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Respiratory

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1. What is an association and potential complication of paraseptal emphysema
Superior portion of right inferior lobe
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Lung cancer

2. What happens to lung volumes in restrictive lung disease
Dec
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Milky fluid with inc TGs
Inc EPO leading to erythrocytosis

3. What cells in the lung produce surfactant and What does it do
Squamous cell carcinoma - keratin pearls and intracellular bridges
Carcinoid - carcinoid
Dec - due to lactic acidosis
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration

4. What happens as a result of hypoxia in sleep apnea
Elastase
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals
Inc EPO leading to erythrocytosis
Inc excretion of bicarb to compensate for respiratory alkalosis

5. Define vital capacity (VC)
Elastic properties
Dec - due to lactic acidosis
Inc shear stress leading to endothelial injury
Everything but RV - TV + IRV + ERV

6. What organisms cause interstitial PNA and What are the characteristics
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
IRV + TV + ERV + RV
Chroniclly tired
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right

7. increases In what substances favor the taut form of hemoglobin and which direction does that shift the O2 dissociation curve
Drainage
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Type II pneumocytes - after week 35

8. What happens to diffusing capacity in interstiial lung diseases
Lowered
CO2 - acid/altitude - DPG - Exercise - Temperature
Deep leg veins
Alpha1- antitrypsin def - also cirrhosis

9. What do pulmonary arteries carry - and how are pulm arterial pressures maintained during the cardiac cycle
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Deoxygenated blood - elastic walls
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals

10. What lung abnl is associated with bronchial breath sounds over lesion - dullness and increased fremitus
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Elastic properties
Viral - URIs - allergens and stress
Lobar PNA

11. What is the pathology of emphysema
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Exposed collagen fibers provides impetus for clotting cascade

12. What is positive cooperativity of hemoglobin refer to...
4 polypeptide subunits - 2 alpha and 2 beta
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Incr - right - dec - left
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound

13. What lung abnl is characterized with dec breath sounds - hyperresonance - absent fremitus - towards which side does the trachea deviate
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
Tension pneumo - away from lesion
Deep leg veins
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]

14. Which has a greater affinity for hemoglobin - CO or O2 and by how much
CO - 200x
Upper lobes
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
20.1 mL O2 /dL

15. What lung abnl is associated with dec breath sounds over lesion - dullness - dec fremitus
Both highest in the base
PA02 = 150 - PACO2/0.8
Pleural effusion
Chronic hypoxic vasocxn

16. What is sleep apnea associated with
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Upper lobes - cor pulmonale - caplan's syndrome
Milky fluid with inc TGs

17. What can amniotic fluid emboli lead to...
Squamous cell carcinoma - keratin pearls and intracellular bridges
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
On expiration as radius dec
DIC - especially postpartum

18. At what PaO2 does hypoxemia begin
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
<75
Defect in coagulative cascace proteins
Elastic properties

19. What spinal nerves innvervate the diaphragm and where can pain from the diaphragm be referred
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Centriacinar
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
N- terminus - carbaminohemoglobin

20. What are the lab/study findings in adenocarcinoma of the lung
Mesothelioma - pleura - psammoma bodies
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
P = 2ST/radius
Clara cells - type II pneumocytes; multiple densitites on CXR

21. What changes in O2 consumption change during exercise
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Air in lung after maxmimal expiration - cannot be measured on spirometry
Inc O2 consumption
CT angio

22. Define functional residual capacity (FRC)
RV + ERV - volume in lungs after nl expiration
Surfactant
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
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

23. What happens with the O2 curve shifts to the right and What does it facilitate
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Weight loss - CPAP - surgery
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Air that can still be breathed out after nl expiration

24. What is the protein content in a transudative pleural effusion and What are the potential causes
0 - negative - prevents pneumothorax
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Right lung - right main stem bronhus is wider and more vertical
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis

25. What is the airway and alveolar pressure at FRC - What is the intrapleural pressure - and What does that prevent
Elastic properties
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
0 - negative - prevents pneumothorax
Hypoxic vasocxn

