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Respiratory

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. What is the formula for A- a gradient - and What is it normally
Chroniclly tired
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Clara cells - type II pneumocytes; multiple densitites on CXR
PAO2 - PaO2 = 10-15 mmHg

2. What does kallikrein do
Incr - right - dec - left
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Inc mitochondria
Activates bradykinin

3. What is the imaging test of choice for PE
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
Inc 2 -3- DPG - righward shift
Tight jxns
CT angio

4. What is methemoglobin
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Hyaline membrane disease
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
N- terminus - carbaminohemoglobin

5. What are fat emboli associated with
Long bone fractures and liposuction
More indolent
Inoperable - responsive to chemotherapy
<60

6. What are the causes of hypoxia
FRC - inward pull of lung balanced by outward pull of chest wall
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
More indolent

7. What is central sleep apnea
Inc mitochondria
Inc
1 g of Hb can bind 1.34 mL of O2 - nl O2 in blood is 15 g/dL - cyansosis when deoxy Hb > 5 g/dL
No respiratory effort

8. What happens to O2 content and O2 sat as Hb falls
Squamous cell carcinoma - keratin pearls and intracellular bridges
Small airways
Dec - no change
Pa > PA > Pv

9. What are the SPHERE of complications in lung cancer
Right lung - right main stem bronhus is wider and more vertical
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Heart

10. What increases the risk of PDA in neonatal RDS
Inc shear stress leading to endothelial injury
Air that can still be breathed out after nl expiration
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia
Persistently low O2 tension

11. What is positive cooperativity of hemoglobin refer to...
L/S > 2 = lecithin/sphingomyelin
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
Inc to meet O2 demand

12. Which pts are at risk for apriation PNA
Histiocytosis X - Langerhans cells
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Gland depth/total thickness of broncial wall - >50%
Alchoholics or epileptics

13. What happens to arterial PO2 in chronic lung disease and why
Squamous cell carcinoma - keratin pearls and intracellular bridges
Dec - because physiologic shunt dec O2 extraction from ratio
PA02 = 150 - PACO2/0.8
Right shift - favors taut - low affinity for O2 - O2 unloading

14. What accounts for the sigmoid shaped O2 dissociation curve with hemoglobin
Positive cooperativity and negative allostery - unlike myoglobin
Inc O2 consumption
Inc excretion of bicarb to compensate for respiratory alkalosis
Airways close prematurely resulting in inc RV and dec FVC

15. What are the causes of ischemia
Acetazolamide - inhibits CA and acidifies the blood
Loss of blood flow - impeded arterial flow - reduced venous drainage
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers

16. In what cells do you find lamellar bodies
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Exposed collagen fibers provides impetus for clotting cascade
Hypertrophy of mucus secreting glands in the bronchioles
Type II cells

17. What enzyme increases activity in emphysema
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Elastase
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
P = 2ST/radius

18. What are the histological findings in asbestosis and what occupations are associated
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Pleural effusion
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-

19. What is surfactant made of...
Bicarb (90%) - bound to globin (5%) and dissolved (5%)
Histiocytosis X - Langerhans cells
Dipalmatoyl phosphatidylcholine
Lower portion of right inferior lobe

20. What are the subtypes of pneumoconioses

21. What kind of space is in the conducting tree and what kind of muscle exists there
0 - negative - prevents pneumothorax
CO2 - acid/altitude - DPG - Exercise - Temperature
Anatomic dead space and smooth muscle
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)

22. What doe FAT BAT stand for
High alveolar pressure compresses capillaries
Lowered
Inoperable - responsive to chemotherapy
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types

23. Lung absecss often reults From what organisms
Viral - URIs - allergens and stress
Loss of blood flow - impeded arterial flow - reduced venous drainage
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
S. aureus or anaerobes

24. 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
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
Apex of healthy lung
In between perfusion limited and diffusion limited

25. What happens to diffusing capacity in interstiial lung diseases
IRV + TV + ERV + RV
Lowered
Persistently low O2 tension
Lower portion of right inferior lobe

26. What effects do O2 and CO2 have on pulm circulation - in relation to the other
Mesothelioma - pleura - psammoma bodies
Inc airway pressure to prevent airway collapse during exhalation
4 polypeptide subunits - 2 alpha and 2 beta
Opposites

