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USMLE > Pulm physio > Flashcards

Pulm physio Flashcards

1
Q

What 3 events increase risk of pneumonia

A

impaired cough reflex, damaged mucocilary elevator, mucus plug

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2
Q

Three types of pneumonia

A

Lobar, broncho, interstitial (atypical)

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3
Q

Four gross phases of lobar pneumonia

A
  1. Congestion
  2. Red hepatization
  3. Gray hepatization
  4. Resolution
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4
Q

Describe red hepatization

A

Exudate, neutrophils and hemorrhage fill alveolar spaces, making spongy lung more solid

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5
Q

Describe gray hepatization

A

Degradation of red cells within exudate

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6
Q

Which cells are responsible for resolution after pneumonia?

A

Type 2 pneumocytes

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7
Q

Which pathogen is the most common cause of community-acquired pneumonia in adults and elderly?

A

Strep pneumo

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8
Q

Which pathogen is the second most common cause of acquired pneumonia in adults?

A

S. aureus

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9
Q

Klebsiella pneumonia commonly affects

A

malnourished in nursing homes, diabetics, alcoholics

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10
Q

What color is the sputum in Kleb pneumo?

A

Currant jelly (red)

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11
Q

COPD patients are at risk of pneumonia from which pathogens (most common to least)

A

H. Influenzae (secondary), Moraxella catarrhalis (community acquired), Legionella (Water source)

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12
Q

Cystic fibrosis patients get pneumonia from which pathogen?

A

Pseudomonas aeruginosa

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13
Q

which patients are at risk of developing aspiration pneumonia

A

Alcoholics and comatose patients

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14
Q

Which three agents most often cause aspiration pneumonia

A

Bacteroides, fusobacterium, peptococcus

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15
Q

Most common cause of interstitial pneumonia in young adults

A

Mycoplasma pneumoniae

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16
Q

Complications of mycoplasma pneumoniae

A

Autoimmune hemolytic anemia (IgM) and erythema multiforme

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17
Q

Second most common interstitial (atypical) pneumonia in young adults

A

Chlamydia trachomitis

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18
Q

Most common cause of atypical pneumonia in infants

A

RSV (respiratory synctival virus)

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19
Q

Most common cause of pneumonia in immunosuppressed (post-transplant, AIDS)

A

CMV

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20
Q

Which virus causes atypical pneumonia in elderly and increases risk of superimposed bacterial pneumonia infection?

A

Influenza virus

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21
Q

Most common cause of pneumonia in farmers and vets

A

Coxiella burnetii

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22
Q

How is coxiella different from other rickettsial organisms

A
  1. causes pneumonia
  2. does not require arthropod vector
  3. does not produce skin rash
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23
Q

Where is aspiration pneumonia commonly seen on XRAY

A

Right lower lobe

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24
Q

Why should a patient have PPD before starting TNF alpha inhibitors?

A

To avoid reactivating (secondary) tuberculosis

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25
Q

What is Pott’s disease

A

destruction of lumbar vertebrae by tuberculosis

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26
Q

What is Goodpasture syndrome?

A

Autoimmune disease against glomerular basement membrane and alpha chain of Type IV collagen that leads to restrictive lung disease and rapid kidney failure

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27
Q

What is Caplan syndrome?

A

pneumoconioses with rheumatoid arthritis (Associated with coal workers’ pneumoconioses)

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28
Q

Why does silicosis increase risk of TB?

A

Impairs phagolysosome formation in macrophages in upper lobe of lung (fibrotic nodules in UL)

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29
Q

Noncaseating granulomas are found in which two restrictive diseases?

A

Sarcoidosis and berryliosis

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30
Q

Asbestosis is typically found in

A

Shipyard workers, construction workers, plumbers

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31
Q

Asbestosis increases risk of which 2 malignancies?

A

Lung carcinoma and mesothelioma

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32
Q

Describe FEV1/FVC, TLC, FRC in restrictive diseases

A

FEV1/FVC >80% (FVC <

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33
Q

Describe FRC, RV, TLC, FEV1/FVC in obstructive lung diseases

A

FRC increases, RV increases, TLC increases, FEV1/FVC decreases

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34
Q

List 4 obstructive diseases

A

chronic bronchitis
emphysema
asthma
bronchiectasis

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35
Q

Classic presentation of primary pulmonary hypertension

A

Young adult female with exertional dyspnea

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36
Q

Mutation in primary pulmonary hypertension

A

Inactivating mutation of BMPR2, proliferation of vascular smooth muscle

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37
Q

Etiology of secondary pulmonary hypertension

A

Hypoxemia or increased pulmonary circuit volume; or recurrent pulmonary embolism

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38
Q

Who is at risk of developing small cell carcinoma?

A

Male smokers

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39
Q

Which cells are mutated in small cell carcinoma?

