Chapter 36: Alterations of Pulmonary Function

Which condition is capable of producing alveolar dead space? Pulmonary edema Pulmonary emboli Atelectasis Pneumonia

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. Alveolar dead space is not the result of pulmonary edema, atelectasis, or pneumonia.

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 Increased partial pressure of arterial carbon dioxide (PaCO2) Stimulation of stretch or J-receptors Fatigue of the intercostal muscles and diaphragm

ANS: A 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. The medulla oblongata contains the respiratory center and is where the autonomic functions of respiration originate. An increased PaCO2 would lead to Kussmaul respirations. The intercostal muscles help move the chest wall during breathing and if fatigued, might lead to hypoventilation.

A patient has been diagnosed with primary emphysema but claims there is no history of smoking. What action by the healthcare professional is most appropriate? Facilitate genetic testing on the patient. Ask the family if the patient smokes. Schedule pulmonary function studies. Get baseline arterial blood gasses.

ANS: A Although emphysema is usually caused by smoking, a mutation in the a1-antitrypsin gene results in the development of the disease in younger, nonsmokers. The healthcare professional would facilitate this test. There is no reason to ask the family of a patient about the patient's smoking history unless the patient was unable to answer questions on his or her own. Pulmonary function studies will be done at some time, but does not help determine the etiology of the disease. Baseline arterial blood gasses would not be needed.

Which of these is the most common route of lower respiratory tract infection? Aspiration of oropharyngeal secretions Inhalation of microorganisms Microorganisms spread to the lung via blood Poor mucous membrane protection

ANS: A 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. Inhalation of microorganisms and spread of organisms via the blood do occur but much less frequently. Poor mucus membrane protection would increase a person's risk of infection but is not a common direct route of infection.

In what form of bronchiectasis do both constrictions and dilations deform the bronchi? Varicose Symmetric . Cylindric Saccular

ANS: A Bronchiectasis is persistent abnormal dilation of the bronchi. Bronchial dilation may be cylindrical (cylindrical bronchiectasis), with symmetrically dilated airways, as can be seen after pneumonia and is reversible; saccular (saccular bronchiectasis), in which the bronchi become large and balloon-like; or varicose (varicose bronchiectasis), in which constrictions and dilations deform the bronchi, creating a bulbous appearance

A healthcare professional is educating a patient on asthma. The professional tells the patient that the most successful treatment for chronic asthma begins with which action? Avoidance of the causative agent Administration of broad-spectrum antibiotics Administration of drugs that reduce bronchospasm Administration of drugs that decrease airway inflammation

ANS: A Chronic management of asthma begins with the avoidance of allergens and other triggers. The need for other treatments is reliant on the avoidance of triggers.

A patient has silicosis. Which medication classification does the healthcare professional educate the patient about? a. Corticosteroids b. Antibiotics c. Bronchodilators d. Expectorants

ANS: A No specific treatment exists for silicosis, although corticosteroids may produce some improvement in the early, more acute stages. Patients with silicosis are not usually treated with antibiotics, bronchodilators, or expectorants unless individual circumstances warrant these drugs.

Pulmonary artery hypertension (PAH) results from which alteration? a. Narrowed pulmonary capillaries b. Narrowed bronchi and bronchioles c. Destruction of alveoli d. Ischemia of the myocardium

ANS: A 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. This process does not occur in bronchi and bronchioles and does not include destruction of the alveoli or ischemia of the myocardium.

Fluid in the pleural space characterizes which condition? a. Pleural effusion b. Atelectasis c. Bronchiectasis d. Ischemia

ANS: A Pleural effusion is the presence of fluid in the pleural space. Atelectasis is the collapse of small airways. Bronchiectasis is persistent and abnormal dilation of bronchi. Ischemia is inadequate blood supply to the tissues.

