Pulmonary Flashcards
In the lungs, the binding of O2 to hemoglobin drives the release of ___ and ___ from hemoglobin
H+
CO2
Strep pneumoniae is gram _____, ___-hemolytic, optochin-______, and bile-______
positive
alpha
sensitive
soluble
Prolonged neuromuscular paralysis after succinylcholine administration is due to what autosomal recessive disorder
pseudocholinesterase deficiency
What cells function to regenerate the alveolar lining following injury
type II pneumocytes
also produce surfactant
The ____ carries lymph from most of the body and drains into the junction between the left subclavian and jugular veins
thoracic duct
In an anemic patient, what changes occur to the oxygen content of blood, oxygen saturation, and PaO2
oxygen content: low (bc low hemoglobin)
oxygen saturation: normal
PaO2: normal
How are phosphatidylcholine and sphingomyelin used to determine lung maturity in utero
fetal lung lectin (phosphatidylcholine) production increases sharply afer 30 weeks gestation and sphingomyelin levels should remain constant
a lectin/sphingomyelin ratio of 2 or more indicates adequate surfactant production
What are the two mechanisms that cause a malignant pleural effusion
inflammation induced increase in vascular permeability
malignant cells can occlude the pleural lymphatic stromal and prevent pleural fluid reabsorption
Cystic fibrosis is most commonly due to a 3 base pair deletion in the CF transmembrane conductance regulator gene leading to impairment of what
impaired post-translational processing of CTFR –> shunting of CTFR towards the proteasome with complete absence of the protein in the cell surface
What amino acid content/structure contributes to elastin’s rubber-like properties
high content of nonpolar amino acids and extensive cross-linking between elastin monomers facilitated by lysyl oxidase (oxidatively deaminates lysine residues –> desmosine cross links)
How are the following affected during physical exercise: venous CO2 and O2, arterial CO2 and O2
venous CO2: increased
venous O2: constant or decreased
arterial CO2 and O2: remain constant (increases in alveolar ventilation and gas exchange efficiency)
How does congenital diaphragmatic hernia cause respiratory distress in a neonate
herniation of the abdominal contents into the thorax causes pulmonary hypoplasia from compression of the lungs
Where in the airway does pseudostratified epithelium become simple cuboidal epithelium
terminal bronchioles
gradually transitions up until there
Ciliated cells are present in the airway from the trachea through where?
proximal portions of the respiratory bronchioles
not present in alveolar ducts or alveoli themselves
which have glands and cartillage: bronchi or bronchioles?
bronchi
What drugs interact with sextromethorphan
serotonergic drugs (can cause serotonin syndrome due to its ability to increase serotonin activity in the CNS)
Airway resistance is highest at ____ and lowest at what point in the airway
highest: medium sized bronchi
lowest: alveoli
Nocardia most commonly causes what manifestations in immunocompromised patients
pneumonia and brain abscesses
How is Legionella pneumophila most often spread
contaminates water –> organism is inhaled in aerosolized water and establishes infection via the pulmonary route
_____ is the most common mutation in the CFTR protein in patients with cystic fibrosis
delta F508
What is administered to pregnant women at risk of premature delivery to prevent neonatal respiratory distress syndrome
betamethasone or dexamethasone
cortisol –> accelerate fetal lung maturation by stimulating surfactant production
What neoplasm has sheets of small blue cells with scant cytoplasm and is positive for chromogranin and synaptophysin
small cell carcinoma of the lung
Primary TB causes the formation of Ghon foci in what region of the lungs? Where does secondayr/reactivated tuberculosis often localize?
primary: lower lung lobes
secondary: upper lungs
Cryptococcus neoformans is the only fungus that has a ____ which appears ___ on mucicarmine stain and ____ on india ink
polysaccharide capsule
red
clear
what is the equation for minute ventilation? alveolar ventilation?
minute ventilation = tidal volume * breaths/min
alveolar ventilation = (tidal volume - dead space volume) * breaths/min
The CFTR protein is a transmembrane ___ gated chloride channel
ATP
Aspirated material is more likely to travel down the main bronchus on what side?
right
Supine patients typically aspirate into what lobes as opposed to patients who are upright
supine: posterior segments of upper lobes and superior segments of the lower lobes
upright: basilar segments of lower lobes
Thickened bronchial walls, lymphocytic infiltration, mucous gland enlargement, and patchy squamous metaplasia of the bronchial mucosa are features of what?
