resp Flashcards
alveolar macrophages - features + function
where do they go
- main feature: live in the alveoli - outside the body!
- > eat particles that didnt get trapped by mucous
either move up mucociliary escalator; or move back through into alveolar wall and stay there till death
Alveolar-capillary membrane
- thickness
- surface area
- alveolar volume
- capillary volume
- 0.5 micron
- 50-100m2
- 3-6 L
- 80mL (increases with increased CO)
around how many dichotomous branchings are there in the lungs?
23
At what level do bronchioles start
around 10-15th dichotomous branch
Clinical signs of acute pneumonia? (11)
Relatively well; then acutely ill
- resolves by crisis
signs:
- abrupt onset
- unrelenting cough
- lots of sputum
- fever
- raised WBC
- pleuritic chest pain
- sputum may be blood-stained
- G+ diplococci in sputum
- bacteraemia
- consolidation
- bronchial breathing
Clinical signs of atypical (interstitial) pneumonia (5)
“flu-like”
- symptoms are symptomatic and not as debilitating
- “walking pneumonia” - slower onset; cough a long time
- malaise
- headache
- diarrhoea
- aches; pains
- dry cough
Common cold - is lab diagnosis necessary?
- treatment
unnecessary
supportive treatment
componets of blood-gas barrier
lung: surfactant; type 1 pneumocyte; basal lamina connective tissue
capillary: basal lamina; endothelial cell; plasma
(sometimes basemet membranes are fused and there is no connective tissue)
Crepitations indicate pathology of which site(s) in the lungs?
what is the best test for this area?
terminal lung units - alveoli; parenchyma; interstitium
best test - ct scan (CXR will show gross abnormality)
croup (LTB)
- is lab diagnosis necessary?
- treatment
seldom necessary - clinical diagnosis and usually viral
if severe - inhaled steroids; otherwise no treatment
Definition of asthma
- 2 word
- longer
2 word: reversible bronchoconstriction
longer: increased responsiveness of airways to various stimuli; leading to episodic bronchoconstriction which is at least partially reversible
epiglottitis
- is lab diagnosis necessary?
- treatment
yes - whenever possible
-> be careful - irritation of the area -> inflammation -> closed off airways
treatment
- essential
- always bacterial
- very severe
features of type I pneumocytes - predominance (how much surface area they take up) - function - what are the junctions between cells and basal lamina - can they reproduce
95% of surface area gas exchange tight junctions - prevent leak of ECF into alveoli; basal lamina is thick and prominent - no - die and must be replaced (by type II)
features of type II pneumocytes - how much surface area do they take up? - function - structure - features - can they reproduce
- 5% (though more numerous than type I) - secrete surfactant - cuboidal cells - short microvilli + lamellar bodies that contain surfactant - yes - divide and give rise to both type I and II pneumocytes
How do antibodies neutralise influenza virus?
influenza - binds receptors via receptor-binding site on HA - receptor binding site - surrounded by 5x antigenic sites - antibody binds to one of these -> sterically inhibits binding of HA to receptor (ab is similar size to HA)
How does antigenic drift occur in influenza? in epidemics?
- mutations in antigenic sites are selected for if they prevent the binding of antibodies - antigenic drift = mutation + selection mutation: error of replication of viral RNA-dependent RNA polymerase epidemic - change in all 5 sites - point mutations - or reassortment -> swapping of gene segments on co-infection of a single cell -> get totally different HA/NA (problem: avian have specificity for a2-3 binding; and we have receptors with a2-6 -> but if avian + human co-infect a mixing vessel - eg pig - then we could have recombination such that genes are adapted for human growth; but HA and NA are avian. then there is mutation + selection for a2-6 specificity)
How does consolidation in lobar pneumonia spread through the lung?
Moves through pores between alveoli - get the whole lobe
How does diffusion limitation of oxygen occur in high-altitude environment?
High altitude - have lower atmospheric PO2 -> the gradient between partial pressures is lower -> have slower diffusion across membrane https://onenote.officeapps.live.com/o/GetImage.ashx?Fi=SDFD3144C4D713EDE3%21370&C=1__BAY-SKY-WAC-WSHI&ak=m%3Den%2Dau&ObjectDataBlobId=%7B52701cc9-9860-8048-b1c5-cc06599fc06b%7D%7B1%7D&usid=8e68f0f2-010c-446e-b7c9-63d80c9d17ee&build=16.0.2430.1026 also - the rate of rise of PO2 for a given increase in blood O2 is lessened - steep slope of O2 dissociation curve when PO2 is low => exercise may result in diffusion impairment of O2
how does influenza spread between people?
droplet infection - coughing; sneezing doesn’t spread too far (cf measles)
How does the pulmonary system maintain low P when CO increases?
