Pulmonary Pathophysiology (1) Flashcards
____ refers to the movement of air in and out of the lungs
Ventilation
Ventilation is responsible for the removal of ___ from the body
CO2
_____ refers to the delivery of oxygen to the alveoli and the diffusion of O2 into the pulmonary capillaries
Oxygenation
The processes of ventilation and oxygenation are ___
Linked
The central nervous system regulates ____, ____, and ____ of breathing
Rate, depth, and rhythm
____ ___ have the strongest influence on regulation of ventilation
Central chemoreceptors
A decrease in the pH of ____ ____ increases ventilation
Cerebrospinal fluid
____ ____ also affect ventilation
Peripheral chemoreceptors
What are some examples of peripheral chemoreceptors?
-Aorta (PaO2 and PaCO2)
-Carotid bodies
Carotid bodies can impact ventilation due to changes in…
-PaO2 and PaCO2
-Decreased pH
-Increased temperature
-Low perfusion
-Nicotine, cyanide, carbon monoxide
What two types of receptors also impact ventilation?
-Stretch receptors
-Baroreceptors
What are two baroreceptors?
-Carotid sinus
-Aortic arch
Carotid sinus baroreceptors are responsive to both increases and decreases in arterial pressure, while aortic arch baroreceptors are only responsive to ____
Increases
Stretch receptors and baroreceptors limit how much ___ you can take in and the stretch of the lungs
Oxygen
What are the muscles of ventilation:
-Diaphragm
-Intercostals (internal/external)
-Accessory muscles
What nerve controls your diaphragm?
Phrenic nerve (innervated by C3, C4, C5)
If a spinal cord injury is above the C3, C4, and C5, the patient might not have ____ ____
Diaphragmic breathing
What are three accessory muscles:
-Scalene
-Trapezius
-Sternocleimastoid
What makes up the upper respiratory tract?
-Nasal cavity
-Sinuses
-Naso, Oro, laryngopharynx
-Larynx
What makes up the lower respiratory tract?
-Airways
-Alveoli
-Lymphatics
If you bypass the upper airway, you bypass ____ and over time, the secretion in the lower lungs get too thick and you can’t cough them up
Humidification
Conduction airways generate from branches __-__
1-16
Respiratory airways generate from branches ___-___
17-23
Branch ___-___ is where gas exchange occurs
20-23
____ cells produce mucus (Emphysema and other conditions effect these cells and cause mucous to become too thick)
Goblet
____ cells replace damaged epithelial cells in the airway
Progenitor
Type 1 alveolar cells are ___ ___
Basal alveoli
Type 2 alveolar cells secrete ___
Surfactant
Alveoli must always be open to allow for ___ ___
Gas exchange
A liquid called ____ keeps alveoli open
Surfactant
If there is damage to the alveolar border, ____ and ____ can get into the alveoli which prevents oxygen from getting in; this causes alveolar collapse and damage to type 2 cells
Protein and fluid
When activated/in overdrive, ___ ___ initiate macrophage and cytokine response which damages alveoli
Alveolar macrophages
When activated/in overdrive, ___ ___ initiate macrophage and cytokine response which damages alveoli
Alveolar macrophages
Breathing is a ____ function
Mechanical
Breathing causes changes in ____, ____ and ____
Pressure, volume, flow
What things allow for changes in volume?
-Diaphragm
-Muscles (intercostal and accessory)
With inspiration, the diaphragm _____ downward to allow room for increased air volume of the lungs
Contracts
With inspiration, the thoracic cavity ___
Expands
With inspiration, the external intercostal muscles ___
Contract
With expiration, the thoracic cavity ____
Reduces
With expiration, external intercostal muscles ____
Relax
The diaphragm ____ during expiration
Relaxes
What might impact flow of air into the lungs?
