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RESPIRATORY

SYSTEM
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DEVELOPMENT OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM

CONTENTS
DEVELOPMENT OF RESPIRATORY SYSTEM ................................................................................................................... 5
ANATOMY OF RESPIRATORY SYSTEM ........................................................................................................................... 5
PHYSIOLOGY OF RESPIRATORY SYSTEM ........................................................................................................................ 6
GENERAL FEATURES OF RESPIRATORY PHYSIOLOGY ................................................................................................ 6
INSPIRATION AND EXPIRATION................................................................................................................................. 7
SURFACTANT ............................................................................................................................................................. 8
GASEOUS EXCHANGE ................................................................................................................................................ 8
VENTILATION PERFUSION RATIO AND COMPLIANCE ............................................................................................... 9
HYPERCARBIA AND ALVEOLAR HYPOVENTILATION ................................................................................................ 10
HYPERVENTILATION ................................................................................................................................................ 10
HIGH OXYGEN TENSION .......................................................................................................................................... 10
HYPOXIA .................................................................................................................................................................. 11
FEATURES OF HEMOGLOBIN ................................................................................................................................... 11
OXYHEMOGLOBIN DISSOCIATION CURVE ............................................................................................................... 12
REGULATION OF RESPIRATION ............................................................................................................................... 13
LUNG VOLUMES, CAPACITIES AND ALVEOLAR VENTILATION ................................................................................. 14
ACCLIMATISATION .................................................................................................................................................. 16
MOUNTAIN SICKNESS ............................................................................................................................................. 16
CAISSONS DISEASE ................................................................................................................................................. 16
SIGNS AND SYMPTOMS OF RESPIRATORY SYSTEM .................................................................................................... 17
GENERAL SIGNS AND SYMPTOMS OF RESPIRATORY SYSTEM ................................................................................ 17
HEMOPTYSIS ........................................................................................................................................................... 18
CYANOSIS ................................................................................................................................................................ 18
CLUBBING................................................................................................................................................................ 19
PANCOAST TUMOR ................................................................................................................................................. 19
CAPLAN SYNDROME................................................................................................................................................ 19
PULMONARY EDEMA .............................................................................................................................................. 20
ARDS............................................................................................................................................................................ 20
PULMONARY EMBOLISM ............................................................................................................................................ 21
PULMONARY HYPERTENSION ..................................................................................................................................... 23
PULMONARY VENOUS HYPERTENSION ...................................................................................................................... 24
COR PULMONALE ........................................................................................................................................................ 24

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DEVELOPMENT OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM

RESPIRATORY FAILURE AND PULMONARY DISEASE ................................................................................................... 24


RESPIRATORY FAILURE ............................................................................................................................................ 24
EMPHYSEMA ........................................................................................................................................................... 25
OBSTRUCTIVE AND RESTRICTIVE LUNG DISEASE .................................................................................................... 26
RESPIRATORY CURVES ............................................................................................................................................ 27
BRONCHIAL ASTHMA .............................................................................................................................................. 27
MANAGEMENT OF ASTHMA ................................................................................................................................... 28
CHRONIC BRONCHITIS ............................................................................................................................................ 30
BRONCHIECTASIS .................................................................................................................................................... 30
INTERSTITIAL LUNG DISEASE ................................................................................................................................... 31
PNEUMOCONIOSIS.................................................................................................................................................. 32
OCCUPATIONAL LUNG DISEASE .............................................................................................................................. 32
ASBESTOSIS ............................................................................................................................................................. 33
SILICOSIS ................................................................................................................................................................. 33
PULMONARY HEMOSIDEROSIS ............................................................................................................................... 34
HYPERSENSITIVE PNEUMONITIS ............................................................................................................................. 34
EOSINOPHILIA ......................................................................................................................................................... 34
ASPERGILLOSIS ........................................................................................................................................................ 34
BRONCHIOLITIS ....................................................................................................................................................... 35
LARYNGOTRACHEOBRONCHITIS ............................................................................................................................. 35
BRONCHIAL FOREIGN BODY .................................................................................................................................... 36
BRONCHOSCOPY ..................................................................................................................................................... 37
SOLITARY NODULE .................................................................................................................................................. 37
PLEURAL EFFUSION, PNEUMOTHORAX AND MEDIASTINITIS ..................................................................................... 37
GENERAL FEATURES OF PLEURA ............................................................................................................................. 37
PLEURAL EFFUSION ................................................................................................................................................. 37
HEMOTHORAX ........................................................................................................................................................ 38
PNEUMOTHORAX .................................................................................................................................................... 39
LUNG SEQUESTRATION ........................................................................................................................................... 40
MEDIASTINUM ........................................................................................................................................................ 40
BRONCHOPLEURAL FISTULA ................................................................................................................................... 41
PNEUMONIA ............................................................................................................................................................... 41
GENERAL FEATURES OF PNEUMONIA ..................................................................................................................... 41
CAUSES OF PNEUMONIA......................................................................................................................................... 42
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DEVELOPMENT OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM

MORPHOLOGY OF PNEUMONIA ............................................................................................................................. 42


VIRAL PNEUMONIA ................................................................................................................................................. 42
STAPHYLOCOCCAL PNEUMONIA ............................................................................................................................. 42
STREPTOCOCCAL PNEUMONIA ............................................................................................................................... 43
ATYPICAL PNEUMONIA ........................................................................................................................................... 43
COMMUNITY ACQUIRED PNEUMONIA ................................................................................................................... 43
CMV PNEUMONIA ................................................................................................................................................... 44
LEGIONNAIRES PNEUMONIA ................................................................................................................................. 44
KLEBSIELLA PNEUMONIA ........................................................................................................................................ 44
PNEUMOCYSTIS CARNII PNEUMONIA ..................................................................................................................... 44
EMPYEMA ............................................................................................................................................................... 45
LUNG ABSCESS ........................................................................................................................................................ 45
BROCHIOLITIS OBLITERANS ..................................................................................................................................... 45
MANAGEMENT OF PNEUMONIA ............................................................................................................................ 46
TUBERCULOSIS ............................................................................................................................................................ 46
MYCOBACTERIUM TUBERCULOSIS ......................................................................................................................... 46
EPIDEMIOLOGY OF TUBERCULOSIS......................................................................................................................... 46
FEATURES OF TUBERCULOSIS ................................................................................................................................. 47
MORPHOLOGY OF TUBERCULOSIS .......................................................................................................................... 49
TUBERCULIN TEST ................................................................................................................................................... 49
SPUTUM EXAMINATION ......................................................................................................................................... 50
CULTURE OF MYCOBACTERIUM.............................................................................................................................. 50
DIAGNOSIS OF TUBERCULOSIS ................................................................................................................................ 51
TREATMENT OF TUBERCULOSIS .............................................................................................................................. 51
SARCOIDOSIS............................................................................................................................................................... 53
BRONCHOGENIC TUMORS .......................................................................................................................................... 54
GENERAL FEATURES OF BROCHOGENIC TUMOR .................................................................................................... 54
SMALL CELL CARCINOMA OF LUNG ........................................................................................................................ 55
NON SMALL CELL CARCINOMA OF LUNGS .............................................................................................................. 56
MANAGEMENT OF BRONCHOGENIC TUMOR ......................................................................................................... 57
BRONCHIAL ADENOMA AND BRONCHIAL CYST ...................................................................................................... 57
CYSTIC FIBROSIS .......................................................................................................................................................... 58
KARTAGENER SYNDROME ........................................................................................................................................... 58
VENTILATOR ................................................................................................................................................................ 59
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DEVELOPMENT OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM

KEY TO THIS DOCUMENT


Text in normal font Must read point.
Asked in any previous medical entrance
examinations
Text in bold font Point from Harrisons
th
text book of internal medicine 18
edition
Text in italic font Can be read if
you are thorough with above two.

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DEVELOPMENT OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM

DEVELOPMENT OF RESPIRATORY SYSTEM


Fetal respiratory movements
Respiratory bronchioles are formed
during
Common Lung anomalies
Bronchopulmonary dysplasia is seen with
Long term complications of
bronchopulmonary dysplasia
Use of steroids in neonates is required in

12 weeks
Pseudoglandular stage of lung
development
Pulmonary hypoplasia, Foregut cysts, Pulmonary
sequestration
Prematurity, Barotrauma, Oxygen therapy
Small airway disease, decreased FRC,
interstitial lung disease
Bronchopulmonary dysplasia

ANATOMY OF RESPIRATORY SYSTEM


Respiratory cilia
Number of rings in trachea
Length of trachea
Diameter of trachea
Right hilum is
Inferior most structure in right hilum
Hilum of right lung is arched by
Mediastinal Surface of Right lung is associated with
Hilum of left lung is arched by
Uppermost structure in left lung hilum
Most cranial structure in root of left lung
Bronchopulmonary segment

Number of bronchopulmonary segments


in right lung
Number of bronchopulmonary segments
in left lung
Segment absent in left lung
Eparterial bronchus is NOT present in
Parts of lower lobe of lung
NOT a part of lower lobe of lung
Lingual
Pulmonary segments in middle lobe of right lung
In lungs, bronchial arteries supply bronchopulmonary
tree
Bronchial arteries supply bronchopulmonary tree till
Blood supply of lungs
Blood supply of Lungs
Sensory supply of trachea

9 microtubular doublet with central


singlets (9 + 2)
16 to 17 rings
10 15 cm
1.2 cm
Lower than left
Inferior pulmonary vein
Azygous vein
Superior vena cava
Arch of aorta
Pulmonary artery
Pulmonary artery
Surgically resectable, Named according to segmental
bronchus supplying it, It is drained by INTERsegmental
branch of pulmonary vein, Largest subdivision of a lobe,
First segment drains more than 1 pulmonary vein
10
9
Medial basal segment
Left lung
Superior, Medial basal, Posterior basal
Anteromedial basal
Left upper lobe
Medial, Lateral
Till respiratory bronchioles
Respiratory bronchioles
Pulmonary artery, Pulmonary vein, Bronchial artery
Two bronchial veins on each side
Vagus

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PHYSIOLOGY OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM
Pulmonary plexus
Normal diameter of Trachea
Lining cells of alveoli
NOT lining alveoli
MC cells in bronchoalveolar lavage
Clara cells are found in
Clara cells in bronchoalveolar lavage seen in
Lepidic pattern
Variants of bronchoalveolar carcinoma
Canals of Lembert in alveolar spaces in lung
Pleural reflection on left mid axillary line is in
Pleural extends up to which rib in mid axillary line
Pectus carinatum
Pectus excavatum
Pectus excavatum
Pectus excavatum
NOT true about pectus excavatum

Cell bodies of post ganglionic


parasympathetic fibres
2 6 cm
Kulchitsky cells, Clara cells, Brush cells
Langerhan cells
Macrophages
Terminal bronchioles
Bronchoalveolar carcinoma
Bronchoalveolar carcinoma
Clara cell, mucinous, type II pneumocyte
Bronchoalveolar connections, Prevent atelectasis, Delay
in collapse
th
10 intercostal space
10
Pigeon chest
Funnel chest
Decrease in lung capacity, Cosmetic deformity,
Depression in chest
Inferior part of sternum depressed in
Gross CVS dysfunction

PHYSIOLOGY OF RESPIRATORY SYSTEM


GENERAL FEATURES OF RESPIRATORY PHYSIOLOGY
Normally lungs are kept dry by
Normal intrapleural pressure
Small airways have laminar flow because
Cough receptors is seen in
Type of receptors in bronchial smooth muscle
Normal intrapleural pressure is negative because
Negative intrapleural pressure is maintained by
Negative intrapleural pressure is maintained by
Intrapleural pressure is negative during both inspiration
and expiration because
Inflated state of lung in maintained by
A person is having normal lung compliance and
increased airway resistance. Most economical way of
breathing
Effort during normal respiration is due to
During inspiration, intrapleural pressure
Airway obstruction if auscultation over trachea during
forced inspiration
Normal expiration
Greatest proportion of airway resistance
More resistance in expiration is due to
Increased airway resistance due to

Osmotic pressure in interstitium


-3 to -5 cm of H2O
Extremely low velocity
Trachea
Beta 2
Chest wall and lung recoil in opposite direction
Absorption lymphatics
Lymphatic drainage of pleura
Thoracic cage and lung are elastic structure
Negative intrapleural pressure
Slow and deep

Lung elasticity
More negative
Breath sounds more than 6 seconds
At the end of normal expiration of air in lungs is ERV
Mid stem bronchi
Increased compression of airway
Forced expiration, Dense air, Low lung volume

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PHYSIOLOGY OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM
Respiration stops in last stage of expiration, in forced
expiration because of
Neutral position of Chest
Plateau pressure
Measurement of intravascular pressure by a pulmonary
catheter should be done
Water fall effect in
Blood flow to apex of lung during
Flow volume curve in RS
Childs respiratory physiology differs from adult
because of
WRONG statement about Compliance
Pulmonary circulation
Pulmonary circulation differ from systemic circulation
Lung circulation
Pulmonary vascular resistance is
decreased by
Bronchial circulation

Recruitment is seen in
During heavy exercise, cardiac output increases up to
five fold while pulmonary arterial pressure is very little.
Physiological ability of pulmonary circulation is best
explained by
Pulmonary circulation in hypoxia
Vascularity of lung
NOT true about lung circulation
Physiological dead space in lung
Physiological dead space
Normal ratio of physiological and anatomical dead
space
Anatomical dead space by
Best known metabolic function of lung
Important non respiratory function of lung

Dynamic compression of airway


End expiratory
End expiratory pressure
At end expiration
Middle lung
Systole
Extrathoracic obstruction
Smaller airways
Compliance is affected only by surfactant
Hypoxia cause vasoconstriction, Blood volume in lung is
450 ml, Low resistance
Pulmonary vasoconstriction in hypoxia, Resistance low,
Capillary pressure low
V/P ratio is 0.8 at rest, In apex ventilation is less than
base
Increase in cardiac output
Contribute 2% of systemic circulation, NO gaseous
exchange, Causes venous admixing of blood, Provide
nutritive function to lung
Lung
Increase in number of wide open capillaries

Vasoconstriction
Distended pulmonary veins in lower lobe
Decreased vital capacity in supine position, Most blood
in pulmonary capillary
Zone 1
150 ml
1:1
Single breath nitrogen curve
Conversion of angiotensin I to angiotensin II
Sodium balance

INSPIRATION AND EXPIRATION


Lattisimus dorsi used in
Inspiratory muscles
Accessory muscles of inspiration
Muscle that does NOT contract during
forced expiration
Discharge spontaneously during quiet
breathing

