1. General information

Supervisor of the module: prof. habil. dr. Albinas Naudžiūnas(vidausligos@med.kmu.lt)

Coordinator of the module: assoc.prof. dr. Palmira Leišytė (pleisyte@gmail.com)

Departments and number of work days:Institute of Anatomy (2 days)Department of Histology and Embryology (2 days)Department of Physiology (4 days)Department of Biochemistry (1 day)Clinic of Pathological Anatomy (2 days)Clinic of Radiology (2 days)Department of Basic and Clinical Pharmacology (1 day)Clinic of Internal Diseases (5 days)Clinic of General Surgery (2 days)

Subjects and responsible persons:Human Anatomy (assoc.prof. V. Aželis ; vidmazel@med.kmu.lt; tel. 32 72 38)Human Histology and Embryology (lect. J. Palubinskienė; jolipalu@itc.kmu.lt; tel. 327235)Physiology (assoc.prof. A.Laukevičienė; ale.laukeviciene@googlemail.com; tel. 32 72 85)Pathological Physiology ( Dr.D.Akramienė; dalia.akramiene@lsmuni.lt; tel. 32 72 85)Biochemistry (prof. D.Vieželienė; daleveze@med.kmu.lt; tel. 36 21 51)Pathological Anatomy (prof.R.Gailys; patologines.anatomijos.klinika@kaunoklinikos.lt; tel. 32 68 79)Radiology (prof.S.Lukoševičius; saulius.lukosevicius@kaunoklinikos.lt; tel. 32 61 54)Pharmacology (lect.R.Jankūnas; rimasjankunas@gmail.com; tel. 32 72 42)Essentials of Medical Diagnosis (assoc.prof.P.Leišytė; pleisyte@gmail.com; tel. 30 60 93)General Surgery (prof. D. Venskutonis; donates.venskutonis@lsmuni.lt; tel. 30 60 59, 30 60 66)Environmental and Occupational Medicine (Dr. R.Raškevičienė; rita.raskeviciene@med.kmu.lt; tel. 32 73 74)42. General content of the module

1. Anatomy of bronchi and lungs:Embryology.Bronchial tree.Topography of lungs, lobes, and pleura.Bronchial and alveolar vessels.Pulmonary lymphnodes.Nerves of the respiratory system.Respiratory muscles.

2. Histology of bronchi, lungs and pleura:The structure of trachea and bronchial mucosa, epithelial cells.

Barrier function of respiratory epithelium.Secretory function of respiratory epithelium.Submucosa.Alveoli.Pleura.Immunocompetent cells of airways and pulmonary parenchyma: alveolar macrophages,lymphocytes, neutrophils, eosinophils, mast cells.Supportive structures of the lungs.

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

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

5. Pathology of the respiratory system:Morphology of bronchial pathology: emphysema, chronic bronchitis, asthma,bronchiectases.Morphology of pulmonary and pleura pathology: pneumonia, pleuritis.Tumors of lungs and pleura.

6. Medicines acting on the respiratory system:Bronchodilators.Antiinflammatory and antiallergic drugs.

Cough and cold medicines (secretolytics, mucolytics, antitusives).Antihistamines.Thrombolytics and anticoagulants.Antibiotics.

7. Radiological investigations of lungs:Fluoroscopy and radiography of the chest.Computed tomography (CT) of lungs.Angiography of pulmonary and bronchial arteries.Lung ventilation and perfusion scintigraphy.Ultrasonography of lungs.Magnetic resonance imaging (MRI) of lungs.

8. Clinical cases :Syndrome of bronchial obstruction.Pulmonary embolism (PE).Respiratory failure.Syndrome of pulmonary restriction.Pulmonary consolidation.Syndromes of air and fluid accumulation in the pleural cavity.Syndrome of cavity in the lungSyndrome of increased airiness.Syndrome of airway irritation.

3. Aim and objectives of the module

Aim :To study theory and aquire practical skills on morphology, physiology, biochemistry, pathology, pathophysiology, pharmacology, clinical examination of respiratory system, respiratory syndromes; be able to relate the theory with clinical symptoms and syndromes.

Objectives:1. To study anatomy and function of respiratory system; to know the mechanisms of pulmonary ventilation, gas exchange; nervous and humoral regulation of breathing, alterations in base-acid balance.2. To study pathophysiological mechanisms of changes of respiratory system.3. To know histology and defence mechanisms of respiratory system.4. To study the medicines acting on the respiratory system.5. To know pathology of respiratory system, radiological diagnosis.6. To look into the clinical diagnosis and syndromes of respiratory system; relate clinical skills and practical knowledge.

4. Tutorials

4.1. Case 1. Dyspnea of an allergic boy.

A 18-year-old student of Kaunas University of Medicine visited his general practitioner‘s office because of attacks of dyspnea, nonproductive cough, and sneezing early in the morning. He has been suffering from these complaints for three weeks. One month ago he was ill with allergic conjunctivitis, attended ophthalmologist‘s office, and antiallergic eye drops were prescribed. In childhood he suffered from frequent bronchitis and pneumonia, allergic reactions to fish products, chocolate, penicillin. On examination he looked fair; his respiratory rate was 22 breaths per minute; pulmonary auscultation revealed diffuse sibilant wheezes over the chest of both sides. His heart rate was 92 beats per minute, and a blood pressure was 140/80 mmHg. The findings of examination of other systems were normal.What syndrome do you suppose?Explain the findings of clinical examination.

Concept of the problem: bronchial obstruction.

Clinical signs: paroxysmal dyspnea, sibilant wheezes.

AimTo learn anatomy and histology of bronchi; mechanisms of bronchial obstruction, functional and clinical diagnosis, principles of pharmacotherapy.

Learning objectives and contents

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

1. Anatomy and innervation of bronchi.Subject – Human anatomyInstitute of AnatomyReferences:Gray‘s anatomy for students, 2005, p. 140-146, 149

2. Functioning of respiratory muscles (definitions of main and accesssory muscles), physiology of bronchi.3. Mechanics of breathing, functioning of main and accessory respiratory muscles during breathing.4. Compliance of the lungs and the chest wall. Alveolar surface tension. Airway resistance. Work of breathing.Subject - PhysiologyDepartment of PhysiologyReferences:W.F.Ganong. Review of Medical Physiology. 22nd ed. Lange Medical Books / McGraw-Hill, 2005, ch. 34, p. 649-658.

5. Explanation of bronchial spasm according to static and dynamic volumes, and resistance of airways; recognition the changes of lung function parameters characteristic to the syndrome of bronchial obstruction.

6. Respiratory failure: ventilatory failure, gas exchange failure. Disturbances in nasal breathing, narrowing of larynx and trachea. Mechanisms of cough and sneezing. Mechanism of bronchial spasm. Disturbances of functioning of bronchi. Expiratory dyspnea.Subject- Pathological PhysiologyDepartment of PhysiologyReferences:Porth CM. Pathophysiology : Concepts of Altered Health States. Lippincott Williams & Wilkins, 7th ed, 2005. p. 694-705Supplementary readingsRobbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 713-728 Ado A.D. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453.

7. Histological structure of the bronchial wall, mucociliary clearance.Subject- Human Histology and EmbryologyDepartment of Human Histology and EmbryologyReferences:1. Basic Histology. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p.340-3492. Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press, 2002, p. 228-230.3. Histologie. R. Lullmann-Rauch. Thieme 2003, p. 285-289.4. Color Textbook of Histology. Leslie P. Gartner, James L. Hiatt, 2nd ed. Saunders. p. 349-355.

8. Morphological changes of lung and heart vessels in asthma.Subject- Pathological AnatomyClinic of Pathological AnatomyReferences:Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 717-728

9. Action of bronchodilators and inhaled steroids in patients with asthma.Subject - PharmacologyDepartment of Basic and Clinical PharmacologyReferences:1. Katzung BG, editor. Basic & Clinical Pharmacology. 10th ed. Boston 2007:121-135,315-327. 112. Harvey RA, Champe PC, editors. Lippincott’s Illustrated Reviews: Pharmacology. 3rd ed. Philadelphia 2006:65-80,315-322.Supplementary readings:Hardman JG, Limbird LE, editors. Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 11th ed. New York 2006.

10. Clinical and functional diagnosis of bronchial obstruction syndrome.Subject– Essentials of Medical DiagnosisClinic of Internal DiseasesReferences:1. Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th ed., Churchill Livingstone,2001, p.136-141.

2. Medicine at a Glance. 2nd ed. Ed. by Patrick Davey. Blackwell publishing, 2006, p.188-189.3. Davidson‘s Principles and Practice of Medicine. 19th ed., Elsevier Science Limited, 2002, p.513-520.Supplementary readings:Kasper D., Braunwald E., Fauci A., Hauser S., Longo D., Jameson J. Harrison’s Principles of Internal Medicine (single volume), 17th edition, 2008, p.1596-1606.

