Patho Exam #4

Upper Respiratory Tract

• nose

• pharynx

  • nasopharynx

  • oropharynx

  • laryngopharynx

• throat

• associated structures

Lower Respiratory Tract

• larynx

• trachea

• bronchi

• lungs

Airway Branching

Conducting Zone (where air will travel through but there is no exchange)

1. main bronchi

2. lobar bronchi (right has 3 and left has 2)

3. segmental bronchi

4. bronchioles

5. terminal bronchioles

Respiratory Zone (where gas exchange occurs)

6. respiratory bronchioles

7. alveolar ducts

8. alveolar saccules

9. alveoli

role of sufactant

• lung expansion to overcome resistance

• reduces the surface tension of alveoli

• keeps alveolar walls from collapsing

• keeps capillary fluids from invading lungs

Pulmonary functions

• gas exchange

  • happens within the capillaries

• nutrients to lung tissues

• reservoir for left ventricle

• filtering system

1. ventilation (air flow)

2. external respiration

3. internal respiration

3 processes for respiration

• the respiratory cycle is one sequence of inspiration and expiration

Perfusion

blood flow

Pulmonary ventilation

1. inhalation

   1. diaphragm contracts so it moves down

   2. thoracic cavity volume increases and the pressure decreases meaning that air moves in

2. Gas Exchange

3. Exhalation

   1. diaphragm relaxes so it moves up

   2. thoracic cavity volume decreases and the pressure increases so the air moves out

External Respiration

from the alveoli capillary to the pulmonary capillary, so the CO2 will move to the alveolar capillary to be exhaled

Internal Respiration

from systemic capillaries into the tissue cells, so CO2 will move into the systemic capillary to be put into venous blood (to the heart)

Muscles of Breathing

• diaphragm

• external intercostals

• sternocleidomastoid muscles (in)

• scalene muscles (in)

• abdominal muscles (out)

• internal intercostal muscles (out)

Gas Exchange

1. Pulmonary Respiration

   1. Atmospheric Pressure

      1. CO2 moves out of the lungs

         1. pressure in the atmosphere was lower

   2. Pulmonary Alveolar Pressure

      1. O2 moves into the lungs

         1. pressure in the lungs was lower

2. Oxygenated Systemic Circulation

   1. Oxygenated Blood

      1. CO2 moves from the tissues to the blood vessels

         1. pressure in the blood vessels was lower

   2. Systemic Tissue Cells

      1. O2 moves from the oxygenated blood vessels to the tissues

         1. pressure in the tissues was lower

3. Deoxygenated Systemic Circulation

   1. Systemic Tissue Cells

   2. Deoxygenated Blood

      1. pressure is the same for both of the types so this will drive it to the heart

Tidal Volume (TV)

Single, quiet, resting-breathing

500 mL of air, that one is exchanging

Ventilation-Perfusion (V/Q) Ratio

normal is 0.8

when the breathing is low, there will be more fluid

Haldane effect

This causes the oxygen to not bond to the heme and it makes the partial pressure of oxygen low causing the hemoglobin to easily bond to CO2

Vasoconstriction

Constriction of the blood vessels

Vasodilation

dilation of the blood vessels

Bronchoconstriction

constriction of the bronchioles

Bronchodilation

dilation of the bronchioles

Congenital Heart Defects (children)

There are two different types:

1. Acyanotic

   1. Left to Right Shunt

      1. Ventricular Septal Defect

      2. Patent Ductus Defect

      3. Atrial Septal Defect

   2. Outflow Obstruction

      1. Pulmonary Stenosis

      2. Aortic Stenosis

      3. Coarctation of aorta

2. Cyanotic (Right to Left Shunt)

   1. Tetralogy of fallot

   2. Tricuspid atresia

   3. Transportation of great vessels

   4. Truncus arteriosus

   5. TAPVR

   6. Ebstein’s anomaly

Patent Ductus Arteriosus (children)

What is it?

• Failure of the ductus arteriosus to close

Where is it?

• located as a connection between the aorta and pulmonary trunk

What happens?

• Blood from the aorta backflows into the pulmonary trunk

• less blood goes into systemic circulation

• oxygenated blood goes into the lungs

Manifestations?

• Asymptomatic or signs of pulmonary distress

• Characteristic machinery-like murmur

Complications?

• Risk for bacterial endocarditis

• Pulmonary hypertension later in life

Atrial Septa Defect

What is it?

• Abnormal opening between the atria

What happens?

• blood flows from left to right atria

Manifestations?

• Asymptomatic at early age

• pulmonary symptoms on exertion at later age

Ventricular septal defect

What is it?

• opening between the ventricles

What happens?

• blood flows from left to right ventricle

• Impacts the pulmonary flow

Manifestations?

• Can be asymptomatic

• Increased pulmonary blood flow from left to right shunt

• pulmonary hypertension

Relationship between Atrioventricular canal defect (AVCD) and Down Syndrome

What is it?

• incomplete fusion of the endocardial cushion

Where is it?

• between the atria and ventricle valcles and speta

Manifestations?

• left to right shunt

• pulmonary overcirculation

• Irreversible pulmonary hypertension

Down Syndrome Connection?

• It is connected to chromosome 21, and since there are more in those with down syndrome it is more prevalent

Coarctation of aorta

What is it?

• localized narrowing of the lumen of the aorta that impedes blood flow

What happens?

• There is a decreased output in the rest of the body

Manifestations?

• decreased cardiac output

• acidosis

• hypotension

• hypertension (older age)

• pulse discrepancy between right and left arms

Aortic Stenosis

What is it?

• narrowing of the left ventricular outlet

What happens?

• increased workload on left ventricle and left ventricular hypertrophy

Manifestations?

• Infant

  • faint pulse

  • hypotension

  • tachycardia

  • poor feeding

• Older

  • exercise intolerance

  • risk of bacterial endocarditis

Pulmonary Stenosis

What is it?

• Narrowing of the pulmonary valve causing resistance to flow from right ventricle to pulmonary artery

What happens?

• right ventricular hypertrophy

• pulmonary atresia

  • the valve that controls blood flow from heart to lungs does not develop

Manifestations?

• cyanosis

• decreased cardiac output

• harsh systolic murmur and ejection

Tetralogy of Fallots

What is it?

• A syndrome represented by 4 defects

  • large ventricular septal defect

  • overriding aorta that straddles the VSD

  • Pulmonary valve stenosis

  • Right ventricle hypertrophy

Manifestations?

• acute

  • cyanosis at birth

  • episodes of cyanosis

  • hypoxia

• gradual cyanosis

• difficulty feeding

• poor growth

Tricuspid atresia

What is it?

• failure of the tricuspid valve to develop

What happens?

• lack of communication between the right atrium and ventricle so the blood goes straight to the pulmonary veins

Manifestations?

• Newborn

  • cyanosis

  • tachycardia

  • dyspnea

  • poor feeding

• older children

  • chronic hypoxemia

  • clubbing

Associated defects?

• pulmonary stenosis

• transposition of great arteries

Truncus Arteriosus

What is it?

• Failure of the embryonic artery and the truncus arteriosus to divide into the pulmonary artery and the aorta

What happens?

• results in a single vessel

• blood will mix

Manifestations?

• Asymptomatic

• moderate heart failure

• variable cyanosis

• poor growth

• activity intolerance

Complications?

• brain abscess

• bacterial endocarditis

Hypoplastic left heart syndrome

What is it?

• underdevelopment of the left side of the heart

Where is it?

• underdevelopment of left ventricle, aorta and aortic arch

What happens?

• obstruction to blood flow from the left ventricular outflow tract

• Blood will mix

Manifestations?

• cyanosis

• tachypnea

• decreased cardiac output

Complications?

• fatal if untreated

-pnea

breathing

-capnia

CO2 levels

Dyspnea

What is it?

• A subjective sensation of uncomfortable breathing

• Usually characterized as “shortness of breath”

Causes?

• Airway obstruction (greater force is needed in order to provide adequate ventilation)

Manifestations?

• mild discomfort after exertion to extreme difficulty

• decreased compliance of lung tissue

• uses accessory muscles for breathing

• retraction of intercostal spaces

Orthopnea

What is it?

• the sensation of breathlessness in the recumbent position

• Dyspnea when a person is lying down

• Orthostatic hypotension

Hyperpnea

What is it?

• slightly increased ventilatory rate

• very large tidal volume

• no expiratory pause

Cheyne-Stokes respiration

What is it?

• alternating periods of deep and shallow breaths

Manifestations?

• apnea lasts 15-60 seconds which is followed by ventilations that increase in volume until a peak is reached, which will lead to apnea again

Hypercapnia

What is it?

• An increase in CO2 concentration in the arterial blood

Cause?

• V/Q abnormalities

• Shunting

• Alveolar Dead Space

Hypocapnia

What is it?

• reduced O2 in the arterial blood

Cause?

• V/Q abnormalities

• Shunting

• Alveolar Dead Space

Hyperventilation

What is it?

• a increased drive to breathe (neurological)

• overstimulation to respond to ventilatory stimulation (pulmonary)

Causes?

• Anxiety

• Head injury

• Severe hypoxemia

What happens?

• Hypocapnia

  • There is a decrease CO2 in the arterial blood

  • There is too much O2 which passes the metabolic demands

Leads to?

• Respiratory Alkalosis

  • pH above 7

Hypoventilation

What is it?

• a decreased drive to breathe (neurological)

• inadequate ability to respond to ventilatory stimulation

What happens?

• Hypercapnia

  • There is increased CO2 in the arterial blood

Leads to?

• Respiratory Acidosis

  • pH below 7

Cyanosis

What is it?

• Bluish discoloration of the skin and mucous membranes

Causes?

• when 5 g of desaturated hemoglobin

Types?

1. Peripheral

   1. Caused by poor circulation that is seen in the nail beds

2. Central

   1. caused by decreased arterial oxygenation (low PO2) that is seen in buccal mucous and lips

Clubbing

What is it?

• Bulbous enlargement of the end of a digit (finger or toes)

Relation?

• associated with diseases that cause decreased oxygenation

  • Lung cancer

  • Cystic fibrosis

  • Lung abscess

  • Congenital Heart Disease

Acute Respiratory Failure

What is it?

• There is not enough supply of oxygen throughout the body and in the lungs

Types of Failure?

1. Hypoxemia

   1. low O2 supply

2. Hypercapnia

   1. high CO2 supply

Additional information:

• Is there a problem?

• What is the problem?

  • acidosis - less than pH 7

  • alkalosis - above pH 7

• What is to blame?

  • Acidosis

    • High CO2 (respiratory)

    • Low HCO3- (metabolic)

  • Alkalosis

    • Low CO2 (respiratory)

    • High HCO3- (metabolic)

• What helps?

  • Acidosis

    • respiratory - excretion H+ from metabolic will raise the pH

    • metabolic - increased CO2 intake from respiratory will raise the pH

  • Alkalosis

    • respiratory - retention of H+ from metabolic will drop the pH

    • metabolic - retention of CO2 from respiratory will drop the pH

Ventilation-Perfusion abnormality

Where is it?

• Alveolar Dead Space

What is it?

• the alveoli receives no blood supply because of pulmonary disorders

Results in?

• hypoxemia

  • has a lot of deoxygenated blood

Chest wall disease

What is it?

• A compromised chest wall

Manifestations?

• Ventilation might be compromised because of the decrease in tidal volume

• impaired respiratory muscles

• deformation, immobilization and/or obesity

An example of this condition?

• Flail Chest

  • the instability of a portion of the chest wall from the chest wall because there are ribs that are broken allowing for the lung to expand farther than intended

pneumothorax

Types?

• Open

• Tension

  • Accumulation of air in the pleural space under pressure so air fills the cavity and the lung shrinks

• Spontaneous

• Secondary

pleural effusion

What is it?

• There is a fluid in the pleural space

Types?

• Transudative - watery

• Exudative - WBC and plasma proteins

• Hemothorax - blood

• Empyema - pus

• Chylothorax - lymph leakage

Atelectasis

What is it?

• Collapse of the lung tissue

Types?

• Compression

  • external pressure on the lung

• Obstructive

  • gradual absorption of air from obstructed alveoli

• Surfactant Impairment

  • decreased or inactive production of surfactant

Bronchiectasis

What is it?

• Persistent and abnormal dilation of the bronchi

  • they are unable to work productively

Manifestations?

• Chronic productive cough

  • mucus comes out

Pulmonary Fibrosis

What is it?

• excessive amount of fibrous or connective tissues in lung

What happens?

• the alveoli have reduced space within the lungs, so less air is able circulate within the body

Pneumoconiosis

aka black lung disease

What is it?

• occupational lung diseases

Manifestations?

• scarring of the lung tissue

Causes?

• silica that comes from mining

• asbestos that can come from working in factories

• coal which can result in black lung

Pulmonary edema

What is it?

• when excess fluid accumulates within the blood

Causes?

1. valve dysfunction (heart)

   1. leads to increased left atrial pressure

   2. Increased capillary pressure

   3. movement of fluid into the interstitial space

2. ARDS

   1. injury to capillary endothelium

   2. surfactant production is going to be disrupted

   3. fluid into the interstitial space and alveoli

3. fibrosis

   1. blockage of the lymph vessels

   2. inability to remove excess fluid

   3. accumulation of fluid in interstitial space and alveoli

ARDS

aka Acute Respiratory Distress Syndrome

What is it?

• acute lung inflammation and diffuses alveolocapillary injury

Causes?

• heart edmena might not even be seen

• acute lung inflammation

• alveolocapillary injury

• There is a low partial pressure of oxygen

Manifestations?

• dyspnea

• hypoxemia despite enough oxygen

• respiratory alkalosis (hyperventilation)

• respiratory acidosis (hypercapnia)

Children?

Asthma

What is it?

• A chronic inflammation of the airways

Causes?

• Allergen or irritant exposure

Manifestations?

• tachypnea

  • trying to compensate for the lack of air, so the lungs will try harder than normal

• expiratory wheezing

• dyspnea

In Children?

Chronic Bronchitis (COPD)

aka Blue Bloater

What is it?

• hypersecretion of mucus and chronic productive cough that last for at least three months of the year and for at least 2 consecutive years

Obstructive or Restrictive?

• obstructive

Pathophysiology?

• Inspired irritants increases mucus production and the size and number of mucous glands

Manifestation?

• Chronic productive cough, purulent sputum, hemoptysis, mild dyspnea, cyanosis, hypoxemia, Peripheral Edema, Crackles, Wheezes, Obese, Prolonged Expiration

Emphysema (COPD)

aka Pink Puffer

What is it?

• abnormal permanent enlargement of the gas-exchange airways accompanied by destruction of alveolar walls without obvious fibrosis

Obstructive or Restrictive?

• obstructive

Pathophysiology?

• destruction of alveolar septa

• bigger alveoli

• loss of supporting structures

• difficulty exhaling

• air trapped in alveoli

• increased diameter of chest

• decreased pulmonary muscle effectivement

• hypoventilation

• chronic hypoxia

Manifestation?

• Dyspnea, minimal cough, increased minute ventilation, pink skin, pursed-lip breathing, accessory muscle use, cachexia, hyperinflation, decreased breath sounds, tachypnea

Types?

• centriacinar

• panacinar

Pneumonia

What is it?

• Lower respiratory tract infection

Causes?

• Bacterial

• Viral

• Atypical

• Fungal

Response of Streptococcus Pneumoniae?

• Inflammatory response

Types?

• community acquired (CAP)

  • Streptococcus pneumoniae

  • Influenza

• Healthcare acquired (HCAP)

• Ventilator-associated (VAP)

Manifestations?

• preceded by an upper respiratory infection

• cough

• dyspnea

• fever

• chills

• malaise

• pleuritic chest pain

Children?

Tuberculosis

What is it?

• An infection caused by Mycobacterium tuberculosis

Transmission?

• Airborne

Manifestations?

• fever

• cough

• chills

• sputum production

• pleural pain

• severe cough

• copious amount of often foul-smelling sputum

• hemoptysis

Pulmonary Embolism

What is it?

• occlusion of a portion of the pulmonary vascular ben by an embolus

Where can it originate?

• from DVT which can travel to lungs

Manifestations?

• sudden onset of pleuritic chest pain

• dyspnea

• tachypnea

• tachycardia

• unexplained anxiety

• decreased surfactant

• pulmonary edema

• atelectasis

Lung Cancer

aka bronchogenic carcinoma

Types?

• Non-small cell

  • squamous cell carcinoma

    • nonproductive cough or hemoptysis

  • adenocarcinoma

    • tumor arising from glands

    • asymptomatic or pleuritic chest pain and SOB

    • Surgical resection

  • large cell carcinoma

    • undifferentiated

• Small cell

  • neuroendocrine tissue

• Other?

  • mesotheliomas

    • associated with asbestos

    • shows up with dyspnea and chest pain

Causes?

• Cigarette smoking

Pathophysiology?

1. starts in the breathing tubes

2. proceeds to grow very quickly

3. creates large tumors and spreading

Viral Croup (children)

aka acute laryngotracheobronchitis

recurrent (spasmodic) croup (children)

bacterial tracheitis (children)

aka pseudomembranous croup

Acute epiglottis (children)

Tonsillitis (children)

Bronchiolitis (children)

SDD (children)

RDS (children)

RSV (children)

Asthma

Cystic Fibrosis (children)

SIDS (babies)

Restrictive

limiting the freedom of someone or preventing something from growing

Obstructive

The airway is being blocked

Structures in the Kidney

• Major and Minor Calyx

• Renal Pelvis

• Renal Papilla

• Renal Column

• Renal Pyramid

• Renal Medulla

• Renal Cortex

• Renal Capsule

Nephrons

Functional Unit of the kidney

Membrane?

1. Inner capillary endothelium

2. Basement membrane

3. outer capillary epithelium

Why is it important? GFR!

Structure?

• Renal Capsule (glomerulus - network of bv)

• Proximal Convoluted Tubule

• Descending Limb

• Ascending Limb

• Distal Convoluted Tubule

• Collecting Duct

Types?

1. Juxtamedullary

   1. Type of Urine - Concentrated

2. Cortical

   1. Type of Urine - Dilute

Structures of Urinary System

2 Kidneys

2 Ureters

1 Bladder

• Transitional Epithelium that helps with the expansion of the bladder

1 Urethra

Sequence of blood vessel distribution

1. Renal Artery

2. Segmentay

3. Interlobar

4. Arcuate

5. Cortical Radiate

6. Afferent

7. Glomerular Capillary

8. Efferent

9. Peritubular

10. Peritubular

11. Cortical Radiate

12. Arcuate

13. Interlobar

14. Renal vein

Solvent (in bodies)

Water

Solutes

The ions, chemicals, electrolytes

Juxtaglomerular apparatus

Made up of the Juxtaglomerular cells (renin release) and Macula Densa (sodium sensing)

Nephron Functions

1. Filtration (Glomerulus)

   1. net filtration pressure

2. Reabsorption (Tubules)

   1. PCT

      1. Na

   2. Loop of Henle

      1. Sodium and Water

   3. DCT

      1. Water (solutes follow)

3. Secretion (Tubules)

   1. PCT

      1. H+

   2. Loop of Henle

      1. Urea

   3. DCT

      1. Waste like urea, drugs

4. Excretion (CD)

Acid-Base Balance

• Works with the respiratory system

Filtration Rate

180 L/day

• we only have 5 L of blood, but this is a cycle that keeps repeating

120 mL/min

Countercurrent Exchange

Juxtamedullary nephron

300 —> 1200

Urine Composition

pH ranges from 4.6 to 8.0

Specific Gravity from 1.001 to 1.035

Urinary Hormones

• RAA system

  • Retains sodium via vasoconstriction

  • increased bv = decreased GFR

• Aldosterone

  • reabsorbs solutes and water

  • increased bv = decreased GFR

• ADH

  • water will be reabsorbed

  • increased bv = decreased GFR

• Atrial Natriuretic Peptides

  • Sodium excretion so water follows

  • decreased bv = increased GFR

• Erythropoietin

  • Stimulate RBC production — kidneys stimulate becuase of hypoxia

What should not be leaving in urine?

1. RBC’s

2. medium to large proteins

Urinary Tract Obstruction

Caused by?

• anatomical change

• functional defect

Severity is based on…

• location

• completeness

• involvement of ureters and/or kidneys

• duration

• cause

Types?

1. Transitional cell carcinoma of

   1. renal pelvis

   2. bladder

2. polycystic kidney

3. hydronephrosis

4. dysplasia-agenesis of ureter

5. blood clot

6. ureteral stone

7. Extrinsic Compression

   1. Carcinoma of Cervix

   2. Endometriosis

   3. Pregnancy

8. Posterior vesicoureteral valve reflux

9. Prostate hypertrophy

10. Stenosis

    1. urethral

    2. ureter

11. fibrous band

12. ureteropelvic stricture

13. ureteropelvic valve

Hydroureter

This is a upper urinary tract obstruction!!!

Dilation of ureter

Hydronephrosis

This is a upper urinary tract obstruction!!!

Enlargement of the renal pelvis and calyces

Ureterohydronephrosis

This is a upper urinary tract obstruction!!!

dilation of both the ureter and the pelvico-caliceal system

Compensatory Hypertrophy and Hyperfuntion

This is a upper urinary tract obstruction!!!

bodies response to unilateral obstruction

growth factor causes unobstructed kidney to increase in size and function

Kidney Stones

This is a upper urinary tract obstruction!!!

Classified by the mineral that make up the stone via crystallization or agglomeration

Called?

• Nephrolithiasis

• renal calculi

• urinary stones

Manifestations

• Renal Colic (pain in kidney dilation and spasms)

Risk Factors?

• Gender, age, and face

• geographic location

• seasonal factor

• fluid intake and diet

• occupation

• genetic predisposition

Overactive Bladder Syndrome (OBS)

This is a lower urinary tract obstruction!!!

Manifestations?

• Frequency

• Urgency

• nocturia

Detrusor Hyperreflexia

• involuntary and uninhibited detrusor muscle contractions

• It can backflow into the ureter

Renal Cell Carcinoma

Pathogenesis?

• Comes from tubular epithelium

• May have familial pattern (more common in older men)

• widely metastatic (can go to blood vessels

• golden yellow with areas of necrosis

Manifestations?

• staging system I - IV

• asymptomatic until it ends

• hematuria

• flank pain

• palpable mass

Risk Factors?

• Smoking

• Obesity

• Hypertension

Urinary Tract Infections (UTIs)

Inflammation of the urinary epithelium caused by bacteria

Uncomplicated?

• mild, uncomplicated, individuals with normal urinary tract

Complicated?

• abnormality in urine system or health problem that compromises immunity

Children?

• Common in 7-11 year old girls

  • usually caused by E. coli

• Vesicoureteral reflux (VUR)

  • backflow of urine from the bladder into the ureters or kidney or both

  • can lead to frequent pyelonephritis

Pyelonephritis

Acute?

• infection of the ureter and renal pelvis

• an ascending infection and WBC casts

Chronic?

• recurring episodes of acute pyelonephritis that can lead to scarring

• associated with chronic UTI’s, vesicoureteral reflux or kidney stones

Cystitis

Inflammation of the bladder (type of UTI)

Causes?

• Escherichia coli

• Staphylococcus saprophyticus

Manifestations?

• Frequency and Urgency

• Dysuria

• suprapubic and low back pain

Glomerulonephritis

inflammation of the glomerulus

Manifestations?

• Edema

• Hematuria

• Proteinuria (exceeds 3-5 g/day)

• Oliguria (frequent urination)

• Hypertension

  • high bp = high volume = high filtration rate = more urination

Types?

1. Membranous nephropathy

2. Goodpasture syndrome

3. Chronic glomerulonephritis

4. Diabetic nephropathy

Diabetic Nephropathy

Poor control in…

• Diabetes

• Hypertension

Manifestations?

• Microhematuria

• proteinuria

Atypical vs. Typical Differences?

• tubular atrophy in atypical