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93 Cards in this Set

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FEV1/FVC
nl is 0.8
decr in obstructive dz
not decr in restrictive dz
Muscles of expiration
abdominal muscles compress abdominal cavity
push diaphragm up and push air out of lungs
internal intercostals:
pull ribs dnwd and inwd - ex
transmural lung pressure
alveolar press minus intrapleural press
hysteresis
inspiration follows a different curve than expiration.
compliance of chest wall lung system
At FRC press in lungs is equal to ATM.
Equal negative transmural press by chest wall versus the positive intramural press by lungs
Emphysema and compliance
lung compliance is incr
thus at the original FRC the tendency for the lung to collapse is much less than that of the chest wall to expand. Thus a higher FRC equilibrium and a barrel chest.
Lung fibrosis and compliance
Compliance is decr thus FRC will decr and chest wall smaller at equilibrium.
Causes of decr lung compliance
(4)
Fibrosis
Incr pulm venous press
High expanding pressures
Lack of surfactant
Causes of incr lung compliance
Emphysema
Age
Law of Laplace
P = 2T/r

T=surface tension
Surfactant
Synth by Type II pneumocytes
DPPC
Mature surfactant 2:1 lecithin:sphingomyelin ratio.
Lung volumes and airway resistance
radial traction exerted on the airways by surrounding lung tiss
High lung vol: great traction and lower resistance (asthmatics learn to breath at high lung vol)
Lower lung vol: less traction, incr airway resistance.
Site of highest airway resistance
Medium sized bronchi
Perfusion limited exchange vs diffusion limited exchange
Perfusion limited: N20 and O2 under nl conditions. gas equilibrates early along the length of the capillary
Diffusion limited exchange: CO2 and O2 during strenuous exercise or lung fibrosis. gas does not equilibrate by the time the blood reaches the end of the pulm cap.
diffusion continues as long as the partial pressure gradient is maintained.
Adult Hb
Fetal Hb
Adult - alpha2/beta2
HbF - alpha2/gamma2 - higher O2 affinity because it binds 2,3 dpg less avidly.
O2 content
total amount of O2 in the blood. = O2 binding capacity x % sat + dissolved O2.
PO2 at 40mmHg (venous blood)
PO2 at 25 mmHg
PO2 at 40 mmHg - Hb is 75% saturated - 3/4 heme groups on each Hb has O2 bound.
PO2 at 25 mmHg = P50 = Hb is only 50% saturated.
Hb dissociation curve shift to the right
Hb affinity for O2 is decr, P50 increases.
Caused by incr CO2, decr pH, incr in temp (during exercise), incr 3-DPG concentration (which binds deoxy Hb) - it is part of the adaptation to chronic hypoxemia.
CO and Hb
occupied O2 binding sites
decr O2 content of blood
Causes a left shift bc of incr affinity for O2 in remaining binding sites.
Cloride shift
90% of CO2 is carried as Bicarb in Hb.
CO2 in tissue diffuses into venous plasma then into RBC
In RBC it combines with H20 to form H2CO3 which dissociates via carbonic anhydrase.
HCO3- diffuses out of RBC in exchange for Cl and is transported to the lungs in the plasma.
H+ remains in the RBC and is buffered by deoxyHb (much better than oxyHb. )

