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BR-Respiratory
5/15/06
| Question | Answer |
|---|---|
| Development of Respiratory System | 4th wk = lung bud from foregut; lining of lower tract = endoderm; CT, cartilage, muscle = mesoderm; complete development separates from esophagus at level of larynx; incomplete separation = Tracheoesophageal fistula |
| MC Tracheoesophageal fisula: proximal atresia with distal fistula | air enters stomach, copious secretions, possible aspiration w/respiratory distress, inability to pass nasogastric tube |
| Stages of Bronchial Development | Pseudoglandular (5-17wks); Canalicular Period (15-25wks); Terminal Sac Period (24wks to birth; respiration possible at 25wks d/t Type II pneumocytes); Alveolar Period (29wks-8yo; alveoli maturation) |
| Surfactant (phosphatidylcholine/lecithin); how can you judge respiratory distress? | lecithin:sphingomyelin ratio of 2:1 is NORMAL in a newborn; any ratio less than 2:1 can cause neonatal respiratory distress, especially in C-sections |
| Diaphragm is derived from: | septum transversum, paired pleuroperitoneal membranes, dorsal mesentery of esophagus and body wall; innervated by C3,4,5; hernias a/w polyhydraminos usu on L side (flat abd, cyanosis, inability to breath at birth d/t lung hypoplasia) |
| Important lung products: | surfactant (type II; dec alveolar surface tension & inc compliance), prostaglandins, histamine, ACE (inactivates bradykinin), Kallikrein (activates bradykinin) |
| Bradykinin | dilates blood vessels to dec BP and inc capillary permeability (stimulated by ACE inhibitors = cough/angioedema) |
| Residual volume | air in lung after max expiration |
| Expiratory reserve volume (ERV) | air that can still be exhaled after normal expiration |
| Tidal volume | air that moves into lung with each quiet inspiration (~500mL) |
| Inspiratory reserve volume | air in excess of tidal volume that moves into lung on maximum inspiration |
| Vital capacity | TV + IVR + ERV; "everything but the residual volume" |
| Functional reserve capacity | RV + ERV (volume in lungs after normal expiration) |
| Inspiratory capacity | IRV + TV |
| Total lung capacity | IRV + TV + ERV + RV |
| Volumes measured by spirometry | Inspiratory reserve vol, Tidal vol, Expiratory Reserve vol, Inspiratory capacity, Vital capacity |
| Values not measured by spirometry | Total lung capacity, functional residual capacity, residual volume |
| any "capacity" referring to lung volumes means: | the sum of at least 2 volumes |
| FEV1/FVC | >80% is normal; >80% in restrictive lung dz; <80% in OBSTRUCTIVE lung dz |
| Obstructive lung disease | barrel chested; pt can inhale fine, but exhalation takes time and FEV1 is very low; a/w chronic bronchitis or emphysema; high compliance of chest wall expansion |
| Restrictive lung disease | pt cannot fully inhale because of stiffness/fibrosis; the FEV1 for these pts contains the majority of ERV (the lung volume is greatly decreased); a/w pulmonary fibrosis; low compliance of chest wall expansion |
| Laplace's Law | an alveolus w/a small radius has more collapsing pressure than an alveolus with a large radius; hence the importance of surfactant |
| Why do allergies/allergic asthma cause increased airway resistance? | the release of histamine causes constriction of airway smooth muscle |
| Slow-reacting substance of anaphylaxis (SRS-A) | a combo of leukotrienes C4 and D4 (LTC4, LTD4); |
| Zileuton: Treatment of asthma | blocks production of leukotrienes by inhibiting lipoxygenase enzyme |
| Zafirlukast: Treatment of Asthma | blocks leukotriene receptors |
| Leukotrience A4 (LTA4) | precursor for LTB4, C4, D4); it is responsible for chemotaxis of neutrophils and adhesion of WBCs |
