potentially life-threatenin...

RESPIRATORY DISEASE

Respiratory Disease This is an essay, evaluating the importance of histology, cytology and immunochemistry in the diagnosis and treatment of non-malignant diseases of the respiratory tract. Our human body is composed of ten functioning systems, all of which are working interdependently with the other systems in order for us to survive with the changes within our body and adapt from pressures from the environment. One of which is our respiratory system, also known as, respiratory tract. This system is one of the vital forces essential for living, as the old saying goes, we breathe to stay alive. The tract main purpose is to serve as a piping system where air passes towards that grape-like structure inside our lungs where Gas-exchange happens (, 2000). To better understand the works of the respiratory tract, it is essential to have a brief background of the respiratory tract’s physiology; after all, in order to understand the body as a whole, it is necessary to have a rich perspective at the tissue-level organization. Respiratory tract has two main parts: the upper respiratory tract (URT) and lower respiratory tract (LRT) (, 2000). The upper respiratory tract starts as the air enters our nasal cavity by process of inhalation, to the pharynx (compose of nasopharynx, oropharynx and laryngopharynx), larynx (voice box) down to the trachea (windpipe). While the lower respiratory tract starts as the air enters the thoracic cavity (lungs), to the bronchi (primary, secondary and terminal), bronchioles and to the alveoli to the alveolar ducts where gas-exchange happens as stated earlier (, 2000). This organ comprises our respiratory tract, each of which has a special function aided with special groups of cells for them to work well. In order to decipher the importance of these organs in the diagnosis and management of non-malignant diseases of the respiratory tract, it is important to know what makes composes these organs, namely their histology and cytology, and how these properties do contributes to each other. The respiratory system has three main functions: respiration, gas-exchange and acid-base balance (, 2004). In order for the respiratory tract to perform these functions, our respiratory organs are equipped with specialized cells with specialized properties in order to work effectively alongside with the demands of our body. Most of which can only be found in our respiratory system. Examples are stratified squamous cell, pseuostratified ciliated columnar, goblet cells, and type II granular pneumocyte. Nasal cavity alone is lined with stratified squamous cell, a type of cell which is the usual outer covering of other organs, its main function is to protect. It also has pseudostratified ciliated columnar cells, the cilia (meaning: hair-like) acts as an air filter that traps bacteria and foreign objects that could obstruct the airway and removes them. Pseudo-stratified ciliated columnar cells also contain ‘goblet cells’ which secretes mucus when exposed to irritation, an allergen or pollution. Our nasal cavity also has folds by bony projections called conchae which condition the air, making it warmer and moist to be more suited with our internal environment. The lungs which is the main organ of respiration is made of type II granular pneumocyte, roughly a cuboidal type of cell, which is responsible for the production and secretion of surfactant, a product that resist fiction within the lung, thus, preventing lung/alveolar collapse and facilitates a better air passage. Lastly, the alveoli, the site of gas-exchange between carbon dioxide and oxygen, it is made of exceptionally thin squamous epithelial cells to facilitate easier gas exchange. With these examples, we can easily point-out the importance of knowing the normal histology and cytology of the respiratory system as changes or abnormalities in these could bring about a cease in the normal functions of an organ. (, 2000) Let’s take a smoker’s lung for example, considering the fact that smoking is the leading cause of one of the most common non-malignant respiratory disease- Chronic Obstructive Pulmonary Disease (COPD)- where it ranks 5th as the leading cause of death worldwide and it expected to rank 3rd by the year of 2020. (, 2006) A smoker’s lung gives a detailed view of the changes that tissues and cells undergoes one’s it become exposed to nicotine. This is the normal lining of a bronchus under a microscope. Source <img alt=":(" class="wp-smiley" src="http://localhost/research-work/wp-includes/images/smilies/icon_sad.gif" /> , 2007) Fig. 1. On the top we see the cilia, labeled (H). They are attached to columnar cells, labeled (I). The cilia sweep the mucous produced in the goblet cells, labeled (J) as well as mucous coming from deeper glands within the lungs and the particulate matter trapped in the mucous. The bottom layer of cells, labeled (L) is the basal cells. (, 2007) This is the lung as a person starts to smoke:  Source <img alt=":(" class="wp-smiley" src="http://localhost/research-work/wp-includes/images/smilies/icon_sad.gif" /> , 2007)   Fig. 2. The columnar cells are starting to be crowded out and displaced by additional layers of basal cells. Not only are fewer cilia present but the ones that are still functioning is doing so at a much lower level of efficiency. Many chemicals in tobacco smoke are toxic to cilia, first slowing them down, soon paralyzing them all together and then destroying them. Eventually though, the ciliated columnar cells are totally displaced. As can be seen below ominous changes have taken place. Not only is the smoker more prone to infection from the loss of the cleansing mechanism of the cilia, but these abnormal cells (O) are cancerous squamous cells. These cells will eventually break through the basement membrane wall and invade into underlying lung tissue and often spread throughout the body long before the person even knows they have the disease. (, 2007) Cells like the columnar-shaped cell would assume a cuboidal-shaped as a compensatory mechanism against irritation in the bronchial lining. These changes in the cellular level would alter the entire normal functioning of the cell and the tissue as