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1. Atelectasis and Thoracic or abdominal surgery is an indication for incentive spirometry. 2.

The volume of air that the patient inspires when performing incentive spirometry should approximate inspiratory capacity. 3. Retained secretions, Respiratory muscle insufficiency, Hypoventilation, contribute to the development of atelectasis. 4. Hypoxemia, Postanesthesia recovery, Acute myocardial infarction are indications for oxygen therapy.

5. IPPB is indicated in all of the following situations, inability to clear secretions atelectasis that does not respond to other therapies short term ventilation aerosol delivery when muscle fatigue is present 6. Increased temperature, patchy markings on CXR, tracheal shift toward the affected area, elevated diaphragm, are clinical signs of atelectasis.

7. Maintain normoxia, decrease myocardial work, provide enriched oxygen environment for increased metabolic needs associated with severe trauma, are therapeutic objectives of oxygen therapy. 8. The optimal patient response to treatment with incentive spirometry would be Chest radiograph is negative for atelectasis. 9. Upper airway edema, Sputum induction, Postextubation edema, Bypass of the upper airway, are indications for aerosol therapy.

10. Asthma may be described as either Intrinsic, or extrinsic. 11. The initial ABG during an acute asthmatic episode usually describes the acid base status as Acute hyperventilation. 12. All of the following therapeutic agents are recommended for use during acute asthmatic episodes, Albuterol Epinephrine Corticosteroids Oxygen

13. A critical cell count in determining prophylactic treatment as well as monitoring disease progression in AIDS is : CD4 14. Pentamidine aerosolization is found helpful in preventing : Pneumocystis infection 15. All of the following are routinely used in the treatment of pulmonary infection in AIDS patients, Trimethoprim / sulfamethoxazole Aerosolized pentamidine Glucocorticoids Isoniazid

16. The key practice in preventing cross contamination in the health care setting is : Practicing universal precautions 17. Maintain clear CXR , is an appropriate therapeutic goal for pentamidine aerosol therapy. 18. Obtaining of sputum samples , Foreign body aspiration , Assessment of the airway , An aid in intubation , are indications for flexible fiberoptic bronchoscopy.

19. Responsibilities involved in bronchoscopy assisting include : Setup of the scope Cleaning of the instruments Specimen retrieval and preparation for laboratory studies Delivery of aerosolized drugs Evaluating the patient response

20. Elements of proper sputum induction include : Use of hypertonic saline aerosol Ultrasonic nebulization Good patient effort Bronchoalveolar lavage and aspiration Oral cavity gargling ( preferably with hypertonic saline ) before procedure . 21. Obesity , Cor pulmonale , Excessive daytime Sleepiness , Abnormal heart rhythms are routinely associated with OSAS .

22. Presence of muscular ventilatory efforts during apneic period are noted on EMG , are true of OSAS but not Central Sleep Apnea . 23. After physical assessment of a patient presenting for sleep study , you note jugular venous distention , significant hypertension , and a history of COPD . You also find that the patient is polycythemic . What problem is illustrated by this data ? Cor pulmonale .

24. During polysomnography of a person who has been sleeping for 4 hours , the EEG tracing abruptly flattens . All other parameters remain unchanged . The technician should : Carefully reattach the electrode . 25. Indications for the institution of Continuous Positive Airway Pressure include all of the following : > For treatment of Obstructive Sleep Apnea > To increase FRC > To treat apnea of prematurity > As an adjunct in bronchial hygiene .

26. Acceptable objectives for CPAP intervention in the treatment of Obstructive Sleep Apnea are : > To reduce the number of sleep apnea episodes > To decrease oxygen desaturation during sleep > To minimize or prevent cardiac dysrhythmias during sleep > To minimize daytime somnolence as reported by patient > To significantly decrease the incidence of symptoms including headache , agitation , and loud snoring

27. Alternate treatments for sleep apnea include : > Weight reduction > Sleep positioning > Tongue retaining devices > Tracheostomy > Pharmacological intervention

28. Diagnosis of Guillain Barre syndrome is supported by : High protein concentration in the cerebrospinal fluid .

29. Relative contraindications to directed coughing include all of the following : > Inability to control possible transmission of infection from the patients suspected or known to have pathogens transmittable by droplet nuclei . > Elevated intracranial pressure or intracranial aneurysm . > Reduced coronary artery perfusion , such as in myocardial infarction . > Acute head , neck , or spine injury .

30. Indications for postural drainage include : > Evidence of difficulty mobilizing secretions > Presence of atelectasis > Presence of foreign body in the airway . 31. Following are true regarding IPPB : > It may cause pulmonary barotrauma > It should produce a Vt greater than the spontaneous one > It is contraindicated when evidence of tracheoesophageal fistula is present .

32. Indications for PEP therapy include : > The need to reduce air trapping in obstructive disease > The need to mobilize secretions > The need to reverse atelectasis

33. Following pulmonary data signify an intact , well functioning pulmonary system : > Spontaneous Vt = 7 mL / kg > Spontaneous VC = 15 mL / kg

34. Laryngotracheobronchitis ( LTB ) is usually Viral in nature . 35. The usual prodrome for LTB consists of : > Upper respiratory infection ( URI ) > Low grade fever 36. The drug of choice for inpatient treatment of LTB is : Racemic epinephrine 37. LTB would be considered severe when : > PaCO2 increases with a corresponding drop in pH > Inspiratory stridor is present > Oxygen saturation <90 percent

38. Perform CPR , Defibrillate @ 200 J , Defibrillate at 200 to 300 J , Defibrillate @ 360 J , Administer lidocaine , is the correct sequence for treatment of ventricular fibrillation .

39. Cao2 , Sao2 , Pao2 , Fio2 , is required to calculate an estimated shunt .

40. Following medications may be administered via endotracheal tube in an emergency resuscitation: > Epinephrine > Atropine > Lidocaine > Naloxone

41. Information needed to compute a static compliance are : > Corrected tidal volume > Plateau pressure > PEEP 42. The hemodynamic factor most reflective of left heart function is : PCWP 43. Following are likely causes of pulmonary edema : > Ventricular failure

> Pulmonary aspiration > Near drowning > Head injury

44. The normal gradient between arterial and end tidal carbondioxide ( PaetCO2 ) is : 4.5 mm Hg 45. The ECG changes associated with myocardial infarction include : > ST segment elevation > Inversion of T waves > Appearance of Q waves 46. Following are risk factors contributing to coronary artery disease : > Obesity > Smoking > Sedentary lifestyle > Elevated LDLC 47. Creatine kinase , Lactate dehydrogenase , are the enzymes routinely used in diagnosing and monitoring myocardial infarction .


1.) Heart rate 60 90 2.) systemic BP Systolic : 90 140 Diastolic : 60 90 3.) Central venous pressure 1 6 4.) Pulmonary artery pressure Systolic : 15 25 Diastolic : 5 15 5.) Pulmonary capillary wedge pressure 5 12 6.) Cardiac output 5 8 L / min 7.) Arterial partial pressure of oxygen ( Pao2 ) 80 100

48. When a patient is on positive pressure ventilation , he or she may experience the adverse effects of : > Hyperinflation of the lungs > Gastric irritation > Decreased transmural heart pressures > Decreased renal perfusion 49. Current guidelines for reimbursement of home oxygen include : Presence of Sao2 < 85 % 50. During basic life support delivery , using a manual resuscitator for ventilation , the RCP sees that the victims abdomen becomes markedly distended . The RCP should recommend : Endotracheal intubation

51. Signs associated with a tension pneumothorax include all of the following : > Absence of breath sounds over the affected area > Lack of markings on CXR > Increased inspiratory pressures > A decrease in dynamic lung compliance

52. The first line drug for the treatment of ventricular dysrhythmia in adults is : Lidocaine 53. Urine output is considered within the normal range if it is : 30 to 50 mL / h

54. Evaluation of proper airway placement includes : > Auscultation of breath sounds > Chest X ray > Passage of a suction catheter through the tube > End tidal CO2 measurement 55. All of the following describe the neonatal airway : > It has a relatively large tongue > The narrowest part is the cricoid ring > The epiglottis lies horizontally > It has a very compliant chest wall

56. When the RCP suctions a nasally intubated neonate who has a size 3.0-mm endotracheal tube in place , respiratory distress is noted . To correct this , the RCP should : Hyperoxygenate before the procedure 57. The CXR associated with meconium aspiration syndrome will likely reflect : Hyperinflation 58. To drain an empyema , the chest tube should be inserted in : The 6th or 7th interspace in the midaxillary or posterior axillary line

59. Following represent suctioning complications in the neonate : > Infection > Atelectasis > Increased BP > Bradycardia > Pneumothorax 60. When a neonate is being resuscitated in the delivery room and he or she is found to have a heart rate of 40 bpm without spontaneous respirations , what should be done ? > Give chest compressions > Perform mechanical ventilations

61. Following are limitations to the use of pulse oximetry : > Motion artifact > Low perfusion states > Skin pigmentation > Abnormal hemoglobin's

62. Oxygen in the home care setting is indicated when : Sao2 < 85% in subjects breathing room air
63. Respiratory distress syndrome ( RDS ) is generally associated with : Low-birth-weight neonates

64. Fluid status may be evaluated by assessing : > Urine output > Blood pressure > Skin turgor > Jugular venous distention 65. Measurement of central venous pressure is most closely reflected by : Right atrial pressure 66. Hypokalemia is detected when :

Potassium < 3.5 mEq / L

67. If a patient were to contract a nosocomial staphylococcal infection , IMPROPER HANDWASHING is the most likely transmission route . 68. Respiratory distress may occur when carboxyhemoglobin levels reach : 5 to 10 percent

69. An absolute contraindication to the use of postural drainage is : Acute spinal injury

70. Respiratory failure is the inability to maintain either the normal delivery of oxygen to the tissues or the normal removal of carbondioxide from the tissues 71. Acute respiratory failure is identified by a Pao2 < 60 mmHg and / or a PaCo2 > 50 mmHg in otherwise healthy individuals at sea level . 72. Type 1 ( Hypoxemic ) respiratory failure occurs when the primary problem is inadequate oxygen delivery .

73. The primary causes of hypoxemia are : > Ventilation / Perfusion mismatch > Shunt > Alveolar hypoventilation > Perfusion / diffusion impairment > Decreased inspired oxygen 74. Type 2 ( Hypercapnic ) respiratory failure describes bellows failure of the lungs resulting in elevated carbondioxide levels . Hypercapnic respiratory failure is also known as Ventilatory failure .

75. The three major disorders responsible for hypercapnic respiratory failure ( ventilatory failure ) are : > Decreased ventilatory drive > Respiratory muscle fatigue or failure > Increased work of breathing 76. The use of PEEP during mechanical ventilation allows the clinician to Splint the lung in a position of function by increasing the FRC . An increase in the FRC opens collapsed alveoli and small bronchioles , thereby improving Ventilation Perfusion ratios .

77. PEEP is defined as the maintenance of positive airway pressure at the end of expiration . 78. The main goal of PEEP is to achieve a Pao2 of greater than 55 60 mmHg with an Fio2 of less than or equal to 60 % while avoiding significant cardio-vascular sequelae . 79. COPD is a chronic disorder , that limits a patients ability to work and , in severe cases , impairs the activities of daily living . 80. The most prominent symptoms of COPD are ,dyspnea and an impaired exercise capacity . 81. Rehabilitation :- restoration of the individual to the fullest mental , emotional , social , and vocational potential of which he (or) she is capable .

82. Patients with COPD manifest decreased exercise tolerance . The most important factors thought to contribute to this limitation are :-

> Alterations in pulmonary mechanics . > Dysfunction of the respiratory muscles . > Peripheral muscle dysfunction . > Abnormal gas exchange . > Malnutrition . > Development of dyspnea . > Active smoking .

83. The first heart sound ( S1 ) is created by closure of the Tricuspid valve and Mitral valve 84. In most respiratory illness , what symptom is present in 80% to 90% of the patients ? Cough 85. What is the name for the sensation of difficult or uncomfortable breathing ? Dyspnea 86. What type of chest pain is characterized by a crushing tightness often radiating to the neck , shoulders , and arms ? Angina pectoris 87. Patients who have chronic pulmonary disease with swelling of the lower extremities may have : Cor pulmonale

88. Bradycardia is a heart rate less than : 60 beats / min

89. What is the normal range of adult blood pressure ? 110 - 130 / 70 - 80 mmHg 90. What is the normal inspiratory expiratory ratio ( I : E ) of bronchial breath sounds in adults ? 1 : 1.5

91. Chest percussion is a useful diagnostic clinical tool in which of the following entities ? The level of diaphragmatic excursions 92. In which clinical entities would hyperresonance over the thorax be heard ? Pneumothorax 93. What added lung sound is characterized as high pitched , sibilant , or whistling from partial obstruction of airways ? Wheeze 94. Heart sounds heard over the right second intercostal space near the right sternal border originate from the : Aortic valve

95. According to the 1987 statement of standardization of spirometry by the ATS , spirometers must meet the following minimal standards for measuring vital capacity ( VC ) ? > Accumulate volume for at least 30 seconds > Be capable of measuring volumes of at least 7 L > Measure volume independent of flow between 0 and 12 L / sec > Have an accuracy of at least + or 3% of reading or 50 mL , whichever is greater 96. How should the adult patient be positioned when a pulmonary function test is performed ? Sitting or Standing 97. For forced vital capacity ( FVC ) reproducibility to be present according to ATS standards , what criteria must be met ? The best two of at least three acceptable attempts should be within + or 5% or 100 mL , whichever is greater

98. In what time period is the maximum voluntary ventilation ( MVV ) maneuver performed ? 12 seconds 99. All actual spirometry values should be converted to : Body temperature , ambient pressure , saturated with water vapor ( BTPS ) 100. Following methods can be used to determine FRC : > Helium dilution > Nitrogen washout > Body plethysmography 101. What gas law describes how the body plethysmograph operates ? Boyles law

102. What gas analyzer measures concentration by actually counting the relative number of ionized molecules of each gas ? Mass spectrometer