-Diameter of the airway
-Compliance of the lung
-Compliance of the chest wall
-Elastance
Those with ____ have low compliance of the chest wall
Burns
Changes in pressure of the lungs are due to ___ ___
Muscle contraction
When the chest wall expands, it brings the ___ with it so that air can fill
Lungs
With a long and/or narrow breathing tube, there would be ___ resistance
High
With a small and/or wide tracheotomy tube, there would be ____ resistance
Low
Transpulmonary pressure is ___ mm Hg
4
Intrapleural pressure is ___ mm Hg
-4
Pneumothorax is when air gets into the ___ ___ of the lungs
Pleural space
Normally, we do not get rid of ___ ___ of oxygen in the lungs, meaning there will always be some oxygen in the lungs
Residual volume
Tidal volume is equal to…
Dead space + alveolar ventilation
___ of tidal volume does not participate in gas exchange and is considered anatomic deadspace ventilation
1/3
(Deadspace ventilation)/(tidal volume)=
(PaCO2 - PECO2)/PaCO2
Dead space is normal, but we don’t want dead space in the ____ because that would be there is no gas exchange through the lungs
Alveoli
Volume and speed of air flow can be measured using ____
Spirometry
What can spirometry measure:
-Forced vital capacity (FVC)
-Forced expiratory volume (FEV1)
-FEV1/FVC
-Peak expiratory flow rate (PEF)
We can also measure someone’s response to ____ or ____ to look at lung function
Bronchodilators; exercise
We are able to determine lung size by measuring volume with what two tests?
-Total lung capacity
-Residual volume
We can measure gas exchange with what test?
Diffusing capacity for carbon monoxide (DLCO)
If someone has reversible airway disease, they would have a ____ forced vital capacity on bronchodilators
Increased
Technique of spirometry:
-Obtain height, age, gender
-Patient blows into a device that records volume and the speed gas leaves the lungs
What three things does spirometry calculate?
-Predicted: norm based on height, age, and gender
-Best: highest flow
-% predicted: % of normal
Percent predicted should be at least ____%
80
The ___-___ ___ is a plot of inspiratory and expiratory flow against volume during the performance of maximally forces inspiratory and expiratory maneuvers
Flow-Volume Loop
Someone with a forces vital capacity 65% of predicted, a forced expiratory volume 37% of predicted, and a FEV1/FVC 46% of predicted would have ____ lung disease
Obstructive
The goals of spirometry include:
-Diagnose type of dysfunction
-Determine extent of dysfunction
-Monitor change over time (normal 20 mL/year or greater)
-Monitor response to treatment
-Preop, disability assessment
Bronchodilators improve ____
Volume
Obstructive lung diseases can affect the ___ or ___ airway
Upper or lower
What are three obstructive upper airway lung diseases?
-Croup/Epiglottitis
-SUID
-Sleep apnea
What are three lower airway obstructive lung diseases?
-Cystic fibrosis
-Asthma
-COPD
What are 4 categories of restrictive lung diseases:
-Lung tissue
-Dust diseases
-Nerves/muscles
-Chest wall
What are three lung tissue restrictive diseases?
-Idiopathic
-Pulmonary fibrosis
-Covid (long haul)
What three things can cause dust-related restrictive lung diseases?
-Silica
-Asbestos
-Coal
What things can cause nerve/muscle related restructed lung disease?
-ALS
-Post-Polio
-High cord injury
What types of chest wall deformities can cause restrictive lung disease?
-Kyphoscoliosis
-Flail chest (fractured ribs)
What are examples of vascular lung diseases?
-ARDS
-Pulmonary emboli
-Pulmonary hypertension
Obstructive lung diseases affect ____ of air
Flow
Restrictive lung diseases affect ____ of inspired air
Volume
Vascular lung diseases affect ___ and ___
Fluid and flow
What can cause airway obstruction?
-Narrowing of airways
-Object obstructing flow
-Loss of lung tissue
What can cause narrowing of airways?
-Airway inflammation
-Smooth muscle contraction
What objects might obstruct flow?
-Sputum
-Tumor
-Foreign body
What might cause a loss of lung tissue?
