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Respiratory

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1. What does alveolar pressure do to capillaries in the apex of the lung
Chronic hypoxic vasocxn
Lobar PNA
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
High alveolar pressure compresses capillaries

2. What is compliance and When is it decrease
Positive cooperativity and negative allostery - unlike myoglobin
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema

3. What is sleep apnea associated with
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Methylene blue
Dec release of fetal glucocorticoids

4. What does ACE do
Pa > PA > Pv
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Dec release of fetal glucocorticoids
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals

5. What is another name for neonatal RDS
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Hyaline membrane disease
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

6. What is pulmonary surfactant made of - and What does it do
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Dipalmatoyl phosphatidylcholine - decreases surface tension
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia
Mismatch

7. What renal changes occur at high altitude and What are they compensating for
O2 binding x O2 sat + dissolved O2
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
Inc excretion of bicarb to compensate for respiratory alkalosis
Anatomic dead space and smooth muscle

8. What does kallikrein do
Dec cross sectional area of pulm vasc bed
Inc
Activates bradykinin
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound

9. What happens to bicarb once it is created in an RBC
Bicarb/Cl - exchanger - brings a Cl - into the RBC and expels bicarb into the serum
FRC - inward pull of lung balanced by outward pull of chest wall
Low resistance and high compliance
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells

10. What changes in CO2 occur during exercise
Inc production
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Dec dec in FEV1 - dec in FVC

11. What changes occur to pulm blood flow during exercise
Inc due to inc CO
Dec in the FEV1/FVC
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Inc EPO leading to erythrocytosis

12. What do pulmonary arteries carry - and how are pulm arterial pressures maintained during the cardiac cycle
Deoxygenated blood - elastic walls
Mesothelioma - pleura - psammoma bodies
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Chroniclly tired

13. What lung abnl is associated with dec breath sounds over lesion - dullness - dec fremitus
IRV + TV
Incr - right - dec - left
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Pleural effusion

14. How many lobes does each lung have - and What is the lingula
L/S < 1.5
RV + ERV - volume in lungs after nl expiration
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung

15. Which muscles are involved in quiet breathing and What part of respiration do the control
Bronchial obstruction - toward side of lesion
Inspiration by diaphragm - expiration is passive
Chroniclly tired
Alchoholics or epileptics

16. 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
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
Activates bradykinin

17. What is positive cooperativity of hemoglobin refer to...
Weight loss - CPAP - surgery
Respiratory bronchioles - clear debris in alveoli - bronchi
Bicarb/Cl - exchanger - brings a Cl - into the RBC and expels bicarb into the serum
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound

18. How does sleep apnea or high altitude cause pulm HTN
Hypoxic vasocxn
Alpha1- antitrypsin def - also cirrhosis
Metastasis - breast - colon - prostate - bladder -
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. In which zone of the lung is Pa > Pv >PA
Dec - because physiologic shunt dec O2 extraction from ratio
P = 2ST/radius
Zone 3
C3 - 4 - 6 - phrenic nerve - referred to shoulder

20. Define inspiratory reserve volume (IRV)
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Air in excess of tidal volume that moves into lung on maximal inspiration
Acetazolamide - inhibits CA and acidifies the blood

21. Where are ventilation and perfusion highest in the lung - respectively
Both highest in the base
Respiratory effort against airway obstruction
Shunting
Inc excretion of bicarb to compensate for respiratory alkalosis

22. What is methemoglobin
Positive cooperativity and negative allostery - unlike myoglobin
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Dec

23. What are the subtypes of pneumoconioses

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24. Why is cesarean delivery a risk factor for neonatal RDS
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
Dec release of fetal glucocorticoids
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Viral - URIs - allergens and stress

25. What lung product is deficient in neonatal RDS
FRC - inward pull of lung balanced by outward pull of chest wall
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
Surfactant
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis

26. How does autoimmune dz cause thromboemboli
CO - 200x
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
O2 binding x O2 sat + dissolved O2
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy

27. What is the formula for A- a gradient - and What is it normally
Acute/chronic inc in vent
PAO2 - PaO2 = 10-15 mmHg
CO2 - acid/altitude - DPG - Exercise - Temperature
TB - silica disrupt phagolysosomes and impair MACS

28. Which lung is the more common site for an inhaled foreign body and why
Gland depth/total thickness of broncial wall - >50%
Inc airway pressure to prevent airway collapse during exhalation
500mL
Right lung - right main stem bronhus is wider and more vertical

29. What kind of connection exists between endothelial cells in the capilaries
In between perfusion limited and diffusion limited
Chronic hypoxic vasocxn
Tight jxns
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)

30. What is the initial damage of ARDS caused by
Elastase
Bicarb/Cl - exchanger - brings a Cl - into the RBC and expels bicarb into the serum
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals

31. What is the V/Q ratio at the apex and base of the lung
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Type II cells
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

32. What ratio is used to measure lung maturity and What is the value is neonatal RDS
L/S < 1.5
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
Inc production
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells

33. Toxicities of what drugs include interstitial lung disease
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals
Air in lung after maxmimal expiration - cannot be measured on spirometry
Bleomycin - busulfan - anmiodorone
Retinopathy of maturity

34. What happens to V/Q ratio in COPD
IRV + TV + ERV + RV
Mismatch
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Coal miner's - silicosis - abestosis

35. What is are the symptoms of a pulmonary embolism
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Chest pain - tachypnea and dyspnea
Inc excretion of bicarb to compensate for respiratory alkalosis
Inc airway pressure to prevent airway collapse during exhalation

36. What cells in the lung produce surfactant and What does it do
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
Hypoxic vasocxn
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)

37. What changes in pH occur during strenuous exercise and why
Exposed collagen fibers provides impetus for clotting cascade
Dec
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
Dec - due to lactic acidosis

38. What does the conducting zone consist of...
4 polypeptide subunits - 2 alpha and 2 beta
Air that moves into lung with each quiet respiration
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles

39. What increases the risk of PDA in neonatal RDS
Persistently low O2 tension
Dec - no change
Inc O2 consumption
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema

40. 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
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Carcinoid - carcinoid
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
High alveolar pressure compresses capillaries

41. What is a potential test for asthma
Methacholine challenge
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
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
Lungs collapse inwards and chest wall spring out

42. What is the imaging test of choice for PE
Dec
Dec - no change
CT angio
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue

43. What is the alveolar gas equation
Loss of elastic fibers
Milky fluid with inc TGs
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2

44. What does CADET face to the right stand for
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
CO2 - acid/altitude - DPG - Exercise - Temperature
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma

45. What organism thrives in high O2 and where in the lung does it flourish
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Centriacinar
Deoxygenated blood - elastic walls
TB - apex

46. What is the formula for resistance
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Air in lung after maxmimal expiration - cannot be measured on spirometry
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)

47. What spinal nerves innvervate the diaphragm and where can pain from the diaphragm be referred
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Shunting
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Ratio from apex to base becomes more uniform

48. What is the tendency of the lungs vs the chest wall
Lungs collapse inwards and chest wall spring out
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Deep leg veins
Lowered

49. 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
Inc excretion of bicarb to compensate for respiratory alkalosis
Elastase
20.1 mL O2 /dL

50. What reaction and enzyme create bicarb and Where does it happen
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
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
Repeated cycles of lung injury and wound healing with inc collagen

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