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558 Cards in this Set
- Front
- Back
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conducting zone
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nose, pharynx, trachea, bronchi, bronchioles, terminal bronchioles
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cartilage is present where?
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trachea and bronchi
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where is anatomic dead space
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conducting zone (nose to the terminal bronchioles)
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where does gas exchange occur
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respiratory zone
(resp bronchioles, alveolar ducts, alveoli) |
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pseudostratified columnar ciliated cells extends to
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respiratory bronchioles
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goblet cells extend to
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terminal bronchioles
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type 1 pneumocytes
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97% of alveolar surfaces
line alveoli squamous thin for gas diffusion |
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type II pneumos
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secrete surfactant (dec surface tension)
cuboidal and clustered precursors to type I and 2 proliferate during lung damage |
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clara cells
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non ciliated
columnar secretory granules secrete part of surfactant degrade toxins reserve cells |
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what indicates fetal lung maturity
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lecithin to sphingomyelin ratio or > 2 in amniotic fluid
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bronchopulmonary segment
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center:
tertiary bronchus 2 arteries (bron and pulmonary) borders: veins and lymphatics |
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what runs in the center of bronchopulmonary segment
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arteries and airways
(bronch and pulm artery, bronchus) |
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what runs along borders of bronchopulmonary segment
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veins and lymphatics
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pulmonary arteries carry
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deoxygenated blood from right side of heart
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what maintains pulmonary arterial pressure at relatively constant levels throughout cardiac cycle
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elastic walls
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right lung has how many lobes
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3
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left lung has how many lobes
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2 (and then the lingula)
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side of inhaled foreign bodies and why
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right
right main stem bronchus is wider and more vertical |
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aspirate a peanut while upright
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lower part of right inferior lobe
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aspirate a peanut while supine
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superior part of right inferior lobe
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relation of pulmonary artery to bronchus at each lung hilus
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RALS
right anterior left superior |
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horizontal fissure
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sep superior and middle lobes of right lung
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oblique fissure
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sep middle and inferior lobes or right lung
or sep superior and inferior or the left lung |
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what perforates diaphragm at T8
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IVC
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what perforates diaphragm at T10
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Esophagus
vagus |
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what perforates diaphragm at T12
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aortic hiatus (red)
thoracic duct (white) azygous vein (blue) |
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diaphragm innervation
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C3,4,5
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pain from diaphragm is referred
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to shoulder
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muscles of inspiration, normal breathing
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diaphragm
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muscles of expiration, normal breathing
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passive
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muscles of inspiration, exercise
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external intercostals
scalenes sternomastoids |
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muscles of expiration, exercise
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rectus abdominas
internal and ext obliques transversus abdominis internal intercostals |
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dipalmitoyl phosphatidylcholine (lecithin)
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surfactant
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what does surfactant do
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dec alveolar surface tension
inc compliance dec work of inspiration |
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deficient in neonatal RDS
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surfactant
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collapsing pressure
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2(tension)/radius
surfactant decreases T as r decreases |
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lung products (5)
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1. surfactant
2. PGs 3. histamine 4. angiotensin converting enzyme 5. kallikrein |
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kallikrein
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activates bradykinin
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ACE
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angio 1 to angio 2
inactivates bradykinin |
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ACE inhibitors cause cough: mech
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inhibit ACE, so
can't inactivate bradykinin, so increased bradykinin means cough and angioedema |
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histamine does what
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bronchoconstricts
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lung has tendency to what on expiration as radius decreases
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collapse
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what prevents lung collapse on expiration as radius decreases
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surfactant (2T/r)
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residual volume (RV)
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air in lung after maximal expiration
can't be measured on spirometry |
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expiratory reserve volume (ERV)
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air that can still be breathed out after normal expiration
(your maximum expiration) |
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tidal volume (TV)
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air that moves into lung with each quiet inspiration (500 ml)
(normal breath) |
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inspiratory reserve volume (IRV)
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air in excess of tidal volume
maximum inspiration |
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vital capacity
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everything but RV:
TV + IRV + ERV (normal breath + max insp + max exp) |
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functional residual capacity
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RV + ERV = 0 energy state
Residual vol + max exp vol in lungs after normal expiration |
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0 energy state
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functional residual capacity
FRC = RV + ERV |
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inspiratory capacity
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IRV + TV
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Total lung capacity
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IRV + TV + ERV + RV
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physiological dead space equation
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Vd= Vt (PaCO2 -PeCO2)/PaCO2
Tidal vol(arterial - expired air PCO2)/arterial anatomical dead space in airways + functional dead space in alveoli |
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largest contributor of functional dead space
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apex of healthy lung
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anatomical dead space of conducting airways + functional dead space in alveoli
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physiological dead space
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tendency for lungs and chest wall
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lungs to collapse in
chest to expand out |
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at FRC, what is the lung/chest wall relationship
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lung inward pull is balanced by chest wall outward pull
system pressure is atmospheric |
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at FRC, pleural pressure is
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negative (lungs inward pull balances chest wall outward pull)
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inc Cl-
right or left shift |
R
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inc H+
right or left shift |
R
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inc CO2
right or left shift |
R
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inc 2,3 BPG
right or left shift |
R
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inc temp
right or left shift |
R
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right shift means what
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inc O2 unloading to tissues
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fetal Hem shifts curve left- why?
