Kania small group lecture/ CIS on Respiratory (10/14)

Question 1

pertinent sympathetics to respiratory

Answer 1

T1-2- upper airway, head. (superior cervical ganglion, stellate ganglion - inferior cervical and 1st thoracic)

T2-6 = bronchioles, lungs

Superior Cervical Ganglion

• fused ganglia of C1 through C4
• provides postganglionic innervation to the head and neck

Stellate Ganglion

• fusion of the inferior cervical sympathetic ganglion with the ganglion of T1
• middle cervical and stellate ganglia innervate the heart, lungs, and bronchi.

Question 2

pertinent parasympathetics to respiratory

Answer 2

vagus –> lungs and upper airway

pterygopalatine (sphenopalatine) ganglia supply parasympathetic innervation to the sinuses, nose, lacrimal gland, and blood flow to the nasal mucosa

Question 3

sympathetic stimulation leads to

Answer 3

response tends to be more general

mucus glands and blood vessels are heavily innervated by the sympathetic nervous system

smooth muscles are not

stimulation of the sympathetic nerves in the mucous glands increases water secretion and decreases the viscosity of mucus.

(opens airways to breathe better while running away)

Question 4

Parasympathetic stimulation leads to

Answer 4

slightly constricted smooth muscle tone in the normal resting lung

innervation is greater in the larger airways, and it diminishes toward the smaller conducting airways in the periphery
bronchial glands, increases the synthesis of mucus glycoprotein and
increases the viscosity of mucus

Question 5

What’s the biggest problem of SNS activity in a sick person?

Answer 5

blood vessel constriction–> decreased delivery of oxygen, nutrients, removal of wastes, impaired O2-CO2 exchange

Question 6

why do we want PNS activity in a sick person?

Answer 6

increased synthesis of mucus glycoprotein because it is part of the innate immune system and contains more:

• lactoferrin (antibacterial, antiviral and antifungal, particularly in infants; highest lactoferrin in colostrum, then human breast milk)
• lysozymes (active against G+ bacteria - strep, bacillus. Have reduced activity when glycolated - diabetes
• beta-defensins- cationic proteins that bind to cell membranes of bacteria and fungi and change the permeability; also active against viruses
• IgA- S. pneumo and H flu type B release a protease that destroys IgA

Question 7

Chapman’s Reflex points- how to approach

Answer 7

treat lymphatics first

posterior points are diagnostic, secondarily for treatment

anterior points are for treatment

treat with vibratory or rotary motion, or deep kneading

Alternative way: hold angerior and posterior points, with connection between fingers, wait for connection to resolve

Question 8

Most likely causative organisms of sinusitis?

Answer 8

viral

Rhinovirus, coronavirus, influenza A & B, parainfluenza, respiratory syncytial virus (RSV), adenovirus, enterovirus

about 10% proceed to bacterial

Question 9

fever helps what?

Answer 9

increases lactoferrin, fighting off the critters

Question 10

sympathetic ganglia are close to

Answer 10

rib heads

Question 11

Muscles of ventilation: external intercostals

Answer 11

inferrror margin of rib above–> superior margin of rib below

Innervation: intercostal nerves: T1-T11

Most active during instpiration
supports intercostal space
moves ribs superiorly

Question 12

muscles of ventilation: internal intercostal

Answer 12

lateral edge of costal groove of rib above–> superior margin of rib below deep to the attachment of the related external intercostal

Innervation: intercostal nerves T1-T11

Function: most active during expiration; supports intercostal space, moves ribs inferiorly

Question 13

Muscles of ventilation: innermost intercostal

Answer 13

medial edge of costal groove of rib above –> internal aspect of superior margin of rib below

Innervation: intercostal nerves: T1-T11

Acts with internal intercostal muscles

Question 14

Muscles of ventilation: subcostales

Answer 14

internal surface (near angle) of lower ribs –> internal surface of second or third rib below

innervation: related intercostal nerves
function: may depress ribs

Question 15

muscles of ventilation: transversus thoracis

Answer 15

inferior margins and internal surfaces of costal cartilages of second to sixth ribs–> inferior aspect of deep surface of body of sternum, xiphoid process and costal cartilages ribs IV-VII

innervation: related intercostal nerves
function: depresses costal cartilages

Question 16

Effects of Kyphosis on Mechanical Ventilation

Answer 16

Reduction of thoracic kyphotic angles demonstrated a reduced vital capacity, inspiratory capacity, total lung capacity, and lateral expansion

There is also a significant negative correlation between the increased kyphotic angle and inspiratory capacity, vital capacity, and lateral expansion of the thorax.

