Pulmonary Flashcards
(130 cards)
1
Q
Embryonic
A
weeks 4-7
lung bud –> trachea –> bronchial buds –> mainstem bronchi –> secondary bronchi –> tertiary bronchi
ERROR => tracheoesophageal fistula
2
Q
Pseudoglandular
A
Weeks 5-17
endodermal tubules –> terminal bronchioles
surrounded by capillary network
RESPIRATION IMPOSSIBLE
3
Q
Canalicular
A
Weeks 16-25
Terminal bronchioles –> respiratory bronchioles –> alveolar ducts
Surrounded by prominent capillary network
airways increase in diameter
Respiration at 25 weeks
Pneumocytes develop at 20 weeks
4
Q
Saccular
A
week 26-birth
alveolar ducts –> terminal sacs (separated by sepate)
5
Q
Alveolar
A
week 36- 8 years
Terminal sacs –> adult alveoli
in utero breathing via aspiration and expulsion of amniotic fluid –> increase vascular resistance
at birth fluid gets replaced with air –> decrease pulmonary vascular resistance
6
Q
Pulmonary hypoplasia
A
poorly developed bronchial tree with abnormal histo
Associated with congenital diaphragmatic hernia (L side), bilateral renal agenesis (potter)
7
Q
Bronchogenic cysts
A
caused by abnormal budding of the foregut and dilation of terminal/large bronchi
Discrete round, sharply defined fluid filled density on CXR
asymptomatic, drain poorly –> airway compression or recurrent respiratory infection
8
Q
club cells
A
nonciliated low columnar/cuboidal with secretory granules
Located in bronchioles
Degrade toxins, secrete component of surfactant
9
Q
Type 1 pneumocytes
A
squamous
thinly line alveoli for optimal gas exchange
10
Q
Type 2 pneumocytes
A
cuboidal and clustered
stem cell for Type 1 and Type 2 pneumocytes and secrete surfactant.
11
Q
Surfactant
A
decrease alveolar surface tension, decrease alveolar collapse, decrease lung recoil and increase compliance
Composed of lechithins (DPPC)
synthesis begins 20 weeks and achieves mature levels at week 35
CORTICOSTEROIDS –> surfactant
12
Q
Alveolar macrophages
A
phagocytes
release cytokines and alveolar proteases
hemosiderin macrophages found in pulmonary edema or alveolar hemorrhage
13
Q
Neonatal RDS
A
surfactant deficiency –> high surface tension –> alveolar collapse, ground glas
risk: premature, Maternal DM, C section
Tx: maternal steroids before birth, exogenous surfactant
Therapeutic O2 –> retinopathy, intraventricular hemorrhage, bronchopulmonary dysplasia
L/S >2 is healthy
14
Q
Conducting zone of Respiratory tree
A
large airways consist of nose, pharynx, larynx, bronchi
airway resistance highest in large to medium bronchi
Warm, humidifies and filters air BUT NO GAS EXCHANGE
Cartilage and goblet cells extend to bronchi
Pseudostratified ciliated columnar cells= bronchus to beginning of terminal bronchioles then transition to cuboidal cells
15
Q
Respiratory zone of respiratory tree
A
lung parenchyma (respiratory bronchioles, alveolar ducts, alveoli.
