Final Written Flashcards
Which respi ms?
With the head fixed, it elevates the sternum and increases the AP diameter.
SCM
Which respi ms?
Braces and stabilizes the scapula, enabling other muscles to elevate the ribs.
Traps
Which respi ms?
When the scapula is fixed, it acts to elevate the rib to which it is attached.
Serratus anterior
Which respi ms?
When its superior attachment is fixed, it elevates the first 2 ribs during inspiration.
Scalenes
Which respi ms?
When the arms are fixed, it draws the ribs towards the arms, thereby increasing thoracic diameter.
Pec major
T or F
In sidelying, the uppermost lung fields are preferentially ventilated compared to the lowermost lung fields.
F
T or F
The main accessory muscles of breathing tend to increase the transverse diameter more than the anterior posterior (A-P) diameter of the thorax.
F.
T or F
The primary muscles of inspiration are active only during quiet breathing.
F
T or F
The parasternals are primary muscles of inspiration.
T
T or F
The rectus abdominus contributes most to increasing intra-abdominal pressure during a forced expiration.
F
T or F
The upper airway muscles are more active during sleeping.
F
T or F
At the start of inspiration, the upper regions of the lungs are inflated more than the lower regions.
T
T or F
There is more blood in the dependent areas of the lung.
T
T or F
Activation of the abdominal muscles during expiration results in diaphragm shortening.
F
T or F
Diaphragm excursion is greater in sitting than in supine.
F
It’s the opposite.
Which of the following occur(s) during inspiration?
A. Intra-abdominal pressure decreases B. Pleural pressure decreases C. Intra-thoracic pressure increases D. Intra-alveolar pressure equals atmospheric pressure E. None of the options provided
B. Pleural pressure decreases
An individual can have a weak cough due to which of the following?
A. Poor closure of the vocal chords B. Damaged and ineffective beating cilia C. Weak inspiratory muscles D. Weak expiratory muscles E. None of the options provided
A. Poor closure of the vocal chords
C. Weak inspiratory muscles
D. Weak expiratory muscles
T or F
The bronchial arteries deliver deoxygenated blood from the right ventricles to the lungs.
F
Which of the following airways have cartilage in their walls?
A. Segmental bronchi B. Lobar bronchi C. Trachea D. Lobular bronchioles E. Terminal bronchioles
A. Segmental bronchi
B. Lobar bronchi
C. Trachea
T or F
An increased accumulation of fluid in the pleural space is call a pneumothorax.
F
T or F
Pulmonary arteries dilate in the presence of hypoxia.
F
T or F
Mild hypoxic vasoconstriction will lead to pulmonary hypertension.
F
T or F
Hypoxic vasoconstriction increases dead space.
F
T or F
Dead space is increased by shallow breathing.
T
The primary cause of a decline in DLco in a patient following removal of a lung lobe (Lobectomy) is:
A. Decreased pulmonary blood flow B. Decreased alveolar surface area C. Decreased diffusion across the alveolar-capillary membrane D. Decreased V/Q matching E. All or none of the above
B. Decreased alveolar surface area
T or F
Lung fissures may appear shifted in the presence of lung pathology.
T
T or F
In a properly exposed chest x-ray, the intervertebral spaces can be very clearly seen to be superimposed on the shadow of the heart.
F
T or F
“Lung markings” visible on chest x-rays are the larger airways that branch out from the mediastinum to the periphery.
F
T or F
The definitive location of lung pathology can be established solely from the PA view when the silhouette sign is present.
F
T or F
Lateral decubitus films can be helpful in identifying the presence of increased fluid in the pleural space
T
T or F
The PEFR has a high variability precluding its clinical usefulness.
F
T or F
A 20% improvement in PEFR is the gold standard for evaluating a significant response to bronchodilator.
F
T or F
The FEF25-75% is the average volume that is exhaled during the middle portion of the FVC.
F
T or F
The FEV1/FVC ratio must be greater than 70% of the predicted value to be considered normal.
F
A patient has the following blood gas values: pH=7.32, PaCO2=68, and HCO3-=28. Which of the following statements is the MOST accurate interpretation?
A. Uncompensated metabolic acidosis
B. Partially compensated metabolic acidosis
C. Partially compensated respiratory acidosis
D. Uncompensated respiratory acidosis
E. None of the above
C. Partially compensated respiratory acidosis
What does it mean when someone has a mixed acid-base disorder? How is it identified?
A disorder of metabolic and respiratory alkalosis and acidosis. It is identified when an apparent compensatory change is not in the same direction of as the primary disorder. It can also be a mixed acid-base disorder if the compensation is greater than what is expected based in the rule of thumb.
T or F
The silhouette sign on a CXR occurs when structures of different density are next to each other.
F
T or F
The location of the silhouette sign can assist in identifying the location of the lung pathology.
T
T or F
Deviation of the trachea is identified by the silhouette sign.
F
T or F
A lateral film may be necessary to confirm a pathology in the right lower lobe (RLL).
T
Abnormalities in which of the following electrolytes can result in an altered level of consciousness?
A. Na+
B. K+
C. Cl-
D. Ca2+
A. Na+
D. Ca2+
Which of the following is/are a sign of respiratory distress.
A. Jugular venous distention B. Nasal flaring C. Diaphoresis D. Hyperinflation E. None of the above
B. Nasal flaring
C. Diaphoresis
Which of the following pathological features relate(s) to COPD?
A. Destruction of the alveolar walls. B. Inflammation of the mucosal lining of the airways. C. Retained secretions. D. Hyperinflation of the alveoli. E. None of the answers provided.
A. Destruction of the alveolar walls.
B. Inflammation of the mucosal lining of the airways.
C. Retained secretions.
D. Hyperinflation of the alveoli.
Which of the following pathological changes contribute to the reduction in lung elastic recoil that occurs in a patient with COPD secondary to inhaled cigarette smoke?
A. Narrowing of the airways. B. Hypertrophy of the submucosal glands. C. Reduction in airway remodeling. D. Loss of alveolar attachments. E. None of the answers provided.
D. Loss of alveolar attachments.
A patient with COPD with a score of 8 on the Bode index is associated with which of the following?
A. High mortality rate B. Less severe COPD C. Stage II COPD D. FEV1=50% E. None of the above
A. High mortality rate
What abnormal physiological change develops in response to the presence of arterial hypoxemia in a patient with COPD?
A. Polycythemia B. Tachypnea C. Thrombocytopenia D. Anemia E. None of the above
A. Polycythemia
T or F
Individuals with asthma have a higher rate of FEV1 decline compared to healthy individuals.
T
T or F
Mucous hypersecretion in asthma increases the rate of FEV1 decline over time.
T
T or F
Exercise induced asthma is defined as a decline in FEV1 or PEF after exercise of at least 15%.
F
T or F
Symptoms of exercise induced asthma only appear following exercise.
F
T or F
Certain secretion clearance techniques should not be used with patients who have asthma because they may trigger bronchospasm.
T
Which of the following is/are NOT typically seen in patients who have asthma?
A. Mucopurulent secretions B. Finger clubbing C. Dyspnea D. Wheezing E. Cor pulmonale
A. Mucopurulent secretions
B. Finger clubbing
E. Cor pulmonale
An irreversible dilatation of one or more bronchi with chronic inflammation and infection is characterized by which of the following lung diseases?
A. Emphysema
B. Chronic bronchitis
C. Bronchiectasis
D. Asthma
C. Bronchiectasis
Wheezes are described by which of the following auscultated sounds?
A. Soft, low-pitched sounds heard primarily during inspiration.
B. Discontinuous adventitious lung sounds similar to brief bursts of popping bubbles.
C. An abnormal sound similar to two pieces of leather or sandpaper rubbing together.
D. Continuous adventitious lung sounds with a constant pitch and varying duration.
E. None of the above
D. Continuous adventitious lung sounds with a constant pitch and varying duration.
Which of the following conditions would increase transmission of lung sound?
A. Consolidation B. Shallow breaths taken C. Obesity D. Pulmonary hyperinflation E. None of the answers provided
A. Consolidation
What are the 3 roles of the nose?
Filters air
Humidifies air
Warms air
What is the role go course hairs in the nose (vibrissae)?
Trap inhaled particles
What is the role of the nasal chonchae?
Increase the surface area
What is the role of the mucous and the serous secretions in the nose?
Trap foreign particles and bacteria
What is the impact of smoking on the ciliated epithelium of the nose?
Smoking paralyses the cilia = decrease the filtering capacity of the nose = increase risk of developing infection
What are the 3 roles of the pharynx?
Swallowing
Coughing
Gag reflex
What is the role of the epiglottis?
Protects the airway from food
What are the 2 roles of the larynx?
Talking
Coughing
How are called the 2 cartilages found in the larynx?
Cricoid
Thyroid
What is the rima glottis?
Opening in the vocals chords of the larynx
What is the default position of the rima glottis?
Open
What is the position of the rima glottis during forced expiration?
Vocal chords are
Widened
Vocal chords are ABD or ADD during forced expiration?
ABD
Vocal chords are ABD or ADD during speech?
ADD
What is the position of the rima glottis during coughing?
Closed to increase intrathoracic pressure when the larynx is open
What are the anatomical landmarks for the trachea?
C6 -> T4
Where is the carina?
T4
Is the trachea in front or behind the esophagus?
In front
T or F
R mainstream bronchus is shorter and wider and deviates less from the axis of the trachea than the L
T
What is the clinical significance concerning the difference btw the R and L mainstem bronchus anatomical position?
