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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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1. What are the risk factors for neonatal RDS
FEV1/FVC > 80%
S. aureus or anaerobes
Prematurity - maternal RDS - cesarean delivery
Upper lobes

2. What changes in 2 -3 - DPG occur at high altitude
High alveolar pressure compresses capillaries
Prematurity - maternal RDS - cesarean delivery
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
On expiration as radius dec

3. What direction does an increase in metabolic need shift the O2 dissociation curve
Right
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Inspiration by diaphragm - expiration is passive
Lowered

4. What is positive cooperativity of hemoglobin refer to...
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
High alveolar pressure compresses capillaries

5. What are the findings of chronic bronchitis
Chroniclly tired
Both highest in the base
Shunting
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater

6. If you aspirate a peanut while supine - where will it go
Inc to meet O2 demand
20.1 mL O2 /dL
Dec in the FEV1/FVC
Superior portion of right inferior lobe

7. What organisms cause a bronchoPNA and What are the characteristics
CO - 200x
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
On expiration as radius dec
Stasis - hypercoagulability - endothelial damage

8. In which zone of the lung is PA > Pa > Pv
Zone 1
Surfactant
RALS - righ anterior - left superior
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

9. What do hemoglobin modifacations lead to...
CO2 - acid/altitude - DPG - Exercise - Temperature
Small airways
Tissue hypoxia from dec O2 sat and dec O2 content
PAO2 - PaO2 = 10-15 mmHg

10. What is the course of of pulm HTN
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis

11. Lung cancer in peripheral reason - highly anaplastic - undifferentiated tumor - cancer - histo - TX
Anatomic dead space and smooth muscle
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Low resistance and high compliance

12. What is virchow's triad
Right shift - favors taut - low affinity for O2 - O2 unloading
Ivory white calcified pleural plaques
Stasis - hypercoagulability - endothelial damage
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

13. What is the formula for A- a gradient - and What is it normally
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
PAO2 - PaO2 = 10-15 mmHg
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals

14. Where does exercise sit on the graph of PaO2 vs length along the pulm capillary
In between perfusion limited and diffusion limited
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Inc 2 -3- DPG - righward shift
Alpha1- antitrypsin def - also cirrhosis

15. What is occupied in the space that would have been the left middle lobe
Heart
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Opposites

16. What happens in diffiusion limited pulmonary circulation and what gases does this apply to...
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Alchoholics or epileptics
PA02 = 150 - PACO2/0.8
Everything but RV - TV + IRV + ERV

17. What are the two forms of hemoglobin
Ciliated cells
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
Type II cells

18. What is the tendency of the lungs vs the chest wall
Pa > PA > Pv
Bicarb/Cl - exchanger - brings a Cl - into the RBC and expels bicarb into the serum
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Lungs collapse inwards and chest wall spring out

19. What are the SPHERE of complications in lung cancer
Trachea and bronchi
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
Air that moves into lung with each quiet respiration
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)

20. 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
<60
Inc shear stress leading to endothelial injury
Opposites

21. What is the protein content an exudative pleural effusion and What are the potential causes
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Air in lung after maxmimal expiration - cannot be measured on spirometry
<75
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma

22. What is the equation for physiologic dead space
Positive cooperativity and negative allostery - unlike myoglobin
Bronchial obstruction - toward side of lesion
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
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]

23. What lobes does Coal Miner's pneumoconioses affect - and What can it result in

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24. Chronic bronchitis is a disease of what kind of airways
Small airways
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Type II pneumocytes - after week 35
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism

25. What is the initial damage of ARDS caused by
P = 2ST/radius
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
No change - but inc venous CO2 content
Small airways

26. What is the response for ventilation of high altitude
Coal miner's - silicosis - abestosis
Clara cells - type II pneumocytes; multiple densitites on CXR
Acute/chronic inc in vent
Both highest in the base

27. What TX is the mother given before delivery - and what TXs are given to the infant
Elastase
Steroids to mom - artificial surfactant and thyroxine to neonate
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism

28. What lobes are affected in silicosis
Upper lobes
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Hypertrophy of mucus secreting glands in the bronchioles
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy

29. What is the pathology of chronic bronchitis
Hypertrophy of mucus secreting glands in the bronchioles
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Low resistance and high compliance
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles

30. What kind of space is in the conducting tree and what kind of muscle exists there
Anatomic dead space and smooth muscle
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Productive cough for greater than 3 months in at least 2 years
Acute/chronic inc in vent

31. What is the main complication of therapeutic supplemental O2?
Retinopathy of maturity
0 - negative - prevents pneumothorax
Apex of healthy lung
Upper lobes - cor pulmonale - caplan's syndrome

32. Why is there eventual loss of capillary beds in emphysema
Hypoxic vasocxn
Lost with alveolar walls
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest

33. What does ACE do
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
500mL
Viral - URIs - allergens and stress
Positive cooperativity and negative allostery - unlike myoglobin

34. What are the 3 reasons for an increased A- a gradient
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
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
Dipalmatoyl phosphatidylcholine
Hypoxemia because of shunting - V/Q mistmatch - fibrosis

35. What is the alveolar gas equation
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Positive cooperativity and negative allostery - unlike myoglobin
Weight loss - CPAP - surgery
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed

36. What is the relation fo the pulmonary artery to the bronchus at each lung hilus
Bicarb (90%) - bound to globin (5%) and dissolved (5%)
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
RALS - righ anterior - left superior
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary

37. What is sleep apnea associated with
Inc mitochondria
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Histiocytosis X - Langerhans cells
Inspiration by diaphragm - expiration is passive

38. What is the pathology of emphysema
Positive cooperativity and negative allostery - unlike myoglobin
Tight jxns
Alpha1- antitrypsin def - also cirrhosis
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance

39. What changes in V/Q throughout the lung during exercise
Ratio from apex to base becomes more uniform
Anatomic dead space and smooth muscle
Clara cells - type II pneumocytes; multiple densitites on CXR
Alpha1- antitrypsin def - also cirrhosis

40. What is the definition of sleep apnea
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Airway obstruction (shunt) 100% O2 does not improve PO2
Pleural effusion
Person stops breathing for at least 10 seconds repeatedly during sleep

41. What is the formula for pulm vasc resistance
CT angio
Type II cells
PVR = (PpulmA - PleftA)/CO
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange

42. How does autoimmune dz cause thromboemboli
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Productive cough for greater than 3 months in at least 2 years
Superior portion of right inferior lobe
Ciliated cells

43. What are the subtypes of pneumoconioses

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44. What are the causes of hypoxia
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
IRV + TV
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-

45. What is methemoglobin
Heart
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Brings air in and out - warms - humidifies - filters
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed

46. What kind of emphysema is caused by smoking
Centriacinar
Shunting
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG

47. What is a consequence of pulm HTN
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Inc mitochondria
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Low resistance and high compliance

48. What are the 3 forms that CO2 is transported from tissues to lungs
Bicarb (90%) - bound to globin (5%) and dissolved (5%)
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Heparin
L/S > 2 = lecithin/sphingomyelin

49. Susceptibility to what infection is increased in silicosis and why
Chroniclly tired
<75
TB - silica disrupt phagolysosomes and impair MACS
Bicarb (90%) - bound to globin (5%) and dissolved (5%)

50. What does pulm HTN result in
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
Upper lobes - cor pulmonale - caplan's syndrome
<75
Tissue hypoxia from dec O2 sat and dec O2 content