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1

What are the components of the conducting portion of the lungs?  That we cover at this time...

Trachea

Bronchi

broncioles (to terminal bronchiole)

2

What are the four characteristic of the trachea we covered histologically

Basement membrane

Lamina propria

Submucosa

Mucous cells

3

What shape does tracheal cartilage have?

C shaped rings (16-20 hyaline cartilage rings)

4

When does bronchus become bronchiole?

Cartilage plates no longer present and caliber of bronchial tube less than 1mm

5

How do you determine when you enter a terminal bronchiole?

changes from pseudostratified columnar to simple columnar

two types of columnar cells present (ciliated and non-ciliated secretory)

  Goblet cells disappear

  glands disappear

  smooth muscle increases

  elastic fibers increase

6

Club or - Clara cells secrete?  It serves to?

Clara cell secretory protein, similar to lung surfactant.  

Engulf and break down toxins.  Also progenitor cells for regeneration of ciliated epithelial cells

7

In the respiratory region of the lung, what are the five components?

respiratory bronchioles (RB)

  alveolar ducts (AD)

  atrium (At)

  alveolar sacs (AS)

  alveoli (A)

8

What is shown here?

Respiratory bronchiole

9

What is this?

Alveolus

10

What is shown here?  What are the arrows indicating?  What is the function of the structure the arrows show?

What negative consequence of this structure is there?

Alveoli

Alveolar pores

prevent alveolar collapse from pressure build up in adjacent alveolus

may permit spread of infection.

11

What cells form alveolar wall?  List by group.

2 groups...

  surface cells

    type I alveolar cell

  type II alveolar cell

  intramural cells

  endothelial cells

    fibroblasts (CT cells)

    smooth muscle cells

12

What cell type is described?

squamous cell with:

    attenuated cytoplasm

  mitochondria (M)

  Golgi complex (G)

Type I alveolar cell

13

What do type II alveolar cells produce?  What does it do?

Surfactant

  1. reduces surface tension
  2. stabilizes alveolus
  3. keeps alveoli dry

14

What is indicated by the arrows?

Type II alveolar cell

large round cell, may protrude from alveolar wall

15

Globular surfactant is contained within what structure of the Type II cell?

Lamellar bodies

16

What are heart failure cells?  What do they do?  What are they derived from?

AKA alveolar macrophages, AKA dust cells

Phagocytose material in lungs.  

Monocytic derivatives

17

How thick is the alveolar membrane?

.3 to .7 um thick

18

pulmonary arteries carry...

  bronchial arteries carry...

deoxygenated blood to lung for reoxygenation

oxygen/nutrient-rich blood to lung tissue

19

What is described here?

medium muscular arteries

    enter lung at hilum

  distribute to lung

  follow bronchial tree 

bronchial arteries

20

What is described here?

 

large elastic arteries

  enter lung at hilum

  distribute to lung

  follow bronchial tree 

Pulmonary arteries

21

Pulmonary veins tend to run within?

Parenchyma

22

What are the muscles of inspiration?


–Diaphragm
–External intercostals
–Accessory muscles of inspiration include the scalenes and sternocleidomastoids
 

23

What are the muscles of expiration?


–(Passive during rest)
–Forced expiration can involve the internal intercostals and abdominal muscles
 

24

Transpulmonary pressure = ?

Transpulmonary pressure (PTM) = alveolar pressure (Palv) – intrapleural pressure (Ppl)

25

Lung elastic recoil pressure is always equal and opposite to?

Transpulmonary pressure

26

What is the formula for lung compliance?

Lung Compliance = ΔV/ΔP

27

What are the two collapsing forces in the respiratory system that determine compliance?

Elastic recoil

surface tension

28

Formula for Laplace law?

P = 4T/r

For alveoli where only one surface is involved in a liquid-lined sphere the numerator is 2.

29

Surfactant functions include?


1.Lowers surface tension
2.Increases alveolar stability
3.Keeps alveoli dry
 

30

Obstructive disease patients strugge with...

exhalation

31

Restrictive disease patients struggle with...

inhalation

32

On this compliance curve, what do A and B show?

A - respiratory distress syndrome

B - deficiency of surfactant

33

Describe ventilation at the top of the lung within the context of...

  • Intrapleural pressure
  • transmural pressure
  • alveoli size
  • compliance
  • degree of ventilation 

  • more negative intraplueral pressure
  • greater transmural pressure gradient
  • larger alveoli
  • less compliance
  • less ventilation

34

Describe ventilation at bottom of lung in the context of...

  • Intrapleural pressure
  • transmural pressure
  • alveoli size
  • compliance
  • degree of ventilation 

 

  • less negative intrapleural pressure
  • smaller transmural pressure gradient
  • alveoli smaller
  • alveoli more compliant
  • greater ventilation

35

Describe perfusion of the upper lung within context of...

