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Cardio Pulm Eval > Pulmonary Part 1 > Flashcards

Pulmonary Part 1 Flashcards

1
Q

What does the respiratory system refer to?

A

the entire system from openings on the surface of the body for gas inhalation/exhalation to the tissue and cellular utilization of O2 and removal CO2

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2
Q

Functions of Respiratory System

A
  • Provide O2
  • Eliminate CO2
  • Regulate pH
  • Speech
  • Defend body against microbes
  • Hormonal regulation of body
  • Involved in thrombo-embolism
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3
Q

Upper Respiratory Tract Anatomy

A

Nasal and oral airway down to vocal cords

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4
Q

Functions of upper respiratory tract

A
  • provide low resistance pathway
  • defend against microbes, toxins, and foreign bodies
  • warm and moisten air
  • provide for vocalization
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5
Q

upper respiratory tract pathology

A

paralysis or loss of sensation in any part of the pharynx can result in dysphasia and/or aspiration (sets you up for pneumonia)

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6
Q

what does the lower respiratory tract connect?

A

vocal cords to alveoli

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7
Q

two parts of the lower respiratory tract

A
  • conducting airway
  • acinar or terminal respiratory units
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8
Q

What is the conducing airway?

A

Tracheobronchial tree

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9
Q

Conducting airway characteristics

A
  • not involved in gas exchange
  • 16 generations of branching from 1 inch in diameter in trachea to 1 mm in terminal bronchioles
  • cartilaginous rings support upper part
  • lower part is muscular
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10
Q

Acinar or terminal reparatory units

A

alveoli and alveolar ducts

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11
Q

parts of the conducting airways

A

trachea and bronchi

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12
Q

Trachea

A
  • From cricoid to bifurcation
  • Deviates to R before bifurcation
  • 16 to 20 incomplete cartilaginous rings
  • first is thicker & broader, last has carina
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13
Q

Bronchi

A

mainstem, secondary, tertiary, 4th, so on

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14
Q

Bronchi characteristics

A
  • R mainstem is wider and shorter than L
  • R leaves trachea at 25 degree angle
  • L mainstem bronchus leaves at 40 degree angle (R often involved in aspiration or foreign body obstruction)
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15
Q

Parenchyma

A

functional tissue of the lung

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16
Q

Superior aspect of the lungs

A

extend 1 inch above level of the middle of the clavicle into the root of the neck

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17
Q

Base of the lungs:

A

concave, resting on convex surface of diaphragm

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18
Q

Cardiac impression

A
  • the indentation for the heart
  • more notable on the left secondary to apex
  • lines up with 5th ICS and MCL
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19
Q

Hilus

A
  • entrance/exit of vessels to lung
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20
Q

pulmonary ligament

A

extension of the hilus inferiority

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21
Q

can you hear the inferior lobe anteriorly?

A
  • not really
  • you can hear it posteriorly or laterally
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22
Q

Parietal Pleura

A
  • Serous membranous lining of thoracic cavity
  • costovertebral
  • diaphragmatic
  • cervical
  • mediastinal (innervation & vascular supply via intercostal N and vessels)
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23
Q

Visceral Pleura

A
  • thin serous tissue which is adherent and inseparable from the lung parenchyma
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24
Q

where does innervation and vascular supply to the visceral pleura come from?

A

phrenic nerve and bronchial blood supply

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25
Q

Pleural Space

A
  • potential space between the layers
  • fluid accumulates here in disease states
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26
Q

What do segmental bronchi ramify within a segment to form?

A
  • bronchopulmonary segments
  • surrounded by CT layer, continuous with visceral pleura
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27
Q

Division of the bronchopulmonary unit

A

– secondary lobule: smaller unit surrounded by CT
– served by lobular bronchiole
– pyramid shaped
– terminal bronchioles ramify forming respiratory
bronchioles

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28
Q

Review the bronchial tree on slide 14

A
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29
Q

bronchioles are to the respiratory system what…

A

arterioles are to the circulatory system

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30
Q

What does secondary lobule contain?

