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CRNA Adv. A&P > Pulmonary Pt1 > Flashcards

Pulmonary Pt1 Flashcards

1
Q

What are the 3 processes required for respiration

A

1) Ventilation (breathing)
2) External (pulmonary) respiration - gas exchange in the lungs
3) Internal (tissue) respiration - gas exchange in the tissues

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2
Q

2 Structural categories of the Resp. Sys. vs 2 Functional categories of the Resp Sys.

A
  • Structural
    1) Upper respiratory system - nose, pharynx, paranasal sinuses and assoc. structures
    2) Lower respiratory system - larynx, trachea, bronchi and lungs
  • Functional
    1) Conducting zone - dead space up to terminal bronchioles
    2) Respiratory zone - gas exchange in alveoli
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3
Q

Mallampati Score

A

-Used to predict ease of intubation or if the pt has OSA.
Class I - Full visibility of tonsils, uvula, and soft palate
Class II - Visibility of hard and soft palate, upper portion of tonsils and uvula
Class III - Soft and hard palate and base of the uvula are visible
Class IV - Only hard palate visible

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4
Q

How are the 12 pairs of ribs categorized?

A

1) True Ribs (1-7) - Directly attached to sternum via costal cartilage
2) False Ribs (8-10) - Indirectly attached
3) Floating ribs (11-12) - Not attached to sternum

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5
Q

Supernumerary Ribs

A
  • Extra ribs
    1) Cervical - Elongation of transverse process of 7th cervical vertebra (0.5% incidence)
    2) Lumbar - Elongation of transverse process of lumbar vertebrae (less common)
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6
Q

How do the ribs accommodate physiological function

A

1) Allows flexibility for movement that is needed for ventilation
2) Oblique orientation allows for elevation of rib cage with lung expansion

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7
Q

3 parts of the Sternum

A

1) Manubrium - uppermost part
2) Body - middle part
3) Xyphoid process - lower most part

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8
Q

Suprasternal notch

A
  • aka Jugular notch
  • trachea lies posterior to and in line with the jugular notch
  • same horizontal plane as 2nd thoracic vertebra
  • signifies midpoint of trachea and ideal location for the distal tip of the ET tube
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9
Q

Sternal Angle

A
  • aka angle of Louis
  • where the manubrium joins the body of the sternum
  • bifurcation of the trachea (carina) occurs at this level (t4-t5)
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10
Q

Manubriosternal Joint

A
  • hinge-like joint btw manubrium and body of sternum

- allows hinge-like forward movements of sternum during inspiration and backward movement during expiration

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11
Q

Functions of the Nose 👃

A

1) Warms, cleanses, and humidifies inhaled air
2) Detects odors
3) Resonating chamber amplifies the voice

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12
Q

Bony and cartilaginous supports of the nose

A

1) Superior Half - nasal bones medially and maxillary laterally
2) Inferior Half - Lateral and alar cartilages
3) Ala Nasi - Flared portion shaped by dense CT, forms lateral wall of each nostril

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13
Q

Nasal Cavity

A

1) Extends from nostrils to posterior nares
2) Includes Vestibule and nasal septum
3) Vestibule - dilated chamber inside ala nasi (stratified squamous epithelium, vibrissae: guard hairs)
4) Nasal septum - divides cavity into r and l chambers called nasal fossae.

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14
Q

Which part of the nasal anatomy specifically warms, cleans and moistens the air for the lungs?

A

Turbinates and sinuses

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15
Q

Nasal Conchae

A
  • 3 folds of tissue on lateral wall of nasal fossa

- mucous membranes supported by thin scroll-like turbinate bones

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16
Q

*Nasal Meatuses

A
  • narrow air passage beneath each conchae

* - narrowness and turbulence ensures air contacts mucous membranes

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17
Q

*Olfactory mucosa vs. Respiratory mucosa

A

1) Olfactory mucosa - Lines roof of nasal fossa

* 2) Respiratory mucosa - Lines rest of nasal cavity with ciliated pseudo-stratified epithelium.

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18
Q

*Defensive role of mucosa?