4.2. Case 2. Dyspnea and pain in the calfs.A 19-year-old man complained having severe breathlessness in the rest, which increased on slight exertion, and episodes of recurrent chest pain with increasing breathlessness. He felt ill three months ago during his service in the Soviet Army in Leningrad (Sankt- Petersburg). After “marching“ the pain in his legs occured with running temperature to 380 C . He was admitted to the military hospital, pneumonia was diagnosed, antibiotics were given. When he became better he was discharged from the hospital, and returned to the military subunit. Two weeks later the pain in his calfs occurred again, there was an episode of dyspnea, and after some days fever was detected. The soldier was hospitalized again in the military hospital. The diagnosis of chronic pneumonia and cor pulmonale was made. The youth was demobilized. He went back to Šilutė. During his way home he suffered from dyspnea, weakness, palpitation. As soon as his parents saw him, they took him to the hospital. He suffered from measles and pneumonia in his childhood. The patient was recruited to military service just after finishing his secondary school. His brother died from seminoma at the age of 16. The patient‘s apparent state of health was serious. The height 180 cm, weight 70 kg. His breath rate was 28 breaths per minute, accessory respiratory muscles took part in the breathing. Dilated and overfilled jugular veins were seen. On auscultation, vesicular breath sound was audible, adventitious sounds were absent. He had a pulse rate of 105 beats per minute, S2 accentuated, and an arterial blood pressure 130/80 mmHg. The liver size determined by percussion along the right midclavicular line was 10 cm. The left calf was thicker as compared to the right one, the palpation of the left calf revealed tenderness. The Homans‘ sign was positive.ECG: the strain pattern of right atrium and right ventricle. The chest X-ray examination (standard posteroanterior view): the branches of pulmonary artery were broad, shortened due to hypertension, the right branch – 25 mm. V.cava superior and conus pulmonalis were dilated. The diagnosis was confirmed by pulmoangiography. Systolic blood pressure in pulmonary artery was 80/40 mmHg. A lot of contrast medium filling defects were detected in lobar, segmental, subsegmental branches of pulmonary artery. During venocavagraphy the floating thrombus was detected in v.cava inferior. During general anesthesia v.cava inferior was tied up (caval filters in the hospital were absent). After operation, six hours later, heparin therapy was continued. Retroperitoneal hematoma complicated the postoperative period. Despite the anticoagulant therapy the patient’s state became worse, pulmonary hypertension was increasing, respiratory failure was progressing and 8 weeks later after hospitalization the patient died. The findings of autopsy: v.cava inferior, v.iliaca and deep veins of left leg were obstructed by thrombi. Thrombi were detected in most of segmental and subsegmental pulmonary arteries.What is your opinion of this clinical case?How do you estimate the clinical signs?How do you interprete the laboratory and instrumental examinations?

How do you estimate the treatment given to this patient?

Concept of the problem: pulmonary embolism (PE)

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

AimTo study etiopathogenesis of pulmonary embolism, Virchov‘s triad, to know clinical signs of acute pulmonary embolism, to have comprehension of the treatment of pulmonary embolism.

Learning objectives and contents

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

1. Anatomy of pulmonary circulation.Subject - AnatomyDepartment – Institute of AnatomyReferences:Gray‘s anatomy for students, 2005, p. 146, 194.

2. Histology of vessels.Subject – Human HistologyDepartment of Histology and EmbryologyReferences:Basic Histology. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p. 213-217Supplementary readings:Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press, 2002, p. 143-144.

3. Peculiarities of pulmonary circulation, blood gas transference, dissociation of oxyhemoglobin, compounds of carbon dioxide in blood.

Subject - PhysiologyDepartment of PhysiologyReferences:W.F.Ganong. Review of Medical Physiology. 22nd ed. Lange Medical Books / McGraw-Hill, 2005. ch. 34, p. 661-664, Ch. 35. p. 666-670.

4. Pathogenesis of pulmonary hypertension. Mechanisms and alterations of pulmonary perfusion. Mismatching of ventilation to perfusion. The role of pathological reflexes.

Subject – Pathological PhysiologyDepartment of PhysiologyReferences:Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 713-728Supplementary readings:

Porth C.M. Pathophysiology : Concepts of Altered Health States. Lippincott Williams & Wilkins, 7th ed, 2005. p. 638-649Ado A.D. Patologičeskaja fiziologija, Maskva, 2002. p. 427-453

5. Alterations of right heart and lungs in pulmonary hypertension, morphology of pulmonary embolism, Virchov‘s triad.

Subject – Pathological AnatomyClinic of Pathological AnatomyReferences:Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 742-745

6. Radiological signs in case of PE and pulmonary hypertension – evaluation of filling defects of contrast enhancement in CT and MRI.

7. Evaluation criteria of PE comparing lung perfusion scintigrams to lung ventilation scintigrams and chest radiographs.

Subject - RadiologyClinic of RadiologyReferences:1. D. P. Naidich, N.L.Muller, E.A.Zerhouni, W.R.Webb and al. Computed tomography andmagnetic resonance of the thorax, 1998. p.168-241.2. H.N. Wagner, Zszabo, J Buchanan Principles of Nuclear Medicine, 1995.p.881-906Supplementary readings:www. radiologyeducation.com - teaching files

8. Clinical diagnosis of pulmonary embolism.Subject – Essentials of Medical DiagnosisClinic of Internal DiseasesReferences:1. Medicine at a Glance. Ed. by Patrick Davey. 2nd ed., Blackwell publishing, 2006, p.164-165.2. Davidson‘s Principles and Practice of Medicine. 19th ed. 2002, Elsevier Science Limited, 2002, p.562-566.Supplementary readings:Kasper D., Braunwald E., Fauci A., Hauser S., Longo D., Jameson J. Harrison’s Principles of Internal Medicine (single volume), 17th ed., 2008, p1651-1657.

9. Medicines affecting blood clotting. Oral and parenteral anticoagulants: mechanism of action, pharmacokinetics, adverse effects, overdose, and antidotes. Anticoagulants: mechanism of action, therapeutic indications, dosage.

Subject - PharmacologyDepartment of PharmacologyReferences:1. Katzung BG, editor. Basic & Clinical Pharmacology. 10th ed. Boston 2007:542-555.2. Harvey RA, Champe PC, editors. Lippincott’s Illustrated Reviews: Pharmacology. 3rd ed. Philadelphia 2006:227-244.Supplementary readings:

Hardman JG, Limbird LE, editors. Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 11th ed. New York 2006:1443-1489.

4.3. Case 3. A silicate brick-maker‘s tale.A 73-year-old man presented to the emergency department with a complain of worsening breathlessness. He also suffered from cough with mucous sputum production, palpitation, swelling of legs at the end of the day, persistent boring pain in the right hypochondrium. He has been ill for 20 years. In the beginning he suffered from cough and sputum production, later increasing beathlessness on moderate exertion occured. During the last two years breathlessness became very strong, increased on slight exertion (during walking in the room); palpitation, boring pain in the right hypohondrium, swelling of legs occured. During the last two weeks he suffered from breathlessness at rest, edema in legs was also increasing.He was ill with children infectious diseases, chronic bronchitis (later chronic obstructive pulmonary disease was diagnosed), pneumonia, three years ago he experienced intermittent paroxysmal ischemia of brain. He was a smoker for 40 years: he smoked 20 cigarettes per day. During the last two years he was ex-smoker. He worked as a silicate brick-maker for 30 years. Now he is a pensioner. He has no allergy, he is married and has two children. His father died of lung cancer, mother – of cerebrovascular stroke. The patient‘s apparent state of health is serious. He is conscious, but his answers to questions are slow. He is in the active forced sitting position. Cyanosis of the face and lips, accessory respiratory muscles are seen. His chest is of barrel shape, intercostal spaces are increased. His breath rate is 26 breaths per minute, epigastrium pulsation is seen. The chest palpation revealed reduced elasticity. Tactile fremitus is normal. Cardiac beat is palpable. On percussion, hyperresonance note is audible over both sides of the chest, his heart borders are shifted to both sides, especially right border. His heart rate (HR) is 100 beats per minute. On auscultation of the heart, II-IIIº diastolic murmur over the pulmonary artery is audible. He has a blood pressure of 90/60 mmHg. An abdomen is soft, with small tenderness in the right hypochondrium. Kurloff‘s ordinates: 16-12-10 cm, determined by percussion. Significant edemas in his legs are seen.Investigations:Haematology: Hb 180 g/L, RBCs 5,8x1012/L, WBCs 8,5x109/L, differential WBC count - segmented neutrophils 72%, lymphocytes 20%, monocytes 8%.ECG: sinus tachycardia, HR 100 beats/min, P “pulmonale” II-III-aVF leads, biphasic P in V1 and V2 leads.Blood gas examination (blood was taken from a radial artery): pH 7,28, PaCO2 70 mmHg, PaO2 60 mmHg.Posteroanterior radiographic view: Lung pattern is increased, fibrosis in the basal areas is seen, on the right side - pleurodiaphragmatic adhesions. The shadow of the heart is shifted to both sides, but the enlargement of right chambers of the heart predominates.Ultrasonography of upper abdomen: Liver is markedly enlarged but homogeneous. Gall-bladder is normal.