A

–Terminal bronchiole
–Reparatory bronchioles
–Primary lobules
-Alveolar ducts
-Alveolar sacs

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31
Q

what are alveoli/primary lobules

A

terminal respiratory unit containing alveolar ducts & sacs
– 50 primary lobules/secondary lobule
– 300 million alveoli/mature lung
– mean surface area of 143 m2 (large for gas exchange)

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32
Q

Type I alveolar cells

A

provide for gas exchange

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33
Q

Type II alveolar cells

A
  • produce surfactant
  • Dipalmitoyl lecithin: phospholipid detergent, decreases surface tension
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34
Q

Alveolar-capillary septum

A
  • epithelium and endothelium
  • very, very thin membranes –> RBC traveling through there, so the gas doesn’t have far to go to get through
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35
Q

review overview of steps of respiration slide 18

A
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36
Q

Specialized cells within the lung

A
  • Type I alveolar epithelial cells (pneumocytes)
  • Type II alveolar cells (granular)
  • others: specialized paracrine cells, mucous
    producing cells, inflammatory cells, WBC & support cells
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37
Q

Type I alveolar epithelial cells (pneumocytes)

A

walls & septa of sac, squamous, thin & broad
* Function in gas exchange
* cover 93% of alveolar surface

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38
Q

Type II alveolar cells (granular)

A
  • produce surfactant
  • occupy the corners of the terminal sac
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39
Q

4 periods of respiratory system development

A
  1. Pseudoglandular period: 5-17 weeks
  2. Canalicular period: 16-25
  3. Terminal Sac period: 24th week to birth
  4. Alveolar period: years after birth
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40
Q

Pseudoglandular Period

A

5-17 weeks
- secondary bronchi to level of pulmonary segments

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41
Q

Canalicular Period

A

Weeks 16-25
Most of the branching and framework of
respiratory tree occurs:
* pulmonary segments to respiratory bronchioles
* alveolar ducts and beginning of terminal sacs

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42
Q

Terminal Sac Period

A

24th week to birth
– pulmonary alveoli develop
– capillaries and lymphatics
– surfactant is produced at about 28 weeks

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43
Q

Alveolar Period

A

Late fetal period to 5-7 years after birth
– 1/6 to 1/8th of the adult number of pulmonary alveoli are present at birth
– over the next 5 - 7 years pulmonary alveoli mature and come “on line”

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44
Q

After Birth:

A

▪ About 1/3 of the fluid in the lungs of the neonate is squeezed from the lung in birth canal.
▪ During the next few breaths another 1/3 of the fluid is absorbed into the capillaries.
▪ Remaining fluid is drained by lymphatics

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45
Q

What two problems does the neonate have in breathing?

A
  • viscosity of the remaining fluid.
  • high surface tension
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46
Q

what occurs during birth?

A

During birth, placental gas exchange is disrupted,
resulting in fetal hypoxemia & hypercapnia

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47
Q

Neonatal breathing

A

▪ First breath requires almost 60 mmHg trans-
pleural pressure to open lung
▪ Each successive breath requires less trans-pleural pressure

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48
Q

structure of the airways:

A
  • upper regions and conducting airways
  • lower regions (terminal & respiratory bronchioles)
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49
Q

Upper regions and conducting airway:

A

– basal lamina sits on smooth muscle
– ability to constrict

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50
Q

Lower regions (terminal & respiratory
bronchioles)

A

– single layered, cuboidal and mostly non-ciliated
– basal lamina on which they sit has bands of
elastin
- provides elastic recoil during exhalation

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51
Q

Innervation of the Respiratory System

A
  • Receives sympathetic & parasympathetic
    fibers
    – Parasympathetic innervation from Vagus Nerve
    – Sympathetic from upper sympathetic ganglia
    (cardiac plexus)
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52
Q

what do both SNS and PNS fibers form?

A

anterior and posterior plexi

53
Q

Activation of PNS

A

bronchiolar constriction, dilation of arterioles,
increased glandular secretion

54
Q

Activation of SNS

A

bronchiolar dilation, vasoconstriction,
decreased glandular secretion

55
Q

what does gas transport include?

A

lungs, muscles of respiration, upper and lower respiratory tract

56
Q

ventilation

A

the physical movement of respiratory
gases (CO2 and O2) in & out of the lungs

57
Q

Diffusion

A

how gas gets across the membranes

58
Q

Perfusion

A
  • the interface between blood and gas
  • mismatching of ventilation & perfusion
59
Q

Respiration

A

all of the above plus the cellular utilization of oxygen

60
Q

Maintenance of Lung Integrity

A
  • Transpulmonary P keeps the lung from collapsing
  • Difference in P from inside the alveoli to intrapleural space
  • Elastic recoil is the tendency of a tissue to resist stretch & return to pre-stretched shape
61
Q

Compliance

A
  • change in volume/ change in pressure
  • ability of a material to deform when subjected to a deforming surface
62
Q

Wall tension or stress (T)

A
  • the tension required to inflate a sphere
63
Q

Law of LaPlace

A

P = 2T/r, P = pressure & r = radius
– smaller radius sphere requires greater wall tension to remain open
– Small alveoli prone to collapse!