  • intravascular pressures
  • recruitment
  • distension
  • resistance
  • blood flow

  • lower intravascular pressures
  • less recruitment
  • less distension
  • higher resistance
  • less blood flow

36

Describe perfusion of the lower lung within context of...

  • intravascular pressures
  • recruitment
  • distension
  • resistance
  • blood flow

  • greater intravascular pressures
  • more recruitment
  • more distention
  • lower resistance
  • greater blood flow

37

At what point in the lung cycle are we here?

Total lung capacity

38

What stage in lung cycle are we looking at?

Resting position for chest wall

39

What lung volume is depicted here based on the forces shown.

FRC

40

What lung volume is depicted here?

Residual volume

41

Scoliosis is an example of which kind of lung pathology?

Restrictive

42

Which graph is normal, what does the other one show?

Left is normal 

right is kyphoscoliosis

43

Obesity is an example of what kind of respiratory pathology?

Restrictive

44

What forces oppose respiratory flow?  Which is the dominant force?

Airway resistance - due to properties of the tubes.  Responsible for 85% of total resistance

Elastic resistance

45

Ohms law for airflow?

Change in pressure = Flow * resistance

46

At what reynolds number does flow become turbulent?

What is the formula?

>2000

Re=(2rvd)/n

47

Resistance is proportional to?

1/r4

48

Highes total resistance occurs in what airway generations?

5-7

49

Velocity is greatest in?

Central airways

50

According to bernoulli's principle...

Higher velocity begets lower pressure

lower velocity begest higher pressure

51

The oft cited example of bernoulli's principle in airways is...

the reduction in pressure which occurs when the fluid speed increases.  

52

What factors determine the cross-sectional area of airways?


1.Lung volume - holds airways open
2.Lung elasticity - contributes to the tethering effect
3.Bronchial smooth muscle tone in the medium-sized airways 
 

53

What impact does increased lung volume have on airway resistance?

Decreases resistance

54

How do patients with obstructive diseases tend to breath?

Slowly, and at high lung volumes to decrease airway resistance

55

What do the following do to airway resistance?


ØParasympathetic nervous system (acetylcholine and methacholine)
ØHistamine 
ØIrritants (i.e. cigarette smoke)
Ø↓ in PCO2, apparently by direct action on bronchiolar smooth muscle
 

Bronchoconstrictors, increase resistance by contraction of SM

56

What are three examples of things that bronchodilate?


ØSympathetic nervous system (norepinephrine via β2 receptors)
ØAgonists for β2 receptors (e.g., isoproterenol, albuterol)
Ø↑ in PCO2
 

57

During ________, 
•transmural pressure remains positive during exhalation

Quiet respiration

58

During forced expiration, engagement of expiratory respiratory muscles raises... 

Intraplueral pressure.  

59

What happens if intrapleural pressure exceeds airway pressure?

Transmural pressure becomes negative and the airway will collapse unless supported (smooth muscle or cartilage)

60

What is represented by the section indicated with an arrow?

Effort-independent, flow limitation

61

What is the driving force of airway compression?

difference between the alveolar pressure and pleural pressure

62

What determines the location of the equal pressure point (EPP)?

Elastic recoil pressure

63

What is a typical presentation in the flow-volume loop of a patient with emphysema?

Expiratory coving

64

This is the forced expiratory curve of what kind of patient?

One with an obstructive disease

65

This is an example of the forced expiratory and forced vital capacity of what kind of patient?

Restricted

66

What type of patient?

Normal

67

Label the graphs according to the disease state

left to right

Normal, Restrictive, obstructive

68

Where is airflow limitation in a patient with obstructive lung disease vs. a healthy person?

Limitation occurs at an earlier point

69

What can't be measured with spirometry?

RV, FRC and TLV

70

What are the two ways to determine FRC?

Helium dilution

Whole body plethysmography

71

What is the anatomic dead space?


1.Anatomic dead space is the volume of conducting airways ~150 ml (150 lb individual)
 

72

What is the physiologic dead space?


1.Physiologic dead space is the total dead space for the system (1/3 of total)
 

73


__________________ consists of alveoli containing air but not participating in gas exchange
 

1.Alveolar dead space

74

What is the formula for alveolar ventilation?

VA = (VT – VD)f

 

VT = tidal volume 

VD = dead space

   f   = respiratory rate 

75


•CO2 can be used to measure alveolar ventilation due to the fact that...
 

little CO2 is retained in the anatomic dead space at the end of inspiration

76


•If alveolar ventilation is halved, what happens to alveolar and arterial CO2?
 

They will double

77

What is diffusion across capillaries proportional to?

