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Respiratory

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1. What are the 3 forms that CO2 is transported from tissues to lungs
Carcinoid - carcinoid
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
Deep leg veins
Bicarb (90%) - bound to globin (5%) and dissolved (5%)

2. What happens as a result of hypoxia in sleep apnea
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
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
Inc EPO leading to erythrocytosis
Lungs collapse inwards and chest wall spring out

3. How is pulmonary circulation characterized in terms of resistance and compliance
Inspiration by diaphragm - expiration is passive
Low resistance and high compliance
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
N- terminus - carbaminohemoglobin

4. What changes at high altitude can result in RVH
Everything but RV - TV + IRV + ERV
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Chronic hypoxic vasocxn
N- terminus - carbaminohemoglobin

5. What does the conducting zone consist of...
Milky fluid with inc TGs
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Chroniclly tired
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG

6. At what PaO2 does cyanosis begin
Brings air in and out - warms - humidifies - filters
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
<60
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2

7. What organisms cause a bronchoPNA and What are the characteristics
FEV1/FVC > 80%
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Alpha1- antitrypsin def - also cirrhosis

8. What is a chronic complication of sleep apnea
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Everything but RV - TV + IRV + ERV
Chroniclly tired

9. What is the leading cause of cancer death
Deoxygenated blood - elastic walls
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Apex of healthy lung
Lung cancer

10. What are the findings associated with sarcoidosis
500mL
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Type II cells
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium

11. What is the formula for oxygen delivery to tissues
Air that can still be breathed out after nl expiration
Coal miner's - silicosis - abestosis
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
CO x O2 content of blood

12. What is the formula for O2 content
O2 binding x O2 sat + dissolved O2
Stasis - hypercoagulability - endothelial damage
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
<60

13. What changes in V/Q throughout the lung during exercise
Ciliated cells
FEV1/FVC > 80%
Ratio from apex to base becomes more uniform
Air in lung after maxmimal expiration - cannot be measured on spirometry

14. What is the tendency of the lungs vs the chest wall
FRC - inward pull of lung balanced by outward pull of chest wall
Long bone fractures and liposuction
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
Lungs collapse inwards and chest wall spring out

15. Define functional residual capacity (FRC)
RV + ERV - volume in lungs after nl expiration
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Type II pneumocytes - after week 35

16. What lung abnl is associated with bronchial breath sounds over lesion - dullness and increased fremitus
Lobar PNA
Shed epithelium from mucus plugs
Inc to meet O2 demand
L/S > 2 = lecithin/sphingomyelin

17. What must occur with a exudate pleural effusion
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Mesothelioma - pleura - psammoma bodies
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Drainage

18. What happens with the O2 curve shifts to the right and What does it facilitate
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Long bone fractures and liposuction
Histiocytosis X - Langerhans cells
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue

19. What accounts for the sigmoid shaped O2 dissociation curve with hemoglobin
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Positive cooperativity and negative allostery - unlike myoglobin
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Lower portion of right inferior lobe

20. What is the pathology of asthma

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21. Define inspiratory reserve volume (IRV)
Air in excess of tidal volume that moves into lung on maximal inspiration
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
Tight jxns

22. What is used to treat CN poisoning and why
Prematurity - maternal RDS - cesarean delivery
Mesothelioma - pleura - psammoma bodies
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
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

23. What happens to arterial PO2 in chronic lung disease and why
Tissue hypoxia from dec O2 sat and dec O2 content
Dec - because physiologic shunt dec O2 extraction from ratio
Superior portion of right inferior lobe
Bronchial obstruction - toward side of lesion

24. What kind of space is in the conducting tree and what kind of muscle exists there
Anatomic dead space and smooth muscle
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
Tight jxns
Long bone fractures and liposuction

25. What do PFTs show in restrictive lung disease
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
FEV1/FVC > 80%
Lungs collapse inwards and chest wall spring out
S. aureus or anaerobes

26. What are the lab/study findings in adenocarcinoma of the lung
Productive cough for greater than 3 months in at least 2 years
Right shift - favors taut - low affinity for O2 - O2 unloading
Steroids to mom - artificial surfactant and thyroxine to neonate
Clara cells - type II pneumocytes; multiple densitites on CXR

27. What does each bronchopulmonary segment have in the center and along its border
Inc excretion of bicarb to compensate for respiratory alkalosis
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis

28. What changes occur to PaO2 and PaCO2
Steroids to mom - artificial surfactant and thyroxine to neonate
It binds to Hb -
No change - but inc venous CO2 content
RV + ERV - volume in lungs after nl expiration

29. What are the causes of hypoxia
Inc airway pressure to prevent airway collapse during exhalation
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning

30. What are potential triggers for asthma
Viral - URIs - allergens and stress
TB - silica disrupt phagolysosomes and impair MACS
Lower portion of right inferior lobe
Methacholine challenge

31. What is a consequence of pulm HTN
S. aureus or anaerobes
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Heparin

32. In COPD - what happens to airways at high lung volumes
Airways close prematurely resulting in inc RV and dec FVC
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
C3 - 4 - 6 - phrenic nerve - referred to shoulder

33. What happens to O2 content and O2 sat as Hb falls
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
20.1 mL O2 /dL
Dec - no change
L/S > 2 = lecithin/sphingomyelin

34. What is the diffustion formula and what happens to the variables in emphysema and pulmonary fibrosis
Heart
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Deoxygenated blood - elastic walls

35. What area of the lung is the largest physiologic contributor of fxnal dead space
PVR = (PpulmA - PleftA)/CO
Apex of healthy lung
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Dec in lung volumes - FVC - TLC

36. Why is cesarean delivery a risk factor for neonatal RDS
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
<75
Dec release of fetal glucocorticoids

37. Other than surfactant - what other important substances are produced by the lungs
PA02 = 150 - PACO2/0.8
Prostaglandins - histamine - ACE - kallikrein
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc

38. What are the subtypes of pneumoconioses

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39. What happens to lung volumes in obstructive lung disease
Superior portion of right inferior lobe
Ivory white calcified pleural plaques
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Inc

40. 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
Persistently low O2 tension
Methylene blue
Zone 3

41. What is the characteristic lymphatic pleural effusion
Milky fluid with inc TGs
Acetazolamide - inhibits CA and acidifies the blood
Carcinoid - carcinoid
Chroniclly tired

42. What layers must CO2 and O2 traverse to complete gas exchange
Heparin
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
<60

43. What is the appoximate O2 binding capacity
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Inc airway pressure to prevent airway collapse during exhalation
Fe 2+
20.1 mL O2 /dL

44. What happens to diffusing capacity in interstiial lung diseases
Airways close prematurely resulting in inc RV and dec FVC
Lowered
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
Air that moves into lung with each quiet respiration

45. What does the oxygenation of Hb in the lungs do to the equilibirum of the CA rxn
Prematurity - maternal RDS - cesarean delivery
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest

46. What is the order of decreasing pressures among the alveola - capillaries and veins in zone 2 of the lungs
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Pa > PA > Pv

47. At what PaO2 does hypoxemia begin
Surfactant def leading to inc surfact tension and alveolar collapse
Centriacinar
<75
Chest pain - tachypnea and dyspnea

48. Define physilogic dead space
L/S < 1.5
Low resistance and high compliance
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli

49. Lung cancer in peripheral reason - highly anaplastic - undifferentiated tumor - cancer - histo - TX
Repeated cycles of lung injury and wound healing with inc collagen
Surfactant def leading to inc surfact tension and alveolar collapse
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy

50. What properties determine the combined volumes of the chest wall and lungs
S. aureus or anaerobes
Elastic properties
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing

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