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Respiratory

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. What is a consequence of pulm HTN
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Histiocytosis X - Langerhans cells
Bronchial obstruction - toward side of lesion
Respiratory bronchioles - clear debris in alveoli - bronchi

2. What are the associations with bronchiectasis

3. What is the protein content an exudative pleural effusion and What are the potential causes
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Inspiration by diaphragm - expiration is passive
Anatomic dead space and smooth muscle
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise

4. increases In what substances favor the taut form of hemoglobin and which direction does that shift the O2 dissociation curve
L/S > 2 = lecithin/sphingomyelin
Lost with alveolar walls
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
O2 binding x O2 sat + dissolved O2

5. In which zone of the lung is PA > Pa > Pv
Zone 1
Deoxygenated blood - elastic walls
Persistently low O2 tension
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis

6. What kind of pleural plaques are the result of asbestosis
TB - silica disrupt phagolysosomes and impair MACS
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Ivory white calcified pleural plaques
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly

7. What is the criteria for chronic bronchitis
Type II pneumocytes - after week 35
PVR = (PpulmA - PleftA)/CO
Productive cough for greater than 3 months in at least 2 years
Pleural effusion

8. What changes in pH occur during strenuous exercise and why
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Dec - due to lactic acidosis
On expiration as radius dec
0 - negative - prevents pneumothorax

9. What is the response for ventilation of high altitude
Long bone fractures and liposuction
Hypoxic vasocxn
Repeated cycles of lung injury and wound healing with inc collagen
Acute/chronic inc in vent

10. What lab ration indicates fetal lung maturity
Both highest in the base
4 polypeptide subunits - 2 alpha and 2 beta
RV + ERV - volume in lungs after nl expiration
L/S > 2 = lecithin/sphingomyelin

11. How does autoimmune dz cause thromboemboli
Inc EPO leading to erythrocytosis
Dec in the FEV1/FVC
RALS - righ anterior - left superior
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy

12. What lung abnl is associated with dec breath sounds over lesion - dullness - dec fremitus
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
It binds to Hb -
Right lung - right main stem bronhus is wider and more vertical
Pleural effusion

13. What changes in lung volunes occur as a result of restrictive lung disease
Airway obstruction (shunt) 100% O2 does not improve PO2
PAO2 - PaO2 = 10-15 mmHg
Dec release of fetal glucocorticoids
Dec in lung volumes - FVC - TLC

14. What is the initial damage of ARDS caused by
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Type II pneumocytes - after week 35
Dec in lung volumes - FVC - TLC

15. How is pulmonary circulation characterized in terms of resistance and compliance
RV + ERV - volume in lungs after nl expiration
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Low resistance and high compliance

16. What does alveolar pressure do to capillaries in the apex of the lung
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
C3 - 4 - 6 - phrenic nerve - referred to shoulder
High alveolar pressure compresses capillaries
Coal miner's - silicosis - abestosis

17. What is the course of of pulm HTN
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Persistently low O2 tension
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema

18. At what PaO2 does cyanosis begin
DIC - especially postpartum
Tension pneumo - away from lesion
<60
L/S < 1.5

19. Define total lung capcaity
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Clara cells - type II pneumocytes; multiple densitites on CXR
Dec dec in FEV1 - dec in FVC
IRV + TV + ERV + RV

20. Which lung is the more common site for an inhaled foreign body and why
Right lung - right main stem bronhus is wider and more vertical
S. aureus or anaerobes
Bronchial obstruction - toward side of lesion
Respiratory effort against airway obstruction

21. What are the subtypes of pneumoconioses

22. What is a potential test for asthma
Dec
Methacholine challenge
Bleomycin - busulfan - anmiodorone
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents

23. What causes primary pulm HTN
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
Alpha1- antitrypsin def - also cirrhosis

24. What drug therapy is used to augment the changes in bicarb exretion
<75
Ciliated cells
Lungs collapse inwards and chest wall spring out
Acetazolamide - inhibits CA and acidifies the blood

