Respiratory Exam 1

1
Respiratory Exam 1

• Flashcards

2
felton

• microbiology

3
What is the most common infectious disease of
humans?

• The common cold
• Also, the leading cause of acute morbidity and of
  visits to a physician in the US
• Major cause of industrial and school absenteeism

4
What microorganism grows optimally at a temp
lower than normal core body temp?

• RHINOVIRUS
• In tissue culture grow optimally at 33C, the
  temperature of the nasal mucosa of humans

5
Where does the rhinovirus multiply?

• In the cytoplasm of host cells

6
What type of virus is the rhinovirus

• Small, single stranded RNA virus
• Related to poliovirus
• Member of the family picornaviruses

7
What types of viruses are coronaviruses?

• Single stranded RNA viruses
• Round or petal shaped projections around the
  viral capsid resembling a crown
• Lipid envelopes are labile to ether or chloroform
• SARS-CoV caused by coronavirus

8
Respiratory syncytial virus

• Infects infants and children more
• Causes colds, bronchopneumonia, or bronchitis
• Paramyxovirus
• RNA, enveloped
• Two antigenic types

9
Orthomyxoviruses

• Influenza viruses
• 3 antigenic types

10
Paramyxoviruses

• Parainfluenza viruses
• 4 antigenic types
• Enveloped, SS RNA viruses
• In kids, can cause severe diseases
• Croup, bronchitis, pneumonia
• In adults can cause adult respiratory diseases
• Are one of the major causes of viral laryngitis
  and pharyngitis in adults

11
List the possible modes of transmission of a
virus

• Direct contact with infectious secretions on skin
  and environmental surfaces
• Large particles of respiratory secretions that
  are briefly transported in air
• Infectious droplet nuclei suspended in air
• Combination of these methods

12
How long is the incubation period for the common
cold?

• 48-72 hours

13
What are the symptoms of the common cold?

• Nasal discharge
• Nasal obstruction
• Sneezing
• Sore or scratchy throat
• Cough
• Anorexia and slight fever may be present

14
What is sinusitis?

• Acute, inflammatory affliction of one or more of
  the paranasal sinuses
• Usually after
• Rhinitis
• Dental extraction
• Or in pts with predisposing factors such as
  nasal polyps, deviation of the nasal septum,
  tumors, foreign bodies, trauma, abrupt change of
  pressure in the nasal passages, and conditions
  such as cystic fibrosis

15
What bacteria most commonly cause acute sinusitis?

• Strep pneumoniae and H. influenzae

16
Things that can predispose you to purulent
sinusitis

• Nasal polyps
• Deviation fo the nasal septum
• Tumors
• Foreign bodies
• Trauma
• Abrupt change of pressure in the nasal pasages
• Cystic fibrosis

17
Type of bacteria more commonly associated with
chronic sinusitis

• Anaerobic bacteria
• Often as a combined infection with aerobes

18
What is the pathogenesis of sinusitis?

• Obstruction of the paranasal sinusal ostia
  impedes drainage
• Infections impair the cilliary activity of the
  sinuses
• Results in accumulation of mucous secretions
• Mucus converted to mucopus by bacterial
  multiplication in the sinus cavities
• The pus irritates the underlying mucosa causing
  further edema and aggravating the obstruction

19
When is sinusitis most prevalent?

• Fall, winter, and spring

20
Clinical manifestations of sinusitis

• Facial pain
• Purulent nasal discharge
• Photophobia and tearing may be present

21
Diagnosis of sinusitis

• Can be made without radiographic exams when there
  is a hx of upper respiratory tract infection or
  allergic rhinitis, pain and tenderness over a
  sinus, and purulent discharge
• Microbial etiology is determined by culture of an
  exudate or a rinse obtained by sinus puncture and
  aspiration
• Cultures obtained from nasal pus or by rinsing of
  the nose are unreliable because of contamination
  with resident bacterial flora

22
Tx of sinusitis

• Responds well to antimicrobial therapy

23
Bacteria that causes mostly asymptomatic
pharyngitis

• N. gonorrhoea
• Occasional case of mild pharnygitis

24
When does most pharyngitis occur?

• Winter

25
Type of pharyngitis most commonly caused by
adenoviruses

• Pharyngoconjunctival fever
• Usually more severe than the common cold
• Temperature elevations persist for 5-6 days
• MARKED sore throat
• Distinguishing feature
• CONJUNCTIVITIS which occurs in 1/3 to ½ of cases
• Follicular type
• Bilateral
• Cough, hoarseness, and substernal pain occur in
  acute respiratory disease ARD in military
  recruits.

26
Symptoms of pharyngitis with influenza

• Sore throat major complaint
• Coryza symptoms may be present
• Temperature elevations are common in children and
  adults
• Edema and erythema of the pharynx is NOT marked
• NO pharyngeal exudates or painful exudate
• Recovery in 3-4 days

27
Symptoms of pharyngitis with the common cold

• Mild to moderate pharyngitis discomfort, but not
  the primary complaint
• Rhinorrhea and post-nasal discharge usually
  present
• NO
• Severe pharyngeal pain or dysphagia
• Pharyngeal and tonsillar exudates or painful
  lymphadenopathy

28
Adenoviruses can cause what 3 types of
respiratory diseases?

• Acute, febrile, self-limiting condition
• Pharyngoconjunctival fever
• Pertussis-like syndrome indistinguishable
  clinically from infection with Bordetella
  pertussis
• Adenoviruses are major etiologic agents of acute
  respiratory disease ARD and pharyngitis. Also
  indicated in pathogenesis of epidemic
  keratoconjunctivitis, hemorrhagic cystitis,
  gastroenteritis, and rashes.

29
Symptoms of acute herpetic pharyngitis

• Primary infection may present as acute
  pharyngitis
• Severe cases inflammation and exudate may mimic
  full blown streptococcal pharyngitis
• Vesicles and ulcers of the palate
• Vesicles and ulcers on the labial and buccal
  mucosa when there is an assoc. gigivostomatitis

30
Characteristics of herpes simplex viruses

• Large DNA virus
• Lipid containing capsids
• Inactivated by ether
• Will see
• eosinophilic intranuclear inclusion bodies in
  infected cells
• Tend to produce latent infection
• Role in recurrent fever blisters

31
What type of pharyngitis is caused by
coxsackieviruses?

• Herpangina
• Small vesicles on soft palate, uvula, and
  anterior tonsillar pillars
• Lesions rupture to become small, white ulcers
• Mostly in kids severe, febrile illness with
  marked sore throat with dysphagia

32
Cocksackieviruses

• Picornaviruses
• Can cause
• Aseptic meningitis
• Myocarditis
• Upper respiratory tract infections
• Group A
• Types 2,4,5,6,8,10 can cause aherpangina
• Type 10 is also associated with a summer febrile
  disease in children called acute lymphonodular
  pharyngitis

33
Symptoms of infectious mononucleosis

• Exudative tonsillitis or pharyngitis in about ½
  the cases
• Fever and cervical adenopathy usually present
• Enlargement of spleen in ½ the cases

34
What does the presence of eosinophilic
intranuclear inclusion bodies suggest?

• Infection with herpes simplex virus

35
Symptoms of anaerobic pharyngitis

• Pharyngeal and tonsillar infection
• Mix of anaerobic bacteria and spirochetes
• Purulent exudate coats the membrane
• May be a foul odor to the breath
• With development of an abscess, pharyngeal pain
  is usually severe, dysphagia and low grade fever
  are common
• Infection usually limited to one side, but when
  bilateral, partial obstruction of the pharynx
  occurs

36
Symptoms of streptococcal pharyngitis

• In severe cases marked pharyngeal pain,
  dysphagia, and a temperatures of 39.4C or greater
• Pharyngeal membrane is fiery red
• A thick exudate covers the posterior pharynx
  tonsilar area
• Edema of uvula is often pronounced
• Tender, enlarged cervical nodes
• A leukocyte count of over 12,000/mm3
• Infection with S. pyogenes that produces
  erythrogenic toxin results in the characteristic
  erythemetous rash of scarlet fever.

37
Symptoms of DIPHTHERIA

• Low grade temperature elevation
• Tonsillar or pharyngeal pseudomembrane varies
  from light to dark gray and is firmly attached to
  the tonsil and pharyngeal mucosa

38
Mycoplasma pneumoniae

• Pharyngitis is usually mild with no
  distinguishing clinical features
• M. pneumoniae characteristically causes
  bronchitis and primary atyptical pneumonia

39
What does the presence of exudate suggest?

• Streptococcal pharyngitis
• Vincents angina
• Pharyngoconjunctival fever
• Herpes simplex virus infection
• Infectious mononucleosis

40
What does the presence of small vesicles or
ulcers suggest?

• Herpes simplex virus infection
• Herpangina

41
What does the presence of exudate and small
vesicles or ulcers suggest?

• Herpes simplex virus infection
• Will also see eosinophilic intranuclear
  inclusion bodies

42
Medial displacement of one or both tonsils is
seen with

• Peritonsillitis
• Peritonsillar abscess

43
Type of agar that can be used to detect N.
gonorrhoea

• Thayer-Martin agar

44
HOW is Vincents angina diagnosed?

• Crystal violet stained smear of the pharyngeal or
  tonsillar exudate showing the presence of
  numerous fusobacteria and spirochetes

45
Medium used to detect DIPTHERIA

• Loefflers medium

46
Small, pleomorphic, gram negative rod that is
nonmotile, nonsporulating, and usually capsulated

• H. influenzae
• Aerobic or facultative
• Requires
• Iron protoporphrin compound X factor
• Pyridine nucleotide V factor

47
What is the virulence of H. influenzae associated
with?

• Capsulation
• 6 antigenic types a-f
• Type b formerly accounted for almost all serious
  infection in humans
• Vaccination has reduced the frequency of this
  disease in young children

48
Drugs used to treat respiratory airway infections
caused by H. influenzae

• Chloramphenicol
• Ampicillin
• Penicillin G
• Tetracycline
• Sulfonamindes

49
Classic sites for localization of diptheria
infection

• Larynx and pharynx

50
What microorganism causes whooping cough?

• Bordetella pertussis
• Small, ovoid
• Nonmotile
• Nonsporeforming
• Gram NEGATIVE rod
• Fastidious requirements for grouth
• Phase I virulent, encapsulated, piliated
• produces several toxins
• Phase IV pleomorphic, noncapsulated, avirulent
• ONLY PHASE I BACILLI ARE SUITABLE FOR THE
  PREPARATION OF VACCINES

51
What is the major cause of bacterial pneumoniae
in adults and children?

• Strep. Pneumoniae!

