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Denver School of Nursing – ADN & BSN Programs No Laboratory component for this class BIO 206 & 308 – Ch 25 & 26 – Pulmonary Phys / Path What are the three most important structures of the Respiratory System??? What are the three most important structures of the Respiratory System??? 1. Lungs – WHY? 2. Muscles of Respiration – WHY? 3. Brain – WHY? Primary = Secondary = Tertiary= Muy Importante!= The Respiratory System is divided into two general parts: The Upper Respiratory Tract The Lower Respiratory Tract Where do you think the division starts? What is the respiratory mucosa? Proper Definition: From A&P Thibodeau: “Mucous membranes are epithelial membranes that line body surfaces opening directly to the exterior (latin name, mucosa)... Their name is derived from the fact that they produce a film of mucus that coats and protects the underlying cells.” In addition to protection, the mucus has other purposes, can you tell me what they are?? Function of Mucosa: Protection – for underlying tissue Immune Support! Mechanically capture debris Presence of “mucins” (proteoglycans) Bacterial interface Lubricant – to allow food to move in digestive tract, and if aspiration occurs in respiratory tract the mucosa will also allow for the pleasantry of “regurg” / emesis. Nose Pharynx Larynx Trachea Bronchi Bronchioles Alveoli Lungs Pleura What is the purpose and function of each of these structures??? Remember what these are REALLY called? Bronchioles What are the serious membranes in the body? Image from http://www.augustatech.edu/anatomy Where are the 3 primary serous membranes found in the human body? Image from http://www.augustatech.edu/anatomy Serous membranes: Heart, lungs, GI Image from http://www.augustatech.edu/anatomy Illustration of the mechanism of respiration Major and accessory muscles Major muscles of inspiration ▪ Diaphragm ▪ External intercostals Accessory muscles of inspiration ▪ Sternocleidomastoid and scalene muscles Accessory muscles of expiration ▪ Abdominal and internal intercostal muscles Alveolar surface tension and ventilation Function of surfactant Elastic properties of the lung and chest wall Elastic recoil Compliance Airway resistance Work of breathing Four steps Ventilation of the lungs Diffusion of oxygen from the alveoli into the capillary blood Perfusion of systemic capillaries with oxygenated blood Diffusion of oxygen from systemic capillaries into the cells Diffusion of CO2 occurs in reverse order IN the PONS (of the Brain Stem) 1) Apneustic Center Stimulates neurons to promote Inspiration via External intercostals and the diaphragm 2) Pneumotaxic Center Stimulated neurons to promote Expiration via the Internal intercostals and rectus abdominis Neurochemical control Respiratory center ▪ Dorsal respiratory group ▪ Ventral respiratory group ▪ Pneumotaxic center ▪ Apneustic center Chemoreceptors 1) Central Chemoreceptors ~ located in the medulla 2) Peripheral Chemoreceptors ~ located in the Aorta & the carotid bodies Both detect increased levels in Carbon Dioxide, and then stimulate Increase in RR Ventilate the alveoli Diffuse gases into and out of the blood Perfuse the lungs so the body receives oxygen Ventilation Mechanical movement of gas or air into and out of the lungs Minute volume ▪ Ventilatory rate multiplied by the volume of air per breath Alveolar ventilation Lung Volume chart Image Source: http://www.anaesthetist.com Spirometry Diffusion capacity Residual volume Functional reserve capacity (FRC) Total lung capacity Arterial blood gas analysis Chest radiographs Conducting airways Upper airways ▪ Nasopharynx ▪ Oropharynx Larynx ▪ Connects upper and lower airways Lower airways ▪ Trachea ▪ Bronchi ▪ Terminal bronchioles Gas-exchange airways Respiratory bronchioles Alveolar ducts Alveoli ▪ Epithelial cells ▪ Type I alveolar cells Alveolar structure Where diffusion of