Pulm Flashcards
A girl presents with SOB that is worse when it is cold. She should be given?
Asthma Give corticosteroids (block phospholipase A2)
A pt with recurrent infections is believed to have an immunodeficiency that results from defective PMN destruction of catalse-producing microorganisms. How would you confirm?
Chronic granulomatous dz
Defective PMN phagocytosis due to a lock of nicotinamide adenosine dinucleotide phosphate (NADPH)
Low fluorescent activity on dihydrorhodamine (DHR) flow cytometry assay (asses production of superoxide radicals)
Negative nitroblue tetrazolium
A pt with nodular sclerotic lesions and high alk phos likely has?
Metastatic neoplasia
Usually do to prostate cancer
A pt with a 50ppd history is presenting with HTN, wheezing, and cyanotic hands should not receive?
Nonselective beta blockers (nadolol, propanolol, timolol, pindolol) because it can further cause bronchoconstriction
Also contraindicated in cocaine use (unopposed alpha agonism)
Is goodpasture obstructive or restrictive?
restrictive (FEV1:FVC > 0.8)
Which drug promotes smoking cessation by reducing nicotine cravings and decrease the pleasurable effects of cigarettes
Varenicline
Partial alpha4beta2 nicotinic acetylcholine rec eptor, competes with nicotine
A pt with Pulmonary HTN will have dyspnea because they have?
Decreased lung compliance
A pt with CF has symptoms because?
They have a 3 bp deletion that leads to abnormal posttranslational processing of a transmembrane protein that will be targeted to the proteasome
a pt gets a fish bone stuck in his left piriform recess. A nerve is injured during removal. What is likely to be impaired?
Cough reflex
Superior laryngeal n. (CNX)
MHC I has which components?
Heavy chain and B2-microglobulin
MHC I is on all nucleated cells
MHC II has which components?
alpha and beta polypeptide chains
Function of MHCI
On all nucleated cells
Present to CD8+
Recognizes viruses, tumors and process Ag in cytoplasm
APC to CD8+ results in apoptosis of the presenting cell
Function of MHC II
Found on APC’s (B cell, Macrophages, DC, Langerhans)
Presents to CD4+
Recognizes bacterial Ag which are processed by lysosomes
Activation of TH cells stimulate humoral and cellular response
Sputum cultures growing budding yeast and form germ tubules at 37C
Candida
A woman is give a blood transfusion with O type packed RBCs develops facial swelling, hibes and SOB. Why?
Selective IgA deficiency
Typically have recurrent sinopulmonary and GI infections (no secretory IgA), autoimmune dz, anaphylaxis during transfusion (form IgE against IgA)
Dx - low IgA
What type of transmembrane protein is CFTR?
ATP-gated NaCl channel
M. TB can cultur in parallel chains (serpentine cords) this correlates with?
Virulence. Cord factor, a mycoside composed of two mycolic acid molecules bound to the disaccharide trehalose. Without cord factor the mycoside can’t cause dz because it inactivates PMNs, damages mitochondria, and induce TNF
Asbestos exposure is most likely to cause?
Bronchogenic carcinoma
What test should you use when you want to compare the means of two or more group?
Analysis of variance (ANOVA)
determines variability within groups as well as between boots.. Tests a null hypothesis that all groups are random samples of the same population before comparing the groups
A premature infant that was treated for ARDS presents with abn retinal vascularization that extends into the vitreous. What happened?
Neonatal oxygen supplementation
Can progress to blindness
Caused by upregulation of VEGF
After leaving the alveolar beds, capillaries have a drop in O2 saturation before entering the LA. Why?
Mixture with deoxygenated blood (1. bronchial v., 2. Small cardiac (thebesian v.))
Female with no smoking history presenting with a mass in the lower lobe of the left lung. Dx?
Adenocarcinoma
What happens in the first week following exposure to TB?
