Ventilation & Gas Exchange (Ch. 31)-- Definition First Flashcards by Hannah Hinckley

Movement of blood through pulmonary circulation

Perfusion

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O₂ from air in alveoli diffuses into blood in pulmonary capillaries

CO₂ moves from blood in pulmonary capillaries into alveoli

Location– Alveolar-capillary membrane

Gas Exchange

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Traumatic
Tension
Spontaneous

Types of Pneumothorax

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Newborns

Lack of surfactant
Aspiration of amniotic fluids

Primary Atelectasis

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Adults

Airway obstruction
Lung compression– tumor, exudate, pneumothorax

risk factors– sedation, pain, narcotics, immobility

Acquired Atelectasis

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Sudden inflammation that starts at the lungs → Disruption of gas exchange at alveolar-capillary membrane

Hypoxemia
- Less severe form

Acute Lung Injury (ALI)

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S/S Primary Chronic Lung Disease– Chronic Bronchitis
- Cyanosis
- Polycythemia
  - ⇡ RBCs
- ⇣ SpO₂
- Drowsiness
- Altered Mental Status (AMS)
  - ⇡ CO₂
S/S R Sided HF
- Venous congestion
- Peripheral edema
- SOB
- Productive cough

Management– Treatment of lung disease & HF, Low-flow O₂ Therapy

Cor Pulmonale Manifestations

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Collection of fluid in the pleural cavity

Pleural Effusion

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Hypoxemia, ⇡ RR, absent breath sounds, dyspnea, chest asymmetry

Treatment– Fix cause, supplement O_2,thoracentesis (large needle aspiration)

Tension– ⇡ HR, ⇣ cardiac output, shock, tracheal deviation (treat w/ chest tube)

Pneumothorax Clinical Manifestations

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Limited expiratory airflow →Trapped air → Flattened diaphragm

Low V/Q–

Bronchial Asthma
COPD
Cystic Fibrosis (CF)

Obstructive Airway Disorders

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⇡ Pulmonary artery pressure with normal LV pressure

d/t– Genetics, Venous HTN, Hypoxemia, Thrombotic/Embolic Disease, Pulmonary Fibrosis

SOB
⇣ Exercise tolerance
R HF
Peripheral edema
- Legs/ankles
Functional limitations
- ⇣ ability to perform ADLs

⇡ Pulmonary artery pressure AND HF or Lung Disease

d/t– COPD, HF, Sleep Apnea, PE, Interstitial Lung Disease

Chronic Hypoxemia
- Pulmonary blood vessels constrict
Resistance to pulmonary venous drainage
- Diastolic dysfunction of LV
- Mitral/Aortic valve disorders
- Chronic thromboembolism

Pulmonary Hypertension Clinical Manifestations

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PaO2 < 60 mmHG d/t problem with O2 uptake

Causes– COPD, severe PNA, Atelectasis, ARDS, Pulmonary edema, V/Q mismatch (d/t shunt, dead air space…)

Decreased O₂to alveoli (d/t high altitude or hypoventilation)
Impaired diffusion of O₂from alveoli to blood (d/t V/Q mismatch or alveolar-capillary impairment)
- Vasodilation (Systemic circulation)
Inadequate circulation through pulmonary capillaries (d/t pulmonary embolus or arteriovenous malformation)
- Pulmonary blood vessels constrict

Hypoxemic/Oxygenation Failure

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Loss of negative pressure in pleural cavity → Collapsed lung

Pleural effusion
Pneumothorax
Atelectasis

Disorders of Lung Inflation

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Chest Injury (penetrating or non-penetrating)

fractured or dislocated ribs
CPR
Central line insertion
Intubation
Positive pressure ventilation

Traumatic Pneumothorax

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Oxygenated Blood

Pulmonary Veins

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Movement of O₂ and CO₂ across the alveolar-capillary membrane

Diffusion

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Clear, thin fluid (hydrothorax), specific gravity <1.020

d/t– CHF, renal failure, nephrosis, liver failure, malignancies (cancer)

Transudate

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Infection in pleural cavity d/t exudate

Empyema

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High V, Low Q (100:1)

Dead air space
Low flow states
Pulmonary embolism (PE)

High V/Q

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Exaggerated Type I IgE-mediated hypersensitivity response to inflammatory mediators

