oxford desk reference - respiratory medicine

OXFORD MEDICAL PUBLICATIONS
Oxford Desk Reference:
Respiratory
Medicine
Oxford University Press makes no representation, express
or implied, that the drug dosages in this book are correct.
Readers must therefore always check the product informa-
tion and clinical procedures with the most up-to-date pub-
lished product information and data sheets provided by
the manufacturers and the most recent codes of conduct
and safety regulations. The authors and the publishers do
not accept responsibility or legal liability for any errors in
the text or for the misuse or misapplication of material in
this work.
2 Except where otherwise stated, drug doses and recom-
mendations are for the non-pregnant adult who is not
breast-feeding.
Oxford Desk Reference
Respiratory
Medicine
Nick Maskell
Senior Lecturer and
Consultant Physician in Respiratory Medicine
North Bristol Lung Centre
University of Bristol
and
Ann Millar
Professor of Respiratory Medicine
North Bristol Lung Centre
University of Bristol

1
1
Great Clarendon Street, Oxford OX2 6DP
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First published 2009
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British Library Cataloguing in Publication Data
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Typeset by Cepha Imaging Private Ltd., Bangalore, India
Printed in Great Britain
on acid free paper by
CPI Antony Rowe,
Chippenham, Wiltshire
ISBN 978–0–19–923912–2
10 9 8 7 6 5 4 3 2 1
v
This book aims to act as a rapid reference for busy health professionals and covers the
main respiratory disorders that would be encountered both in the inpatient and outpatient
setting. Each section has been written by an expert in a particular fi eld and is focused on
providing a clear, concise clinical message on how best to investigate the relevant condition.
In order to make the book as user-friendly as possible we have included a lot of images and
illustrations to make the information more accessible. We believe it is one of the only
books in the fi eld where chest radiology lies alongside clinical information. Each chapter
also includes authors’ tips and key messages and is laid out in a format which makes the
information easy to fi nd and digest.
The book includes many common-sense approaches and has a guide for further reading in
each area. It should be possible to use as a ‘fi rst-line’ reference book either to jog your
memory or to read about a condition with which you are not familiar. It is likely that you
will also need to consult other texts and data sources. However, this is a very portable
book which can be carried around with you in your bag or left on the ward for quick and
easy reference. We hope that you will enjoy this new approach.
Preface
vi

In editing this book we are indebted to colleagues and friends who have kindly given up their
time and expertise to write each of the separate sections of the book. We acknowledge that
many of them are national and international experts in their fi eld and we know that this has
helped to enhance the quality and clarity of the book, Our special thanks to our families for
tolerating our endeavour with this book.
Acknowledgements
vii
Brief contents
Detailed contents ix
Abbreviations xi
Contributors xv
1 The healthy lung
1
2 Respiratory physiology
9
3 Clinical presentations
35
4 Asthma
59
5 Chronic obstructive pulmonary disease
89
6 Oxygen
123
7 Diffuse parenchymal lung disease
127
8 Infection
165
9 The immunocompromised host
201
10 Bronchiectasis

223
11 Cystic fi brosis
231
12 Pulmonary vascular problems/issues
259
13 Lung cancer
281
14 Pleural disease
321
15 Sleep
359
16 Occupation and environment
383
17 Lung transplantation/ITU
417
18 Orphan lung diseases/BOLD
441
Index 461
BRIEF CONTENTS
viii
ix
Abbreviations xi
Contributors xv
1 The healthy lung 1
1.1 Pulmonary anatomy 2
1.2 Radiology of the healthy chest 4
2 Respiratory physiology 9
2.1 Basic physiology 10
2.2 Lung function tests: a guide to
interpretation

18
2.3 Exercise testing 24
2.4 Interpretation of arterial blood gases and
acid/base balance
28
2.5 Respiratory muscle function 32
3 Clinical presentations 35
3.1 Chronic cough 36
3.2 Breathlessness 38
3.3 Haemoptysis 40
3.4 Chest pain 42
3.5 Pre-operative assessment 44
3.6 Solitary pulmonary nodule 46
3.7 Wheeze 50
3.8 The acute admission with a new unilateral
pleural effusion
54
3.9 Unexplained respiratory failure 56
4 Asthma 59
4.1 Pathophysiology 60
4.2 Allergic rhinitis 64
4.3 Pharmacology 68
4.4 Asthma in pregnancy 76
4.5 Acute asthma 78
4.6 Chronic asthma management 82
5 Chronic obstructive pulmonary
disease
89
5.1 COPD genetics and epidemiology 90
5.2 COPD pathophysiology 92

5.3 Investigations in COPD 98
5.4 Pharmacological therapy (including cor
pulmonale)
100
5.5 Non-pharmacological management for
COPD
106
5.6 Management of an exacerbation
of COPD
112
5.7 Surgery for COPD 116
5.8 Alpha-1-antitrypsin defi ciency 120
6 Oxygen 123
6.1 Home oxygen therapy 124
7 Diffuse parenchymal lung
disease
127
7.1 Usual interstitial pneumonia 128
7.2 Non-specifi c interstitial pneumonia 132
7.3 Respiratory bronchiolitis-associated
interstitial lung disease
136
7.4 Desquamative interstitial pneumonia 138
7.5 Acute interstitial pneumonia 140
7.6 Lymphoid interstitial pneumonia 142
7.7 Cryptogenic organising pneumonia 144
7.8 Extrinsic allergic alveolitis 148
7.9 Sarcoidosis 152
7.10 Pulmonary manifestations of connective
tissue disorders

156
7.11 Pulmonary manifestations of systemic
diseases
160
8 Infection 165
8.1 Community-acquired pneumonia 166
8.2 Hospital-acquired pneumonia 172
8.3 Aspiration syndromes 176
8.4 Lung abscess 180
8.5 Nocardia and actinomycosis 182
8.6 Viral infections of the respiratory
tract
184
8.7 Respiratory tuberculosis 188
8.8 Non-respiratory tuberculosis 192
8.9 Opportunist (non-tuberculous)
mycobacteria
194
8.10 Fungal and parasitic lung disease 196
9 The immunocompromised
host
201
9.1 Pneumonia in the non-HIV
immunocompromised patient 202
9.2 Infection in the HIV compromised
host 210
9.3 Non-infectious HIV-related lung
disease
218
Detailed contents

x
10 Bronchiectasis 223
10.1 Bronchiectasis (aetiology) 224
10.2 Chronic disease management 228
11 Cystic fi brosis 231
11.1 Cystic fi brosis diagnosis 232
11.2 Managing acute infective
exacerbations 236
11.3 Chronic disease management 242
11.4 Cystic fi brosis genetics 248
11.5 Extra-pulmonary manifestations of cystic
fi brosis
252
12 Pulmonary vascular problems/
issues
259
12.1 Pulmonary embolism 260
12.2 Pulmonary hypertension 264
12.3 Pulmonary vasculitis and
haemorrhage
272
13 Lung cancer 281
13.1 Epidemiology of lung cancer 282
13.2 Symptoms and signs (including
SVCO)
284
13.3 Work-up of patients with a suspected
diagnosis of lung cancer
288
13.4 Treatment of non-small cell lung

cancer
292
13.5 Treatment of small cell lung cancer 298
13.6 PET-CT 300
13.7 Lung cancer screening 304
13.8 Carcinoid 306
13.9 Benign lung tumours 310
13.10 Transbronchial fi ne needle
aspiration 316
13.11 Interventional bronchoscopy
techniques
318
14 Pleural disease 321
14.1 Normal physiologic fl uid volume and
cellular contents
322
14.2 Assessment and investigation of an
undiagnosed pleural effusion (including
thoracoscopy)
326
14.3 Pneumothorax 332
14.4 Exudative pleural effusions (excluding
malignancy)
338
14.5 Transudative pleural effusions 340
14.6 Malignant effusions 342
14.7 Malignant mesothelioma 346
14.8 Pleural effusions in systemic
disease
350

14.9 Pleural infection 352
14.10 Surgery for pleural diseases 356
15 Sleep 359
15.1 Obstructive sleep apnoea 360
15.2 Driving 368
15.3 The overlap syndrome 370
15.4 Non-invasive ventilatory support in the
acute setting 372
15.5 Nocturnal hypoventilation 374
15.6 Cheyne–Stokes respiration associated
with left ventricular failure 378
15.7 Other causes of sleepiness
380
16 Occupation and
environment
383
16.1 Drugs and toxins 384
16.2 Pneumoconiosis 390
16.3 Disability assessment 394
16.4 Occupational asthma 398
16.5 The effects of high altitude on the lung 404
16.6 Diving 408
16.7 Occupational chronic obstructive
pulmonary disease 412
16.8 Asbestos-related diseases (excluding
mesothelioma)
414
17 Lung transplantation/ITU 417
17.1 Lung transplantation: considerations for
referral and listing 418

17.2 Complications after lung
transplantation 422
17.3 The care of lung transplant candidate
or recipient 426
17.4 Acute respiratory distress
syndrome 430
17.5 Severe acute respiratory syndrome 432
17.6 The ventilated patient
434
18 Orphan lung diseases/BOLD 441
18.1 Pulmonary alveolar proteinosis 442
18.2 Churg–Strauss syndrome 446
18.3 Ciliary dyskinesia 448
18.4 Pulmonary Langerhans’ cell
histiocytosis 450
18.5 Lymphangioleiomyomatosis 452
18.6 Primary tracheal tumours 454
18.7 Pulmonary arteriovenous
malformations 456
18.8 Pulmonary amyloidosis
458
Index 461
DETAILED CONTENTS
xi
Abbreviations
6 therefore
∝ proportional
7 approx
> greater than
< less than

