Final Exam

Question 1

In healthy individuals the respiratory central pattern generator and “drive to breathe” is regulated primarily by which blood gas concentration?
A.CO2 (Carbon Dioxide)
B.O2 (Oxygen)
C.N2 (Nitrogen)
D.HCO3 (Bicarbonate)

Are there situations where this might change?

Answer 1

CO2; COPD can change this since CO2 levels are higher and O2 and CO2 levels are off

Nitrogen stays in the lungs and acts as a filler to help them stay open

Question 2

The muscles of inspiration work against which of the following forces?
A.Weight of the lungs
B.Airway resistance
C.Elastic recoil of the chest wall
D.Both B and C

Why is this important?

What are situations where these forces may change?

Answer 2

D. Both B and C; they have to resist against the recoil and whatever resistance is introduced to the airway but not the weight of themselves

Increased resistance can impact airflow (bronchorestriction); impaired diaphragm can have huge consequences

emphysema, and CF can both increase airway resistance

Question 3

The thoracic wall/rib cage moves in what direction when the diaphragm contracts?
A.Superior, lateral and anterior
B.Superior, lateral and posterior
C.Inferior, lateral and anterior
D.Inferior, lateral and posterior

What about the abdomen?

Are there any conditions where this might be different?

Answer 3

B. Superior, lateral and posterior; decreases pressure and increased the thoracic cavity

the abdomen should expand outward as you inhale

Paradoxical movement can be seen in post polio patients and quadriplegics as well as severe COPD

Question 4

Which of the following diseases is characterized by air trapping, increased residual volume, and a flattened diaphragm?
A.Asthma
B.Emphysema
C.Idiopathic Pulmonary Fibrosis
D.Cystic Fibrosis

Why do lung and chest volumes increase in patients with COPD?

Answer 4

B. Emphysema; pink puffers that decrease recoil with increased resistance

IPF is destruction of alveoli; impaired gas exchange
asthma is a hyperactive airway/bronchorestriction
CF is increased mucus production; defect in NaCl channels

Volumes increase in patients with COPD since they have a limited ability to expell air so lots of air stays trapped in lungs

Question 5

What are some explanations for the functional limitations and impaired tolerance to activity in patients with COPD?

Answer 5

Uncomfortable for them to exercise; can’t handle the increase in respiratory rate; takes lots of energy to do less due to the metaboreflex

Question 6

Which genetic disorder results in defects to Na+ and Cl-channels resulting excessive in salty mucous formation that causes multisystem disease?
A.Alpha trypsin-1 deficiency
B.Cystic Fibrosis
C.Asthma
D.Sarcoidosis

What type of condition is this disorder?

Answer 6

B. Cystic fibrosis; increased mucus production due to impaired NaCl channels

Septic Obstructive disorder

Question 7

A lesion above which spinal cord level would require a patient with a spinal cord injury (SCI) to require mechanical ventilation?
A.C7
B.C3
C.C5
D.C6

Answer 7

B. C3

C3-5 keep you alive; not enough innervation for the diaphragm to work properly

Question 8

Which of the following is an occupational cause of intrinsic restrictive lung disease?
A.Idiopathic Pulmonary Fibrosis (IPF)
B.Obesity
C.Asbestosis
D.Rheumatoid arthritis

Answer 8

C. Asbestosis; all others are acquired through lifestyle or genetic factors

Question 9

Which areas of the lungs would you normally appreciate vesicular lung sounds?
A.Trachea
B.Parasternal borders
C.Peripheral

Answer 9

C. Peripheral - soft, low pitched rustling

Tracheal is loud, high pitched

Parasternal borders are bronchovesicular

Question 10

Which segments are most likely to develop atelectasis following bed rest in a supine position?A.Apical
B.Middle Lobe and Lingula
C.Anterior upper
D.Posterior basal

What are some additional examinations or procedures to perform if crackles are observed?

Answer 10

D. Posterior basal since that is the way gravity will pull the mucus
Atelectasis is small airway collapse

additional examinations are vitals; take 10 full breaths per hour; frequently change positions; encourage to cough; incentive spirometry

Question 11

You examine a patient in the ICU following CABGx3 who present with decreased breath sounds and crackles in bilateral posterior basal segments that resolve with coughing. Their respiratory rate is slightly elevated (24 breaths/min), Blood pressure (118/72mmHg) and HR (84bpm) are within normal limits. The patient is afebrile (37 deg C). What is the most likely cause of these findings?
A.Pulmonary Edema
B.Pulmonary Embolism
C.Post operative atelectasis
D.Pleural effusion

Answer 11

C. Post-operative atelectasis; resolves with coughing

PE would have a fever

Pulm Edema would not clear with a cough

Question 12

Which of the following symptoms are not associated with a bacterial pneumonia (PNA)? A.Productive Cough
B.Dry/non productive cough
C.Abrupt onset
D.Segmental lung consolidations

What is lung consolidation?

