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Respiratory

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Answer 50 questions in 15 minutes.
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1. If you aspirate a peanut while upright - where will it go
Lower portion of right inferior lobe
Person stops breathing for at least 10 seconds repeatedly during sleep
<75
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis

2. What is compliance and When is it decrease
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
C3 - 4 - 6 - phrenic nerve - referred to shoulder

3. What is the TX for small cell lung cancer
It binds to Hb -
Airways close prematurely resulting in inc RV and dec FVC
Inoperable - responsive to chemotherapy
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers

4. What are curschmann's spirals
TB - apex
L/S < 1.5
Shed epithelium from mucus plugs
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)

5. What is a chronic complication of sleep apnea
Chroniclly tired
Pleural effusion
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Long bone fractures and liposuction

6. What does kallikrein do
Inc EPO leading to erythrocytosis
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals
Tight jxns
Activates bradykinin

7. An increase in all things (except pH) causes what shift in the O2 curve - What does a decrease in all things (except pH) cause
<60
Incr - right - dec - left
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Milky fluid with inc TGs

8. What are the two forms of hemoglobin
Inc resistance leading to inc pressure
Squamous cell carcinoma - keratin pearls and intracellular bridges
Chronic hypoxic vasocxn
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)

9. What is the formula for O2 content
Dec cross sectional area of pulm vasc bed
Air in lung after maxmimal expiration - cannot be measured on spirometry
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
O2 binding x O2 sat + dissolved O2

10. What is a consequence of pulm HTN
Dec - because physiologic shunt dec O2 extraction from ratio
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Dec dec in FEV1 - dec in FVC

11. What changes in V/Q throughout the lung during exercise
Defect in coagulative cascace proteins
Pleural effusion
Ratio from apex to base becomes more uniform
Inc resistance leading to inc pressure

12. What happens as a result of hypoxia in sleep apnea
Tissue hypoxia from dec O2 sat and dec O2 content
Inc EPO leading to erythrocytosis
Lower portion of right inferior lobe
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers

13. What is the ideal V/Q ratio and why
Matched - =1 adequate gas exchange
Stasis - hypercoagulability - endothelial damage
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-

14. What is Homan's sign
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
Dorsiflexion of food leads to tender calf muscle
Inoperable - responsive to chemotherapy

15. What reaction and enzyme create bicarb and Where does it happen
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
S. aureus or anaerobes
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-

16. What is the protein content in a transudative pleural effusion and What are the potential causes
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
On expiration as radius dec

17. What is the pathology of bronchiectasis
N- terminus - carbaminohemoglobin
Low resistance and high compliance
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Inc to meet O2 demand

18. At what lung volume is system pressure atmospheric and why
FRC - inward pull of lung balanced by outward pull of chest wall
Right shift - favors taut - low affinity for O2 - O2 unloading
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis

19. What kind of space is in the conducting tree and what kind of muscle exists there
Tissue hypoxia from dec O2 sat and dec O2 content
Brings air in and out - warms - humidifies - filters
Anatomic dead space and smooth muscle
L/S < 1.5

20. Define expiratory reserve volume (ERV)
<60
No change - but inc venous CO2 content
Air that can still be breathed out after nl expiration
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death

21. What enzyme increases activity in emphysema
Dec - because physiologic shunt dec O2 extraction from ratio
Low resistance and high compliance
Chroniclly tired
Elastase

22. Synthesis of what substance increases with altitude and What does that do for the O2 sat curve
Dec in lung volumes - FVC - TLC
Air that can still be breathed out after nl expiration
Inc due to inc CO
Inc 2 -3- DPG - righward shift

23. What are the findings of chronic bronchitis
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Chroniclly tired
No change - but inc venous CO2 content
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater

24. What does a V/Q ratio of 0 indicate
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
Airway obstruction (shunt) 100% O2 does not improve PO2
Methylene blue
Milky fluid with inc TGs

25. What are the histological findings in asbestosis and what occupations are associated
Long bone fractures and liposuction
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
Superior portion of right inferior lobe
Shed epithelium from mucus plugs

