Respiratory Flashcards
1
Q
List the parts of the upper respiratory tract
A
nose
nasal cavity
paranasal sinuses
pharynx
larynx
2
Q
List the parts of the lower respiratory tract
A
trachea
bronchi and smaller bronchioles
lungs
alveoli
3
Q
What is the purpose of the nose and nasal cavity?
A
provides airway for resp
moistens and warm air
filters inhaled air
contains olfactory receptors
involved in speech
4
Q
What is the purpose of paranasal sinuses?
A
air containing cavities in the skull
lined with mucous membrane
5
Q
What is the function of paranasal sinuses?
A
decrease weight of skull
increase resonance of voice
buffer against facial trauma
insulates sensitive structures from rapid temperature fluctuations
humidifies and heats air
immunological defense
6
Q
What is the purpose of nasopharynx?
A
simply an air passageway
closes while swallowing
contains nasopharyngneal and tubal tonsil
7
Q
What is the purpose of oropharynx?
A
food and air passageway
epiglottis closes during inspiration to prevent aspiration
contains palatine and lingual tonsils
8
Q
What is the purpose of laryngopharynx?
A
connects throat to esophagus
extends to branching of respiratory and digestive pathways
9
Q
What is the purpose of larynx?
A
connects the laryngopharynx to the trachea
contains vocal folds
thyroid glands sits on the outside of the larynx
10
Q
What is the main function of larynx?
A
protection
aids in coughing and other reflexes
prevents food/fluid from entering lungs
11
Q
What is the breakdown of bronchi and smaller bronchioles?
A
primary bronchi
secondary bronchi
tertiary bronchi
terminal –> respiratory bronchioles
12
Q
What is the purpose of bronchi and smaller bronchioles?
A
contains mucus and cilia to remove contaminants
can constrict or dilate to modify airflow
13
Q
How many lobes are on each lungs?
A
right lung contains three lobes
left has two lobes
14
Q
What is visceral pleura?
A
it covers the lungs
15
Q
What is the parietal pleua?
A
it covers the ribs and diaphragm
16
Q
What the space between lungs and ribs?
A
pleural cavity
17
Q
What is the breakdown of alveoli?
A
type I cells
type II cells
18
Q
What is types I cells?
A
squamous epithelium
19
Q
What is types II cells?
A
cuboidal epithelium
contain lamellar bodies for surfactant secretion
20
Q
What is alveolar macrophages?
A
the janitor of the alveoli and bronchioles
21
Q
What are pathway of cells in the alveoli?
A
alveolar type I cell –>
alveolar basement membrane –>
capillary basement membrane –>
capillary endothelial cells
22
Q
What is the purpose of alveoli?
A
capillaries surround the alveoli to facilitate gas exchange
CO2 is diffused out of the blood and into the alveoli for exhaustion
O2 diffuses out of the alveoli and into the blood
23
Q
What governs how well the lungs/alveoli can inflate and deflate?
A
Compliance and elasticity
24
Q
What is the two pathways of blood supply?
A
pulmonary vessels
bronchial vessels
25
What is the purpose of pulmonary vessels?
responsible for gas exchange
deoxygenated blood arrives through pulmonary artery from the right ventricle
arrives at resp membrane and becomes oxygenated
pulmonary veins return oxygenated blood to left atrium
26
What is the purpose of bronchial vessels?
come from systemic circulation
oxygenates the lung tissue itself
27
What is conducting system?
includes all sites involved in conducting air into the lungs
28
What is the respiratory zone?
consists of where gas exchange occurs
29
List where the respiratory zones are?
respiratory bronchioles
alveolar ducts
alveolar sacs
alveoli
30
What is respiration?
the exchange of gases between the atmosphere, blood and cells
cells continually use O2 and release CO2
31
What is the stages of respiration?
pulmonary ventilation
external respiration
internal respiration
32
Explain inspiration
air is pulled into the lungs when alveolar pressure < atmospheric pressure
air is pushed out of the lungs when alveolar pressure > atmospheric pressure
pressure is controlled by contraction or relaxation of the diaphragm
33
What does the external intercostal muscles do?
aid in expanding or contracting thorax
34
Define quiet inspiration
an active process representing normal breathing
involves diaphragm and intercostal muscles
35
Define forced inspiration
used in times of extra need
sternocleidomastoids, scalenes, pectoralis minor used
36
Define quiet expiration
a passive process
diaphragm relaxes and raises upwards
37
Define forced expiration
uses obliques and intercostals to contract inwards to help force air out
activated when air movement out of the lungs impeded
38
What is external respiration?
exchange of gases
CO2 removed O2 gained
occurs via diffusion
39
What is a normal partial pressure oxygen gradient?