Answer 12

B. Dry/non productive cough; these patients will have a productive cough; very abrupt onset

Lung consoldiation is when air in the lungs is replaced by something else - pus, blood, water, etc.

Question 13

A 55-year-old male patient status post Right Total Knee Arthroplasty presents to the clinic. The patient is reporting dyspnea, sharp chest pain, tachycardia, and hemoptysis.
A.Pulmonary Edema
B.Pulmonary Embolism
C.Pleural Effusion
D.Post operative atelectasis

Answer 13

B. Pulmonary embolism; post-op patient coughing up blood

POA would not be painful
Pulm edema would have pink, frothy speutum

Question 14

You are providing field coverage for a college rugby match and witness a player collapse to the ground grasping his left side after taking a hard blind-sided tackle. You rush onto the field to examine him. The patient is in distress however conscious and reports sharp 9/10 left-sided chest pain, worsening with inspiration. He is dyspneic and tachycardic with dropping blood pressure and trachea deviated to the right. His chest wall is extremely painful to palpation. On auscultation, you appreciate absent breath sounds in all of the left lung segments. What is the most likely diagnosis?
A.Pulmonary embolism
B.Tension Pneumothorax
C.Dislocated rib
D.Rib fracture

Answer 14

B. Tension pneumothorax; trauma induced

PE would not be a sudden onset and usually in post-op patients

Rib fx/dislocation would not cause that many symptoms in a patient

Question 15

Which airway clearance technique would be the most appropriate for a patient who is independent with mobility, and coughing with increased pulmonary secretions due to bacterial pneumonia?
A.Active cycle of breathing
B.Manual Chest Percussion
C.High frequency mechanical Percussive Vest D.Manual Chest Vibration

Answer 15

A. ACB since they are able you want to do something more active than passive

Rule of 3s then cough

Question 16

Which ventilatory/breathing technique is effective at improving tolerance to activity in patients with COPD?
A.Pursed Lip Breathing
B.Paced Breathing
C.Valsalva
D.Both A and B

Can this be used for other patients?

Answer 16

D. Both A and B; paced is more related to activities

Can also use this technique for patients with asthma

Question 17

What would be the most effective breathing technique to reduce chest wall pain following median sternotomy?
A.Faciliatory/Segmental Breathing
B.Braced/Splinted Breathing
C.Active Cycle of Breathing
D.Deep Slow Breathing

Answer 17

B. Braced splinted breathing is the only once used specifically for pain

Question 18

You receive a referral to evaluate a patient in the surgical intensive care unit status post right total hip replacement. This is postoperative day 1. The patient’s lab values are the following:
Hgb: 9.0 Hct: 30 WBC: 12,500 Platelets: 200,000 RBC: 4.4

Are these normal expected values?
What else would you want to check?

Answer 18

Hgb and Hct are low while WBC and Platelets are high but these values are normal and expected after having surgery due to blood loss and immune response.
Would want to go off of vitals, temperature, symptoms, and wound integrity to see if something is wrong instead of labs

Question 19

Which of the following medications is a long-acting beta-2 agonist?
A.Albuterol (Ventolin)
B.Salmeterol (Serevent)
C.Tiotropium (Spiriva)
D.Fluticasone (Flovent)

Answer 19

B. Salmetrol is long acting

Albuteral is short acting, rescue

Titropium is an antagonist

Fluticasone is a glucosteroid inhaler

Question 20

Which of the following drinks contain Methylxanthines?
A.Caffeinated coffee
B.Orange Juice
C.Tomato Juice
D.Water

Answer 20

A. Coffee! and chocolate can act as bronchodilators; inhibits PDE and cAMP

Question 21

Patients with which diagnosis would benefit the most from a Leukotriene Inhibitor?
A.Asthma
B.Emphysema
C.Idiopathic Pulmonary Fibrosis
D.Sarcoidosis

Answer 21

A. Asthma; leukotrine inhibitor is an anti-inflammatory

Emphysema and IPF arm more for damage to the alveoli/air sacs

Question 22

Which statement is true regarding smoking cessation?
A.Most smokers report that they want to quit
B.Lung function of smokers may improve by a considerable degree within a 1 week of cessation.
C. Difficulty quitting is best predicted by how much one smokes daily and if they begin smoking within 30 minutes of waking?
D.All of the above

Answer 22

D. All of the above

Question 23

T or F: The evidence regarding the benefits of pulmonary rehabilitation is not observed in patients with IPF and is only observed in patients with COPD.

