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325 Cards in this Set
- Front
- Back
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Neural Crest Cells
what does enterochromafin cell give out? |
"MOTEL PASS"
Melanocytes Odontocytes Tracheal cartilage Enterochromaffin cells=> 5-HT Laryngeal cartilage Parafollicular cells/Pseudounipolar cells Adrenal medulla/ All ganglion cells Schwann cells Spiral membrane |
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when does the notochord, brain and lung develop?
what is what is the complication if 90% of the lung does not develop? |
Notochord develops by 4 weeks, Brain by 8 wks, Lung by 12 wks
• If 90% lung doesn't develop ⇨ pulmonary aplasia ⇨ die |
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when is surfractant made?
how is it tested? how to indicate the maturity of the lung |
Surfactant is made by 33 wks = alveoli lubricant (decreases surface tension to prevent atelectasis)
• Phophatidyl glycerol = surfactant precursor, can test for this Lecithin:Sphingomyelin ratio is 2:1 to indicate maturity (brain sphingomyelin is done) |
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tx for baby with out/ not enough surfractant
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Tx: Beclomethasone/Betamethasone IM to Mom=> surfactant production in baby
• Tx: Blow surfactant into neonate lungs (intubation) |
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Premie Lung Progression management
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will have to leave baby on O2 for for 18-24 mo
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complication of lung premies: (4)
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Atelectasis
RDS Hyaline membrane dz BPD "bronchopulmonary dysplasia" |
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RDS "respiratory distress
syndrome (tx) |
(Tx: 02 ⇨ free radicals)
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Hyaline membrane dz
pathogenesis restrictive/obstructive what is increased? |
⇨ thicken membrane ⇨ decrease diffusion (restrictive) ⇨ ⇧goblet cells
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BPD "bronchopulmonary dysplasia"
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⇨ mucus, narrow lumen (obstructive)
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Atelectasis
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collapsed alveoli
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ARDS "Adult Respiratory Distress Syndrome": presentation
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tachypnea, hypoxemia, diffuse infiltrate
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ARDS: pathogenesis, most common cause of what?
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PMNs cause alveocapillary damage -> increase permeability of alveolar capillaries
• Most common cause = sepsis |
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ARDS:
how does NO cause ARDS? PO2/FiO2 = |
NO dilates aa = > washes of surfactant, leaks proteins into interstitium
pO2/FiO2 < 150 |
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ARDS:
what would you see on CXR? Tx |
CXR: "fluffy" infiltrates although lungs sound clear
• Tx: Glucocorticoids, Ventilator (⇧Fi02, ⇧pressure, ⇧RR, ⇧I:E ratio, ⇩TV) |
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Predicting 02 Saturation:
p02 dissolved / 02 bound = 100 mmHg/? 02 sat = ? |
100%
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Predicting 02 Saturation:
p02 or dissolved 02 = 90mmHg 02 sat or bound 02 = |
98%
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Predicting 02 Saturation:
p02: 02 sat: dissolved 02/ bound 02 60mmHg |
90%
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Predicting 02 Saturation:
p02: 02 sat: dissolved 02/ bound 02 40mmHg |
75%
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Predicting 02 Saturation:
p02: 02 sat: dissolved 02/ bound 02 80mmHg |
96%
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Predicting 02 Saturation:
p02: 02 sat: dissolved 02/ bound 02 25mmHg |
50%
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p02 Predictors: If p02=50
02 Sat: Action: |
02 Sat: 85%
Action: Intubate |
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p02 Predictors: p02=80
02 Sat: Action: |
02 Sat: 96%
Action: Normal |
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p02 Predictors: p02=55
02 Sat: Action: |
88%
Home 02 |
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Pneumothorax: describe and tx
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decreased breath sounds on one side,
do tx if it covers > 25% of chest |
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3 type of pneumothorax
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Spontaneous
Tension Asymptomatic |
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Spontaneous Pneumothorax: risk factors
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oral contraceptives, thin male smokers, collagen vascular dz
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Tension Pneumothorax: describe and tx
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(can't breathe out): air in pleural space pressures lungs => tracheal shift
Tx: needle in 2nd intercostal mid-clavicle above rib on exhalation; vaseline gauze |
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Asymptomatic Pneumothorax:
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observe if air occupies <25%
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how to predict ABG, likely to die from
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decide whether or not the disease is a restrictive or obstructive process, you can predict their blood gas, chest x-ray, and what they are most likely to die from.
