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Respiratory

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Answer 50 questions in 15 minutes.
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1. What causes primary pulm HTN
More indolent
No change - but inc venous CO2 content
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis

2. What are the findings associated with sarcoidosis
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals
Inc EPO leading to erythrocytosis
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

3. What are the 3 forms that CO2 is transported from tissues to lungs
P = 2ST/radius
Respiratory bronchioles - clear debris in alveoli - bronchi
Bicarb (90%) - bound to globin (5%) and dissolved (5%)
Airways close prematurely resulting in inc RV and dec FVC

4. What organism causes a lobar PNA and What are the characteristics
Deoxygenated blood - elastic walls
PVR = (PpulmA - PleftA)/CO
Prostaglandins - histamine - ACE - kallikrein
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung

5. Peripheral mass develops in site of prior pulmonary inflammation or injury - cancer and epi
Inc O2 consumption
Everything but RV - TV + IRV + ERV
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers

6. What is the protein content in a transudative pleural effusion and What are the potential causes
Inc to meet O2 demand
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
<75

7. What is the ideal V/Q ratio and why
Methylene blue
DIC - especially postpartum
Matched - =1 adequate gas exchange
Air that can still be breathed out after nl expiration

8. What are potential triggers for asthma
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Dipalmatoyl phosphatidylcholine - decreases surface tension
Tension pneumo - away from lesion
Viral - URIs - allergens and stress

9. What changes in ventilation rate occur during exercise
PA02 = 150 - PACO2/0.8
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Inc to meet O2 demand
IRV + TV + ERV + RV

10. What is the fxn of the conducting zone
Tension pneumo - away from lesion
Lowered
Brings air in and out - warms - humidifies - filters
Everything but RV - TV + IRV + ERV

11. What spinal nerves innvervate the diaphragm and where can pain from the diaphragm be referred
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
N- terminus - carbaminohemoglobin
In between perfusion limited and diffusion limited

12. If you aspirate a peanut while supine - where will it go
Alpha1- antitrypsin def - also cirrhosis
Pa > PA > Pv
PA02 = 150 - PACO2/0.8
Superior portion of right inferior lobe

13. What is a chronic complication of sleep apnea
Methylene blue
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types
Mismatch
Chroniclly tired

14. What is the diffustion formula and what happens to the variables in emphysema and pulmonary fibrosis
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
RALS - righ anterior - left superior
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Respiratory bronchioles - clear debris in alveoli - bronchi

15. What is the equation for physiologic dead space
Inc
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
In between perfusion limited and diffusion limited
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude

16. What is the most common cancerous lesion in the lun
Metastasis - breast - colon - prostate - bladder -
Inc O2 consumption
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism

17. How much O2 can 1 g of Hb bind - What is nl Hb in the blood and When does cyanosis happen
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
Shunting
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
PAO2 - PaO2 = 10-15 mmHg

18. What is the airway and alveolar pressure at FRC - What is the intrapleural pressure - and What does that prevent
Acetazolamide - inhibits CA and acidifies the blood
0 - negative - prevents pneumothorax
Hyaline membrane disease
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism

19. Why do pts with emphysema exhale through pursed lips
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Methacholine challenge
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
Inc airway pressure to prevent airway collapse during exhalation

20. What organisms cause interstitial PNA and What are the characteristics
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Inc 2 -3- DPG - righward shift
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes

21. What are fat emboli associated with
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
Lobar PNA
Long bone fractures and liposuction

22. What do type II cells do - What is their morphology - when do they proliferate
Right
Lowered
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage
Right lung - right main stem bronhus is wider and more vertical

23. 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)
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Air that can still be breathed out after nl expiration
Inspiration by diaphragm - expiration is passive

24. Why is cesarean delivery a risk factor for neonatal RDS
Elastase
Dec release of fetal glucocorticoids
Zone 1
Matched - =1 adequate gas exchange

25. What cells make surfactant and At what week is produced most abundantly
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Methylene blue
Type II pneumocytes - after week 35
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma

26. What is early onset hypoxemia from in chronic bronchitis
Shunting
Bleomycin - busulfan - anmiodorone
IRV + TV
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage

27. Where does exercise sit on the graph of PaO2 vs length along the pulm capillary
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
CO x O2 content of blood
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
In between perfusion limited and diffusion limited

28. What happens in perfusion limited circulatioin and which gases does this apply to...
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
Hyaline membrane disease

29. What direction does an increase in metabolic need shift the O2 dissociation curve
Right
Deoxygenated blood - elastic walls
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
20.1 mL O2 /dL

30. What are the findings in asthma
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Metastasis - breast - colon - prostate - bladder -
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Lost with alveolar walls

31. Lung cancer in peripheral reason - highly anaplastic - undifferentiated tumor - cancer - histo - TX
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
Type II pneumocytes - after week 35
Bronchial obstruction - toward side of lesion

32. Chronic bronchitis is a disease of what kind of airways
Inc shear stress leading to endothelial injury
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Productive cough for greater than 3 months in at least 2 years
Small airways

33. What do pulmonary arteries carry - and how are pulm arterial pressures maintained during the cardiac cycle
Methylene blue
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Deoxygenated blood - elastic walls
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary

34. At what PaO2 does cyanosis begin
Acute/chronic inc in vent
<60
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males

35. What reaction and enzyme create bicarb and Where does it happen
FEV1/FVC > 80%
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
RV + ERV - volume in lungs after nl expiration
Hyaline membrane disease

36. If you aspirate a peanut while upright - where will it go
Lower portion of right inferior lobe
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
Alchoholics or epileptics

37. Define expiratory reserve volume (ERV)
Drainage
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Both highest in the base
Air that can still be breathed out after nl expiration

38. What is the formula for collapsing pressure
In between perfusion limited and diffusion limited
Upper lobes - cor pulmonale - caplan's syndrome
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
P = 2ST/radius

39. What changes in O2 consumption change during exercise
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Inc O2 consumption

40. What does pulm HTN result in
20.1 mL O2 /dL
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
Lungs collapse inwards and chest wall spring out
Inc resistance leading to inc pressure

41. What is the nl form of iron in hemoglobin
PVR = (PpulmA - PleftA)/CO
Fe 2+
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
Incr - right - dec - left

42. Eggshell calcificant of hilar lymph nodes - associtated with foundries - sandblasting and mines - pneumoconioses and path
Drainage
Inc
CO - 200x
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis

43. What kind of connection exists between endothelial cells in the capilaries
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Tissue hypoxia from dec O2 sat and dec O2 content
Tight jxns

44. What happens with the O2 curve shifts to the right and What does it facilitate
Stasis - hypercoagulability - endothelial damage
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
Activates bradykinin

45. Which lung is the more common site for an inhaled foreign body and why
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
P = 2ST/radius
Right lung - right main stem bronhus is wider and more vertical

46. What increases the risk of PDA in neonatal RDS
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
N- terminus - carbaminohemoglobin
Persistently low O2 tension
Superior portion of right inferior lobe

47. At what lung volume is system pressure atmospheric and why
FRC - inward pull of lung balanced by outward pull of chest wall
TB - silica disrupt phagolysosomes and impair MACS
Brings air in and out - warms - humidifies - filters
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc

48. What is methemoglobin
Ivory white calcified pleural plaques
More indolent
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy

49. What is positive cooperativity of hemoglobin refer to...
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Histiocytosis X - Langerhans cells
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound

50. What is used to treat CN poisoning and why
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
PA02 = 150 - PACO2/0.8
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
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

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