- recruitment of pulmonary vessels that are not normally perfused - dilatation of vessels
How many subtypes of influenza A and B are there?
B - no subtypes A - subtypes according to which HA; NA combo it has - HA1-17 - NA1-10
If there are signs that abnormality is respiratory; but the chest sounds clear - what could this indicate? examples?
pathology is VASCULAR ** - PE - infarct can irritate pleura (pleuritic pain); cause haemoptysis; but chest sounds clear - pulmonary hypertension; pulmonary vasculitis -r are
Influenza virus - family - genome structure - envelope? what are the different types?
- Orthomyxoviridae family - genome: segmented ssRNA; -ve sense; arranged as 8 RNP’s RNP = ribonucleoprotein (genome wrapped in helix; nucleoproteins; attached RNA-dependent RNA polymerase) - enveloped 3 types - A; B; C - structurally similar; but no immunological cross-reactivity - only A and B are major human pathogens - A can also infect other species
Influenza: ion channel blockers - name drugs - influenza A or B? - how does it work? - administration - populations
- adamantanes - amantadine; rimantadine - only A - blocks M2 ion channel - no acidification of virus interior; RNP’s remain fused to matrix - oral; daily - children; prophylactic in nursing homes - but developing drug resistance so used rarely
Influenza: NA inhibitors - name drugs - influenza A or B? - how does it work? - administration - populations
- relenza (zanamivir); tamiflu (oseltamivir) - both A and B - blocks NA -> virus can’t cleave sialic acid; clumps around release site as HA binds receptor - both 2x daily - relenza: inhalation by mouth; tamiflu: oral - all ppopulations -but circulating H1N1 strains are showing resistance to tamiflu
Interesting features in 1918-1919 flu pandemic
25-30% of human population clinically infected; 20-50million deaths deaths unusually high in 15-35 age group; often rapid symptoms: pulmonary oedema; haemorrhage; cyanosis
Interesting features of avian H5N1 flu
- HA has a different cleavage site- can be cleaved by enzymes in any cell in body -> systemic infection - kills rapidly - highly lethal (~60%) - so far no jump human to human - susceptible to NA inhibitors - but need to get them quickly
Interesting features of swine-origin H1N1
- greater ability to replicate in lungs than seasonal flu - some health; young adults getting viral pneumonia - death in younger people
Lung volumes
https://onenote.officeapps.live.com/o/GetImage.ashx?Fi=SDFD3144C4D713EDE3%21370&C=1__BAY-SKY-WAC-WSHI&ak=m%3Den%2Dau&ObjectDataBlobId=%7B6bf1b254-cfc1-42b2-a1bc-da5366896ab7%7D%7B1%7D&usid=8e68f0f2-010c-446e-b7c9-63d80c9d17ee&build=16.0.2430.1026
On what basis is diagnosis of asthma made? clinical/physiological/histological…?
clinical + physiological evidence histology: features on biopsy are largely non-specific
otitis media
- is lab diagnosis necessary?
- treatment
lab diagnosis - seldom necessary (know is normal commensal bacteria)
(can aspirate fluid from middle ear
treatment: antibiotics if: 48hrs) and severe
- generally children do better w/out antibiotics
Pathogenesis of the common cold (applies to most URT viruses)
virus enters airway virus adsorved onto respiratory epithelium virus replicates in epithelial cells virus shedds - clear fluid outpours from lamina propria (runny nose) - cell damage - infection spreads host defences are activated secondary infection by bacterial commensals - epithelium and cilia have been damaged - overgrowth of commensals - fluid becomes purulent then recovery - clearing of bact/virus by interferon and antibodies; regeneration of epithelium
pharyngitis/tonsillitis - is lab diagnosis necessary? - treatment
lab diagnosis if possible (kit - swab back of throat - look for grp A strep antigens) can’t clinically diagnose if bacterial or viral treat with antibiotics if bacterial; otherwise supportive
pleural histology
parietal pleura: mesothelium; supported by basal lamina and fibrous connective tissue visceral pleura: have microvilli on surface - can trap hyaluronic acid for lubrication; but is conduit for bugs
sinusitis - is lab diagnosis necessary? - treatment
