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Respiratory

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. What is an association and potential complication of paraseptal emphysema
Dec in lung volumes - FVC - TLC
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance

2. What is hemoglobin composed of...
4 polypeptide subunits - 2 alpha and 2 beta
IRV + TV + ERV + RV
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
More indolent

3. What is the pathology of ARDS
Pleural effusion
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
Air in lung after maxmimal expiration - cannot be measured on spirometry

4. What is nl pulmonary artery pressure and At what point is it considered pulm HTN
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Surfactant def leading to inc surfact tension and alveolar collapse
Inc due to inc CO
Alchoholics or epileptics

5. An increase in all things (except pH) causes what shift in the O2 curve - What does a decrease in all things (except pH) cause
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Inc production
Dorsiflexion of food leads to tender calf muscle
Incr - right - dec - left

6. What are the lab/study findings in adenocarcinoma of the lung
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
DIC - especially postpartum
Inc shear stress leading to endothelial injury
Clara cells - type II pneumocytes; multiple densitites on CXR

7. What is compliance and When is it decrease
Incr - right - dec - left
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis

8. What do hemoglobin modifacations lead to...
On expiration as radius dec
Tissue hypoxia from dec O2 sat and dec O2 content
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Surfactant def leading to inc surfact tension and alveolar collapse

9. Why is cesarean delivery a risk factor for neonatal RDS
Dec release of fetal glucocorticoids
IRV + TV + ERV + RV
P = 2ST/radius
Stasis - hypercoagulability - endothelial damage

10. If you aspirate a peanut while supine - where will it go
Dec release of fetal glucocorticoids
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Upper lobes
Superior portion of right inferior lobe

11. Lung cancer in central region - undifferentiated beoming very aggressive - associated with ectopic production of ACTH - ADH and Lambert Eaton syndrome - cancer and histo
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Upper lobes - cor pulmonale - caplan's syndrome
Carcinoid - carcinoid
Zone 1

12. If you aspirate a peanut while upright - where will it go
RV + ERV - volume in lungs after nl expiration
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Lower portion of right inferior lobe

13. What happens to lung volumes in restrictive lung disease
Exposed collagen fibers provides impetus for clotting cascade
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
Dec
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung

14. What is a particular cause of eosinophilic granulomas - and what cells infiltrate
Histiocytosis X - Langerhans cells
Weight loss - CPAP - surgery
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue

15. What is Homan's sign
In between perfusion limited and diffusion limited
Anatomic dead space and smooth muscle
Chroniclly tired
Dorsiflexion of food leads to tender calf muscle

16. Define vital capacity (VC)
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Everything but RV - TV + IRV + ERV
Matched - =1 adequate gas exchange

17. What is the airway and alveolar pressure at FRC - What is the intrapleural pressure - and What does that prevent
0 - negative - prevents pneumothorax
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
In between perfusion limited and diffusion limited

18. What do PFTs show in restrictive lung disease
Acute/chronic inc in vent
FEV1/FVC > 80%
Carcinoid - carcinoid
CO x O2 content of blood

19. Define expiratory reserve volume (ERV)
Centriacinar
Defect in coagulative cascace proteins
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
Air that can still be breathed out after nl expiration

20. What kind of space is in the conducting tree and what kind of muscle exists there
Coal miner's - silicosis - abestosis
Airways close prematurely resulting in inc RV and dec FVC
Anatomic dead space and smooth muscle
Inc shear stress leading to endothelial injury

21. Define residual volume (RV)
Low resistance and high compliance
Air in lung after maxmimal expiration - cannot be measured on spirometry
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
Lung cancer

22. What does the respiratory zone consist of and What is its fxn
FRC - inward pull of lung balanced by outward pull of chest wall
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Right lung - right main stem bronhus is wider and more vertical
Mismatch

23. What changes in O2 consumption change during exercise
Inc O2 consumption
Tight jxns
Loss of elastic fibers
Drainage

24. In COPD - what happens to airways at high lung volumes
N- terminus - carbaminohemoglobin
Airways close prematurely resulting in inc RV and dec FVC
Inc resistance leading to inc pressure
Zone 1