103. What device is used to determine physiologic dead space ? Douglas bag 104. The respiratory quotient is defined as : CO2 production / O2 consumption 105. What type of oxygen electrode is in arterial blood gas analyzers ? Polarographic

106. When a blood sample is introduced into a blood gas analyzer , carbondioxide diffuses across the membrane according to what gas law ? Henrys law 107. Carboxyhemoglobin and Methemoglobin can be determined by spectrophotometry

108. Bronchial breath sounds over lung periphery indicate ? Pneumonia 109. Flattening of the diaphragms on chest film are generally consistent with which clinical entity ? Emphysema

110. Elevated serum creatinine is indicative of : Renal disease 111. Which of the following would be the darkest on an X ray film ? Air 112. What is a desirable platelet count to prevent spontaneous bleeding ? > 40,000
113. Hypoalbuminemia and hypoproteinemia may lead to : Pulmonary edema 114. What technique can be used to visually inspect the airways ? Bronchoscopy

115. What is the advantage of magnetic resonance imaging ( MRI ) over a lateral X ray film ? Better three dimensional perspective 116. What estimate of postoperative forced expiratory volume in 1 second ( FEV1 ) indicates that pulmonary resection will usually be tolerated ? > 800 mL 117. An ( FEV1 / FVC ) which is > 73% usually rules out : Obstructive lung disease 118. Which pulmonary function test should be used to evaluate the reversibility of small airway diseases ? Pre and postbronchodilator spirometry

119. Which agent is used to image pulmonary perfusion ? Technetium macroaggregated albumin

120. Following are considered risks for surgery ? > Cigarette smoking > Old age > Obesity > Chronic lung disease 121. Which of the following tests evaluates the patients motivation to cooperate following surgery ? MVV 122. Which tests evaluates the surface area of the alveolar capillary membrane ? DLco

123. The ventilatory pump is a bellows comprised of the ribs , bony thorax , and respiratory muscles . > Contraction of the diaphragm during inspiration causes an enlargement of the thoracic cage , producing relatively negative pressures at the alveolar level . This causes atmospheric air to be drawn into the alveoli . With expiration the diaphragm relaxes , the thorax becomes smaller , and air flows from the alveoli back out into the atmosphere through the same system of conducting airways . Ventilation is therefore a to and fro movement of air .

124. Motor innervation to the diaphragm occurs via the phrenic nerve , which is derived from the third through fifth cervical nerves 125. The visceral and parietal pleura join one another at the lung hila 126. The parietal pleura contains abundant pain fibers derived from the intercostal nerves 127. The visceral pleura does not contain pain fibers 128. At rest , average intra pleural pressure is about 4 cm H2O 129. The upper respiratory tract is primarily designed to purify , warm , and humidify the air ; it consists of the nose , paranasal sinuses , pharynx , and larynx

130. Resistance to airflow is higher in the nose than in the mouth because of this intricate system of baffles ( the nose contains baffles that are bathed by thin , watery secretions designed to trap foreign particles and add moisture to the inspired air ) . This explains mouth breathing during vigorous exercise . In this case , the valuable air conditioning function of the nose is lost , and dry , cold air may enter the lower airways . In patients with abnormal irritability of the bronchi , inspiration of cold air through the mouth during exercise may initiate bronchospasm 131. Normally , there are about 23 generations of airways , of which the first 16 are conducting airways and the last 7 are respiratory airways 132. Hoarseness is an ominous sign in patients with carcinoma of the lung . Other diseases , such as granulomas , lymphomas , and aortic aneurysms , may also interrupt the left recurrent laryngeal nerve in the mediastinum

Mechanisms in Asthma
1. Triggers : - ( Allergens , Viruses , Bacteria , Fungi , Irritants ) 2. Cell Activation : - Antibodies and immune cells activate leukocytes and tissue cells 3. Mediator Release : - Cell activation and subsequent release of cell toxic mediators like ECP ( Eosinophil Cationic Protein ) , EPX ( Eosinophil Protein X ) , EPO ( Eosinophil Peroxidase ) , MPO ( Myeloperoxidase ) destroy the epithelium and other tissue . This open up for direct contacts between allergens and other triggers and nerve cells , resulting in direct irritation , secretion , leakage , oedema , and bronchoconstriction as well as formation of new connective tissue 4. Physiological responses : - Oedema , Glandular secretions , Plasma leakage , Epithelial permeability , Connective tissue formation , Muscle constriction , Nerve activation 5. Symptoms : - Wheezing , Shortness of breath , Coughing , Phlegm , Chest tightness

Postural Drainage Positions

Upper Lobes : 1. ) Apical Segments of both Upper Lobes Sitting Upright 2. ) Posterior Segment of Right Upper Lobe Left side lying , turned 45 degree towards prone 3. ) Posterior Segment of Left Upper Lobe Right side lying , turned 45 degree towards prone , shoulders raised 30 cm 4. ) Anterior Segments of both Upper Lobes Supine

Middle Lobe : 1. ) Lateral and Medial Segments Supine , quarter turned to left , foot of bed raised 35 cm Lingula : 1. ) Superior and inferior Segments Supine , quarter turned to right , foot of bed raised 35 cm

Lower Lobe : 1. ) Apical Segments of both lower lobes Prone , head turned to side 2. ) Anterior basal Segments of both Lower Lobes Supine , foot of bed raised 45 cm 3. ) Posterior basal Segments of both Lower Lobes Prone , head turned to side , foot of bed raised 45 cm 4. ) Medial basal Segment Right side lying , foot of bed raised 45 cm 5. ) Lateral basal segment Left side lying , foot of bed raised 45 cm

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Mechanical Ventilation
Indications :1. ) Severely impaired gas exchange 2. ) Rapid onset of respiratory failure 3. ) An inadequate response to less invasive medical treatments 4. ) Increased work of breathing with evidence of respiratory muscle fatigue

Parameters that can help to guide the decision as to whether mechanical ventilation is needed include respiratory rate ( >35 ) ; vital capacity ( <10-15 ml / kg ) ; PaO2 ( <60 mmHg with FiO2 >60% ) ; PaCO2 ( >50 mmHg with pH <7.35 ) ; and an absent gag ( or ) cough reflex Arterial blood gases should be checked 15 minutes after initiation of mechanical ventilation , and settings changed accordingly

Complications of Mechanical Ventilation :-

1. ) Barotrauma has traditionally referred to the rupture of small airways and alveolar walls by high pressure 2. ) Volutrauma has been described as pulmonary edema , diffuse alveolar damage , and epithelial and microvascular permeability resulting from overdistention of airspaces rather than actual rupture

To minimize lung trauma resulting from excessive airway and alveolar pressure and volume , two measurements are noted : 1. ) Plateau pressure ( P plat ) , is static pressure measured at end inspiration . P plat represents the pressure imposed on distended alveoli 2. ) Auto-PEEP , is the pressure remaining in airways and alveoli at the instant before inspiration

Auto-PEEP develops when a positivepressure breath is delivered before complete exhalation of the previous breath . As a result , air becomes trapped and pressure within the lungs increases . This can lead to complications such as barotrauma and pneumothorax

Ventilator ; is an electro-mechanical device , that an amount of air is pushed to the Respiratory system
Two forms of therapeutic device may be used , 1. ) Positive pressure ventilation 2. ) Negative pressure ventilation

Positive pressure ventilation :- Delivering positive

pressure to the airway

Negative pressure ventilation :- Providing

intermittent negative pressure within pleural space / around the thoracic cage

Primary function of ventilators :1. To facilitate the movement of gas into the lungs 2. To ensure adequate oxygenation 3. To ensure adequate elimination of CO2 4. To control the rate of alveolar ventilation 5. To increase the lung volume 6. To increase the chest wall compliance 7. To decrease the work of breathing

As a general rule , the cuff on an endotracheal ( or ) tracheostomy tube should be inflated . The pressure within the cuff should be the lowest possible that allows delivery of adequate tidal volumes and prevents pulmonary aspiration .

Usually the pressure is maintained at less than 25 cm H2o to prevent injury and at more than 20 cm H2o to prevent aspiration . Cuff pressure must be monitored at-least every 8 hours

Complications of Intubation
1. 2. 3. 4. 5. Tube malposition Esophageal intubation Significant aspiration Laryngeal damage Pneumothorax

Tube malposition can be identified shortly after intubation by auscultation of bilateral axillae

Causes of Respiratory acidosis :1. 2. 3. 4. 5. 1. 2. 3. 4. 5. COPD Severe asthma CNS depression Mechanical under ventilation Neuromuscular disease Asthma Mechanical over ventilation Restrictive lung disease Hepatic failure Hypoxemia

Causes of Respiratory alkalosis :-

In mechanically ventilated patients , respiratory acidosis is corrected by an increase in the minute ventilation ( Vt * RR )
Oxygenation may be improved by an increase in FiO2 ( or ) PEEP
Mean arterial pressure = SBP + 2 ( DBP ) / ( divided by ) 3 = 70 105 mm Hg

The most common complication of mechanical ventilation is barotrauma . High pressure can lead to rupture of the alveolar wall , which in turn can lead to pneumomediastinum , pneumothorax , pneumoperitoneum , and subcutaneous emphysema . Other common complications include increased intracranial pressure , fluid retention , local trauma to the nares and mouth , tracheal necrosis , renal failure .

PEEP ( Positive End Expiratory Pressure ) ; is defined as the maintenance of positive airway pressure at the end of expiration . In so

doing , the alveoli fail to collapse and functional residual capacity increases . The end result is improved ventilation-perfusion matching in the pulmonary circulation . PEEP is usually set at 2.5 ( or ) 5.0 cm H2o . It can be applied to the spontaneously breathing patient in the form of CPAP ( or ) to the patient who is receiving mechanical ventilation . The appropriate

application of PEEP usually increases lung compliance and oxygenation while decreasing the shunt fraction and the work of breathing . PEEP is used primarily in patients with hypoxic respiratory

failure ( e.g., ARDS ; Cardiogenic Pulmonary Edema ) . Low levels of PEEP

( 3-5 cm H2o ) may also be useful in patients with COPD , to prevent dynamic airway collapse from occurring during expiration . The main goal of PEEP is to

achieve a PaO2 of greater than 55-60 mm Hg with an FiO2 of less than ( or ) equal to 60% while avoiding significant cardiovascular sequelae .
Usually , PEEP is applied in 3 to 5 cm H2o increments during monitoring of oxygenation , organ perfusion , and haemodynamic parameters . Patient who receive significant levels of PEEP ( i.e., > 10 cm H2o ) should not have their PEEP removed abruptly , because removal can result in collapse of distal lung units , the worsening of shunt , and potentially life threatening hypoxemia .

Modes of Ventilation
1. CMV ( Continuous Mandatory Ventilation or Controlled Mechanical Ventilation ) :- In this mode , the rate and tidal volume are controlled by the machine . All breaths are mandatory breaths and there is no mechanism for patient triggering ( if patients can trigger , it becomes Assist Control ) . CMV is used for patients who are unconscious ( or ) whose respiratory muscles are paralysed and for those who need their PaCO2 tightly controlled .

2. In Assist-Control Ventilation , the patient can breath at his own rate assisted by the machine but in addition , the machine delivers a minimum set number of controlled breaths at the rate set on the machine . 3. In Intermittent Mandatory Ventilation ( IMV ) , the patient is allowed to breath spontaneously with no machine assistance but the machine delivers a minimum set rate and tidal volume . The potential danger is that the timing of machine rate has no correlation to the inspiratory effort of the patient so stacking of breaths can occur ( the machine could try to force a tidal volume during a spontaneous exhalation phase ) .

4. In Synchronised Intermittent Mandatory

Ventilation ( SIMV ) , which is similar to IMV , breath stacking is sought to be avoided by synchronising the mandatory breath delivered by the machine to the patients inspiratory effort i.e. the mandatory breath is triggered by the patient . If no triggering occurs for a specified duration , the mandatory breath is delivered .

5. Pressure Support : Set inspiratory assist pressure No set tidal volume ( or ) rate Patient must be able to initiate breaths , after which the ventilator delivers a preset airway pressure May need to convert to another mode if patient is sedated and can no longer initiate breaths Monitor RR , exhaled Vt and patient effort

Acclimatisation to altitude involves progressive increase in ventilation over days and progressive polycythaemia over weeks . Too rapid an ascent to altitude risks life-threatening pulmonary and cerebral oedema The presence of a pneumothorax , recent sub aqua diving ( or ) severe respiratory failure are contraindications to commercial aircraft flight Pulmonary infections , especially tuberculosis ( or ) pneumocystis carinii may be the presentation of , as well as a complication of , AIDS HIV infection impairs immunity by the slow , steady attrition in CD4+Th lymphocyte numbers . PCP becomes inevitable when CD4-lymphocyte counts fall below 200 mm3 In COPD ; the airways obstruction is due principally to loss of airway supports and small airway fibrosis rather than the potentially more reversible obstruction due to bronchial inflammation in asthma

The most relevant , sleep-associated , respiratory changes are the diminution of muscle tone , especially during REM sleep . This risks both respiratory under ventilation and increased upper airway resistance ( or ) closure .
Thoracoscopy :- Traditionally , a single , rigid ,

viewing scope with an operating channel is inserted percutaneously into the pleural space . Thoracoscopy allows both pleural surfaces to be inspected , biopsies to be taken and insufflation of a sclerosant for pleurodesis .