Forced EXPIRATION
Diaphragm, external intercostal
Serratus anterior, Serratus posterior, Scalene
External intercostalis
Inspiratory neuron

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PHYSIOLOGY OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM

SURFACTANT
Surfactant is produced by
Size and number of inclusions in type II
alveolar epithelial cells producing
surfactant is increased by
Accelerates maturation of surfactant in
lung
Surfactant production in lungs start at
Surfactant is made up of
Major constituent of Surfactant
Action of surfactant in human body is done by
Hyaline membrane contains
Functions of surfactant

Mechanism of action of surfactant in alveoli


Pulmonary surfactant
Stability of alveoli is maintained by
Stability of alveoli maintained by
Blood air barrier

Type II pneumocytes
Thyroxine

Glucocorticoid
28 weeks
Phospholipid
Dipalmityl Phosphotidyl Choline
Lipid and protein
Fibrin
Increases compliance of lung, reduces
surface tension of alveolar fluid, prevents
collapse of alveoli
Break the structure of water in alveoli
Maintains alveolar integrity
Increase in alveolar surface area by surfactant
Reduced surface tension by surfactant
Type II pneumocytes

GASEOUS EXCHANGE
Oxygen cascade

In a normal healthy person, arterial


oxygen is considered satisfactory if spO2 is
more than
When blood passes through systemic capillaries

PCO2 in atmospheric air


Alveolar CO2
Arterial carbon dioxide level
Least pCo2
In alveolar gas, Mixed venous PCO2 is more than
Movement of CO2 from pulmonary capillaries to alveoli
CO2 diffuse more easily than O2 because
CO2 is primarily transported in blood as
Percentage of O2 carried in chemical combination
PaCO2
PAO2 = FiO2 PB PH2O
R
Alveolar gas pressure is equal to

Oxygen cascade describes the process of


declining oxygen tension from atmosphere
to mitochondria
90%

Increased protein content, Increased hematocrit,


Decreased Ph, Shift of hemoglobin dissociation curve to
right
0.3 mm Hg
40 mm Hg
40 mm Hg
Arterial blood
Alveolar PCO2
Simple diffusion
More soluble in plasma
Bicarbonate
97%
Alveolar gas equation, Barometric pressure = 760 mm
Hg, Water vapor pressure = 47 mm Hg, Respiratory
quotient = 0.8
Body surface pressure

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PHYSIOLOGY OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM
Po2 in atmospheric air
Partial pressure of O2 at atmospheric pressure of 760
mm Hg
Atmospheric pressure 760mm Hg. O2 = 21%, partial
pressure of 02?
Po2 In Alveoli
Normal value of PO2 in healthy man is
At attitude of 6500 m, atmospheric pressure is 347 mm
Hg. inspired pO2
pO2 in pulmonary capillary
pO2 of aorta
Partial pressure of oxygen in venous blood
Concentration of O2 in blood 0.0025 ml, atm 760 mm
Hg, approximate oxygen tension
Normal level of Oxygen in blood when hemoglobin is
saturated with O2
Arterial blood O2 in ml of O2 per dL
Amount of dissolved oxygen transported in 100 ml of
plasma in a subject breathing 100% oxygen at 4 ATA
Additional amount of oxygen transported in 100 ml of
blood in a subject breathing 100 % oxygen under
hyperbaric conditions of 4 ATA compared to
normobaric conditions (1 ATA)
If hemoglobin is completely absent,
amount of plasma for basal oxygen
requirement
Gas used to measure diffusion in lung
Fraction of inspired air in mouth to mouth respiration
Respiratory quotient
Respiratory quotient of carbohydrate
Non Protein Respiratory Quotient
Rupture of mucosal blood vessels of trachea
Venous admixture by

160 mm Hg
159 mm Hg
104 mm Hg
80 mm Hg
73 mm Hg
97 mm Hg
95 mm Hg (because of physiological shunt)
4o mm Hg
80 mm Hg
20 ml/dl
19.8
9 ml
6 ml

83 L

CO
0.16 (16%)
VCO2/VO2
1
0.75
40 mm Hg
Thebesian veins, high V/Q areas of lung,
bronchial vein

VENTILATION PERFUSION RATIO AND COMPLIANCE


Normal respiratory system compliance
Specific lung compliance is decreased in
Specific lung compliance is NOT decreased in
Pulmonary ventilation
Ventilation perfusion ratio is maximum at
High oxygen tension in alveoli is due to
Function of shunt

0.2 L/cm H2O


Pulmonary congestion, Pulmonary fibrosis, Decreased
surfactant
Chronic bronchitis
PaO2 is maximum at apex
Apex of lung
Ventilation perfusion mismatch
Perfusion of non ventilated lung

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PHYSIOLOGY OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM

HYPERCARBIA AND ALVEOLAR HYPOVENTILATION


Gradient of alvelolar arterial oxygen tension in
Hypoventilation is
Gradient of alveolar arterial oxygen tension is increased
in
Alveolar hypoventilation in
Hypoventilation
NOT associated with alveolar hypoventilation
Management of hypoventilation
Hypercarbia is characterized by
CO2 retention is seen in
Apnoea is
Sleep apnoea, temporary pause for at least

Normal
Diffusion effect, Right to left shunt, Ventilation
perfusion abnormality
Bulbar poliomyelitis, COPD, Kyphoscoliosis
Excess of plasma bicarbonate in absence of volume
depletion
Lobar pneumonia
NIPPV
Hypertension, Tachycardia, Mydriasis due to
sympathetic stimulation
Respiratory failure, Ventilator failure, Pulmonary
edema, Drowning
Cessation of respiration
10 seconds

HYPERVENTILATION
Hyperventilation caused by
Voluntary hyperventilation at rest is
associated with
NOT a cause of hyperventilation
Initial change after Hyperventilation
In hyperventilation
Reduction in arterial oxygen tension caused by
Arterial blood gas determination in hyperventilation
shows
After hyperventilation for some time
holding breath is dangerous, due to
Alveolar O2 tension is
Solubility of CO2 is

Decreased pH in CSF, decreased plasma HCO3,


increased adrenergic levels
Washing out of CO2, alkalosis, convulsions,
decrease in arterial CO2 pressure,
decreases H+ ion (increases pH)
CO poisoning
Decreased PCo2 with Increased pH
P50 decreases and O2 affinity increases
Hypoventilation
Reduced PCO2
Lack of stimulation by CO2, anoxia can go
into dangerous level
Increased by hyperventilation
20 times than that of O2

HIGH OXYGEN TENSION


Hyperbaric oxygen is dangerous because it
Toxic effects of high oxygen tension
NOT an effect of high oxygen tension
Decreased cerebral blood flow in high oxygen tension is

Is toxic to tissues
Pulmonary edema, Retinal damage, CNS excitation and
confusion
Hyperthermia
Protective effect

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PHYSIOLOGY OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM

HYPOXIA
O2 content of arterial blood
Decrease in respiration causes
Hypoxia

Hypoxia is characterized by
Tachycardia in hypoxia is due to
Hypoxia causes
MC physiological cause of hypoxemia
Most prone for hypoxic injury
Neurons may get irreversibly damaged if exposed to
significant hypoxia for
No stimulation of ventilation by hypoxia
until pO2 falls below
Hypoxia does NOT cause vasodilatation in
Hypoxemia does NOT depend on
Variant of hypoxia NOT stimulating peripheral
chemoreceptors
Anemic hypoxia is due to
Best test for anemic hypoxia
Hypoxia seen in general anesthesia
Best parameter for analysis of hypoxic hypoxia
Condition leading to tissue hypoxic without alteration of
blood oxygen content
Stagnant hypoxia is due to
Best test for stagnant hypoxia
Histotoxic hypoxia
Best test for histotoxic hypoxia
Oxygen therapy is NOT effective in
Does NOT used to prevent hypoxia
Stimulus for pulmonary vasoconstriction
Pulmonary Vasoconstrictor
Primary pulmonary hypoventilation

19.4 ml/100 ml
Decreased pH + Increased PCO2
When it is severe, it causes stimulation of sympathetic
nervous system, It leads to accumulation of hydrogen
and lactate ions, If it is chronic, causes rightward shift of
oxygen Hb curve.
Intense chemoreceptor response, Low arterial
PO2,favourable response to 100 % CO2
Diffuse vasodilatation
Decrease in cerebral blood flow
Hypoventilation
Hippocampus
8 minutes
60 mm Hg
Lung
Hb
Anemic hypoxia
Decreased O2 content in arterial blood
Oxygen content or Hb%
Hypoxic hypoxia
Arterial pO2
Cyanide poisoning
Reduced blood flow
AV difference
CO and cyanide
AV difference of PO2 of venous blood
Histotoxic anoxia
Pin Index
Hypoxemia, Hypercapnia, Thromboxane
Low PaO2
Does not respond to chemical stimuli

FEATURES OF HEMOGLOBIN
Hemoproteins
Hemoprosthetic group is found in
Heme synthesis require
Initially important for hemoglobin synthesis
First step of heme synthesis
Key enzyme in heme biosynthesis
Hemoglobin is a buffer because of

Cytochrome c, Cytochrome 450, Myoglobin,


Hemoglobin, Catalase
Myoglobin, Cytochrome oxidase
Ferrous ion, Glycine, Succinyl coA
Glycine
Glycine + Succinyl CoA
ALA synthase
Histidine residue
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PHYSIOLOGY OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM
Buffer NOT involved in non rapid achievement of Renal
pH
Allosteric protein
Quarternary Structure
Hemoglobin is present in
Hemoglobin structure

