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Respiratory

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. What is the order of decreasing pressures among the alveola - capillaries and veins in zone 2 of the lungs
Prematurity - maternal RDS - cesarean delivery
Pa > PA > Pv
Drainage
Positive cooperativity and negative allostery - unlike myoglobin

2. What TX is the mother given before delivery - and what TXs are given to the infant
Dorsiflexion of food leads to tender calf muscle
Steroids to mom - artificial surfactant and thyroxine to neonate
Small cell (oat cell) carcinoma - neoplasm of neuroendocrine with Kultchitsky cells (small dark blue cells)
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries

3. What is the pathology of ARDS
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Air in excess of tidal volume that moves into lung on maximal inspiration
Loss of blood flow - impeded arterial flow - reduced venous drainage
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane

4. What changes in EPO occur at high altitude
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
PVR = (PpulmA - PleftA)/CO
S. aureus - H flu - Klebsiella - S pyogenis; acute inflmmatory infiltrates from bronchioles into adjacent alveoli; pathy distribution involving 1 or more lobes

5. How does sleep apnea or high altitude cause pulm HTN
P = 2ST/radius
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Hypoxic vasocxn
Bleomycin - busulfan - anmiodorone

6. What changes in V/Q throughout the lung during exercise
Steroids to mom - artificial surfactant and thyroxine to neonate
Exposed collagen fibers provides impetus for clotting cascade
Weight loss - CPAP - surgery
Ratio from apex to base becomes more uniform

7. Define physilogic dead space
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
Fe 2+
Dec release of fetal glucocorticoids
Right lung - right main stem bronhus is wider and more vertical

8. If you aspirate a peanut while supine - where will it go
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Superior portion of right inferior lobe
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Surfactant def leading to inc surfact tension and alveolar collapse

9. What happens as a result of hypoxia in sleep apnea
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage
O2 binding x O2 sat + dissolved O2
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Inc EPO leading to erythrocytosis

10. What are the two forms of hemoglobin
Inc
It binds to Hb -
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
Dec cross sectional area of pulm vasc bed

11. What is the definition of sleep apnea
Person stops breathing for at least 10 seconds repeatedly during sleep
TB - apex
IRV + TV + ERV + RV
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

12. 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
Prostaglandins - histamine - ACE - kallikrein
Alpha1- antitrypsin def - also cirrhosis
Inc

13. Where does exercise sit on the graph of PaO2 vs length along the pulm capillary
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types
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
In between perfusion limited and diffusion limited
Tissue hypoxia from dec O2 sat and dec O2 content

14. Define residual volume (RV)
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Air in lung after maxmimal expiration - cannot be measured on spirometry
Dec release of fetal glucocorticoids
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)

15. What happens to lung volumes in obstructive lung disease
Heart
Anatomic dead space and smooth muscle
Shed epithelium from mucus plugs
Inc

16. In COPD - what happens to airways at high lung volumes
PVR = (PpulmA - PleftA)/CO
Gland depth/total thickness of broncial wall - >50%
Airways close prematurely resulting in inc RV and dec FVC
Defect in coagulative cascace proteins

17. What are mucus secretion swept out by
Inc protein - cloudy content - malignancy - PNA - collagen vascular dz - trauma
Upper lobes
Inc to meet O2 demand
Ciliated cells

18. What does the respiratory zone consist of and What is its fxn
Airways close prematurely resulting in inc RV and dec FVC
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Inspiration by diaphragm - expiration is passive

19. Define functional residual capacity (FRC)
Hypertrophy of mucus secreting glands in the bronchioles
RV + ERV - volume in lungs after nl expiration
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane

20. Which structures perforate the diaphragm and where
Dec in lung volumes - FVC - TLC
Mesothelioma - pleura - psammoma bodies
Lowered
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12

21. What is the response for ventilation of high altitude
Acute/chronic inc in vent
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
High alveolar pressure compresses capillaries
Dipalmatoyl phosphatidylcholine - decreases surface tension

22. What are the causes of hypoxia
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Right shift - favors taut - low affinity for O2 - O2 unloading
Low resistance and high compliance

23. What is the formula for resistance
Loss of elastic fibers
Bronchial obstruction - CF - poor ciliary motility - Kartagener's syndrome - and the potential to develop aspergillosis
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius

24. Lung absecss often reults From what organisms
500mL
Alchoholics or epileptics
Retinopathy of maturity
S. aureus or anaerobes