ask yourself if they have trouble breathing in or out, and whether they have small stiff, lungs or. big mucus-filled lungs, then tell me everything you know |
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Restrictive: describe lungs, presentation, what capcity is decreased, FEV/FVC
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interstitial problem (non-bacterial)
• Small stiff lungs a decrease VC • Trouble breathing in=> FEV/FVC: > 0.8 |
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Restrictive:
ABG: CXR: (3) |
They cannot breath in and therfore the pO2 is decreased =>ABG: ⇩p02 => ⇩pC02, ⇧RR, ⇧pH
• CXR: reticula-nodular pattern, ground-glass apperance or interstitial infiltrate |
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Restrictive:
what do they usually die of and give an cause (3) |
Die of cor pulmonale (hypoxia leads to low energy state; heart failure due to lung disease is called cor pulmonale)
• Ex: NM diseases (breathing out is passive), drugs, autoimmnne dz |
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Restrictive: disease tx
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Tx: Give pressure support on ventilator, ⇧O2, ⇧RR, ⇧inspiratory time
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Obstructive:
pathogenesis what is increased? FEV/FVC ratio |
airway problem (bacterial)
• Big mucus-filled lungs (⇧RV, ⇧Reid index = ⇧airway thickness/ airway lumen) • Trouble breathing out=> FEV/FVC: < 0.8 |
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Obstructive:
ABG MCC of death |
They cannot breath out and therfore the pCO2 is accumulating => ABG: ⇧pC02 => ⇧RR, ⇩pH
Die of bronchiectasis |
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Obstructive:
example and tx |
Ex: COPD
• Tx: Manipulate rate on ventilator, ⇧RR, ⇧expiratory time, ⇧02 only if needed |
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Cough: name some dieseases that causes this
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each cough moves mucus 1 inch
• Postnasal drip: cold, allergies • Pertussis: whooping cough • COPD • Asthma • GERD |
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Neck Films: Steeple sign
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=> Croup
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Neck Films: Thumb sign
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=> Epiglottitis
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Amniotic fluid: function and who makes it ?
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keeps pressure off the baby
80% is mom's plasma 20% made by baby (must be able to swallow, absorb, filter, urinate) |
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Polyhydramnios: pathogenesis
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baby can't swallow
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Polyhydramnios: tx
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Tx: Indomethicin <34wk: stops baby's pee
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Polyhydramnios:
• NM problem: • G I problem: |
• NM problem: Werdnig-Hoffman
• G I problem: Duodenal atresia |
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Oligohyramnios:
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baby can't pee
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Oligohyramnios:
• Abdominal muscle problem: tx and its complications • Renal agenesis: |
• Abdominal muscle problem: Prune Belly => can't pee (Tx: catheter ~> UTI)
• Renal agenesis: Potter's syndrome: ⇧ atmospheric pressure => flat face |
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Oligohyramnios: Abdominal muscle problem: Prune Belly tx
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=> can't pee (Tx: catheter ~> UTI)
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Diaphragmatic hernia:
define what are the two types? which one is more common? |
intestines are in thoracic cavity=> hypoplasia of one lung
• Bokdalek (90%): hole in back of diaphragm • Morgagni (10%): hole in the middle of diaphragm |
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Bokdalek Diaphragmatic hernia
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(90%): hole in back of diaphragm
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Morgagni Diaphragmatic hernia
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(10%): hole in the middle of diaphragm
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Diaphragmatic hernia: Dx and tx
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Dx: CXR with air-fluid levels
Tx: Orogastric tube with suction (to prevent bowel distension) |
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Lung Anatomy: describe the type of muscle and epithelium
top and bottom |
Top: skeletal muscle (squamous cell epithelium)-
Bottom: smooth muscle (tall columnar ciliated epithelium) |
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Lung Anatomy: which zone top or bottom is increased by smoking
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Top zone: smoking increases this zone
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Lung Anatomy:
Extrathoracic: location, protection and what happens during inpiration |
lips to glottis (not protected by rib cage)- narrows on insp
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which part of the lung anatomy causes stridor
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extrathoracic
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Intrathoracic: location, protection
what happens during inspiration and what sound does it make pathologically? |
glottis to alveoli (protected by rib cage) - expands on inspiration⇦wheeze ·
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which part of the lung anatomy causes wheeze?
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intrathoracic
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C-shape cartilage rings
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compresses airway w/ swallowing to prevent aspiration
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Fully encircling cartilage
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where mainstem bronchus dives into lung parenchyma
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where does the Trachea divide
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divides into main stem bronchi "carina" at T4
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which bronchus goes straight down?
what is the other name? |
Right main stem bronchus ⇨ goes straight down (bronchus intermedius)
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where do aspiration go to? if on the side
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Aspirations ⇨ Right Lower Lobe (or upper lobe if on the side)
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where does the aspiration go if ie child is playing around (upright)?
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Posterior segment
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where does the aspiration go if patient is supine
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Superior segment
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aspiration of foreign objects:
presentation, management |
Recurrent R upper lobe pneumonia=> foreign objects (do insp/exp film)
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Most common aspirations:
in order |
#1 peanut, #2 popcorn, #3 hot dog
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if the foreign body reaches the stomach, management?
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leave it alone
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if a patient apirated a foreign body, and can't talk, Dx
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Where stuff likes to get stuck: can't talk
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if the foreign body is stuck on the glottis? tx
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Tx: Heimlich maneuver (adults) or back blows (kids)
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what sits on midway between glottis and carina?
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LA sits on it
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Main-stem bronchus: resistance and function
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branches in parallel => ⇩resistance, humidify and warm air
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Medium size bronchioles
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most dilation/ constriction
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Terminal broncioles
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most dependant (small particles settle, primary lung cancer starts)
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where are the most SM and β2 receptors
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Medium size bronchioles
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where does 1° lung cancer starts?
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Terminal broncioles
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what happens to the velocity from the Trachea to the alveoli?