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lower affinity for 2,3 BPG
so higher O2 affinity |
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relaxed form of hemoglobin-
right or left |
L
high affinity for O2 |
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taut form of hemoglobin-
right or left |
R
low affinity for O2 |
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Most CO2 transported in blood is in what form
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bicarb
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CO2 transport form that is bound to hemoglobin
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carbamate-
CO2 binds to amino acids in globin chain at N terminus (not bound to heme) |
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CO2 binding favors what form of hemoglobin
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taut (right)
promotes O2 unloading negative allosteric regulation |
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methemoglobin
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oxidized form of hemoglobin (Fe 3+)
does not bind O2 as readily inc affinity for CN- |
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methemoglobin causes
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tissue hypoxia
from dec O2 sat and dec O2 content |
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carboxyhemoglobin causes
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tissue hypoxia
from dec O2 sat and dec O2 content due to dec O2 carrying cap (left shift) so dec O2 unloading to tissues |
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carboxyhemoglobin
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form of hemoglobin bound to CO in place of O2
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CO vs O2 affinity for hemoglobin
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CO has 200x greater affinity than O2 for hemoglobin
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treat CN- poisoning
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nitrites to oxidize hemoglobin to methemoglobin, which binds CN-
then use thiosulfate to bind the CN-, forms thiocyanate, renally excreted |
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tx methemoglobinemia
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methylene blue
and vit C |
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shape of oxygen hemoglobin dissociation curve and why
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sigmoidal
positive cooperativity each binding has higher affinity for O2 |
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right shift changes affinity how
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decreases hem affinity for O2
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inc pH
right or left shift |
left (dec H+)
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altitude
right or left shift |
R
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exercise
right or left shift |
R
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inc metabolic needs
right or left shift |
R
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inc P50
right or left shift |
R
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pulmonary circulation-
resistance is high or low compliance is high or low |
low resistance
high compliance |
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dec in PAO2 causes
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hypoxic vasoconstriction that shifts blood away from poorly ventilated areas of lungs to well ventilated areas
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perfusion limited gases
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O2
CO2 N2O |
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O2
perfusion or diffusion limited |
perfusion
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CO2
perfusion or diffusion limited |
perfusion
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N2O
perfusion or diffusion limited |
perfusion
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perfusion limited means
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crosses membrane easily, early eq
gas equilibrates early along the length of the capillary must inc blood flow to inc diffusion |
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diffusion limited means
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doesn't cross membrane easily, late eq
gas does not equilibrate by the time blood reaches the end of the capillary |
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diffusion limited gases
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O2 in emphysema or fibrosis
CO |
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CO
perfusion or diffusion limited gas |
diffusion
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consequence of pulmonary hypertension
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cor pulmonale-
right ventricular failure (Jug venous distension, edema, HSM) |
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diffusion equation
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Vgas = A/T x Dk(P1-P2)
A= area T= thickness Dk(P1-P2) = diff in partial pressures |
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Diffusion equation
emphysema- what variable changes? |
A (area) decreases
Vgas = A/T x Dk(P1-P2) |
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diffusion equation
what variable changes with pulmonary fibrosis? |
T (thickness) increases
Vgas = A/T x Dk(P1-P2) |
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normal pulmonary artery pressure is
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10-14 mmHg
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pulmonary htn pressure
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greater than or equal to 25 mmHg or
greater than 35 mmHg w/exercise |
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pulmonary htn leads to
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atherosclerosis
medial hypertrophy intimal fibrosis of pulmonary arteries |
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primary pulmonary htn is due to
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inactivating mutation in BMPR2 gene which normally inhibits vascular smooth muscle proliferation
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secondary pulmonary htn is due to
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COPD (destroys lung parenchyma)
mitral stenosis (inc resist->inc press) recurrent thromboemboli autoimmune (fibrosis, med hypert) sleep apnea (hypoxia-> vasocon) high altitude (vasoconstriction) left to right shunt (inc sheer stress causes endothelial injury) |
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course of pulmonary htn
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severe resp distress ->
cyanosis and RVH -> death from decompensated cor pulmonale |
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pulmonary vascular resistance equation
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PVR = Ppulm art - P Latrium/ C.O.
PLatrium is pulm cap wedge press |
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resistance
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R = deltaP/Q
R = 8nl/pi r^4 n= viscosity, l = length, r = radius |
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change in pressure
|
delta P = QR
(remember- it goes in alphabetical order!) |
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arterial O2 content
|
(O2 binding cap x % sat) + dissolved O2
=1.37(Hgb)(%sat) +0.0031PaO2 |
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1.37(Hgb)(%sat) +0.0031PaO2
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oxygen content (CaO2)
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8nl/(pi r^4)
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= R
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P/Q
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=R
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QR
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=P
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normal Hgb amount in blood
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15g/dL
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1 gram of Hgb binds how much O2
|
1.34 mL O2
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cyanosis results when deoxygenated Hb is
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> 5 g/dL
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O2 content of arterial blood falls as
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Hb falls
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as Hb falls, what happens
|
O2 content falls
O2 sat is the same PO2 is the same |
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arterial PO2 dec with chronic lung disease because
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physiologic shunt decreases O2 extraction ratio
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oxygen delivery to tissues =
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C.O. x O2 content of blood =
C.O. x (CaO2 -CvO2) |
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alveolar gas equation
|
PAO2 = PIO2 - PACO2/R
PAO2 = (PB-PH2O)F1O2 -PACO2/R =(760-47)0.21- PACO2/R = 150- PACO2/ 0.8 |
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PIO2
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PO2 in inspired air
(PB-PH2O)F1O2 |
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Respiratory quotient (R)
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part of alveolar gas equation
= 0.8 =CO2 produced/O2 consumed |
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A-a gradient
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PAO2-PaO2 = 10-15 mmHg
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increased A-a gradient
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hypoxemia due to:
shunt V/Q mismatch fibrosis (diffusion block) |
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hypoxemia with normal A-a gradient
|
high altitude
hypoventilation |
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hypoxemia definition
|
decreased PaO2
(arteriolar PO2) |
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hypoxia definition
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decreased O2 delivery to tissues
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causes of hypoxia
|
dec Cardiac Output
hypoxemia anemia cyanide poisoning CO poisoning |
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ischemia definition
|
loss of blood flow
|
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2 general causes of ischemia
|
impeded arterial flow
reduced venous drainage |
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V/Q normal values
|
normally V/Q = 1 for gas exchange
apex = 3 (wasted ventilation) base = 0.6 (wasted perfusion) |
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where are V and Q the greatest?
|
base of the lung
|
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zone 1 of the lung
|
PA > Pa > Pv
V/Q = 3 increased dead space (wasted ventilation) high alveolar pressure compresses capillaries |
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zone 2 of the lung
|
Pa > PA > Pv
Q is increased |
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zone 3 of lung
|
Pa > Pv > PA
V/Q = 0.6 both V and Q are greater than at apex recruitment and distention!!! |
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where is V greatest
|
base
|
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where is Q greatest
|
base (it's greater than V)
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where is V/Q greatest
|
apex
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where is PO2 greastest
|
apex
|
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where does TB live and why
|
apex
greatest PO2 |
|
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exercise/inc cardiac output does what to apical capillaries
what is the result? |
vasodilates them
result is a V/Q ratio that approaches 1 |
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V/Q = 0
|
shunt (airway obstruction)
V is 0 100% O2 does not improve PO2 |
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|
V/Q = infinity
|
dead space
blood flow obstruction 100% O2 improves PO2 |
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no V
|
shunt
V/Q = 0 |
|
|
no Q
|
dead space
V/Q = infinity |
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shunt is what type of problem
|
no V
oxygen problem |
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dead space is what type of problem
|
no Q
CO2 problem |
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3 forms of CO2 transport
|
bicarb
carbamino (bd to hgb) dissolved in blood |
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|
how does CO2 become bicarb?