| Anatomic shunts | passageways of blood flow that go from venous circulation to the arterial circulation w/o passing thru the lungs; usu 2% of Cardiac Output is shunted; Atrial or Ventricular Septal defects may have up to 50% shunting from R-->L heart |
| Anatomic Dead Space | measured by Fowler method; ~150mL |
| Physiologic Dead Space | measured by Bohr method; considered to be teh volume of the lung that doesn't eliminate CO2 |
| O2-Hb Dissociation Curve: Left shift (inc affinity) | All factors decrease except pH; (P50, PCO2, temp, H+, 2,3-DPG); this is an example of Fetal Hb |
| O2-Hb Dissociation Curve: Right Shift (dec affinity) | facilitates unloading of O2 into tissues; all factors increase except pH (P50, metabolic needs, PCO2, temp, H+, 2,3-DPG); this is an example of ascending to a high altitude; Right shift = CADET face Right (CO2, Acid/Altitude, DPG, Exercise, Temp) |
| Consequence of pulmonary hypertension | Cor pulmonale and R ventricular failure; a/w jugular venous distention, edema, hepatomegaly |
| Pulmonary circulation: a dec in PO2 | causes hypoxic vasoconstriction that shifts blood away from poorly ventilated areas to well-ventilated areas |
| Perfusion limited pulmonary circulation | O2 (normal health), CO2, N2O; gas equilibrates early along the length of the capillary. Diffusion can be inc only if blood flow increases |
| Diffusion limited pulmonary circulation | O2 (exercise, emphysema, fibrosis), CO; Gas does not equilibrate by the time blood reaches the end of the capillary |
| Airway resistance will increase if radius decreases; this is under control of: | Parasympathetic (constriction, SRS-A, mucus secretion) and Sympathetic (dilation, responds b2-agonists for asthma/allergy, provides O2 during fight or flight) Nervous Systems |
| Ventilation/Perfusion (V/Q) Ratio | Ideally = 1; the rate of alveolar ventilation to the rate of pulmonary blood flow; higher in apices (3 = wasted ventilation), lower in bases (0.6 = wasted perfusion) |
| Airway obstruction and V/Q Ratio | reduces ventilation and decreases ratio; if V/Q = 0, it is considered a shunt and no gas exchange occurs despite perfusion |
| Blood Flow Obstruction and V/Q Ratio | blockage of pulmonary artery or smaller vessel reduces perfusion; the V/Q can approach infinity and is considered "physiologic dead space;" a/w Pulmonary Embolisms |
| With exercise (inc CO), there is vasodilation in apical capillaries | this results in a V/Q ratio that appraoches 1 |
| Hypoxia affects on pulmonary versus systemic ciruculation | constriction of local lung vasculature (inc pulm vascular resistance) VERSUS vasodilation in the systemic circulation |
| Zone 1 (apex) of lung | lowest blood flow, capillaries collapse d/t high alveolar pressure; ventilation is in excess of perfusion...ratio approaches 0 |
| Zone 2 (middle) of lung | capillaries remain open b/c arterial pressure is greater than alveolar pressure; ventilation is nearly equivalent to perfusion (ratio of 1) |
| Zone 3 (base) of lung | highest blood flow; capillaries remain open b/c arterial pressure is higher than both alveolar and venous pressure; perfusion is in excess of ventilation |
| CO2 Transport | 90% is in bicarbonate form (5% bound to Hb, 5% dissolved) |
| Haldane Effect | in lungs, oxygenation of Hb promotes dissociation of CO2 from Hb |
| Bohr Effect | in peripheral tissue, inc H+ shifts curve to right, unloading O2 |
| CO2 + H2O <--> H2CO3 | H2CO3 <--> H+ + HCO3- (and H+ + Hb- <--> HHb) |
| Peripheral Chemoreceptors | carotid/aortic bodies at aortic bifurcation respond to dec PO2 (<60mmHg), inc PCO2 and dec pH of blood; low O2 is usu d/t lung disease |
| Central Chemoreceptors | in medulla; [H+] inc as PCO2 crosses BBB, to inc breathing; Responsible for "Cushing Reaction" - response to cerebral ischemia/inc ICP causing HTN (SNS) and bradycardia (PSNS) |