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velocity decreases
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Respiratory unit function
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the ONLY oxygen exchange system
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what is the Respiratory unit made up of?
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resp bronchiole + alveolar duct + alveolus (1 layer of epithelium)
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Ventilation: Dead space (VD ):
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lip to terminal bronchiole (everything except your respiratory unit)
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Ventilation: Alveolar ventilation (Va): location
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(Va) respiratory bronchiole to alveoli. the respiratory unit
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Ventilation: Total ventilation =
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VD + VA
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Minute Ventilation (Vm): define and formula
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TV x RR =how much you breathe in during 1 min
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normal Vm minute ventilation
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10-15 cc/kg (have a Vm for V0 , Va, VT, etc.)
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Histology: Goblet cells:
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secrete mucus to trap dirt (most abundant cell type)
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Histology: Cilia
histology movement |
9+2 actin configuration: orade movement "toward mouth" (not back and forth)
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Histology: Dyenin arm
what paralyses the cillia and what is its complications? |
flexibility for cilia (viruses and smoke paralyzes cilia ⇨ green sputum)
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Histology: Type I pneumocytes
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(5%) =macrophage (in terminal bronchiole)
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Type II pneumocytes
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(95%) = surfactant producers (in alveolar bronchioles)
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after an injury, what can type II cells do?
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Type II cells can demote themselves to type I cells after injury.. .
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what are Clara cells
where do they live |
"dust cells": MP that eat dust (live in the terminal bronchiole)
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Kartagener's
pathogenesis 3 clues |
(broken dyenin arm): situs inversus, bronchiectasis, male infertility
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Stridor: describe and management
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extrathoracic narrowing=> narrows when breathe in => neck x-ray
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Wheeze: describe and management
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intrathoracic narrowing=> narrows when breathe out=> chest x-ray
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Rhonchi: describe and common in what disease?
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mucus in airway=> obstructive lung disease
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Grunt: describe and what type of disease
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blows collapsed alveoli open=> restrictive lung disease
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Dull percussion
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something b/w alveoli and chest wall absorbing sound (fluid, air, solid)
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Hyperresonance
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air
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Tracheal deviation
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away from pneumothorax OR toward atelectasis "air-phobic"
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Fremitus, egophony, bronchophony:
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consolidation=> pathognomonic for pneumonia
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Crackles "rales": describe and causes
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alveoli are collapsed
No surfactant Alveolar fibrosis |
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causes of No surfactant in an adult
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washed out due to pulmonary edema or CHF
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Alveolar fibrosis: drugs and disease
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Pneumoconioses, Bleomycin, Busulfan, Amiodarone, Tocainide
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Barking cough (viral pathogen, x-ray)
Dx and tx |
Dx: Croup, steeple sign on xray, (Parainfluenza)
Tx: 02, Dexamethasone, racemic Epi, |
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Stacatto cough
Dx and tx |
Pneumonia (Chlamydia)
Fluoroquinolone |
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Whooping cough
Dx and tx |
Dx: Pertussis (Bordatella)
tx: Erythromycin |
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Muffled voice/ drool (thumb x-ray)
Dx and tx (2) |
Dx: Epiglottitis (H. influenza B)
tx:OR Intubation, Ceftriaxone |
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Expiratory wheeze- kid
Dx and tx |
Dx: Bronchiolitis (RSV)
tx: Ribaviran, Albuterol |
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Inspiratory stridor - kid
Dx and tx |
Dx: Laryngomalacia
tx: Observe |
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Inspiratory stridor - adult
Dx and tx |
Dx: Subglottic stenosis
tx: Dilation |
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what is Asthma?
define and 2 types |
wheeze on expiration
intrinsic and extrinsic asthma |
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Intrinsic Asthma
define and factors that can trigger it? |
Genetic (cold air, exercise, NSAIDs make it worse)
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Extrinisic asthma: causes and what part of the immune system reacts?
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Environment-induced (dust mites, roach droppings), IgE/ Eosinophils
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Benign Pulmonary Nodule
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Popcorn calcifications
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Radiolucent (black) X-rays
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=> air
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Radiopaque (white) X-rays
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=> fluid/ solid
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Bronchiectasis: presentation
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digestion of airways ⇨ hemoptysis
Honeycomb lung = bronchiole dilation, halitosis |
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Bronchiectasis
Dx Tx |
Dx: high resolution CT
Tx: Antibiotics, 02 |
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Acute bronchitis
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increased mucus production
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Chronic bronchitis
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3 consecutive months over 2 yrs
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Bugs that can cause bronchitis
color of sputum of most common cause of brochitis |
Strep pneum (rusty colored sputum), H influenza, Neisseria cattaralis
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Bronchitis: pathogenesis
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Inflammation ⇨ dilate airways ⇨ secretion buildup ⇨ bronchial destruction
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Bronchiolitis: definition
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asthma symptoms< 2y/o
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Bronchiolitis: presentation and caused by what bug
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⇧AP diameter, flat diaphragm, usually due to RSV
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Bronchiolitis: more succeptible to what?
