Chapter 9 Adult Resp.

Question 1

The primary function of the resp. system is

Answer 1

Continous exchange of gases between the body cells and the ATM by the process of ventilation, gas exchange, and transport

Question 2

The Primary function of the Resp. system

Answer 2

Is the continuous exchange of gases between the body cells and the ATM by the processes of ventilation, gas exchange, and transport.
- CO2 is continually produce by the cells of the body and must be continuously removed and excreted into the atm
- body cells also need a continuous supply of O2 which must be absorbed from the atm
-both CO2 and O2 are transported to and from the lungs by the blood.

Question 3

Inhaled air must be

Answer 3

• warmed to body temp
  -humidified to the point of saturation
  -filtered before it reaches the alveoli

Question 4

Once air is in the lungs

Answer 4

the air in the alveoli and the blood in the pulmonary capillaries has to be equally matched on either side of the extremely thin A/C membrane (V/Q) matching.

Question 5

External respiration

Answer 5

describe the process of breathing which includes the processes of ventilation, gas exchange, and gas transport.
- refers to alveolar ventilation ( breathing )
-passage of inhaled and exhaled gas through the conditioning-conducting region airways.
-inhaled gas through resp. bronchioles into the alveolar sacs
-exhaled gas from the alveolar sacs into the trachea-bronchial tree and exhalation through the airway opening.

Question 6

Respiration ( aka internal respiration)

Answer 6

properly refers to the metabolic processes that mitochondria in the cells use to obtain energy by oxidizing glucose to produce ATP
- gas exchange (diffusion) of gases from the blood to the tissue cells.
- gas diffusion across the A/C membrane into the pulmonary capillary blood
-gas diffusion across the erythrocyte membrane into the red blood cells (RBCs) that are located in the pulmonary capillary blood.
-gas diffusion across the tissue capillary membrane into the tissue interstitial spaces around the body cells
-gas diffusion from the tissue interstitial fluid across the tissue cell membranes into the cytosol ( fluid inside the cells)

Question 7

Mechanical process

Answer 7

moving air into and out of the alveoli is usually called breathing or ventilation.

Question 8

The central anterior thoracic landmark

Answer 8

the sternum is made of three fused bones
-the manubrium, the body (gladiolus) and the xiphoid process.
> the xiphoid is the smallest of the three bones.
> - it provides an attachment point for attachment of some of the abdominal muscle
- during CPR the xiphoid process can be fractured and damage underlying organs.

Question 9

The thorax

Answer 9

• Bony cage that contain and protect the cardiopulmonary system structure.
• The costal cartilage are normally flexible and allow the thorax to increase and decrease its size during breathing
• The clavicles, sternum, ribs, scapulae, and vertebrae are bony anatomical landmarks of the anterior, lateral and posterior thorax.
• The suprasternal notch- depressed at the base of the neck.
  The angle of louis, aka the sternomanubrio angle, about 5cm below, the cartilage of the second ribs attach to the sternum at the sternal angle.
• The intercostal spaces are named for the rib above each space.
• The first intercostal pace is located below rib 1 and above rib 2
• The intercostal VEIN, ARTERY, and nerve run along the costal grove on the inferior margin of each rib.

Question 10

Thoracic landmarks to locate underlying structures

Answer 10

• The trachea bifurcates into the right and left mainstem bronchi (the tracheal carina) at the angle of Louis, anteriorly and at about the level of the 4 and 5 thoracic vertebra ( T4 or 5) posteriorly.
• At the end tidal expiration the right dome of the diaphragm is at about the level of the 5th rib anteriorly and T8 or T9 posteriorly (pushed up by the liver)
  -The left dome of the diaphragm is at about the 6th
  rib anteriorly and T9 or T10 posteriorly.
  -The superior lung boarders are about 2-4 cm (Text says 1-2 cm) above the medial third of the
  clavicles anteriorly and T1 posteriorly.
  -The inferior lung boarders (bases) are at about the 6th
  rib on the midclavicular line anteriorly,
  extending to the 8 th rib laterally, and between T9 and T12 posteriorly (depending on the level of
  ventilation).
  -The pulmonic valve of the heart is located at the 2nd
  left intercostal space near the sternal boarder.
• The diaphragm has its normal dome shape. - the liver pushes the right dome of the diaphragm up about 1-3 cm higher than the left dome.

