Clinical Pulm. Physical Therapy

Functions of pulmonary system

Exchange gases between tissue, blood and air; maintain acid-base balance; temp. homeostasis; metabolism and excretion of toxins

rib numbers

12 pairs, 7 true, 3 false, 2 floating

head of rib articulates with

thoracic vertebra

inspiratory muscles

diaphragm, intercostals, accessory mucles (SCM, scalenes, others)

expiratory muscles

at rest its passive, forced is intercostals and abdominals

origins of diaphragm

xiphoid, ribs 11-12, lumbar vertebrae, arcuate ligaments

insertion of diaphragm

central tendon

diaphragm innervation

left and right phrenic nerves

These structures pass through the diaphragm at what level? : aortic, esophagus, IVC

T12, T10, and T8 respectively

diaphragm excursion

quiet breathing: 2/3 inch

  maximal ventilation: 2.5-4 inches

the right lung has ____ segments, the left lung has ___ segments

10, 8

conducting airways

mouth/nasal cavity, pharynx, larynx, trachea, bronchi, bronchioles

respiratory airways

respiratory bronchioles, alveolar ducts, alveolar sacs - gas exchange occurs here

hilum

place where blood vessels, nerves, ducts, and lymphatic vessels enter and leave

pleura of lungs

serous membranes, visceral to parietal and pleural space in middle (in to out)

suprasternal notch corresponds to …..

T2- clavicle articulates with the manubrium at lateral border of manubrium

Sternal angle of loius

inferior aspect of manubrium at sternal angle - palpable as a ridge, corresponds to T4/5 and second rib/second intercostal space

sternal angle is location of carina - bifurcation into L and R mainstem bronchi

carina

bifurcation into L and R mainstem bronchi, at T4/5 or rib 2 by sternal angle

visceral pleura is ________

not well innervated, why lung cancer not painful until later stages

there is significant potential space in lungs pleura for

negative pressure, which keeps lungs expanded

Bronchopulmonary segments (numbers)

10 in right lung (upper lobe 3, middle lobe 2, lower lobe 5) and 8 in left lung (upper lobe 4, lower lobe 4)

Name each segment starting at 1 going clockwise

L apico-posterior, L anterior, L superior lingular, L inferior lingular, L anterior basal, L lateral basal, L posterior, R medial basal, R posterior basal, R lateral basal, R anterior basal, R medial, R lateral, R posterior, R anterior, R apical

Name each segment starting at 1, going clockwise

R apical, R posterior, R anterior, R superior, R lateral, R lateral basal, R posterior basal, L posterior basal, L lateral basal, L superior, L singular lingular, L anterior, L apico-posterior

lambert canals connect __________ nearby alveoli

terminal bronchioles

Pores of Kohn

connect adjacent alveoli to one another

alveolar type 1 and 2 cells are _____ in number, but type ____ cells make up 95% of surface area of alveoli

equal, 1

what can type 2 alveloar cells do that type 1 cannot

proliferate and restore both types via cell division, and secrete surfactant

tidal volume

the amount of air that moves in and out of the lungs with each normal, resting breath, usually 500mL

Functional residual capacity (FRC)

the volume of air left in the lungs after a normal, passive exhalation, aka buffer volume, 2.6-3.4 L (mixes with air coming in helps dilute)

Inspiratory reserve volume (IRV)

the maximum extra volume of air that can be inhaled forcefully after a normal, quiet tidal volume inhalation, 1.9-2.5L

Expiratory Reserve Volume (ERV)

the extra amount of air you can forcibly exhale after finishing a normal, quiet tidal breath, 1.1-1.5L

residual volume (RV)

the amount of air that stays in your lungs after you breathe out as hard as you can, 1.5-1.9L

Total Lung Capacity (TLC)

maximum volume of air the lungs can hold after a maximal inhalation, IRV, TV, ERV, RV) 4.9-6.4L

