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Respiratory

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Answer 50 questions in 15 minutes.
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1. How does recurrent thromboemboli cause pulm HTN
Inc EPO leading to erythrocytosis
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Dec cross sectional area of pulm vasc bed

2. If you aspirate a peanut while upright - where will it go
Lower portion of right inferior lobe
Bronchial obstruction - toward side of lesion
<75
L/S < 1.5

3. What is the V/Q ratio at the apex and base of the lung
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Dec - because physiologic shunt dec O2 extraction from ratio
On expiration as radius dec

4. Malignancy associated with asbestosis - results in hemorrhagic effusions and pleural thickening - cancer - location - histo finding
Mesothelioma - pleura - psammoma bodies
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli

5. What happens to FEV1 and FVC in both obstructive and restrictive lung disease and What is the difference
Viral - URIs - allergens and stress
Dec release of fetal glucocorticoids
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
FRC - inward pull of lung balanced by outward pull of chest wall

6. What is used to treat methemoglobin
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
Methylene blue
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
Low resistance and high compliance

7. What changes in ventilation rate occur during exercise
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
Chest pain - tachypnea and dyspnea
Inc to meet O2 demand
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes

8. What organism causes a lobar PNA and What are the characteristics
Dorsiflexion of food leads to tender calf muscle
Ivory white calcified pleural plaques
Dec - due to lactic acidosis
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung

9. What is the diffustion formula and what happens to the variables in emphysema and pulmonary fibrosis
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
PA02 = 150 - PACO2/0.8
Dec release of fetal glucocorticoids

10. What is the leading cause of cancer death
Clara cells - type II pneumocytes; multiple densitites on CXR
Retinopathy of maturity
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Lung cancer

11. What is central sleep apnea
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
Superior portion of right inferior lobe
No respiratory effort
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation

12. Where does exercise sit on the graph of PaO2 vs length along the pulm capillary
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Right shift - favors taut - low affinity for O2 - O2 unloading
In between perfusion limited and diffusion limited
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals

13. Susceptibility to what infection is increased in silicosis and why
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
Deoxygenated blood - elastic walls
Dipalmatoyl phosphatidylcholine
TB - silica disrupt phagolysosomes and impair MACS

14. What happens to arterial PO2 in chronic lung disease and why
Dec - because physiologic shunt dec O2 extraction from ratio
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
Inc to meet O2 demand

15. Where do you find type I cells - What is their morphology - and What do they do
Ivory white calcified pleural plaques
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Stasis - hypercoagulability - endothelial damage

16. Where are ventilation and perfusion highest in the lung - respectively
Inc airway pressure to prevent airway collapse during exhalation
PAO2 - PaO2 = 10-15 mmHg
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Both highest in the base

17. How does autoimmune dz cause thromboemboli
4 polypeptide subunits - 2 alpha and 2 beta
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Dec dec in FEV1 - dec in FVC
Centriacinar

18. What causes secondary pulm HTN
Repeated cycles of lung injury and wound healing with inc collagen
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Shunting

19. What are the findings associated with sarcoidosis
Dec - no change
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Air that can still be breathed out after nl expiration
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane

20. What is the Reid index and what perfectange is characteristic of chronic bronchitis
Elastase
Gland depth/total thickness of broncial wall - >50%
Bicarb/Cl - exchanger - brings a Cl - into the RBC and expels bicarb into the serum
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types

21. Define inspiratory capacity (IC)
500mL
Mesothelioma - pleura - psammoma bodies
Bronchial obstruction - toward side of lesion
IRV + TV

22. Why is cesarean delivery a risk factor for neonatal RDS
Dec release of fetal glucocorticoids
Air that moves into lung with each quiet respiration
Everything but RV - TV + IRV + ERV
Bicarb (90%) - bound to globin (5%) and dissolved (5%)

23. What is the formula for oxygen delivery to tissues
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
TB - apex
CO x O2 content of blood
No change - but inc venous CO2 content

24. What are curschmann's spirals
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
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
Shed epithelium from mucus plugs
Ivory white calcified pleural plaques

25. What are the histological findings in asbestosis and what occupations are associated
Respiratory effort against airway obstruction
Everything but RV - TV + IRV + ERV
PAO2 - PaO2 = 10-15 mmHg
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing

26. What does the combination of increased CO2 and increased proton binding do to the O2 dissociation curve
Right shift - favors taut - low affinity for O2 - O2 unloading
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Dec release of fetal glucocorticoids
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%