Emergency Medications
1. 2. 3. 4. 5. 6. 7. 8. 9. Adrenaline Nor-adrenaline Atropine Dopamine Dobutamine Lignocaine Pethidine Morphine Aminophylline

acute asthma

Reversible airways obstruction ; Severe


To treat mucosal congestion of rhinitis and is a vasopressor used in shock

acute sinusitis ; to relieve bronchial asthmatic paroxysms

Nor-adrenaline Atropine
and salivation

Pre-operative medication to inhibit secretions

In treatment of ventricular arrhythmias Sibutramine is an orally administered agent for the

treatment of obesity

1. ) Inhalational corticosteroids :
Beclomethasone inhalers

Aminophylline Levosalbutamol Budesonide inhalers Formoterol inhalers Fluticasone inhalers

2. ) Systemic corticosteroids :

1. 2. 3. 4. 5. Lignocaine Digoxin Propranolol Amiodarone Adenosine

1. 2. 3. 4. Reserpine Propranolol Sodium Nitroprusside Hydralazine

1. 2. 3. 4. Amantadine Ribavirin Interferon-Alpha Acyclovir

1. Amphotericin-B 2. Fluconazole 3. Griseofulvin

Anti-infective Drugs
1. 2. 3. 4. Providone Iodine Chloramphenicol Sulfonamides Nystatin

Antihistamines ( Non-Sedative )
1. 2. 3. 4. 5. Levocetirizine Astemizole Terfenadine Loratadine Cetirizine

are used for suppression of cough are used mainly for unproductive dry cough and if the cough is hazardous . ( e.g. Cardiac disease , Hernia , Ocular surgery ) The principal antitussives are Codeine , Dextromethorphan , Oxolamine , Morphine

Retreatment Agents ( for MDR-TB )

1. 2. 3. Capreomycin Ethionamide Kanamycin

Neuromuscular Drugs
1. 2. Succinyl choline Pancuronium

are drugs which reduce viscosity of bronchial secretion , hence the removal is facilitated by coughing E.g. :- Potassium iodide , Ammonium chloride , Potassium and Sodium citrate , Vasaka , Balsum of Tolu

Oxygen delivery techniques

1. ) Nasal cannula : Flow rate ( L / min ) :- 1 - 6 Conc. delivered ( % ) :- 24 44 Other :- Inspired O2 conc. depends on flow rate and patients tidal volume

2. ) Simple face mask : Flow rate ( L / min ) :- 6 10 Conc. delivered ( % ) :- 35 60 Other :- May promote CO2 retention at lower flow rates

3. ) Venturi mask : Flow rate :- 2 12 lts / min Conc. delivered :- 24 60 % Other :- Accurately controls proportion of inspired O2 . Use in patients with chronic hypercarbia ( i.e., COPD ) 4. ) Face mask with O2 reservoir : Flow rate :- 12 15 lts / min Conc. delivered :- 60 90 % Other :- Provides high inspired O2 concentration 5. ) BagValvemask : Flow rate :- 15 lts / min Conc. delivered :- 100 % Provides the highest inspired O2 concentration

Spirometry is a precise diagnostic test used to determine the condition of a patients lungs An instrument called a spirometer quickly and accurately measures the flow rate ( speed of air ) and the volume ( amount ) of air exhaled by the patient while performing a standardized maneuver A spirometer can assist a physician in early diagnosis and detection of pulmonary disease . Once treatment has begun , a spirometer can determine the response to therapy and document the course of the disease Spirometry is often performed as a screening procedure Spirometry is recommended as the gold standard for diagnosis of obstructive lung disease Behavior modification such as smoking cessation can be reinforced by spirometry Spirometry is a reimbursable test both by Medicare and third party carriers

Spirometry is a patient dependent test . If the patient does not do the maneuver properly the results are not meaningful The flow / volume curve is more sensitive than the volume / time curve . In addition , when an inspiratory breath is included in the FVC maneuver , a complete flow / volume loop can be generated The purpose of the curve is to confirm that the test was done correctly and that the patient gave their best effort

The patients effort is compared to a set of normal values ( or ) predicted values based on the age , height , sex and race of the patient
The inability to reach the normal level of volume could indicate the possibility of restriction ( or ) restrictive lung disease If the flow rate is less than normal it could be an indication of obstruction ( or ) obstructive lung disease

The American Thoracic Society suggests that individuals meeting any one of the following criteria should have at least one spirometry test performed annually :
Smokers over 40 years old History of shortness of breath upon exertion ( or ) at rest History of chronic cough ( or ) sputum production History of wheezing ( or ) chest tightness History of frequent colds ( or ) allergic rhinitis Occupational exposure to inhaled dust ( or ) chemicals All patients with asthma , bronchitis and other lung diseases All patients on bronchodilator Pre-operatively for all patients scheduled for thoracic ( or ) upper abdominal surgery

1. 2. 3. 4. 5. 6. 7. 8. 9.

Restrictive Defects
This category of disease includes chest wall dysfunction , neurologic diseases resulting in paralysis of the muscles of inspiration , dysfunction of the diaphragm , absent lung tissue , and scarring of the lungs as with interstitial lung disease . Atelectasis and obesity are two of the more common causes of a restrictive lung defect . Atelectasis , is caused by persistent ventilation with small tidal volumes ( or ) by resorption of gas distal to obstructed airways . Patients who have undergone upper abdominal ( or ) thoracic surgery are at the greatest risk for atelectasis . Lung expansion therapy ( Incentive Spirometry Sustained , maximal inspiration ) corrects atelectasis by increasing the transpulmonary pressure gradient . This can be accomplished by deep spontaneous breaths ( or ) by the application of positive pressure . The most common problem associated with lung expansion therapy is the onset of respiratory alkalosis , which occurs when the patient breathes too fast .

Combined Defects
Certain diseases can result in both obstructive and restrictive defects . Two examples are , i. ) Sarcoidosis ii. ) Severe emphysema i. ) Sarcoidosis , in its final stages severely reduces volume and limits airflow . ii. ) Severe emphysema , which results in obstruction to airflow out of the lungs . Thus the residual volume gas in the lung slowly increases and eventually restricts the volume of air that can be inspired . The net result is a combined obstructive and restrictive defect .

Vital Capacity
Both restrictive and obstructive diseases can decrease VC . i. ) Restrictive lung disorders reduce FVC by shrinking the lung . ii. ) Obstructive lung dysfunction , causes a decrease in the FVC by causing a slow rise in the RV .

A slow exhalation may allow more air to be exhaled from the lung because , a slow exhalation helps reduce air trapping . In some patients , forceful exhalation causes airways to close prematurely because of the high intrathoracic pressures produced . This early closure may spuriously decrease the measured VC volume as gas is trapped distal to the airway closure and cannot be exhaled .

Vital capacity is an important pre-operative assessment factor . Significant reduction in VC ( less than 20 ml / kg of ideal body weight ) indicates that the patient is at a high risk for post-operative respiratory complications . This is because VC reflects the patients ability to take a deep breath , to cough , and to clear the airways of excess secretions . VC is also useful in evaluating the patients need for mechanical ventilation . A vital capacity of less than 15 ml / kg indicates that the adult patients ventilatory reserve is decreased significantly .

Closed-system Helium Dilution Method

Helium is used because , it is an inert gas and is not significantly absorbed from the lungs by the blood . This test is based on the principle that if a known volume and concentration of helium are added to the patients respiratory system , the helium will be diluted in proportion to the size of the lung volume to which it is added . Helium is breathed at Vt , while oxygen is added to replace the oxygen that is consumed by the patient during the test . The CO2 must be absorbed out of the closed system to prevent an increase in the dilutional effect on the helium and a falsely enlarged FRC measurement . If leaks occur with this method , the measured volumes will be overestimated . Other factors influencing the quality of the test include ; 1. ) the blower speed of the device . 2. ) how soon the technician stops the test after equilibrium is achieved . 3. ) the ventilatory pattern of the patient being tested . 4. ) if parts of the lung communicate poorly with the atmosphere , the results will be inaccurate .

The use of helium in laryngeal ( or ) tracheal obstruction , is based on the relationship of breathing energy to gas density . If obstruction is significant and the work of breathing air ( or ) oxygen is very high , mixtures of helium and oxygen may be respired with less effort . Helium is an inert gas with limited medical applications ; its widest use is probably in deep diving . Helium is usually mixed with 20% oxygen for this purpose to replace nitrogen . Among its advantages are low density ( one seventh that of nitrogen ) , which allows easier breathing of the mixture under hyperbaric conditions , and lower solubility in tissue lipids than nitrogen ( one third ) . The result is less stress in breathing , with reduced decompression sickness and decompression time .

Clinical features of hypoxaemia

1. 2. 3. 4. 5. 6. Cyanosis Tachypnoea Tachycardia arrhythmias / bradycardia Peripheral vasoconstriction Respiratory muscle weakness Restlessness Confusion Coma .

Clinical features of hypercapnia

1. 2. 3. 4. 5. 6. 7. Flapping tremor of hands Sweating Tachypnoea Tachycardia Bradycardia Peripheral vasodilation leading to warm hands and headache Respiratory muscle weakness Drowsiness Hallucinations Coma .

Diffusion Capacity
The ability of gas to diffuse across the alveolar-capillary membrane can be measured . The determinants of gas exchange across the membrane include the following :1. ) Diffusion coefficient of the gas used in testing . 2. ) Surface area of the membrane . 3. ) Thickness of the membrane . 4. ) Blood volume and flow in the pulmonary capillary tree . 5. ) Distribution of the inspired gas . 6. ) Hematocrit ( is the ratio of red cell volume to that of whole blood ) .

Diffusion , is measured by using carbon-monoxide at minute levels ( 0.4% ) . Because of carbon-monoxides intensive affinity for hemoglobin ( over 200 times greater binding power to hemoglobin than oxygen ) , the ability of carbon-monoxide to diffuse is limited by the membrane and not by capillary blood flow . It is therefore , a diffusion-limited gas rather than a perfusion-limited gas . -----------*---------*--------*---------*---------*----------*--------*-------- Obesity is a multifactorial disorder of energy balance in which chronic calorie intake is greater than energy output . Obesity hinders movement of the diaphragm and increases the work of breathing ( making inspiration more difficult ) . The main treatment of obesity is a suitable diet and increased exercise . There are , at present only two drugs licensed for the treatment of obesity , Sibutramine and Orlistat .

Disorders of the Neuromuscular Junction

1. 2. 3. Myasthenia gravis Lambert-Eaton syndrome Poisoning ( Organophosphate , Tetanus , Botulism )

Disorders of the Nerves

1. 2. Guillain-Barre syndrome Phrenic Nerve damage and Diaphragmatic Paralysis

Disorders of the Spinal Cord

1. 2. Amyotrophic Lateral Sclerosis Poliomyelitis

Disorders of the Brain

1. Stroke

Disorders of the Thoracic Cage

1. 2. 3. Kyphoscoliosis Flail Chest Ankylosing Spondylitis

Lower Respiratory Tract Infections

1. 2. 3. Pneumonia Lung abscess Tuberculosis

Neonatal Cardio-pulmonary Disorders

1. 2. 3. Respiratory distress syndrome Bronchopulmonary dysplasia Meconium aspiration

Airway Disorders of the Pediatric Patient

1. 2. 3. 4. 5. Epiglottitis Laryngotracheobronchitis ( Croup ) Bronchiolitis Cystic Fibrosis Foreign Body Aspiration

Chronic Obstructive Pulmonary Disease

1. 2. 3. 4. 5. Emphysema Chronic bronchitis Asthma Cystic Fibrosis Bronchiectasis


Forced Vital Capacity :- is the maximum volume of gas that can be expired when the patient exhales as forcefully and rapidly as possible after a maximal inspiration . Criteria for Acceptability FVC maneuver :Maximal effort ; no cough ( or ) glottic closure during the first second ; no leaks ( or ) obstruction of the mouthpiece . Good start-of-test ; back-extrapolated volume less than 5% of FVC ( or ) 150 ml Tracing shows 6 seconds of exhalation ( or ) an obvious plateau ; no early termination ( or ) cutoff . Three acceptable spirograms obtained ; two largest FVC values within 200 ml ; two largest FEV1 values within 200 ml .

3. 4.

Look at the FEV1 / FVC ratio first if obstruction is suspected . If the FEV1 / FVC ratio is lower than expected , obstruction is present . If the ratio is normal ( or ) elevated , check the percent predicted for FVC and FEV1 . If FVC and FEV1 are both reduced compared with the expected values , and FEV1 / FVC is normal ( or ) high , restriction may be present .

The term air trapping is sometimes used to describe an increase in FRC and RV . The term hyperinflation is used to describe the absolute increase in TLC .

Total Lung Capacity ( TLC ) is an important diagnostic tool in both obstructive and restrictive lung diseases . In restriction , the TLC is usually less than 80% of the predicted value . In obstruction , the TLC is either normal ( or ) increased ( hyperinflation ) .
FRC values greater than approximately 120% of predicted values represent air trapping .

FRC , RV , and TLC are typically decreased in restrictive diseases .

Bronchial challenge testing is used to identify and characterize airway

hyperresponsiveness . Challenge tests are performed in patients with symptoms of bronchospasm who have normal pulmonary function studies . Bronchial challenge tests are sometimes used to screen individuals who may be at risk from environmental ( or ) occupational exposure to toxins . Several commonly used provocative agents can be used to assess airway hyperreactivity . These include the following : 1. ) Methacholine challenge 2. ) Histamine challenge 3. ) Eucapnic voluntary hyperventilation 4. ) Exercise

Methacholine is a chemical that increases parasympathetic tone in

bronchial smooth muscle . Histamine triggers a similar response producing bronchoconstriction .

Hyperventilation , either at rest ( or ) during exercise , results in heat

and water loss from the airway . This provokes bronchospasm in susceptible patients .

If FEV1 / FVC ratio is greater than 70% and FEV1 is also greater than 70% ; we should do Bronchoprovocation test . Patients to be tested should be asymptomatic , with no coughing ( or ) obvious wheezing . Their baseline FEV1 should be greater than 70% of their expected value . If the patient has an FEV1 less than 1.0 to 1.5 L , there is a risk that a large drop in FEV1 following methacholine challenge might leave the individual with compromised lung function . Bronchial challenge by inhalation of methacholine is performed by having the patient inhale increasing doses of the drug . Most clinicians consider the test positive when inhalation of methacholine precipitates a 20% decrease in FEV1 . The methacholine concentration at which this 20% decrease occurs is called the Provocative Concentration ( or ) PC20% . Patients who truly have asthma usually display a 20% decrease in FEV1 . The lower the dose of methacholine , the more sensitive , ( or ) hyperresponsive , the patients airways are . If FEV1 decreases 20% after the diluent ( or ) the first dose of methacholine , PC20 should be reported as less than the lowest concentration administered . If FEV1 does not decrease by at least 20% after the highest dose , PC20 should be reported as greater than 16 mg/ml .