26. What happens to arterial PO2 in chronic lung disease and why
Brings air in and out - warms - humidifies - filters
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Dec - because physiologic shunt dec O2 extraction from ratio
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage

27. Where does exercise sit on the graph of PaO2 vs length along the pulm capillary
Lower portion of right inferior lobe
In between perfusion limited and diffusion limited
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
Pa > PA > Pv

28. What does each bronchopulmonary segment have in the center and along its border
Chronic hypoxic vasocxn
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Acute/chronic inc in vent
L/S < 1.5

29. Define residual volume (RV)
CO - 200x
RALS - righ anterior - left superior
Air in lung after maxmimal expiration - cannot be measured on spirometry
In between perfusion limited and diffusion limited

30. What direction does an increase in metabolic need shift the O2 dissociation curve
Respiratory bronchioles - clear debris in alveoli - bronchi
Carcinoid - carcinoid
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
Right

31. What are clara cells What is their morphology and What do they do
CT angio
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy

32. Why is there eventual loss of capillary beds in emphysema
Lost with alveolar walls
Lower portion of right inferior lobe
Dec in the FEV1/FVC
500mL

33. What is the defect in panacinar emphysema - and what else do you see
Alpha1- antitrypsin def - also cirrhosis
Chronic hypoxic vasocxn
DIC - especially postpartum
Lungs collapse inwards and chest wall spring out

34. What are the SPHERE of complications in lung cancer
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Upper lobes
<75

35. What is the leading cause of cancer death
Lung cancer
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Airways close prematurely resulting in inc RV and dec FVC
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways

36. What changes in ventilation rate occur during exercise
Lungs collapse inwards and chest wall spring out
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Inc to meet O2 demand

37. How happens to the proton from the rxn the created bicarb
IRV + TV + ERV + RV
Shunting
Surfactant def leading to inc surfact tension and alveolar collapse
It binds to Hb -

38. What causes neonatal RDS
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
PVR = (PpulmA - PleftA)/CO
Surfactant def leading to inc surfact tension and alveolar collapse

39. What is occupied in the space that would have been the left middle lobe
Heart
Apex of healthy lung
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG

40. How does left to right shunt cause pulm HTN
Inc shear stress leading to endothelial injury
Hypertrophy of mucus secreting glands in the bronchioles
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Surfactant def leading to inc surfact tension and alveolar collapse

41. In what cells do you find lamellar bodies
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
Elastase
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
Type II cells

42. What does a V/Q ratio of 0 indicate
Positive cooperativity and negative allostery - unlike myoglobin
Type II pneumocytes - after week 35
Airway obstruction (shunt) 100% O2 does not improve PO2
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage

43. What happens in diffiusion limited pulmonary circulation and what gases does this apply to...
Loss of blood flow - impeded arterial flow - reduced venous drainage
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Dec dec in FEV1 - dec in FVC

44. How does sleep apnea or high altitude cause pulm HTN
L/S > 2 = lecithin/sphingomyelin
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
Mismatch
Hypoxic vasocxn

45. What lung product is deficient in neonatal RDS
N- terminus - carbaminohemoglobin
Surfactant
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types
Viral - URIs - allergens and stress

46. What does CADET face to the right stand for
CO2 - acid/altitude - DPG - Exercise - Temperature
Ratio from apex to base becomes more uniform
P = 2ST/radius
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale

47. What changes in 2 -3 - DPG occur at high altitude
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
More indolent
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly

48. What is the ideal V/Q ratio and why
Matched - =1 adequate gas exchange
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
0 - negative - prevents pneumothorax
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale

49. What happens to O2 content and O2 sat as Hb falls
Dec - no change
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
<60

50. What is tha hallmark finding of COPD
PA02 = 150 - PACO2/0.8
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Airways close prematurely resulting in inc RV and dec FVC
Dec in the FEV1/FVC

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