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Heliox has been used to treat acute asthmatic patients generic penegra 50 mg without prescription prostate 12 core biopsy, perhaps because ﬂow within narrowed buy penegra 50 mg with amex prostate cancer 7 out of 10, inﬂamed airways becomes turbulent discount penegra 100mg online mens health 6 week challenge. Laminar ﬂow normally occurs at around the 11th airway generation because: • The velocity of gas ﬂow decreases with successive airway generations • In small airways the entrance length (distance required for laminar ﬂow to become established) becomes short enough for laminar ﬂow to develop before the next airway division cheap kamagra gold online amex. As lung volume is reduced all air containing components order 40mg levitra super active amex, including conducting airways order zoloft with visa, reduce in size and therefore resistance increases. At low lung volumes or during a rapid expiration airway collapse occurs and may result in gas becoming trapped distally. With prolonged and severe increased resistance a second compensation occurs over a few minutes, resulting from hypercapnia. This is most commonly seen with artiﬁcial ventilation, increased expiratory ﬂow resistance, or mucus retention. Alveolar pres- sures will rise with increased lung volumes and reduced lung compliance. Detrimental haemodynamic effects may also occur as a result of high alveolar pressure. Pathophysiology of lung mechanics Restrictive disease These conditions result in reduced lung volumes (total lung capacity and vital capacity) because of either: • Disease of lung parenchyma characterized by inﬂammation, scarring, and exudate-ﬁlled alveoli (e. Compensatory mechanisms include hyperventilation to maintain minute ventilation with smaller lung volumes. Obstructive disease In pathological states small airways obstruction is most important. In asthma, the increase in resistance is mostly due to airway mucosal inﬂam- mation and contraction of airway smooth muscle due to an exaggerated physiological response, both of which are quickly reversible. Pulmonary circulation The lungs receive the entire blood volume but unlike the systemic circula- tion the pulmonary circulation is a low-pressure system because: • Pulmonary arteries and arterioles contain only a small amount of smooth muscle compared with systemic vessels • Pulmonary capillary networks surround alveoli to produce sheet-like blood ﬂow to maximize the surface area for gas exchange • With resting cardiac output pulmonary capillaries in non-dependent areas of the lung have little or no blood ﬂow and can be ‘recruited’ if cardiac output increases • Pulmonary capillaries are distensible vessels, easily doubling in diameter to accommodate large increases in ﬂow with little change in driving pressure. Pulmonary vascular resistance pulmonary vascular resistance = pulmonary driving pressure/cardiac output • The relationship is not linear due to ﬂow being a mixture of laminar and turbulent forms. Alveolar capillaries lie between adjacent alveoli and so are compressed when lung volume increases. In the upright position hydrostatic pressure signiﬁcantly affects blood ﬂow as there may be a 20mmHg difference in vascular pressure between apex and lung bases • Alveolar pressure—pulmonary capillary blood ﬂow and vessel patency depend on both vascular and alveolar pressures, and lungs are traditionally divided into three zones: • Zone 1—Palveolus > Partery > Pvenous: no blood ﬂow and therefore alveolar dead space • Zone 2—Partery > Palveolus > Pvenous: blood ﬂow depends on the difference between arterial and alveolar pressure; venous pressure has no inﬂuence • Zone 3—Partery > Pvenous > Palveolus: blood ﬂow depends only on arterio-venous pressure difference • Systemic vascular tone—the systemic vascular system has greater vasomotor activity so blood is diverted into the pulmonary circulation when vasoconstriction occurs and vice versa • Left heart failure—pulmonary venous hypertension is likely to increase pulmonary blood volume and reduce ﬂow in all three zones • Positive pressure ventilation increases alveolar pressure, changing zone 3 areas into zone 2, and also reduces venous return, reducing global cardiac output. Hypoxic pulmonary vasoconstriction This reﬂex occurs in response to regional hypoxia in the lung, and is believed to optimize V/Q· · matching by diverting pulmonary blood ﬂow away from areas of low oxygen tension. The reﬂex occurs within a few seconds of the onset of hypoxia, with constriction of small arterioles. With prolonged hypoxia the reﬂex is biphasic, with the initial rapid response being maximal after 5–10min and followed by a second phase of vasoconstriction, occurring gradually and reaching a plateau after 40min. Hypoxic pulmonary vasoconstriction is patchy in its onset even in healthy individuals exposed to global alveolar hypoxia. At high altitude the response also may be highly variable between individuals, explaining why some patients develop pulmonary hyperten- sion with respiratory disease and some do not.
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A: Treatment should be given according to the cause: • In bronchial carcinoma—Radiotherapy in non small cell carcinoma and chemotherapy for small cell carcinoma buy discount penegra 100 mg online prostate oncology 360. Presentation of a Case (Leg or Abdomen): • Veins in the legs are engorged buy 50 mg penegra mastercard mens health your body is your barbell, fow is upwards buy penegra overnight delivery prostate 42. Engorged vein Engorged vein Engorged vein Engorged vein in abdomen in chest in back in thigh mebooksfree safe silvitra 120 mg. Hair in other parts of the body buy cheap penegra on-line, chest and back (increased) generic super avana 160 mg on-line, hair in midline below the umbilicus to groin (increased), excess hair in the upper and lower limbs. A: It is the excess growth of hair in women as male pattern due to excessive secretion of androgen. Increase hair growth indicates excessive androgen, either adrenal or ovarian in origin. If adrenal origin, following tests should be done— • If adrenal carcinoma or adenoma—urinary 17-ketosteroid is high. Local therapy: • Plucking, bleaching, depilatory cream, shaving, electrolysis, epilation. Systemic therapy (given in severe cases): • Cyproterone acetate (antiandrogen) 50–100 mg daily for 1–14 days of each cycle. Hypertrichosis in back Hypertrichosis Hypertrichosis in thigh and leg Q: What is hypertrichosis? A: It is the generalized excess hair growth in any sex which is nonandrogenic in origin. A: As follows: • Hirsutism is male pattern of hair growth in women due to excess of androgen. Virilizing tumour of the adrenal or ovary (rapid onset of signs of virilization, very high serum testosterone). A: It is syndrome in which there are multiple cysts in the ovary and hyperandrogenemia, characterized by amenorrhoea or oligomenorrhoea, obesity and hirsutism (triad). Other features are infertility (due to anovulation) and virilization (in severe cases). Look at the following points carefully: • Site of ulcer (one or both legs or feet or tip of toes). There may be wet gangrene, pigmentation and eczema, usually painless unless infected. Presentation of a Case (Supposing Right Foot): • In the lateral aspect and dorsum of foot, there is a large necrotic ulcer with ragged bluish-red, gangrenous overhanging margin, purulent surface with pustules and plaque. Pyoderma gangrenosum Pyoderma gangrenosum Pyoderma Pyoderma gangrenosum on foot on foot and leg gangrenosum on leg on finger My diagnosis is pyoderma gangrenosum. A: History of diarrhoea or bloody diarrhoea (suggestive of infammatory bowel disease). A: It is a disease of unknown aetiology characterized by non-infective, necrotizing ulceration, starts as a nodule or pustule, that frequently ulcerates. Ulcer may be single or multiple with clear bluish- black (gangrenosum) undermined edge and purulent surface (pyoderma).