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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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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. What is the cycle of idiopathic pulmonary fibrosis
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Prostaglandins - histamine - ACE - kallikrein
Respiratory effort against airway obstruction
Repeated cycles of lung injury and wound healing with inc collagen

2. Define expiratory reserve volume (ERV)
Shed epithelium from mucus plugs
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Air that can still be breathed out after nl expiration
Zone 1

3. What kind of emphysema is caused by smoking
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
Centriacinar
L/S > 2 = lecithin/sphingomyelin
Tension pneumo - away from lesion

4. What is the alveolar gas equation
IRV + TV + ERV + RV
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG

5. What is used to treat methemoglobin
Prostaglandins - histamine - ACE - kallikrein
Air in excess of tidal volume that moves into lung on maximal inspiration
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
Methylene blue

6. What causes secondary pulm HTN
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
In between perfusion limited and diffusion limited
TB - apex

7. At What terminal does CO2 bind the globin molecule
N- terminus - carbaminohemoglobin
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
Hyaline membrane disease
Inc resistance leading to inc pressure

8. How does sleep apnea or high altitude cause pulm HTN
Air in lung after maxmimal expiration - cannot be measured on spirometry
Hypoxic vasocxn
N- terminus - carbaminohemoglobin
Hypoxemia because of shunting - V/Q mistmatch - fibrosis

9. What is the V/Q ratio at the apex and base of the lung
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Acute/chronic inc in vent
Squamous cell carcinoma - keratin pearls and intracellular bridges
CO2 - acid/altitude - DPG - Exercise - Temperature

10. Lung cancer in central region - undifferentiated beoming very aggressive - associated with ectopic production of ACTH - ADH and Lambert Eaton syndrome - cancer and histo
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Respiratory effort against airway obstruction
Prematurity - maternal RDS - cesarean delivery

11. What is the formula for pulm vasc resistance
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
PVR = (PpulmA - PleftA)/CO
Fe 2+
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis

12. What do PFTs show in restrictive lung disease
FEV1/FVC > 80%
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Dipalmatoyl phosphatidylcholine
Lung cancer

13. What are the potential causes of poor breathing mechanics leading to restrictive lung disease - and What are examples in each
Shunting
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Upper lobes
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2

14. What drug therapy is used to augment the changes in bicarb exretion
DIC - especially postpartum
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
PVR = (PpulmA - PleftA)/CO
Acetazolamide - inhibits CA and acidifies the blood

15. At what PaO2 does cyanosis begin
RV + ERV - volume in lungs after nl expiration
Defect in coagulative cascace proteins
<60
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG

16. What layers must CO2 and O2 traverse to complete gas exchange
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
Prostaglandins - histamine - ACE - kallikrein
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Tension pneumo - away from lesion

17. Why do pts with emphysema exhale through pursed lips
Chronic hypoxic vasocxn
Lungs collapse inwards and chest wall spring out
Type II cells
Inc airway pressure to prevent airway collapse during exhalation

18. What is the presentation of lung cancer

19. What does kallikrein do
Retinopathy of maturity
TB - silica disrupt phagolysosomes and impair MACS
CO x O2 content of blood
Activates bradykinin

20. What is the pathology of emphysema
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Inc shear stress leading to endothelial injury
500mL

21. What happens to lung volumes in obstructive lung disease
Activates bradykinin
Chest pain - tachypnea and dyspnea
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Inc

22. What is virchow's triad
Heparin
CT angio
Stasis - hypercoagulability - endothelial damage
Retinopathy of maturity

23. What happens with the O2 curve shifts to the right and What does it facilitate
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Loss of blood flow - impeded arterial flow - reduced venous drainage
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung

24. 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
CO x O2 content of blood
Stasis - hypercoagulability - endothelial damage
Elastase

25. What is the pathology of ARDS
DIC - especially postpartum
Opposites
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
FEV1/FVC > 80%

26. Why is there eventual loss of capillary beds in emphysema
Type II cells
Steroids to mom - artificial surfactant and thyroxine to neonate
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Lost with alveolar walls

27. What lung abnl is characterized with dec breath sounds - hyperresonance - absent fremitus - towards which side does the trachea deviate
Tension pneumo - away from lesion
Incr - right - dec - left
Respiratory effort against airway obstruction
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane

28. What does CADET face to the right stand for
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
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-
CO2 - acid/altitude - DPG - Exercise - Temperature

29. What is the diffustion formula and what happens to the variables in emphysema and pulmonary fibrosis
Squamous cell carcinoma - keratin pearls and intracellular bridges
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
On expiration as radius dec
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. Susceptibility to what infection is increased in silicosis and why
Respiratory bronchioles - clear debris in alveoli - bronchi
TB - silica disrupt phagolysosomes and impair MACS
Inc shear stress leading to endothelial injury
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis

31. Chronic bronchitis is a disease of what kind of airways
Small airways
P = 2ST/radius
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
Respiratory effort against airway obstruction

32. How does left to right shunt cause pulm HTN
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
Inc shear stress leading to endothelial injury

33. Lung absecss often reults From what organisms
S. aureus or anaerobes
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
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

34. What happens in perfusion limited circulatioin and which gases does this apply to...
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
Type II pneumocytes - after week 35
Squamous cell carcinoma - keratin pearls and intracellular bridges
TB - silica disrupt phagolysosomes and impair MACS

35. What are the risk factors for neonatal RDS
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
Prematurity - maternal RDS - cesarean delivery
Histiocytosis X - Langerhans cells
Loss of elastic fibers

36. What does the law of Laplace state about tendency of alveoli to collapse
On expiration as radius dec
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Low resistance and high compliance
Superior portion of right inferior lobe

37. What happens to diffusing capacity in interstiial lung diseases
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
PAO2 - PaO2 = 10-15 mmHg
Air that moves into lung with each quiet respiration
Lowered

38. What are the lab/study findings in adenocarcinoma of the lung
Air in lung after maxmimal expiration - cannot be measured on spirometry
Clara cells - type II pneumocytes; multiple densitites on CXR
Air that can still be breathed out after nl expiration
Air that moves into lung with each quiet respiration

39. What increases the risk of PDA in neonatal RDS
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Persistently low O2 tension
Heparin
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%

40. What causes neonatal RDS
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Surfactant def leading to inc surfact tension and alveolar collapse
Matched - =1 adequate gas exchange

41. Define physilogic dead space
PVR = (PpulmA - PleftA)/CO
Person stops breathing for at least 10 seconds repeatedly during sleep
Methacholine challenge
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli

42. What properties determine the combined volumes of the chest wall and lungs
Dipalmatoyl phosphatidylcholine
Elastic properties
On expiration as radius dec
Centriacinar

43. What is a potential test for asthma
Incr - right - dec - left
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
Methacholine challenge
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration

44. 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
Right lung - right main stem bronhus is wider and more vertical
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
In between perfusion limited and diffusion limited

45. What are curschmann's spirals
Shed epithelium from mucus plugs
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
Weight loss - CPAP - surgery
Anatomic dead space and smooth muscle

46. In which zone of the lung is Pa > Pv >PA
Zone 3
Alpha1- antitrypsin def - also cirrhosis
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
Inc production

47. What area of the lung is the largest physiologic contributor of fxnal dead space
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Clara cells - type II pneumocytes; multiple densitites on CXR
Apex of healthy lung
Zone 1

48. Define tidal volume (TV)
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Air that moves into lung with each quiet respiration
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
It binds to Hb -

49. What is the equation for physiologic dead space
Persistently low O2 tension
Inc airway pressure to prevent airway collapse during exhalation
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Opposites

50. How does mitral stenosis cause pulm HTN
Dorsiflexion of food leads to tender calf muscle
PVR = (PpulmA - PleftA)/CO
Inc resistance leading to inc pressure
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals