Pulmonary Flashcards
Alveolar Gas equation
PAO2=
PIO2 - (PaCO2/R)
Can be approximated PAO2= 150 - PaCO2/0.8***
A-a gradient
PAO2-PaO2 = 10-15 mmHG
increased indicates underlying lung pathology
Air in the stomach on CXR in an infant be concerned w/
Early warning in the mother?
Trachealoesophageal fistula and esphageal atresa
Polyhydrominos
Most common type of tracheal esophageal fistula
C type w/ esophageal atresia and distal fistula
Type E (or H type) is the just a fistula
Diaphragm is made by the joining of what 4 structures?
Failure leads to?
septum transversum (from the cranial aspect) fuses w/ pueroperitonela folds, abdominal walls, and esophageal mesentery
Failure congenitally leads to herniation and lung hypoplasia (usually the L) polyhydraminos associated
Presentation of congenital diaphragm heniation
polyhydraminos in utero
hypoplastic lung -> cyanosis and inability to breath
flattened stomach
5 structures perforating the diaphragm and at what level?
T8 - IVC
T10 - esophagus
T12 - aorta, azygos vein, thoracic duct
innervation of the diaphragm
Phrenic C3-5
leads to referred pain to the shoulder (spleen and cholecysitis)
Aspiration pneumonia is more likely going to be found in what lobe?
R lobe due to wider and more vertical
Peanut inspiration the same but if lying down will be in the superior portion od the right inferior lobe while standing up it will be inferior portion of R inferior lobe
Importance of bronchopulmonary segments? Contains?
separated by connective tissue - has a bronchus, and 2 arteries per segment, veins are in the periphery
Spepaerates out the right 3 lobes and the L 2 lobes further
Smokers will see what transformation in their trachea
columnar ciliated cells -> stratified squamous through metaplasia
Chronic sinusitis, infertility and situs inversis?
Cause?
Kartagener syndrome
Due to dyenin not functioning leading to cilia defects all over
Important measure of fetal lung maturity
lecithen:Springomyelin ratio being greater than 2.0
See if enough dipalmitolphasphatidylcholine is being made
Product of type II pneumocytes?
dipalmitolphasphatidylcholine
other type II and I pneumocytes during injury
Role of type I pneumocytes?
gas diffusion - very thin
muscles of inspiration
- quiet
- exercise(3)
diaphragm
Sternocleidomastoid, scalenes, external intercostals
muscles of expiration
- quiet
- exercise
quiet is passive
exercise - internal intercostals, transverse abdominus, rectus abdominus, internal and external obliques
TLC is the combination of?
Functional Residual capacity and Inspiratory capacity or
Inspiratory reserve volume and Tidal volume and experatory reserve volume and residual volume
Inspiratory capacity is a combination of?
Tidal volume and inspiratory reserve volume
Vital capacity is a comination of
expiratory reserve capacity, tidal volume and inspiratory reserve capacity
Functional reserve capacity
residual volume and expiratory reserve volume
Determining the physiologic dead space formula
Dead space
= Tidal volume x [(PaCO2 - PeCO2)]/PaCO2
a= arterial
e expired air
Functional residual capacity (FRC) what is the relationship between chest wall and lungs
how does it change in emphysema?
How does it change in fibrosis?
they are balanced in their pull - airway and alveolar pressure are 0 and the intrapleural pressure is negative
in emphasymia there is increased compliance so the FRC is increased. More volume at given pressure
in fibrosis there is decreased compliance so less volume at a given pressure
Diffusion limited gases are?(2)
what does that mean?
CO and O2 (in diseased state: emphysema/fibrosis)
means that the partial pressure of the arterial will not be saturated upon leaving the lung - amount of gas carried limited by the diffusion
Perfusion limited gases(3)
what does that mean?
CO2, O2, N20
it means that the amount of gas that leaves the lung, the amount of gas carried is limited by the perfusion of the lung, equilibrates very quickly
How does COPD lead to Cor pulmonale
Cor pulmonale is heart failure due to lung disease. In COPD there is less oxygen perfusing the pulmonary vasculature leading to vasoconstriction and increased pressure. This increased pressure feeds back on the R heart leading to failure
-normally vessels expand w/ decreased O2, lungs shunt away
Pulmonary hypertension is defined as?