25. What kind of connection exists between endothelial cells in the capilaries
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
Fe 2+
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
Tight jxns

26. Where are ventilation and perfusion highest in the lung - respectively
IVC at T8 - esophagus and vagus at T10 - aorta - thoracic ducts - azygous at T12 - I ate 10 eggs at 12
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
500mL
Both highest in the base

27. What does alveolar pressure do to capillaries in the apex of the lung
High alveolar pressure compresses capillaries
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Heart
Productive cough for greater than 3 months in at least 2 years

28. Susceptibility to what infection is increased in silicosis and why
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation
Oxidized form of hemoglobin (ferric - Fe 3+) that does not bind O2 as readily - but has high affinity for CN-
TB - silica disrupt phagolysosomes and impair MACS
Zone 3

29. What is a potential test for asthma
Methacholine challenge
CO2 - acid/altitude - DPG - Exercise - Temperature
Exposed collagen fibers provides impetus for clotting cascade
Defect in coagulative cascace proteins

30. At what PaO2 does hypoxemia begin
<75
Carcinoid - carcinoid
Apex of healthy lung
Mismatch

31. What is the alveolar gas equation approximation
Air that can still be breathed out after nl expiration
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Shunting
PA02 = 150 - PACO2/0.8

32. What does the oxygenation of Hb in the lungs do to the equilibirum of the CA rxn
Inc shear stress leading to endothelial injury
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Histiocytosis X - Langerhans cells
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation

33. What lung product is deficient in neonatal RDS
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Surfactant
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
PA02 = 150 - PACO2/0.8

34. What is a particular cause of eosinophilic granulomas - and what cells infiltrate
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Histiocytosis X - Langerhans cells
Bronchial obstruction - toward side of lesion
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy

35. What is virchow's triad
Ivory white calcified pleural plaques
Pa > PA > Pv
Stasis - hypercoagulability - endothelial damage
Steroids to mom - artificial surfactant and thyroxine to neonate

36. Which pts are at risk for apriation PNA
Alchoholics or epileptics
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
Zone 3
Right lung - right main stem bronhus is wider and more vertical

37. Which lung is the more common site for an inhaled foreign body and why
Tight jxns
Chest pain - tachypnea and dyspnea
Right lung - right main stem bronhus is wider and more vertical
Superior portion of right inferior lobe

38. What is the course of of pulm HTN
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
Person stops breathing for at least 10 seconds repeatedly during sleep
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale

39. What does PFTs show in COPD
Viral - URIs - allergens and stress
Dec dec in FEV1 - dec in FVC
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Steroids to mom - artificial surfactant and thyroxine to neonate

40. What do PFTs show in restrictive lung disease
Everything but RV - TV + IRV + ERV
FEV1/FVC > 80%
Hypoxic vasocxn shifts blood away from poorly ventilated regions of lung to well ventilated regions of lung
Dec in lung volumes - FVC - TLC

41. What is pulmonary surfactant made of - and What does it do
Dipalmatoyl phosphatidylcholine - decreases surface tension
DIC - especially postpartum
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
Type II pneumocytes - after week 35

42. What is the criteria for chronic bronchitis
Deoxygenated blood - elastic walls
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Productive cough for greater than 3 months in at least 2 years
Alchoholics or epileptics

43. What is the formula for collapsing pressure
P = 2ST/radius
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Acetazolamide - inhibits CA and acidifies the blood
Brings air in and out - warms - humidifies - filters

44. How does mitral stenosis cause pulm HTN
Inc 2 -3- DPG - righward shift
Airways close prematurely resulting in inc RV and dec FVC
Inc resistance leading to inc pressure
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound

45. In what cells do you find lamellar bodies
Air that can still be breathed out after nl expiration
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Type II cells
Inoperable - responsive to chemotherapy

46. What organism causes a lobar PNA and What are the characteristics
TB - silica disrupt phagolysosomes and impair MACS
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor

47. What happens in diffiusion limited pulmonary circulation and what gases does this apply to...
Acetazolamide - inhibits CA and acidifies the blood
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
FEV1/FVC > 80%
Upper lobes - cor pulmonale - caplan's syndrome

48. What is used to treat CN poisoning and why
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
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Superior portion of right inferior lobe

49. In which zone of the lung is PA > Pa > Pv
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
Pa > PA > Pv
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
Zone 1

50. What is surfactant made of...
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Deep leg veins
Dipalmatoyl phosphatidylcholine
Hypoxemia because of shunting - V/Q mistmatch - fibrosis