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⇧Risk of future asthma/ ear infections
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Bronchiolitis: tx
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Tx: Isolation/ Albuterol, Ribavirin (if resp failure)
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Blue Bloater
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Bronchitis
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Pink Puffer
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Emphysema
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give 3 examples of COPD diseases?
how is prognosis determined? |
Bronchitis, Emphysema, Asthma
Prognosis is determined by FEV1 |
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COPD Tx:
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1) 02
2) Albuterol (bronchodilator) 3) Me-Prednisolone (glucocorticoid) 4) Levofloxacin |
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which of the treatments for COPD can alter the natural history of dz
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oxygen
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Asthma:Early Phase: cause and tx
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IgE (Tx: Antihistamines)
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asthma Late Phase: cause and tx
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Cytokines (Tx: Steroids)
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how do you get a steeple sign in Croup?
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swelling around the glottis => steeple sign on x-ray
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Croup: pt. presentation
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Barking cough, stridor on inspiration
• Fluctuating course (improves/worsens within 1 hr) |
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what are the 4 viral pathogens that causes croup?
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Viruses:
• Parainfluenza • RSV • Adenovirus • Influenza virus |
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treatment of RSV
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(Tx: Ribavirin)
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the most severe croup is caused by what virus?
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RSV
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Croup tx
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Tx: Dexamethasone, racemic Epi, 02
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Pulmonary Eosinophilia:
drugs, parasites and fungus |
Aspergillosis
Parasites: Strongyloides Drugs: Nitrofurantoin, Sulfonamide |
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Cystic Fibrosis:
mode of inheritance and chromosome, etiology and test |
>>(AR): Chr #7 CFTR: Cl channel broken=> more Cl in secretions
>>Test: Pilocarpine sweat test (Cl >60mEq/L => have CF) |
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Cystic Fibrosis:
Tx vaccination |
>>Tx: N-acetylcysteine (breaks mucus disulfides), chest percussions, future lung transplant
>>Vaccinations: Influenza |
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CF: bug and tx
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Bugs: Staph/Pseudo like to attack them
Tx: Tobramycin + Piperacillin |
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CF: Newborn with CF are succeptible to what? and tx
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= > meconium ileus
(Tx: gastrografin enema) |
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lung and nose of a CF patient:
restrictive or obstructive |
Lung => obstructive pulmonary disease
Nose => obstruction |
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what Pancreatic problem do CF succeptible to?
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=> malabsorption=> Vit. A,D,E,K. def
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what Epididymis problem do patients with CF are succeptible to?
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= >infertility
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what urinary problem do patients with CF are succeptible to?
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oxylate stones (malabsorption)
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what GI problem do patients with CF are succeptible to?
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Stool => steatorrhea
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Emphysema:
restrictive or obstructive predict its ABG how do they breath? name the all 4 types of emphysema. |
obstructive (⇧pC02,⇧RR, ⇩pH)
pursed lip breathing 4 types: Pan-acinar Centro-acinar Distal acinar Bullous "pneumatocele" |
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Pan-acinar
mode of inheritance pathogenesis test |
(AR)
α1-AT def can't inhibit elastase PAS(+) restrictive |
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Centro-acinar: etiology
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smoking
"comes in through the center" |
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Distal acinar
what is it due to complication |
aging (least blood supply) ⇨ spontaneous pneumothorax
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Bullous "pneumatocele"
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elastase positive bacteria = Pseudo/Staph aureus
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pathogenesis of Epiglottitis?
xray? |
inflammation above glottis => thumb sign on x-ray
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Epiglottitis: presentation
pathogen |
>>Drooling, stridor, muffled voice, high fever
>>Bug: HI-B "stick out thumb to Say HI" |
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Epiglottitis: tx
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Tx: Intubate immediately in the OR, Ceftriaxone
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Flash Pulmonary Edema:
describe treatment |
X-ray white out
Tx: 02, Morphine, Furosemide, Nitroglycerin (⇩BP) |
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Laryngomalacia
management |
epiglottis roll in from side-to-side => feed in upright position
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Pneumoconioses
associated cancer name all 5 |
promote adenocarcinoma
Asbestosis Silicosis Beryliosis Byssinosis Anthracosis |
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4 examples of patients with increase risk of Asbestosis?
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shipyard workers, pipe fitters, brake mechanics, insulation installers
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Asbestosis; what is seen (2)
complication what is the pathogenisis of this complication |
o Crocodilite fibers
o Fe coating: ''ferruginous body" ⇨ MP take to pleural cavity ⇨ mesothelioma |
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Silicosis:
who is at risk (3)? complication |
sandblasters, glassblowers, monument engravers ⇨ pulmonary TB
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Beryliosis: describe and tx
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radio TV welders, dental ceramics
"Berry' the newscaster" (Tx: steroids) |
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Byssinosis:
presentation increased risk |
cotton workers
"Cotton blankets in bassonettes" chest tightness |
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Anthracosis:
who is at risk lung cancer? complication |
coal workers=> Not promote lung cancer, may get massive fibrosis
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Pneumonia:
define and PE the 3 types of pneumonia |
consolidation of airway (dull percussion, rales, tactile fremitus, egophony)
typical, atypical, fungal pneumonia. |
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Hemoptysis DDx: (5)
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• Bronchiectasis
• Bronchitis • Pneumonia • TB • LungCA |
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Typical PNA: name all types
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Streptococcus pneumoniae
Haemophilus influenza Neisseria cattarhalis Staphylococcus aureus Pseudomonas Klebsiella Anaerobes |
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most common typical pneumonia?