A

Neuroedocrine cells (Kulchitsky)

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40
Q

What co-morbidities can develop with small cell carcinoma?

A

Eaton-Lambert Syndrome and ADH/ACTH increase

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41
Q

A man with gradually worsening proximal muscle weakness, fatigue, weight loss, hypertension, high cortisol levels and a smoking history likely has

A

small cell carcinoma Eaton-Lambert

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42
Q

Histology of small cell carcinoma

A

Poorly differentiated cells (extremely dark nuclei, pleomorphic)

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43
Q

What is the most commmon lung cancer in male smokers?

A

Squamous cell carcinoma

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44
Q

Which co-morbidity develops from Squamous cell carcinoma?

A

Pancoast tumor (PTHrP–> Hypercalcemia)

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45
Q

Histology of squamous cell carcinoma

A

Keratin pearls and intercellular bridges

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46
Q

Who is at risk of developing Adenocarcinoma?

A

nonsmokers and female smokers

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47
Q

Histology of Adenocarcinoma

A

glands/mucin in alveolar spaces

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48
Q

prognosis for adenomarcinoma

A

likely lymphatic mets, poor

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49
Q

Which lung cancer presents with paraneoplastic syndrome and gynecomastia

A

Large cell caricnoma

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50
Q

What is the prognosis of large cell carcinoma

A

Very poor, extremely malignant

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51
Q

Which cells are mutated in broncheoalveolar carcinoma?

A

Clara cells

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52
Q

Which lung cancer hows pneumonia-like consolidation on imaging

A

Bronchoalveolar carcinoma

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53
Q

Which lung cancer is chromogranin positive

A

Carcinoid tumors

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54
Q

How does carcinoid tumor present on biopsy

A

polyp-like mass on bronchus

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55
Q

Two most common locations for metastasis

A

breast or colon

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56
Q

Define cyanosis

A

Bluish tinge of skin due to unsaturated Hgb >5g/dl

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57
Q

Define hypoxemia

A

Decreased oxygen tension (PaO2)

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58
Q

How do anemic patients present cyanosis different from normal patients?

A

Anemic patients may be hypoxemic before presenting with cyanosis because they have less hemoglobin and become cyanotic at a lower oxygen tension

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59
Q

What causes Horner syndrome (ptosis, anhidrosis, miosis) in squamous cell carcinoma?

A

Pancoast tumor in apical lung can compress sympathetic chain

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60
Q

Ipsilateral tracheal shift is seen in

A

spontaneous pneumothorax

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61
Q

Contralateral tracheal shift is seen in

A

tension pneumothorax

62
Q

physical exam of a pleural effusion

A

dullness to percussion, decreased tactile fremitus, egophony, decreased breath sounds

63
Q

What causes transudative pleural effusion

A

CHF, hepatic hydrothorax, chronic renal disease all lead to imbalance in absorption and formation of fluid

64
Q

What are the pH, glucose, LDH and protein levels in transudative effusion?

65
Q

Increased wbc, LDH, protein in fluid of pleural effusion implies

A

Exudative effusion due to infection or malignancy

66
Q

what is SPARTAS of ARDS

A 
Sepsis
Pancreatitis, pneumonia
Aspiration
uRemia
Trauma
Amniotic fluid embolism
Shock
67
Q

What is found on histology of ARDS?

A

Hyaline membrane formation around alveoli

68
Q

How can nocturnal hypoxia in sleep apnea cause death?

A

systemic/pulmonary hypertension, arrhythmias

69
Q

What is another name for spontaneous pneumothorax?

A

Atelectasis

70
Q

What physiological abnormalities lead to transudate effusions?

A

Increased hydrostatic pressure or decreased oncotic pressure

71
Q

How does a lymphatic effusion present?

A

Milky fluid, increased triglycerids, due to duct injury from trauma or malignancy

72
Q

Who is at greatest risk of primary spontaneous pneumothorax?

A

Tall, thing young males

73
Q

Best treatment for lung abscess

A

Clindamycin

74
Q

Histology of mesothelioma

A

Psammoma bodies

75
Q

Cytokeratin and calretinin + indicates

A

Mesothelioma

76
Q

What are signs of SVC syndrome?

A

Edema of upper extremities, facial plethora, jugular venous distension, increased ICP (headaches, dizziness)

77
Q

What increases the production of surfactant?

A

Cortisol and thyroxine

78
Q

Which hormone decreases production of surfactant?

79
Q

What are three risk factors for developing neonatal respiratory distress syndrome?

A

Prematurity, C-section, maternal diabetes

80
Q

Is ARDS hypoxemia responsive to oxygen therapy (ventilation)?

81
Q

Where do majority of pulmonary emboli originate from?

A

Lower extremities (usually below knee)

82
Q

Which lung volumes are NOT measured directly by spirometry?