Question 11

Thorax rib structure and articulation

Answer 11

• 12 pairs of ribs are elastic (flexible) arches of bones.
• The joints of the thorcic cage bones allow the thorax to change its anteroposterior and lateral dimensions during breathing

Question 12

Intervertebral joints and disks

Answer 12

give the spinal column a degree of flexibility without reducing its stability.

Question 13

Costovertebral joints

Answer 13

allow the heads of ribs 2-9 to articulate (joint, where two bones are attached to allow parts to move ) with the costal articular facets of the vertebra above and the one below.
- The costovertebral joints of rib 1, 10, 11 and 12 articulate with one facet on the adjacent vertebra ( rib 1 with the articular facet on t1, etc) and differ in other ways which is why they are called atypical ribs

Question 14

Costotransverse joint

Answer 14

allow the tubercle of the rib to articulate with the articular facet on the transverse process of the adjacent vertebra

Question 15

Costochondral joint

Answer 15

exits because the distal end of the ribs are connected to the sternum by flexible HYALINE cartilage
-The posterior rib attachments are higher than the anterior joints, so the ribs have a downward slant.
-All of these articulations gives the ribs two basic arcs of rotation called pump handle and the bucket handle movement.
1. The pump handle movement, muscle contraction rotates the rib head around the costovertebral joints. This rotation pulls up the distal ends of the ribs, especially rib 2 through 7, lifting the sternum and displacing it anteriorly. This rotation increase the anterposterior dimension of the thorax.
2. Bucket movement, the same muscle contraction rotates the long axis of the ribs and reduces their downward slant. This movement increases the lateral ( transverse) dimension of the thorax.

Question 16

Typical ribs

Answer 16

consists of head, a neck and body.
- head is wedge shape and has two articular facets separated by a wedge of bone, one facet articulate with the verterbra, the other facets articulates with the vertebra above.
- The neck contains no bony prominences, but simple connects the head with the body, where the neck meets the body there is a roughed tubercle, with a facet for articulation with the transverse process of the corresponding vertabrae
- The body or shaft of the ribs is flat and curved
- The internal surface of the shaft has a groove for the neurovascular supply of thorax, protecting the vessel and nerves from damage.

Question 17

Atypical ribs

Answer 17

Ribs 1,2,10,11 and 12 are atypical ribs because they have characteristics that are different than the other ribs.
- Rib 1 is the shortest, strongest, broadest, and most curved of all ribs.
- The rib only has one facet on its head for articulation with its corresponding vertebrae, this is because there is not a vertebra above rib 1.
The superior surface has two grooves, which make way for the subclavian vessels.
- Rib 2 is atypical for several reasons:
o It is thinner and longer than the rib above (rib 1).
o Rib 2 has a roughened area on its upper surface.
o The serratus anterior muscle attaches to rib 2 on this roughened surface.
- Rib 10 only has one facet for articulation with its numerically corresponding vertebrae.
- Ribs 11 and 12 have no neck, and have only one facet, for articulation with their corresponding
vertebrae

Question 18

The thorax is covered with integumentary tissue (skin and subcutaneous fat) over a layer of skeletal muscle

Answer 18

Fascia ( a type of connective tissue covers the muscle and anchors it to any adjacent tissues)
The complex articulations between the thoracic vertebrae, the ribs and costal cartilages and the sternum produce a series of skeletal arches and planes that both stabilize the thorax and limit thoracic movement during breathing.

Question 19

Xray

Answer 19

• The radiation is blocked by dense (radio opaque) material such a bone, muscle, tissue and liquid, producing a white or grey image.
• Air filled lung tissue is radiolucent, it does not block the radiation.
• In pleural effusion, it take about 175-200 ml of fluid to cause blunted costophrenic( place where the diaphragm meets the ribs) angles.