27. Which structures perforate the diaphragm and where
CO2 - acid/altitude - DPG - Exercise - Temperature
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Hyaline membrane disease

28. What is the airway and alveolar pressure at FRC - What is the intrapleural pressure - and What does that prevent
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
O2 binding x O2 sat + dissolved O2
Methylene blue
0 - negative - prevents pneumothorax

29. What lung abnl is associated with dec breath sounds over lesion - dullness - dec fremitus
0 - negative - prevents pneumothorax
Pleural effusion
Inc O2 consumption
Air in excess of tidal volume that moves into lung on maximal inspiration

30. 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
PVR = (PpulmA - PleftA)/CO
Dec dec in FEV1 - dec in FVC
Right lung - right main stem bronhus is wider and more vertical

31. What renal changes occur at high altitude and What are they compensating for
Matched - =1 adequate gas exchange
Inc excretion of bicarb to compensate for respiratory alkalosis
Bicarb/Cl - exchanger - brings a Cl - into the RBC and expels bicarb into the serum
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

32. What is nl pulmonary artery pressure and At what point is it considered pulm HTN
Respiratory effort against airway obstruction
Inspiration by diaphragm - expiration is passive
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise

33. What happens to lung volumes in restrictive lung disease
Dec
Ratio from apex to base becomes more uniform
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
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound

34. What happens in diffiusion limited pulmonary circulation and what gases does this apply to...
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
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
TB - apex

35. What does CADET face to the right stand for
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Inc shear stress leading to endothelial injury
CO2 - acid/altitude - DPG - Exercise - Temperature
Air that can still be breathed out after nl expiration

36. What are fat emboli associated with
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Airways close prematurely resulting in inc RV and dec FVC
Long bone fractures and liposuction
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor

37. What lung abnl is characterized with dec breath sounds - hyperresonance - absent fremitus - towards which side does the trachea deviate
CO x O2 content of blood
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
Tension pneumo - away from lesion
Dorsiflexion of food leads to tender calf muscle

38. Why is there eventual loss of capillary beds in emphysema
Right shift - favors taut - low affinity for O2 - O2 unloading
Air that can still be breathed out after nl expiration
Lost with alveolar walls
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange

39. Synthesis of what substance increases with altitude and What does that do for the O2 sat curve
Inc airway pressure to prevent airway collapse during exhalation
Carcinoid - carcinoid
Air that moves into lung with each quiet respiration
Inc 2 -3- DPG - righward shift

40. An increase in all things (except pH) causes what shift in the O2 curve - What does a decrease in all things (except pH) cause
Pleural effusion
Incr - right - dec - left
More indolent
Mismatch

41. What is the characteristic lymphatic pleural effusion
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
Pa > PA > Pv
In between perfusion limited and diffusion limited
Milky fluid with inc TGs

42. What is the fxn of the conducting zone
Dec cross sectional area of pulm vasc bed
Brings air in and out - warms - humidifies - filters
<60
Inoperable - responsive to chemotherapy

43. What changes occur to PaO2 and PaCO2
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
No change - but inc venous CO2 content
PAO2 - PaO2 = 10-15 mmHg
Incr - right - dec - left

44. What changes in CO2 occur during exercise
Both highest in the base
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Inc production
Shunting

45. What reaction and enzyme create bicarb and Where does it happen
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
CO2 - acid/altitude - DPG - Exercise - Temperature
Apex of healthy lung

46. What accounts for the sigmoid shaped O2 dissociation curve with hemoglobin
Inc EPO leading to erythrocytosis
Inc 2 -3- DPG - righward shift
Positive cooperativity and negative allostery - unlike myoglobin
P = 2ST/radius

47. increases In what substances favor the taut form of hemoglobin and which direction does that shift the O2 dissociation curve
CO2 - acid/altitude - DPG - Exercise - Temperature
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Dorsiflexion of food leads to tender calf muscle

48. What are the causes of hypoxia
Chronic hypoxic vasocxn
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Lower portion of right inferior lobe

49. What TX is the mother given before delivery - and what TXs are given to the infant
Steroids to mom - artificial surfactant and thyroxine to neonate
500mL
Fe 2+
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12

50. What is the pathology of emphysema
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Viral - URIs - allergens and stress
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage
Dorsiflexion of food leads to tender calf muscle

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