General Reminders - Pulmonary

Absent breath sounds = if breath sounds are absent on one side, examiner is to
consider
(p. 180):
1. pneumothorax, hydrothorax, or hemothorax
2. obstruction of a mainstream bronchus
3. surgical or congenital absence of the lung

Acid-Base status = to monitor arterial blood acid-base status, look at (p. 191):
1. pH
2. PCO2
3. serum bicarbonate (HCO3-)
- Normal Values for Arterial Blood Gases (Table 16-1)
o PO2 = 104 – 0.27 x age
o PCO2: 36-44
o pH: 7.35-7.45
o Alveolar-arterial O2 difference = 2.5 + 0.21 x age
o (HCO3: 25)

Acute Respiratory
Failure = two major functions of respiration are to add oxygen to and
remove carbon dioxide from the blood, in this case, either or both
of these functions decline (p. 224)

Adventitious sounds = extra breath sounds heard during auscultation not heard in
normal lungs (p. 180)

Apneustic breathing = consists of sustained inspiratory pauses resulting from damage

to the midpons, most commonly caused by a basilar artery infarct
(p. 218)

Arterial Blood Gas

Measurement (ABG) = evaluation of gas exchange (p. 191)
1. Samples are analyzed for:
a. pH
b. the partial pressure of arterial oxygen (PaO2)
i. the % Hb saturation is routinely calculated
from the PaO2 & is an accurate estimate of
Hb saturation except in the case of carbon
monoxide poisoning
ii. PaO2 reflects the adequacy of gas
exchange
c. the partial pressure of arterial carbon dioxide
(PaCO2)
i. PaCO2 reflects ventilation

Asthma = a chronic inflammatory disorder of the airways (p. 194)

1. it is characterized by episodic airway narrowing,
increased airway reactivity to a variety of stimuli &
pharmacologic or spontaneous reversibility
2. it is an inflammatory response which involves Mast
cells, T lymphocytes, & eosinophils
Patho – Pulm Reminders Page 1 of 22
 3. the trigger or stimulus that provokes the inflammatory
response may be exposure to extrinsic allergens or
intrinsic host factors with no identifiable external cause
4. some non-allergic factors which can ppt or exacerbate
asthma:
a. postnasal drip
b. gastroesophageal reflux disease
c. exposure to cold
d. exercise
e. exposure to gases or fumes
f. emotional stress
g. hormones
h. respiratory infections
5. Classic Triad of Symptoms:
a. Persistent wheeze
b. Chronic episodic dyspnea
c. Chronic cough
6. acute severe asthma: (p. 195)
a. aka = status asthmaticus
i. an attack of severe bronchospasm that is
unresponsive to routine therapy
b. hyperacute asthma:
i. sudden asthmatic attack that can be fatal
before medical assistance can even begin

Ataxic breathing = a haphazard random pattern of deep and shallow breaths, is

caused by disruption of the respiratory rhythm generator in the
medulla (p. 218)
1. aka = Biot’s breathing

Atelectasis = a collapse of lung tissue affecting part or all of one lung. This
condition prevents normal oxygen absoption to healthy tissues.

Berylliosis = lung inflammation caused by inhaling dust or fumes that

contain
the metallic element beryllium. Found in rocks, coal, soil, and
volcanic dust, beryllium is used in the aerospace industry and in
many types of manufacturing (answer.com)

Bordetella pertussis = whooping cough (p. 177)

Bronchial breath sounds = are heard over the central airways and are louder and coarser
than vesicular breath sounds, which are heard at the periphery
and the base of the lungs (p 180)
1. Brochovesicular sounds are a combo of the 2 & are
heard over medium-sized airways
2. Bonchial sounds have a longer inhaled component
3. Vesicular sound a have a much longer expiratory
component & are much softer

Bronchiectasis = an abnormal & persistent dilation of the bronchi, results from

destructive changes in the elastic & muscular layers of bronchial
walls that may be diffue or localized (p. 196)

Patho – Pulm Reminders Page 2 of 22

 1. Common causes, in developed countries:
a. Allergic bronchopulmonary aspergillosis
i. Allergic bronchopulmonary aspergillosis is
an allergic lung reaction to a type of
fungus (most commonly Aspergillus
fumigatus) that occurs in some people with
asthma or cystic fibrosis, causing cough
and wheezing and sometimes fever. If
untreated, chronic lung damage may
develop. The fungus Aspergillus fumigatus
flourishes in soil, decaying vegetation,
foods, dusts, and water.
(http://www.merck.com/mmhe/sec04/ch05
1/ch051d.html)
b. immunoglobulin deficiencies predisposing to
chronic respiratory infections
c. abnormal airway clearance mechanisms
d. cystic fibrosis (CF)
i. MOST common
2. Diagnosis:
a. History of chronic cough, which may be dry or
productive of large volumes of sputum
i. Can have dry develop into cough w/
sputum
b. Blood-streaked sputum common
i. Massive hemoptysis occurs rarely
c. Auscultation  crackles over the affected lung
segment
d. Occasionally digital clubbing seen
3. Classical Findings:
a. Parallel lines in peripheral lung fields (“tram
tracks”) that represent thickened bronchial walls
that do not taper from proximal to distal sites

