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Clinical assessment > Respiratory A & P > Flashcards

Respiratory A & P Flashcards

1
Q
A
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2
Q

Olfactory mucosa contains

A

afferent fibers from olfactory nerve (cranial nerve 1)

damage from covid = parosomia-stellate ganglion block

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3
Q

Sensory nerve of upper respiratory tract

A

Both branches of cranial V: opthamic and maxillary

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4
Q

Tonsils act as

A

first line of defense for bacterial invasion of nose and mouth

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5
Q

Tonsils are three types of lymph tissue:

A
  1. palatine tonsils - major
  2. lingual tonsil
  3. Pharyngeal tonsils (adenoids)
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6
Q

Pharynx upper airway innervation is what nerve(s)?

sensory or motor?

A

Trigeminal (V) (V1, V2, V3)
Glossopharyngeal (IX)

sensory and motor

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7
Q

Larynx level

A

C3-6

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8
Q

Circothyroid membrane

A

site for emergency laryngotomy and transtracheal block

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9
Q

Thyrohyoid membrae

A

suspends larynx from the hyoid bone

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10
Q

Vestibule

A

supraglottic area of 1st compartment of larynx

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11
Q

Laryngeal ventricles

A

area between false cords and true cords (in 2nd compartment)

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12
Q

Rima glottdis aka _____ is ____

A

true glottis is the space between the vocal cords

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13
Q

Which muscles cause abduction of the cords?

A
  1. Posterior CricoArytenoids (please come apart)
  2. ThyroaRtyenoid (They Relax)
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14
Q

Which muscles cause adduction of the cords?

A
  1. Lateral CricoArytenoid (lets close airway)
    2.CricoThyroid muscle (CordsTense)
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15
Q

Injury to the superior laryngeal nerve causes

A

inability to adduct (close)

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16
Q

Injury to recurrent laryngeal nerve causes

A

inability to abduct (open)

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17
Q

Bilateral injury

A

emergency

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18
Q

Primary muscular barrier to regurgitation in awake mt

A

cricopharyngeus msucle

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19
Q

Superior laryngeal nere innervation

A

crycothyroid muscle (SCAR)

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20
Q

what provides sensation from laryngeal side of epiglottis to true cords

A

internal branch of superior laryngeal nerve

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21
Q

Laryngospast man be caused by

A

simulation of the superior laryngeal nerve external branch

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22
Q

Damage to inferior laryngeal nerves (Recurrent laryngeal nerve) may lead to

A

hoarseness or dyspnea

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23
Q

True vocal cord ligaments are innervated or not?

A

not innervated

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24
Q

Superior laryngeal nerve innervates (sensory)

A

posterior side of epiglottis - level of VC

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25
Q

Recurrent laryngeal nerve innervates (sensory)

A

below level of vocal cords - trachea

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26
Q

Motor innervation of larynx

A

SCAR
Superior laryngeal nerve: Cricothyroid
All others: Recurrent laryngeal nerve:

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27
Q

Glossopharyngeal airway block

A

needle at base of palatoglossal archS

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28
Q

Superior laryngeal airway block

A

interior border of hyoid bone

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29
Q

Transtracheal airway block

A

cricothyroid membrane

inject local as patient takes deep breath

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30
Q

at the bronchi, cellular structure changes to

A

cuboidal epithelium

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31
Q

Which bronchus has a less acute angle from trachea

A

R bronchus less acute (25 deg)

easier to mainstem, more liekly for ETT to migrate here, more likely place of foreign bodies

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32
Q

Left bronchus angle is

A

45 degrees

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33
Q

Bronchopulmonary segments in right vs L

A

R: 10 segments
L: 8 segments

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34
Q

The last structures perfused by bronchial circulation:

A

Terminal bronchioles, at the end of the CONDUCTING airways

perfused, but no air exchange

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35
Q

conducting zone means:

examples:

A

air delivery but no gas exchange

trachea
mainstem bronchi
lobar bronchi
small bronchi
Bronchioles
Terminal bronchioles

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36
Q

Respiratory zone:

examples:

A

exchanges air with blood
Respiratory bronchioles
alveolar ducts
alveolar sacs

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37
Q

as airway division progress, what increases?

A
  1. number of airways
  2. cross sectional area
  3. muscle layer
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38
Q

as airway division progresses, what decreass?

A
  1. air flow velocity
  2. cartilage
  3. Goblet cells
  4. ciliated cells
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39
Q

mucous glands are absent in the

A

bronchioles

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40
Q

First place in airway that are perfused by pulmonary circulation?

does gas exchange occur here?

