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Respiratory

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Answer 50 questions in 15 minutes.
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1. What is Homan's sign
Persistently low O2 tension
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
Alpha1- antitrypsin def - also cirrhosis
Dorsiflexion of food leads to tender calf muscle

2. What is the diffustion formula and what happens to the variables in emphysema and pulmonary fibrosis
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
PVR = (PpulmA - PleftA)/CO
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Acetazolamide - inhibits CA and acidifies the blood

3. What is carboxyhemoglobin and What does it cause
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
Stasis - hypercoagulability - endothelial damage
Steroids to mom - artificial surfactant and thyroxine to neonate

4. At what lung volume is system pressure atmospheric and why
Histiocytosis X - Langerhans cells
Bronchial obstruction - toward side of lesion
FRC - inward pull of lung balanced by outward pull of chest wall
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius

5. What is the protein content an exudative pleural effusion and What are the potential causes
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
Dec in the FEV1/FVC
Steroids to mom - artificial surfactant and thyroxine to neonate

6. What changes in EPO occur at high altitude
PA02 = 150 - PACO2/0.8
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Chronic hypoxic vasocxn
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia

7. What is fetal hemoglobin made of and why does it have a higher affinity for O2
Inc
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest

8. A carcinoma in the apex of the lung can cause what syndrome and What is the tumor called

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9. What cells in the lung produce surfactant and What does it do
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
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)
No change - but inc venous CO2 content

10. What changes in O2 consumption change during exercise
Inc O2 consumption
Pleural effusion
PA02 = 150 - PACO2/0.8
Inoperable - responsive to chemotherapy

11. An increase in all things (except pH) causes what shift in the O2 curve - What does a decrease in all things (except pH) cause
Lung cancer
Type II cells
DIC - especially postpartum
Incr - right - dec - left

12. What is an example of hypercoagulability
Low resistance and high compliance
Opposites
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Defect in coagulative cascace proteins

13. What happens to V/Q ratio in COPD
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Mismatch
Right lung - right main stem bronhus is wider and more vertical
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema

14. What are the risk factors for neonatal RDS
Methacholine challenge
Prematurity - maternal RDS - cesarean delivery
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound

15. How much O2 can 1 g of Hb bind - What is nl Hb in the blood and When does cyanosis happen
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Dec - because physiologic shunt dec O2 extraction from ratio
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
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

16. What does the oxygenation of Hb in the lungs do to the equilibirum of the CA rxn
It binds to Hb -
CO2 - acid/altitude - DPG - Exercise - Temperature
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways

17. Define total lung capcaity
Gland depth/total thickness of broncial wall - >50%
IRV + TV + ERV + RV
Matched - =1 adequate gas exchange
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung

18. What does CADET face to the right stand for
Dec - because physiologic shunt dec O2 extraction from ratio
CO2 - acid/altitude - DPG - Exercise - Temperature
DIC - especially postpartum
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis

19. What doe FAT BAT stand for
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types

20. What lung abnl is associated with dec breath sounds over lesion - dullness - dec fremitus
Pleural effusion
Chest pain - tachypnea and dyspnea
Ivory white calcified pleural plaques
Histiocytosis X - Langerhans cells

21. What TX is the mother given before delivery - and what TXs are given to the infant
Acetazolamide - inhibits CA and acidifies the blood
Methacholine challenge
Steroids to mom - artificial surfactant and thyroxine to neonate
Lost with alveolar walls

22. What is the alveolar gas equation
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
Air in lung after maxmimal expiration - cannot be measured on spirometry
Retinopathy of maturity
Inc mitochondria

23. What are the findings of chronic bronchitis
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
N- terminus - carbaminohemoglobin
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis

24. How happens to the proton from the rxn the created bicarb
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
It binds to Hb -
Deep leg veins
Loss of elastic fibers

25. What renal changes occur at high altitude and What are they compensating for
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types
Inc excretion of bicarb to compensate for respiratory alkalosis
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities

26. What is used to treat methemoglobin
<60
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Productive cough for greater than 3 months in at least 2 years
Methylene blue

27. Hilar mass arising from the bronchus; cavitation - hx of smoking - PTHRP - cancer and histo
Productive cough for greater than 3 months in at least 2 years
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Squamous cell carcinoma - keratin pearls and intracellular bridges

28. What are the 3 reasons for an increased A- a gradient
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Dec dec in FEV1 - dec in FVC
Deep leg veins

29. What is the appoximate O2 binding capacity
More indolent
Shunting
20.1 mL O2 /dL
Right lung - right main stem bronhus is wider and more vertical

30. What happens in perfusion limited circulatioin and which gases does this apply to...
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Dec cross sectional area of pulm vasc bed
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
S. aureus or anaerobes

31. Define functional residual capacity (FRC)
Heart
Milky fluid with inc TGs
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
RV + ERV - volume in lungs after nl expiration

32. What are the two forms of hemoglobin
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
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
Low resistance and high compliance
Clara cells - type II pneumocytes; multiple densitites on CXR

33. At What terminal does CO2 bind the globin molecule
More indolent
N- terminus - carbaminohemoglobin
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Lobar PNA

34. What organisms cause a bronchoPNA and What are the characteristics
Superior portion of right inferior lobe
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Inc O2 consumption

35. Other than surfactant - what other important substances are produced by the lungs
Upper lobes - cor pulmonale - caplan's syndrome
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Lobar PNA
Prostaglandins - histamine - ACE - kallikrein

36. What happens to FEV1 and FVC in both obstructive and restrictive lung disease and What is the difference
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Zone 1
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

37. What increases the risk of PDA in neonatal RDS
Persistently low O2 tension
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Air in excess of tidal volume that moves into lung on maximal inspiration
Upper lobes - cor pulmonale - caplan's syndrome

38. What changes occur to pulm blood flow during exercise
Surfactant def leading to inc surfact tension and alveolar collapse
Opposites
Inc due to inc CO
Dec dec in FEV1 - dec in FVC

39. What lab ration indicates fetal lung maturity
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
L/S > 2 = lecithin/sphingomyelin
Right

40. What does pulm HTN result in
Loss of elastic fibers
20.1 mL O2 /dL
Apex of healthy lung
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries

41. What is used to treat CN poisoning and why
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Ciliated cells
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
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

42. What does the conducting zone consist of...
Mismatch
Low resistance and high compliance
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
TB - silica disrupt phagolysosomes and impair MACS

43. What does the respiratory zone consist of and What is its fxn
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium

44. Define physilogic dead space
Deoxygenated blood - elastic walls
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
N- terminus - carbaminohemoglobin
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis

45. 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
Air that can still be breathed out after nl expiration
Apex of healthy lung
Carcinoid - carcinoid
Squamous cell carcinoma - keratin pearls and intracellular bridges

46. At what PaO2 does hypoxemia begin
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
<75
Tension pneumo - away from lesion
Elastic properties

47. What effects do O2 and CO2 have on pulm circulation - in relation to the other
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Clara cells - type II pneumocytes; multiple densitites on CXR
Opposites
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis

48. What is methemoglobin
L/S < 1.5
Elastase
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis

49. What is another name for neonatal RDS
Hyaline membrane disease
Lobar PNA
Inc resistance leading to inc pressure
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli

50. What kind of space is in the conducting tree and what kind of muscle exists there
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Incr - right - dec - left
Both highest in the base
Anatomic dead space and smooth muscle

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