|
carbonic anhydrase:
CO2 + H2O -> H+ +HCO3- |
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|
in lungs, what promotes dissociation of H+ from Hb and then what happens?
|
oxygenation of Hb promotes dissociation,
this shifts eq towards CO2 formation so CO2 is released from RBCs (Haldane effect) |
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Haldane effect
|
oxygenation of Hb promotes dissociation of H+
this shifts eq towards CO2 formation so CO2 is released from RBCs |
|
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Bohr effect
|
in peripheral tissues, inc H+ shifts curve to right, unloading O2 and picking up CO2
|
|
|
high altitude does what to ventilation
|
acute and chronic inc
|
|
|
high altitude does what to erythropoietin
|
inc
(which inc hematocrit and hemoglobin) this is chronic hypoxia |
|
|
high altitude does what to 2,3 DPG
|
inc it
(it binds to Hb so Hb can release more O2) |
|
|
high altitude does what to mitochondria
|
inc
|
|
|
high altitude does what renally
|
inc excretion of bicarb to compensate for metabolic alkalosis
|
|
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high altitude does what to pulmonary vessels
|
chronic hypoxic vasoconstriction->
RVH |
|
|
exercise does what to CO2 production
|
inc
|
|
|
exercise does what to O2 consumption
|
inc
|
|
|
exercise does what to ventilation rate VA
|
inc ventilation rate to meet O2 demand
|
|
|
exercise does what to V/Q ratio
|
it becomes more uniform from apex to base
|
|
|
exercise does what to pulmonary blood flow
|
inc it due to inc cardiac output
|
|
|
exercise does what to cardiac output
|
inc
|
|
|
exercise does what to pH
|
dec it with strenuous exerc, due to inc lactic acid
|
|
|
exercise does what to PaO2
|
nothing
|
|
|
exercise does what to PaCO2
|
nothing
|
|
|
exercise does what to venous CO2 content
|
inc
|
|
|
COPD
|
obstruction of air flow resulting in air trapping in the lungs,
airways close prematurely at high lung volumes |
|
|
COPD:
airways close prematurely at high lung volumes, which results in |
inc RV and dec FVC
|
|
|
COPD
PFTs |
dec FEV1
dec FVC dec FEV1/FVC ratio V/Q mismatch inc TLC inc RV |
|
|
chronic bronchitis
blue bloater |
hypertrophy of mucous secreting glands in bronchioles,
disease of small airways inc Reid index |
|
|
Reid index
|
gland depth/thickness of bronchial wall
> 50% with chronic bronchitis |
|
|
chronic bronchitis criteria
|
productive cough for > 3 consecutive months in > 2 yrs
|
|
|
chronic bronchitis symptoms
|
wheezing
crackles cyanosis (early hypoxemia) late onset dyspnea |
|
|
emphysema
pink puffer |
enlargement of air spaces
decreased recoil from destruction of alveolar walls |
|
|
centriacinar emphysema is caused by
|
caused by smoking
|
|
|
panacinar emphysema is caused by
|
alpha 1 antitrypsin deficiency
liver cirrhosis |
|
|
paraseptal emphysema is associated with
|
bullae that can rupture
spontaneous pneumothorax in young healthy males |
|
|
centriacinar emphysema location
|
prox acinar
upper lobes |
|
|
panacinar emphysema location
|
diffuse
lower lobes |
|
|
paraseptal emphysema location
|
distal acinar
|
|
|
emphysema findings
|
dyspnea
dec breath sounds tachycardia late onset hypoxemia due to loss of capillary beds early dyspnea |
|
|
inc elastase activity
|
emphysema
|
|
|
inc elastase activity in emphysema causes what
|
inc lung compliance due to loss of elastic fibers
|
|
|
exhale through pursed lips- what and why?
|
emphysema
inc airway pressure and prevent airway collapse during exhalation |
|
|
asthma
|
bronchial hyperresponsiveness causes reversible bronchoconstriction
|
|
|
asthma path features
|
smooth muscle hypertrophy
curshman spirals (shed epithelium from mucus plugs) charcot ledyen crystals (eosinophils) |
|
|
asthma triggers
|
viral URI
allergens stress |
|
|
asthma findings
|
cough
wheezing dyspnea tachypnea hypoxemia pulsus paradoxus dec I/E ratio mucus plugging |
|
|
bronchiectasis
|
chronic necrotizing infection of bronchi
permanently dilated airways |
|
|
bronchiectasis findings
|
purulent sputum
recurrent infections hemoptysis |
|
|
bronchiectasis is associated with
|
bronchial obstruction
CF poor ciliary motility Kartaganers can dev aspergillosis |
|
|
types of COPD
|
chronic bronchitis
emphysema asthma bronchiectasis |
|
|
restrictive lung disease
|
restricted lung expansion
dec lung volumes either poor breathing mechanics or interstitial lung disease |
|
|
restrictive lung disease
PFTs |
dec FVC
dec TLC FEV1/FVC ratio > 80% |
|
|
restrictive lung disease:
poor muscular effort causes |
polio
myasthenia gravis |
|
|
restrictive lung disease:
poor structural apparatus causes |
scoliosis
morbid obesity |
|
|
restrictive lung disease-
interstitial lung diseases |
ARDS and neonatal hyaline memb.
pneumoconioses (coal minors) sarcoid idiopathic pulm fibrosis goodpastures, wegners eosinophilic/histiocytosis X drugs |
|
|
drugs causing IPF
|
bleomycin
busulfan amiodarone |
|
|
neonatal respiratory distress
|
surfactant def
inc surface tension alveolar collapse |
|
|
when is surfactant made during gestation
|
after 35th week
|
|
|
lecithin to sphingomyelin ratio in amniotic fluid is what in neonatal resp distress
|
< 1.5
|
|
|
risk of what with neonatal resp distress
|
persistantly low O2 tension-> inc risk of PDA
|
|
|
risk factors for neonatal resp distress
|
premature
maternal diabetes (high insulin) cesarean |
|
|
treat neonatal resp distress
|
maternal steroids before birth
artificial surfactant after birth |
|
|
ARDS is caused by
|
trauma
sepsis/shock gastric aspiration uremia acute panc amnio fluid embolism |
|
|
ARDS
|
diffuse alveolar damage -> inc alveolar capillary permeability -> protein rich leakage into alveoli->
formation of intra alveolar hyaline membrane |
|
|
ARDS
initial damage is due to |
neutrophils
toxic to the alveolar wall this activates coag cascade or ROS |
|
|
obstructive lung volumes are
|
greater than normal
|
|
|
restrictive lung volumes are
|
less than normal
|
|
|
FEV1/FVC ratio in obstructive and restrictive lung diseases
|
FEV1 and FVC are reduced in both but FEV1 is more reduced in obstructive,
sooo dec ratio with obstructive. |
|
|
witches hat curve
(flow volume curve) |
restrictive
|
|
|
higher volume, scooped out curve
(flow volume curve) |
obstructive
|
|
|
sleep apnea
|
stops breathing for at least 10 sec repeatedly during sleep
|
|
|
central sleep apnea
|
no respiratory effort
|
|
|
obstructive sleep apnea
|
respiratory effort
|
|
|
sleep apnea associations
|
obesity
snoring pulm htn arrhythymias |
|
|
tx sleep apnea
|
wt loss
CPAP surgery |
|
|
asbestosis
|
diffuse pulmonary interstitial fibrosis caused by inhaled asbestos fibers
|
|
|
asbestosis increases the risk of
|
meseothelioma
bronchogenic carcinoma |
|
|
asbestosis histo and gross
|
ferruginous bodies in lung (asbestos fibers covered with hemosiderin)
ivory white pleural plaques |
|
|
asbestosis location
|
lower lobes
|
|
|
coal workers lung affects what part of lungs
|
upper lobes
|
|
|
asbestosis professions
|
shipbuilders
roofers plumbers |
|
|
absent/dec breath sounds
dec resonance dec fremitus (99) trachea deviates towards lesion |
bronchial obstruction
|
|
|
dec breath sounds
dull resonance dec fremitus (99) no tracheal deviation |
pleural effusion
|
|
|
may have bronchial breath sounds
dull resonance inc fremitus (99)- why? no tracheal deviation |
pneumonia (lobar)
inc fremitus due to inc vibration over consolidation |
|
|
dec breath sounds
hyperresonant absent fremitus trachea deviates away from lesion |
tension pneumothorax
|
|
|
leading cause of cancer death
|
lung
|
|
|
lung cancer presentation
|
cough
hemoptysis bronchial obstruction wheezing pneumonic coin lesion on x ray |
|
|
presentation:
1) mets to lung vs 2) primary lung cancer |
1) dyspnea
vs 2) cough |
|
|
SPHERE of complications of lung ca
|
superior vena cava syndrome
pancoasts tumor horners endocrine recurrent laryngeal effusions |
|
|
central location
cancer? |
squamous
small cell |
|
|
peripheral location
cancer? |
adenocarcinoma
large cell |
|
|
hilar mass arising from bronchus
cavitation |
squamous cell ca
|
|
|
ca linked to smoking
|
squamous
|
|
|
parathyroid like activity
|
squamous cell ca
|
|
|
keratin pearls
|
sq cell ca
|
|
|
intracellular bridges
|
sq cell ca
|
|
|
Non smokers lung ca
|
bronchioalveolar adenocarcinoma
|
|
|
develops in site of prior pulmonary inflammation or injury
|
adenocarcinoma
|
|
|
most common lung ca in females
|
adenocarcinoma
|
|
|
cancer that grows along airways and can present like pneumonia
|
adenocarcinoma
|
|
|
clara cells
type II pneumos glandular cancer? |
adenocarcinoma
|
|
|
aggressive undifferentiated cancer
|
small cell
|
|
|
ADH or ACTH producing cancer
|
small cell
|
|
|
cancer that may lead to Lambert Eaton
|
small cell
|
|
|
neoplasm of neuroendocrine Kulchitsky cells (small, dark blue)
|
small cell
|
|
|
cancer that doesnt respond to chemo
|
large cell
|
|
|
highly anaplastic undifferentiated cancer with poor prognosis,
removed with surgery |
large cell
|
|
|
pleomorphic giant cells with leukocyte fragments in cytoplasm
|
large cell
|
|
|
cancer that secretes serotonin
|
carcinoid syndrome
|
|
|
carcinoid symptoms
|
flushing
diarrhea wheezing salivation |
|
|
mets from what organs to lung
|
brain
bone liver |
|
|
pancoast tumor
|
carcinoma in apex of lung
affects cervical plexus causes horners |
|
|
carcinoma in apex of lung
affects cervical plexus causes horners |
pancoasts
|
|
|
intra alveolar exudate
consolidation may involve entire lung |
lobar pneumonia
|
|
|
acute inflammatory infiltrates from bronchioles into adjacent alveoli
patchy 1 or more lobes |
bronchopneumonia
|
|
|
diffuse patchy infiltrate
localized to interstitial areas at alveolar walls 1 or more lobes |
interstitial (atypical) pneumonia
|
|
|
localized collection of pus within parenchyma, resulting from bronchial obstruction or aspiration
|
lung abscess
|
|
|
lung abscess organisms
|
staph
fusiform bacteriodes peptostreptococcus |
|
|
transudate
|
pleural effusion with dec protein content
|
|
|
transudate is caused by
|
CHF
nephrotic syndrome hepatic cirrhosis |
|
|
exudate
|
pleural effusion with inc protein content, cloudy
|
|
|
exudate is caused by
|
malignancy
pneumonia collagen vascular disease trauma (states of inc vasc perm) |
|
|
milky pleural effusion
inc triglycerides |
lymphatic effusion
|
|
|
H1 blockers
|
reversible inhibitors of H1 histamine receptors
|
|
|
1st gen H1 blockers