What syndromes do you suppose? Why?How do you interprete the complaints and the findings of physical examination?How do you estimate the data of laboratory and instrumental examination?Would you explain radiographic changes?

How do you treat this patient?

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

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

AimTo study etiopathogenesis, semiotics, arterial blood gas alterations, clinical diagnosis of chronic respiratory failure, and chronic cor pulmonale.

Learning objectives and contents

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

1. Anatomy of pulmonary circulation.Subject - AnatomyInstitute of AnatomyReferences:Gray‘s anatomy for students, 2005, p. 146, 194

2. Nervous and humoral regulation of breathing, rhythmicity of breathing, breathing centers and their activity.

Subject - PhysiologyDepartment of PhysiologyReferences:W.F.Ganong. Review of Medical Physiology. 22nd ed. Lange Medical Books / McGraw-Hill, 2005. ch. 36, p. 671-678.

3. Pathogenesis of pulmonary hypertension, developement of secondary erythrocytosis.4. Chronic respiratory failure. Disorders of ventilation, diffusion, perfusion; mechanisms of

these disorders. Hypoxia, types and mechanisms. Alterations of tissue respiration.Subject – Pathological PhysiologyDepartment of PhysiologyReferences:Porth C.M. Pathophysiology : Concepts of Altered Health States. Lippincott Williams & Wilkins, 7th ed, 2005. p. 112-113, 717Supplementary readings:1. Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 713-728 2. Ado A.D. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453

5. Morphological changes of the heart in pulmonary hypertension.Subject – Pathological AnatomyClinic of Pathological AnatomyReferences:· Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 717-728

6. Radiological signs of chronic pulmonary hypertension: roentgenosemiotic syndromes of alterations of lung pattern and hiluses.

Subject - RadiologyClinic of RadiologyReferences:A Global TexBook of Radiology. Editor H.Peterson, The NICER Institute. Oslo,1999. p.547-51.

7. Clinical diagnosis of chronic respiratory failure and chronic cor pulmonale.Subject – Essentials of Medical DiagnosisClinic of Internal DiseasesReferences:1. Medicine at a Glance. Ed. by Patrick Davey. 2nd ed. Blackwell publishing, 2006, p.178-179.2. Kasper D., Braunwald E., Fauci A., Hauser S., Longo D., Jameson J. Harrison’s Principles of Internal Medicine (single volume), 17th ed., 2008, p. 1586-1592.Supplementary readings:1. James Thomas, Tanya Monagham. Oxford Handbook of Clinical Examination and Practicall Skills. Oxford University Press, 2007.2. Lynn S., Bickley MD. Bates’ Guide to Physical Examination and History Taking, 9th edition. Lippincott, Williams&Wilkins, 2007.3. Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th edition. Churchill Livingstone, 2001.

4.4. Case 4. A roofer with increasing breathlessness.A 52-year-old roofer sought a medical advice: he complained of increasing breathlessness on exertion, cough, mucous sputum production. For the whole year he suffered from nonpurulent productive cough accompanied by increasing breathlessness during moderate physical exercise (going upstairs to the 2nd floor). He suffered from acute bronchitis and pneumonia in the past, an operation due to appendicitis was performed on him. He is a roofer for 30 years. He slated roofs for more than 20 years. He has been smoking 10-15 cigarettes per day for 20 years. The patient‘s apparent state of health is fair. His breath rate is 12 breaths per minute. A barrel shaped chest is seen. Elasticity of the chest is decreased. Percussion of the chest revealed hyperresonance. Vesicular breath sounds and fine rales in basilar areas were detected during auscultation of the lungs. The general practitioner has sent the patient to the pulmonologist.

Laboratory and instrumental investigations:

Peripheral blood examination: Hb 145 g/L; RBCs 5,1x1012/L; WBCs 8,1x109/L, differential white blood cell count is normal; ESR 35 mm/h.

Chest X-ray examination: small reticulonodular changes in both lungs with predominating changes over the right lung. Here and there pulmonary tissue resembles″honeycomb″.

Spirometry:1. Vital capacity (VC) 3,8 L (64 % of predicted)2. The forced expiratory volume in 1 second (FEV1) 2,4 L (88% of predicted)

3. FEV1/VC (Tiffeneau index 63%, 89% of predicted).

Arterial blood gas analysis: PaO2 60 mmHg, PaCO2 45 mmHg, pH 7,35

Examination of bronchoalveolar lavage:Cellularity 30x104/ml (Norm 10-20x104/ml)Macrophages 67% (Norm 80-90%)Neutrophils 10% (Norm < 2%)Lymphocytes 23% (Norm 7-15%).

Transbronchial biopsy of pulmonary tissue: Pulmonary fibrosis. Asbestos bodies were revealed after dyeing it by Prusse.

Which syndrome do you suppose?Interprete the findings of clinical and laboratory examination.Explain the detected disorders.

Concept of the problem: pulmonary restriction.

Clinical signs: exertional dyspnea, dry cough.

AimTo learn pathophysiology, functional and clinical diagnosis of restriction syndrome, gas diffusion mechanisms, pathology of alveolitis, mechanisms of developement of fibrosis.

Learning objectives and contents

To complete analysis of this problem the students must know:

1. Gas diffusion and gas exchange mechanisms, acid-base balance regulation.Suject - BiochemistryDepartment of BiochemistryReferences:1. C. Smith, AD Marks, DB. M Lieberman. Marks basic medical biohemistry: a clinical approach, 2nd ed, Lippincott Williams & Wilkins, 2005, p. 41-53,102-106.2. J. Baggot. Gas transport and pH regulation in book MD. Devlin Textbook of biochemistrywith clinical correlations. Wiley-Liss; 4th ed, 1997, p. 1025 – 1052.Supplementary readings:WJ Marshal, SK Bangert. Clinical chemistry, 5th ed Mosby, 2004, p. 41-61.

2. Histological structure of alveoli, relationship to pulmonary volumes, ventilation mechanisms in norm and in pulmonary fibrosis (syndrome of restriction).

Subject - Human HistologyDepartment of Histology and EmbryologyReferences:1. Basic Histology. Y. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p.349-357.

2. Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press,2002, p. 230-234.Supplementary readings:1. Histologie. R. Lullmann-Rauch. Thieme 2003, p. 289-294.2. Color Textbook of Histology. Leslie P. Gartner, James L. Hiatt, 2nd ed. Saunders. p. 356-36

3. Gas exchange in the lungs; inspiratory, expiratory and alveolar air composition (partial presures of gases), pulmonary ventilation parameters, pulmonary volumes and capacities. Dead space and alveolar ventilation. Ventilation and blood flow (ventilation/perfusion ratio).

Subject - PhysiologyDepartment of PhysiologyReferences:W.F.Ganong. Review of Medical Physiology. 22nd ed. Lange Medical Books / McGraw-Hill, 2005. Ch. 34, p. 651-652, 658-661.

4. Pathophysiology of hypoxia and hypercapnia in pulmonary fibrosis.5. Mechanisms of cough and sputum production. Alterations of lung function. Restrictive

ventilatory pattern. Alveolar ventilation disorder, asphyxia.Subject – Pathological PhysiologyDepartment of PhysiologyReferences:Porth CM. Pathophysiology : Concepts of Altered Health States. Lippincott Williams & Wilkins, 7th ed, 2005. p. 647-657Supplementary readings:1. Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 676-6822. Ado A.D. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453

6. Etiology, pathology of interstitial lung diseases, the role of alveolar macrophages, the genesis of pulmonary fibrosis.

Subject – Pathological AnatomyDepartment of Pathological AnatomyReferences:Robbins and Cotran. Pathologic Basis of Disease. Elsevier Inc, 7th ed, 2005. p. 728-741.

