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Respiratory

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Answer 50 questions in 15 minutes.
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1. What organism thrives in high O2 and where in the lung does it flourish
S. aureus or anaerobes
Hypoxic vasocxn
TB - apex
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways

2. Why is endothelial damage a risk factor for DVT
Anatomic dead space and smooth muscle
Everything but RV - TV + IRV + ERV
Hypertrophy of mucus secreting glands in the bronchioles
Exposed collagen fibers provides impetus for clotting cascade

3. What does the combination of increased CO2 and increased proton binding do to the O2 dissociation curve
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Right shift - favors taut - low affinity for O2 - O2 unloading
More indolent

4. What do hemoglobin modifacations lead to...
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
0 - negative - prevents pneumothorax
Air that moves into lung with each quiet respiration
Tissue hypoxia from dec O2 sat and dec O2 content

5. If you aspirate a peanut while supine - where will it go
Both highest in the base
Long bone fractures and liposuction
Superior portion of right inferior lobe
PAO2 - PaO2 = 10-15 mmHg

6. What is a consequence of pulm HTN
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Inc resistance leading to inc pressure
Loss of blood flow - impeded arterial flow - reduced venous drainage
Inoperable - responsive to chemotherapy

7. What does ACE do
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Mesothelioma - pleura - psammoma bodies
CO2 - acid/altitude - DPG - Exercise - Temperature

8. Peripheral mass develops in site of prior pulmonary inflammation or injury - cancer and epi
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers
Weight loss - CPAP - surgery
It binds to Hb -
Hypoxic vasocxn

9. What changes in V/Q throughout the lung during exercise
Deoxygenated blood - elastic walls
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
Ratio from apex to base becomes more uniform

10. Malignancy associated with asbestosis - results in hemorrhagic effusions and pleural thickening - cancer - location - histo finding
Mesothelioma - pleura - psammoma bodies
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Lungs collapse inwards and chest wall spring out
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale

11. What is the formula for A- a gradient - and What is it normally
Bronchial obstruction - toward side of lesion
Dec - due to lactic acidosis
PAO2 - PaO2 = 10-15 mmHg
Superior portion of right inferior lobe

12. What causes neonatal RDS
Stasis - hypercoagulability - endothelial damage
Methylene blue
<75
Surfactant def leading to inc surfact tension and alveolar collapse

13. What is a chronic complication of sleep apnea
Chroniclly tired
Persistently low O2 tension
Inc production
Respiratory bronchioles - clear debris in alveoli - bronchi

14. What changes at high altitude can result in RVH
Ratio from apex to base becomes more uniform
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
Surfactant def leading to inc surfact tension and alveolar collapse
Chronic hypoxic vasocxn

15. How happens to the proton from the rxn the created bicarb
It binds to Hb -
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
TB - silica disrupt phagolysosomes and impair MACS
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly

16. What are the 3 forms that CO2 is transported from tissues to lungs
Bicarb (90%) - bound to globin (5%) and dissolved (5%)
Squamous cell carcinoma - keratin pearls and intracellular bridges
PA02 = 150 - PACO2/0.8
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2

17. What does CADET face to the right stand for
Viral - URIs - allergens and stress
Inc resistance leading to inc pressure
Loss of elastic fibers
CO2 - acid/altitude - DPG - Exercise - Temperature

18. In which zone of the lung is PA > Pa > Pv
Zone 1
Clara cells - type II pneumocytes; multiple densitites on CXR
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
Exposed collagen fibers provides impetus for clotting cascade

19. What causes primary pulm HTN
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Low resistance and high compliance
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis

20. In emphysema - What is increased lung compliance due to...
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
Inc O2 consumption
Loss of elastic fibers
Tissue hypoxia from dec O2 sat and dec O2 content

21. How do you prevent DVT
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
Heparin
Inc 2 -3- DPG - righward shift
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale

22. What kind of space is in the conducting tree and what kind of muscle exists there
Right lung = 3 lobes - left lung = 2 lobes; lingula is homologue of right middle lobe in the left lung
Prematurity - maternal RDS - cesarean delivery
Inoperable - responsive to chemotherapy
Anatomic dead space and smooth muscle

23. increases In what substances favor the taut form of hemoglobin and which direction does that shift the O2 dissociation curve
C3 - 4 - 6 - phrenic nerve - referred to shoulder
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy

24. Why is there eventual loss of capillary beds in emphysema
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Mismatch
Lost with alveolar walls
Type II pneumocytes - after week 35