R lung is more likely to have complication (infections) bcuz tubes are more likely to slip into it due to the deviation from the midline axis is smaller and bronchus is shorter/wider
How many lobes in the R lung?
3
How many lobes in the L lung?
2
Which generation are in the conducting airways?
1-16
What 4 structures are considered upper airway?
Nose
Pharynx
Epiglottis
Larynx
What 3 structures are considered lower airway?
Trachea
Airways
Alveoli
What is the purpose of the conducting airways?
Tranport gas to the respiratory bronchioles and alveoli
Which 3 “structures” are considered the conducting airways?
Lobar bronchi
Segmental bronchi
Terminal bronchioles
The terminal bronchioles extend from which generations?
12-16
The terminal bronchioles extend from which generations?
12-16
What is the lung parenchyma?
pulmonary alveoli and respiratory bronchioles
substance of the lung that is involved with gas exchange
What keeps the terminal bronchioles open?
The elastic properties of the parenchyma bcs these bronchioles are embedded in the parenchyma
Which structure is found in the transitional zone of the lung?
Respiratory bronchioles
The respiratory bronchioles extend from which generations?
17-19
T or F
Respiratory bronchioles have occasional alveoli budding from their walls.
T
T or F
In the respiratory bronchioles, the number of alveoli decreases with each generation.
F
it increases
How big is the anatomical dead space?
150 mL
What is essential to maintain the lumen of the respiratory bronchioles and why?
Traction of the parenchyma as the walls of the bronchioles are buried in the lung parenchyma.
Where does the gas exchange happen in the lung?
Respiratory zone
What are 2 structures found in the respiratory zone?
Alveolar duct
Alveolar sac
The alveolar ducts extend from which generations?
20-22
The alveolar sac extend from which generations?
23
Which structure represent the end of the lung?
Alveolar sacs
What are the walls of the alveolar ducts composed of?
Alveoli
Which 4 lung structures composed an acinus?
Respiratory bronchioles
Alveolar ducts
Alveolar sacs
Alveoli
Alveolus are made primarily of which type of cells?
Epithelial cells
What is the name of the structure that acts as a communication between the bronchioles and the alveoli?
Canals of Lambert
What is the name of the channels in the alveolar walls?
Pores of Kohn
What is the angle of Louis?
Joint btw manubrium and sternum
Where the 2nd rib inserts
In which thoracic cavity the lungs would be in an X-ray?
posterior mediastinum
T or F
The intrapleural fluid is between the parietal pleura and the visceral pleura.
T
The axis of rotation of the ribs is defined by what?
Articulation w/ TP
For the upper ribs, how is the articulation aligned? What is their role?
Articulation nearly parallel to the frontal plane = pump-handle motion
Increase the AP diameter
For the upper ribs, how is the articulation aligned? What is their role?
Articulation nearly parallel to the frontal plane = pump-handle motion
Increase the AP diameter
For the lower ribs, how is the articulation aligned? What is their role?
Articulation is oriented dorsally = bucket-handle
Cause lateral displacement of thoracic cage
What are the 3 primary inspiratory muscles?
Diaphragm
External intercostals
Parasternals
What are the 6 inspiratory accessory muscles?
Scalenes SCM Pec major/minor Serratus anterior Trapezius Erector spinae
What are the 2 expiratory muscles?
Abs
Internal intercostals
Why does diaphragm works less in sitting/standing compared then supine?
Gravity pulls on the muscles, making it harder for it to contract
T or F
The diaphragm contributes to 40% of the vital capacity.
F
60%
Guess who
I arise from the bodies of the first threes lumbar vertebra and extend to the central tendon.
Crural portion of the diaphragm
Guess who
I arise from the inner surfaces of the lower four ribs and lower six costal cartilages. I insert into the anterolateral part of the central tendon.
Costal portion of the diaphragm
Which nerve innervates the diaphragm? What are the spinal levels of this nerve?
Phrenic nerve
C3-C4-C5
Guess who
Area where the diaphragm is directly apposed to the rib cage. I represent 30% go the total surface ares of the rib cage.
Zone of apposition of the diaphragm
Explain the appositional component of the diaphragm function.
Rise in intra-abdo pressure during inspiration is transmitted through the apposed diaphragm to expand the lower rib cage
Appositional force greater when the zone of apportion and the rise in abdo pressure are larger
Explain the insertional component of the diaphragm action
During inspiration, as the costal diaphragm fibers contrat and shorten, they exert a force on the lower ribs. If the abdo viscera opposes and resists the descent of the diaphragm dome, the force will be oriented cranially and the ribs will be lifted and rotated outwards.
What is the thoraco-abdominal synchrony in breathing?
During inspiration, the abdomen and the thorax both move outwards (diaphragm contracts, chest expands) pleural and alveolar pressures drop and air flows into the lungs.
T or F
The external intercostals are more deep than the internal intercostals.
F, they more superficial
What is the innervation of the intercostal muscles?
Adjacent intercostal nerves
Guess who
I elevate the lower rib cage and descent the sternum. I am always active during inspiration when the diaphragm contracts.
Parasternal intercostal muscles
Guess who
I am the ease with which a lateral stretches when an external force is applied to me. I depend on volume and pressure.
Compliance
Guess who
I am the stiffness to a stretch.
Elastance
How does the lung act during inflation/deflation if it is filled with saline?
Distending pressure are the same during inflation and deflation
How does the lung act during inflation/deflation if it is filled with air?
Higher pressure on inflation and lower on deflation
What is hysteresis?
The fact that the inflation and deflation curves are not the same when the lungs are filled with air (normal breathing).
Results from the effects of surface tension forces caused by air-liquid interface in the alveoli
What is responsible for the lung’s elastic behavior? (2)
- Elastic tissues of the lung
- Elastin and collagen fibers in alveolar walls, vessels and bronchi
- Geometrical arrangement of the fibers (nylon stocking) - Surface tension forces in the lung caused but the alveolar-liquid interface
Surfactant is secreted by who?
Type II pneumocystises
Why does premature babies sometimes have respiratory problems?
Don’t have type II pneumocystes so lungs are stiffer and less compliant.
What are the 3 functions of surfactant?
- Reduces surface tension in the alveolar lining fluid = reduce tendency of alveolus to collapse
- Increases lung compliance
- Prevents transudation of fluid into alveoli = less negative pressure in the interstitial space -> lower hydrostatic pressure gradient btw pulmonary capillary and interstitial space
What can decrease lung compliance? (4)
- Intersitial edema = fluid in interstitial fluid outside alveoli (early HF)
- Pulmonary edema (HF = pressure going back up into lungs)
- Decrease ventilation of lung for an extended period (inflation of lung increases surfactant production)
- Diseases causing pulmonary fibrosis
What can increase lung compliance? (2)
Age
Emphysema
Guess who
P alveolar - P barometric
Transrepiratory (trans-total system) pressure
Guess who
P alveolar - P pleura
Transpulmonary pressure
Guess who
P pleura - P barometric
Transthoracic (trans-chest wall) pressure
On inspiration, what happens to :
- Alveolar pressure
- Intrapleura pressure
- Decreases then increases until reach 0
2. Decreases
On expiration, what happens to :
- Alveolar pressure
- Intrapleura pressure
- Increases then decreases until reach 0
2. Inceases
Airflow is driven by what?
Changes in alveolar pressure
If Palv < Patm, where the airflow goes?
Into the lungs
If Palv > Patm, where the airflow goes?
Out of the lungs
If Palv = Patm, where the airflow goes?
Nowhere, there is no flow
Guess who
Pressure difference btw alveolar and atmospheric pressure divided by airflow.
Resistance to airflow
What these factors will do on airway resistance?
- Reduced lung volumes
- Increased bronchial motor tone
- Reduced airway caliber
- Increase in density and viscosity of inspired air
Increase airway resistance
T or F
Total cross-sectional area decreases as descend the tracheo-bronchial tree, causing an increase in airflow
F, it increases and causes a drop in flow
The biggest airway resistance is where in the respiratory system?
Nose, mouth, upper airway
T or F
Airway obstruction in the smaller airways can often go undetected.
T
Explain dynamic airway collapse during forced expiration.
Dynamic pressure drop from alveolus to the airway is caused by airway resistance
Pressure in the lumen of the airway may be lower than the external wall pressure (-ve transmural pressure), leading to collapse of airway
In emphysema, how is the P alveolar different from healthy pt?
P alveolar is smaller bus lung is less elastic (more compliant, more floppy)
T or F
As pH decreases, ventilatory rate increases which in turn lowers the CO2, eventually returning the body to a homeostatic balance.
T
T or F
Both CO2 and O2 diffuse through the blood-brain barrier which separates the CSF and arterial blood.
F, only CO2 crosses
T or F
More CO2 = more H+ = decreased pH
T
Which receptors are responsible to respond to H+ dissolved in the CSF?
Where are they located?
Central chemoreceptors
Below the ventrolateral surface of medulla
Which receptors are responsible to sense PO2, PCO2 and pH of arterial blood?
Where are they located?
Peripheral chemoreceptors
Aortic bodies located on the aortic arch +
Carotid bodies located at the bifurcation of internal and external carotid arteries in neck
What is the threshold for a clinically significant response from the peripheral receptors?
60 mmHg = very hypoxemic
Ventilatory response to CO2 is modified by? (4)
- State of wakefulness
- Acid-base status of body
- Narcotics, anesthesia, alcohol
- Arterial oxygenation
What is the difference of the pleural pressure in the base of the lung vs in the apex?
Why?
Pleural pressure is less in negative (so bigger) in the base
Bcs of the weight of the lung
What is the difference of the compliance in the base of the lung vs in the apex?