chronic bronchitis
Pulmonary arterial hypertension is often caused by inactivating mutations involving the ____ gene resulting in ___ and ____ cell proliferation –> vascular remodeling –> vascular resistance
BMPR2
endothelial
smooth muscle
Bosentan MOA
endothelin receptor antagonist
endothelin is a potent vasoconstrictor that also stimulates endothelial proliferation
what medication improves symptoms in pulmonary arteriole hypertrophy by decreasing pulmonary arterial pressure and lessening the progression of vascular remodeling
Bosentan
Infants with secondhand smoke exposure are at increased risk for pneumonia becuase cigarette smoke affects _____ and ____ function
alveolar macrophage
mucocilliary
Pulmonary embolism causes increased _____ which leads to hypoxemia due to consequent ventilation/perfusion mismatch
dead space
When being weaned from mechanical ventilation, patients typically breath at ___ (high/low) tidal volumes and ____ (increased/decreased) respiratory rate which leads to increase in wasted ventilation (increased dead space)
low tidal volumes
increased respiratory rate
With chronic irritation, such as smoking, normal columnar epithelium of the bronchi are replaced with ______ which is more resistant to irritation but has reduced mucociliary clearance
squamous epithelium
this is reversible
Histologic findings of what disease include patchy lymphoplasmacytic infiltrates, focal fibroblastic proliferation with dense fibrosis, honeycombing, and hyperplasia of type 2 pneumocytes
idiopathic pulmonary fibrosis
Pirfenidone is used to treat idiopathic pulmonary fibrosis. What is its MOA
antifibrotic agent that inhibits TGF-beta
Nintedanib is used to treat idiopathic pulmonary fibrosis, what is its MOA
tyrosine kinase inhibitor that inhibits PDGF, FGF, and VEGF
Therapies for idiopathic pulmonary fibrosis are directed at slowing the progression of fibrosis by inhibiting what fibrogenic growth factors
TGF beta
PDGF
fibroblastic growth factor
VEGF
In a transplant patient, pneumonia with intranuclear and cytoplasmic inclusion bodies histologically points to opportunistic infection with what organism?
cytomegalovirus
Cytomegalovirus is a (enveloped or not?) virus that contains (double or single) stranded (RNA or DNA)
enveloped
double stranded DNA
Thoracentesis should be performed below the __ rib in midclavicular line, __ rib along midaxillary line, or ___ rib along paravertebral line in order to minimize risk of lung injury
6
8
10
Insertion of a needle for throacentesis lower than the 9th rib increases risk of penetrating _____
abdominal structures (ie. liver)
During thoracentesis, the needle should be inserted along the (upper or lower) border of the rib to prevent injury to the intercostal vessels
upper
How are total lung capacity, residual volume, and expiratory flow rate affected in COPD
total lung capacity: increased
residual volume: increased
expiratory flow rate: decreased
what leads to expiratory airflow obstruction in COPD
anatomic narrowing of bronchi (chronic bronchitis)
decreased lung elasticity from destruction of interalveolar walls (emphysema) promotes dynamic compression of airways during expiration
When inserting a chest tube at the 4th or 5th intercostal space at the midaxillary line, the tube traverses through what muscle?
serratus anterior (and intercostals)
What is the causative agent of walking pneumonia
mycoplasma pneumoniae
Mycoplasma pneumoniae requires ___ supplementation to grow on artificial media
cholesterol
In severe emphysema, what is the typical acid base status and how are the following affected: PaCO2, bicarb, pH, PaO2
respiratory acidosis with metabolic compensation
PaCO2: high (cause of resp acidosis is CO2 retention)
bicarb: high (compensation)
pH: slightly acidic
PaO2: low
Blood in the left atrium and ventricle has a slightly lower pO2 than blood in pulmonary capillaries due to mixing of deoxygenated blood from the _____ and ___ veins emptying into the left heart
bronchial veins (which empty into pulmonary veins which empty into left heart) and thebesian veins which are small cardiac veins
After a few weeks of primary TB, ____ lymphocytes are stimulated to release ____ which activates macrophages and leads to control of the infection
CD4
interferon gamma
What lung neoplasm has neural cell adhesion molecule
small cell carcinoma
What is the characteristic histopathologic feature of sarcoidosis
noncaseating granulomas
How does hyperventilation cause dizziness
hypocapnia –> reduced cerebral blood flow
What is seen on lung imaging of sarcoidosis
bilateral hilar adenopathy
pulmonary reticular infiltrates
What lab values are elevated in sarcoidosis?
calcium
ACE
Sarcoidosis has large number of ____ lymphocytes which release ___ and ___ to drive ___ activation and granuloma formation
CD4
interferon gamma
tumor necrosis factor alpha
macrophage
What is the most common cause of clubbing in adults
lung adenocarcinoma (tumor secretes VEGF)
Theophylline MOA
adenosine receptor antagonist and phosphodiesterase inhibitor (sometimes used as an alternate therapy for asthma and COPD)
What antibiotics are CYP450 inhibitors
isoniazid
macrolides (except azithromycin)
quinolones
During hypoxia, such as at high elevations, how is aldosterone effected
hypoxia –> aldosterone suppression –> diuresis and reduced plasma volume
How is diffusing capacity for carbon monoxide effected in emphysema
decreased
due to destruction of alveoli and adjoining capillary beds
What is the primary virulence factor of strep pneumoniae
polysaccharide capsule that inhibits opsonization and phagocytosis
What organism can be seen on microscopic examination of lung tissue as spherules packed with endospores
coccidioides immitis
_____ is characterized by bilateral pulmonary infiltrates and hypoxemia in the absence of heart failure
acute respiratory distress syndrome
In acute respiratory distress syndrome, inflammatory cytokines recruit ___ resulting in endothelial damage, capillary permeability and leakage of protein rich fluid into alveolar spave
neutrophils
at high altitude for 2 days, how are pH, PaO2, PaCO2, and bicarb affected
pH: increased (respiratory alkalosis)
PaO2: decreased
PaCO2: decreased (hyperventilation)
bicarb: increase
Acid fast staining is due to what being present in the organism walls
mycolic acid
Electrical stimulation of what nerve increases the diameter of the oropharyngeal airway and decreases the frequency of apneic events
hypoglossal (causes the tongue to move forwards slightly)
How does pneumocystis jirovecii appear on methenamine silver stain
the cell wall appears as a crescent, crushed ping pong ball, or a circular ring around a clear center
what is first line treatment for pneumocystis pneumonia (pneumocystis jirovecii)
trimethoprim-sulfamethoxazole
TMX
Lobar pneumonia is marked by cytokine-mediated accumulation of ___ and ____ material in the alveoli
neutrophils
proteinaceous
When saline is applied to the nasal mucosa of a patient with CF, increased ____ causes a more negative nasal transepithelial potential difference which can be used to diagnose cystic fibrosis
sodium absorption
Pneumoconioses are disease from the inhalation of fine dust particles that reach the respiratory bronchioles and alveoli. Particles that lodge in this region are usually cleared by what mechanism
macrophages
what effect does normal aging have on chest wall compliance, lung compliance, residual volume, forced vital capacity and total lung capacity
chest wall compliance: decrease lung compliance: increase residual volume: increase forced vital capacity: decreased total lung capacity: relatively unchanged
What are the 3 leading pathogens that cause bacterial pneumonia
streptococcus pneumoniae
staphylococcus aureus
haemophilus influenza
Compare the FEV1, FVC, and FEV1/FVC in restrictive (fibrosis) vs obstructive (COPD) lung diseases
Restrictive: FVC reduced, FEV1 reduced, FEV1/FVC normal or sometimes increased
obstructive: FVC normal or reduced, FEV1 reduced, FEV1/FVC decreased
The superficial alveoli in the apices experience greater pressure changes due to weight of the lungs pulling down on the apical tissue, predisposing them to formation of ___ which can spontaneously rupture causing a primary spontaneous pneumothorax
subpleural blebs
What CD4 counts are required for a aspergillus pneumonia infection? Pneumocystis pneumonia?