|
diphenhydramine
dimenhydrinate chlorpheniramine |
|
|
diphenhydramine
|
1st gen H1 blocker
|
|
|
dimenhydrinate
|
1st gen H1 blocker
|
|
|
chlorpheniramine
|
1st gen H1 blocker
|
|
|
1st gen H1 blockers use
|
allergy
motion sickness sleep aid |
|
|
1st gen H1 blocker toxicity
|
sedation
anti muscarinic anti alpha adrenergic |
|
|
2nd gen H1 blockers
|
loratadine
fexofenadine desloratadine cetirizine |
|
|
2nd gen H1 blocker use
|
allergy
|
|
|
2nd gen H1 blocker toxicity
|
far less sedating
dec entry into CNS |
|
|
loratadine
|
2nd gen H1 blocker
|
|
|
fexofenadine
|
2nd gen H1 blocker
|
|
|
desloratadine
|
2nd gen H1 blocker
|
|
|
cetirizine
|
2nd gen H1 blocker
|
|
|
-dine, zine
|
2nd gen H1 blocker
|
|
|
bronchoconstriction is mediated by what 2 pathways
|
1) inflammatory
2) sympathetic tone |
|
|
asthma drugs- general categories (7)
|
non selective beta agonists
beta 2 agonists methylxanthines muscarinic antagonists cromolyn corticosteroids antileukotrienes |
|
|
isoproterenol
|
nonspecific beta agonist
relaxes smooth muscle adverse tachycardia effects |
|
|
nonselective beta ag used for asthma
|
isoproterenol
|
|
|
beta 2 ags used for asthma
|
albuterol
salmeterol |
|
|
albuterol
|
asthma-acute
beta 2 ag relexes smooth muscle |
|
|
salmeterol
|
asthma
long acting beta 2 ag |
|
|
salmeterol side effects
|
tremor
arrhythmia |
|
|
formoterol
|
asthma
beta 2 ag long term use |
|
|
use beta 2 agonist long term agents for asthma with what in order to decrease toxic effects
|
inhaled corticosteroids
|
|
|
methylxanthine used for asthma
|
theophylline
|
|
|
theophylline
|
for asthma
a methylxanthine bronchodilation by inhibiting phosphodeiesterase, dec cAMP hydrolysis |
|
|
bronchodilation by inhibiting phosphodeiesterase, dec cAMP hydrolysis
|
theophylline (methylxanthine)
|
|
|
theophylline tox
|
cardio
neuro met by P450 |
|
|
muscarinic antagonist used for asthma
|
ipratropium
tiotropium |
|
|
ipratropium
|
muscarinic antagonist for asthma
blocks musc receptors prevents bronchoconstriction also used for COPD |
|
|
cromolyn
|
asthma prophylaxis
prevents release of mediators from mast cells |
|
|
corticosteroids used for asthma
|
beclomethasone
prednisone |
|
|
corticosteroid mech for asthma treatment
|
inhibits NF-KB, the transcription factor that induces TNFa
|
|
|
antileukotrienes for asthma
|
zileuton
zafirukast montelukast |
|
|
zileuton mech
|
5 LPO inhibitor
blocks arachidonic acid conversion to leukotrienes |
|
|
zafirlukast, montelukast
mechanism |
block leukotrienes receptors
|
|
|
expectorants
|
guaifenesin
N-acetylcysteine |
|
|
Guaifenesin mech
|
removes excess sputum but large doses necessary
does not suppress cough reflex |
|
|
N-acetylcysteine mech
|
mucolytic-> loosen mucous plugs in CF
|
|
|
hypoxemia due to what increases A-a gradient
|
pulmonary causes
|
|
|
hypoxemia due to what causes normal A-a gradient
|
extrapulmonary causes
|
|
|
high Aa gradient values
|
greater than or equal to 30 mmHg
|
|
|
A-a gradient inc with
|
age
|
|
|
example of ventilation defect
|
airway collapse due to respiratory distress syndrome
|
|
|
example of perfusion defect
|
PE
|
|
|
example of diffusion defect
|
interstitial fibrosis
pulmonary edema |
|
|
cardiac prob that can cause inc A-a gradient
|
R to L shunt
|
|
|
dyspnea is due to
|
stimulation of J receptors causing decrease in full inspiration
|
|
|
causes of dyspnea (4 mechs)
|
decreased compliance (interst fib)
inc airway resistance (chronic bronc) chest bellows disease (obesity) interstitial inflamm/fluid (left HF) |
|
|
cough receptors are
|
located at bifurcations of airways, larynx, distal esophagus
|
|
|
cough with normal chest xray
|
postnasal discharge is most common
|
|
|
productive cough: 3
|
chronic bronch- cigarettes
typical bacterial pneum bronchiectasis |
|
|
hemoptysis causes: 6
|
chronic bronchitis- most common
pneumonia bronch carcinoma TB bronchiectasis aspergillas |
|
|
normal resp rate
|
14-20 bpm
|
|
|
normal resp rate is up to what in kids
|
44 bpm
|
|
|
tachypnea: how many bpm?
|
greater than 20
|
|
|
causes of tachypnea:3
|
restrictive lung disease
pleuritic chest pain PE with infarction |
|
|
tracheal shift mechanism
|
due to large changes in pleural fluid volume
|
|
|
causes of tracheal shift
|
large tension pneumo
large pleural effusion large spontaneous pneumo |
|
|
vocal tactile fremitus
|
palpable thrill (vibration) transmitted thru chest when patient says E, 123, or 99
|
|
|
decreased fremitus causes:
|
emphysema
asthma (inc AP with inc in TLC) |
|
|
absent fremitus causes:
|
atelectasis (airway collapse)
fluid air (pneumothorax) in pleural space |
|
|
increased fremitus:
|
alveolar consolidation (lobar pneum)
|
|
|
dull percussion:
|
pleural effusion
lung consolidation atelectasis (no air in alveoli) |
|
|
hyperresonant percussion with
|
pneumothorax
asthma emphysema |
|
|
effects of inflammation in small airways (cb, asthma)
|
air trapping
wheezing inc airway resistance |
|
|
bronchial breath sounds
|
always abnormal
loud high pitched due to consolidation (bronchi are patent and partially collapsed) |
|
|
crackles
|
usually inspiratory
|
|
|
early to midinspiratory crackles
|
secretions in large to mid airways
|
|
|
late insp crackles
|
interstitial fluid- due to reopening of distal airways partially occluded by interstitial pressure (CHF)
|
|
|
wheezing
|
high pitched
expiration due to inflam (asthma, CB) due to pulmonary edema or infarct |
|
|
inspiratory sound
|
crackles
|
|
|
expiratory sound
|
wheezing
|
|
|
ronchi
|
low pitched snoring sound
insp or exp secretions in large airways Chronic bronchitis |
|
|
inspiratory stridor
|
high pitched inspiratory sound