PARTICIPATE IN GAS EXCHANGE
cuboidal cells in respiratory bronchioles –> simple squamous
cilia terminate in respiratory bronchioles
alveolar macrophages clear debris
16
Q
Lingula homologous to
A
right middle lobe
17
Q
Relation of pulmonary artery to bronchus
A
Right anterior, Left superior
18
Q
Carina position
A
posterior to ascending aorta and anteromedial to descending aorta
19
Q
Most common site for inhaled foreign bodies
A
right lung
supine: superior segment of right lower lobe
lying on right side- right upper lobe
upright- enter right lower lobe
20
Q
T8 Diaphragm
A
IVC
right phrenic N
21
Q
T10 Diaphragm
A
esophagus
Vagus N
22
Q
T12 Diaphragm
A
aorta
thoracic duct
azygous vein
23
Q
Inspiratory reserve volume
A
air that can still be breathed in after normal inspiration
24
Q
Tidal volume
A
air that moves into lung with each quiet inspiration (500)
25
Expiratory reserve volume
air that can still be breathed out after normal expiration
26
Residual volume
air in lung after maximal expiration
| RV and any lung capacity that includes RV cannot be measured by spirometry
27
Inspiratory Capacity
IRV+TV
| air that be breathed in after normal exhalation
28
Functional residual capacity
RV + ERV
| volume of gas in lungs after normal expiration
29
Vital capacity
TV + IRV + ERV
| Maximum volume of gas that can be expired
30
Total Lung Capacity
IRV + TV + ERV + RV
| volume of gas present in lungs after a maximal inspiration
31
Elastic recoil
Tendency of lungs to collapse inward and chest wall to spring outward
At FRC airway and alveolar pressure = Patm and intrapleural pressure is negative, PVR at minimum
32
Compliance
change in lung volume for a change in pressure
inversely proportional to wall stiffness and increased by surfactant
High compliance --> lung easy to fill (emphysema, aging)
Low compliance --> lung hard to fill (pulm fibrosis, pneumonia, ARDS, pulm edema)
33
Hysteresis
lung inflation follows a different pressure volume curve than lung deflation due to need to overcome surface tension forces in inflation.
34
Respiratory system changes in the elderly
TLC remains the same
increased compliance, RV, V/G mismatch, A-a gradient
Decreased chest wall compliance, FVC and FEV1, respiratory muscle strength, ventilatory response to hypoxia
35
CO poisoning
Normal Hb conc
low O2 sat Hb
Normal dissolved O2
low total O2
36
Anemia
Low Hb conc
Normal O2 sat Hb
Normal Dissolved O2
Low total O2
37
Polycythemia
High Hb concentration
Normal O2 sat Hb
Normal dissolved O2
High total O2 content
38
Methemoglobin
Iron in Hb is normally reduced (2+)
oxidized Iron (3+) does not bind O2 readily but has increased affinity to CN- --> tissue hypoxia from low O2 saturation and low O2 content
CYANOSIS AND CHOCOLATE COLORED BLOOD
39
Shift right on ODC
```
low Hb affinity for O2 --> high P50
low pH
high PCO2
Exercise
high 2,3 BPG
High altitude
high temperature
```
40
Shift left on ODC
```
low O2 unloading --> renal hypoxia --> high EPO synthesis --> compensatory erythrocytosis
basic
low PCO2
low 2,3 BPG
low temp
high CO
high MetHb
high HbF
```
41
CN- poisoning
Byproduct of combustion
Tx: hydrocobalamin, nitrites, sodium thiosulfate
Sx: breath has bitter almond odor, CV collapse
ODC normal
42
CO poisoning
odorless gas from fires, car exhaust or has heaters
Tx: 100% O2
Sx: HA, dizzy, bilateral globus pallidus lesions on MRI
Left shift in curve, bind competitively to Hb
43
Pulmonary circulation
Low resistance, high compliance
| low PaO2 --> hypoxic vasoconstriction that shifts blood away from poorly ventilated region
44
Perfusion limited
O2, CO2, N2O
| gas equilibrates early along the length of the capillary. Exchange can be high only if blood flow high
45
Diffusion limited
O2, CO
| gases does not equilibrate by the time blood reaches the end of the capillary
46
Ventilation/ perfusion mismatch
