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Respiratory

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Answer 50 questions in 15 minutes.
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1. Where are ventilation and perfusion highest in the lung - respectively
Superior portion of right inferior lobe
Dec - due to lactic acidosis
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Both highest in the base

2. What is the TX for small cell lung cancer
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Inoperable - responsive to chemotherapy
Viral - URIs - allergens and stress
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary

3. What is a consequence of pulm HTN
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage
No respiratory effort
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly

4. What lung abnl is associated with dec breath sounds over lesion - dullness - dec fremitus
Pleural effusion
Dipalmatoyl phosphatidylcholine
Stasis - hypercoagulability - endothelial damage
PVR = (PpulmA - PleftA)/CO

5. Where is cartilage present in the respiratory tree
Trachea and bronchi
Air that can still be breathed out after nl expiration
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Drainage

6. What is the most common cancerous lesion in the lun
Metastasis - breast - colon - prostate - bladder -
Opposites
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy
S. aureus or anaerobes

7. How does recurrent thromboemboli cause pulm HTN
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Inc resistance leading to inc pressure
Dec cross sectional area of pulm vasc bed
Long bone fractures and liposuction

8. If you aspirate a peanut while upright - where will it go
Lower portion of right inferior lobe
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Ratio from apex to base becomes more uniform
L/S > 2 = lecithin/sphingomyelin

9. Define tidal volume (TV)
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Air that moves into lung with each quiet respiration
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
Acetazolamide - inhibits CA and acidifies the blood

10. What changes in V/Q throughout the lung during exercise
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
On expiration as radius dec
Ratio from apex to base becomes more uniform

11. What is the formula for pulm vasc resistance
PVR = (PpulmA - PleftA)/CO
Bleomycin - busulfan - anmiodorone
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)

12. Define residual volume (RV)
Retinopathy of maturity
Air in lung after maxmimal expiration - cannot be measured on spirometry
Heparin
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude

13. What can amniotic fluid emboli lead to...
DIC - especially postpartum
IRV + TV
CO - 200x
Inc airway pressure to prevent airway collapse during exhalation

14. What happens to O2 content and O2 sat as Hb falls
Lost with alveolar walls
Dec - no change
Right
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen

15. What increases the risk of PDA in neonatal RDS
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Brings air in and out - warms - humidifies - filters
Persistently low O2 tension

16. What is tha hallmark finding of COPD
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia
Dec in the FEV1/FVC
No respiratory effort
Squamous cell carcinoma - keratin pearls and intracellular bridges

17. What is the characteristic lymphatic pleural effusion
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
Milky fluid with inc TGs
Dec - due to lactic acidosis

18. What is the presentation of lung cancer

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19. What enzyme increases activity in emphysema
Respiratory effort against airway obstruction
Inc mitochondria
Inspiration by diaphragm - expiration is passive
Elastase

20. In emphysema - What is increased lung compliance due to...
Dipalmatoyl phosphatidylcholine
Loss of elastic fibers
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Adenocarcinoma of the lung - bronchioalveolar - hypertrophic osteoarthropathy

21. Which pts are at risk for apriation PNA
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents
Ratio from apex to base becomes more uniform
Alchoholics or epileptics
Inc 2 -3- DPG - righward shift

22. What are the findings of chronic bronchitis
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Type II cells
Trachea and bronchi
Asbestos bodies are golden brown fusiform rods resembling dumbells located inside macrophages - shipbuilding - roofing - and plumbing

23. What is the relation fo the pulmonary artery to the bronchus at each lung hilus
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
RALS - righ anterior - left superior
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways

24. What are the findings associated with sarcoidosis
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Chronic hypoxic vasocxn
Upper lobes
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

25. Define inspiratory capacity (IC)
0 - negative - prevents pneumothorax
RV + ERV - volume in lungs after nl expiration
Inc shear stress leading to endothelial injury
IRV + TV

26. What is the pathology of chronic bronchitis
Everything but RV - TV + IRV + ERV
Upper lobes - cor pulmonale - caplan's syndrome
Loss of elastic fibers
Hypertrophy of mucus secreting glands in the bronchioles

