A 43-year-old female presents with fever, chest pain, shortness of breath and a productive cough with a

rusty sputum. On auscultation, you hear a bronchial breath sound. X-ray shows consolidation (pulmonary
infiltrate) in the lung parenchyma. What is the most likely diagnosis? (Auscultation = listening to lung by
a stethoscope)

Pneumonia

CASE 5
1. What is pneumonia?
Pneumonia is an acute pulmonary infection where bacterial invasion of the lung evokes CONSOLIDATION
of the lung tissue.

2. What does consolidation mean?

It means solidification of the lung tissue as a result of exudative infiltration (fluid filling instead of air)
into the lung parenchyma.

3. Explain the pathophysiology of pneumonia?

1) Damage to the muco-ciliary apparatus of the lungs (as a result of predisposing factors) allows
bacterial invasion of the lung.
2) Bacteria (of 1-3micrometer size) enter the alveoli and start multiplying.
3) Bacterial replication evokes an acute inflammation
4) Acute inflammation results in capillary congestion (dilation) in the area1
5) Cytokines released by inflammatory cells result in increased capillary permeability.
6) This results infiltration of fluid into the alveolar spaces resulting in solidification of the lung
parenchyma (this is the main pathology…we call this CONSOLIDATION)

4. What are the risk factors (predisposing factors) for pneumonia?

 Age
 Alcohol
 Smoking
 Intra venous drug use (IVDU)
 Underlying respiratory diseases like Cystic Fibrosis, bronchiectasis, COPD, viral infections
 Immunosuppressive drugs

The above factors predispose to pneumonia by damaging the muco-ciliary clearance mechanisms
(including the nasal clearance, tracheobronchial clearance and alveolar clearance).

5. What age groups are at highest risk?

Over 65 and under 16

6. How do you diagnose pneumonia? What is the diagnostic criteria?

1
For example, when there is an inflammation in the skin, capillaries become congested. That’s why the skin
becomes hyperemic.
1
Cough and fever + new radiological infiltrate (without other explanation). X-ray (radiography) is not
enough. Symptoms (at least cough and fever) should be there.

7. How is pneumonia classified?

a) Based on the site of acquisition
b) Based on etiologic agent
c) Based on morphology (gross anatomic distribution of the disease)

8. How is pneumonia classified based on the site of acquisition?

1) Community acquired pneumonia
2) Hospital acquired pneumonia

9. How is pneumonia classified based on etiologic agent?

1) Typical pneumonia – caused by typical organisms. Patients have fever.
2) Atypical pneumonia – caused by atypical organisms. Patients are afebrile.

10. What are the causative agents of typical pneumonia?

Streptococcus Pneumoniae, Hemophilus Influenzae, Staphylococcus aureus, Streptococcus pyogenes,
Klebsiella pneumoniae

11. What is the causative agent for atypical pneumonia?

Mycoplasma pneumoniae

12. How do you classify pneumonia morphologically?

1) Lobar pneumonia
2) Bronchopneumonia (aka lobular pneumonia)
3) Interstitial pneumonia

13. Which of the above morphologic types are grouped under typical?
Lobar pneumonia and Bronchopneumonia are causes of typical pneumonia. Interstitial pneumonia is a
cause of atypical pneumonia.

14. What is lobar pneumonia?

A type of pneumonia which involves an entire lobe or a large portion of a lobe.

15. What is the causative agent for lobar pneumonia?

Streptococcus Pneumoniae (aka Pneumococci) …also the most common cause of meningitis.

16. What are the 4 stages of lobar pneumonia?

1) Congestion
2) Red Hepatization
3) Gray Hepatization
4) Resolution
2
Note that this are stages for untreated lobar pneumonia.

17. What happens in congestion phase? (CRAP)

 Congestion (Dilation) of capillaries…results infiltration of exudative2 fluid into alveolar spaces
 Replication and spread of Pneumococci
 Acute inflammation
 Pleural effusion (unlike bronchopneumonia, lobar pneumonia can involve the pleura and pleural
cavity resulting in fluid infiltration into the pleural space causing pleural effusion).

18. True/False. In the congestion phase, NO significant infiltration can be noted on

radiography (x-ray).
True.