High at apex and low at base
| with exercise there is vasodilation of apical capillaries so ratio approaches 1
47
V/Q = 0
obstruction
| 100% O2 does not improve PaO2
48
V/Q = infinity
blood flow obstruction
| 100% O2 improves PaO2
49
Response to high altitude
low atmospheric oxygen--> low PaO2 --> high ventilation --> low PaCO2 --> respiratory alkalosis -->altitude sickness
increase EPO, 2,3 BPG, mitochondria, renal excretion of HCO3-
Vasoconstriction --> pulmonary HTN and RVH
50
Response to exercise
High CO2 production, high O2 consumption
Right shift
high ventilation rate meet O2 demand
V/Q ratio from apex to base becomes more uniform
increase pulmonary blood flow due to increased cardiac output
low pH
51
Rhinosinusitis
obstruction of sinus drainage into nasal cavity --> inflammation and pain over are (Maxillary --> drain against gravity)
superior meatus- drain sphenoid, posterior ethmoid
middle meatus- drain frontal, maxillary and anterior ethmoid
inferior meatus0 drain nasolacrimal duct
VIRAL URI + H. influenz, S. pneumoniae, M. catarrhalis
52
Epistaxis
most common in anterior segment of nostril
life threatening in posterior segment
caused by foreign body, trauma, allergic rhinitis and nasal angiofibromas
53
Head and neck cancer
SCC
Risk: tobacco, alcohol, HPV 16, EBV
Field cancerization: carcinogen damages wide mucosal area --> multiple tumors that develop independently
54
DVT
blood clot within deep vein --> swelling, redness, warmth, pain
predisposed: stasis, hypercoaguability, endothelial damage
D dimer --> rule out DVT
Imaging with compression US with Doppler
use unfractioned heparin or LMWH for acute management
oral anticoagulants for long term prevention
55
Pulmonary emboli
V/Q mismatch, hypoxemia, respiratory alkalosis
sudden onset dyspnea, pleuritic chest pain, tachypnea
CT pulmonary angiography
56
Lines of Zahn
platelets and fibrin- RBC streaks
ONLY IN THROMBI
postmortem finding
57
Fat emboli
associated with long bone fractures and liposuction
| hypoxemia, neuro abnormalities, petechial rash
58
Air emboli
nitrogen bubbles precipitate in ascending divers. treat with hyperbaric O2
59
Amniotic fluid emboli
during labor or postpartum
due to uterine trauma
lead to DIC
60
Mediastinal mass anterior
Thyroid, thymic neoplasia, Teratoma, Lymphoma
61
Mediastinal mass Middle
esophageal carcinoma, metastases, hiatal hernia, bronchogenic cysts
62
Mediastinal mass Posterior
neurogenic tumor, multiple myeloma
63
Mediastinitis
post op complication of cardiothoracic procedures, esophageal perforation, infection
fever tachy leukocytosis, chest pain, sternal wound drainage
64
chronic mediastinitis
high proliferative connective tissue
Histoplasma capsulatum
fever tachy leukocytosis, chest pain, sternal wound drainage
65
pneumomediastinum
presence of gas in mediastinum
via rupture of pulmonary bleb, trauma, Boerhaave syndrome
ruptured alveoli allow tracking of air into the mediastinum via peribronchial and perivascular sheaths
chest pain, dyspnea, voice change, subcutaneous emphysema, + Hamman sign
66
Obstructive Lung Disease
Air trapping in lungs, airways close prematurely at high lung volumes
High RV, FRC, TLC
LOW FEV1, FVC, FEV1:FVC
V/Q mismatch, chronic hypoxic vasoconstriction can lead to cor pulmonale
COPD, chronic bronchitis, emphysema
67
Restrictive lung disease
Low RV, FRC, TLC, FEV1, FVC
| Normal or high FEV1: FVC
68
Chronic bronchitis
wheezing, crackles, cyanosis, dyspnea CO2 retention, secondary polycythemia
Hypertrophy and hyperplasia of mucus secreting glands in bronchi
DLCO normal
Productive cough for > 3 months in a year for > 2 consecutive years
69
Sarcoidosis
immune mediated widespread noncaseating granulomas
high ACE levels, high CD4/CD8 ratio
enlarged LN
bilateral adenopathy and coarse reticular opacities
