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Pulmonary RT 210 A&P Unit A Upper airway Nose Warms, humidifies and filters gas External opening-nares Conchae-nares to nasal pharynx Nasal conchae-turbinates, allows maximum air surface contact Posterior nose is ciliated pseudostratified columnar epithelium whose purpose is to filter, humidify and warm Upper airway Mouth – oral cavity Lined with stratified squamous Upper airway Pharynx Extends from base of skull to esophagus (about 5 inches) The nasal cavities and mouth to the point where the airway and digestive tract separate Three parts Nasopharynx (behind the nose) Aconchae to uvula Lined with pseudostratified ciliated columnar epithelium Purpose: gas conduction to airways, filters and houses adenoids (defense) Upper airway Pharynx Three parts (con’t) Oropharynx (behind the mouth) Uvula to epiglottis Function: defense, holds tonsils, gas conduction, food conduction, filtration Stratified squamous epithelium Upper airway Pharynx Three parts (con’t) Laryngopharynx (below the hyoid bone behind the larynx) Lined with stratified squamous epithelium Function: gas and food conduction Larynx divides upper and lower airway at the vocal cords Opening to larynx at the glottis Lower Airway Larynx Functions: Conduct gas Protect lower airway Cough Speech Extends from c-3 to c-6 Lower Airway Larynx (cont) Unpaired cartilage Epiglottis covers the superior larynx opening on swallowing, preventing food from entering trachea Thyroid - adam’s apple Cricoid - only complete ring of cartilage Lower Airway Larynx (cont) Paired cartilage Arytenoid - allows vocal cord movement Corniculate-supports walls of the larynx Cuneiform-connect epiglottis to the arytenoid cartilage Tracheobronchial Tree Functions for air conduction Pseudostratified ciliated columnar epithelium Layers (change further down T.B. tree): Cartilaginous layer Lamina propria - contains vessels and nerves epithelium Tracheobronchial Tree Trachea (generation 0) Approximately 4.5 - 5.5 inches in length, or 1012 cm Approximately 1 inch in diameter, or 2-2.5 cm 16-20 c-shaped cartilage rings prevent collapse Anterior to esophagus Ciliated pseudostratified columnar epithelium Divides at carina into 2 mainstem bronchus Tracheobronchial Tree Mainstem Bronchus (generation 1) Right 20-30 degree angle – less acute angle Shorter and wider than left Left 40-60 degree angle – more acute angle Smaller and longer than right Structurally similar to trachea Tracheobronchial Tree Lobar bronchi (generation 2) Right mainstem divides into 3 lobar divisions (accommodates 3 lobes) Upper Middle Lower Left mainstem divides into 2 lobar (2 lobes) Upper Lower Tracheobronchial Tree Segmental Bronchi (generation 3) are named to the segments they represent Right upper lobe Apical Posterior Anterior Right middle lobe Lateral Medial Tracheobronchial Tree Segmental Bronchi (generation 3) are named to the segments they represent Right lower lobe Superior Medial basal Anterior basal Lateral basal Posterior basal Tracheobronchial Tree Segmental Bronchi (generation 3) are named to the segments they represent Left upper lobe Apical-posterior* (upper division) Anterior (upper div.) Superior lingula (lower div.) Inferior lingula (lower division) Left lower lobe Superior Anteromedial*(antero basal) Lateral basal Posterior basal *Some authors feel that the left lung should be numbered so that there are eight segments, the apical-posterior is numbered 1 and anteromedial is numbered 6 Tracheobronchial Tree Subsegmental bronchi (generation #4-9) Diameter from 1-4 mm Tubes greater than 1 mm with connective tissue are bronchi Bronchioles (generation # 10-15) Less than 1 mm No connective tissue Decreasing number of goblet cell/cilia Ciliated cuboidal epithelium Tracheobronchial Tree Terminal bronchioles (generation# 16) About 0.5mm in diameter Cuboidal epithelium to squamous epithelium Clara cells may secrete mucous/surfactant End of conducting airways Canals of Lambert Parenchyma of the Lung Purpose Gas exchange between alveolar air/blood called external respiration Start at the respiratory bronchioles Generation #17-19 Gas exchange is beginning to occur Some cuboidal but mostly squamous Alveolar Ducts (generation #20-22) Alveoli separated by septal walls Alveolar Sacs (generation #23) Clusters of 15-20 alveoli Walls are other alveoli Alveoli Air spaces that contain capillary walls Approximately 300-600 million total Simple squamous epithelium Alveolar communication – pores of Kohn (collateral ventilation) Three types of alveolar cells Type I Type II (Clara Cells) Squamous epithelium – thin and flat 95% of alveolar cells Allows gas diffusion High metabolic rate Produce surfactant Type III Pneumocystic macrophages Ingest and eliminates foreign bodies The Lung Location In thorax Surrounds heart in mediastinum Superior to the diaphragm Surrounded by pleura in the thorax Parietal pleura - on the thorax Visceral pleura - on the lung Small potential space between the two filled with small amount of serous fluid which decreases friction Structure Upper lung Apices – apex Extends 1-2 inches above clavicle Root or hilum is attachment of mainstem bronchus and arteries Base Shape is concave due to diaphragm Right side is higher than the left due to the liver Structure Bony thorax Surrounds and protects the lung Aids in ventilation Sternum 18 cm long Parts Manubrium - superior portion Body or Gladiolus - middle portion Xiphoid process – inferior portion Notch above is the suprasternal notch Trachea is palpable behind it Structure Sternum (cont) Junction of manubrium and body is the Angle of Louis The point of tracheal bifurcation (carina) True ribs Pairs 1-7 Connect directly to the sternum False ribs Pairs 8-10 Connect to the sternum indirectly via the costal cartilage Structure Sternum (cont) Floating ribs Pairs 11 and 12 No attachment to sternum or other ribs May also be called false ribs Structure Mediastinum Heart Great vessels Trachea Esophagus Thymus gland Lymphatic structures Nerves Thymus Mucus Production and Movement Goblet Cells Submucosal Glands In the surface of the tracheobronchial tree Secrete mucus Below the lamina propria Secrete mucus & bronchial secretions Mucus Composition 95% water 2% glyco protein 1 % carbohydrate Mucus Production and Movement Mucus Composition (cont) Traces of lipid, debris, DNA, and foreign bodies 100 – 150 ml produced daily Traps foreign bodies Mucus Blanket Continuous blanket of mucus over the tracheobronchial tree Layers Sol layer * Near the tissue * Is more liquid Gel layer * Near air * Is more thick Mucus Production and Movement Layers (cont) Cilia * Hair-like projections * Extend into the sol layer Mucociliary escalator * Formed by mucus blanket and cilia * Cilia move in a wave like fashion * Moves mucus upward at 2cm per minute toward the mouth * Means to remove the mucus from the lung Mucus Production and Movement Sputum Mucus, saliva and nasal secretions Mobilized and expelled by cough Alveolar Fluid Surfactant Detergent-like phospholipid Decreases surface tension Prevents alveolar collapse Continuously produced, secreted, and eliminated Muscles of Ventilation Diaphragm Separates thorax and abdomen Muscular hemi-diaphragms Normally dome-shaped Right side higher than left due to liver Flatten on inspiration Phrenic nerve stimulates Major muscle of ventilation Normal diaphragmatic excursion is 1.5cm during quiet breathing May increase to 6-10cm during labored ventilation Muscles of Ventilation Intercostal Muscles Between ribs 2 layers Internal - helps with exhalation External - helps with inhalation T- 1 to T- 11 innervation External-contraction pulls ribs up and out Increases anterior-posterior chest diameter for inspiration Internal-contraction pulls ribs down and in for forced expiration Muscles of Ventilation Accessory Muscles Elevate and stabilize chest for labored breathing Neck and shoulder muscles Scalene Sternocleidomastoid Trapezium Pectoralis Muscles of Ventilation Expiratory Muscles Normally passive Muscles of forced exhalation External oblique Rectus abdominus Internal oblique Transverse abdominus Types of Breathing Eupnea Normal breathing 12-20 breaths per minute Hyperventilation: Rapid and/or deep breathing Hypoventilation: Slow and/or shallow breathing Dyspnea: Labored or difficult breathing Apnea: No breathing occurs Types of Breathing Biot’s Breathing Several short breaths followed by long, irregular periods of apnea Caused by brain damage and increased ICP Cheyne-Stokes Breathing Increasing and decreasing depth and rate of respirations followed by periods of apnea Caused by CHF, decreased blood flow to respiratory center, and brain damage Types of Breathing Kussmaul Breathing Deep gasping type of respiration Caused by diabetic acidosis Tachypnea: Respiratory rate >20 bpm Bradypnea: Respiratory rate < 12 Regulation of Breathing Medullary Respiratory Center Medulla is lowest part of brain stem Contains widely dispersed respiratory neurons Dorsal Respiratory Groups Mainly inspiratory neurons Send impulses to diaphragm and external intercostals muscles Regulation of