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Basic Pulmonary & Critical Care Topics

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Basic Pulmonary & Critical Care Topics An Integrated Goal-directed Narrative for the In-Training Exam JEFFREY B HORN MD STEPHEN SAMS MD FIRST EDITION WHITNEY FALLAHIAN MD JASON HAFER MD An ntegrated oal-directed arrative for the n- raining xam I G N I T E An Integrated Goal-directed Narrative for the In-Training Exam You are always a student, never a master. You have to keep moving forward. –Conrad Hall [An Integrated Goal-directed Narrative for the In-Training Exam] PULMONARY & CRITICAL CARE – BASIC EXAM LUNG ANATOMY 1 SUPERIOR VENA CAVA INFERIOR VENA CAVA 9 2 3 RIGHT ATRIUM 6 1 4 4 AORTIC NOTCH 5 5 MAIN PULMONARY ARTERY 8 8 6 SCAPULA 3 7 LEFT VENTRICLE 7 2 8 HILA 10 9 TRACAHEA (BIFURCATION à T4 / T5) 10 DIAPHRAGM LUNG ANATOMY RIGHT LUNG LEFT LUNG HORIZONTAL FISSURE 1 6 SUPERIOR LOBE SUPERIOR LOBE 2 2 7 OBLIQUE FISSURE 6 MIDDLE LOBE 3 8 CARDIAC NOTCH OBLIQUE FISSURE 4 1 9 INFERIOR LOBE 3 INFERIOR LOBE 5 8 7 10 LINGULA 9 4 10 SHORTER SIZE THAN THE LEFT LUNG 8 SMALLER SIZE THAN THE RIGHT LUNG WIDER THAN THE LEFT LUNG 5 LONGER & MORE NARROW THAN RIGHT LUNG An Integrated Goal-directed Narrative for the In-Training Exam È FRC à FASTER INHALATIONAL INDUCTION LUNG LOBES & SEGMENTS NORMAL VALUES RIGHT LUNG LEFT LUNG FUNCTIONAL RESIDUAL CAPACITY 40 mL/kg LOBES 3 2 VITAL LUNG CAPACITY 70 mL/kg SEGMENTS 10 9 TOTAL LUNG CAPACITY 90 mL/kg SUB-SEGMENTS 22 20 PUCC - (B)-4 [An Integrated Goal-directed Narrative for the In-Training Exam] PULMONARY & CRITICAL CARE – BASIC EXAM BRONCHIAL ANATOMY RIGHT MAIN STEM BRONCHUS 1 RIGHT UPPER LOBE BRONCHUS 2 RIGHT APICAL SEGMENTAL BRONCHUS 3 RIGHT ANTERIOR SEGMENTAL BRONCHUS 4 RIGHT POSTERIOR SEGMENTAL BRONCHUS 5 BRONCHUS INTERMEDIUS 6 RIGHT MIDDLE LOBE BRONCHUS 7 RIGHT LATERAL SEGMENTAL BRONCHUS 8 RIGHT MEDIAL SEGMENTAL BRONCHUS 9 RIGHT LOWER LOBE BRONCHUS 10 3 18 19 RIGHT SUPERIOR SEGMENTAL BRONCHUS 11 20 4 1 16 RIGHT MEDIAL BASAL SEGMENTAL BRONCHUS 12 2 17 22 RIGHT ANTERIOR BASAL SEGMENTAL BRONCHUS 13 5 21 6 8 7 10 RIGHT LATERAL BASAL SEGMENTAL BRONCHUS 14 25 23 9 11 24 26 RIGHT POSTERIOR SEGMENTAL BRONCHUS 15 14 LEFT MAIN BRONCHUS 16 27 13 12 LEFT UPPER LOBE BRONCHUS 17 15 29 28 LEFT APICOPOSTERIOR SEGMENTAL BRONCHUS 18 LEFT APICOPOSTERIOR SEGMENTAL BRONCHUS 19 LEFT ANTERIOR SEGMENTAL BRONCHUS 20 LINGULAR BRONCHUS 21 SUPERIOR LINGULAR SEGMENTAL BRONCHUS 22 INFERIOR LINGULAR SEGMENTAL BRONCHUS 23 LEFT LOWER LOBE BRONCHUS 24 LEFT SUPERIOR SEGMENTAL BRONCHUS 25 LEFT MEDIAL BASAL SEGMENTAL BRONCHUS 26 LEFT ANTERIOR BASAL SEGMENTAL BRONCHUS 27 LEFT LATERAL BASAL SEGMENTAL BRONCHUS 28 LEFT POSTERIOR SEGMENTAL BRONCHUS 29 HYPOXIC PULMONARY VASOCONSTRICTION (HPV) Diversion of Blood (Vasoconstriction) from Lung Segments with È Oxygenation MECHANISM È Ventilation / Perfusion Mismatch È PaO2 à Ç HPV Inhalational Agents Ç Pulmonary Vascular Resistance Nitroglycerin Nitroprusside DIRECT INHIBTION OF HPV Nitric Oxide Dobutamine HYPOcapnia HYPOthermia Epinephrine Norepinephrine INDIRECT INHIBITION OF HPV Phenylephrine Dopamine PEEP An Integrated Goal-directed Narrative for the In-Training Exam PUCC - (B)-5 [An Integrated Goal-directed Narrative for the In-Training