The tracheobronchial tree anatomy is important for anesthesiologists to understand. It begins with the trachea, which branches into the right and left main bronchi. Each main bronchus then divides into lobar, segmental and smaller bronchi. The trachea and bronchi are supplied by arteries and veins. Tracheostomy is the creation of an opening in the trachea and is used in cases requiring long-term ventilation or airway management. Percutaneous dilatational tracheostomy is now commonly performed but surgical tracheostomy may be preferred in some situations. Understanding the anatomy helps anesthesiologists properly position patients and perform procedures involving the airways.

1. ANATOMY OF TRACHEOBRONCHIAL
TREE AND ITS IMPORTANCE FOR
ANAESTHESIOLOGIST
By::Dr. HUNNY
NARULA
Moderator::Dr.
Kanchan Chauhan

2. TRACHEA
 The tracheobronchial tree and the lung parenchyma comprise
the lower respiratory tract.
 Trachea is a midline structure that extends from lower end of
cricoid cartilage at level of C6 vertebra to its termination at
bronchial bifurcation.
 In preserved dissected room cadever : At level of T4 vertebrae
 Living subject in erect position : Extends to level of upper border
of 5th thoracic vertebrae or in full inspiration upto 6th thoracic
vertebrae.
 Comprises 16-20 C shaped cartilage rings, cartilages are
joined vertically by fibroelastic tissue and closed posteriorly by
non striated trachealis muscle

3.  Adult
 Length 10-12cm.
Diameter 15-20mm.
 Children : Trachea is smaller, deeply placed and more
mobile.
 1 st post natal year – Diameter doesn’t exceed 4 mm
 During later child hood : Diameter in mm is approx. equal
to age in years.

5. EMBRYOLOGY

6. Formation of lung bud takes place
 When embryo is approx. 4 wk old & it (Respiratory
diverticulum, lung bud) appears as an outgrowth from ventral
wall of foregut
 Initially lung bud communicates with foregut. When diverticulum
expands caudally, 2 longitudinal ridges (k/a tracheoesophageal
ridges) separate it from foregut. These ridges subsequently fuse
to form Tracheoseophageal septum. Foregut is divided into
dorsal portion to form oesophagus and ventral portion to form
trachea and lung buds. During its separation from foregut, lung
bud form the trachea and 2 lateral outpocketings, the bronchial
buds.

7.  At beginning of 5th wk, each of these buds enlarge to form
Contd.. And
Rt. Lt. main bronchi.
 Rt. then form 3 secondary bronchi and Lt. two, for 3 lobes
of Rt. And 2 for Lt. respectively.
 Epithelium and internal lining – endodermal origin
 Cartilagenous, muscular and connective tissue –
splanchnic mesoderm surrounding the foregut

9. TRACHEOBRONCHIAL
TREE
ANATOMY

11.  Trachea divides into right- and left- primary main bronchi.
Each further divides into lobar bronchi which in turn give rise to
segmental bronchi-supply air to bronchopulmonary
segments.
 Segmental bronchi divide dichotomously, eventually giving rise to
terminal bronchioles which further terminates into respiratory
bronchioles.
 Originating from each respiratory bronchioles are 2-11 alveolar
ducts leading to the alveolar sacs which are extended as a
group of alveoli.
 Airway becomes progressively narrower, shorter and more
numerous, and Cross sectional area, enlarges.
 Areas of tracheobronchial tree furthest from the trachea are
collectively called the "distal respiratory tree"

12. BRONCHOSCOPIC VIEW SHOWING CARINA
AND LEFT & RIGHT BRONCHUS (MORE
VERTICAL).

13. RIGHT MAIN BRONCHUS
 The right main bronchus is 2 cm long on average
and has an internal diameter of 10-16 mm. This is
slightly larger than the diameter of the left main
bronchus.
 The bronchus intermedius of the right bronchial tree
is actually quite short ,extending for 1.0-2.5 cm until
its anterior wall extends into and becomes the
middle lobe bronchus. Its posterior wall extends into
and becomes the right lower lobe bronchus.
 Volume loss caused by pleural
effusion, atelectasis, elevated right
hemidiaphragm, as well as traction or torsion
from a fibrotic or scarred upper lobe often cause

14.  The RIGHT UPPER LOBE BRONCHUS
divides into (3)
a. The apical bronchus
b. The anterior bronchus
c. The posterior bronchus
 Distally just beyond the bronchus
intermedius, another division occurs into :
 The MIDDLE LOBE BRONCHUS with its anterior
direction, dividing into(2)
a).medial and
b).lateral segmental bronchus.