A patient with emphysema comes to the clinic and reports increased, productive cough. What diagnostic test should the healthcare professional facilitate as the priority? Chest x-ray Peak expiratory flow Pulmonary function tests Sputum culture

ANS: A The cough in emphysema is generally not productive, unless the patient has an acute exacerbation, which can be caused by a pulmonary infection. The best way to diagnose an infection such as pneumonia is with a chest x-ray. A sputum culture would be helpful to specify the organism for tailored treatment, but is not required for the diagnosis. Pulmonary function studies might be ordered later to see if the patient's disease has progressed, but would not be ordered during an acute illness. Peak expiratory flow is usually used to monitor asthma. The professional should expedite a chest x-ray.

A patient has been diagnosed with acute respiratory distress syndrome (ARDS). For what other health condition should the healthcare professional assess this patient for as the priority? Heart failure Pneumonia Pulmonary emboli Acute pulmonary edema

ANS: B ARDS is a fulminant form of respiratory failure characterized by acute lung inflammation and diffuse alveolocapillary injury not attributed to heart failure or fluid overload. All disorders causing ARDS cause acute immune cell-mediated injury to the alveolocapillary membrane producing massive inflammation, increased capillary permeability, and alveolar flooding with protein-rich fluid that overwhelms ion channels and lymphatic removal of fluid. The most common predisposing factors for ARDS are genetic factors, sepsis, and multiple trauma (especially when multiple transfusions are received). However, there are many other causes, including pneumonia, burns, aspiration, cardiopulmonary bypass surgery, pancreatitis, drug overdose, smoke or noxious gas inhalation, oxygen toxicity, radiation therapy, and disseminated intravascular coagulation. Alcohol abuse and smoking are preventable environmental risk factors.

Which immunoglobulin (Ig) may contribute to the pathophysiologic characteristics of asthma? IgA IgE IgG IgM

ANS: B 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. The pathophysiologic characteristics of asthma are not associated with other immunoglobulins.

A patient has long-standing pulmonary disease and chronic hypoxia. The student assesses the patient's fingertips and notices bulbous enlargement of the distal segment of the digits. How does the student document this finding? Edema Clubbing Angling Osteoarthropathy

ANS: B Clubbing is the selective bulbous enlargement of the end (distal segment) of a digit (finger or toe) and is commonly associated with diseases that interfere with oxygenation, such as bronchiectasis, cystic fibrosis, pulmonary fibrosis, lung abscess, and congenital heart disease. Edema is swelling caused by fluid retention. The normal angle of the fingernail at the nail plate/proximal end of the nail is 160 degrees or less. Angling would describe an angle of >180 degrees indicates clubbing. Osteoarthropathy is a generic term for any disease of bone or joint.

Which condition involves an abnormally enlarged gas-exchange system and the destruction of the lung's alveolar walls? Transudative effusion Emphysema Exudative effusion Abscess

ANS: B Emphysema is abnormal permanent enlargement of gas-exchange airways (acini) accompanied by the destruction of alveolar walls without obvious fibrosis. An effusion is the presence of fluid in the pleural space that can be caused by hypoproteinemia (transudative) or malignancy, infection, or inflammation (exudative). An abscess is a collection of pus.

A patient has pulmonary edema. For what condition should the healthcare professional assess the patient as the priority? Right-sided heart failure Left-sided heart failure Mitral valve prolapse Aortic stenosis

ANS: B The most common cause of pulmonary edema is left-sided heart failure. 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, leading to pulmonary edema.

A patient is brought to the Emergency Department with a gunshot wound to the chest. The healthcare professional assesses an abnormality involving a pleural rupture that acts as a one-way valve, permitting air to enter on inspiration but preventing its escape by closing during expiration. What action by the healthcare professional is the priority? Draw arterial blood gasses. Assist with a chest tube insertion. Give the patient low-flow oxygen. Assess for clubbing of fingernails.

ANS: B In a 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. Air pressure in the pleural space pushes against the already recoiled lung, causing compression atelectasis, and against the mediastinum, compressing and displacing the heart, great vessels, and trachea. This is an emergency condition requiring chest tube insertion or immediate needle decompression. Arterial blood gas results will not change the treatment plan. This patient may need oxygen if definitive treatment is delayed, but it would need to be high-flow oxygen. Clubbing of fingernails occurs in chronic hypoxemic conditions. The professional should assist with immediate needle decompression or chest tube insertion.

