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Respiratory

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Answer 50 questions in 15 minutes.
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1. What happens to arterial PO2 in chronic lung disease and why
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Dec - because physiologic shunt dec O2 extraction from ratio
DIC - especially postpartum

2. What does pulm HTN result in
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
4 polypeptide subunits - 2 alpha and 2 beta
Apex of healthy lung
Tissue hypoxia from dec O2 sat and dec O2 content

3. What is a chronic complication of sleep apnea
Hypoxic vasocxn
<60
Chroniclly tired
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy

4. What TX is the mother given before delivery - and what TXs are given to the infant
Dec cross sectional area of pulm vasc bed
Respiratory bronchioles - clear debris in alveoli - bronchi
Right shift - favors taut - low affinity for O2 - O2 unloading
Steroids to mom - artificial surfactant and thyroxine to neonate

5. What organisms cause a bronchoPNA and What are the characteristics
Mesothelioma - pleura - psammoma bodies
Deoxygenated blood - elastic walls
No change - but inc venous CO2 content
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes

6. What do hemoglobin modifacations lead to...
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Tissue hypoxia from dec O2 sat and dec O2 content
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Chroniclly tired

7. What is the protein content an exudative pleural effusion and What are the potential causes
Dec in lung volumes - FVC - TLC
Weight loss - CPAP - surgery
Ivory white calcified pleural plaques
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma

8. What happens in perfusion limited circulatioin and which gases does this apply to...
Inspiration by diaphragm - expiration is passive
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc

9. What are fat emboli associated with
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Type II cells
Long bone fractures and liposuction
Incr - right - dec - left

10. What happens to FEV1 and FVC in both obstructive and restrictive lung disease and What is the difference
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Opposites

11. What causes secondary pulm HTN
Dec release of fetal glucocorticoids
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Surfactant
TB - apex

12. What does the combination of increased CO2 and increased proton binding do to the O2 dissociation curve
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Right shift - favors taut - low affinity for O2 - O2 unloading
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12

13. What enzyme increases activity in emphysema
Lung cancer
Heart
Elastase
<60

14. What is a consequence of pulm HTN
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Dipalmatoyl phosphatidylcholine - decreases surface tension
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium

15. What are the various causes of ARDS
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
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
Inc 2 -3- DPG - righward shift

16. How does sleep apnea or high altitude cause pulm HTN
Hypoxic vasocxn
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
Histiocytosis X - Langerhans cells
Carcinoid - carcinoid

17. What is the relation fo the pulmonary artery to the bronchus at each lung hilus
L/S > 2 = lecithin/sphingomyelin
Lung cancer
RALS - righ anterior - left superior
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater

18. What is the order of decreasing pressures among the alveola - capillaries and veins in zone 2 of the lungs
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
High alveolar pressure compresses capillaries
Dec - due to lactic acidosis
Pa > PA > Pv

19. Which structures perforate the diaphragm and where
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
0 - negative - prevents pneumothorax
P = 2ST/radius
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12

20. What is the pathology of emphysema
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Chest pain - tachypnea and dyspnea
Pleural effusion
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance

21. What are clara cells What is their morphology and What do they do
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
Inc
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells

22. What is pulmonary surfactant made of - and What does it do
Dipalmatoyl phosphatidylcholine - decreases surface tension
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Inc excretion of bicarb to compensate for respiratory alkalosis

23. What changes in 2 -3 - DPG occur at high altitude
PAO2 - PaO2 = 10-15 mmHg
Viral - URIs - allergens and stress
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance

24. What are the potential causes of poor breathing mechanics leading to restrictive lung disease - and What are examples in each
Drainage
Lobar PNA
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Coal miner's - silicosis - abestosis

25. In emphysema - What is increased lung compliance due to...
Loss of elastic fibers
Methylene blue
Defect in coagulative cascace proteins
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy

26. What is the formula for resistance
Alchoholics or epileptics
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Methacholine challenge
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude

27. What changes in ventilation rate occur during exercise
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Inc to meet O2 demand
Inc airway pressure to prevent airway collapse during exhalation
Airway obstruction (shunt) 100% O2 does not improve PO2

28. What happens to lung volumes in restrictive lung disease
Dec
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
20.1 mL O2 /dL
Methacholine challenge

29. What changes occur to PaO2 and PaCO2
Tissue hypoxia from dec O2 sat and dec O2 content
No change - but inc venous CO2 content
Lower portion of right inferior lobe
Dipalmatoyl phosphatidylcholine

30. What is hemoglobin composed of...
4 polypeptide subunits - 2 alpha and 2 beta
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Elastase
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly

31. What drug therapy is used to augment the changes in bicarb exretion
P = 2ST/radius
Respiratory effort against airway obstruction
Prematurity - maternal RDS - cesarean delivery
Acetazolamide - inhibits CA and acidifies the blood

32. In which zone of the lung is Pa > Pv >PA
Defect in coagulative cascace proteins
Zone 3
Type II pneumocytes - after week 35
Deep leg veins

33. What area of the lung is the largest physiologic contributor of fxnal dead space
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Apex of healthy lung
Tissue hypoxia from dec O2 sat and dec O2 content
PA02 = 150 - PACO2/0.8

34. What does the law of Laplace state about tendency of alveoli to collapse
On expiration as radius dec
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis

35. Lung cancer not linked to smoking - peripheral - grows along airywas - can present like a PNA - cancer and complication
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation
TB - silica disrupt phagolysosomes and impair MACS
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

36. What layers must CO2 and O2 traverse to complete gas exchange
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
Alchoholics or epileptics
Lower portion of right inferior lobe
Carcinoid - carcinoid

37. Define residual volume (RV)
N- terminus - carbaminohemoglobin
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Air in lung after maxmimal expiration - cannot be measured on spirometry
Heart

38. Peripheral mass develops in site of prior pulmonary inflammation or injury - cancer and epi
Loss of elastic fibers
Positive cooperativity and negative allostery - unlike myoglobin
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
C3 - 4 - 6 - phrenic nerve - referred to shoulder

39. What are the causes of hypoxemia
Loss of elastic fibers
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Methacholine challenge
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion

40. What is early onset hypoxemia from in chronic bronchitis
Ivory white calcified pleural plaques
Shunting
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Right shift - favors taut - low affinity for O2 - O2 unloading

41. What muscles are involved in breathing during exercise and What do they control
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals

42. Where are ventilation and perfusion highest in the lung - respectively
Air that can still be breathed out after nl expiration
Both highest in the base
Prostaglandins - histamine - ACE - kallikrein
Prematurity - maternal RDS - cesarean delivery

43. What is the formula for collapsing pressure
Right lung - right main stem bronhus is wider and more vertical
Type II pneumocytes - after week 35
P = 2ST/radius
CO2 - acid/altitude - DPG - Exercise - Temperature

44. What is the formula for oxygen delivery to tissues
CO x O2 content of blood
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance

45. What is methemoglobin
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Respiratory effort against airway obstruction
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Deep leg veins

46. What can amniotic fluid emboli lead to...
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Everything but RV - TV + IRV + ERV
DIC - especially postpartum

47. What effects do O2 and CO2 have on pulm circulation - in relation to the other
Milky fluid with inc TGs
Opposites
TB - apex
Ciliated cells

48. In which zone of the lung is PA > Pa > Pv
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
PA02 = 150 - PACO2/0.8
Zone 1
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc

49. What spinal nerves innvervate the diaphragm and where can pain from the diaphragm be referred
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
Elastase

50. What is the pathology of ARDS
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
Drainage
Low resistance and high compliance

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