Leads to–

Bronchoconstriction
Vascular permeability
⇡ Mucus production
Prolonged expiration → Air trapping
- Lung hyperinflation
- ⇡ Pulmonary artery pressure

Atopic Asthma Etiology

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Reduced oxygenation of cells in tissues

Does not always indicate reduced oxygenation of arterial blood

Hypoxia

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Cyanosis
Fluid retention
- R-sided HF (cor pulmonale)
Productive cough
⇣ RR
Crackles and wheezes
- d/t mucus in the lungs

Chronic Bronchitis Clinical Manifestations

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Abnormal elevation of pressure within pulmonary arterial circulation

⇣ Size of lumen in pulmonary arteries
- Vasoconstriction → Hypoxia
⇡ Inflow of blood to pulmonary arteries
Occlusion of outflow of blood from pulmonary circulation
- ⇡ Pressure in LV

Pulmonary Hypertension

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⇣ Lung elasticity & abnormal enlargement of air spaces → Alveolar wall & capillary bed destruction

⇡ Serine elastase (Protease) release from neutrophils → Digestion of elastic fibers → ⇣ Alveolar recoil
Lung hyperinflation → ⇡ Total lung capacity

d/t– Genetics, Smoking, Alpha 1 antitrypsin (AAT) (antiprotease enzyme) deficiency

Emphysema Etiology

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Pulmonary insult → **Inflammatory response** (neutrophils secrete proteases, cytokines, & ROS) ⇡ **Permeability** of alveolar-capillary membrane → **Fluid, plasma, proteins, and blood cells** **into interstitium** & alveoli **Loss of surfactant & damage** (Type I & Type II pneumocytes) → ⇣ Pulmonary compliance → **Lung collapse** Injury to alveolar epithelium → Disorganized repair → **Fibrosis** → Lungs stiffen (difficult to inflate, **⇡ WOB**) **⇣ Gas exchange** at alveolar-capillary membrane → **⇡ Intrapulmonary shunting** (find alveolus that has O₂) → **⇣ V/Q Ratio** Hypoxemia refractory to supplemental O₂ **→ Alveoli collapse**

ALI/ARDS Pathophysiology

**⇡ RR, ⇡ HR, dyspnea, cyanosis, hypoxemia,** decreased chest expansion**, absent breath sounds,** intercostal retractions Prevention-- **incentive spirometer, frequent position changes, ambulate, hydrate** Treatment-- fix cause, **supplemental O₂**

Atelectasis Clinical Manifestations

**Sudden inflammation** that starts at the lungs **→ Disruption of gas exchange** at alveolar-capillary membrane * Life-threatening **Hypoxemia** * **Refractory to supplemental O₂Therapy** * Diffuse **crackles** * **Dyspnea** * Severe, **sudden onset** * w/i 12-18 hrs. of insult * Hypoxia * **Cyanosis** * **Tachypnea** * ⇡ RR * **Tachycardia** * Diaphoresis * Sweating * **Pulmonary infiltrates** * White on x-ray * **Systemic response** * Multiple organ failure dysfunction syndrome **(MODS)** * **Renal, GI, CV, CNS**

Acute Respiratory Distress Syndrome (ARDS) Clinical Manifestations

Thick mucus hypersecretion → **Mucus plugs** → Gas trapped in distal portion of lungs * Lung hyperinflation * Chronic, productive cough * **Smoking** * ⇡ mucus production * ⇡ size and # of mucus glands

Chronic Bronchitis Etiology

**Prevention** is key * **DVT Prevention** * **Hospital** * Sequential Compression Devices **(SCDs)** * **Heparin** (SC) * 2X/day * **Outpatient** * **Warfarin** (PO) * **Lovenox** (SC) * Low molecular wt. heparin * **Multiple or large pulmonary emboli** * Thrombolytic therapy * Streptokinase * Anistreplace * Recombinant tissue plasminogen activators **(tPA)** * “clot buster” * **MI/Stroke**

Pulmonary Embolism Treatment

Reduced oxygenation of **arterial blood** * **Always** leads to **reduced oxygenation** of cells in **tissues**