What’s the impact?
Better compliance at the base of the lung
Basal lung expands better on inspiration
What is the dependent areas of lung?
The lowest part of the lung in relation to gravity.
T or F
Distribution of ventilation (airflow) is lower in dependent area of the lung
F, it is greater in lower part of lung because compliance is better.
T or F
Gravity dependent regions of the lung get more blood aka better perfusion.
T
Where in the lung is the best V/Q matching?
Base of the lung
Bcs better ventilation and better perfusion
Which rib level is the optimum gas exchange?
Rib 3
Guess who
Perfusion but no ventilation. V/Q = 0
Shunt (aka blockage in airways)
Guess who
Ventilation but no perfusion. No gas exchange. V/Q = infinity
Dead space
Guess who
I am the most cost effective test in medicine.
Chest x-ray
On radiography, more dense structures appear which color?
Why?
White
Block the radiation so won’t expose it on the image
On radiography, less dense tissues appear which color?
Black
What are the 3 common views on chest radiography? Describe each.
AP = plate is behind, radiations passing from front
PA = plate is in front, radiations passing from behind
Lateral projections = plate on one side and radiations passing from the other
AP view for chest radiography is usually used when?
When a portable x-ray is required for pt on bed rest
T or F
Heart can appear enlarged and its outline softer with AP because the heart is closer from the x-ray plate.
F
Heart is further from the plate
When supine, how the diaphragm move? How does this impact the lung volume?
Diaphragm pushed up which decreases lung volume
How do you orient the film properly on the screen to read a chest x-ray?
Pt has to be facing you = their L is on your R
T or F
On a normal film, the intervertebral spaces should be superimposed (darker areas) on the shadow of the trachea.
T
What over-exposed film means?
How can you know a film is over-exposed?
Increased blackness
If intervertebral spaces are clearly apparent superimposed on the shadow go the heart = film is too black
What under-exposed film means?
Increased whiteness
If intervertebral spaces are not apparent superimposed on the shadow of the trachea and heart = film is too white
If on a film the trachea is off center and the clavicles are not at a uniform distance from the midline, what could that mean?
pt is rotated
What is the landmark to evaluate the lung volumes in a chest x-ray?
If lung volumes are normal, the anterior end of the 5-7 ribs should be visible above the diaphragm int he mid-clavicular line.
What are the 2 landmarks to evaluate the mediastinal structures in a chest x-ray?
- Trachial shadow should be in mid-line (black tube over Cx spine)
- Carina overlies the 4th Tx vertebrae
What are the 4 landmarks to evaluate the heart and great vessels in chest x-ray?
- Heart shadow slightly to the L and in contact w/ diaphragm
- Aortic knob L of midline
- Cardiothoracic ratio should not me greater than 50%
- Cariophrenic angle should be apparent
A cardiothoracic ratio greater than 50% is a sign of what?
Enlarged heart that can be caused by hypertension or other conditions (usually to R heart)
T or F
R hemidiaphragm should be higher than L hemidiaphragm.
T
Because liver is on the R side
T or F
Bubbles under L hemidiaphragm is abnormal.
F
It is normal because of stomach or splenic flexure
T or F
Costophrenic angle can disappear on film when there is a condition
T
Pleural effusions can make this angle disappear due to accumulation of fluid in the pleural space
What we look for in normal chest x-ray when evaluating the lung fields and boundaries? (3)
- Lung boundaries in contact w/ chest wall and diaphragm
- Pleura not visible
- Vascular markings are visible
If there is a pneumothorax, what will appear on the chest x-ray?
No vascular markings = everything is black in lung area
Guess who
I am the profile of soft tissues superimposed on the lung fields on a chest x-ray.
Silhouette sign
T or F
Absent silhouette sign is indicative of airspace disease or fluid-occupying lesions.
T
T or F
Atelectactic or pneumonic lungs appear denser then soft tissues on a chest x-ray.
F
They all have the same density
T or F
Consolidation or collapse density similar to that of heart or muscle
T
T or F
Image of the collapsed lung will become confluent with the heart or diaphgram and respective borders will be obliterated.
T
T or F
Diaphragm in black in a lateral chest x-ray
F
It is white and superimposed
What are the 2 most common tests for lung function?
Spirometric
Lung volume measures
What exactly is assess in spirometry?
Which exact parameter?
Mechanical state of the lung
FEV1 and FVC
Guess who
I am the volume exhaled in the 1st second of a forced expiration.
FEV1 aka proved expiratory volume
Guess who
I am the total volume exhaled in an forced expiration.
FVC aka forced vital capacity
T or F
FVC is slightly more than the slow vital capacity.
F
FVC is slightly less than slow vital capacity
T or F
FEV1 is about 80% of slow FVC
T
What is the normal ratio of FEV1/FVC?
80%
What FEV1/FVC ratio is considered an obstructive disease?
What will the FVC look like for obstruction?
ratio < 70%
FVC = normal or low
What can cause a reduction of FEV1? (4)
- Reduction of TLC
- Obstruction of airways
- Loss of lung recoil
- Significant weakness of respiratory ms
If there is a lung restriction, what will FEV1/FVC and FVC will look like?
What about lung volumes?
ratio = normal
FVC = low
smaller lung volumes = lungs can’t expand as much
Body plethysmography, helium dilution and nitrogen washout are methods to measure which pulmonary capacity?
FRC = functional residual capacity
How does TLC and RV can be calculated?
Once FRC is measured with fancy equipment and VC is obtained w/ spirometry, use subtraction
Guess who
I measure the ability of a gas to transfer from alveolar gas into the pulmonary capillary blood.
Diffusion capacity (DLco)
What are the 4 major factors determining DLco?
- Gas exchange surface area (lung-blood interface)
- Thickness of alveolar wall
- Difference btw partial pressure of the gas in the alveolus and in the red blood cell
- Blood flow to the alveoli that receive ventilation
How is the DLco measured?
Pt blow into machine that calculate the concentration of CO picked up by the blood
What is the cut off for normal DLco?
+/- 20% predicted (80-120% predicted)
T or F
Exercise can increase DLco.
T. Can increase it by 2x
All these factors can be a sign of ___ diffusion capacity?
- Anemia
- Increased interstitial fluid (CHF, renal failure)
- Mismatching of alveoli and capillaries (COPD, pulmonary vascular disease)
- Thickening of alveolar capillary membrane (fribrosing alveolitis)
- Reduced area of alveolar capillary membrane (emphysema)
Reduced
What is the %change after bronchidilatator to conclude that is it is effective and thus suggesting asthma?
12-15%
Normal value for pH (range)
7.40 (7.35-7.45)
Normal value for PaO2 (range)
90 mmHg (80-100)
Normal value for PaCO2 (range)
40 mmHg (35-45)
Normal value for HCO3 (range)
24 mEq/L (22-26)
Normal value for BE
+/- 2
Guess who
Increase in blood H+ by retention of CO2 due to decrease alveolar ventilation.
Respiratory acidosis
Guess who
Decrease in blood H+ from blowing off CO2 due to increase alveolar ventilation.
Respiratory alkalosis
Guess who
Increase in blood pH from ingestion, infusion, production of a fixed acid or elimination of HCO3.
Metabolic acidosis
Guess who
Decrease in blood pH by excessive loss of fixed acids or ingestion, infusion of HCO3 or alkalides.
Metabolic alkalosis
What is the difference btw the compensations for the respiratory system vs the renal system?
Respiratory = rapid compensation (w/i min) Renal = slow compensation (hours-days)
What is the difference btw a partial compensation and a full compensation?
Partial compensation = change in PaCO2 or HCO3 but pH is still abnormal
Full compensation = change in PaCO2 or HCO3 but pH is normalized
How the respiratory acidosis is compensated?
Increase in HCO3, increase BE
How the respiratory alkalosis is compensated?
Decrease in HCO3, decrease BE
How the metabolic acidosis is compensated?
Decrease in PaCO2
How the metabolic alkalosis is compensated?
Increase in PaCO2
These expected compensation is related to which primary disorder:
- For a 10 mmHg increase in PaCO2, the HCO3 increases 1 mEq/L
- For every 10 mmHg decrease in PaCO2, HCO3 decreases 2 mEg/L
- If HCO3 > 30 mEq/L
- PaCO2 = (1.5x HCO3) + 8 +/-2
- PaCO2 change is variable but doesn’t elevate above 50-55 mmHg
- Acute respiratory acidosis
- Acute respiratory alkalosis
- Chronic respiratory acidosis
- Metabolic acidosis
- Metabolic alkalosis
What are the 5 more common causes of hypoxia?
Alveolar hypoventilation Diffusion impairment V/Q mismatch Shunt High altitude
What is the rule of thumb relating to hypoxemia and hypoventilation?
If hypoventilation is the major cause of hypoxemia, the PaO2 should only be decreased 1 mmHg for every 1 mmHg increase in PaCO2.
If the decrease is greater, there is likely another cause for the hypoxemia.
Respiratory failure is defined as : (2 components)
PaO2 < 55 mmHg
+/- PaCO2 > 45 mmHg
Critical value for hemoglobin
< 50-70 g/L
> 200 g/L
Guess who
Increase in hemoglobin/hematocrit
Polycythemia
Guess who
Decrease in hemoglobin/hematocrit
Anemia
When do we use a symptom-based approach for anemia
hemoglobin < 80 g/L
hematocrit < 25%
Guess who
Increase WBC
leukocytosis
Guess who
Decrease WBC
leukopenia
PT is contraindicates if WBC count is ____?
