CHAPTER 13 Respiratory System Physiology of Lungs 75%of quiet respiration comes from diaphragmatic action.

At rest, 6-8 liters/min air taken in. At maximum ventilation intake exceeds 125 liters/min. In one day we inhale 10,000 liters. Intrathorasic pressure approximately -2.5 mm Hg. During inspiration that drops to about -6 mm Hg. The airway branches approximately 23 times from trachea to terminal alveolar sacs. There is no oxygen exchange in the first 16 branches even though the surface area in these first 16 branches is 2000 that of the trachea. There are approximately 300 million alveolar sacs and has a surface area of 750 square feet. Only 70% of inspired air reaches the alveolar sacs. During expiration, about 85% of inhaled air is expelled in the first second but it takes two more seconds to expel another 12-15% during maximum effort. Particles greater than 10 micrometer stay within the tidal flow of air. Particles 3-10 :m get trapped by cilia on trachea and bronchus. Coughing and sneezing and cilia generally remove these. Particles less than 3 :m reach terminal alveolar sacs. These are removed by macrophages. ATELECTASIS (collapse or loss of lung volume). (slide 8) Resorption Atelectasis: Airway obstruction results in continued absorption of air from the lungs with gradual collapse. (reversible) Compression Atelectasis: Results from fluid, blood, or air in the thorax. Pneumothorax and congestive heart failure among the most common causes. (reversible) -pneumothorax usually from trauma introducing air - resorption and compression are the most common Microatelectasis: (non-obstructive atelectasis) Adult Respiratory Distress Syndrome (ARDS) and Neonatal Respiratory Distress Syndrome (NRDS). Commonly results from a lack of surfactant in NRDS. Post surgery, lungs cannot reinflate. (inflammatory problems, structure of the lung problem- irreversible) Contraction Atelectasis: Scar formation. A non-reversible process whereas the others may be (but not always).

Atopic asthma generally has two phases, an acute phase which occurs within minutes of exposure. The second phase occurs hours later (sort of a relapse phase which lasts longer than the acute phase). Status asthmaticus is a protracted condition. (IgE reactions w/ smooth muscle component) (slide 14) mast cell degranulation on mucosal surface and submucosal Bronchiole constriction and the thick mucus causes airway obstruction and the wheezing associated with asthma. Intrinsic - non-immune mediated. Most often stress, exercise, or irritant induced. Chronic Obstructive Pulmonary Diseases (COPD) A group of pulmonary conditions that causes irreversible airway obstruction (unlike asthma). Emphysema: Overinflation results in rupture of alveolar sacs. While there are three "flavors" of emphysema, they are not easy to distinguish among them. The most severe form is that which results from a deficiency of alpha-1 antitrypsin deficiency . Smoking recruits PMNs which produces excess elastase. Clinical signs include dyspnea and hyperventilation. Death results from respiratory acidosis or rightsided heart failure.

Chronic Bronchitis: Smokers or persons living in smog-laden areas. Diagnostic criteria are: 1) persistent productive cough and 2) lasting at least 3 consecutive months in 2 consecutive years. Results in fibrosis (scarring), inflammation and bronchiole narrowing. Excess mucus production a feature of CB as well. Generally produces cyanosis . Occasionally, CB and emphysema overlap.

OBSTRUCTIVE LUNG DISEASES (The four biggies are asthma, emphysema, chronic bronchitis and cystic fibrosis.) see Table 13-2 Asthma: (reversible) -inflammatory problem- difficutly in breathing, expiring Extrinsic - type I hypersensitivity response. Atopic asthma the most common form.

Bronchiectasis: permanent dilation of bronchioles. Results from obstructions such as tumors or foreign bodies, cystic fibrosis, immunodeficiencies, or chronic necrotizing pneumonias (resulting in scar formation).

Ex.) Cystic Fibrosis: severe bronchiectasis from constant infection brought about by copious mucous production. The most lethal AR disorder that affects whites.

Embolism/Thromboembolism: From venous or right ventricle emboli. Results in ~50,000 deaths a year in hospitals. The vast majority of pulmonary thrombi are silent (60-80%). 95% result from deep leg thrombi. (Hip fractures were a common cause; but, current therapy has reduced the incidence.) Usually more than 60% pulmonary occlusion required to cause death (although several small infarcts may result in death).

RESTRICTIVE LUNG DISEASES Result in loss of compliance of lung tissues (become stiff). Interstitial disease.

Acute Restrictive Diseases Ex.): Adult Respiratory Distress Syndrome (ARDS) 1) decreased arterial oxygen pressure, 2) decreased compliance, and 3) pulmonary infiltrates without leftsided heart failure. See Table 13-1 for list of causative factors. >+ 50% mortality.

PULMONARY INFECTIONS Lobar Pneumonia: Consolidated and involves one (or two) lobes. Typically, the organism involved is Streptococcus pneumoniae or "pneumococcus" (90%+) which also accounts for most "community acquired" infections.

Chronic Restrictive Diseases (an interstitial disease) Table 13-3 lists some causes. Forced vital capacity (FVC) and forced expiratory volume (FEV) both reduced but not the ratio between the two.

Bronchopneumonia: also known as "patchy" pneumonia. Less specific than lobar pneumonia.

Ex.): Idiopathic (cryptogenic) Pulmonary Fibrosis: Interstitial infiltrate and edema. Macrophages secrete growth factors which causes fibroblastic proliferation. Loss of type I pneumocytes and replacement by type II pneumocytes. Death commonly results from cor pulmonale and heart failure. Prognosis unpredictable.

Tuberculosis: Mycobacterium tuberculosis causes 8-10 million new infection a year and about 3 million deaths. About 25,000 new cases in USA a year. A type IV hypersensitivity reaction causes most damage associated with TB. Primary TB: Ghon focus. The primary lesion and contiguous lymph node(s) create this lesions. Secondary TB: classically located at the apex of one or both lungs. Cavitation also consistent. Miliary TB involves multiple sites and may become systemic. Pott disease (TB in vertebrae) and Addison disease (uncommon today).

VASCULAR LUNG DISEASES

LUNG TUMORS

95% are bronchogenic carcinoma. 40-70 years, males (2X that of females). Smokers 510 times more like to die. 80% of lung cancers occur in heavy smokers. Exposure to asbestos increases the risk by 55 times.

2 major groups: a.non-small cell type-

b. small cell type-

Malignant Mesothelioma: a tumor arising from pleural surface. Almost always associated with asbestos.