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Respiratory

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Answer 50 questions in 15 minutes.
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1. How many lobes does each lung have - and What is the lingula
Drainage
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
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
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung

2. 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-
Inc airway pressure to prevent airway collapse during exhalation
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Exposed collagen fibers provides impetus for clotting cascade

3. What is the appoximate O2 binding capacity
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
L/S > 2 = lecithin/sphingomyelin
20.1 mL O2 /dL
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-

4. At what lung volume is system pressure atmospheric and why
FRC - inward pull of lung balanced by outward pull of chest wall
Dec dec in FEV1 - dec in FVC
Zone 1
Mismatch

5. What is the formula for oxygen delivery to tissues
Deoxygenated blood - elastic walls
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Methylene blue
CO x O2 content of blood

6. What is the order of decreasing pressures among the alveola - capillaries and veins in zone 2 of the lungs
Alpha1- antitrypsin def - also cirrhosis
Acetazolamide - inhibits CA and acidifies the blood
<75
Pa > PA > Pv

7. Lung cancer in central region - undifferentiated beoming very aggressive - associated with ectopic production of ACTH - ADH and Lambert Eaton syndrome - cancer and histo
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
IRV + TV + ERV + RV
Both highest in the base
20.1 mL O2 /dL

8. What are the findings in asthma
Acetazolamide - inhibits CA and acidifies the blood
Positive cooperativity and negative allostery - unlike myoglobin
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration

9. What happens to O2 content and O2 sat as Hb falls
Air in excess of tidal volume that moves into lung on maximal inspiration
Pleural effusion
Dec - no change
Steroids to mom - artificial surfactant and thyroxine to neonate

10. What changes in pH occur during strenuous exercise and why
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Dec - due to lactic acidosis
Dec
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary

11. What is the alveolar gas equation approximation
CO2 - acid/altitude - DPG - Exercise - Temperature
Long bone fractures and liposuction
PA02 = 150 - PACO2/0.8
Incr - right - dec - left

12. What is pulmonary surfactant made of - and What does it do
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
IRV + TV + ERV + RV
Lower portion of right inferior lobe
Dipalmatoyl phosphatidylcholine - decreases surface tension

13. Why do pts with emphysema exhale through pursed lips
Inc to meet O2 demand
Opposites
Inc airway pressure to prevent airway collapse during exhalation
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis

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
Coal miner's - silicosis - abestosis
Respiratory bronchioles - clear debris in alveoli - bronchi
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
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

15. What is another name for neonatal RDS
Incr - right - dec - left
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
Hyaline membrane disease
Inc excretion of bicarb to compensate for respiratory alkalosis

16. What do pulmonary arteries carry - and how are pulm arterial pressures maintained during the cardiac cycle
Steroids to mom - artificial surfactant and thyroxine to neonate
Stasis - hypercoagulability - endothelial damage
Elastase
Deoxygenated blood - elastic walls

17. What is the V/Q ratio at the apex and base of the lung
Elastase
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung

18. What is the diffustion formula and what happens to the variables in emphysema and pulmonary fibrosis
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
More indolent

19. What does CADET face to the right stand for
CO2 - acid/altitude - DPG - Exercise - Temperature
Inc
1 g of Hb can bind 1.34 mL of O2 - nl O2 in blood is 15 g/dL - cyansosis when deoxy Hb > 5 g/dL
PVR = (PpulmA - PleftA)/CO

20. What organism causes a lobar PNA and What are the characteristics
Ivory white calcified pleural plaques
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Bleomycin - busulfan - anmiodorone

21. How do you prevent DVT
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
Heparin
RV + ERV - volume in lungs after nl expiration
Lobar PNA

22. What is an association and potential complication of paraseptal emphysema
Dec - because physiologic shunt dec O2 extraction from ratio
500mL
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
TB - apex