Question 20

Chest x-ray background

Answer 20

X-ray are electromagnetic waves produced when high electrical voltage bombard s a cooper anode inside a vacuum tube.
-Dense material ( bone and liquid) absorb x-ray energy and stop it from passing through to the film.
- Dense materials that block energy are called opaque or radiopaque
-Radiopaque materials allow less energy to reach the film and produce whitish images on the films
- The white area on x-ray are called opacifications
- white areas in the lung tissue are called infiltrates.
- Less dense materials that allow x-ray energy to pass through are called lucent or radiolucent.
- the dark areas on xray are called lucencies.

Question 21

When evaluating X-ray

Answer 21

Ideally chest films are taken with the patient standing, this way is called PA (posterior anterior or posteroantero) films.
To check for rotation- The medial ends of the clavicles and the spinous processes of the vertebra.
- spinous process should be midway between the medial ends of clavicles, trachea should be aligned with vertebral column.

Question 22

Over and under exposure of xray

Answer 22

overexposed films have very dark lung fields in which the peripheral blood vessel cant be seen.
Underexposed films the lungs are whiter than normal and the vertebrae cant be seen through the heart shadow.

Question 23

The Silhourette sign and Air Bronchogram sign

Answer 23

Help localize causes of opacities to the lung paraenchyma(issue which conducts the specific function of the organ) as opposed to the pleura and the thorax

Question 24

The Silhourette sign

Answer 24

exist because the dense heart produces a white shadow with sharply defined borders in sharp contrast to the dark shadows of normal lung tissue.
- if the lung tissue in front or on either side of the heart becomes dense ( due to consolidation or atelectasis) the sharp contrast is lost and heart margins become “ blurred”
- Since the heart is located in the anterior chest, any lung density that obscures the heart borders must also be located in front of the heart in the anterior chest.
- If opacities appear to overlap the heart borders but dont obscure them, the area of lung density must be located behind the heart in the posterior chest and the dense lung tissue is not touching the heart

Question 25

Air Bronchogram

Answer 25

relies on the fact that normal, air filled bronchi are very difficult to identify on an Xray. - if air filled bronchi pass through dense consolidated or inflamed alveoli, the bronchi will produce a contrast and appear as tubular luncencies ( dark lines) opaques( whiter) lung fields. - The air bronchogram sign indicates that the disease process is located in the alveolar spaces of the lung and not in the interstitium or the pleural space. - if the lesion fills the airways as well as the alveoli, the air bronchogram sign will not be seen.

Question 26

The pulmonary air meniscus sign

Answer 26

crescent shaped pocket of air (radiolucency) bordering (around) a mass lesion( an area of consolidated lung tissue)

Question 27

Blunting of Costophrenic angles

Answer 27

sign of pleural effusion ( Fluid can accumulate around the lungs due to poor pumping by the heart or by inflammation)

Question 28

Kerley Lines

Answer 28

are a pattern of whitish linear streaks throughout the lung. Kerley lines are seen in diffuse interstitial disease due to thickening or infiltration of the interlobular septa - Kerley A lines - are long linear streaks - Kerley B lines are short horizontal transverse streaks usually seen in the lung base, early cardiogenic pulmonary edema causes engorgement of the pulmonary lymphatics and a thickening of the interlobular septa, which is one entity that produces KERLY B lines. - Kerley C lines are a diffuse network of streaks caused by the overlapping of A and B lines.

Question 29

Disk, Discoid, or plate atelectasis ( collapse lung)

Answer 29

also called Fleischer's lines, is pattern of one or more transverse, linear opacities that look like the edge of a dinner plate, often seen with the atelectasis caused pulmonary embolus and painful chest conditions like rib fractures and pleurisy.