25. What is the pathology of asthma

26. What is virchow's triad
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
P = 2ST/radius
Stasis - hypercoagulability - endothelial damage
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude

27. What is another name for neonatal RDS
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
Hyaline membrane disease
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue

28. What is the formula for pulm vasc resistance
Dec cross sectional area of pulm vasc bed
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
N- terminus - carbaminohemoglobin
PVR = (PpulmA - PleftA)/CO

29. How many lobes does each lung have - and What is the lingula
Apex of healthy lung
Inc due to inc CO
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Lobar PNA

30. If you aspirate a peanut while upright - where will it go
Lower portion of right inferior lobe
Both highest in the base
Shed epithelium from mucus plugs
Long bone fractures and liposuction

31. What is surfactant made of...
Dipalmatoyl phosphatidylcholine
IRV + TV
Deep leg veins
Chronic hypoxic vasocxn

32. What is the TX for small cell lung cancer
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
TB - apex
Inoperable - responsive to chemotherapy
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema

33. What does the combination of increased CO2 and increased proton binding do to the O2 dissociation curve
Dipalmatoyl phosphatidylcholine
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals
Right lung - right main stem bronhus is wider and more vertical
Right shift - favors taut - low affinity for O2 - O2 unloading

34. At what lung volume is system pressure atmospheric and why
Stasis - hypercoagulability - endothelial damage
FRC - inward pull of lung balanced by outward pull of chest wall
Apex of healthy lung
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude

35. What are fat emboli associated with
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Stasis - hypercoagulability - endothelial damage
Long bone fractures and liposuction
Shunting

36. What changes at high altitude can result in RVH
Chronic hypoxic vasocxn
Inc
Type II pneumocytes - after week 35
Alchoholics or epileptics

37. Malignancy associated with asbestosis - results in hemorrhagic effusions and pleural thickening - cancer - location - histo finding
Mesothelioma - pleura - psammoma bodies
500mL
20.1 mL O2 /dL
Matched - =1 adequate gas exchange

38. What changes in EPO occur at high altitude
Surfactant
Opposites
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia

39. What are the findings associated with sarcoidosis
Metastasis - breast - colon - prostate - bladder -
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Inc airway pressure to prevent airway collapse during exhalation
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium

40. 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
Inc mitochondria
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Methacholine challenge

41. What does the respiratory zone consist of and What is its fxn
Hyaline membrane disease
Everything but RV - TV + IRV + ERV
Inspiration by diaphragm - expiration is passive
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange

42. What lung abnl is characterized with dec breath sounds - hyperresonance - absent fremitus - towards which side does the trachea deviate
L/S < 1.5
Respiratory bronchioles - clear debris in alveoli - bronchi
Tension pneumo - away from lesion
Respiratory effort against airway obstruction

43. What doe FAT BAT stand for
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types
Positive cooperativity and negative allostery - unlike myoglobin
0 - negative - prevents pneumothorax
On expiration as radius dec

44. What is the protein content in a transudative pleural effusion and What are the potential causes
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Methylene blue

45. What is the alveolar gas equation approximation
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Inc resistance leading to inc pressure
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
PA02 = 150 - PACO2/0.8

46. How far to the pseudostratified ciliated columnar epithelium extend - What do MACS do in the alveoli - and how far do the goblet cells extend
Tissue hypoxia from dec O2 sat and dec O2 content
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Ciliated cells
Respiratory bronchioles - clear debris in alveoli - bronchi

47. What happens in diffiusion limited pulmonary circulation and what gases does this apply to...
Upper lobes - cor pulmonale - caplan's syndrome
O2 binding x O2 sat + dissolved O2
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary

48. In COPD - what happens to airways at high lung volumes
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
On expiration as radius dec
Airways close prematurely resulting in inc RV and dec FVC
Methylene blue

49. What can amniotic fluid emboli lead to...
Dec - no change
DIC - especially postpartum
Type II pneumocytes - after week 35
Inc

50. What findings are associated with emphysema
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Lost with alveolar walls