Intracellular bacterial proliferation (alveolar macrophage)
A pt with an extensive smoking history presents with hemoptysis and shoulder pain
Pancoast syndrome
Tumor at the lung apex (superior sulcus)
Causes shoulder pain, Horner syndrome (ipsi ptosis, miosis, anhydrosis), upper extremity edema, spinal cord compression
Stimulation of which nerve can alleviate symptoms associated with obstructive sleep apnea?
Hypoglossal n.
increases the diamete of the oropharyngeal airway
Why is the chloride content of RBCs much lower in arterial than venous blood?
Carbonic anhydrase
Sarcoidosis is believed to be due to disregulation of cell-mediated immune response to an Ag leading to increased activity of?
Th1 (CD4+) which secretes IL-2 and IFN-gamma
IL-2 stimulates proliferation of Th1
IFN gamma activates macrophages (promotes granuloma formation)
A pt with dyspnea, hypoxemia, hypocapnia has?
alveolar hyperventilation
hypocapnia = alveolar hyperventilation
Pt with decreased breath sounds, hemithorax, deviation of trachea toward opaque lung. Dx?
Pneumothorax due to bronchial obstruction (obs of mainstream bronchus). Loss of lung volume due to alveolar collapse and trachea will then deviate toward.
A CXR on a pneumonia pt shows a round density with an air-fluid level in the lower lobe of the right lung. What contributed to this?
Lysosomal content release by macrophages will cause tissue damage and form an abscess
A pt has SOB and crackles. CXR shows nodular densities in both lungs that are most prominent in the apical area, calcification of hilar LN. Bx = birefringent particles surrounded by dense collagen fibers. Cause?
Silicosis
Dyspnea on exertion, nodular density on XR, calcified hilar LN (eggshell calcification), birefringent on bx
10-20 years post exposure
What is a major risk factor for acute respiratory distress syndrome in an adult?
Pancreatitis
Diffuse injury to pulmonary endothelium and alveolar epithelium increasing pulmonary capillary permeability and leaky alveolocapillary membrane. Causes noncardiogenic pulmonary edema and normal pulmonary cap wedge pressure
Elevated PCWP suggestes cardiogenic edema (ie decomenstated LV failure)
CXR shows pleural thickening and calcifications along the posterolateral midlung regions and diaphragm. Cause?
Asbestos exposure
What change is seen on the oxy-hgb dissociation curve at altitude?
The curve shifts to the right secondary to an increase in the stabilization of dexoygenated Hgb
Increased 2,3 DPG and facilitates oxygen uloading in the periphary. Altitude stimulates 2,3 dpg production and shifts the curve to the right
50 y/o chronic smoker presents with a barrel-chest and other syx associated with COPD. Dx?
Centriacinar emphysema
IVDU presents with SOB x 3 days and an autopsy with wedge shaped hemorrhagic lesion in the periphery of the lung. Dx?
Pulmonary emboli
In an IVDU - septic pulmonary emboli due to tricuspid valve endocarditis
The mucosa in a CF pt would demonstrate what changes?
Increased Na Absorption
Impaired CFTR reduces luminal Cl secretion and increases Na and water absorption causing dehydrated mucusand a more negative transepithelial potential difference.
In sweat glands abn CFTR fxn causes reduced luminal salt absorption = hypertonic sweat
7 mo old boy presents with candida, recurrent episodes of otitis media. Electrophorysis shows lo levels of gamma blobulin levels
CXR lacks a tymic shadow. Dx?
SCID
T and B cell dysfunction.
Absent T cells, hypogammaglobulinemiaand thymic shadow is absent in severe T cell deficiency
What changes would be expected during peak exertion?
Increased CO2 content in the mixed venous blood
Thanks to homeostasis ABG and arterial pH will stay near resting values
48 y/o in a fatal MVA has small fibrotic focus in the RLL and a calcified lymph node in the right lung hilus. Dx?
Primary TB exposure
Ghon complex and ipsilateral hilar adenopathy
What would be found in a bx of small cell lung cancer?
Neural cell adhesion molecule
Stain for neuroendocrine markers - neural cell adhesion molecule (NCAM), enolase, chromogranin, synaptophysin, and some express neurofilaments
Believed to have a neuroendocrine tumor. and contain neurosecretory granules in the cytoplasm
Chronic smoker presents iwth HA, dyspnea, Puffy face x 2 wks. No shoulder pain, symmetrical facial swelling and conjunctival edema. Dilated vessels over neck and upper trunk. What caused this?
Mediastinal mass
SVC syndrome impairs venous return from the body
Dyspnea, facial swelling, dilated collateral v. in the upper trunk
African American woman is being evaluated for fatigue and a nodular rash on her bilateral lower extremities. CXR - Large epithelioid cells, occasional giant cells and no areas of necrosis. Dx?
Sarcoidosis
Young black woman with malaise, cough, and cutaneous findings (erythema nodosum).
CXR - bilateral lymphadenopathy
Bx - non-caseating granulomas is necessary for dx
A recent African immigrant that used to work in the gold mines presents with TB syx. Why is he susceptible to this infection?
Impaired macrophage fxn
Silicosis impaires macrophage arm of immunity and is essential for the immune response to mycobacteria.
Calcification of the rim of hilar nodes (eggshell calcification) surrounded by fibrous tissue. Dx?
Silicosis
A 40 y/o woman presents with episodic SOB and cough. FEV1 is 71% of predicted on spirometry. Sputum shows predominant eosinophils. Dx?
House dust mite exposure triggering asthma attacks
Sputum eos + reduced FEV1 with Nl CXR = asthma
Common triggers = exercise, cold air, respiratory infection, and exposure to inhaled allergens (dust mites, cockroaches, pet dander, mold, pollen)
What is a abnFEV1?
When a infant is exposed to second hand smoke, what condition are they at high risk for?
Sudden Infant death syndrome
Others - increased risk of low birth weight, asthma, middle ear dz
Up to half of all SIDS cases are due to tobacco exposure.
Following an MI a pt develops progressive SOB and insists on sitting up in bed. What is most likely present in his lung tissue/
Transudate accumulating in the alveolar lumen
MI in the LV -> LV failure -> rapid onset of pulmonary HTN and acute pulmonary edema
Cardiogenic pulmonary edema -> increased filtration of plasma and water and electrolytes in the the interstitum and alveoli.
Transudate = ultrafiltrate of plasma caused by hemodynamic changes
exudate - extravasation not only of plasma water and small ions but also plasma protein components and circulating leukocytes as seen in inflammatory states
52 y/o woman presents with cough and exterional dyspnea. FEV1/FVC = 87%. Dx?
Idiopathic pulmonary fibrosis
Progressive exertional dyspnea + dry cough + restrictive profile
Bx = dense fibrosis, fibroblast proliferation, and cyst formation prominent in the subpleural regions.
“honeycomb” changes on CT
An anxiety pt is hyperventilating. What changes can be seen in her cerebral blood flow?
Hypocapnia causes cerebral vasoconstriction and decreased cerebral blood flow.
What causes an ESR to increase?
IL-6
IL-1
TNF alpha
These three mediate the systemic inflammatory response and stimulate hepatic secretion of acute-phase proteins (fibrinogen). High levels of fibrinogen increases the ESR which is a nonspecific marker for inflammation
Presentation of a fat embolism
Following a major fracture (long bone or pelvic)
Neurologic abnormalities (mental status change) + hypoxemia + petechial rash
Occlusion of pulmonary microvessels by fat globules
with in 24-72 hours of injury
2 day old refuses to breast feed. Normal pregnancy/delivery. Significant abdominal distension, palpable intestinal loops, dark green emesis. XR - air-fluid levels and small bowel dilation. Laparotomy to remove a inspissated green fecal mass obstructing the distal ileum. What is the most likely COD in pts with this syndrome?