Alveolar space = 100 mgHg
deoxygenated blood = 40 mgHg
40
Normal partial pressure carbon dioxide gradient?
alveolar space = 40 mmHg
deoxygenated blood = 45 mgHg
41
ventilation - perfusion mismatch
can occur in severe lung disease
- ventilation and blood flow are not at an optimal ratio
42
Ventilation and Perfusion Matching
exchange of gas and blood supply must be balanced for poper external respiration
must be enough air in the alveoli, bloodflow in the capillaries and hemoglobin to carry oxygen
43
V/Q mismatch can lead to
hypoxemia
44
Define eupnea
normal, good healthy unlabored breathing
45
Define apnea
potentially serious sleep disorder in which breathing repeatedly stops and starts
46
Define tachypnea
abnormally rapid breathing
47
define costal breathing
a mode of breathing that requires contraction of the intercostal muscles
48
Define diaphragmatic breathing
an exercising technique to help strengthen your diaphragm and fill your lungs with air more efficiently
49
Define of type 1 respiratory failure
the inability of lungs to perform adequate gas exchange
can lead to hypoxemia
50
What are some potential causes of type 1 resp failure?
lung disorder
pneumonia
pulmonary edema, fibrosis, embolism, hypertension
51
What is hypoxemia?
Oxygen saturation falls <90%
CO2 levels remain normal or can be low
52
What is type 2 respiratory failure?
also called ventilatory failure
it occurs when breathing is not sufficient to rid the body of CO2
leads to hypercapnia
53
What are potential causes of Type 2 resp failure?
decreased CNS drive
impaired neuromuscular function
chronic bronchitis or COPD
excessive inspiratory load
54
What are arterial blood gases used for?
determine acid-base balance which helps determine causes of resp issues
blood ph controlled by action of the lungs and kidneys
useful to diagnosis the underlying cause of a breathing disorder
55
What is PaCO2
pressure or tension exerted by dissolved CO2 gas in blood
56
What is PaO2
indicates the level of oxygenation of arterial blood
57
What is respiratory compensation?
lungs can modulate how much CO2 is retained or excreted
58
What is metabolic compensation?
kidneys can modulate how much HCO3 is retained or excreted
59
What is disturbances of respiratory acidosis
have acidic
normal HCO3
high PaCO3
60
What is disturbances of respiratory alkalosis?
have basic
normal HCO3
low PaCO3
61
What is the disturbances of metabolic acidosis?
have acid
low HCO3
normal PaCO3
62
What is the disturbance of metabolic alkalosis?
have acid
high HCO3
normal PaCO3
63
What are the two main tests for lung function?
Spirometry
Peak flow meter
64
Explain what a spirometry
a spirometry objectively assesses an individual's pulmonary performance
measures how much air you can move in and out of lungs
65
Explain how a peak flow meter works?
utilized in people with asthma
used by an individual to compare current results to personal best
66
What does spirometry measure?
Lung volume
lung capacity
airflow measures
67
List the factors of lung volume
tidal volume
inspiratory reserve volume
expiratory reserve volume
residual volume
68
List the factors of lung capacity
total lung capacity
functional residual capacity
vital capacity
69
List the factors of airflow measures
forced expiratory volume in 1 second (FEV1)
forced vital capacity (FVC)
FEV1/FVC ratio
70
What does the FEV1/FVC tell us?
helps differentiate between restrictive and obstructive lung disease
71
What ratio shows obstructive lung disease?
low FEV/FVC, normal FVC
72
What ratio shows restrictive lung disease?
normal FEV1/FVC ratio but low FVC
73
What is spirometry is used to determine?
reversibility of airway obstruction
test repeated 10-15 m after inhaling a bronchodilator
if FEV1 increases, obstruction is present
74
What improves as fitness does
lungs can accommodate higher volumes of air
increased diffusion of resp gases
strengthen cilia and diaphragm
strengthens other muscles of inspiration/expiration
VO2 max increases
75
People who smoke have poor exercise tolerance for many reasons
nicotine causes bronchoconstriction
lung fibrosis
excess mucous secretion
inhibited cilia
destruction of elastic fibers
76
What is age-related impact on lung function
respiratory tissues and chest wall becomes more rigid
weak resp muscles
vital capacity gradually decreases
macrophages activity decreases
cilia less active
77
What are the characteristics of asthma?
paroxysmal or persistent symptoms
dyspnea, wheezing, cough, chest tightness sputum production
airway hyper-responsiveness to a variety of stimuli
78
What is the epidemiology of asthma?
over 3 million canadians have it
canada has one of the highest rates in the world
79
How many people with asthma do not have it under control?
6 out of 10
80
What are some of the risk factors of asthma?
genetic predispoition
hygiene hypothesis
atopic vs no atopic
gender
maternal factors
perinatal factors
factors during childhood
factors during adulthood
81
Explain genetic predisposition
development of asthma --> pre-disposing to atopy
severity of condition --> airway hyperresponsiveness
response to therapy
82
What are some factors that childs who had lower risk of asthma?
are exposed to high levels of bacteria or endotoxin
have older siblings
have early enrollment into child care
experience exposure to fewer antibiotics
83
Explain atopic vs non-atopic
allergic responses can result in asthma
the greater an individual's sensitization, the higher the likelihood of asthma
high levels of IgE found
exposure to high levels of allergenes increase likelihood of asthma
84
Explain the etiology factor of sex
childhood asthma has a greater prevalence in males
equal around 20-40
more females at the age of 40 and above
85
How does maternal factors affect asthma?
increasing maternal age --> lower risk of asthma
diet during pregnancy can also be a factor
86
What perinatal factors increase the chance of having asthma?
pre-eclampsia
prematurity
mode of delivery (C section)
lack of vitamin D supplementation
87
What factors during childhood increase the odds of having asthma?
viral infections predictive of asthma later in life
use of medication in infancy
air pollution
tobacco smoke exposure
88
What factors during adulthood increase the odds of having asthma?
obesity
tobacco smoke
occupational exposures
rhinitis
89
List some asthma triggers
irritants
respiratory tract infections
weather
stress
hormonal fluctuations
GERD
medications
sulfites
90
List the hallmarks of asthma
bronchial hyperreactivity
bronchial inflammation
airway obstruction
91
What is the physiology of bronchial hyper-reactivity?
begins with sensitization to an allergen
allergen exposure --> production of specific IgE antibodies
92
What is regulate for IgE?
They are regulated by Th2 cells
it is overexpressed in sensitized individuals (this is activated by dendritic cells)
93
What does IgE is bind to?
mast cells
subsequent exposure to allergen --> binds to iGE antibody on mast cell --> release of mediators
94
List some mediators that are released
histamine
leukotrienes
cytokines
tumor necrosis factor alpha (TNF-a)
95
List non allergen induced
irritants
exercise
cold air
NSAIDs or ASA
stress
96
What is three mechanisms that mast cell mediators?
spasmodic state
inflammation of bronchi
excessive mucous production
97
Explain spasmodic state
from the parasympathetic nervous system releasing acetylcholine
98
How does allergen induced bronchoconstriction?
mast cell mediators bind to smooth muscle, causing bronchoconstriction
99
Explain early phase reaction of physiology of bronchial inflammation
occurs within several minutes of inhalation of allergens
mast cells release mediators --> histamine and leukotrienes acts quickly
leads to bronchospasm and constriction
100
Explain late phase reaction of physiology of bronchial inflammation
occurs within hours
cytokines and TNF-a recruit inflammatory cells
continued bronchospasm and constriction
inflammation builds
hyper responsiveness increases
101
Explain the physiology of airway remodeling
remodeling is irreversible
increases airflow limitations and exacerbation of previous processes
102
List pathologic changes in the airways remodeling
vascular dilation
edema
subepithelial fibrosis
epithelial damage
inflammatory cell infiltration
smooth muscle hypertrophy
mucous gland hypertrophy
sub basement membrane thickening
103
What is the clinical presentation of asthma?
intermittent episodes of wheezing, cough and dyspnea
chest tightness and chronic cough in some
symptoms often worse at night or upon waking
presence of repeatable triggers
possible signs of atopy
104
What is lung function testing results of asthma?