Hypoxemia

**Space** between **parietal pleura** and **visceral pleura**

Pleural Cavity

**Air** stuck in **pleural space** (intrapleural pressure \> atmospheric pressure) Leads to-- * compression atelectasis * trachea and sternum shift L * L lung shift * Vena cava compression * ⇣ venous return * ⇣ cardiac output

Tension Pneumothorax

* **Accessory muscle & pursed-lip breathing** * ⇡ positive pressure * **Barrel chest** * d/t air trapping * ⇣ Breath sounds * **⇡ RR** * **Non-productive cough** * NO cyanosis

Emphysema Clinical Manifestations

Low V, High Q (1:100) * **Shunt** * **Chronic bronchitis** * **Asthma**

Low V/Q

Brain, lungs, and heart need O₂→ **Compensatory mechanisms** activate ⇣ O₂ → Anaerobic Metabolism → ⇡ Lactic Acid → **Metabolic Acidosis**

**Hypoxemia** Etiology

* **Cl^- unable to move into epithelial lumen of airway** * Cl^- remains w/i cell * Na⁺ & H₂O move from airway into blood * **Respiratory secretions thicken** * **⇣** H₂O in mucous membranes * **Dehydration** * **Accumulation** of mucus * **Airway obstruction** * Pancreatic & biliary duct dysfunction * **Pancreatic enzyme deficiency** * Vas deferens dysfunction * **Azoospermia** * Increased **risk of pulmonary infection**

Cystic Fibrosis Pathogenesis

* **Small** emboli * **Asymptomatic** * Not usually * **Moderately-sized** emboli * **Rapid, shallow respirations** * **Pleuritic pain** * Cough * **Blood-streaked sputum** * **Massive** emboli * **Sudden collapse** * **Crushing substernal chest pain** * Can be confused w/ MI * Shock * **LOC** * Rapid, weak pulse * **Hypotension** * Distended neck veins **(JVD)** * **Cyanosis** * Fatal

Pulmonary Embolism Clinical Manifestations

Movement of **air** into the **lungs**

Ventilation

**Deoxygenated** Blood

Pulmonary Artery

Chronic and recurrent obstruction of **expiratory** airflow * **Chronic Bronchitis** * **Chronic Emphysema**

COPD Types

Limit exposure to allergens **Pharmacologic Agents** Immediate * **Bronchodilator** * Albuterol (SABA) * **Anti-Inflammatory** * Corticosteroid (ICS) Long-Term * Mometasone **(ICS)** * Salmeterol **(LABA)** * Symbicort-- Combination **(LABA + ICS)**

Asthma Treatment

**Extrinsic/Allergic/Atopic** Response * **2-8 hrs.** after exposure * Mucosal edema, ⇡ secretion, ⇡ WBC, epithelial damage, bronchospasm * **Lasts several days** Treatment-- **Corticosteroids (ICS)**

Late Phase Response

Goals-- * **Oxygenate lungs and vital organs** * Recognize & **treat underlying medical condition** * **Prevent further injury** and complications * Venous thromboembolism * Aspiration * Infection * Decrease risk for mortality Treatment-- **Intubation & Mechanical ventilation**

ARDS Treatment

Beta-adrenergic receptors → **Bronchodilation**

Sympathetic Stimulation

⇡ **CO₂**in the **arterial blood → Hypercapnia**/Hypercarbia → **Respiratory Acidosis** d/t-- **⇣ RR**

Hypoventilation

**⇣ CO₂**in the **arterial blood → Hypocapnia**/Hypocarbia → **Respiratory Alkalosis** d/t-- Panic attack, pain, **⇡ RR**, hypoxemia

Hyperventilation

**Air** in **pleural space** → ⇡ Pressure → Partial or complete lung collapse

Pneumothorax

* **Inadequate gas exchange** * V/Q mismatch * PaO₂\< 60 mmHg or PaCO₂\> 50 mmHg & pH \<7.30 or **BOTH** * **Severe Hypoxemia + Hypercapnia + Respiratory Acidosis** * Post-Surgery * Atelectasis * PNA * Pulmonary edema * Pulmonary emboli → Respiratory failure * Smoking + lung Disease * Underlying disease/infection * **Renal, cardiac, neurologic, or hepatic**