In hemoglobin, iron is bound to


In hemoglobin, the innate affinity of heme for carbon
monoxide is diminished by presence of
Function of histidine E7 in hemoglobin
Fe++ is attached to
HbM
HbF
HbS
Hb Sydney
In lung R state favors
T structure is stabilized by
Decreased glycolytic activity impairs oxygen transport
by hemoglobin due to
Embryonal hemoglobin
Type of hemoglobin with least affinity for 2,3-DPG
ADT test for
NOT true about fetal hemoglobin
Hemoglobin unlike myoglobin shows
Feature common to both hemoglobin and myoglobin
Each gram of hemoglobin carry
Carbon dioxide is carried in blood as

Hemoglobin
Hemoglobin
Hemoglobin
Hydrophobic pockets
Hb has 4 polypeptide, Iron is present in ferrous state,
Hb is structurally similar to myoglobin, Ferrous ions are
in porphyrin rings
Histidine
His E7
Hindered environment, protects CO
poisoning
Histidine F8 of globin chain
Histidine F8 to tyrosine
Histidine 21 to serine
Glutamate for valine
Valine for alanine
Oxygenation (breaks salt bridge)
2,3 DPG
Decreased production of 2,3 bisphosphoglycerate
Zeta epsilon
HbF
HbF
Strong affinity for 2,3 DPG
Sigmoid curve of oxygen dissociation, Positive co
operativity
Heme at hydrophobic pockets
1.39 ml of O2
Carbaminocompounds, dissolved gas,
bicarbonate

OXYHEMOGLOBIN DISSOCIATION CURVE


Amount of oxygen consumed per minute
under basal condition
Oxyhemoglobin dissociated curve is
Oxyhemoglobin dissociation curve is sigmoid shaped
because
Oxygen dissociation curve is sigmoid in shape because
of
Myoglobin dissociation curve
Myoglobin is
Myoglobin does NOT use oxygen
True about conversion of deoxy hemoglobin to
oxyhemoglobin
Normal value of P50 on oxyhemoglobin dissociation

250 ml
S shaped
Binding of one oxygen molecule increases the affinity of
binding other O2 molecules
Shifting affinity for Oxygen
Hyperbolic
8 alpha helix
Because p50 is low
Binding of O2 cause release of H+
3.6 pKa

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PHYSIOLOGY OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM
curve in an adult
During exercise, increase in O2 delivery to muscle
increase because of
Role of 2,3-DPG
Major role of 2,3-DPG
Feature of 2,3-DPG
Increase in 2,3-DPG seen in
In anemia concentration of 2,3-DPG
Fetal hemoglobin has higher affinity for oxygen due to
Shift of Oxygen dissociation curve to right is by
Oxygen curve shift to right
Compound shifting curve to right
Shift to right in
Acidosis shift curve to
Right shift in oxygen dissociation curve does NOT occur
in
Oxygen dissociation curve does NOT shift to right in
Does NOT shift ODC to right
Curve shift of left by
Increased pH causes O2 dissociation curve to
What causes O2 curve to left
Oxygen dissociation in peripheral tissues is NOT altered
by
Does NOT influence dissociation curve
Oxygen affinity is increased by
Oxygen affinity is NOT increased by
Oxygen affinity is NOT increased in
O2 delivery to tissue does NOT depend on
Decrease in affinity of hemoglobin when pH of blood
falls
O2 delivery to tissue is decreased by

Oxygen dissociation curve shifts to right, Increased


stroke volume, Increased extraction of oxygen from
blood, Increased blood flow to muscles
Unloading oxygen to tissues
Release of oxygen
Higher concentration in adult blood
Anemia, Hypoxia, Inosine
Increased
Reduced 2,3 DPG concentration
Temperature, pH, DPG concentration
Decrease pH, increased temperature, increase in 2,3
DPG
2,3 DPG
Hypercarbia, Sickle Hb
Right
Transfusion
Blood transfusion, Metabolic alkalosis
Increased pH
Increased oxygen affinity of hemoglobin
Left
Decreased temperature
Anemia
Chloride ion concentration
Alkalosis, Increased HbF, Hypothermia
Hypoxia
Hyperthermia
Type of fluid administered
Bohr Effect
Decreased hemoglobin level, Decreased PaO2,
Increased Ph

REGULATION OF RESPIRATION
Pacemaker of respiration
Spontaneous rhythmic respiration is initiated in
Rhythmic control of respiration lies at
Rhythm of Respiration is maintained by
Most important stimulus of respiratory centre
Respiratory centre is stimulated by
Respiratory centre
Respiratory centre depression NOT caused by
Complete transaction of brain stem above
the pons
Section above pons inhibit
Pneumotaxic centre

Pre Botzinger complex


Pre Botzinger complex
Dorsal respiratory centre
Dorsal medulla
Decreased PaO2
Hypercarbia
Inhibited during swallowing
Strychnine
Prevent any voluntary holding of breath
Apneustic centre
Pons