| Medulla | mediates inspiration/expiration rhythm; Input (vagus, glossopharyngeal nn); Output (phrenic n. to diaphragm AND spinal n. to intercostals/abd wall); Can be overridden by Cerebral Cortex for Voluntary breathing if desired |
| Increased arterial H+ directly stimulates chemoreceptors | this is independent of [PaCO2]; causes increased respiration in metabolic acidosis |
| Stimulant of irritant receptors in large airways and stretch receptors in small airways | inhibit inspiration |
| Cheyne-Stokes Breathing | tidal volumes variably increase and decrease and are separated by a period of apnea; a/w drug overdose, hypoxia, CNS depression |
| Kussmaul's breathing | rate and depth of respiration are increased; a/w diabetic ketoacidosis and other forms of metabolic acidosis |
| Sleep apnea: Obstructive | middle aged, male, obese, smoker, HTN, pharyngeal malformations, EtOH/drugs; Ventilatory effort exists, airway obstructed, terminated by self-arousal, usu in naso/oropharynx relaxation during REM sleep |
| Central Sleep Apnea | NO ventilatory effort, airway is NOT obstructed, pt does NOT arouse self; occurs in REM sleep; It is CO2-threshold dependent (a dec # of chemoreceptors sensitive to O2 and CO2) |
| Treatment for sleep apnea | wt loss (osbstructive) and continuous positive airway pressure (CPAP) |
| Gas Exchange/Diffusion depends on difference in pressure across blood-air barrier which is made of: | 1. membrane and cytoplasm of type 1 pneumocytes, 2. Fused basement membrane of type 1 pneumocytes and endothelial cells, 3. Membrane and cytoplasm of endothelial cells |
| Alveolar partial pressure of O2 (PAO2) = | (760mmHg - 47mmHg) FiO2 - (PCO2/0.8)....FiO2 is usu 0.21; PACO2 is usu 40; |
| For CO2, higher partial pressures in blood (lower in alveoli) will | force more CO2 out of blood and into lungs where it can be expired |
| The amount of CO2 delivered to lungs and O2 delivered to tissues is also determined by: | hemoglobin concentration and red blood cell number (hematocrit) |
| Diseases affect diffusion capacity of lungs: | Fibrosis (thickens interstitium, hinders perfusion across blood-air barrier); Emphysema (destroys alveolar walls and dec available area for gas exchange) |
| Aspirated particals usu end up in which bronchus? | Right main bronchus; it is more vertically oriented |
| Deposition of particles into the airway: at rest versus during exercise | slow, deep breaths = sedimentation and diffusion; rapid breathing and higher rate of airflow = deposition by impaction |
| Impaction of particles | >10microns; nasopharynx |
| Sedimentation of particles | 2-10microns; settle d/t weight in small airways |
| Diffusion of particles | 0.5-2microns; engulfed by alveolar macrophages in alveoli |
| Suspension of particles | <0.5microns; remain suspended in air |
| Other lung defenses | mucociliary elevator, cough, secretory IgA and complement |
| Hyaline membrane disease | a/w diabetes of mother |
| Flail chest | d/t multiple fractures of 4+ consecutive ribs; paradoxical respirations |
| ARDS (diffuse alveolar damage/hyaline membrane in adults) | d/t shock, infxn, trauma; impaired gas exchange d/t blood, edema, atelectasis; cyanosis, hypoxemia, wet lungs, diffuse pulmonary infiltrates, pneumothorax can be fatal |
| NRDS (premature infant hyaline membrane disease) | lack of surfactant production; inc work required to expand lungs and infant can't fill lungs with air; atelectasis; cyanosis, hypoxemia, wet lungs, diffuse pulmonary infiltrates |
| Simple pneumothroax | spontaneous rupture of bleb; men 20-40; sudden chest pain, SOB, cough, no breath sounds over affected lung; 50% recurrence |
