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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 is the alveolar gas equation approximation
Surfactant
L/S > 2 = lecithin/sphingomyelin
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
PA02 = 150 - PACO2/0.8

2. What does ACE do
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Anatomic dead space and smooth muscle
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Zone 3

3. What does each bronchopulmonary segment have in the center and along its border
Inc airway pressure to prevent airway collapse during exhalation
Retinopathy of maturity
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Incr - right - dec - left

4. Where do 95% of PE arise from
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Deep leg veins
Loss of blood flow - impeded arterial flow - reduced venous drainage
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue

5. What is nl pulmonary artery pressure and At what point is it considered pulm HTN
L/S > 2 = lecithin/sphingomyelin
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
Inc airway pressure to prevent airway collapse during exhalation

6. What renal changes occur at high altitude and What are they compensating for
Inoperable - responsive to chemotherapy
Surfactant def leading to inc surfact tension and alveolar collapse
Right shift - favors taut - low affinity for O2 - O2 unloading
Inc excretion of bicarb to compensate for respiratory alkalosis

7. What is a chronic complication of sleep apnea
Chroniclly tired
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation

8. How does sleep apnea or high altitude cause pulm HTN
Hypoxic vasocxn
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Zone 3

9. What is the nl form of iron in hemoglobin
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Fe 2+
Chest pain - tachypnea and dyspnea
Superior portion of right inferior lobe

10. What direction does an increase in metabolic need shift the O2 dissociation curve
Methylene blue
Right
Opposites
Fe 2+

11. What is the formula for resistance
Dipalmatoyl phosphatidylcholine - decreases surface tension
Brings air in and out - warms - humidifies - filters
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Steroids to mom - artificial surfactant and thyroxine to neonate

12. What is the alveolar gas equation
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
Dipalmatoyl phosphatidylcholine - decreases surface tension
L/S < 1.5

13. What are the 3 reasons for an increased A- a gradient
Carcinoid - carcinoid
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Zone 1
Lobar PNA

14. 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
More indolent
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Lobar PNA

15. What is the initial damage of ARDS caused by
Airway obstruction (shunt) 100% O2 does not improve PO2
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Bleomycin - busulfan - anmiodorone
Chroniclly tired

16. What is the pathology of emphysema
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
IRV + TV + ERV + RV

17. What accounts for the sigmoid shaped O2 dissociation curve with hemoglobin
Zone 3
Positive cooperativity and negative allostery - unlike myoglobin
CO x O2 content of blood
Pa > PA > Pv

18. What does the combination of increased CO2 and increased proton binding do to the O2 dissociation curve
Right shift - favors taut - low affinity for O2 - O2 unloading
TB - silica disrupt phagolysosomes and impair MACS
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Fe 2+

19. What is the appoximate O2 binding capacity
Respiratory bronchioles - clear debris in alveoli - bronchi
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
No respiratory effort
20.1 mL O2 /dL

20. Define functional residual capacity (FRC)
Persistently low O2 tension
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
RV + ERV - volume in lungs after nl expiration
Apex of healthy lung

21. What are the histological findings in asbestosis and what occupations are associated
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
Inc EPO leading to erythrocytosis
Bronchial obstruction - toward side of lesion
Lungs collapse inwards and chest wall spring out

22. Why is there eventual loss of capillary beds in emphysema
IRV + TV + ERV + RV
Lost with alveolar walls
TB - silica disrupt phagolysosomes and impair MACS
Matched - =1 adequate gas exchange

23. What does kallikrein do
Activates bradykinin
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
TB - apex

24. What do hemoglobin modifacations lead to...
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Tissue hypoxia from dec O2 sat and dec O2 content
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Right shift - favors taut - low affinity for O2 - O2 unloading

25. What is the presentation of lung cancer

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26. What happens to V/Q ratio in COPD
Productive cough for greater than 3 months in at least 2 years
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Mismatch
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals

27. Why is endothelial damage a risk factor for DVT
Dec in lung volumes - FVC - TLC
Exposed collagen fibers provides impetus for clotting cascade
Ratio from apex to base becomes more uniform
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells

28. What do PFTs show in restrictive lung disease
FEV1/FVC > 80%
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Inc resistance leading to inc pressure
Right

29. What is the formula for pulm vasc resistance
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
PVR = (PpulmA - PleftA)/CO
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Elastic properties

30. Susceptibility to what infection is increased in silicosis and why
CO2 - acid/altitude - DPG - Exercise - Temperature
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
TB - silica disrupt phagolysosomes and impair MACS
Hyaline membrane disease

31. What changes occur to PaO2 and PaCO2
No change - but inc venous CO2 content
TB - apex
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2

32. Which has a greater affinity for hemoglobin - CO or O2 and by how much
Retinopathy of maturity
CO - 200x
Exposed collagen fibers provides impetus for clotting cascade
Right shift - favors taut - low affinity for O2 - O2 unloading

33. What happens to FEV1 and FVC in both obstructive and restrictive lung disease and What is the difference
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Inc O2 consumption
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning

34. Define physilogic dead space
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
Methacholine challenge
Air in lung after maxmimal expiration - cannot be measured on spirometry
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli

35. What does the conducting zone consist of...
Upper lobes
Acetazolamide - inhibits CA and acidifies the blood
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
FRC - inward pull of lung balanced by outward pull of chest wall

36. What happens in diffiusion limited pulmonary circulation and what gases does this apply to...
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
Methacholine challenge
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Inc O2 consumption

37. What is the cycle of idiopathic pulmonary fibrosis
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
Repeated cycles of lung injury and wound healing with inc collagen
Dec in lung volumes - FVC - TLC
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

38. What is compliance and When is it decrease
Right shift - favors taut - low affinity for O2 - O2 unloading
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Trachea and bronchi

39. What is a potential test for asthma
N- terminus - carbaminohemoglobin
Methacholine challenge
Defect in coagulative cascace proteins
Inc resistance leading to inc pressure

40. What are fat emboli associated with
Long bone fractures and liposuction
Matched - =1 adequate gas exchange
S. aureus or anaerobes
Type II pneumocytes - after week 35

41. What happens with the O2 curve shifts to the right and What does it facilitate
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Dec cross sectional area of pulm vasc bed
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
Deep leg veins

42. At What terminal does CO2 bind the globin molecule
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
Dec cross sectional area of pulm vasc bed
N- terminus - carbaminohemoglobin
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death

43. What properties determine the combined volumes of the chest wall and lungs
PAO2 - PaO2 = 10-15 mmHg
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
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
Elastic properties

44. Define tidal volume (TV)
Right
Air that moves into lung with each quiet respiration
Histiocytosis X - Langerhans cells
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration

45. How does recurrent thromboemboli cause pulm HTN
Chronic hypoxic vasocxn
Dec cross sectional area of pulm vasc bed
Dec in the FEV1/FVC
Zone 3

46. What are the potential causes of poor breathing mechanics leading to restrictive lung disease - and What are examples in each
Metastasis - breast - colon - prostate - bladder -
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Dec release of fetal glucocorticoids

47. What is the Reid index and what perfectange is characteristic of chronic bronchitis
Repeated cycles of lung injury and wound healing with inc collagen
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Dec in the FEV1/FVC
Gland depth/total thickness of broncial wall - >50%

48. What muscles are involved in breathing during exercise and What do they control
Dipalmatoyl phosphatidylcholine
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
Chest pain - tachypnea and dyspnea
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals

49. Define inspiratory reserve volume (IRV)
IRV + TV
Hyaline membrane disease
Anatomic dead space and smooth muscle
Air in excess of tidal volume that moves into lung on maximal inspiration

50. What is a lung abscess and What does usually result from
Bleomycin - busulfan - anmiodorone
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
No respiratory effort
Ivory white calcified pleural plaques