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Streptococcus pneumoniae:
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Haemophilus influenza: clue
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2nd most common pneumonia, Gram(-) coccobacilli, kids
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Neisseria cattarhalis
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3rd most common pneumonia
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Staphylococcus aureus
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secondary infection after influenza virus
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Pseudomonas
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found in cystic fibrosis
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Klebsiella
sputum where is it found in the lung increased risk |
currant jelly sputum, bulging fissures, found in alcoholics, DM
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Anaerobes pneumonias presentation?
who is at risk? (2) |
gas, foul sputum, aspiration in dementia pt, alcoholics
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name the 4 Atypical PNA? common presentation and tx
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dry cough
(Tx: Erythromycin) Mycoplasma Chlamydia Legionella Actinomyces |
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most common atypical pneumonia in 0-2 mo?
presentation |
Chlamydia
stacatto cough, eosinophils |
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most common atypical pneumonia in college:
presentation ears xray test |
Mycoplasma
reticulonodular, bullous myringitis, cold agglutinins |
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Legionella:
define acquired test patient presentation |
most common atypical pneumonia in >40y/o patients.
A/C ducts CYAE and silver stain low Na, CNS changes |
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Actinomyces
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sulfur granules
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Fungal PNA: name all
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Histoplasma
Blastomyces Coccidioides Paracoccidioides Aspergillus |
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Coccidioides
location disease describe how they look like (2) |
(San Joaquin Valley), desert bump fever
budding yeast, thin walled cavity |
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Blastomyces
how is it acquired (2) how does it look like location |
pigeon droppings (NY), broad-based hyphen, rotting wood in beaver dams
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Histoplasma
location how is it acquired how does it look like signs |
bat droppings (Mississippi river),
no true capsule, MP oral ulcers |
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Aspergillus
where can one aquire it (2) complication treatment |
fungal ball, moldy hay
pulmonary bleed (Tx: Prednisone) |
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Paracoccidioides
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looks like a ship's wheel
(S. America) |
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Pulmonary Embolus
describe and presentation |
blockage of blood flow in lungs=> tachypnea
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PE:
what would be seen in EKG? test for diagnosis. name all 3 which one is the most reliable? |
EKG: S1Q3T3
• ⇧V /Q scan: perfusion defects, most reliable • Venous US • Spiral CT |
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PE gold standard test?
what would you see on CXR? |
Pulmonary angiogram- gold standard
CXR: Hampton's hump: wedge opacification |
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Only reason for: Radiation
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small cell CA
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Only reason for: Surgery:
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V-Q mismatch (palliative)
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PE: x-ray
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Hampton's hump: wedge opacification
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5 PE Tx:
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• Anticoagulation: Heparin, Coumadin, IVC fllter
• Intervention angiography, Surgery |
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1° Pulmononary HTN:
pregnancy and pathogenesis |
• ⇧PA pressure (enlarged right heart leads to cor pulmonale)
• ⇧Mortality rate with pregnancy |
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1° Pulmonary HTN: what happens in pre and post capillary
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Pre-capillary: ⇧resistance to flow in pulmonary arteries (Ex: ASD/VSD/PDA/L⇨R shunts)
• Post-capillary: ⇧resistance to flow in pulmonary veins (Ex: LV dysfxn/constrictive pericarditis) |
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1° Pulmonary HTN + ⇧PCWP+ =Dx
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⇧PCWP (LA pressure): cardiac problem
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1° Pulmonary HTN + ⇩PCWP = Dx
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⇩PCWP: lung problem (1⁰ Pulm HTN, ARDS, cor pulmonale)
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1° Pulmonary HTN tx
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Tx: Coumadin + Amlodipine
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Sarcoidosis: what would be seen on x-ray, legs, lympnode
|
Hilar lymphadenopathy
Erythema nodosum Non-caseating granulomas Lymph node "eggshell califications" |
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sarcodisis presentation
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"Potatoe nodes" ⇨ face weakness
Uveitis |
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sarcodisis:labs, test and tx
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⇧ACE, ⇧Ca,⇩T cells
• Test: Parotid gland biopsy • Tx: Prednisone (if eye/ heart involved) |
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Sinusitis: presentation, pathogenesis and tx
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bacterial infection obstructing maxillary sinus
• Pain worse when bend forward • Tx: Amoxicillin |
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Tonsillitis: presentation and tx
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sore throat, pooling of saliva, muffled voice
• Tx: needle drainage, Abx |
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Tracheitis:
presentation labs |
=Diphtheria: vascularized grey pseudomembrane (don't scrape it)
Look toxic, stridor w/ cyanosis, leukocytosis |
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Tracheitis: bugs
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Bugs: Staph, Strep
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Tracheitis: pathogenesis and tx
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Toxin ADP-ribosylates EF-2 => cells die
Tx:Ceftriaxone,cricothyroidotomy if suffocating |
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Tracheomalacia
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soft cartilage, stridor since birth, outgrow by 1 y/o
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what are the Physiologic Parts of Lung?