Respiratory gasses occurs ▪ Type II alveolar cells Surfactant production Pulmonary circulation has a lower pressure than the systemic circulation One third of pulmonary vessels are filled with blood at any given time Pulmonary artery divides and enters the lung at the hilus Each bronchus and bronchiole has an accompanying artery or arteriole Alveolocapillary membrane Formed by the shared alveolar and capillary walls Gas exchange occurs across this membrane Membrane formed by what cells? Barometric pressure Partial pressure Partial pressure of water vapor Barometric pressure Partial pressure Speaking of partial pressure… Have you ever wondered what the partial pressure of O2 is at sea level is? Distribution of ventilation and perfusion Gravity and alveolar pressure Ventilation-perfusion ratio(0.8) Oxygen transport Diffusion across the alveolocapillary membrane Determinants of arterial oxygenation ▪ Hemoglobin binding, oxygen saturation Oxyhemoglobin association and dissociation ▪ Oxyhemoglobin dissociation curve ▪ Bohr effect Carbon dioxide transport Dissolved in plasma Bicarbonate(HCO3) Carbamino compounds (hemaglobin) Haldane effect Dissolved in plasma-Pco2 Arterial -5% Venous-10% Bicarbonate-HCO3 Arterial-90% Venous-60% Carbamino compounds-Hb Arterial-5% Venous-30% Hypoxic pulmonary vasoconstriction Caused by low alveolar PO2 Blood is shunted to other, well-ventilated portions of the lungs ▪ Provides better ventilation and perfusion matching ▪ If hypoxia affects all segments of the lungs, the vasoconstriction can result in pulmonary hypertension Acidemia also causes pulmonary artery constriction Image Source: http://www.gilmerfreepress.net Dyspnea Subjective sensation of uncomfortable breathing Orthopnea ▪ Dyspnea when a person is lying down Paroxysmal nocturnal dyspnea (PND) Dyspnea Subjective sensation of uncomfortable breathing Orthopnea ▪ Dyspnea when a person is lying down Paroxysmal nocturnal dyspnea (PND) Generally w LV Failure Abnormal breathing patterns Kussmaul respirations (hyperpnea) Cheyne-Stokes respirations Hypoventilation Hypercapnia Hyperventilation Hypocapnia Cough Acute cough Chronic cough Hemoptysis Cyanosis Pain Clubbing Abnormal sputum Hypercapnia Hypoxemia Hypoxemia versus hypoxia Ventilation-perfusion abnormalities ▪ Shunting Acute respiratory failure Pulmonary edema Excess water in the lungs What is missing from this cartoon? Aspiration Passage of fluid and solid particles into the lungs Atelectasis Compression atelectasis Absorption atelectasis Bronchiectasis Persistent abnormal dilation of the bronchi Squeeze Bronchiolitis Inflammatory obstruction of the small airways Most common in children Occurs in adults with chronic bronchitis, in association with a viral infection, or with inhalation of toxic gases (50% of the time due to what virus??) Bronchiolitis obliterans Late-stage fibrotic disease of the airways Can occur with all causes of bronchiolitis Pneumothorax Open pneumothorax Tension pneumothorax Spontaneous pneumothorax Secondary pneumothorax One way valve Pleural effusion Transudative effusion Exudative effusion Hemothorax Empyema ▪ Infected pleural effusion Chylothorax Pleural space Blood Abscess formation and cavitation Abscess Consolidation Cavitation Pulmonary fibrosis Excessive amount of fibrous or connective tissue in the lung Chest wall restriction Compromised chest wall ▪ Deformation, immobilization, and/or obesity Flail chest Instability of a portion of the chest wall Inhalation disorders Exposure to toxic gases Pneumoconiosis ▪ Silica ▪ Asbestos ▪ Coal Allergic alveolitis ▪ Extrinsic allergic alveolitis ▪ (hypersensitivity pneumonitis) Acute respiratory distress syndrome (ARDS) Fulminant form of respiratory failure characterized by acute lung inflammation and diffuse alveolocapillary injury Injury to the pulmonary capillary endothelium Inflammation and platelet activation Surfactant inactivation Atelectasis