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PHYSIOLOGY OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM
Inhibition of Pneumotaxic centre causes
Lesion of pneumotaxic centre
In cat apneustic centre is destroyed along with cutting
of vagi
Lesion of prebotzinger complex
Transection at mid pons level result in
Transaction at mid pons level with intact
vagii
Apneusis is caused by
What will be effect of respiration if transaction made
between pons and medulla
Lesion below medulla
NOT a stimulus for pulmonary vasoconstriction
Central chemoreceptors are most sensitive to
Chemoreceptor reflex primarily causes
Primary direct stimulus for excitation of central
chemoreceptors
Central and peripheral chemoreceptors respond to
Peripheral chemoreceptors stimulated by
Administration of pure O2 to hypoxic patients is
dangerous because
Does NOT stimulate peripheral chemoreceptors
Does NOT stimulate peripheral chemoreceptors
Tidal volume excessive load is prevented by activation
of
Inflation of lung induce further inflation
Herring Breuer inflation reflex
Affect resting ventilation
Does NOT affect resting ventilation
J receptors are present in
Stimulation of J receptors cause
J receptor stimulation causes
J receptor reflex
J receptor reflex
Lung reflexes are mediated by

Prolonged Inspiratory spasm


Deep gasping as if tidal volume is high
Prolonged inspiratory spasm
Ondine curse (involuntary respiration is
affected)
Apneusis
Slow and deep breathing
Parabrachial nucleus and vagus
Irregular and gasping
Total loss of respiration
PGI2
Increased PCO2
Bradycardia, Vasoconstriction
Increased H+
Increased arterial CO2
Hypoxia, Acidosis, Low perfusion pressure
Apnea occurs due to hypostimulation of peripheral
chemoreceptors
Hypocapnia
Anemic hypoxia
Bronchial stretch receptors
Heads paradoxical reflex
Protective, involves pulmonary stretch
receptor, inhibition of inspiratory centre
Stretch receptors, Oxygen, PCO2
J receptor
Pulmonary interstitium
Apnea followed by tachypnea
Apnea, hyperapnea, hypotension,
bradycardia
A.S.Paintal (India)
Sensitive to pulmonary congestion, Stimulated by
Bradykinin
Myelinated nerve fibres

LUNG VOLUMES, CAPACITIES AND ALVEOLAR VENTILATION


PFT

Best indication of alveolar ventilation is provided by


measurement of
Volume of air taken in and given out during normal

Total lung volume increases in emphysema, Compliance


decreases in interstitial lung disease, Compliance is total
lung distensibility
Tidal Volume
Tidal volume

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PHYSIOLOGY OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM
respiration
Tidal volume calculated by
Tidal Volume in both Men and women
Resting tidal ventilation
Minimal tidal volume for adult resuscitation
Maintenance of tidal volume
Expiratory reserve volume
Inspiratory reserve volume
Residual volume
Inspiratory capacity (TV + IRV)
Normal vital capacity (TV + IRV + ERV)
Functional residual capacity (ERV + RV)
Total lung capacity
Amount of air in lungs at the end of tidal breath
Volume of air in Lungs when respiratory muscles are at
rest
Functional residual capacity is
Functional residual capacity
Normal functional residual capacity
Functional residual capacity is measured following
At functional residual capacity, trans respiratory pressure
system
Nitrogen washout method for
During quiet inspiration, alveolar
pressure
Alveolar ventilation
Total alveolar volume in litre per minute
Alveolar Ventilation if an adult shows tidal volume 600
ml, dead space of 150 ml and respiratory rate of 15/min
Alveolar PaO2
FEV1
FEV1 is
Instrument used for measuring vital capacity and FEV
Vital Capacity
Critical Closing volume is
Closing Capacity depends of
Breathing reserve
Hyaline membrane disease
Decreased maximum mid expiratory flow rate indicates
obstruction in
Used to measure resistance to smaller airways
Total lung capacity depends on
Normal Vd/Vt ratio in adult
Better vision in video assisted thoracoscopic surgery
created by
Spirometry used in diagnosis of
Volume that can NOT be measured by spirometer
Spirometry does NOT measure
Routine spirometry can NOT measure

Inspiratory capacity minus inspiratory reserve volume


500 ml
5 L/min
600 ml
Bronchial stretch receptors
1000 ml
3300 ml
1200 ml
3800 ml
4800 ml
2200 ml
6000 ml
FRC
Functional Residual capacity
Volume remaining of normal respiration
ERV + RV
2.2 L
Normal expiration
Zero
Functional residual capacity
0 cm H2O
(tidal volume dead space volume) X respiratory rate
4.2
6.75 L/min
100 120 mm Hg
Forced expiratory volume in first second
80% of Vital capacity
Vitalograph
TV+IRV+ERV
Close to Residual Volume
Dependent Small Airways
Maximum breathing capacity
respiratory minute volume
FRC below closing volume
Small airway
Mid respiratory flow rate
Compliance of lung
0.3
Collapse of Ipsilateral Lung
Asthma
Functional Residual capacity
Residual volume
RV, FRC

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PHYSIOLOGY OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM
In body plethysmography, a person is asked to expire
against closed glottis. change in pressure in the lung
and the box
Man connected to body plethysmograph for estimation
of FRC