Respiratory Failure Manifestations

* Respiratory * **Accumulation of thick mucus** in bronchi * Impaired mucociliary clearance * **Lung infections** * **Bronchiectasis** * Mucus buildup in the lungs * **Chronic bronchitis/bronchiolitis** * Abnormal **pancreatic function** * **Steatorrhea** * Fatty stool * Diarrhea * **Abdominal pain** * **Malabsorption** * Malnutrition

Cystic Fibrosis Clinical Manifestations

**Perfusion without ventilation** (LOW V/Q) * Hypoxemia * Atelectasis * PNA * Asthma * COPD * Chronic bronchitis * Emphysema

Shunt

Histamine, leukotrienes, prostaglandins → **Bronchoconstriction**

Inflammatory Mediators

**Incomplete expansion** of lung/alveoli d/t-- **Pleural effusion, Pneumothorax, loss of surfactant**

Atelectasis

**PaCO2 \> 50 mmHg AND pH \<7.30** **Causes--** ⇣ RR or WOB * Upper airway obstruction-- **infection, laryngospasm, tumors** * Weakness or paralysis of respiratory muscles-- **brain injury, sedation, drug overdose (opioids), Guillen-Barre syndrome, Muscular Dystrophy, spinal cord injury** * Chest wall injury-- **physiologic dead space** Leads to-- **Vasodilation** (systemic circulation), **Pulmonary blood vessel constriction** **Diagnosis** * ABG-- **elevated CO₂**

**Hypercapnic**/Ventilation **Failure**

Low V, Very High Q (1:1000) * **Atelectasis** * **ARDS** * **Pneumonia**

Very Low V/Q

* Genetic * **Autosomal recessive** * Chronic respiratory disease * Exocrine glands in **epithelium of respiratory, GI, & reproductive tracts** * Pancreatic exocrine deficiency * **⇡ NaCl in sweat** * **Mutation** in cystic fibrosis transmembrane regulator **(CFTR)** * Chloride channel in airway epithelium * **Impermeable to chloride**

Cystic Fibrosis

**Dyspnea, Hypoxemia** * ⇣ lung expansion on affected side * Dull to percussion * ⇣ breath sounds **Treatment--** antibiotics, thoracentesis (large needle aspiration), chest tube

Pleural Effusion Clinical Manifestations

**Purulent, thick fluid**, specific gravity \>1.020 d/t-- **elevated LDH & protein, inflammatory cells**

Exudate

**Acute:** Mild-- SANS activation * **⇡ HR,** * **⇡ RR** * **⇣ mental acuity** * **Vasoconstriction** * **Pale skin** * **Diaphoresis** Moderate/Severe-- Altered mental status * **Confusion** * **Stupor** * **Coma** **Chronic:** * **⇡ RR** * **Pulmonary vasoconstriction** * **Polycythemia (⇡ RBC)** * **Cyanosis** * **Clubbing**

**Hypoxemia** Clinical Manifestations

* **Aspiration** * Near drowning * Gastric contents * Drugs & Toxins * Heroin * Free-base cocaine smoking * Inhaled gases * **Smoke, ammonia** * High O₂Concentrations * **Radiation** * Infections * **Sepsis** * Trauma & Shock * **Burns** * Fat embolism * **Chest trauma** * Disseminated Intravascular Coagulation **(DIC)** * Multiple blood transfusions

ALI/ARDS Causes

**Ventilation without perfusion** (HIGH V/Q) * Hypoxemia

Dead Air Space

* **Smoking cessation** * Avoid bronchospasm triggers * **Pulmonary rehab** * ⇡ efficiency * ⇣ WOB * Prevent RTIs * Bronchodilators * **Albuterol** (SABA) * **Anticholinergics** * Ipratropium bromide * **O₂therapy** w/ significant hypoxemia (PaO₂\< 55 mmHg) * 1-2 L low-flow oxygen * Limit to stimulate breathing * Goal: PaO₂55-65 mmHg * Goal: SpO₂88-92%

COPD Treatment

**Chronic inflammation** of airway → airflow **obstruction** & airway **hyperresponsiveness** * **Extrinsic/Allergic/Atopic** * Type I IgE-mediated hypersensitivity reaction * Genetic component * **Intrinsic/Non-allergic/Non-Atopic** * no allergy component

