Pulm – Flashcard
119 test answers
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trachibronchial tree: conducting zone
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trachea is covered in C-shaped hyaline cartilage and smooth muscle; pseudostratified ciliated columnar cells with goblet, basal, and club/ clara cells; divides into two mainstem bonchi at the level of the sternal angle, T4/5 right branch is more vertical, and wider --thus aspiration almost always goes to the right right branch --three lobar bronchi left branch --two lobar bronchi; bronchi have circular shaped hyalin cartilage and smooth muscle cartilage ceases at the bronchioles and terminal bronchioles, which still have smooth muscle but simple ciliated columnar epithelium
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where does the trachea divide ?
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T4/T5; level of the sternal angle right mainstem bronchi is more vertical and wider
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where along the respiratory tree does hyalin cartilage cease?
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at the level of the bronchioles, which still have smooth muscle
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respiratory zone
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made of the respiratory and terminal bronchioles: cuboidal ciliated cells, club cells, and smooth muscle alveolar sacs: simple squamous layer of pneumocytes, alveolar macrophages and capillaries
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particle passage through lung:
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large particles stuck in mucus at the trachea, bronchi, or bronchioles are swept up and out by cilia small particles wi the respiratory bronchioles and alveoli are eaten by macrophages
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structures passing through diaphragm
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IVC: T8 esophagus and vagus: T10 aorta: T12 i ate ten eggs at twelve
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aspiration from standing
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base of the R lower lobe
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aspiration from supine
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posterior R upper lobe or R lower lobe
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tracheal histo
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pseudostratified ciliated columnar epithelium 16-20 C shaped hyaline cartilage rings with the opening facing posteriorly smooth muscle clara cells secrete surfactant-like lecethin goblet cells and basal cells
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bronchial histo
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pseudostratified ciliated columnar epithelium O shaped hyaline cartilage rings smooth muscle clara cells secrete surfactant-like lecethin goblet cells and basal cells
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goblet cells
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mucus producing cells found at the trachea and bronchi but not bronchioles
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clara club cells
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secrete a surfactant like substance w high IgA which protects the lining most abundant at the terminal bronchioles
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bronchioles and terminal bronchioles histo
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conducting zone: simple ciliated columnar epithelium with club/clara cells and smooth muscle no hyalin cartilage
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respiratory bronchioles histo
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cuboidal ciliated cells with club/clara cells epithelium some smooth muscles but no cartilage
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alveolar sacs
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NON CILIATED respiratory epithelium of pneumocytes and alveolar macrophages capillaries some smooth muscles but no cartilage
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tidal volume
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tidal volume inspiratory reserve volume expiratory reserve volume residual volume
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functional residual capacity
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residual vol+ expiratory reserve vol
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inspiratory capacity
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tidal vol + inspiratory reserve vol
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vital capacity
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inspiratory capacity + expiratory reserve vol (inspiratory reserve vol+tidal vol+expiratory reserve vol)
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total lung capacity
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vital capacity + residual vol inspiratory capacity + functional residual capacity inspiratory reserve vol + tidal vol + expiratory reserve vol + residual vol
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high altitude
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hypoxemia due to reduction in partial pressure of oxygen hyperventilation --respiratory alkalosis (blowing off acid) renal compensation --mild metabolic acidosis increased excretion of HCO3
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prolonged altitude stats
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1. hypoxemia pO2 lower than 76 2. respiratory alkalosis LOW pCO2 below 33 3. ALKALOTIC pH above 7.45 4. compensatory metabolic acidosis, loss of HCO3 below 22
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ventilation V
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air through the alveoli
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perfusion Q
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blood coursing by the alveoli
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the four major causes of hypoxemia
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alveolar hypoventilation VQ mismatch diffusion impairment right-left shunting
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MCC VQ mismatch
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PE --where ventilation continues but there is no perfusion V>Q thus HIGH V/Q
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VQ zones
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zone I apex: V>Q high V/Q (like a PE) zone II midd: V~Q zone III base: V<Q low V/Q (airway obstruction, atelectasis)
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VQ zone I
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apex: V>Q more ventilation than perfusion bc gravity high V/Q (like PE)