upper airway obstruction (epiglottitis or croup) |
|
|
insp and exp stridor
|
sign of fixed airway obstruction (cancer)
|
|
|
causes of pleuritis
|
cancer
infarct pneumonia SLE serositis |
|
|
grunting in newborns
|
always abnormal after 24 hrs
common in RDS |
|
|
hypoxemia + normal A-a:
3 mech |
depress resp center
upper airway obstruction chest bellows disease |
|
|
chest bellows (muscles of respiration) disease
|
paralyzed diaphragm
ALS |
|
|
spirometry does not measure
|
FRC
TLC RV |
|
|
FVC
|
total air expelled after max inspiration
5 L |
|
|
FEV1sec
|
forced exp volume in 1 sec
4L |
|
|
normal FVC/FEV1
|
80%
5L/4L |
|
|
end of max inspiration
|
TLC
|
|
|
end of max expiration
|
RV
|
|
|
nonuniform emptying
expiratory curve shifts to left |
obstructive
|
|
|
exp curve shifts to right
|
restrictive
|
|
|
choanal atresia
|
newborn cant breathe through nose
cyanosis while breast feeding unilateral or bilateral bony septum between nose and pharynx |
|
|
most common cause of nasal polyp
|
allergic polyp
|
|
|
patient that takes aspirin and has nasal polyp
|
asthma patient
|
|
|
nasal polyps in child
|
CF
|
|
|
obstructive sleep apnea pathogenesis
|
airway obstruction causes CO2 retention, leading to hypoxemia
|
|
|
dec what during apneic episodes
|
PO2
O2 sat |
|
|
inc in PCO2
|
is resp acidosis
|
|
|
complications of obst sleep apnea
|
pulm htn leading to RVH
(cor pulmonale) secondary polycythemia (hypoxia stim erythro) |
|
|
sinus infection location in adult
|
maxillary
|
|
|
sinus infection location in kid, and most common cause
|
ethmoid
viral URI |
|
|
diabetics commonly have sinusitis due to
|
mucor
|
|
|
nasopharyngeal carcinoma (squamous)
|
men
china africa EBV |
|
|
laryngeal cancer
|
smoking
alcohol squamous papillomas 6 and 11 |
|
|
atelectasis
|
loss of lung volume due to inadequate expansion of airspaces
|
|
|
most common cause of fever 24 to 36 hrs after surgery
|
resporption atelectasis (airway obstruction due to thick secretions)
|
|
|
resporption atelectasis: mech of alveolar collapse
|
lack of air and distal resorption of preexisting air through pores of kohn in alveolar walls
|
|
|
absent vibratory sensation
dullness to percussion absent breath sounds |
resorption atelectasis
|
|
|
compression atelectasis
|
air under pressure or fluid in pleural cavity:
tension pneumo or pleural effusion |
|
|
surfactant is stored in
|
lamellar bodies
|
|
|
synthesis of surfactant begins
|
in 28th week of gestation
|
|
|
synthesis of surfactant is inc with
|
cortisol
thyroxine |
|
|
synth of surfactant is dec with
|
insulin
|
|
|
maternal diabetes causes RDS: mech
|
fetal hyperglycemia inc insulin release, insulin dec surfactant synthesis
|
|
|
C section causes RDS: mech
|
lack of stress induced cortisol release, cortisol inc surfactant synthesis
|
|
|
widespread atelectasis (from RDS) results in
|
massive intrapulmonary shunting (perfusion but no ventilation)
|
|
|
newborn with:
grunting tachypnea intercostal retractions |
RDS
|
|
|
infants with RDS dev
|
hypoxemia and resp acidosis
|
|
|
RDS complications
|
blindness from O2 therapy ROS
bronchopulmonary dysplasia PDA necrotizing enterocolitis (gut ischemia) hypoglycemia |
|
|
most common cause of pulm edema
|
left sided heart failure
|
|
|
edema due to alterations in starling pressure
|
transudate
(CHF, nephrotic syndr, cirrhosis) |
|
|
edema due to microvascular or alveolar injury
|
exudate
(sepsis, pneumonia, aspiration, drugs, high altitude, ARDS) |
|
|
ARDS mech
|
damage to alveolar walls->
macs release cytokines-> cytokines attract neutrophils-> damage capillaries and cause protein leak and hyaline membrane |
|
|
damage to alveolar walls->
macs release cytokines-> cytokines attract neutrophils-> damage capillaries and cause protein leak and hyaline membrane |
ARDS mech
|
|
|
severe hypoxemia not responsive to O2 therapy
|
ARDS
|
|
|
PaO2 < 50 mmHg
pulm artery wedge < 18 |
ARDS
|
|
|
interstitial pneumonia, no signs of consolidation
|
atypical pneumonia
|
|
|
TB resides where
|
in phagosomes of alveolar macs
produces protein that prevents fusion of lysosomes with phagosome |
|
|
produces protein that prevents fusion of lysosomes with phagosome of alveolar macs
|
TB
|
|
|
cord factor is virulence factor
|
TB
|
|
|
responsible for positive PPD
|
protein in cell wall
|
|
|
TB drug resistance mech
|
mutations involving mycolic acid
mutations involving catalase peroxidase |
|
|
enzyme required to activate isoniazid
|
catalase peroxidase
|
|
|
primary TB location
|
upper part of lower lobes
|
|
|
secondary TB location
|
lower part of upper lobes
|
|
|
Ghon focus
|
caseous necrosis in periphery
|
|
|
Ghon complex
|
caseous necrosis in hilar lymph nodes
|
|
|
cavitary lesion of TB is due to
|
release of cytokines from memory T cells
|
|
|
fever
night sweats wt loss |
TB
|
|
|
miliary TB spread: extrapulmonary sites
|
kidney is most common (via pulmonary veins)
adrenal--> addisons |
|
|
tx TB
|
isoniazid
rifampin pyrazinamide |
|
|
when do you become noninfectious with TB tx
|
2-3 weeks (keep treating for 9-12 mo)
|
|
|
TB in vertebra
|
Potts disease
|
|
|
tx MAC
|
clarithromycin
rifabutin ethambutol |
|
|
lung abscess most common cause
|
aspiration of oropharyngeal material
|
|
|
risk factors of lung absess
|
alc
loss of consc recent dental work |
|
|
spiking fever with productive foul smelling cough
|
lung abscess
|
|
|
most common site of aspiration
|
superior right lower lobe
|
|
|
tx lung abscess
|
clindamycin
|
|
|
majority of PEs come from
|
femoral
|
|
|
consequences of pulmonary artery occlusion
|
inc in pulmonary artery pressure
dec blood flow to pulm parenchyma-> hemorrhagic infarct |
|
|
bronchial arteries arise from
|
intercostals
aorta |
|
|
