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Respiratory

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Answer 50 questions in 15 minutes.
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1. How do you prevent DVT
Heparin
Right
Elastase
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging

2. What is the formula for oxygen delivery to tissues
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
CO x O2 content of blood
Long bone fractures and liposuction

3. Why do pts with emphysema exhale through pursed lips
Inc airway pressure to prevent airway collapse during exhalation
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Airways close prematurely resulting in inc RV and dec FVC

4. What is the tendency of the lungs vs the chest wall
Respiratory effort against airway obstruction
Deep leg veins
Lungs collapse inwards and chest wall spring out
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males

5. What spinal nerves innvervate the diaphragm and where can pain from the diaphragm be referred
Squamous cell carcinoma - keratin pearls and intracellular bridges
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
C3 - 4 - 6 - phrenic nerve - referred to shoulder
PVR = (PpulmA - PleftA)/CO

6. What lung product is deficient in neonatal RDS
Right shift - favors taut - low affinity for O2 - O2 unloading
Surfactant
Chroniclly tired
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis

7. What is surfactant made of...
Dipalmatoyl phosphatidylcholine
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung

8. How does sleep apnea or high altitude cause pulm HTN
Hypoxic vasocxn
Air that can still be breathed out after nl expiration
Upper lobes - cor pulmonale - caplan's syndrome
Small airways

9. What is virchow's triad
Stasis - hypercoagulability - endothelial damage
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Pa > PA > Pv
Elastic properties

10. What does kallikrein do
Air in excess of tidal volume that moves into lung on maximal inspiration
Activates bradykinin
Opposites
4 polypeptide subunits - 2 alpha and 2 beta

11. How does recurrent thromboemboli cause pulm HTN
Type II pneumocytes - after week 35
On expiration as radius dec
Dec cross sectional area of pulm vasc bed
Gland depth/total thickness of broncial wall - >50%

12. What organism thrives in high O2 and where in the lung does it flourish
Prostaglandins - histamine - ACE - kallikrein
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Activates bradykinin
TB - apex

13. What is the presentation of lung cancer

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14. What are the causes of ischemia
Viral - URIs - allergens and stress
Chronic hypoxic vasocxn
Loss of blood flow - impeded arterial flow - reduced venous drainage
No change - but inc venous CO2 content

15. What are the risk factors for neonatal RDS
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Inc due to inc CO
Prematurity - maternal RDS - cesarean delivery

16. What lung abnl is characterized by absent or decreased breath sounds over affected area - dec resonance - dec fremitus - and which side is the trachea deviated towards
PAO2 - PaO2 = 10-15 mmHg
Bronchial obstruction - toward side of lesion
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
Upper lobes - cor pulmonale - caplan's syndrome

17. Which has a greater affinity for hemoglobin - CO or O2 and by how much
Acute/chronic inc in vent
CO - 200x
Everything but RV - TV + IRV + ERV
Inc to meet O2 demand

18. What are the 9 interstitial lung diseases

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19. How does mitral stenosis cause pulm HTN
Deep leg veins
Inc resistance leading to inc pressure
Airways close prematurely resulting in inc RV and dec FVC
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-

20. What does alveolar pressure do to capillaries in the apex of the lung
High alveolar pressure compresses capillaries
Heparin
PVR = (PpulmA - PleftA)/CO
CO2 - acid/altitude - DPG - Exercise - Temperature

21. What is the definition of sleep apnea
Productive cough for greater than 3 months in at least 2 years
Person stops breathing for at least 10 seconds repeatedly during sleep
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
N- terminus - carbaminohemoglobin

22. What happens to FEV1 and FVC in both obstructive and restrictive lung disease and What is the difference
Dipalmatoyl phosphatidylcholine
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Pleural effusion

23. What is Homan's sign
Tissue hypoxia from dec O2 sat and dec O2 content
Dorsiflexion of food leads to tender calf muscle
Person stops breathing for at least 10 seconds repeatedly during sleep
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater

24. What happens to arterial PO2 in chronic lung disease and why
Inc 2 -3- DPG - righward shift
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
Dec - because physiologic shunt dec O2 extraction from ratio