Bronchial Asthma Types

* **Airways narrow** d/t * Bronchospasm * Bronchial mucosal edema * Mucus plugging * **Prolonged expiration** → Air trapping * Lung hyperinflation * **⇡ WOB** → ⇡ O₂demands * Dyspnea * Fatigue * ⇣ Alveolar ventilation → **Low V/Q** * Hypoxemia * Hypercapnia

Asthma Clinical Manifestations

Pulse Oximetry Arterial Blood Gas **(ABG)**

Measures of blood oxygenation

Diagnosis-- * **Respiratory & GI manifestations** * **Family history** * **Newborn screening** * **+** = ⇡ immunoreactive trypsinogen * **Sweat chloride test** * 2X normal NaCl in sweat * **CFTR** functional testing & genetic analysis Treatment-- * Goal: **Slow progression** of secondary organ dysfunction * **Chronic lung infection** * **Antibiotics** * **Bronchodilators** * **Chest percussion** * Postural draining * **Pancreatic insufficiency** * **Pancreatic enzyme replacement** * Vitamin supplements

Cystic Fibrosis Diagnosis & Treatment

* **RTIs** * **Exercise (EIB)** * **Drugs** * ASA-- ⇣ COX, ⇡ LOX → ⇡ Leukotrienes * Morphine-- Histamine release * **Emotional Upset** * **Bronchial irritants** * Smoke * Toxins

Asthma Attack Triggers

**Virchow Triad** * **Venous stasis (slowing) & Venous endothelial injury** * Bed rest, hip or femur fracture, surgery, childbirth, MI, HF, spinal cord injury * **Hypercoagulability states** * Cancer * Pregnancy * HRT * Oral contraceptives

Pulmonary Embolism Risk Factors

* **Hypoxemic--** Oxygenation Failure * (PaO₂\< 60 mmHg) * COPD * PNA * Atelectasis * Impaired diffusion * Pulmonary edema * ALI/ARDS * **Hypercapnic/Hypoxemic--** Ventilation & Oxygenation Failure * (PaO₂\< 60 mmHg, PaCO₂\> 50 mmHg & pH \<7.30) * Upper airway obstruction * Infection * Laryngospams * Weakness or paralysis of respiratory muscles * Brain injury * Overdose * Guillain-Barre * Muscular Dystrophy * Spinal Cord Injury * Chest wall injury Diagnosis-- **ABGs** (determine if hypoxemic, hypercapnia **or** **BOTH**)

Types of Respiratory Failure

**VQ ratio not 1:1** * Ventilation **(V)** * Perfusion/Blood Flow **(Q)**

**VQ Mismatch**/Inadequate Gas Exchange

Cholinergic receptors → **Bronchoconstriction**

Parasympathetic Stimulation

Bloodborne substances lodged in pulmonary artery → Bloodflow obstructed **(High V/Q)** d/t-- Thrombus **(DVT) → Pulmonary circulation**, **Injected air (IV)**, **Fat mobilization** after long bone fracture (femur, humerus, pelvis), **Amniotic fluid entering maternal circulation** during childbirth

Pulmonary Embolism

**Blood** in pleural cavity d/t **lung puncture** (trauma) * Chest injury, chest surgery complications, malignancies, rupture of great vessel (aortic aneurysm) Treatment-- **Chest tube**

Hemothorax

**Right Sided Heart Failure** d/t-- Primary Lung Disease, Pulmonary Hypertension, Chronic Bronchitis * ⇡ Pulmonary circulation pressures * Fluid retention * **⇡ Work of RV** * **Hypertrophy** → R sided HF

Cor Pulmonale

**Bleb/Blister** ruptures **→ Air** flows from alveoli into **pleural space** **Primary** * Bleb @ top of lungs * Tall, thin people * Smokers **Secondary** * **Lung disease** * Asthma, TB, CF, COPD, lung CA * Potentially life threatening

Spontaneous Pneumothorax

**Extrinsic/Allergic/Atopic** Response * **5-30 mins.** after exposure * ⇡ Release of inflammatory mediators * Vasodilation, vascular damage, bronchospasm Treatment-- **Albuterol** (SABA)

Early Phase Response

Ventilation & Gas Exchange (Ch. 31)-- Definition First Flashcards

Exam 2