Bronchiolitis obliterans w/
Organizing pneumonia = a rare interstitial lung disease (p. 208)
1. thought to be a response to pulmonary injury resulting
from infection, inhaled toxin, or autoimmune disease
2. lumen of distal bronchiles found to have inflammatory
cells & fibrous tissue accompanied by an adjacent
alveolitis
3. disease is patchy, with abnormal and normal lung tissue
often juxtaposed
4. responds well to oral corticosteroids & usually does not
cause permanent lung fibrosis

Bronchorrhea = Excessive discharge of mucus from the bronchial mucous

membranes

Bronchospasm = airway smooth muscle contraction (p. 183)

Byssinosis = a chronic, asthma-like narrowing of the airways. Also

Patho – Pulm Reminders Page 3 of 22

 called brown lung disease, byssinosis results from inhaling
particles of cotton, flax, hemp, or jute. (answer.com)

Chest wall disease = any disease that restricts chest wall movement or interferes
with
neuromuscular function may produce hypoventilation. In these
diseases, the total lung capacity & vital capacity are decreased,
but the residual volume is usually normal or even increased (p.
211)
1. Vertebral disorders:
a. Scolosis
b. Kyphosis
2. Obesity
3. Diaphragmatic paralysis
a. Unilateral
b. Bilateral

Cheyne-Stokes respiration = the regular cycleing of crescendo-decrescendo tidal

volumes
separated by apneic or hyponeic pauses (p. 218)

Chronic Bronchitis = persistent cough resulting in sputum production for more than
3
months in each of the last 3 years (p. 177)
1. Cigarette smoking is the major cause, although exposure
to other pollutants may play a role
2. Pathologic findings are: goblet cell hyperplasia, mucus
plugging, and fibrosis

Chronic Obstructive
Pulmonary Disease
(COPD) = slowly progressive, irreversible airway obstruction…punctuated
by
periodic exacerbations of characterized by increased dyspnea,
increased sputum production, a change in character of the
sputum, & occasionally acture respiratory failure (p. 195)
1. usually takes years to become clinically significant
2. dyspnea on exertion is the earliest symptom
a. often not reported until late in disease because
patients gradually reduce their exercise to avoid
symptoms
3. PE may reveal:
a. A-P chest diameter increased
i. Indicating chronic lung overinflation
b. Use of accessory muscle of respiration
c. Peripheral cyanosis
d. On auscultation of chest, decreased breath
sounds & a prolonged expiratory phase
4. Pulm Fxn Testing is the most sensitive means of making
the Dx
5. Cigarette smoking is by far the most frequent cause
6. most pts have elements of both emphysema & chronic
bronchitis

Patho – Pulm Reminders Page 4 of 22

 7. small airway obstruction = the earliest manifestation of
COPD is in the peripheral airway
8. Treatment: (p. 197)
a. No curative therapies rather therapy is aimed to
control symptoms & avoiding harmful
environments
b. Pharmacologic therapy
i. Bronchodilators
1. sympathomimetics
a. i.e., albuterol, theophylline,
etc.
ii. Anti-inflammatories
1. inhaled corticosteroids
iii. Antibiotics
iv. Mucolytics
v. Oxygen therapy
vi. Airway clearance techniques
vii. Pulmonary rehabilitation programs
viii. Surgical therapy

Chyle = A fluid consisting of a mixture of lymphatic fluid (lymph) and

chylomicrons that has a milky appearance. Chylomicrons are
small fat globules composed of protein and lipid (fat) which are
combined in the lining of the intestine. Chylomicrons are found in
the blood and in lymphatic fluid where they serve to transport fat
from its port of entry in the intestine to the liver and to adipose
(fat) tissue.

Collagen Vascular
Disease = Collagen is a tough, glue-like protein that represents 30% of
body
protein. It shapes the structure of tendons, bones, and connective
tissues. Problems with the immune system can affect these
structures. This is known as collagen vascular disease. Collagen
vascular diseases include:
1. Rheumatoid arthritis
2. Systemic lupus erythematosus
3. Scleroderma
4. Dermatomyositis
5. Polyarteritis nodosa

Consolidation = there is increased transmission vocal sounds (p. 180):

1. whispered pectoriloquy
2. egophany (“e”  “a”)

Cough Variant
Asthma = patients with asthma often have cough, and on occasion it is
their
only symptom (p. 177)

Crackles = can be course rattles or fine, Velcro-like sounds (p.180)

1. Course crackles are often caused by mucus in the
airways
Patho – Pulm Reminders Page 5 of 22
 or by the opening of large and medium-sized airways
2. Fine crackles, produced on inspiration by the opening of
collapsed alveoli, are most common at he bases and are
heard in pulmonary edema and interstitial fibrosis, as
well as in healthy elderly patients during deep
inspiration

Cystic Fibrosis (CF) = an autosomal recessive genetic disorder that affects

multiple
organs (i.e., pulmonary, GI, GU) (p. 197)
1. Failure to produce normal CFTR (CF transmembrane
conductance regulator) protein results in defective
chloride transport & increased Na reabsorption in
airway & ductal epithelia & creates abnormally thick &
viscous secretions in the respiratory tracts & in the
pancreas
a. These abnormal secretions cause luminal
obstruction & destruction of various exocrine
ducts
2. In patients with CF in upper and lower respiratory
tracts…progressive airway obstruction ensues & most
pts die of respiratory failure
3. Diagnose via measuring the concentration of chloride in
sweat
4. Core treatment: aggressive airway hygiene, nutritional
support including pancreatic enzyme replacement,
antibiotics, bronchodilators & aerosolized recombinant
human DNase, which decreases sputum viscosity by
digesting inflammatory cell DNA
5. Discussed during Obstructive Lung Disease Chapter

