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ANZCA Primary > Functional Anatomy Respiratory > Flashcards

Functional Anatomy Respiratory Flashcards

1
Q

What are the functions of the nose? (7)

A
  1. Olfaction
  2. Humidification and warming of inspired air
  3. Filter of inspired air
  4. Reclamation of expired moisture
  5. Sneezing (protective reflex)
  6. Speech
  7. 1-2 cmH2O PEEP
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2
Q

What is the blood supply to the nose?

A

External carotid artery
- Facial artery branch
- Maxillary artery branch
Venous drainage
- Facial vein, cavernous sinus, pterygoid plexus

Kieselbach’ plexus = where epistaxis occurs

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3
Q

How does humidification and warming in the nose occur?

A
  1. Humidification - Superior, middle and inferior tubrinates on the lateral wall of the nose increase the surface area and generate turbinate flow
    - This allows for maximal vapourisation of air
    - Water comes from the nasal mucosa
  2. Warming - heat transfer from the vascular cavernous plexus arranged longitudinally
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4
Q

How long is the pharynx?

A

12cm

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5
Q

What are the four layers of the pharynx?

A
  1. Mucous membrane
  2. Submucous layer
  3. Muscular layer
  4. Buccopharyngeal layer
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6
Q

What are the functions of the pharynx? (4)

A
  1. Swallowing
  2. Immune function (Waldeyer’s ring)
  3. Phonation
  4. Separates the digestive and respiratory tract
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7
Q

What is the narrowest point of the pharynx?

A

Where the inferior pharyngeal constrictor muscle attaches to the cricoid cartilage

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8
Q

What is the blood supply to the larynx?

A
  1. Upper half
    - Arterial supply: superior laryngeal branch of the superior thyroid artery
    - Venous drainage: Superior laryngeal vein of the superior thyroid vein
  2. Lower half
    - Arterial supply: inferior laryngeal branch of the inferior thyroid artery
    - Venous drainage: Inferior laryngeal vein of the inferior thyroid vein
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9
Q

What is the innervation of the larynx?

A

Recurrent laryngeal nerve
EXCEPT:
Cricothyroid muscle = EXTERNAL branch of the superior laryngeal nerve

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10
Q

What doe the INTERNAL branch of the superior laryngeal nerve supply?

A

Sensory ABOVE the vocal cords

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11
Q

What are the 4 borders of the larynx?

A

Superior = hyoid bone (C4)
Posterior = Laryngopharynx
Inferior = trachea (T4)
Anterior = Thyroid cartilage

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12
Q

What are the functions of the larynx? (4)

A
  1. Phonation
  2. Conductive airways (respiration)
  3. Cough reflex
  4. Swallowing
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13
Q

List the cartilages of the larynx (paired and unpaired)

A

Unpaired (3)
- Thyroid
- Cricoid (level C6)
- Epiglottis
Paired (3)
- Arytenoid
- Cuneiform (suspended in quadrangular membrane)
- Corniculate (Superior to arytenoid)

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14
Q

List the ligaments of the larynx (intrinsic and extrinsic)

A

Intrinsic (2)
- Quadrangular membrane: forms the vestibular fold = false vocal cords
- Cricothyroid ligament: forms the vocal fold = true vocal cord
Extrinsic (3)
- Thyrohyoid membrane (Between thryoid cartilage and hyoid bone)
- Hyoepiglottic ligament (Between the hyoid bone and epiglottis)
- Cricotracheal ligament (Between cricoid cartilage and trachea)

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15
Q

Which ligament does the MAC blade put tension on to move the epiglottis out of the way?

A

Hyoepiglottic ligament

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16
Q

Which is superior? The quadrangular membrane of the cricothyroid ligament?

A

Quadrangular membrane

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17
Q

What are the intrinsic muscles of the larynx? (6 but 4 categories)

A
  1. Cricothyroid muscle
    - Between cricoid cartilage and thyroid cartilage
    - Action: pull thyroid cartilage down and forward = tense vocal cords = high pitched sounds
    - Acts on the cricothyroid joint
  2. Cricoarytenoid muscles
    A) Posterior part - swivels arytenoid cartilage LATERALLY = OPENS rima glottis (Think O in posterior for Opens)
    B) Lateral part - swivels arytenoid cartilages MEDIALLY = CLOSES rima glottis
  3. Interarytenoid muscles
    A) Oblique = CLOSES LARYNGEAL inlet
    - There are fibres that continue past the arytenoid to the epiglottis
    B) Transverse = ADDUCT VOCAL cords
  4. Thyroarytenoid muscle
    - Also has an attachment to the epiglottis = thyro-epiglottic part
    - Action: Decreased tension on vocal cords = low pitched sounds
    - Vocalis muscle (sometimes considered separate muscle): fine tunes tension of vocal cords
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18
Q

How long and wide is the trachea?

