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Respiratory

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1. What cells make surfactant and At what week is produced most abundantly
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Drainage
Type II pneumocytes - after week 35

2. Why is there eventual loss of capillary beds in emphysema
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Inc to meet O2 demand
FEV1/FVC > 80%
Lost with alveolar walls

3. What are the 3 reasons for an increased A- a gradient
Matched - =1 adequate gas exchange
Opposites
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Inspiration by diaphragm - expiration is passive

4. Peripheral mass develops in site of prior pulmonary inflammation or injury - cancer and epi
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Dec in the FEV1/FVC

5. What does the law of Laplace state about tendency of alveoli to collapse
On expiration as radius dec
Weight loss - CPAP - surgery
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
Mesothelioma - pleura - psammoma bodies

6. What is the airway and alveolar pressure at FRC - What is the intrapleural pressure - and What does that prevent
Surfactant
Ratio from apex to base becomes more uniform
PA02 = 150 - PACO2/0.8
0 - negative - prevents pneumothorax

7. What lung abnl is associated with bronchial breath sounds over lesion - dullness and increased fremitus
Low resistance and high compliance
Inspiration by diaphragm - expiration is passive
S. aureus or anaerobes
Lobar PNA

8. What are the causes of hypoxemia
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
Hypertrophy of mucus secreting glands in the bronchioles
<60

9. What is a lung abscess and What does usually result from
20.1 mL O2 /dL
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
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
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2

10. Where do you find type I cells - What is their morphology - and What do they do
Respiratory effort against airway obstruction
Tight jxns
Zone 1
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange

11. What is are the symptoms of a pulmonary embolism
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
Steroids to mom - artificial surfactant and thyroxine to neonate
IRV + TV + ERV + RV
Chest pain - tachypnea and dyspnea

12. What does ACE do
CO - 200x
Methacholine challenge
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)

13. Hilar mass arising from the bronchus; cavitation - hx of smoking - PTHRP - cancer and histo
Acetazolamide - inhibits CA and acidifies the blood
Squamous cell carcinoma - keratin pearls and intracellular bridges
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Superior portion of right inferior lobe

14. What does a V/Q ratio of infinity indicate
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
CO - 200x
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2

15. Define physilogic dead space
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
Lost with alveolar walls
0 - negative - prevents pneumothorax
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli

16. What does the conducting zone consist of...
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Clara cells - type II pneumocytes; multiple densitites on CXR
Everything but RV - TV + IRV + ERV

17. Why is endothelial damage a risk factor for DVT
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
Lowered
Exposed collagen fibers provides impetus for clotting cascade
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor

18. What is the pathology of ARDS
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Ciliated cells
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis

19. What are the SPHERE of complications in lung cancer
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
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
O2 binding x O2 sat + dissolved O2
Shunting

20. What doe FAT BAT stand for
Right
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2

21. How does sleep apnea or high altitude cause pulm HTN
Defect in coagulative cascace proteins
Hypoxic vasocxn
Inspiration by diaphragm - expiration is passive
It binds to Hb -

22. How many lobes does each lung have - and What is the lingula
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
Lower portion of right inferior lobe
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung

23. What are the causes of hypoxia
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
L/S < 1.5
Pleural effusion
500mL

24. What happens to arterial PO2 in chronic lung disease 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
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Dec - because physiologic shunt dec O2 extraction from ratio

25. What is the criteria for chronic bronchitis
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Loss of blood flow - impeded arterial flow - reduced venous drainage
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Productive cough for greater than 3 months in at least 2 years

26. Malignancy associated with asbestosis - results in hemorrhagic effusions and pleural thickening - cancer - location - histo finding
20.1 mL O2 /dL
Mesothelioma - pleura - psammoma bodies
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types

27. Where is cartilage present in the respiratory tree
Dec
Person stops breathing for at least 10 seconds repeatedly during sleep
Trachea and bronchi
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males

28. What changes in 2 -3 - DPG occur at high altitude
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
S. aureus or anaerobes
PA02 = 150 - PACO2/0.8
Pleural effusion