Question 30

Miliary densities

Answer 30

small ( 2-4 mm in diameter) nodules seen diffusely throughout the lung. Tuberculosis probably the most common disease associated with a milary pattern, but fungal infections, sarcoidosis, and other conditions can produce a pattern of miliary densities

Question 31

Solitary pulmonary nodule

Answer 31

single discrete pulmonary opacity that is surrounded by normal lung tissue and is not associated with adenopathy or atelectasis A nodule is defined as a lesion smaller than 3cm, any larger is called Mass

Question 32

Primary resp. muscles

Answer 32

The diaphragm is the major and most important muscle of ventilation along with external intercostals. -Normally, it accounts for about 75% of the change in thoracic volume during quiet, resting breathing -Normal diaphragmatic excursion is about 1.5 cm ( range 1-2cm), max. contraction is about 10cm. Each centimeter of diaphargmatic movement increase thoracic volume by about 350ml and moves 440ml of air. - In some disease cond. copd and status asthmaticus, the hyperinflated lungs push the diaphragm down into the flatter position, reducing the diaphragm's mechanical efficiency. -During inspiration- Intrapulmonary pressure drop 1mmhg below ambient - During expiration- the intrapulmonary pressure rise 1mmhg above ambient

Question 33

The Diaphragm

Answer 33

The Muscle fibers of the diaphragm are divided into two functionally separate groups, the costal fiber s and the crural fiber. The fibers are arranged in a radial configuration and converge ( come together) at a fibrous aponeurosis called central tendon. - The muscle fibers of the thoracic diaphragm are estimate to be about: -55% slow oxidative - 21% fast oxidative and - 24% fast glycolytic.

Question 34

The anterior costal fibers

Answer 34

-The anterior costal fibers originate from the inner borders of the lower ribs and the posterior aspect of the xiphoid process. The anterior portion is called the sternal diaphragm. -The lateral costal fibers originate from the medial surface of ribs 7 to 12 and are attached to the abdominal wall muscles on either side. The lateral portions are called the costal diaphragm -The posterior crural fibers originate from the first three lumbar vertebrae (L1 to L3) and form two bands of muscle called the left and right crura. The crura are not attached to the ribs. The posterior portions are called the lumbar diaphragm

Question 35

The central tendon divides the diaphragm into two leaflets called hemidiaphragms

Answer 35

The left and right hemidiaphragms each receive motor impulses from a separate branch of the phrenic nerve on the corresponding side. The nerves originate from cervical spinal nerves C3, C4, C5. o Normally both hemidiaphragms move in synchrony, but separate innervation allows one side to function even if nerve damage paralyzes the other side

Question 36

The superior (cranial) surface of the diaphragm

Answer 36

is covered with the same serous membrane, the (parietal) pleural layer, that lines the inside of the thorax and the outer aspect of the mediastinum. The inferior (caudal) surface is covered with the same serous membrane the (peritoneum), that lines the abdominal cavity..

Question 37

The large right lobe of the liver is located below the dome of the right hemidiaphragm

Answer 37

When the body is in the upright position at the end of a quiet expiration (the diaphragm relaxed) the liver pushes the right hemidiaphragm about 1 cm higher than the left hemidiaphragm. – The liver, the esophagus, and part of the colon are attached to the diaphragm by ligaments

Question 38

In the supine position

Answer 38

the abdominal contents push the diaphragm up and limit its downward excursion reducing thoracic expansion and limiting inspired tidal volume (VT). – This explains why patients with lung disease often find breathing easier in the upright position

Question 39

The diaphragm has three major openings (hiatuses

Answer 39

* The aortic hiatus. * The esophageal hiatus. * The vena caval hiatus An abnormal condition called hiatus hernia occurs when the upper part of the stomach protrudes into the thorax through a weakened area or a tear in the diaphragm

Question 40

There are 3 layers of intercostals

Answer 40

external, internal, and infracostal (or innermost).

Question 41

The external intercostals that connect ribs 1-11 are the outermost of the three layers of the intercostal muscles

Answer 41

They attach to the inferior margin of the rib above and are oriented obliquely downward and anteriorly to attach to the superior margin of the rib below The fibers extend from the tubercle posteriorly of the rib to the costochondral junctions anteriorly The fibers of the lowermost 7 or 8 external intercostals blend with the external oblique muscle of the abdomen When the first 4 or 5 external intercostals contract, they increase the thorax transverse diameter (bucket handle effect) and flex the sternum to increase the anterior-posterior (AP) diameter (pump handle effect).