7. Sources of the atmosphere pollution, components of air pollution, the impact on health, the means of prevention.

Subject – Environmental MedicineDepartment of Environmental and Occupational MedicineReferences:Yassi A., Kjellstrom T., de Kok T., Guidotti T. Basic Environmental Health, Oxford universitypress, 2001. p. 180-201.Supplementary readings:1. Aw T.C., Gardiner K., Harrington J.M. Pocket consultant Occupational health, BlackwellPublishing, 2007, p. 249- 270.2. WHO Air quality and health website: http://www.euro.who.int/air

8. Radiological signs of alveolitis and pulmonary fibrosis: roentgenosemiotic syndromes of alterations of lung pattern, hiluses and dissemination.

Subject - RadiologyClinic of RadiologyReferences:A Global TexBook of Radiology. Editor H.Peterson, The NICER Institute. Oslo,1995. p.547-51.

9. Clinical and functional diagnosis of pulmonary restriction syndrome.Subject – Essentials of Medical DiagnosisClinic of Internal DiseasesReferences:1. Davidson‘s Principles and Practice of Medicine. 19th ed. Elsevier Science Limited, 2002, p.492-494.2. The Merck Manual of Diagnosis and Therapy, 18th edition. Merck Publications, 2006, 364- 373, 469-480.3. Medicine at a Glance. Ed. by Patrick Davey. 2nd ed., 2006, Blackwell publishing, 2006, p.208-209.Supplementary readings:1. Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th ed. Churchill Livingstone,2001, p.117-144.2. Kasper D., Braunwald E., Fauci A., Hauser S., Longo D., Jameson J. Harrison’s Principles of Internal Medicine (single volume), 17th ed., 2008, p. 1611-1618.

4.5. Case 5. An acute illness of a wood-cutterA 48-year-old wood-cutter complains of fever up to 39,50C, sweating, right-sided chest pain, cough with rusty sputum, moderate breathlessness. Three days ago he suddenly got ill after lying for some hours on a cold and wet ground (after abundant alcohol consumption). He thought that he had caught a cold, and that is why he didn‘t visit his general practitioner. An ambulance was called when breathlessness and rusty sputum production occured.In the past he suffered from children infections, grippe, pneumonia, prostatitis. He is a smoker: he smokes 20 cigarettes daily. He uses alcohol 2-3 times per week. He is married, and has two children. The patient‘s apparent state of health is serious. Flushed face. He is in the forced active right lateral decubitus position, broken into a sweat, with a herpetic rash around his lips. His body temperature is 39,50C. His breath rate is 25 breaths per minute. Asymmetric respiration is seen: the right side of the chest follows the left one. Elasticity of the chest is normal, tactile fremitus is stronger on the right side of the chest. Percussion along l.axillaris anterior, media, posterior and l.scapularis in the right side of the chest – below 4th rib - revealed dullness. On auscultation of right chest, bronchial breath sound is audible, bronchophony is present. He has a regular pulse of 120 beats per minute and a blood pressure of 90/50 mmHg. Palpation of the abdomen revealed tenderness below the right hypochondrium.

Investigations were performed urgently:

Haematology: Hb 130 g/L, RBCs 4,1x1012/L, platelets 180x109/L, WBCs 22,5x109/L; differential WBC count: segmented neutrophils 80%, lymphocytes 12%, monocytes 8%; ESR 60 mm/h; CRP 95 mg/L.Cytologic examination of sputum: a lot of RBCs, WBCs.Gram stain of sputum: Gram+ diplococci.Chest radiograph: On the right inferior area the confluent infiltration is evident, slight right-sided pleural effusion is possible.

What syndrome do you suppose? Indicate the diagnostic criteria.How do you interprete the complaints and the findings of physical examination?What is the cause of tachycardia and reduced blood pressure?How do you interprete the examinations of peripheral blood and sputum?How would you explain the radiographic changes?What treatments do you consider?

Concept of the problem: pulmonary consolidation.

Clinical signs: breathlessness, cough, fever, sputum production.

AimTo study etiopathogenesis, semiotics, morphological, clinical, radiographic signs of pulmonary consolidation.

Learning objectives and contents

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

1. Anatomy of the lung lobes.Subject - AnatomyInstitute of AnatomyReferences:Gray‘s anatomy for students, 2005, p. 140-146

2. Histological structure of the lung tissue.Subject – Human HistologyDepartment of Histology and EmbryologyReferences:References:1. Basic Histology. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p. 345-358.2. Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press,2002, p. 228-233.

3. Formation of intrapleural pressure, the physiological role.Subject - PhysiologyDepartment of PhysiologyReferences:

W.F.Ganong. Review of Medical Physiology. 22nd ed. Lange Medical Books / McGraw-Hill, 2005. Ch. 34, p. 650-651.

4. Pathogenesis of pneumonia, changes of peripheral blood in inflammation. Disorder of alveolar function. Disorders of ventilation, diffusion, perfusion, mechanisms of those disorders.

5. Dyspnea, mechanism of dyspnea.Subject – Pathological PhysiologyDepartment of PhysiologyReferences:Porth CM. Pathophysiology : Concepts of Altered Health States. Lippincott Williams & Wilkins, 7th ed, 2005. p. 647-655Supplementary readings:1. Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 713-7282. Ado A.D. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453

6. Pathology of pulmonary consolidation.Subject – Pathological AnatomyDepartment - Clinic of Pathological AnatomyReferences:Robbins and Cotran. Pathologic Basis of Disease. Elsevier Inc, 7th ed, 2005.

7. Radiological signs of lung infiltration: syndromes of local opacity of lung field, round opacity, ring-shaped opacity and dissemination.

Subject - RadiologyDepartment – The Clinic of RadiologyReferences:A Global TexBook of Radiology. Editor H.Peterson, The NICER Institute. Oslo,1999. p.535-52.

8. The changes of sound transmission in consolidation. Clinical signs of pulmonary consolidation, semiotics.

Subject – Essentials of Medical DiagnosisClinic of Internal DiseasesReferences:1. Davidson‘s Principles and Practice of Medicine. 19th ed., Elsevier Science Limited, 2002,p.527-530.2. Medicine at a Glance. Ed. by Patrick Davey. 2nd ed. Blackwell publishing, 2006, p.184-185.3. Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th edition. Churchill Livingstone, 2001, p.117-144.Supplementary readings:1. Bacevicius E. Propedeutics to Internal Medicine. Kaunas, 1998, p. 52-53.2. James Thomas, Tanya Monagham. Oxford Handbook of Clinical Examination and Practicall Skills. Oxford University Press, 2007.3. Lynn S., Bickley MD. Bates’ Guide to Physical Examination and History Taking, 9th edition. Lippincott, Williams&Wilkins, 2007.

9. Antibiotics, cough and cold medicines (secretolytics, mucolytics, antitusives).Subject - PharmacologyDepartment of PharmacologyReferences:1. Katzung BG, editor. Basic & Clinical Pharmacology. 10th ed. Boston 2007.2. Harvey RA, Champe PC, editors. Lippincott’s Illustrated Reviews: Pharmacology. 3rd ed. Philadelphia 2006:353-380.Supplementary readings:Hardman JG, Limbird LE, editors. Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 11th ed. New York 2006:725-737.

4.6. Case 6A. A brick-layer‘s case.A 46-year-old brick-layer with previously good health complains of fever up to 38ºC, right–sided chest pain, that is increasing during the deep inspiration. Two weeks ago he fell down to the right side in the building site. Some days later the pain in the right side occurred. This pain increased during the deep inspiration. He was running a temperature up to 38ºC, exertional dyspnea developed. He used analgetics. His health state became worse and he refered to his doctor for medical advice.In the past he suffered from pneumonia, prostatitis. He is a smoker. He smokes 20 cigerettes per day. His father died of lung cancer at the age of 58. His mother is still alive.The patient‘s apparent state of health is fair. Active forced lateral decubitus position is seen: he lies on the right side. During breathing the right side of the chest follows the left one. His breath rate is 20 breaths per minute. The findings of palpation: elasticity of the chest is normal, tactile fremitus is weaker on the right side. Percussion along l. medioclavicularis, l.axillaris anterior, media, posterior, and l. scapularis revealed dullness below right fourth rib. Auscultation of this place detected the absence of breath sounds. His heart rate is 90 beats per minute, a blood pressure is 120/80 mmHg. Kurloff ordinates: 10 x 9 x 7 cm. The abdomen on palpation is soft, without tenderness. The liver and the spleen are nonpalpable. Edema in legs is absent.Laboratory and instrumental investigations:Haematology: Hb 140 g/L; RBCs 4,2x1012/L; WBCs 8,2x109/L; differential WBC count –neutrophils 72%, lymphocytes - 20%, monocytes - 8%.The chest radiographs (anteroposterior and lateral views): On the right side, below the 4th rib a dense uniform opacification with oblique fluid line is evident, mediastinum is displaced to the left.