Pulmonary edema in acute respiratory distress syndrome (ARDS) is the result of an increase in what? Levels of serum sodium and water Capillary permeability Capillary hydrostatic pressure Oncotic pressure

ANS: B 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. The pulmonary edema seen in ARDS is not the result of sodium and water concentrations, capillary hydrostatic pressure, or oncotic pressure.

The student asks a professor to explain how tuberculosis (TB) can remain dormant in some people. What explanation by the professor is best? a. It does not remain dormant but some host defenses can kill the bacteria. b. The bacilli can become isolated within tubercles in the lungs. c. Macrophages attack and phagocytize new areas of infection. d. Virulence factors in the bacilli weaken over time leading to apoptosis.

ANS: B Neutrophils, lymphocytes, and macrophages seal off colonies of the TB bacilli, forming granulomatous tubercles of scar tissue that isolates them. In this manner, and with developing immunity, TB can remain dormant sometimes for years or for life. Some bacilli are killed by host defenses but not enough to rid to body of the disease. Macrophages do phagocytize some of the bacilli. Virulence factors do not weaken over time.

Which type of pulmonary disease requires more force to expire a volume of air? Restrictive Obstructive Acute Communicable

ANS: B Obstructive pulmonary disease is characterized by airway obstruction that is worse with expiration. Either more force (i.e., the use of accessory muscles of expiration) or more time is required to expire a given volume of air. Restrictive disorders are characterized by decreased lung tissue compliance. Acute means sudden onset, or severe. Communicable means transmittable.

A patient reports needing to sit up at night in order to breathe. What term does the healthcare professional document about this condition? Hyperpnea Orthopnea Apnea Atelectasis

ANS: B Orthopnea is seen in patients with heart failure. When they lie down, abdominal pressure on the lungs causes dyspnea and the person needs to sit up in order to breathe. Hyperpnea is an increased rate and depth of breathing. Apnea is the absence of breathing. Atelectasis is the collapse of lung tissue.

A patient has been diagnosed with pneumoconiosis and asks the healthcare professional to explain this disease. What description by the professional is best? Pneumococci bacteria Inhalation of inorganic dust particles Exposure to asbestos Inhalation of cigarette smoke

ANS: B Pneumoconiosis represents any change in the lung caused by the inhalation of inorganic dust particles, which usually occurs in the workplace. The dusts of silica, asbestos, and coal are the most common causes of pneumoconiosis. Others include talc, fiberglass, clays, mica, slate, cement, and metals. Pneumococci bacteria would cause pneumococcal pneumonia. Asbestos exposure can cause mesothelioma. Cigarette smoke is the leading cause of lung cancer.

A patient is diagnosed with a pneumothorax and asks the healthcare professional to explain this condition. What statement by the professional is most accurate? a. Blood in your chest cavity b. Air in the pleural space c. Pus in the pleural space d. Collapse of small airways

ANS: B 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. Blood in the pleural space describes a hemothorax. Pus in the pleural space is an empyema. Collapse of small airways describes atelectasis.

A patient has a pulmonary capillary wedge pressure of 30mmHg. What assessment finding by the healthcare professional would be most consistent with this reading? Normal lung sounds Pink, frothy sputum Eupnea Rhonchi

ANS: B Pulmonary edema usually begins to develop at a pulmonary capillary wedge pressure or left atrial pressure of 20 mmHg. Signs of pulmonary edema include dyspnea, hypoxemia, and increased work of breathing. Physical examination may reveal inspiratory crackles (rales), dullness to percussion over the lung bases, and evidence of ventricular dilation (S3 gallop and cardiomegaly). In severe edema, pink, frothy sputum is expectorated, hypoxemia worsens, and hypoventilation with hypercapnia may develop. Eupnea is normal work of breathing. Rhonchi are low-pitched rumbling lung sounds due to turbulent airflow due to obstruction or secretions in the large airways.