| Tension pneumothorax | flap allows air into pleural space, but not out; pressure displaces mediastinum and trachea AWAY from lesion; JVD, uneven breath sounds; CV and resp compromise = fatal |
| Open sucking chest wound | penetrating trauma to chest wall/pleura; if diameter of lesion is similar to trachea, air will preferentially enter thru defect |
| Pulmonary HTN | 2* d/t COPD or inc blood flow from shunt; LOUD S2, RVH, leads to Cor Pulmonale |
| Pulmonary Embolism | usu d/t proximal DVT d/t "Virchow's Triad" of blood stasis, endothelial damage (fat, infxn, trauma), and hypercoagulable states); Hemorrhagic wedge infarct; V/Q = infinity; Saddle embolus; CV collapse and sudden death possible |
| Pulmonary Edema | alveolar collapse d/t accumulation of fluid; Heart Failure/overload (inc HYDROSTATID pressure); Inflammatory Rxns (drugs, pneumonia, sepsis = INC CAPILLARY PERMEABILITY); hypoxia |
| Wegener's Granulomatosis | focal NECROTIZING vasculitis (sm - med vessels); Granulomas in UPPER/LOWER resp tract; Bilat nodules/cavities, c-ANCA, fatal w/in yrs if not treated |
| Clinical settings for pulmonary embolus | cancer, multiple fractures, oral contraceptive use, prolonged bed rest, CHF |
| Fat emboli | d/t crush injury w/fracture of long bones and orthopedic surgery |
| COPD | airflow obstruction; increased TLC and decreased FEV1; emphysema and bronchitis often coexist in same pt |
| Restrictive pulmonary diseases | defective lung expansion; decreased TLC and increased FEV1 |
| Status asthmaticus | prolonged asthmatic attack that doesn't respond to therapy and can be fatal |
| Asthma | inc bronciole sensitivity, muscle hypertrophy, mucus plugs, "Charcot-Leyden crystals;" infxn, emphysema, bronchitis; WHEEZING, SOB, Curschmann's mucus spirals; Tx = inhaled b-agonists and cc-steroids |
| Bronchitis | d/t persistant irritants/infxns; hyperplasia of goblet cells (Reid index >50%); excess mucus; possible cor pulmonale; "Blue Bloater;" productive cough >3mo over 2yrs; must quit smoking |
| Emphysema | dilated alveoli/damaged walls; DEC Elastic Recoil; centrilobar (smoking); panacinar (a1-antitrypsin deficiency w/liver cirrhosis); "Pink Puffer;" must quit smoking |
| Bronchiectasis | IRREVERSIBLE; necrotizing bronchial dilation; chronic infxn; d/t obstruction (tumor); purulent sputum, hemoptysis, possible lung abscess; a/w CF and Kartagener's Syndrome |
| Restrictive Lung Disease | lung expansion causes dec lung volumes (dec VC and TLC) and Normal FEV1/FVC ratio >80%; can be extrapulmonary (polio, myasthenia gravis, scoliosis) or pulmonary (interstitial lung diseases) |
| Interstitial lung diseases | Demonstrate alveolar wall inflammation and fibrosis w/o infxn or malignancy; ARDS, NRDS, Pneomoconioses, Sarcoidosis, Idiopathic pulmonary fibrosis, Goodpasture's Syndrome, Wegener's granulomatosis, Eosinophilic granuloma; Dx usu requires Biopsy |
| Eosinophilic granuloma | interstitial/restrictive lung dz; Birbeck granules, Langerhans-like cells, former smokers; lesions in lung, ribs, pneumothorax; subset of histiocytosis X |
| Goodpasture's syndrome | interstitial/restrictive lung dz; Anti-BM Abs; pulmonary hemorrhage, anemia, glomerulonephritis; middle aged males; Hemoptysis and hematuria |
| Idiopathic pulmonary fibrosis | interstitial/restrictive lung dz; chronic Inflammation of Alveolar Wall; fibrosis, cystic spaces; 50s; "Honeycomb Lung" fatal w/in yrs |
| Sarcoidosis | interstitial/restrictive lung dz; Non-caseating Granulomatous Lesions (dz via Bx), uveitis, polyarthritis; young black females; dyspnea on exertion, dry cough, fever, bilateral hilar lymphenopathy ("Potato Nodes"); anergy to tuberculin skin test |
