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Conducting zone nose, pharynx, trachea, bronchi,

bronchioles, and terminal
Consists of bronchioles.

Respiratory zone
respiratory bronchioles, alveolar
ducts, and alveoli.
Consists of

Pneumocytes
respiratory bronchioles;
Pseudocolumnar ciliated cells
extend to the

Pneumocytes
Pseudocolumnar ciliated cells
extend to the respiratory
bronchioles

Pneumocytes
terminal bronchioles.
goblet cells extend to the

Pneumocytes
goblet cells
extend to the terminal
bronchioles.
 Type I cells (97% of alveolar
Pneumocytes
surfaces)
%'s
Type II cells (3%)

role of
line the alveoli.
Type I cells

-secrete pulmonary surfactant.

role of
-serve as precursors to type I
cells and other type II cells. Type
Type II cells
II cells

role of secrete a component of surfactant

- degrade toxins - act as reserve
clara cells cells

ratio of in amniotic
A lecithin-to-sphingomyelin
fluid is indicative of fetal
ratio of > 2.0
lung maturity.

bronchopulmonary segment
structure
what is described by RALS––
3°(segmental) bronchus
- 2 arteries (bronchial
and pulmonary) in the center -
veins and lymphatics drain along
the borders.
the heart. The relation of the
pulmonary artery to the
bronchus at each lung hilus
is described by RALS––
Right Anterior; Left
Superior.
 -T8: IVC.

Structures perforating diaphragm -T10: esophagus, vagus (2

trunks).
what and levels
-At T12: aorta (red), thoracic duct
(white), azygous vein (blue).

Pain from the diaphragm can be

the shoulder.
referred to

Inspiration––external intercostals,
scalene muscles, sternomastoids.
Muscles of respiration
Expiration––rectus abdominis,
in exercise internal and external obliques,
transversus abdominis,internal
intercostals.
-Surfactant
-ACE
5 Important lung products -Prostaglandins
-histamine
-Kallikrein
dipalmitoyl phosphatidylcholine
Surfactant
or
aka
lecithin
2T/R
Collapsing pressure =
T=tension
R= radius
 what activates bradykinin Kallikrein

role of Kallikrein activates bradykinin

angiotensin I → angiotensin II;

role of ACE in lung
inactivates bradykinin

lung effects of ACE inhibitors and ACE inhibitors ↑ bradykinin and

other effect cause cough, angioedema)

↓ alveolar surface tension

role of surfactant/mech
↑ compliance

TLC = IRV + TV + ERV + RV

VC = TV + IRV + ERV
 TV + IRV + ERV
IRV + TV + ERV + RV
what causes a shift of the curve
to the right.
what causes a shift of the curve to
the left.
Pulmonary circulation
normal resistnace and compliance
Pulmonary circulation
A ↓ in PaO2 causes
Pulmonary circulation
Perfusion limited
what molecules / when / describe
/ how to change
VC
TLC
An ↑ in all factors (except pH)
A ↓ in all factors (except pH)
Normally a low-resistance, high-
compliance system.
a hypoxic vasoconstriction that
shifts blood away from
poorly ventilated regions of lung
to well-ventilated regions of lung.
O2 (normal health),
-CO2,
-N2O.
Gas equilibrates early along the
length of the capillary. Diffusion
can be ↑ only if blood flow ↑.
 –O2 (exercise, emphysema,
Pulmonary circulation
fibrosis),
-CO.
-Gas does not equilibrate by the
Diffusion limited
time blood reaches the end of the
what molecules / when / describe
capillary.
Normal pulmonary artery pressure
Normal pulmonary artery pressure
= 10–14 mm Hg; or >35 mm Hg
=
during exercise.
and when is it changes
-pulmonary HTN ≥25 mm Hg
Primary––unknown etiology, poor
prognosis.
Pulmonary hypertension

primary vs secondary Secondary––usually caused by

COPD, also can be caused by L
→ R shunt.

(O2 binding capacity × %

O2 content =
saturation) + dissolved O2.

O2 content of arterial blood ↓ as

[Hgb] falls,
O2 changes as Hb falls
but O2 saturation and arterial
PO2 do not.
chronic lung disease; physiologic
shunt ↓ O2 extraction ratio
Arterial PO2 ↓ with
not decrease in Hb
 -1 g Hgb can bind 1.34 mL O2;
-Normally 1 g Hgb can bind
-Hgb amount in blood is 15 g/dL.
-normal Hgb amount in blood
-O2 binding capacity ≈ 20.1 mL
-Normal O2 binding capacity
O2 / dL.