In the lungs: bicarb enters RBC in exchange for Cl. Recombines with H+ to form H2CCO3 -> H2O and CO2 and CO2 is expired.
Pulm Circ
press, resistance
Pressures are much lower in the pulm circ mainly because the resistance is much lower than in the systemic circ.
Zone 1 pulm blood flow
alveolar press>arterial press>venous press
Q way decr
V decr
V/Q incr
Zone 2 pulm blood flow
arterial press>alveolar press>venous press
Zone 3 pulm blood flow
arterial press>venous press>alveolar press
Q way incr
V incr
V/Q decr
R->L shunt
L->R shunt
R->L shunt: tet of fallot -
shunted blood leads to admix of venous blood in arterial blood.
Can be estimated by having pt breath 100% O2 and measuring degree of dilution of art blood
L->R shunt much more common
Do no lead to a decr in art PO2, PO2 will be elevated on the right side.
V/Q ratios
>1.0 at the apex
<0.8 in the base
Apex: PO2 is highest and PCO2 is lowest bc gas exchange is more efficient
Base: PO2 is lowest and PCO2 is highest bc gas exchange is less efficient.
Lung Stretch rec
Irritant Rec
J rec
Joint and muscle rec
Hering Breuer Reflex: when stretch rec in smooth muscle of airways is stimulated by distention of the lungs - decr breathing freq
Irritant: btw airway epith cells - stim by noxious subs
Juxtacapillary rec: alveolar walls close to caps. Engorgement of pulm caps (LVF) stimulates ->rapid shallow breathing
Jt and muscle rec: activated by mvmt of limbs, stim breathing during exercise.
V/Q during exercise
distribution is more even throughout lung during exercise.