| Hypersensitivity Pneumonitis (Farmer's Lung) | interstitial/restrictive lung dz; long exposure to organic antigens = interstitial inflammation and alveolar damage; h/o farming or bird-keeping; Dry cough, Chest Tightness, malaise, fever |
| Interstitial lung disease can be a side effect of: | bleomycin, methotrexate, amiodarone |
| Subsets of Histiocytosis X | Eosinophilic Granuloma, Letterer-Siwe, Hand-Schuller-Christian |
| Physical findings of Bronchial Obstruction | no breath sounds over area; dec resonance, dec fremitus, tracheal deviation TOWARDS lesion |
| Physical findings of Pleural Effusion | Dec breath sounds over area; dull resonance, dec fremitus, no deviation of trachea |
| Physical findings of Lobar Pneumonia | may have bronchial breath sounds over area; dull resonance, INC fremitus, no deviation of trachea |
| Physical Findings of Pneumothorax | decreased breath sounds, hyperreonance, NO fremitus, deviation of trachea AWAY from lesion |
| Pneumoconiosis (environmental) Lung Diseases | workplace exposure to organic or chemical irritants; Anthracosis, Asbestosis, Coal Worker's Pneumoconiosis, Silicosis, Berylliosis |
| Anthracosis | carbon dust ingested by alvoelar MQs; visible black deposits; asymptomatic |
| Asbestosis | fibers ingested by alveolar MQs; fibroblast prolif/interstitial fibrosis in lower lobes; "Asbestos Bodies, Ferruginous Bodies;" pleural plaques/effusions; bronchogenic carcinoma and MALIGNANT MESOTHELIOMA (asbestos + tobacco) |
| Coal Worker's Lung | Carbon dust ingested by alveolar MQs, forming "Bronchiolar Macules;" can progress to fibrosis, pulmonary HTN and cor pulmonale |
| Silicosis | Silica dust ingested by alveolar MQs causing enzymatic release and "Silicotic Nodules;" Nodules obstruct air/blood flow...often concurrent w/TB ("Silicotuberculosis") |
| Berylliosis | Induces Cell-mediated immunity, non-caseating granulomas; IDENTICAL to SARCOIDOSIS; Increased risk of lung cancer |
| Kartagener's Syndrome | immotile cilia d/t dynein arm defet; also a/w male and female infertility, bronchiectasis, recurrent sinusitis, situs inversus (reversal of organ positioning ex: liver on L, stomach on R) |
| "Typical Pneumonia" | acute fever, purulent sputum, pleuritic pain, lobar "whited out" infiltrate on CXR (ex: S. pneumoniae) |
| "Atypical Pneumonia" | slow onset, non-productive cough, HA, GI symptoms, patchy infiltrate on CXR (ex: Mycoplasma pneumoniae) |
| Typical Lobar Pneumonia Organism | S. pneumonia (pneumococcus); intra-alveolar infiltrate w/consolidation that may involve entire lung |
| Typical Bronchopneumonia Organism | S. aureus, H. influenza, Klebsiell, S. pyogenes; acute inflammatory bronchiolar-alveolar infiltrate; patchy >1 lobe |
| Atypical Interstitial Pneumonia Organism | Mycoplasma pneumoniae, Legionella, Chlamydia; viruses (RSV, adenovirus); diffuse patchy infiltrate in alveolaor wall usu >1 lobe |
| S. pneumonia (pneumococcus) | Adults; typical; MCC of pneumonia; Tx with PCN |
| H. influenza | Elderly; Typical; Complicates viral infxn; chronic respiratory dz |
| S. aureus | Typical community-acquired AND immunocompromised hospital pts; Abscesses; complicates viral infxn |
| S. agalactiae | Neonates (E. coli, too); Typical; similar to S. pneumoniae |
| Mycoplasma pneumonia | Young Adults; MCC of Atypical pneumonia; Positive Cold-Agglutinin Test |
| Legionella pneumophilia | Immunocompromised; Atypical; Found in drinking water and airconditioning |
| Klebsiella pneumoniae | Alchololics; Atypical; d/t aspiration of gastric contents |
| Chlamydia psittaci | Pet Bird Owners; Atypical; Bradycardia, Splenomegaly |
| Chlamydia trachomatis | Neonates; Atypical; MCC of preventable blindness |
| Chlamydia pneumoniae | Young Adults; Atypical; Upper and lower respiratory tract infxn |
| Coxiella burnetti | Dairy Workers (via Inhalation); Atypial; Fever |