Diffuse Alveolar
Hemorrhage = (p. 206)
1. discussed in ILD section
- Diffuse alveolar hemorrhage syndrome is persistent or
recurrent pulmonary hemorrhage
o Symptoms and signs of milder diffuse alveolar
hemorrhage syndrome are dyspnea, cough, and fever;
however, many patients present with acute respiratory
failure
o http://www.merck.com/mmpe/sec05/ch059/ch059a.html

Drug-Induced Interstial
Lung Disease
= See Table 18.6 for Common Drug-Induced Lung Disease
1. i.e., Chemotheraputics, Antimicrobials, CV,
Antiinflammatory, Illicit, and Tocolytics
2. Discussed under ILD section

Dyspnea = shortness of breath (p. 177)

Emphysema = abnormal enlargement of the air spaces as a result of

progressive
destruction of alveolar walls (p. 196)

Patho – Pulm Reminders Page 6 of 22

 1. in some pts the air spaces coalesce to form giant,
essentially nonfunctional air spaces (bullae) that
compress surrounding areas of more normal lung
2. Pathology = uncertain but suspect that a repeated &
prolonged inflammation releases proteolytic enzymes
into the lungs in amounts too great to be neutralized…
the unopposed protease digests lung tissue and results
in permanent distruction
3. Cigarette smoking is the major causes

Empyema = pus in the pleural space (p. 210)

Environmental &
Occupational Lung
Injury = air pollution, noxious gases and fumes, smoke inhalation, high-
altitude injury and drowning and near-drowing (p. 219-220)

Epitaxis = the growth on a crystalline substrate of a crystalline substance

that
mimics the orientation of the substrate (webster.com)

Fremitus = a faint vibration felt best with the edge of the hand against the
pt’s chest wall while the patient speaks (p. 180)
1. Fremitus is increased in pats with underlying
consolidation
2. Fremitus is decreased over a pleural effusion

Forced Expiration
Volume in 1 sec (FEV1) = the volume exhaled in 1 sec with maximal effort starting from a
full
Inspiration (p. 190)
1. the ratio of FEV1 to FVC is the most useful measure of
airway obstruction

Forced Vital Capacity

(FVC) = total amount of air exhaled starting from a full inspiration
1. the ratio of FEV1 to FVC is the most useful measure of
airway obstruction

Hamman’s crunch = hearing a crunching sound timed with the cardiac cycle (p. 180)
1. heard in pts with pneumomediastinum

Hematemesis = vomiting of blood

Hemoptysis = coughing up blood

1. more than 500 mL of blood in 24 hours is rare but is a
medical emergency (p. 178)

Heerfordt’s syndrome = triad of uveitis, parotitis, & facial nerve palsy [called
uveoparotid fever] (p. 203)
1. syndrome discussed during sarcoidosis

Patho – Pulm Reminders Page 7 of 22

Histoplasmosis = an infectious disease caused by inhaling the microscopic spores
of the fungus Histoplasma capsulatum. Histoplasmosis is an
airborne infection. The spores that cause this disease are found in
soil that has been contaminated with bird or bat droppings.
(answer.com)

Hypercapnia = A condition marked by an unusually high concentration of

carbon dioxide in the blood as a result of hypoventilation.

Hypercarbia = to have more than normal CO2 (Carbon dioxide) levels in the
blood

Hypersensitivity
Pneumonitis = dyspnea that is seasonal or triggered by environmental
exposure
(p. 177)
1. can also be a sign of asthma instead of hypersensitivity
pneumonitis
- aka: extrinsic allergic alveolitis (p. 205)
o an immunologically mediated disease that results from
repeated inhalation of & sensitization to certain organic
dusts
o symptoms include: cough, dyspnea, fever, chills, &
malaise
o there are acute, subacute, and chronic forms
o early diagnosis allows avoidance of offending agent &
prevents the progression of lung damage
 chronic form results in progressive fibrosis &
restrictive lung disease
o diffuse crackles are the predominant PE
o DDx of any pt w/ restrictive lung disease
o Should be highly suspected in patients with respiratory
sysmptoms that worsen in certain environments
o Treatment requires eliminating exposure to the
offending antigen.
 Systemic corticosteroids can relieve symptoms in
the acute phase.
 Although the efficacy of these agents in the
chronic form of the disease is less clear, trial of
corticosteroids is usually given

Hypoventilation = ventilation inadequate to keep PaCO2 from increasing above

normal (p. 186)
1. produces hypercapnia and progressive atelectasis

Hypoxemia = Insufficient oxygenation of the blood.