Question 42

During quiet breathing, the internal intercostal’s main role appears to be to stabilize the chest wall and keep the lungs from bulging through the intercostal spaces The internal intercostals have a more complicated role since portions of the internals function as part of both the inspiratory and expiratory accessory muscle groups

Answer 42

As the illustration shows, the 11 pairs of internal intercostals lie deeper than the externals and their fibers are orientated at right angles to the fibers of the externals. The illustration doesn’t show that the two sets are separated by a layer of loose (areolar) connective tissue. – The internals arise from the superior margins of the ribs and costal cartilages and pass obliquely upward and anteriorly. – They insert on the inferior margins of the rib above. * The internal intercostal muscles are often referred to as if they were two separate muscle groups: The parasternals or interchondrals (near the sternum) and the interosseous between the ribs). – Both the parasternals and interosseous are between the ribs, but the parasternals also have an upper insertion into the sternum. * Contraction of different portions the internal intercostal muscle fibers perform different functions: – Contraction of the parasternal parts of the upper 4 or 5 internals tends to raise the ribs and assist the externals during inspiration. – Contraction of the interosseous parts of the lower 7 or 8 internals depresses the ribs and assist during expiration

Question 43

Scalene anterior, medial, posterior

Answer 43

action in breathing - elevate the 1st and 2nd rib

Question 44

Sternocleidomastoid

Answer 44

action in breathing- when the head is held fixed, elevates the sternum and 1t rib

Question 45

Trapezius

Answer 45

action in breathing- Fixes the head

Question 46

Pectoralis minor

Answer 46

action in breathing - elevated 3rd -5th ribs when scapulae are fixed

Question 47

pectoralis major

Answer 47

action in breathing- sternum

Question 48

expiratory accessory group

Question 49

External oblique, internal oblique, transverse abdominus, rectus abdominus

Answer 49

compress ribs and pull abdominal wall inward

Question 50

Serratus anterior

Answer 50

Compress ribs when arms are fixed and elevates the ribs when the scapula is fixed

Question 51

Serratus posterior superior

Answer 51

Elevates ribs during energetic breathing

Question 52

Serratus posterior inferior

Answer 52

Compresses ribs during forced exhalation

Question 53

Latissimus dorsi

Answer 53

Costal attachment assists in energetic inspiration and expiration

Question 54

when ventilatory demand and/or airway resistance increases to the point where the subject has to increase WOB to a level that reduces intraalveolar pressure to -10cmH2O

Answer 54

the subject has to recruit the scalenes and sternocleidomastoid muscles -The scalene and the sternomastoid muscles are always used when exercise requires the subject to increase minute volumes (V̇ E) to 50 to 100 L/minute

Question 55

Tripod position

Answer 55

allows the patient to fix the head and the pectoral (shoulder) girdle allowing the pectoralis muscles to generate some anterior thoracic lift

Question 56

Trapezius

Answer 56

muscle use usually produces visible clavicular lift where the clavicles rise > 5 cm with each inspiration

Question 57

Strap

Answer 57

muscle use produces a visible rise in the anterior upper chest.

Question 58

Retractions

Answer 58

when airway resistance is high the patient must produce a large trans-chest wall pressure gradient (PTCW). This causes atmospheric pressure to press the skin of the chest tightly against the ribs during spontaneous inspiration.

Question 59

Abdominal paradox

Answer 59

is often seen in patients with advanced COPD who have an atrophied, weakened diaphragm. – When the accessory muscles lower intrathoracic pressure the flaccid diaphragm is drawn upward into the thoracic cavity and the anterior abdominal wall is drawn inward.

Question 60

Respiratory alternans

Answer 60

occurs in patients who retain some use of the diaphragm. They use accessory muscles for several minutes then switch to the diaphragm for several minutes

Question 61

The pleura

Answer 61

is the folded over serous membrane that surrounds the “pleural space,” covers the lung, and lines the thoracic cavity.