seldom necessary - can see fluid in cxr if need be; or ent surgeon can aspirate fluid treatment: if bacterial and severe - antibiotics otherwise - supportive
Steps in pathogenesis of influenza? what causes pathology? consequences of infection
Pathogenesis: 1. droplets containing virus enter respiratory tract 2. virus binds to sialic acid-containing receptors on non-ciliated respiratory epithelium3. Virus replicates in epithelial cells of upper and lower respiratory tract; particularly in large airways Pathology: tissue damage and inflammatory response -> local symptoms cytokines; interferon [DC and macrophages] -> fever (IL-1); malaise; head and muscle aches (IFN) Consequences:- Acute infection - in immunocompetent individuals; the pre-existing and developing immunity is sufficient to clear virus - in some; viral replication occurs in lung parenchyma -> primary viral pneumonia- secondary bacterial infection - viral replication may occur in ciliated epithelium of trachea/bronchi - destruction of cilia - allows commensals to invade lower down
Steps in replication cycle of influenza (10)
- Viral HA binds sialic acid-containing receptor on surface of respiratory epithelial cell 2. Virus taken in by receptor-mediated endocytosis 3. Endosome becomes acidic; HA changes (because has been cleaved by trypsin Clara previous) and hydrophobic region is exposed - fusion of viral envelope + endosomal membrane 4. Viral RNPs are released - M2 ion channel has acidified environment inside virus - releases RNPs (bound to matrix protein) - RNPs enter nucleus 5. Viral RNA amplification; production of mRNA 6. Viran NPs and proteins are synthesised in cytoplasm; shunted back to nucleus; combine with RNA => RNPs are formed 7. HA and NA are also formed; glycosylated in ER and golgi; and deposited onto cell surface 8. Biruses bud out of cell - RNP’s acquire surface glycoproteins and envelope 9. NA cuts salic acid receptors from cell surface -> allows budding viruses to move away from cell 10. Virus HA is cleaved by tryptase Clara outside cell -> becomes infectious
structure of alveoli: - what type of epithelium? - what is bw alveoli?
epithelium: simple squamous intra-alveolar septum between alveoli - pores (allow air to equilibrate bw alveoli) - reticular + elastin fibres - keep alveoli open
structure of bronchiole
- have slightly changed respiratory epithelium (progressive loss of goblet + ciliated cells; gain in Clara cells) - still have smooth muscle - but no cartilage
structure of respiratory bronchioles
- epithelium: cuboidal -> squamous - have intermittent alveoli -> eventually just peter out and become wall-to-wall alveoli
Target populations for influenza vaccine
> 65 yo immunocompromised health workers diabetes; cancer chronic lung; heart; kidney disease
Termial bronchiole structure
- epithelim: no goblet cells; clara cells + cuboidal epithelium with some cilia - and 1-2 layers of smooth muscle
trachea - histology - what are the 3 layers - what is defining histology of trachea?
mucosa (resp epithelium) submucosa (glandular) adventitia (cartilage + CT) - defining: C-shaped hyaline cartilage
Upper respiratory microbiota - aerobic or anaerobic?
both - significant amounts of anaerobobic in nasal washings; saliva; tooth surfaces; gingival scrapings
What % of people typically are infected with influenza each year in Australia?
10-20% of population
What 3 groups of microbes cause pneumonia? Examples of each when they cause disease
- URT flora - normal commensals - S. pneumoniae; H. influenzae; Staph aureus - cause disease when host immune system is compromised 2. Enteric saprophytes - E. coli; Pseudomonas - see in hospitalised patients - cause pneumonia by contaminating airways; or via blood 3. Extraneous pathogens - floating in environment - Legionella phenumophilia; tuberculosis
what are 3 obstructive lung diseases
asthma
COPD (emphysema; chronic bronchitis; small airways disease)
bronchiectasis
what are 4 restrictive lung disease
idiopathic pulmonary fibrosis
pneumoconiosis -
asbestosis
sarcoidosis “honeycomb lung”
What are 4 ways that pathogens enter the lower respiratory tract?