Why?
> 150,000 x 10^6/L
Risk of low flow state in vessels
Guess who
Increase in neutrophils
neutrophilia
Guess who
Decrease in neutrophils
neutropenia
Guess who
Increase in lymphocytes
lymphocytosis
Guess who
Decrease in lymphocytes
lymphocytopenia
Fall risk awareness when for platelets?
< 20,000 x 10^6/L
Guess who
Increase in platelets
thrombocytocis
Guess who
Decrease in platelets
thrombocytopenia
When platelets count are < 5000 uL what is the PT activities?
strict bed rest
When platelets count are < 10,000 uL what is the PT activities?
minimal and cautious activity with close monitoring and assistance to prevent falls for ADLs
When platelets count are 10,000-20,000 uL what is the PT activities?
active ROM (no weights), walking in room, light ADLs w/ supv
What platelet level is required to start some low resistance training in PT?
20,000-40,000 uL
When platelets count are 150,000-450,000 uL what is the PT activities?
Normal activity
What platelet level is required to start chest physio (percussions/vibrations)?
> 70,000 uL
What platelet level is required to start massage and stretching?
> 10,000 uL
What is the risk with a high aPTT?
What is the contra-indication for PT?
Higher risk of bleeding
No agressive chest PT
What is hyperkalemia?
High potassium
What is hypernatremia?
High sodium
For COPD postbronchodilator what is the normal range observed of FEV1/FVC?
Why?
< 70%
COPD is not fully reversible
What are the 3 main obstructive lung disease?
COPD
Asthma
Bronchiectasis
COPD is caused primarily by what?
Cigarette smoking
What is the 2 main differences btw COPD and asthma?
Asthma is reversible. COPD is not.
Postbronchodilator: COPD FEV1/FVC < 70%
What are the 2 conditions that COPD include?
Emphysema
Chronic bronchitis
What are the 4 symptoms to consider a diagnosis of COPD?
Cough
Sputum production
Dyspnea
History of exposure to risk factors for the disease (> 65 y.o, smoker or ex-smoker)
To classify COPD in severity what spirometric values to we use?
Post-bronchodilator FEV1 and FEV1/FVC ratio
Guess who
FEV1/FVC < 0.7
FEV1 ≥ 80% predicted
Chronic cough and sputum production may be present (not always)
Individuals usually unaware that lung function is abnormal
Mild COPD
Guess who
FEV1/FVC < 0.7 30% ≤ FEV1 < 50% predicted Great SOB Decreases exs capacity Fatigue Repeated exacerbations Decreased QoL
Severe COPD
Guess who
FEV1/FVC < 0.7 FEV1 < 30% predicted or FEV1 < 50% predicted Increase jugular venous pressure Pitting ankle edema Decreased QoL +++
Very severe COPD
Often accompanied with chronic respiratory failure
Guess who
FEV1/FVC < 0.7 50% ≤ FEV1 < 80% predicted SOB on exertion Cough and sputum sometimes present Patients typically seek medical attention bcs chronic respiratory symptoms or exarcerbation
Moderate COPD
When does symptoms arise in COPD?
When FEV1 declines significantly
What are the 5 main spirometry observations in COPD?
Dog-leg = limited max expiratory flow Smaller volumes Smaller maximum flows High flows at rest Hyperinflation during exs but limited by dog leg
What is cor pulmonale?
What are the symptoms? (2)
R heat failure
Increased jugular venous pressure
Pitting ankle edema
What are the extra-pulmonary (systemic) effects of COPD? (6)
Weight loss = cachexia
Skeletal muscle dysfunction:
- decrease ms mass
- increase ms weakness
- decrease type I fibers = slow oxidative
- increase type II fibers = fast oxidative
- decrease oxidative enzyme activity
What are the factors contributing to extra-pulmonary effects in COPD? (5)
Negative nutritional balance Oral corticosteroids = increase ms weakness Physical inactivity Hypoemia = oxidative stress Systemic inflammation
T or F
COPD increase risk of MI, angina, osteoporosis, bone fricatives, respiratory infection, lung Ca, depression, diabetes, sleep-disorders, anemia, glaucoma.
T
Guess who
Permanent enlargement of airspaces distal to the terminal bronchioles. Destructive changes of the alveolar walls and without obvious fibrosis.
Emphysema
Emphysema result in : (5 anatomic/pneumo modifications)
Airway collapse during expiration Air trapping distally Increase FRC Decrease lung elastic recoil Uneven distribution of ventilation
The type of emphysema is based on what?
Portion of acinus most affected by the desease.
Describe centrilobular emphysema.
Respiratory bronchioles, ULs and superior segments of LLs are affected
Describe panlobular emphysema.
Acinus and LLs are affected.
Describe paraseptal emphysema.
Alveolar ducts and sacs and LLs are affected.
What is bullous emphysema?
Walls of alveoli are destroyed and formed spaces > 1cm (may go to 10cm) called bullae
What is found on auscultation for emphysema? (3)
Decreased breath sounds
Prolonged expiratory phase
No adventitious breath sound
Patient characteristics of which patho?
Thin
No cough or a mildly production cough
Very dyspneic
Use accessory ms of breathing
Paradoxical indrawing of the lower margins of the rib cage (Hoover’s sign)
Hyperinflated (Barrel-shaped chest, flattened diaphragm on CXR)
Emphysema
What is Barrel-shaped chest?
Increased A-P chest diameter
Pulmonary function of which patho?
Decrease FEV1
Increase RV, TLC, FRC, RV/TLC
Decrease DLco
Emphysema
Why is FEV1 decrease in emphysema?
Related to dynamic airway compression
Why is TLC increase in emphysema?
Due to decreased elastic recoil
What are the x-ray findings of emphysema? (3)
Lungs are large and hyperinflated
Low set diaphragm and vertical heart
Presence of blebs and paucity of vascular markings in the outer third of the film
T or F
V/Q inequalities play a bigger role in emphysema as destruction of the alveolar walls may impair both regional ventilation and perfusion.
F
V/Q inequalities play a lesser role
Guess who
Chronic or recurrent productive cough on most days for a min of 3 months/year for 2 consecutive years.
Chronic bronchitis
Characteristics for which patho?
Increase size go tracheonbronchial mucous glands
Goblet cell hyperplasia
Decrease number of cilia
Chronic bronchitis
Chronos bronchitis is characterized by airflow obstruction primarily due to a narrowing of \_\_\_\_(1)\_\_\_\_ by : (2) (3) (4) (5)
- airway lumen
- mucous hypersecretion
- loss of ciliated epithelial cells
- chronic inflammatory changes
- edema
Chronic bronchitis result in : (3)
Increase WOB due to increased airflow resistance
Uneven distribution of ventilation
Decrease arterial oxygenation
Patient characteristics of which patho?
Often stocky Cyanotic Nail clubbing Chronically productive cough Frequent bouts of upper respiratory tract infections Less dyspnea than in emphysema Crackles and wheezes on auscultation Signs of R heart failure Cardiomegaly on CXR
Chronic bronchitis
ABGs for which patho?
Decrease PaO2 (hypoxemia) Increase PaCO2 (hypercapnia)
Chronic bronchitis
PFTs for which pathos?
Decrease FEV1
TLC and VC usually normal
RV may be slightly increase
Normal DLco
Chronic bronchitis
For chronic bronchitis, what does the CXR look like?
Dirty lung = irregular contours for bronchovascular structures
Might see cardiomegaly for severe cases
What does decreased PaO2 do locally?
Hypoxic vasoconstriction: to prevent blood from joint to the areas that are under ventilated = heart has to pump more = cardiomegaly
What’s pulmonary hypertension?
What might cause it?
Increase pulmonary artery pressure
Hypoxic vasoconstriction
What are the main 5 PT intervention passion with COPD?
Education
Pulmonary rehab
Interventions for reducing dyspnea = breathing exs, positioning
Enhancing airway mucus clearance
Optiminzing alveolar ventilation and V/Q matching
What are the main 5 PT intervention passion with COPD?
Education
Pulmonary rehab = exs training
Interventions for reducing dyspnea = breathing exs, positioning
Enhancing airway mucus clearance = postural drainage, breathing exs, manual techniques
Optiminzing alveolar ventilation and V/Q matching = breathing exs, position
Guess who
Acute event characterized by a worsening in the pt’s baseline dyspnea, cough and/or sputum and beyond normal day-today variations, that may warrant a change in regular meds.
Acute exacerbation of COPD
How do you manage COPD exacerbation? (5)
Controlled oxygen therapy and serial ABGs
Bonchodilators
Oral/intravenous corticosteroids
Antibiotics when signs of bacterial infection
Non-invasive mechanical ventilation
Guess who
Chronic inflammation disorder of the lungs characterized by airway hyperresponsiveness resulting in variable airway obstruction and recurrent symptoms of wheezing, dyspnea, chest tightness and coughing.
Asthma
What is the cutoff to confirm asthma post bronchodilator?
What response to other meds could confirm asthma?
> 12% (12-15) increase in FEV1
Sustained improvement in symptoms and lung function with corticosteroids
What are the 3 host factors for asthma?
Genetic
Obesity
Being a male (adult) or being a woman (adults)
T or F
Viral infections can trigger asthma.
T
What are the 3 main histological findings in asthma?
Hypertrophy and spasm of smooth ms
Increase in mucous glands
Inflammation of the airways with edema
To clinically diagnose asthma which test is done in relation to variability?
PEF measured with a peak flow meter. Symptoms and lung function are usually variable within the day.
Variability needs to be >20% to confirm asthma.