19. If there is no finding on x-ray, how are then patients diagnosed?

Patients are febrile during this stage (due to the ongoing acute inflammation). This makes it easy to do a
sputum culture and diagnose the bacteria (S. Pneumoniae aka. Pneumococci).

20. What happens in the Red Hepatization phase? (CRAB)

 Congestion. Capillaries become widely dilated. Because of this, several RBC are seen (hence
the name Red Hepatization phase)
 Radiographic findings (consolidation can be seen on radiography)
 Acute Inflammation
 Bronchial breath sound3

21. Which of the 4 stages of lobar pneumonia is the severe stage for the patient?
Red Hepatization phase

22. What happens in Grey Hepatization phase?

 Congestion subsides…but the exudate from previous stages still remains
 Fever subsides (i.e., acute inflammation subsides)

23. What happens during Resolution?

 The exudate finally becomes removed.

24. What is bronchopneumonia?

A type of pneumonia characterized by a patchy consolidation of one or more lobes. [patchy = means one
after the other; not diffuse…bronchopneumonia skips a lobule4 after involving the other. You find a small
consolidation in one lobe and another small consolidation in another lobe. This is called a patchy and

2
Exudative fluid = means fluid rich in protein (blood provided that there is no liver or renal dx is considered to be
an exudative fluid).
3
The normal breath sound heard over the lungs is vesicular. Bronchial sound indicates consolidation.
4
Lobules are microscopic parts of the lungs which together make up a lobe. Lobules include terminal bronchioles
and alveoli.
3
multilobar pattern of consolidation. This pattern is not seen in lobar pneumonia. In lobar pneumonia, there
is a diffuse involvement of the entire lobe (larger portion of the lobe) before the involvement of another
lobe].

25. What organisms cause bronchopneumonia?

Unlike lobar pneumonia, which is caused only by S. pneumonia, bronchopneumonia is caused by many
organisms:

 Hemophilus Influenzae,
 Staphylococcus aureus,
 Streptococcus pyogenes,
 Klebsiella pneumoniae

26. What is interstitial pneumonia (aka atypical pneumonia)?

A type of pneumonia characterized by patchy inflammatory changes of the pulmonary interstitium.
(Unlike lobar pneumonia and bronchopneumonia which involve the lung parenchyma or the alveolar
spaces, interstitial pneumonia involves the interstitium or the alveolar septa).

27. What is the interstitium?

It is the space found between the alveolar spaces and the capillaries.

28. What happens in interstitial pneumonia?

The capillaries and alveolar spaces become widely separated (as a result of the consolidated interstitium).
This causes a mismatch of Ventilation and Perfusion resulting a very low V/P ratio.

29. What is the clinical course in interstitial pneumonia?

Unlike typical pneumonia (lobar and bronchopneumonia), interstitial pneumonia (atypical pneumonia)
causes a very mild disease and its progression is slow. Because of this, it is also known as walking
pneumonia. In atypical pneumonia, patients are afebrile (do not have fever).

30. What is the causative agent of interstitial pneumonia?

4
Mycoplasma pneumoniae is the most common cause of interstitial pneumonia followed by influenza
viruses and respiratory syncytial virus (RSV). Because interstitial pneumonia can be caused by atypical
organisms like viruses, it is also known as primary atypical pneumonia.

31. What is Q-fever?

Q-fever is another type of atypical pneumonia caused by a bacterium called Coxiella burnetii. It may
infect people working with cattle or sheep, who inhale dust particles containing the organism, or those
people who drink unpasteurized milk from infected animals.

32. What is the most common cause pneumonia in patients with AIDS?
Pneumocystis jiroveci. (A fungus). Previously known as Pneumocystis carinii

33. What is the most common opportunistic infection in AIDS patients?

Pneumocystis jiroveci pneumonia.

34. What we discussed so far are all grouped under community acquired pneumonia. What is
a hospital acquired pneumonia?
Community acquired pneumonias are fatal type of pneumonias which occur in hospitalized patients,
usually in those with serious diseases.

35. What organisms can cause hospital acquired pneumonia?

Gram negative bacteria like Pseudomonas aeruginosa, Escherichia Coli, Klebsiella pneumonia,
Legionella, and Staph aureus

36. How do patients with pneumonia present?

1) Cough – dry or productive
2) Fever
3) Shortness of Breath
4) Chest pain (pleuritic type of chest pain…meaning pain during breathing).
5) Bronchial breath sound
6) Other non-pulmonary symptoms – like headache, fatigue, muscle pain etc.