aspergillus <50
pnueumocystis pneumonia: <200
During the initial phase of respiratory distress, interstitial and intraalveolar edema, inflammation, and fibrin depostion cause the alveoli to become line with _____ membranes
waxy hyaline
Pleural plaques (focal or band-like pleural thickening) are a hallmark of ____ exposure
asbestos (chronic inflammation and collagen deposition within the pleura)
Haemophilus influenza is a gram negative coccobacillus that requires what 2 things to grow
X factor: hematin
V factor: NAD+
What virulence factor allows H. flu type B to spread hematogenously and cause invasive disease such a septic arthritis and meningitis
antiphagocytic polysaccharide capsule
Ketamine can be used for anesthesia induction. Why is it particularly useful in patients with bronchospasm
increased catecholamine release –> bronchodilation
What lung changes are seen in chronic rejection of a lung transplant
bronchiolitis obliterans: lymphocytic inflammation, fibrosis, and ultimately destruction of the bronchioles
During aerobic exercise, what changes happen to minute ventilation, ventilation/perfusion ratio, and mixed venous oxygen content
minute ventilation: increased (increased respiratory rate and tidal volume –> increased oxygen uptake and carbon dioxide removal)
ventilation/perfusion ratio: increased (increased ventilation –> decreased pulmonary vascular resistance –> reduced dead space)
mixed venous oxygen content: decreased (lactic acid in blood –> oxygen unloading from hemoglobin)
Left sided heart failure has what effect on lung compliance
decreases lung compliance dur to accumulation of edema in the pulmonary interstitium that makes the lungs heavy and stiff, restricting expansion and decreasing compliance
Arterial pressure of ____ is the major stimulator for central chemoreceptors to trigger increased ventilation. ____ is the major chemoreceptor for peripheral chemoreceptors (carotid body).
CO2
O2
How are PaO2, PaCO2 and A-a gradient effected by normal aging
PaO2: decreased (via basilar microatelectasis from decreased muscle and chest wall stiffening –> intrapulmonary shunting: perfusion of blood through non ventilated alveoli)
PaCO2: unchanged (resting hypoventilation at any age is always pathologic)
A-a: increased (alveolar-arterial oxygen gradient; due to ventilation perfusion mismatch)
What medications can be used to treat pulmonary arterial hypertension by lowering pulmonary arterial pressure and improving dyspnea
endothelin receptor antagonists: bosentan and ambrisentan
Legionella pneumophila has what clinical presentation and elicits what abnormal blood test
high fever cough confusion diarrhea hyponatremia
The Reid index determines the severity of bronchitis by comparing the thickeness of the ____ divided by the thickness of what
submucosal bronchial glands
bronchial wall between the epithelial basement membrane and the bronchial cartilage (do not include the epithelium or cartilage)
Pulmonary alveolar proteinosis is a rate condition characterized by progressive respiratory dysfunction due to the accumulation of _____ within the alveolar space which most often occurs due to impaired clearance by the ____
surfactant
alveolar macrophages
Substance found in the alveoli that is periodic acid-Schiff positive and forms lamellar bodies is what
surfactant
Peptosteptococcus and fusobacterium are anaerobic bacteria that are part of normal mouth flora. Presence of these organsims in the lung is highly suggestive of what lung pathology
lung abscess
what are symptoms of lung abscess
fever night sweats weight loss cough foul smelling sputum
Malignant mesothelioma is a rare neoplasm typically arising from the _____. Histopathology reveals tumor cells with numerous _____ and abundant _____
long, slender microvili
tonofilaments
How are the following effected by pneumothorax: tactile fremitus, breath sounds, resonance to percusion
tactile fremitus: decreased
breath sounds: decreased
hyperresonance to percussion
How does septic shock cause an anion gap acidosis
tissue hypoxia –> impaired oxidative phosphorylation –> shunting of pyruvate to lactate –> lactic acidosis
How does corticosteroid treatment improve response to albuterol
in addition to their anti-inflammatory effect, they upregulate B2 receptors and increased cellular responsiveness to adrenergic stimuli and potentiate the bronchodilatory response to B2 agonists
____ is an encapsulated, lactose-fermenting (appears pink on macconkey agar), gram negative bacillus
Klebsiella
What treatment for asthma are used chronically and can prevent inflammatory cellular reactions in the airways
inhaled corticosteroids (fluticasone)
What acid base disorder is caused by pulmonary embolism
acute respiratory alkalosis
due to hyperventilation –> low CO2
in a 19 yr old, small airways filled with mucin plugs containing abundant inflammatory cells and a dilated bronchial tree are findings in what condition
cystic fibrosis
What cause of granulomas in the lungs can spread lymphatically and collect in the reticuloendothelial system (spleen and liver) and may appear on radiographic imaging as they calcify overtime
histoplasma capsultaum
Why are patients with silicosis at an increased risk for TB
internalized silica particles impair macrophage function disrupting phagocytosis and promoting apoptosis
How is putting a patient with acute respiratory distress syndrome in the prone position able to improve arterial oxygenatoin
reduced compression of posterior lung segments (location of majority of alveoli) –> more evenly distributed ventilation –> reduced shunting –? improved vent-perfusion matching
_____ can cause pulmonary disease in immunocompetent host resulting in granuloma formation and is endemic to states adjacent to and east of the mississippi and ohio river valleys
blastomyces dermatitidis
The leading bacterial cause of upper respiratory infections that exacerbate COPD is____
H flu
Why is there an elevated central venous oxygen saturation in a patient with sepsis?