64
Q

Effect of Surfactant

A
  • Surface tension is greater in a smaller alveolus compared to a larger one (Law of Laplace) - air will move into the larger alveoli.
  • Surfactant prevents this by decreasing T in the smaller alveoli.
  • Sighing/deep breathing stimulates type II cells to make more surfactant
65
Q

Surfactant

A

– Dipalmitoylphospatidylcholine:
– non-polar end (tail)
– polar end (head) dissolves in the surface film of water while the non-polar ends bind the actual alveolar surface, reducing surface tension

66
Q

What does constant-volume breathing allow?

A

surfactant to equilibrate between alveoli, diminishing effectiveness

67
Q

Resistance to Gas Flow - Low rate of Flow

A

Laminar Flow: P = flow rate x c

68
Q

Resistance to Gas Flow - High rate of flow

A

Turbulence: P = flow rate x c

69
Q

Effect of volume

A

As lung V increases, the
radius of the smallest airways increases, decreasing resistance

70
Q

Normal motion of chest wall:

A

he chest rises slightly (1-1/2 inches), the diaphragm descends and the stomach moves out in normal quiet breathing

71
Q

Paradoxical breathing chest wall motion

A

paralysis of intercostals
* chest moves in secondary to loss of motor function and negative intrathoracic cavity pressure

72
Q

normal breathing - inspiration

A

Active (work done by diaphragm and ICs

73
Q

normal breathing - Expiration

A

*Passive at rest (work done by elastic recoil of lung

74
Q

when does paradoxical breathing pattern occur

A

paraplegia

75
Q

Rib movement in breathing:

A
  • Upper ribs (3-6) move in “pump handle” motion
  • Lower ribs (7-10) move with “bucket handle motion
76
Q

any disease that restricts rib movement affects ….

A

ventilation (restrictive lung disease)

77
Q

Kyphoscoliosis (severe kyphosis)

A

causes ribs to approximate each other decreasing excursion
*affects more males than females

78
Q

scoliosis

A

ribs on convex side of bend diverge while ribs on concave side approximate each other

79
Q

minute ventilation

A
  • volume moved through the lung/min
  • Vmin = Vt x RR
  • for given Vmin, patients with decreased TV, must breathe at a faster rate
80
Q

dead space (anatomic)

A
  • the portion of gas in the lung not in contact with blood (that part that does not participate in gas exchange)
  • Vd = about 150 ml in a normal healthy adult
  • for a person breathing at a higher RR, dead air/min is increased (wasted effort and increased work of breathing)
81
Q

primary muscles of respiration

A

Diaphragm
* External Intercostals: run diagonally inferior and
anterior –> probably inspiration
* Internal Intercostals: run diagonally inferior and
posterior –> Fx- probably inspiration
* Innermost Intercostals: same as internal

82
Q

excursion of diaphragm in varying body positions:

A

– Supine: expiratory excursion is greatest
- Moves further into thoracic cavity
– Standing and side lying: intermediate excursion.
– Sitting: minimal excursion

83
Q

quiet breathing

A

diaphragm moves 2/3 inch

84
Q

maximal breathing

A

2.5-4 inches

85
Q

Accessory Muscles of Respiration

A
  • Sternocleidomastoid
  • Scaleni
  • Trapezius:(upper only)
  • Pectoralis Major & Minor
  • Serratus Anterior
  • Latissimus Dorsi
  • Serratus Posterior/ Superior
  • Quadratus Lumborum
  • Iliocostalis
86
Q

Scaleni

A

– anterior: attaches to 1st rib
– middle: attaches to 1st rib
– posterior: attaches to 2-3 rib

87
Q

Number of pulmonary arteries and veins

A

fixed at birth at level of terminal respiratory units

88
Q

Number of arterioles and venules in respiratory units

A

increase with age, parallel with addition of new RUs

89
Q

what is pulmonary artery pressure at birth?

A
  • high
  • declines over next 4 months
  • if pressure remains high, artery wall changes
90
Q

pulmonary capillaries

A

very fine network of branches capillaries

91
Q

where are pulmonary capillaries located

A

in the septa and walls of alveoli

92
Q

what do pulmonary veins serve as?

A

a reservoir for LV, negating the pulsatile flow of the RV and changes in flow with inspiration/expiration.