37. How else might pneumonia present in the elderly (>65)?

Confusion and recurrent falls. This happened with Hilary Clinton last time when she was campaigning
and it was pneumonia.

38. What is the unique feature of pneumonia caused by Streptococcus pneumoniae?

Rust colored sputum

39. What is the usual outcome of pneumonia?

Resolution without damage of the alveoli. In cases of highly virulent strains of pneumococci (strep
pneumo) infections, complications can occur. Bronchopneumonia, if caused by virulent organisms like
staph aureus, can also result in complications.
5
40. What are the complications of pneumonia?
1) Abscess
2) Empyema
3) Endocarditis and meningitis (as a result of bacterial dissemination).
 Staph aureus causes endocarditis5 and Strep pneumo causes meningitis.

41. What does abscess lead to?

Cavitation (cavity formation) in the lung parenchyma (as a result of pus collection and bursting of the pus).
Abscess means localized collection of pus around an inflamed tissue. Abscess can be a complication of
both bronchopneumonia and lobar pneumonia. Abscess (cavitation) is shown below.

42. What is empyema?

Empyema means accumulation of pus in the pleural cavity. This pus undergoes replacement by
granulation tissue => which is in turn replaced by dense fibrous C.T. This may obliterate pleural space.
Empyema is a complication of lobar pneumonia only. Since bronchopneumonia doesn’t involve the pleura,
it doesn’t cause empyema.

43. How do you treat pneumonia?

 Amoxicillin 500mg to be taken 3 times a day
 If penicillin allergic, use clarithromycin

44. In which antimicrobial group is amoxicillin grouped?

Amoxicillin is a broad-spectrum penicillin.

45. How are antimicrobials classified?

 Based on their action (effect they bring)
 Based on their mechanism of action

46. How do you classify antimicrobials based on the effect they bring?
 Bacteriostatic – stops growth

5
Endocarditis = inflammation of the endocardium
6
  Bactericidal – kills

47. How do you classify antimicrobials based on their mechanism of action?

a) Cell wall synthesis inhibitors
b) Protein synthesis inhibitors
c) Nucleic acid synthesis inhibitors
d) Bacterial metabolism inhibitors

48. Give examples of cell wall inhibitors.

1) Penicillins
2) Cephalosporins
3) Vancomycin – used in MRSA infection

49. Give examples of protein synthesis inhibitors.

1) Aminoglycosides
2) Tetracyclines
3) Chloramphenicol
4) Erythromycin, Clarithromycin, Azithromycin (ACE)
5) Clindamycin

50. Give examples of nucleic acid synthesis inhibitors

1) Rifampin
2) Fluoroquinolones
3) Metronidazole

51. What drugs serve as inhibitors of bacterial metabolism.

1) Sulfonamides

52. What’s the basic structure of all penicillins?

Penicillins contain a β-lactam ring.

53. What is the mechanism of action of penicillins?

Penicillins bind and inactivate penicillin-binding proteins (PBPs) involved in bacterial cell wall synthesis.

54. How do bacteria develop resistance to penicillins?

There are 4 mechanisms.

1) By producing β-lactamases (penicillinases) which cleave penicillin’s β-lactam rings.

2) Downregulation of porins that allow penicillins to enter
3) Mutations of PBP to weaken penicillin binding
4) Upregulation of efflux channels that pump penicillin out.

55. Are penicillins bactericidal or bacteriostatic?

Bactericidal. Gram positive organisms with thick cell wall are often susceptible.
7
56. How are penicillins classified?
1) Narrow spectrum penicillins
2) Broad spectrum penicillins (aka extended spectrum)
3) β-lactamase resistant penicillins
4) Antipseudomonal penicillins

57. What drugs are included under narrow spectrum penicillins?

 Penicillin G (benzylpenicillin)
 Penicillin V

58. What drugs are grouped under broad spectrum (extended spectrum) antibiotics?
 Amoxicillin
 Ampicillin

59. What drugs are grouped under beta lactamase (penicillinase) resistant penicillins?
 Methicillin,
 Oxacillin,
 Naficillin
 Dicloxacillin.