A alpha
B beta
κ kappa
γ gamma
ARDS acute respiratory distress syndrome
ASA American Society of Anaesthesiologists
AT antitrypsin
BAL bronchoalveolar lavage
BALF bronchoalveolar lavage fl uid
BAPE benign asbestos pleural effusion
BOOP bronchiolitis obliterans organising
pneumonia
BOS bronchiolitis obliterans syndrome
BR breathing reserve
BTS British Thoracic Society
CABG coronary artery bypass graft
CAP community-acquired pneumonia
CBAVD congenital bilateral absence of the vas
deferens
CF cystic fi brosis
CFA cryprogenic fi brosing alveolitis
CFLD cystic fi brosis liver disease
CFRD cystic fi brosis-related diabetes mellitus
CFTR cystic fi brosis transmembrane
conductance regulator
CHF chronic heart failure
CKD chronic kidney disease
cm centimetre
CMV cytomegalovirus or controlled mechanical
ventilation

CNS central nervous system
CO carbon monoxide
CO
2
carbon dioxide
COAD chronic obstructive airways disease
COP cryptogenic organising pneumonia
COPD chronic obstructive pulmonary disease
CPAP continuous positive airway pressure
CPET cardiopulmonary exercise testing
CPG central pattern generator
CRQ Chronic Respiratory Questionnaire
CRT cardiac resynchronisation therapy
CSF cerebrospinal fl uid
CSS Churg–Strauss syndrome
CTD connective tissue disorder
CTEPH chronic thromboembolic pulmonary
hypertension
CVID common variable immunodefi ciency
CVS chorionic villus sampling
CWR constant work rate
CXR chest X-ray
DAD diffuse alveolar damage
DH dynamic hyperinfl ation
DIP desquamative interstitial pneumonia
D
L
co diffusing capacity for carbon monoxide
DRG dorsal respiratory group
EAA extrinsic allergic alveolitis

EB eosinophilic bronchitis
EBUS endobronchial ultrasound
ECG electrocardiogram
EELV end-expiratory lung volume
EMG electromyography
EPAP expiratory positive airway pressure
EPP equal pressure point or extrapleural
pneumonectomy
ERV expiratory reserve volume
ESR erythrocyte sedimentation rate
ESWT endurance shuttle walk test
ETT endotrachael tube
FBC full blood count
FEF
25–75
forced mid-expiratory fl ow rate
FEV
1
forced expiratory volume in 1 second
FNA fi ne needle aspiration
FOB fi bre-optic bronchoscopy
FRC functional residual capacity
FVC forced vital capacity
g gram
GCS Glasgow coma scale
GI gastrointestinal
GMCSF granulocyte monocyte colony stimulating
factor
GOR gastro-oesophageal refl ux
GORD gastro-oesophageal refl ux disease

GR glucocorticoid receptor
GVHD graft versus host disease
HAART highly active antiretroviral therapy
HAP hospital-acquired pneumonia
HCAP health-care-associated pneumonia
HDM house dust mite
HDU High Dependency Unit
HIV human immunodefi ciency virus
HLA human leucocyte antigen
xii
PRELIM RUNNING HEAD
HME heat and moisture exchanger
HPV hypoxic pulmonary vasoconstriction
HRCT High-resolution computed tomography
HSCT haematopoietic stem cell transplantation
IC inspirator y capacity
ICU Intensive Care Unit
Ig immunoglobulin
IIP idiopathic interstitial pneumonia
ILD interstitial lung disease
IPAP inspiratory positive airway pressure
IPF idiopathic pulmonary fi brosis
IRIS immune reconstitution infl ammatory
syndrome
IRT immunosuppressive trypsin
IRV inspiratory reserve volume
ISWT incremental shuttle walk test
ITU Intensive Therapy Unit
IV intravenous
kPa Kilopascal

KS Kaposi sarcoma
LABA long-acting beta agonist
LAM lymphangioleiomyomatosis
LC Langerhans’ cells
LCH Langerhans’ cell histiocytosis
LDH lactate dehydrogenase
LIP lymphoid interstitial pneumonia
LMWH low-molecular-weight heparin
LTBI latent tuberculosis infection
LTOT long-term oxygen therapy
LTRA leukotriene receptor antagonist
LVF left ventricular failure
LVRS lung volume reduction surgery
m metre
MALT mucosa-associate lymphoid tissue
MAU Medical Admission Unit
MDI metered dose inhaler
MDR multi-drug resistant
MEF maximal expiratory fl ow
MIF maximal inspiratory fl ow
ml millilitre
MND motor neuron disease
MPA microscopic polyangiitis
MPE malignant pleural effusion
MPO myeloperoxidase
MRC Medical Research Council
MRI magnetic resonance imaging
MSLT multiple sleep latency testing
MVC maximum voluntary contraction
NETT National Emphysema Treatment Trial

NG nasogastric
NHL non-Hodgkin lymphoma
NIV non-invasive ventilation
NO nitric oxide
NRT nicotine replacement therapy
NSAID non-steroidal anti-infl ammatory drug
NSIP non-specifi c interstitial pneumonia
NYHA New York Heart Association
O
2
oxygen
OGTT oral glucose tolerance test
OI opportunistic infections
OSA obstructive sleep apnoea
OSAH obstructive sleep apnoea/hypopnoea
OSAS obstructive sleep apnoea syndrome
PA postero-anterior
PaCO
2
partial pressure of carbon dioxide in
arterial blood
PaO
2
partial pressure of oxygen in arterial blood
PAH pulmonary arterial hypertension
PAP pulmonary alveolar proteinosis
PAVM pulmonary arteriovenous malformation
PCD primary ciliary dyskinesia
PCP Pneumocystis pneumonia
PCR polymerase chain reaction

Pcrit critical collapsing pressure
PDT photodynamic therapy
PE pulmonary embolism
PEA pulmonary endartectomy
PEEP positive end-expiratory pressure
PEF peak expiratory fl ow
PET positron emisson tomography
PFT pulmonary function test
PI phosphoinositide
PIV parainfl uenza
PKA protein kinase A
PLCH pulmonary Langerhans’ cell histiocytosis
PLMS periodic leg movement in sleep
PPH primary pulmonary hypertension
PRG pontine respiratory group
PSV pressure support ventilation
PTLD post-transplantation lymphoproliferative
disorder
RA rheumatoid arthritis
RAR rapidly adapting receptor
RAST radio-allergo-sorbent test
RBILD respiratory bronchiolitis-associated
interstitial lung disease
RCT randomised controlled trial
REM rapid eye movement
RSI rapid sequence intubation
RSV respiratory syncitial virus
RV residual volume
s second/s
SaO

2
arterial oxygen saturation
SAR slowly adapting receptor
SARS severe acute respiratory syndrome
SBOT short-burst oxygen therapy
ABBREVIATIONS
xiii
SCC squamous cell carcinoma
SEPCR European Society of Clinical Respiratory
Physiology
SGRQ St George’s respiratory questionnaire
SIADH syndrome of Inappropriate antidiuretic
hormone
SLE systemic lupus erythematosus
SNIP sniff nasal inspiratory pressure
SNP single nucleotide polymorphism
SOT solid organ transplant
SPECT single-photon emission computed
tomography
SPN solitary pulmonary nodule
SSc systemic sclerosis
SVC superior vena cava
SVCO superior vena cava obstruction
TB tuberculosis
TBB transbronchial biopsy
TBNA transbronchial needle aspiration
TLC total lung capacity
TMN tumour–nodal–metastasis
TNF tumour necrosis factor
TOSCA transcutaneous oxygen and carbon dioxide

monitoring
TTAB transthoracic aspiration biopsy
TV tidal volume
U&E urea and electrolytes
UARS upper airway resistance syndrome
UIP usual interstitial pneumonia
V/P ventilation/perfusion
VAP ventilator-associated pneumonia
VATS video-assisted thoracoscopic surgery
VC vital capacity
VCD vocal cord dysfunction
VEGF vascular endothelial growth factor
VILI ventilator-induced lung injury
VRG ventral respiratory group
WG Wegener’s granulomatosis
WLL whole-lung lavage
ABBREVIATIONS
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xv
Dr Anthony Arnold
Department of Respiratory Medicine
Castle Hill Hospital
Hull
Dr Janice Ash-Miles
Department of Radiology
University Hospitals Bristol
Bristol
Dr Angela Atalla
Department of Respiratory Medicine
Derriford Hospital

Plymouth
Dr David Baldwin
Department of Respiratory Medicine
Nottingham University Hospitals
Nottingham
Dr Phillip Barber
North West Lung Centre
University Hospital of South Manchester
Manchester
Professor Peter Barnes
Airway Diseases Section
National Heart & Lung Centre
Imperial College
London
Dr Nick Bell
Dept of Respiratory Medicine
University Hospitals Bristol
Bristol
Dr Diane Bilton
Adult CF Unit
Papworth Hospital
Cambridge
Dr Stephen Bourke
Department of Respiratory Medicine
Royal Victoria Infi rmary
Newcastle-upon-Tyne
Professor Sherwood Burge
Department of Respiratory Medicine
Birmingham Heartlands Hospital
Birmingham

Professor Peter Calverley
School of Clinical Sciences
University of Liverpool
Liverpool
Dr James Calvert
North Bristol Lung Centre
Southmead Hospital
Bristol
Dr G Cardillo
Department of Surgery
Glenfi eld Hospital
Leicester
Dr Jim Catterall
Respiratory Department
Bristol Royal Infi rmary
Bristol
Dr Colin Church
Scottish Pulmonary Vascular Unit
Western Infi rmary
Glasgow
Dr Ian Coutts
Department of Respiratory Medicine
Royal Cornwall Hospitals
Cornwall
Dr Michael Darby
Department of Radiology
Southmead Hospital
Bristol
Dr Chris Davies
Department of Respiratory Medicine

Royal Berkshire Hospital
Reading
Dr Helen Davies
Oxford Centre for Respiratory Medicine
Churchill Hospital
Oxford
Professor Robert Davies
Oxford Centre for Respiratory Medicine
Churchill Hospital
Oxford
Professor David Denison
Emeritus Professor in Clinical Physiology
Hospital Royal Brompton
London
Dr Paddy Dennison
Department of Respiratory Medicine
Dorset County Hospital
Dorset
Dr A Degryse
Vanderbilt University Medical Center
Nashville
Tennessee, USA
Dr Amber Degryse
Fellow in Pulmonary Disease
Vanderbilt Medical Center
Nashville
Contributors
xvi
PRELIM RUNNING HEAD
Dr David Derry

