Chapter 35: Alterations of Pulmonary Function

Besides dyspnea, what is the most common characteristic associated with pulmonary disease?cough
Pulmonary disease is associated with many signs and symptoms, and their specific characteristics often help in identifying the underlying disorder. The most common characteristics are dyspnea and cough. Others include abnormal sputum, hemoptysis, altered breathing patterns, hypoventilation and hyperventilation, cyanosis, clubbing of the digits, and chest pain. (1248)
Sitting up in a forward-leaning position generally relieves which breathing disorder?orthopnea
orthopnea is generally relieved by sitting up in a forward-leaning posture or supporting the upper body on several pillows. (1249)
Kussmaul respirations as a respiratory pattern may be associated with which characteristic(s)?Slightly increased ventilatory rate, large tidal volumes, and no expiratory pause
Kussmaul respirations are characterized by a slightly increased ventilatory rate, very large tidal volume, and no expiratory pause. (1249)
Respirations that are characterized by alternating periods of deep and shallow breathing are a result of which respiratory mechanism?Decreased blood flow to the medulla oblongata
Alternating periods of deep and shallow breathing are characteristic of Cheyne-Stokes respirations and are the result of any condition that slows the blood flow to the brainstem, which in turn slows impulses that send information to the respiratory centers of the brainstem. (1250)
With a total hemoglobin of 9 g/dl, how many grams per deciliter of hemoglobin must become desaturated for cyanosis to occur?5
Cyanosis generally develops when 5 g/dl of hemoglobin is desaturated, regardless of hemoglobin concentration. (1250)
Which statement is true regarding ventilation?Hyperventilation causes hypocapnia.
Hyperventilation is alveolar ventilation that exceeds metabolic demands. The lungs remove carbon dioxide at a faster rate than produced by cellular metabolism, resulting in decreased PaCO2 or hypocapnia. (1250)
What term is used to describe the selective bulbous enlargement of the distal segment of a digit that is commonly associated with diseases that interfere with oxygenation of the blood?clubbing
Clubbing is the selective bulbous enlargement of the end (distal segment) of a digit (finger or toe) (see Figure 35-1) and is commonly associated with diseases that interfere with oxygenation, such as bronchiectasis, cystic fibrosis, pulmonary fibrosis, lung abscess, and congenital heart disease. (1250)
Pulmonary edema and pulmonary fibrosis cause hypoxemia by which mechanism?Impairing alveolocapillary membrane diffusion
Diffusion of oxygen through the alveolocapillary membrane is impaired if the alveolocapillary membrane is thickened or if the surface area available for diffusion is decreased. Abnormal thickness, as occurs with edema (tissue swelling) and fibrosis (formation of fibrous lesions), increases the time required for diffusion across the alveolocapillary membrane. (1251-52)
High altitudes may produce hypoxemia through which mechanism?Decreased inspired oxygen
The presence of adequate oxygen content of the inspired air is the first factor. Oxygen content is lessened at high altitudes. (1251)
Which condition is capable of producing alveolar dead space?Pulmonary emboli
A pulmonary embolus that impairs blood flow to a segment of the lung results in an area where alveoli are ventilated but not perfused, which causes alveolar dead space. (1252)
What is the most common cause of pulmonary edema?Left-sided heart failure
The most common cause of pulmonary edema is heart disease. When the left ventricle fails, filling pressures on the left side of the heart increase and cause a concomitant increase in pulmonary capillary hydrostatic pressure. (1260)
Pulmonary edema usually begins to develop at a pulmonary capillary wedge pressure or left atrial pressure of how many millimeters of mercury (mm Hg)?20
Pulmonary edema usually begins to develop at a pulmonary capillary wedge pressure or left atrial pressure of 20 mm Hg. (1260)
The collapse of lung tissue caused by the lack of collateral ventilation through the pores of Kohn is referred to as what type of atelectasis?Absorption
Absorption atelectasis is a result of the gradual absorption of air from obstructed or hypoventilated alveoli or from inhalation of concentrated oxygen or anesthetic agents. (1256-1257 | Figure 35-5)
In what form of bronchiectasis do both constrictions and dilations deform the bronchi?Varicose
Varicose bronchiectasis exists when both constrictions and dilations deform the bronchi. (1256-58)
Which pleural abnormality involves a site of pleural rupture that acts as a one-way valve, permitting air to enter on inspiration but preventing its escape by closing during expiration?Tension pneumothorax
