The respiratory system is crucial to the human body because of its ability to provide necessary oxygen and rid the body of waste, such as carbon dioxide. The respiratory system is comprised of an Upper and Lower Respiratory Tract. The Upper Respiratory Tract begins in the nose and the nasal passages; this is where the air enters the body. As the air enters the body is filtered of allergens and other toxins by the hair present in the nose, but also by the cilia, or hair like projections, that line the entire upper respiratory airway. As the air enters the body, it is also warmed and humidified to match the internal temperature of the body. This is achieved through nasal secretions from the paranasal sinuses, that surround the nasal passageways. Air can also enter through the mouth, passing through the pharynx, which has multiple parts: nasopharynx, oropharynx, and laryngopharynx. The nasopharynx lies at the base of the of the nasal passages and transitions into the back of the throat, known as the oropharynx. As the airway continues down, the laryngopharynx follows, which is then met by the larynx, also known as the voice box. The larynx is where the vocal cords are held and produces the sound necessary for speech. In males, the larynx is larger due the deeper voice tone, thus the organ is more prominent, creating an Adam’s Apple, which is visible on the anterior portion of the throat.
Entering into the Lower Respiratory Tract, the larynx is met by the trachea. The trachea is a hollow tube that provides the air a pathway to reach the lungs. From the trachea, the airway moves into the bronchi, which are extensions of the trachea into right and left sides that connect to each lung. The bronchi then divide into the smaller passages called bronchioles, that will eventually house the alveoli. Alveoli are small air sacs that house the place where gas exchange occurs. The lungs are home to a huge number of capillary beds that are met by the alveoli, so that when oxygenated air enters the sacs, the gas exchange of oxygen and carbon dioxide occurs. In order for air to enter the lungs, the inspiratory muscles must work to expand the chest, this includes the diaphragm and the scalenes. As the diaphragm contracts, it creates a floor of the thoracic cavity, opening up the chest to allow for more room for the lungs to expand. The scalenes work in a similar way, but focus more on the superior portion of the chest. As the area of the thoracic cavity is increased, this creates a pressure change within the body; the air pressure on the outside is greater than that within the lungs. The air then moves from a higher concentration (outside) to lower concentration (lungs) thus inflating the lungs and creating a chest rise. When the inspiratory muscles relax, the size of the thoracic cavity is decreased and the air is pushed out with the help of expiratory muscle groups. The right and left lungs are each divided into lobes, the right lung having 3 lobes (upper, middle, and lower), and the left lung only having 2 (upper and lower); this is due to the position of the heart sitting at an angle to the left.
When beginning an evaluation for pathology of the lungs or respiratory system, it is important to get a good history. This can include any family or past history of respiratory issues, the length of time that the problem has been occurring, any trauma that may have occurred, the severity, and things seem to exacerbate the issue. After attaining a good history, it will be easier to determine the source of the problem and how to test for it. Next in the evaluation is inspection, or looking at the body to notice any deformities or abnormal breathing patterns. This can be evaluated by looking at, not only the lungs and chest rise, but the thoracic cavity as a whole; looking for vertebral problems such as kyphosis, or excessive curvature of the thoracic spine, or scoliosis, which is lateral curvature of the spine. It is important to note the posture of the patient as well. You also want to notice any bilateral differences, this can be in breathing, or chest rise, any deformities present, and any changes in color, for example ecchymosis within the chest wall or ribs.
Upon inspiration, the chest should rise as air enters the lungs, but the stomach, or abdominal region, should also expand due to the contraction of the diaphragm. To know if you are properly breathing and using your diaphragm, you can clasp your hands together over your abdomen with the ends of your middle fingers touching over your umbilicus. When you breathe correctly, using your diaphragm, your hands should separate to the point where the fingers no longer touch, this ensures proper use of the diaphragm when breathing, also called “belly breathing.” Some people are dominant chest breathers, meaning they rely on the expansion of the chest to increase area in the cavity, rather than the diaphragm. This can be problematic because that is not the true intention and it can cause overuse injury to the costal cartilage, which can become inflamed. When evaluating breathing patterns and breath sounds, it is important to understand what is normal in order to identify what is abnormal. The normal respiratory rate for an adult is 12-20 breaths per minute. Tachypnea is when breaths are greater than 24 breaths pre-minute, and hyperpnea is a type of tachypnea that is characterized by larger, deep breaths that result in hyperventilation. Bradypnea are when breaths are less than 12 breaths per minute, and hypopnea are a type of bradypnea that are slow and shallow breaths that often occur as an adaptive response to painful pleuritic situations. Dyspnea is a term used to describe difficulty breathing, and in more severe situations comes apnea, which is an absence of spontaneous breathing.
When completing an evaluation of any kind, palpation is a good diagnostic tool. When palpating the chest as part of a respiratory evaluation, the main thing to feel for is tactile fremitus. Tactile fremitus are palpable vibrations that originate in the larynx and travel down into the bronchi and lungs, then on to the chest wall. These vibrations can be felt on the posterior chest using the palmar surface of the hand, all while the patient is speaking in order to create the vibrations.
Auscultation refers to listening of the sounds of the body; and in reference to the respiratory system in particular, breath sounds. This can be done with the use of a stethoscope and can be heard in various spots on the anterior and posterior sides of the chest. A lot can be gained from the sounds of breathing, it can indicate where the pathology lies and possibly lead to the source of the problem. Normal breath sounds include: bronchial, which are expiratory sounds that occur in larger airways, Bronchovesicular are heard both in inspiration and expiration and occur in midsized airways, and Vesicular, which are heard upon inspiration and occur within small air passages. One must listen repeatedly in order to able to recognize these sounds, because in order to hear an abnormal sound, you must first be able to identify normal sounds. Some common abnormal breath sounds are crackles that are associated with fluid blockage, and wheezes and stridors that are caused by some sort of airway obstruction.
Asthma is one of the most well-known respiratory pathologies and is a condition that is characterized by airway obstruction caused by hyperactivity of the muscular walls of the air passages. Asthma attacks can happen when the patient is exposed to certain triggers that stimulate the attacks. Common triggers for asthma can be allergens, stress/anxiety, smoke/other environmental pollutants, cold temperatures, and exercise. These attacks are characterized by bronchospasms of smooth muscle in the airway in combination with inflammation and production of mucus that adds greater resistance in the airway. Signs and symptoms include episodic, paroxysmal attacks of SOB, wheezing, dry cough, and chest tightness, with attacks lasting from several minutes to several hours depending on the severity. To be diagnosed and recommended for treatment of asthma, you must see a physician for diagnostic testing. Treatment will depend on the severity of the condition and will include medication for long term management, as well as a rescue inhaler for use during attacks.
Bronchitis is an inflammatory condition of the bronchial passages that is most commonly the result of a self-limited viral infection, though rarer, it can be caused by a bacterial infection. Signs and symptoms can include a productive cough with sputum having a clear/yellowish tint, mild shortness of breath, and some common cold symptoms (ie. runny nose, sore throat). For diagnosis of bronchitis, see a physician. Diagnostic testing includes taking blood to look for an elevated white blood cell count. Treatment for bronchitis is cough suppressants and nonsteroidal anti-inflammatory (NSAID) drugs to treat symptoms, if the condition is bacterial, antibiotics can be used.
Anti-inflammatory medication is used to reduce or slow the inflammatory process within the body, it can also decrease pain and fever. Many types of nonsteroidal anti-inflammatory drugs are available over the counter and are used by a majority of the population. Some side effects to anti-inflammatory medications include an array of gastrointestinal upset, such as heartburn, vomiting, nausea, abdominal pain, and GI bleeding. Anyone who is allergic to or has a hypersensitivity to anti-inflammatory medications should not take it, as well an those on blood thinners because the medication has a similar effect.
Anti-fungal medication is for the use of treating fungal infections. This can be common in athletics because the population produces more sweat, which is a conducive environment for fungi to grow. Anti-fungal can be topical medication as well oral and can be used simultaneously. Topical medications are usually prescribed first, and if the fungus persists or is recurring, then the oral medication will be added as needed. Griseofulvin is a common oral anti-fungal used for wrestlers. It has side effects of headache, dizziness, trouble sleeping, rash and hives, and sensitivity to light.
Narcotic Analgesics are medications used to treat pain. They are able to stimulate the opiate receptors in the brain and help alleviate pain by changing the way that pain is perceived in the body. Opiate agonists can cause a disassociation from painful stimuli in the body. Some common side effects with narcotic medications are sedation and drowsiness, nausea, vomiting, and slowed breathing. These medications also have a very high risk of addiction, so they are prescription only and are highly regulated.
The cardiovascular system is made up of the heart and blood vessels throughout the body. The heart is a muscular organ comprised of 4 chambers, 2 atria on the superior portion, and 2 ventricles on the inferior portion. As blood enters the heart from the Superior an Interior, it then travels through the tricuspid valve to the right ventricle. After leaving the ventricle it then travels to the lungs to become oxygenated, then travels back to the heart to enter the left atria. The blood then travels through the mitral valve and into the left ventricle to be pushed out into the Aorta to be distributed to the body.
