Pulm/RenalExam.txt

• 1. Nasopharynx
• 2. Pharynx
• 3. Epiglottis
• 4. Larynx
• 5. Vocal cords
• 6. Trachea
• 7. CARINA
• 8. Main Stem Bronchus
• 9. Bronchi
• 10. Bronchiole
• 11. Respiratory Bronchioles
• 12. Alveolar Ducts
• 13. Alveolar Sacs

• Nose
• Sinuses
• Pharynx
• Larynx

• Trachea
• Primary bronchi
• Lungs

• 2 layers of pleura
• Visceral (inside)
• Parietal (outside)

• Potential space
• Allows lungs to expand

• Negative pressure
• Makes body suck in air

During swallowing, prevents food from going into the trachea and instead directs it to the esophagus, which is posterior.

• 1. Heat and humidify air
• 2. Resonate voice
• 3. Lighten weight on skull
• 4. Cushioning effect when blow to the face

• Frontal sinus
• Ethmoid sinus
• Maxillary sinus

Above the eyes

Sides of the nose

Under the eyes

• Within the upper respiratory tract
• Paired structures

Alveolar sacs

They vibrate, modulating the flow of air being expelled from the lungs during phonation

• 2 cells are required for exchange of gas at the alveolar membrane: The Alveolar Type 1 Cells and the Capillary Endothelial Cells
• Type 2 alveolar cells produce surfactant and are NOT involved in the passive diffusion of oxygen and carbon dioxide

Alveolar cells

Diffusion of oxygen and carbon dioxide

In the lungs

• Produce surfactant
• Reduces the surface tension of the moisture that covers the alveolar walls
• No role in diffusion

Smooth muscle surrounding the bronchiole tubes

• Sympathetic (beta 2 receptors): dilate
• Parasympathetic (M3 cholinergic): constrict

One breath in, one breath out

Time breathing in versus time breathing out

1:2

1:4

1:1

• Respiratory rate
• The number of breathing cycles per minute

12-16/min

• Faster as infant, young child
• By about age 16, to normal range

Take a breath in and blow it out

The movement of air in and out of the lungs

• Transfer gases through the cell membrane
• Move oxygen into cells and carbon dioxide out of cells

Carry oxygen through the body (via hemoglobin)

Inhalation: Expansion of the thoracic cage reduces alveolar pressure below atmospheric pressure, so air moves into the lungs

Due to elastic recoil in a normal state, the Palv will > Patmospheric. Exhalation that requires forced skeletal muscle contraction occurs when forcing a breath out such as using a peak flow meter, blowing up a balloon, performing an FEV1, or during an asthma attack. Here Palv also is > Patmospheric , so there is air flow out.

Pip (transpleural pressure) = pressure between the pleural and outside chest

• Diaphragm and inspiratory intercostals contract
• Thorax expands

Air not contacting an alveolar sac

• TV
• Amount of air moved in the airways in a single breath

• RV
• How much air is left over in the lungs following maximal exhalation

How much air goes in/out in a maximal force breath

• Total amount of air the lung can accommodate
• VC + RV

• Amount of air that is forcibly exhaled in one second
• Should be a majority of the air

How much air flows or is exchanged in one minute

• Alveolar ventilation= minute ventilation – dead-space ventilation
• Alveolar ventilation is how much air actually makes to the alveolus

A measure of the lung’s “stretchability”

• The lungs might fail to hold themselves open
• Prone to collapse

The work of breathing is increased

A compound that lowers the surface tension of a liquid

• Lowers hydrostatic pressure/surface tension
• Increases lung compliance
• Makes lungs easier to expand
• Allows alveoli’s to stay open

Increases

• Late in gestation
• Neonatal infants cannot produce surfactant, leading to respiratory distress

Lining the type 1 cells, in the inner surface of the alveolus

Phospholipids and protein

• Diffusion of oxygen into (toward the blood) the cells
• Outward (toward the alveolar air) diffusion of carbon dioxide
• Pressure change from higher to lower after diffusion

Bound to hemoglobin

As bicarbonate HCO3- (ionic form of CO2)

• Increasing respiratory efforts and increasing minute ventilation
• Breathing off lots of CO2 so the equation pushes right and as a result H+ ion decreases and thus blood pH increases

• SLOWING down your respiratory efforts so the Minute Ventilation is decreased
• Arterial P CO2 will rise and thus push the carbonic anhydrase equation to the left
• Causing an increase in H+ ion concentration and lowering blood pH

H+ + HCO3- = H2CO3 = H20 + CO2

Coma due to carbon dioxide intake

Death by lack of oxygen

About 21%

16%, yes

• Contains 4 protein subunits (called globins)
• 2 Alpha subunits, 2 Beta subunits
• Each subunit has one Heme group

Each Heme group binds one O2 molecule at the Fe++ atom

• Heme: one O2 molecule
• Hb: four O2 molecules

As the concentration of oxygen increases, the percentage of hemoglobin saturated with bound oxygen increases until all of the oxygen-binding sites are occupied (100% saturation)

Hb-O2

Hb

Hemoglobin binds the O2, and thus makes more O2 diffuse to the blood because the gradient is still lower in the blood (unbound O2)

• 1. Arterial blood pH
• 2. Partial pressure of oxygen
• 3. Partial pressure of carbon dioxide
• 4. Oxygen saturation
• 5. Bicarbonate

PaO2

PaCO2

SaO2

HCO3-

Blood pH is less than 7.35

Blood pH is greater than 7.45

PaO2 is less than 70mmHg

PaCO2 is greater than 60mmHg

PaCO2 less than 30mmHg

Hb-O2 is less than 90%

• Arterial blood: PaCO2= 40mmHg PaO2=100mmHg Oxygen saturation=near 100%
• Venous blood: PaCO2= 46mmHg PaO2=40mmHg Oxygen saturation less than 75%

• Pulse oximetry machine
• Calculates the Hb-O2 amount by sensing its wavelength
• Different wavelengths of Hb-O2 and Hb

Arterial oxygen pressure (P O2), arterial carbon dioxide pressure (P CO2) and blood pH

Aortic and carotid bodies sense changes in these 3 chemical parameters and send that afferent information to the DRG / VRG respiratory control center located in the medulla oblongata. The Pons has more respiratory control from inputs from the cerebral cortex (such as fright, excitement, muscle movement)

CN9 and CN10

• In the brainstem
• Medulla: input for chemosensory afferent input and efferent output to diaphragm and intercostals muscles
• Pons: regulatory role in I/E transitions

Deep hyperventilation to blow off CO2

Metabolic acidosis

As PaCO2 rises, pH blood lowers

• Airway
• Breathing
• Circulation

• “Sniffing Position”
• Neck neutral and chip up; mandible moved forward

Bluing of the skin

When 1/3 of Hb is present as Deoxy-Hb

• HR
• RR
• BP
• Temperature

• Nasal cannula
• Face mask
• Mask/reservoir

• Nasal Cannula: 7%
• Face Mask: 19%
• Mask/Reservoir: 39%

Will only ventilate dead space, no ventilation actually exchanging in the alveoli

Pop lungs, way too much air for the neonates lungs

• Bag/mask ventilation
• Intubation and ventilator

• The placement of a tube inserted into the trachea
• Serves as an open passage through the upper airway
• Permits air to pass freely to and from the lungs in order to ventilate the lungs
• Can be connected to ventilator machines to provide artificial respiration

• Below clavicles
• Above carina

• Full cardiopulmonary arrest or rapid decline in vital signs
• Patient needs immediate stabilization to prevent death

• Drawing up meds (epinephrine)
• Making sure correct dose

• “Alien”
• Atropine
• Lidocaine
• Inhaled (anesthetics, steroids)
• Epinephrine
• Naloxone

• Partial or complete collapse of a lung due to filling the thorax with air between the visceral and parietal pleura
• Elevates intrathoracic pressures leading to impaired lung ventilation and impaired lung perfusion

• Rapidly alter respiratory dynamics
• Elevated pressure leads to severe hypoxemia and death due to inadequate ventilation, oxygenation, venous return to heart

• Apnea
• Resuscitation
• General anesthesia

• 1. Sedative/hypnotic
• 2. Skeletal muscle paralytic
• 3. Atropine/lidocaine

• 1. External smooth muscle contraction (broncho-constriction)
• 2. External bronchial wall edema
• 3. Intra-lumical inflammation and mucous plugging

• 1. Sympathetic (Beta2): dilation
• 2. Parasympathetic (Cholinergic): constriction