Pneumonia
Meconium ileus = distal small bowel obstruction due to abnormally dehydrated meconium in a pt with CF. Persistent, treatment-resistant infectious pneumonias, bronchiectasis, and cor pulmonale account for most deaths in CF
45 y/o woman presents with dyspnea and fatigue with raynaud’s phenomenon. PE - skin tightening over the fingers, accentuated S2 over the upper left sternal border and mild hepatomegaly. Bilateral pitting edema. Spiromothry is WNL. Dx?
Sclerodactyly (CREST syndrome)
Develop pulmonary HTN due to damage of the pulmonary arterioles.
Presents with accentuated pulmonary sound on S2 and signs of right sided heart failure due to cor pulmonale
What is the Reid index?
ratio of the thickness of the mucous gland layer in the bronchial wall submucosa to the thickness of the bronchial wall between the respiratory epithelium and bronchial cartilage (does not include the cartilage).
Sensitive measure of mucous gland enlargement (ie chronic bronchitis)
>40% = abn, correlates with duration and severity of chronic bronchitis
Describe the gray hepatization stage of lung infection
Bray-brown firm lobe
RBCs disintegrate, alveolar exudate contains PMNs, fibrin
days 4-6
Describe the congestion phase of a lung infection
First 24 hours
The lobe is red, heavy, and boggy
Vascular dilatation, alveolar exudate contains mostly bacteria
Describe the red hepatization of lung infection
2-3 days
Red, firm lobe (liver-like consistency)
Alveolar exudate contains RBCs, PMNs, and fibrin
Describe the resolution phase of lung infection
Restoration of normal architecutre
Enzymatic digestion of the exudate
Which cytokine can cause rapid PMN chemotaxis?
Leukotriene B4
Stimulates PMNs to sites of inflammation. Other important chemotactics - 5-HETE (leukotriene precursor), C5a, and IL-8
What pulmonary changes are expected as we age?
Decrease in chest compliance but increases in lung compliance due to loss of elastic recoil
Increase in residual volume
Decreased FVC
Unchanged TLC
MOA of cromolyn
Mast cell stabilizing agents that inhibit mast cell degranulation
Also nedocromil
Second line tx of allergic rhinitis and bronchial asthma
What measurement is used to assess fetal lung development?
Lecithin : sphnigomyelin ratio (>2.0)
Lecithin = phophatidulcholine, major constituent of surfactant
What happens to CFTR in CF?
deltaF508 -> ABn post translational processing of CFTR -> proteasome
CF pts have complete absence of the protein on the apical side of epithelial cells
When is total pulmonary vascular resistance at its lowest?
At the lowest point of your exhale in TV
As you inhale PVR will increases due to stretching of alveolar capillaries
When you force to exhale the alveoli collapse and put more pressure on the capillaries
Chromogranin + cancer?
Small cell carcinoma
Arises from the basal layer of the bronchial epithelium
+ for neuroendocrine markers (neuron-specific enolase, chromogranin, synaptophysin)
Long term use of which med can prevent the cellular rxn in astma?
Glucocorticoids
Corner stone of chronic asthma tx
Cytokine that promotes class-switching to IgE?
IL-4, IL-13
Secreted by Th2
Th2 - stimulate B cell fxn for adaptive immunity
Th2 may be overexpressed in asthma causing excessive IL-4 production
Cytokine that activates eosinophils and IgA?
IL-5
Secreted by Th2
Why does a pneumonia pt develop green sputum?
Myeloperoxidase
Blue-green heme based pigment within PMN’s that forms hypochlorous acid during respiratory burst
Seen in bacterial infection
What would be expected in an alpha-1-antitrypsin pt for:
FEV1/FVC
TLC
CO diffusion
FEV1/FVC - low
TLC - increased
CO diffusion - low
A1A deficiency is a type of emphysema which have decreased diffusion capacity
Decreased diffusion capacity due to destruction of alveli and capillary beds
Pt has NL PaO2 and % Sat O2 but low oxygen content. Dx?