| Francisella tularensis | Exposure to Rabbits or Squirrels; Atypical; Granulomatous Nodules |
| Respiratory Syncytial Virus Pneumonia | Also causes croup; Atypical; Winter |
| Influenza Pneumonia | Complicated by Bacterial Infection; Atypical |
| Aspirin therapy for fever in influenza and varicella zoster infxns in kids is contraindicated d/t: | possibility of Reye's Syndrome: encephalopathy and fatty liver |
| Histoplasma capsulatum pneumonia | usu subclinical; bugs found in MQs; Atypical |
| Coccidioides immitis pneumonia | usu subclinical; "Valley Fever;" Atypical |
| Pneumocystis carinii | AIDS pts; Often fatal if not treated; Atypical |
| Less common fungal pneumonias in AIDS pts: | Cryptococcus neoformans AND Aspergillus (fungus ball) |
| Clinical Dx of Bacterial Pneumonia | any age, often <2yo; Fever >39*; Abrupt onset; Healthy relatives; Productive Cough; Splinting Chest Pain; Tubular Breath Sounds that are Dull to Percussion; Consolidated "whited out" lobe |
| Clinical Diagnosis of Viral Pneumonia | Any age; Fever <39*; Gradual Onset; Sick Relatives; Dry Cough; No Chest Pain; Bilateral, Diffuse Rales; Bilateral Diffuse Patchy CXR |
| Clinical Diagnosis of Mycoplasma Pneumonia | Young Adults; Abrupt Fever <39* but Gradual Cough; Family sick 2-3wks prior; Parosysmal Cough; No chest pain; Rales in 1-2 segments; CXR is patchy in 1-2 lobes w/o consolidation |
| MC causes of Pneumonia in Kids | RSV, Mycoplasma pneumoniae, Chlamydia pneumoniae, S. pneumoniae |
| MCC of Pneumonia in Young Adults (20-40yo) | Mycoplasma pneumoniae, S. pneumoniae |
| MCC of Pneumonia in Adults (40-60yo) | S. pneumoniae, Mycoplasma pneumoniae, H. influenza |
| MCC of Pneunomia in Elderly (60+yo) | S. pneumoniae, Anaerobes, H. influenza, RSV, Gram(-) rods |
| Nosocomial pneumonia | Staphylococcus, Gram(-) rods |
| Immunocompromised pneumonia | Staphylococcus, G(-) rods, fungi, viruses, Pneumocystis carinii |
| Aspiration Pneumonia | anaerobes |
| Alcoholic/IV drug user Pneumonia | S. pneumoniae, Klebsiella, Staphylococcus |
| Post viral Pneumonia | Staph, H. influenza |
| Neonatal pneumonia | Group B Strep (agalactiae), E. coli |
| Atypical pneumonia | Mycoplasma, Legionella, Chlamydia |
| Primary Tuberculosis | Hilar node granulomas/tubercles forming "Ghon Complex;" Caseating Necrosis w/Langerhans' giant cells; usu asymptomatic; heals with Calcification on CXR |
| Secondary Tuberculosis | Apices of upper lobe; reactivation of primary; hematogenously spread; weakness, hemoptysis, wt loss; Cavitary lesions may rupture into bronchi; can extend beyond lung: Miliary, meninges, spine (Pott's), psoas muscle |
| Ghon Complex | combo of both Ghon focus (lower lobe, subpleural) and Hilar node Caseous Lesions |
| SIDS | unexplained cause of death in child <1yo; h/o sleeping prone and having respiratory infxn |
| Sinusitus | obstructed drainage outlets; S. pneumoniae, H. influenza, Moraxella |
| Rhinitis | Viral (adenovirus = common cold); Bacterial (usu 2* to viral infxn; Strep, Staph, H. influenza); Allergic (type I hypersensitivity; eosinophilia) |
| Laryngitis | edema and inflammation of vocal cords; d/t infection (M. pneumoniae, parainfluenza virus) or overuse |
| Croup | Parainfluenza type 2 virus; Inflammation of subglottic trachea; 6mo - 2yo; Fever <39*; Gradual bark --> Stridor; Rhinorrhea, hoarseness, conjunctivitis; non-toxic; writhing/anxious baby w/sublottic edema on xray; self-limiting |
| Epiglottitis | d/t H. influenza; Inflamed epiglottis; 1-5yo; Fever >39*; Abrupt stridor; no other sx; Toxic illness; Quiet pt in "sniffing position," drooling; Thumb-print epiglottis on xray; EMERGENCY - 90% need surgery to reestablish airway |