A

terminal bronchioles

gas exchange does NOT occur here

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41
Q

Most air exchange takes place in

A

alveolar-capillary membrane

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42
Q

What cell type forms alveoli

A

Type I, Type II pneumocytes, Type III

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43
Q

what do type II pneumocytes do

A

produce surfactant (reduces alveolar collapse from surface tensino)

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44
Q

Mediastinum is

A

the region between the parietal pleura and visceral pleura

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45
Q

Pleura

A

serous membrane that lines thoracic wall and lungs

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46
Q

Parietal pleura

A

lines chest wall, diaphragm, mediastinum

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47
Q

visceral pleura

A

lines mediastinum back toward lungs

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48
Q

pleural space

A

layer of fluid between thoracic wall and lungs

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49
Q

What is responsible for quiet breathing

A

diaphragm

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50
Q

diaphragm is innervated by

A

phrenic nerve

c3,4,5

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51
Q

Expiration occurs by

A

passive recoil - no muscular contraction

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52
Q

What controls breathing?

A

respiratory sensors in brainstem
central and peripheral sensors

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53
Q

Where are central censors located

A

medulla, pons (secondary)

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54
Q

Most important central sensors - chemical control

A

chemoreceptors that respond to changes in hydrogen ion concentration

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55
Q

What is most important in brain to establish ventilatory volume and rate?

A

CO2 via arterial and cerebrospinal fuid

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56
Q

Apneic threshold

A

CO2 at which ventilation is 0

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57
Q

Central receptors and hypoxia

A

depressed by hypoxia - NOT stimulated

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58
Q

Principal peripheral chemoreceptors

A

carotid bodies

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59
Q

Central chemoreceptors respond to

A

PaCO2

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60
Q

peripheral receptors are most sensitive to

A

PaO2 (<50)

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61
Q

What abolishes peripheral ventilatory response to hypoxemia?

A
  1. antidopaminergic drugs
  2. most anesthetics
  3. bilateral carotid surgery
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62
Q

Central sleep apnea and CO2

A

central sleep apnea exhibits a depressed response to CO2 during sleep

may be caused by a defect in chemoreceptors in the brain

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63
Q

Lung receptors are carried

A

centrally by the vagus nerve

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64
Q

Chemical or mechanial irriation can produce

A

reflex cough or sneeze
hyperpnea
bronchoconstriction
increased blood pressure

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65
Q

vagus nerve prodcues

A

afferent pathways for all irritant receptors (except nasal mucosa receptor)

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66
Q

Intrapleural pressure is

A

the pressure within the pleural cavity

it is always negative - acts like suction to keep lungs inflated

67
Q

elasticity of lungs causes

A

lung recoil and pull lung inward away from thoracic wall

68
Q

elasticity of thoracic wall causes

A

thoracic wall to pull away from the lungs, further enlarging pleural cavity and creating negative pressure

69
Q

intrapleural pressure is

A

always negative - causes expanding effect called compliance

70
Q

airflow =

A

pressure/resistance

71
Q

Area of airway with greatest resistance

A

medium sized bronchi

smooth muscle tone - asthma occurs here

72
Q

What constricts bronchioles?

A

Acetylcholine (PNS), histamine

73
Q

What dilates bronchioles?

A

Epinephrine (SNS)

74
Q

Lung compliance:

A

elastic ffibers - ease with which lungs expand

75
Q

Factors that determine lung compliance

A
  1. stretchability of the elastic fibers
  2. surface tension within alveoli
76
Q

How does surface tension within the alveoli effect lung compliance?

A

Lower surface tension = increased lung compliance

surfactant LOWERS surface tension

77
Q

Compliance equastino

A

V/P
change in volume divided by change in pressure

78
Q

CL (lung compliance) =

A

TV/PIP-PEEP

79
Q

Pulmonary surfactant role

A

decreases surface tension and holds alveoli open

80
Q

lines of alveoli are made of lipoprotien mixture consisting mostly of

A

dipalomyl lechitin

81
Q

Pulmonary surfactant is secreted by

A

Type II alveolar epithelial cells

82
Q

Surface tension law

A

Laplace (P=T/r)

without surfactant, law of Laplace WOULD hold true.

