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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 SPHERE of complications in lung cancer
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Methylene blue
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale

2. What organisms cause interstitial PNA and What are the characteristics
RALS - righ anterior - left superior
Tissue hypoxia from dec O2 sat and dec O2 content
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

3. Susceptibility to what infection is increased in silicosis and why
Long bone fractures and liposuction
Anatomic dead space and smooth muscle
Right lung - right main stem bronhus is wider and more vertical
TB - silica disrupt phagolysosomes and impair MACS

4. What are the histological findings in asbestosis and what occupations are associated
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
Lower portion of right inferior lobe

5. What is used to treat CN poisoning and why
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
Productive cough for greater than 3 months in at least 2 years
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Air in lung after maxmimal expiration - cannot be measured on spirometry

6. What kind of emphysema is caused by smoking
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Centriacinar
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration

7. What are the causes of ischemia
Low resistance and high compliance
Loss of blood flow - impeded arterial flow - reduced venous drainage
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-

8. What effects do O2 and CO2 have on pulm circulation - in relation to the other
Gland depth/total thickness of broncial wall - >50%
Airways close prematurely resulting in inc RV and dec FVC
Inc
Opposites

9. What are the findings of chronic bronchitis
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Dec - because physiologic shunt dec O2 extraction from ratio
Dec in lung volumes - FVC - TLC
O2 binding x O2 sat + dissolved O2

10. Chronic bronchitis is a disease of what kind of airways
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Small airways
Inc production
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)

11. Where does exercise sit on the graph of PaO2 vs length along the pulm capillary
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
In between perfusion limited and diffusion limited
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Prostaglandins - histamine - ACE - kallikrein

12. What is central sleep apnea
Incr - right - dec - left
No respiratory effort
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Right shift - favors taut - low affinity for O2 - O2 unloading

13. What changes in lung volunes occur as a result of restrictive lung disease
CO x O2 content of blood
Dec in lung volumes - FVC - TLC
RALS - righ anterior - left superior
Dec

14. How is pulmonary circulation characterized in terms of resistance and compliance
Low resistance and high compliance
It binds to Hb -
Fe 2+
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12

15. Peripheral mass develops in site of prior pulmonary inflammation or injury - cancer and epi
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
Methacholine challenge
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Inc to meet O2 demand

16. Which structures perforate the diaphragm and where
In between perfusion limited and diffusion limited
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

17. What is early onset hypoxemia from in chronic bronchitis
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
Shunting

18. At what lung volume is system pressure atmospheric and why
FRC - inward pull of lung balanced by outward pull of chest wall
Lost with alveolar walls
Squamous cell carcinoma - keratin pearls and intracellular bridges
Retinopathy of maturity

19. What spinal nerves innvervate the diaphragm and where can pain from the diaphragm be referred
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Inc 2 -3- DPG - righward shift

20. What is the characteristic lymphatic pleural effusion
Deoxygenated blood - elastic walls
PAO2 - PaO2 = 10-15 mmHg
Milky fluid with inc TGs
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-

21. Eggshell calcificant of hilar lymph nodes - associtated with foundries - sandblasting and mines - pneumoconioses and path
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
Inc mitochondria

22. Why is there eventual loss of capillary beds in emphysema
Lost with alveolar walls
PAO2 - PaO2 = 10-15 mmHg
RV + ERV - volume in lungs after nl expiration
Alpha1- antitrypsin def - also cirrhosis

23. What is the relation fo the pulmonary artery to the bronchus at each lung hilus
Dec - because physiologic shunt dec O2 extraction from ratio
RALS - righ anterior - left superior
Hypoxic vasocxn
Dipalmatoyl phosphatidylcholine - decreases surface tension

24. What is an example of hypercoagulability
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
<60
Defect in coagulative cascace proteins

25. How far to the pseudostratified ciliated columnar epithelium extend - What do MACS do in the alveoli - and how far do the goblet cells extend
Fe 2+
Retinopathy of maturity
Respiratory bronchioles - clear debris in alveoli - bronchi
Inc shear stress leading to endothelial injury