Which syndrome and why do you suspect?How do you interpret the complaints and the findings of physical examination?How do you interpret the findings of peripheral blood examination?How do you explain the radiographic changes?How can you help the patient?What findings of pleural fluid examination do you expect?

4.6. Case 6B. Urgent help is required.

A 74-year-age retired man complains of acute dyspnea and the pain in the right chest that occurred suddenly on getting up after endoscopic procedure. The patient was treated in the department of gastroenterology because of peptic ulcer in the duodenum. After the treatment the controlling fibroesophagogastroduodenoscopy procedure was performed. The conclusion of fibroesophagogastroduodenoscopy was made: the ulcer was healed up, the procedure passed without complications.Past medical history: pneumonia, chronic bronchitis, five years ago – myocardial infarction. He is a smoker for 40 years: he smokes 20 cigarettes per day. He is married and has two children. His parents are dead: his mother died of brain stroke, and his father – of myocardial infarction.The patient‘s apparent state of health is serious. Active forced sitting position. Cyanosis of the face and lips is seen. His breath rate is 30 breaths per minute. During breathing the right chest follows the left one. Tactile fremitus is absent over the right chest. There is tympany to percussion over the right chest wall. Breath sounds and voice sounds are absent over the same area on auscultation. His heart rate is 120 beats per minute, and a blood pressure is 80/40 mmHg.The radiographic examination of the chest was performed urgently:The posteroanterior radiographic view of the chest: Air in the right pleural cavity, the mediastinum is displaced to the left.

What syndrome is it? Why?What are the pathogenesis and semiotics of this syndrome?Is the complication associated with the performed procedure? Do you consider it a jatrogenic one?How do you interpret the findings of physical and radiographic examination?What help are you going to give urgently?

Concept of the problem: fluid in pleural cavity, air in pleural cavity.

Clinical signs: pain in the chest, dullness to percussion, tympany to percussion.

AimTo study etiopathogenesis, morphology, clinical signs of fluid and air accumulation in pleural cavity.

Learning objectives and contents

To complete analysis of this problem the students must know:

1. Anatomy of pleura.Subject – Human AnatomyInstitute of AnatomyReferences:Gray‘s anatomy for students, 2005, p. 136-140

2. Histology of pleura.Subject - HistologyDepartment of Histology and Embryology

References:1. Basic Histology. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p.3582. Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press, 2002, p. 234.Supplementary readings:Histologie. R. Lullmann-Rauch. Thieme 2003, p. 294.

3. Mechanisms of pneumothorax, their role in the development of pneumothorax.Subject – Pathological PhysiologyDepartment of PhysiologyReferences:Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 713-728Supplementary readings:Ado AD. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453.

4. Pathogenesis of air accumulation in pleural cavity.5. Pathogenesis of fluid accumulation in pleural cavity.6. Disorders of function of pleura.7. Pneumothorax: etiology, pathogenesis, alterations of organism functions.8. Hydrothorax: etiology, pathogenesis, alterations of organism functions.

Subject – Pathological PhysiologyDepartment of PhysiologyReferences:Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 766-770.

9. Fluid accumulation in pleural cavity: etiology, morphological changes, cytological examination of pleural fluid.

Subject – Pathological AnatomyClinic of Pathological AnatomyReferences:Robbins and Cotran. Pathologic Basis of Disease. Elsevier Inc, 7th ed, 2005.

10. Radiological signs of pleural effusion: roentgenosemiotic syndromes of total and local opacification.

11. Ultrasonography of pleural effusion and evaluation of fluid volume.12. Radiological signs of air in pleural cavity: roentgenosemiotic syndrome of brightening of

lung field.Subject - RadiologyClinic of RadiologyReferences:A Global TexBook of Radiology. Editor H.Peterson, The NICER Institute. Oslo,1999. p.547-51.

13. The clinical diagnosis of fluid accumulation in pleural cavity.14. The clinical diagnosis of air accumulation in pleural cavity; the changes of sound

transmission; the principles of treatment.Subject – Essentials of Medical Diagnosis

Clinic of Internal DiseasesReferences:1. Medicine at a Glance. Ed. by Patrick Davey. 2nd ed. Blackwell publishing, 2006, p.27-28.2. Davidson‘s Principles and Practice of Medicine. 19th ed. Elsevier Science Limited, 2002, p.502-503, 569-573.Supplementary readings:1. Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th edition. Churchill Livingstone, 2001, p.117-144.2. Bacevicius E. Propedeutics to Internal Medicine. Kaunas, 1998, p. 54-55.3. Kasper D., Braunwald E., Fauci A., Hauser S., Longo D., Jameson J. Harrison’s Principles of Internal Medicine (single volume), 17th ed., 2008, p.1651-1657.

5. Lectures

5.1. Anatomy of the respiratory system (2 hours)Institute of AnatomyIn charge – assoc.prof. V. Giedrimas, assoc. prof. V.Aželis.Description: anatomy of bronchial tree and lungs.

5.2. Histology of the respiratory system (2 hours)Department of Histology and EmbryologyIn charge - lect. J. PalubinskienėDescription: Histology of airways (the structure of trachea and bronchial wall, histology ofpulmonary tissue). Defense structures and mechanisms of the respiratory system, mucociliaryclearance. The structure of pleura. The structure of the vessel wall. Developement of lungs,disorders of developement.

5.3. Physiology of the respiratory system (2 hours)Department of PhysiologyIn charge - assoc.prof. R. MiliauskasDescription: Mechanics of external respiration, types of respiration; formation of intrapleuralpressure; alveolar pressure; lung volumes and capacities, pulmonary and alveolar ventilation;pressure-volume relationship (compliance), alveolar surface tension. Pulmonary circulation;ventilation/perfusion ratio; composition of inspiratory, expiratory, and alveolar air. Oxygentransport; carbon dioxide transport. Nervous and humoral (chemical) regulation of respiration.Rhythmicity of respiration. Respiratory centers and their activity.

5.4. Pathological physiology of the respiratory system (2 hours)Department of PhysiologyIn charge – prof. A. KondrotasDescription: Etiology, pathogenesis of external respiratory failure, alterations of organismfunctions. Etiology, pathogenesis of disorders of ventilation, diffusion, perfusion. Etiology,pathogenesis of alterations of airways and lung functions. Sneezing, cough, sputum production;causes, alterations of organism functions. Dyspnea, causes and types. Asphyxia, etiology,pathogenesis, stages. Bronchial spasm, etiology, pathogenesis, alterations of organism functions.

Pneumothorax, hydrothorax, etiology, pathogenesis, alterations of organism functions.Comprehension of internal respiration, etiology, pathogenesis, alterations of organism functions.

5.5. Pathological anatomy of the respiratory system ( 2 hours)Clinic of Pathological AnatomyIn charge – prof. R. Gailys, prof. V. LesauskaitėDescription: The most common dysplasias of the respiratory system. Pulmonary endoinfections:bronchitis, bronchopneumonia, lobar pneumonia. Morphology of chronic obstructive pulmonarydiseases (chronic bronchitis, pulmonary emphysema, asthma, bronchiectases) and restrictivediseases (pneumoconioses). Secondary pulmonary hypertension and cor pulmonale syndrome. Lung tumors. Pathological anatomy of smoking.

5.6. Radiology of the respiratory system (2 hours)Clinic of RadiologyIn charge – assoc.prof.S.LukoševičiusDescription: Radiological methods of the investigation of the respiratory system: fluoroscopy and radiography of the chest, computed tomography (CT), magnetic resonance imaging (MRI),ultrasonography, lung ventilation and perfusion scintigraphy. Radiological topographic anatomy of the chest, methods of investigation, interpretation of pathological symptoms.

5.7. Gas exchange and molecular mechanisms of gas transference (2hours)Department of BiochemistryIn charge – prof.L.Ivanovienė, prof.V.BorutaitėDescription: Molecular mechanisms of oxygen tranfer in human organism. Oxygen carriers inblood and tissues. Hemoglobin structure, types, allosteric effects, factors that influence oxygentransfer. Molecular mechanisms of carbon dioxide transfer. Types and causes ofhemoglobinopathies.

5.8. Medicines acting on the respiratory system (2hours)Department of Basic and Clinical PharmacologyIn charge – lect. R. JankūnasDescription: Studies of medicines acting on the respiratory system.

5.9. Understanding of clinical examination. Thrombosis of deep veins. Pulmonary thromboembolism. ( 2 hrs)Clinic of Internal Diseases (2 hours)In charge – prof.A.Naudžiūnas, assoc.prof.E.KalinauskienėDescription: The main clinical symptoms, laboratory and instrumental examinations in DVT and pulmonary embolism.

5.10. The sources of air pollution, the components of air pollution, their impacton health, the means of prevention (2hours)Department of Environmental and Occupational MedicineIn charge – assoc.prof. R. UstinavičienėDescription: The assessment of air pollution. The main sources of air pollution: transport, industry and energetics enterprises, their contribution to the pollution of the environment. The

main components of air pollution (sulphur oxides, nitrogen oxides, dust, hydrocarbons, cancerogenic substances), their physical and chemical properties, the impact on health. The prevention of environmental air pollution: organizational and legislation means, air cleaning in industry and energetics.

5.11. Clinical diagnostics of pathology of the respiratory system (2 hours)Clinic of Internal DiseasesIn charge - assoc.prof. P. LeišytėDescription: Clinical examination of the respiratory system (the main complaints and theircharacteristics, findings of inspection, palpation, percussion, auscultation).

5.12. Functional diagnostics of pathology of the respiratory system (2 hours)Clinic of Internal DiseasesIn charge - assoc.prof. P. LeišytėDescription: Examination of lung function in clinical practise (the main lung function tests used in clinical practise, the main functional parameters, normal and pathological values, interpretation).

5.13. Syndromes of respiratory pathology (2 hours)Clinic of Internal DiseasesIn charge - assoc.prof. P. LeišytėDescription: Clinical-structural, clinical- functional syndromes of the respiratory system affection.

6. Practicals

6.1. Anatomy of the respiratory system (3 hours)Institute of AnatomyAnatomy of the respiratory system. Trachea, its structure. Main, lobar, and segmentalbronchi. Bronchial tree. Acinus. Lungs: surfaces, lobes, fissures, topography. Vascularisationof bronchi and lungs, innervation, lymphatic drainage.References:Richard L.Drake. Gray‘s anatomy for students, 2005, p. 140-149, 188

6.2. Anatomy of pulmonary circulation and the heart (3 hours)Institute of AnatomyPulmonary circulation. Heart chambers, orificies, valves. Pulmonary artery, branches.Pulmonary veins. Pleura: parietal and visceral pleura, pleural cavity, sinuses. Innervation,vascularisation, topography of pleura. Anatomy of muscles involved in respiration.References:Richard L.Drake.. Gray‘s anatomy for students, 2005, p. 136-140, 146, 154-180

6.3. Histology of trachea, bronchi, bronchioles. Histophysiology of bloodvessels (2 hours)Department of Histology and EmbryologyHistological structure of trachea, bronchus and bronchioles. Histophysiology of pulmonary blood

vessels and of muscular vein of lower extremity.Histological micropreparations:1. Trachea (H-E, azan);2. Lungs (H-E, azan);3. Vein of muscular type (H-E).4. Lungs (azan)1. Using medium magnification find mucosa, submucosa layer, C-shaped hyaline cartilage andadventitia in the preparation of cross-sectioned trachea. Find columnar ciliated epithelial cells,goblet cells, basal cells and intermediate cells using the highest magnification, and make adrawing. Pay attention at a rather thick basement membrane. Find and draw serous glands in thesubmucosa layer. There is no smooth muscle between the cartilage and the submucosa layer, except the smooth muscle, connecting the ends of the cartilage, which constitutes the supportive structure. Some of the glands are behind the muscle. The outer layer is adventitia. Pay attention at the rich vascular network in the lamina propria, which is well defined in the longitudinal section of the trachea.2.Find bronchus in the H-E stained preparation of lungs, inspect it under the highest magnification and draw: mucosa with respiratory epithelium (pseudostratified columnar ciliated epithelium), the layer of smooth muscle cells, submucosa layer with serous bronchial glands, hyaline cartilage rings and plates, and tunica adventitia. In some slides bronchus-associated lymphoid tissue may be observed: lymphatic follicles with multiple lymphocytes just under the epithelium near the branching points of bronchial tree. The bronchiole’s wall is without glands and cartilage plates, it has a prominent muscular layer between the mucosa and the submucosa layers, epithelium is lowering columnar with longitudinal folds due to contraction of muscular layer.3.Muscular vein. Evaluate the form of the muscular type vein lumen using the lowestmagnification. Using the highest magnification find endothelial cells in tunica intima, smoothmuscle cells and collagen fibers in the tunica media which runs into tunica adventitia without clear border. Remember the functional and structural peculiarities of tunica intima and the endothelial cells.4.In the azan stained section of lungs find a large bronchus and a blood vessel in its neighbourhood. It is a branch of pulmonary artery with multiple elastic lamina in the tunica media. Elastic fibers are unstained, collagen fibers stain blue, smooth muscle cells are red. Branches of the bronchial arteries are of much smaller diameter and are found in the adventitia of the wall of bronchus. Tributaries of pulmonary veins are usually away from larger bronchi, somewhere between the lobules. Make a drawing of pulmonary vessels and remember the peculiarities of pulmonary circulation.References:Basic Histology. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p.214-216, 345-349.Supplementary readings:http://www.usuhs.mil/pat/surg_path/nlhist/lung.html

6.4. Histology of pleura and pulmonary parenchyma (2 hours)Department of Histology and EmbryologyHistological microreparations: Lungs (H-E, Rezorcin-fuchsin)1.Find the natural border of the hematoksilin-eosin stained prepatation of the lungs. It is the pleura. With large objective lens you may see one layer of squamous cells with elongated nuclei.

That is mesothelium. A translucent space just under the epithelium is the layer of elastic fibers, which are unstained using this staining method. The layer of the collagen fibers is stained in rose-red, there may be found small tributaries of pulmonary veins.2.Using medium magnification find respiratory bronchioles, alveolar ducts, sacs and alveoli. Using the highest magnification find type I pneumocytes with flattened nuclei and type II pneumocytes with round nuclei and transparent cytoplasm.3.Rezorcin-fuchsin stains elastic fibers in dark red or purple. Determine them with the help of thehighest magnification in the pleura and in the interstitium of the alveolar septa. Alveolarmacrophages may be observed in the alveolar spaces. Make a drawing of the air-blood barrier.References:Basic Histology. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p. 349-358.Supplementary readings:http://www.usuhs.mil/pat/surg_path/nlhist/lung.html

6.5. Comparative spirometry (3 hours)Department of PhysiologyObjectives:

1. To observe and compare spirograms collected from resting, healthy patients to those taken from an emphysema patient.2. To observe and compare spirograms collected from resting, healthy patients to those taken from a patient suffering an acute asthma attack.3. To observe and compare spirograms collected from an asthmatic patient while suffering an acute asthma attack to that taken after the patient uses an inhaler for relief.4. To observe and compare spirograms collected from volunteers engaged in moderate exercise and heavy exercise. Description:

The simulatory laboratory work will be performed. You will record spirograms for healthy , an emphysem and asthmatic patients and compare them. References:Pathophysiology; Lee-Ellen C. Copstead and J.L. Banasik, 5th ed. Saunders Elsevier 2013. p. 476-482, 487-489.

6.6. Obstructive airway diseases and tumors (3 hours)Clinic of Pathological AnatomyAnalysis of macro-, histological preparations, and electron micrographs. Students learn themorphologic changes in chronic bronchitis, pulmonary emphysema, and asthma, theircomplications (pulmonary hypertension, cor pulmonale), and causes of death.Smoking induced morphologic changes; the role of smoking for developement of respiratorydiseases. Morphology of pneumoconiosis. Classification of lung tumors, complications and causes of death.Obstructive emphysema and pneumosclerosis. Electron micrograph (x 15000).Find out obliteration of alveolar capillaries by collagen and elastic fibres.Regeneratio epithelii bronchi (metaplasii). Histological slide (H+E). Find section of bronchuswhere normal ciliated columnar epithelial cells were replaced by metaplastic stratified squamousepithelium.

Carcinoma epidermoide (planocellulare) – cornescens. Histological slides (H+E). Find the site where the basement membrane of the stratified squamous epithelium is penetrated by atypical cells with invasion to the underlying connective tissue. At greater depth, the tumor cells are keratinized forming keratinous pearls. Note the multitude of immune cells.References:Pathologic Basis of Disease/Eds I. L. Robbins, R.S. Cotran. 7 th edition 2005, p. 717-728, 743-745,757-766.6.7. Endoinfections of the respiratory system and pathology of the pleura (3hours)Analysis of macro-, histological preparations, and electron micrographs. Students learn thepathogenesis of endoinfections (acute bronchitis, bronchopneumonia, lobar pneumonia), theirmorphology, complications, and causes of death.Migration of neutrophil through capillary . Electron micrograph (x20 000, 12 000). Draw three steps of extravasation of leucocytes: 1. Margination of leucocytes in the lumen of capillary; 2.Transmigration across the endothelium. 3. Migration in interstitial tissues.Bronchitis purulenta et bronchopneumonia (seu pneumonia focalis. Histological slide (H+E). Find the purulent exudate and the desquamated epithelial cells in the lumen of the bronchus. There are pulmonary alveoli in the vicinity filled with a purulent exudate. Notice that those alveoli free of exudate are enlarged (a compensatory mechanism). There is hyperaemia in the lung.Pneumonia lobaris (crouposa). Histological slide (H+E). Pay attention that all alveoli are filled by fibrinous exudate and neutrophils. There are and some red blood cells in alveoli.References:Pathologic Basis of Disease/Eds I. L. Robbins, R.S. Cotran. 7 th edition 2005, p. 747-756, 766-769.

6.8. Medicines acting on the respiratory system (2 hours)Department of Basic and Clinical PharmacologySelective, nonselective and indirect-acting adrenergic agonists, methylxanthines, antileukotrienedrugs: pharmacodynamics, therapeutic indications, adverse effects, overdose, antidotes.Medicines that increase the adrenoreceptor sensitivity to adrenergic agonists. Mechanisms ofdrug-resistance.References:1. Katzung BG, editor. Basic & Clinical Pharmacology. 10th ed. Boston 2007:121-135,315-327.2. Harvey RA, Champe PC, editors. Lippincott’s Illustrated Reviews: Pharmacology. 3rd ed.Philadelphia 2006:65-80,315-322.

6.9. Thrombosis of deep veins. Pulmonary embolism (3 hrs)Clinic of Internal DiseasesInduction course with clinical signs and diagnostic principles of deep vein thrombosis and pulmonary thromboembolism.References: P. Kumar & M. Clark. Clinical medicine. Sixth edition. Elsevier Saunders. EdinburghLondon New York Oxford Philadelphia St. Louis Sydney Toronto, 2005, p.866-871,844-846.

Supplementary readings:1. E. Bacevičius. Propedeutics to internal medicine. Kaunas, 1998.2. R. M. Babarskienė, R. Benetis, J. Braždžionytė, S. Giedraitis, R. Jonkaitienė et

al.Cardiology. The essentials. 3rd edition. KMU, 2006.3. P. Ramrakha, J. Hill. Oxford handbook of cardiology. Oxford University Press, NewYork,

2006.4. J. S. Alpert, G. A. Ewy. Manual of cardiovascular diagnosis and therapy. Fifth edition.5. Lippincott Williams & Wilkins, Philadelphia Baltimore New York London Buenos Aires

Hong Kong Sydney Tokyo, 2002.6. E. R. Beck, R. L. Souhami, M. G. Hanna, D. R. Holdright. Tutorials in differential diagnosis.

Fourth edition. Churchill Livingstone. Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto, 2003.

7. L. S. Bickley. Bates’ Pocket guide to physical examination and history taking. Fifth edition. Lippincott Williams & Wilkins, Philadelphia Baltimore New York London Buenos Aires Hong Kong Sydney Tokyo, 2007.

6.10. Clinical diagnostics of respiratory disorders (4 hours)Clinic of Internal DiseasesClinical examination of the respiratory system.References:1. Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th ed. Churchill Livingstone,2001, p.117-144.Supplementary readings:1. Bacevicius E. Propedeutics to Internal Medicine. Kaunas, 1998, 21-44.2. James Thomas, Tanya Monagham. Oxford Handbook of Clinical Examination and PracticallSkills. Oxford University Press, 2007.3. Lynn S., Bickley MD. Bates’ Guide to Physical Examination and History Taking, 9thedition. Lippincott, Williams&Wilkins, 2007.

6.11. Functional diagnostics of respiratory disorders (4 hours)Clinic of Internal DiseasesFunctional examination of the respiratory system. Sputum and pleural fluid clinicallaboratoryassessment. The main clinical-functional syndromes: irritation of the airways,bronchial obstruction, pulmonary restriction, respiratory failure.References:The Merck Manual of Diagnosis and Therapy, 18th ed. Merck Publications, 2006, p.364-373, 378.Supplementary readings:Pellegrino R., Viegi G., Brusasco V. et al. Interpretative strategies for lung function tests. Eur Respir J 2005; 26: 948-968.

6.12. Syndromes of respiratory disorders (4 hours)Clinic of Internal DiseasesThe main clinical-structural syndromes of the respiratory system: pulmonary consolidation,cavity in the lung, increased airiness of the lung, fluid and air accumulation in the pleuralcavity.

References:Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th ed. Churchill Livingstone, 2001,p.117-144.Bacevicius E. Propedeutics to Internal Medicine. Kaunas, 1998, p.52-55.

6.13. Radiology of the respiratory system (1) (3 hours)Clinic of RadiologyTopographic anatomy of the chest radiographs. Cross-sectional anatomy of CT and MRI of thechest. Methods of evaluation. Radiological signs of pulmonary embolism (PE) and pulmonaryhypertension, Evaluation criteria for pulmonary scintigrams. Radiological signs of chronicpulmonary hypertension – roentgenosemiotic syndromes of alterations of lung pattern and hyluses.References:A Global TextBook of radiology. Ed. H.Pettersson.1995Supplementary readings:1. Atlas of Radiologic Anatomy. Ed. A. N. Taylor.19942. Principles of chest roentgenology. Ed. L.R.Goodman.1999.3. D. P. Naidich, N.L.Muller, E.A.Zerhouni, W.R.Webb and al. Computed tomography andmagnetic resonance of the thorax.4. www. radiologyeducation.com- teaching files.

6.14. Radiology of the respiratory system (2) (3 hours)Clinic of RadiologyRadiological signs of alveolitis and pulmonary fibrosis: roentgenosemiotic syndromes ofalterations of lung pattern, hiluses and dissemination. Radiological signs of lung infiltration:syndromes of local opacity of lung field, round opacity, ring-shaped opacity, and dissemination.References:A Global TextBook of radiology. Ed. H.Pettersson.1995Supplementary readings:1. Atlas of Radiologic Anatomy. Ed. A. N. Taylor.19942. Principles of chest roentgenology. Ed. L.R.Goodman.1999.3. D. P. Naidich, N.L.Muller, E.A.Zerhouni, W.R.Webb and al. Computed tomography andmagnetic resonance of the thorax.4. www. radiologyeducation.com- teaching files.

6.15. Radiology of the respiratory system (3) (3 hours)Clinic of RadiologyRadiological signs of pleural effusion: roentgenosemiotic syndromes of total and localopacification. Radiological signs of air in pleural cavity: roentgenosemiotic syndrome ofbrightening of lung field. Ultrasonography of pleural effusion, evaluation of fluid volume.References:A Global TextBook of radiology. Ed. H.Pettersson.1995Supplementary readings:1. Atlas of Radiologic Anatomy. Ed. A. N. Taylor.19942. Principles of chest roentgenology. Ed. L.R.Goodman.1999.3. D. P. Naidich, N.L.Muller, E.A.Zerhouni, W.R.Webb and al. Computed tomography and

magnetic resonance of the thorax.4. www. radiologyeducation.com- teaching files.

7. Seminars

7.1. Biochemistry of respiration and gas transport (2 hours)In charge – prof.L.Ivanovienė, prof.V.Borutaitė1. Buffer systems in blood, extracellular fluids and cells. 2. Components and mechanism of action of bicarbonate buffer. 3. Compensatory mechanisms of acid-base balance: respiratory acidosis and alkalosis and

metabolic acidosis and alkalosis. 4. Evaluation of acid base balance disturbances. 5. Nonphysiological ligands and oxidators; their effect on Hb function. 6. Hemoglobinopathias; types, molecular origin an consequences.

References:1. Devlin Textbook of biochemistry with clinical correlations. Wiley-Liss; 4th ed, 1997, p. 1025– 1052.2. C Smith, AD Marks, DB. M Lieberman. Marks basic medical biohemistry: a clinicalapproach, 2nd ed, Lippincott Williams & Wilkins, 2005, p. 41-53.Supplementary readings:WJ Marshal, SK Bangert. Clinical chemistry, 5th ed Mosb

7.2. Environmental dust pollution, classification, physical and chemical properties.Pneumoconioses (2 hours)Department of Environmental and Occupational MedicineIn charge – lect.R.RaškevičienėClassification of dust (organic, inorganic). Factors that influence the effect of inhaled particles: thesize, density, the shape, chemical properties, penetration, fibrogenity, interaction with tissues,antigenity. Pneumoconioses, classification and etiology. Occupations and works, associated withthe dust exposure. Asbestosis, silicosis, silicatosis, anthracosis, other pneumoconioses. Theprevention of pneumoconioses. The individual preventive measures for protection of airways.References:1. Aw T.C., Gardiner K., Harrington J.M. Pocket consultant Occupational health, BlackwellPublishing, 2007, p. 249- 270.2. WHO Air quality and health website: http://www.euro.who.int/air

8. Module final examination programme

8.1. Anatomy1. The structure of the bronchial tree. Acinus.2. The lungs, surfaces, fissures, lobes. Pulmonary hilus and radix.3. Skeletotopy of the lungs and their lobes.4. Vascularisation of the bronchi and lungs. Lymphatic drainage.5. Innervation of the bronchi and lungs.6. Pleura, its layers. Pleural cavity, sinuses.