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VQ zone III
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base: V<Q more perfusion than ventilation bc gravity low V/Q (like airway obstruction, atelectasis)
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Hg dissociation curve: right shift
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increased metabolic demand: decreased pH, BPG increase, temp increase MCC: lactic acidosis
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Aa gradient
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A: alveolar a: arteriolar normally around 10-12 mmHg wide Aa suggests hypoxemia be O2 not getting from Alveoli to arteriorles
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MCC wide Aa
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PE pt. w tachypnea, history of DVT or risk factors
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Alveolar gas equation
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[150mmHg/pO2 in air] - [paCO2/.8]
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hyperventilation
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blowing off CO2 causes respiratory alkalosis
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hypoventilation
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retaining CO2 causes respiratory acidosis
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cerebral blood flow is mostly determined via
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pCO2: high CO2 causes higher cerebral blood flow once pO2 drops below 50mmHg, cerebral blood flow determined by pO2
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hypercapnia
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high CO2 levels ie patients w COPD, will tend to have higher cerebral plasma flow
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carotid bodies
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chemoreceptor and baroreceptor measures pO2, pCO2, H+, and stretch transmission via glossopharyngial (IX) and solitary nucleus of medulla
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aortic bodies
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chemoreceptor measures pCO2 and H+ transmission via vagus (X) and solitary nucleus of medulla
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chemoreceptors
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peripheral: carotid and aortic bodies; stimulated by drop on PO2 (below 60), increase in PCO2, and decrease of pH central: stimulated by drop on pCO2 wi brain interstitial fluid
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baroreceptors
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carotid bodies: stimulated with drop in arteriolar pressure or decreased stretch to increase efferent sympathetic firing, and decrease efferent parasympathetic firing thus increasing vasoconstriction, HR, and contractility via glossy (IX) which synapses at the solitary nucleus of medulla
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chronic COPD pt and oxygen supplementation
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the chronic COPD pt. is perpetually hypercapnic, due to air trapping thus their peripheral chemoreceptors have been desensitized to high CO2 and low O2 thus when given extra O2, the chemoreceptors think there is plenty of oxygen, and thus the pt. might stop breathing
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breathing centers of the brain
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apneustic center detects hypoxia (low O2) pneumotactic center detects hypercapnia (high CO2) both at the pons, blood from superior cerebellar, AICA, and basilar
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apneustic breathing
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lesion to the pneumotactic center of the pons leads to long inhalations and short exhalations assoc. w chronic COPD bc pneumotactic is desensitized to pCO2
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medullary breathing
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the medulla has a respiratory rate of about 16 --faster than usual
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Cheyne Stokes breathing
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faster faster faster drop. increased speed in breathing followed by apnea MCC brain stem leasion or increased ICP
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Biots breathing
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gasps and short pauses, characteristic of severe meningitis, head trauma, or active dying
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Kussmaul's breathing
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compensatory tachypnea and hyperpnea --fast deep breaths compensatory with metabolic acidosis, DKA, renal failure
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Juxtacapillary J receptors
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within the lung interstitum increase respiratory rate in response to pulm edema, PE, or consolidation
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slow adapting lung receptors
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found at the sternocostal junction stimulated w stretch and inflation responsible for exhalation
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pulsus paradoxus
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exaggerated drop in BP or pulse of more than 10 on inspiration MCC: pericardial tamponade, pneumothorax
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Kussmaul sign
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increased jvd on inspiration MCC pneumothorax
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retinopathy of prematurity
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premies are on 100% O2, when taken off, the body things its hypoxic and increases VEGF leading to increased neovascularization creating friable wee arteries
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hyalin membranes
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RDS: respiratory distress syndrome
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ARDS
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widespread pulmonary microvascular endothelum damage causes leaky capillaries, increased cytokine damage, and alveolar edema compensatory goblet cell hyperplasia leads to increased REID index, exacerbating hypoxia intra-alveolar edema, inflammation, hyalin membranes with normal pulmonary capillary wedge pressure (bc not a cardiogenic prob)
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Obstructive pulmonary disease findings
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air trapping !! increased compliance and increased stretch normal to increased lung capacity normal forced vital capacity DECREASED FEV1 DECREASED FEV1/FVC