-hypoxemia; causes include

↑ A-a gradient may occur in shunting, high V/Q mismatch,
fibrosis (diffusion block)

1. Bicarbonate (90%)
2. Bound to hemoglobin as
CO2 transport forms
carbaminohemoglobin (5%)
3. Dissolved CO2 (5%)

In lungs, oxygenation of
Haldane effect hemoglobin promotes dissociation
of CO2 from hemoglobin

In peripheral tissue, ↑ H+ shifts

Bohr effect
curve to right, unloading O2
 1. Acute ↑ in ventilation
2. Chronic ↑ in ventilation
3. ↑ erythropoietin
4. ↑ 2,3-DPG
5. Cellular changes (↑
mitochondria)
7 Response to high altitude
6. ↑ renal excretion of bicarbonate
to
compensate for the respiratory
alkalosis
7. Chronic hypoxic pulmonary
vasoconstriction results in RVH
Centriacinar: caused by smoking.
Emphysema
Panacinar: α1-antitrypsin
types with causes
deficiency

Panacinar Emphysema and liver

α1-antitrypsin deficiency leads to
cirrhosis

associated with bullae →can

Paraseptal emphysema: what and rupture →pneumothorax;
who often in young, otherwise healthy
males.

associated with bullae →can

rupture →pneumothorax;
Paraseptal emphysema
often in young, otherwise healthy
males.
 ↑ elastase activity.
Emphysema
Enlargement of air spaces and ↓
recoil resulting from destruction of
pathology
alveolar
walls.
Hypertrophy of mucus glands in
Chronic Bronchitis the bronchioles →Reid index =
gland depth / total thickness of
pathology bronchial wall; in COPD, Reid
index > 50%.

gland depth / total thickness of

Reid index bronchial wall; in COPD, Reid
index > 50%.

Bronchiectasis Chronic necrotizing infection of

bronchi →permanently dilated
pathology airways,

Bronchiectasis
purulent sputum, recurrent
infections, hemoptysis.
complications

Associated with bronchial

obstruction, CF, poor ciliary
causes of Bronchiectasis
motility, Kartagener’s
syndrome.

Can be triggered by viral URIs,

Asthma triggers
allergens, and stress.
 Restrictive lung
a. Poor muscular effort––polio,
disease causes
myasthenia gravis
b. Poor structural apparatus––
Poor breathing mechanics
scoliosis, morbid obesity
(extrapulmonary):
1. (ARDS) 2. Neonatal RDS
Restrictive lung 3. Pneumoconioses
disease 8 types 4. Sarcoidosis
5. Idiopathic pulmonary fibrosis
Interstitial lung diseases 6. Goodpasture’s syndrome
(pulmonary): 7. Wegener’s granulomatosis
8. Eosinophilic granuloma

Pneumoconioses
coal miner’s silicosis, asbestosis
name some

Neonatal respiratory distress

maternal steroids before birth;
syndrome
artificial surfactant for infant.
Tx

Diffuse alveolar damage →↑

Adult acute respiratory distress
alveolar capillary permeability
syndrome (ARDS)
→protein-rich leakage into alveoli.
Results in formation of intra-
pathophys
alveolar hyaline membrane.
-neutrophilic substances toxic to
Adult acute respiratory distress
alveolar wall,
syndrome (ARDS)
-activation of coagulation
cascade,
initial damage due to
-oxygen-derived free radicals.
 Central sleep apnea––no
respiratory effort.
Sleep apnea
Obstructive sleep apnea––
types
respiratory effort
against airway obstruction.

Sleep apnea Person stops breathing for at

least 10 seconds
define repeatedly during sleep.

- systemic/pulmonary
Sleep apnea hypertension,
-arrhythmias,
complications -possibly sudden death.
-chronic fatigue

Asbestosis Diffuse pulmonary interstitial

fibrosis caused by inhaled
mech asbestos fibers.

↑ risk of:
asbestos
pleural mesothelioma
wrt malignancy
bronchogenic carcinoma.
Asbestosis Mainly affects lower
pneumoconioses
lobes. Other pneumoconioses
affect upper lobes (e.g., coal
where in lungs
worker's lung).