> 25mmHg in rest
35 mmHg exercising
Normally 10-15 mmHg
Pressure is equal to?
How does radius affect the system?
∆P = Q x R
R = (8 x length x viscosity)/(pi x r^4)
IN pulmonary resistance, what can change? What can’t generally?
radius of the tube
viscosity of the fluid
can’t really change the length
R = (8 x length x viscosity)/(pi x r^4)
Adding He to Oxygen does what
decreases the viscosity of the air and thus leads to less pressure
R = (8 x length x viscosity)/(pi x r^4) ∆P = Q x R
Primary pulmonary hypertension is due to
BMPR2 mutation -> increased smooth muscle proliferation
Loss of function mutation where normally BMPR2 regulates growth and lose radius
Causes of secondary pulmonary hypertension (6)
COPD/fibrosis (vasoconstriction w/ low alveolar oxygen) Mitral stenosis(feeds back)
Autoimmune (infammation -> intimal fibrosis)
sleep apnea/ high altitude
thromboembolic events
Left to right shunt (increased circulation)
Rx for pulmonary hypertension (4)
bosentan/ambriasentan
prostaglandin analogs
Sildenafil - phosphodiesterase inhibitors
Dihydropyradine CCB - nifedipine
Adult Hemoglobin is normally made out of?
How does it compare to fetal hemoglobin?
4 globin molecules (2 alpha 2 beta)
w/ 4 heme molecules
Fetal hemaglobin(2 alpha 2 gamma) has a higher preference for oxygen by being less affinity high 2,3 BPG, allows acquiring of oxygen from
2 types of states hemoglobin can be in and what favors each state
Taut - favors tissue and unloading
- in the presence of high: H, temp, 2,3 BPG, CO2
relaxed form favors O2 binding
-in the presence of low CO2, how H concentration and temp and 2,3 BPG
Hard working muscles leads to what type of hemoglobin state?
taught form and unloading of oxygen
lactic acidosis, low CO2, increased temp and metabolites of oxidation (2,3 BPG)
Methoglobin is what?
Ferric form (Fe 3+), oxidized iron in the hemoglobin instead of ferrous (Fe+2) form
Toxic for it favors cyanide more readily and does not favor O2 as much
Nitrates indue this and is Useful Rx cyanide poisoning w/ thiosulfate to excrete the thiocyante
Rx for methomoglobinemia (2)
methylene blue and Vitamin C
Also can give cimetidine over longer time
Agents known to cause methoglobin(6)
Methelglobin is the oxidized form of hemoglobin (Fe +3)
Nitrates/nitrities Antimalarials - chloroquine/primaquine Dapsone sulfonamide local anesthetics - lidocaine metoclopramide
Carboxyhemaglobin is?
Complications associated w?
hemoglobin bound to CO, see cherry red lips
- have decreased oxygen unloading in the tissues as a result
Causes a L shift in the graph due to readily binding of CO to the hemoglobin and thus not able to carry as much oxygen
(thus why pulse ox still shows high % sat because cannot differentiate what the hemoglobin is saturated w)
CO causes what kind of shift in the oxygen hemoglobin curve
Left shift
Causes a L shift in the graph due to readily binding of CO to the hemoglobin and thus not able to carry as much oxygen
(thus why pulse ox still shows high % sat because cannot differentiate what the hemoglobin is saturated w)
that causes a right shift in the hemoglobin oxygen curve and what does that mean from a oxygen unloading stanpoint
increased: CO2, [H] (low pH), temp and 2,3 BPG causes a right shift. Meaning there is left hemoglobin saturation at a given partial pressure of oxygen favoring unloading into the tissue(taut form)
The opposite is true for low CO2, [H], temp and 2,3 BPG and CO-> fairs Hg saturation at lower arterial pressure
Anemia leads to what changes in the the following lab results:
PaO2
Total oxygen content
O2 saturation
PaO2 normal
total oxygen content decreased
O2 saturation normal
COPD leads to what changes in the the following lab results:
PaO2
Total oxygen content
O2 saturation
PaO2 decreased
Total oxygen content down
O2 Saturation decreased
Physiologic shunt moves oxygen away from healthy tissue
Exercise leads to what changes in the the following labs
PaO2
venous O2
PaO2 normal
venous O2 is lower
-due to increased metabolites -> right shift on the hemoglobin oxygenation curve
Normal A-a gradient?