15. The RIGHT LOWER LOBE BRONCHUS(5)
 The right lower lobe bronchus divides immediately
into a a).superior segmental bronchus(jsut across
from the right middle lobebronchus), and
b).medial basal segmental bronchus
a bit more distally and along its medial wall.
 Finally dividing into three lower lobe bronchi
(Three musketeers):
c).Antero-basal
d).Latero-basal
e).Postero-basal

16. Right upper lobe bronchus and bronchus
intermedius (sec. carinas)
•The carina dividing the right upper lobe from the bronchus
intermedius is called the right carina 1 or RC-1.
•On the right, the carina between the right middle lobe
bronchus and the bronchus to the right lower lobe is
named the right carina2 or RC-2.

17. Bronchus intermedius and right lower
lobe bronchus

18. LEFT MAIN BRONCHUS
 The left main bronchus is usually 4-5cm
long(Rt. 2cm long).Its lumen is narrower and
relatively horizontal. The usual length of the left
lower lobe bronchus beyond the origin of the
superior segmental bronchus is 1cm.
 Divides into : (2)
 a).upper and
 b).lower lobe bronchus.

19.  The UPPER LOBE BRONCHUS divides into :
a). Upper division(3) Apical
Posterior
Anterior
b).Lingular bronchus(2) Superior
div.
inferior div.
 The LOWER LOBE BRONCHUS(4):
Apical
Ant.basal
Post basal
Lat basal
Med basal

20. Left upper lobe bronchus:
Upper division and Lingula
LC-1
LC-2

21. Contd… TRACHEA
Rt. Main bronchus Lt. Main bronchus
Middle
Superior lobar Inf. Lobar Sup. Lobar Inf. Lobar
lobar
Bronchus(3) bronchus(5 bronchus(5 bronchus(4
bronchus(2
) ) )
)
• Superior • Apical
• Apical • Lateral •Apical
•Medial basal •Posterior
• Posterior • Medial •Ant basal
• Ant. Basal • Anterior
•Anterior •Lat basal
• Post basal •Superior lingular
•Post basal
• Lateral basal •Inferior lingular

22. VASCULAR SUPPLY OF TRACHEA AND
BRONCHI
 Arterial supply : Upper 2/3 - Inferior thyroid artery
Lower 1/3 – Bronchial artery
 Venous supply : Inferior thyroid vein
 Lymphatic : drain into Deep cervical, pretracheal, paratracheal LN.
 Nerve supply : RLN with sympathetic fibres from middle cervical ganglion
Bronchial arteries :
 Rt. Bronchial artery - branch of 3rd posterior intercoastal artery.
 2 Lt. bronchial arteries – branch of thoracic aorta.
Bronchial vein communicates with pulmonary vein.
 Rt. Side  Azygous vein
 Lt. Side  Accessory hemiazygous vein

23. LINING EPITHELIUM
Trachea Terminal bronchioles:
ciliated psuedo stratified columnar epithelium
Respiratory bronchioles alveolar ducts alveoli:
non ciliated cuboidal epithelium

24. Bronchopulmonary semgments
RIGHT(10 LEFT
)
3 3+2
2
4
5

26. TRACHEOBRONCHIAL
TREE
CLINICAL
RELEVANCE

27. ANGLE OF MAIN BRONCHI
A). B).
Rt Lt
RIGHT LEFT
45
2 45
45
5
•A). In Adults: Hence more chances of rt bronchial intubation
•B). In Children (under the age of 3yrs the angulation
of the two main bronchi at the carina is equal on both
sides.)