What are the methacholine or histamine challenge tests?
How are the test results expressed?
Measurement of airway responsiveness to diagnose asthma.
Test results expressed as the provocative concentration of the agonist causing a 20% in the FEV1.
Who are more at risk of developed exercise induced asthma?
Asthmatic elite athletes who are exposed to cold air
When does exercise induced asthma usually develop?
When does it resolve?
5-10 min after completing exs
Within 30-45 min
What is the Rx for exercise induced asthma?
Administration of inhaled SABA 15 min before exs
How to diagnose exercise induced asthma?
> 10% drop in FEV1 after exs
S&S of which patho?
Dyspnea Chest tightness Cough: may have stringy, clear secretion, may be troublesome at night Increase WOB CXR may have hyperinflation Prolonges expiratory phase Wheezing Crackles Orthopnea Agitation
Acute asthma
What’s status asthmaticus?
Continuation of acute increase of asthma for hours or days
LIFETHRETENING
What are the main PT interventions for asthma? (3)
Education to improve self-management, weight control, annual flu shot
Breathing techniques
Exs training
Guess who
Irreversible dilation of medium -sized bronchi and bronchioles from the destruction of the muscular and elastic properties of the lung.
Bronchiectasis
How is the sputum in bronchiectasis?
Purulent
Bronchiectasis usually happens following ___?
Necrotizing infection
T or F
Bronchiectasis usually invades the whole lung.
F
Localized to a few segments or a lobe
In which segment is bronchiectasis more common?
Basal segment of LL
How often is bronchiectasis bilateral?
40-50%
Pathophysio for which patho?
Intense inflammation.
Edema and ulceration of airway mucosa.
Epithelium replaced with hyper plastic non-ciliated mucus-secreting cells.
Destruction of the elastic and muscular airway structures.
Dilation and fibrosis.
Pooling of secretions = chronic infection = further damage and irritation.
Bronchiectasis
Guess who
Chronic productive cough Purulent sputum Unpleasant tasting of foul-smelling sputum Recurrent infections Hemoptysis Nail clubbing (25%) Increased incidence of cor pulmonale Weight loss, fatigue and decreased exs tolerance
Bronchiectasis
Describe what you might hear on auscultation when there is a bronchiectasis.
Crackles, ronchi and pleural rubs
How are PFTs for bronchiectasis? (2)
May show little or no abnormalities (small areas)
OR
Decrease FEV1, DLco, MVV, RV (bigger areas)
What do you see on a bronchiectasis CXR?
Non-specific/hyperinflatted
Focal areas of atelectasis = distal collapse of airways
How is PT management for bronchiectasis?
Airway clearance techniques (postural drainage, active cycle breathing, autogenic drainage, manual techniques) Exs training (STR + endurance) Active lifestyle encouragement
Which of the following techniques directly promote(s) alveolar re-expansion?
A. Pursed-lips breathing B. Coughing C. End-inspiratory hold D. Paced beathing E. None of the above
C. End-inspiratory hold
Which of the following statements is/are TRUE?
A. Residual volume is always decreased in restrictive lung disorders.
B. Rapid shallow breathing is seen in both restrictive lung and chest wall disorders.
C. Pulmonary fibrosis can cause V/Q mismatch.
D. Chest wall flexibility may be increased with physiotherapy in restrictive chest wall disorders.
E. None of the options provided.
B. Rapid shallow breathing is seen in both restrictive lung and chest wall disorders.
C. Pulmonary fibrosis can cause V/Q mismatch.
D. Chest wall flexibility may be increased with physiotherapy in restrictive chest wall disorders.
A patient with restrictive lung disease develops a rise in pulmonary circulation pressure subsequently increasing the work of the right ventricle. This is BEST described as:
A. Tachypnea B. Hypoxia C. Pulmonary hypertension D. Low lung volume E. None of the above
C. Pulmonary hypertension
Which of the following are signs and symptoms of restrictive lung disease?
A. Tachypnea B. Dyspnea C. Chronic productive cough D. Cyanosis E. None of the above
A. Tachypnea
B. Dyspnea
D. Cyanosis
A patient with pulmonary hypertension, who experiences dyspnea walking short distances, is participating in a pulmonary rehabilitation program. Which of the following exercises is/are contraindicated in this individual?
A. ROM exercises of the upper extremities
B. Isometric exercises
C. Stretching exercises
D. Moderate intensity aerobic exercise
B. Isometric exercises
Which of the following occur(s) with aging?
A. Increased ventilatory response to hypercapnia B. Decreased chest wall compliance C. Decreased lung compliance D. Increased cough reflex E. None of the above
B. Decreased chest wall compliance
Obesity is a risk factor for which of the following?
A. Pulmonary embolism B. Post-operative respiratory complications C. Sleep apnea D. Hyperventilation syndrome E. None of the above
A. Pulmonary embolism
B. Post-operative respiratory complications
C. Sleep apnea
Which condition(s) can result in adherence of the pleura?
A. Empyema B. Lung contusion C. Pleural transudate effusion D. Pleural exudate effusion E. None of the above
A. Empyema
D. Pleural exudate effusion
Which condition(s) can cause hemoptysis?
A. Lung contusion B. Pneumothorax C. Pneumonia D. Atelectasis E. None of the above
A. Lung contusion
C. Pneumonia
Which of the following statements is/are TRUE?
A. In right sidelying, the left hemidiaphragm dome rises further into the chest compared to the right dome.
B. FRC is larger in supine than in sitting.
C. Tidal breaths are effective in ventilating dependent atelectatic lung areas in postoperative patients.
D. Patients with unilateral disease should be positioned sidelying with the affected lung lowermost.
E. None of the options provided are true.
E. None of the options provided are true.
Premature airway closure:
A. Occurs more readily in smokers. B. Occurs at higher lung volumes in younger compared to older individuals. C. Occurs in the dependent lung regions. D. Is unaffected by body position. E. None of the answers provided.
A. Occurs more readily in smokers.
C. Occurs in the dependent lung regions.
T or F
A huff initiated from mid to low lung volume moves secretions in the upper airways.
F
Moves secretions in lower airways
Which of the following is/are characteristics of an effective huff technique?
A. Glottis open
B. No abdominal muscle recruitment
C. It only clears secretions from the upper airways
D. It can be performed independently by the patient.
E. None of the above
A. Glottis open
D. It can be performed independently by the patient.
Which of the following statements is/are TRUE regarding ACBT?
A. It cannot be used in combination with percussion and vibrations.
B. It is more effective when performed in sitting.
C. It only clears secretions from the upper airways
D. It can be performed independently by the patient.
E. None of the above.
D. It can be performed independently by the patient.
Which of the following cannot be combine with postural drainage?
A. ACBT B. Acapella C. Flutter D. Chest wall vibrations E. None of the above
C. Flutter
Which of the following statements is/are TRUE?
A. Individuals with COPD do not tolerate high-intensity interval training.
B. The intensity of exercise training in COPD is titrated using heart rate.
C. Because of the extra-pulmonary effects of COPD on the peripheral muscles, individuals with COPD do not tolerate measurement of the 1-repetition maximum.
D. Upper extremity training is effective in improving arm exercise capacity in individuals with COPD.
E. None of the above
D. Upper extremity training is effective in improving arm exercise capacity in individuals with COPD.
Which of the following statements is/are TRUE?
A. The incremental shuttle walk test (ISWT) is a self-paced exercise test.
B. The time walked can be used as an outcome measure for both the 6MWT and the ISWT.
C. The peak VO2 can be estimated from both the 6MWT and the ISWT.
D. The 6MWT can provided information about the specific cause of exercise limitation.
E. None of the options provided.
C. The peak VO2 can be estimated from both the 6MWT and the ISWT.
Pursed-lips breathing:
A. Increases end-expiratory lung volume B. Increases tidal volume C. Decreases respiratory rate D. Decreases dyspnea E. None of the above
B. Increases tidal volume
C. Decreases respiratory rate
D. Decreases dyspnea
The Trendelenberg position should be avoided in patients with:
A. Reduced level of consciousness B. A recent severe head trauma (elevated ICP) C. GERD D. Hypotension E. None of the above
A. Reduced level of consciousness
B. A recent severe head trauma (elevated ICP)
C. GERD
What are the key elements of a pulmonary rehabilitation program?
A. Education B. Supplemental oxygen C. Airway clearance techniques D. Aerobic exercise E. None of the above
A. Education
C. Airway clearance techniques
D. Aerobic exercise
On a stethoscope, what kind of sound the bell catches?
Give an example.
How should it be used?
Low-frequency
Heart sounds
Should press lightly with it
On a stethoscope, what kind of sound the diaphragm catches?
Give an example.
How should it be used?
High-frequency
Breath sounds
Press firmly with it
What does auscultation assess? (3)
Intensity (loudness)
Pitch
Quality of breath sounds
What are the 4 normal breath sounds?
Where are they usually heard?
- Tracheal = over trachea
- Vesicular = over lungs
- Bronchial = above manubrium
- Bronchonvesicular = angle of Louis = mainstem bronchi = 1st or 2nd intercostal space
What kind of breath sound am I?
Loud, harsh, tubular
I and E sounds +/- equal in length
Distinct pause during transition from E
Tracheal
What kind of breath sound am I?
Soft, low pitched sound
I louder and longer than E
No pause btw E and I
Vesicular
When vesicular breath sound may sound harsher? (3)
Kids
Thin-walled adults
After exs
When vesicular breath sound may sound diminished? (3)
Thick-walled adults (muscular/obese)
Elderly
Emphysema (less air moving in/out)
What kind of breath sound am I?