bacterial components and acute phase cytokines trigger production of free radicals –> damage mitochondria –> decreased oxidative phosphorylation –> decreased oxygen use
Work of breathing is the energy expended during respiration and comprises the work required to over come ___ and ____
elastic resistance
airflow resistance
What is elastic resistance and what type of lung diseases have increased elastic resistance
opposition to lung expansion
restrictive lung diseases
(interstitial fibrosis, severe obesity)
what is airflow resistance and what type of lung diseases have increased airflow resistanct
opposition to airflow created by limited airway diameter and turbulent airflow
obstructive lung diseases
(asthma, COPD; due to bronchoconstriction or airway collapse)
In patients with restrictive lung diseases, work of breathing is minimized in what relative tidal volume and respiratory rate
tidal volume: low
to compensate for low lung volumes, rapid, shallow breathing is favored
in patients with obstructive lung disease, the work of breathing is minimized at what relative tidal volumes and respiratory rates
respiratory rate: low
tidal volume: high
The inflammatory immune response to radiation induced lung damage, for example, can have what acute and what delayed histological effects
acute: exudative alveolitis and hyaline membrane formation
delayed: dense fibrosis
infection with ______ can cause a brassy, barking cough, dyspnea following a recent upper respiratory infection in children
croup (parainfluenza, a member of paramyxoviridae family)
What medication can be used to reduce withdrawal cravings and attenuate the rewarding effects of nicotine
varenicline (partial nicotinic agonist)
What pulmonary disease can be caused directly by rheumatoid arthritis as well as its treatment including methotrexate, cyclophosphamide, and sulfasalazine)
interstitial lung disease
A green inspissated mass (dehydrated meconium) in the distal ileum points to the diagnosis of meconium ileus as a source of obstruction which is a very specific finding in what disease
cystic fibrosis
Nearly all cases of mesothelioma will stain positive for ___ and many will also typically stain positive for ____
cytokeratins
calretinin
(EM shows polygonal tumor cells with numerous long, slender microvilli and abundant tonofilaments)
In a patient with cystic fibrosis presenting with acute onset shortness of breath and subcutaneous crepitus, what is the cause of the acute shortness of breath
spontaneous pneumothorax
common in CF
A patient with bilateral hilar adenopathy, elevated serum ACE levels, skin lesions, and hepatomegaly likely have what diagnosis
sarcoidosis
What malignancies are patients with a long history of asbestos exposure at risk for developing
bronchogenic carcinoma (more common) mesothelioma (only caused by asbestos but less common)
histology of what condition shows lymphocytic infiltrate, poorly formed noncaseating granulomas, and septal fibrosis on biopsy
hypersensitivity pneumonitis
ferruginous bodies (translucent fibers coated with a golden iron containing material) are histopathologic signs on lung biopsy of what
asbestosis exposure
Etomidate is a ____ agonist that is often used for anesthesia induction
GABA
Which anesthesia has the advantage of being the most hemodynamically neutral
Etomidate
What anesthesia has the advantage of reducing airway resistance but causes vasodilation –> hypotension
propofol
What anesthesia has the benefit of an analgesic effect
ketamine
Describe the strep pneumoniae vaccination for infants vs the elderly
infants: polysaccharide vaccine, contains 23 serotypes, T cell independent response driven largely by B cell activation
elderly: conjugate vaccine, capsular polysaccharides from 13 serotypes covalently attached to recombinant, inactivated diptheria toxin. protein allows histocompatibility complex to display –> Tcell mediated B cell lymphocyte activation
An aspergilloma (mycetoma) represents Aspergillus colonization which may develop in old lung cavities from what?