There is an electrical current that regulates the contraction of the heart and keeps the heart beat constant. It begins in the superior portion of the heart with the Sinoatrial node, to the Atrioventricular node, to the Bundle of His, to the Bundle Branches, to the Perkingie Fibers.
There are many pathologies of the heart that can occur for many different reasons, thus cardiologists must be prepared for many different types of situations. Hypertrophic cardiomyopathy is a thickening of the muscular walls of the heart. Symptoms can include fatigue, difficulty breathing, chest pain when exercising, and feeling faint. Sickle cell anemia is characterized by abnormal shaped red blood cells, which can cause problems with the cell being able to hold and transport oxygen. This can lead to low iron concentration in the blood, as well as low oxygen concentration. The abnormal shape of the cells can also cause problems with clots, as the sickle shape makes it more difficult for the cells to pass through small capillaries. When exercising these athletes needs to be monitored closely.
The gastrointestinal system is the digestive system and is made up of the abdominal organs. Evaluation of the abdomen begins with a good history, followed by palpation and percussion of the abdominal organs, feeling for rigidity or tenderness, and listening for abnormal sounds when percussing. You can also use a stethoscope to listen for digestion sounds to note any abnormalities. Like with the lungs, you must practice listening to normal sounds to be able to identify abnormal sounds. Some of the most common problems associated with the gastrointestinal system are nausea, vomiting, and diarrhea. This can be the result of many different things, such a food poisoning, GI irritation as the result of medication, and virus or bacteria. When GI irritation occurs, it is best to avoid acidic, spicy, or greasy foods as to not agitate the stomach even more. Some medications can be used to calm the stomach and ease symptoms, such as anti-nausea medications.
Gastrointestinal symptoms can also be caused by stress. This can produce symptoms of abdominal pain, cramps, vomiting, diarrhea, and anorexia. Stress-Induced Gastrointestinal symptoms are diagnosed when all other possible causes are ruled out. It is important to remind the athlete that their symptoms are real and try to reduce the stress to alleviate the symptoms.
Appendicitis is the inflammation of the Appendix. Once this process has begun, the appendix must be removed because if the condition worsens to a rupture, the effect can be life-threatening. Symptoms of this include pain in the lower right side of the abdomen, and presents with rebound pain, meaning that pressure on the appendix is not painful, but when you release the pressure it elicits pain. To diagnose appendicitis, diagnostic testing using a computerized tomography scan must be used. Once the diagnosis is confirmed, the appendix will most likely be removed.
Genitourinary and Gynecological Systems:
The Genitourinary and Gynecological systems include the anatomy of the kidneys, ureters, bladder, urethra, and male and female gentiles. The body forms urine by a filtration of the blood done in the kidneys, which is then drains down muscular tubes called ureters to pool in the bladder. Once the bladder becomes full, the urine is expelled from the body through the urethra, which is the opening located in the genitals. In females, menstruation occurs as a result of the body not getting pregnant, and the body sheds the uterine lining resulting in bleeding from the vagina lasting for about a week.
Kidney stones are a build of sodium in the kidneys that can crystalize. These stones will travel through the entire urinary system including the ureters, bladder, and urethra and will usually pass on their own. Kidney stones are very painful and symptoms usually begin on the effected side of the posterior back and radiate toward the groin. For the first kidney stone, the patient should be referred to a physician. Treatment includes pain management with narcotics or NSAIDS.
A urinary tract infection can occur in either the upper or lower portions of the urinary system. Signs and symptoms include painful urination and increased frequency of urination. Refer to a physician for diagnosis. Testing will include a urine specimen that is examined for elevated white blood cell count and nitrite. Treatment includes the use of antibiotics.
The neurological system is responsible for all the electrical impulses within the body. It is comprised of the brain, spinal cord, and all peripheral nerves. The brain is divided into lobes that each are responsible for different functions of the body. The lobes are frontal, temporal, parietal, and occipital, and each lobe has 2 sections because the brain is divided into left and right sides.
A stroke, also known a cerebrovascular accident, occurs when blood supply to the brain is compromised and the brain experiences cell death. This can lead to reversible or irreversible paralysis, speech problems, or dementia, and can be life threatening. Anyone experiencing symptoms of a stroke should seek immediate care. Diagnostic testing includes an electroencephalogram, or ECG, to analyze the brain’s electrical activity. Treatment for a stroke involves extensive rehabilitation that can begin as soon as 2 days after the stroke has occurred in order to get the individual back to daily function, or as close to it as possible.
