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Respiratory

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1. What happens to bicarb once it is created in an RBC
Dec in lung volumes - FVC - TLC
Bicarb/Cl - exchanger - brings a Cl - into the RBC and expels bicarb into the serum
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Brings air in and out - warms - humidifies - filters

2. What happens in perfusion limited circulatioin and which gases does this apply to...
Dec protein - CHF - nephrotic syndrome - hepatic cirrhosis
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
0 - negative - prevents pneumothorax
Productive cough for greater than 3 months in at least 2 years

3. What is carboxyhemoglobin and What does it cause
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
<75
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
It binds to Hb -

4. What lab ration indicates fetal lung maturity
More indolent
Type II pneumocytes - after week 35
L/S > 2 = lecithin/sphingomyelin
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%

5. What happens to FEV1 and FVC in both obstructive and restrictive lung disease and What is the difference
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
CT angio
Loss of blood flow - impeded arterial flow - reduced venous drainage

6. Where do you find type I cells - What is their morphology - and What do they do
Methylene blue
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange
Air in lung after maxmimal expiration - cannot be measured on spirometry

7. In what cells do you find lamellar bodies
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Dec - no change
PAO2 = PIO2 - (PACO2/R) R = respiratory quotient = CO2 produced/O2 consumed
Type II cells

8. What can amniotic fluid emboli lead to...
DIC - especially postpartum
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Chroniclly tired
Brings air in and out - warms - humidifies - filters

9. What is fetal hemoglobin made of and why does it have a higher affinity for O2
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Methylene blue
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Centriacinar

10. What is the nl form of iron in hemoglobin
Type II pneumocytes - after week 35
Fe 2+
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest
20.1 mL O2 /dL

11. What are the causes of hypoxia
4 polypeptide subunits - 2 alpha and 2 beta
Defect in coagulative cascace proteins
High alveolar pressure compresses capillaries
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning

12. What direction does an increase in metabolic need shift the O2 dissociation curve
Centriacinar
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Repeated cycles of lung injury and wound healing with inc collagen
Right

13. What lung product is deficient in neonatal RDS
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
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
Surfactant
Tert (segmental) bronchus - 2 arteries (bronch/pulm) - veins and lymph drain along the borders - arteries run with airways

14. What are the SPHERE of complications in lung cancer
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Dec - no change
Inspiration by diaphragm - expiration is passive
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor

15. What kind of pleural plaques are the result of asbestosis
Superior 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
Type II cells
Ivory white calcified pleural plaques

16. What is the formula for A- a gradient - and What is it normally
PAO2 - PaO2 = 10-15 mmHg
Dec - no change
Centriacinar
Inc O2 consumption

17. What is the formula for oxygen delivery to tissues
Air in lung after maxmimal expiration - cannot be measured on spirometry
CO x O2 content of blood
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)
Lungs collapse inwards and chest wall spring out

18. What is central sleep apnea
Dec cross sectional area of pulm vasc bed
Upper lobes
No respiratory effort
Superior portion of right inferior lobe

19. What is the ideal V/Q ratio and why
Matched - =1 adequate gas exchange
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Ratio from apex to base becomes more uniform
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities

20. How far to the pseudostratified ciliated columnar epithelium extend - What do MACS do in the alveoli - and how far do the goblet cells extend
Exposed collagen fibers provides impetus for clotting cascade
Respiratory bronchioles - clear debris in alveoli - bronchi
O2 (emphysema - fibrosis) - CO - gas does not equilibrate by the time blood reaches the end of the capillary
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange

21. What TX is the mother given before delivery - and what TXs are given to the infant
Centriacinar
Retinopathy of maturity
Respiratory effort against airway obstruction
Steroids to mom - artificial surfactant and thyroxine to neonate

22. What changes at high altitude can result in RVH
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Chronic hypoxic vasocxn
Tissue hypoxia from dec O2 sat and dec O2 content

23. Why do pts with emphysema exhale through pursed lips
Inc airway pressure to prevent airway collapse during exhalation
Surfactant def leading to inc surfact tension and alveolar collapse
Mesothelioma - pleura - psammoma bodies
PAO2 - PaO2 = 10-15 mmHg

24. What are the subtypes of pneumoconioses

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25. What is virchow's triad
Loss of elastic fibers
Inc mitochondria
Stasis - hypercoagulability - endothelial damage
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest

26. What are the causes of hypoxemia
Dec PaO2 - high altitude - hypoventilation - V/Q mismatch - shunting - diffusion
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
IRV + TV
Tissue hypoxia from dec O2 sat and dec O2 content