Chronic blood loss
3 variables affect the total oxygen content of blood:
1. Hgb concentration
2. Oxygen saturation of hemoglobin
3. Partial pressure of oxygen dissolved in blood
Angemia = decreased [Hgb]
Which 3 cytokines are essential for the formation and maintenance of granulomas (M. TB and sarcoidosis?
IFN gamma - screted by Th1 to activate macrophages
IL-12 - secreted by macrophages to induce Th differentiation into Th1
TNF-alpha - recruits monocytes and macrophages
Which feature is the last to disappear as the epithelium changes along the respiratory tube?
Cilia
Bronchi - pseudostratified columnar ciliated epithelium with goblet cells and submucosal glands, cartilage
Bronchioles, terminal bronchiles, respiratory bronchioles lack goblet cells, glands, and cartilage
terminal broncioles - ciliated simple cuboidal
Epithelial cilia persist to the end of the respiratory bronchioles
What enzyme would be most active in the nucleolus?
RNA pol I
nucleolus = primary site of rRNA transcription
Can see overexpression in malignant cells
Pt has progressive dyspnea due to centriacinar emphysemadue to heavy smoking. Pathology is caused by which cells?
Heavy smoking induces release of proteinases (asp elastase) from infiltrating PMN’s and alveolar macrophages
Describe the airway resistance through the bronchi
Resistance is maximal in 2nd-5th generations (medium sized bronchi)
A COPD pt has a drop in their respiratory rate after starting nasal cannular oxygen. This is due to decreased stimulation of?
Carotid bodies
PaCO2 is the main respiratory driver for healthy individuals but this is blunted in COPD and hypoxemia becomes an important contributor for respiratory drive. Peripheral chemoreceptors (carotid and aortic bodies) sense PaO2 and can be suppressed with O2 administration
Bilateral hilar adenopathy
Elevated serum Ca2+
Elevated ACE
Sarcoidosis
Accumulation of activated macrophages and formation of noncaseating granulomas
CXR - bilateral hilar adnopathy, diffuse interstitial infiltrates
Sarcoid granulomas produce ACE and active Vit D (hypercalcemia)
In a morbidly obese pt what would be expected for:
FEV1, FVC, ERV, RV, TKC
FEV1, FVC, ERV, TLC - decreased
RV - NL
Restrictive PFT’s
What is Laplace’s law?
P=2T/r
as the radius decreases the pressure increases causing smaller spheres to collapse
Foreign bodies getting stuck in the piriform recess can cause to impairment in which reflex?
Cough
Due to damage to internal laryngeal (afferent)
CN X - a and e
Child presents with asthmatic syx and eosinophilia. He improves following use of a receptor antagonist. What receptor does the drug act on?
Leukotriene D4 (zafirlukast, montelukast) Leukotrienes are synthesized by mast cells, eos, and basophils. Promote bronchial constriction, hyperreactivity, mucosal edema, and hypersecretion Pt has atopic asthma (common, but stimulated by extrinsic allergens) Only leukotrienes (LTC4, LTD4, and LTE4) and ACh have pharmacologic receptor antagonists that have a clear benefit
Pt with acute pancreatitis develops respiratory distress, bilateral lung crackles, and bilateral infiltrates on CXR. What happened?
Pancreatitis is a major RF for acute respiratory distress syndrome
Releases large amounts of inflammatory cytokines and pancreatic enzymes leads to PMN activation in the alveolar tissues.
Initially see interstitial and intraalveolar edema, inflammation, and fibrin deposistion that cause the alveoli to become lined with waxy hyaline membranes
pt presents with progressive SOB and non productive cough. Crackles bilaterally and drumstick fingers
Decreased FVC causing an increased FEV1/FVC. Dx?
Pulmonary fibrosis
Interstitial lung dz = decreased lung volume, increased recoil due to fibrotic tissue
Increased recoil = increased traction (outward pulling) on the airways -> increased expiratory flow rate causes and increased ratio