Interstitial Lung Disease

(ILD) = diseases characterized by diffuse lung injury & inflammation
that
frequently progresses to irreversible fibrosis & severely
compromised gas exchange (p. 201)

Patho – Pulm Reminders Page 8 of 22

 1. Known causes include: pneumoconiosis, hypersensitivity
pneumonitis, drugs, and toxic gas inhalation, sarcoidosis,
collagen vascular disease, pulmonary vasculitis, alveolar
hemorrhage, bronchiolitis obliterans w/ organizing
pneumonia, and some rare eosinophil granuloma &
lymphangioleiomyomatosis

Kartagener’s syndrome = immotile cilia; is a rare inherited abnormality of ciliary

microtubules
that impairs airway clearance (p. 196)
1. Classic Triad:
a. Sinusitis, situs inversus (= a condition in which
the organs of the chest and abdomen are
arranged in a perfect mirror image reversal of the
normal positioning), & infertility
i. This was discussed under bronchiectasis

Kussmaul breathing = is the very deep and labored breathing with normal or reduce
frequency, found among people with severe acidosis; it is a form
of hyperventilation. The cause of Kussmaul breathing is
respiratory compensation for a metabolic acidosis, most
commonly occurring in diabetics in diabetic ketoacidosis.
(answer.com)

Medialstinal fibrosis = the progressive proliferation of fibrous tissue in the

mediastinum
that encroaches on major airways & blood vessels & results in
inexorably progressive airway or vascular obstruction & death; no
effective therapy is available for this disease. (p. 211)

Mesothelioma = A usually malignant tumor of mesothelial tissue, especially that

of the pleura or peritoneum. (answer.com)

Metabolic Acidosis = a pH imbalance in which the body has accumulated too much
acid and does not have enough bicarbonate to effectively
neutralize the effects of the acid.

Metabolic acidosis, as a disruption of the body's acid/base

balance, can be a mild symptom brought on by a lack of insulin, a
starvation diet, or a gastrointestinal disorder like vomiting and
diarrhea. Metabolic acidosis can indicate a more serious problem
with a major organ like the liver, heart, or kidneys. It can also be
one of the first signs of drug overdose or poisoning. (answer.com)

The values for Metabolic Acidosis:

pH: ↓ HCO3: ↓ pCO2: ↓

Metabolic Alkalosis = results from altered metabolism. It is the most common acid-
base disorder seen in hospital in the United States. Is a result of
decreased hydrogen ion concentration leading to increased
bicarbonate and carbon dioxide concentrations, or alternatively a

Patho – Pulm Reminders Page 9 of 22

 direct result of increased bicarbonate concentrations. There are
four mechanisms of metabolic alkylosis:

1. Loss of hydrogen ions Most often occurs via two

mechanisms, either vomiting or renally. Vomiting results in
the excretion hydrogen ions and the retention of
bicarbonate. Renal losses of hydrogen occur when excess
aldosterone induces the retention of sodium and hence the
excretion of hydrogen.

2. Shift of hydrogen ions into intracellular space. Seen in

hypokalemia. Due to a low extracellular potassium
concentration, potassium shifts out of the cells, and in
order to maintain electrical neutrality, hydrogen shifts into
the cells, leaving behind bicarbonate.

3. Alkalotic agents Alkalotic agents, such as bicarbonate,

administered in excess of excretion capabilities by the
kidney can lead to an alkylosis.

4. Contraction alkalosis This results from a loss of water in

the extracellular space which is poor in bicarbonate,
typically from diuretic use. Since water is lost while
bicarbonate is retained, the concentration of bicarbonate
increases.

Compensation of Metabolic Alkalosis:

The body attempts to compensate for the increase in pH by

retaining carbon dioxide (CO2) through hypoventilation
(respiratory compensation). CO2 combines with elements in
the bloodstream to form carbonic acid, thus decreasing pH.

Renal compensation for metabolic alkalosis consists of

increased excretion of HCO3- (bicarbonate), because the
filtered load of HCO3- exceeds the ability of the renal tubule
to reabsorb it.

The values for Metabolic Alkalosis:

pH: ↑ HCO3: ↑ pCO2: ↑

Lofgren’s syndrome = constellation of erythema nodosum (= a type of skin

inflammation
that is located in a certain portion of the fatty layer of skin.
Results in reddish, painful, tender lumps most commonly located
in the front of the legs below the knees. The tender lumps, or
nodules, range in size from 1 to 5 centimeters. The nodular
swelling is caused by a special pattern of inflammation in the
fatty layer of skin), arthralgias, & hilar
adenopathy (p. 203)

Lung Perfusion = blood flow in the normal lung (p. 184)

Patho – Pulm Reminders Page 10 of 22
 1. the relationship between alveolar & pulmonary
vasculature pressure largely determine this

Lymphangioleiomyo-
Matosis = a rare interstitial lung disease (p. 207)
1. disease of pre-menopausal women
2. characterized by proliferation of smooth muscle in the
walls of the pulmonary lymphatics and venules &
causing mixed obstruction & restriction
3. accelerated during pregnancy
4. pathologic cells resemble uterine muscle cells
5. therapy: hormonal manipulation has been used w/o
success

Obstructive Lung
Disease = characterized by decreased airflow rates during expiration,
often
accompanied by and elevated functional residual capacity
resulting from trapped gas (p. 193)
1. Include: asthma, bronchiectasis, emphysema & chronic
bronchitis
2. COPD is the term applied to both emphysema & chronic
bronchitis, diseases usually caused by cigarette smoking or
other chronic irritant inhalation, although long-standing
poorly controlled asthma can also result in COPD

Oximetry = a reliable non-invasive method for estimating arterial Hb

oxygen
saturation. Relies on the different absorption spectra of oxy-Hb
and deoxy-Hb to estimate the O2 saturation. Sensors are usually
placed on digits or ear lobes, which allow transmission of light
from the source on one side of the tissue to the sensor on the
other side. (p. 192)