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decreased FEV1
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obstructive
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decreased FEV1/FVC
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obstructive
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Restrictive pulmonary disease findings
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reduced expansion/elasticity decreased lung capacity decreased forced vital capacity normal to low FEV1 normal FEV1/FVC (bc both are lowered together)
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normal FEV1/FVC
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restrictive -both are lowered together
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chronic bronchitis dx details
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obstructive lung volumes productive cough for more than three mos (not necessarily consecutive) per year for more than two years cyanotic due to shunting dyspnea due to hypercapnia wheezing and crackles
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chronic complications of chronic bronchitis
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recurrent bacterial infections, increased PMS and inflammation secondary polycythemia pulmonary htn and cor pulmonale
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chronic bronchitis pathophys
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hyperplasia of mucus secreting glands of the bronchi (goblet cells) with patchy squamous metaplasia thickened walls w Reid index ;50%
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asthma pathology
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eosinophilic mediated: Il5 released recruits eosinophils curshmann spirals: shed epithelum leading to whorled mucus plugs charcot-leyden crystals: eosinophil bkdwn product increased sensitivity leads to muscle hypertrophy
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Curshmann spirals
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epithelial slophing into whorled mucus plugs seen with asthma
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Charcot-Leyden crystals
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eosinophilic hexagonal double pointed needle like crystals from excessive breakdown of eosinophils in sputum
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Panacinar emphysema
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assoc w a1 antitrypsin deficiency
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Centriacinar emphysema
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assoc. w smokers
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PAS staining
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periodic acid schiff stains for glycoproteins positive stain assoc. a1 antitrypsin deficiency (RE ALL also PAS +)
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expiratory wheeze
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caused by constriction assoc. w asthma bronchoconstriction
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inspiratory wheeze
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stridor caused by obstruction assoc. w croup (paramyxoid virus)
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bronchiolitis
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RSV
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epiglottitis
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H. flu drooling, leaning forward, w stridor
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croup, laryngotracheitis
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paramyxovirus, cornybacterium diptheria inspiratory seal like stridor
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rust colored sputum
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strep pneumo due to extravasation of RBC
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green sputum
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CAP: from myeloperoxidase released from PMN teen CF: pseudamona pyocyanin (re babe CF s.aureus)
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currant jelly sputum
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klebsiella due to extravasation of RBC
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pneumonia after flu
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staph aureus
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foul smelling sputum
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anarobes -pseudamona esp assoc. w alcoholics and homeless tx w clindamycin
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legionellosis
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pontiac fever: acute self-limiting flu like symptoms pneumonia GI upset, diarrhea bradycardia, confusion, headache hyponatremia sputum gram stain w high PMNs but no bacteria (doesnt gram stain)
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hyponatremia w flu-like symptoms, GI upset, pneumonia
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legionarres also assoc: bradycardia, headache, confusion
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anthracosis
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coal miners lung coal laden macrophages and pleural thickening with calcifications NO increase in cancer risk restrictive lung pattern and exertional dyspnea
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asbestosis
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shipyard, old buildings restrictive lung pattern w increased risk of cancer calcified pleural plaques and ferruginous bodies
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ferruginous bodies
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asbestosis restrictive lung disease
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silicosis
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sand and glass impairs macrophages, thus increased susceptibility to Tb egg shell calcifications and restrictive lung pattern
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egg shell calcifications
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silicosis
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idiopathic pulmonary fibrosis
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restrictive lung pattern with honeycombing of the lungs repeated cycles of lung injury and wound healing with increased collagen deposition assoc. digital clubbing
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honey combing of the lungs
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diffuse small reticulonodular opacities more pronounced at the lower lobes on CXR IDIOPATHIC pulmonary fibrosis