In tension pneumothorax, the site of pleural rupture acts as a one-way valve, permitting air to enter on inspiration but preventing its escape by closing up during expiration. As more and more air enters the pleural space, air pressure in the pneumothorax begins to exceed barometric pressure. (1254)
In which type of pleural effusion does the fluid become watery and diffuse out of the capillaries as a result of increased blood pressure or decreased capillary oncotic pressure?Transudative
In transudative pleural effusion, the fluid, or transudate, is watery and diffuses out of the capillaries as a result of disorders that increase intravascular hydrostatic pressure or decrease capillary oncotic pressure. (1254)
Which condition involves an abnormally enlarged gas-exchange system and the destruction of the lung’s alveolar walls?Emphysema
Emphysema is abnormal permanent enlargement of gas-exchange airways (acini) accompanied by the destruction of alveolar walls without obvious fibrosis. (1268)
Which term is used to identify a circumscribed area of suppuration and destruction of lung parenchyma?Abscess
An abscess is a circumscribed area of suppuration and destruction of lung parenchyma. (1274)
Which condition is not a cause of chest wall restriction?Pneumothorax
Unlike the other options that result in chest wall restriction, a pneumothorax is the presence of air or gas in the pleural space caused by a rupture in the visceral pleura (which surrounds the lungs) or the parietal pleura and chest wall. (1254)
Which conditions are causes of chest wall restriction?Severe kyphoscoliosis
Gross obesity
Neuromuscular disease
What causes pneumoconiosis?Inhalation of inorganic dust particles
Pneumoconiosis represents any change in the lung caused by the inhalation of inorganic dust particles, which usually occurs in the workplace. (1259)
Which condition is a fulminant form of respiratory failure characterized by acute lung inflammation and diffuse alveolocapillary injury?Acute respiratory distress syndrome (ARDS)
ARDS is a fulminant form of respiratory failure characterized by acute lung inflammation and diffuse alveolocapillary injury. (1261)
Which structure(s) in acute respiratory distress syndrome (ARDS) release inflammatory mediators such as proteolytic enzymes, oxygen-free radicals, prostaglandins, leukotrienes, and platelet-activating factor?Neutrophils
The role of neutrophils is central to the development of ARDS. Activated neutrophils release a battery of inflammatory mediators, among them proteolytic enzymes, oxygen-free radicals (superoxide radicals, hydrogen peroxide, hydroxyl radicals), arachidonic acid metabolites (prostaglandins, thromboxanes, leukotrienes), and platelet-activating factor. These mediators cause extensive damage to the alveolocapillary membrane and greatly increase capillary membrane permeability. (1261)
Pulmonary edema in acute respiratory distress syndrome (ARDS) is the result of an increase in:Capillary permeability
Increased capillary permeability, a hallmark of ARDS, allows fluids, proteins, and blood cells to leak from the capillary bed into the pulmonary interstitium and alveoli. The resulting pulmonary edema and hemorrhage severely reduce lung compliance and impair alveolar ventilation. (1261)
In acute respiratory distress syndrome (ARDS), alveoli and respiratory bronchioles fill with fluid as a result of which mechanism?Inactivation of surfactant and the impairment of type II alveolar cells
Lung inflammation and injury damage the alveolar epithelium and the vascular endothelium. Surfactant is inactivated, and its production by type II alveolar cells is impaired as alveoli and respiratory bronchioles fill with fluid or collapse. (1261)
Which type of pulmonary disease requires more force to expire a volume of air?IgE
Asthma is a familial disorder, and more than 100 genes have been identified that may play a role in the susceptibility of and the pathogenetic mechanisms that cause asthma, including those that influence the production of interleukin (IL)-4, IL-5, and IL-13; IgE; eosinophils; mast cells; adrenergic receptors; and leukotrienes. (1263-64)
Which statement about the late asthmatic response is true?The release of toxic neuropeptides contributes to increased bronchial hyperresponsiveness.
The late asthmatic response begins 4 to 8 hours after the early response when the release of toxic neuropeptides contributes to increased bronchial hyperresponsiveness. (1264)
FalseNorepinephrine causes bronchial smooth muscle contraction and mucus secretion.
FalseThe release of epinephrine causes bronchial smooth muscle contraction and increases capillary permeability.
FalseImmunoglobulin G initiates the complement cascade and causes smooth muscle contraction and increased capillary permeability.
Clinical manifestations of inspiratory and expiratory wheezing, dyspnea, nonproductive cough, and tachypnea are indicative of which condition?Asthma
At the beginning of an attack, the individual experiences chest constriction, expiratory wheezing, dyspnea, nonproductive coughing, prolonged expiration, tachycardia, and tachypnea. Severe attacks involve the use of accessory muscles of respiration, and wheezing is heard during both inspiration and expiration. (1264.1266)
The most successful treatment for chronic asthma begins with which action?Avoidance of the causative agent
Chronic management of asthma begins with the avoidance of allergens and other triggers. (1266)
Which factor contributes to the production of mucus associated with chronic bronchitis?Increased Goblet cell size
Continual bronchial inflammation causes bronchial edema and increases the size and number of mucous glands and goblet cells in the airway epithelium. Thick, tenacious mucus is produced and cannot be cleared because of impaired ciliary function (see Figure 35-13). The lung’s defense mechanisms are therefore compromised, increasing a susceptibility to pulmonary infection, which contributes to airway injury. Frequent infectious exacerbations are complicated by bronchospasm with dyspnea and productive cough. (1267)
Clinical manifestations of decreased exercise tolerance, wheezing, shortness of breath, and productive cough are indicative of which respiratory disorder?Chronic bronchitis
The symptoms that lead individuals with chronic bronchitis to seek medical care include decreased exercise tolerance, wheezing, and shortness of breath. Individuals usually have a productive cough (“smoker’s cough”). (1267)
Clinical manifestations that include unexplained weight loss, dyspnea on exertion, use of accessory muscles, and tachypnea with prolonged expiration are indicative of which respiratory disorder?Emphysema
Individuals with emphysema usually have dyspnea on exertion that later progresses to significant dyspnea, even at rest (see Table 35-3). Little coughing and very little sputum are produced. The individual is often thin, has tachypnea with prolonged expiration, and must use accessory muscles for ventilation. The anteroposterior diameter of the chest is increased (barrel chest), and the chest has a hyperresonant sound with percussion. (1270)
Which of the following is the most common route of lower respiratory tract infection?Aspiration of oropharyngeal secretions
Aspiration of oropharyngeal secretions is the most common route of lower respiratory tract infection; thus the nasopharynx and oropharynx constitute the first line of defense for most infectious agents. (1271)
What is the initial step in the management of emphysema?Cessation of smoking
Chronic management of emphysema begins with smoking cessation. Pharmacologic management includes inhaled anticholinergic agents, and beta agonists should be prescribed. Pulmonary rehabilitation, improved nutrition, and breathing techniques all can improve symptoms. Oxygen therapy is indicated in chronic hypoxemia but must be administered with care. In selected patients, lung volume reduction surgery or transplantation can be considered. (1270-71)
In tuberculosis, the body walls off the bacilli in a tubercle by stimulating which action?Apoptotic infected macrophages that activate cytotoxic T cells
In defense, macrophages and lymphocytes release interferon, which inhibits the replication of the microorganism and stimulates more macrophages to attack the bacterium. Apoptotic infected macrophages can also activate cytotoxic T cells (cluster of differentiation [CD] 8). (1273-74)
The progression of chronic bronchitis is best halted by which intervention?Smoking cessation
By the time an individual seeks medical care for symptoms, considerable airway damage is present. If the individual stops smoking, then disease progression can be halted. If smoking is stopped before symptoms occur, then the risk of chronic bronchitis decreases considerably and eventually reaches that of nonsmokers. (1267)
Clinical manifestations of inspiratory crackles, increased tactile fremitus, egophony, and whispered pectoriloquy are indicative of which respiratory condition?Pneumonia
Physical examination may reveal signs of pulmonary consolidation, such as inspiratory crackles, increased tactile fremitus, egophony, and whispered pectoriloquy, which support a diagnosis of pneumonia. (1273)
Pulmonary artery hypertension (PAH) results from which alteration?Narrowed pulmonary capillaries
PAH is characterized by endothelial dysfunction with an overproduction of vasoconstrictors (e.g., thromboxane, endothelin) and decreased production of vasodilators (e.g., nitric oxide, prostacyclin), resulting in narrowed pulmonary capillaries. (1277)
Squamous cell carcinoma of the lung is best described as a tumor that causes which alterations?Airway obstruction and atelectasis
Typically, the tumors are centrally located near the hila and project into bronchi. Because of this central location, nonproductive cough or hemoptysis is common. Pneumonia and atelectasis are often associated with squamous cell carcinoma. Chest pain is a late symptom associated with large tumors. These tumors can remain fairly well localized and tend not to metastasize until late in the course of the disease. (1280-1281 | Table 35-4)
What medical term is used to identify the accumulation of air in the pleural space?Pneumothorax
Pneumothorax is the presence of air or gas in the pleural space caused by a rupture in the visceral pleura (which surrounds the lungs) or the parietal pleura and chest wall. (1254)
What medical term is used to identify the presence of pus in the pleural space?Empyema
Empyema is the presence of pus in the pleural space. (1255)
Fluid in the pleural space characterizes which condition?Pleural effusion
Pleural effusion is the presence of fluid in the pleural space. (1254)
Which statement is true regarding hypoxemia?Respiratory alterations cause hypoxemia.