28. Some more..
 The presence of 5cm of bronchial lumen
uninterrupted by any branching makes the left
main bronchus particularly suitable for intubation
and blocking during thoracic surgery.
 The patency of the rt middle lobe bronchus is
particularly vulnerable to glandular swelling
because it is closely related to the right
tracheobronchial groups of glands.

29. Relationship B/W Posture And The
Focal Incidence Of Lung Abcess
 Patient Lying On Side: inhaled materials collect
in posterior segment of right upper lobe.
 Patient lying on back: inhaled materials collect
in apical segment of right lower lobe.
 Bronchopulmonary segments are functionally
and anatomically distinct from each other -
which matters because a segment of diseased
lung can be removed surgically without
adversely affecting the rest of the lung.

30. PDT(POSITIONING)

31. TRACHEOSTOMY
 creation of permanent or semi permanent
opening(surgical airway) in the anterior wall of trachea.
Also k/a tracheotomy, laryngotomy, pharyngotomy.
 If a cannula is in place, an unsutured
opening heals into a patent stoma within
a week. If decannulation is performed
(ie, the tracheostomy cannula is removed),
the hole usually closes in a similar amount
of time.

32. Indications:
 In The Acute Setting, indications for tracheotomy
include such conditions as severe facial trauma, head
and neck cancers, large congenital tumors of the
head and neck (e.g., branchial cleft cyst), and
acute angioedema and inflammation of the head and
neck.
In the context of failed orotracheal or nasotracheal
intubation, either tracheotomy orcricothyrotomy may
be performed.
 In The Chronic Setting, indications for tracheotomy
include the need for long-term mechanical ventilation
and tracheal toilet (e.g. comatose patients, or
extensive surgery involving the head and neck).
 In extreme cases, the procedure may be indicated as
a treatment for severe Obstructive Sleep Apnea seen
in patients intolerant of Continuous Positive Airway
Pressure (CPAP) therapy.

33. Elective tracheostomy:
Anaesthesia: GA
Position: dorsal recumbent with sand bag under the shoulder.
Incision: horizontal incision 1 finger breadth above supra sternal
notch parallel to it from one SCM to opp. side or vertical
incision in midline extending from cricoid cartilage to
suprasternal notch.
Division /retraction of thyroid isthmus thus exposing 3rd & 4th
tracheal rings.
Opening of Trachea and insertion of tube.
Emergency Tracheostomy:
Within 2-4 mins with vertical incision.
Cricothyrotomy/mini tracheostomy:
Transverse incision over the cricothyroid membrane. Kept only for
3-5 days,to be replaced with standard tubes after patient’s
stabilization..

34. Peadiatric tracheostomy
 Vertical incision in trachea b/w 2nd and 3rd ring.
 No excision of ant. Wall of trachea.
 Secure the tube with neck by two sutures.
Percutaneous dilatational tracheostomy
 Percutaneous dilatational tracheostomy (PDT) has become a
commonly performed procedure in the intensive care unit (ICU) in
those patients subjected to prolonged mechanical ventilation.
 It has largely replaced the conventional surgical tracheostomy in
critical care patients, with benefits in terms of cost, ease of
performance, and reduced complications.
 Use of guide wire and Dilators.
 Under the vision of Bronchoscope through endotracheal tube.
 Not suitable for thick neck and in emergency.
 Significant complications associated with PDT, including
haemorrhage, pneumothorax, and paratracheal placement, have
ranged in various series from 3 to 18%

35. PERCUTANEOUS DILATATIONAL
TRACHEOSTOMY
LANDMARKS
Daigram showing anterior
structures of neck

36. PROCEDURE:
Cricoid cartilage is palpated and local
anaesthetic infilterated,Solutions containing
adrenaline may be used to decrease
bleeding at the incision site.
Horizontal incision is made at chosen
insertion site of sufficient size to accept
a tracheostomy tube(say about 1.5 to
2cm). At this stage it may be of benefit
to perform an exploratory blunt
dissection(keeping in midline) to
identify the anatomical landmarks.