52
Paramyxoviruses with binding sites for
erythrocytes

• Parainfluenza viruses
• Contain RNA core enclosed in an ether sensitive
  envelope
• Multiply in the cytoplasm of infected cells
• 4 types that parasitize humans 1,2,3,4

53
Clinical symptoms associated with parainfluenza
viruses

• 1,3,4 common cold and pharyngitis
• 1,2,3 croup
• 1,3 bronchitis and bronchopneumonia

54
Crystal violet stained smear of the pharyngeal or
tonsillar exudate showing the presence of
numerous fusobacteria and spirochetes suggests

• Vincents angina

55
Do influenza viruses normally cause upper or
lower respiratory tract infections?

• lower

56
Respiratory infections caused by RSV

• Usually bronchiolitis or bronchopneumonia in
  infants
• Sometimes croup

57
What are the symptoms of acute laryngitis?

• Barking cough and hoarseness
• In kids airway obstruction due to infection of
  the larynx and tracheobronchial tree
• Diagnose by clinical characteristics of the
  illness and may be confirmed by examination of
  the larynx

58
How do you treat acute laryngitis?

• Rest the voice until hoarseness and aphonia have
  subsided
• Inhalation of moistened air on a regular basis
  may give relief

59
What is acute epiglottitis?

• Rapidly progressive cellulitis of the epiglottis
  and adjacent structures that has the potential of
  causing abrupt, complete airway obstruction
• Frequency has decreased dramatically since the
  introduction of the H. influenzae vaccine

60
What are the clinical manifestations of
epiglottitis?

• Typically, a 2-4 year old child with a 6-12 hour
  hx of fever and dysphagia
• Sore throat is the most prominent symptom in
  older children and in adults
• Varying degrees of respiratory distress may be
  present

61
How do diagnose epiglottitis?

• By finding an edematous cherry red epiglottis
• Labs
• Leukocytosis
• Positive cultures of blood and epiglottis
• Evidence of pneumonia on CXR
• H. influenzae type b is isolated from cultures of
  blood and/or the epiglottis in most pts with
  acute epiglottitis
• Others pneumococci, staphylococci, streptococci

62
How do you treat acute epiglottitis?

• Establish airway
• Culture blood epiglottis
• IV antibiotic therapy against H. influenzae

63
Is immunity conferred after an episode of H.
influenzae epiglottitis?

• Yes!
• High levels of serum antibody to capsular
  polysaccharide make second cases of epiglottitis
  very rare.

64
What is CROUP?

• Acute laryngotracheobronchitis
• Age specific viral infection of the upper lower
  respiratory tracts
• Produces inflammation in the subglottis
• Results in dyspnea accompanied on inspiration by
  the characteristic stridulous notes of croup

65
What virus most commonly causes CROUP?

• Parainfluenza type 1
• Parainfluenza type 3 is the 2nd most frequently
  associated agent.
• Influenza A produces this disease in a broader
  age range of children and with a higher frequency
  of hospitalization and tracheotomy.

66
Epidemiology of CROUP

• Mostly in kids 3 months - 3 years
• Peak occurrence in the 2nd year of life
• More common in boys than girls

67
Clinical manifestations of CROUP

• Hoarseness
• Deepening, non-productive, brassy-tone cough
• Most kdis have fever
• Resp rate is elevated
• Fluctuating course of infection

68
What is ACUTE BRONCHITIS?

• Inflammatory condition of the tracheobronchial
  tree
• Usually associated with a generalized respiratory
  infection
• Occurs most commonly during winter months
• Common during influenza epidemics
• Rhinoviruses are an important cause of acute
  bronchitis
• Among military recruits, adenovirus infections
  are a major cause of acute bronchitis
• Mycoplasma pneumoniae Bordetella pertussis are
  nonviral causes of severe acute bronchitis

69
What are the clinical manifestations of ACUTE
BRONCHIITIS?

• Cough begins early and tends to become prominent
  as the illness progresses
• Frequency and duration of cough is prolonged in
  cigarette smokers
• In adults, influenza virus, adenovirus, and M.
  pneumoniae infections are commonly associated
  with temperature elevation

70
How do you diagnose and treat ACUTE BRONCHITIS?

• Diagnosis of exclusion
• Tx is symptomatic

71
What is CHRONIC BRONCHITIS?

• Condition in which cough
• a chronic and excessive secretion of mucus
• is present in the tracheobronchal tree
• is NOT due to specific diseases such as asthma
  or TB
• Pts who have coughed up sputum on most days
  during at least 3 consecutive months for more
  than 2 successive years.

72
Etiologic factors in CHRONIC BRONCHITIS

• Cigarette smoking
• Infection
• Inhalation of dust or fumes in the workplace

73
Clinical manifestations of CHRONIC BRONCHITIS

• Incessant cough advanced bronchitis
• Emphysema
• Patients maintain normal body weight and tend to
  be obese

74
What is BRONCHIOLITIS?

• Acute LOWER respiratory illness of VIRAL etiology
  occurring within the first 2 years of life

75
Major etiologic agents of BRONCHIOLITIS

• Viruses
• RSV
• Parainfluenzae virus type 1 and 3
• Adenoviruses
• M. pneumoniae
• These make up 87 of the isolates obtained from
  children.
• In the hospital, RSV involvement is higher.

76
BRONCHIOLITIS is a common illness during what age?

• First year of life
• Peak rate between 2 and 10 months of age

77
What are the clinical manifestations of
BRONCHIOLITIS?

• Coryza and cough onset
• Mild fever Prodromal period
• Dehydration
• from paroxysms of coughing that may trigger
  vomiting
• Poor oral intake related to respiratory distress
  and lethargy
• Acute course lasts 3-7 days

78
How do you diagnose and treat BRONCHIOLITIS?

• Diagnosis
• Characteristic clinical and epidemiologic
  findings
• Viral isolation from nasal wash
• Therapy
• Oxygen administration with careful supportive
  care
• Aerosolized ribavirin is approved for treatment
  of infants with more severe bronchiolitis due to
  RSV.
• Monoclonal antibody and polyclonal immune
  globulin are available for passive immunization.

79
which of the following is least likely to be
directly affected by CROUP?