Some patients whose FEV1 drops 20% ( or ) more at low doses of methacholine may not have asthma . Hyperreactive airways are also found in some patients with COPD who smoke ( or ) in patients who have allergic rhinitis .

A negative methacholine challenge ( i.e., a decrease in FEV1 < 20% at the highest dose ) may occur in patients who have asthma that has been suppressed by anti-inflammatory medications .
Some asthmatics may have their asthma triggered by exposure to a specific agent such as cold dry air .


When the PaCO2 is chronically above 50 mmHg the respiratory center becomes relatively insensitive to CO2 as a respiratory stimulant , leaving hypoxemia as the major drive for respiration . Oxygen administration may remove the stimulus of hypoxemia , and the patient develops Carbondioxide narcosis unless the situation is quickly reversed . Therefore , oxygen is only administered with extreme caution . Certain infections , such as Mycobacterium tuberculosis ; atypical tuberculosis ; Pneumocystis carinii ; histoplasmosis ; and mycoplasma ; are readily diagnosed by Broncho Alveolar Lavage . Moraxella Catarrhalis is being increasingly recognized as a cause of bacterial pneumonia , especially in the elderly . It is the second most common bacterial cause of acute exacerbation of COPD .

Indications for Flexible Bronchoscopy 1. Diagnostic : Lung Cancer Positive Sputum Cytology Paralyzed Vocal Cord Unexplained Pleural Effusion Hemoptysis Cough Diffuse interstitial infiltrates Immuno Compromised patient with Pulmonary infiltrates Ventilator-associated Pneumonia Endotracheal tube position / patency Atelectasis Tracheal esophageal fistula Acute inhalation injury Bronchography

2. Therapeutic : Mucous plugs Foreign body removal Difficult intubation Stent placement Balloon dilation Laser ablation Brachy therapy Acute lobar collapse Electrocautery Hemoptysis -----*----------*----------*----------*----------*----------*-----

Sleep a period of rest for the body and mind , during which volition and
consciousness are in abeyance and bodily functions are partially suspended ; also described as a behavioral state , with characteristic immobile posture and diminished but readily reversible sensitivity to external stimuli .

Snore rough , noisy breathing during sleep , due to vibration of the

Uvula and Soft palate . Sleep is regulated by the reticular formation . Epilepsy , brain tumor , brain abscess , cerebral trauma , subdural hematoma , meningitis , encephalitis , cerebral vascular accident , and congenital defects of the brain represent types of conditions in which electroencephalography is useful . The electroencephalogram is widely used as a guide in surgery of the epileptic .

German psychiatrist Hans Berger , introduced the term

electroencephalogram ( EEG ) to denote the record of the variations in brain potential . The interpretation of the EEG depends on the frequency , amplitude , form , and distribution of the wave activity present .

Sleep Disorders :1. 2. Insomnia :- It can be relieved temporarily by Sleeping Pills , especially benzodiazepines , but prolonged use of any of these pills is unwise . Sleep-walking ( Somnambulism ) :- Episodes of sleep-walking are more common in children than in adults and occur predominantly in males . They may last several minutes . Somnambulists walk with their eyes open and avoid obstacles , but when awakened they cannot recall the episodes . Bed-wetting ( nocturnal enuresis ) . Narcolepsy :- is a disease in which there is episodic sudden loss of muscle tone and an eventually irresistible urge to sleep during daytime activities . Sleep apnea :- is caused by obstruction of the airway during inspiration . This can occur at any age and is produced when the pharyngeal muscles relax during sleep . In some cases , failure of the genioglossus muscles to contract during inspiration contributes to the blockage , these muscles pull the tongue forward , and when they do not contract the tongue falls back and obstructs the airway . The symptoms are loud snoring , morning headaches , fatigue , and daytime sleepiness . When severe and prolonged , the condition apparently causes hypertension and its complications . Sleep apnea can be relieved by teaching subjects not to sleep on their backs , by avoidance of respiratory depressants such as hypnotics and alcohol , and , in more severe cases , by positive airway pressure during sleep .

3. 4. 5.

NREMs ( non-rapid eye movement sleep ) :- the deep , dreamless period of sleep during which the brain waves are slow and of high voltage , and autonomic activities , such as heart rate and blood pressure , are low and regular . ( or ) Slow-wave sleep :- four stages of progressively deepening sleep ( i.e., it becomes harder to wake the subject ) . REMs :- the period of sleep during which the brain waves are fast and of low voltage , and autonomic activities , such as heart rate and respiration , are irregular . This type of sleep is associated with dreaming , mild involuntary muscle jerks , and rapid eye movements ( REM ) .

Distribution of sleep stages :- In a typical

night of sleep , a young adult first enters NREM sleep , passes through stages 1 and 2 , and spends 70-100 minutes in stages 3 and 4 . Sleep then lightens , and an REM period follows . This cycle is repeated at intervals of about 90 minutes throughout the night . The cycles are similar , though there is less stage 3 and 4 sleep and more REM sleep toward morning . Thus , there are Four to Six REM periods per night .

Sleep apnea , is defined as a cessation of airflow for at least 10 seconds , which occurs during sleep . Obstructive apnea occurs , when respiratory effort is present but the upper airway is so occluded that no air enters the lungs . Central apnea , is characterized by the absence of respiratory effort .

OSA is thought to occur because of an upper airway occlusion during sleep . This occlusion may be caused by several factors , including micrognathia ( small lower jaw ) , large tongue , large tonsils , retrognathia ( underdevelopment of the mandible ) and deviated septum . Although the exact mechanism remains unclear , it is clear that the most common site of the obstruction is in the pharynx .

Pathophysiology ( OSA ) :- During sleep , the tissues in the

upper airway relax to levels not seen during the waking state . As the airway becomes occluded there is a tremendous increase in upper airway resistance . In response to the occlusion , the inspiratory muscles contract more forcefully and cause an increased negative intrathoracic pressure to overcome the obstruction . This is analogous to breathing through a wet soda straw . As you try to pull air through the straw , it actually closes more tightly . The upper airway obstruction may cause apnea , hypercarbia , and hypoxemia . The events eventually rouse the patient to a lighter stage of sleep ( or ) wakefulness , and muscle tone returns to the upper airway . Breathing resumes and the patients blood gases return to baseline levels . As the patient returns to a deeper stage of sleep the process starts again . Thus , the patient with OSA may cycle between deeper and lighter stages of sleep several hundred times each night .

The Multiple Sleep Latency Testing , is a reliable and valid test used to assess objective daytime sleepiness . The patient who consistently falls asleep in less than 8 minutes during a daytime nap is suffering from a sleep disorder that needs immediate attention . If patients fall asleep quickly ( within 8 minutes ) and enter REM sleep in less than 15 minutes , this is highly suggestive of narcolepsy .

1. 2. 3.

4. 5.

6. 7. 8.

Montelukast :- a leukotriene antagonist used as an antiasthmatic in the prophylaxis and chronic treatment of asthma . Midazolam :- a benzodiazepine tranquilizer , used as the maleate ester for sedation and in the induction of anesthesia . Morphine :- the principal and most active alkaloid of Opium ; used as narcotic ( inducing drowsiness ( or ) very sleepy ) analgesics ( pain killing drugs ) . Gentamicin :- an antibiotic complex , effective against many gram negative bacteria , especially Pseudomonas species . Ribavirin :- a broad spectrum antiviral used in the treatment of severe viral pneumonia caused by respiratory syncytial virus , particularly in high - risk infants . Pentamidine :- an anti-infective used as the isethionate salt and effective against Pneumocystis carinii . Amiodarone :- a potassium channel blocker used in the treatment of Ventricular arrhythmias . Above and beside the vocal cords is a pair of Vestibular folds , usually called False Vocal Cords . The True vocal cords are held in place and regulated by a pair of Arytenoid , Cuneiform and Corniculate Cartilages .

Bronchial Hygiene Therapy , involves the use of non-invasive airway clearance techniques designed to help mobilize and remove secretions and improve gas exchange . Traditionally , BHT involves Postural Drainage , Percussion , and Vibration ( PDPV ) , combined with cough training . Chest Physical Therapy , involves not only airway clearance techniques but also various exercise protocols and breathing retraining methods .

1. 2. 3. 4. 5. 6. 7.

Cardio Pulmonary Resuscitation :- Aim is to fill the Left Ventricle with blood . Cardiac Arrest :- Causes ; Hypoxia Hypotension Hypovolemia Hypokalaemia Electrolyte imbalance Tension Pneumothorax Tamponade

Defibrillator , should be used only if the patient has Ventricular Fibrillation ( or ) Ventricular Tachycardia . There is no use of using defibrillator , if the patient has Asystole .

1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11. 12. 13. 14.

Terms Commonly Used To Describe Breathing :Apnea : Absence of spontaneous ventilation Dyspnea : Unpleasant awareness of difficulty breathing Hypopnea : Decreased depth of breathing Eupnea : Normal rate and depth of breathing Bradypnea : Less than normal rate of breathing Tachypnea : Rapid rate of breathing Hyperpnea : Increased depth of breathing with ( or ) without an increased rate Hypoventilation : Decreased alveolar ventilation , caused by either a decreased rate ( or ) decreased depth of breathing ( or ) both Hyperventilation : Increased alveolar ventilation caused by either an increased rate ( or ) increased depth of breathing ( or ) both Orthopnea : Dyspnea in the recumbent position but not in the upright ( or ) semi vertical position Treopnea : Dyspnea in one lateral position but not in the other lateral position Platypnea : Dyspnea caused by upright posture and relieved by a recumbent position Orthodeoxia : Arterial oxygen desaturation ( hypoxemia ) that is produced by assuming an upright position and relieved by returning to a recumbent position Air hunger : A grave sign indicating the need for immediate transfusion

Paroxysmal Nocturnal Dyspnea : is the sudden onset of difficult breathing that occurs when a sleeping patient is in the recumbent position . It is often associated with coughing and is relieved when the patient assumes an upright position . In patients with congestive heart failure , PND usually occurs 1 to 2 hours after lying down . In COPD patients , PND usually occurs on lying down and is often relieved by coughing and expectorating sputum . Chronic Dyspnea : is almost always progressive . It begins with dyspnea on exertion and overtime progresses to dyspnea at rest . COPD , Chronic Congestive Heart Failure , and severe Anemia are the most common causes in adults .

P / F ratio = PO2 / FiO2 = e.g. : 33 / 21% = 33 / 0.21 Maximum Heart Rate for a person during Cardio Pulmonary Exercise Testing should be 220 age . Body Mass Index , can be used to determine if ones weight is proportion to ones height . It is also valuable for determining health risks and dietary interventions .

The most prevalent disorders of connective tissues are auto-immune diseases ( diseases in which antibodies produced by the immune system fail to distinguish what is foreign from what is self and attack the bodys own tissues ) Some Auto-immune diseases :Rheumatoid arthritis SLE Myasthenia gravis ( Result :- Progressive neuromuscular weakness , breathing difficulty ) Multiple Sclerosis Good pastures syndrome ( Result :- Pulmonary hemorrhage , Kidney failure )

1. 2. 3. 4. 5.

An acute self-limiting cough is usually due to the Common Cold Chronic persistent cough is most commonly caused by postnasal drip syndrome , followed by asthma , gastro esophageal reflux , chronic bronchitis , bronchiectasis , and other conditions such as left heart failure , bronchogenic cancer and sarcoidosis . In smokers , chronic cough is usually due to chronic bronchitis .

1. 2. 3. 4. 5. 6. 7. 8.

Appearance of sputum and the possible cause :

Clear , colorless like egg white Normal Black Smoke ( or ) coal dust inhalation Brownish Cigarette smoker Frothy white ( or ) Pink Pulmonary edema Silicone-like casts Bronchial asthma Yellow ( or ) green , copious Pseudomonas pneumonia , advanced chronic bronchitis , bronchiectasis ( separates into layers ) Foul odor ( fetid ) Lung abscess , Bronchiectasis Blood streaked ( or ) hemoptysis Bronchogenic carcinoma , Tuberculosis , coagulopathy

What is the maximum depth that the standard adult bronchoscope can visualize in most patients ? Sixth-level bronchi For what purpose are lasers used during bronchoscopy ? To obliterate obstructing tumors What is the most common indication for the use of a bronchoscope ? To help diagnose abnormalities seen on chest X-ray For what condition is the rigid bronchoscope most likely to be used ? Massive hemoptysis Why is the patient undergoing bronchoscopy who develops hypoxemia less likely to demonstrate arrhythmias ? Use of Xylocaine before the procedure The respiratory therapist assisting the pulmonologist during a bronchoscopy should have medication cups of Xylocaine , normal saline , and epinephrine ( Adrenaline : Use Cardiac arrest ) ready before beginning the procedure What is the most common sign of Xylocaine overdose during bronchoscopy ? Seizures Stable vital signs ; no bleeding present ; and gag reflex present are most important criteria before discharge of the patient after bronchoscopy

Intermittent absence of respiratory effort , is the key concept related to the

definition of Central

Sleep Apnea

Relaxation of the upper airway muscles ; tremendous increase in upper airway resistance ; more forceful contraction of the inspiratory muscles ; is believed to be responsible for the onset of Obstructive

Apnea Enlarged tonsils and adenoids ; is most likely to cause

Obstructive Sleep Apnea in children

More than 40 apneas per hour of sleep , is the criterion

for severe Sleep Apnea Normal body temperature ( euthermia ) varies between 97* and 99.5* F ( 36* and 37.5* C ) orally . Fever ( hyperthermia , pyrexia ) is an elevation of body temperature above the normal range . Pulmonary infections , including lung abscess , empyema ( infection within the pleural space ) , tuberculosis , and pneumonia are all accompanied by fever Early morning headache may be the first indication that the patient is retaining abnormally high amounts of carbon dioxide

Pursed Lips Breathing exercise is to delay the airway closure in COPD patients Gold standard for the diagnosis of COPD is Spirometry High pressure alarms in ventilators are due to bronchospasm ; increased secretions ; and cough Low pressure alarms are due to disconnection ( or ) leak in the tubing's and inadequate cuff pressure Long Term Oxygen Therapy is most useful for COPD and Central Sleep Apnea patients Collapse :- a state of extreme prostration ( exhaustion ) and depression , with failure of circulation Prednisone :- used as an anti-inflammatory and immunosuppressant Creatinine :- measurements of its rate of urinary excretion are used as diagnostic indicators of kidney function and muscle mass

1. 2. 3. 4. 5. 6.