well. These changes are important to note as they become the basis for assessment of different non-malignant diseases of the respiratory tract. From these assessments, one could derive their diagnosis and make measures for medical management. Human body is an organization itself. From a single unit of cell, to the group of cells that makes up a tissue, to a group of tissues that makes up an organ, to a group of organ that makes up a system and to the group of systems that makes up a fully functioning individual. It is impossible to fully appreciate how an organ works without analyzing what makes an organ works inside. It’s like when we studied chemicals in Chemistry class, it is essential for us to know the number of atoms, the presence of a proton, neutron and electron, and the molecular content that makes up a certain chemical before we could make chemical bonds. Based from what I have discussed earlier and from the examples I have given, I have derived several reasons to why it is essential for one to be knowledgeable in the histological, cytological and immunochemistry branch before considering making a diagnosis and management to any non-malignant diseases of the respiratory tract. First because it is important to know the root/cause of everything. A good private investigator does not only look at the picture laid upon them, they look more at the details that makes up a picture rather that focusing on the picture as a whole. To make accurate diagnosis, one must not look at a certain disease as a whole, but should look at the parts that make up a whole. For example, in a lung autopsy, you just don’t look at the lung as a whole; you have to open it and dig deeper into the tissues for further observation to detect presence of a foreign body and fluid. Second, certain bodily functions could be better understood with the help of a histological, cytological and immunochemistry perspective. (, 2006)  In cases of inflammation disorders such as tonsillitis, certain lab test is to be performed to detect the presence of a pathogen by means of culture and sensitivity, throat culture and immunoflourescence by obtaining sputum sample from the client. Diagnostic procedures like this depend greatly at microscopic observation and usage of certain chemicals for different staining procedures. Another example is laryngitis; one should take into account the normal cell-shaped of the larynx which is Pseudostratified columnar ciliated would assume a cuboidal-shaped due to the presence of irritants and mucus production. Also, other diagnostic procedures such bronchoscopy, an insertion of a rigid/flexible bronchoscope via incision or through the mouth/nose to detect any diseases involving the airway (,1996) and thoracentesis where a tissue sample is aspirated just like a procedure in biopsy (,1996). Both of these examples depend greatly on critical observation under a microscope. Third, knowledge in histology and cytology has a great deal of relevance to almost any field in medicine (, 2006). Specific facts in these areas would provide better understanding about the course of the disease and for a more accurate diagnosis and treatment. Also, some non-malignant respiratory diseases such as benign lung tumors (bronchial adenoma, benign papilloma and parenchymal tumors) are in a tissue-level organization (, 2006). Certain cancer cells and process of metastasis could easily be detected with an understanding about the characteristics of a cell, like most cancerous cells changes from a normal cell to what is term as anaplasia, metaplasia, dysplasia and hyperplasia (, 1999). Even though disease detection like this is usually the job of a pathologist, it wouldn’t hurt to have knowledge of this as well. Fourth, considering the fact that medicines’ effectiveness are observed with how they react usually in a cellular level, knowledge on how certain medicines affects each cell would help you plan a more suitable treatment, you can point-out possible side effects and adverse reaction, that would be less damaging to a cell. Though, this part mostly concerns immunosuppressant/chemotherapeutic agents that are used in treating early cancer cells.  Fifth, the client may require further explanation to why you have arrived to a certain diagnosis and why this kind of medical management is necessary (, 2006). Most of the time, particularly after one undertook such test likes a sputum exam to detect presence of tuberculosis. Most clients would found themselves dumbfounded as physicians wouldn’t even try to explain the results in a more detailed way. Most physician’s are used to explaining the disease’s pathophysiology in general rather than giving the client a more detailed view of what is happening to her/his body. Clients nowadays are smarter, they want to be more involved in overcoming the disease process, and they also seek alternative way since the prevalence of eastern traditional medicine such as acupuncture and reflexology. As his/her medical practitioner, it is your duty to see to it that the client understands his/her condition to make her/him more cooperative during treatments. Lastly, additional knowledge is always a good thing. Especially that we are in the age where people continues to seek better, faster, affordable, safer way to treat common non-malignant diseases of the respiratory tract, it will be very helpful to have a vast knowledge in these areas. After all, cytological, histological and immunochemistry is interrelated with each other, these three could serve as a fundamental tool in making diagnosis and providing medical management. Furthermore, in regards to what I’ve said earlier that disease detection with the means of histological and cytological is usually the job of a pathologist, knowledge in this area would allow you to use this as a communication vehicle, you could exchange viewpoints and learn from them, the pathologist could also participate with regards to medical management.             References:                                                                             Credit:ivythesis.typepad.com

RESPIRATORY DISEASE

Respiratory Disease This is an essay, evaluating the importance of histology, cytology and immunochemistry in the diagnosis and treatmen...