Question 17

Effects of balloon kyphoplasty on mechanical ventilation

Answer 17

Measured pain scores reduced significantly
FVC and maximum voluntary ventilation (MVV) are significantly increased after 3 days
MVV continues to improve at 1 month afterwards
Decreased pain scores had remarkable positive correlation with improvement of FVC (r=0.536) and MVV 3 days afterward (r=0.614)

Question 18

Effects of Diminished Lymphatic Flow

Answer 18

Diminished antigen/allergen presentation

• Tissue congestion
• Sinus congestion
• Pleural effusion
• Pulmonary infiltrates

Prolonged recovery from infectious etiologies

Diminished delivery of pharmacologic agents

Question 19

Anterior Chapman’s Points for respiratory (see separate deck for individual cards)

Answer 19

upper lungs: between ribs 3-4 close to the sternum
lower lungs: between ribs 4-5 close to the sternum
bronchus (esophagus and thyroid): between ribs 2-3 close to the sternum
nose: costochondral junction of 1st rib
tonsils: between 1st and 2nd ribs (1st intercostal space) close to the sternum
sinuses: 3 ½” from the sternum, on the upper edge of 2nd rib and in the 1st intercostal space
** middle ear/otitis media: upper edge of the clavicle, just lateral where it crosses the 1st rib
pharynx: front of 1st rib ¾-1” medial to where the clavicle crosses the1st rib
larynx: upper surface of 2nd rib, 2-3” lateral from the sternum

Question 20

Posterior Chapman’s Points

Answer 20

upper lungs: intertransverse space, midway between spinous and transverse processes of the T3-T4 vertebrae
lower lungs: intertransverse space, midway between spinous and transverse processes of the T4-T5 vertebrae
Bronchus (esophagus, thyroid): midway between the tip of the transverse process and spinous process of T2 on the posterior aspect of the transverse process
nose: lateral aspect of the transverse process of C1
tonsils: posterior surface of C1 transverse process, midway between the nuchal ligament and lateral most aspect of the C1 transverse process
sinuses: midway between the tip of the transverse and spinous processes of C2 on the posterior aspect of the transverse process
middle ear: (otitis media) upper edge of the posterior aspect of the tip of C1 transverse process
pharynx: midway between the spinous process and tip of the transverse process of C2, on the posterior aspect of the transverse process
larynx: midway between the tip of the transverse process and spinous process of C2 on the posterior aspect of the transverse process

Question 21

What are the most common causative organisms in community acquired pneumonia?

Answer 21

Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Rhinovirus
Influenza 
Klebsiella pneumoniae (usu. in ETOHics w/ current jelly sputum)

Question 22

What are the preferred antibiotics for Community Acquired Pneumonia?

Answer 22

Macrolide
– azithromycin, clarithromycin, erythromicin

Doxycycline

For folks with comorbidities (DM, chronic heart/lung/kidney dz, malignancy, immunosuppression, prior antibiotics within 90 days)
– Fluoroquinolones (moxifloxacin, levofloxacin)

Beta-lactam (+ macrolide or doxycycline)

• High-dose amoxicillin
• Amoxicillin-clavulanate
• Ceftriaxone, cefpodoxime, cefuroxime

Question 23

Pearls for Asthma (good thing to know for exams and practice!)

Answer 23

Ribcage is children is very pliable
Address dysfunction here quickly to avoid respiratory failure due to accessory muscle fatigue in acute situations
Avoid supine techniques in acute situations
Avoid HVLA in general in kids
Avoid HVLA of thoracic spine (“Kirksville crunch” and Texas twist”) as this would squeeze air out of the lungs
Avoid thoracic lymphatic pump for same reason (pedal pump OK)

Question 24

Pearls for COPD (good thing to know for exams and practice!)

Answer 24

Avoid supine techniques in acute situations
Avoid HVLA of thoracic spine (“Kirksville crunch” and Texas twist”) as this would squeeze air out of the lungs
Seated HVLA may be useful if patient’s situation is not too acute
Avoid thoracic lymphatic pump for same reason (pedal pump OK)

Question 25

Galbreath Technique

Answer 25

Purpose – to increase blood flow through the pterygoid plexus of veins and lymphatics, drainage of the Eustachian tube, stretching of the peri-pharyngeal muscles and fascia

Patient supine (or seated in treating physician’s lap)

Affected side down (or away from physician’s treating hand)

Grasp mandible of affected side

Draw mandible downward and transversely with mild force for 3-5 seconds, repeating for 30-60 seconds

Question 26

Vertebropleural “Ligament”

Answer 26

The function of this “ligament” is to ensure that each lung is
equally aerated much like guide ropes on a hot air balloon.

Restriction here can limit lung 
function and C7 motion.