Idiopathic Pulmonary Fibrosis :- Chronic inflammation and progressive fibrosis of the pulmonary alveolar walls ; with progressive dyspnea and potentially fatal lack of oxygen ( or ) right heart failure . The acute form is called Hammanrich syndrome Pulmonary Tuberculosis :- infection of the lungs by Mycobacterium tuberculosis , with tuberculous pneumonia , formation of tuberculous granulation tissue , caseous necrosis , calcification and cavity formation . Symptoms include ; Weight loss Fatigue Night sweats Purulent sputum Hemoptysis Chest pain

Interstitial Lung Disease :- Diseases that affect the supporting

structures of the lung rather than the airspaces are covered by the umbrella term ILD . Inflammatory changes lead to alveolitis , which may resolve ( or ) progress to patchy fibrosis , thickened alveolar septa , remodeling of parenchyma and shrunken , stiff lungs . Smoking augments the damage . Involvement of alveoli means involvement of capillaries , and the term Collagen Vascular Disease can overlap with ILD . The two main effects are : Increased lung stiffness , which increases the work of breathing Decreased surface area of the alveolar-capillary membrane , which impairs gas exchange Fibrosing alveolitis is the commonest ILD Pneumoconiosis SLE Scleroderma Sarcoidosis
Rheumatoid disease

1. 2.

A chest drainage system is an extension of the patients pleural space The anterior chest ( second interspace in the mid clavicular line ) is used for draining a pneumothorax ; the axillary area ( 4th , 5th or 6th costal interspace in the mid-axillary line ) is used for fluid drainage The mediastinum is the extra pleural space of the thorax . It is bounded by the ; i. ) lungs laterally ii. ) chest wall anteriorly iii. ) paraspinous gutters posteriorly iv. ) thoracic inlet superiorly v. ) diaphragm inferiorly Thoracentesis is the basic pleural investigation in all conditions associated with significant pleural effusion . Thoracentesis is a mandatory diagnostic step , if imaging findings show the presence of accessible pleural fluid collections . The main complications of thoracentesis is pneumothorax

Medical thoracoscopy was introduced into diagnosis of diseases of the chest by Jacobaeus in Sweden .

Thoracoscopy :- gold-standard technique for the diagnosis of pleural disease . Thoracoscopy allows visualization of most intrathoracic structures . Therefore , apart from pleural
effusion , the classical spectrum of indications also includes interstitial lung disease , pneumothorax and localized disease of the lung , chest wall and diaphragm , as well as mediastinal lesions . Thoracoscopy also provides considerable management advantages both in effusion and in pneumothorax because it ensures optimal visual placement of drains . In addition it may be used for therapeutic interventions such as pleurodesis in malignant effusion and pneumothorax


Blood supply to and from the lungs can be divided into two components bronchial circulation and pulmonary circulation ) Arterial blood flowing through the bronchial circulation is supplied by the aorta . Bronchial circulation is but one component of the total systemic circulation , and it serves to meet the metabolic demands of the lung tissue . Bronchial circulation supplies blood to and from the entire tracheobronchial tree to the level of the terminal bronchioles ) The pulmonary circulation begins in the right ventricle and ends in the left atrium , and supplies blood to the respiratory bronchioles , alveolar ducts and alveoli . Blood flow through the pulmonary circulation allows gas exchange to occur . The pulmonary circulation is a high-flow and lowpressure circuit


During inspiration , the diaphragm contracts and the lung expands as a result of pressure in the pleural space becoming increasingly sub atmospheric . The pressure gradient created between the airway opening of the mouth and alveoli causes air from the atmosphere to fill the lungs Discontinuous adventitious lung sounds ( e.g., Crackles ) are produced by the sudden opening of collapsed airways ( or ) by the movement of air through excessive airway secretions . Crackles are present predominantly during the inspiratory phase , while continuous sounds , ( e.g., wheeze ) , are heard more commonly during exhalation A Lung abscess is a cavitated , infected , necrotic lesion of the lung parenchyma . Most lung abscesses are secondary to aspiration of oropharyngeal secretions . It is important to exclude malignancy ( or ) other cause of endobronchial obstruction , so bronchoscopy is usually necessary

Summary of the control of oxygen and CO2 content in the blood :-

1. ) Oxygen is taken into the lungs during inspiration , and CO2 is expelled during expiration 2. ) Oxygen diffuses through the alveolar membrane into the blood , and CO2 diffuses from the blood into the lumen of the alveolus 3. ) Oxygen rich blood passes from the lungs to the heart and from the heart to the body cells 4. ) Oxygen diffuses from the blood into the body cells , and CO2 diffuses from the body cells into the blood 5. ) Blood poor in oxygen and rich in CO2 passes from body cells to the heart , and then to the lungs 6. ) Increased CO2 in the blood stimulates chemo receptors in the heart ( aortic bodies ) and in blood vessels ( carotid bodies ) 7. ) Carotid and aortic bodies send nerve impulses to the respiratory center in the brain stem 8. ) The respiratory center in the brain stem sends impulses to the diaphragm , internal intercostal muscles , and heart 9. ) Impulses to diaphragm and intercostal muscles increase respiratory rate to excrete excess CO2 10. ) Impulses to heart increase heart rate , which pumps more blood to the lungs in order to eliminate excess carbon dioxide

1. 2. 3. 4. 5. 6. 7. 8. 9.

Finger Clubbing :- loss of the nail-fold angle to bulbous expansion of the finger-tip
Causes of clubbing :Carcinoma of the bronchus Lymphomas Leukemia Pulmonary fibrosis Empyema Lung abscess Bronchiectasis ( including Cystic fibrosis ) Chronic tuberculosis Liver disease ( Cirrhosis )

Very sudden dyspnoea is rare and usually associated with severe disease e.g., Pneumothorax ; Pulmonary embolism ; Left
ventricular failure ( or ) sudden asthma

1. 2. 3. 4. 5.

Causes of Haemoptysis :Bronchial Carcinoma Tuberculosis Bronchiectasis Lung abscess Pulmonary infarction

1. 2. 3.

Blue discoloration , termed Cyanosis , is usually due to increased circulating desaturated hemoglobin
In COPD :Hyper-expanded chest with intercostal recession of COPD Flat diaphragm Horizontal ribs

Broncho Alveolar Lavage :- is a minimally invasive bronchoscopic

procedure used to sample material from the terminal airways and the alveolar spaces BAL is broadly indicated in every patient with unclear diffuse lung disease ( or ) unclear pulmonary shadowing

Side effects : include alveolar infiltration , wheezing and bronchospasm , fever

in the first 24 hrs after BAL BAL is safe procedure and associated with virtually no morbidity , and collects samples from a much larger area of the lungs , giving a more representative picture of inflammatory and immunological changes In some disorders , specific information may be obtained , e.g., alveolar proteinosis , diffuse alveolar hemorrhage , malignant infiltrates ( or ) dust exposure . Here BAL can replace lung biopsy Bronchial lavage ( or ) bronchial washing , which requires relatively little instilled fluid 10-30 ml , and is used for bacteriological study and ( or ) tumor cytology . To avoid lavage contamination by blood , the BAL should always be made before any concomitant procedure , e.g., biopsy ( or ) bronchial brushing . In diffuse lung disease , the middle ( or ) lingular lobe is used as a standard site of BAL

Lignocaine :- Indication : Local anesthetic

Contraindication : Hypovolaemia , heart block , hypersensitive patients Special precautions : Respiratory depression , Epilepsy , CHF , Bradycardia , Myasthenia gravis Side effects : Confusion , respiratory depression , convulsions , bradycardia , hypotension , and hypersensitivity

Inhaled steroids providing long-term symptomatic relief are the first line drugs for treatment of bronchial asthma
Vancomycin :- it is primarily active against gram-positive bacteria . Strains of staphylococcus aureus and those which are resistant to methicillin ( MRSA ) are inhibited by vancomycin

Doxapram :- Respiratory stimulant

1. 2. 3. 4. 5. 6.

The rate and depth of breathing will increase with :

Acidosis ( metabolic ) Central nervous system lesions ( Pons ) Anxiety Aspirin poisoning Oxygen need ( hypoxemia ) Pain

1. 2. 3. 4. 5.

The rate and depth of breathing will decrease with :

Alkalosis ( metabolic ) Central nervous system lesions ( Cerebrum ) Myasthenia gravis Narcotic Overdoses Obesity ( extreme )

Respiratory insufficiency and failure are major life threatening complications of COPD Because hypoxemia is a stimulus for respiration in the patient with long-standing COPD , increasing the oxygen flow rate may raise the oxygen level in the patients blood but lead to depression of the respiratory drive and retention of carbon dioxide . Monitoring the patients respiratory response to oxygen administration is a priority Bullae , are a feature of progressive emphysema . Bullae are seen most
frequently in smokers and located in the apices of the lungs , more often on the right than on the left side

Acute epiglottitis in children is mostly caused by Haemophilus influenzae type B . Antibiotic of choice for
acute epiglottitis is Cephalosporin . Securing an airway by intubation must be first line of treatment in a child with suspected diagnosis of epiglottitis

1. 2.

Examples of Drug-induced Pulmonary Disease : Bleomycin ; Amiodarone Pneumonitis and Fibrosis Methotrexate ; Nitrofurantoin Hypersensitivity pneumonitis Aspirin Bronchospasm Left ventricular failure causes dyspnoea , because of a rise of pressure in the left atrium and pulmonary capillaries leading to interstitial and alveolar oedema . This makes the lungs stiff ( less compliant ) , which increases the amount of respiratory effort necessary to breathe Adult Respiratory Distress Syndrome is known by various
synonyms such as Shock-lung syndrome ; diffuse alveolar damage ; traumatic wet lungs . ARDS occurs from the following causes , i. ) Pancreatitis ii. ) Oxygen toxicity iii. ) Diffuse pulmonary infections ; except deficiency of surfactant . The lungs are characteristically stiff , congested and heavy


Ventricular tachycardia and Ventricular fibrillation are life threatening arrhythmias . Defibrillation is a technique to bring very rapid and chaotic rhythm back to normal by applying an electrical shock over the chest with a machine called defibrillator . The most common cause of sudden cardiac death is Ventricular fibrillation Myocardial infarction , better known as a heart attack , is death of a section of heart muscle due to prolonged , progressive ischaemia Cardiac tamponade occurs when sufficient fluid , usually
blood accumulates within the pericardial cavity to restrict filling of the heart during diastole , leading to reduced blood pressure , tachycardia and eventually cardiac arrest if the tamponade is not relieved by a pericardial puncture

1. Smoking history

Not necessarily


2. May start in childhood 3. Atopy

4. Provocation of symptoms 5. Cough at night 6. Sputum 7. Bronchodilator response 8. Steroid response

Sometimes Weak stimulus , e.g., Cold air Patient wakes coughing Contains eosinophils Yes

No Strong stimulus , e.g., infection Wakes then coughs Contains neutrophils Sometimes



Differences 1. Age 2. Smoking history 3. Auscultation

Bronchiectasis Varied Not necessarily Noisy , maybe localized

COPD Older Usually Diffuse Crackles

4. Sputum

Excessive , often thick and green

Sometimes Sometimes Specific


5. Haemoptysis 6. Finger Clubbing 7. X-ray

No No Variable

Exercise induced asthma :- This is present in 80% of

asthma sufferers and in some is the only manifestation of the disease . Hyperventilation during exercise , especially in cold weather , leads to evaporation of airway surface liquid , hyperosmolality and heat loss , causing bronchospasm . Bronchospasm occurs during ( or ) up to 10 minutes after exertion , and recovery is usually complete 30 minutes later

Occupational asthma :- This may take weeks ( or ) years to

develop . Symptoms usually worsen during the week and ease at weekends but several work-free days may be needed before improvement is apparent . It is usually diagnosed by a fall in FEV1 of more than 20% over the working day ( or ) working week

Status asthmaticus :- Specifically describes an asthma

attack prolonged over 24 hours , leading to dehydration and exhaustion

Nocturnal asthma :- This occurs in 80% of people with asthma , mostly during REM sleep . It is diagnosed from a morning dip in Peak Flow of over 20% compared to the previous evening . The term applies only to those who suffer at night and are symptomfree in the day . It causes fatigue and interferes with sexual activity . Possible trigger factors are an exaggerated bronchial response to cold bedrooms , reduced lung volume in supine , allergens in bedding . Airways are narrowest at about 4 a.m . Effect of Obesity :- The obese and the elderly share a tendency towards poor basal ventilation . Obesity reduces lung volumes and lung compliance . Breathing patterns tend to be rapid , shallow and apical . When upright , the weight of the viscera is normally borne by the pelvis but in obese people it pulls down on the ribs and increases the work of inspiration . When supine , the pressure of the viscera on the diaphragm hinders inspiration

Effect of Ageing
1. 2. Decreased elastic recoil , dilation of alveoli , increased lung volume ( senile emphysema ) , leading to reduced surface area for gas exchange Narrowing of small airways , leading to raised closing volume , premature closure of small airways , alveolar collapse and ventilation-perfusion mismatch Increased residual volume because closure of small airways prevents full exhalation Greater dependence on collateral ventilation because of airway closure Decreased chest wall compliance Decreased exercise capacity Decreased ventilatory response to both hypoxemia and hypercapnia Decreased vital capacity by 30 ml per year Decreased FEV1 by 30 ml per year and decreased response to Beta 2 agonist drugs such as salbutamol Increased Blood Pressure , esp. Systolic , because a greater pressure is needed to overcome the resistance of hardening arteries

4. 5. 6. 7. 8. 9. 10.