Associated Bells Palsy, Uveitis, granulomas, Lupus pernio, Intersititial fibrosis, erythema nodosum, RA like, high Ca
Tx steroids
70
Inhalation injury sequelae
chemical tracheobronchitis, edema, pneumonia, ARDS
secondary to burns, CO, CN, arsenic
singed nasal hairs or soot
severe edema, congestion of bronchus and soot deposition
71
Asbestosis
Shipbuilding, roofing, plumbing
ivory white calcified supradiaphragmatic and pleural plaques
Bronchogenic carcinoma > mesothelioma, increase risk of Caplan syndrome
LOWER LOBES
ferruginous bodes are golden brown fusiform rods resembling dumb ells
increase risk pleural effusion
72
Berylliosis
aerospace and manufacturing industry
granulomatous
increase risk of cancer and cor pulmonale
UPPER LOBES
73
Coal Workers
macrophages with carbon --> inflammation and fibrosis
increase risk of Caplan
UPPER LOBES
small rounded nodular opacities
74
Caplan Syndrome
RA, pneumoconioses with intrapulmonary nodules
75
silicosis
sandblasint, foundries, mines
macrophages release fibrinogenic factors --> fibrosis
increase susceptibility to Tb, increase risk of cancer, cor pulmonale, Caplan syndrome
UPPER LOBES
eggshell calcifications of hilar LN
76
Mesothelioma
malignancy of pleura associated with asbestosis
may result in hemorrhagic pleural effusion, pleural thickening
Psammoma bodies
Calretinin and cytokertain +
77
ARDS
alveolar insult --> pro inflammatory cytokines --> neutrophils --> endothelial damage and increasesed permeability --> hyaline membranes
Loss of surfactant --> alveolar collapse
via sepsis, aspiration, pneumonia, trauma, pancreatitis
Dx: bilateral lung opacities, resp failure, low PaO2/FiO2, hypoxemia, not HF issues
impaired gas exchange, low lung compliance, pum HTN
78
Sleep apnea
repeated cessation of breathing > 10 seconds during sleep --> disrupted sleep --> daytime somnolence
Dx sleep study
Nocturnal hypoxia --> systemic/ pulm HTN, arrhythmias, sudden death
Hypoxia --> increase EPO --> increase erythropoiesis
79
Obstructive sleep apnea
respiratory effort against airway obstruction
Normal PaO2during the day
Associated with obesity, loud snoring, daytime sleepiness
caused by parapharyngeal tissue in adults, adenotonsillar hypertrophy in children.
Tx weight loss, CPAP, dental device
80
Central sleep apnea
impaired respiratory effot due to CNS injury, HF, opioids
| Associated wtih Cheyne Stokes respirations
81
Obesity hypoventilation syndrome
obesity --> hypoventilation --> high PaCO2 during waking hours, low PaO2 and high PaCO2 during sleep
Pickwickian syndrome
82
Pulm HTN
normal 10-14
HTN >25 at rest
results in arteriosclerosis, medial hypertrophy, intimal fibrosis of pulmonary A, plexiform lesions
severe resp distress --> cyanosis and RVH --> death from decompensated cor pulmonale
83
Pulm A HTN
Heritable can be due to inactivation of BMPR2 gene
poor prognosis
increase vasoconstrictors and decrease vasodilators
84
Left Heart Disease
caused by systolic/ diastolic dysfunction and valvular disease
85
Lung diseases or hypoxia
destruction of lung parenchyma, lung inflammation/ fibrosis, hypoxemic vasoconstriction
86
Chronic thromboembolic
recurrent microthrombi --> decreased cross sectional area of pulmonary vascular bed
87
Multifactorial pulm HTN
hematologic, systemic, metabolic disorders, compression of pulmonary vasculature by a tumor
88
Pleural effusion
```
Excess accumulation of fluid between pleural layers --> restricted lung expansion during inspiration
decreased breath sounds
dull to percussion
decreased fremitus
Tracheal deviation none
```
89
Atelectasis
```
Alveolar collapse
decreased breath sounds
dull to percussion
decreased fremitus
trachea deviate to side of lesion
```
90
Simple pneumothorax
```
accumulation of air in pleural space
Sx dyspnea, uneven chest expansion, chest pain
decreased breath sounds
hyperresonant