Use of corticosteroids, antihistamines, leukotriene inhibitors

Responsible for synthesizing mediators of inflammation

Bronchodilation

Bronchoconstriction

• Can help a patient decide if there is a need for medication or doctor’s visit
• Especially a quick acting bronchodialator

Because bronchial lumen is already narrowed, greater intrathoracic pressure is needed to exhale air (more positive pressure)

• EVERYTHING can trigger!
• Acute respiratory infections
• Allergens
• Weather changes
• Air quality
• Inhalant irritants
• Etc

Helps patients decide whether their breathing is good, or needs medication, or needs medical attention

• Routine control medications in green zone
• In yellow/red zone, use of fast acting bronchodilators (Maxair/Albuterol)

10 pack years

Over 20, significant increase in cancer

• Asbestos
• Radon

Increased risk

• Metastatic: started in another organ; breast, colon, prostate
• Primary lung cancer: started in lung (airway tumors usually present)

• Neuro/endocrine origin
• Epithelial origin
• Pleural origin

• Hemoptysis (coughing up blood)
• Shortness of breath
• Weight loss

• Obstruct larger and small airways
• Restrict lung expansion
• Induce lung collapse
• Hemorrhage into airways
• Reduce effective surface area for diffusion
• Fluid/blood accumulation in pleural space

Viral infection of the respiratory tract

Bacterial infection of the sinuses

Bacterial/viral infection of the bronchi

Bacterial/viral infection of the lungs

• Viral: fluids, rest
• Bacterial: antibiotics

• Drug resistance
• Unwanted side effects
• Kill of natural flora
• Allergies great in antibiotics

• 1. Regulation of water, inorganic ion balance, and acid-base balance
• 2. Removal of metabolic waste products from the blood
• 3. Removal of foreign chemicals from the blood
• 4. Gluconeogenesis
• 5. Production of hormones/enzymes (erythropoietin, Renin, Vitamin D)

• 1. Filtration
• 2. Secretion
• 3. Reabsorption

Movement of fluid and solutes from the glomerular capillaries into Bowman’s space

• Proteins and protein-bound substances
• Cannot be filtered due to the small pore size and negative charge of the membrane (repels proteins)

• Transport or diffusion of solutes from the peritubular capillaries into the tubules
• Addition of solutes into fluid
• Waste products, when filtration didn’t get rid of enough

• Transport or diffusion of materials from the filtrate into the tubules
• Materials that the body wants to keep

• Plasma that enters nephron is completely cleared of the substance
• Examples: toxins, metabolic wastes

• A certain fraction is excreted, sometimes subject to physiological control
• Examples: inorganic ions (sodium, potassium, calcium)

• Kidney has no effect on levels of these substances
• Examples: glucose, other nutrients

• Juxtamedullary—near the border with medulla, loops of Henle go deep into medulla
• Cortical—corpuscle and most of loop in cortex

• Only 15%
• Important function in generating osmotic gradient

Amount excreted = amount filtered + amount secreted – amount reabsorbed

Sum of opposing pressures: hydrostatic pressure from the heart favors filtration, osmotic and hydrostatic pressure of the filtrate oppose it

• 180 L/day
• 125mL/min

Changing the radius of the arterioles

• Constrict afferent arterioles
• Dilate efferent arterioles

• Dilate afferent arterioles
• Constrict efferent arterioles

Glomerulus (capillary endothelium, basement membrane, podocyte foot processes)

• Water
• Sodium
• Urea, wastes
• Inorganic ions
• Drugs

• Glucose
• Nutrients that are needed by the body

Amount of plasma from which a substance is completely removed

0, all is reabsorbed

• Reabsorption is finite, maximum can be reached
• Plasma glucose concentration saturates transporters, with excess glucose remaining in the tubules

• Completely or almost completely cleared
• Clearance equal to GFR

• If a substance has a clearance greater than GFR, secreted
• If clearance is less than GFR, reabsorbed

• PSNS inhibited, detrusor muscle relaxed
• SNS input keeps internal sphincter contracted (closed)
• Somatic motor input keeps external sphincter closed

• 1. Afferents detect stretch of bladder wall
• 2. PSNS activated, detrusor muscle contracts
• 3. SNS inhibited, opens internal sphincter
• 4. Somatic motor input can be voluntarily inhibited to allow urine release

• Yes
• Extreme sweating, diarrhea, salty meals