1. 2. 3. 4. 5. 6.

The following have been described after regular physical activity :

Decreased morbidity and mortality Decreased resting heart rate Decreased hypertension , heart disease , diabetes , Osteoporosis , anxiety and depression Increased respiratory muscle strength With Swimming training , increased lung volumes Exercise that is vigorous and regular reduces the risk of Myocardial infarction by 50%

Effect of immobility
Immobility is known to increase the risk of Pneumonia , Deep Vein Thrombosis , Osteoporosis and bedsores Immobility leads to Constipation , Urine retention , Deconditioning and depression Disuse muscle atrophy is most marked

Effect of Sleep
Sleep is restorative but , for some respiratory patients , risky

1. 2. 3. 4. 5. 6.

Changes during sleep include :

Decreased mucociliary clearance and decreased cough Decreased muscle tone , including muscles that preserve patency of the airway in the throat Decreased ventilatory response to hypoxia and hypercapnia Decreased Minute Ventilation by 10-15% , with consequent rise in PaCO2 During REM sleep , 25% drop in tidal volume Ventilation-Perfusion mismatch due to decreased lung volumes and hypoventilation REM sleep occupies about 20% of total sleep time and is the restorative , dreaming and physiologically eventful phase when oxygen consumption is highest . Sleep and COPD have a particular relationship . Nocturnal oxygen desaturation speeds pulmonary hypertension and hypercapnia . Death from lung disease usually occurs at night

The trachea may be shifted from mid-line with unilateral upper lobe collapse , pneumothorax , pleural effusion , ( or ) lung tumors The trachea shifts toward the collapsed lung but away from the pneumothorax , pleural effusion , ( or ) lung tumors Abdominal paradox and respiratory alternans indicates diaphragmatic fatigue COPD would cause a bilateral decrease in chest expansion Unilateral chest expansion and reduced ( or ) absent breath sounds would be consistent for a patient with pleural effusion Pneumothorax would cause an increased resonance to percussion of the chest Hepatomegaly may be accompanied by the collection of serous fluid in the peritoneal cavity known as ascites . Severe ascites may restrict diaphragm movement , and contribute to the onset of Respiratory Failure

Hypoxemia produces pulmonary vasoconstriction , the

right ventricle must work harder than normal whenever significant hypoxemia exists . This chronic workload on the right ventricle may result in right ventricular hypertrophy and poor venous blood flow return to the heart . When the venous return to the right side of the heart is reduced , the peripheral blood vessels engorge , resulting in an accumulation of fluid in the subcutaneous tissues of the ankles , called pedal edema . The edematous tissues pit ( indent ) when pressed firmly with the finger tips . Pedal edema suggests chronic lung disease that has resulted in Cor-pulmonale ( or ) Chronic Heart Failure

Epworth Sleepiness Scale

1. 2. 3. 4. 5. 6. 7. 8.

Do you fall asleep ? SITUATION :Sitting and reading Watching Television Sitting , inactive in a public place ( e.g., a theatre ( or ) meeting ) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car , while stopped for a few minutes in the traffic

0 = Would never doze . 1 = Slight chance of dozing 2 = Moderate chance of dozing . 3 = High chance of dozing The Epworth sleepiness score ; a validated way to assess the impact of sleepiness on daily activities . The overall score is the addition of each individual
item ( scored 0-3 ) ; thus it can vary between 0 ( no sleepiness ) and 24 ( maximum sleepiness ) . Normal subjects average 6 with 9 being regarded as the upper limit of normal . Patients with sleep apnoea average 16

Inward depression of the skin during inspiration is known as

retraction . Retractions may be seen between ribs ( intercostal ) , below the ribs ( subcostal ) , ( or ) above the clavicles ( supraclavicular ) . The opposite movement of the skin during exhalation is known as bulging
Limited pulmonary reserve ( e.g., COPD ) Ventilation-Perfusion mismatch ( e.g., Atelectasis ) Stiff lungs ( e.g., Adult Respiratory Distress Syndrome ) Low Oxygen availability ( e.g., High altitude )

Iatrogenic pneumothorax , may be caused by puncture of the lung with the aspirating needle , used for the procedure

Cystic Fibrosis is an inherited disease of secretory epithelia that affects the airways , liver , pancreas , and sweat glands . It is the most common lethal genetic disease in whites . The cause of cystic fibrosis is a genetic mutation affecting a transporter protein that carries chloride ions across the plasma membranes of many epithelial cells

1. 2.

There are a number of age-related physiologic changes in the pulmonary system :Structurally , the trachea and bronchi become more rigid with age Smooth muscle fibers in the lungs are progressively replaced with fibrous connective tissue Alveolar septa gradually deteriorate Although the number of alveoli does not change , loss of alveolar walls increases the size of the alveoli and reduces surface area for gas exchange The alveolar capillary membrane thickens , reducing diffusion of pulmonary gases Aging lungs have less elastic recoil , which leads to an increase in anteroposterior diameter The chest wall becomes stiffer The stiffer chest wall and reduction in elastic recoil are factors in an age related increase in FRC and RV Ciliary activity slows down , and the loss of an effective cough reflex contributes to the increased susceptibility of older patients to lung infections

3. 4.
5. 6. 7. 8. 9.

2. 3. 4. 5.

Laryngeal complications of Endotracheal Intubation :Glottic edema The cardinal clinical sign of glottic edema is inspiratory stridor Subglottic edema Vocal cord paralysis Sore throat and Hoarse voice Vocal cord ulceration , Granuloma , and Polyp


Potential results of retained secretions :Inflammation and Partial plugging Increased airflow resistance Uneven distribution of ventilation Ventilation-Perfusion mismatch Hypoxemia Increased work of breathing Total plugging Absorption atelectasis Decreased lung compliance Increased work of breathing Stasis Pneumonia Fever

2. 3.

Sleep apnea is a breathing disorder characterized by

repeated collapse of the upper airway during sleep , with consequent cessation of breathing . Patients may also unknowingly experience frequent arousals during the night , resulting in chronic day time sleepiness ( or ) fatigue There are two discrete types of sleep apnea :Central Sleep Apnea , characterized by a lack of airflow in the absence of ventilatory effort , is rare Obstructive Sleep Apnea is characterized by closure of the upper airway , resulting in the cessation of airflow despite persistent ventilatory effort



Weight reduction , can increase upper airway crosssectional area and , in some individuals , OSA may be cured

Apnea is defined as cessation of airflow for more than 10 seconds . A related event , hypopnea , is characterized by a
reduction in airflow associated with a decrease in oxygen saturation The average number of apnea-hypopnea events per hour of sleep is called the Apnea-Hypopnea Index ( AHI ) Patients with sleep apnea are more likely to fall asleep at inappropriate times and have a higher rate of automobile crashes and work-related accidents The cardiovascular system is also adversely affected by sleep apnea . There also seems to be a higher prevalence of sleep apnea in the hypertensive population

Pickwickian Syndrome ( also known as ObesityHypoventilation Syndrome ) , which consists of daytime hypercapnia and hypoxemia , pulmonary hypertension , polycythemia

1. 2. 3.

Aspergillus colonises in the bronchi causing allergic bronchopulmonary aspergillosis ( ABPA ) ABPA has the following characteristics :
Chest radiography shows opacities Peripheral eosinophilia is present High serum IgE , IgM antibodies to Aspergillus , and proximal cystic bronchiectasis are characteristic findings

Non-steroidal Anti-inflammatory agents are , aspirin ; ibuprofen ; sodium salicylate

Short-term cough is most frequently caused by viral infection . Smoking is the most common cause of chronic cough . Post nasal drip syndrome ; asthma and gastro-oesophageal reflux are responsible for most causes of persistent cough in nonsmokers

CPAP acts as a pneumatic splint by increasing the

pressure in the oropharyngeal airway , thereby maintaining airway patency throughout the ventilatory cycle Atropine :- Pre-operative medication to inhibit secretions
and salivation , sinus bradycardia , antidote for organophosphorus poisoning

Digoxin :- The main action is its direct effect on heart to increase the force of myocardial contraction . Indications :
Congestive Cardiac Failure , Cardiac dysarrhythmias

We must administer 100% oxygen for the patients who has got pneumothorax till he gets well . This causes nitrogen to be washed out of the body ( or ) so that the trapped air is more rapidly absorbed

Congestive Heart Failure is a complex clinical syndrome

that can result from any functional ( or ) structural cardiac disorder that impairs the ventricles ability to fill with ( or ) eject blood . CHF results in pulmonary vascular congestion and reduced cardiac output . The measurement of serum brain natriuretic peptide and echocardiography have substantially improved the accuracy of diagnosis . The cornerstone of treatment is a combination of an angiotensinconverting-enzyme inhibitor and slow titration of a beta-blocker

Patients with CHF are prone to pulmonary complications , including Obstructive Sleep Apnea , Pulmonary edema , and Pleural effusions CPAP and NIPPV benefit patients in CHF exacerbations

Criteria for the diagnosis of CHF :-

1. Neck-vein distention 2. Orthopnea ( or ) Paroxysmal Nocturnal Dyspnea 3. Cardiomegaly on chest radiograph 4. S3 gallop 5. Left ventricular dysfunction on echocardiogram

6. Hepatomegaly 7. Central Venous Pressure > 12 mmHg 8. Weight loss > 4.5 kg in response to CHF treatment

Pulmonary Arterial Hypertension is a pathological condition of the small pulmonary arteries . PAH is characterized histopathologically by vasoconstriction , vascular proliferation , in situ thrombosis . These pathologic changes result in progressive increase in the mean pulmonary artery pressure and pulmonary vascular resistance , which , if untreated , leads to right-ventricular failure and death

Hemodynamically , PAH is defined as an increase in the mean pulmonary arterial pressure to > 25 mmHg at rest ( or ) > 30 mmHg during exercise Transthoracic echocardiogram is an excellent screening tool to evaluate PAH , but every patient requires a right-side heart catheterization to help stage the disease and guide therapy

1. 2. 3.

Diseases that affect both Lungs and the Kidneys :Wegeners Granulomatosis Systemic Lupus Erythematosus Good pastures Syndrome

1. 2. 3. 4. 5. 6.

Major indications for Lung Transplantation by procedure :COPD Pulmonary fibrosis Bronchiectasis Cystic Fibrosis Sarcoidosis Alpha-1 antitrypsin deficiency

Pleural effusion
Definition :- Pleural effusion occurs when too much fluid collects in the pleural space . It is commonly known as water on the lungs . It is characterized by shortness of breath , chest pain , gastric discomfort ( dyspepsia ) , and cough Description :- There are two thin membranes in the chest , ( the visceral pleura ) lining the lungs , and ( the parietal pleura ) covering the inside of the chest wall . Normally , small blood vessels in the pleural linings produce a small amount of fluid that lubricates the opposed pleural membranes so that they can glide smoothly against one another during breathing movements . Any extra fluid is taken up by blood and lymph vessels , maintaining a balance . When either too much fluid forms ( or ) something prevents its removal , the result is an excess of pleural fluid ( an effusion ) .


There are two types of pleural effusion ; the transudate and the exudate
A transudate is a clear fluid , similar to blood serum , that forms not because the pleural surfaces themselves are diseased , but because the forces that normally produce and remove pleural fluid at the same rate are out of balance An exudate which often is a cloudy fluid , containing cells and much protein results from disease of the pleura itself . The most common causes are infections such as bacterial pneumonia and tuberculosis


1. 2.

Causes of transudative pleural effusion :

Congestive Heart Failure Cirrhosis

1. 2. 3. 4.

Causes of exudative pleural effusion :

Pleural tumors Tuberculosis in the lungs Pneumonia Pulmonary embolism

Diagnosis :- When pleural effusion is suspected , the best way to confirm it is to take chest X-rays , both straight-on and from the side . In order to learn what has caused the effusion , a needle ( or ) catheter is often used to obtain a fluid sample , which is examined for cells and its chemical makeup . This procedure , called a thoracentesis , is the way to determine whether an effusion is a transudate ( or ) exudate , giving a clue as to the underlying cause . If the effusion is caused by lung disease , placing a viewing tube ( bronchoscope ) through the large air passages will allow the examiner to see the abnormal appearance of the lungs Treatment :- The best way to clear up a pleural effusion is to direct treatment at what is causing it , rather than treating the effusion itself . Because pleural effusion is a secondary effect of many different conditions , the key to preventing it is to promptly diagnose the primary disease and provide effective treatment . Timely treatment of infections such as tuberculosis and pneumonia will prevent many effusions . If large effusions continue to recur , a drug ( or ) material that irritates the pleural membranes can be injected to deliberately inflame them and cause them to adhere close together a process called sclerosis . This will prevent further effusion by eliminating the pleural space

Chronic bronchitis : it is defined by productive cough on most days for at least three months for at least two consecutive years and which cannot be attributed to other pulmonary causes Emphysema : it is characterized by destruction of alveolar walls , resulting in abnormal and permanent enlargement of airspaces and loss of lung elasticity , with consequent obstruction of peripheral airways distal to the terminal bronchiole Bronchiectasis : Copious purulent sputum , Clubbing , Coarse crackles , confirmed by HRCT scan Bronchodilator reversibility testing : This test should be performed when patients are clinically stable and free from infection . An increase in FEV1 ( or ) FVC that is both greater than 200 ml and a 12% increase over the Pre-bronchodilator value indicates reversibility

Smoking history : 1 pack-year = 20 cigarettes smoked per day for 1 year

years of smoking / 20

Total pack-years = ( No. of cigarettes smoked / day ) multiply by number of

1. 2. 3. 4. 5. 6. 7. 8.