- what does it mean
what may raise A-a gradient
15-10 mmHg
means the difference in the O2 content in the alveoli - the O2 content in the arterial
elevated gradient may mean hypoxemia
- V-Q mismatch
- older age
- elevated FiO2 (giving O2)
- fibrosis
If PaCO2 increases and all else is the the same, what happens to PAO2?
It decreases
PAO2 =150 - (PaCO2/0.8)
What may change the PI02 in the alveolar gas equation
normally PAO2 = PIO2 (PaO2/R)
-> PAO2= 150 - (PaCO2/0.8)
PI O2 varries w/ atmospheric pressure and FiO2( the % oxygen content)
high altitude lowers PAO2
A-a ratio
PaO2/FiO2
normally equals 300mmHg
<200 = severe hypoxemia
What may cause normal A-a gradient hypoxeima?(2)
Elevated ?(4)
normal ( low O2 in alveoli -> low O2 in blood)
- elevated altitude
- hypoventilation
Elevated (not transfering)
- fibrosis
- VQ mismatch
- R to L Shunt
What is ischemia and what are some causes?(2)
lack of blood FLOW
Obstruction - MI/stroke
Venous blockage - traffick jam
What is hypoxia and some causes? (4)
hypoxia is lack of O2 in the tissue
heart failure, low CO output
anemia
hypoxemia
CO poisoning
V/Q ratio at the base of the lungs?
is < 1
due to gravity there is excess perfusion to the amount of ventillation
V/Q ratio at the apex of the lungs
> 1
due to blood falling down, there is excess ventilation ( why TB loves it here)
With exercise the ratio approaches 1 w/ capillary recruitment of the apex
V/Q in pulmonary edmea
approaches 0 and is known as a shunt
airway obstruction limits the ventilation no mater how much blood flows through
Which of the following circumstances benefits from O2 High V/Q or low V/Q
Higher ventilation to perfusion would benefit more because of capillary recruitment
low V/Q or ~ 0 would be a shunt and no mater how much O2 you give it will not make it
V/Q ratio in a PE
Blood obstruction leads to V/Q ratio approaching infinity
The small flow can be increased w/ other capillaries being recruited with the ventilation
-assuming less than 100% deadspace
CO2 is carried in the blood how (3)
- dissolve in blood
- Bicarb
- carried on the N terminal of the glob in (NOT heme group) as carbaminohemoglobin
- -binding encourages taut form (O2 release)
Exercise has what effect on the following?
V/Q ratio pulmonary blood flow pH PaO2 PaCo2 Venous O2 Venous Co2
V/Q-> 1 pulmonary blood flow increases w/ CO pH drops w/ lactic acidosis Pa O2 - No∆ Pa Co2 - no ∆ Venous O2 - decreases Venous CO2 - increases
How does hematocrit and Hemoglobin change in high altitude
Increases
40%-> 60% hematocrit
15 g/dL -> 20 g/dL
Responses of the bode to high altitude(5)
Increase in ventilation
Increase in EPO -> (increased Hct and Hbg)
Increased bicarb excretion (renal comp for Resp alkalosis)
Increase in 2,3 BPG -> right curve shift
Increase in mitcochondria
How does acetazolamide help with acute mountain sickness
acetazolimide augments the loss of bicarb already being losses to help with respiratory alkalosis due less alveolar oxygen pressure -> hypoxemia
How many Gs needed to pass out
why do you pass out
4-6 Gs
Due to blood pooling in the legs and abdomen -> lack of return to the heart and lack of brain perfusion
Clinical derangements seen in acute MTN sickness(4)
HA
Fatigue
Acute cerebral edema (hypoxia induced vasodialtion)
Acute pulmonary edema (hypoxia induced vasoconstriction -> local HTN and permeability)
Chronic MTN sickness see? (6)
increase in RBC mass and hematocrit increased blood viscosity -> decreased flow elevated pulmonary artery pressure -> right sided heart enlargement -> peripheral artery pressure falls -> CHF
How is the following affected by zero gravity?