A

11cm long, 1.8cm diameter

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19
Q

How many tracheal rings are there?

A

22 C shaped cartilaginous rings

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20
Q

What is the posterior muscle of the trachea called?

A

Trachealis muscle

21
Q

What type of mucosa is the trachea lined by?

A

Pseudostratified ciliated columnar epithelium

22
Q

What are the functions of the trachea? (2)

A
  1. Conducting airways
  2. Mucocilliary elevator
23
Q

What are the surface landmarks of the trachea?

A

Cricoid cartilage (C6) - superior aspect
Sternal angle (T4) or second ribs = carina

24
Q

What are the related structures of the trachea?

A

Organs
- Thyroid gland - isthmus crosses trachea at 3rd tracheal ring
- Oesophagus - L) posterior border

Bone
- Vertebral bodies - R) posterior border

Nerves
- Recurrent laryngeal nerve - R) under R) subclavian artery to cricoid, L) under arch of aorta to cricoid cartilage

Vessels
- Brachiocephalic artery (Anterolateral surface)
- L) common carotid artery (L) lateral border)
- SVC (R) lateral border
- Azygous vein (R) lateral border, joins SVC)
- Pulmonary trunk (Anterior to carina)

25
Q

What is the blood supply to the trachea?

A

Upper trachea
- Inferior thyroid arteries

Lower trachea
- Bronchial arteries from aorta

Venous drainage = inferior thyroid plexus

26
Q

What is the innervation of the trachea?

A

Vagus nerve
Sympathetic chain (T2-T6)

27
Q

What are the alveolar cell types

A

Type 1
- 95% surface area
- No organelles
- Do NOT replicate
- Sensitive to damage with increased FiO2

Type 2
- Function not structural cells
- Cuboidal with microvilli and contain lamellar bodies (vesicles with surfactant)

28
Q

What are the functions of type 1 alveolar cells?

A
  1. Gas exchange - super thin
  2. Barrier with tight junctions and impermeable to water
29
Q

What are the functions of type 2 alveolar cells?

A
  1. Secrete surfactant
  2. Replenish type 1 cells (transform into type 1 cells over 48-72 hours)
30
Q

Other than alveolar cells, what other cells are in the alveoli?

A
  1. Capillary endothelial cells
  2. Macrophages
  3. Mast cells
  4. Fibroblasts
31
Q

What are pores of Kohn?

A

Holes (30microm) in alveolar walls
Absent in newborns and develop at age 4
Increase in size and become confluent with age
Mostly filled with surfactant
Function = collateral ventilation

32
Q

When does cartilage become absent in the airways?

A

Bronchioles onwards

33
Q

What generations are the conducting airways and what is the volume of anatomical dead space?

A

1 to 16, 150ml

34
Q

What generations are the respiratory airways and what is their volume?

A

17-19 = respiratory bronchioles
20-22 = alveolar ducts
23 = alveolar sacs
3000ml

35
Q

When does flow in the airways become laminar? (What generation?

A

Turbulent flow up until generation 11 - beyond this the flow becomes laminar

36
Q

How does gas move in the airways?

A

In the conducting airways via forward velocity, in the respiratory airways via diffusion

37
Q

Describe the cough reflex

A

Function = clear the airway of debris before reaching lungs, involuntary but can be initiated by voluntary control

Sensors = Irritant receptors in the epithelium of the respiratory tract (trachea, pharynx, carina, less prominent in the distal airways and absent beyond respiratory bronchioles)

Afferent pathway = INTERNAL branch of the superior laryngeal nerve vis VAGUS nerve to the MEDULLA

Central control = no cough centre

Efferent pathway = Cranial nerve X and SUPERIOR LARYNGEAL NERVE
Effectors = glottis, external intercostals, diaphragm and major inspiratory/expiratory muscles

Response = Three phases of the cough reflex

38
Q

What are the three phases of the cough reflex?