Usually , there is a smoking history of > 20 pack-years Risk factors that can contribute to the causation of COPD History of regular smoking for at least 10 years Alpha-1 antitrypsin deficiency Age > 40 years Occupational exposure e.g., coal mines ; cotton industries Chest infections during the first year of life Reduced intake of antioxidant vitamins E & C Low birth-weight Low socio-economic status


Treatment of COPD :Smoking cessation : is the only way by which the accelerated rate of decline of FEV1 can be arrested . This is the most cost-effective treatment Drug therapy : Bronchodilators ( Anticholinergics and Beta2-agonists ) are the cornerstone in the management of COPD Nutrition Vaccination : Influenza and pneumococcal vaccines are recommended Domiciliary oxygen therapy : is indicated in patients with persistent hypoxaemia . LTOT must be given for at least 15 hours at a rate of 2-4 L / min daily to achieve benefit
Pulmonary rehabilitation : involves patient education , psychosocial support , chest physiotherapy , exercise and muscle training . It helps the patient to cope with his/her disease Lung volume reduction surgery ( LVRS ) is applicable to patients with severe disease in whom there is a very marked increase in Functional Residual Capacity ( FRC ) and air trapping

3. 4. 5.



1. 2. 3. 4.

Tumors are classified as benign and malignant :Benign tumors :

Usually have a capsule surrounding them Remain localized Do not invade neighboring tissue ( or ) metastasize Have cells resembling the normal cells from which they originate

1. 2. 3. 4.

Malignant tumors :
Are not capsulated Infiltrate tissue , adhering to the skin , muscle and bone Invade at a distance , with adenopathy and metastasis Do not resemble the cells from which they originate

The symptoms most often found in cancer of the lung are cough , haemoptysis , loss of weight , thoracic pain and dyspnea

The diaphragm is a musculo-aponeurotic sheath that separates the thoracic and abdominal cavities Depression of the diaphragm may be due to pleural effusions , pneumothorax , asthma ( or ) emphysema Lesions to the cervical nerves ( 3 , 4 , 5 ) and phrenic nerve can give
rise to a bilateral paralysis of the diaphragm If administered for a long period , oxygen can promote a hemorrhagic pneumonia , termed oxygen poisoning . Concentrations in the range of 55-60% for prolonged periods can produce changes such as atelectasis , pneumonitis , coma and even death Patients with chronic lung disease breathing 100% oxygen may evidence a marked decrease in the respiratory minute volume

The causes of diminished breath sounds are as follows :- 1. ) Fluid in the pleural space 2. ) Air in the pleural space 3. ) Thickening pleura caused by fibrosis 4. ) COPD ,as a result of over inflation of the lung 5. ) Bronchial obstruction 6. ) Hypoventilation of the lung

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Signs and symptoms of pulmonary distress :Dyspnea Cyanosis Palpitations Tachypnea Chest pain Cough Sputum Wheezing Stridor Paradoxical breathing patterns Trachea positioned off midline Cavitations of chest wall during inspiration Unequal excursions of chest wall during inspiration

The surfactant is secreted by the Type 2 alveolar cells , and lines the alveolar surface . Chemically , the surfactant contains the surface tension lowering agent , dipalmitoyl lecithin , and also a few proteins . Lowering of the surface tension by the surfactant improves the distensibility of the lungs . Reducing the muscular effort required for breathing is the first function of the surfactant

Alpha-1-antitrypsin ; protects the respiratory tract from

neutrophil elastase , an omnivorous connective tissue protease capable of cleaving all forms of connective tissue , including lung parenchyma . The central tenet of the pathogenesis of emphysema is that alveolar walls are destroyed , because of insufficient protection against neutrophil elastase

2. 3. 4.

Cyanosis :is an unreliable sign

can only be detected when saturation falls to 85% may be absent when associated with severe anaemia is exaggerated when associated polycythemia

2. 3. 4. 5.

Clubbing :is usually bilateral and usually affects both fingers and toes
lesser degrees are difficult to identify clinically increased curvature of the nail bed increase in the bulk of the nail bed and terminal phalanx ( if extreme this gives the appearance of a drumstick ) sponginess of the nail bed , which gives the feeling that the nail is floating on its bed

1. 2. 3.
4. 5.

Vital signs :Temperature ( Wunderlich curves ) Pulse rate ( speed , force and duration ) Respiratory rate (is the only vital sign that is under voluntary control)
Blood pressure Arterial oxygen saturation

Takuo Aoyagi of japan discovered the basic principle of pulse

oximetry :- Pulsatile transmission of light through tissue depends on the patients arterial saturation . The most common causes of inadequate oximeter signals are poor perfusion due to cold ( or ) hypotension ; excessive ambient light ; and motion artifact . Limitations of pulse oximetry :- Because pulse oximetry readings indicate only the degree of oxygen saturation of hemoglobin , they fail to detect problems of poor oxygen delivery ( e.g., anemia ; poor cardiac output ) ; hyperoxia ; and hypercapnia

Cell death is called necrosis . One example of necrosis is the pressure sore which may occur over a bony point in a bedridden patient Gangrene :- When necrosis affects a mass of tissue such as a digit ( or ) limb , it is called gangrene . An example , is the gangrene of a toe resulting from an obstructed blood supply . The toe becomes purplish and may eventually go black . This blackening is probably due to the slow drying and oxidation of haemoglobin in the tissues . The main cause of the necrosis is lack of oxygen ( tissue anoxia ) Pleura :- a delicate serous membrane Pleural space ( or ) cavity :- normally has minimal volume , unless lungs collapse ( or ) air / fluid collects between the two layers . In anatomy , the pleural cavity is the potential space . The pleura that is connected to the chest wall is parietal pleura and is highly sensitive to pain

Pleural Fluid Examination

Normal pleural fluid is clear and pale yellow in color . Usually only small amounts of fluid are present ( < 20 ml ) . Increased pleural fluid
occurs most commonly with heart failure but also with liver disease , infections , and tumors . Opaque ( or ) turbid fluid is characteristic of infections in which there are large numbers of WBCs in the fluid . Actual cell counts may be performed on the fluid . The type of WBC present may be useful in determining the type of infection present . The level of protein occurring in pleural fluid may also be determined . Fluid may accumulate in the pleural cavity as transudate ( or ) exudate . Exudate is cloudy with a high protein content as opposed to transudate which is clear with a low protein content . Consequently exudate tends to become consolidated where as transudate can be reabsorbed if the underlying condition is treated . A protein level of less than 3g/dL is

characteristic of a transudate . Exudates have a protein content of 3g/dL ( or ) more . Culture of the fluid for microbiologic organisms and
cytologic examination for malignant cells are other tests commonly performed on pleural fluid

The ambient pressure increases by 1 atmosphere for every 10 m of depth in seawater . The invention of SCUBA gear ( self-contained underwater breathing apparatus , a tank-andvalve system carried by the diver ) transformed diving from a business into a sport

1. 2. 3. 4.

Potential problems associated with exposure to increased barometric pressure :Oxygen toxicity Nitrogen narcosis Decompression sickness ( Caisson disease ; Bends ; Divers paralysis ; Dysbarism ) Air embolism Surfactant , reduces the work of breathing ( increases compliance ) by decreasing alveolar surface tension

Dyspnea ; is the symptom of abnormal awareness of breathing . It may occur following exertion , after excitement ( or ) after a heavy meal The persons respiratory functions may be normal and still dyspnea may be experienced because of an abnormal state of mind . This is called neurogenic dyspnea ( or ) emotional dyspnea . Example :- Person who have a psychological fear of not being able to receive a sufficient quantity of air , such as on entering small ( or ) crowded rooms

The normal adult thorax , has an antero-posterior diameter less than the transverse diameter . The antero-posterior diameter normally increases gradually with age and prematurely increases in patients with COPD . This abnormal increase in antero-posterior diameter is called barrel chest . When the antero-posterior diameter increases , the ribs lose their normal 45* angle of slope in relation to the spine and become horizontal

1. 2. 3. 4.

Common features of Obstructive Sleep Apnea :Day time :

Daytime sleepiness Morning headache Increased frequency of accidents Falling asleep during routine activities ( e.g., working or driving ) Hallucinatory images , irritability , personality changes


1. 2. 3. 4.

Nocturnal / while sleeping :

Snoring Apneic episodes Restlessness , flailing about in bed Frequent urination , bed wetting , loss of libido

Patients with COPD may use pursed-lip breathing during exhalation . Some patients naturally begin to pucker their lips during exhalation , to provide a slight resistance to the exhaled breath . This resistance theoretically provides a slight back-pressure in the airways during exhalation and prevents their premature collapse Nasal flaring ; is identified by observing the external nares flare outward during inhalation . This occurs especially in neonates with respiratory distress and indicates an increase in the work of breathing When respiratory disease results in reduced oxygenation of the arterial blood , cyanosis may be detected , especially around the lips and oral mucosa . The ability to see cyanosis depends on the lighting in the room and the patients hemoglobin level . Reduced hemoglobin concentration in the blood prevents visible cyanosis , even if hypoxemia is present

The patients breathing pattern often provides strong clues to the underlying pathologic condition :

1. Rapid and shallow breathing suggests a loss of lung volume 2. A prolonged expiratory time indicates intrathoracic airway obstruction 3. A prolonged inspiratory time indicates upper airway obstruction Anastomosis :- a natural communication , direct ( or ) indirect , between two blood vessels Aneurysm :- Localized abnormal dilatation of a blood vessel

Respiratory acidosis :- An acid-base imbalance characterized by a pH less than 7.35 , because of an increased level of carbon dioxide in the blood Respiratory alkalosis :- An acid-base imbalance characterized by a pH greater than 7.45 , because of excessive ventilation Shunt :- A bypass ; in the lungs , an area in which blood flows through the lungs without coming into contact with alveolar gas
Exercise , is the bodys most common physiological stress , and it places major demands on the cardiopulmonary system

Ventilatory Oxygen uptake ( VO2 ) ; is the amount of oxygen that is extracted from inspired air as the body performs work

2. 3.

Relative contraindications to performing spirometry :Hemoptysis of unknown origin ( Forced expiratory maneuvers may aggravate these conditions )
Pneumothorax Unstable cardiovascular status ( or ) recent myocardial infarction ( or ) pulmonary embolus ( Forced expiratory maneuver may worsen angina ( or ) cause changes in blood pressure ) Thoracic , abdominal , ( or ) cerebral aneurysms ( danger of rupture resulting from increased thoracic pressure ) Recent eye surgery ( e.g., Cataract ) Presence of an acute disease process that might interfere with test performance ( e.g., nausea , vomiting ) Recent surgery of thorax ( or ) abdomen

4. 5. 6. 7.

1. 2. 3. 4. 5. 6. 7.

Hazards and Complications of performing spirometry :Pneumothorax Increased intracranial pressure Syncope , dizziness , light-headedness Chest pain Paroxysmal coughing Bronchospasm Oxygen desaturation resulting from interruption of oxygen therapy

8. Prone to get nosocomial infections

Spirometry is often performed as a screening procedure ( examination of

a group , to separate well persons from those who have an undiagnosed pathologic condition ( or ) who are at high risk ) . It may be the first test to indicate the presence of pulmonary disease

Flow Volume Loop :- Also known as F / V curve the forced

expiratory maneuver plotted with flow expressed as liters per second on the vertical axis , and volume expressed as liters on the horizontal axis . When compared with a traditional spirogram tracing , it
has the advantage of allowing easier recognition of unacceptable ( or ) poorly reproducible maneuvers and small ( or ) upper airway obstruction

Hyatt popularized plotting flow versus volume to display a Flow Volume Loop Vital Capacity is an important indicator of the patients ventilatory reserve . A significant reduction in VC indicates that the patient is at higher risk
for respiratory failure , especially after surgery

Collapse ( most commonly due to bronchogenic carcinoma ) Fibrosis ( commonly in tuberculosis ) Cavity ( Tuberculosis ; Lung abscess ) Consolidation ( Pneumonias ) Intercommunicating channels for collateral ventilation are Alveolar pores of kohn ; and Canals of Lambert Left Ventricular Failure ( Cardiac asthma ) The term respiratory insufficiency ; may be used to describe the condition in which the blood gases are normal at rest but become abnormal on exercise 1 KPa unit = 7.5 mmHg

Pulmonary Vascular Disease

Pulmonary embolism :- the blockage of a pulmonary artery by foreign matter . The
obstruction may be fat , air , tumor tissue , ( or ) a thrombus that usually arises from a peripheral vein ( most frequently arising from the deep veins of the legs ) . Pulmonary embolism is detected by chest radiographic films , and pulmonary angiography Patients with venous thrombosis in the proximal venous system of the lower extremities and in the upper extremities are at high risk of development of pulmonary embolism Conditions predisposing to venous thrombosis and pulmonary thromboembolism :- Prolonged bed rest ; Pregnancy ; Long periods of travel ; Obesity ; Carcinoma Symptoms :- Dyspnea ; Pleuritic pain ; Cough ; Leg swelling ; Leg pain Management of Venous thromboembolism includes anticoagulation therapy ( heparin and warfarin ) . Mechanical measures include early ambulation ; wearing elastic stockings ; pneumatic calf compression and electric stimulation of calf muscles

Pulmonary hypertension :- a condition characterized by abnormally high pulmonary artery pressures , that is , mean pulmonary artery pressures in excess of 22 mmHg . Normal mean pulmonary artery pressure is 10 20 mmHg

Myocardial infarction :- Occlusion of a coronary artery resulting in distal myocardial tissue necrosis , often accompanied by significant complications Angina pectoris :- a paroxysmal attack of severe chest pain associated with coronary insufficiency ; commonly radiates from the heart to the shoulders and arms Shock :- a condition in which perfusion to vital organs is inadequate to meet their metabolic needs ; includes hypovolemic , cardiogenic , septic , anaphylactic , and neurogenic forms Prolonged bronchoconstriction has been reported following methacholine inhalation challenge . This only occurs if very high concentrations of methacholine are used . Also , methacholine is unstable when diluted in phosphate buffered saline ; therefore normal saline must be used as the diluent . Both histamine and methacholine are stable in solution for up to 3 months at the concentrations commonly used . Inherent disadvantages to inhaled histamine are the development of systemic side-effects , such as flushing , headache and tachycardia , when high concentrations are inhaled . These side-effects are generally not seen with even high concentrations of inhaled methacholine

1. 2. 3.

