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Respiratory

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Answer 50 questions in 15 minutes.
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1. What are the lab/study findings in adenocarcinoma of the lung
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes
Clara cells - type II pneumocytes; multiple densitites on CXR
Airway obstruction (shunt) 100% O2 does not improve PO2
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

2. What are curschmann's spirals
RALS - righ anterior - left superior
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Shed epithelium from mucus plugs

3. What organisms cause interstitial PNA and What are the characteristics
Prostaglandins - histamine - ACE - kallikrein
It binds to Hb -
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
Right shift - favors taut - low affinity for O2 - O2 unloading

4. What layers must CO2 and O2 traverse to complete gas exchange
L/S < 1.5
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
S. aureus or anaerobes
High alveolar pressure compresses capillaries

5. What kind of space is in the conducting tree and what kind of muscle exists there
Viral - URIs - allergens and stress
Anatomic dead space and smooth muscle
Methylene blue
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes

6. What do type II cells do - What is their morphology - when do they proliferate
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
DIC - especially postpartum
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage

7. Define residual volume (RV)
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Productive cough for greater than 3 months in at least 2 years
Airways close prematurely resulting in inc RV and dec FVC
Air in lung after maxmimal expiration - cannot be measured on spirometry

8. What is the main complication of therapeutic supplemental O2?
Lost with alveolar walls
L/S > 2 = lecithin/sphingomyelin
Retinopathy of maturity
Mesothelioma - pleura - psammoma bodies

9. What are the findings in asthma
CO2 - acid/altitude - DPG - Exercise - Temperature
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Shed epithelium from mucus plugs
In between perfusion limited and diffusion limited

10. Define total lung capcaity
<60
PAO2 - PaO2 = 10-15 mmHg
IRV + TV + ERV + RV
P = 2ST/radius

11. Where do you find type I cells - What is their morphology - and What do they do
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Hypertrophy of mucus secreting glands in the bronchioles
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Inc O2 consumption

12. What happens to arterial PO2 in chronic lung disease and why
Dorsiflexion of food leads to tender calf muscle
Milky fluid with inc TGs
Shunting
Dec - because physiologic shunt dec O2 extraction from ratio

13. What is a potential test for asthma
It binds to Hb -
Dec - no change
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

14. What kind of course does interstitial PNA follow in comparison to bronchoPNA
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Incr - right - dec - left
More indolent
RALS - righ anterior - left superior

15. What kind of pleural plaques are the result of asbestosis
Bicarb/Cl - exchanger - brings a Cl - into the RBC and expels bicarb into the serum
Ivory white calcified pleural plaques
Repeated cycles of lung injury and wound healing with inc collagen
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest

16. What cellular changes occur at high altitude
Squamous cell carcinoma - keratin pearls and intracellular bridges
Inc mitochondria
Small airways
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2

17. What are mucus secretion swept out by
Hypoxic vasocxn
Dipalmatoyl phosphatidylcholine
Viral - URIs - allergens and stress
Ciliated cells

18. What are the potential causes of poor breathing mechanics leading to restrictive lung disease - and What are examples in each
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals
Repeated cycles of lung injury and wound healing with inc collagen
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways

19. What is another name for neonatal RDS
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Hyaline membrane disease

20. What is a chronic complication of sleep apnea
Chroniclly tired
Fe 2+
Inc resistance leading to inc pressure
Dec - no change

21. What is the pathology of bronchiectasis
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Loss of elastic fibers
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Defect in coagulative cascace proteins

22. What organism causes a lobar PNA and What are the characteristics
Air that moves into lung with each quiet respiration
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Histiocytosis X - Langerhans cells

23. What is the Reid index and what perfectange is characteristic of chronic bronchitis
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Inc EPO leading to erythrocytosis
Gland depth/total thickness of broncial wall - >50%
Inc 2 -3- DPG - righward shift

24. What effects do O2 and CO2 have on pulm circulation - in relation to the other
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
No change - but inc venous CO2 content
Hypertrophy of mucus secreting glands in the bronchioles
Opposites

25. What changes at high altitude can result in RVH
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Airways close prematurely resulting in inc RV and dec FVC
Chronic hypoxic vasocxn

26. Why is cesarean delivery a risk factor for neonatal RDS
Dec release of fetal glucocorticoids
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Air in excess of tidal volume that moves into lung on maximal inspiration
L/S > 2 = lecithin/sphingomyelin

27. What is the relation fo the pulmonary artery to the bronchus at each lung hilus
Mesothelioma - pleura - psammoma bodies
RALS - righ anterior - left superior
Surfactant def leading to inc surfact tension and alveolar collapse
Dec

28. What is the course of of pulm HTN
Respiratory effort against airway obstruction
Steroids to mom - artificial surfactant and thyroxine to neonate
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Drainage

29. How far to the pseudostratified ciliated columnar epithelium extend - What do MACS do in the alveoli - and how far do the goblet cells extend
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
Viral - URIs - allergens and stress
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Respiratory bronchioles - clear debris in alveoli - bronchi

30. Where do 95% of PE arise from
4 polypeptide subunits - 2 alpha and 2 beta
Deep leg veins
Dec dec in FEV1 - dec in FVC
Hyaline membrane disease

31. What is used to treat methemoglobin
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Methylene blue
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries

32. What is the pathology of emphysema
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Ciliated cells
Surfactant

33. What is the formula for O2 content
Milky fluid with inc TGs
O2 binding x O2 sat + dissolved O2
Shunting
Weight loss - CPAP - surgery

34. What does the law of Laplace state about tendency of alveoli to collapse
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Inspiration by diaphragm - expiration is passive
Inc 2 -3- DPG - righward shift
On expiration as radius dec

35. Why do pts with emphysema exhale through pursed lips
IRV + TV + ERV + RV
Dipalmatoyl phosphatidylcholine - decreases surface tension
Inc airway pressure to prevent airway collapse during exhalation
P = 2ST/radius

36. What changes in lung volunes occur as a result of restrictive lung disease
Methylene blue
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Dec in lung volumes - FVC - TLC
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)

37. What changes occur to PaO2 and PaCO2
Deep leg veins
Dipalmatoyl phosphatidylcholine - decreases surface tension
No change - but inc venous CO2 content
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

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

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39. What findings are associated with emphysema
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Pa > PA > Pv
Airways close prematurely resulting in inc RV and dec FVC
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung

40. What are the 3 forms that CO2 is transported from tissues to lungs
Bicarb (90%) - bound to globin (5%) and dissolved (5%)
L/S < 1.5
Lungs collapse inwards and chest wall spring out
Airway obstruction (shunt) 100% O2 does not improve PO2

41. What is the formula for resistance
RV + ERV - volume in lungs after nl expiration
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Opposites
CO2 - acid/altitude - DPG - Exercise - Temperature

42. What accounts for the sigmoid shaped O2 dissociation curve with hemoglobin
Positive cooperativity and negative allostery - unlike myoglobin
Repeated cycles of lung injury and wound healing with inc collagen
Zone 3
Lowered

43. What lung abnl is associated with bronchial breath sounds over lesion - dullness and increased fremitus
Respiratory effort against airway obstruction
Lowered
Lobar PNA
Zone 3

44. In which zone of the lung is PA > Pa > Pv
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Dec - no change
Zone 1
Clara cells - type II pneumocytes; multiple densitites on CXR

45. What cells make surfactant and At what week is produced most abundantly
Type II cells
Type II pneumocytes - after week 35
Dec - due to lactic acidosis
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange

46. In emphysema - What is increased lung compliance due to...
Heparin
Brings air in and out - warms - humidifies - filters
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Loss of elastic fibers

47. What is the pathology of asthma

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48. What is positive cooperativity of hemoglobin refer to...
S. aureus or anaerobes
Right lung - right main stem bronhus is wider and more vertical
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes

49. What lab ration indicates fetal lung maturity
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
Ivory white calcified pleural plaques
Chroniclly tired
L/S > 2 = lecithin/sphingomyelin

50. What happens to V/Q ratio in COPD
Mismatch
Matched - =1 adequate gas exchange
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
Heparin

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