26. What is the imaging test of choice for PE
TB - apex
CT angio
Repeated cycles of lung injury and wound healing with inc collagen
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers

27. What is central sleep apnea
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
Dec dec in FEV1 - dec in FVC
Tension pneumo - away from lesion
No respiratory effort

28. What do pulmonary arteries carry - and how are pulm arterial pressures maintained during the cardiac cycle
Deoxygenated blood - elastic walls
Dec release of fetal glucocorticoids
Matched - =1 adequate gas exchange
Weight loss - CPAP - surgery

29. What are the causes of ischemia
PVR = (PpulmA - PleftA)/CO
Carcinoid - carcinoid
Loss of blood flow - impeded arterial flow - reduced venous drainage
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)

30. At what PaO2 does hypoxemia begin
Right lung - right main stem bronhus is wider and more vertical
Heparin
<75
RALS - righ anterior - left superior

31. What is the formula for resistance
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Acetazolamide - inhibits CA and acidifies the blood
In between perfusion limited and diffusion limited

32. How does left to right shunt cause pulm HTN
Surfactant
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Inc shear stress leading to endothelial injury

33. What are the associations with bronchiectasis

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34. Define functional residual capacity (FRC)
Long bone fractures and liposuction
Pa > PA > Pv
RV + ERV - volume in lungs after nl expiration
Centriacinar

35. What properties determine the combined volumes of the chest wall and lungs
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Elastic properties

36. At What terminal does CO2 bind the globin molecule
Long bone fractures and liposuction
N- terminus - carbaminohemoglobin
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
RALS - righ anterior - left superior

37. What renal changes occur at high altitude and What are they compensating for
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
Exposed collagen fibers provides impetus for clotting cascade
Inc excretion of bicarb to compensate for respiratory alkalosis
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning

38. Malignancy associated with asbestosis - results in hemorrhagic effusions and pleural thickening - cancer - location - histo finding
Lost with alveolar walls
FEV1/FVC > 80%
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Mesothelioma - pleura - psammoma bodies

39. What cells make surfactant and At what week is produced most abundantly
Upper lobes - cor pulmonale - caplan's syndrome
In between perfusion limited and diffusion limited
Type II pneumocytes - after week 35
Heparin

40. What is the Reid index and what perfectange is characteristic of chronic bronchitis
Small airways
Gland depth/total thickness of broncial wall - >50%
Fe 2+
L/S > 2 = lecithin/sphingomyelin

41. Which pts are at risk for apriation PNA
Alchoholics or epileptics
Lung cancer
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals
Lower portion of right inferior lobe

42. What are potential triggers for asthma
Viral - URIs - allergens and stress
Inc due to inc CO
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
High alveolar pressure compresses capillaries

43. What are the causes of hypoxia
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
On expiration as radius dec

44. What is the diffustion formula and what happens to the variables in emphysema and pulmonary fibrosis
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Coal miner's - silicosis - abestosis

45. What does the conducting zone consist of...
Bicarb/Cl - exchanger - brings a Cl - into the RBC and expels bicarb into the serum
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
Air in excess of tidal volume that moves into lung on maximal inspiration

46. Define tidal volume (TV)
Air that moves into lung with each quiet respiration
Inc due to inc CO
Exposed collagen fibers provides impetus for clotting cascade
Inspiration by diaphragm - expiration is passive

47. What is the initial damage of ARDS caused by
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Clara cells - type II pneumocytes; multiple densitites on CXR
Alpha1- antitrypsin def - also cirrhosis
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity

48. A carcinoma in the apex of the lung can cause what syndrome and What is the tumor called

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49. How does mitral stenosis cause pulm HTN
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Inc excretion of bicarb to compensate for respiratory alkalosis
Inc resistance leading to inc pressure
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange

50. Peripheral mass develops in site of prior pulmonary inflammation or injury - cancer and epi
Person stops breathing for at least 10 seconds repeatedly during sleep
Exposed collagen fibers provides impetus for clotting cascade
Long bone fractures and liposuction
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers

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Respiratory

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