Oxygen saturation = red blood cells must carry sufficient oxygen through your
arteries to all of your internal organs to keep you alive. Normally,
when red blood cells pass through the lungs, 95%-100% of them
are loaded, or "saturated," with oxygen to carry. If you have lung
disease or other types of medical conditions, fewer of your red
blood cells may be carrying their usual load of oxygen, and your
oxygen saturation might be lower than 95%. Your blood oxygen
level can be measured in two ways.
(http://www.health.harvard.edu/diagnostic-tests/oxygen-
saturation-test.htm)

Pack years = Number of pack years = (number of cigarettes smoked per day
x number of years smoked)/20

Pancoast’s syndrome = Pancoast tells you where the cancer is, rather than what type it
is.
Tumours grow right at the top of the lung (the apex). This
position makes them rare, as most lung cancers develop lower

Patho – Pulm Reminders Page 11 of 22

 down in the lungs. The cancer is at the top of the lungs, it may
put P on or damage a group of nerves that runs from the upper
chest into your neck & face (brachial plexus). This can have
several symptoms:
- severe pain in the shoulder of the shoulder blade (scapula)
- pain in the arm
- Horner’s sydrome: the medical name for a group of symptoms.
You get flushing on one side of the face & that side doesn’t
swear. The eye on the same side has a smaller (constricted)
pupil with a drooping or weak eyelid.
- http://www.cancerhelp.org.uk/help/default.asp?page=10809

Parenchyma = The tissue characteristic of an organ, as distinguished from

associated connective or supporting tissues

Paroxysmal Noctural
Dyspnea = dyspnea that occurs on to several hours after lying down and is
associate with congestive heart failure (p.177)
1. it is caused by increased venous return to the heart
resulting in mild pulmonary edema
2. can also be associated with asthma

Percussion = always compare sides [posterior, anterior, and lateral] (p. 180)
1. If dullness present, consider:
a. Pleural effusion, consolidation, a mass, or an
elevated diaphragm
2. If hyperresonane is present, consider:
a. Pnuemothorax or hyperinflation

Pleural effusion = fluid accumulating in the pleural space (p. 209-210)

1. fluid accumulates b/c dynamics are altered by changes
in hydrostatic or osmotic Ps, by increased permeability
of pleural capillaries, or by lymphatic obstruction
2. Tansduative effusion:
a. Result from increases in vascular hydrostatic P or
decreases in plasma oncotic P
b. Treatment:
i. Seldom require drainage, & they will
resolve w/o consequence if the underlying
abnormality is corrected
3. Exudateive effusion:
a. Result from increases in vascular permeability,
from trauma, or, rarely, from abnormal
communications btwn the pleural space & other
structures such as the pancreas, esophagus,
peritoneal space or lung parenchyma
b. Treatment:
i. May or may not require drainage
4. pts may be asymptomatic or may have dyspnea or
chest pain
5. pleuritic chest pain is classically described as sharp and
is exacerbated by coughing or deep breathing
6. PE signs:

Patho – Pulm Reminders Page 12 of 22

 a. Dullness to percussion
b. Decreased breath sounds over the effusion
c. Decreased vocal fremitus
d. Bronchial breath sounds
e. Egophany at the superior edge of the effusion
resulting from lung compression
7. a pleural effusion of unknown cause requires
thoracentesis
8. treatment: depends on the cause & on the degree of
impairment of lung function
a. should be directed at the underlying cause when
known

Pneumochoniosis = lung disease caused by inhalation of inorganic dusts (p. 219)

1. 4 major pneumochonioses result from inhalation of:
a. asbestos
i. asbestos fibers are not easily cleared from
the lung & continue to stimulate ongoing
inflammation & fibrosis
ii. fibers appear on histologic exam as
“asbestos bodies” (ferruginous bodies) b/c
of the accumulation of iron & protein on
their surface over time
b. coal dust
i. Coal Workers’ pneumoconiosis = results
from long and intense inhalation of coal
dust
c. silica
i. silicosis = resulting from significant silica
exposure
ii. radiographical finding:
1. eggshell calcification of hilar nodes
d. beryllium

Pneumothorax = air in the pleural space (p. 211)

1. Spontaneous pneumothorax:
a. Idiopathic & occurs in young people w/o any
known predisposition
b. Classic symptoms: dyspnea & sharp chest pain
2. Tension pneumothorax:
a. Accumulation of air creating positive P in the
pleural space
b. Can cause hempdynamic collapse, therefore it is
a medical emergency that requires immediate
decompression
c. Pts with mechanical ventilation require a chest
tube
d. Pts w/o mechanical ventilation, a small
pneumothoaces may resolve w/o intervention
e. Occasionally, needle drainage can be performed
w/o reaccumulation
f. Small-bore catheters placed percuaneously may
suffice

Patho – Pulm Reminders Page 13 of 22

Polysomnography = used to evaluate patients for sleep disturbances. Diagnoses are
made from continuous recordings of an electroencephalogram, an
electrocardiogram, chest wall movement, a diaphragmatic
electromyogram, pulse oximetry, & video-recorded observation
during sleep. From such measurements, it is possible to establish
the presence of sleep-disordered breathing & to distinguish btwn
CNS & peripheral causes of the disorder. (p. 191)

