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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. Where does lung cancer met to...
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
N- terminus - carbaminohemoglobin
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
High alveolar pressure compresses capillaries

2. What is the ideal V/Q ratio and why
Matched - =1 adequate gas exchange
Inspiration by diaphragm - expiration is passive
Lungs collapse inwards and chest wall spring out
Diffuse alveolar damage leads to ince alveolar capillary perm and protein rich leakage into alveoli resulting in formation of intra - alveolar hyaline membrane

3. What do pulmonary arteries carry - and how are pulm arterial pressures maintained during the cardiac cycle
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
TB - silica disrupt phagolysosomes and impair MACS
PVR = (PpulmA - PleftA)/CO
Deoxygenated blood - elastic walls

4. What changes in EPO occur at high altitude
Ivory white calcified pleural plaques
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia
Air that can still be breathed out after nl expiration
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right

5. What are the findings of chronic bronchitis
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Zone 1
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater

6. What are curschmann's spirals
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Shed epithelium from mucus plugs
No respiratory effort
Cor pulmonale - subsequent RVF - JVD - edema - hepatomegaly

7. What is a particular cause of eosinophilic granulomas - and what cells infiltrate
Vgas = (A/T) [Dk(P1- P2)] - A = area - T= thickness ; A dec in emphysema and T inc pulmonary fibrosis
Histiocytosis X - Langerhans cells
Tissue hypoxia from dec O2 sat and dec O2 content
Alveolar space - type I epithelial cell - BM - endothelial cell capillary lumen

8. What changes in 2 -3 - DPG occur at high altitude
Chronic hypoxic vasocxn
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Vd = Vt x[(PaCO2 - PeCO2)/PaCO2]
Chroniclly tired

9. What is the formula for O2 content
Air that can still be breathed out after nl expiration
Type II pneumocytes - dec alveolar surface tension - inc compliance - dec work of inspiration
O2 binding x O2 sat + dissolved O2
<60

10. What is early onset hypoxemia from in chronic bronchitis
4 polypeptide subunits - 2 alpha and 2 beta
Inc shear stress leading to endothelial injury
Surfactant def leading to inc surfact tension and alveolar collapse
Shunting

11. What are potential triggers for asthma
Dec in lung volumes - FVC - TLC
Viral - URIs - allergens and stress
4 polypeptide subunits - 2 alpha and 2 beta
Lungs collapse inwards and chest wall spring out

12. What is the definition of sleep apnea
Airways close prematurely resulting in inc RV and dec FVC
Chest pain - tachypnea and dyspnea
Person stops breathing for at least 10 seconds repeatedly during sleep
Retinopathy of maturity

13. Define tidal volume (TV)
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
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Air that moves into lung with each quiet respiration
Right

14. What is are the symptoms of a pulmonary embolism
Chest pain - tachypnea and dyspnea
Respiratory bronchioles - alveolar ducts - alveoli - participates in gas exchange
Right lung - right main stem bronhus is wider and more vertical
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-

15. What happens to lung volumes in restrictive lung disease
Alpha1- antitrypsin def - also cirrhosis
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Hypoxemia because of shunting - V/Q mistmatch - fibrosis
Dec

16. What is the V/Q ratio at the apex and base of the lung
Lost with alveolar walls
Small airways
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)
Chest pain - tachypnea and dyspnea

17. What does the law of Laplace state about tendency of alveoli to collapse
Silicosis - MACS respond to silica and release fibrogenic factors leading to fibrosis
On expiration as radius dec
Coal miner's - silicosis - abestosis
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

18. If you aspirate a peanut while supine - where will it go
Lung cancer
Inc excretion of bicarb to compensate for respiratory alkalosis
Zone 3
Superior portion of right inferior lobe

19. What are the two forms of hemoglobin
Air that moves into lung with each quiet respiration
ARDS - neontatal RDS - pneumoconiosis - sarcoidosis - idiopathic pulmonary fibrosis - goodpasture's - wegeners - eosinophilic granuloma - or drug toxicities
Steroids to mom - artificial surfactant and thyroxine to neonate
Taut form - low affinity for O2; relaxed form has high affinity for O2 (300x)