1. Larynx
2. Pharynx
3. Trachea
4. Bronchi

• B.
• CROUP is
• acute
• laryngo-tracheo-bronchitis

80
What virus has the most number of antigenic types?

• RHINOVIRUS over 110 different types
• Parainfluenza 3
• RSV 2
• Corona 3 or 4

81
What virus can cause severe pharyngitis with
fever and conjunctivitis?

• Adenovirus
• Pharyngoconjunctival fever

82
Is recurrent infection common in cases of acute
epiglottitis?

• NO!

83
Microorganism resistant to drying and harsh
chemicals

• Mycobacterium tuberculosis

84
What is the most common cause of BRONCHIOLITIS in
infants and kids?

• RSV

85
Foley

• physiology

86
Partial pressure of gas equation

• Pgas fractional concentration x barometric
  pressure

87
Equation or inspired Pgas

• Fractional concentration x barometric pressure -
  47mmHg

88
What is the partial pressure of water vapor at
body temp 37C?

• 47mmHg
• regardless of the ambient barometric pressure

89
Effect of water vapor pressure

• Inspired air is rapidly saturated with water
  vapor
• Partial pressure of water vapor at body temp of
  37C is 47mmHg regardless of ambient barometric
  pressure
• Total pressure of the DRY gases in the airways is
  reduced by 47mmHg
• Inspired Pgas Fractional concentration x
  barometric pressure - 47mmHg

90
How does altitude affect barometric pressure?

• Increased altitude decreased barometric pressure

91
Equation for respiratory exchange ratio

• R pulmonary CO2 elimination rate
• pulmonary O2 uptake rate

92
What is the volume of anatomic dead space in the
normal adult?

• 150 ml

93
How is anatomic dead space volume measured?

• Fowlers method

94
What is the physiological dead space volume?

• All portions of the system not available for gas
  exchange
• or
• the sum of the anatomic dead space and the
  alveolar dead space volumes

95
What is alveolar dead space?

• Any ventilated alveoli which are not perfused
  with pulmonary capillary blood

96
How is physiological dead space volume measured?

• Bohr method
• VD VT(PaCO2 PECO2)/PaCO2
• Dead space volume increases slightly during
  inspiration as the airways expand. It then
  decreases again during expiration.

97
What is alveolar ventilation?

• The rate at which the alveoli are ventilated
• Alveolar vent expired volume dead space
  volume
• Alveolar ventilation brings fresh air into the
  gas exchange areas of the lungs. Dead space
  ventilation does not.

98
What happens to alveolar air composition as
alveolar ventilation increases?

• Alveolar air composition becomes more similar to
  inspired air.
• As alveolar ventilation decreases, gas tensions
  become similar to those in systemic venous blood.

99
Kuehn

• embryology

100
What does the endoderm form?

• Lines the inner portions of the embryonic pharynx

101
What does the ectoderm form?

• Lining of the outer and part of the inner oral
  cavity

102
What does the stomadeum form?

• Embryonic mouth
• after rupture of oral plate

103
What does the failure of the secondary palate to
fuse with the primary palate cause?

• Cleft palate

104
Failure of fusion of the nasolabial grove will
result in

• Cleft palate
• Cleft lip
• Agenesis of the nasal septum
• Agenesis of the nasal concha

105
What are the alveoli of the lung derived from?
106
What does the muscular part of the diaphragm
arise from?

• Cervical wall
• C3,4,5

107
The bud that will eventually develop in to the
trachea, bronchi, and lungs arises from the

• Dorsal surface of the esophagus

108
The new limiting factor for which fetuses
slightly below 500g weight still cannot survive
is

• The kidney is not functioning

109
What are the divisions of the external nares in
the early stages?

• Frontonasal prominence
• Maxillary division branchial arch I
• Buccopharyngeal plate
• Mandibular division branchial arch I

110
From what branchial arch does the thyroid arise?

• 4

111
From what brachial arch does the cricoid
cartilage arise?

• 6

112
Where do the arytenoid cartilages arise from?

• Arytenoid swellings

113
Where does the epiglottus arise from?

• Epiglottoid swelling

114
What nerve innervates the internal muscles of the
larynx?

• Recurrent laryngeal nerve
• Goes inferior to aortic arch 6 to enter the larynx

115
What nerve innervate the internal mucosa of the
larynx?

• Internal br. of superior laryngeal nerve
• From the vagus n, which travels superior to
  branchial arch 4

116
What nerve innervates the cricothyroid?

• External br of superior laryngeal n

117
Where does the trachea arise from?

• Epithelium and glands from the endoderm of the
  laryngiotracheal grove
• Everything else from splanchnic mesoderm

118
What do the lungs arise from?

• Primary bronchial buds

119
When is surfactant 1st produced?

• 20 weeks

120
What happens during the canalicular period 16-25
weeks?

• Enlargement of the terminal bronchioles
• Somewhat increased vasculature
• Surfactant produced at 20 weeks
• Only fetuses born at the end of this period have
  a chance of survival

121
How far have the lungs developed during the
pseudoglandular period 5-17 weeks?

• Broncholes developed
• No alveoli
• Poor vascular
• Birth during this phase results in death of fetus

122
What happens during the terminal sac period 24
weeks to birth?

• Terminal sacs develop
• Epithelium becomes squamous
• Improvement of vasculature
• Surfactant producing cells increase in number
• Births during this period usually survive

123
When is the alveolar period?

• Birth to 8 years
• Increase in size of lung
• Formation of mature alveoli superior parts of
  lung develop 1st

124
What has to happen at birth to establish
respiration?

• Increased surfactant production
• Lungs go from being primary secretory to being a
  gas exchange organ
• Mature pulmonary circulation is established