Increase in lung and decrease in box

inspired against closed glottis

ACCLIMATISATION
During acclimatization

Features of acclimatization

Earliest change in high altitude


pH and arterial pCO2 in a climber
Adaptation will be apt to increase the work capacity at
high altitude
Mountaineer ascents 18000 feet in 2 days without
supplemental oxygen.
Seen in high altitude climbers
Feature of pulmonary edema in high altitude climbers
Compensating mechanisms involved in acclimatization
to altitude
A person goes to mountains, when he reaches about
5000 feet, he develops dyspnea.
Does NOT occur in High altitude acclimatization

Increase in minute ventilation, increased in sensitivity of


central chemoreceptors, increase in sensitivity of
carotid body to hypoxia
Polycythemia, increased diffusion
capacity of lung, increased pulmonary
ventilation, pulmonary vasoconstriction
Hyperventilation
pH will rise and pCO2 will fall
(respiratory alkalosis)
Decreasing work load, increasing duration of exercise
Decreased barometric pressure, Decreased PaO2,
Increased pH
Hyperventilation, Decreased PaCO2, Pulmonary edema
increased pulmonary capillary pressure, Normal left
atrial pressure
Hyperventilation, Respiratory alkalosis
CO2 washout
Increased Blood glucose

MOUNTAIN SICKNESS
Acute mountain sickness is associated with
Treatment of acute mountain sickness
Monges disease

Sleep desaturation
Acetazolamide
Chronic mountain sickness

CAISSONS DISEASE
For every 20 meter depth
Decompression sickness
Decompression sickness seen in
Caisson disease
Feature of Caisson disease
Pathological changes in Caisson disease is due to
Main danger in deep sea divers is due to
Nitrogen narcosis is due to

3 atm pressure (1 atm due to atmosphere, 2 atm due to


water level)
1 in 10,000 divers
Diver, pilot
Gas embolism
Myonecrosis, paraplegia
N2
Oxygen and nitrogen
Increased solubility of nitrogen in nerve cell membrane

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16

SIGNS AND SYMPTOMS OF RESPIRATORY SYSTEM

RESPIRATORY SYSTEM

SIGNS AND SYMPTOMS OF RESPIRATORY SYSTEM


GENERAL SIGNS AND SYMPTOMS OF RESPIRATORY SYSTEM
Hypoxemia
MC fetal response to acute hypoxia
Platypnea
Wheeze in children is caused by
Bilateral rhochi
Rhonchi NOT in
Vocal Resonance is increased in
Vocal resonance is increases in
Cavernous respiration
Consolidation
Tubular breathing
NOT a finding of consolidation
Homogenous opacification of right hemithorax with
right sided shift of mediastinum may be caused by
Golden S sign
Fever malaise, on examination tracheal shift to right
side, VR, VPL heard, percussion note dull
Emphysema COPD
Decreased static compliance
Wide Alveolar O2 gradient
Bronchial hyperplasia caused by
Bronchial hyperplasia NOT caused by
Lung granuloma with necrosis
Bulls eye granuloma
Large granuloma is seen in
Bagassosis is most likely caused due to inhalation of
MC cause of secondary tracheomalacia
Sandstorm appearance on chest X ray
Diffuse parenchymal lung disease

Cause of pulmonary renal syndrome


Pulmonary renal syndrome is seen in
APUD cells seen in
Vascular ring causing external airway compression can
be diagnosed by

Hypoventilation, Decreased FiO2, Myasthenia gravis,


Pulmonary emboli
Bradycardia
Pleural effusion, Pulmonary embolism, Cirrhosis, COPD
Foreign body, Bronchial asthma
Pulmonary edema, Bronchiectasis, Emphysema
Pulmonary embolism
Consolidation
Lobar pneumonia, localized fibrosis of lung, cavity in
apex
Cavity
Trachea midline, Dull percussion note, Bronchial breath
sounds, Increased vocal resonance
Consolidation
Dullness
Collapse of right lung
Right upper lobe collapse
Apical fibrosis
INCREASED static compliance. Decreased dynamic
compliance
ARDS, Pulmonary edema, Interstitial fibrosis, Fibrosing
alveolitis, Pulmonary congestion, Decreased surfactant
ARDS, Bronchiectasis, Intestinal fibrosis
Smoking, prematurity, allergy
Theophylline
Tuberculosis, Histoplasmosis, Cryptococcosis, Wegener
granulomatis
Pulmonary granuloma
Berylliosis, sarcoidosis
Sugar cane
Aberrant innominate artery
Pulmonary alveolar microlithiasis
Activation of macrophages leads to laying
down of fibrous tissue and irreversible
lung scarring
Leptospirosis, Hanta virus, Paraquat poisoning
Goodpasture syndrome, Leptospirosis, Hanta virus
infection, Wegeners granulomatosis
Bronchial carcinoid
Angiography of aortic and pulmonary circulation

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