Department of Respiratory Medicine
Derriford Hospital
Plymouth
Dr Lee Dobson
Respiratory Department
Torbay Hospital
Torquay
Dr James Dodd
Department of Respiratory Medicine
Royal Devon & Exeter NHS Foundation Trust
Exeter
Dr Anne Dunleavy
Department of Respiratory Medicine
Royal Free Hospital
London
Professor Jim Egan
Department of Respiratory Medicine
Master Misericordiae Hospital
Dublin
Dr Ugo Eleowa
Cambridge Institute for Medical Research
University of Cambridge
Cambridge
Dr Rachel Evans
Department of Respiratory Medicine
University Hospitals of Leicester
Leicester
Professor Tim Evans
Department of Intensive Care Medicine
Royal Brompton Hospital

London
Dr Hosnieh Fathi
Division of Cardiovascular and
Respiratory Studies
Castle Hill Hospital
Cottingham
Dr Tony Fennerty
Department of Respiratory Medicine
Harrogate District Foundation Trust
Harrogate
Dr Rhian Finn
North Bristol Lung Centre
Southmead Hospital
Bristol
Dr Andrew Fisher
Department of Respiratory Medicine
Freeman Hospital
Newcastle-upon-Tyne
Dr Helen Firth
Consultant Clinical Geneticist
Addenbrookes Hospital
Cambridge
Jane French
Nurse Consultant
Papworth Hospital
Cambridge
Dr Peter Froeschle
Department of Thoracic and Upper GI Surgery
Royal Devon and Exeter Hospital
Exeter

Professor Duncan Geddes
Royal Brompton Hospital
London
Dr Fergus Gleeson
Department of Radiology
The Churchill Hospital
Oxford
Dr Mark Glover
Hyperbaric Medicine Unit
St Richard’s Hospital
Chichester
Dr Anna Goodman
Wellcome Trust Centre for Human Genetics
University of Oxford
Oxford
Dr Mark Grover
Hyberbanic Medicine Unit
St Richard’s Hospital
Chichester
Dr Melissa Hack
Chest Clinic
Newport Hospital
Wales
Dr P. Halder
Institute of Lung Heath
Glenfi eld Hospital
Leicester
Dr Praneb Haldar
Institute for Lung Health
Glenfi eld Hospital

Leicester
Dr David Halpin
Department of Respiratory Medicine
Royal Devon & Exeter NHS Foundation Trust
Exeter
Dr Kim Harrison
Respiratory Unit
Morriston Hospital
Swansea
Dr John Harvey
North Bristol Lung Centre
Southmead Hospital
Bristol
Dr Melissa Heightman
Department of Thoracic Medicine
University College Hospital
London
CONTRIBUTORS
xvii
Dr Martin Hetzel
Department of Respiratory Medicine
University Hospitals Bristol
Bristol
Dr Bernard Higgins
Respiratory Medicine Department
Freeman Hospital
Newcastle-upon-Tyne
Dr Mathew Hind
Royal Brompton Hospital
London

Dr Nik Hirani
MRC Centre for Infl ammation Research
Queen’s Medical Research Institute
Edinburgh
Professor Margaret Hodson
Department of Cystic Fibrosis
Royal Brompton Hospital
London
Dr Clare Hooper
North Bristol Lung Centre
Southmead Hospital
Bristol
Dr John Hurst
Academic Unit of Respiratory Medicine
Royal Free Hospital Medical School
London
Professor Richard Hubbard
Division of Epidemiology and Public Health
University of Nottingham
Nottingham
Dr Phil Hughes
Chest Clinic
Derriford Hospital
Plymouth
Dr Jane Hurst
Consultant in Clinical Genetics
Oxford Radcliffe Hospitals NHS Trust
Oxford
Dr Nabil Jarad
Department of Respiratory Medicine

University Hospitals Bristol
Bristol
Dr Simon Johnson
Division of Therapeutics and Molecular Medicine
University of Nottingham
Nottingham
Dr Andrew Jones
Adult Cyctic Fibrosis Centre
University Hospitals
NHS Foundation Trust
Wythenshawe
Manchester
Dr Adrian Kendrick
Consultant Clinical Scientist
University Hospitals Bristol
Bristol
Professor Keith Kerr
Department of Pathology
University of Aberdeen
Aberdeen
Dr Ayaz Khan
North Bristol Lung Centre
Southmead Hospital
Bristol
Dr Will Kinnear
Department of Respiratory Medicine
University Hospital
Nottingham
Dr Malcolm Kohler
Oxford Centre for Respiratory Medicine