25. What is occupied in the space that would have been the left middle lobe
Dec
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Viral - URIs - allergens and stress
Heart

26. What are the 9 interstitial lung diseases

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27. What is the formula for A- a gradient - and What is it normally
PAO2 - PaO2 = 10-15 mmHg
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Tissue hypoxia from dec O2 sat and dec O2 content
Prostaglandins - histamine - ACE - kallikrein

28. What is a lung abscess and What does usually result from
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
<75
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly

29. What is early onset hypoxemia from in chronic bronchitis
Shunting
Upper lobes
TB - apex
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents

30. What is the tendency of the lungs vs the chest wall
Lungs collapse inwards and chest wall spring out
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
High alveolar pressure compresses capillaries

31. What does the law of Laplace state about tendency of alveoli to collapse
4 polypeptide subunits - 2 alpha and 2 beta
On expiration as radius dec
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
C3 - 4 - 6 - phrenic nerve - referred to shoulder

32. increases In what substances favor the taut form of hemoglobin and which direction does that shift the O2 dissociation curve
Bicarb/Cl - exchanger - brings a Cl - into the RBC and expels bicarb into the serum
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Type II cells

33. What happens to FEV1 and FVC in both obstructive and restrictive lung disease and What is the difference
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy

34. Define tidal volume (TV)
Apex of healthy lung
L/S > 2 = lecithin/sphingomyelin
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
Air that moves into lung with each quiet respiration

35. What is the formula for O2 content
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
On expiration as radius dec
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
O2 binding x O2 sat + dissolved O2

36. What is the TX for small cell lung cancer
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Methacholine challenge
Inoperable - responsive to chemotherapy
Exposed collagen fibers provides impetus for clotting cascade

37. What does decreased PAO2 do
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
<60
Air that can still be breathed out after nl expiration
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung

38. What must occur with a exudate pleural effusion
Pa > PA > Pv
Drainage
Squamous cell carcinoma - keratin pearls and intracellular bridges
Air that moves into lung with each quiet respiration

39. Why is endothelial damage a risk factor for DVT
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
Exposed collagen fibers provides impetus for clotting cascade
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Heart

40. What findings are associated with emphysema
Ratio from apex to base becomes more uniform
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
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest

41. What does each bronchopulmonary segment have in the center and along its border
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
No respiratory effort
Trachea and bronchi
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways

42. What is the pathology of bronchiectasis
IRV + TV
Respiratory bronchioles - clear debris in alveoli - bronchi
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Right shift - favors taut - low affinity for O2 - O2 unloading

43. What is the formula for oxygen delivery to tissues
Tissue hypoxia from dec O2 sat and dec O2 content
IRV + TV + ERV + RV
CO x O2 content of blood
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging

44. What is the formula for collapsing pressure
Long bone fractures and liposuction
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
CO - 200x
P = 2ST/radius

45. What changes in lung volunes occur as a result of restrictive lung disease
Dec in lung volumes - FVC - TLC
Acute/chronic inc in vent
On expiration as radius dec
Inc to meet O2 demand

46. What is tha hallmark finding of COPD
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Dec in the FEV1/FVC
O2 binding x O2 sat + dissolved O2
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death

47. What is the alveolar gas equation approximation
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
PA02 = 150 - PACO2/0.8
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Positive cooperativity and negative allostery - unlike myoglobin

48. What is the appoximate O2 binding capacity
Airway obstruction (shunt) 100% O2 does not improve PO2
Acetazolamide - inhibits CA and acidifies the blood
20.1 mL O2 /dL
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly

49. How far to the pseudostratified ciliated columnar epithelium extend - What do MACS do in the alveoli - and how far do the goblet cells extend
Coal miner's - silicosis - abestosis
Dec in lung volumes - FVC - TLC
Respiratory bronchioles - clear debris in alveoli - bronchi
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals

50. 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
Dec dec in FEV1 - dec in FVC
Carcinoid - carcinoid
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG