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Respiratory

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Answer 50 questions in 15 minutes.
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1. At What terminal does CO2 bind the globin molecule
RV + ERV - volume in lungs after nl expiration
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Retinopathy of maturity
N- terminus - carbaminohemoglobin

2. What are the findings of chronic bronchitis
Right
Exposed collagen fibers provides impetus for clotting cascade
Gland depth/total thickness of broncial wall - >50%
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater

3. What are the various causes of ARDS
Positive cooperativity and negative allostery - unlike myoglobin
Prostaglandins - histamine - ACE - kallikrein
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Apex of healthy lung

4. What is the diffustion formula and what happens to the variables in emphysema and pulmonary fibrosis
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Ratio from apex to base becomes more uniform
Right shift - favors taut - low affinity for O2 - O2 unloading

5. What renal changes occur at high altitude and What are they compensating for
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
Retinopathy of maturity
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Inc excretion of bicarb to compensate for respiratory alkalosis

6. What are the potential TX for sleep apnea
Exposed collagen fibers provides impetus for clotting cascade
Air in excess of tidal volume that moves into lung on maximal inspiration
Lobar PNA
Weight loss - CPAP - surgery

7. What is the imaging test of choice for PE
CT angio
Dec dec in FEV1 - dec in FVC
Inc O2 consumption
Fe 2+

8. Define inspiratory reserve volume (IRV)
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Air in excess of tidal volume that moves into lung on maximal inspiration
Dipalmatoyl phosphatidylcholine
Inc shear stress leading to endothelial injury

9. What does CADET face to the right stand for
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
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
Upper lobes
CO2 - acid/altitude - DPG - Exercise - Temperature

10. What is another name for neonatal RDS
500mL
Tension pneumo - away from lesion
Hyaline membrane disease
Methylene blue

11. What direction does an increase in metabolic need shift the O2 dissociation curve
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Mismatch
Right
CO x O2 content of blood

12. Define inspiratory capacity (IC)
Repeated cycles of lung injury and wound healing with inc collagen
IRV + TV
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
Inc

13. What is positive cooperativity of hemoglobin refer to...
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Lungs collapse inwards and chest wall spring out

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
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Respiratory bronchioles - clear debris in alveoli - bronchi
Shed epithelium from mucus plugs

15. Which structures perforate the diaphragm and where
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Carcinoid - carcinoid
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
Retinopathy of maturity

16. What is the order of decreasing pressures among the alveola - capillaries and veins in zone 2 of the lungs
No change - but inc venous CO2 content
O2 binding x O2 sat + dissolved O2
Pa > PA > Pv
Viral - URIs - allergens and stress

17. Malignancy associated with asbestosis - results in hemorrhagic effusions and pleural thickening - cancer - location - histo finding
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Acetazolamide - inhibits CA and acidifies the blood
Mesothelioma - pleura - psammoma bodies
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance

18. Define total lung capcaity
Lost with alveolar walls
IRV + TV + ERV + RV
Viral - URIs - allergens and stress
Lungs collapse inwards and chest wall spring out

19. What is nl pulmonary artery pressure and At what point is it considered pulm HTN
Right shift - favors taut - low affinity for O2 - O2 unloading
Opposites
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise

20. Which pts are at risk for apriation PNA
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Alchoholics or epileptics
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis

21. Susceptibility to what infection is increased in silicosis and why
Trachea and bronchi
Shed epithelium from mucus plugs
TB - silica disrupt phagolysosomes and impair MACS
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema

22. If you aspirate a peanut while upright - where will it go
Lower portion of right inferior lobe
Right
Bicarb (90%) - bound to globin (5%) and dissolved (5%)
More indolent

23. What is central sleep apnea
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
No respiratory effort
Weight loss - CPAP - surgery

24. What is the ideal V/Q ratio and why
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
Matched - =1 adequate gas exchange
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12

25. What changes in O2 consumption change during exercise
Lungs collapse inwards and chest wall spring out
Inc O2 consumption
Chronic hypoxic vasocxn
Histiocytosis X - Langerhans cells

26. What does the combination of increased CO2 and increased proton binding do to the O2 dissociation curve
Dec in the FEV1/FVC
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Brings air in and out - warms - humidifies - filters
Right shift - favors taut - low affinity for O2 - O2 unloading

27. What are fat emboli associated with
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Bicarb (90%) - bound to globin (5%) and dissolved (5%)
Long bone fractures and liposuction
No respiratory effort

28. What is the Reid index and what perfectange is characteristic of chronic bronchitis
Loss of blood flow - impeded arterial flow - reduced venous drainage
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing
Gland depth/total thickness of broncial wall - >50%
Deep leg veins

29. What is the TX for small cell lung cancer
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia
Air that moves into lung with each quiet respiration
Inoperable - responsive to chemotherapy

30. Toxicities of what drugs include interstitial lung disease
Productive cough for greater than 3 months in at least 2 years
Bleomycin - busulfan - anmiodorone
Mismatch
<60

31. What is the characteristic lymphatic pleural effusion
Milky fluid with inc TGs
Shed epithelium from mucus plugs
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
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange

32. What is the criteria for chronic bronchitis
Inc resistance leading to inc pressure
Productive cough for greater than 3 months in at least 2 years
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Elastase

33. What are the SPHERE of complications in lung cancer
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
Heart
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)

34. What is methemoglobin
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Brings air in and out - warms - humidifies - filters
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Acetazolamide - inhibits CA and acidifies the blood

35. What is the pathology of chronic bronchitis
Prostaglandins - histamine - ACE - kallikrein
Hypertrophy of mucus secreting glands in the bronchioles
Both highest in the base
Air that moves into lung with each quiet respiration

36. What does alveolar pressure do to capillaries in the apex of the lung
Tight jxns
500mL
High alveolar pressure compresses capillaries
Pleural effusion

37. What changes in ventilation rate occur during exercise
Inc production
Acetazolamide - inhibits CA and acidifies the blood
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Inc to meet O2 demand

38. What is the formula for pulm vasc resistance
Carcinoid - carcinoid
PVR = (PpulmA - PleftA)/CO
Ratio from apex to base becomes more uniform
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells

39. What lobes does Coal Miner's pneumoconioses affect - and What can it result in

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40. What is the pathology of emphysema
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
TB - silica disrupt phagolysosomes and impair MACS
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Superior portion of right inferior lobe

41. What organisms cause a bronchoPNA and What are the characteristics
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
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)

42. What is a particular cause of eosinophilic granulomas - and what cells infiltrate
Histiocytosis X - Langerhans cells
Incr - right - dec - left
Chroniclly tired
Anatomic dead space and smooth muscle

43. What is virchow's triad
Low resistance and high compliance
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Stasis - hypercoagulability - endothelial damage
Activates bradykinin

44. What does kallikrein do
Superior portion of right inferior lobe
Activates bradykinin
Drainage
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents

45. What lung product is deficient in neonatal RDS
Surfactant
Inc mitochondria
4 polypeptide subunits - 2 alpha and 2 beta
Positive cooperativity and negative allostery - unlike myoglobin

46. How does left to right shunt cause pulm HTN
Inc shear stress leading to endothelial injury
Tissue hypoxia from dec O2 sat and dec O2 content
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage
Chronic hypoxic vasocxn

47. How does mitral stenosis cause pulm HTN
Lungs collapse inwards and chest wall spring out
Inc resistance leading to inc pressure
Methylene blue
Retinopathy of maturity

48. What can amniotic fluid emboli lead to...
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Centriacinar
Histiocytosis X - Langerhans cells
DIC - especially postpartum

49. What area of the lung is the largest physiologic contributor of fxnal dead space
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
Dec cross sectional area of pulm vasc bed
Zone 1
Apex of healthy lung

50. 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
Shed epithelium from mucus plugs
Upper lobes - cor pulmonale - caplan's syndrome
Steroids to mom - artificial surfactant and thyroxine to neonate

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