Pressure-cycled mode = mechanical ventilation which provides positive P applied during

inspiration during spontaneous breaths (p. 225)

Primary carcinomas of
the lungs = are classified as small cell or non-small cell carcinomas (p. 213-
214)
1. Small cell carcinoma: A highly malignant carcinoma of
the lungs composed of small ovoid undifferentiated cells
2. Non-small cell "non-small cell lung cancer" applies to
the various types of bronchogenic carcinomas (those
arising from the lining of the bronchi); these tumors are
divided into:
a. Squamous cell carcinoma
i. carcinoma that arises from squamous
epithelium
b. Adenocarcinoma:
i. malignant tumor originating in glandular
tissue
c. Large cell (or anaplastic) carcinoma:
i. Carcinoma composed of large
undifferentiated cells
d. Bronchoalveolar carcinoma
e. Note: the highest rate of cure in non-small cell
lung cancer occurs with complete surgical
resection
3. symptoms vary but can include: cough, hemptysis,
dyspnea, or postobstructive pneumonia, chest pain
4. Dx and Eval:
a. A lesion that is radiographically stable for more
than 2 years is assumed to be benign
b. Cytological exam of sputum
c. Fiberoptic bronchoscopy
d. Transthoracic needle aspiration
i. A negative needle biopsy does not rule out
malignancy
e. Thoracoscopic wedge resection
5. See Table 20.2 for “International Statging System for
Lung Cancer” (p. 215)
6. Small cell cancer: (p. 215-216)
a. Staged and treated differently than non-small cell
lung cancer
b. Classifications:
i. Limited stage:

Patho – Pulm Reminders Page 14 of 22

 1. tumor is encompassed entirely w/in
a single radiation port
ii. Extensive stage:
1. therapy is chemotherapy combined
with irradiation
c. small cell lung cancer is very chemosensitive
i. responds with clinical remission but rarely
is patient cured
d. small cell lung cancer frequently metastasizes to
the brain

Pulmonary alveolar
Proteinosis = a rare interstitial lung disease (p. 207)
1. alveoli fill with protein & phospholipids material similar
to surfactant
2. origin unknown

Pulmonary cachexia = in patients with severe obstructive or restrictive lung disease,

the work of breathing may be a major contributor to the resting
metabolic rate. In extreme cases, this increae in energy
expenditure can resulting in weight loss known as pulmonary
cachexia (p. 183)
1. with normal lungs, the work of breathing uses only 4-5%
of the total calories burned, but in sever lung disease up
to 30% of the total-body oxygen consumption can be
consumed by the work of breathing

Pulmonary eosinophilic
Granuloma = a rate interstitial lung disease (p. 207)
1. characterized by proliferation of Langerhan’s cells
2. unlike most pts with ILD, these pts have normal lung
volumes
3. associated with smoking & has a highly variable course

Pulmonary hamartoma = the most common benign peripheral lung tumor which has a
characteristic “popcorn” patter of calcification (p. 213)

Pulmonary Infiltrates
With Eosinophilia = discussed in ILD section (p. 207)
1. Eosinophilic Lung Disease = Pulmonary disease
affecting the major airways or parenchyma (or both)
associated with either blood or tissue eosinophilia (or
both)
a. http://www.learningradiology.com/lectures/chestl
ectures/eosinophiliclungdisease_files/frame.htm

Pulmonary Function
Test = evaluates four areas of lung function (p. 189):
1. air flow (spirometry)
2. lung volume
3. gas exhange (diffusing capacity)
4. lung mechanism

Patho – Pulm Reminders Page 15 of 22

 a. Note: variable that affect the standard values
include: age, sex, height, race, and Hb
concentration
b. Pulm Fxn Testing divides the lung into 4 volumes
and 3 capacities
i. All volumes except the residual volume can
be measured directly by spirometry
1. Measuring the functional residual
vapacity indirectly & subtracting the
expiratory reserve colume calculates
residual volume

Pulmonary Vasculitis = (p. 206)  discussed in ILD section

1. Vasculitis refers to a varied group of disorders which all
share a common underlying problem of inflammation of a
blood vessel or blood vessels. The inflammation may affect
any size blood vessel, anywhere in the body. It may affect
either arteries and/or veins. The inflammation may be
focal, meaning that it affects a single location within a
vessel; or it may be widespread, with areas of inflammation
scattered throughout a particular organ or tissue, or even
affecting more than one organ system in the body.
Inflammation is a process which occurs when the immune
system of the body responds to either an injury or a foreign
invader (virus, bacteria, or fungi). The immune system
response involves sending a variety of cells and chemicals
to the area in question. Inflammation causes blood vessels
in the area to leak, causing swelling. The inflamed area
becomes red, hot to the touch, and tender. (answer.com)

Respiratory Acidosis = Respiratory acidosis is a condition in which a buildup of carbon

dioxide in the blood produces a shift in the body's pH balance and
causes the body's system to become more acidic. This condition
is brought about by a problem either involving the lungs and
respiratory system or signals from the brain that control
breathing.