Churchill Hospital
Oxford
Dr Sophie Kravinskas
Division of Therapeutics and Molecular Medicine
University of Nottingham
Nottingham
Dr Gabriel Laszlo
Department of Respiratory Medicine
Bristol Royal Infi rmary
Bristol
Professor Y C Gary Lee
University of Western Australia
Sir Charles Gairduer Hospital
Perth
Professor Richard Light
Vanderbilt University Medical Center
Nashville
Dr Lim Wei Shen
Department of Respiratory Medicine
Nottingham University Hospitals
Nottingham
Dr Marc Lipman
Consultant in Respiratory and HIV Medicine
Royal Free Hospital
London
Professor David Lomas
Cambridge Institute of Medical Research
Cambridge University
Cambridge
Dr Toby Maher

Royal Brompton Hospital
London
Dr Adam Malin
Respiratory Unit
Royal United Hospital
Bath
CONTRIBUTORS
xviii
PRELIM RUNNING HEAD
Dr William Man
Royal Brompton Hospital
London
Dr Nick Maskell
North Bristol Lung Centre
University of Bristol
Bristol
Dr Matthew Masoli
North Bristol Lung Centre
University of Bristol
Bristol
Dr Andrew R L Medford
Department of Respiratory Medicine
Derriford Hospital
Plymouth
Professor Ann Millar
North Bristol Lung Centre
University of Bristol
Bristol
Professor Rob Miller
Centre for Sexual Health & HIV Research

University College Hospital
London
Dr Robert Milroy
Department of Respiratory Medicine
Stobhill Hospital
Glasgow
Dr John Moore-Gillon
Department of Respiratory Medicine
Barts and the London NHS Trust
London
Professor Alyn Morice
Division of Cardiovascular and
Respiratory Studies
Castle Hill Hospital
Cottingham
Dr Cliff Morgan
Department of Critical Care & Anaesthesia
Royal Brompton Hospital
London
Professor Mike Morgan
Department of Respiratory Medicine
University Hospitals of Leicester
Leicester
Professor Nick Morrell
Division of Respiratory Medicine
Department of Medicine
University of Cambridge
Dr Suranjan Mukhersee
Directorate of Respiratory Medicine
University Hospitals of North Staffordshire

Stoke-on-Trent
Dr John T Murchison
Department of Radiology
Royal Infi rmary of Edinburgh
Edinburgh
Dr Mitzi Nisbet
Host Defence Unit
Royal Brompton Hospital
London
Professor Marc Noppen
International Endoscopy Clinic
University Hospital
Brussels
Professor Peter Ormerod
Department of Respiratory Medicine
Royal Blackburn Hospital
Blackburn
Professor Paulo Palange
Department of Clinical Medicine
University of Rome
Rome
Dr Timothy Palfreman
Adult Intensive Care Unit
Royal Brompton Hospital
London
Dr Timothy Palfreyman
Department of Intensive Care Medicine
Royal Brompton Hospital
London
Dr Manish Pareek

Infectious Disease Unit
Leicester Royal Infi rmary
Leicester
Dr S Parker
Department of Respiratory Medicine
Freeman Hospital
Newcastle-upon-Tyne
Dr Bipen Patel
Department of Respiratory Medicine
Royal Devon & Exeter NHS Foundation Trust
Exeter
Dr Sam Patel
Dept of Respiratory Medicine
University Hospitals Bristol
Bristol
Professor Ian Pavord
Institute of Lung Heath
Glenfi eld Hospital
Leicester
Professor Andrew Peacock
Scottish Pulmonary Vascular Unit
Western Infi rmary
Glasgow
Dr Mike Peake
Dept of Respiratory Medicine
University Hospitals of Leicester
Leicester
Dr Justin Pepperell
Department of Respiratory Medicine
Taunton and Somerset Hospital

Taunton
CONTRIBUTORS
xix
Dr Gerrard Phillips
Department of Respiratory Medicine
Dorset County Hospital
Dorset
Dr Martin Plummeridge
North Bristol Lung Centre
Southmead Hospital
Bristol
Professor Jose Porcel
Department of Internal Medicine
Lleida, Spain
Dr Susan Poutanen
University Health Network & Mount
Sinai Hospital
Department of Microbiology
Toronto, Canada
Dr R Ragendram
Department of General Medicine
John Redcliffe Hospital
Oxford
Dr Kasper F Remund
Department of Respiratory Medicine
Mater Misericordiae Hospital
Dublin
Dr Gerrit Van Rensburg
Respiratory Unit
Royal United Hospital

Bath
Professor Douglas Robinson
Laboratories Leti, Madrid
and Imperial College, London
Dr Grace Robinson
Department of Respiratory Medicine
Royal Berkshire Hospital
Reading
Dr Francisco Rodriguez-Panadero
MD El Mirador
Tomares (Sevilla)
Dr Robin Rudd
Consultant Physician
London
Dr Pallav Shah
Royal Brompton Hospital
London
Dr Clare Shovlin
National Heart & Lung Institute
Imperial College
London
Dr Anita Simonds
Sleep and Ventilation Unit
Royal Brompton & Harefi eld
NHS Trust
London
Dr Nicholas Simmonds
Department of Cystic Fibrosis
Royal Brompton Hospital
London