Exam] PULMONARY & CRITICAL CARE – BASIC EXAM VENTILATORY MUSCLES INNERVATION C3, C4, C5 NON-STRENUOUS BREATHING Generation of Negative Intrathoracic Pressure in CONTRACTION Intrapleural Space (Inflow of Air) RELAXATION Expiration (Passive) MUSCULATURE Fatigue-Resistant, Slow-Twitch Fibers DIAPHRAGM STRENUOUS BREATHING (Ç USE OF ACCESSORY MUSCLES) External Intercostal Muscles INHALATION Cervical Strap Muscles (Elevate Sternum & Upper Chest à Ç Thoracic Cavity Dimensions) Internal Intercostal Muscles (Provide Support for Exhalation) FORCED EXHALATION Abdominal Muscles (Contract à È Ribs à Ç Intra-Abdominal Pressure) MECHANICS OF BREATHING PHYSIOLOGY OF BREATHING Greater than Intrathoracic Pressure ALVEOLAR PRESSURE Atmospheric (0 cmH2O) at End Inspiration & Expiration INTRATHORACIC PRESSURE —5 cmH2O at End Expiration (Prevents Lung Collapse) TRANSPULMONARY PRESSURE Pressure Gradient Across Lung OR Distending Pressure Applied to the Lung TRANSPULMONARY PRESSURE = ALVEOLAR PRESSURE– INTRAPLEURAL (INTRATHORACIC) PRESSURE (0 cmH2O) - (-5 cmH2O) = 5 cmH2O SPONTANEOUS VENTILATION Ç Intrathoracic Pressure from Baseline à —9cmH2Os INSPIRATION Ç Alveolar Pressure from Baseline à —4cmH2O Intrathoracic Pressure to Baseline Value as Diaphragm & EXPIRATION Intercostal Muscles Relax (—5 cmH2O) Alveolar Pressure to Baseline Value (0 cmH2O) 1. All of the Following Decrease Lung Compliance, EXCEPT: A. È Secretions APNEIC PATIENT B. Fluid Overload Ç CO2 6 mmHg During the 1st Minute of Apnea C. Fibrosis Ç CO2 3 mmHg Each Additional Minute of Apnea D. Inflammation An Integrated Goal-directed Narrative for the In-Training Exam NON-PULMONARY LUNG FUNCTIONS Air à Warmed, Humidified & Cleaned Olfactory Sensation Secretes Pulmonary Macrophages Immune Function Surfactant Production PUCC - (B)-6 [An Integrated Goal-directed Narrative for the In-Training Exam] PULMONARY & CRITICAL CARE – BASIC EXAM ALVEOLAR SURFACE TENSION Alveolar Fluid Results in Ç Surface Tension TYPE I ALVEOLAR CELLS Alveolar Gas Membrane TYPE II ALVEOLAR CELLS Production of Surfactant SURFACE TENSION Ç Surface Tension (Ç Propensity for Alveolar Collapse) SURFACTANT Lines Each Alveoli (È SURFACE TENSION) TYPE III ALVEOLAR CELLS Alveolar Macrophages PRESSURE = 2 * SURFACE TENSION Ç Surface Tension à Ç Risk of Alveolar Collapse LAW OF La PLACE RADIUS È à Ç Alveolar Radius Risk of Alveolar Collapse EFFECTS OF GENERAL ANESTHESIA ON PULMONARY FUNCTION È Functional Residual Capacity (FRC) È Lung Compliance È Sensitivity to Hypoxia / Hypercarbia Ç Atelectasis (Ç Physiologic Dead Space) Ç Ventilation Perfusion Mismatch Bronchodilation EFFECTS OF SURGERY & ANESTHESIA ON PULMONARY FUNCTION Ç Atelectasis Acute Respiratory Failure Diaphragmatic Dysfunction Pneumonia Pleural Effusion VENTILATOR INDUCED KIDNEY INJURY (VIKI) Associated with Ç Acute Kidney Injury (Independent of Tidal Volume / PEEP Settings) An Integrated Goal-directed Narrative for the In-Training Exam LUNG COMPLIANCE Measurement of ELASTIC RECOIL OF LUNG Ç Secretions PHYSIOLOGY COMPLIANCE = ∆V/∆P FACTORS AFFECTING COMPLIANCE Fluid Overload (Ç Pressure à È Compliance) Inflammation Fibrosis NORMAL VALUE 150-200 mL/cmH2O CLUNG = Change in Lung Volume CCHEST WALL = Change in Chest Volume LUNG COMPLIANCE CHEST WALL COMPLIANCE Change