26. What lung abnl is characterized by absent or decreased breath sounds over affected area - dec resonance - dec fremitus - and which side is the trachea deviated towards
Matched - =1 adequate gas exchange
Bronchial obstruction - toward side of lesion
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Airways close prematurely resulting in inc RV and dec FVC

27. What is another name for neonatal RDS
No change - but inc venous CO2 content
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Hyaline membrane disease
Inc mitochondria

28. How much O2 can 1 g of Hb bind - What is nl Hb in the blood and When does cyanosis happen
Inc mitochondria
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
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers

29. What is the ideal V/Q ratio and why
Loss of elastic fibers
Matched - =1 adequate gas exchange
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Inc resistance leading to inc pressure

30. What is occupied in the space that would have been the left middle lobe
Surfactant
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Heart
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest

31. What changes occur to pulm blood flow during exercise
Fe 2+
Prematurity - maternal RDS - cesarean delivery
Inc due to inc CO
L/S > 2 = lecithin/sphingomyelin

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

33. Why is endothelial damage a risk factor for DVT
Right
Exposed collagen fibers provides impetus for clotting cascade
Prostaglandins - histamine - ACE - kallikrein
Drainage

34. What properties determine the combined volumes of the chest wall and lungs
Steroids to mom - artificial surfactant and thyroxine to neonate
Elastic properties
Inc shear stress leading to endothelial injury
Both highest in the base

35. What is the protein content an exudative pleural effusion and What are the potential causes
Air in lung after maxmimal expiration - cannot be measured on spirometry
Lung cancer
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Ratio from apex to base becomes more uniform

36. Synthesis of what substance increases with altitude and What does that do for the O2 sat curve
Histiocytosis X - Langerhans cells
Inc 2 -3- DPG - righward shift
In between perfusion limited and diffusion limited
FEV1/FVC > 80%

37. What lung product is deficient in neonatal RDS
Surfactant
FRC - inward pull of lung balanced by outward pull of chest wall
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Dec - no change

38. What causes neonatal RDS
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Surfactant def leading to inc surfact tension and alveolar collapse
Surfactant
Centriacinar

39. What is methemoglobin
Person stops breathing for at least 10 seconds repeatedly during sleep
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Inspiration by diaphragm - expiration is passive

40. What happens to O2 content and O2 sat as Hb falls
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Dec - no change
Incr - right - dec - left
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude

41. What are mucus secretion swept out by
Inc resistance leading to inc pressure
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Ciliated cells
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung

42. What does a V/Q ratio of infinity indicate
Methacholine challenge
Bleomycin - busulfan - anmiodorone
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals

43. What renal changes occur at high altitude and What are they compensating for
Inc excretion of bicarb to compensate for respiratory alkalosis
Inc mitochondria
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals

44. Which muscles are involved in quiet breathing and What part of respiration do the control
Alchoholics or epileptics
Exposed collagen fibers provides impetus for clotting cascade
Inspiration by diaphragm - expiration is passive
Dec release of fetal glucocorticoids

45. What is obstructive sleep apnea
PA02 = 150 - PACO2/0.8
Respiratory effort against airway obstruction
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Airway obstruction (shunt) 100% O2 does not improve PO2

46. Define total lung capcaity
IRV + TV + ERV + RV
No change - but inc venous CO2 content
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways

47. Lung cancer in peripheral reason - highly anaplastic - undifferentiated tumor - cancer - histo - TX
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
Metastasis - breast - colon - prostate - bladder -
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-

48. What does each bronchopulmonary segment have in the center and along its border
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
IRV + TV
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-

49. Where do 95% of PE arise from
Elastase
Deep leg veins
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
Stasis - hypercoagulability - endothelial damage

50. What is the fxn of the conducting zone
Dipalmatoyl phosphatidylcholine
Chest pain - tachypnea and dyspnea
CO2 - acid/altitude - DPG - Exercise - Temperature
Brings air in and out - warms - humidifies - filters