A

*Mucus (from goblet cells) traps inhaled particles (i.e. bacteria) which is then destroyed by lysozyme and IgA

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19
Q

Function of cilia of respiratory epithelium

A

sweep debris-laden mucus into pharynx to be swallowed

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20
Q

Erectile tissue of inferior concha

A

venous plexus that rhythmically engorges with blood and shifts flow of air from one side of fossa to the other once or twice an hour to prevent drying

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21
Q

3 Divisions of the pharynx

A

1) Nasopharynx - psuedostratified epithelium
2) Oropharynx - stratified squamous epithelium
3) Laryngopharynx - stratified squamous

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22
Q

*Nasopharynx

A
  • posterior to choanae
  • dorsal to soft palate
  • receives auditory tubes and *contains pharyngeal tonsil
  • 90 degree downward turn traps large particles ( >10μm)
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23
Q

Oropharynx

A
  • space between soft palate and root of tongue
  • inferiorly down to hyoid bone
  • contains palatine and lingual tonsils
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24
Q

Laryngopharynx

A
  • hyoid bone to level of cricoid cartilage
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25
Q

Glottis

A

Vocal cords and opening between

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26
Q

Epiglottis

A

Flap of tissue that guards glottis, directs food and drink to esophagus

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27
Q

Differences in infants’ larynx

A
  • higher in throat, forms a continuous airway from nasal cavity that allows breathing while swallowing
  • by age 2, more muscular tongue forces larynx down
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28
Q

Attachments of true vocal chords

A

True vocal cords are attached anteriorly to the thyroid cartilage and posteriorly to the arytenoid cartilage

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29
Q

Larynx

A
  • Located between c3-c6 (in adults) and c3-c5 superiorly (in children)
  • framework formed by 9 total pieces of cartilage (3 paired and 3 unpaired)
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30
Q

3 paired vs unpaired cartilage of the larynx

A
  • Paired (arytenoid, corniculate, and cuneiform)

- Unpaired (Epiglottis, thyroid, cricoid)

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31
Q

Vertebral levels in the Larynx

A

1) Hyoid - c2/c3
2) Thyrohyoid membrane - c4
3) Laryngeal prominence - c5
4) Cricoid cartilage and start of trachea - c6

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32
Q

The 9 cartilages of the Larynx

A

1) Epiglottic - most superior
2) Thyroid - largest; forms laryngeal prominence
3) Cricoid - connects larynx to trachea
4/5) Arytenoid x2 - posterior to thyroid cartilage
6/7) Corniculate - attached to arytenoid cartilages like a pair of little horns
8/9) Cuneiform - support soft tissue between arytenoids and epiglottis

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33
Q

Narrowest portion of the airway on a pediatric patient?

A

Used to be considered the cricoid. but newer studies suggest it is the glottic opening

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34
Q

Laryngeal Cavity

A
  • Includes the rima glottidis and the glottis, and is narrowest portion of the upper airway in the adult
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35
Q

Rima Glottidis

A

Opening between true vocal cords and the arytenoid cartilages

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36
Q

Glottis

A

True vocal cords and the rima glottidis

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37
Q

Etrinsic Muscles

A
  • Connects larynx to hyoid bone
  • Elevates larynx up and forward during swallowing
  • Includes supra hyoid and infra hyoid muscles
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38
Q

Suprahyoid muscles

A

stylhyoid, mylohyoid and diagstric

39
Q

Infrahyoid muscles

A

omohyoid, sternothyroid, thyohyoid, and sternohyoid

40
Q

Aryepiglottic

A
  • narrows inlet

- closes glottis

41
Q

Oblique Aretynoid

A
  • narrows inlet

- closes glottis

42
Q

Result of Aryepiglottic and Oblique Aretynoid acting together

A

Together, they act as a purse-string sphincter during swallowing

43
Q

Thyroepiglottic

A

Widens inlet

44
Q

Intrinsic muscles

A
  • rotates cornicate and arytenoid cartilages
  • adducts vocal cords (tightens for high pitch sounds)
  • Abducts vocal cords (loosens for low pitch sounds)
45
Q

Muscles involved with movement of vocal cords?