A

TLC, FRC, RV

83
Q

Which cells are responsible for fibrosis in interstitial lung diseases?

A

Leukocytes release cytokines to stimulate fibrosis

84
Q

What happeens to compliance and elasticity in restrictive lung diseases?

A

Decreased compliance, increased elasticity

85
Q

What causes an increase in PaCO2 in chronic bronchitis?

A

Mucus plugs in lumens block CO2 exit from tissue

86
Q

Which cytokine stimulates IgM -> IgE class switch?

87
Q

Which cytokine recruits eosinophils?

88
Q

Which T cell secretes IL-4, IL-5 and IL-10?

A

TH2 CD4+ T cell

89
Q

Describe the biopsy of chronic bronchitis

A

Thickened bronchial walls, neutrophilic and lymphocytic infiltrates, mucus gland enlargement with increased mucus production and patchy squamous metaplasia of bronchial mucosa

90
Q

What is the most common mutation in CF?

A

3-base pair deletion of phenylalaline at 508 (delta F508). Causes impared post-transcriptional processing

91
Q

Which CF mutation is seen in the Askenazi jewish population?

A

Premature termination of transmembrane protein (nonsense, frameshift), leading to complete absence of membrane CFTR

92
Q

An African American presenting with constitutional symptoms (weight loss, fevers), bilateral hilar adenopathy and pulmonary complaints is at concern for which malignancy

A

Sarcoidosis

93
Q

Biopsy of sarcoidosis shows

A

Non-caseating granulomas

94
Q

What are 3 key clinical features of Legionella pneumonia?

A

High fever with bradycardia
Headache and confusion
Watery diarrhea

95
Q

Lab findings of Legionella pneumonia

A

Hyponatremia

Sputum gram stain shows neutrophils but no bacteria

96
Q

Best test to dx Legionella

A

Urine test

97
Q

How to identify cryptococcus neoformans infection

A

Stains red with mucicarmine

98
Q

Symptoms of cryptococcal lung disease

A

IC patient with cough, pleuritic chest pain, dyspnea and hemoptysis

99
Q

Best treatment for aspiration pneumonia (anaerobic bacteria)

A

Clindamycin or macrolides

100
Q

Alcoholics are at increased risk of developing pneumonia from which pathogens?

A

Anaerobic oral flora (Bacteroides, Prevotella, Fusobacterium, Peptostreptococcus); best treated with clindamycin

101
Q

Air fluid levels in CXR indicates

102
Q

How does cyanide poisoning affect PaO2, SaO2 and CaO2

A

All normal (CN only affects ETC, lowering peripheral oxygen consumption)

103
Q

Mechanism of cyanide poisoning

A

inhibits Fe3+ in cytochrome c oxidase in ETC, thus inhibiting cellular oxphos and tissue oxygen consumption falls–> decreases arterial-venous oxygen gradient since venous oxygen increases

104
Q

How does high elevation affect PaO2, SaO2 and CaO2

A

Decreases all three

105
Q

Which ion helps maintain erythrocyte electroneutrality as HCO3- (CO2) diffuses out?

106
Q

Chest tube placement through 4th/5th intercostal space in midaxillary line traverses through which 3 anatomic structures?

A

Serratus anterior, intercostal (external, internal, innermost), and parietal pleura

107
Q

Aspiration while supine likely leads to pneumonia in which lung regions?

A

posterior segments of upper lobe

superior segments of lower lobes

108
Q

Aspiration while upright leads to pneumonia in which region of lung

A

basilar segment of lower lobes (R > L)

109
Q

Transplant patients are at increased risk of pneumonitis from which pathogen?

A

CMV (dsDNA)

110
Q

How does CMV present on biopsy

A

enlarged cells with intranuclear and intracytoplasmic inclusions (owl’s eye)

111
Q

Which compounds induce bronchospasm?

A

Leukotrienes C4, D4, E4 and acetylcholine

112
Q

How do you minimize work of breathing in restrictive lung disease?

A

Minimize tidal volume, maximize respiratory rate (fast, shallow breaths)

113
Q

Restrictive diseases have increased

A

elastic resistance

114
Q

Which diseases cause high airflow resistance

A

COPD, asthma

115
Q

How is work of breathing minimized in conditions with increased airflow resistance?

A

deep, slow breaths (increase tidal volume, decrease rate)

116
Q

Which structures store and transport surfactant

A

Lamellar bodies

117
Q

Which condition results from excessive activity of intra-alveolar proteases released by locally infiltrating leukocytes?

118
Q

What is the etiology behind chronic bronchitis

A

Cells secrete a lot more mucus to protect against irritants

119
Q

What accounts for the rubber-like properties of elastin?

A

Desmosine cross-links between lysines

120
Q

Which part of the lungs does Klebsiella pneumonia commonly infiltrate?