Dr Pasupathy Sivasothy
Department of Respiratory Medicine
Addenbrooke’s Hospital
Cambridge
Dr David Smith
North Bristol Lung Centre
Southmead Hospital
Bristol
Professor Monica Spiteri
Department of Respiratory Medicine
University Hospital of North Staffordshire
Stoke-on-Trent
Professor Stephen Spiro
Department of Thoracic Medicine
University College Hospital
London
Dr Iain Stephenson
Infectious Diseases Unit
Leicester Royal Infi rmary
Leicester
Dr John Strading
Oxford Centre for Respiratory Medicine
Churchill Hospital
Oxford
Dr Jay Suntharalingam
Respiratory Unit
Royal United Hospital
Bath
Dr Richard Teoh
Department of Respiratory Medicine

Castle Hill Hospital
Hull
Dr Matthew Thornber
Department of Acute Medicine
North Bristol NHS Trust
Bristol
Dr Joseph Unsworth
Department of Immunology
Southmead Hospital
Bristol
Mr David Waller
Department of Surgery
Glenfi eld Hospital
Leicester
Dr Neil Ward
Department of Respiratory Medicine
Royal Devon and Exeter Hospital
Exeter
CONTRIBUTORS
xx
Professor Kevin Webb
Adult Cystic Fibrosis Centre
University Hospitals NHS Foundation Unit
Manchester
Professor Jadwiga Wedzicha
Academic Unit of Respiratory Medicine
Royal Free Hospital Medical School
London
Professor Athol Wells
Royal Brompton & Harefi eld NHS

London
Dr Adam Whittle
Department of Respiratory Medicine
University Hospitals Bristol
Bristol
Dr R Wilson
Host Defence Unit
Royal Brompton Hospital
London
Dr Robert Winter
Addenbrooke’s Hospital
Cambridge University Hospitals
NHS Foundation
Cambridge
Dr Nick Withers
Department of Respiratory Medicine
Royal Devon and Exeter Hospital
Exeter
CONTRIBUTORS
Chapter contents
1.1 Pulmonary anatomy 2
1.2 Radiology of the healthy chest 4
The healthy lung
1
Chapter 1
2
1.1 Pulmonary anatomy
Lobes and fi ssures
Each lung is divided into lobes by the presence of fi ssures;
the left lung by the oblique fi ssure into an upper and lower

lobe, whilst the right is split into an upper, middle, and
lower lobe by the oblique and transverse fissures
(Fig. 1.1.1). Accessory fi ssures can occur, of which the one
formed if the azygos vein arches laterally to the mediasti-
num instead of medially, giving rise to the ‘azygos lobe’ is
the most common (up to 1%).
AUTHOR’S TIPS
The visceral pleura is continued on to the major
fi ssures, its visibility as a horizontal hairline is a normal
fi nding in almost half of all chest X-rays.
The horizontal fi ssure is often incomplete medially,
allowing collateral ventilation between lobes.
•
•
Airways
The trachea bifurcates into the right and left main bronchi
at the level of the manubrio-sternal joint. The right is typi-
cally wider, shorter (3cm) and less steeply angled than the
longer (5cm) left. The main bronchi divide into lobar and
segmental branches which continue until they reach 1mm
in diameter, when they lose their cartilage and become
bronchioles.
Both lungs have 10 wedge-shaped bronchopulmonary
segments, each with its own air and blood supply.
Fig. 1.1.1
Lobes and fi ssures.
Larynx
Oblique
fissure
Right

lower
lobe
Left
lower
lobe
Oblique
fissure
Trachea
Left
upper
lobe
Right
upper
lobe
Horizontal
fissure
Middle
lobe
Parenchyma
Terminal bronchioles (0.5mm diameter) are the last airway
before the alveolar lined respiratory bronchioles start.
There are 20,000–30,000 terminal bronchioles, each ending
in an acinus (primary bronchiole). Respiratory bronchioles
within an acinus will branch several times until they reach
the further divided alveolar ducts which lead to the alveo-
lar sacs and their alveoli.
The secondary lobule is the smallest section of lung which
can be seen on high resolution computed tomography
(HRCT); it contains 5 or 6 acini, whose interlobular septum
consists of pulmonary lymphatics, veins and a discrete layer

of connective tissue (Fig. 1.1.2).
Fig. 1.1.2
Secondary lobule.
Pulmonary veins
Bronchiole
Visceral pleura
Interlobular septum
Pulmonary artery
Lymphatics
Pulmonary veins
Bronchiole
Visceral pleura
Interlobular septum
Pulmonary artery
Lymphatics
Nerve supply to the lung
Sympathetic supply is from thoracic segments 3 to 5 via the
sympathetic chain which supplies the bronchial airway and
pulmonary artery muscle.
Parasympathetic supply is from the vagus nerve which con-
stricts bronchial muscle and has secretomotor action to
the mucous glands.
Sensory supply is stretch sensation to the lung and visceral
pleura and pain to the parietal pleura. The diaphragmatic
portion is via the phrenic nerve whilst the costal portion is
from intercostals nerves.
Blood supply
The lung receives both a pulmonary and a bronchial artery
supply. The pulmonary arterial circulation follows the
branching of the bronchi, the bronchial arterial circulation