A healthcare professional is educating a patient about asthma. The professional states that good control is necessary due to which pathophysiologic process? Norepinephrine causes bronchial smooth muscle contraction and mucus secretion but it also causes high blood pressure. Uncontrolled inflammation leads to increased bronchial hyperresponsiveness and eventual scarring. The release of epinephrine leads to development of cardiac dysrhythmias. Immunoglobulin G causes smooth muscle contraction which will eventually weaken the respiratory muscles.

ANS: B The late asthmatic response begins 4 to 8 hours after the early response when the release of toxic neuropeptides contributes to increased bronchial hyperresponsiveness. Untreated inflammation leads to increased scarring and remodeling of pulmonary tissue, so good control of asthma is necessary to prevent that complication. Poor asthma control does not specifically lead to hypertension or dysrhythmias, nor will it permanently weaken respiratory muscles.

Squamous cell carcinoma of the lung is best described as a tumor that causes which alterations? a. Abscesses and ectopic hormone production b. Pneumonia and atelectasis c. Pleural effusion and shortness of breath d. Chest wall pain and early metastasis

ANS: B 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. Ectopic hormone secretion can occur with small cell carcinoma of the lung. Adenocarcinoma, large cell carcinoma, and mesothelioma can produce pleural effusions. Early metastasis and chest wall pain occur with large cell carcinoma although many types do have early metastases. Chest pain is also a common finding, although chest wall pain is specific to large cell carcinoma.

A patient has recently been diagnosed with emphysema. What initial step in management of this disease does the healthcare professional discuss with the patient? a Inhaled anticholinergic agents b. Beta agonists c. Cessation of smoking d. Surgical reduction of lung volume

ANS: C Chronic management of emphysema begins with smoking cessation. As long as the patient continues to smoke, the disease will worsen. Pharmacologic management includes inhaled anticholinergic agents and beta agonists. 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.

Which factor contributes to the production of mucus associated with chronic bronchitis? Airway injury Pulmonary infection Increased Goblet cell size Bronchospasms

ANS: C 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. 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.

What does the student learn about ventilation? Hypoventilation causes hypocapnia. Hypoventilation causes alkalosis. Hyperventilation causes hypocapnia. Hyperventilation causes acidosis.

ANS: C 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. A decreased PaCO2 would lead to alkalosis. Hypoventilation would lead to hypercapnia and acidosis.

A patient has a transudative pleural effusion but has minimal symptoms. What action by the healthcare professional is best? Prepare for an immediate chest tube insertion. Encourage the patient to use the incentive spirometer. Facilitate a blood draw to check protein stores. Arrange for an oncology consultation.

ANS: C 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. Examples are congestive heart failure, in which venous and left atrial pressures are increased, and liver or kidney disorders that cause hypoproteinemia. Hypoproteinemia decreases capillary oncotic pressure, which promotes diffusion of water out of the capillaries. The best action for the professional is to assess the patient's protein stores through blood analysis. The patient does not need a chest tube since the symptoms are minimal. An incentive spirometer will not provide definitive information to treat the problem. Exudative effusions are caused by inflammation, infection, or malignancy, so this patient does not need an oncology consult.

22. In acute respiratory distress syndrome (ARDS), alveoli and respiratory bronchioles fill with fluid as a result of which mechanism? Compression on the pores of Kohn, thus preventing collateral ventilation Increased capillary permeability, which causes alveoli to fill with fluid Inactivation of surfactant and the impairment of type II alveolar cells Increased capillary hydrostatic pressure that forces fluid into the alveoli

ANS: C Lung inflammation and injury damage the alveolar epithelium and the vascular endothelium in ARDS. Surfactant is inactivated, and its production by type II alveolar cells is impaired as alveoli and respiratory bronchioles fill with fluid or collapse. The other processes would not trigger the described response.

Besides dyspnea, what is the most common characteristic associated with pulmonary disease? Chest pain Digit clubbing Cough Hemoptysis

ANS: C 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.

A patient has a lung problem caused by dysfunction in the pores of Kohn. What action by the healthcare professional is best? Have the patient drink plenty of water. Give the patient supplemental oxygen. Have the patient do breathing exercises. Withhold pain medicine so the patient stays awake.

ANS: C The pores of Kohn, which open only during deep breathing, allow air to pass from well-ventilated alveoli to obstructed alveoli. A dysfunction in this system would lead to absorption atelectasis, which is the result of gradual absorption of air from obstructed or hypoventilated alveoli. The professional should have the patient do breathing exercises, including using an incentive spirometer. Water will thin any secretions the patient has but will not directly improve ventilation. The patient may need oxygen if the oxygen saturations are low, but this does not address the cause. Withholding pain medication will lead to a patient being unwilling to move about or do breathing exercises.

High altitudes may produce hypoxemia through which mechanism? Shunting Hypoventilation Decreased inspired oxygen Diffusion abnormalities

ANS: C The presence of adequate oxygen content of the inspired air is the first factor to consider regarding hypoxia. Oxygen content is lessened at high altitudes which can produce hypoxemia. High altitudes do not produce shunting, hypoventilation, or diffusion abnormalities.

A patient comes to the Emergency Department with inspiratory and expiratory wheezing, dyspnea, nonproductive cough, and tachypnea. What treatment does the healthcare professional anticipate for this patient as the priority? Sputum culture History of illness exposure Antibiotics Inhaled bronchodilator

ANS: D Asthma is characterized by 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. The treatment consists of inhaled b-agonist bronchodilators, oxygen if needed, and corticosteroids. After the patient has been stabilized, the healthcare professional attempts to determine the cause of the attack, which would include a possible sputum culture and getting a history of any recent exposures to illness. Antibiotics will be given for a bacterial infection, such as pneumonia or pharyngitis, that led to the attack.

What medical term is used for a condition that results from pulmonary hypertension, creating chronic pressure overload in the right ventricle? a. Hypoxemia b. Hypoxia c. Bronchiectasis d. Cor pulmonale

ANS: D 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. Hypoxemia is low oxygen in the blood. Hypoxia is low oxygen in tissues. Bronchiectasis is persistent abnormal dilation of bronchi.

The student asks the healthcare professional to explain how pulmonary edema and pulmonary fibrosis cause hypoxemia. What description by the professional is best? Creates alveolar dead space Decreases the oxygen in inspired gas Creates a right-to-left shunt Impairs alveolocapillary membrane diffusion

ANS: D 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. These diseases do not create dead space, decrease the FIo2 of inspired air, or create a shunt.

Kussmaul respirations as a respiratory pattern may be associated with which characteristic(s)? Alternating periods of deep and shallow breathing Increased work of breathing Inadequate alveolar ventilation in relation to metabolic demands Slightly increased ventilatory rate, large tidal volumes, and no expiratory pause

ANS: D Kussmaul respirations are characterized by a slightly increased ventilatory rate, very large tidal volume, and no expiratory pause. Alternating periods of deep and shallow breathing characterize Cheyne-Stokes breathing. Increased work of breathing is seen in labored breathing. Inadequate alveolar ventilation describes hypoventilation.

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? Complement cascade Mast cells Macrophages Neutrophils

ANS: D 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. The described responses are not associated with the other options.

A hospitalized patient is complaining of shortness of breath, but the student does not notice cyanosis. The patient's hemoglobin is 9 g/dL, so the student asks the healthcare professional to explain. The professional tells the student that what amount of hemoglobin must be desaturated before cyanosis occurs? 3 5 7 9

Cyanosis generally develops when 5 g/dL of hemoglobin is desaturated, regardless of hemoglobin concentration. So even though the patient is anemic and has less oxygen-carrying capacity, if less than 5 g/dL of hemoglobin is desaturated, the patient will not show cyanosis.

A patient has been diagnosed with an empyema. What does the healthcare professional tell the patient about this condition? a. We will have to drain the pus out of your pleural space. b. You will be given a long course of antiviral medication. c. These blebs in your lungs can rupture with exercise. d. We will watch you for respiratory muscle fatigue.

Empyema is the presence of pus in the pleural space. The usual treatment is drainage of the pleural space with a chest tube and administration of antibiotics (not antivirals). Blebs are the cause of some cases of spontaneous pneumothorax and they can rupture with exercise. Respiratory muscle fatigue may develop with empyema, but this is a vague finding not directly related to empyema.