acute right ventricular strain and sudden death
|
saddle embolus
|
|
|
dyspnea and tachypnea most common
respiratory alkalosis hypoxemia fever pleurtic pain |
pulmonary infarct
|
|
|
pulm infarct expiratory wheezing mech
|
release of TXA2 from platelets
|
|
|
PCO2 < 30
PO2 < 80 inc in A-a gradient inc in D dimers |
PE
|
|
|
cut off sign of one or more pulmonary arteries on CXR
|
PE
|
|
|
hamptons hump
|
wedge shaped area of consolidation due to PE
|
|
|
normal Ventilation scan
abnormal perfusion scan |
PE
|
|
|
main cause of secondary pulm htn
|
respiratory acidosis and hypoxemia
|
|
|
vascular hyperreactivity with proliferation of smooth muscle
|
primary pulm htn
|
|
|
mutations in genes assoc with transforming growth factor beta
|
primary pulm htn
|
|
|
secondary pulm htn mech
|
endothelial cell dysfunction
loss of vasodilators NO inc in vasoconstrictors endothelin hypoxemia and resp acidosis result causes smooth muscle hyper |
|
|
5 general categories of mech causing secondary pulm htn
|
chronic hypoxemia- high alt
chronic resp acidosis- CB, OSA loss of pulm vasc left to right shunt mitral stenosis |
|
|
atherosclerosis of main elastic pulm arteries
|
pulm htn
|
|
|
exertional dyspnea
chest pain tapering pulm arteries on cxr accentuated P2 |
pulm htn
|
|
|
left parasternal heave
|
sign of right ventricle hypertrophy
|
|
|
pulm htn imposes what on right ventricle
|
inc afterload
|
|
|
tx pulm htn
|
diuretics
oxygen vasodilators |
|
|
earliest manifestation of interstitial fibrosis
|
alveolitis
|
|
|
leukocytes release cytokines, which stimulate fibrosis, causing
|
interstitial fibrosis
|
|
|
dec lung compliance
dec expansion of lung parenchyma inc lung elasticity (recoil on expiration) |
interstitial fibrosis
|
|
|
CWP: anthracotic pigment where
|
alveolar macs (dust cells) in interstitial tissue and hilar lymph nodes
|
|
|
dust cells
|
coal workers pneum.
|
|
|
coal deposits next to respiratory bronchioles cause
|
centriacinar emphysema
|
|
|
black lung disease
|
complicated coal workers pneum:
progressive massive fibrosis |
|
|
caplan syndrome
|
pneumoconiosis and cavitating rheumatoid nodules
|
|
|
most common occupational disease
|
silicosis
|
|
|
silicosis mech
|
quartz in macs stimulates cytokines that stim fibrosis
|
|
|
ground glass cxr
|
silicosis
|
|
|
egg shell calcification in hilar nodes
|
silicosis
|
|
|
inc risk of lung cancer and TB with
|
silicosis (not coal workers pneum)
|
|
|
amphibole
|
straight asbestos fibers
produce interstitial fibrosis, mesothelioma, lung cancer |
|
|
asbestos fibers deposit where
|
respiratory unit: resp bronch, alveolar ducts, alveoli
|
|
|
benign pleural plaques
|
most common lesion of asbestosis
|
|
|
most common asbestos related cancer
|
primary bronchogenic carcinoma
|
|
|
cancer arising from serosa of pleura
no assoc with smoking encases lung 20-40 yrs after exposure |
mesothelioma (asbestosis)
|
|
|
berylliosis
|
exposure to nuclear and aerospace industry
interstitial fibrosis, noncase granulomas cor pulmonale and lung ca risk |
|
|
sarcoidosis- what is it and epi
|
multisystem granulomatous disease
blacks women nonsmokers |
|
|
sarcoid pathogenesis
|
disorder in immune regulation
CD4 T cells react with unknown antigen release cytokines-> granulomas |
|
|
disorder in immune regulation
CD4 T cells react with unknown antigen release cytokines-> granulomas |
sarcoid
|
|
|
sarcoid granulomas location
|
interstitium
mediastinal LNs hilar LNs |
|
|
granulomas with multinuc giant cells
|
sarcoid
|
|
|
schaumann bodies (laminated calcium concretions)
|
sarcoid
|
|
|
stellate inclusions/asteroid bodies
|
sarcoid
|
|
|
most common symptom of sarcoidosis
|
dyspnea
|
|
|
sarcoidosis organ involvement
|
lung
skin nodules eye lesions/uveitis liver lesions enlarged glands hypothal and pituitary bone marrow spleen |
|
|
inc ACE
|
sarcoidosis
|
|
|
hypercalcemia due to inc synth of 1 alpha OH
|
sarcoidosis
|
|
|
tx sarcoid
|
most have spontaneous remission
corticosteroids |
|
|
idiopathic pulmonary fibrosis
|
alveolitis leading to interstitial fibrosis
|
|
|
honeycomb lung
|
IPF
|
|
|
IPF epi
|
males
40-70 |
|
|
IPF pathogenesis
|
repeated cycles of alveolitis triggered by unknown agent
release cytokines-> fibrosis-> proximal dilation of small airways |
|
|
repeated cycles of alveolitis triggered by unknown agent
release cytokines-> fibrosis-> proximal dilation of small airways |
IPF pathogenesis
|
|
|
fever
dyspnea with exertion chronic nonprod cough late insp crackles |
IPF
|
|
|
collagen vascular disease with interstitial fibrosis
|
SLE
RA |
|
|
pleural effusion in young woman
|
SLE
|
|
|
pulmonary findings in RA
|
rheum nodules
interstitial fibrosis |
|
|
hypersensitivity pneumonitis
|
extrinsic allergic alveolitis
known antigen No IgE or esoinophilia |
|
|
types of hypersens pneumonia
|
farmers lung
silo fillers disease byssinosis |
|
|
farmers lung
|
thermophilic actinomycetes in moldy hay
IgG antibodies and antigen form immune complexes |
|
|
farmers lung hypersensitivity
|
acute is type 3 (IgG + antigen)
chronic is type 4- develop granulomas |
|
|
inhale gases from plant material
(oxides of nitrogen) |
silo fillers disease
|
|
|
dyspnea with contact with cotton, linen, hemp products-> monday morning blues
|
byssinosis
|
|
|
interstitial fibrosis drugs
|
bleomycin
amiodarone cyclophosph methotrexate methysergide nitrosourea nitrofurantoin |
|
|
emphysema targets what
|
respiratory unit (permanent enlargement of all or part)
|
|
|
increased compliance
decreased elasticity |
emphysema
|
|
|
pathogenesis of emphysema
|
elastase and oxidants derive from neutrophils and macs--> destroy elastic tissue
|
|
|
how does cigarette smoke cause emphysema?