Asbestosis and smoking greatly

↑ risk of bronchogenic cancer
Asbestos and smoking
(smoking not additive with
mesothelioma).
 Ferruginous bodies in lung
Asbestosis
(asbestos fibers coated with
hemosiderin). Ivory-white pleural
histo
plaques
-Absent/↓ over affected area
Bronchial obstruction
-↓
-Breath Sounds
-Resonance
-↓
-Fremitus
-Tracheal Deviation
-Toward side of lesion
-↓ over effusion
Pleural effusion
-Dullness
-Breath Sounds
-Resonance
-↓
-Fremitus
-Tracheal Deviation
- NC
-May have bronchial
Pneumonia (lobar) breath sounds over lesion

-Breath Sounds -Dullness

-Resonance
-Fremitus -↑
-Tracheal Deviation
-NC
-↓
Pneumothorax
-Hyperresonant
-Breath Sounds
-Resonance
-Absent
-Fremitus
-Tracheal Deviation
-Away from side of lesion
Breath Sounds, Resonance,
Fremitus, Tracheal Deviation

-Absent/↓ over affected area Bronchial obstruction

-↓
-↓
-Toward side of lesion
Breath Sounds, Resonance,
Fremitus, Tracheal Deviation

-↓ over effusion Pleural effusion

-Dullness
-↓
- NC
Breath Sounds, Resonance,
Fremitus, Tracheal Deviation

-May have bronchial

Pneumonia (lobar)
breath sounds over lesion
-Dullness
-↑
-NC
Breath Sounds, Resonance,
Fremitus, Tracheal Deviation

-↓ Pneumothorax
-Hyperresonant
-Absent
-Away from side of lesion
SPHERE of complications:
-Superior vena cava syndrome
-Pancoast’s tumor
Lung cancer -Horner’s syndrome
-Endocrine (paraneoplastic)
complications -Recurrent laryngeal symptoms
(hoarseness)
-Effusions (pleural or
pericardial)
 Lung cancer -Squamous cell carcinoma

which types are central -Small-cell

Adenocarcinoma:
Lung cancer Bronchial
Bronchoalveolar
which types are peripheral
Large cell carcinoma
Lung cancer
Hilar mass arising from bronchus;
describe Squamous cell Cavitation;
carcinoma (gross)

Lung cancer
-Squamous cell carcinoma
which have strong smoking
-Small-cell
association

Lung cancer
Small-cell (oat-cell) carcinoma
Undifferentiated → very
aggressive

Lung cancer
Small-cell (oat-cell) carcinoma
ectopic production of ACTH or
ADH

Lung cancer
Small-cell (oat-cell) carcinoma
Lambert-Eaton syndrome.
 Lung cancer histology Neoplasm of neuroendocrine
Kulchitsky cells → small dark
Small-cell (oat-cell) carcinoma blue cells.

Lung cancer histology

Keratin pearls and intercellular
bridges.
Squamous cell carcinoma

Lung cancer histology

Neoplasm of neuroendocrine Small-cell (oat-cell) carcinoma

Kulchitsky cells → small dark
blue cells
Lung cancer histology
Squamous cell carcinoma
Keratin pearls and intercellular
bridges
Lung cancer histology
both types of Adenocarcinoma:
Bronchial
Clara cells → type II pneumocytes
and
multiple densities on x-ray of
Bronchoalveolar
chest.
Lung cancer histology

Pleomorphic giant cells with Large cell carcinoma

leukocyte fragments in
cytoplasm.

Lung cancer histology Both Types: Clara cells → type II

pneumocytes multiple densities
Adenocarcinoma on x-ray of chest.
 Lung cancer histology Pleomorphic giant cells with
leukocyte fragments in
Large cell carcinoma cytoplasm.

Lung cancer characteristics

Develops in site of prior
pulmonary inflammation or injury
Adenocarcinoma: Bronchial

Lung cancer characteristics

Adenocarcinoma: Bronchial
most common lung CA in non-
smokers

Lung cancer characteristics

Adenocarcinoma: Bronchial
Develops in site of prior
pulmonary inflammation or injury

Lung cancer characteristics

Adenocarcinoma:
Bronchoalveolar
Not linked to smoking.

Lung cancer characteristics

Squamous cell carcinoma
parathyroid-like activity → PTHrP

Lung cancer characteristics

Squamous cell carcinoma
Hilar mass arising from bronchus;
Cavitation
 Lung cancer characteristics
Large cell carcinoma
Highly anaplastic undifferentiated
tumor; poor prognosis.

Lung cancer characteristics

Highly anaplastic undifferentiated
tumor; poor prognosis.
Large cell carcinoma

Secretes serotonin, can cause

Lung cancer characteristics carcinoid
syndrome (flushing, diarrhea,
Carcinoid tumor wheezing,
salivation).
Lung cancer characteristics
Carcinoid tumor
flushing, diarrhea, wheezing,
salivation
Lung cancer characteristics

most common. Brain (epilepsy),

Metastases
bone (pathologic fracture), and
liver (jaundice,
hepatomegaly).

cough, hemoptysis, bronchial

Lung cancer common
obstruction, wheezing, pneumonic
presentation features
“coin” lesion on x-ray film.

cough, hemoptysis, bronchial

obstruction, wheezing, pneumonic Lung cancer
“coin” lesion on x-ray film.
 Carcinoma that occurs in apex of
Pancoast’s tumor
lung and may affect cervical
sympathetic plexus, causing
where and findings
Horner’s syndrome.

Carcinoma that occurs in apex of

lung and may affect cervical
sympathetic plexus, causing
Horner’s syndrome.
Kulchitsky cells
Lambert-Eaton syndrome
findings
Pancoast’s tumor
Enterochromaffin (EC) cells
(Kulchitsky cells) are a type of
enteroendocrine cell[1] occurring
in the epithelia lining the lumen of
the gastrointestinal tract. also
implicated in the origin of small
cell lung cancer.
progressive weakness that does
not usually involve the respiratory
muscles and the muscles of face.
In patients with affected ocular
and respiratory muscles, the
involvement is not as severe as
myasthenia gravis. The proximal
parts of the legs and arms are
predominantly affected.

Lambert-Eaton syndrome
small-cell lung cancer, lymphoma,
non-Hodgkin's lymphoma
causes
progressive weakness that does
not usually involve the respiratory
muscles and the muscles of face.
In patients with affected ocular
and respiratory muscles, the Lambert-Eaton syndrome
involvement is not as severe as
myasthenia gravis. The proximal
parts of the legs and arms are
predominantly affected.

Small-cell carcinoma
oat-cell carcinoma
aka

oat-cell carcinoma
Small-cell carcinoma
aka

Lobar - Pneumococcus usually

Bronchopneumonia - S. aureus,
H. flu, Klebsiella, S. pyogenes
Pneumonia types with different
organism causes
Interstitial (atypical) pneumonia -
viruses (RSV, adenoviruses),
Mycoplasma,
Legionella, Chlamydia

Intra-alveolar exudate →
Lobar pneumonia Characteristics consolidation; may involve entire
lung
 Acute inflammatory infiltrates
from bronchioles into
Bronchopneumonia
adjacent alveoli; patchy
Characteristics
distribution involving ≥ 1
lobes

Diffuse patchy inflammation

Interstitial (atypical) localized to interstitial areas
pneumonia Characteristics at alveolar walls; distribution
involving ≥ 1 lobes

Which type of pneumona

Intra-alveolar exudate → Lobar

consolidation; may involve entire
lung
Which type of pneumona

Acute inflammatory infiltrates

from bronchioles into Bronchopneumonia
adjacent alveoli; patchy
distribution involving ≥ 1
lobes
Which type of pneumona

Diffuse patchy inflammation Interstitial (atypical)

localized to interstitial areas at pneumonia
alveolar walls; distribution
involving ≥ 1 lobes

Which type of pneumona

Lobar
Pneumococcus most frequently
 Which type of pneumona
Bronchopneumonia
S. aureus

Which type of pneumona

Interstitial (atypical)
pneumonia
Viruses (RSV, adenoviruses)

Which type of pneumona

Interstitial (atypical)
pneumonia
Mycoplasma, Chlamydia

Which type of pneumona

Interstitial (atypical)
pneumonia
Legionella

Interstitial pneumonia
atypical pneumonia
aka

atypical pneumonia Interstitial

aka pneumonia

Which type of pneumona

Bronchopneumonia
S. aureus
 Which type of pneumona
Bronchopneumonia
H. flu

Which type of pneumona

Bronchopneumonia
Klebsiella

Which type of pneumona

Bronchopneumonia
S. pyogenes

Localized collection of pus within

parenchyma, usually resulting
from bronchial
obstruction (e.g., cancer) or
what are Lung abscess and who
aspiration of gastric contents
gets them
(especially in patients
predisposed to loss of
consciousness, e.g., alcoholics or
epileptics).
Pleural effusions what and causes ↓ protein content.
of
Due to CHF, nephrotic syndrome,
Transudate or hepatic cirrhosis.

Pleural effusions what and causes ↑ protein content, cloudy. Due to

of malignancy, pneumonia, collagen
vascular disease,
Exudate trauma.
Which type of Pleural effusion
Transudate
↓ protein content

Which type of Pleural effusion

Transudate
CHF

Which type of Pleural effusion

Transudate
nephrotic syndrome

Which type of Pleural effusion

Transudate
hepatic cirrhosis

Which type of Pleural effusion

Exudate
↑ protein content, cloudy

Which type of Pleural effusion

Exudate
malignancy

Which type of Pleural effusion

Exudate
pneumonia,
Which type of Pleural effusion
Exudate
collagen vascular disease

Which type of Pleural effusion

Exudate
↑ protein content

Which type of Pleural effusion

Exudate
cloudy

Which type of Pleural effusion

Exudate
trauma

1st generation H1 blockers Diphenhydramine,

dimenhydrinate,
names chlorpheniramine.