Respiratory acidosis is an acid imbalance in the body caused by a

problem related to breathing. In the lungs, oxygen from inhaled
air is exchanged for carbon dioxide from the blood. This process
takes place between the alveoli (tiny air pockets in the lungs) and

Patho – Pulm Reminders Page 16 of 22

 the blood vessels that connect to them. When this exchange of
oxygen for carbon dioxide is impaired, the excess carbon dioxide
forms an acid in the blood. The condition can be acute with a
sudden onset, or it can develop gradually as lung function
deteriorates. (answer.com)

The values for Respiratory Acidosis:

pH: ↓ HCO3:↑ pCO2: ↑

Respiratory Alkalosis = results from increased alveolar respiration (hyperventilation)

leading to decreased plasma carbon dioxide concentration. This
leads to decreased hydrogen ion and bicarbonate concentrations.

1. There are two types of respiratory alkalosis: chronic and

acute.

a. In acute respiratory alkalosis, increased levels of

carbon dioxide are "blown off" by the lungs,
which are hyperventilating. During acute
respiratory alkalosis, the person may lose
consciousness where the rate of ventilation will
resume to normal.
b. In chronic respiratory alkalosis, for every 10 mM
drop in pCO2 in blood, there is a corresponding 5
mM of bicarbonate ion drop. The drop of 5 mM of
bicarbonate ion is a compensation effect which
reduces the alkalosis effect of the drop in pCO2 in
blood. This is termed metabolic compensation.
(answer.com)

The values for Respiratory Alkalosis:

pH: ↑ HCO3:↓ pCO2: ↓

Respiratory rate = 12-20 respirations per min is the norm

Rub = a pleural sound caused by inflamed pleural surfaces rubbing

together (p. 180)

Sarcoidosis = systemic disease of elusive origin (p. 201-204)

1. noncaseating epithelioid granulomas that contain giant
cells
2. can affect any organ system
3. commonly affects the lungs and LNs
4. most common in adults 20-40
5. slightly more common in women
6. in US, African Americans are more commonly affected
7. also prevalent in Scandinavian countries
8. Infectious, allergic & environmental exposures have all
been proposed as triggers of the disease in pts w/ genetic
susceptibility, but neither genetic factors nor specific
triggers have been established
Patho – Pulm Reminders Page 17 of 22
 9. has a distinct immunologic features, including:
- circulating CD4+ lymphocytes are decreases…
10. symptoms reflect the organ systems involved
- most common complaints are cough & dyspnea
- fatigue & low-grade fever are less common but
high fever can occur
- skin manifestations
- ocular symptoms
- liver granulomas
- cardiac involvement
- neurologic involvement
- Heerfordt’s syndrome
- Lofren’s syndrome
- in general, may have: skin lesions, lacrimal &
salivary gland enlargement, cranial nerve
abnormalities, or hepatomegaly
11. treatment with systemic corticosteroids though long-
term prognosis therapies have not yet been proven

Shock = the profound & widespread failure of adequate tissue perfusion that lead to cell
injury and death (p. 223)
1. Four categories of shock:
- hypovolemic:
~ may be related to dehydration or
hemorrhage
- cardiogenic:
~ signs of L sided heart failure are usually
present unless the cause is an isolated RV
infarct
- obstructive:
~ results from significant obstruction to blood
flow w/in the CV circuit (i.e., pulmonary
embolism)
- distributive:
~ results from systemic vasodilation so
profound that even a hyperdynamic heart
cannot produce a cardiac output sufficient to
maintain blood pressure
2. Hypotension and tachycardia are characteristic of shock
from any cause
- with the exception of cardiogenic shock which may
be accompanied by bardycardia

Shunt = the portion of the blood that goes from the R side of the heart to the L without an
opportunity for exchange of O2 & CO2 (p. 186)
1. Via: anatomic shunt (i.e., intracardiac septal defect),
from a small % of venous return from cardiac &
bronchial circulations that empties directly into the LA,
and physiological shunt

Sleep apnea = patients with apnea (= complete cessation of airflow for 10 or

more seconds) and hypopneas (= significant decrease in airflow)
are increased in frequency & duration to a degree sufficient to

Patho – Pulm Reminders Page 18 of 22

 fragment sleep & produce clinically significant hypoxia &
hypercapnia (p. 217)
1. Obstructive:
a. Upper airway obstruction
b. Risk factors:
i. Obesity
ii. Upper airway anatomy
1. i.e., enlarged tonsils, etc.
2. Central:
a. Decreased central respiratory drive
b. May be due to a structural abnormality of the
brain stem, which may be discovered only at
autopsy
c. Lower brain stem and upper pontine lesions may
cause central hyperventilation
3. Note: can have a mixture of obstructive and central
sleep apnea
4. Consequences of sleep apnea:
a. Excessive daytime somnolence
b. Increased risk for vehicular accidents
c. Irritability
d. Headache
e. HTN
f. Increased sudden death (probably resulting from
cardiac arrythmias)
5. More common in men
6. Weight loss can eliminate or reduce severity
7. Hypothyroidism, acromegaly, & amyloidosis are rate
causes of sleep apnea that should be ruled out
8. Treat: use a sleeping device to increase airflow, surgery
to remove obstructing anatomic abnormalities,
tracheostomy is a last resort but highly effective

Sputum = does not signify a bacterial infection but is influenced by the

concentration of cellular debris, predominately white cells,
present in any inflammatory process (p. 177)
1. sputum is abnormal and should be characterized by
quantity, color, presence or absence of blood, & timing
a. frequency and volume of sputum should also be
asked of the pt