- inhalation of pathogens - air droplets 2. aspirations of infected secretions from URTI 3. aspiration of infected particles - gastric contents; food; drink; foreign bodies 4. haematogenous spread
what are clara cells? where are they found and why are they importat in that location? what other fuctions do they have?
columnar-cuboidal cells with short microvilli secrete surfactant found lower down in bronchioles - important there because it is wet and sticky; but there is no cartilage - surfactant neeeded to keep them open also have glycoprotin granules; and may neutralise toxins
what are components of load of respiratory work
stiff lungs narrow airways chest wall diaphragm
What are microbial causes of acute exacerbations of chronic bronchitis? (2)
pneumococci and/or H. influenzae -> commensals
What are some airways diseases that cause dyspnoea
upper airways - tumour; foreign body; croup
lower airways - asthma; COPD; bronchitis
what are some alveolar diseases that cause SOB (4)
pneumonia;
lung collapse;
pulmonary oedema;
pulmonary fibrosis
What are some common causes of croup (LTB) (3) usually viral or bacterial?
viral parainfluenza virus influenza A RSV
What are some common causes of laryngitis? (3) usually bacterial or viral?
usually viral - some bact parainfluenza virus influenza H. influenzae
What are some common causes of pharyngitis/tonsillitis with nasal involvement? (5) usually bacterial or viral?
usually viral; maybe bacterial enterovirus adenovirus influenza reovirus s.pyogenes - group A; C; G
What are some common causes of pharyngitis/tonsillitis without nasal involvement (4) usually viral or bact?
usually viral parainfluenza virus enterovirus adenovirus influenza
What are some common causes of primary sinusitis? viral or bacterial?
usually part of common cold syndrome -> viral
What are some common causes of secondary sinusitis? (2) usually bacterial or viral?
usually bacterial involvement due to decreased immunity (after common cold etc) s. pneumoniae - commensal H. influenzae - commensal
What are some common causes of the common cold syndrome (7) usually bacterial or viral?
usually viral rhinovirus parainfluenza virus enterovirus (in summer) influenza coronavirus HMPV - human metapneumovirus RSV
What are some complications of pneumonia?
acute lobar: - pleural fibrosis -> pleuritis - empyema - collection of pus in pleura; walled off by fibrosis bronchopneum: - abscess atypical: - bronchiectasis - interstitial fibrosis - cystis
What are some microbiota found in latent state in some healthy people? - in lung (2) - in lymph nodes; sensory nerves (3)
P. jirovecii carinii M. tuberculosis sensory/lymph - CMV - HSV - EBV
what are some pleural/chest wall diseases that cause SOB (3)
pleural effusion;
pneumothorax;
chest wall deformity
what are some pulmonary vascular diseases that cause dyspnoea
PE; vasculitis; primary pulmonary hypertension
what are some resp muscle diseases that cause SOB (2)
resp muscle weakness;
phrenic nerve palsy
What are some risk factors for different pathogens in pneumonia?
Occupation - contact wiht animals - Chlamydophyla (birds) - hides - anthrax - air conditioning - C. pneumophilia; Legionella - soils - Legionella longbechea Travel - diff species Homelessness - mycobacteria - alcoholism - Klebsiella
What are some specimen types for lab analysis of pneumonia?
- sputum (must be properly collected; not contaminated by URT flora) - transtracheal aspirate - aspiration via tracheostomy; endotracheal tube; bronchoscope - pleural tap - lung biopsy - blood - culture and serology
What are some URT microbes that are carried in 1-10% of healthy people? (2)
Strep. pyogenes meningococci (Neisseria)
What are some URT microbes that are carried in >50% of all people (7)
viridans streptococci (common source of endocarditis - after dental work) Neisseria spp (low grade Neisserias) Corynebacterium spp G- anaerobes H. influenzae (not type B) C. albicans S. pneumoniae (in 15-85%) - tend to be the less pathogenic serotypes
What are some URT microbiota that are carried in <1% of healthy people (uncommon) (3)
Enterobacteria Pseudomonas C. diphtheriae
What are the 3 other cell types found in respiratory epithelium (other than ciliated columnar; basal stem cells; goblet cells)
brush cells with microvilli - maybe sensory? serous cells - secretory small granule cells - endocrine
What are the 4 stages of lobar pneumonia?
Congestion Red hepatisation - PMNs but early haemorrhage into alveoli Grey hepatisation - mesh of fibrin + PMN + macrophages Resolution
What are the actions of antibodies in influenza virus?
- inhibit attachment of HA to epithelial receptors -> neutralises - Ab + C’ lysis of cells - promotes phagocytosis
What are the cassic features of lobar acute pneumonia?
Consolidation affecting entire lobe; often involves pleura
What are the classic pathological features of bronchopneumonia
patchy; multifocal consolidation - areas involved are centred around small airway?
what are the classic pathological features of interstitial pneumonia
widened alveolar septa infiltrated by inflammatory cells - inflammatory cells involved are “chronic” - see also bronchiolitis
What are the clinical systems that can cause SOB? (6)
- respiratory
- cardiac
- muscle weakness
- metabolic
- anaemia
- psychogenic
what are the components of drive of respiratory work
higher centres (limbic system) mechanoreceptors irritant receptors chemoreceptors baroreceptors temperature
what are the conducting airways of the lung
trachea bronchi bronchioles -> to terminal bronchioles
What are the current influenza type A subtypes?