Emphysema
With emphysema, tissue is destroyed which causes a ___ airway that closes early during expiration
Small
Emphysema leads to ___ ___
Air trapping
With emphysema, there is ____ elastic recoil and ____ closing volume
Decreased; increased
Emphysema causes lungs to be ____, so they can’t get the air out on exhale which makes it hard to get the next breath in
Overcomlpliant
What may be done for treatment of emphysema?
-Lung reduction surgery
-Valves to help deflate lungs on exhale
Obstructive lung diseases cause a change in the inspiratory:expiratory ratio from ____ to ____
1:2 (normal) to 1:3-4 (this means that it takes a lot longer for people to exhale)
For those with obstructive lung diseases, it helps to create ____ to the inhale by inhaling through pursed lips to create back pressure to open the airways to the exhale
Resistance
Someone with an obstructive lung disease would have _____ intercostal spaces and a ___, ___ diaphragm
Wide; low and flat
On a chest X-ray of someone with obstructive lung disease, you would see a lot of ___ space which indicates excess oxygen since they are chronically in an air-trapping system
Black
What are some signs of respiratory distress in someone with obstructive lung disease?
-Frequent coughing or wheezing
-Excess phlegm or sputum
-Shortness of breath
-Trouble taking a deep breath
-Exacerbation
-Hypoxemia
-Pedal edema
-COPD
Pulmonary vasoconstriction might lead to ___ ___ ___
Right ventricular failure
___ ___ is dilation of the right ventricle caused by attempts to pump against increased peripheral vascular resistance
Cor pulmonale
Right ventricular failure may lead to distension of the ___ ___
Jugular vein
Right ventricular failure can also lead to ___ ___ since blood backs up to arms and legs
Peripheral edema
With obstructive lung diseases, ____ is used to monitor severity
FEV1
Classifications of severity for obstructive lung disease:
Mild: FEV1 > 70-79% predicated
Moderate: FEV1 60-69%
Moderately severe: FEV1 50-59% predicted
Severe: FEV1 35-49% predicted
Very severe: <35% predicted
All severities of obstructive lung disease have a FEV1/FVC less than ____%
70
With obstructive lung diseases, you can’t get air ____, whereas with restrictive lung diseases, you can’t get air ___
Out; in
What conditions can restrict lung function?
-High spinal cord injury (C3-C5)
-Amyotrophic lateral sclerosis
-Duchenne’s Muscular Dystrophy
-Idiopathic pulmonary fibrosis
-Dust (silicosis, asbestosis, pneumoconiosis)
-Kyphoscoliosis
-Fractured ribs
What are three possible causes of a volume problem?
-Chest wall cannot move normally
-Muscles and nerves do not work
-Lung tissue is fibrous/dust filled
With restrictive diseases, there is ___ volume in and ____ volume out, but a normal speed of respiration
Less, less
What are three consequences of restrictive lung diseases?
-Tidal volume is decreased
-CO2 is not flushed from the lungs
-Acid-base balance is affected
Restrictive lung diseases cause ___ ___
Respiratory acidosis
Respiratory acidosis causes ___ PaCO2 and ____ pH
Increased; decreased
With restrictive lung disease, the airway is not ____, so simple measures may help increase tidal volume
Obstructed
What are some options to increase tidal volume?