Very loud, high-pitched, tubular
Louder on E
E longer than I
Distinct pause btw I and E
Bronchial
If bronchial sound is heard anywhere other than the normal site, what’s up?
Consolidation space that contains fluid or solid lung tissue
What kind of breath sound am I?
Intermediate pitch and intensity-muffled blowing sound
No pause btw I and E
Bronchovesicular
For all these conditions, what is the abnormal breath sound usually heard?
Atelectasis Emphysema Hemothorax ARDS Asthma MSK deformities Pain Pneumothorax Obesity
Decreased or absent
Bcs less air entry
What breath sound am I?
Happens most on I
Happens most in lower airways
Alveoli popping open
Crackles
What breath sound am I?
Musical sounds Happens most on E (but also on I) Happens most in upper airways Often sign of obstruction of larger airway by secretions Usually clear by coughing
Rhonchi
What breath sound am I?
Continuous, high-pitched
Happens most on E
Happens most in lower airways
Often sign of secretions/obstruction lesions
Often seen in asthma, chronic bronchitis, COPD, pneumonia
Wheeze
What breath sound am I?
Musical
Happens most on I
Happens most in trachea
Often sign of obstruction
Stridor
If you hear A on egophony, what’s up and why?
Increase lung density (consolidation)
Less air in lung so air travels better
If decrease fremitus, what’s up?
Decrease lung density = air or fluid in pleural space
If increase fremitus, what’s up?
Increase lung density = no air in lungs (consolidation)
On bronchophony, if 99 is heard loud and clear, what’s up?
Increase lung density = less air in lung = sound travels better
On whispered pectoroliquy, if 99 is head loud and clear, what’s up?
Increase lung density = less air in lung = sound travels better
What breath sound am I? (be precise)
Discontinuous, non-musical, brief sounds Heard more commonly on I
High pitched, soft, brief
Opening of previously closed alveoli and small airways during I
Often seen in atelectasis, interstitial pulmonary fibrosis
Fine crackles
What breath sound am I? (be precise)
Discontinuous, non-musical, brief sounds
Low pitched, louder, last longer
Air bubbles through secretions or incomplete closed airways during E
Coarse crackles
What’s happening when you hear a monophonic wheeze?
Single/partial airway obstruction
Consider sputum plug
What’s happening when you hear polyphonic wheeze?
Widespread airway involvement
Consider bronchospasm
T or F
Stridor may be life threatening?
Yes baby, consult MD
What breath sound am I?
Discontinuous or continuos creaking sound
Usually localized to a particular place on the chest wall
Heard during both I and E
Pleural friction rub
What will you feel if there is a pleural friction fremitus?
Catch or grating sensation secondary to roughened pleural surfaces
If you feel a rhonchal fremitus, what’s up?
There is secretions : the vibration is caused by air moving thru secretions
Why it cardiopulmonary exs testing performed? (3)
Level of exs intolerance
Identification of mechanisms limiting exs
Evaluation of disease progression and response to interventions
What are the 2 main symptoms limiting cardiopulmonary exs testing?
Dyspnea
Leg discomfort
What is the mechanism behind dyspnea?
Imbalance btw central respiratory efferent drive and response of the respiratory muscular pump in presence of disease
What are the 3 causes of reduced peak VO2 in lung diseases?
Decrease cardiac output
Decrease arterial O2 content
Decrease O2 utilization in tissues
What can cause a decrease cardiac output? (2)
Increase vascular pulmonary resistance
Cardiac involvment
What can cause a decrease arterial O2 content? (3)
Hypoventilation
Decrease DLco
V/Q mismatch
What can cause decrease O2 utilization in tissues? (3)
Sedentarism/physical inactivity
Poor nutritional state
Corticosteroid therapy
What is the normal VEmax/MVV?
plus petit ou égal 0.80
If VEmax/MVV > 0.80, what’s up?
Possible pulmonary limitation to exercise
Decrease ventilatory capacity will be seen in both ______.
obstructive and restrictive lung diseases
What happens to expiratory flow and EELV w/ age and COPD?
Expiratory flow is limited and EELV increase
Bcs expiratory ms are shortened = can’t produce force to fully E
T or F
W/ age and COPD, the capacity for producing inspiratory flow declines at higher lung volumes bcs of decreased inspiratory ms length.
T
T or F
W/ age and COPD, tidal inspiratory flows come closest to the max available flows at the smaller lung volumes.
F, its at higher lung volumes
What’s P(A-a)O2 at peak exs?
< 20-30 mmHg
T or F
PaO2 decreases during exs.
F
it does not decrease
What happens to gas exchange in COPD, ILD and pulmonary vascular disease?
Impaired gas exchange efficiency
What happens to regional V/Q and DLco in COPD, ILD and pulmonary vascular disease?
Both decrease
What happens to peak exs P(A-a)O2 in COPD, ILD and pulmonary vascular disease?
> 30mmHg
What happens to SaO2 and PaO2 in COPD, ILD and pulmonary vascular disease?
both decrease
SaO2 < 88%
PaO2 < 55 mmHg
What could stop pt w/ interstitial lung disease during exs? (2)
Dyspnea
Leg fatigue
Which disease reacts like this during exs?
Increase dyspnea intensity
Breathing pattern is rapid and shallow
Vt larger proportion of IC at any given ventilation
Increase tidal inspiratory pressure swings/max force-generation capacity (Pes/PImax)
Decrease Vt response/predicted VC = increase effort-displacement ratio
COPD, baby
Which disease reacts like this during exs?
Increase dyspnea/VO2 slopes
Decrease compliance and increase WOB = rapid and shallow breathing pattern and increase slope of tidal Pes/PImax and VO2
Smaller operational lung volumes
ILD
Increase VT in IDL pt during exs is due by what?
Increase dynamic EILV
Who am I?
Loss of compliance of the lungs and/or chest wall which prevents the lungs from expanding fully.
Restrictive Lung Disease
How are PFTs for restrictive lung disease?
Decrease VC Decrease IC Decrease TLC Normal or decrease RV Decrease DLco (if restriction pulmonary in origin)
4 main S&S of restrictive lung disease?
Tachypnea
Decreased breath sounds (dry inspiratory rales)
Dyspnea
Couch: dry, irritating, non-productive
In restrictive lung disease, when does V/Q mismatch and weight loss happen?
More advanced disease
Who am I?
Abnormal healing response to multiple microscopic sites of acute alveolar injury that progress to fibrosis.
Interstitial pulmonary fibrosis
What are the causes of insterstitial pulmonary fibrosis? (3)
Occupational and environment exposure
Connective tissue disorders
General link
Who am i?
Fall into interstitial pulmonary category
Chronic progressive irreversible disease of unknown cause
Most common cause of lung restriction
Slightly higher incidence in male
Median survival 2-4 years after Dx
20-4-% surviving to 5 years
Unknown pathogenesis
Idiopathic pulmonary fibrosis
S&S of which disease?
Fatigue Chronic unproductive cough Dyspnea : on exertion --> at rest Digital clubbing Rapid/shallow breathing Decrease chest expansion Cyanosis as disease progresses Weight loss, decrease in appetite Sleep disturbances w/ loss of REM sleep
Idiopathic pulmonary fibrosis
PFTs for idiopathic pulmonary fibrosis? (5)
Decrease static lung volumes and capacities Spirometric function preserved Decrease lung compliance Decrease DLco Hypoxemia w/ exs --> at rest
How does pulmonary fibrosis appear on CXR?
Interstitial patter is rough w/ evidence of honeycombing in the bases
What happens for respiratory rate on exertion in restrictive lung disease?
Increases
What are the 2 types of occupational lung disease?
Mineral dusts (pneumoconiosis) Organic dusts (hypersensitivity pneumonitis)
What kind of occupational lung disease am i?
Onset 15-20 years following initial exposure
Hard nodular deposits in lung parenchyma and peribronchial vascular regions (affects ULs > LLs)
Asymptomatic/dry cough and mild dyspnea
Complication = severe pulmonary restriction
Silicosis (exposition to silica dusts) = mineral dusts
What kind of occupational lung disease am i?
10-15 year latency
Small black nodules or areas of discoloration
Pathogenesis related to quantity in the dust
Chronic bronchitis - blak secretions
Progressive fibrosis
Form of centrilobular emphysema also common
Coal dust = mineral dusts
What kind of occupational lung disease am i?
Pleural effusions, plaque dev
Macrophages engulf the dust in lung and pulmonary intersitium = fibrous tissue deposition
Honeycomb appearance of lung parenchyma
Pulmonary carcinoma, malignant mesothelioma
Restrictive lung disease, decrease DLco
Asbestos = mineral dusts
What is a characteristic on CXR or CT for asbestosis?
Calcific pleural plaques and interstitial parenchyma pattern
What causes hypersensitivity pneumonitis?
M-o, animal or insect protein
What are the patterns acutely and chronicle for hypersensitivity pneumonitis?
Acute = obstructive Chronic = restrictive
Describe the acute inflammatory response for hypersensitivity pneumonitis.
Lymphocytes, plasma cells and eosinophils in alveolar septa and around bronchioles
What is the diff in CXR for diff organic dusts for hypersensitivity pneumonitis?
Similar regardless the type of organic dust.
Varies according to the intensity of exposure.
CXR for what patho?
Reversible, multiple, small, modular radio densities scattered bilateral
Lung apices may be spared
Early stages hypersensitivity pneumonitis
CXR for what patho?