Acute respiratory distress syndrome (ARDS) Manifestations ▪ Hyperventilation ▪ Respiratory alkalosis ▪ Dyspnea and hypoxemia ▪ Metabolic acidosis ▪ Hypoventilation ▪ Respiratory acidosis ▪ Further hypoxemia ▪ Hypotension, decreased cardiac output, death Acute respiratory distress syndrome (ARDS) Evaluation and treatment ▪ Physical examination, blood gases, and radiologic examination ▪ Supportive therapy with oxygenation and ventilation and prevention of infection ▪ Surfactant to improve compliance Postoperative respiratory failure Atelectasis Pneumonia Pulmonary edema Pulmonary emboli Prevention ▪ Frequent turning, deep breathing, early ambulation, air humidification, and incentive spirometry Airway obstruction that is worse with expiration Common signs and symptoms Dyspnea and wheezing Common obstructive disorders Asthma Emphysema Chronic bronchitis “Chronic inflammatory disorder of the airways” Inflammation results from hyperresponsiveness of the airways Can lead to obstruction and status asthmaticus Symptoms include expiratory wheezing, dyspnea, and tachypnea Peak flow meters, oral corticosteroids, inhaled beta-agonists, and antiinflammatories used to treat Chronic bronchitis Hypersecretion of mucus and chronic productive cough that lasts for at least 3 months of the year and for at least 2 consecutive years Inspired irritants increase mucus production and the size and number of mucous glands Chronic bronchitis The mucus is thicker than normal Bronchodilators, expectorants, and chest physical therapy used to treat Emphysema Abnormal permanent enlargement of the gas-exchange airways accompanied by destruction of alveolar walls without obvious fibrosis Loss of elastic recoil Centriacinar emphysema Panacinar emphysema ULL Pneumonia Community-acquired pneumonia ▪ Streptococcus pneumoniae Hospital-acquired (nosocomial) pneumonia Pneumococcal pneumonia Viral pneumonia Lobar Tuberculosis Mycobacterium tuberculosis Acid-fast bacillus Airborne transmission Tubercle formation Caseous necrosis Positive tuberculin skin test (PPD) Cavitary Acute bronchitis Acute infection or inflammation of the airways or bronchi Commonly follows a viral illness Acute bronchitis causes similar symptoms to pneumonia but does not demonstrate pulmonary consolidation and chest infiltrates Pulmonary embolism Occlusion of a portion of the pulmonary vascular bed by a thrombus, embolus, tissue fragment, lipids, or an air bubble Pulmonary emboli commonly arise from the deep veins in the thigh Virchow triad ▪ Venous stasis, hypercoagulability, and injuries to the endothelial cells that line the vessels Pulmonary hypertension Mean pulmonary artery pressure 5 to 10 mm Hg above normal or above 20 mm Hg Pulmonary hypertension Classifications ▪ Pulmonary arterial hypertension ▪ Pulmonary venous hypertension-CHF ▪ Pulmonary hypertension due to a respiratory disease or hypoxemia-COPD ▪ Pulmonary hypertension due to thrombotic or embolic disease-PE ▪ Pulmonary hypertension due to diseases of the pulmonary vasculature Primary pulmonary hypertension Idiopathic Diseases of the respiratory system and hypoxemia are more common causes of pulmonary hypertension Pulmonary heart disease Right ventricular enlargement Secondary to pulmonary hypertension Pulmonary hypertension creates chronic pressure overload in the right ventricle Lip cancer Most common form Exophytic Stages Laryngeal cancer Forms ▪ Carcinoma of the true vocal cords (most common) ▪ Supraglottic ▪ Subglottic Bronchogenic carcinomas Most common cause is cigarette smoking Heavy smokers have a 20 times’ greater chance of developing lung cancer than nonsmokers Smoking is related to cancers of the larynx, oral cavity, esophagus, and urinary bladder Environmental or occupational risk factors are also associated with lung cancer of Pathopysiology!! Remember to… KEEP UP WITH YOUR: 1) Text READING 2) Powerpoint Review 3) Study Guide Prep