|
cigs are chemotactic to neuts,
inactivate alpha 1 antitrypsin and glutathione via free radicals and elastases |
|
|
destruction of elastic tissue (emphysema) causes
|
loss of radial traction-> small airways collapse on expiration
|
|
|
destruction of distal terminal bronchioles and RBs, apical segments of upper lobe:
|
centriacinar emphysema
|
|
|
Genetics of AAT deficiency
|
AD
MM phenotype is normal homozygous ZZ has decreased AAT synth by liver |
|
|
distal terminal bronchioles and entire respiratory unit, lower lobes
|
panacinar emphysema (AAT def)
|
|
|
absent alpha 1 globulin peak in serum protein electrophoresis
|
AAT def
|
|
|
breath sounds diminished due to hyperinflation
cxr- hyperlucency, inc AP, depressed diaphragms |
emphysema
|
|
|
targets alveolar ducts and alveoli
subpleural |
paraseptal emphysema
|
|
|
cyanosis of skin and mucous membranes
-due to dec O2 sat (hypoxemia) |
chronic bronchitis
|
|
|
arterial PCO2 > 45
bicarb > 30 |
chronic bronchitis
|
|
|
loss of ciliated epithelium and presence of squamous metaplasia
|
chronic bronchitis
|
|
|
turbulent airflow occurs in
|
bronchi
|
|
|
laminar airflow occurs in
|
terminal bronchioles
|
|
|
emphysema PCO2
|
normal to decreased
|
|
|
chronic bronch PCO2
|
inc
|
|
|
chronic bronch pH
|
dec
|
|
|
emphysema pH
|
normal to inc
|
|
|
cor pulmonale is common consequence of what obstructive airway disease
|
chronic bronchitis
|
|
|
onset of hypoxemia in emphysema
|
late
|
|
|
onset of hypoxemia in chronic bronch
|
early
|
|
|
onset of dyspnea in emphysema
|
early
|
|
|
onset of dyspnea in chronic bronch
|
late
|
|
|
IL4
|
isotype switching to IgE
|
|
|
isotype switching to IgE
|
IL4
|
|
|
IL5
|
production and activation of eosinophils
|
|
|
production and activation of eosinophils
|
IL5
|
|
|
asthma- helper T cells release what
|
IL4-> IgE
IL5- eosinophils |
|
|
inhaled antigens in asthma cross link what
|
IgE on mast cells-> histamine release
|
|
|
late phase reaction of asthma
|
eotaxin is produced- chemotactic for eosinophils
|
|
|
in asthma, what do eosinophils produce
|
major basic protein and cationic protein which damage epithelial cells and constrict airway
|
|
|
eotaxin
|
chemotactic for eosinophils
|
|
|
patchy loss of epithelial cells
goblet metaplasia thick BM smooth muscle hypertrophy |
asthma
|
|
|
expiratory wheeze
nocturnal cough initial alkalosis inc AP due to air trapping |
asthma
|
|
|
indicates need for intubation in bronchial asthma
|
normal pH or resp acidosis
|
|
|
O3
|
free radical
from O2 + oxides of nitrogen or sulfur (ozone) can cause asthma |
|
|
4 causes of bronchiectasis
|
CF
infections- TB bronchial obstruction primary ciliary dyskinesia |
|
|
sputum
hemoptysis digital clubbing cor pulmonale |
bronchiectasis
|
|
|
CF pathogenesis
|
defective CF transmembrane conductance regulator CFTR for chloride ions,
CFTR is degraded in golgi--> dec Na and Cl reabsorption |
|
|
lung cancer is declining in __ and increasing in __
|
decline in men
inc in women |
|
|
most lung cancers are
|
non small cell (87%)
|
|
|
most common site of lunc ca mets
|
hilar LNs
|
|
|
solitary pulm nodule is most often
|
granuloma (peripheral coin lesion)
|
|
|
most common met to lung
|
breast (then colon and renal)
|
|
|
scar carcinoma- dev in old scar
|
adenocarcinoma
|
|
|
carcinoma that tends to cavitate
|
squamous
|
|
|
cancer with no relation to smoking
|
adenocarcinoma and large cell
|
|
|
most common primary lung tumor in kids
|
carcinoid
|
|
|
bronchial hamartoma
|
cartilage
adipose solitary coin lesion popcorn calcification |
|
|
cartilage
adipose solitary coin lesion popcorn calcification |
bronchial hamartoma
|
|
|
mediastinal mass in older patient
|
metastatic lung ca
|
|
|
mediastinal mass in young patient
|
primary disease
|
|
|
most common primary mediastinal mass
|
neurogenic tumor- usually benign in adults, malignant in kids
|
|
|
most common site for mediastinal mass
|
anterior compartment
|
|
|
malignant mediastinal mass in kids
|
neuroblastoma
|
|
|
benign mediastinal mass in adult
|
ganglioneuroma
|
|
|
neurogenic tumors location
|
posterior mediastinum
|
|
|
5 masses of mediastinum
|
neurogenic tumor
thymoma pericardial cyst malignant lymphoma teratoma |
|
|
middle mediastinum mass
|
pericardial cyst
|
|
|
anterior mediastinal mass in younger woman
|
lymphoma
|
|
|
benign cystic mass in anterior mediastinum
|
teratoma
|
|
|
thymoma location
|
anterior mediastinum
benign |
|
|
thymoma is made up of
|
epithelium
(not lymphoid tissue) |
|
|
thymomas are associated with
|
myasthenia gravis (Ach receptor antibodies)
|
|
|
associated with:
hypogammaglobulinemia pure RBC aplasia autoimmune diseases |
thymoma
|
|
|
most common cause of pleural effusion
|
CHF
|
|
|
most common cause of pleural exudate
|
TB and malignancy
|
|
|
chylous pleural effusion
|
blockage of thoracic duct
due to malig or trauma milky turbid appearance chylomicrons form supranate |
|
|
pesudochylous effusion
|
RA (inc in cholesterol caused by inflammation)
|
|
|
transudate pH
|
> 7.4
|
|
|
exudate pH
|
< 7.4
|
|
|
large effusion shift
|
contralateral shift
|
|
|
subpleural blebs secondary to
|
high negative intrapleural pressures
|
|
|
shift:
spontaneous vs tension pneumo |
spontaneous: trachea towards side of collapse
tension: trachea to contralat side |
|
|
tension pneumo
|
trauma to lungs
inc in pleural cavity pressure with each breath |