blood volume RBC mass muscle strength Cardiac Output bone mass
all is decreased
Bone mass lost due to loss of Ca and phosphate
What is nitrogen necrosis and pathophys
nitrogen necrosis is when N in the air is dissolved into the neural membrane causing reduced neuronal excitability in high pressure environments
Diver -> jovial and carless (drunk)
- loss of strength and coordination
Hyperbaric treatment is useful for what 4 conditions
CO poisoning
Decompression sickness
Gas gangrene - clostridium
Osteomyolitis
Symptoms of decompression sickness(3)
Pain ->in the joints, and muscles of arms/legs Neurologic symptoms -> dizziness, paralysis, syncope Chokes -> SOB, pulmonary edema and death
Virchows triad -> risk of DVT
hypercoagability
-post partum, sickle cell, polycythemia, CHF, estrogen
Stasis
-post op, long trips, pregnancy
Endothelial damage
- fracture, infection, post op
Symptoms of DVT
swollen foot or ankle +/-:
- pain
- homan’s sign - pain with calf dorsiflexion
- palable cord
Diagnosis of DVT?(2)
- D dimer if low probability
- compression US if high
Rx for DVT
heparin or enoxaparin until the Warfarin is therapeutic
PE symptoms(5)
can mimic?
Pleuritic chest pain* SOB* cough hemptysis - rare fever
tachypenia*
tachycardia*
acute mental status ∆*
MI
Studies that can help diagnosis a PE (6)
elevated D dimer large A-a gradient EKG CT VQ scan pulmonary angiogram
What is seen in 20% of PE EKGs
S1Q3T3
-acute pressure an R ventricle overload
wide S on lead 1
Lead 3:
large Q and inverted T wave
Causes of emboli and respective sources(6)
Fat emboli - long bone fractures and liposuction
Bacteria - endocarditis
amniotic fluid - post partum
Thrombi - vichows triad
tumor
air- IV(rarely); the bends
A negative D dimer tells you what?
rules out clotting and PE for lack of fibrin degeneration products, plasmin is not dissolving things
Positive does not tell you much
Primary pneumothorax is due to?
tall younger thin males that have blebs that rupture
no lung disease prior
obstructive lung disease:
FEV1
FVC
FEV1/FVC
TLC
FEV1 decreased a lot
FVC decreased
Ratio is decreased - less than 80%
TLC is increased
Restrictive lung disease
FEV1
FVC
FEV1/FVC
TLC
FEV1 decreases the same amount as FVC. FVC may a little more ->
Normal to slightly increased ratio
TLC is decreased
blue bloater
chronic bronchitis
hypoxemia, hypercapneia
pink puffer
emphysemia
hyperventilation, dypsnea
Most common cause of pulmonary hypertension?
COPD
chronic bronchitus is defined clinically as
Productive cough > 3months over 2 years
Reid2 ty index
Measure of chronic bronchitis where goblet cells hypertrophied to greater than 50% the distance of the bronchial wall
chronic bronchitis pathophysiology
a form a COPD (blue bloater), the patin has constant exposure to som irritant leading to mucal hyperplasia and narrowing of bronchial wall
-> hypoxemia, wheezes, crackles, cyanosis, and late onset dypsnea
Emphysema pathophysiology
destruction of lung parenchyma either through increased elastase activity w/ lack of alpha1 antitrypsin deficiency or due to smoking leads to increased lung compliance and enlargement of air spaces
NOT cyanotic
2 types of emphysema and etiologies
Panacinar in the lower lung fields is associated w/ alpha 1 antitrypsin deficiency
Centriacinar is in the upper lung fields and associated w/ smoking
Have a patient w/ history of emphysema that presents with acute exacerbated SOB be worried of?
pneumothorax
Key feature of asthma as an obstructive lung disease
it is reversible
Curschmanns spirals
sloughed off epithelium that forms mural plugs in asthma
Charcot leyden crystals
breakdown of eosinophils from inflammation associated w/ asthma
Findings in asthma
cough, wheeze, tachypnea, dypsnea, hypoxemia, low I/E ratio, pulsus paradoxis
Pulsus paradoxis is?