37. A 14G needle and cannula(with
syringe attached) is inserted in the
midline in a caudal direction(to avoid
the likelihood of the guidewire being
passed into pharynx.). The needle is
advanced until free withdrawal of air
into the syringe confirms the entry of
the needle and the cannula into the
trachea.this may be facilitated by
using fluid filled syringe,allowing
visualization of withdrawn air
bubbles. some secretions & mucus
may be aspirated during this
process,which is normal.
The guide wire introducer is
eased out from its sheath & the
“J” tip is straigthened ,the
introducer is inserted into the
cannula & the guidewire is
advanced into the trachea

38. Immediately prior to insertion, the
distal end of the “single stage”
dilator, “rhino horn” is immersed in
water or saline to act as the
lubricious coating on the dilator. The
dilator is passed over the guiding
catheter until it reaches the “safety
stop”.
The lubricated tracheostomy tube is inserted
loaded on its lubricated introducer over the
guiding catheter through the stoma with a slight
twisting motion.The cuff of the tube is inflated
and the tube secured using sutures &/or cotton
straps.

39.  Types of PCT :
 Ciaglia technique
 Grigg’s technique
 Blue rhino / Rhino horn technique
 Fantony’s technique
 Perc twist technique
 Surgical Tracheostomy preferable to PCT in the
following situations:
 Coagulation abnormality
 High level of ventilatory support (FiO2 >.7 & PEEP
> 10 cm H2O)
 Unstable / Fragile cervical spine
 Neck injury
 Unfavorable neck anatomy (previous surgery, tumor
etc.)
 Obesity

40. AIRWAY
HYPERREACTIVITY
AND
PERIOPERATIVE
BRONCHOSPASM

41.  A mild tonic constriction exists in all normal human airways. Mainly
maintained by the efferent vagal activity .
 In some individuals, intense bronchoconstriction is provoked
following airway stimulation with low level of stimulus as compared
to normal persons. This bronchial hyperresponsiveness is termed
“Reactive Airways”.
 BRONCHOSPASM, the clinical feature of exacerbated underlying
airway hyperreactivity, is characterized by abnormal bronchial
smooth muscle contraction leading to narrowing of respiratory
airways. During the perioperative period, bronchospasm usually
arises during induction of anesthesia but may also be detected at
any stage of the anesthetic course.
 The commonest disease condition that falls into this entity is
bronchial asthma. Others include ::chronic
bronchitis, emphysema, allergic rhinitis and upper/lower respiratory
tract infections. This category of patients constitutes a problem to
the anaesthetist especially when the airway has to be tempered
with.

42.  Often, precise testing is not practicable preoperatively and
clinicians have to rely on history to identify factors suggesting an
increased likelihood for perioperative bronchospasm.
 One of the most important is history of recent upper respiratory
tract infection characterized by cough and fever. Respiratory
symptoms like nocturnal dyspnoea, chest tightness on
awakening, associated breathlessness and wheezing in
response to various respiratory irritants, appear highly predictive
of increased bronchial reactivity
 Bronchospasm encountered during the perioperative period and
especially after induction/intubation may involve
a)an immediate hypersensitivity reaction including IgE-mediated
anaphylaxis or
b).a nonallergic mechanism triggered by factors such as
mechanical (i.e., intubation-induced bronchospasm) or
pharmacologic-induced (via histamine-releasing drugs such as
atracurium or mivacurium) bronchoconstriction in patients with
uncontrolled underlying airway hyperreactivity.

43.  Intraoperatively bronchospasm is diagnosed
by ventillatory difficulties characterized by:
Difficult mask ventillation.
Increased peak airway pressure.
Expiratory wheezing.
Decreased or absent breath sounds.
ETco2 demonstrated a marked prolonged expiratory
upstroke of the capnogram.
Low concentrations of EtCO2.
Desaturation.
Hypotension.