Answer 23

False, rehab for IPF is included in recommentations and is deemed integral and essential

Question 24

Which of the following is a relevant clinical examination in a Pulmonary Rehabilitation setting? A.BEST Balance Test
B.Timed Up and Go
C.6 minute Walk Test
D.All of the above

Answer 24

D. All of the above - treat the impairments!

Question 25

Which of the following measures are NOT expected to improve following pulmonary rehab?
A.6MWT distance
B.Quality of Life
C.Pulmonary function scores
D.Dyspnea Rating
What is the value of a maintenance pulmonary rehab?

Answer 25

C. PFT scores will not be expected to increase since we are mainly just treating the symptoms and not reversing the disease

We can’t reverse but we can improve QOL and function or slow progression

Question 26

Why might interval-based exercise program work better for patients with a more severe pulmonary disease compared to a moderate-intensity continuous endurance exercise program?
Are there any other possible modes of exercise training that might work well too?

Answer 26

They have trouble sustaining exercise for long periods since symptoms continually get worse as they go; can go 3x as long if they interval train instead of aerobic

Resistance training can also have a big impact without sustained aerobics

Question 27

How does respiratory muscle training improve dyspnea and exercise tolerance?

Answer 27

Increases muscle strength and endurance
Increases exercise capacity
Decreases dyspnea rating

More efficient muscles! Spares blood flow and energy to other muscles; chills out the metaboreflex

Question 28

What are some patient populations that may benefit the most from RMT/IMT?

Answer 28

COPD; heart failure

Question 29

Which of the following tests involves the assessment of continuous respiratory muscle pressure recorded from RV to TLC?
A.Maximal Static Inspiratory Pressure (MIP)
B.The Test of Incremental Respiratory Endurance (TIRE)
C.Maximal Static Expiratory Pressure (MEP)
D.Constant Load Respiratory Muscle Endurance Test

Answer 29

B. TIRE

Question 30

Lung transplant candidates with this diagnosis will more likely require a bilateral lung transplant.
A.Hypersensitivity Pneumonitis
B.IPF
C.COPD
D.Sarcoidosis

Answer 30

C. COPD since a single can actually get compressed by the other lung and chest wall

All the other diseases affect the lungs individually

Question 31

Which of the following is a hallmark sign of acute rejection in a patient who received a lung transplant?
A.Tachycardia
B.A respiratory rate of 22
C.Decreased FEV1 >10%
D.Muscle atrophy

Answer 31

C. Decreased FEV1 >10%

An increased HR can be normal
RR of 22 isn’t far off from normal
Muscle atrophy would not happen that quickly and may already have atrophy

Question 32

Which of the following is a not hallmark sign of acute rejection in a patient who received a heart transplant?
A.Jugular vein distension
B.S3 gallop
C.Decreased exercise tolerance
D.Elevated heart rate at rest

Answer 32

D. normal to see an elevated HR in these patients

Top 3 are all signs of heart failure so makes sense

Question 33

Which of the following is true regarding lung transplantation?
A.Quad muscle biopsies show increased oxidative capacity
B.Exercise capacity typically only improves to 40-60% of predicted values
C.These patients will demonstrate a blunted heart rate response to exercise
D.The majority of patients report activity limitations

Answer 33

B. Exercise capacity typically only improves to 40-60% of matched norms

Quad muscles will have reduced oxidative capacity; they will have a normal HR but it takes time to build it up due to denervation; majority don’t have limitations

Question 34

T or F: Most patients will attain normal age and gender-matched levels of fitness following heart transplantation.

Answer 34

False; due to side effects from immunosuppressants, change from type 1 to type 2 fibers and peripheral muscles being less efficient

Question 35

What are some unique things to consider when working with patients awaiting and following either a heart or lung transplantation?

Answer 35

Both use education and aim to maximize function; awaiting is more preservation while following is more optimization