Guilain-Barre Syndrome is an acute demyelinating disorder occurring at the spinal nerve roots and in the peripheral nerves. This disorder is characterized by weakness in the muscles progressively moves proximally as the disorder worsens. There is often pain associated with the disorder and occurs with even the slightest movements as well as nocturnal cramps that can disrupt sleep patterns. To diagnose this disorder, an electromyogram and a nerve conduction velocity test are requested. There is no cure for Guilain-Barre Syndrome. Treatment of symptoms can include the use of corticosteroids and rehabilitation.
The eye is the organ responsible for sight. It is a small organ located within the skull that is spherical in nature. It is comprised on several parts that are each essential to the function of the organ. The cornea is the exterior barrier of the eye and serves as the “window of the eye.” Behind the cornea is the pupil, which is essentially a hole that light passes through to reach the lens. The lens is round, transparent part that refracts the light passing through. The light ultimately reaches the retina, which is where the light focuses and then travels to the optic nerve that leads to the occipital lobe of the brain, where the image is processed to produce the picture you see.
The eye can have a number pathologies, some because of aging and genetics, and other as a result of trauma. You can test the acuity of the eye with a series of tests, including the Snellen chart, which tests sight from far away. Using an ophthalmoscope is used to examine the integrity of the retina and posterior eye. When examining the eye, some pathologies can be present; myopia is nearsightedness, hyperopia is far sightedness, and astigmatism is when the eye is misshapen like a football rather than a sphere.
Some pathologies that can occur because trauma are hyphema, subconjunctival hemorrhage, corneal laceration, orbital fracture, and ruptured globe. These injuries can be caused by blunt or sharp trauma to the eye and should be referred to an ophthalmologist immediately, as they are dangerous to the life and function of the eye.
Ear, Nose, Throat, and Mouth:
The ear has 3 main portions: inner, middle, and outer ear. The external ear is where the sound is received and aimed to travel toward the middle ear, stopping at the tympanic membrane, otherwise known as the eardrum. The middle ear houses the 3 smallest bones in the body: the incus, malleus, and stapes. The inner ear contains the cochlea, which is responsible for transmitting the sounds to the vestibulocochlear nerve. As sound enters the outer ear, it is then channeled toward the middle ear where it hits the tympanic membrane causing it to vibrate, the Incus, Malleus, and Stapes lie on the other side and transmit those vibrations to cochlea, which then transforms the vibrations into electrical impulses and transmits them to the nerves to the brain.
The nose is divided into internal and external sections. The external nose is made up of the nasal bone, which covers about 1/3 of the external nose, and the remaining 2/3 is made of cartilage. The external nose is responsible for humidifying, filtering, and warming the air that enters the body. The internal nose is divided even further into 2 anterior cavities, and this is also where the Olfactory nerve is house, which provides the ability to smell.
The oral cavity is made up of the cheeks, tongue, lips, teeth, and salivary glands. The throat, also known as the pharynx, is divided up into several sections as well. It begins in the nasopharynx, beginning up toward the nasal passages, then moves into the oropharynx that is located at the back of the oral cavity, then into the laryngopharynx that just superior the larynx.
Systemic disorders can be in reference to almost any part of the body, thus there are many different types of disorders covered, including systemic diseases and autoimmune diseases. Raynaud’s Phenomenon is a systemic disease that results in color changes to the skin when exposed to cold temperatures. This is due to a vasospasm of the arteries and if primarily found in the hands, feet, and ears. Non-Hodgkin Lymphoma is a type of cancer that can develop from white blood cells within the body. Symptoms of this can include: flu-like symptoms, skin rash, and swollen lymph nodes. The treatment is radiation and chemotherapy, but the cure rate is on 35-50%. Lyme Disease is a bacterial disease found to be transmitted my ticks. The disease has a very distinct marker at the site of the bite that looks like a bullseye. Early symptoms of the disease include flu-like symptoms and a noticeable bullseye rash. Later symptoms worsen and you can begin to see symptoms like neurological disturbances and joint pain.
Systemic Lupus Erythematosus is an autoimmune that is characterized by autoantibodies, which means the body forms antibodies toward its own proteins. The disorder often effects the musculoskeletal system, the skin, kidneys, heart muscle, and nervous tissue. The disorder can present with a butterfly rash, which covers the face over the cheek region, giving it the shape of a butterfly. It can also effect the central nervous system causing stroke, coma, or seizures. Treatment includes NAIDs for musculoskeletal pain and corticosteroids for neurological symptoms.