20. Where does exercise sit on the graph of PaO2 vs length along the pulm capillary
In between perfusion limited and diffusion limited
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Gland depth/total thickness of broncial wall - >50%
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning

21. Which pts are at risk for apriation PNA
Bicarb (90%) - bound to globin (5%) and dissolved (5%)
Alchoholics or epileptics
N- terminus - carbaminohemoglobin
Atherosclerosis - medial hypertrophy - and intimal fibrosis of pulm ateries

22. What is a lung abscess and What does usually result from
Fat - Air - Thrombus - Bacteria - Amniotic fluid - Tumor - embolus types
Air in lung after maxmimal expiration - cannot be measured on spirometry
L/S < 1.5
Localized collection of pus within parenchyma - usually resulting from bronchial obstruction - apsiration of oropharyngeal contents

23. Why do pts with emphysema exhale through pursed lips
Promotes dissociation of H+ from Hb and shifts equilibrium back towards CO2 formation for exhalation
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Inc airway pressure to prevent airway collapse during exhalation
Bronchial hyperresponsiveness causes reversible bronchocxn - smooth muscle hypertrophy and curschmann's spirals

24. What does PFTs show in COPD
Dec in the FEV1/FVC
Repeated cycles of lung injury and wound healing with inc collagen
Dipalmatoyl phosphatidylcholine - decreases surface tension
Dec dec in FEV1 - dec in FVC

25. What cellular changes occur at high altitude
Horners syndrome from affect of cervical sympathetic plexus - pancoast's tumor
Inc mitochondria
Dec - due to lactic acidosis
O2 binding x O2 sat + dissolved O2

26. 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
Wheezing - crackles - cyansosis - late - onset dyspnea - blue bloater
TB - apex
PAO2 - PaO2 = 10-15 mmHg

27. Which muscles are involved in quiet breathing and What part of respiration do the control
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis
Inc EPO causing inc hemotocrit and hemoglobin - chronic hypoxia
Anatomic dead space and smooth muscle
Inspiration by diaphragm - expiration is passive

28. What is used to treat methemoglobin
Airway obstruction (shunt) 100% O2 does not improve PO2
Methylene blue
500mL
4 polypeptide subunits - 2 alpha and 2 beta

29. increases In what substances favor the taut form of hemoglobin and which direction does that shift the O2 dissociation curve
Inc EPO leading to erythrocytosis
Cl - - H+ - CO2 - 2 -3- BPG - temperature - shifts to the right
Lung cancer
No change - but inc venous CO2 content

30. What are the subtypes of pneumoconioses

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31. What is the nl form of iron in hemoglobin
Mesothelioma - pleura - psammoma bodies
Air that can still be breathed out after nl expiration
Dec O2 delivery to tissues - dec cardiac output - anemia - CN poisoning - CO poisoning
Fe 2+

32. What is the order of decreasing pressures among the alveola - capillaries and veins in zone 2 of the lungs
Adrenals - brain (epilepsy) - bone (pathologic lesions) - liver (jaundice - hepatomegaly)
Neutrophilic substance toxic to alveolar wall - activation fo coagulation cascade or oxygen derived free radicals
Bilateral hilar lymphadenopathy - noncaseating granuloma - inc ACE and calcium
Pa > PA > Pv

33. What can amniotic fluid emboli lead to...
DIC - especially postpartum
Histiocytosis X - Langerhans cells
Inc shear stress leading to endothelial injury
COPD and destruction of lung parenchyma - mitral stenosis - recurrent thromboemboli - autoimmune dz - left to right shunt - sleep apnea - or living at high altitude

34. What does alveolar pressure do to capillaries in the apex of the lung
Incr - right - dec - left
Change in lung volume for a given change in pressure - decreased in pulmonary fibrosis - insuff surfactant - pulmonary edema
Tissue hypoxia from dec O2 sat and dec O2 content
High alveolar pressure compresses capillaries

35. What happens as a result of hypoxia in sleep apnea
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Inc 2 -3 DPG - binds to Hb so the Hb releases more O2
Inc 2 -3- DPG - righward shift
Inc EPO leading to erythrocytosis

36. What is the pathology of emphysema
Enlargement of air spaces and decreased recoil resulting from destrcution of alveolar walls - inc compliance
Decrease in both - though in obstructive FEV1 is more dramatically reduced resulting in FEV1/FVC ration < 80%
Small airways
Inactivating mutation in the BMPR2 gene which nl fxns to inhibit vasc smooth musc proliferation - poor prognosis