D is proportional to SOLUBILITY/(SQRT:Molecular weight)

78


•____________________- amount of gas transported is limited by blood flow (partial pressure gradient is not maintained)
 

Perfusion limited

79


•_______________- amount of gas that is transported depends on the diffusion process (diffusion will continue as long as the partial pressure gradient is maintained)
 

Diffusion limited

80

Under normal conditions, O2 is limited how?

Perfusion limited

81

CO is subject to what kind of limitation?

Diffusion limited

82

How does diffusion rate for COcompare to that of O2?

 


•Generally, hypercapnia is rare but there is a potential for elevated levels of CO2 due to?
 

20x higher

 thickening of the blood-gas barrier.

83

What does diffusing capcity include?

distance that a gas travels across membranes into the blood and the time it takes to react with hemoglobin

84

What impact would iron deficient anemia have on diffusing capacity?

Reduced diffusing capacity

85

Name 4 pathological changes that reduce diffusing capacity (DL)

Diffuse interstitial pulmonary fibrosis

chronic obstructive pulmonary diease

loss of functional lung tissue

Anemia

86

What is described?

 


–Loss of lung elastic tissue and pulmonary capillaries (decreases surface area and total Hb content)
 

Chronic obstructive pulmonary disease

87

What is described?


–Thickening of the interstitium, alveolar wall and destruction of capillaries
 


•Diffuse interstitial pulmonary fibrosis
 

88


•O2 is normally perfusion limited but can become diffusion limited in what circumstances?
 

  1. Intense exercise
  2. thickening of the blood-gas barrier
  3. reduced PIO2

89

Examples of obstructive diseases?

COPD, Asthma, cystic fibrosis, emphysema

90

What impact do obstructive diseases have on lung tissue compliance?

Increased lung tissue compliance (loss of elastic recoil)

91

What impact do restrictive diseases have on compliance?

decreased compliance due to enhanced elastic recoil

92

Characterise the breathing of patients with restrictive diseases

Small, rapid breaths

93

A 57 y/o female presents with dyspnea on exertion. Pulmonary function studies with plethysmography demonstrate an increase in the work of breathing and a higher oxygen consumption. Which of the following will decrease the oxygen consumption of the respiratory muscles?


A.A decrease in lung compliance
B.A decrease in airway resistance
C.A decrease in the diffusing capacity of the lung
D.An increase in the rate of respiration
E.An increase in tidal volume
 

B.A decrease in airway resistance

(double check)

94

Which diagnosis would be consistent with the patient’s lung compliance curve If they have curve Z?

A.Asthma
B.Emphysema
C.Dyspnea with aging
D.Full-term infant
E.Pulmonary edema

E.Pulmonary edema

95

A 27 y/o male develops acute respiratory distress syndrome (ARDS) after near-drowning. Conventional mechanical ventilation on 100% O2 together with inhaled nitric oxide do not provide sufficient oxygenation. Porcine surfactant is instilled via bronchoscope, and the PaCO2, PaO2, and shunting improve. The improvements in respiratory function occurred because surfactant increased which of the following?

A.Bronchiolar smooth muscle tone
B.Lung elastic recoil
C.Lung compliance
D.Alveolar surface tension
E.The work of breathing

C. Lung compliance

96

What would you see in the absence of surfactant?


– Stiff lungs, atelectasis, alveoli filled with transudate
 

97

The patient presents with severe asbestosis, pulmonary function tests are ordered and the patient is instructed to take in a maximal inspiration and then exhale as hard and fast as he can to generate a maximal expiratory flow-volume (MEFV) curve. As the result, the patient would most likely generate which curve below?

C (I believe, since asbestosis is an example of extrinsic restrictive pathology, it would not have coving like A, lung volume would be small also, and I believe would have reduced flow rate)

98

The asbestosis patient would likely have which values?

C. - indicative of restrictive diseases.  note the high FEV1/FVC ratio

99

Which statement accounts for Elena’s (who has idiopathic pulmonary fibrosis) FEV1/FVC ratio (90%)?

A.Intrapleural pressure is reduced in restrictive lung diseases.
B.Airways are tethered open due to fibrotic changes in the lung parenchyma.
C.Lower lung volumes result in an increased FEV1/FVC ratio.
D.Restrictive lung diseases result in increased compliance.


C.Lower lung volumes result in an increased FEV1/FVC ratio.

 

I think...
 

100

A 68 y/o patient with shortness of breath is referred for pulmonary function testing, including lung volumes, flow-volume curves, and lung compliance. Which one of the following statements correctly characterizes lung compliance?

A.It is equivalent to DP/DV
B.It is inversely related to lung elastic recoil pressure.
C.It decreases with advancing age.
D.It increases with a deficiency of surfactant.
E.It increases in patients with pulmonary edema.