23. What drug therapy is used to augment the changes in bicarb exretion
Acetazolamide - inhibits CA and acidifies the blood
L/S < 1.5
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
Centriacinar

24. What is hemoglobin composed of...
Zone 1
4 polypeptide subunits - 2 alpha and 2 beta
Dorsiflexion of food leads to tender calf muscle
Alpha1- antitrypsin def - also cirrhosis

25. What is a typical tidal volume
FRC - inward pull of lung balanced by outward pull of chest wall
C3 - 4 - 6 - phrenic nerve - referred to shoulder
TB - silica disrupt phagolysosomes and impair MACS
500mL

26. What changes in CO2 occur during exercise
Inc production
Carcinoid - carcinoid
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
0 - negative - prevents pneumothorax

27. What kind of emphysema is caused by smoking
Centriacinar
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Bronchial obstruction - toward side of lesion

28. Lung cancer in peripheral reason - highly anaplastic - undifferentiated tumor - cancer - histo - TX
Long bone fractures and liposuction
FEV1/FVC > 80%
CT angio
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy

29. What are the causes of hypoxemia
CT angio
4 polypeptide subunits - 2 alpha and 2 beta
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium

30. What are the SPHERE of complications in lung cancer
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
CO - 200x
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)

31. Where do you find type I cells - What is their morphology - and What do they do
Prostaglandins - histamine - ACE - kallikrein
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Trachea and bronchi
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange

32. What lung abnl is associated with dec breath sounds over lesion - dullness - dec fremitus
<75
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Pleural effusion
Lung cancer

33. What does kallikrein do
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
Activates bradykinin
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Air that can still be breathed out after nl expiration

34. What TX is the mother given before delivery - and what TXs are given to the infant
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
High alveolar pressure compresses capillaries
Steroids to mom - artificial surfactant and thyroxine to neonate
Ciliated cells

35. Where does exercise sit on the graph of PaO2 vs length along the pulm capillary
It binds to Hb -
In between perfusion limited and diffusion limited
Dec
Type II cells

36. What is carboxyhemoglobin and What does it cause
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
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Histiocytosis X - Langerhans cells
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema

37. What does pulm HTN result in
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Inc O2 consumption
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries

38. How is pulmonary circulation characterized in terms of resistance and compliance
Low resistance and high compliance
Airways close prematurely resulting in inc RV and dec FVC
Inc
Centriacinar

39. What happens to lung volumes in restrictive lung disease
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia
Weight loss - CPAP - surgery
Dec

40. What are the associations with bronchiectasis

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41. What are the findings of chronic bronchitis
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
On expiration as radius dec
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater

42. What happens to diffusing capacity in interstiial lung diseases
L/S < 1.5
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
Lowered
Steroids to mom - artificial surfactant and thyroxine to neonate

43. What changes in ventilation rate occur during exercise
Methacholine challenge
Air in excess of tidal volume that moves into lung on maximal inspiration
Tissue hypoxia from dec O2 sat and dec O2 content
Inc to meet O2 demand

44. Synthesis of what substance increases with altitude and What does that do for the O2 sat curve
Carcinoid - carcinoid
Low resistance and high compliance
Inc 2 -3- DPG - righward shift
No respiratory effort

45. What is sleep apnea associated with
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Bicarb (90%) - bound to globin (5%) and dissolved (5%)

46. How does left to right shunt cause pulm HTN
Inc shear stress leading to endothelial injury
On expiration as radius dec
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Bleomycin - busulfan - anmiodorone

47. What is the imaging test of choice for PE
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
CT angio
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration

48. What does the respiratory zone consist of and What is its fxn
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Weight loss - CPAP - surgery
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
Incr - right - dec - left

49. What are the causes of hypoxia
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types
Persistently low O2 tension
500mL
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning

50. What does a V/Q ratio of 0 indicate
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
Airway obstruction (shunt) 100% O2 does not improve PO2
L/S > 2 = lecithin/sphingomyelin
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT

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