decreased fremitus
```
91
Tension pneumothorax
air enters pleural space but cannot exit. Increasing trapped air
decreased breath sounds
Hyperresonant
decreased fremitus
Tracheal deviation away from side of lesion --> mediastinal displacement --> kinking IVC --> decrease venous return --> decreased cardiac output
92
Consolidation
bronchial breath sounds, late respiratory crackles, egophony
dull to percussion
increased fremitus
93
Causes of atelectasis
obstructive: prevent new air reaching distal airways, old air resorbed
Compressive: external compression on lung decreases lung volumes
Contraction: scarring of lung parenchyma that distorts alveoli
Adhesive: due to lack of surfactant
94
Lymphatic Pleural effusion
thoracic duct injury from trauma or malignancy
| Milky appearing fluid high TG
95
Exudate pleural effusion
high protein content, cloudy
due to malignancy, inflammation, trauma
MUST BE DRAINED DUE TO RISK OF INFECTION
96
Transudate effusion
low protein, clear
| via increased hydrostatic pressure or decreased oncotic pressure
97
Primary spontaneous pneumothorax
due to rupture of apical subpleural bleb or cyst
| in tall thin young males and smokers
98
Secondary spontaneous pneumothorax
due to diseased lung, mechanical ventilation with use of high pressure
99
Traumatic pneumothorax
blunt, penetrating or iatrogenic trauma
100
Lobar Pneumonia
S. pneumoniae, Legionella, Klebsiella
| intra alveolar exudate
101
Bronchopneumonia
S. pneumoniae, S. aureus, H. influenzae, Klebsiella
acute inflammatory infiltrates from bronchioles into adjacent alveoli
Patchy distribution in >1 lobe
102
interstitial pneumonia
Mycoplasma, chlamydophila pneumoniae, chlamydophila psittai, Legionella, viruses
diffuse patchy infiltrate localized to interstitial areas of alveolar wall
bilateral multifocal opacities
Indolent
103
Cryptogenic organizing pneumonia
chronic inflammatory diseases or medication (amiodarone) - sputum culture
Noninfectious with inflammation of bronchioles and surrounding structures
104
Lung cancer
cough, hemoptysis, bronchial obstruction, wheezing, coin lesion
Metastasize to liver, adrenals, bone, brain,
Metastasis from breast, colon, prostate, bladder
Complications: SVC syndrome, pancoast tumor, Horner syndrome, endocrine, recurrent laryngeal N compression, effusions
Risk factors: smoking, radon, asbestos, fam hx
105
Small cell carcinoma of the lung
```
Central location
undifferentiated (very aggressive)
May produce ACTH, ADH, Lambert Eaton
Amplification of myc oncogenes
Neoplasm of neuroendocrine Kulchitsky cells
Chromogranin A +
Neuron specific enolase +
synaptophysin +
```
106
Adenocarcinoma of the lung
```
Peripheral location
nonsmoking women
activate KRAS, EGFR, ALK
associated with clubbing
glandular pattern on histo
mucin +
Bronchioalveolar subtype grows along alveolar septa --> thickening of alveolar walls. Tall, columnar cells containing mucus
```
107
Squamous cell carcinoma of the lung
Central location
Hilar mass arising from the bronchus
cavitation, cigarettes, hypercalcemia
keratin pearls and intracellular bridges
108
Large cell carcinoma of the lung
```
Peripheral location
highly anaplastic undifferentiated tumor
poor prognosis
less responsive to chemo
STRONG ASSOCIATION WITH SMOKING
pleomorphic giant cells
```
109
Bronchial carcinoid tumor
```
central or peripheral
excellent prognosis
mass effect or carcinoid syndrome
nests of neuroendocrine cells
chromogranin A +
```
110
Lung abscess
pus within parenchyma
caused by aspiration of oropharyngeal contents or bronchial obstruction
Air fluid levels seen on CXR
Due to anaerobes
111
Pancoast tumor
apex of the lung
| can compress recurrent laryngeal N, stellate ganglion, SVC, brachiocephalic V, brachial plexus, phrenic N
112
SVC syndrome
impair blood drainage from the head, neck, upper extremities.
Caused by malignancy and thrombosis
MEDICAL EMERGENCY
can rain intracranial pressure --> HA dizzy, increased risk of aneurysm
113
Histamine 1 blockers first generation
Diphenhydramine,dimenhydrinate, chlorpheniramine, doxylamine
used for allergy, motion sickness, sleep aid
adverse: sedation, antimuscarinic, anti a adrenergic
114
Histamine 1 blockers second generation
-adine
used for allergy
Adverse: far less sedating than 1st generation because of low entry into CNS
115
Guaifenesin
thins respiratory secretions, does not suppress cough reflex
116
N acetylcysteine
liquifies mucus in chronic bronchopulmonary diseases by disrupting disulfide bonds
117
Dextromethorphan
antagonize NMDA glutamate receptors
Has mild opioid effect when used in excess
Naloxone can be given for overdose
mild abuse potential
May cause 5HT syndrome if combined with other serotonerigic agents
118
Pseudoephedrine, phenylephrine
a adrenergic agonists
used to reduce hyperemia, edema, open obstructed eustachian tubes
Adverse: HTN. rebound congestion if used more than 4-6 days
Can also cause CNS stimulation, anxiety
119
Endothelin receptor antagonists
decrease pulmonary vascular resistance
Hepatotox
treat pulm HTN
120
PDE5 inhibitors
increase cGMP --> prolonged vasodilatory effect of NO
treat pulm HTN and erectile dysfunction
don't use nitro
121
Prostacyclin analogs
inhibit platelet aggregation
treat pulm HTN
side effects: flushing, jaw pain
122
Albuterol
B2 agonist
relax bronchial smooth M
acute exacerbation of asthma
can cause tremor arrhythmia
123
Salmeterol, formoterol
B2 agonist for asthma
long acting agents for prophylaxis
cause tremor arrhythmias
124
Fluticasone, budesonide
inhaled corticosteroids for asthma
inhibit synthesis of all cytokines
Inactivate NFkB
1st line therapy for chronic asthma
125
Tiotropium, ipratropium
muscarinic antagonist for asthma
prevent bronchoconstriction
used for COPD
126
Montelukast, zafirlukast
block leukotriene receptors (CysLT1)
| good for aspirin induced and exercise induced asthma
127
Zileuton
5 lipoxygenase pathway inhibitor
blocks conversion of arachidonic acid to leukotrienes
Hepatoxic
128
Omalizumab
anti IgE monoclonal therapy
bind unbound IgE and blocks binding to FceRI
used in allergic asthma with high IgE levels resistant to inhaled steroids and long acting B2 agonists
129
Theophylline
methylxanthines for astma
likely causes bronchodilation by inhibiting phosphodiesterase --> high cAMP due to low cAMP hydrolysis
limited use due to narrow therapeutic index
cardiotox, neurotox
block actions of adenosine
130
Anti IL5 monoclonal therapy
prevent eosinophil differentiation maturation, activation and survival mediated by IL5 stimulation.
Mepolizumab, reslizumab --> against IL5
Benralizumab --> against IL5 receptor a