These are effective against Staph aureus infections except methicillin because of appearance of MRSA
(Methicillin Resistant Staphylococcus Aureus).

60. Mention some examples of antipseudomonal penicillins.

Piperacillin and Ticarcillin

61. What is the only use of Penicillin G?

To treat Syphilis

62. What is the use of Penicillin V?

To treat Group A Streptococcus (Streptococcus Pyogenes) infection like pharyngitis. Remember if GAS
pharyngitis is left untreated, it can cause Rheumatic fever, a fatal condition. Rheumatic fever can be
avoided by a simple shot of Pen V.

63. True/False. Broad spectrum antibiotics are penicillinase (beta lactamase) resistant.
False. They are penicillinase susceptible like narrow spectrum antibiotics. The difference is broad
spectrum antibiotics have a broad gram negative coverage (hence the name broad/extended spectrum).

64. What is the difference between ampicillin and amoxicillin?

Amoxicillin has an excellent oral absorption and hence is preferred over ampicillin.

65. What is the clinical use of amoxicillin?

For community acquired pneumonia AND for endocarditis prophylaxis, plus otitis media, and sinusitis
8
66. What drugs are grouped under beta lactamase (penicillinase) resistant penicillins?
Methicillin, Oxacillin, Naficillin and Dicloxacillin. These are effective against Staph aureus infections except
methicillin because of appearance of MRSA (Methicillin Resistant Staphylococcus Aureus).

67. What is peculiar about oxacillin, naficillin and dicloxacillin?

They undergo biliary excretion. All other penicillins undergo renal excretion.

68. What is clinical use of dicloxacillin?

For mastitis (inflammation of the breast) which is often caused by Staph aureus.

69. What is the clinical use of antipseudomonal penicillins?

For treatment of pseudomonas aeruginosa and Klebsiella pneumonia (causes of Hospital acquired
pneumonia).

70. What drugs are often co-administered with penicillins?

1) Beta lactamase inhibitors
2) Probenecid

This drugs are used to enhance activity of penicillins by preventing resistance AND slowing down excretion
respectively.

71. Give some examples of beta lactamase inhibitors?

Clavulanic acid and sulbactam

72. Why are beta lactamase inhibitors given with penicillins?

Beta lactamase inhibitors enhance the activity of narrow and broad spectrum penicillins by preventing
resistance through inhibiting beta lactamases of the bacteria.

73. What combination is used for the treatment of pneumonia?

Amoxicillin + Clavulanic acid. This is a common combination found in the market as Augmentin.

74. Why is probenecid used along with penicillins?

Probenecid slows down excretion of penicillins in the renal tubules.

75. What is the main clinical use of probenecid?

Probenecid is a gout drug. Its mechanism of action is to increase excretion of uric acid by the kidneys.

76. What are the adverse effects of penicillins?

 Hypersensitivity – in 10% of patients (from simple rash to anaphylactic shock)
 Methicillin can cause interstitial nephritis. It is enough if you know hypersensitivity.

77. What are the general characteristics of the genus Streptococcus?

Streptococcus species in general are:
9
  Gram-positive cocci – found in grape like clusters
 Facultative anaerobes
 Catalase negative – this distinguishes them from Staphylococcus which is catalase positive.

78. What are the general characteristics of the genus Staphylococcus?

 Gram positive cocci – found in chains or pairs
 Facultative anaerobes
 Catalase positive – this distinguishes them from Streptococcus species

79. How do you classify genus streptococcus?

Streptococci can be divided based on their cell wall’s carbohydrate antigen –the carbohydrate (C) antigen
into 4.

1) Group A Streptococcus (GAS)

2) Group B streptococcus (GBS)
3) Group D streptococcus (GDS)
4) Non-groupable Streptococci

80. What is a Group A Strep (GAS)?

Streptococcus pyogenes

81. What is a Group B Strep (GBS)?

Streptococcus agalactiae

82. What is Group D strep?

Enterococci

83. What are the non-groupable ones?

Streptococcus pneumoniae and viridians streptococci. These can’t be grouped in the above classification
system hence are called non-groupable streptococcus.