TB
emphysema
sarcoidosis
Intermittent respiratory symptoms in a patient with a normal chest xray, sputum eosinophils, and reduced FEV1 suggests what diagnosis
asthma
describe the histological changes that cause emphysema
interalveolar septal destruction with bronchial wall inflammation
What type of embolism should be strongly suspected in a patient with severe longbone and/or pelvic fractures who develops acute onset neuro abdnormalities, hypoxemia, and petechial rash
fat
Abscess formation is largely driven by ____ recruitment and activation
neutrophil
Inhibition of glycosyltransferase has what effect on bacteria
gaps in bacterial cell wall –> cell lysis from osmotic stress
why are organisms from the mycoplasma genus immune to the follow agents: penicillins, cephalosporins, carbapenems, vanco
they lack a cell wall
Montelukast MOA
leukotriene receptor antagonist (treats asthma by preventing leukotrienes to bind their receptors which causes bronchoconstriction, mucus secretion and edema)
define cor pulmonale
hypertrophy and/or dilation of the right ventricle due to disease of the lungs or pulmonary blood vessels
How does sarcoidosis cause hypercalcemia
activated macrophages produce 1,25 dihydroxyvitamin D which leads to increased intestinal absorption of calcium
What complication of asthma can result in transient recurrent pulmonary infiltrates and eventual proximal bronchiectasis
allergic bronchopulmonary aspergillosis
exudative effusions are typically due to what?
inflammation and consequent increased vascular membrane permeability
What dimorphic fungus is a large round yeast with doubly refreactile wall and single broad based bud on biopsy (37 C)
blastomyces dermatitidis
what dimorphic fungus appears as oval yeast cells within macrophages on biopsy (37 C)
histoplasma capsulatum
What dimorphic fungus appears as cells covered in budding blastoconidia on biopsy (37 C)
paracoccidioides brasiliensis
what dimorphic fungus appears as thick walled spherules filled with endospores on biopsy (37 C)
coccidioides immitis
what dimorphic fungus appears as round or cigar shaped budding yeasts on biopsy (37 C)
sporothrix schenckii
What fluid type should be administered for volume resuscitation as seen in septic shock
isotonic: .9% normal saline or lactated ringer solution
isotonic is similar tonicity to blood
Generally, the most important protection from influenza A includes a humoral response with antibodies directed against ____.
hemagglutinin
(neutralize the virus and primarily block its binding to host cells)
(neuraminidase antibodies have some protective effect by decreasing extent of viral invasion and shedding but not the main source of protection against reinfection)
Eosinophils are recruited and activated by what cytokine secreted by what cells?
IL-5
TH2 type T cells
Positive end-expiratory pressure helps treat ARDS by opening collapsed alveoli to reduce intrapulmonary shunting and increase functional residual capacity. Increased FRC has what benefits
decreased ventilation perfusion mismatching
increased oxygen reserve
How do advanced hypoxic lung diseases such as COPD cause pulmonary hypertension
mainly from diffuse hypoxic vasoconstriction and to a lesser degree from vascular remodeling
Hamartomas are common, slow-growing, benign lung neoplasm microscopically characterized by nodules of disorganized, mature _____ and entrapped respiratory epithelium
connective tissue
MOA of cromoglycates/cromolyn/nedocromil
inhibit mast cell degranulation and prevent release of preformed chemical mediators
Staph aureus strains that express _____, a protease that kills leukocytes and causes necrosis, are most likely to cause skin or soft-tissue abscess and invasive disease
Panton-Valentine leukocidin (PVL)
Particles in or proximal to the terminal bronchioles are cleared by what mechanism? How are particles distal to the terminal bronchioles mainly cleared?
terminal bronchioles: cilia
distal to terminal bronchioles: macrophages
Describe the changes that occur in the following with a pneumothorax: intrapleural negative pressue, volume of effected hemithroax, inspiratory compliance
negative pressure: decreased
volume of hemithorax: increased
inspiratory compliance: decreased
_____ results from an exaggerated immunologic response to an inhaled antigen. Bronchoalveolar lavage typically shows high relative lymphocyte count which helps support the diagnosis
hypersensitivity pneumonitis
What causes central sleep apnea
diminished respiratory drive from a neurologic disorder
Does cystic fibrosis cause a obstructive or restrictive lung disease
obstructive
What cause of pneumoconiosis appears histologically as birefringent silicate particles within dense, whorled collagenous nodules durrounded by dust-laden macrophages
silica
In community acquired pneumonia, a patient may have improved oxygenation shortly after treatment initiation despite no changes in alveolar debris or edema. What mechanism is responsible for this initial clinical improvement?
in inflammatory states, hypoxic pulmonary vasoconstriction is impaired –> vasodilation in regions that are not ventilated.