Inspiratory capacity (IC)

total amount of air you can breathe in after a normal breath out (TV + IRV) 2.3-3.0L

Functional Residual Capacity (FRC)

the volume of air remaining in the lungs after a normal, passive exhalation, (ERV + RV) 2.6-3.4L

Vital Capacity (VC)

the maximum amount of air a person can exhale from their lungs after taking a maximum inhalation (ERV + TV + IRV) 3.4-4.5L

capacity

sum of 2 or more volumes

ventilation

exchanges air between lungs and atmosphere so that O2 can be absorbed and CO2 eliminated, mostly changes PCO2

oxygenation

the addition of oxygen to the body, mostly changes PaO2

minute ventilation equation

= respiratory rate (rr) x tidal volume (Vt)

hypoventilation

CO2 increases

hyperventilation

CO2 decreases

as you breath in, the chest _______, the diaphragm _________ and the pressure in the lungs ________

expands, drops and contracts, decreased

when you breath out, the chest _______, the diaphragm _________ and the pressure in the lungs ________

deflates, rises passively, increases

compliance equation

= change in volume/ change in pressure

if change in pressure is small and change in volume is large, compliance is……

high, lungs inflate easily

if change in pressure is large and change in volume is small, compliance is….

low, lungs are stiff

normal infant airway diameter is _____, adult is _______ Edema for each is:

4mm, 10 mm (2mm, 8mm)

resistance equation

1/radius^4, so if diameter is ½ the resistance is 16x!

airway compression

occurs during forced exhalation in healthy individuals bc muscles, but MUCH more in people with obstructive diseases like emphysema as airways collapse more

ventilation and perfusion are both greater in the _______ than in the ______

apices, bases

Zone 2

in upper lung of healthy, ventilation in excess of perfusion

Zone 4

in lower lung of healthy, perfusion is excess of ventilation

Zone 1

dead space, not found in healthy lung

at the top of lung V/Q is ________ and excess _______, at bottom of lung V/Q is _____ and excess _______, and around middle is _____ with 1.0

3.0 ie there is ventilation in excess of perfusion

0.7 ie, there is perfusion in excess of ventilation

first rib is 1.0

at apex of lung, is ventilation or perfusion in excess?

ventilation

at base of lung, is ventilation or perfusion in excess?

perfusion (bc blood more dense than air)

physiologic dead space

ventilation with no perfusion bc no blood flow (ex. pulm embolism)

shunt

Perfusion with no ventilation bc airflow is blocked (ex. alveoli fluid filled from pneumonia)

gas exchange in lungs/tissues is mostly ______, bc of ________

passive via diffusion, large surface area small distance and gradients present

alveolar gas values

O2 100-105, CO2 40

venous blood in pulmonary capillaries blood gas

PO2 40, PCO2 46

arterial blood in pulmonary veins blood gas

PO2 100-105, PCO2 40

cells and tissues blood gas

varies, usually PO2 <40 (mitochondrial <5) and PCO2 >46

respiratory center includes the

dorsal respiratory center (DRG), ventral respiratory center (VRG), apneustic center, and pneumotaxic center

dorsal respiratory center

active during inspiration, makes connections with skeletal muscle motor neurons

ventral respiratory center

active during forced respiration

apneustic center

signals to the DRG to delay the switch off signal provided by pneuomtaxi ccenter

pneumotaxic center

Inhibitory input to DRG, during expiration, PTC is active shutting off DRG neurons

peripheral chemoreceptors

aortic and carotid bodies located in aortic arch and at bifurcation of carotid artery, moniter arterial PO2, pH, maybe PCO2, homeostatic negative feedback

irritant receptors

-increase frequency of breathing

  -decrease tidal volume

  -limit inspiration of irritant molecules

juxtacapillary receptors (J receptors)

  -located in alveolar walls

• sensitive to congestion, pneumonia, interstitial fluid

• produce increased respiratory rate with decreased tidal volume

• bradycardia, hypotension, dyspnea

stretch receptors

in airways

-responsible for the Hering-Breuer reflex

  -stretch during large inspiration inhibits DRG resulting in expiration and loss of stimulus for inspiration

  -shuts off inspiration during generation of high minute ventilation

obstructive disease

a flow limitation due to increased resistance to expiratory flow from reduced diameter of airways

characteristics: obstructed/narrowed airways, loss of normal structure/retention of secretions

presentation: SOB, dyspnea with exertion, prolonged expiration, cough/secretions, postural deficits, wheezing

examples of obstructive disease

COPD (chronic bronchitis, emphysema, asthma), bronchiectasis, cystic fibrosis

chronic bronchitits

inflammation of bronchi causing irritation and productive cough on most days for 3 months for 2 consecutive years, may have hyperinflation, primary in airways

emphysema

irreversible enlargement of airspaces distal to terminal bronchioles with wall destruction. primary in walls

common x-ray findings

air is dark from hyperinflation, horizontal ribs less movement as limited joint mobility, flattened diaphragm disadvantage and blunted costophrenic angles, barrel chest

COPD treatment

stop smoking, medications, oxygen therapy (if PaO2 <55, SaO2 <89%), surgery, pulm rehab

asthma

obstructive, inappropriate smooth muscle contraction, acute inflammatory, immune system hypersensitivity

Bronchiectasis

obstructive, irreversible dilation of one or more bronchi with chronic inflammation and infection, usually from infections or inhalation of toxins, wall injury

cystic fibrosis

obstructive, males infertile, chromosome 7 CFTR protein

Restrictive dysfunction

a volume limitation, abnormal reduction in ventilation due to restriction of expansion of chest wall or lungs, NOT a disease itself

common causes of restrictive dysfunction

birth, pneumonia, connective tissue disorders, trauma, theraputic, occupational disorders

pathophysiological changes of restrictive

decreased lung volume and capacities, increased rr, dyspnea, cough, decreased vent-perf match, compliance sighing

signs of restrictive

tachypnea, hypoxemia, decreased breath sounds, crackles, decreased diffusing capacity, cor pulmonale, dyspnea, dry cough, anorexia

cor pulmonale

an alteration in the structure (enlargement or hypertrophy) and function of the right ventricle of the heart caused by a primary disorder of the respiratory system or lungs

restrictive treatments

primary treat of cause, supplemental O2, antibiotics, vent, secretion clearance, nutrition

idiopathic pulmonary fibrosis

insidious progressive restrictive disorder, honeycombing on scans, supportive treatment like lung transplant

obstructive disease affects the ______ while restrictive affects the ______

airways, lung parenchyma and thoracic pump

obstructive is difficult with ______ and restrictive with ______

expiration, inspiration

pathophysiology of obstructive is _______ while restrictive is ______

increased airway resistance, decreased lung/thoracic compliance

useful measurement for obstructive is ____ while restrictive is

flow rates, volumes/capacities

pneumonia

ususally RLD, 4 types, Inflammation of parenchymal structures of the lung such as alveoli, bronchioles

tuberculosis

leading cause of death from single infections agent, strict aerobe so likes lungs,

lung cancer

non-small cell is more common (squamous, adenocarcinoma, large cell) and small cell ,

adeno, squamous cell tend to have better prognosis because of tendency to remain localized longer.

pleural effusion

restrictive, collected fluid in pleural space, exudate (protein), hemothorax (blood),

pneumothorax

collapsed lung, open means are can move in and out of pleural space frely, closed means air enters during inspiration but cannot exit…this is medical emergency

acute respiratory distress syndrome

3 phases (exudate, cellular proliferation, fibroproliferation)

broncho dilators

beta agonists, xanthine derivatives, theophylline, anticholinergics, glucocorticoids, cromones, leukotriene inhibitors