A

1) Cricothyroids
2) Thyroarytenoids
3) Lateral Cricoarytenoids
4) Transverse arytenoids
5) Oblique Arytenoids
6) Posterior Cricoarytenoids

46
Q

Cricothyroids

A

Tense vocal cords

47
Q

Thyroarytenoids

A

relax vocal cords, also includes the vocals muscle which adjusts the tension of the cords

48
Q

Lateral Cricoarytenoids

A

adducts and classes cords

49
Q

Transverse arytenoids

A

adducts and closes cords

50
Q

Oblique Arytenoids

A

adducts and classes cords

51
Q

Posterior Cricoarytenoids

A

abducts, folds and open vocal cords

52
Q

Blood Supply to the Larynx

A

Blood supply to the larynx is supplied via the external carotids & subclavian arteries and internal jugular vein

53
Q

Sensory innervation of the larynx

A
  • Via CN X/vagus
  • Interior branch of superior laryngeal provides sensation for upper portion of the larynx own to and including upper half of the vocal cords
  • recurrent laryngeal nerve - transmits sensation below the true cords and half of the lower cords
54
Q

Motor innervation of the larynx

A
  • all intrinsic muscles except the cricothyroid are innervated by the RECURRENT LARYNGEAL nerve
  • crycothyroid muscle is innervated by superior laryngeal nerve
55
Q

Trachea characteristics

A

1) Fibrocartilaginous tube, approximately 10-20cm long and 12mm in diameter
2) Begins at the end of the larynx (C6) and extends to T5-6
3) Supported by 16-20 C-shaped rings of cartilage with smooth muscle posteriorly
4) The carina is the lower most portion of the trachea where it divides into primary bronchi
5) Lined with ciliated pseudostratified epithelium which functions as mucociliary escalator

56
Q

Removing Inhaled Particles

A

1) The lungs produce 100mL of mucous per day
2) Turbulent flow helps trap precipitate
3) Cough Reflex
4) Mucociliary escalator mechanism - Ciliated epithelial cells beat particles up the airway to be swallowed in the oropharynx which is Impaired by endotracheal intubation and volatile anesthetics

57
Q

Flow of inspired air from trachea to alveoli

A

Trachea&raquo_space;> L/R main bronchi&raquo_space;> Lobar bronchi&raquo_space;> Segmental Bronchi&raquo_space;> Bronchioles&raquo_space;> Terminal Bronchioles&raquo_space;> Respiratory Bronchioles&raquo_space;> Alveolar Ducts&raquo_space;> Alveolar Sacs&raquo_space;> Alveoli

58
Q

Conducting/Dead space includes ______ ?

A

Trachea&raquo_space;> L/R main bronchi&raquo_space;> Lobar bronchi&raquo_space;> Segmental Bronchi&raquo_space;> Bronchioles&raquo_space;> Terminal Bronchioles

59
Q

Respiratory/Gas Exchange includes _____ ?

A

Respiratory Bronchioles&raquo_space;> Alveolar Ducts&raquo_space;> Alveolar Sacs&raquo_space;> Alveoli

60
Q

Secondary (Lobar) Bronchi

A
  • Bronchospasm occurs here

- Three on the right, two on the left (related to lobes)

61
Q

SEGMENTAL BRONCHI

A
  • Bronchospasm occurs here, can be treated by increasing positive pressure, deepening the anesthetic, increasing the inspiratory time of ventilation, and directly spraying lidocaine into the trachea
  • Ten on right, eight on left
62
Q

TERMINAL BRONCHIOLES

A
  • Diameter of 1 mm and contain NO cartilage
  • Relatively thick smooth muscle wall compared to lumen
  • Can contract during asthma attack
  • No goblet cells
63
Q

Bronchial Circulation

A
  • Supplied by systemic circulation
  • Some mixes with alveolar venous return, causing an anatomic shunt – area of the lung where there is perfusion but no ventilation.
64
Q

Bronchial Innervation

A

1) Sensory & Motor via Vagus
2) Parasympathetic: Ach bronchoconstriction
3) Sympathetic: Epi/Norepi bronchodilation

65
Q

Respiratory Zone

A

-Composed of Acinus (terminal respiratory unit)
(Respiratory bronchioles Alveolar ducts, Alveoli
(Alveoli are formed from birth to age 4, they continue to maximally expand until age 8)

66
Q

Respiratory bronchioles

A

first segment of airway where gas exchange occurs (transitional zone)

67
Q

Alveolar ducts

A

walls completely lined with alveoli

68
Q

Alveolar sac

A

located at end of each 3rd generation of alveolar ducts

69
Q

What is the main mechanism for gas transfer from the alveoli into the blood?

A

Diffusion - More lipid soluble anesthetics will diffuse easier, resulting in build up in the blood stream

70
Q

Diffusion calculation

A

Diffusion = Area/Thickness

71
Q

In a normal lung, how large is the the area of the blood gas interface?

A

About the size of a tennis court

72
Q

Alveoli characteristics

A
  • 300 million in the adult
  • Polygon shape maximizes surface area
  • Surrounded by 1,000 pulmonary capillaries each
  • Two types
73
Q

Type I alveolar cells

A
  • Squaous
  • Form walls of alveoli
  • Involved in gas exchange
74
Q

Type II alveolar cells

A
  • Cuboidal
  • Produce surfactant
  • Differentiate into type I cells when needed
  • not significant component of the respiratory membrane
75
Q

Why is gas exchange limited in a chronically injured lung i.e. pulmonary fibrosis

A

because alveolar epithelium is lined entirely by type II cells

76
Q

Role of alveolar macrophages

A

eliminates foreign debris

77
Q

What are alveolar pores

A

aka pores of Kohn are opening in the walls btw adjacent alveoli that allow for collateral ventilation

78
Q

What is alveolar interdependence

A

If an alveolus start to collapse, the surrounding alveoli are stretched and then recoil, exerting expanding forces in the collapsing alveolus to open it.

79
Q

3 things that prevent alveoli collapse

A

1) Surfactant
2) Alveolar pores
3) Interpdependence

80
Q

Right vs Left Lung

A
  • Right lung (3 lobes, receives 60% of CO)

- Left lung (2 lobes and narrower; receives 40% of CO)

81
Q

Innervation of lungs

A
  • The lungs are innervated by the pulmonary plexus

- Sympathetic fibers T2-T6 and parasympathetic fibers from the vagus

82
Q

Pain receptors in lungs?

A

There are few to no pain receptors in lungs

83
Q

Parasympathetic vs Sympathetic innervation of the lungs

A

1) Parasympathetic fibers produce constriction of the airways and increase mucus secretion by the mucus glands
2) Sympathetic hormones produce dilation of the airways (beta-2 response)

84
Q

Pleural Fluid

A

10cc produced per lung to prevent friction in pleural cavity and create a pressure gradient

85
Q

Visceral vs. parietal pleura

A

1) Visceral pleura - attached to outer surface of the lungs

2) Parietal pleura - line the wall of the thoracic cavity

86
Q

Diaphragm

A
  • Accounts for most tidal volume (60-75%)
  • Dome shaped muscle that forms the floor of the thorax and separates the thoracic cavity and the abdominal cavity
  • rvation is supplied by paired phrenic nerves (c3-c5; c4 = 70% contribution)
  • Allows for half of the diaphragm to continue working if one side is damaged
  • Motor AND sensory nerves
87
Q

2 halves of the diaphragm

A

1) Hemidiaphragms - Right side, which is higher (raised up by liver), pushes left side down.
2) Major diaphragmatic foramina - Includes vena cava foramen, esophageal hiatus and aortic hiatus

88
Q

Referral areal for diaphragmatic pain

A

shoulders

89
Q

Major factors affecting the position of the diaphragm

A

1) Recoil of lungs
2) Thoracic viscera pressure (i.e. CHF)
3) Abdominal viscera pressure (i.e. pregnancy)
4) Abdominal muscle activity (contraction pushes diaphragm upward)

90
Q

Movement of diaphragm during normal breathing

A

1) 1-2cm normal tidal breathing

2) 7-13cm with deep breathing

91
Q

Intercostal Muscles

A

1) External Intercostals - Oriented obliquely forward and downward, responsible for 25% of TV, lifts up ribs during inspiration
2) Internal Intercostals - Oriented backwards and downwards, assist in expiration by pulling ribcage down and aids in forced expiration.

92
Q

3 factors affecting ventilation

A

1) Surface Tension - Inwardly directed force in the alveoli which must be overcome to expand the lungs during each inspiration
2) Elastic Recoil - Decreases the size of the alveoli during expiration
3) Compliance - Ease with which the lungs and thoracic wall can be expanded

93
Q

Whta is Spontaneous Epistaxis? Where is it most common?

A

Spontaneous nosebleed - most common site is the inferior Concha

94
Q

8 Differences in Infant/pediatric airway vs. Adult airway

A

Infant/Pediatric airway:

1) Narrow nostrils
2) Round occiput
3) Tongue relatively large for mouth
4) Epiglottis omega shaped and floppy
5) Larynx higher in neck
6) Vocal cords slant anteriorly
7) Short Neck
8) Cricoid ring narrowest in diameter

CRNA Adv. A&P (8 decks)

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