Honeycomb pattern w/ UL predominance
Repeated exposures hypersensitivity pneumonitis
What are the PT interventions in restrictive lung disease to increase ventilation? (2)
Breathing exs
Chest mobility, posture exs
What are the 2 main goals in pulmonary rehab for restrictive lung disease pt?
Progessive exs training (monitor hypoxemia during exs)
Respiratory ms strength and endurance training (paced breathing + supl O2 for hypoxemia pts)
Who am I?
Loss of lung volume due to collapse of lung tissue (alveoli)
Atelectasis
Whats a compression atelectasis?
Can be due by what?
Physical compression of lung tissue
Pleural effusion, pneumothorax, space-occupying lesion
Whats a resorption atelectasis?
Can be due by what?
Complete obstruction of an airway
Secretions, mucus plug, tumour
Whats a passive atelectasis?
Inadequate inspiratory volume
Neuro conditions, MSK conditions, post-anesthetic effects, splinting due to pain, trauma
What happens to lung compliance and WOB in atelectasis?
Why?
Decrease lung compliance
Increase WOB
Bcs takes more energy to open up lung tissue that has been collapse
What kind of atelectasis (localized or extensive)?
Hypoxic vasoconstriction usually limits V/Q matching
Relatively normal gas exchange maintained
Localized
What kind of atelectasis (localized or extensive)?
Increase pulmonary arterial pressure overrides the vasoconstriction
Intrapulmonary shunt
Decrease gas exchange
Extensive
T or F
Fever, tachypnea and dyspnea, productive cough are common S&S of atelectasis.
T
What are you gonna find on auscultation for atelectasis?
If lobar collapse, what’s up?
Decrease/absent breath sounds over the area
End-inspiratory crackles at involved site
Lobar collapse = absent/bronchial breath sounds
If extensive atelectasis, what happens to the trachea and diaphragm?
Tracheal shift towards affected side w/ diaphragm elevation
T or F
PaO2 and SpO2 are increased in atelectasis.
F
They decreased bcs lung units are perfused but not ventilated (shunt)
What an atelectasis look like on CXR?
Increased opacity
What are 3 possible physio Rx for atelectasis?
Deep breathing w/ end-inspiratory hold, incentive spirometry
Airway clearance techniques
Positioning and mobilization (optimizing V/Q matching)
Who am I?
Inflammation of the lung parenchyma as a result of infection
Pneumonia
What can be the causes for infection in pneumonia?
Inhalation of airborne organism
Hematogenous (circulation)
Infection from trauma or chest tube
Aspiration
T or F
Chronic obstructive lung disease can be associated w/ an increased risk of developing pneumonia.
T
What is bronchopneumonia?
Spread and involvement along the bronchi and bronchioles.
What is lobar pneumonia?
Localized to one or more lobes of a lung.
What is interstitial pneumonia?
Involves interstitial inflammation
What kind of pneumonia can cause consolidation?
Lobar pneumonia
What kind of pneumonia can cause rusty sputum?
Lobar penumonia
What kind of pneumonia can cause yellow-green sputum?
Bronchopneumonia
What kind of pneumonia is asso w/ these symptoms?
Fever Dyspnea Tachypnea Tachycardia Loss of apetite Myalgia Persistent non-productive cough Normal breath sounds thru-out both lungs w/ scattered inspiratory crackles Normal WBC count
Viral pneumonia
What’s the etiological classification for pneumonia?
Viral
Bacterial
Fungal
Parasitic
What’s the 5th most common cause of death in NA?
Bacterial pneumonia
What is the 2 categories of bacterial pneumonia?
Gram +
Gram -
How is the chest expansion in affected area for bacterial pneumonia?
Decrease (lobar pneumonia)
What do you hear on auscultation for bacterial pneumonia?
Bronchial breath sounds (consolidation); crackles (if consolidation starts to drain), reduced breath sounds
How are mediate percussion for bacterial pneumonia?
Dull
How are PaO2 and PaCO2 for bacterial pneumonia?
PaO2 decreased
PaCO2 may be decreased
How the CXR look for bacterial pneumonia?
Atelectasis, infiltrates, consolidation
Physio Rx for bacterial pneumonia? (4)
Deep breathing and positioning for poor gas exchange
Relaxation, supported cough for pain due to coughing or pleurisy
Secretion clearance techniques (for some pts)
Bed mobility -> ambulation
Who am i?
Cavitated infected necrotic lesion within the parenchyma.
Lung abscess
What are the common symptoms for lung abscess?
Fever
Malaise
Cough w/ purulent foul sputum
Hemoptysis
What is the etiology for lung abscess? (many answers possible)
Aspiration of foreign body Cavitary TB Obstruction by a neoplasm Unresolved pneumonia Infection of an infarct Sepsis
What does CXR look like for lung abscess?
lighter areas bcs of fluid accumulation
What is the physio Rx for lung abscess? (2)
Deep breathing and positioning for poor gas exchange (if problematic)
Secretion clearance techniques for retained secretions or if lung access draining into the airway
Who am i?
Collection of non-purulent fluid in the pleura space.
Pleural effusion
Who am i?
I am a form of liquid seen in infectious/inflamm diseases
I am high in protein (albumin) and inflammation cells
Exudates
Who am I?
I am a fluid that leave the vascular spaces because of elevated hydrostatic pressure in the pleural capillaries.
I am low in protein and contain no inflammation cells
Transudates
What is the most common symptom for pleural effusion?
Pleuritic chest pain w/ deep breathing and cough
The trachea shifts to which side in pleural effusion?
to the unaffected side = pleural effusion pushed the trachea
What happens to chest expansion and VC in pleural effusion?
both decreases bcs effusion compresses the lung tissue
How is the cough in pleural effusion?
Dry and unproductive
What you gonna hear on ausculatation for pleural effusion?
Absent breath sounds = bcs fluid obstruct the transmission of sound
Potentially bronchial breathing just above the effusion = bcs lung tissue is compressed
Potentially pleural friction rub
What you gonna hear on mediate percussion for pleural effusion?
Full to flat over the effusion
How can we measure the height of a pleural effusion?
Lie pt on the side of the effusion for the CXR = fluid will move down with gravity towards the chest cavity
What is thoracocentesis?
MD Rx used for pleural effusion
Needle aspiration
What is thorascopy?
MD Rx used for pleural effusion
Regid scope used to remove fluid or perform talc pleurodesis (recurrent malignant pleural effusion)
What is the physio Rx for pleural effusion? (4)
Segmental and diaphragm breathing
Mobility
Arm ROM when chest tube inserted
Optimizing V/Q matching while lying on unaffected side
What condition pauses a major risk of pleural effusion?
Atelectasis
Who am I?
Inflammation of the pleura.
Pleurisy
What are the 3 main S&S of pleurisy?
Pain = dull, non specific/sharp, localized
Doorstop breathing
Pleural friction rub
Who am I?
Leakage of air into the pleural space?
Pneumothorax
What are the 4 types of pneumothorax?
Give an example for each.
Traumatic = car accident Iatrogenic = something happening at the hospital Artificial/induced = Rx of TB Spontaneous = asthma, CF, emphysema
T or F
A small pneumothorax has symptoms of dyspnea, chest pain and dry cough.
F
Small pneumothorax is asymptomatic.
In pneumothorax, the trachea shifts to which side.
Opposite side = pneumothorax pushes the trachea
What do you hear on auscultation for pneumothorax?
Diminished breath sounds
What do you hear on mediate percussion for pneumothorax?
Tympanic = because more air/less dense
What are the 4 MD Rx for pneumothorax?
Observation
Needle aspiration
Chest tube
Pleurodesis = adhere the parietal and visceral pleura (to prevent recurrence)
Describe a tension pneumothorax.
Check-valve mechanism permits air to enter on I but not exit on E the pleural space --> compress both lungs and viscera --> decrease CO, hypotension, shock LIFE THREATHENING (chest tube stat)
What do you see usually on CXR for pneumothorax?
big black area = more air
Who am i?
Hemorrhage into the pleura
Hemothorax
Who am i?
Traumatic rupture of the thoracic duct which causes lymphatic fluid to enter the pleural space.
Chylothorax
Who am I?
I am a localized collection of pus in the pleural cavity.
I am an effusion that has become infected.
I often am accompanied by formation of fibrous adhesions.
Empyema
What is flail chest?
How does this influence breathing?
What are the consequences of this condition?
Free floating segment of ribs due to multiple # of the rib/sternum
Flail segment moves in opposite direction of the rib cage on I/E
Result in a restrictive defect = inefficient ventilation, impaired gas exchange
Who am I?
Hemorrhage in the lung parenchyma.
Lung contusion
What are the signs of lung contusion? (3)
Decrease lung compliance
Decrease V/Q matching
Decrease PaO2
What are the 3 main chest trauma?
Rib #
Flail chest
Lung contusion
What do you hear on auscultation for chest trauma?
Reduced breath sounds
Crackles if atelectasis
How long usually is pulmonary rehab?
2-3 months
2-3 days/wk
1.5h/session
T or F
Giving pulmonary rehab after exacerbations protects patient from re-hospitalization for the same cause.
T
Which grades of COPD are usually referred to pulmonary rehab?
2-4
Who am I?
Enlargement of the right side of the heart.
Cor pulmonale
T or F
We should refer only to their COPD grade to refer pt to pulmonary rehab.
F
We should mainly refer to S&S and clinical picture.
Who am I?
Condition in which the lungs can’t take in sufficient O2 and expel sufficient CO2 to meet the needs of the cells of the body
Respiratory insufficiency
What kind of exercise training in pulmonary rehab has shown the best evidence (Grade A)?
What is the min exs content in pulmonary rehab?