A

Right upper lobes (due to supine aspiration)

121
Q

How long does it take for kidneys to compensate for alkalosis/acidosis via bicarb?

122
Q

How is PaO2 affected in pulmonary embolism?

A

Decrease; increased A-a gradient due to V/Q mismatch

123
Q

Describe the three receptors epinephrine acts on in anaphylactic shock

A

alpha-1 on peripheral vasculature: causes constriction to increase blood pressure
beta-1 on heart: increases heart rate
beta-2 on bronchioles: causes bronchodilation

124
Q

What is the Reid index

A

The ratio of the thickness of the mucous gland layer to the thickness of the wall between the epithelium and cartilage in bronchi/bronchiole

125
Q

How do you measure the severity of chronic bronchitis?

A

Ratio of thickness of mucous gland layer to the thickness of the wall between epithelium and cartilage (nl = 0.4). Reid index increases in growing severity

126
Q

Presence of anaerobic bacteria in lungs (Peptostreptococcus and Fusobacterium) is highly suggestive of

A

Lung abscess formation

127
Q

Most common cause of lung abscesses

A

Oropharyngeal aspiration due to conditions with loss of consciousness or dysphagia (alcoholism, drug use, seizure disorders, prolonged anestheia, neuro dzes)

128
Q

The presence of multiple lung abscesses in lungs due to septicimia or infectious endocarditis is likely due to

A

Staphylococcus or Streptococcus species

129
Q

Three reasons why emphysema causes decrease FVC and increase in both TLC and RV

A

Destruction of intraalveolar walls, decrease in elastic lung recoil, distal airspace enlargement

130
Q

Frequent respiratory infections is characteristic of which obstructive condition

A

Chronic bronchitis

131
Q

Progressive exertional dyspnea is characteristic of which obsructive condition

132
Q

A patient comes with in progressive exertional dyspnea and worsening cough. His lung XRays show bilateral, LL, diffuse pattern of small irregular opacities. Lung exams finds end-inspiratory crackles. findings most consistent with

A

Pulmonary fibrosis.

133
Q

Diminished air volume in part of lung commonly due to obstruction of corresponding bronchus or bronchiole. Shows up as distinct opacification of a lobe/lobule on CXR

A

Atelectasis

134
Q

Which gas is the major stimulator for respiration in healthy individuals?

135
Q

What is the major stimulator of respiration in central chemoreceptors of the medulla?

A

PaCO2 levels, indicating pH (decreased pH increases RR)

136
Q

Peripheral chemoreceptors in the aortic and carotid bodies are primarily driven by which gas in hypoxemic (PaO2 <60 mmHg) patients?

137
Q

Which chemoreceptors are important for responding to hypercapnia/hypocapnia?

A

Central chemoreceptors in the medulla

138
Q

Reddish-pink granules in periportal hepatocytes stained with acid-Schiff reaction in a patient who complains of progressive dyspnea likely suggests

A

Alpha-1 antitrypsin deficiency (AD inheritance)

139
Q

Emphysema results from

A

Destruction of alveoli (either induced by smoking or autoimmune by AAT deficiency)

140
Q

Where is alpha-1-antitrypsin synthesized?

141
Q

Bronchial hyperreactivity is a hallmark of

A

chronic asthma

142
Q

Chronic rejection after lung transplantation causes damage to which part of the lung?

A

Small bronchioles (presents with dyspnea, nonproductive cough and wheezing years after transplantation)

143
Q

Bilateral hilar adenopathy and elevated serum calcium and ACE levels are suggestive of

A

Sarcoidosis

144
Q

Which immune cells will be elevated in sarcoidosis?

A

CD4+ T cells

145
Q

Which cells carry elastase in the lungs?

A

Neutrophils and macrophages

146
Q

Which enzyme protects alveoli elastin from degradation by elastase?

A

alpha-1-antitrypsin (damaged by smoking)

147
Q

Causes of ARDS (SPARTAS)

A

Sepsis, Pneumonia, Aspiration, uRemia, Trauma, Amniotic fluid embolism, Shock

148
Q

clinical presentation of ARDS

A

Acute onset shortness of breath (respiratory failure), hypoxemia, CXR with bilateral lung opacities but no evidence of HF/fluid overload

149
Q

What causes initial alveolar damage in ARDS

A

Neutrophilic substances release substances toxic to alveoli, activate coagulation cascade and oxygen-derived free radicals

150
Q

Etiology of ARDS

A

Endothelial cell damage–> increased permeability of alveolar capillaries–> protein leaks into alveolar spaces–> hyalinization–> decreased lung compliance, increased work of breathing, decreased oxygen diffusion capacity

151
Q

Mechanism of cough-induced syncope

A

Increased intrathoracic pressure decreases venous return to heart, thus decreasing CO and cerebral perfusion

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