29. What does decreased PAO2 do
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
Deoxygenated blood - elastic walls
Exposed collagen fibers provides impetus for clotting cascade
Metastasis - breast - colon - prostate - bladder -

30. What changes at high altitude can result in RVH
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Chronic hypoxic vasocxn

31. What is a typical tidal volume
500mL
Inc airway pressure to prevent airway collapse during exhalation
Persistently low O2 tension
Air in lung after maxmimal expiration - cannot be measured on spirometry

32. At What terminal does CO2 bind the globin molecule
N- terminus - carbaminohemoglobin
FRC - inward pull of lung balanced by outward pull of chest wall
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death

33. What causes secondary pulm HTN
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Small airways
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

34. What is a consequence of pulm HTN
Type II pneumocytes - after week 35
L/S < 1.5
Inc 2 -3- DPG - righward shift
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly

35. What are the potential TX for sleep apnea
High alveolar pressure compresses capillaries
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Weight loss - CPAP - surgery
Inc EPO leading to erythrocytosis

36. Lung cancer in central region - undifferentiated beoming very aggressive - associated with ectopic production of ACTH - ADH and Lambert Eaton syndrome - cancer and histo
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation
Alpha1- antitrypsin def - also cirrhosis
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)

37. What is the alveolar gas equation approximation
O2 binding x O2 sat + dissolved O2
Upper lobes
Air that moves into lung with each quiet respiration
PA02 = 150 - PACO2/0.8

38. Define residual volume (RV)
PVR = (PpulmA - PleftA)/CO
Air in lung after maxmimal expiration - cannot be measured on spirometry
Inc due to inc CO
L/S > 2 = lecithin/sphingomyelin

39. What changes in lung volunes occur as a result of restrictive lung disease
Inc excretion of bicarb to compensate for respiratory alkalosis
Prostaglandins - histamine - ACE - kallikrein
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Dec in lung volumes - FVC - TLC

40. Tumor secreting serotonin causes a syndrome with flushing - diarrhea - wheezing - salvation; fibrous deposits in the right heart valves may lead to tricuspid insuff - pulmonary stenosis - right heart failure - tumor and syndrome
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Tissue hypoxia from dec O2 sat and dec O2 content
Carcinoid - carcinoid
Hypoxic vasocxn

41. Synthesis of what substance increases with altitude and What does that do for the O2 sat curve
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Inc 2 -3- DPG - righward shift
Inc mitochondria
Surfactant

42. What are the risk factors for neonatal RDS
High alveolar pressure compresses capillaries
Elastic properties
Lower portion of right inferior lobe
Prematurity - maternal RDS - cesarean delivery

43. What is the relation fo the pulmonary artery to the bronchus at each lung hilus
Defect in coagulative cascace proteins
Deoxygenated blood - elastic walls
RALS - righ anterior - left superior
Hypertrophy of mucus secreting glands in the bronchioles

44. What lobes are affected in silicosis
Lost with alveolar walls
Upper lobes
Inspiration by diaphragm - expiration is passive
Bicarb (90%) - bound to globin (5%) and dissolved (5%)

45. What reaction and enzyme create bicarb and Where does it happen
Dec - no change
L/S > 2 = lecithin/sphingomyelin
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Air in excess of tidal volume that moves into lung on maximal inspiration

46. What is pulmonary surfactant made of - and What does it do
Dipalmatoyl phosphatidylcholine - decreases surface tension
Loss of blood flow - impeded arterial flow - reduced venous drainage
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Inc 2 -3- DPG - righward shift

47. Which structures perforate the diaphragm and where
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Chest pain - tachypnea and dyspnea
Dipalmatoyl phosphatidylcholine

48. What does alveolar pressure do to capillaries in the apex of the lung
<75
High alveolar pressure compresses capillaries
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism

49. In what cells do you find lamellar bodies
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
Type II cells
Shed epithelium from mucus plugs

50. What is carboxyhemoglobin and What does it cause
L/S > 2 = lecithin/sphingomyelin
Carcinoid - carcinoid
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
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen

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