->DECREASE IN DEAD SPACE
High Altitude adaptations
hypoxemia ->
hyperventilation -> resp alkalosis (tx with acetazolamide)
Incr EPO -> incr O2 capacity and incr O2 content
2,3 DPG incr
PULMONARY VASOCONSTRICTION -> RVH
When the O2 dissociation curve shifts right
what happens to p50
how about O2 carrying capacity of Hb
Shifts to the right incr P50
has no effect on carrying capacity of Hb that is determined by Hb CONCENTRATION
Changes and non changes during strenuous exercise
Incr in vent ratematches incr in O2 consumption and CO2 generation - thus mean values for art PO2 and PCO2 do not change
Art pH may change bc of lactic acidosis
Venous PCO2 increases
Chest tube
inserted through 5th intercostal space in the anterior axillary line.
Tube penetration: skin->superficial fascia->serratus anterior-> external intercostal->internal intercostal-> innermost intercostal -> parietal pleura.
Pleuritis
visceral pleuritis - no innervation
parietal pleura innervated by intercostal nerves and phrenic C3-C5. Pain may be referred to thoracic wall and root of the neck.
Compression of the trachea
can occur via enlarged thyroid or an aortic arch aneurysm
Bronchogenic ca
Adenoca: most common type, peripheral lesions, less ass with smoking
SCC: 2nd most common, strong smoking ass, centrally located lesions, cavitation, may secr PTH
Small Oat cell: Kulchitsky cells of neurocrest origin, ACTH secr, ADH secr
Intrathoracic spread of bronchogenic ca sequele
Horners
Superior Vena Caval syndrome
Dysphagia
Hoarseness
Paralysis of diagphragm
Pancoast tumor (ulnar nerve pain and horners)
Lobar Pneumonia Stages
Initial stage: acute congestion, intraalveolar fluid, many bacteria
Early Consolidation: Red hepatization, 2-4 days, consolidation with N/T and fibrin. Lung is red from RBC firm and airless.
Late Consolidation: Gray hepatization, 4-8 days, large amounts of fibrin with decr red and white cells.
Resolution in 8 days.
Bronchial Asthma
extrinsic (type 1 hs) vs intrinsic
Mucus plugs
whorl like accumulations of epith cells - curschmann spirals
Charcot leyden crystals (crystalloids of eosinophil derived proteins)
Chronic Bronchitis
Productive cough at least 3 consecutive mos over at least 2 consecutive years.
Linked to smoking and can lead to cor pulmonale
Hyperplasia of mucus secreting submucosal glands
Emphysema subtypes
(4)
Centrilobular: dilation of resp bronchioles - upper part of lobes
Panacinar: Alpha 1 antitrypsin def, dilation of entire acinus, loss of elasticity
Paraseptal: subpleural blebs
Irregular: inflamm, irreg involvement of acinus with scarring within walls of enlarged spaces.
Emphysema cause
SMoking - brings in N/T and MP elastase
Alpha1 antritrypsin def:
piZ allele - interferes with hepatic secr - liver damage
homozygous piZZ allele - greatly decr activity, hepatic cirrhosis
Kartageners syndrome
rare, AR
sinusitis, bronchiectas, situs inversus, male infertility.
Problem with Dynein
Restrictive lung dz
Interstitial lung dzs:
ARDS, pneumoconioses, Sarcoid, idiopathic pulm fibrosis, SLE, Scleroderma, wegners, goodpastures, Eosinophillic Granuloma
Hyaline membrane dz
cause, pulm maturity
Complications
neonatal resp distress syndrome
def of surfactant
Surfactant: lecithin incr in 33rd week and sphingomyelin levels stay the same. 2:1 is pulm maturity.
Complications:
Bronchopulm dysplasia from ventilation
PDA, IVH, necrotizing enterocolitis.
Coal workers pneumoconiosis
Simple: coal macules around bronchioles, MP ingesting coal dust, inconsequeantial
Progressive massive fibrosis: fibrotic nodules, bronchiectasis, pulm HTN, resp failure or RHF
Silicosis
incr risk for TB
Abestosis
Diffuse interstitial fibrosis
Ferruginous bodies
hyalinized fibrocalcific plaques of parietal pleura
Predisposes to BRONCHOGENIC CARCINOMA, and MALIGNANT MESOTHELIOMA
Sarcoid
restrictive lung dz
Intersitial lung dz, enlarged hilar LN, anterior uveitis, erythema nodosum of skin, polyarthritis
Polyclonal hypergammaglobinemia
hypercalcemia and hypercalciuria
Incr serum ACE
Idiopathic Pulm fibrosis
Chronic inflamm and fibrosis of alveolar wall. Begins with alveolitis-> fibrosis-> ends in distored fibrotic lung filled with cystic spaces - HONEYCOMB lung
Eosinophillic Granuloma
Interstital lung dz
histiocytic cells, birbeck granules, lung or ribs
Grouped with Hand-Schuller-Christian dz and Letterer-Siew synddrome as variants as histiocytosis X sydnrome
secondray Pulm HTN
most often COPD
incr pulm blood flow (L->R shunt)
incr resistance (emboli, vasoconstrict from hypoxia)
polycythemia
Extrapulm TB
TB meningitis, potts dz, paravertebral abcess, psoas abcess
Most common lung cancer
Cancer mets to lung
bronchogenic Ca
survival
Smoking
Air pollution
Radiation
Asbestos + Smoking
Exposure to Nickel and Chromates
5yr survival < 10%
Chronic Bronchitis
Test?
COPD
Marked hyperplasia of bronchial and submucosal glands and bronchial smooth muscle hypertrophy. Quantified by Reid index: ratio of glandular thickness to bronchiolar thickness
Most common lobar pneumonia
Strep Pneumonia
Distinguish btw primary and secondary TB
cavitation only in 2'
Apical Lung - 2'
1' ghon complex near hilar LN
Carcinoid Syndrome
Typically lung or GI can
Flushing, wheezing, recurrent diarrhea, carcinoid heart dz.
Seratonin causing diarrhea
PCP
tx and path
tx with TMP/SMX
Kills type 2 pneumocytes, damages alveolar epith
serum leaks
Aortic Hiatus
T12 - aorta, azygous vein, thoracic duct
Esophageal Hiatus
T10 - esophagus and Vagus
Caval Hiatus
Inferior vena cava - T8
Bohr Effect
Haldane Effect
Bohr Effect: incr H+ leads to peripheral O2 unloading
Haldane Effect: oxygenation of Hb in lungs unloads CO2 from Hb.
Blue Bloaters
Chronic bronchitis
hypertrophy of mucus secr glands
wheezing, crackles, cyanosis
Pink Puffers
emphysema
dyspnea, decr breath sounds, tachycardia,
Treatment for Neonatal ARDS
maternal steroids before birth
artificial surfactant for infant
Most common places for lung cancer mets
Brain, bone, liver
Lung Cancer presentation
Cough, hemoptysis, bronchial obstruction, wheezing, Pneumonic coin lesion on xray.
Pancoast tumor
Carcinoma that affects apex of lung - affecting cervical sympathetic plexus -> HORNERS SYNDROME
Lobar
Bronchopneumonia
Interstitial
Lobar: Intraalveolar exudate, consolidation
S. Pneumococcus
Broncho: Acute inflamm infiltrate from bronchioles into adjacent alveoli
S. Aureus, H. Flu, Klebsiella, S. Pyogenes
Interstitial (atypical):diffuse patchy infiltrate: Mycoplasma, RSV, adenovirus, legionella, chlamydia, coxiella burnetti
PGI
prostacyclin
decr:
platelet aggregation
vasc tone
bronchial tone
uterine tone
PGE, PGF
prostaglandins
Incr uterine tone
Decr vasc tone + bronchial tone
TXA
thromboxane
incr platelet aggregation
incr vasc tone
incr bronchial tone
1st gen H1 blocker
Diphenhydramine, dimenhydrinate, chlorpheniramine
Tox - sedation, antimuscarinic, anti-alpha-adrenergic
2nd gen H1 block
Loratadine, fexofenadine, desloratadine
less sedation
Bronchial tone
(+)
(-)
Bronchial dilation:
incr cAMP
Bronchoconstriction:
Ach + Adenosine
Most common cause of laryngeal cancer
SCC
cigarette smoking is the most important risk factor
Lymphoepithelioma
SCC that most freq occurs in the nasopharynx, less commonly in larynx.
Rich in lymphs
Common in China and Africa -
EBV
Sqaumous papilloma
benign laryngeal neoplasm by HPV 6 +11.
Old age and lungs
age leads to higher compliance of lungs. Decr elastic recoil.
How much can O2 can art blood nl carry?
1gm of Hb
100 ml blood
1 gm Hb carries 1.34 g O2
100 ml art blood - carries about 20 ml of O2 at nl Hb of 15g/dl.
Esophageal Atresia
post deviation of the tracheoesophageal septum.
Feeding causes fluid to spill into trachea and leads to aspiration pneumonia.
Strep Pneumoniae virulence
Acidic polysacharide capsule. Antibody to specific capsule is necessary for resolution of infection. There are many capsule types.
Bordet Gengou Augar
used for isolation of Bordatella Pertussis
Exudative effusion characteristics
one or more of the following:
1. pleural fluid protein/serum protein >0.5
2. PLeural fluid LDH /Serum LDH >0.6
3. Pleural fluid LDH more than 2/3 nl upper limit for serum.
Alveolar Ventilation eqn
and what happens to Alveolar PCO2 if you hyperventilate x 4
VA= VCO2/PACO2