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• Intrathoracic space: chest wall, pleural space
• Pulmonary vasculature • Pulmonary airway |
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Compliance:
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Δ V/ΔP
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Elastisticity:
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provides recoil
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what are the lung volumes?
which on the volume are not on PFT? |
Lung Volumes: "LITER"
1) IRV 2) TV 3) ERV 4) RV (not on PFT) |
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IRV "Inspiratory Reserve Volume":
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air you can force in after a normal breath
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TV "Tidal Volume"
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normal breath
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what is ERV "Expiratory Reserve Volume"?
what part of the lung does it fill |
can force out after normal exp
fills dead space |
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RV "Residual Volume"
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air in lungs after forced exp, keeps alveoli open (not on PFTs)
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what are the Lung Capacities:
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IC
VC TLC FRC |
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IC "Inspiratory Capacity":
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total amount of air you can breathe in = 1 +2
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VC "Vital Capacity"
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all the air you can breathe in after forced expiration = 1 +2+ 3
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TLC "Total Lung Capacity":
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air in lungs after deep breath = 1 +2+ 3+4
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FRC "Functional Residual Capacity"
what does TLC equal to? |
baseline (where you stop/ start breathing) = 3+4
"FIT": FRC + IC = TLC |
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above/ below the FRC what is the pressure?
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Above FRC = > positive pressure
Below FRC =>negative pressure |
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FEV/FVC normal ratio?
FEV and FVC |
= 0.8
• FEV,: forced expiratory volume in 1 sec • FVC: forced vital capacity |
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Obstructive Lung Dz:
what volume changes first? what volume changes last? what capacity changes first? |
⇧RV (or FRC) first; last to change is TV
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Restrictive Lung Dz:
what capacity changes first? volume to change last |
⇩VC (or TLC) first; last to change is TV
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what happens during normal inspiration:
what volume is measured? |
=> Tidal volume
Diaphragm - goes down External intercostals - used during exercise "externals breathe in" Innermost intercostals - right muscles (along sternum) move left chest wall |
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what muscles are used for Forced inspiration?
what volume is measured? |
=> IRV
Pectoralis major and minor Head and neck muscles: • Scalenes • Sternocleidomastoid • Trapezius |
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Normal expiration
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Recoil only (know this!)
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what muscles are used for Forced expiration:
what volume is measured? |
=> ERV
Internal intercostals "internals breathe out" Abdominal muscles: • Obliques • Rectus abdominis • Transversus abdominis • Quadratus lurnborum |
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Intrathoracic Pressure:
function positive/negative |
>necessary to pull blood into thorax
>Pleural space is always negative |
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A-a Gradient (A = Alveoli; a = arteriole) : increased
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Extracts 02 (restrictive)
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A-a Gradient (A = Alveoli; a = arteriole) : decreased
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Lose 02 (polycythemia)
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High Altitude:Chronic:
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Kidneys pee off bicarbonate
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Acute: Mountain Sickness: tx
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Tx: Acetazolamide to pee off bicarbonate)
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Intrathorasic pressure for the ff.
Resting: Normal breath: Deep breath: |
Resting: -3 to -5
Normal breath: -10 to -12 Deep breath: -20 to -24 |
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+ intrathorasic pressure: Dx
Risk factors |
Pneumothorax:
RF: oral contraceptives, thin male smokers, Staph/Pseudo |
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intrathorasic pressure of -40 to -60>
Dx complication |
Restrictive lung disease (negative pressure sucks in=> GERD, hiatal hernia)
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Breathing: describe the pressures is the following areas: intrathorasic, pulmonary alveolar and air way pressure
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Pulmonary alveolar (PA) =airway pressure= opposite sign of intrathoracic pressure)
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where is the highest compliance? what does this mean for the alveoli?
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Highest compliance (mid-inspiration or mid expiration) => max airflow into alveoli
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during Inspiration, how does the blood move?
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moves air into lungs and blood into heart
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describe inspiration
start: chest wall vs lung expansile force, PA vs Patm mid inspiration: end of inspiration when is compliance increased? what is the pressure in the alveoli at end of inspiration? |
>Start: chest wall > lung expansile force, PA = PATM
>Mid-inspiration (50-99%): lung > chest wall expansile force, ⇧compliance, PA<< PATM >End-inspiration: recoil of chest wall= expansile force of lung (alveoli negative pressure) |
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describe expiration:
start: chest wall vs lung recoil, PA vs Patm mid-expiration: end expiration: which one is effort dependant/independent when is compliance increased when is airway positive pressure? |
Start: chest wall> lung recoil, PA >> PATM, effort dependant=> can force out
Mid-expiration (50-99%): lung > chest wall recoil, ⇧compliance, effort indep, collapse airway End of expiration: lung recoil = chest wall expansion, PA = PATM (airway positive pressure) |
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Flow and Ventilation: Top of lung
when does more air flows at the bottom of the lung? |
more air (more air flows into bottom during inspiration only)
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Flow and Ventilation: Bottom of lung:
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more blood flow (gravity, dilated capillaries, dilated arterioles)
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how does a pt. with V/Q mismatch present? (restrictive or obstructive)
what does it lead to? |
Every V / Q mismatch presents with a restricive pattern, leads to hypoxia
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Dead space:
example and describe V/Q and why? |
High V /Q =>no blood flow
• Ex: PE, shock |
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Shunt:
describe V/Q and why example |
Low V /Q => no ventilation
• Ex: atelectasis, pneumonia |
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At FRC: PA vs Patm
Inspiration: Expiration: End of deep breath: |
At FRC: PA=Pamt
Inspiration: PA<< Pamt Expiration: PA >> Pamt End of deep breath: PA=Pamt |
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Breathing Receptors:
J receptors: |
in interstitium = > tachypnea, restrictive dz
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Breathing Receptors: Slow-adapting receptors
location what does it sense disease |
b/ w ribs and muscle fibers; sense stretch, obstructive dz
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Carotid Body:
another name measures what? how does it work? |
carotid chemoreceptor (measures everything: pO2, pC02, H+)
CN9 ⇨ carotid body ⇨ CN10/ phrenic nerve |
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Aortic Body:
what is it? what does it measure how does it work? |
aortic arch chemoreceptor (measures pC02, H+)
CN10 ⇨ aortic body ⇨ CN10/ phrenic nerve |
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how is O2 controlled?
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02: controlled by diffusion and perfusion
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how is CO2 controlled?
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⇩C02: controlled by ⇧ventilation (i.e. airway being open)
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why not give O2 to COPD patients?
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Don't give >1L 02 to COPD pts b/c hypoxia is the drive for ventilation
1) fills airways => C02 can't leave 2) knocks out apneustic center (pneumotactic center desensitized) =>coma |
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management for COPD?
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Tx: Bronchodilators (create more space so C02 can leave)
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what is the normal oxygen level in COPD?
|
COPD normal O2: 55-60
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Forms of pCO2
90%: 7%: 3%: |
90%: Bicarbonate
7%: Attached to Hb (can't measure this stuff) "carboxyhemoglobin" 3%: Dissolved (this goes to pneumotactic center) = .03 x pC02 |
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what affect CNS more
|
CNS is affected more by high pC02
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what is PNS affected more
|
PNS is affected more by low p02 (you're almost dead if have low p02 and high pCO2
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how does the oxygen diffuse
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Oxygen diffusion: alveolar endothelium ⇨ interstitium -⇨ capillary endothelium
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most potent vasodilator of the lungs
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Oxygen is the most potent vasodilator in the lung
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Pneumotactic center (top):
function sensitivity |
Breathing Control Center:
prevents pneumothorax=> breath out (C02 sensitive) |
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Apneustic center (bottom):
function sensitivity |
Breathing Control Center
prevents apnea=> makes you breathe in (02 sensitive) |
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Pons:
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Breathing Control Centers:
reaction center |
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who sets the repiratory rate and what is the normal?
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Medulla: sets respiratory rate (RR=8-10)
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|
why do brain dead people can still breathe?
|
Brain death (everything above medulla is gone, can still breath)
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Central apnea of neonates: pathogenesis and tx
|
no inspiratory effort for 20 sec
• Tx: Theophylline or Caffeine to stimulate the brain |
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Obstructive apnea "Pickwickian"
|
=>chronic hypoxia (opposite of COPD)
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treatment for Obstructive apnea "Pickwickian?
|
CPAP:
Weight loss Uvulopalatophatyngoplasty (cut out soft palate) |
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contraindicated drugs for Obstructive apnea "Pickwickian"
|
No BZ! (respiratory depression)
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|
why do pregnant women breath faster?
|
Progesterone to stimulate respiration (pregnant women breath faster)
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Carotid Body:
|
chemoreceptor
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Carotid Sinus:
|
Baroreceptor
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normal Breathing Patterns:
|
breathe in ⇨ hold 1 sec ⇨ breathe out ⇨ hold 1 sec
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Restrictive breathing pattern
|
=>more time in inspiration (I)
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Obstructive breathing pattern
|
=>more time in expiration (E)
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Apneustic breathing:
describe and example |
breathe in⇨hold for a long time⇨breathe out
Ex: Pontine hemorrhage |
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Cheyne-Stokes breathing:
describe and what are some of the causes (2) |
deep breathing followed by apnea (sigh)
• Lesion medulla (or low blood glucose) • Blow to back of head cuts off blood supply to medulla via the vertebral aa. |
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Thoracic outlet syndrome:
|
extra rib compress subclavian, turn neck=> paresthesia
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Subclavian steel syndrome:
|
raised arm compress subclavian=> cyanosis
|
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|
Reversal of flow in vertebral aa how does this affect the brain?
|
steals blood from brain
|
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|
Kussmaul breathing:
describe pathogenesis |
rapid deep breathing (must stop talking to breathe)
• Metabolic acidosis produces GABA, which fight each other to breathe fast or slow |
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|
Anencephaly how do they breathe?
|
Medullary breathing:RR=8-10
(only have medulla) |
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|
Paroxysmal Nocturnal Dyspnea:
|
wake up from sleep with air hunger
Ex: CHF |
|
|
Foul Sputum: give 3 DDx?