27. Which has a greater affinity for hemoglobin - CO or O2 and by how much
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Airways close prematurely resulting in inc RV and dec FVC
CO - 200x
Deep leg veins

28. What are the 3 reasons for an increased A- a gradient
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Inc mitochondria
Steroids to mom - artificial surfactant and thyroxine to neonate

29. What is the formula for collapsing pressure
Type II cells
P = 2ST/radius
Prostaglandins - histamine - ACE - kallikrein
Weight loss - CPAP - surgery

30. What are mucus secretion swept out by
Ciliated cells
Weight loss - CPAP - surgery
Loss of elastic fibers
High alveolar pressure compresses capillaries

31. What happens in perfusion limited circulatioin and which gases does this apply to...
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Inc to meet O2 demand
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
More indolent

32. What lung abnl is associated with bronchial breath sounds over lesion - dullness and increased fremitus
Lung cancer
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
FEV1/FVC > 80%
Lobar PNA

33. What cells in the lung produce surfactant and What does it do
DIC - especially postpartum
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
4 polypeptide subunits - 2 alpha and 2 beta
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration

34. What are the 3 forms that CO2 is transported from tissues to lungs
Bicarb (90%) - bound to globin (5%) and dissolved (5%)
Apex of healthy lung
Lowered
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals

35. In COPD - what happens to airways at high lung volumes
Inc airway pressure to prevent airway collapse during exhalation
Airways close prematurely resulting in inc RV and dec FVC
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
L/S > 2 = lecithin/sphingomyelin

36. What is methemoglobin
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Air that can still be breathed out after nl expiration
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
Superior portion of right inferior lobe

37. What changes in O2 consumption change during exercise
More indolent
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Inc O2 consumption
RV + ERV - volume in lungs after nl expiration

38. What muscles are involved in breathing during exercise and What do they control
Defect in coagulative cascace proteins
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Respiratory bronchioles - clear debris in alveoli - bronchi
Inc airway pressure to prevent airway collapse during exhalation

39. Define total lung capcaity
Prostaglandins - histamine - ACE - kallikrein
Shed epithelium from mucus plugs
Bullae - rupture leading to spontaneous pneumothorax often in young - otherwise healthy males
IRV + TV + ERV + RV

40. Why do pts with emphysema exhale through pursed lips
Inc airway pressure to prevent airway collapse during exhalation
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals
500mL

41. What causes neonatal RDS
Inc excretion of bicarb to compensate for respiratory alkalosis
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Fe 2+
Surfactant def leading to inc surfact tension and alveolar collapse

42. Other than surfactant - what other important substances are produced by the lungs
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
20.1 mL O2 /dL
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Prostaglandins - histamine - ACE - kallikrein

43. What doe FAT BAT stand for
Zone 3
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types
Clara cells - type II pneumocytes; multiple densitites on CXR
Retinopathy of maturity

44. What happens to FEV1 and FVC in both obstructive and restrictive lung disease and What is the difference
Hypertrophy of mucus secreting glands in the bronchioles
<75
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries

45. What are clara cells What is their morphology and What do they do
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Metastasis - breast - colon - prostate - bladder -

46. What is virchow's triad
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Stasis - hypercoagulability - endothelial damage
L/S < 1.5

47. Why is endothelial damage a risk factor for DVT
Clara cells - type II pneumocytes; multiple densitites on CXR
Inc excretion of bicarb to compensate for respiratory alkalosis
Exposed collagen fibers provides impetus for clotting cascade
Pa > PA > Pv

48. What is a potential test for asthma
Everything but RV - TV + IRV + ERV
Methacholine challenge
Gland depth/total thickness of broncial wall - >50%
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death

49. What is are the symptoms of a pulmonary embolism
Inc O2 consumption
Bronchial obstruction - toward side of lesion
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Chest pain - tachypnea and dyspnea

50. What kind of course does interstitial PNA follow in comparison to bronchoPNA
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
On expiration as radius dec
Type II pneumocytes - after week 35
More indolent

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Respiratory

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