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Respiratory

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Answer 50 questions in 30 minutes.
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1. What accounts for the sigmoid shaped O2 dissociation curve with hemoglobin
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Surfactant
O2 binding x O2 sat + dissolved O2
Positive cooperativity and negative allostery - unlike myoglobin

2. What organisms cause a bronchoPNA and What are the characteristics
Heparin
Persistently low O2 tension
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor

3. What is the airway and alveolar pressure at FRC - What is the intrapleural pressure - and What does that prevent
0 - negative - prevents pneumothorax
Coal miner's - silicosis - abestosis
Acute/chronic inc in vent
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity

4. What are the 9 interstitial lung diseases

5. What is early onset hypoxemia from in chronic bronchitis
Trachea and bronchi
Air in lung after maxmimal expiration - cannot be measured on spirometry
Inc EPO leading to erythrocytosis
Shunting

6. In emphysema - What is increased lung compliance due to...
Alchoholics or epileptics
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Loss of elastic fibers
Dec release of fetal glucocorticoids

7. What are the causes of ischemia
Loss of blood flow - impeded arterial flow - reduced venous drainage
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Hypoxic vasocxn
Pa > PA > Pv

8. What is an example of hypercoagulability
Defect in coagulative cascace proteins
Productive cough for greater than 3 months in at least 2 years
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Long bone fractures and liposuction

9. What cellular changes occur at high altitude
Inc mitochondria
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
Surfactant def leading to inc surfact tension and alveolar collapse
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

10. What is the leading cause of cancer death
Ivory white calcified pleural plaques
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
P = 2ST/radius
Lung cancer

11. What lobes are affected in silicosis
Upper lobes
Methacholine challenge
Dec
0 - negative - prevents pneumothorax

12. What is a typical tidal volume
Metastasis - breast - colon - prostate - bladder -
Zone 1
500mL
Inspiration by diaphragm - expiration is passive

13. What kind of course does interstitial PNA follow in comparison to bronchoPNA
Repeated cycles of lung injury and wound healing with inc collagen
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Loss of blood flow - impeded arterial flow - reduced venous drainage
More indolent

14. How is pulmonary circulation characterized in terms of resistance and compliance
Pa > PA > Pv
PVR = (PpulmA - PleftA)/CO
Low resistance and high compliance
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes

15. 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
On expiration as radius dec
Pa > PA > Pv
Bronchial obstruction - toward side of lesion
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy

16. How many lobes does each lung have - and What is the lingula
Inc
Tight jxns
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Gland depth/total thickness of broncial wall - >50%

17. What does pulm HTN result in
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
IRV + TV + ERV + RV
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries

18. In which zone of the lung is Pa > Pv >PA
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Stasis - hypercoagulability - endothelial damage
Dipalmatoyl phosphatidylcholine - decreases surface tension
Zone 3

19. What do type II cells do - What is their morphology - when do they proliferate
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage
S. aureus or anaerobes
Small airways
Dec release of fetal glucocorticoids

20. What must occur with a exudate pleural effusion
Metastasis - breast - colon - prostate - bladder -
Drainage
Inc excretion of bicarb to compensate for respiratory alkalosis
Hyaline membrane disease

21. How does left to right shunt cause pulm HTN
Air in excess of tidal volume that moves into lung on maximal inspiration
Inc shear stress leading to endothelial injury
Pa > PA > Pv
Matched - =1 adequate gas exchange

22. What does the oxygenation of Hb in the lungs do to the equilibirum of the CA rxn
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Dorsiflexion of food leads to tender calf muscle

23. Why is endothelial damage a risk factor for DVT
Exposed collagen fibers provides impetus for clotting cascade
Carcinoid - carcinoid
Inoperable - responsive to chemotherapy
Dec in the FEV1/FVC

24. What is the equation for physiologic dead space
0 - negative - prevents pneumothorax
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude

25. Define vital capacity (VC)
Dec in lung volumes - FVC - TLC
Bicarb/Cl - exchanger - brings a Cl - into the RBC and expels bicarb into the serum
Dec in the FEV1/FVC
Everything but RV - TV + IRV + ERV

26. What happens to V/Q ratio in COPD
Viral - URIs - allergens and stress
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Lost with alveolar walls
Mismatch

27. Why do pts with emphysema exhale through pursed lips
Inc production
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Air in lung after maxmimal expiration - cannot be measured on spirometry
Inc airway pressure to prevent airway collapse during exhalation

28. What does the conducting zone consist of...
Surfactant def leading to inc surfact tension and alveolar collapse
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
Dec - because physiologic shunt dec O2 extraction from ratio

29. Where does lung cancer met to...
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
Dec dec in FEV1 - dec in FVC
Mesothelioma - pleura - psammoma bodies
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy

30. increases In what substances favor the taut form of hemoglobin and which direction does that shift the O2 dissociation curve
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
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Dec - no change
Bicarb/Cl - exchanger - brings a Cl - into the RBC and expels bicarb into the serum

31. What is the order of decreasing pressures among the alveola - capillaries and veins in zone 2 of the lungs
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Pa > PA > Pv
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Inoperable - responsive to chemotherapy

32. Hilar mass arising from the bronchus; cavitation - hx of smoking - PTHRP - cancer and histo
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Squamous cell carcinoma - keratin pearls and intracellular bridges
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Stasis - hypercoagulability - endothelial damage

33. Lung cancer in peripheral reason - highly anaplastic - undifferentiated tumor - cancer - histo - TX
0 - negative - prevents pneumothorax
Right lung - right main stem bronhus is wider and more vertical
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

34. What is the pathology of chronic bronchitis
Hypertrophy of mucus secreting glands in the bronchioles
Anatomic dead space and smooth muscle
0 - negative - prevents pneumothorax
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange

35. What is tha hallmark finding of COPD
Dec in the FEV1/FVC
Dec - no change
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Positive cooperativity and negative allostery - unlike myoglobin

36. What is surfactant made of...
Tissue hypoxia from dec O2 sat and dec O2 content
Matched - =1 adequate gas exchange
Dipalmatoyl phosphatidylcholine
More indolent

37. What does each bronchopulmonary segment have in the center and along its border
Heparin
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Low resistance and high compliance
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right

38. What is the TX for small cell lung cancer
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
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
Inoperable - responsive to chemotherapy
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed

39. Where do you find type I cells - What is their morphology - and What do they do
Superior portion of right inferior lobe
PVR = (PpulmA - PleftA)/CO
Dipalmatoyl phosphatidylcholine - decreases surface tension
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange

40. An increase in all things (except pH) causes what shift in the O2 curve - What does a decrease in all things (except pH) cause
No change - but inc venous CO2 content
Inc
Incr - right - dec - left
Dec

41. What happens to diffusing capacity in interstiial lung diseases
Lowered
High alveolar pressure compresses capillaries
Lost with alveolar walls
Inc mitochondria

42. What happens to arterial PO2 in chronic lung disease and why
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
CO - 200x
Dec - because physiologic shunt dec O2 extraction from ratio
Steroids to mom - artificial surfactant and thyroxine to neonate

43. What do PFTs show in restrictive lung disease
Both highest in the base
Upper lobes
500mL
FEV1/FVC > 80%

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

45. Define tidal volume (TV)
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Air that moves into lung with each quiet respiration
Dipalmatoyl phosphatidylcholine - decreases surface tension
Inc shear stress leading to endothelial injury

46. 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
Inc
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Carcinoid - carcinoid
High alveolar pressure compresses capillaries

47. What happens in perfusion limited circulatioin and which gases does this apply to...
Inc resistance leading to inc pressure
Lobar PNA
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc

48. What are the risk factors for neonatal RDS
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Prematurity - maternal RDS - cesarean delivery
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung

49. What is the presentation of lung cancer

50. Which pts are at risk for apriation PNA
Alchoholics or epileptics
Fe 2+
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc

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Respiratory

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