|
Bropchiectasis
Lung abscess Aspiration pneumonia |
|
|
Steroid Side Effects: Low Dose:
|
thrush, dysphonia
|
|
|
Steroid Side Effects: High Dose:
|
osteoporosis; cataracts, purpura, adrenal suppression
|
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|
Managing Ventilators:
02 amount: |
Restrictive needs more, Obstructive needs less
|
|
|
Managing Ventilators:
Rate: |
12-16 (all lung diseases have tachypnea)
|
|
|
Managing Ventilators:
Tidal Volume: how does this lead to low energy state |
10-15cc/kg, peripheral hypoventilation (high pCO2 =>low E state)
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Managing Ventilators:
I:E ratio by how much incriment |
Restrictive needs more I, Obstructive needs more E (increment by 0.1)
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|
Managing Ventilators:
CMV: |
Controlled Mandatory Ventilation- total
machine control (not used anymore) |
|
|
Managing Ventilators:
Assist Control: when is it used |
machine breathes, pt helps the least. (use during sepsis)
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|
Managing Ventilators:
SIMV / IMV (Synchronized Intermittent Mandatory Vent.): how is it used and what is it used for? 4 types: |
pt adds extra breaths
- used to wean patient off ventilation Pressure Support: PEEP ZEEP AutoPEEP CPAP |
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|
Managing Ventilators:
Pressure Support: who has control when is it used? |
SIMV / IMV
pt has control, machine just helps (use w/ restrictives) |
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|
PEEP:
what does it do? when is it used? |
SIMV / IMV
Positive End Expiratory Pressure: increase FRC (use while intubated) |
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|
ZEEP:
|
SIMV / IMV
Zero PEEP |
|
|
AutoPEEP:
|
breath stacking
|
|
|
CPAP:
define when is it used? |
Continuous Positive Airway Pressure (use in sleep apnea, CHF)
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|
Arachadonic Acid Pathways:
Cyclooxygenase "COX" : what do they form and what are made? |
forms Prostaglandins
PGA2, PGE1, PGE2, PGF1, PGF2, PGI2 |
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|
PGA1:
name function |
"Thromboxane": vasoconstriction, thrombosis
|
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|
PGE1
function example SE |
vasodilation
Ex:(keeps PDA open) Misoprostyl for GI ulcers =>induces labor |
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|
PGE2
|
vasodilation, SM relaxation, used to keep PDA open
|
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PGF1
|
vasoconstriction
|
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|
PGF2
|
vasoconstriction, menstrual cramps,abortions, found in semen
|
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|
PGI2
name where is it made function |
"Prostacyclin": vasodilation, anti-thrombosis, made by endothelium
|
|
|
easier way to remember the prostaglandin functions
|
PG Summary:
A/F: vasoconstrict/ thrombose E/I: vasodilate/ anti-thrombosis |
|
|
asa vs NSAIDs
|
asa:irreversible inhibition
NSAIDs: reversible inhibition |
|
|
Lipooxygenase "LOX" (forms Leukotrienes)
produced by what cell pathogenesis of asa sensitive asthma |
• Produced by mast cells
• asa-sensitive asthma results from closing of the COX pathway leading to LOX |
|
|
what form of leukotriene is the most potent bronchoconstrictor?
|
LT-C4D4E4 "SRSA" = the most potent bronchoconstrictor
|
|
|
pathogenesis of aspirin induced asthma
|
asa-sensitive asthma results from closing of the COX pathway leading to LOX
|
|
|
Steroid Anti-inflammatory Actions:
|
• Stabilizes: mast cells/ endothelium
• Inhibits: MP migration/ PLA • Kills: T cells/ eosinophils |
|
|
what are the asthma treatments?
|
B2 Agonists
"RATS" • Ritodine • Albuterol • Terbutaline • Salmeterol |
|
|
B2 Agonists:
MOA used for effects on the lungs |
acute tx
bronchodilation low K.+ levels (pushes K± into cells) |
|
|
Ritodrine
|
#1 stop preterm labor
|
|
|
Albuterol
|
q4h inhalers
|
|
|
Tetbutaline
|
#2 stop preterm labor, q4h bronchodilator inhaler pm
|
|
|
Salmeterol
|
8-10 hr inhalers
|
|
|
what needs to be adminstered with steroids?
|
need adjuvant calcium /vit D/insulin
|
|
|
name all the Steroids and which one is inhaled
|
Triamcinalone - inhaled
• Prednisone • Beclamethasone |
|
|
Anti-Cholinergics:
example MOA effects on the lung |
ie Ipratropium
decreases cGMP bronchodilate |
|
|
PDE Inhibitors:
example and what is it used for? |
acute tx
• Theophylline (IV) |
|
|
LT receptor blockers: when are they used?
|
use if steroids fail
• Zileuton • Zafirlukas • Montelukast |
|
|
Zileuton
|
inhibits LOX
|
|
|
Zafirlukast
|
inhibits LTD4 * "Leukotriene inhibitor"
|
|
|
name the 2 Prophylactic agents: which one is used before excercising?
|
• Cromolyn sodium- use before exercising (eye or nasal drops)
• Nedocromil |