44. Management:
 The key to therapy is inhalation of sympathomimetics such as
albuterol. These drugs produce more rapid and effective
bronchodilation than intravenous aminophylline. The beta-
adrenergic aerosols like salbutamol, when inhaled before
induction of anaesthesia prevents bronchospasm.
 Intravenous lignocaine (1.5–2 mg/kg), hydrocortisone (4 mg/kg)
or glycopyrrolate (1 mg) may also help in reversing the reflex
response to bronchoconstriction.
Glycopyroolate may also be administered directly through the
endotracheal tube. These dugs are likely to be more effective
before the stimulus.
Lignocaine has been shown to prevent such bronchospasm by
blockade of the airway response to irritation and direct
attenuation of smooth muscle response to irritation. Its use could
therefore be employed when endotracheal intubation and some
drugs likely to trigger bronchospasm are indicated.

45.  Inhalational anaesthetic agents like halothane produce
bronchodilatation & if inhalation anaesthesia is indicated, it
has been considered the agent of choice; but its
myocardial depressant and arrhythmic effects in the
presence of catecholamines may limit its use. At high MAC
(>1.5), both enflurane and isoflurane prevent vagally
mediated bronchospasm. These agents could hence be
considered useful for inhalation anaesthesia in the
asthmatics. However in 1997, Rooke et al observed
clinically in humans that sevoflurane at 1.1 MAC may be
more efficacious than both iso- and enflurane.

46. Differential diagnosis:
The differential diagnosis includes:
 inadequate anesthesia,
 mucous plugging of the airway,
 esophageal intubation,
 kinked or obstructed tube/circuit, and pulmonary
aspiration.
 Unilateral wheezing suggests endobronchial intubation or
an obstructed tube by a foreign body (such as a tooth).
 If the clinical symptoms fail to resolve despite appropriate
therapy, other etiologies such as pulmonary edema or
pneumothorax should also be considered.

47. Congenital
anomalies:
tracheoesophageal
fistula

48.  Seen in 1:4000 live births.
 M:F::25:3
 10-40% are pre-term
 Ass. with polyhydramnios(60%)
Embryology:
 Derived from primitive foregut
 4th week of gestation tracheoesophageal diverticulum forms
from the laryngotracheal groove
 Tracheoesophageal septum develops during 4th-5thweeks –
muscular + submucosal layer of T + E formed
 Elongates with descent of heart and lung
 7thweek reaches final length

50. CLINICAL PRESENTATION:
 Choking on 1st feed
 Drooling of saliva
 Coughing
 Cyanosis
 Aspiration pnuemonia
 Associated anomalies:VACTRAL anomalies in 35-65%
DIAGNOSIS:
Antenatal: In ultrasound polyhydramnios, distended stomach
Immediately after birth: Inability to pass suction catheter into the
stomach.
CXR: coiled orogastric tube in the cervical pouch; air in the
stomach & intestine

51. PREOPERATIVE PREPARATION
2 OBJECTIVES:
1.Minimize pulmonary complications (resulting from gastric
acid reflux into pulmonary system)
NPO, head up position, sump tube on low continuous
suction, gastrostomy under LA
2.Manage dehydration & electrolyte imbalance
CONVENTIONAL TEF
OPERATIVE MANAGEMENT CLOSURE
ENDOSCOPIC TEF
REPAIR

52. ANAESTHETIC MANAGEMENT:
THREE APPROACHES:
1. Induction with inhalational agent+ topical spray+
spontaneously breathing infant+ intubation
2. Iv or inhalational induction+ muscle paralysis+ intubation
3. Intubation in sedated awake neonates
ASSESSMENT OF ETT POSITION:
GOAL:ETT just above the carina & just below the fistula
 Rt. main stem intubation & withdraw ETT until breath sounds
are equal bilateral.
(Lt. main stem bronchial intubation is poorly tolerated d/t insufficient
pulmonary reserve.)

53. contd:
 If g tube present, place the end under water seal:ETT is above
fistula----(+)bubbles.
 Connect capnograph to g-tube: ETCO2 (+), if ETT is above the
fistula
 Rigid bronchoscopy, not proven.
Beware of gastric distension
give gentle positive pressure ventillation
keep gastrostomy open, if present.
INTRAOPERATIVE PROBLEMS:
 Endobronchial intubation
 Intubation of fistula
 ETT obstruction
 V/Q mismatch
 Vagal response to tracheal manipulation

54. Post operative management
 EARLY EXTUBATION DESIRABLE
Caution: disruption of surgical repair with reintubation
 POST OP PAIN MANAGEMENT:
1. Iv narcotics
2. Epidural infusion:0.1%bupivacaine+fentanyl 0.5mcg/ml
@ 0.1-0.2ml/kg/hr
3. Rectal analgesic + LA infilteration of incision.

55. BRONCHOSCOPY
 INDICATIONS
 INSTRUMENTS OF CHOICE
 ANAESTHESIA FOR BRONCHOSCOPY

56. INDICATIONS:
DIAGNOSTIC THERAPEUTIC
 Cough  Foreign Bodies
 Hemoptysis  Accumulated Secretions
 Wheez  Aspiration
 Atelectasis  Lung abcess
 Unresolved pnuemonia  Reposition endotracheal tubes
 Diffuse lung dis.  Placement of endobronchial tubes
PREOPERATIVE EVALUATION  LASER surgery for airways.
 Rule out metastases
 RLN palsy
 Diaphragm paralysis
 Exclude tracheo esophageal fistula
 During mech ventillation
 Selective bronchography
 Abn. Chest radiograph

57. INSTRUMENTS OF CHOICE
RIGID FIBEROPTIC/FLEXIBLE
 Forein Body Removal  Mechanical problems of neck
 massive hemoptysis  Upper lobe &peripheral lesions
 Vascular tumors  Limited hemoptysis
 Small children  During mech ventillation
 Endobronchial resections  Pnuemonia for selective cultures
 Positioning of double lumen tubes
 Difficult intubation
 Cheking position of of ETT
 Bronchial blockade

58. Anaesthetic techniques:
LOCAL ANAESTHESIA:
 Pretreated with drying agent
 LA: lidocaine & tetracaine
 Oropharynx: nebulization or gargle
 LA soaked pledgets in pyriform fossa(int. branch of sup. LN)
 Tracheal anaesthesia: transtracheal inj. of LA or spraying of vocal
cords under direct vision of laryngoscope
 Alternatively sup. LN block along with glossopharyngeal N. block to
depress gag reflex
 Blocks blunt patients reflexes: pt. must be NPO for several hours
after examination
 Advantages: awake cooperative spontaneously breathing patient
 Disadv.: poor tolerance to bleeding, occasional lack of cooperation

59. GENERAL ANAESTHESIA:
1. APNEIC OXYGENATION:
 Preoxygenation+ induction+ skeletal muscle paralysis+ cessation
of IPPV increase in PCO2
 1st minute: increase is approx. 6mmHg
 Subsequently @ 3mmHg/min.
 Oxygen insufflated at 10-15ml/min
 Apneic period should not extend beyond 5mins
 Technique is limited by build up of CO2,respiratory
acidosis, cardiac dysrrhythmias
2. APNOEA & INTERMITTENT VENTILLATION
 Oxygen & anaesthesia gases delivered to bronchoscope via
anaesthesia circuit
 Ventilation possible only when eyepiece is in place,limits
interventional period by surgeon
 Disadv: leak around the bronchoscope

60. 3. SANDER’S INJECTION SYSTEM:
 Oxygen from high pressure source(50 psig),using controllable
using pressure reducing valve & toggle switch to a 18-16G needle
inside & parallel to the long axis of the bronchoscope.
 Pressing the toggle switch jet of oxygen entraining the room air &
O2-air mixture emerges at a pressure to provide adequate
ventilation & oxygenation
 Intraluminal tracheal pressure depends upon: driving pressure from
reducing valve, the size of needle jet, & the length, int. diameter &
the design of bronchoscope.
 Pressure varies inversely with cross sectional area of the
bronchoscope so insertion of catheter or biopsy forceps into the
lumen causes the intra tracheal pressure to rise.
4. HFPPV
5. MECH VENTILLATION

61. PHYSIOLOGICAL CHANGES ASSOCIATED WITH
FIBEROPTIC BRONCHOSCOPY:
 In all patients: hypoxemia, average decline in Pao2 is 20mmHg &
lasts for 1-2hrs.By 24hrs blood gases are back to normal.
 During or after bronchoscopy patients experience increased airway
obstruction: inc FRC ,dec in PaO2, VC, Fev1& Forced inspiratory
flow. all return to baseline by 24hrs.changes are secondary to
activation of irritative reflexes or mucosal edema.
 If suction at 1atm is applied, air is removed @ 14L/min this causes
dec in FiO2, PAO2, & FRC leading to dec PaO2,therefore suctioning
should be kept brief.
 If fibroscopy is planned ETT of largest possible diameter should be
used.
 Insertion leads to significant rise in PEEP, may cause barotrauma so
if PEEP is already being used, it should be discontinued.
 With Nd-YAG LASERS FiO2 should be kept minimum & titrated
against saturation, to reduce chances of catching endobronchial
fire.

62. COMPLICATIONS:
 Trauma to teeth
 Hemorrhage
 Bronchospasm
 Perforation
 Subglottic edema
 In most cases, it is best to intubate the trachea with an ETT
after bronchoscopy under general anaesthesia. This permits
avoidance or treatment of some of these problems, particularly
increased airway reactivity. It also facilitates suctioning and
allows the patient more gradual recovery.

63. SMOKING CESSATION TIMELINE – THE HEALTH
BENEFITS OVER TIME
 In 20 minutes, blood pressure and pulse rate decreases, and
the body temperature of hands and feet increases.
 Carbon monoxide in cigarette smoke reduces the blood’s
ability to carry oxygen. At 8 hours, the carbon monoxide level
in blood decreases, With the decrease in carbon
monoxide, blood oxygen level increases to normal.
 At 24 hours, risk of having a heart attack decreases.
 At 48 hours, nerve endings start to regrow and the ability to
smell and taste is enhanced.
 Between 2 weeks and 3 months, circulation
improves, walking becomes easier and coughing or wheezing
is not as often. Phlegm production decreases. Within several
months, there is significant improvement in lung function.

64.  In 1 to 9 months, coughs, sinus congestion, fatigue and
shortness of breath decreases as there is continuous significant
improvement in lung function. Cilia, tiny hair-like structures that
move mucus out of the lungs, regain normal function.
 In 1 year, risk of coronary heart disease and heart attack is
reduced to half that of a smoker.
 Between 5 and 15 years after quitting, risk of having a stroke
returns to that of a non-smoker.
 In 10 years, risk of lung cancer drops. Additionally, risk of cancer
of the mouth, throat, esophagus, bladder, kidney and pancreas
decrease. Even after a decade of not smoking however, risk of
lung cancer remains higher than in people who have never
smoked. Risk of ulcer also decreases.
 In 15 years, risk of coronary heart disease and heart attack in
similar to that of people who have never smoked. The risk of
death returns to nearly the level of a non-smoker.

65. POSTURAL
DRAINAGE
THERAPY
(POSITIONING)

66. HALF LYING
UPPER LOBE POSTERIOR SEGMENT
LEFT
RIGHT SIDE LYING,
45 DEGREE TURN
TOWARDS FACE SIDE,
THREE PILLOW

67. SUPINE LYING
FROM SUPINE 45 DEGREE
TURN TOWARDS RIGHT,
PILLOW FROM SHOULDER
TO HIP,
FOOT END RAISED 14”

68. FROM SUPINE 45DEGREE
TURN TOWARDS
LEFT, PILLOW FROM
SHOULDER TO HIP,
FOOT END RAISED 14”.
LOWER LOBE ANT.
BASAL SEGMENTS
SUPINE,
PILLOW UNDER HIP,
FOOT END 18” ELEVATED.

69. PRONE LYING,
PILLOW UNDER HIP,
FOOT END ELEVATED 18”.
CONTRALATERA
L SIDE LYING,
PILLOW BELOW
HIP,FOOT END
18” RAISED

70. PRONE LYING,
PILLOW UNDER HIP.

71. THANKS