Bronchodilator medications must be avoided before the inhalation test :Short acting Beta-2 adrenoceptor agonists and anticholinergic agents for at least 8 hours Short acting xanthines for at least 24 hours Long acting xanthines , Beta-2 agonists and some antihistamines for at least 48 72 hours Inhaled ( or ) Oral corticosteroids , Cromolyn ( or ) nedocromil are continued without interruption during the inhalation test because , the effects of inhaled corticosteroids are slowly progressive over time and may persist for more than 3 months after they are discontinued in mild asthmatics


Prolonged usage of Corticosteroids frequently results in severe side effects , such as Cushingoid features ; Osteoporosis ; diminished resistance to infection ; Sodium retention ; Potassium loss ; Peptic ulceration ; mental changes ; and diabetes mellitus Systemic Corticosteroids have a number of adverse side effects , including reduction in bone density and adrenal suppression Inhaled steroids have relatively few side effects :- Fungal infection of the Oral Cavity is a common problem ( Oral Candidiasis or dysphonia ) and decrease bone density , and their effect on growth in children is not completely understood

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Adrenergic Bronchodilators :- Adverse effects ;

Tachycardia Palpitations Shakiness Nervousness Tremor Headache Insomnia CFC propellant induced bronchospasm Hypokalemia Tachyphylaxis ( repeated exposure to a drug results in diminished pharmacologic response )

11. Loss of bronchoprotection

Ipratropium may be preferred in patients who experience tachycardia ( or ) tremor caused by adrenergic drugs
Side effects seen with Anticholinergic aerosol Ipratropium Bromide :Dry mouth Cough Eye pain Urinary retention Precautions : Use with caution in patients with narrow-angle glaucoma , prostatic hypertrophy , constipation ( or ) tachycardia Non-steroidal anti-inflammatory ( or ) Anti-asthma agents include Cromolyn sodium , nedocromil sodium and the antileukotrienes ( Zafirlukast ; Montelukast )

1. 2. 3. 4.

Pathogenesis of Cor pulmonale

Chronic lung diseases and Pulmonary vascular diseases Pulmonary resistance Pulmonary hypertension Pressure Overload Right ventricular enlargement Cor pulmonale Acute Cor pulmonale occurs following massive pulmonary embolism Congestive Heart Failure , is often used synonymously with left ventricular failure . Failure of the left ventricle may be caused by systemic hypertension , Coronary artery disease , ( or ) aortic insufficiency


The Disadvantages of Artificial Airways : An artificial airway bypasses the normal defence mechanisms which counter bacterial contamination of the airways . The airways and lungs are more prone to nosocomial infection 2. An endotracheal tube removes the effectiveness of cough because the vocal cords are non-functional ; a tracheostomy bypasses the cords 3. An artificial airway prevents the patient from communicating vocally . This can be frustrating and frightening , and it is important , in a conscious patient , to provide a pad and a pen to help the patient communicate in writing

The chief indications for an immediate airway are :-

1. Severe life threatening upper airways obstruction 2. Cardiac ( or ) Respiratory arrest ( or ) impending cardiorespiratory arrest 3. Fulminant Pulmonary oedema

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Care over suction of secretions :Use no touch sterile technique Pre-oxygenate ( with high FIO2 ) a haemodynamically unstable patient before suction Do not suck for more than 10 seconds Do not use a very large bore catheter for suction If possible , suck through an adaptor so that ventilator support on high flow oxygen is not interrupted Stop suction if bradycardia ( or ) hypotension occur ; increase FIO2 to 100 percent for a short time Liquefy viscid secretions ; use physiotherapy Humidify inspired gas

Care of cuff :- Measure cuff pressure daily , and keep this

within acceptable limits ( 14 24 cm H2O )

Complications of Oxygen therapy :1. Progressive Hypercapnia 2. Circulatory Depression 3. Drying and Crusting of secretions in the respiratory tract 4. Danger of Oxygen withdrawal 5. Oxygen toxicity a. ) Lung toxicity b. ) Retrolental Fibroplasia c. ) Cerebral Oxygen toxicity

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Features of a severe attack of asthma :-

Inability to complete sentence in one breath Disturbance in level of consciousness Respiratory rate > 30 / min Silent chest Respiratory muscle fatigue Tachycardia > 110 / min Peak expiratory flow ( PEF ) < 30 percent of predicted ( or ) known best 8. Cyanosis

Definition :- Obstructive airway disease characterized by reversible airway narrowing , mucus hypersecretion , inflammation , and episodic shortness of breath
Increased airway responsiveness is related to inhalation of antigens , viral infections , air pollution , ( or ) occupational exposure . Spirometry is the most useful tool for detecting reversible airway obstruction . Improvement in the FEV1 ( or ) FVC is the hallmark of reversibility . Peak expiratory flow ( PEF ) , measured using portable peak flow meters , can provide immediate information for a clinician ( or ) patient to modify therapy . There appears to be a hereditary component to asthma ; many cases occur in patients who have a family history of asthma ( or ) allergic disorders . Agents ( or ) events that cause an asthmatic episode are called triggers . Bronchial provocation tests using methacholine , histamine , exercise , ( or ) hyperventilation are often used to make the diagnosis of hyperreactive airways in patients who appear normal but have episodic symptoms . Skin testing is also used to demonstrate sensitivity to inhaled antigens . Asthma education

usually focuses on helping the affected individual identify and avoid triggers

Chronic Obstructive Pulmonary Disease

Definition :- The term COPD is often used to describe long-standing airway obstruction caused by emphysema , chronic bronchitis , ( or ) asthma . These three conditions may be present alone ( or ) in combination . Bronchiectasis is sometimes considered a component of COPD . COPD is characterized by dyspnea at rest ( or ) with exertion , often accompanied by a productive cough COPD is a chronic disorder that limits a patients ability to work and , in severe cases , impairs the activities of daily living . The most prominent symptoms of COPD are dyspnea and an impaired exercise capacity Patients with COPD manifest decreased exercise tolerance . The most important factors thought to contribute to this limitation are :Alterations in pulmonary mechanics Dysfunction of the respiratory muscles Peripheral muscle dysfunction Abnormal gas exchange Malnutrition Development of dyspnea Active smoking

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Calibration is the process in which the signal from an instrument is adjusted to produce a known output . The verification step should include a range of flows to demonstrate volume accuracy that is independent of flow
Technologists comments :- Scoring ( or ) grading the quality of a
patients test is an important component of quality assurance for pulmonary function testing . The technologists comments should be added to the final report . The commentary should be based on standardized criteria . If a particular test meets all criteria , that fact should be stated . Failure to meet any of the laboratorys criteria should be documented as well . The reason the patient was unable to perform the test acceptably should be explained whenever possible . Failure to meet criteria for acceptability does not necessarily invalidate a test . For some patients , their best performance may fail one ( or ) more of the criteria

Allens test :- Momentary occlusion of the radial and ulnar arteries to establish adequacy of collateral circulation BMR ( Basal metabolic rate ) :- the metabolic rate ( i.e., oxygen consumption ) of a healthy individual at rest Borg scale :- One of several numeric scales used to rate perceived exertion during exercise testing Deconditioned :- Refers to the effects of lack of exercise , usually including elevated heart rate and blood pressure and muscular inefficiency Dead space :- The volume of the lung that is ventilated but not perfused by pulmonary capillary blood flow Desaturation :- Reduction of oxygen level caused by dissociation of O2 from Hb Predicted value :- The expected ( or ) reference value for a lung function test ; usually derived from studying a large population of healthy individuals

Respiratory acidosis :- An acid-base imbalance characterized by a pH less than 7.35 because of an increased level of CO2 in the blood Respiratory alkalosis :- An acid-base imbalance characterized by a pH greater than 7.45 because of excessive ventilation Metabolic acidosis :- An acid-base imbalance characterized by a pH less than 7.35 resulting from accumulation of acid ( other than that produced by CO2 ) ( or ) loss of base Metabolic alkalosis :- An acid-base imbalance characterized by a pH greater than 7.45 resulting from accumulation of base ( or ) loss of acid ( other than that produced by CO2 ) Pulse Oximetry :- Estimation of arterial saturation by analysis of light absorption of blood pulsing through a capillary bed ( finger ( or ) earlobe )

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Medullary centers :- Those areas of the medulla oblongata that are responsible for controlling the rate and depth of breathing Airways :Divided into a conducting zone and a respiratory zone Volume of the anatomic dead space is about 150 ml Volume of the alveolar region is about 2.5 3.0 liters Gas movement in the alveolar region is chiefly by diffusion Most of the area of the alveolar wall is occupied by capillaries When oxygen moves through the thin side of the blood-gas barrier from the alveolar gas to the hemoglobin of the red blood cell it traverses the following layers in order : Surfactant , epithelial cell , interstitium , endothelial cell , plasma , red cell membrane

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The mean pressure in the pulmonary artery is only about 15 mm Hg at rest Following statements about the removal of inhaled dust in the lung are TRUE :Particles that deposit on the airways are removed by the mucus escalator The escalator is propelled by millions of tiny cilia The mucus comes from mucous glands and goblet cells in the bronchial walls Particles that reach the alveoli are engulfed by macrophages



Lung Volumes :Tidal volume and vital capacity can be measured with a simple spirometer TLC , FRC and RV need an additional measurement by helium dilution ( or ) the body plethysmograph Helium is used because of its very low solubility in blood The body plethysmograph depends on Boyles Law PV = K at constant temperature

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Ventilation :Total ventilation is tidal volume * respiratory frequency Alveolar ventilation is the amount of fresh gas getting to the alveoli Anatomic dead space is the volume of the conducting airways , about 150 ml Physiologic dead space is the volume of gas that does not eliminate CO2 The two dead spaces are almost the same in normal subjects , but the physiologic dead space is increased in many lung diseases

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Ficks Law of Diffusion :- Rate of diffusion of a gas through a tissue slice is proportional to the area but inversely proportional to the thickness . Diffusion rate is proportional to the partial pressure difference Measurement of Diffusing Capacity :Carbon monoxide is used because the uptake of this gas is diffusionlimited Normal diffusing capacity is about 25 Hg-1 Diffusing capacity increases on exercise

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All of the following would be expected to reduce the diffusing capacity of the lung for carbon monoxide :Emphysema which causes loss of pulmonary capillaries Asbestosis which causes thickening of the blood-gas barrier Pulmonary embolism which cuts off the blood supply to part of the lung Severe anemia


Pulmonary Vascular Resistance :Decreases on exercise because of recruitment and distention of capillaries Increases at high and low lung volumes Increases with alveolar hypoxia because of constriction of small pulmonary arteries

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Four causes of Hypoxemia :Hypoventilation Diffusion limitation Shunt Ventilation-perfusion inequality

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Hypoventilation :Always increases the Pco2 Decreases the Po2 unless additional O2 is inspired Hypoxemia is easy to reverse by adding O2

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Shunt :Hypoxemia responds poorly to added inspired O2 When 100% O2 is inspired , the arterial Po2 does not rise to the expected level a useful diagnostic test CO2 carried as : dissolved , bicarbonate , carbamino Respiratory Muscles :Inspiration is active ; expiration is passive during rest Diaphragm is the most important muscle of inspiration ; it is supplied by phrenic nerves which originate high in the cervical region

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Pulmonary Surfactant :Reduces the surface tension of the alveolar lining layer Produced by type 2 alveolar epithelial cells Contains dipalmitoyl phosphatidylcholine Absence results in reduced lung compliance , alveolar atelectasis , and tendency to pulmonary edema

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Respiratory Centers :Responsible for generating the rhythmic pattern of inspiration and expiration Located in the medulla and pons of the brain stem Receive input from chemoreceptors , lung and other receptors , and the cortex Major output is to the phrenic nerves

Central Chemoreceptors :-

1. Located near the ventral surface of the medulla 2. Sensitive to the Pco2 but not Po2 of blood 3. Respond to the change in pH of the ECF / CSF when CO2 diffuses out of cerebral capillaries

Peripheral Chemoreceptors :-

1. Located in the carotid and aortic bodies 2. Respond to decreased arterial Po2 , increased Pco2 and H+ 3. Rapidly responding


Ventilatory Response to CO2 :Arterial Pco2 is the most important stimulus to ventilation under most conditions and it is normally tightly controlled Most of the stimulus comes from the central chemoreceptors but the peripheral chemoreceptors also contribute and their response is faster The response is magnified if the arterial Po2 is lowered


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Ventilatory Response to Hypoxia :Only the peripheral chemoreceptors are involved There is negligible control during normoxic conditions The control becomes important at high altitude , and in long-term hypoxemia caused by chronic lung disease

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Acclimatization to High Altitude :Most important feature is hyperventilation Polycythemia is slow to develop and of minor value Other features include increase in cellular oxidative enzymes and the concentration of capillaries in some tissues Hypoxic pulmonary vasoconstriction is not beneficial


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Decompression Sickness :Caused by the formation of N2 bubbles during ascent from a deep dive May result in pain ( bends ) and neurological disturbances Can be prevented by a slow , staged ascent Treated by recompression in a chamber Incidence is reduced by breathing a helium-oxygen mixture

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Changes at ( or ) shortly after birth :Baby makes strong inspiratory efforts and takes its first breath Large fall in pulmonary vascular resistance Ductus arteriosus closes , as does the foramen ovale Lung liquid is removed by lymphatics and capillaries
Alveolar ventilation increases by the largest percentage at maximal exercise Helium-oxygen mixtures rather than nitrogen-oxygen mixtures ( with the same oxygen concentration ) are preferable for very deep diving because all of the following are reduced : 1. ) Risk of decompression sickness 2. ) Work of breathing 3. ) Airway resistance 4. ) Risk of inert gas narcosis

Recommended suction pressure for different age groups are : infants 80 100 mm Hg ; children 100 125 mm Hg ; and adults 120 150 mm Hg The diameter of the suction catheter should be less than half the inner diameter of the ETT ( or ) tracheostomy tube , to prevent hypoxia . A simple formula to find out the appropriate size of the suction catheter is as follows : Size of ETT ( mm ) * 3 / 2 Read the tracheal tube cuff pressure on the manometer . It should be between 20 25 mm Hg