treatment decreases vasoactive inflammatory mediators which restores hypoxic pulmonary vasoconstriction and decreases perfusion to unventilated areas
How is A-a gradient effected in low respiratory drive such as benzo overdose
A-a is not effected because efficiency of gas transfer between the lungs and the circulation is intact
Will a pneumothorax produce hyper, hypo or normal resonance on percussion
hyper
What does a lung biopsy showing engorged alveolar capillaries with acellular pink material represent
acute pulmonary edema
What complication of ascites may cause a transudative right-sided pleural effusion
hepatic hydrothorax: passage of intraabdominal fluid into chest cavity through small fenestrations in the diaphragm
What 3 cell types are the primary mediators of disease in COPD
neutrophils
macrophages
CD8 T cells
(secrete enzymes and proteases that cause and perpetuate alveolar destruction and mucus hypersecretion)
What is empyema
bacterial invasion of intrapleural space -> progressive inflammation, pus accumulation, and organized fibrosis
In empyema, drainage with a chest tube is often difficult due to loculations and high fluid viscosity, but it can be aided by the intrapleural administration of ____ in combination with ____
fibrinolytic agent (TPA) nucleic acid cleaving enzyme (deoxyribonuclease (DNase)) (these help break down organized fibrin and cleave nucleic acids that increase fluid viscosity after being deposited by lysed leukocytes)
how is group B strep in a newborn prevented
intrapartum (during birth) administration of penicillin or ampicillin
what is the cause of exudative pulmonary edema in acute respiratory distress syndrome
neutrophilic lung inflammation with widespread alveolar damage due to proteases and reactive oxygen species, leading to failure of the vascular barrier and exudative pulmonary edema
Mucicarmine staining of lung tissue and bronchoalveolar washings revealing budding yeast forms with thick capsules indicates what diagnosis
cryptococcus neofromans
what is the most common presentation of a cryptococcus neoformans infection
meningoencephalitis
lung infection occurs first but is usually asymptomatic
Patients with alcohol use disorder are at increased risk for lung abscess due to aspiration of bacteria from where? what type of pathogens should be covered in emperic treatment
oral flora
strict and facultative anaerobic oral flora (bacteroides, prevotella, fusobacterium, peptostreptococcus)
What is CREST syndrome
calcinosis Raynaud phenomenon esophageal dysmotility sclerodactyly telangiectasia
What is the initial treatment of choice in sarcoidosis
oral glucocorticoids
What is atelectasis
diffuse alveolar collapse (as seen in neonatal respiratory distress syndrome)
Normal aging as what effect on the following: total respiratory compliance , lung compliance, dead space
total respiratory system compliance: decreased
lung compliance: increased (but chest wall is stiffer so decreased total compliance)
dead space: increased (loss of alveolar surface area)
What electrolyte imbalance is caused directly by cystic fibrosis
hyponatremia and hypochloremia due to excessive sodium chloride loss through sweat
What fungus replicates within macrophages and spreads throughout the reticuloendothelial system as small, ovoid yeasts
histoplasma capsulatum
What would cause unilateral lower lobe dullness on percussion, breath sounds that are loud hollow and high pitched, and higher clarity when the patient says “ninety nine” in a normal voice
alveolar consolidation due to being filled with fluid, ie bacterial pneumonia
Massive life-threatening hemoptysis is typically due to hemorrhage from _____ . How is bronchiectasis a common etiology
high pressure bronchial circulation
chronic airway inflammation –> hypertrophied bronchial arteries which are prone to rupture with coughing
Intrapleural negative pressure peaks at maximal inspiration at a value of approximately ____ cm H2O. During passive expiration the chest wall relaxes and the respiratory system returns to its equilibrium position, in which intrapleural pressure is approximately ___ cm H2O
- 8
- 5
The ____ of type II pneumocytes store and release pulmonary surfactant into the fluid layer lining the inner surface of alveoli
lamellar bodies
What shunting is present due to neonatal respiratory distress syndrome caused by surfactant deficiency
intrapulmonary right-to-left shunt due to decreased ventillation/perfusion ration
extrapulmonary right-to-left shunt within the heart or patent ductus arteriosus due to compensatory pulmonary vasoconstriction
What shunting is present due to neonatal respiratory distress syndrome caused by surfactant deficiency
intrapulmonary right-to-left shunt due to decreased ventillation/perfusion ration
extrapulmonary right-to-left shunt within the heart (foramen ovale) or patent ductus arteriosus due to compensatory pulmonary vasoconstriction
Why does a tension pneumothorax cause hypotension
increased intrapleural pressure –> vena cava collapse –> decreased venous return –> hypotension, tachycardia, obstructive sock
A child presenting with high fever and shortness of breath who is leaning forward, with their neck extended and mouth open to breath likely has what diagnosis
H. flu with epiglottitis
posture described is the tripod position
What will be seen on a chest x ray of a collapsed lung due to bronchial obstruction
trachea deviated toward affected side (other organs such as the heart and esophagus may also shift in the same direction)
completely opacified hemithorax due to loss of radiolucent air
A patient with interstitial lung disease will have a significant drop in arterial partial pressure of oxygen during exercise due to what normal physiologic change during exercise
increased pulmonary blood flow
decreases time that for oxygen extraction in a person who already has a limited oxygen diffusion across the membrane
What causes high RBC chloride content in venous blood compared to arterial blood
CO2 from tissues is converted to bicarb by carbonic anhydrase in RBC, bicarb is then transferred into the plasma via exchange with chloride ions
Explain how high altitude can cause pulmonary edema
reduced oxygen –> hypoxic pulmonary vasoconstriction and pulmonary arterial hypertension
if pulmonary vasoconstriction is uneven areas of high capillary perfusion pressure can disrupt the alveolar-capillary membrane leading to patchy, bilateral pulmonary edema
Under normal conditions, pleural fluid enters the pleural space via ____ and exit via ____
intercostal microvessels lymphatic stomata (holes in the pleura) that drain into parietal pleura lymphatics
How are the following affected in idiopathic pulmonary fibrosis: type 1 pneumocytes type 2 pneumocytes basement membrane fibroblasts
type 1: decreased (due to repetitive injury)
type 2: increased (due to proliferation in order to repair damage)
basement membrane: abnormal
fibroblasts: increased (produces honeycomb appearance and dilation of terminal bronchioles)
Pertussis is what kind of organism
gram negative coccobacillus
What should be suspected in a patient presenting with facial weakness and hypoventilation causing respiratory failure
myasthenia gravis
Which of the following cause increased breath sound intensity and increased tactile fremitus: lobar consolidation pericardial effusion pneumothorax pleural effusion pulmonary edema
pulmonary edema
lobar consolidation
(vibration travels faster and more efficiently through liquids than gases)
(fluid in the pleural space acts to insulate sound vibrations so pleural effusion causes decreased sounds)
What protects the lungs from infarction during a pulmonary artery occlusion (ie pulmonary embolism)
collateral circulation from the bronchial arteries
How does Histoplasma capsulatum appear on lung biopsy
ovoid/round yeast predominantly within the intracellular space of macrophages
In interstitial lung disease, what 2 changes cause an increased expiratory flow rate when corrected for the low lung volume
increased elastic recoil
increased radial traction (outward pulling on the airways)
According to Light criteria, pleural fluid/serum lactate dehydrogenase ratio > ____ is an exudative effusion
.6
The green discoloration of pus or sputum seen during common bacterial infections is due to the presence of ______, a blue-green heme-based enzyme that is released from ___ azurophilic granules
myeloperoxidase
neutrophil
In neonate respiratory distress syndrome, how are the following affected before treatment/intervention:
alveolar compliance
functional residual capacity
airway resistance
alveolar compliance: decreased
functional residual capacity: decreased
Prolonged, untreated obstructive sleep apnea can cause what complication
pulmonary hypertension and right heart failure
Describe why hereditary hemorrhagic telangiectasia causes pulmonary hypertension
systemic arteriovenous malformations –> high output heart failure
How will pulmonary arterial levels of the following be affected in pulmonary arterial hypertension: endothelin thromboxane nitric oxide prostacyclin
endothelin and thromboxane: increased
nitric oxide and prostacyclin: decreased
(endothelial dysfunction –> increased releases of vasoconstrictive, proproliferative mediators and decreased vasodilative, antiprolferative mediators)
What is the most common primary lung cancer in the general population
adenocarcinoma
Albuterol is a ___ receptor agonist which increases ____ levels in bronchial smooth muscle to induce bronchodilation
beta 2
cyclic AMP
How does excessively high oxygen supplementation cause confusion and lethargy in patients with COPD
oxygen induced hypercapnia
high PaO2 –> reversal of pulmonary vasoconstriction in underventilated areas –> inability to excrete CO2