125
What does the diaphragm arise from?

• Cervical region
• Septum transversum ? middle of central tendon
• Pleuroperitoneal folds? seal off edges of central
  tendon
• Mesoesophagus? crura
• Cervical body wall C3,4,5? muscular diaphragm

126
What does a cleft palate result from?

• Failure of the secondary palate to fuse with the
  primary palate

127
Walters

• pharmacology

128
Where is histamine found in the periphery?

• Mast cells bronchioles, skin, intestinal mucosa
• Basophils

129
Where is histamine found in the brain?

• Cell bodies of histaminergic neurons are in
• POSTERIOR basal hypothalamus
• RETICULAR FORMATION

130
What is the consequence of having histaminergic
neurons in the reticular formation?

• The reticular formation plays a role in the level
  of arousal
• Histamine pays a role in keeping you alert
• So if you take an ANTI-histamine, it could make
  you drowsy!

131
What is the main stimulus for histamine release?

• Ag ? IgE crossbridging ? degranulation of mast
  cell ? release of histamine

132
What drugs stimulate the release of histamine?

• Neuromuscular blockers for use during surgery
• Morphine TX dyspnea with left ventricular
  failure
• Vancomycin cell wall inhibitor

133
What drug can cause red man syndrome?

• Vancomycin
• Typically after rapid IV infusion
• Characterized by flushing of the upper body and
  facial area, hypOtension, tachycardia

134
Why is morphine sometimes used to tx dyspnea with
LV failure?

• Will allay anxiety
• Histamine release with cause vasodilation, which
  decreases preload and afterload

135
How does vancomycin cause tachycardia?

• Histamine ? vasodilation ? drop in BP ? reflex
  tachy

136
What are the symptoms of a drug induced
anaphylactoid rxn?

• Burning, itching sensation in the hands face,
  scalp and ears
• Followed by a feeling of intense warmth
• These areas and the whole trunk turn red
• BP falls ? reflex tachy
• Headache
• Hives accompanied by nausea
• Acid secretion
• Bronchospasms

137
What does the H3 receptor do?

• Regulates the release of various NTs thru
  autoreceptor and heteroreceptor mechanisms

138
Blockage of which histamine receptor may decrease
the release of neurotransmitters?

• H3

139
Stimulation of what receptor causes increased
gastric acid secretion?

• H2

140
Which histamine receptor mediates rapid onset but
short lived vasodilation?

• H1

141
Which histamine receptor mediates slow onset but
sustained vasodilation?

• H2

142
Mechanism of H1R

• Coupled to phospholipase C
• Hydrolyzes membrane phospholipids to form IP3 and
  DAG

143
What does IP3 do?

• Releases Ca from the sarcoplasmic reticulum
• Ca will activate myosin light chain kinase and
  phospholipase A2

144
What does myosin light chain kinase do?

• Phosphorylates myosin
• Causes bronchoCONSTRICTION and increased
  peristalsis

145
What does phospholipase A2 do?

• Produces NO and prostacyclin PGI2
• Vasodilators!

146
What does DAG do?

• Activates protein kinase C which facilitates Ca
  release from the SR

147
What is the mechanism of H2R?

• Stimulates adenylyl cyclase ? increase in cAMP
  activates a protein kinase that
• Phosphorylates and ACTIVATES a Ca pump that pumps
  Ca out of the cell and into the SR
• Phosphorylates and INACTIVATES myosin light chain
  kinase? inhibits contraction, causes vasodilation

148
What 3 things characterize the allergic response
to histamine?

• bronchoCONSTRICTION
• vasoDILATION
• Increased capillary permeability see edema,
  swelling

149
What is the TRIPLE RESPONSE?

• Flare and wheal reaction seen in bee stings,
  insect bites
• Localized red spot
• Few seconds
• Few mm
• Immediate vasodilation
• Stimulation of H1
• Bright flare
• Delayed
• Few cm
• Stimulation of H2
• Wheal
• 1-2 minutes
• From edema

150
What are the () inotropic/chronotropic effects
of histamine?

• Direct
• Increased automaticity of SAN, atria, ventricle
• Indirect
• Baroreflex increases heart rate
• Due to actions at the H2 site

151
Stimulation of which histamine receptor can cause
pain itching?

• H1 receptors
• in the dermis ? pain
• In the epidermis ? itching

152
What are the physiological effects of histamine?

• Allergic response
• Triple response
• ino/chrono effects
• Histamine shock
• Increased gastric secretion
• Pain and itching

153
Common effects of 1st generation H1 antagonists

• Penetrate CNS- highly sedating
• Anticholinergic activity
• antiemetic
• Can cause cognitive decline in elderly

154
Characteristics of 2nd generation H1 antagonists

• Poorly penetrate CNS- little or no sedation
• Little or no anticholinergic or antiemetic
  activity

155
List the 1st generation H1 antagonists

• Diphenhydramine benadryl
• Doxylamine
• Dimenhydrinate
• Meclizine
• Hydroxyzine
• Promethazine
• Chlorpheniramine
• Prompheniramine dimatapp
• Cyproheptadine
• Azelastine
• olopatadine

156
What are the uses of diphenhydramine?

• Type I IgE mediated hypersensitivity reactions
• Motion sickness
• Night time sleep aid
• Antitussive
• Topical antipuritic
• Topical with maalox for canker sores in kids

157
What 1st generation H1 antagonists are the most
sedating?

• Diphenhydramine
• and
• Doxylamine

158
What is doxylamine used for?

• Night time sleep aid

159
What is dimenhydrinate used for?

• NV
• Dizziness and vertigo
• Very sedating!!!