| Cystic Fibrosis | mc lethal genetic dz in whites; AR mutation on Chrom 7 (CRTR gene); altered Cl & H20 transport; High Na & Cl [ ] on sweat test; Exocrine glands: inc mucus viscosity/malfxn; Chronic Pulmonary dz; Pancreatic Insufficiency; Meconium Ileus; Tx = gene Rx/sympt |
| Chronic pulmonary disease in CF pts | most serious complication; leads to death; Pseudomonas aeruginosa infxns are common; Inc RV and TLC; atelectasis, bronchiectasis |
| Pancreatic insufficiency in CF pts | nutritional deficiencies (esp fat soluble vitamins: A, E, D, K); Steatorrhea |
| Superior sulcus tumors ("Pancoast") | involve apices of lung and result in Horner's Syndrome (ptosis, miosis, anhydrosis) d/t involvement of cervical sympathetic plexus |
| Superior vena cava syndrome | d/t obstruction; results in facial cyanosis and swelling |
| Lung neoplasms | leading cause of cancer death for both men & women; 2nd mc type of cancer (behind prostate and breast); Sx: cough, hemoptysis, airway obstruction, wt loss, paraneoplastic syndromes |
| There is an association between Epstein-Barr virus causing nasopharyngeal carcinoma in | SE Asia and East Africa |
| Paraneoplastic syndromes | biochemical disturbance d/t a neoplasm that is not directly related to primary tumor or mets; PTH-like secretion (hypercalcemia); Ectopic ADH (SIADH); Ectopic ACTH (Cushings) |
| Peripheral Cancers of the Lung | Adenocarcinoma (mc; K-ras oncogene, CEA+); Bronchioalveolar (less likely a/w smoking); Large Cell (smoking, poor Px, mets to brain) |
| Central Cancers of Lung | Small/Oat Cell (most aggressive; undifferentiated, small dark blue cells Smoking, ectopic ACTH, ADH); Squamous Cell (bronchus mass; cavitation; keratin pearls; ectopic PTH; smoking) |
| Carcinoid tumor of lung | bronchi; spread by direct extension; ectopic 5-HT; low malignancy; flushing, wheezing, heart dz |
| "SPHERE" of complications from lung cancer | Superior vena cava syndrome, Pancoast's tumor, Horner's syndrome, Endocrine (paraneoplastic), Recurrent laryngeal sx (hoarseness), Effusions (pleural/pericardial) |
| Lung cancer metastases | very common; Brain (epilepsy), Bone (pathologic fx); liver (jaundice, hepatomegaly) |
| Antitussives, Expectorants, Mucolytics | acetylcysteine, codeine, dextromethorphan, guaifenesin, hydrocodone |
| Asthma therapies | adenosine, albuterol, cromolyn sodium, epinephrine, ipratropium bromide, prednisone, terbutaline, theophylline, zafirlukast, zileuton |
| Antimicrobials | amoxicillin, cephalosporin, clindamycin, erythromycin, nafcillin, penicilin, TMP-SMX (trimethoprim-sulfamethoxazole), vancomycin |
| Antineoplastic | cisplatin, paclitaxel |
| Sleep apnea | tricyclic antidepressants |
| Antituberculosis drugs | ethambutol, isoniazid, pyrazinamide, rifampin |
| Diphenhydramine, dimenhydrinate, chlorpheniramine | 1st generation H1 blockers; reversibly inhibit histamine recptors; use for allergy, motion sickness, sleep aid; (toxicity = sedation, antimuscarinic, anti-a-adrenergic) |
| Loratadine, fexofenadine, desloratadine | 2nd generation H1 blockers; reversibly inhibit histamine receptors; used for allergies only; much less sedating than earlier generation |
| Isoproterenol | non-specific b-agonist; relaxes bronchial smooth muscle (b2) BUT can cause tachycardia (b1); used for asthma |
| Albuterol | b2 agonist; relaxes bronchial smooth muscle; used during acute exacerbations of asthma |
| Salmeterol | b2 agonist; long-acting agent for PROPHYLAXIS; adverse effects - tremor/arrhythmia |
| Theophylline | likely causes bronchodilation by inhibiting phosphodiesterase; dec cAMP hydrolysis; LIMITED usage b/c of narrow therapeutic index (cardio/neurotoxicity) |
| Ipratropium | muscarinic antagonist; competitive receptor blocker; prevents bronchoconstriction in asthma |