FEV1/FVC <0.7 is diagnostic of asthma
significant reversibility post bronchodilator challenge
sensitive to bronchoprovocation testing
105
What is complicated asthma called?
Status asthmaticus (asthma exacerbation)
106
Describe the symptoms of complications of asthma
episode of worsening asthma symptoms, lung function and hyperresponsiveness
most common in those with underutilized anti-inflammatory therapy
107
Explain the feedback loop of asthma exacerbation
inflammation --> increased bronchial hyperresponsiveness --> increased inflitration of allergic and inflammatory mediators --> bronchoconstriction and obstruction --> inflammation
108
What happens if asthma treatment is delayed?
cardiac arrest
respiratory failure
hypoxemia
pneumothorax
109
What are complications are asthma?
airway remodeling
fatigue
underperformance at work/school
inability to exercise
frequent hospitalization
pneumonia and influenza
GERD
sleep apnea
110
Define COPD
chronic respiratory condition characterized by
persistent symptoms
airflow limitation and narrowing airways
chronic inflammation
mucociliary dysfunction
mix of obstructive bronchiolitis and emphysema
111
What is the epidemiology?
affects 5 % of canadians >35 years old
85% of COPD deaths mainly caused by continued smoking or exposure
4th leading cause of death in Canada
3rd leading cause death world wide
112
Risk Factors of COPD
exposure to particles
airway responsiveness
genetic polymorphisms
old age
113
Explain the risk factor of exposure to particles
cigarette smoking most prominent cause
general air quality and pollution
114
Explain the risk factor of airway responsiveness
higher responsiveness increase COPD risk
115
Explain the risk factor of genetic polymorphisms
matrix metalloproteinases (MMPs) excess
alpha 1 antitrypsin deficiency
116
Define Emphysema
refers to airways collapse due to loss of lung recoil caused by alveolar wall destruction
caused by an imbalance between proteolysis and anti-proteolysis in the lungs
117
Define Elastase
the main enzyme responsible for proteolysis in lungs
118
What produces elastase?
neutrophils and macrophages
119
What irreversibly inhibits elastase?
alpha-1-antitrypsin
120
What does emphysema lead to?
air trapping
impaired gas diffusion
lung hyperinflation
121
Define Chronic Bronchitis
chronic inflammation of the bronchioles
122
What are the changes caused by chronic bronchitis?
Increased oxidative stress and inflammatory mediators
Increase in goblet cells mucous hypersecretion
Hyperplasia of submucosal mucous glands
Ciliary dysfunction
Fibrosis and thickening of bronchiole walls
Edema and smooth muscle contraction
123
What are the two forms of clinical presentation?
pink puffer
blue bloater
124
What are symptoms of emphysema?
Shortness of breath
Barrel chest
Enlarged lungs
Weight loss
Pink skin
Accessory muscle use
Pursed lip breathing
Hypoxemia/co2
125
What are symptoms of chronic bronchitis?
Shortness of breath
Chronic productive cough
Excessive mucous production
Wheezing
Pulmonary hypertension (due to alveolar hypoxia shunting blood to healthy alveoli)
Weight gain
Peripheral edema
Cyanosis
Hypoxemia
Hypercapnia (resp acidosis)
Right-sided heart-failure
Fluid retention
126
What is the nickname for emphysema?
pink puffer
127
what is the nickname for chronic bronchitis
blue bloater
128
Are emphysema and chronic bronchitis on a spectrum or two sides of it?
They represent extremes, mixed type presentation is more likely
129
What is COPD prognosis?
COPD is progressive; cannot halt decline of lung function and FEV1
Depends on severity of disease, management of comorbidities, level of fitness
130
What are predictors of mortality?
Low FEV1 and rate of decline
Continued smoking
Low BMI (<21)
Increased airway bacterial load
Rate of exacerbations
Decreased exercise capacity
Males
Emphysema predominant
Development of comorbidities
131
Common Comorbidities for COPD
Lung cancer
Cardiovascular disease
Ischemic heart disease
Heart failure (cor pulmonale)
Arrhythmias
Peripheral artery disease
Hypertension
Sleep apnea
Metabolic syndrome
Osteoporosis
132
What are the broad categories of asthma treatment?