LE (walking, biking, stairs) aerobic training
4-8 weeks
What is the intensity of exs recommended in pulmonary rehab?
Both high and low
What are the new direction for exs prescription in pulmonary rehab these days?
We can be more flexible towards exs and adapt them to pt’s needs and lifestyle
Why do supporting the arms work in relieving SOB?
Accessory muscles can function primarily in respiration and not in supporting the shoulder girdle.
Why does foreword lean form in relieving SOB?
Facilitates downward excursion of the diaphragm due to gravity.
What kind of ROM exs we give in pulmonary rehab?
Thoracic extension, rotation, side flexion
Stretch accessory ms
Exs intensity should not go over which scoreon the Borg scale for pulmonary rehab?
6
What decrease in systolic BP we should not tolerate with exs?
> 10 mmHg drop = sign of hypotension
What increase in diastolic BP we should not tolerate with exs?
> 105-110 mmHg = sign of hypertension
Which intervention is really beneficial in pt w/ COPD in reducing visits to MD and improving QoL?
Disease-specific self-management
What are the current 2 main challenges in pulmonary rehab?
Program availability
Long-term maintenance of program’s benefits and maintenance of physical activity
T or F
Home rehab is less effective than outpatient rehab in pt w/ COPD.
F
It is as effective and as useful.
Post pulmonary rehab, ppl who are most likely to maintain activity are ppl who ___
(name 4 characteristics)
Least prone ti exacerbations
Most likely to do exs before the rehab
Best self-efficacy
Least barriers
What are the most common used respiratory drugs and mainstay of COPD Rx?
What is the mechanism of action?
Bronchodilators
Inhibit constriction of bronchial smooth muscles in asthma and COPD
What kind of drug am I?
I facilitate the clearance of bronchial secretions
Mucolytic agents
T or F
oxygen is considered a drug.
T
What is the controversy about expectorants drugs?
They have little physiological effects and could have big negative cardiac effects so they are not recommended.
What is the cutoff for hypoxemia?
When it is attributed to respiratory failure?
PaO2 < 80
PaO2 < 60
For respiratory drugs, what are the 3 main method of delivery?
Aerosol inhalation (pMDI) Dry powder inhaler (DPI) Ultrasonic nebulizer (USN)
What are the 2 major classes of bronchodilators?
Explain their mechanisms.
- B2-Agonist = bind to B2-adrenergic receptors on airway-smooth muscle cells, promoting bronchodilator and increasing ciliary beat frequency
- Muscarinic antagonists (anticholinergics) = block M1 and M3 muscarinic receptors, preventing parasympathetic bronchoconstriction of airway-smooth muscle and inhibiting goblet cell mucus secretion
What is a SABA?
Name one example
Short acting B2-adrenergic agonist
Sulbutamol = ventolin
What is LABA?
Name one example.
Long acting B2-adrenergic agonist
Salmeterol
What is epinephrine?
What are its effects?
What are its side effects
B-adrenergic drug
a, B1, B2 mixed effects
Headaches, increased nervousness, anxiety, tachycardia, hypertension, angina, cardiac arrhythmias, palpitations
What is the indication for salbutamol?
Recue med Rx for asthma,
Before exs to prevent exercise-induced asthma
What are the side effects for salbutamol?
Cough (when inhaled) Nervousness Slight palpitations Remor Dry mouth and throat (when inhaled)
When is LABA recommended over SABA?
For pt who uses SABA more than 2-3x/wk
What is usually the Rx for asthma?
LABA + ICS
What are the side effects for LABA?
Headache
Feeling a little shaky
Slight palpitations
What’s the duration of a LABA?
Starts improving breathing w/i 1-3 min and typically lasts 12hrs
What kind of drug is formoterol fumarate?
LABA
What kind of drug is indacaterol maleate?
LABA
What is a SAMA?
Short active muscarinic antagonist
What kind of drug is ipratropium bromide?
SAMA
What are the common side effects of SAMA?
Dry mouth and throat
Bad taste
Tremor
What is a LAMA?
Long-acting muscurinic antagonist
What are the common side effects of LAMA?
Dry mouth Chest pain Sinus congestion Upset stomach Headache
With what sound LAMA finished with?
ium
What is theophylline?
What’s its impact? (2)
What’s its side effects?
Methylxanthine
Relief bronchospasm in COPD + increases diaphragm’s ability to work (greater fatigue resistance and greater contractile force)
Nervousness, insomnia, irritability, headaches, seizures, etc
Why drug am I?
I am taken on a long-term basis to prevent inflammatory-mediated bronchoconstriction
I inhibit inflammation cells
I suppress release of inflammatory mediators
I enhance production of anti-inflame proteins
I reverse the enhanced capillary permeability so I reduce edema.
Corticosteroid
What are the 3 possible combinaison of drug therapy?
ICS + LABA
SAMA + SABA
LABA + LAMA
What are the side effects of systemic administration of corticosteroids?
Catabolism of muscle, bone and tissues Weight gain Hypertension Hyperglycemia Glaucoma Gastric ulvers Psychosis
Whats a nebulizer?
Changes liquid medicine into fine droplets that are inhaled through a mouthpiece of mask.
Requires a compressed air machine.
What’s the advantage of a spacer?
Make it easier to inhale the drug
Usually used in children <3
Explain to a pt how to use a MDI.
- Shake the inhaler after removing the cap
- Breathe out for 1-2 sec
- Put the inhaler in your mouth and start to breathe in slowly, like sipping hot soup.
- While starting to breath in, press the top of the inhaler.
- Breathe slowly until your lungs are full (this should take 5-6 sec)
- Hold your breath 4-6 sec
- Breathe out and repeat the procedure.
What is the mechanism for PEP?
Air during inspiration enters the peripheral airways via collateral channels
During expiration, pressure build up behind the mucus which moves the secretion towards the central airways
How many times a day chest PT needs to be done to be really effective?
3-4x/day
What is an important condition to respect for the flutter to work?
it must be positioned correctly for the ball to properly dislodged against gravity
What’s easier to clean: the acapella or the aerobika?
aerobika
What kind of device is a quake device?
What’s its characteristic?
Vibratory positive expiratory pressure
Has an rotating handle to adjust frequency oscillations
What kind of device is a bubble PEP?
Vibratory positive expiratory pressure
What is the advantage of having oscillation in a secretion clearance device?
Help dislodge secretions
In the quake device, slow rotations mean ___ frequency oscillation and ___ pulsatile expiratory pressure.
low
high
Who am I?
Secretion clearance device with tubing connecting tit to an air-use generator which injects and withdraws small amounts of air/gas at a rapid rate.
High frequency chest wall compression
Which secretion clearance device usually eliminates the need for deep airway suctioning?
mechanical insufflation-exsufflation
Who am I?
Secretion clearance device where pt is passive and machine expands the lungs, vibrate and enlarge the airways and deliver gas into the vital lung units beyond retained secretions.
Intrapulmonary percussive ventilation
What do PImax and PEmax reflect?
Reflect the pressure dev by the respiratory ms plus the passive elastic recoil go the respiratory system (chest wall + lung)
Do PImax and PEmax vary with lung volume?
Yes
How is the pressure on max inspiratory effort?
negative
How is the pressure on max expiratory effort?
positive
What is the purpose of the leak in respiratory muscle strength measurement?
PImax = prevent glottis closure PEmax = reduce buccal muscle use
What is an alternative from mouth measurement of PImax and PEmax?
Sniff inspiratory pressure
Contraindications for respiratory muscle testing.
Recent surgery Pneumothorax Myocardial infarction Ascending aortic aneurysm Haemoptysis Pulmonary embolism Acute diarrhea/stress incontinence Severe hypertension Confused/demented pt Pt discomfort Infection control issue
Who am i?
Ability to sustain a specific respiratory muscular task over time.
Respiratory muscle endurance
Name 3 tests to measure respiratory muscle endurance.
- Hyperpnea Endurance Test = max ventilation that can be sustained for 8 min
- Ventilation against a known external load-threshold = 1st pressure that can be maintained for 10 min
- Incremental threshold loading = highest load that can be sustained for 2 min
For endurance respiratory muscle training, muscles are required to work how?
At high shortening velocities for prolonged periods of time
Mimicking breathing during intense exs
What is the main difference btw inspiratory flow resistive training and inspiratory ms training devices?
First one = resistance is flow dependant -> low flow = low resistance
Second one = indep of inspiratory flow
What is the mechanism behind tapered flow resistive training?
Device tapers the inspiratory load as muscle force declines with lung inflation.
Is inspiratory muscle training in adults with COPD efficient?
Yes: Increase ms strength Decrease dyspnea Increase exs capacity Increase QoL
Inspiratory ms training should be contraindicated for pt with ___
Recent pneumothorax Hx of pneumothorax Large bullae on CXR Recent lung surgery Burst eardrum Marked OA
How long a inspiratory ms training should last minimally?
4 weeks
What is the inspiratory load recommended?
At least 30% of MIP
What is the normal respiratory rate in adults?
14-20/min
Who am I?
Periods of deep breathing alternate with periods of no breathing.
Cheyne-Stokes Breathing
How is the expiration phase in obstructive lung disease?
Why?
Prolonged expiration
Bcs narrowed airways increase the resistance to air flow
How is the breathing usually in restrictive lung disease?
Tachypnea = rapid shallow breathing
Who am i?
Unpredictable irregular breathing.
Ataxic or Biot’s breathing
How the abdomen and rib cage move in normal breathing?
Both diaphragm and intercostal ms on active on inspiration (both move up)