| Cromolyn | prevents release of inflammatory mediators from MAST CELLS; use only as PROPHYLAXIS of asthma (not effective during acute attack); toxicity is rare |
| Beclomethasone, Prednisone | ccsteroids that inhibit synthesis of cytokines in asthmatics; 1st line therapy for CHRONIC ASTHMA (inactivates NF-kB the transcription factor for TNFa; etc) |
| Zileuton | antileukotriene; a 5-lipoxygenase pathway inhibitor; blocks conversion of arachidonic acid to leukotrienes |
| Zafirlukast, Montelukast | antileukotriene; blockes leukotriene recptors |
| Histoplasma capsulatum | 2-5um yeast w/thin cell wall but not true capsule; ohio river valley |
| Cryptococcus | 4-10um yeast w/broad slimy capsule; AIDS |
| Blastomyces | 5-25um yeast w/thick refractile wall and broad based budding; Mid-Atlantic states |
| Paracoccidioides | 10-60um yeast w/multiple budding; South/Central America |
| Coccidioides | 20-60um nonbudding spherule filled with endospores; SW USA, San Joaquin Valley Fever |
| B-blockers for non-allergic bronchospastic pts (emphysema, chronic bronchitis) | selective b1; metoprolol or atenolol |
| Otitis externa bug | Pseudomonas |
| Tx for Pneumocystis carinii | Trimethoprim-Sulfamethoxazole |
| Thoephylline drug interactions | erythromycin inhibits CYP450 system, potentiating side effects of other drugs (tachycardia, insomnia, agitation) in asthma or COPD pts |
| metabolic acidosis and respiratory alkalosis is a/w with what kind of poisoning? | salicylates |
| acetaminophen toxicity yields: | N/V, abdominal pain, shock, irreversible hepatic failure which can be prevented with administration of N-acetylcysteine |
| Carbon monoxide poisoning yields: | hypoxia, cherry red mucous membranes and lips |
| chronic lead poisoning | anemia (basophilic stippling of RBCs), neuropathy, abdominal pain |
| chronic mercury poisoning | CNS atrophy, gingivitis, gastritis, renal tubular changes (acute toxicity can have renal tubular necrosis and necrosis of GI epithelium) |
| Transudative effusion | contains less protein and few inflammatory cells; d/t decreased oncotic pressure (cirrhosis, nephrotic syndrome) or increased hydrostatic pressure (CHF) |
| Exudative effusion | pleural fluid ptn/serum ptn >0.5 and pleural fluid LDH/serum LDH >0.6; results from leakage of ptn rich fluid from plasma into interstitium d/t increased vascular permeability from inflammation; contains inflammatory cells |
| Pneumocytes | ciliated cells extending to respiratory bronchioles; goblet cells extend only to terminal bronchiles; mucus secretions are swept out of lungs by cilia |
| Type I pneumocytes | 97% of alveolar surface lining the alveoli; permits gas exchange |
| Type II pneumocytes | 3% of alveolar surface; secrete pulmonary surfactant (dipalmitoylphosphatidylcholine; lecithin), which decreases surface tension; serve as precursors of type I & II cells (proliferate w/damage); lecitin:sphingomyelin >2 indicates fetal lung maturity |
| Bronchopulmonary segments | arteries run with airways; each segment has a 3* (segmental) bronchus and 2 arteries (bronchial and pulmonary) in the center; veins and lymphatics drain along the borders |
| Right lung | has 3 lobes; it is the more common site for inhaled foreign bodies d/t a less acute angle of its main stem bronchus |
| Left lung | has 2 lobes and lingula (homologue of a middle lobe) with space for heart; shart acute angle for mainstem bronchus |
| Relation of the pulmonary artery to the bronchus at each lung hilus | RALS = Right Anterior, Left Superior |
| Response to high altitude | inc ventilation; inc erythropoeitin (crit & Hb); 2,3-DPG (binds Hb to release O2); mitochondria; bicarb excretion (kidney; acetazolamide), pulmonary vasoconstriction = RVH if chronic |
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bscaryp