VA = alveolar ventilation
VCO2 = CO2 production
PACO2 = alveolar PCO2

PACO2 = goes down to 10 mmHG
Monoclonal antibody for RSV
Palivizumab
directed against the fusion protein of RSV
preventing infection
Radial traction
restrictive dz vs obstructive
When lung vol decr radial traction decrs -> airway diameter decr.
In interstitial fibrosis the airways are tethered more strongly to lung parenchyma thus airways held open to a greater extent at each lung vol. -incr radial traction.
Morbid obesity and respirations
peripheral hypoventilation
Pickwickian Syndrome
Press of fatty neck causes intermittant airway obstruction.
Rx that binds IgE to inhibit mast cell and basophil rxn
Omalizumab - monoclonal abs
Inhibits binding of IgE to high affinity Fc rec on surface of mast and basophils.
Indicated in 12+, moderate to severe persistant asthma
Administered subQ every 2-4 wks
Incr surfactant
Thyroxine, prolactin, cortisol
Gestational Diabetes
leads to incr insulin production from baby - decrs surfactant
Peripheral hypoventiation causes
vs
Central Hypovent
Fatty neck, submersion, suffocation, skeletal abnl (broken rib), trauma, phrenic nerve paralysis, polio, tetanus

Central Hypoven: barbs, opioids, benzos