27. What is the diffustion formula and what happens to the variables in emphysema and pulmonary fibrosis
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Dec
Pleural effusion

28. What is the formula for oxygen delivery to tissues
Inc to meet O2 demand
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
CO x O2 content of blood
Person stops breathing for at least 10 seconds repeatedly during sleep

29. At what PaO2 does cyanosis begin
S. aureus or anaerobes
<60
Bicarb (90%) - bound to globin (5%) and dissolved (5%)
Coal miner's - silicosis - abestosis

30. What causes secondary pulm HTN
Dorsiflexion of food leads to tender calf muscle
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Pleural effusion

31. How does recurrent thromboemboli cause pulm HTN
Inc excretion of bicarb to compensate for respiratory alkalosis
Type II cells
Mesothelioma - pleura - psammoma bodies
Dec cross sectional area of pulm vasc bed

32. What does PFTs show in COPD
Tissue hypoxia from dec O2 sat and dec O2 content
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
Right shift - favors taut - low affinity for O2 - O2 unloading
Dec dec in FEV1 - dec in FVC

33. How does left to right shunt cause pulm HTN
Inc EPO leading to erythrocytosis
Inc shear stress leading to endothelial injury
Low resistance and high compliance
Productive cough for greater than 3 months in at least 2 years

34. What changes occur to PaO2 and PaCO2
Deep leg veins
No change - but inc venous CO2 content
Exposed collagen fibers provides impetus for clotting cascade
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis

35. What is a typical tidal volume
Inc EPO leading to erythrocytosis
500mL
Positive cooperativity and negative allostery - unlike myoglobin
Long bone fractures and liposuction

36. What lung abnl is associated with dec breath sounds over lesion - dullness - dec fremitus
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Pleural effusion
Activates bradykinin
PA02 = 150 - PACO2/0.8

37. What are the 3 reasons for an increased A- a gradient
PVR = (PpulmA - PleftA)/CO
More indolent
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Both highest in the base

38. What is the ideal V/Q ratio and why
Matched - =1 adequate gas exchange
Hypoxic vasocxn
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Bleomycin - busulfan - anmiodorone

39. What is used to treat methemoglobin
Acetazolamide - inhibits CA and acidifies the blood
Methylene blue
Viral - URIs - allergens and stress
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)

40. Lung cancer in central region - undifferentiated beoming very aggressive - associated with ectopic production of ACTH - ADH and Lambert Eaton syndrome - cancer and histo
Mesothelioma - pleura - psammoma bodies
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Dec in the FEV1/FVC
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)

41. Why is there eventual loss of capillary beds in emphysema
Lost with alveolar walls
Upper lobes - cor pulmonale - caplan's syndrome
CO - 200x
Inc

42. What lung abnl is associated with bronchial breath sounds over lesion - dullness and increased fremitus
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Surfactant def leading to inc surfact tension and alveolar collapse
Lobar PNA
1 g of Hb can bind 1.34 mL of O2 - nl O2 in blood is 15 g/dL - cyansosis when deoxy Hb > 5 g/dL

43. What is the defect in panacinar emphysema - and what else do you see
<75
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Clara cells - type II pneumocytes; multiple densitites on CXR
Alpha1- antitrypsin def - also cirrhosis

44. 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
Apex of healthy lung
Dec - due to lactic acidosis
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

45. What organisms cause interstitial PNA and What are the characteristics
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
It binds to Hb -
Right
Trachea and bronchi

46. What is a particular cause of eosinophilic granulomas - and what cells infiltrate
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
Lobar PNA
Histiocytosis X - Langerhans cells
Airways close prematurely resulting in inc RV and dec FVC

47. What cellular changes occur at high altitude
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Inc mitochondria
RV + ERV - volume in lungs after nl expiration
Exposed collagen fibers provides impetus for clotting cascade

48. What are the potential causes of poor breathing mechanics leading to restrictive lung disease - and What are examples in each
Anatomic dead space and smooth muscle
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Productive cough for greater than 3 months in at least 2 years

49. What is the relation fo the pulmonary artery to the bronchus at each lung hilus
Inc airway pressure to prevent airway collapse during exhalation
Heart
RALS - righ anterior - left superior
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%

50. What is carboxyhemoglobin and What does it cause
L/S < 1.5
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
Alpha1- antitrypsin def - also cirrhosis
Inc to meet O2 demand