Associated w?
smaller pals pressure associated with decrease L ventricular filling due to overfilling of the R ventricle upon inspiration
asthma
Bronchiectasis is associated w/ what pathology(4)
kartageners syndrome
CF
Smoking
allergic bronchopulmonary aspergillosis
Bronchiectasis pathophysiology
chronic necrotizing infection of bronchi -> permanently dilated airways w/ purulent sputum discharge
abcesses
Concern w/ beta 2 agonists?
there is some spillover to beta 1, levabuterol has less
see tachycardia and arrhythmia at higher doses
adenosine may not work in emergency cardio situations due to the presence of what other drug>
Theophylline
If a patient is having to use their albuterol inhaler more than 2x/week consider adding on a
inhaled steroid
- fluticasone
- beclomethasone
- budesonide
antihistamine used in N/V
promethazine
antihistamine used in vertago
meclizine
antihistamine used in appetite stimulation
cyproheptadine
Expectorants (2)
Guaifenesin
N acytelcysteine
Types of restrictive lung disease
(3 general categories)
Poor breathing mechanics
-poor muscular effort(Guillian barrie, myasthenia gravis, polio)
-poor structural apparatus (scoliosis, kyphosis, obesity)
Interstitial lung disease
- ARDS
- Neonatal RDS
- Pneumoconioses
- Sarcoidosis
- idiopathic pulmonary fibrosis
- Goodpastures syndrome
- Granulamatosis w/ polangiitis - wegeners
- Langerhans histiocytosis/eosinophilic granuloma
- Hypersensitivity pneumonitis
- drug toxicity
Interstitial Lung disease causes (10)
- ARDS
- Neonatal RDS
- Pneumoconioses
- Sarcoidosis
- idiopathic pulmonary fibrosis
- Goodpastures syndrome
- Granulamatosis w/ polangiitis - wegeners
- Langerhans histiocytosis/eosinophilic granuloma
- Hypersensitivity pneumonitis
- drug toxicity
Sarcoidosis associations/presentation
A GREULING Disease
ACE increase Granulomas - noncaseating RA - sometimes Erythema nodosum Uveitis LAD (hilar, bilateral) Idiopathic Not TB Gamma globulinema D- Vit D increase -> hypercalcemia
honeycombing of the lungs
idiopathic pulmonary fibrosis
tennis racket shape cytoplasmic organelles
Beirbeck granules in langerhans histiocytosis, eosinophilic granuloma
Hypersensitivity pneumonitis examples?
Restrictive lung cause
- organic dust leading to farmers lung or pidgins lung
Pneumoconioses (4) and brief cause
Anthracosis - Coal miners lung
Silacosis - sand balding and the mines
Asbestosis - pumbers/shipyards/roofers
Berylliosis - aerospace manufacturing
Anthracosis is and associations?
Coal miners lung
- > restrictive lung disease in the upper lobes
- damage due to macrophage response
No risk of CA
Silacosis
hisology?
associations?(2)
Eggshell calcification of hilar lymph nodes
-> macrophages respond to silica and release fibrogenic factors -> restrictive lung disease in the upper lung
Associated w/ increase risk of TB and bronchogenic carcinoma
Asbestosis
histology (3)
Associations?
see ivory white calcified pleural plaques in the lower lobes
Asbestos bodies - golden brown fusiform rods (dumbbells) w/in
ferruginous bodies - hemosiderin (Fe) laden bode asbestos fibers
Higher risk of
-bronchogenic carcinoma*
mesothelioma
golden brown fusiform rods resembling dumbbells found on histology
asbestos bodies
Beryllliosis
2 associations
aerospace manufacturing
- > noncaseasting granulomas
- > increased lung cancer risk
Therapeutic oxygen in neonatal respiratory distress carries what risk?(2)
retinopathy of prematurity( white reflex due to vascular prolix in the inner retina)
and bronchopulmonary dysplasia
Maternal steroids should be given how soon before a premature mother gives birth
24-48 hrs
Causes of ARDS
truama sepsis shock gastric aspitation pancreatitis toxic gas inhalation high O2 uremia infection heroin overdose
the pathophysiology of ARDS
Injury due to (shock, sepsis, High O2, Heroin OD…. ) -> inflammatory cells and mediators and oxygen free radicals
- > alveolar damage to the Type I pneumocytes or endothelial cells
- > increase alveolar capillary permeability
- > Diffuse Alveolar Damage and Hylaine Membrane Disease
Which feeds back and causes more damage w/ recruited cell mediators
Immune system causes more damage after the initial insult
Complication Risks of ARDS?