H1N1; H3N2
what are the differences between structure of trachea and bronchi?
- cartilage rings become cartilage plates - there is smooth muscle between lamina propria in mucosa and submucosa
what are the distinguishing features of influenza? other common symptoms? other significant clinical features
- muscle aches; fatigue; loss of apetite - fever/chills; cough; headache normal xray acute infection lasting ~7+ days weakness/cough may last weeks no persistence of virus
What are the forms that CO2 is carried in blood (3)
- dissolved (10%) - attached to proteins (inc Hb) as carbamino compound (30%) - as bicarbonate (60%) - formed in RBCs under carbonic anhydrase
What are the lung sensors involved in control of breathing?
pulmonary stretch irritannt j receptors (proprioceptive)
What are the main 3 components of the respiratory epithelium
ciliated columnar cells (30%) - move mucous goblet cells (30%) - produce mucous basal stem cells (30%) - renew epithelium
What are the main functions of the lung (3)
oxygenate pulmonary blood remove CO2 from blood maintain acid-base balance
What are the metabolic requirements of O2 at rest How much CO2 is produced (ml/min)
use 250ml/min O2 produce 200 ml/min CO2
What are the metabolic requirements of O2 during exercise How much CO2 is produced (ml/min)
use >4000ml/min O2 produce >4000 ml/min CO2
What are the most common microbial causes of pneumonia (broad) What are the others
Bacteria - 85% Viruses fungi/protozoa - immunocompromised host
What are the patterns of alveolar pneumonia?
Lobar pneumonia Bronchopneumonia https://onenote.officeapps.live.com/o/GetImage.ashx?Fi=SDFD3144C4D713EDE3%21411&C=1__BAY-SKY-WAC-WSHI&ak=m%3Den%2Dau&ObjectDataBlobId=%7B5f13613f-e9d8-45ef-970d-e21e5380854d%7D%7B1%7D&usid=6da1a1dd-7c3b-45ba-a071-61c158b455bc&build=16.0.2430.1028
what are the possible causes of disease (1 + 11) (categories)
Congenital/Genetic Acquired = I DIVINE TIME - Infectious - Degenerative - Inflammation/Immune reaction - Vascular - Iatrogenic (Drugs; Surgery; Radiotherapy) - Neoplastic - Environmental - Trauma - Idiopathic - Metabolic - Endocrine
What are the predominant causes of alveolar “classical” pneumonia? Which pattern (lobar/broncho) do they cause?
Don’t cause one or the other -depends on the virulence of organism; or state of patient defense Bacterial primarily: pneumococci (commonest) H. influenzae Staph. Klebs. Legionella TB Chlamydophilla Lobar: most common - S. pneumonia (90%) Broncopneumonia: Gram negative (esp pseud); Staph.
What are the predominant pathogens in intersitital “atypical” pneumonia?
viruses + bacteria of “atypical” pneumonia Bacterial: Mycoplasma pneumoniae (commonest) Coxiella burnetti Legionella spp. Chlamydia pneumoniae Viral: influenza RSV adenovirus
What are the respiratory causes of dyspnoea (anatomical approach) (5)
Airways disease Alveolar Disease Pulmonary vascular disease pleural and chest wall disease respiratory muscle disease
what are the respiratory structures of the lung
respiratory bronchioles alveoli
What are the stages in asthma?
Sensitisation phase Asthma phase - trigger - acute/immediate response - late phase response
What are the structural components of influenza virus?
viral envelope surface glycoproteins - HA - hemagglutinin - “gripper” - binds receptor - NA - neuraminidase - “snipper” - cuts of SA on viral release - allows virus to go off and infect others matrix - M1 protein - matrix - M2 ion channel - allows H+ in; acidify interior of virus; and allow RNP release inside cell genome - 8 RNPs
What are the targets of vaccine-induced immunity?
antibody to HA - prevents attachment of virus to cell antibody to NA - blocks the release of virus (can’t cleave sialic acid - clumps around cell)
What are the three broad groups of patients that need to be considered when there is clinical presentation of pneumonia? Why are they significant? What do they indicate
Significant - guides empirical treatment (the groups are associated with specific pathogens) -> only small % of pneumonias actually get a microbiological diagnosis 1. Community acquired -> 50% of these are Strep. pneumoniae 2. Hospital acquired -> gram negatives 3. Immune compromised host - bacteria; fungi; protozoa (eg Pneumocystic jirovecii)
What are the two groups of antivirals?