Question 62

The parietal pleural layer lines the inner surface of the thoracic cavity, including the mediastinum, the diaphragm, and the ribs:

Answer 62

-Each pleural membrane consists of a single layer of mesothelial cells on top of a basement membrane (aka basal lamina) that contains blood vessels, lymphatic capillaries, nerves, and other structures -The blood supply to the parietal pleura comes from the intercostal arteries, which also supply the thoracic body wall -Only the parietal layer has nerve fibers that sense pain. -They open directly into the pleural space medially and connect to the parietal lymphatic capillaries

Question 63

The Visceral pleural layer

Answer 63

covers all the surfaces of the lungs, including the inter-lobar fissures There are no pain sensing nerve fibers in the visceral pleura. The visceral layer also has a dual blood supply; from both the bronchial and pulmonary vessels The blood supply to the visceral pleura comes from the bronchial arteries, which also supplies the lungs

Question 64

The visceral and Parietal layers

Answer 64

join at the hila where airways, blood vessels, and nerves enter the lungs

Question 65

The visceral and parietal pleural layers are flush against each other, normally separated only by the thin layer of pleural fluid

Answer 65

The parietal layer normally remains attached to the chest wall (the ribs tend to spring outward). – The visceral layer normally remains attached to the lung surface (the elastic lungs tend to contract inward).

Question 66

These attachments tend to pull the pleural layers apart slightly producing a subambient pressure in the pleural space according to Boyle’s Law

Answer 66

The surface tension of the fluid in the pleural cavity acts to hold the pleural layers together The layers can slide up and down and from side to side, but it is hard to separate them

Question 67

Hilus ( Hilum)

Answer 67

The bronchi, pulmonary vessels, pulmonary arteries and vein enter and leave each lung through the part of the medial pleural surface.

Question 68

The pulmonary ligament

Answer 68

is a fold of the pleura that connects the medial aspects of the lung root to the pericardium.

Question 69

The division of the lung into lobes, segments, and lobules tends to make each subdivision into a functionally independent unit

Answer 69

This helps to reduce the spread of infection in the lung.

Question 70

Pleural Fluid

Answer 70

-Healthy people have a small amount of pleural fluid in the pleural space between the pleural layers (aka the pleural cavity) -Some texts state that about 10 ml of pleural fluid (≈ 0.3 ml/kg of body mass) normally flows through the pleural space -The fluid is produced in the apical areas of the parietal pleura -It is drained by the stomata connected to parietal lymphatics located mostly in the mediastinal and diaphragmatic areas of the parietal layer. -The key fact is that there is a rapid turnover as fluid is produced near the top of the lung and drained by a number of mechanisms toward the bottom.

Question 71

Pleural fluid serves at least two major purposes

Answer 71

It acts as a lubricant between the visceral and parietal layers to aid in lung movement during breathing It also acts to cohesively bind the two pleural layers together so that chest wall forces can be transmitted to the lungs

Question 72

Section of Parietal Pleura

Answer 72

The cervical (cupular) pleura covers the opercula. The costal pleura is in contact with the ribs. * The diaphragmatic pleura is in contact with the diaphragm

Question 73

Pleural effusion

Answer 73

Pleural effusion an accumulation of fluid in the pleural space It is not a disease in itself, it will result from any process that either increases the production of fluid or reduces the body’s ability to remove it (in other words, disrupt the balance between production and removal Specific causes include: o Heart failure, cancer, pulmonary embolism, inflammation, infection There are two types of pleural effusion fluid, Transudative and Exudative: When pleural effusion fluid has a milky appearance and contains a large amount of fat, it is called a chylothorax When pleural effusion fluid contains pus, it is called an empyema (not emphysema) If air enters the pleural space the condition is called a pneumothorax. A large accumulation of air or liquid in the pleural space will compress the lung and reduce ventilation by restricting alveolar expansion. A major sign will be blunted costophrenic angles on chest X-ray (CXR).