DIC and coagulation cascade activation
Sleep apnea is defined as
repeatesd cessation of Breathing >10s during sleep -> disrupted sleep -> disrupted daytime
Pulmonary HTN w/ Sleep Apnea?
due to hypoxemia and responding vasoconstriction of the lungs can lead to systemic?
4 common METS of lung cancer
BLAB
Bone
Liver
Adrenal
Brain
Presentation of lung Ca? (variety)
Cough and hoarseness - Recurrent laryngeal Horners syndrome Weight loss coin lesion wheezing Dysphagia paraneoplastic syndromes -Hypercalcemia w/ squamous cell -SIADH, Lambert Eaton, and Cushings in Small cell
4 traditional tumors and their respective locations
Non small cell
- Adrenocarcinoma - periphery
- Large cell carcinoma - periphery
- Squamous cell - central
Small cell - central
Lung Cancers associated w/ Smoking(4)
Large cell
Bronchioalveolar subtype of adrenocarcinoma
squamous cell
small cell/ Oat cell
Lung cancers not associated w/ Smoking(3)
Adrenocarcinoma
mesothelioma
Bronchial Carcinoid tumor
Most common cancer in nonsmokers and associated mutation
Adrenocarcinoma
- k RAS
CEA +
Subtype bronchioalveolar is associated w/ smoking and presents as hazy infiltrates ~ pneumonia
Cancer that may first appear as pneumonia or hazy infiltrate
bronchioloalveolar subtype of adenocarcinoma
Highly anapestic, undifferentiated tumor made of pleomorphic giant cells in the periphery of the lung?
Large cell carcinoma
poor prognosis
Squamous cell carcinoma of the lung presents as (4)
hilar mass in the bronchus
Keratin pearls
Cavitations on CXR or CT
Hypercalcemia w/ paraneoplastic PTHrP
Small cell carcinoma presents as (5)
Paraneoplastic
- SIADH
- Cushings w/ ACTH produced
- Lambert Eaton (weakness due to Ab against presynaptic Ca channels)
Central and undifferentiated
Kylchitsky cells - small dark blue cells
myc associated
Kulchitsky cells
small dark blue cells in small cell carcinoma
myc oncogene associated
Lung tumor associated with right sided heart lesions and murmurs. What also may be seen (3)
Bronchial carcinoid tumor
-neuroendocrine cells secreting serotonin
BFDR
Bronchospasm
Flushing
Diarrhea
R Sided Heart symptoms and murmurs
Pancoast tumor may present as(2)
Horner syndrome
- ptosis
- myosis
- anhydrosis
hoarsness (recurrent laryngeal nerve compression)
Radon exposure leads to an increase risk of?
Lung cancer - seen in mines and basements
Mesothelioma is found where and presents as? (3)
associated w/ apsestosis and found in the pleural lining
hemorrhagic pleural effusions
pleural thickening
psammoma bodies
Most common cause of pneumonia in immunecompromised
pneumocystis jirovecii
most common cause of atypical pneumonia
mycoplasma pneumonia
common pneumonia in alcoholics
Klebsiella
common cause of pneumonia in bird handlers
chlamydophilia psittaci
often causes pneumonia in a patient w/ a history of exposure to bat or bird droppings
histoplasma
Often cause pneumonia w/ a history of traveling to S Cali, New mexico, W Texas
Coccidiodes
current jelly sputum pneumonia
klebsiellia
q fever pneumonia
Coxiella burnetti
Most common cause of pneumonia in children 1 yr old or younger
RSV
Most common cause of pneumonia in neonate (birth -28days)
Group B
E coli
Most common cause on pneumonia in children and young people
mycoplasma pneumonia
Most common cause of viral pneumonia
RSV
Wool sorter’s disease pneumonia due to
Bacillus anthacis
Common cause of pneumonia in ventilator patients and those w/ CF
Pseudomonas
lung abcesses are often due to
aspiration of oropharyngeal contents
- anaerobes (bacteriodes, fusobacterium, peptostreptococcus)
- S aureus
- Klebsiella
Chylothorax
lymphatic tissue from the thoracic duct that has been damaged leaking into the pleural space causing an effusion
milky white appearance
Transudate causes of pleural effusion
Volume overload - CHF, cirrosis
Lack of protein - nephrotic syndrome
Exudate causes of pleural effusion
malignancy, pneumonia, callogen vascular disease, trauma
all due to increase vascular permeability w/ inflammation