7. The boundaries of the parietal pleura.8. Innervation and vascularisation of the parietal pleura.9. Skeletal muscles involved in respiration.10. Anatomy of the vessels of pulmonary circulation.11. The mediastinum.

8.2. Histology and Embryology1. The structure of wall of trachea.2. The structure of wall of bronchus.3. The structure of wall of bronchioles.4. Histophysiology of lower airway mucosa.5. Characterize the differences of bronchus and bronchiole wall structure.6. The structures and cells which participate in defense against foreign substances in airways andalveoli.7. The structure of pulmonary acinus.8. Draw and explain the structure of air-blood barrier.9. The structure and function of the pleura.10. The histogenesis of lungs and pleura. 11. Stages of lung development.

8. 3. Physiology1. The mechanics of pulmonary ventilation. Intrapleural and alveolar pressure changes during thebreathing cycle.2. Lung volumes and capacities.3. Pulmonary ventilation, dead space and alveolar ventilation.4. Pulmonary circulation and ventilation/perfusion ratio. Autoregulation of pulmonary blood flow.5. Composition of inspired, expired, and alveolar air. Gas exchange in the lungs.6. Oxygen transport by the blood. Oxyhemoglobin dissociation curve.7. Carbon dioxide transport by the blood.8. Neural regulation of respiration. Respiratory centers and their activity.9. Central and peripheral chemical regulation of respiration.

8.4. Pathological physiology1 Etiology, pathogenesis and changes of body functions during the changes of ventilation. 2.Etiology and pathogenesis of the disorders of gas diffusion and blood perfusion in the lungs.3.Dyspnea: causes and types. Bronchial spasm, its etiology and pathogenesis, changes of body functions.4.Respiratory failure: types, etiology, pathogenesis and changes of body functions. 5.Hypoxia, types, pathogenesis and compensatory mechanisms of the body. Hyperoxia, its etiology, positive and negative effects on body functions.

8.5. Pathological anatomy

1. General characteristic of chronic obstructive lung diseases. Pulmonary emphysema, its pathogenesis, morphological forms, complications and causes of death.

2. Chronic bronchitis and bronchiectasis, its pathogenesis, morphology, complications and causes of death.

3. Bronchial asthma, its pathogenesis, morphology, complications and causes of death.4. Hypertension of the minor ratio (pulmonary) blood circulation: causative factors,

pathogenetic mechanisms, morphology and causes of death (cor-pulmonale syndrome).5. Causes and mechanisms of pulmonary endoinfections, its classification. Bronchopneumonia:

etiology, pathogenesis, morphology, causes of death.6. Lobar pneumonia: etiology, pathogenesis, stages and morphology, complications and causes

of death.7. Essence of the neoplastic growth, peculiarities of neoplastic cells, microstructure of tumors.8. Causative factors of neoplasms development. Characteristics of benign and malignant

neoplasms. Macroscopical forms of neoplasms growing and reguliarities of spreading.9. Preneoplastic processes, its morphology and significance for neoplasm development.10. Principles of the neoplasms classification. Lung carcinoma: localization, macroscopical and

microscopical forms, complications, causes of death.11. Morphology of pleural pathology, complications, causes of death.12. Smoking induced pathology of lung and other organs.

8.6. Radiology1. Radiological diagnostic modalities, techniques and principles. 2.The algorithm of radiological diagnosis of the respiratory system. The scheme for evaluation of radiological images3. Chest x-ray, tomography and its types, rentgenoanatomy and indications, evaluation of radiological images.4. Computer tomography (CT) of the chest, cross-sectional anatomy and indications, evaluation criteria of radiological images.5.Ultrasonography of pleural cavity and thoracic wall, method of investigation and application, evaluation and signs of radiological images.6.Magnetic resonance imaging (MRI): the principle of the method, cross-sectional anatomy of the chest, fields of application, evaluation and signs of radiological images.7.Classification of contrast media, fields, ways and methods of application.8.Angiographic investigations of pulmonary arteries, evaluation and signs of radiological images, an investigation technique, contraindication.9.Pulmonary ventilation and perfusion scintigraphy (V/Q scan); radiopharmaceuticals, their dose calculation, patient preparation, scan procedure, indications and contraindications.10.Differential diagnosis of opacity and infiltration of lung field, evaluation and signs of radiological images.11. Differential diagnosis of brightening of lung field, evaluation and signs of radiological images. Pneumothorax, hydropneumothorax.12. Radiological investigations in case of sharp chest pain, radiological detection of pulmonary bleeding, evaluation and signs of radiological images.13.Evaluation criteria for lung perfusion and ventilation scintigrams.

14.Evaluation criteria of PE comparing lung perfusion scintigrams with ventilation scintigrams and chest radiographs.

8.7. Biochemistry1. Structure of hemoglobin and myoglobin; describe protein and nonprotein parts. Types and composition of hemoglobins.

2. Molecular mechanisms of O2 binding and transport to tissues. Allosteric effectors of Hb; binding and physiological role. Bohr effect.

3. Scheme of CO2 transport from tissues to the lungs.

4. Hemoglobinopathias; types and molecular origin; examples of anomalous Hb. Why these Hbs can not supply organism with oxygen?

5. Molecular basis of action and capacity of bicarbonate buffer. Respiratory acidosis and alkalosis.

8.8. Pharmacology

1. Adrenergic bronchodilators: a) classification including common names, b) mechanism of action, c) effects, d) differences in use method.

2. Selective beta adrenergic agonists: a) common names, b) mechanism of action, c) effects, d) indications, e) advantages and disadvantages of inhalations vs. systemic administration, f) undesirable effects.

3. M cholinergic bronchodilators: a) common names, b) mechanism of action, c) effects, d) indications, e) route of administration, f) undesirable effects.

4. Methylxantine bronchodilators: a) common names, b) mechanism of action, c) effects, d) indications, e) route of administration, f) undesirable effects.

5. Cough and cold medicines: a) common ingredients, b) mechanism of action, c) effects, d) choice.

6. Anti-inflammatory / anti-allergic agents used in the treatment of asthma: a) classification including common names, b) mechanism of action, c) effects, d) advantages and disadvantages of inhalations vs. systemic administration, e) undesirable effects.

8.9. Essentials of Medical Diagnosis1. Complaints of patients with respiratory diseases.2. Thoracocentesis, technique of performance. Examination of pleural fluid, pathologicalmeanings.3. Examination of sputum: macroscopic, microscopical, bacteriological examination, pathologicalfindings, their clinical meanings.4. Spirometry: flow-volume curve (norm and pathology).5. Spirometry: time-volume curve (norm and pathology).

6. Main indices of arterial blood gas analysis: normal and pathological values.7. Pulmonary consolidation syndrome, main clinical signs, clinical meanings.8. Syndrome of cavity in the lung, main clinical signs, clinical meanings.9. Syndrome of increased airiness in the lung, main clinical signs, clinical meanings.10. Syndrome of air accumulation in the pleural cavity, main clinical signs, clinical meanings.11. Syndrome of fluid accumulation in the pleural cavity, main clinical signs, clinical meanings.12. Syndrome of airway irritation, the main clinical signs, clinical meanings.13. Syndrome of bronchial obstruction, the main clinical signs, functional changes, clinicalmeanings.14. Syndrome of pulmonary restriction, the main clinical signs, functional changes, clinicalmeanings.15. Respiratory failure, the clinical sings, functional changes, classification (types and grades),causes.16. Understanding of deep vein thrombosis: causes, clinical signs, principles of diagnosis, relationship with pulmonary embolism.

17. Understanding of pulmonary embolism: causes, clinical signs, principles of diagnosis, relationship with thrombosis of deep veins.

18. Understanding of primary and secondary pulmonary hypertension: causes, clinical signs, principles of diagnosis.

8.10. Environmental and Occupational Medicine

1. Sources of environmental air pollution, their characteristics.2. The main components of environmental air pollution, their impact on health.3. The prevention of environmental air pollution.4. Environmental air dust, classification, impact on health, prevention.5. Occupational risk factors of respiratory diseases, prevention of risks.6. Asbestos: prevalence of environmental exposure to asbestos, asbestos induced pathology.