93
Q

Pulm. A & Vs parallel branching of bronchi to the
level of the segments:

A

veins run between segments and multiple veins drain each segment

94
Q

Bronchial circulation

A
  • One R-bronchial artery, 2 L-bronchial arteries
  • Accompany branching of the bronchi down to the level of the terminal bronchioles
  • Bronchial arteries receive 1-2% of the CO
95
Q

function of bronchial circulation

A

to maintain blood supply in the event of pulmonary embolism

96
Q

Static Lung Volumes

A
  • Tidal Volume (VT)
  • Inspiratory Reserve Volume (IRV)
  • Expiratory Reserve Volume (ERV)
  • Residual Volume (RV)
  • Inspiratory Capacity (IC)
  • Functional Residual Capacity
  • Vital Capacity (VC)
  • Total Lung Capacity (TLC), ERV - RV
97
Q

dynamic lung:

A

volumes/rates

98
Q

PEF

A

peak expiratory flow

99
Q

FVC

A

forced vital capacity

100
Q

FEV1

A

forced expiratory volume in 1 second

101
Q

FER

A

FEV1/FVC ratio

102
Q

what is COPD

A

Class of diseases of respiratory tract caused by
obstruction of the airways

103
Q

COPD signs and symptoms

A

cough, dyspnea on exertion, wheezing expectoration of mucus

104
Q

diagnosis of COPD

A
  • based on pulmonary function tests
    – expiratory flow rate limited
    – residual volume increased
  • Hyperinflated lung: exhalation affected
    – Also: increased mucus production, inflammation of mucosal lining, mucosal thickening, bronchiolar
    muscle spasm
105
Q

COPD includes:

A
  • bronchopulmonary dysplasia
  • cystic fibrosis
  • asthma
  • bronchiectasis
  • chronic bronchitis
  • emphysema
106
Q

bronchopulmonary dysplasia

A

fibrotic changes in lung of infant secondary to ventilation

107
Q

cystic fibrosis

A

excessive mucus production

108
Q

asthma

A

airway hyper-responsiveness to allergens/irritants

109
Q

bronchiectasis

A

dilation/distortion of bronchi secondary to infection

110
Q

chronic bronchitis

A

excessive production of mucus secondary to smoking

111
Q

emphysema

A

enlargement of terminal sacs, destruction of alveolar walls & septa, loss of elastic tissue

112
Q

look at the little pulmonary function testing on 25

A
113
Q

type A COPD - chronic emphysema

A

– SOB
– Little sputum production
– Barrel shaped chest w flat diaphragm & horizontal ribs
– Hypertrophied accessory muscles of
respiration & use of posturing
– Rapid, shallow breathing
– Due to hypercapnia, patients with light complexion may appear paradoxically pinkish

114
Q

type B COPD

A
  • productive cough
  • Over-weight
  • cyanosis
  • associated w/ heart failure and peripheral edema
115
Q

restrictive lung disease

A

an abnormal reduction in pulmonary ventilation with diminished expansion of the lungs

116
Q

causes of restrictive lung disease

A

trauma, radiation Rx, rib or spinal deformity or secondary to primary lung disease

117
Q

compliance =

A

change in V/change in P

118
Q

compliance in restrictive lung disease

A
  • compliance of either or both chest wall and lungs are decreased
  • This results in a stiffer lung which is more difficult to open at any given volume, but especially at high lung volumes when C is minimal already
119
Q

lung volume in restrictive lung disease

A

Because the distensibility of the lung is
decreased, all lung volumes are affected:
– Inspiratory reserve volume: decreased
– VT -initially preserved, but in time decreases
– Expiratory reserve volume: decreased, but especially affected by RLD that is caused by a decrease in lung, not chest wall, compliance.
– Residual Volume: decreased
– TLC and vital capacity also decreased

120
Q

clinical manifestations of restrictive lung disease

A

tachypnea, alveolar hyperventilation, ventilation perfusion mismatching, crackles, decreased diffusing capacity, cor pulmonary

121
Q

RLD- tachypnea

A

increased rate secondary to decreased volume

122
Q

RLD- hyperventilation

A

overcompensation

123
Q

RLD- ventilation perfusion mismatching

A

hypoxemia

124
Q

RLD- crackles

A

secondary to atelectatic alveoli opening

125
Q

RLD- decreased diffusing capacity

A

widening of interstitial space due to scar tissue , stretching

126
Q

RLD- cor pulmonary

A
  • pulmonary arterial HTN secondary to hypoxemia, fibrosis, compression of pulm. capillaries
  • may lead to R-side HF, decreased exercise tolerance
127
Q

RDL symptoms

A
  • Dyspnea/SOB (initially w/exercise, but later at rest)
  • Irritating, dry and unproductive cough –> secondary to irritation from increased velocity of air movement across airways
  • Muscle wasting/cachectic look –> secondary to the increased work of breathing
  • Difficulty eating secondary to increased work of breathing –> decreased appetite
  • Acute and chronic cyanosis –> Clubbing of nails (chronic cyanosis), Bluish discoloration of nail beds and mucosa
128
Q

clubbing of the nails

A
  • broadening of distal phalanges with down-ward angulation and rounding of the nail
  • Common with restrictive lung disease, but may also happen with COPD

Cardio Pulm Eval (10 decks)

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