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Respiratory

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1. What happens as a result of hypoxia in sleep apnea
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
Small airways
Inc EPO leading to erythrocytosis
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy

2. Which pts are at risk for apriation PNA
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Bronchial obstruction - toward side of lesion
On expiration as radius dec
Alchoholics or epileptics

3. What is an association and potential complication of paraseptal emphysema
Inoperable - responsive to chemotherapy
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
CO2 - acid/altitude - DPG - Exercise - Temperature
S. aureus or anaerobes

4. What lung abnl is characterized with dec breath sounds - hyperresonance - absent fremitus - towards which side does the trachea deviate
Air that can still be breathed out after nl expiration
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Pa > PA > Pv
Tension pneumo - away from lesion

5. What is the cycle of idiopathic pulmonary fibrosis
Repeated cycles of lung injury and wound healing with inc collagen
Defect in coagulative cascace proteins
Deep leg veins
Bicarb (90%) - bound to globin (5%) and dissolved (5%)

6. What findings are associated with emphysema
Ivory white calcified pleural plaques
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Dec release of fetal glucocorticoids
FRC - inward pull of lung balanced by outward pull of chest wall

7. What properties determine the combined volumes of the chest wall and lungs
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Milky fluid with inc TGs
Carcinoid - carcinoid
Elastic properties

8. What happens in perfusion limited circulatioin and which gases does this apply to...
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Clara cells - type II pneumocytes; multiple densitites on CXR
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy

9. What changes in CO2 occur during exercise
Inc EPO leading to erythrocytosis
4 polypeptide subunits - 2 alpha and 2 beta
Inc production
Surfactant def leading to inc surfact tension and alveolar collapse

10. How far to the pseudostratified ciliated columnar epithelium extend - What do MACS do in the alveoli - and how far do the goblet cells extend
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Dec dec in FEV1 - dec in FVC
Respiratory bronchioles - clear debris in alveoli - bronchi
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli

11. What kind of course does interstitial PNA follow in comparison to bronchoPNA
PVR = (PpulmA - PleftA)/CO
More indolent
Alpha1- antitrypsin def - also cirrhosis
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)

12. What is the diffustion formula and what happens to the variables in emphysema and pulmonary fibrosis
Dec in the FEV1/FVC
Hypoxic vasocxn
Retinopathy of maturity
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis

13. What is carboxyhemoglobin and What does it cause
Form of hemoglobin bound to CO in place of O2 - causes dec O2 binding capacituy with a left shift in the O2 hemoglobin dissociation curve - dec unloading in tissues
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
RV + ERV - volume in lungs after nl expiration
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2

14. What changes occur to pulm blood flow during exercise
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Inc due to inc CO
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise

15. What are the two forms of hemoglobin
Low resistance and high compliance
CO - 200x
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males

16. Define tidal volume (TV)
Air that moves into lung with each quiet respiration
Lobar PNA
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion

17. What direction does an increase in metabolic need shift the O2 dissociation curve
L/S > 2 = lecithin/sphingomyelin
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Surfactant
Right

18. What must occur with a exudate pleural effusion
In between perfusion limited and diffusion limited
Drainage
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
20.1 mL O2 /dL

19. What is occupied in the space that would have been the left middle lobe
Carcinoid - carcinoid
Hyaline membrane disease
Heart
Bleomycin - busulfan - anmiodorone

20. What is the main complication of therapeutic supplemental O2?
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Surfactant
Retinopathy of maturity
Loss of elastic fibers

21. What changes at high altitude can result in RVH
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Ciliated cells
Chronic hypoxic vasocxn
Ivory white calcified pleural plaques

22. What is the most common cancerous lesion in the lun
Hypertrophy of mucus secreting glands in the bronchioles
Bronchial obstruction - toward side of lesion
Inc due to inc CO
Metastasis - breast - colon - prostate - bladder -

23. What happens with the O2 curve shifts to the right and What does it facilitate
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
PAO2 - PaO2 = 10-15 mmHg
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma

24. What are the risk factors for neonatal RDS
Pleural effusion
Zone 3
Inc mitochondria
Prematurity - maternal RDS - cesarean delivery

25. A carcinoma in the apex of the lung can cause what syndrome and What is the tumor called

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26. What is early onset hypoxemia from in chronic bronchitis
Shunting
Type II pneumocytes - after week 35
Type II cells
Dec

27. What happens to FEV1 and FVC in both obstructive and restrictive lung disease and What is the difference
Trachea and bronchi
Person stops breathing for at least 10 seconds repeatedly during sleep
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
IRV + TV

28. What happens in diffiusion limited pulmonary circulation and what gases does this apply to...
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Upper lobes - cor pulmonale - caplan's syndrome
Dec cross sectional area of pulm vasc bed

29. What is compliance and When is it decrease
IRV + TV + ERV + RV
Dec - no change
Inspiration by diaphragm - expiration is passive
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema

30. Define inspiratory capacity (IC)
IRV + TV
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Dec - because physiologic shunt dec O2 extraction from ratio
Bicarb (90%) - bound to globin (5%) and dissolved (5%)

31. What changes occur to PaO2 and PaCO2
No change - but inc venous CO2 content
Hypertrophy of mucus secreting glands in the bronchioles
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater

32. What is central sleep apnea
Long bone fractures and liposuction
No respiratory effort
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Dec

33. What is the course of of pulm HTN
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
<75
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals

34. What does decreased PAO2 do
<75
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
CO2 - acid/altitude - DPG - Exercise - Temperature

35. What does pulm HTN result in
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
Small airways
Prostaglandins - histamine - ACE - kallikrein
Dec in lung volumes - FVC - TLC

36. Eggshell calcificant of hilar lymph nodes - associtated with foundries - sandblasting and mines - pneumoconioses and path
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
Persistently low O2 tension
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
PVR = (PpulmA - PleftA)/CO

37. What is the equation for physiologic dead space
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Chest pain - tachypnea and dyspnea
Air that can still be breathed out after nl expiration

38. What organism thrives in high O2 and where in the lung does it flourish
Lobar PNA
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Lower portion of right inferior lobe
TB - apex

39. What cells in the lung produce surfactant and What does it do
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
Tight jxns
Pleural effusion

40. What are the findings associated with sarcoidosis
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Lost with alveolar walls
Long bone fractures and liposuction
Alchoholics or epileptics

41. Lung absecss often reults From what organisms
Lung cancer
S. aureus or anaerobes
Both highest in the base
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes

42. How many lobes does each lung have - and What is the lingula
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Elastase

43. What is the formula for O2 content
O2 binding x O2 sat + dissolved O2
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
TB - apex
Methylene blue

44. What TX is the mother given before delivery - and what TXs are given to the infant
CT angio
Steroids to mom - artificial surfactant and thyroxine to neonate
Apex of healthy lung
Exposed collagen fibers provides impetus for clotting cascade

45. What are the various causes of ARDS
O2 binding x O2 sat + dissolved O2
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor

46. What are the causes of hypoxia
IRV + TV
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
It binds to Hb -

47. What is used to treat CN poisoning and why
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
CO2 - acid/altitude - DPG - Exercise - Temperature
Nitrates to oxidize hemoglobin to methemoglobin Which binds CN allowing cyto C oxidase to fxn - use thiosulfate to bind this cyanide forming thiocynate - which is renally excreted
Inc

48. What happens to V/Q ratio in COPD
Mismatch
It binds to Hb -
Stasis - hypercoagulability - endothelial damage
Lost with alveolar walls

49. What is obstructive sleep apnea
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Tension pneumo - away from lesion
Respiratory effort against airway obstruction
L/S > 2 = lecithin/sphingomyelin

50. What organism causes a lobar PNA and What are the characteristics
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Inspiration by diaphragm - expiration is passive
Elastic properties

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