-Mouth held support during the day
-Mask at night (avoids trach)
-Mechanical ventilation at night (no mouth held support during the day)
Mouth held support during the day supplements tidal volume to remove ___
CO2
Decreases in ____ estimates severity of restrictive lung diseases
FVC (forced vital capacity)
Classifications of severity for restrictive lung diseases:
-Mild: FVC <80-70%
-Moderate: FVC <70-55%
-Severe: FVC < 55%
Lower limit of normal for lung disease:
-5th percentile OR
- <80% predicted FEV1 and FVC OR
- <70% predicted FEV1/FVC
With an obstructive pattern, there is ___ air in and ____ rate of expiration
Less, slower
With a restrictive pattern, there is ___ air in and a ____ rate of expiration
Less, normal
If FEV1/FVC is less than lower limit nomal, it would be an ____ lung disease
Obstructive
If FVC is less than lower limit normal for an obstructive disease, it would be _____ or ___ ____
Obstructive or mixed volumes
If FVC is greater than the lower limit normal, this would indicate…
-Mild disease or asthma
If FEV1/FVC is greater than the lower normal limit and FVC is less than lower normal limit, this would indicate ____ lung disease
Restrictive
If FEV1/FVC is greater than the lower normal limit and FVC is greater than the lower normal limit, this would indicate…
Normal lung function
With inflammation of the upper airway structures, there is a risk of ___ ___
Airway obstruction
Why does inflammation of the upper airway cause a risk of airway obstruction?
-Inflammation narrows the airway
-Anatomy restricts ability to expand
-Trachea incomplete rings
-Cricoid cartilage complete ring
The risk of airway obstruction is more common in ___, since their airway is shorter and narrower
Children
What age group is at the highest risk for developing croup?
6 months-3 years
If there is a family history of croup, someone is ___ times more likely to develop croup
3.2
With croup, the virus infects the ___ ___
Nasal mucosa
The croup virus then spreads to the ___ and ___
Larynx and trachea
Croup causes ____ and narrows airways in the subglottic region (below the vocal cords)
Inflammation
The ___ ___ is rigid and cannot expand with croup
Cricoid cartilage
The hallmark of croup is “___ ___”
Steeple sign
With croup, we should evaluate the severity of what symptoms?
-Cough (occasional or frequent)
-Stridor/noisy breathing (none, at rest)
-Retractions (none, mild, marked)
-Agitation (none, at rest)
Therapy to manage mild croup:
-Fluids
-Humidity
-Antipyretics
Therapy to manage severe croup:
-Steriods
-Nebulized epinephrine
Who is at risk for epiglottitis:
-Immunocompromised
-Child not immunized (Haemophilus influenzae)
Pathogenesis of epiglottitis:
-Bacteria infection
-Rapidly progresses
-Cellulitis (edema, narrows airway)
-Life-threatening airway obstruction
What should you evaluate to determine the severity of epiglottitis?
-Visualize epiglottis in a safe setting
-Drooling/anxiety
-Signs and symptoms of infection
How is epiglottitis managed?
Antibiotics
What is an example of an obstructive disease secondary to altered breathing?
Sudden Infant Death Syndrome
___ ____ ___ ___ can either be explained or unexplained
Sudden Unexpected Infant Death
___ ___ ___ ___ is sudden and unexpected death in an infant less than 1-year-old with no obvious causes after autopsy and investigation
Sudden Infant Dead Syndrome
About ___% of SUID cases are SIDS
50
There is the highest risk of SIDS at ___-___ months of age
2-4
90% of SIDS cases occur before ___ ____ of age
6 months
2018 CDC data shows that there were 3400 causes of SUID, which ___ of those being explains and ____ being unexplained
1300; 2100
The 1,300 explained cases of SUID were due to…
Accidental suffocation (sheets, blankets)
Of the 2100 explained cases of SUID, ____ of them were caused by SIDS
1300
SIDS occurs in infants who…
- Have underlying vulnerability
- Experience a trigger event
- Are at vulnerable developmental stage of the CNS
What are some examples of underlying vulnerability?
-Premature birth/low birthweight
-Deficiency in serotonin or alteration signaling
-Cardiac/genetic variants
-Arousal failure
A premature birth/low birthweight causes delayed maturation of regions in the brain that regulate ___ ___ to hypoxia (decreased PaO2) and hypercarbia (increased PaCO2)
Ventilatory response
A deficiency in serotonin or alteration signaling alters ____ in the medulla
Respirations
A deficiency in serotonin or alteration signaling is associated with ____ exposure in utero
Nicotine (maternal smoking/2nd hand smoke)
The trigger event common to all causes of SIDS is ___ ___, which means that the infant doesn’t turn its face or lift its head to inhale, so they inhale CO2 and go into respiratory arrest
Arousal failure
____ position increases risk of arousal failure
Prone
Data on SIDS is not good because we can’t conduct ___ ___ ___, so we do epidemiological research and infer from data
Randomized control trial
Infant risk factors for SIDS:
-Low birth weight, premature
-Sleep position (prone)
-Sleep environment (sleep surface (not firm), bed-sharing, overheating, swaddling)
What are some maternal risk factors for having a child with SIDS?
-Race (African American, American-Indian)
-Smoking (during pregnancy or 2nd hand smoke)
-Drug/alcohol abuse
What is the triple risk model of SIDS?
-Vulnerable infant (preterm, LBW, nicotine exposure)
-Critical period (2-4 months)
-Environment (sleep environment/position)
There is a large variation in rates of SUID between ___ and ____
States and countries
What factors might impact large variations in rates of SUID?
-Smoking rates
-Racial/cultural factors (increased in Native Americans)
-Bed sharing
Another example of an obstructive disease secondary to altered breathing is…
Sleep Disordered Breathing
What are the two distinct stages of sleep?
-NREM
-REM
____ predominates in the first 1/3 of the night, while ____ predominates in the last 1/3
NREM; REM
What happens in REM sleep?
-Breathing is irregular
-Apneas occur in normals
-Muscle activity is reduced
-Decreased depth of breathing (tidal volume)
Who is at risk of sleep-related breathing disorders?
-Those whose airway narrows during sleep
-Those who are obese
-Those with obstructive airways
-Obstructive sleep apnea
Obstructive sleep apnea increases the risk of…
-Myocardial infarction
-Stroke
The location of ___ on the tongue and lateral fat pads may narrow the airway during sleep-related breathing disorders
Fat
If someone has a more narrow ____, they are at higher anatomical risk for sleep-related breathing disorders
Pharynx
Critical factors in the development of sleep-related breathing disorders:
-Fat distribution
-Pharyngeal anatomy
-Arousal threshold
-Response to apnea
With sleep-related breathing disorders, there is a problem with the response to increased ___; a very large level is required to stimulate respiration
CO2
With ____, there is no airflow for 10 or more seconds
Apnea
____ is a decrease in airflow of 50% or more accompanied by 3 or more % drop in SaO2
Hypopnea
Apnea Hypopnea Index is calculated by…
(# apneas + # hypopneas) / hour sleep
AHI of 5-15 per hour would indicate ___ ___ ___ ___
Mild Obstructive Sleep Apnea
AHI of 15-30 would indicate ___ ___ ___ ___
Moderate obstructive sleep apnea
AHI over 30 would indicate ___ ___ ___ ___
Severe Obstructive Sleep Apnea
____, also known as a sleep study, is a comprehensive test used to diagnose sleep disorders
Polysonmography
It is now easier for sleep disorders to be diagnosed because of ____
Telehealth (home sleep test, wireless data transfer, determine pulmonary artery pressure for therapy)
What are non-invasive options to improve sleep apnea?
-Weight loss
-Positioning (off back)
-Pneumatic air splinting (GOLD STANDARD)
-Oral appliance to thrust jaw forward
-Medications
What are some examples of pneumatic air splinting?
-CPAP
-VPAP
-APAP
What are two examples of invasive options for sleep apnea treatment?
-Surgical alteration of tongue/airway
-Hypoglossal nerve stimulation
Pneumatic air splinting helps by adding ___ ____ delivered by mask to keep the airway open
Positive pressure
Pneumatic air splinting is noninvasive and highly ____
Effective
What does CPAP stand for?
Continuous positive airway pressure
With CPAP, there is the ____ pressure on inspiration and expiration
Same
What does VPAPP stand for?
Variable positive airway pressure
With VPAP, pressure ____ and can be less with expiration
Varies
What does APAP stand for?
Adaptive positive airway pressure
APAP adjusts volume to patient’s ___ ___
Tidal volume
APAP avoids ___ ___ to set pressure
Titration study
What are some examples of mask types?
-Full face mask
-Nose mask
-Nasal pillow
___-___% of people abandon pneumatic air splinting within the 1st weeks
10-15
Only ___-___% of people are adherent long term
20-40
There has been no clear improvements past ___ years despite technical advances, behavioral interventions, and telemonitoring systems
20
What does a mandibular jaw advancement do for a patient?
-Pulls lower jaw forward
-Repositions tongue
-Opens airway
A mandibular jaw advancement has been shown to work with an apnea hypopnea index of ___ ___, but there is limited data to show improvement with apnea hypopnea index of severe
Mild moderate
In a randomized crossover study, it was shown that the CPAP is more ____ while the mandibular jaw advancement was used more ____
Effective; frequently
If symptoms of sleep apnea persist, recommend a medication called ____-___
Solriamfetol (Sunosi)
Medication doesn’t improve the apnea, but helps patients ____ better
Sleep
In sleep, the muscles of the ___ relax, which obstructs the airway
Pharynx
____ position is a major factor in sleep apnea and the base can fall back and block the airway
Tongue
What are the three parts of the new technique to stimulate the hypoglossal nerve during sleep?
-Impulse generator
-Sensor of intercostal muscle
-Stimulator attached to hypoglossal nerve
What is the name of one hypoglossal nerve stimulator?
INSPIRE
If symptoms of sleep apnea persist, a ____ alteration of the airway/tongue can be done
Surgical
What are three consequences of sleep apnea?
-Cardiovascular disease risk
-Impaired glucose metabolism (high T2D risk)
-Behavioral issues (memory, attention, sleepiness, fatigue, learning difficulties)
With obstructive sleep apnea, there is attempt to breathe, but with ____ ____ ____, there is no respiratory drive
Central sleep apnea
Central sleep apnea may cause _____ ____ ____ that may be adaptive due to increased CO
Severe heart failure
Management of central sleep apnea includes…
-Heart failure therapies
-CPAP (to prevent apnea)
A recent trial showed that there is increased mortality in someone with central sleep apnea if they have an ejection fraction less than ___%
40%
Respiratory ____ begins with respiratory insufficiency/arrest/failure (RIAF)
Decomposition
Respiratory compromise is a ____ disorder
Progressive
Respiratory compromise type I is…
Hyperventilation Compensated Respiratory Distress
Respiratory compromise type I can be caused by…
-Sepsis
-CHF
-PE
Respiratory compromise type II is…
Progressive Unidirectional Hypoventilation (CO2 Narcosis)
Respiratory compromise type III is…
Sentinel Rapid AIrflow/SpO2 Reduction to Precipitous Fall
Oxygenation and ventilation are two ____ processes
Distinct
____ is the process of getting oxygen to the tissues and get be measured with oximetry
Oxygenation
____ is the process of eliminating CO2 from the body and can be measured using capnography
Ventilation
Partial pressure of arterial CO2 (PaCO2) measures CO2 dissolved in the ___ ___
Arterial plasma
Partial pressure of the end-tidal COs (PetCo2) measures CO2 at ___-___
End-exhalation
The PaCO2-PetCo2 ____ is established by comparing the two values (ABG to end-tidal volume)
Gradient
Usually, the PaCO2-PetCo2 gradient is less than ____ mmHg since PetCo2 is usually 2-5 mmHg lower than PaCO2
6
Capnometry gives a ____/____ measurement
Percent/numeric
Capnography gives a ___ and ___
Measurement and waveform
____ ____ gives a numerical value for end-tidal CO2 (EtCO2)
Wave capnography
With wave capnography, ___ ___ is sampled directly from the airway
Respiratory rate
With wave capnography, there is a ___ ___ for each breath
CO2 waveform
It is sometimes said that waveform capnography is the ___ of respiration
EKG
The ___ ___ test is a test for risk factors of sleep apnea; a score of 3 or more indicates high risk
STOP BANG