Influenza is a common viral infection that is transmitted through droplets when you sneeze or cough. Symptoms include fever, headache, muscle aches, congestion, and cough. Diagnosis of the flu requires a nasal swab from a physician to test for it. Treatment is treating the symptoms, as the flu is a viral infection and has no cure. Symptoms typically lasts 7-10 days. The main prevention for the flu is vaccination, but this can also be achieved by washing your hands and not sharing food or drinks.
Infectious Mononucleosis is caused by the Epstein- Barr virus (EBV), and is also known as the “kissing virus” because it is transmitted through saliva. Symptoms include severe fatigue, cough, sore throat, and patient stating they “cannot get enough sleep.” Mono is diagnosed through a blood test which is confirmed by an elevated number of white blood cells and a noticeable clumping of red blood cells. The treatment is simply to rest and take in adequate amounts of water. You can prevent this from spreading rapidly through your team by educating your athletes not to share cups or put their mouths on the water bottles.
Chicken Pox is a viral disease, most often seen during childhood. It is a viral disease that is extremely contagious through touch. Chicken Pox presents with headaches, and maculopapular rash that can appear almost anywhere on the body and lasts typically lasts about 3-4 days. Shingles is a reactivation of the disease in the later stages of life and presents with worsened symptoms as the age of the patient is greater.
The skin is the largest organ in the body and covers the entirety of the external surface of the body. The skin has 3 main layers: the most superficial, the epidermis, the middle layer, the dermis, which contains all blood vessels and glands, and the deepest layer is the subcutaneous layer, which houses layers of fat and connective tissue. When evaluating the skin, you want to look at the pattern of any lesions, for example clustered, raised, or any lesion this contains fluid or drainage. You also want to look at the color of any lesions as well as the symmetry and size. Lastly, the location, making note if they are on the hairline or surrounding the genitals.
Urticaria is commonly seen as rash or hives and most often caused by an allergic reaction to food. Urticaria can be more severe or more mild depending on the reaction. A severe case would be anaphylactic shock, causing a swollen face and tongue, difficulty breathing, feeling faint, and difficulty speaking. Cholergenic Urticaria occurs when the skin is exposed to heat or during exercise, and presents with hives about 2-20 minutes after exposure.
Basal Cell Carninoma is a type of skin cancer that is considered to be the most common form of skin cancer. Basal Cell Carcinoma has 2 basic types, the nodular presents as a pearly translucent pink papule on the head and neck regions. The superficial presents with asymptomatic, scaly plaque that enlarges very slowly and typically occurs on the trunk or extremities. If caught early, the lesion can be removed and the cure rate is fairly high at that point.
Psychological and Substance Use Disorders:
As athletic trainers, we most often are looking for injury to the body, or musculoskeletal system; meanwhile, disturbances or disorders of the mind are being overlooked. Anxiety is an extremely prevalent form of psychological stress today. Anxiety disorders can cause shortness of breath or difficulty breathing, dizziness, feelings of losing control, and feeling of unreality. Generalized Anxiety Disorder effects over 6.8 million Americans and is twice as likely to be reported by women. This disorder can give you feelings of worry or nervousness for almost every situation in your daily life.
Post-Traumatic Stress Disorder, or PTSD, is also a very prevalent disorder within our population. This disorder can cause flashes of a traumatic event that occurred and give you replicas of the feelings you experienced during that trauma, and these flashes can occur when triggered by thought or feelings similar to the original trauma.
Depression can be mild, moderate, or severe. Signs to look for in an depressed athlete are depressed or lowered mood, substance abuse, loss of interest in usual activities, and social isolation. Treatment will be the use of anti-depressant medication, beginning with low doses and gradually getting higher as the patient begins to improve.
Eating Disorders are present in sport too. High demands from a sport or coach can change an athletes’ attitude toward food. Two of the most common disorders are Anorexia and Bulimia. Anorexia is a distorted view of the body, and the person stops eating in order to achieve a goal weight or look. Anorexia is present when a person drops below 85% of their ideal body weight. Bulimia is characterized by binge eating followed by compensatory behavior to prevent weight gain. This can be done through forcing themselves to vomit, which will produce bruises on the knuckles called Russel’s Sign, or another example would be someone going to work out for 4 hours after a binge episode.
Working with Special Populations:
When working with special populations, it is important to remember to use respectful terminology. There are many types of special needs disorders, some examples include autonomic dysreflexia, which can be a life-threatening condition characterized by spikes in blood pressure that reaches dangerous levels. Another is Down’s Syndrome, this occurs before birth and is a genetic chromosome disorder that can cause developmental and intellectual delays.
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