B.It is inversely related to lung elastic recoil pressure.
 

101

A 37 y/o female is admitted to the hospital with severe kyphoscoliosis and respiratory muscle weakness. Which of the following physiological variables is most likely decreased in this patient?

A.Airway resistance
B.Alveolar surface tension
C.PaCO2 levels
D.Chest wall compliance
E.FEV1/FVC

D. Chest wall compliance

102

Which best fits with curve A?

 


A.A 57 y/o female with pulmonary fibrosis who presents to the ED with shortness of breath
B.A 75 y/o male who has smoked two packs of cigarettes per day for 60 years; decreased bilateral breath sounds; flattening of the diaphragm visible on chest x-ray
C.A 68 y/o male who presents with a persistent dry cough; opacities in the lower and middle lung fields on chest x-ray; asbestos exposure
D.A 84 y/o female with a history of myocardial infarction; presents with shortness of breath that worsens in the recumbent position
E.A healthy 22 y/o male who has never smoked, but who is tired from 2 hours of military PT in cold weather
 


B. A 75 y/o male who has smoked two packs of cigarettes per day for 60 years; decreased bilateral breath sounds; flattening of the diaphragm visible on chest x-ray
 

103

Identify the types of flow-volume loops shown.

104

What are the types of restrictive lung diseases?

Intrinsic

Extrinsic

Neuromuscular

105

The following are types of restrictive conditions, what subtype are they?


•Myasthenia gravis
•Guillian Barre Syndrome

ALS

POLIO
 

Neuromuscular

106

The following are types of restrictive lung diseases, what subtype are they?


•Pleural effusion
Asbestosis

Extrinsic

107

What is an example of intrinsic restrictive lung disease?

Pulmonary fibrosis

108

What are the following typical presentations of?

Symptoms - exertional dyspnea and dry cough

PE - Rales at end of respiration, clubbing, cyanosis

IPF

109

What impact do the following have on diffusion capacity?

Emphysema

Pulmonary fibrosis

Anemia

Pulmonary hemorrhage

  • Emphysema - decreased
  • Pulmonary fibrosis - decreased
  • Anemia - decreased
  • Pulmonary hemorrhage - increased (more blood in the area)

110

What is described?


•Loss of alveolar structure by increased proteolytic breakdown, destruction of elastic tissue in alveolar walls
•Decreased Expiratory flows, FEV1/FVC
•Increased air trapping, RV/TLC
•Decreased capillary surface area for gas exchange
•No response to BD challenge
 

Emphysema

111

Effective gas exchange depends on?

Ventilation

Perfusion

112

CO2 diffuses faster than O2 due to it’s...

greater solubility

113

Define PaO2.  What is it determined by?


–The measure of the dissolved oxygen molecules in the blood.
–Determined by the molecules NOT bound to Hb (they’re “free” and able to interact with the measuring electrode).
 

114

Define SaO2.  What is it determined by?

The degree of saturation of RBC's.


–There are 4 binding sites for oxygen per Hb. The %  of all the available binding sites occupied by (saturated with) oxygen is the Hb O2 sat.
 

115

Define the oxygen content of blood.  What is it determined by?


–The amount of oxygen (# of molecules) in the blood. The SaO2 plus the concentration of hemoglobin determine the total amount of oxygen in the blood.
 

116


1.An increase in which of the following  increases O2 affinity for binding hemoglobin?
A.Temperature
B.PCO2
C.H+ concentration
D.DPG
E.Carbon monoxide
 

E. Carbon Monoxide

117


1.A patient with severe anemia has normal lungs. You would expect:
A.Low arterial PO2
B.Low arterial O2 saturation
C.Low arterial O2 concentration
D.Oxygen dissociation curve shifted to the right
E.Low reading from a pulse oximeter
 

C. Low arterial O2 concentration

118


1.If a patient has decreased PAO2, how/why will the following values change?


A.Hemoglobin concentration
B.PaO2
C.Dissolved blood oxygen
D.O2 saturation
E.Total blood oxygen concentration
 

A.Hemoglobin concentration - no change
B.PaO2 - decrease
C.Dissolved blood oxygen - decrease
D.O2 saturation - decrease
E.Total blood oxygen concentration - decrease

119

________: 
•a state in which the body or a region of the body is deprived of adequate oxygen

Hypoxia

120

_______________: 
•a state in which the blood has low arterial oxygen supply

Hypoxemia

121

What are the 4 primary causes of hypoxemia?


1.Reduction in inspired O2
2.Hypoventilation
3.Diffusion Impairment
4.Ventilation-perfusion inequality & Shunt
 

122

How will giving supplemental oxygen in cases of shunt change the O2 concentration of blood?

It won't

123