Ion channel (M2) blockers NA inhibitors
What are the two patterns of pneumonia?
Classical = alveolar - consolidation (neutrophils) in alveolar spaces Atypical = interstitial - no inflammatory cells in alveoli - may fill up with fluid
What are the two types of alveolar epithelial cells
type I and type II pneumocytes
What are the two types of work of breathing?
Elastic WOB - expansion of lungs/chest wall Resistive WOB - airflow through bronchi
What cell types are found in alveoli? (6)
Alveolar macrophages Type I pneumocytes Type II pneumocytes Fibroblasts Inflammatory cells Endothelial cells
What cells are involved in (alveolar) acute pneumonia? What location?
neutrophils in alveolar spaces
what changes in systolic pressures are seen between inspiration and expiration?
normally: see a difference in BP of pooling of blood in pulmonary system this decreases venous return to left atrium -> decreases cardiac output -> decreases systolic BP on inspiration with forceful breathing: see a difference > 15 mmHg - generate “higher” negative pressures -> see a greater difference between inspiration/expiration pressures
what changes in the respiratory epithelium are seen in bronchioles (compared to further up in airways)
loss of goblet cells loss of ciliated columnar cells (further down than goblet - catch mucous) gain clara cells
what characterises obstructive and restrictive lung disease?
- chronic - diffuse - non-infectious
clinical definition: no infection; no mass; doesn’t go away -> is probably one of these
what characterises obstructive lung disease on spirometry?
decreased FEV1
no change FVC
what characterises restrictive lung disease on spirometry
no change FEV1
decreased FVC
what components make up the submuscosa of the trachea
glands + connective tissue -> keep trachea moist glands: mucous and serous
what componets make up the adventitia in the trachea
cartilage and thin layer of CT (bind into neck)
What determines resistive WOB in a lung where is most resistance?
- airway resistance high: in early bronchi low - in small airways - because of their large number
What determines the elastic WOB? What does this depend on?
- compliance of lungs (how much you need to change P to get a change in Vol) - depends on: tissue composition; surface tension in alveoli
what differentiates bronchiole from bronchus?
bronchiole - no cartilage
What effect does 2;3DPG (BPG) have on oxygen saturation
2;3BPG stabilises deoxyHb -> shifts curve right -> doesn’t allow oxygen binding (insert into cavity between beta units of Hb) 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
What effect does pH have on oxygen saturation
acid stabilises deoxyHb -> low pH -> shift curve right (more likely to give O2) 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
what effect does temperature have on oxygen saturation of blood
heat - weaken bond bw O2 and Hb -> shift saturation curve right (more likely to give O2 at high T) 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
What is a major difference between the systemic and pulmonary circulation?
Pulmonary - low P (15mmHg - mean) Systemic - high P (100 mmHg - mean)
What is are some common causes of otitis media? (3) usually bacterial or viral?
bacterial H. influenzae pneumococci M. catarrhalis (commensal)
what is breathlessness?
- when there is a recognition by the patient of inappropriate relationship between respiratory work and total body work
- increase in load or drive
What is bronchiolitis? symptoms? What micro-organism most commonly causes it? Who normally develops it; and what is the theory behind its development
narrowing of bronchioles; almost exclusively in mother’s antibodies to RSV trigger immune response; inflammation in airways -> narrowing -> bronchiolitis
What is empyema? What organisms? What does it develop secondarily to?
pus in pleural cavity - often walled off by fibrosis Staph. aureus secondary to pneumonia
what is fuction of epiglottis
flap vale - coordinate breathing + eating - keep food away from airways
what is function of larynx
keep fluids out of airways - phonation - vocal chords
what is in the mucosa of the trachea?
respiratory epithelium + lamina propria
what is PaO2/PaCO2 (definition)
concentration of gasses dissolved in plasma -> driving pressure for O2 to bind Hb
What is resting cardiac output? How much O2 does this deliver is this enough during rest?
CO = 5L blood/min delivers 1000ml/min of O2 (blood - 200ml O2/L blood) rest: only need 200ml/min -> this is definitely enough
What is the best-guess treatment for community-acquired pneumonia? When do you modify?
Best guess: beta lactam + something that isn’t a beta-lactam eg pen G/amoxycillin + doxycycline/macrolide -> the second one: for atypical organisms - all of these are intrinsically resistant to beta-lactams Modify if -severe -specific RF’s point to a pathogen -know the cause
What is the cellular-mediated adaptive immune response to influenza? How broad is the response? How long does immunity last?
