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Respiratory

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. What does the respiratory zone consist of and What is its fxn
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Airway obstruction (shunt) 100% O2 does not improve PO2
Gland depth/total thickness of broncial wall - >50%
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema

2. What are the associations with bronchiectasis

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3. Hilar mass arising from the bronchus; cavitation - hx of smoking - PTHRP - cancer and histo
Squamous cell carcinoma - keratin pearls and intracellular bridges
Milky fluid with inc TGs
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
0 - negative - prevents pneumothorax

4. What is the characteristic lymphatic pleural effusion
Alchoholics or epileptics
Dorsiflexion of food leads to tender calf muscle
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
Milky fluid with inc TGs

5. What drug therapy is used to augment the changes in bicarb exretion
Dec - because physiologic shunt dec O2 extraction from ratio
Acetazolamide - inhibits CA and acidifies the blood
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
High alveolar pressure compresses capillaries

6. What direction does an increase in metabolic need shift the O2 dissociation curve
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Right
Elastase
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death

7. What kind of emphysema is caused by smoking
Dec in the FEV1/FVC
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Dec dec in FEV1 - dec in FVC
Centriacinar

8. What is the formula for O2 content
O2 binding x O2 sat + dissolved O2
Dipalmatoyl phosphatidylcholine - decreases surface tension
On expiration as radius dec
Dipalmatoyl phosphatidylcholine

9. What is the V/Q ratio at the apex and base of the lung
Defect in coagulative cascace proteins
Activates bradykinin
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy

10. How much O2 can 1 g of Hb bind - What is nl Hb in the blood and When does cyanosis happen
Methylene blue
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
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

11. What is the tendency of the lungs vs the chest wall
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Pleural effusion
Lungs collapse inwards and chest wall spring out
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2

12. Why is there eventual loss of capillary beds in emphysema
Mismatch
Lost with alveolar walls
Pleural effusion
Right

13. What does CADET face to the right stand for
Airway obstruction (shunt) 100% O2 does not improve PO2
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
CO2 - acid/altitude - DPG - Exercise - Temperature
Hypoxic vasocxn

14. Malignancy associated with asbestosis - results in hemorrhagic effusions and pleural thickening - cancer - location - histo finding
Mesothelioma - pleura - psammoma bodies
Dec dec in FEV1 - dec in FVC
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Inc production

15. What is the main complication of therapeutic supplemental O2?
Inc resistance leading to inc pressure
P = 2ST/radius
Retinopathy of maturity
Dipalmatoyl phosphatidylcholine

16. Which lung is the more common site for an inhaled foreign body and why
Right lung - right main stem bronhus is wider and more vertical
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
No change - but inc venous CO2 content

17. What reaction and enzyme create bicarb and Where does it happen
Dorsiflexion of food leads to tender calf muscle
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning

18. What changes in 2 -3 - DPG occur at high altitude
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Shunting
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

19. What is the cycle of idiopathic pulmonary fibrosis
Inc O2 consumption
Repeated cycles of lung injury and wound healing with inc collagen
Inoperable - responsive to chemotherapy
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types

20. What changes in CO2 occur during exercise
RALS - righ anterior - left superior
Inc production
Methylene blue
Right

21. What area of the lung is the largest physiologic contributor of fxnal dead space
Apex of healthy lung
IRV + TV + ERV + RV
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly

22. What is the equation for physiologic dead space
Methacholine challenge
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Dorsiflexion of food leads to tender calf muscle
Air in lung after maxmimal expiration - cannot be measured on spirometry

23. What does a V/Q ratio of infinity indicate
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Steroids to mom - artificial surfactant and thyroxine to neonate
Lung cancer
Dipalmatoyl phosphatidylcholine - decreases surface tension

24. How does left to right shunt cause pulm HTN
Airways close prematurely resulting in inc RV and dec FVC
Air in lung after maxmimal expiration - cannot be measured on spirometry
Inc shear stress leading to endothelial injury
Chest pain - tachypnea and dyspnea

25. What is the appoximate O2 binding capacity
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
20.1 mL O2 /dL
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Stasis - hypercoagulability - endothelial damage

26. What is a particular cause of eosinophilic granulomas - and what cells infiltrate
Gland depth/total thickness of broncial wall - >50%
Acute/chronic inc in vent
N- terminus - carbaminohemoglobin
Histiocytosis X - Langerhans cells

27. What ratio is used to measure lung maturity and What is the value is neonatal RDS
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
Ratio from apex to base becomes more uniform
L/S < 1.5
Type II cells

28. What does the conducting zone consist of...
High alveolar pressure compresses capillaries
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
RALS - righ anterior - left superior
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation

29. Where are ventilation and perfusion highest in the lung - respectively
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Both highest in the base
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging

30. What is the pathology of emphysema
Dec - due to lactic acidosis
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
PA02 = 150 - PACO2/0.8
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)

31. What is methemoglobin
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
L/S < 1.5
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater

32. Which structures perforate the diaphragm and where
Acute/chronic inc in vent
Dec - because physiologic shunt dec O2 extraction from ratio
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2

33. Which has a greater affinity for hemoglobin - CO or O2 and by how much
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
CO - 200x

34. What are the 9 interstitial lung diseases

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35. What cellular changes occur at high altitude
Dec - due to lactic acidosis
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia
Inc mitochondria

36. Synthesis of what substance increases with altitude and What does that do for the O2 sat curve
PVR = (PpulmA - PleftA)/CO
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
Inc 2 -3- DPG - righward shift
Prematurity - maternal RDS - cesarean delivery

37. What are potential triggers for asthma
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Viral - URIs - allergens and stress
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-

38. How far to the pseudostratified ciliated columnar epithelium extend - What do MACS do in the alveoli - and how far do the goblet cells extend
Respiratory bronchioles - clear debris in alveoli - bronchi
Incr - right - dec - left
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage

39. What is the protein content in a transudative pleural effusion and What are the potential causes
IRV + TV + ERV + RV
Hypertrophy of mucus secreting glands in the bronchioles
Chroniclly tired
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis

40. What is used to treat CN poisoning and why
No respiratory effort
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
Type II pneumocytes - after week 35
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles

41. What lung product is deficient in neonatal RDS
Surfactant
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Mesothelioma - pleura - psammoma bodies

42. What organism causes a lobar PNA and What are the characteristics
In between perfusion limited and diffusion limited
Matched - =1 adequate gas exchange
P = 2ST/radius
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung

43. What changes in V/Q throughout the lung during exercise
Lowered
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
Ratio from apex to base becomes more uniform
Inc production

44. What changes occur to pulm blood flow during exercise
Stasis - hypercoagulability - endothelial damage
Opposites
Hypertrophy of mucus secreting glands in the bronchioles
Inc due to inc CO

45. What are the findings of chronic bronchitis
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Persistently low O2 tension
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Superior portion of right inferior lobe

46. What happens as a result of hypoxia in sleep apnea
Pleural effusion
Inc EPO leading to erythrocytosis
Inc 2 -3- DPG - righward shift
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis

47. Define inspiratory capacity (IC)
Drainage
Matched - =1 adequate gas exchange
IRV + TV
Hyaline membrane disease

48. In which zone of the lung is PA > Pa > Pv
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Zone 1
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
Shunting

49. What is are the symptoms of a pulmonary embolism
Chest pain - tachypnea and dyspnea
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents

50. What lung abnl is associated with bronchial breath sounds over lesion - dullness and increased fremitus
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
Lobar PNA
No change - but inc venous CO2 content
Dipalmatoyl phosphatidylcholine