37. What lung product is deficient in neonatal RDS
Stasis - hypercoagulability - endothelial damage
FRC - inward pull of lung balanced by outward pull of chest wall
Surfactant
Incr - right - dec - left

38. What is a potential test for asthma
Methacholine challenge
Hypertrophy of mucus secreting glands in the bronchioles
SVC syndrome - pancoast tumor - horners - endocrine - recurrrent laryngeal symptoms - effusions (pleural or pericardial)
Pleural effusion

39. Where do you find type I cells - What is their morphology - and What do they do
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals
Lungs collapse inwards and chest wall spring out
Fe 2+
97% of alveolar surfaces - line alveoli - squamous - thin and optimal for gas exchange

40. What are the potential TX for sleep apnea
2alpha and 2 gamma subunits - lower affinity for 2 -3 BPG
Weight loss - CPAP - surgery
Inc 2 -3- DPG - righward shift
Zone 3

41. What muscles are involved in breathing during exercise and What do they control
FRC - inward pull of lung balanced by outward pull of chest wall
Inc mitochondria
L/S > 2 = lecithin/sphingomyelin
Inspiration by external intercostals - scalenes - sternomastoids; expiration by rectus abdominus - internal/external obliques - transversus abdominus - internal intercostals

42. Why is there eventual loss of capillary beds in emphysema
Bind 4 O2 molecules and higher affinity for each subsequent O2 molecule bound
Repeated cycles of lung injury and wound healing with inc collagen
Severe respiratory distress - cyanosis and RVH - death from decompensated cor pulmonale
Lost with alveolar walls

43. What does a V/Q ratio of infinity indicate
<75
Dec cross sectional area of pulm vasc bed
Blood flow obstruction creating physiologic dead space - assuming < 1--% dead - 100% O2 should improve PO2
Apex = 3 (wasted ventilation) Base = 0.6 (wasted perfusion)

44. Define functional residual capacity (FRC)
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
RV + ERV - volume in lungs after nl expiration
Nl = 10-14 - pulm HTN at or above 25 or above 35 during exercise
Ciliated cells

45. What organisms cause interstitial PNA and What are the characteristics
Obesity - loud snoring - systemic/pulmonary HTN - arrhythmias and possible sudden death
N- terminus - carbaminohemoglobin
RSV - adenovirus - mycoplasma - legionella - chlamydia; diffuse patchy inflammation localized to interstitial areas at alveolar walls; distrubtion involving 1 or more lobes
Ivory white calcified pleural plaques

46. What are clara cells What is their morphology and What do they do
Dorsiflexion of food leads to tender calf muscle
Nonciliated - columnar with secretory granules - secrete component of surfactant - degrade toxins - ast as resevoir cells
Clara cells - type II pneumocytes; multiple densitites on CXR
Respiratory effort against airway obstruction

47. What happens to V/Q ratio in COPD
Apex of healthy lung
Mismatch
Angio I to angio II - inactivates bradykinin (ACEi inc bradykinin and cause cough - angioedema)
Metastasis - breast - colon - prostate - bladder -

48. Hilar mass arising from the bronchus; cavitation - hx of smoking - PTHRP - cancer and histo
Chronic necrotizing infection of bronchi leading to permanently dilated airways - purulent sputum - recurrent infections - hemoptysis
In between perfusion limited and diffusion limited
Inspiration by diaphragm - expiration is passive
Squamous cell carcinoma - keratin pearls and intracellular bridges

49. Define vital capacity (VC)
Systemic sclerosis - inflammation leading to intimal fibrosis and medial hypertrophy
Viral - URIs - allergens and stress
Dec - because physiologic shunt dec O2 extraction from ratio
Everything but RV - TV + IRV + ERV

50. What reaction and enzyme create bicarb and Where does it happen
R = 8nl/pir^4 - n=viscosity - l = length - r = vessel radius
Type II cells
CO2 is absorbed into the RBC - carbonic anydrase catalyzes the rxn of CO2 + H2O to yield H2CO3 - which readily dissociateds into H+ and HCO3-
Trachea and bronchi