CD8 cells - kill virus infected cells -> keep viral load low until Ab’s are formed; and assist in clearance of virus Recognise peptides from internal antigens of virus - broadly cross-reactive between different Type A’s (but not bw A and B) Immunity is not long-lived; but you can boost it by repeated exposure to virus Can’t prevent infection - only kills already infected cells
What is the epithelium that covers most of the respiratory system Where in resp system is it found
respiratory epithelium (pseudostratified ciliated) found in the airways and much of nasopharynx
what is the function of sinuses?
phonation conditioning of air
what is the function of the larynx
divert food/drink from airways phonation (sound production) - lungs are like bellows; push air over larynx to vibrate vocal chords
what is the function of turbinate bones? how does it do this
warm and moisten air coming in cool and condense moisture out of air as goes out => avoid dehydration -> mucous membrane
what is the incubation period of influenza? infectious period?
1-5 days (depends on viral load) 5-6 days infectious
what is the lower respiratory tract
below trachea
What is the microbial common cause of acute bronchitis
usually part of viral URTI
What is the most common cause of epiglottitis
H. influenzae type B
What is the most useful first test for obstruction in airways?
lung function tests - spirometry (look for flattened curve); flow-vol
What is the PO2 at 18000 feet
80 mmHg
What is the PO2 at sea level?
160 mmHg
What is the range of pressures in the pulmonary system
25 - 8 mmHg
What is the treatment for hospital-acquired pneumonia?
depends on severity and risk group
What is the upper respiratory tract
above trachea
What is the way of thinking when investigating SOB as clinical sign?
Look at clinical system -> then an anatomical approach -> then clinical exam -> focused tests
Need convergence of RF’s; associated symptoms; clinical signs -> organ directed tests
What keeps alveoli open? (3)
surfactant elastin fibres positive air pressure
What limits change in PaCO2
high PaCO2 - only ever due to inadequate ventilation -> diffusion limitation for CO2 only in very severe abnormalities of A-C membrane There is an inverse relationship between the PaCO2 and alveolar ventilation - if increase ventilation - decrease PaCO2
What limits oxygenation of blood?
Not normally diffusion limitation
- at rest - almost all O2 is transferred within 0.25 seconds; but blood stays in capillary for 0.75 seconds
- at exercise: blood stays in capillary for less time; but still usually enough for oxygen saturation to equilibrate
=> only have diffusion limitation if the A-C membrane is grossly abnormal
=> normally: perfusion limitation (limited by number of Hb binding sites)
what makes up a lobule (3)
terminal bronchiole + respiratory bronchiole + alveolar duct/sac/alveolus
what makes up an acinus? (4)
respiratory bronchiole + alveolar ducts + alveolar sacs + alveoli
What micro-organisms are commonly found in lung abscesses
Mixed anaerobes ?+ Staph.; Klebsiella
What pattern of pneumonia do community-acquired infections present as?
Lobar 20-50 year olds commonly antecedent to viral URTI
What pattern of pneumonia do hospital-acquired infections present as?
bronchopneumonia - esp G- bacteria (pseud); staph - usually secondary to to some pre-existing chronic disease - COPD; congestive HF; malignancy; CF) - or post-op complication
What receptors does influenza recognise? what is significant about the receptor’s structure?
Sialic acid-containing receptors- found on non-ciliated respiratory epithelium receptor has glycoprotein with sidechains - sialic acid is the terminal sugar in sidechain- linked to galactose by an α2-6 linkage in humans
What sensors are involved in the control of breathing?
Chemoreceptors (central and peripheral) Lung receptors Upper airway receptors; joint and muscle receptors; painful stimuli
what strains does the influenza vaccine contain?
most recent strain of type A: H1N1; H3N2; type B
what structures are important in nasopharynx? (3)
sinuses turbinate bones olfactory epithelium
What syndromes does rhinovirus commonly cause?
rhinitis -> only upper respiratory tract - replication needs lower temperature
What tests look at lung parenchyma?