reliever
controller
exacerbations
novel therapy
133
List the relivers
SABA
SAMA
134
List the controllers
ICS
LABA
LTRA
theophylline
135
List exacerbations
oral steroids
136
Explain short acting beta adrenergic agonists
most used agent in asthma
act promptly to cause bronchial smooth muscle relaxation and bronchodilation
137
Example of SABA
salbutamol
138
SABA MOA
binds to B2 receptor in lungs causing
Hyperpolarization of calcium-activated potassium channels in airways
Stimulation of ATP cAMP removal of calcium from muscle
139
Key side effects SABA
Cardiovascular stimulation central to side effects
Tachycardia
Palpitations
Dizziness
Tremor
140
SAMA
not commonly used for astham
useful add on during asthma attacks
141
SAMA acts
promptly to cause smooth muscle relaxation and bronchodilation -
142
Example of SAMA
iprtropium
143
SAMA MOA
Acetylcholine in lungs causes bronchoconstriction and increased mucous secretion
Increased in states of inflammation
Ipratropium is a competitive antagonist of endogenous acetylcholine at muscarinic receptors
144
AE for SAMA
cough
headache
dizziness
dry mouth
145
DI for SAMA
anti choliergic load
146
Inhaled corticosteroids
commonly used first line controller medication
147
Examples of IC include
Beclomethasone ● Fluticasone
Budesonide ● Mometasone
Ciclesonide
148
Benefits of IC
Directly reduces inflammation
Improves symptoms
Improves long-term outcomes
Reduces asthma mortality and frequency and severity of attacks
Reduces airway remodeling and airway hyper-reactivity
149
MOA of IC
Enters target cells in the lung and binds to Glucocorticoid Receptors (GRs)
Then moves into nucleus of cell binds to coactivators to inhibit histone acetyltransferase (HAT) and increase Histone deacetylase 2 (HDAC2)
HAT acetylates inflammatory proteins
HDAC2 deacetylates inflammatory proteins
150
AE for IC
oral thrush
hoarseness of voice
151
AE for high dose long term IC
Adrenal suppression
Increased glucose levels
Pneumonia
Osteoporosis
152
DI for IC
desmopression --> hyponatremia risk
153
LABA
commonly used controller medication
154
Examples of LABA
salmeterol
formoterol
155
LABA MOA
have the same MOA, AE, SI as SABA
156
LRA
oral controller medication used in very mild asthma
157
Example of LRA
montelukast
158
MOA of LRA
Cysteinyl-Leukotriene receptors cause mucous secretion, bronchoconstriction and eosinophil recruitment when activated
Montelukast antagonizes this receptor, preventing these effects
159
AE for LRA
minimal side effects
160
DI for LRA
none
161
Theophylline
rarely used oral last line
162
Negatives for Theophylline
use limited by difficult dosing, toxicity potential and more effective agents
163
Things that theophylline causes
Inhibition of phosphodiesterase increases cAMP
Antagonizing adenosine receptors prevents release of histamine and leukotrienes
Increasing interleukin 10 levels (anti-inflammatory)
Preventing creation of pro-inflammatory mediators
164
AE of theophylline
Significant cardiac toxicity
Tachycardia
Arrhythmias
Significant GI side effects
Nausea
Heartburn
Diarrhea
165
DI for theophylline
Theophylline is a 3A4 substrate and 1A2 substrate
Any inhibitor will increase concentrations of theophylline
166
Explain biologics as a treatment for asthma
new injectable agents that directly target the allerguc response or inflammatory mediators
167
Biologics include
MAB’s
Omalizumab
Mepolizumab, reslizumab, benralizumab
Dupilumab
168
Omalizumab
inhibits IgE
169
Dupilumab
inhibits interleukin 4 and 13
170
Mepolizumab, reslizumab, benralizumab
inhibits interleukin -5
171
COPD Treatment Categories
main therapy
sever disease
exacerbations
rarely used
172
SABA /LABA in COPD
slightly less effective in COPD
173
SAMA and LAMA in COPD
utlized more in COPD
same as asthma
174
Examples of LAMA
Tiotropium
Aclidinium
Glycopyrronium
Umeclidinium
175
IC for COPD
main difference used in end stage COPD
176
Inhalers are often in combinations
LABA / LAMA
SAMA / SABA
LABA / ICS
LABA / LAMA / ICS
177
List different inhaler devices
Metered-dose inhalers (MDIs)
Dry powder inhalers
Turbuhaler
Discus
Handihaler
Soft-mist inhalers