Stridor = term used to describe noisy breathing in general, and to refer

specifically to a high-pitched crowing sound associated with
croup, respiratory infection, and airway obstruction. Occurs when
erratic air currents attempt to force their way through breathing
passages narrowed by: illness, infection, the presence of foreign
objects, throat abnormalities (answer.com)

Superior Vena Cava

Syndrome = results from obstruction of the SVC by central upper lobe
tumors,
usually the small cell tumors (p. 213)

Patho – Pulm Reminders Page 19 of 22

 1. symptoms: facial & upper extremity edema, dilation of
superficial veins over the upper part of the body,
cerebral edema & stridor

Swan-Gaz = “Invention of the percutaneoud flow-directed pulmonary artery

catheter…make continuous measurements of pulmonary artery
and LA pressure and frequent measurements of cardiac output
feasible.” (p. 223)
- soft, flow-directed catheter with a balloon at the tip for
measuring pulmonary arterial pressures, right atrial pressures,
left atrial pressure, and reflected left ventricular end-diastolic
pressure. The catheter permits evaluation of cardiac function
by assessing the effectiveness of right and left pumping action
of the heart and providing a quantitative measurement of
cardiac output, and by allowing for sampling of mixed arterial–
venous oxygen levels and calculation of differences between
the two.
- In medicine pulmonary artery catheterization is the insertion
of a catheter into a pulmonary artery. Its purpose is
diagnostic; it is used to detect heart failure or sepsis, monitor
therapy, and evaluate the effects of drugs. The pulmonary
artery catheter allows direct, simultaneous measurement of
pressures in the right atrium, right ventricle, pulmonary artery,
and the filling pressure ("wedge" pressure) of the left
atrium. (answer.com)
o A Swan-Ganz:
 RA pressures: normal range 0-5
 PA pressure: normal range 12-28/3-13
 PCWP: normal range 3-11
• = Pulmonary Capillary Wedge Pressure

Synchronized intermittent
mandatory ventilation
(SIMV) = delivers a specified number of breath per minute of a specified
tidal volume synchronized with the pt’s efforts (p. 225)

Systemic Inflammatory
Response Syndrome
(SIRS) = a constellation of clinical signs and symptoms resulting from
the
host response to various insults (p. 226)
1. Sepsis
a. when caused by infection
2. Multiple Organ Dysfunction Syndrome
3. Adult Respiratory Distress Syndrome
a. lung dysfunction
- SIRS = The spectrum of elicited pathophysiologic changes
(including blood clotting and changes in metabolism, heart rate,
and respiration) resulting from excess production of inflammatory
mediators (for example, histamines and leukotrienes), which
orchestrate the process of inflammation through various
processes (answer.com)

Patho – Pulm Reminders Page 20 of 22

Tachypnea = rapid breathing

Thoracentesis = Also known as pleural fluid analysis, it is a procedure that

removes fluid or air from the chest through a needle or tube.The
usual place to tap the chest is below the armpit (axilla). Under
sterile conditions and local anesthesia, a needle, a through-the-
needle-catheter, or an over-the-needle catheter may be used to
perform the procedure. Overall, the catheter techniques may be
safer. Fluid or air is withdrawn. Fluid is sent to the laboratory for
analysis. If the air or fluid continue to accumulate, a tube is left in
place and attached to a one-way system so that it can drain
without sucking air into the chest. (answer.com)

Ventilation = the primary short-term homeostatic mechanism for maintaining

normal blood pH, the strongest factor controlling ventilation (p
183)

Volumes = broken down:

1. Alveolar volume (VA) = portion of inhaled breath that fills the
respiratory zone is the alveolar volume (p. 183)
2. Dead space volume (VD) = portion remaining in the
conducting airways (p. 183)
3. Tidal volume (VT) = the sum of alveolar & dead space
ventilation w/ quiet breathing (p. 183)

Volume-cycled modes = mechanical ventilation which is assist controlled by

guaranteeing
a number of breaths per minute at a specificed tidal volume (p.
225)

Wheezing = a higher pitched sound which suggestslarge airway obstruction

(p.
180)
1. Lower pitched wheeze heard in patients with asthma or
CHF
a. It is heard diffusely over all lung fields
2. Localized wheezing can also be heard in conditions such
as pulmonary embolism, obstruction of a bronchus by a
tumor,, & foreign body aspiration

Whole-body
Plethysmography = measures the change in pressure with a change in volume,
measures lung volumes more accurately (than Pulm Fxn Test) in
patients with obstructive lung disease, & also permits
measurements of airway resistance, but the technique is more
cumbersome and time consuming (p. 190)

Food For Thought:

1. The right mainstem bronchus takes off at a less acute angle than the left, & therefore
foreign bodies are more commonly aspirated into the right lung. (p. 181)

Patho – Pulm Reminders Page 21 of 22

2. The distribution of ventilation in the lungs is unequal, with greater ventilation in the
base & less at the apex in the upright position. The same is true for lung perfusion.
This matching of ventilation & perfusion optimizes gas exchange. (p. 183)
3. Pleural disease: (p. 209)
a. Fluid normally enters the space from the visceral pleura and is absorbed by
the parietal pleura
b. Visceral pleural vessels are supplied from the pulmonary circulation & parietal
pleural vessels are part of the systemic circulation
c. Pleural inflammation increases the permeability of the pleural vessels and
causes excessive fluid to enter the space for a given driving force

Patho – Pulm Reminders Page 22 of 22