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interstitial pneumonia bugs
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mycoplasma, chlamydia, legionella RSV, CMV
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stages of a lobar pneumonia
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day 1. congestion w vascular dilation; alveolar exudate of bacteria day 2-3: red hepatization: alveolar exudate of PMNs, fibrin, erythrocytes with a red liver like consistency day 4-6: grey hepatization: RBC disintegrate, alveolar exudate of PMNs and fibrin; lobe grey and brown resolution: enzymatic digestion of infiltrate; restored architecture
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red hepatization of the lungs
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day 2-3 of lobar pneumonia alveolar exudate of PMNs, fibrin, erythrocytes
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grey hepatization of the lungs
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days 4-6 of lobar pneumonia RBC disintegrate, alveolar exudate of PMNs and fibrin
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resolution of lobar pneumonia
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enzymatic digestion of intiltrate w restored architecture
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Mesothelioma histopath
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malignancy of pleura assoc. w asbestosis psammoma bodies and epitheliod papillary projections lined with mesothelial cells cytokeratin+ and calretinin +
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psammoma bodies
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mesolemioma meningioma papillary carcinoma of the thyroid serous papillary cystadenocarcinoma of ovary
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Pancoast superior sulcus tumor
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at the apex of the lung compression syndromes recurrent laryngeal: hoarseness superior cervical ganglia: horners ipsi ptosis, miosis, anhidrosis shoulder pain due to brachial plexus irritation SVC syndrome possible but rare assoc. w non small cell
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SVC syndrome
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impaired venous return from the upper part of the body, manifesting as persistent cough, dyspnea, facial edema, elevated ICP, elevated JVP assoc. w mediastinum mass
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Small cell lung cancer
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aggressive and widely metastatic centrally located syndromes: cushings due to increased ACTH, SIADH, labert eaton presynaptic Ca channel abs
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Small cell lung cancer histopath
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Kulchitsky cells: undifferentiated small blue cells cytokeratin+ synaptophysin+ chromogranin+ neuroenolase+
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Kulchitsky cells
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poorly differentiated, dark blue cells with salt and pepper nucleus neuroendocrine origin cytokeratin+ synaptophysin+ chromogranin+ neuroenolase+
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Adenocarcinoma of the lung
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located peripherally most common lung cancer in nonsmokers and womyn assoc. w finger clubbing, KRAS, EGFR, ALK activating mutations hazy infiltrates on CXR resemble pneumonia thickening of alveolar walls
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Adenocarcinoma of the lung histopath
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glandular pattern w mucin+ stain thickening of alveolar walls
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Squamous cell carc lung
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hilar mass arising from bronchus w central necrosis or cavitation high assoc. smoking: squamous metaplasia of respiratory epithelium secondary to chronic irritation (re similar to barrets) produces PTH causing hypercalcemia --Keratin pearls on histo
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Squamous cell carc lung histopath
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keratin pearls (re hypercalcemia) due to squamous metaplasia secondary to smoking (similar to barrets)
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Large cell carcinoma of lung
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peripherally located highly anaplastic undifferentiated tumor secrete BhCG causing gynecomastia and galactorrea
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Bronchial carcinoid tumor
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low grade, epithelial origin secrete seretonin causing flushing, diarrhea, wheezing nests of neuroendocrine cells, chromogranin A+
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Large cell carcinoma of the lung histopath
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pleomorphic giant cells +BhCG
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digital clubbing
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assoc w large cell lung cancer, adenocarcinoma of the lung, ideopathic pulmonary fibrosis, bronchiectasis, end stage COPD, CF re anemia is spooning
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Ghon complex
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caseating granulomas at hilar nodes, and the ghon focus ie lower lobe classic assoc. primary TB infection
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primary vs reactive tb
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primary lesions at lower of middle lobes of lungs reactive lesions at apex of lungs primary tb is asymptomatic
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hilar node lesions
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silicosis: egg shell primary Tb: granulomas sarcoidosis: lymphadenopathy squamous cell carcinoma: mass
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coin lesion
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on CXR primary lung cancer re: mets have multiple lesions
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highest fetal oxygenated blood
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ductus venosum which bypasses the liver from the umbilical vein to the IVC
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where does a fish bone get stuck ?
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piriform recess by the vocal cords close proximity to laryngeal nerve of X (cough reflex)
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asbestosis cancer assoc.
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malignant mesothelioma vv rare bronchogenic carcinoma
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