160
What drugs are used for motion sickness?

• Diphenhydramine
• Meclizine
• Hydroxyzine
• Promethazine

161
1st generation H1 antagonist that also blocks a1
receptors

• Promethazine
• Used for
• Type I hypersensitivities
• Sedative
• Anti anxiety
• Antiemetic used preop to prevent NV associated
  with general anesthetics
• Motion sickness

162
What is the mechanism of the antiemetic effect of
promethazine?

• Blocks dopamine receptor in the
• chemoreceptor trigger zone
• in area postrema, which is not protected by the
  blood brain barrier

163
What is APAP?

• Acetyl para amino phenol
• Aka tyelenol

164
1st generation H1 antagonist known to cause
weight gain and block 5-HT2 receptors

• Cyproheptadine periactin

165
Uses of Hydroxyzine

• Motion sickness pruritis
• Preop and postop sedation
• antianxiety

166
What 2 drugs can you use for preop/postop
sedation and anxiety?

• Hydroxyzine
• Promethazine

167
Drug that blocks 5-HT2 receptors

• Cyproheptadine

168
What are azelastine and olopatadine used for?

• Itching with allergic conjunctivitis

169
What are the side effects of 1st generation H1
antagonists?

• CAUTION
• Other sedating drugs
• Narrow angle glaucoma
• Other anticholinergic drugs
• Anticholinergic SE
• Blurred vision
• Dry mouth
• Constipation
• CNS stimulation
• Restless, sleeplessness, hallucinations, ataxia
• CONVULSIONS in kids

170
List the 2nd generation H1 antagonists

• Fexofenadine
• Cetirizine
• Loratadine
• Desloratadine

171
Which 2nd generation H1 antagonist is the active
metabolite of hydroxyzine?

• CETIRIZINE
• Hydroxyzine is a 1st generation H1 antagonist

172
Other drugs with antihistaminic activity

• ß agonists
• Cromolyn
• Nedocromyl
• All block degranulation of mast cells

173
What are H2 antagonists used for?

• Block H2 component of allergic response
• Which is inactivation of MLCK which causes
  vasodilation
• Inhibit gastric acid secretion by parietal cells
  in tx duodenal and gastric ulcers

174
List the H2 antagonists

• Cimetidine tagamet
• Ranitidine zantac
• Famotidine pepsid
• Nizatidine axid

175
What are the side effects of H2 antagonists?

• Headaches
• Diarrhea/constipation
• Drowsiness
• RARE CNS effects, more in elderly

176
Which H2 antagonist has the worst side effects?

• CIMETIDINE!
• Only in high doses
• Binds cytochrome P450? significant inhibition of
  drug metabolism

177
What is pepsid complete made of?

• Famotidine
• Calcium carbonate
• Magnesium hydroxide

178
Which H2 antagonist binds to cytochrome P450?

• Cimetidine

179
What are the side effects of Cimetidine?

• Increased estradiol levels in MEN
• Mech inhibits cyt P450, causes failure to
  hydroxylate
• Increased prolactin ? gynecomastia high doses
• High doeses are used to treat Zollenger-Ellison
  Syndrome
• Inhibits conversion of testosterone to
  dihydrotestosterone DHT
• DHT is the form used by the testes
• Mech inhibits 5a reductase
• Inhibits binding of DHT to receptor
• Impotence and decreased libido
• CAUTION change in acidity can alter drug
  absorption
• Weakly acidic reactions decreased absorption
• Weakly basic reactions increased absorption

180
What is Zollinger Ellison Syndrome?

• A tumor gastroma of the pancreatic islets
  causeing secretion of massive amounts of GASTRIN
• Too much acid? life threatening

181
Which enzyme converts testosterone to DHT?

• 5a reductase

182
What is the consequence of inhibition of DHT
binding to its receptor?

• Impotence and decreased libido

183
What happens to the absorption of weakly acidic
reactions when the gastric pH goes UP?

• Acids become ionized
• Decreased absorption!

184
What happens to the absorption of weakly basic
reactions when the gastric pH goes UP?

• Bases become non-ionized
• Increased absorption!

185
MOA of nasal decongestants

• a1 agonists!
• Constrict vessels.
• Except oxymetazolone
• a2 agonist!!!!!!!

186
What is phenylephrine used for?

• Nasal decongestant
• IV for shock or supraventricular tachy
• Systemic vasoconstriction? maintains BP
• Mydriatic pupil dilation
• Contracts dilator muscle
• Sometimes added to local anesthetics to prevent
  systemic effects.

187
List the nasal decongestants

• Phenylephrine
• Psedoephedrine sudafed
• Oxymetazoline afrin ocular decongestant

188
Which nasal decongestant is an a2 agonist?

• Oxymetazoline
• OCULAR DECONGESTANT
• SE hypOtesnsion and pounding HR
• Why? Centrally acting, decreased sympathetic
  outflow? vasodilation

189
What is the best expectorant?

• FLUIDS

190
What is the MOA of expectorants?

• Irritate the lining of the airway
• increase secretions
• dilute, break up phlegm, decrease viscosity
• Decrease surface tension

191
What is Guaifenesin?

• Robitussin
• Expectorant
• Robitussin DM dextromethorphan (antitussive)
  guaifenesin

192
may

• histology

193
What is the conducting portion of the respiratory
system?

• Nasal cavity, nasopharynx, larynx, trachea,
  bronchi, bronchioles, terminal bronchioles
• Function
• Provides a conduit for the passage of air to and
  from the lungs
• conditions the inspired air

194
What is the respiratory portion of the
respiratory system?

• Respiratory bronchioles, alveolar ducts, alveoli
• Function sites for the exchange of oxygen and
  carbon dioxide between the inspired air and blood

195
What are specialized hairs at the entrance to the
nasal cavity called?

• Vibrissae
• Removes coarse particles of dust

196
What is involved in the conditioning of the air?

• Filtration vibrissae
• Moistening goblet cells and glands in lamina
  propria
• Warming richly vascular lamina propria

197
What moistens the inhaled air?

• Goblet cells
• Glands in lamina propria

198
What is the function of the mucous?

• Trap particulate and gaseous impurities

199
What warms the air?

• Lamina propria
• Richly vascular

200
What two parts make up the nasal cavity?

• Vestibule
• Dilated anteroom supported by cartilage of the
  external nose
• The keratinized stratified squamous epithelium is
  continuous with the skin of the face and contains
  coarse hairs vibrissae, sebaceaous glands,
  sweat glands
• Nasal cavity proper
• Divided by the nasal septum
• Septal wall smooth
• Lateral wall superior, middle, inferior conchae
  which increase the surface area to 160 cm2
• Epithelium divided into olfactory and respiratory
  zones

201
What type of epithelium is found in the vestibule
of the nasal cavity?

• Keratinized stratified squamous epithelium

202
Olfactory cells

• Modified bipolar neurons
• Dendrite ends at olfactory knob
• 6-12 non motile olfactory cilia arise from
  olfactory knob
• Axon pierces the basal lamina and joins the other
  axons to form the olfactory nn CNI that
  penetrate the cribiform plate of the ethmoid bone
• Synapse in the olfactory bulb
• While passing thru the lamina propria, the axons
  acquire a schwann cell sheath

203
Sustentacular cells of olfactory epithelium

• Tall, columnar cells with a microvillus border

204
Basal cells of olfactory epithelium

• Undifferentiated
• Believed to be able to differentiate into the
  other cell types

205
Brush cells of olfactory epithelium

• Long microvilli
• Synapses with CN V
• May be involved in the sneeze reflex or in
  modifying the activity of the olfactory bulb

206
What is found in the lamina propria of the
olfactory zone?

• Seromucous olfactory bowmans glands
• Secretions provide a solvent for the olfactory
  stimulus nd washes the olfactory receptors to
  prevent stagnation of the odor
• Branches of ethmoid arteries
• Lymphatics that are in communication with the
  subarachnoid space inside the cranial cavity

207
Secretory cells are found in the epithelial
lining of

• Alveoli
• Terminal bronchioles
• Primary bronchi
• Trachea

208
Olfactory epithelium lines

• Roof and superior concha

209
Surface active agent surfactant is secreted by

• Type II alveolar cells

210
Bronchopulmonary segments are supplied by

• Bronchioles?

211
Clara cells secrete a substance similar in action
to the secretory product of

• Type II pneumocyte

212
Olfactory epithelium is classified as

• Tall pseudostratified columnar
• Contains olfactory, sustentacular, basal, and
  brush cells

213
The larynx is lined by which type of epithelium?

• Respiratory epithelium
• Except vocal cords stratified squamous epithelium

214
What is respiratory epithelium made of?

• Pseudostratified, ciliated columnar with goblet
  cells

215
5 cell types commonly found in respiratory
epithelium

• Goblet cell
• Ciliated cell
• Basal cell
• Granule cell
• Brush cell

216
Goblet cell of respiratory epithelium

• unicellular mucous gland
• Large membrane-bound mucous droplets in the
  atypical cytoplasm

217
Ciliated cell of respiratory epithelium

• 300 cilia on its luminal surface
• Concentration of mitochondria at the apical part
  of the cell

218
Basal cell of respiratory epithelium

• lies along the basal lamina
• Fxn as a reserve cell to repopulate the epithelium

219
Granule cell of respiratory epithelium

• unicellular endocrine gland
• Numerous dense-core granules in the basal
  cytoplasm
• Granules contain seratonin and dopamine are
  released downward into the luminal propria via
  paracrine secretion
• Concentrated at bronchial divisions and
  bronchioalveolar portals
• Believed to be involved in the local regulation
  of airway diameter

220
Brush cell of respiratory epithelium

• Long microvilli and epitheliodendritic synapses
• Involved in the sampling of the airway environment

221
What is the olfactory zone composed of?

• Roof and superior concha

222
What is the respiratory zone composed of?

• Nasal septum and lateral wall below the superior
  concha

223
What is the plexus cavernosum concharum?

• AKA swell bodies
• Erectile tissue found over the lower turbinates
• Smooth muscle is found in the walls, not in the
  speta
• Supplied by veins, not arteries
• Swell bodies on each side of the nasal cavity
  become engorged on an alternating schedule 20-30
  mins
• Cuts the flow of air so that the epithelium can
  rehydrate
• Regulation by the autonomic nervous system
• Adrenergic fibers from the superior cervical
  ganglion cause vasoconstriction
• Cholinergic fibers from the pterygopalatine
  ganglion cause vasodilation
• Arterial flow in the branches of the
  sphenopalatine artery is in the opposite
  direction to the air flow? countercurrent heat
  exchanger to warm or cool and humidify inspired
  air

224
Paranasal sinuses

• Frontal, Ethmoidal, Sphenoidal, Maxillary
• Connected to the nasal cavity by ostia or ducts
• Lined by typical respiratory epithelium
• Cilia of ciliated cells beat TOWARD the nasal
  cavity
• Few goblet cells
• FXN
• lighten the bones in which they are found
• Warm and humidify the inspired air
• Act as resonating chambers for the voice

225
What are the 3 parts of the pharynx?

• Nasopharynx continuous with the NASAL cavity at
  the posterior nares and extends from the base of
  the skull to the level of the soft palate
• Oropharynx continuous with the ORAL cavity at
  the palatoglossal arch and extends from the level
  of the soft palate to the hyoid.
• Laryngopharynx extends from the level of the
  hyoid to the lower border of the cricoid
  cartilage C6. Includes the epiglottis and
  larynx.

226
What cells line the nasopharynx?

• Respiratory epithelium
• Pseudostratified, ciliated columnar with goblet
  cells

227
What cells line the oropharynx?

• Stratified squamous epithelium

228
What cells line the epiglottis?

• Lingual surface the apical portion of the
  laryngeal side
• stratified squamous epithelium
• Toward the base of the epiglottis on the
  laryngeal side
• Transition to respiratory epithelium
• Pseudostratified, ciliated columnar with goblet
  cells

229
What cells line the larynx?

• Respiratory epithelium
• Pseudostratified, ciliated columnar with goblet
  cells
• Except over the vocal cords
• stratified squamous epithelium

230
What connects the pharynx to the trachea?

• Larynx
• Lamina propria contains several irregularly
  shaped cartilages that help to maintain an open
  airway and also to participate in producing
  sounds for phonation

231
What parts of the larynx are made of hyaline
cartilage?

• Thyroid cartilage
• Cricoid cartilage
• Arytenoid cartilage

232
What parts of the larynx are made of elastic
cartilage?

• Cuneiform cartilage
• Corniculate cartilage

233
At what level does the trachea bifurcate?

• Sternal angle/T4-6
• Divides into left and right primary bronchi

234
What are the 4 layers of the tracheal wall?

• Mucosa
• Respiratory epithelium and elastic fiber rich
  lamina propria
• Submucosa
• Slightly more dense CT
• Cartilaginous layer
• C shaped hyaline cartilages
• Adventitia
• CT which binds the trachea to the surrounding
  tissue

235
Trachealis muscle

• Smooth muscle fibers that bridge the gap between
  the free ends of the C shaped cartilage at the
  posterior border of the trachea adjacent to the
  esophagus

236
Which primary bronchus is shorter?

• Right
• Also, larger diameter, more vertical

237
Secondary lobar bronchi

• AKA intrapulmonary bronchi
• Branch from primary bronchi at hilum of lungs
• Left lung gets 2
• Right lung gets 3
• Continually bifurcates for about 7 more
  generations
• Lined by respiratory epithelium
• C shaped cartilages become cartilaginous plates
  as the bronchi become intrapulmonary

238
bronchiole

• Division of intrapulmonary bronchi that have a
  diameter of about 1mm
• Supply pulmonary lobules
• NO cartilage lplates
• Thick later of smooth muscle

239
What cells line bronchioles?

• Large diameter pseudostratified ciliated
  columnar
• Small diameter simple ciliated columnar with
  fewer goblet cells

240
What cells line the terminal bronchioles?

• Simple, cuboidal epithelium
• Containing
• Cliliated cells
• Non-ciliated bronchiolar clara cells
• Brush cells

241
Clara cells

• Have a dome shaped luminal surface projection
• Secretes a surface active agent, a lipoprotein,
  that functions to prevent luminal adhesion during
  expiration

242
Respiratory bronchiole

• Branches of terminal bronchioles
• Concerned with conduction of air AND gas exchange
• Initial portion is lines with both ciliated
  cuboidal and clara cells
• Clara cells predominate in the distal portion
• Alveoli extend from the lumen of these bronchioles

243
Alveolar ducts

• Branches of respiratory bronchioles
• Walls consisting entirely of alveoli
• Lined by a thin simple squamous epithelium
• Lamina propria surrounding the rim of the alveoli
  is a network of smooth muscle cells
• Sphincter like bundles of smooth muscles appear
  as knobs between alveoli
• Terminate as alveolar sacs spaces surrounded by
  clusters of alveoli

244
Alveoli

• The terminal air spaces of the respiratory system
• The site of gas exchange between air and the
  blood
• 100 million alveoli per lung
• About 0.2 mm in diameter
• Separated by a thin CT layer containing numerous
  blood capillaries

245
Alveolar septum

• Tissue between adjacent alveolar air spaces
• Composed of
• Alveolar epithelial cells
• Basal lamina of alveolar epithelium
• Basal lamina of capillary endothelium
• Capillary endothelium
• Other CT elements
• fibroblasts, macrophages, collagen elastic
  fibers

246
Interalveolar pores of Kohn

• Openings in the interalveolar septa that allow
  circulation of air from one alveolus to another

247
What types of cells line the alveoli?

• Type I alveolar cells type I pneumocytes
• Type II alveolar cells septal cells

248
Type I alveolar cells

• Simple squamous cells
• Line 95 of the alveolar surface
• Joined to other epithelial cells by TIGHT
  JUNCTIONS

249
Type II alveolar cells

• Cuboidal cells
• Interspersed among type I cells
• Line about 5 of the alveolar surface
• Cytoplasm contains multilamellar bodies
• Surface active agent SURFACTANT
• Lamellar bodies are released into the alveolar
  space by exocytosis
• Surfactant forms a monomolecular layer over the
  alveolar epithelium
• Reduces surface tension at the air-epithelium
  interface

250
Role of brush cells in the alveoli

• Receptors that monitor the air quality in the
  lung
• Few in numbers

251
Function of alveolar macrophages

• Found in
• Alveolar septum
• Alveolar air spaces scavenge the surface to
  remove inhaled particulate matter such as
  bacteria, dust and pollen
• Become known as DUST CELLS
• Some pass up the bronchial tree in the mucus and
  are disposed of by swallowing or expectoration
• Others return to or remain in the septal CT