in Transpulmonary Pressure Change in Transthoracic Pressure TOTAL LUNG COMPLIANCE LUNG COMPLIANCE + CHEST WALL COMPLIANCE NORMAL LUNG COMPLIANCE VALUE 100 mL/cm H2O Energy Expended to Inhale (Active) & Exhale (Passive) CAVEATà Exhalation Can Be Active (Auto-PEEP, Acute Respiratory Failure) WORK OF BREATHING Elastic Work à 65% (Lung Recoil, Alveolar Surface Tension) Resistance Work à 35% (Ç Airway Resistance, Endotracheal Tube, Turbulent Flow) WORK = PRESSURE * VOLUME PUCC - (B)-7 [An Integrated Goal-directed Narrative for the In-Training Exam] PULMONARY & CRITICAL CARE – BASIC EXAM CHEST WALL RIGIDITY (WOODEN CHEST SYNDROME) Associated with Opioid Use Results in È Chest Compliance (È Efficiency of Spontaneous Ventilation) à REVERSAL Naloxone Also Treated with SHORT-ACTING Neuromuscular Blockade An Integrated Goal-directed Narrative for the In-Training Exam 2. Which of the Following Statements Regarding Muscles of Ventilation are MOST ACCURATE: à A. Passive Expiration is Dependent upon Lung Compliance VALSALVA È Pre-Load B. Muscles Used for Non-Strenuous Breathing are Fatigue-Resistant, Slow Twitch Fibers HAND GRIP MANEUVER à C. The Diaphragm is Innervated by Cervical Verves 4,5,6 Ç Afterload D. Muscles Used for Strenuous Breathing Lower the Position of the Sternum and Upper Chest GAS FLOW POISEUILLE’S LAW R = 8Lh CONCENTRIC MOVEMENT OF GAS FLOW pr4 LAMINAR GAS FLOW RESISTANCE TO LAMINAR FLOW L à Length of the Tube h à Viscosity r à Radius of the Tube Q à Flow of the Fluid REYNOLD’S NUMBER Re = rnl RANDOM MOVEMENT OF GAS MOLECULES µ TURBULENT GAS FLOW RESISTANCE TO TURBULENT FLOW r à Density of the Fluid n à Kinematic Viscosity of the Fluid l à Length µ à Dynamic Viscosity of the Fluid OXYGEN TRANSPORT IN THE BLOOD TRANSPORTATION Transported Bound to Hemoglobin (MAJORITY = SaO2 * Hgb * 1.34) È Affinity of Oxygen for Hemoglobin in BOHR EFFECT (2 FORMS) Transported Dissolved in Blood (MINORITY = 0.003*PaO2) Environments of Ç CO2 / Acidosis CARBON DIOXIDE TRANSPORT IN THE BLOOD Bicarbonate ~70% Present in RED BLOOD CELLS (NOT PLASMA) Carbamino Compound ~23% + - TRANSPORTATION Dissolved in Blood ~7% CARBONIC CO2 + H2O « H + HCO3 (3 FORMS) Bicarbonate Formed from Carbonic Anhydrase Enzymes in Red Blood Cells ANHYDRASE + + H (Buffered by Hemoglobin) Deoxygenated Hemoglobin Buffered with H Combined with CO2 - HCO3 (Transported in Plasma) CO2 ELIMINATION Alveolar Ventilation HALDANE EFFECT Ç Ability of Deoxygenated Hemoglobin to Transport CO2 FACTORS Ç Pulmonary Blood Flow An Integrated Goal-directed Narrative for the In-Training Exam PUCC - (B)-8 [An Integrated Goal-directed Narrative for the In-Training Exam] PULMONARY & CRITICAL CARE – BASIC EXAM VENTILATORY CONTROL CENTRAL CHEMORECEPTORS LOCATION Medulla Oblongata REGULATORY CONTROL pH FIRST CO2 Through Blood Brain Barrier SECOND Conversion of CO2 to Hydrogen Ions PHYSIOLOGY THIRD Ç Hydrogen Ions Lead to Stimulation of Chemoreceptors FOURTH (Rapid Response (1-2 Minutes)) Ç Tidal Volume & Ç Ventilation FIFTH (Several Hours) Bicarbonate Transported into the Cerebrospinal Fluid to Offset È pH CAROTID CHEMORECEPTORS LOCATION Carotid Bifurcation AFFERENT INNERVATION Glossopharyngeal Nerve (Cranial Nerve IX) Respond Primarily
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