27. What are the findings in asthma
Positive cooperativity and negative allostery - unlike myoglobin
Cough - wheezing - dyspnea - tachypnea - hypoxemia - dec I/E ratio - pulsus paradoxus - mucus plugging
S. aureus or anaerobes
Nose - pharynx - trachea - bronchi - brionchioles - terminal bronchioles

28. What enzyme increases activity in emphysema
Brings air in and out - warms - humidifies - filters
Elastase
Loss of blood flow - impeded arterial flow - reduced venous drainage
N- terminus - carbaminohemoglobin

29. What is the pathology of ARDS
Inc production
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane
Clara cells - type II pneumocytes; multiple densitites on CXR
P = 2ST/radius

30. How happens to the proton from the rxn the created bicarb
Loss of elastic fibers
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
It binds to Hb -

31. What does a V/Q ratio of 0 indicate
Loss of elastic fibers
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
Airway obstruction (shunt) 100% O2 does not improve PO2
4 polypeptide subunits - 2 alpha and 2 beta

32. What drug therapy is used to augment the changes in bicarb exretion
Inc 2 -3- DPG - righward shift
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
Acetazolamide - inhibits CA and acidifies the blood
Drainage

33. What lobes are affected in silicosis
Prostaglandins - histamine - ACE - kallikrein
Upper lobes
High alveolar pressure compresses capillaries
<60

34. Why is endothelial damage a risk factor for DVT
Exposed collagen fibers provides impetus for clotting cascade
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
O2 (nl health) - CO2 - N2O - gas equilibrates early along length of capillary - diffusion can be inc only if blood flow inc
Inc resistance leading to inc pressure

35. Where is cartilage present in the respiratory tree
Dec in lung volumes - FVC - TLC
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Elastase
Trachea and bronchi

36. What is the pathology of emphysema
FRC - inward pull of lung balanced by outward pull of chest wall
Inspiration by diaphragm - expiration is passive
Methacholine challenge
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance

37. What must occur with a exudate pleural effusion
Airways close prematurely resulting in inc RV and dec FVC
Drainage
Deoxygenated blood - elastic walls
Chest pain - tachypnea and dyspnea

38. What do type II cells do - What is their morphology - when do they proliferate
L/S < 1.5
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage
Upper lobes
Prostaglandins - histamine - ACE - kallikrein

39. What is the defect in panacinar emphysema - and what else do you see
Bronchial obstruction - toward side of lesion
Alpha1- antitrypsin def - also cirrhosis
Alchoholics or epileptics
Dyspnea - dec breath sounds - tachycardia - late onset hypoxemia due to eventual loss of capillary beds - early onest dyspnea - pink puffer - barrel chest

40. What is the formula for resistance
Dec in lung volumes - FVC - TLC
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Alchoholics or epileptics
Dec in the FEV1/FVC

41. What changes in lung volunes occur as a result of restrictive lung disease
Mismatch
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
TB - apex
Dec in lung volumes - FVC - TLC

42. What is the alveolar gas equation approximation
PA02 = 150 - PACO2/0.8
Repeated cycles of lung injury and wound healing with inc collagen
Hyaline membrane disease
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen

43. What kind of course does interstitial PNA follow in comparison to bronchoPNA
O2 binding x O2 sat + dissolved O2
More indolent
Brings air in and out - warms - humidifies - filters
Inc 2 -3- DPG - righward shift

44. What lung abnl is associated with dec breath sounds over lesion - dullness - dec fremitus
Air in lung after maxmimal expiration - cannot be measured on spirometry
Incr - right - dec - left
Pleural effusion
Volume of inspired air that does not take part in gas exchange - anatomical dead space of conducting airways plus fxnal dead space in alveoli

45. What is the pathology of chronic bronchitis
Deep leg veins
RALS - righ anterior - left superior
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Hypertrophy of mucus secreting glands in the bronchioles

46. What changes in CO2 occur during exercise
Inc production
Bleomycin - busulfan - anmiodorone
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
RALS - righ anterior - left superior

47. How does autoimmune dz cause thromboemboli
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Air in excess of tidal volume that moves into lung on maximal inspiration
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types
<60

48. What happens as a result of hypoxia in sleep apnea
Heparin
No change - but inc venous CO2 content
Inc EPO leading to erythrocytosis
L/S < 1.5

49. What renal changes occur at high altitude and What are they compensating for
Strep pneumo most often - or klebsiella - intra - alveolar exudate leading to consolidation; can involve entire lung
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Inc excretion of bicarb to compensate for respiratory alkalosis
Shed epithelium from mucus plugs

50. What is the definition of sleep apnea
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
3% - secrete pulm surfactant - cuboidal and clustered - precursor to type I and II - proliferate during lung damage
Person stops breathing for at least 10 seconds repeatedly during sleep
Mesothelioma - pleura - psammoma bodies

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