Hypoxemia, or reduced oxygenation of arterial blood (PaO2), is caused by respiratory alterations, whereas hypoxia, or reduced oxygenation of cells in tissues, may be caused by alterations of other systems as well (1251)
FalseHypoxemia results in the increased oxygenation of arterial blood.
FalseHypoxemia results in the decreased oxygenation of tissue cells.
Falsevarious system changes cause hypoxemia
Which medication classification is generally included in the treatment of silicosis?Corticosteroids
No specific treatment exists for silicosis, although corticosteroids may produce some improvement in the early, more acute stages. (1259)
What medical term is used for a condition that results from pulmonary hypertension, creating chronic pressure overload in the right ventricle?Cor pulmonale
Cor pulmonale develops as pulmonary hypertension and creates chronic pressure overload in the right ventricle similar to that created in the left ventricle by systemic hypertension. (1278)
What are the causes of dyspnea? (Select all that apply.)Decreased pH, increased partial pressure of arterial carbon dioxide (PaCO2) and decreased partial pressure of arterial oxygen (PaO2)
Stimulation of stretch or J-receptors
Presence of anxiety
Dyspnea can be triggered by decreased pH, increased PaCO2, and decreased PaO2. Stimulation of either stretch or J-receptors is also known as a cause of dyspnea. Dyspnea may be the result of pulmonary disease or many other conditions, such as pain, heart disease, trauma, and anxiety. (1248-49)
Which inflammatory mediators are produced in asthma? (Select all that apply.)Histamine
Bradykinin
Leukotrienes
Prostaglandins
A large number of inflammatory mediators, such as histamine, prostaglandins, and leukotrienes, are produced by asthma. Neutrophil proteases are not produced in relationship to asthma. (1265 | Figure 35-12)
Which clinical manifestation is associated with pulmonary hypertension? (Select all that apply.)Dyspnea on exertion
Peripheral edema
Jugular venous distention
Symptoms of fatigue, chest discomfort, tachypnea, and dyspnea on exertion, palpitations, and cough are common. Examination may reveal peripheral edema, jugular venous distention, a precordial heave, and accentuation of the pulmonary compartment of the second heart sound. Neither rhonchi nor a systemic blood pressure of 130/90 mm Hg are associated with pulmonary hypertension. (1277-78)
Which statements are true regarding exudative effusion? (Select all that apply.)Exudative effusion contains high concentrations of white blood cells.
Exudative effusion may occur in response to an inflammatory process.
The presence of a malignant cancer can trigger exudative effusion.
Exudative effusion is a result of increased capillary permeability.
Exudative effusion is less watery and contains high concentrations of white blood cells and plasma proteins. Exudative effusion occurs in response to inflammation, infection, or malignancy and involves inflammatory processes that increase capillary permeability. (1254)
Which characteristics are symptomatic of a flail chest? (Select all that apply.)Involves the fracture of several consecutive ribs.
Involves multiple fractures to individual ribs.
Can involve the fracture of the sternum.
A flail chest results from the fracture of several consecutive ribs in more than one place or the fracture of the sternum and several consecutive ribs. Age and inflammation are not generally considered factors in this disorder. (1253)
Which statements regarding Mycobacterium tuberculosis are true regarding the bacilli’s ability to go into dormancy? (Select all that apply.)Neutrophils and macrophages all play a role in its dormancy.
The immune system is the controlling factor regarding its length of dormancy.
The bacilli are sealed off in tubercles to allow for dormancy.
Neutrophils, lymphocytes, and macrophages seal off the colonies of bacilli, forming a granulomatous lesion called a tubercle. Once the bacilli are isolated in tubercles and immunity develops, tuberculosis may remain dormant for life. If the immune system is impaired, however, or if live bacilli escape into the bronchi, active disease occurs and may spread through the blood and lymphatic system to other organs. This microorganism can remain dormant for extended periods. Reverting from dormancy is not related to a lymphocyte attack. (1273-74)
Pulmonary fibrosisis an Excessive amount of connective tissue in the lung
Atelectasisis the collapse of lung tissue.
Bronchiectasisis persistent abnormal dilation of the bronchi.
Aspirationis the passage of fluid and solid particles into the lung.
Bronchiolitisis inflammation of the small airways or bronchioles.