84. What are the different types of hemolysis and what do they mean?
1) Alpha hemolytic – undergo partial hemolysis in blood agar
2) Beta hemolytic – undergo complete hemolysis in blood agar
3) Gamma hemolytic (non-hemolytic) – do not undergo hemolysis in blood agar

85. Which of Streptococcus species are alpha hemolytic?

Streptococcus pneumoniae and Viridians Streptococci (the non-groupable)

86. Which streptococcus species are beta hemolytic?

Streptococcus pyogenes (GAS) and Streptococcus agalactiae (GBS)

87. Which are gamma-hemolytic (non-hemolytic)?

10
Enterococci (Group D strep) are gamma-hemolytic (non-hemolytic).

88. If both Streptococcus pneumoniae and Viridians streptococci are alpha hemolytic, what
do you use to differentiate between them?
 Optochin test
 Bile test
 Strep. Pneumo is sensitive to optochin and bile (is lysed by bile).
 Viridians Streptococcus is optochin and bile resistant.

89. If both GAS and GBS are beta hemolytic, how do you differentiate between them?
GAS (Streptococcus pyogenes) is bacitracin sensitive. GBS (Streptococcus agalactiae) is bacitracin
resistant. Remember these distinguishing properties. This came in a question in the previous exit exam.
Just remember this phrase as a mnemonic – “Gas is sensitive to bacitracin”.

90. What diseases does Streptococcus pneumoniae?

Primarily, Pneumonia. If pneumonia complicates and if the bacteria disseminates, it causes meningitis.
Streptococcus pneumoniae is the most common cause of typical pneumonia AND meningitis in both
children and adults.

91. What are the virulence factors of Streptococcus pneumoniae?

 Protein adhesins
 IgA protease
 Polysaccharide capsule – the most important
 Pneumolysin

92. What is the role of protein adhesins in the pathogenesis?

They help the bacteria to colonize

93. What is the role of IgA protease in the pathogenesis?

It lyses IgA (which is a major protective immunoglobulin of mucosal surfaces).

94. What is the role of the polysaccharide capsule in the pathogenesis?

Inhibits phagocytosis of the bacteria by immune cells.

95. What is the role of Pneumolysin in the pathogenesis?

It hemolyzes cells. And partially reduces hemoglobin into a green pigment (alpha hemolysis).

96. How do you diagnose Streptococcus in Labs?

 Gram stain
 Catalase test
 Hemolysis test
 Glucose fermentation test
 Optochin and bile test
11
  Quellung Reaction

97. What do you expect on gram stain?

Gram positive, lancet shaped diplococci

98. What do you expect on catalase test?

Catalase positive (this helps as to tell they are streptococcus)

99. What do you expect on Hemolysis test?

Alpha hemolysis

100. What do you expect on Glucose fermentation test?

Fermentation of glucose to lactic acid. This is one of the peculiar feature of S. Pneumo

101. What do you expect to see on optochin and bile test?

Optochin and bile sensitivity

102. What is Quellung reaction (aka Capsular swelling test)?

What happens in this test is that when S. pneumo is mixed with a specific matching antibody, the capsule
undergoes swelling. This is a specific test for S. pneumoniae. It is enough if you mention only this capsular
swelling test and Optochin and bile sensitivity test in the diagnosis.

103. Is there a vaccine currently available for Streptococcus pneumoniae?

2 vaccines are available for prevention.

 PCV – for infants

 PPV – for adults (> 65),

104. What does PCV stand for?

Polysaccharide Conjugate Vaccine – 7 valent vaccine

105. What does PPV stand for?

Polyvalent Polysaccharide Vaccine – 23 valent vaccine given for adults (> 65 years), immunocompromised
(AIDS, Diabetic), and those who have undergone splenectomy.

106. How many arteries supply the lung?

2 arteries.
1) Pulmonary artery
2) Bronchial artery

107. From where do the bronchial arteries arise?

From descending aorta.

12
108. What structures of the lung do the bronchial arteries supply?

 Bronchi
 Connective tissue of the lung,
 Visceral pleura

109. From where does the pulmonary artery arise?

From the heart.

110. How many lobes does each lung have?

The right lung has 3 lobes – Superior lobe, middle lobe and inferior lobe.
The Left lung has Less – i.e. 2 lobes – superior and inferior lobes.

111. What are the landmarks found on the lungs?

 The Cardiac notch is a lateral deviation in the anterior border of the left lung, caused by the
position of the heart (which is slightly deviated to the left).

