Respiratory Path Flashcards
Conducting Zone
Mouth/Nose, pharynx, trachea, bronchi to bronchioles
-Has squamous epithelium and progresses to Pseudostratified cliliated columnar epithelium with goblet cells
Bronchi
-Have cartilage and goblet cells. Below have smooth muscle and club cells
Bronchioles to terminal bronchioles
- Smooth muscle with clara cells
- pseudostratified columnar epthelium
Respiratory zone
- Respiratory bronchioles, alveolar ducts, alveoli
- Cuboidal cells in respiratory bronchioles and squamous cells in alveoli
Alveolar Macrophages
-Defense cells of alveoli
Type I pneumocytes
- Thin simple squamous cells that participate in gas exchange
- Comprise 97% of surface area
Type 2 pneuomcytes
- Secrete surfactant to oppose surface tension
- Serve as reserve cells during damage of type 1 cells
- Contain lamellar bodies which are surfactant that will be secreted
- Cuboidal cells
Clara/Club Cells
- Located in the terminal bronchiole area and respiratory bronchiole.
- Secrete defense proteins (IgA components, lysozyme, etc)
- Chew up mucus that has been secreted and degrades surfactant
Collapsing pressure
- Directly proportional to 2*surface tension and inversely proportional to radius.
- Collapse is possible during exhalation.
Surfactant
- Secreted by type 2 pneumocytes and breaks surface tension
- Lecethin to sphingomyelin ratio of greater than 2:1 signals lung maturity
- Doesn’t mature until week 35 (26-35)
Aspiration
-Most likely to occur in the right lower lobe
Diaphragm Structures
- IVC at T8
- Esophagus at T10
- Aorta, azygous, thoracic duct at T12
- Innervation by C3-5, inflammation may lead to referred pain to shoulder
Congenital Diaphragmatic Hernia
-Most commonly on left pleurodiaphragm leads to unilateral lung hypoplasia
Accessory Muscles of inspiration
-External intercostals - Pull up and out
Expiration
-Internal intercostals pull down and in
FRC
- Expiratory reserve volume and residual volume
- The point at which the chest expansion and lung retraction are equalized and alveolar pressure is equal to atmospheric
Physiologic Dead Space
- Anatomic plus functional dead space
- Arterial co2-expired CO2 over arterial co2
Hemoglobin A
- Two alpha and 2 beta subunits
- Taught state has low affinity for oxygen and is observed in a right shift.
- Relaxed state has high affinity for oxygen and is seen in a left shift
- Shift to taught with increase CO2, H+, temp, Cl, 2,3 BPG (increased metabolic activity)
Hgb F
Has two alpha and 2 gamma
-Has decreased affinity for 2,3 BPG meaning it has a higher affinity for oxygen. 2,3 BPG causes increased release in tissues.
Methemoglobin
- Oxygen can only bind when Fe is reduced in the 2+ state.
- If oxidized to 3+ can’t bind oxygen, pulse ox shows decreased saturation
- Has higher affinity for Cyanide
- Can be caused by nitrites, drugs, pyruvate kinase and G6PD
- Cyanide poisoning treted with nitrates to form Fe3+ and take cyanide into hemoglobin and off cytochromes. Then give thisulfate to solubalize and methylene blue to reduce Fe
Carboxyhemoglobin
- Hemoglobin has higher affinity for CO and demonstrates as non-sigmoidal curve
- Causes shift to the left and down in oxygen binding capacity
- Pulse ox often shows normal, need to get a carboxyhemoglobin level
- Symptoms are red color, headache, vommiting, altered mental status
- Treat with hyperbaric oxygen
Pulmonary circulation
- High compliance low resistance circuit
- elevated CO2 causes contsritcion and O2 causes dilation
Perfusion limited
- Normal physiologic conditions all gases are perfusion limited except CO
- Equilibration along length
Diffusion Limited
- Equilibration doesn’t occur and gases are limited by their diffusing capacity
- Diffusion proportional to pressure difference and area and inversely proportional to thickness
- Emphysema causes a loss of area and fibrosis causes and increase in thickness both leading to diffusion limiting
Primary Pulmonary Hypertension
-Defect in BMPR2 leads to smooth muscle proliferation and constricion, poor prognosis
Secondary Pulmonary Hypertension
- Caused by anything that decreases oxygenation or increases CO2 levels leading to vasoconstriction
- Sleep Apnea, Altitude, Multiple Thromboemboli, Right to Left cardiac shunt, systemic sclerosis (scleroderma), Mitral stenosis, COPD
Cyanosis
- Occurs with elevated deoxyhemoglobin, not necessarily decreased oxygen levels
- Content is in bound to Hgb and unbound fractions
Alveolar Gas Equation
- PAo2= PIo2-PCO2/.8
- Alveolar oxygen is equiivlent to space not occupied by CO2
A-a Gradient
- Pressure gradient for oxygen to flow from alveoli to capillaries
- Will be increased in diffusion problems, V/Q mismatches, Shunting
Hypoxemia with normal A-a
- Means there is decreased alveolar oxygen
- Hypoventilation or altitude
Hypoxemia with increased A-a
- There is impaired blood flow/oxygen extraction
- Diffusion, V/Q mismatches, R to L shunt (decreased a of returning blood)
Hypoxia
-Decreased oxygen Delivery to tissues: Decreased CO, anemia, CO poisoning, hypoxemia
Ischemia
- Decreased blood flow to tissues
- Arterial block or venous congestion
V/Q mismatches
- Apex Ventilation 3 times perfusion Zone 1 (wasted ventilaton)
- Zone 2, middle: Ventilation almost equal to perfusion
- Zone 3, base: Ventilation less than perfusion: Physiologic dead space
- Ventialation and perfusion are both the greatest at the base of the lung, but perfusion is proportionally greater.
Exercise
-Capillaries open because of increased perfusion pressures leads to increased perfusion in apex
V/Q is 0
Airway obstruction, supplemental oxygen will not help
V/Q is infinite
- perfusion defect due to embolization etc.
- Leads to shunt and therefore oxygen will help
CO2 Transport
- Majority dissolved in bicarbonate. CA speeds up reaction. Turns to CO2 at lungs and is blown off
- 5% as CO2 bound to N terminus of Hgb, increases liklihiood of tught state and offloading in tissues
- 5% dissolved
- H+ offloaded in lungs increases affinity for O2 and H+ comes on in tissues, decreases affinity
High Altitude
- Acute hyperventiltion leads to alkalosis
- Respond: EPO, Elevated HCO3 excretion (Acetazolamide augments), Elevated 2,3 BPG (Stressed), Increased cellular mitochondria,
- Acute hypoxic vasoconstriction can lead to pulmonary edema
- Chronic hypoxic vasoconstriction can lead to RVH