CXR; ct (good at imaging parenchyma)
What vaccines are used to prevent pneumonia? (3)
Influenza vaccine (influenza is RF for pneum) pneumococcal vaccines - kids: 13 valent conjugate - adults: 23 valent polysaccharide Specialised vaccines for diff high-risk groups (diff pathogens)
When do you have diffusion limitation of oxygen? (3)
- intense exercise - if have some abnormality of A-C membrane - thickening of blood-gas barrier - alveolar hypoxia
When is gas exchange most efficient? How do you measure this measure?
when ventilation and perfusion are matched in all; and across all A-C units (300 million) V/Q = 1 Use V/Q scan - ventilation scan: inhale radioactive; non-absorbable substances - perfusion scan - inject radioactive particles - lodge in small pulmonary arterioles
Where are the central chemoreceptors located what do they respond to
- ventral surface of medulla - surrounded by CSF - sense CSF [H+] - reflection of CO2 in cerebral capillaries
Where are the peripheral chemoreceptors What do they respond to
carotid bodies (bifurcation of common carotids) aortic bodies (arch of aorta) PaO2 pH PaCO2
where do you find laminar flow in the airways?
in small airways - depends on number of tubes
Where do you find turbulent flow in the airways?
in large airways - this is less dependent on diamter of tubes and gas viscosity - affected by density of air
where in the respiratory tract do parainfluenza viruses usually cause infection? what syndromes?
upper and lower more so upper; but throughout the tract cause: - rhinitis - pharyngitis - laryngitis - tracheitis to lesser extent - bronchitis - bronchiolitis - pneumonia
Where is the central control for breathing? (involuntary) what is its input/output
Brainstem - medulla and pons - automatic rhythmic inspiratory stimuli; sometimes expiratory stimuli input: peripheral sensors output: major output - phrenic nerves can be overridden by cortex
where is the central controller for breathing (conscious)
cortex
Which groups are at risk of complications/death from influenza
young elderly underlying chronic heart; lung; renal; metabolic conditions obese people pregnant women
Which pneumonia pathogens can you detect antigens for? (serological diagnosis)
common viruses Bordetella pertussis Legionella pneumophila type 1
Which pneumonia pathogens can you look for antibodies for (Serological analysis) what do you look for?
Mycoplasma pneumoniae Legionella pneumophila Chamydophila and Chlamydia spp Coxiella burnetii specific IgM; rising titre
Which respiratory muscles are used for expiration?
normally: passive - elastic recoil of lungs generates positive intra-pulmonary pressure in active: Internal intercostals Abdominal muscles
Which respiratory muscles are used for inspiration? What are they innervated by Which dimension of thorax do they change
Diaphragm - phrenic nerve - increase longitudinal and lateral dimensions External intercostals - intercostal nerves - increase AP diameter (sternocleidomastoids) - in active inspiration - raise sternum and elevate first 2 ribs
Why does influenza virus require the action of tryptase Clara?
HA (hemogluttinin) needs to be cut at the cleavage site; so that in the acidic environment of the endosome; a hydrophobic fusion peptide will be revealed - allow the viral envelope to fuse with endosome membrane This confines the influenza virus to the respiratory tract
Why is it important to make a specific diagnosis for pneumonia?
- appropriate antibiotic prescribing - there are some pathogens you really want to identify (SARS; MERS; Influenza; Legionella; bioterrorism agents; community-acquired MRSA) - and some that you probs want to know about (gram neg rods; eg P. aeruginosa; penicillin G-resistant S. pneumoniae)
why is the influenza virus localised to the respiratory tract?
requires tryptase Clara to become infections- tryptase Clara cleaves HA - allowing a hydrophobic region to be exposed; and thus allowing virus to fuse with endosome when inside cell and release its genome
What are some causes of medically undiagnosed dyspnoea
Breathlessness in young athletes (maybe normal, performance anxiety, atopic asthma..)
Deconditioning (do aerobic training to confirm)
Psychogenic
What are some clues that dyspnoea may be psychogenic?
- need to take deep inspiration
- oppressive chest, compressed chest
- anxiety: ervous, restless
- tingling in fingers, feet, face, head
- language can give it away - clue to physical manifestation of anxiety
- often SOB at rest - goes away with exercise
- absence of: wheezing, cough, expectoration,
palpitation
What are the two types of respiratory failure?
What are their paO2, paCO2 hallmarks
Type 1 = gas exchange
- something is wrong with the AC membrane (or developed from obstructive because of V/Q mismatch)
- ↓O2, ↓CO2 (trying to compensate for hypoxia)
Type II - ventilatory failure
- can’t ventilate
- eg respiratory muscle fatigue
- ↓O2 (50)
treatment for type 2 respiratory failure
= some form of ventilatory support - eg BIPAP
= or intubation + invasive ventilation
can give O2 if still breathing a bit - but this won’t help to get rid of CO2
-> Drive may be coming from hypoxaemia (dampen down glomerular sensor response to CO2 after long time of hyperkapnia)
So O2 will just decrease his drive to breathe