But because of surfactant, law of Laplace does not apply to alveoli

83
Q

air velocity law

A

Pouseille’s

L/R ^4

84
Q

At resting expiration poing:

A

outward recoil of chest wall is balanced by inward elastic recoil of the lung

85
Q

Transpulmonary pressure

A

fluccuates

is zero whenever airflow is stopped (at end expiration or end inspiration)

as intra alveolar pressure oscillates between slightly negative during inspiration and slightly positive during expiration

86
Q

Pleural pressure is

A

always negative

87
Q

Compliance, volume and pressure

A

increased compliance = greater change in volume at a certain change in pressure

compliance is volume dependent

88
Q

at age 20, closing volume is

A

30% of TLC

89
Q

at age 70, closing volume is

A

55% of TLC

90
Q

closing volume and shunt

A

if closing volume is greater than FRC, have poorly perfused or unventilated alveoli during normal respiration

= intrapulmonary shunt

91
Q

lung volumes that are NOT included in spirometry:

A
  1. FRC
  2. RV
  3. TLC
92
Q

FEV1 =

A

forced expiratory volume in 1 second

93
Q

FEV1 is based on ____ and is normal if ______

A

based on age and gender for a predicted normal range

normal if within 80% of predicted values

94
Q

FVC

A

forced vital capacity

volume of gas that can be exhaled during a forced expiratory maneuver

95
Q

FEV1/ FVC

A

helps distinguish between restrictive at obstructive diseases
< 0.7 = obstruction

96
Q

FEV1/FVC < 0.7

A

Obstruction

97
Q

FEF 25 - 75

A

rate of flow occurring in forced expiration between 25% and 75% of flow

98
Q

What is the most sensitive test for assessing small airway disease?

A

FEF 25-75

99
Q

most effort independent test

A

FEF 25 - 75

100
Q

more reliable measurement of early obstruction

A

FEF 25 - 75

101
Q

When should more sophisticated split lung function testing be done?

A

if FEV1 is less than 2L
and
if FEV1/FVC is less than 50%

102
Q

Diagnosis obstructive dises

A

increased FRC, RV, TLC

103
Q

Diagnosis restrictive lung dises

A

decrease FRC, RV, TLC

104
Q

What is affected by position?

A

FRC but NOT closing capacity

105
Q

Alveoli are most compliant at

A

Lower volumes (lower lung)

expand/ deflate better at lower lung

106
Q

Shunt causes (PAO2, PaO2)

A

PaO2 < PAO2

107
Q

Pulmonary blood flow is regulated locally by

A

changes in O2 and CO2 tension

108
Q

Hypoxic pulmonary vasoconstriction

A

Blood flow is diverted from hypoxic or atelectatic alveolie - attmept to improve matching of VQ

109
Q

high O2 tension and hypocapnia/carbia

(PVR)

A

vasodilate pulmonary vessels to pick up more O2

opposite in other vasculature

110
Q

What brings unoxygenated blood to lungs from right ventricle

A

pulmonary arteries

111
Q

Pulmonary arteris provide blood flow to structures distal to

A

terminal bronchioles

as well as non respiratory tissues and respiratory units

112
Q

PVR vs SVR

A

PVR is 1/8 SVR

113
Q

PVR is increased by

A
  1. NE
  2. serotonin
  3. histamine
  4. hypercapnia
  5. hypoxia
114
Q

PVR is decreased by

A
  1. acetylcholine
  2. isoproterenol
115
Q

west lung zones describe

A

perfusion the lungs

not fixed

functional zones of where the blood will flow n comparison to the alveoli

116
Q

zone 1

A

PA > Pa > Pv
top

117
Q

zone 2

middle

A

Pa > PA > Pv

118
Q

Zone 3
bottom

A

Pa>Pv>PA

119
Q

Zone 3 has

A

continuoublood flow

tip of pulmonary catheter should be here

best perfusion and best ventilation

BUT still more blood flow than ventilation = shunt

120
Q

dependent portion of lungs have:

A
  1. more blood flow d/t gravity
  2. more alveolar compliance

= optimal gas exchange

121
Q

if alveoli are ventilated but not perfused, then Q =

A

0

infinity dead space

122
Q

If alveoli are perfused (Q) bt no ventilated (V) then V =

A

0

so V/Q = 0

shunt

123
Q

shunt-like alveoli have

A

low PO2 and high PCO2 (Low V/Q)

124
Q

What can cause shunt

A
  1. airway obstruction
  2. atelectasis
  3. pneumonia
125
Q

If hypoxemia present and unresponsive to O2

A

suspect significant shunt/diffusion disorder

126
Q

Dead space like alveoli have

A

high PO2 and low PCO2 (high V/Q)

127
Q

causes of dead space

A
  1. Low CO
  2. Pulmonary emboli

blood flow not reaching alveolar membrane, but ventilation is good

128
Q

Hypoxemia is defined as

A

a decrease in PaO2 (<60 mmHg)

129
Q

Hypoxia is defined as

A

reduced level of tissue oxygenation by defective delivery or utilization by tissue

130
Q

Normal A-a gradient

A

age adjusted
5-15 mmhg normal

with supplemental O2: <100 mmHg

131
Q

PaCO2-PACO2 gradient normal

A

2-10 mmHg regardless of inspired O2

132
Q

Respiratory failure diagnosis

A

PaO2 <60 despite supplemental 2 and in absence of R–>L shunt
PaCO2 > 50 mmHg in absence of resp compensation

133
Q

A larger than normal PAO2-PaO2 gardient assesses

A

shunt and v/q mismatch that is not normal

134
Q

Key clinical feature to a R–>L shunt:

A

oxygen administration does not help the arterial PO2

135
Q

why would supplemental oxygen not hel arterial PO2?

A

shunt

blood flow does not come into contact with the alveoli that is getting more O2

136
Q

Hypoxemia without an increase in A-a gradient is

A

hypoventilation

137
Q

Hypoxemia with an increase in A-a gradient is

A
  1. diffusion defect
  2. V/Q mismatch
  3. shunting R–> L
138
Q

Respiratory quotient

A

constant to be used in alveolar equation

ratio of CO2 produced to amount of O2 consumed

RQ = 0.8

139
Q

norma PaO2:FiO2 ratio

A

100mmHg/0.21 = 500

lower ratio = worse disease

140
Q

PaO2: FiO2 ratio ALI

A

< 300

141
Q

PaO2: FiO2 ratio ARDS

A

<200

142
Q

The most direct assessment of oxygenation is the

A

PaO2

143
Q

A-a gradients assess

A

v/q mismatch in the face of hypoxemia

144
Q

with elevated A-a PO2 gradient, to further work up, measure _____. Then:

A

O2 from SVC or distal port in PA catheter (PvO2)

low = anemia, low CO, hypermetabolic state

otherwise, suspect V/Q abnormality

145
Q

Alveolar levels of O2 and CO2 are determined by:

A
  1. amount of alveolar ventilation
  2. inspired concentrations of O2 and CO2
  3. flow of mixed venous blood to lungs
  4. Consumption of O2
  5. Production of CO2
146
Q

O2ER

A

Oxygen extraction

O2ER = VO2/DO2

147
Q

SVO2 is

A

leftover O2 after consumption

148
Q

normal anatomic dead space

A

2mL/kg (about 1/3 of air that enters is dead space)

volume in conducting airway

increases by 50% in paralyzed, mechanically ventilated patient

149
Q

alveolar dead space

A

alveoli that are ventilated but do not participate in gas exchange with blood

150
Q

Bohr equation

A

calculates deadspace

Vd/Vt = [PaCO2 - PECO2]/PaCO2

151
Q

3 determinants of PaCO2

A
  1. PaCO2 production
  2. minute ventilation
  3. dead space fraction
152
Q

what drives ventilation?

A

PaCO2

153
Q

a-A CO2 gradient reflects

A

alveolar dead space

more deadspace = more gradient

normal: 2-5 or 2-10

154
Q

What in blood carries CO2

A

bicarbonate ions 80-90%

155
Q

CO2 dissociation curve
when blood contains mostly oxygenated hgb

A

CO2 shifts right (releases CO2, reduced ability to hold on to CO2)

*Haldane effect

156
Q

CO2 dissociation curve
when blood contains deoxygenated hgb:

A

curve shifts left, blood loads more CO2

157
Q

When does CO2 curve shift right

A

right = release
occurs as blood flows through pulmonary capillaries, facilitates unloading/release of CO2 from pulmonary capillaries

158
Q

What is the hamburger shift

A

chloride shift

bicarb moves out of red blood cells in exchange for chloride ions

159
Q

Bohr effect

A

influence of CO2 on shift of oxyhemoglobin curve

increased CO2 = oxygen will unload

160
Q

amount of dissolved CO2 in blood is

A

0.67 x PCO2 /dL

161
Q

Oxyhemoglobin curve right shift

A

reduced affinity, more O2 offload to tissue

increased temp
increased 2-3 DPG
Inrceased [H]–>decreased pH/acidosis
methemoglobinemia

162
Q

Oxyhemoglobin curve left shift

A

left = love, hgb holds onto oxygen

decreased temp
decreased 2-3 DPG
decreased [H}–>increased pH/alkalosis
CO

163
Q

VO2 (what is it and normal value)

A

oxygen consomption

250 mL/O2/min
3.5 mL/kg/min

164
Q

normal carbon dioxide excretion

A

200 mL CO2/min

Clinical assessment (10 decks)

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