A
  1. Inspiratory phase
    - Diaphragm (phrenic N.) and External intercostals (segmental IC N.) contract
    - Large negative intrathoracic pressure
    - Inflow of air –> Close to vital capacity taken
  2. Compressive phase
    - Glottis closes and vocal cords contract (recurrent laryngeal nerve)
    - Abdominal muscles and expiratory muscles contract
    - Rapid increase in intrapleural pressure (>100mmHg)
  3. Expulsive phase
    - Glottis and vocal cords open = air expelled at rapid velocity (up to 80kph)
    - Collapse of bronchi and non cartilaginous postions of trachea = clearance of material attached to respiratory lining
39
Q

What reduces the effectiveness of the cough reflex (4)

A
  1. Respiratory muscle weakness + neurological conditions
  2. Tracheostomy
  3. Vocal cord pathology
  4. Anaesthesia/paralysis
40
Q

What is the expiration reflex?

A

Same as the cough reflex but NO inspiration phase
Stimulus is at the laryngeal inlet and you do not want to inhale something here

41
Q

Describe the glottic closure reflex/laryngeal adductor reflex/laryngospasm

A

Brainstem mediated involuntary reflex arc

Sensors = Mechano- and chemoreceptors in laryngopharyngeal mucosa

Afferent = INTERNAL branch of the SLN via vagus

Integration = Medulla

Efferent = Recurrent laryngeal nerve

Effect = Adduction of vocal cords (thyroaretenoids & lateral cricoarytenoids)

Laryngospasm = prolonged maladaptive manifestation of this reflex
Occurs with stimulation of upper airway during light anaesthesia

42
Q

Describe the sneeze reflex

A

Same as cough reflex except:
- irritation in nasal cavity
- Afferent pathway = cranial nerve V
- Uvula is depressed resulting in rapid airflow through nose

43
Q

What are the effects of anaesthesia on airway reflexes?

A
  • Irritation of airways = promote airway reflexes
  • Stimulation of airway may cause transient central apnoea (breath holding)

Volatiles
- >1-1.3 MAC = dose dependent suppression of airway reflexes
- Light = increased laryngospasm (esp children)
- Desflurane & Isoflurane = more irritant = more bronchoconstriction

Propofol
- Decreased laryngospasm
- Increased incidence of coughing

44
Q

What is absolute humidity?

A

Mass of water vapour in a given volume of air
gH2O/m3 or mgH2o/L
Temperature INDEPENDENT (except when saturated with maximal amount of water)

45
Q

What is relative humidity?

A

Ratio of the absolute to the mass required to fully saturate that volume of air at a given temperature
Relative humidity = (Absolute humidity)/(humidity at saturation) X 100%
Temperature DEPENDENT
(Decreasing temperature increases relative humidity)

46
Q

Describe how humidification happens in the airways

A

Inspired air = 10g/kg (50% humidity at 22 degrees)
Turbinates = turbulent flow which increases evaporative heat exchange
Lower pharynx = 100% relative humidity T33 degrees
Inspired air = body temperature at the isothermic point which occurs 5cm below the carina
Alveolus = 44mg/L 100% humidity at 37 degrees

During expiration - return some heat and water via condensation
At nares 100% humidified, 32 degrees

47
Q

What would happen in an intubated patient without a HME filter and without warming of the air inspired?

A

Inspiration of dry air
- Insippation of secretions leading to atelectasis and V/Q mismatch
- Impaired mucocillary function from mucosal dehydration
- Increased heat loss

48
Q

What are the non ventilatory functions of the lung? FIRMTAP

A

F = filtration
1. Blood - receives entire cardiac output and filters particles >10microm (venous thromboemboli, microbes, tumour cells)
2. Gas - filtering and particle impaction of upper airways, sedimentation in lower airways

I = immunological
- Alveolar macrophages
- Secretory IgA
- Mast cells
- Lymphoid tissue in the lungs (BALT - bronchus associated lymphoid tissue)
- Barrier functions (mucous and mucociliary escalator)

R = Reservoir
1. Blood (Approx. 450ml with 20% in pulmonary capillaries)
2. Gas - FRC is an oxygen reservoir

M = Metabolism
- Vasoactive substances
- Protein synthesis, carbohydrate metabolism
- Removal of proteases
- Production of surfactant

T = thermo and water regulation
A = Acid base balance
P = Pharmacological
- Administration and elimination of drugs
- Sequesters drugs with first pass uptake

ANZCA Primary (2 decks)

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