Breathing Ventral Respiratory Groups Inspiratory neurons Abduct vocal cords Increase diameter of glottis Innervate diaphragm and external intercostals Expiratory neurons Send impulses to internal intercostals and abdominal expiratory muscles Regulation of Breathing Pontine Respiratory Centers Pons is located above the medulla on the brain stem Apneustic center Sends signals to promote a prolonged, unrestrained inspiration Vagal and pneumotaxic center impulses hold the stimulatory effect in check Pneumotaxic center Controls inspiratory time Strong signals increase respiratory rate Weak signals prolong inspiration and increase tidal volumes Reflex Control of Breathing Hering-Breuer Inflation Reflex Stretch receptors located in smooth muscle of large and small airways When stimulated they send a signal via vagus nerve to the medullary center to stop further inspiration In adults it is activated at a tidal volume of about 800 to 1000 ml Cough One of the most common symptoms associated with lung disease Powerful protective mechanism for the lung and airways Caused by mechanical, chemical, inflammatory, or thermal stimulation of the cough receptors Made up of three phases Inspiratory phase Compression phase Expulsion phase Cough Causes and Clinical Presentation Acute cough most often associated with viral infection of the upper airway Chronic cough often associated with postnasal drip, asthma, COPD, gastroesophageal reflux, and left ventricular failure Cough Descriptions The type of cough present should be documented using commonly accepted adjectives. Productive—mucus is produced with the cough Effective—a strong cough Weak—ineffective Dry—no secretions present Chronic productive—patient produces phlegm most days for at least 3 weeks Sputum Production Sputum is the mucus expelled from the tracheobronchial tree that has been contaminated by the mouth. Phlegm is the term used to describe mucus strictly from the tracheobronchial tree. Sputum Production Causes and Descriptions Caused by inflammation of the mucus secreting glands that line the airways Inflammation occurs with infection, cigarette smoke, and allergies. Sputum should be described as to the color, consistency, quantity, time of day, odor, and presence of blood. Thick but clear sputum is consistent with dehydration. Pink frothy sputum is consistent with pulmonary edema. Thick, purulent (pus-containing) sputum is consistent with infection. Hemoptysis Causes Persistent strong coughing Acute infection Bronchogenic carcinoma Cardiovascular disease Trauma Anticoagulant therapy Hemoptysis Descriptions Streaky hemoptysis refers to blood-tinged sputum. Massive hemoptysis refers to more than 400 ml of blood in 3 hours or 600 ml in 24 hours. It is consistent with trauma, lung cancer, tuberculosis, and bronchiectasis. It also is more common in patients on anticoagulant therapy Hemoptysis Hemoptysis versus Hematemesis Determining if the blood is from the lung versus the stomach is important. Blood from the lung is often associated with pulmonary symptoms. Blood from the stomach is associated with GI symptoms (see Table 3-4 CARC p. 33) Shortness of Breath (Dyspnea) Dyspnea is a common symptom of patients with lung or cardiac problems. Subjectiveness of Dyspnea Dyspnea is a subjective complaint that varies with pathologic and psychological variables. The degree of dyspnea may not correlate with objective measures of impairment. Dyspnea should always be investigated even if initial tests are normal. Shortness of Breath (Dyspnea) Dyspnea Scoring System A variety of scoring systems have developed to help quantify dyspnea at a single point in time to help track changes with treatment. The visual analog scales use a straight line 10 cm long. The patient marks a dash on the line consistent with the level of dyspnea currently experienced. The Modified Borg Scale uses a 0 to 10 scale. Many other tools are also available. Each has its own advantages and disadvantages. Shortness of Breath (Dyspnea) Causes, Types, and Clinical Presentation of Dyspnea Dyspnea tends to occur when the patient experiences increased WOB, increased drive to breathe, and/or decreased ventilatory capacity. The adjectives patients use to describe their dyspnea may correlate with the underlying pathology. For example, patients with CHF tend to feel the sensation of “suffocation.” Asthmatics often describe dyspnea by saying they have “tightness in their chest.” Acute dyspnea is associated with acute illnesses such as asthma, pneumonia, pneumothorax, etc. Chronic dyspnea is almost always progressive. It is most often seen in patients with COPD and CHF. Shortness of Breath (Dyspnea) Descriptions Paroxysmal nocturnal dyspnea (PND) is often seen in CHF patients. It is associated with the collection of fluid in the lung during sleep. Orthopnea is also associated with CHF. Trepopnea (dyspnea while lying on one side) is less common but is seen in patients with unilateral disorders. Platypnea (dyspnea in the upright position) is not common but implies a disorder is present that causes increased shunting of blood from right to left when the upright position is assumed. Egan defines trepopnea & platypnea differently from above with both being in the upright position, and platypnea being relieved by the patient lying down Chest Pain Chest pain is the cardinal symptom of heart disease. Chest pain may be seen in patients with lung disease when the pleural lining is abnormal. Classic chest pain associated with heart disease is known as angina, and it signals a medical emergency. Chest Pain Pulmonary Causes of Chest Pain Pain associated with lung disease is most often the result of pleural inflammation. Pneumonia and pulmonary infarction may cause pleural pain. Descriptions Chest pain from heart disease is often described as aching, squeezing, pressing, or viselike. It often increases with exercise. Patients with pleuritic chest pain may be leaning toward one side and describe the pain as stabbing or burning. They state the pain increases with deep breathing. Dizziness and Fainting (Syncope) Syncope is a temporary loss of consciousness due to reduced blood flow and oxygen to the brain. Syncope is caused by a large variety of disorders from something as simple as dehydration to serious cerebral thrombosis. Patients with lung disease who cough very forcefully may experience syncope. Dizziness and Fainting (Syncope) Descriptions Some patients experience syncope when they suddenly stand up. This is often associated with orthostatic hypotension. Cough syncope occurs with severe coughing and is the result of reduced venous return due to high intrathoracic pressures. Swelling of the Ankles (Dependent Edema) Patients with chronic hypoxemia often develop right heart failure. Right heart failure leads to reduced venous return and increased hydrostatic pressure in the peripheral venous blood vessels especially in the dependent tissues (e.g., ankles). Ankle edema thus can be a sign of chronic lung disease. Ankle edema may also simply be a sign of heart disease not associated with lung disease Swelling of the Ankles (Dependent Edema) Descriptions Pitting edema is present when the edematous tissue is pressed inward and it does not return to its normal position immediately. Fever, Chills, and Night Sweats Descriptions Sustained fever is a continuously elevated fever that varies little during a 24-hour period. Remittent fever is continuously elevated but has larger variations and spikes in a 24-hour period. Intermittent fever refers to spikes in body temperature cycling with periods of normal or subnormal temperatures. Fever is a concern because it may signal infection and it increases oxygen consumption. Fever, Chills, and Night Sweats Fever with Pulmonary Disorders Pneumonia Lung abscess Tuberculosis Empyema A lack of fever does not rule out infection. Headache, Altered Mental Status, and Personality Changes Lung disease can lead to headache when chronic hypoxemia or hypercarbia is present. Sudden changes in personality are common in patients with chronic lung disease and may be due to hypoxia, medications, or psychologic issues. RTs must be sensitive to personality changes because they may be indicative of acute lung problems in the patient with chronic lung disease Snoring Incidence and Causes Snoring occurs in about 5% to 10% of children and 10% to 30% of adults. Snoring is caused by excessive narrowing of the upper airway with breathing during sleep. The airway narrowing increases with inspiration and lessens during exhalation. Obesity is the most common cause of obstructive sleep apnea. Enlarged tonsils, a large tongue, a short thick neck, and nasal obstruction may contribute to the upper airway narrowing during sleep. Alcohol and sleeping medications can also make snoring worse Snoring Clinical Presentation Patients with obstructive sleep apnea always snore during sleep. OSA patients will complain of excessive daytime sleepiness because their sleep continuity is abnormal. OSA patients may also complain of poor concentration skills, bedwetting, impotence, high blood pressure, and other complaints