 The Lingula is an anterior projection of the superior lobe of the Left lung below the cardiac notch.
Both Lingula and Left lung start with “L” … this may help to remember where the landmark is.

112. Describe the surface anatomy of the lungs and pleura

 The apex of the lung: can ascend above level of 1st rib inside the root of the neck.
 The inferior border of the lung: can extend down to the 6th rib anteriorly and 10th rib posteriorly.
Landmark Inferior Border of Lung Reflection of Parietal Pleura
Midclavicular line 6th rib 8th rib
Midaxillary line 8th rib 10th rib
Scapular line 10th rib 12th rib
Know the relations along the midclavicular line…then as you go lateral, add 2 to each level

113. What are the types of pleura?

 Parietal Pleura
 Visceral Pleura – directly in contact with lung; non-sensitive to pain.

13
114. What are the parts of the pleura?

The parietal pleura has 4 parts These are:

1) Cervical pleura (around the neck),

2) Costal pleura (around the ribs),
3) Mediastinal pleura (around the mediastinum)
4) Diaphragmatic pleura (around the diaphragm).

115. What are the 2 types of pleural recess? (Recess = depression/space)

The pleura has 2 Recesses:

1) Costodiaphragmatic recess
2) Costomediastinal recess.

These are two spaces where the lung does not occupy the pleural space totally.

116. Where is the costodiaphragmatic recess?

The costodiaphragmatic recess is between 6th & 8th ribs (along the midclavicular line).

117. What is the clinical significance of the costodiaphragmatic recess?

It is a potential depression – where fluids accumulate (due to gravity).

118. What is the preferred site to do thoracentesis? (thoracentesis = aspiration of fluid from the
pleural cavity)

 9th intercostal space along the MID-AXILLARY LINE.

 The other possibility is 7th intercostal space but along the SCAPULAR LINE (posteriorly)

119. True/False. During thoracentesis, the needle should be inserted inferior to a rib.
False. It should ALWAYS be inserted to the intercostal space superior to a rib. Because the neurovascular
bundles (the intercostal arteries, veins and nerves) travel below (inferior to) the ribs. Approaching inferior
to a rib can injure the neurovascular bundle.

120. What seems the relation between pulmonary artery, pulmonary veins, and the bronchi at
the hilum of each lung? (hilum = gate or entry to the lungs)
 On both lungs: the bronchus is the most posterior structure and the pulmonary veins are always
inferior. The difference between the two involves the pulmonary artery.

 On the right side, the right pulmonary artery is the most anterior structure, lies anterior to the
bronchus and pulmonary veins.

 On the left side, the left pulmonary artery is the most superior structure, even superior to the left
bronchus.

14
Figure 1: Figure 2:

121. Based on answers for question 50, which figure represents the left hilum and which one
is the right hilum?

Figure 1 is the left hilum because the left pulmonary artery is the most superior structure. Figure 2 is the
right hilum because the right pulmonary artery is the most anterior structure.

122. If you aspirate a foreign body through your trachea into the lungs, which lung will the
foreign body enter?
 It enters the right lung. Most commonly the inferior lobe of the right lung.

This is because the of the right main bronchus. Because the right main bronchus is wider and shorter and
runs more vertically than the left main bronchus, aspirated foreign bodies or food is more likely to enter
and lodge in it or one of its branches.

123. What is a bronchopulmonary segment?

It is the anatomic, functional and surgical unit of the lung.

124. What structures are comprised in a single bronchopulmonary segment?

 Bronchus (including terminal and respiratory bronchioles AND alveoli (collectively called lung
lobule))
 Artery
 Lymph vessel
 Autonomic nerve

125. What about a vein? Is it not included in bronchopulmonary segment?

Yes. A vein is found in the connective tissue in between two bronchopulmonary segments.

126. True/False. A diseased bronchopulmonary segment can be removed surgically.

TRUE. Since the bronchopulmonary segment is a single unit, it can be removed safely when diseased
because there are many others and the function of the lung will not be compromised.

15
127. What are the characteristics of a bronchopulmonary segment?
 It is a subdivision of a lung lobe.
 It is pyramid shaped, with its apex toward the lung root.
 It is surrounded by connective tissue.
 It has a segmental bronchus, a segmental artery, lymph vessels, and autonomic nerves.
 The segmental vein lies in the connective tissue between adjacent bronchopulmonary segments.
 Because it is a structural unit, a diseased segment can be removed surgically.

128. Which muscle is used in quiet breathing? (= breathing at rest)

Diaphragm.

 Diaphragm contracts (flattens) during inspiration, increasing the size of thoracic cavity.
 It relaxes (curves) during expiration.

129. Which muscles are used in forced breathing?

 Sternocleidomastoid muscle
 Intercostal muscles

130. What is the Diaphragm?

Diaphragm is a musculotendinous structure which separates the thoracic cavity from the abdominal
cavity.

131. What nerve innervates it?

Phrenic nerve

132. From which nerve roots does phrenic nerve arise from?
From C3, 4 and 5. (C3, 4, 5 keep the diaphragm alive).

133. What structures perforate the diaphragm?

 At T8: Inferior Vena Cava
 At T10: oesophagus and vagus nerve (CN 10)
 At T12: abdominal aorta, thoracic duct, azygos vein (“At T-1-2 it’s the red, white, and blue”)

Mnemonic: Number of letters = T level.

134. At what level of the vertebra does the trachea bifurcate?

 The trachea bifurcates at T4.
 The common carotid bifurcates at C4.
 The abdominal aorta bifurcates at L4.

135. Discuss lung capacities and volumes.

There are 4 lung volumes and capacities. Lung capacity = is a sum of two or more volumes.

16
Lung volumes & Lung Capacities Definitions, formulas, and normal values
Inspiratory reserve volume (IRV) Air that can be inhaled after normal TV inspiration (3100ml)

Tidal volume (TV) Air that moves into the lung with each quiet inspiration (500ml)

Expiratory reserve volume (ERV) Air that can be exhaled after normal TV expiration (1200ml)

Residual volume (RV) Air in lung after maximal expiration; can’t be measured on
spirometry (1200ml)

Inspiratory capacity (IC) IRV + TV (3600ml)

Functional residual capacity (FRC) ERV + RV (2400ml)

Vital capacity (VC) TV + IRV + ERV (maximum amount of gas that can be expired after
a maximal inspiration or simply: amount of gas that we exchange
with the environment. (4800ml)

Total lung capacity (TLC) IRV + TV + ERV + RV (Volume of gas present in lungs after
maximum inspiration); can’t be measured directly by spirometry
(because it contains RV). (6000ml)

Lung Volumes (Mnemonic  LITER; Read ↓ (This may help you building up the graph).

136. What is the epithelium of the respiratory tract?

 Pseudostratified ciliated columnar epithelium (respiratory epithelium) lines respiratory tract
from the trachea to the terminal bronchioles (but not the alveoli)

137. What are goblet cells?

Goblet cells are mucous producing glands which are found only in the bronchi.

138. What is the role of the cilia found in respiratory tract?

They clear out large particles AND mucus – upon which bacteria can establish infection.

139. Which respiratory airways contain smooth muscles?

 Smooth muscles are found in bronchi and both terminal and respiratory bronchioles.

17
  No smooth muscles in trachea, (trachea, rather, has cartilages).
 No smooth muscles in the alveoli

140. What are the 2 types of alveolar cells?

1) Type I Pneumocytes
2) Type II Pneumocytes

141. What kind of epithelial cells are the Type I pneumocytes?

Squamous epithelium cells

142. What kind of epithelial cells are the Type II pneumocytes?

Cuboidal epithelial cells

143. What is the function of the type I pneumocytes?

They are suited for optimal gas diffusion because they are thin (squamous). They line 97% of the alveoli.

144. What is the function of the type II pneumocytes?

 They prevent alveolar collapse (atelectasis)
 They serve as precursors of type I pneumocytes.

145. How do type II pneumocytes prevent atelectasis (alveolar collapse)?

They secrete pulmonary surfactant. The function of pulmonary surfactant is to reduce surface tension.
This helps to prevent alveolar collapse (atelectasis).

146. Which type of cells proliferate during lung damage?

Type II cells

146. From what embryologic structure is the lung derived?

From the foregut endoderm. (same for liver and pancreas). Lung buds appear as a diverticulum from the
foregut endoderm.

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