25. What is carboxyhemoglobin and What does it cause
CO2 - acid/altitude - DPG - Exercise - Temperature
Form of hemoglobin bound to CO in place of O2 - causes dec O2 binding capacituy with a left shift in the O2 hemoglobin dissociation curve - dec unloading in tissues
Long bone fractures and liposuction
Prostaglandins - histamine - ACE - kallikrein

26. What lung abnl is characterized with dec breath sounds - hyperresonance - absent fremitus - towards which side does the trachea deviate
Surfactant def leading to inc surfact tension and alveolar collapse
Retinopathy of maturity
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude
Tension pneumo - away from lesion

27. What is the tendency of the lungs vs the chest wall
PVR = (PpulmA - PleftA)/CO
Large cell carcinoma - pleomorphic giant cells with leukocyte fragments in cytoplasm - removed surgically and less responsive to chemotherapy
Lungs collapse inwards and chest wall spring out
TB - silica disrupt phagolysosomes and impair MACS

28. What happens in diffiusion limited pulmonary circulation and what gases does this apply to...
Right shift - favors taut - low affinity for O2 - O2 unloading
Inc EPO leading to erythrocytosis
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

29. What do PFTs show in restrictive lung disease
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Inc 2 -3- DPG - righward shift
FEV1/FVC > 80%
Hypoxemia because of shunting - V/Q mistmatch - fibrosis

30. What does kallikrein do
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Activates bradykinin
Pleural effusion
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells

31. What are mucus secretion swept out by
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly
Ciliated cells
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema

32. What changes in EPO occur at high altitude
Chroniclly tired
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Cough - hemoptysis - bronchial obstruction - wheezing - pneumonic 'coin' lesion on xray or noncalcefied nodule on CT
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia

33. What is the relation fo the pulmonary artery to the bronchus at each lung hilus
Methacholine challenge
RALS - righ anterior - left superior
Chest pain - tachypnea and dyspnea
Poor muscular effort - polio - myasthenia gravis; poor structural apparatus - scoliosis - morbid obesity

34. Define expiratory reserve volume (ERV)
Pa > PA > Pv
TB - apex
Air that can still be breathed out after nl expiration
Heparin

35. Define functional residual capacity (FRC)
RV + ERV - volume in lungs after nl expiration
Apex of healthy lung
Dec affinity of hemoglobin for O2 - facilates unloading of O2 to tissue
Adenocarcinoma of lung - bronchial - most common cancer in females and non smokers

36. In which zone of the lung is Pa > Pv >PA
RV + ERV - volume in lungs after nl expiration
Incr - right - dec - left
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
Zone 3

37. What reaction and enzyme create bicarb and Where does it happen
Upper lobes
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
High alveolar pressure compresses capillaries
Defect in coagulative cascace proteins

38. 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
Alpha1- antitrypsin def - also cirrhosis
Steroids to mom - artificial surfactant and thyroxine to neonate
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed

39. At what PaO2 does hypoxemia begin
<75
Repeated cycles of lung injury and wound healing with inc collagen
Trauma - sepsis - shock - gastric aspiration - uremia - acute pancreatitis - amniotic fluid embolism
Inc to meet O2 demand

40. What changes occur to pulm blood flow during exercise
Inc due to inc CO
Type II cells
L/S < 1.5
Incr - right - dec - left

41. What is the imaging test of choice for PE
500mL
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
CT angio
IRV + TV + ERV + RV

42. What is the pathology of chronic bronchitis
Airways close prematurely resulting in inc RV and dec FVC
Persistently low O2 tension
Hypertrophy of mucus secreting glands in the bronchioles
Squamous cell carcinoma - keratin pearls and intracellular bridges

43. How does autoimmune dz cause thromboemboli
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Matched - =1 adequate gas exchange
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2

44. What are the two forms of hemoglobin
Inc mitochondria
Positive cooperativity and negative allostery - unlike myoglobin
Deep leg veins
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)

45. What is obstructive sleep apnea
Right
Respiratory effort against airway obstruction
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Dec - no change

46. What happens in perfusion limited circulatioin and which gases does this apply to...
P = 2ST/radius
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
4 polypeptide subunits - 2 alpha and 2 beta
PAO2 - PaO2 = 10-15 mmHg

47. What is a potential test for asthma
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
Elastic properties
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Methacholine challenge

48. What are the subtypes of pneumoconioses

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49. What happens to O2 content and O2 sat as Hb falls
High alveolar pressure compresses capillaries
Dec - no change
Carcinoid - carcinoid
C3 - 4 - 6 - phrenic nerve - referred to shoulder

50. Define physilogic dead space
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents

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