25. What kind of space is in the conducting tree and what kind of muscle exists there
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Chest pain - tachypnea and dyspnea
Anatomic dead space and smooth muscle
Inoperable - responsive to chemotherapy

26. What do type II cells do - What is their morphology - when do they proliferate
Anatomic dead space and smooth muscle
Dec
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage

27. What is an example of hypercoagulability
Bronchial obstruction - toward side of lesion
Dec - no change
<75
Defect in coagulative cascace proteins

28. Susceptibility to what infection is increased in silicosis and why
TB - silica disrupt phagolysosomes and impair MACS
RV + ERV - volume in lungs after nl expiration
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue

29. What is a particular cause of eosinophilic granulomas - and what cells infiltrate
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Dec - due to lactic acidosis
Histiocytosis X - Langerhans cells
Dec dec in FEV1 - dec in FVC

30. What properties determine the combined volumes of the chest wall and lungs
Elastic properties
Lobar PNA
Persistently low O2 tension
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

31. What causes secondary pulm HTN
Dec - because physiologic shunt dec O2 extraction from ratio
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation
Zone 1
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude

32. Where do you find type I cells - What is their morphology - and What do they do
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Deoxygenated blood - elastic walls
Air in excess of tidal volume that moves into lung on maximal inspiration

33. Where is cartilage present in the respiratory tree
Trachea and bronchi
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
More indolent
0 - negative - prevents pneumothorax

34. What does each bronchopulmonary segment have in the center and along its border
Right shift - favors taut - low affinity for O2 - O2 unloading
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)

35. Define expiratory reserve volume (ERV)
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
Air that can still be breathed out after nl expiration
Airways close prematurely resulting in inc RV and dec FVC
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)

36. What is the ideal V/Q ratio and why
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Upper lobes - cor pulmonale - caplan's syndrome
Squamous cell carcinoma - keratin pearls and intracellular bridges
Matched - =1 adequate gas exchange

37. Define inspiratory reserve volume (IRV)
<60
Air in excess of tidal volume that moves into lung on maximal inspiration
Dorsiflexion of food leads to tender calf muscle
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise

38. Where does lung cancer met to...
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-

39. What is the pathology of emphysema
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Dec dec in FEV1 - dec in FVC

40. What are the associations with bronchiectasis

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41. What happens with the O2 curve shifts to the right and What does it facilitate
TB - silica disrupt phagolysosomes and impair MACS
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Lungs collapse inwards and chest wall spring out
Inc shear stress leading to endothelial injury

42. What accounts for the sigmoid shaped O2 dissociation curve with hemoglobin
Positive cooperativity and negative allostery - unlike myoglobin
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Inspiration by diaphragm - expiration is passive
Weight loss - CPAP - surgery

43. What happens to O2 content and O2 sat as Hb falls
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
Surfactant def leading to inc surfact tension and alveolar collapse
Fe 2+
Dec - no change

44. What is compliance and When is it decrease
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Everything but RV - TV + IRV + ERV
P = 2ST/radius
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema

45. Which lung is the more common site for an inhaled foreign body and why
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
Prematurity - maternal RDS - cesarean delivery
Mismatch
Right lung - right main stem bronhus is wider and more vertical

46. What is early onset hypoxemia from in chronic bronchitis
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
Shunting
O2 binding x O2 sat + dissolved O2

47. What is another name for neonatal RDS
Inc excretion of bicarb to compensate for respiratory alkalosis
Hyaline membrane disease
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis

48. What is central sleep apnea
Inc excretion of bicarb to compensate for respiratory alkalosis
No respiratory effort
On expiration as radius dec
Apex of healthy lung

49. What cellular changes occur at high altitude
Inc mitochondria
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
Dec in lung volumes - FVC - TLC
S. aureus or anaerobes

50. What are the histological findings in asbestosis and what occupations are associated
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
4 polypeptide subunits - 2 alpha and 2 beta
TB - apex
Histiocytosis X - Langerhans cells

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