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Respiratory

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Answer 50 questions in 15 minutes.
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1. Synthesis of what substance increases with altitude and What does that do for the O2 sat curve
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
Inc 2 -3- DPG - righward shift
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right

2. What lung abnl is associated with dec breath sounds over lesion - dullness - dec fremitus
Pleural effusion
Chroniclly tired
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Loss of blood flow - impeded arterial flow - reduced venous drainage

3. What are the potential TX for sleep apnea
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Weight loss - CPAP - surgery
RALS - righ anterior - left superior
Inc

4. What happens to lung volumes in restrictive lung disease
In between perfusion limited and diffusion limited
Dec
L/S < 1.5
Inc EPO leading to erythrocytosis

5. What is the leading cause of cancer death
Histiocytosis X - Langerhans cells
Lung cancer
Dec dec in FEV1 - dec in FVC
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right

6. Where are ventilation and perfusion highest in the lung - respectively
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Both highest in the base
Inoperable - responsive to chemotherapy
Inc due to inc CO

7. Why do pts with emphysema exhale through pursed lips
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
Inc airway pressure to prevent airway collapse during exhalation
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals

8. What is used to treat CN poisoning and why
Inoperable - responsive to chemotherapy
Inc
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
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

9. What does kallikrein do
Matched - =1 adequate gas exchange
DIC - especially postpartum
Activates bradykinin
Dipalmatoyl phosphatidylcholine

10. What are curschmann's spirals
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Superior portion of right inferior lobe
Shed epithelium from mucus plugs

11. Define inspiratory capacity (IC)
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals
IRV + TV

12. What is the most common cancerous lesion in the lun
Metastasis - breast - colon - prostate - bladder -
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Everything but RV - TV + IRV + ERV

13. What is the order of decreasing pressures among the alveola - capillaries and veins in zone 2 of the lungs
Pa > PA > Pv
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Lung cancer

14. What do type II cells do - What is their morphology - when do they proliferate
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage
Ciliated cells
Inc resistance leading to inc pressure
Positive cooperativity and negative allostery - unlike myoglobin

15. At what lung volume is system pressure atmospheric and why
Air in lung after maxmimal expiration - cannot be measured on spirometry
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
PAO2 - PaO2 = 10-15 mmHg
FRC - inward pull of lung balanced by outward pull of chest wall

16. What does ACE do
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Deep leg veins
Dec in the FEV1/FVC
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy

17. What are the subtypes of pneumoconioses

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18. What is the criteria for chronic bronchitis
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Productive cough for greater than 3 months in at least 2 years
Bronchial obstruction - toward side of lesion

19. What is the protein content in a transudative pleural effusion and What are the potential causes
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Stasis - hypercoagulability - endothelial damage

20. Define inspiratory reserve volume (IRV)
Prematurity - maternal RDS - cesarean delivery
Loss of blood flow - impeded arterial flow - reduced venous drainage
Inc resistance leading to inc pressure
Air in excess of tidal volume that moves into lung on maximal inspiration

21. Other than surfactant - what other important substances are produced by the lungs
20.1 mL O2 /dL
CO2 - acid/altitude - DPG - Exercise - Temperature
Prostaglandins - histamine - ACE - kallikrein
Long bone fractures and liposuction

22. What are the causes of hypoxemia
P = 2ST/radius
<75
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
It binds to Hb -

23. Define vital capacity (VC)
High alveolar pressure compresses capillaries
Histiocytosis X - Langerhans cells
Everything but RV - TV + IRV + ERV
<60

24. What enzyme increases activity in emphysema
Loss of elastic fibers
Tissue hypoxia from dec O2 sat and dec O2 content
Elastase
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)

25. If you aspirate a peanut while upright - where will it go
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
Dec
Lower portion of right inferior lobe
Mismatch

26. What is the pathology of asthma

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

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28. What findings are associated with emphysema
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Right shift - favors taut - low affinity for O2 - O2 unloading
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes

29. At What terminal does CO2 bind the globin molecule
N- terminus - carbaminohemoglobin
CO2 - acid/altitude - DPG - Exercise - Temperature
Elastase
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

30. What happens to arterial PO2 in chronic lung disease and why
Dec - because physiologic shunt dec O2 extraction from ratio
Loss of blood flow - impeded arterial flow - reduced venous drainage
Matched - =1 adequate gas exchange
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning

31. What is obstructive sleep apnea
Inc 2 -3- DPG - righward shift
Type II cells
Respiratory effort against airway obstruction
Respiratory bronchioles - clear debris in alveoli - bronchi

32. What is occupied in the space that would have been the left middle lobe
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Heart
Inspiration by diaphragm - expiration is passive
Chroniclly tired

33. What does alveolar pressure do to capillaries in the apex of the lung
High alveolar pressure compresses capillaries
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Everything but RV - TV + IRV + ERV
Centriacinar

34. What are the two forms of hemoglobin
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
FRC - inward pull of lung balanced by outward pull of chest wall
Inc excretion of bicarb to compensate for respiratory alkalosis

35. What is fetal hemoglobin made of and why does it have a higher affinity for O2
Acetazolamide - inhibits CA and acidifies the blood
Superior portion of right inferior lobe
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG

36. At what PaO2 does cyanosis begin
<60
Methacholine challenge
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
Inc shear stress leading to endothelial injury

37. How many lobes does each lung have - and What is the lingula
Chroniclly tired
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
Pa > PA > Pv

38. What changes in 2 -3 - DPG occur at high altitude
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Inc to meet O2 demand
Histiocytosis X - Langerhans cells
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema

39. What lung abnl is characterized by absent or decreased breath sounds over affected area - dec resonance - dec fremitus - and which side is the trachea deviated towards
Bronchial obstruction - toward side of lesion
L/S < 1.5
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Mesothelioma - pleura - psammoma bodies

40. What do hemoglobin modifacations lead to...
Fe 2+
Tissue hypoxia from dec O2 sat and dec O2 content
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Airway obstruction (shunt) 100% O2 does not improve PO2

41. What does the law of Laplace state about tendency of alveoli to collapse
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
On expiration as radius dec
Low resistance and high compliance
Dec in lung volumes - FVC - TLC

42. What are the various causes of ARDS
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals

43. Which muscles are involved in quiet breathing and What part of respiration do the control
CO x O2 content of blood
Deep leg veins
Inspiration by diaphragm - expiration is passive
Type II cells

44. What happens to diffusing capacity in interstiial lung diseases
Dorsiflexion of food leads to tender calf muscle
4 polypeptide subunits - 2 alpha and 2 beta
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Lowered

45. What is a potential test for asthma
Drainage
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
Lowered
Methacholine challenge

46. What is an example of hypercoagulability
Defect in coagulative cascace proteins
Lost with alveolar walls
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage

47. What does CADET face to the right stand for
Opposites
CO2 - acid/altitude - DPG - Exercise - Temperature
CT angio
Viral - URIs - allergens and stress

48. What is the presentation of lung cancer

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49. What does PFTs show in COPD
Tension pneumo - away from lesion
Inc 2 -3- DPG - righward shift
Dec dec in FEV1 - dec in FVC
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-

50. What kind of course does interstitial PNA follow in comparison to bronchoPNA
In between perfusion limited and diffusion limited
More indolent
PA02 = 150 - PACO2/0.8
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells

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Respiratory

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