1st generation H1 blockers

Allergy, motion sickness, sleep
aid.
Clinical uses

1st generation H1 blockers

Sedation, antimuscarinic, anti-α-
adrenergic.
Toxicity
 1st generation H1 blockers
Reversible inhibitors of H1
histamine receptors.
mech

2nd generation H1 blockers

Reversible inhibitors of H1
histamine receptors.
mech

2nd generation H1 blockers

Loratadine, fexofenadine,
desloratadine.
names

2nd generation H1 blockers

Allergy.
names

2nd generation H1 blockers

Far less sedating than 1st
generation.
names

Asthma drugs
Isoproterenol
name the Nonspecific β-agonists

Asthma drugs
Isoproterenol Nonspecific β-agonists relaxes
bronchial smooth muscle (β2).
mech and uses
 Asthma drugs
Isoproterenol Nonspecific β-agonists Adverse
effect is tachycardia (β1).
toxicity

Asthma drugs
Albuterol and Salmeterol
name the β2 agonists

Asthma drugs
β2 agonist relaxes bronchial
Albuterol
smooth muscle (β2). Use during
acute exacerbation.
mech and uses

Asthma drugs
Salmeterol β2 agonist long-acting agent for
prophylaxis.
mech and uses

Asthma drugs
Salmeterol Adverse effects are tremor and
arrhythmia.
toxicity

asthma drug
Salmeterol
Adverse effects are tremor and
arrhythmia.

Asthma drugs
Theophylline
name the Methylxanthines
 Asthma drugs Methylxanthine - likely causes
Theophylline bronchodilation by inhibiting
phosphodiesterase, thereby ↓
mech and uses cAMP hydrolysis.

Asthma drugs Usage is limited because

Theophylline of narrow therapeutic index
(cardiotoxicity,
tioxicity neurotoxicity).

Asthma drugs

Usage is limited because Methylxanthines: Theophylline

of narrow therapeutic index
(cardio and neuro toxicity).

Asthma drugs
Ipratropium
name the muscarinic antagonists

Asthma drugs
competitive block of muscarinic
Ipratropium
receptors, preventing
bronchoconstriction.
mech and uses

Prevents release of mediators

Cromolyn from mast cells. Effective
only for the prophylaxis of
mech and uses asthma. Not effective
during an acute asthmatic attack.
1. Nonspecific β-agonists
2.β2 agonists
Asthma drugs 3. Methylxanthines
4. Muscarinic antagonists
7 different Tx drug classes 5. Cromolyn
6. Corticosteroids
7. Antileukotrienes
 Cromolyn
Toxicity is rare.
toxicity

Asthma drugs
Beclomethasone, prednisone
name the corticosteroids

inhibit the synthesis

of virtually all cytokines. Inactivate
Asthma drugs
NF-κB, the
Beclomethasone, prednisone
transcription factor that induces
the production of
mech
TNF-α, among other inflammatory
agents.

1st-line therapy for chronic

Beclomethasone, prednisone
asthma.

Zileuton
name the Antileukotrienes
Zafirlukast, montelukast

A 5-lipoxygenase pathway
Zileuton inhibitor. Blocks conversion of
arachidonic acid to leukotrienes.
mech and uses
asthma

A 5-lipoxygenase pathway
inhibitor. Blocks conversion of Zileuton
arachidonic acid to leukotrienes.
 Zafirlukast, montelukast––block
Zafirlukast, montelukast leukotriene receptors.

mech and uses Especially good for aspirin

induced asthma.

block leukotriene receptors. Zafirlukast, montelukast

Especially good for aspirin

Zafirlukast, montelukast
induced asthma.

-Guaifenesin (Robitussin)
Expectorants

names
-N-acetylcystine

Guaifenesin
Robitussin
aka

Robitussin
Guaifenesin
aka

Removes excess sputum but

Guaifenesin large doses necessary; does not
suppress cough reflex.
mech and uses
Expectorants
Removes excess sputum but
Guaifenesin
large doses necessary

Mucolytic → can loosen mucus

N-acetylcystine
plugs in CF patients.

Mucolytic → can loosen mucus

N-acetylcystine plugs in CF patients.

mech and uses also used as an antidote for

acetaminophen overdose

antidote for acetaminophen

N-acetylcystine
overdose