supplies the airways, visceral pleura and lymphoid tissue.
Lymphatic drainage
There are no lymphatic vessels in the alveoli. The lymphatic
vessels from the alveolar duct and bronchioles follow the
bronchial tree back to the hilum and then the mediastinum.
Lymph nodes may occur along their intrapulmonary
course.
Beneath the visceral pleura a plexus of lymphatics are
present, they drain into the peribronchial lymphatics,
through vessels that run in septae through the acini and
segments. It is distension of these horizontally placed
septae which causes Kerley B lines.
AUTHOR’S TIP
Since there is communication between the pulmonary
and bronchial circulation in the parenchyma, the
bronchial arteries may contribute to gas exchange in
pulmonary vascular disorders.
M THORNBER
3CHAPTER 1.1 Pulmonary anatomy
Pulmonary
veins
Trachea
Carina
1
2
3
1
2
3
4

5
5
4
6
6
7
7
8
8
9
9
10
10
Left
main
bronchus
Right
main
bronchus
RIGHT LEFT
1 Apical (RUL)
2 Posterior (RUL)
3 Anterior (RUL)
4 Lateral (RUL)
5 Medial (RUL)
6 Lateral Basal
7 Posterior Basal
8 Anterior Basal
9 Medial Basal
10 Apical Lower

1 Apical (LUL)
2 Posterior (LUL)
3 Anterior (LUL)
4 Superior Lingular
5 Inferior Lingular
6 Lateral Basal
7 Posterior Basal
8 Anterior Basal
9 Medial Basal
10 Apical Lower
Fig. 1.1.3
Diagram of the bronchial tree with typical segmental bronchi.
Nomenclature is that used most commonly in the UK.
4
1.2 Radiology of the healthy chest
The plain chest X-ray (CXR)
Technical factors
PA (postero-anterior)
Full inspiration (mid-diaphragm crossed by 5th–7th ante-
rior ribs) necessary to assess heart size and mediastinal
contours.
Less = reduced lung volume, obesity or poor patient
cooperation.
More = asthma, emphysema/chronic obstructive airways
disease (COAD) or fi t healthy young adult.
Heart size <50% of max. internal chest diameter.
Emphysema/COAD, ‘normal’ heart size may be signifi -
cantly less, due to over expansion of rib cage – changes
from previous may be more useful.
In elderly/osteoporosis, chest diameter may be relatively

less, and so ‘normal’ heart size could be up to 2/3rds
chest diameter.
Rotation – spinous processes over mid trachea; clavicles
and ribs symmetrical. If not, can cause apparent lucency/
increased density of one lung.
Beware the ‘hidden’ zones – nearly 50% of lung area may
be partially obscured on PA view by mediastinum and dia-
phragm (anterior and posterior costophrenic recesses).
These areas are even less well seen on portable fi lms.
AP (antero-posterior) supine
Magnifi cation of mediastinum makes sizes inaccurate, but
gives useful information on gross lung pathologies and
position of lines, drains and tubes.
Lateral
Allows visualisation of ‘hidden’ areas and localises to a
lobe a lesion seen on PA view.
Normal appearances (Fig 1.2.1)
Mediastinum
Left heart border made up of 4 ‘moguls’ = aortic knuckle
(indents trachea), pulmonary artery, left atrial appendage
and left ventricle.
Right heart border made up from ascending aorta and
right atrium.
Hilar points formed by the crossing of upper and lower
zone broncho-vascular bundles. Left lies 1–1.5cm higher
than right.
Lung parenchyma
Branching pattern of bronchovascular bundles which taper
towards periphery. Arteries accompany airways, but latter
not discernable except above each hilum when seen

end-on as rings.
Absence of discernable structures in outer 1/3 of lungs.
Interstitium only visible when pathological.
Fissures may undulate and frequently incomplete (NB cause
of collateral air drift between lobes). Horizontal fi ssure
joins right hilum. Obliques pass from few centimetres
behind anterior chest wall to 6th thoracic vertebra.
Diaphragms
Right up to 2cm higher than left. If not ‘dome’ shape,
suggests hyperinfl ation. Localised bulge – ‘eventration’ due
to muscle defi ciency, usually antero-medial portion.
•
•
•
Right hilar
point
Horizontal fissure
‘Hidden lung’
Aortic knuckle
Aortic knuckle
Left main
pulmonary
artery
Carina
Right and left
main bronchi
Bronchus
intermedius
Sternum
Ribs

Irregular lower border
smooth upper border
Left pulmonary
artery
Left hilar
point
Fig. 1.2.1 Normal PA CXR.
Assessing the CXR
Systematic approach
Mediastinum, lungs, bones and soft tissues.
Mediastinum
Aorto-pulmonary window is concave (if not, is there nodal
disease?).
Additional, ‘double’ contours to heart border signify
abnormal pathology.
Shift of Hilar points indicates either traction due to col-
lapse/fi brosis or pressure from space-occupying lesions.
Left heart border obscuration indicates lingular disease.
Right heart border obscuration indicates middle lobe
disease.
Superior mediastinal borders may widen in elderly due to
ectasia of vessels, or by obesity.
J ASH-MILES & M DARBY