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USMLE > Pulmonary > Flashcards

Pulmonary Flashcards

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USMLE® Step 1 flashcards
1
Q

Conducting vs respiratory zones

A

Conducting zone

  • large and small airways, as get to smaller airways, have more in parallel and thus less resistance
  • anatomic dead space - no gas exchange
  • cartilage, goblet cells, pseudostratified columnar epithelium to beginning of terminal bronchioles
  • airway smooth muscle cells through terminal bronchioles

Respiratory zone

  • respiratory bronchioles, alveolar ducts, and alveoli
  • site of gas exchange
  • cuboidal epithelium in respiratory bronchioles, simple squamous in alveolar ducts
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2
Q

Type I and type II pneumocytes

A

Type 1: Make up 97% of alveolar surfaces, squamous

Type 2: secrete surfactant, serve as precursors to type 1

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3
Q

Club cells

A

nonciliated, cuboidal cells with secretory granules that secrete a component of surfactant

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4
Q

Surfactant

A

secreted by type II pneumocytes and club cells; made up of lecithins including dipalmitoylphophatidylcholine. Synthesis begins at week 26, mature levels at week 35. Lecithin : sphingomyelin ratio over 2 indicates fetal lung maturity

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5
Q

Aspiration locations

A

When upright: lower portion of R inf lobe

When supine: sup portion of R inf lobe

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6
Q

Relationship between pulmonary artery and brochus

A

Righ: pulm artery anterior to main bronchus
Left: pum artery superior to main bronchus

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7
Q

Structures perforating diaphragm

A

T8: IVC
T10: esophagus and vagus n
T12: aorta

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8
Q

Functional residual capacity

A

residual volume plus expiratory reserve volume (volume of gas in lungs after normal expiration

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9
Q

Physiologic dead space

A

=anatomic dead space of conducting airways + alveolar dead space (most is in apex)

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10
Q

Minute ventilation vs alveolar ventilation

A

Minute ventilation=Total volume of gas entering lungs per minute
=Vt x RR

Alveolar ventilation=Volume of gas per unit time reaching alveoli

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11
Q

Intrapleural pressure

A

Negative at FRC to prevent pneumothorax

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12
Q

Compliance

A

Change in lung volume for given change in pressure. Decreased in pulmonary fibrosis, pneumonia, pulmonary edema. Increased in emphysema, aging.

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13
Q

Methemoglobinemia

A

Oxidized form of Hb with increased affinity for cyanide, decreased affinity for O2

Presents with cyanosis and chocolate-colored blood

Treated with methylene blue

Can induce methemoglobinemia with nitrites to treat cyanide poisoning

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14
Q

Perfusion vs diffusion limited

A

Perfusion limited: Gas equilibrates early along length of capillary; diffusion increased only if blood flow increased; case in normal lung

Diffusion limited: Gas does not equilibrate by time blood reaches end of capillary; seen in emphysema and pulmonary fibrosis

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15
Q

Alveolar gas equation

A

PAo2 = PIo2 - PaCO2/R

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16
Q

Causes of hypoxemia

A

Normal A-a gradient: high altituide, hypoventilation

Increased A-a gradient: V/Q mismatch, diffusion limitation, right to left shunt

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17
Q

V/Q mismatch in normal lung

A

V/Q high at apex: wasted ventilation
V/Q low at base: wasted perfusion
both ventilation and perfusion greater at base than apex
V/Q approaches 1 with exercise due to vasodilation of apical capillaries

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18
Q

Pathology of V/Q

A

V/Q=0 airway obstruction (shunt), 100% O2 does not improve

V/Q=infinity blood flow obstruction, 100% O2 improves PaO2

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19
Q

Transport of CO2

A

90% as HCO3-
5% as HbCO2
5% as dissolved CO2

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20
Q

Vichow triad

A

1) stasis
2) hypercoagulability
3) endothelial damage: exposed collagen triggers clotting cascade

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21
Q

Homan sign

A

dorsiflexion of foot causes calf pain; sign of DVT

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22
Q

Lines of Zahn in PE

A

Interdigitated areas of pink and red found in thrombi that occur prior to death

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23
Q

Classic triad of fat emboli

A

Hypoxemia + neurologic abnormalities + petechial rash

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24
Q

Amniotic fluid emboli - complication

A

Can lead to DIC, especially postpartum

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25
Q

Air emboli

A

Nitrogen bubbles precipitate in ascending divers. Treated with hyperbaric O2

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26
Q

PFTs of obstructive lung disease

A

Decreased FEV1 and decreased FVC with decreased FEV1/FVC ratio (hallmark)

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27
Q

Chronic bronchitis

A

Path: hyperplasia of mucus secreting glands

Clinical: productive cough for over 3 mos per year for over 2 years. Wheezes, crackles, cyanosis, hypercapnea, secondary polycythemia

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28
Q

Emphysema - two forms

A

Centriacinar associated with smoking

Panacrinar associated with alpha1 antitrypsin def

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29
Q

Emphysema findings

A

Increased elastase activity leading to loss of elastic fibers and increased compliance/decreased recoil

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30
Q

Pathologic findings of asthma

A

Smooth muscle hypertrophy
Curschmann spirals: shed epithelium forms mucus plugs
Charcot-Leyden crystals: eosinophilic, hexagonal, double pointed crystals from breakdown of eosinophils in sputum

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31
Q

Sarcoidosis findings

A

Bilateral hilar lymphadenopathy, noncaseating granulomas, increased ACE, increased Ca++

32
Q

Hypersensitivity pneumonitis

A

Mixed type III/IV hypersensitivity. Dyspnea, cough, chest tightness, headache. Classically in farmers and those exposed to birds

33
Q

Asbestosis

A

Exposure: shipbuilding, roofing, plumbing

Pathology: ivory white calcified supradiaphragmatic and pleural plaques. Golden brown rods in alveolar septum.

Presentation: restrictive lung disease. Risk of cor pulmonale. Risk of lung cancer (bronchogenic carcinoma more than mesothelioma)

34
Q

Berylliosis

A

Exposure: aerospace and manufacturing industries

Pathology: granulomas in upper lobes

Presentation: restrictive lung disease

35
Q

Coal workers pneumoconiosis

A

Exposure: prolonged coal dust exposure

Pathology: Macrophages laden with carbon, inflammation, fibrosis in upper lobes

Presentation: restirctive lung disease

36
Q

Silicosis

A

Exposure: foundries, sandblasting, mines

Pathology: Macrophages release fibrogenic factors in response to silica. Eggshell calcifcation of hilar lymph nodes. Effects upper lobes.

Presentation: Restrictive lung disease. Increased risk for bronchogenic carcinoma

37
Q

Neonatal respiratory distress syndrome

A

Pathophysiology: surfactant deficiency causes increased surface tension and alveolar collapse

Imaging: ground glass appearance of lung fields

Treatment: Maternal steroids before birth, artificial surfactant for infant

Complications: PDA due to persistent low O2. Retinopathy, intraventricular hemorrhage, and bronchopulmonary dysplasia due to supplemental O2

38
Q

ARDS

A

Presentation: Acute onset resp failure with bilateral lung opacities and decreased PaO2/FiO2 in absence of HF

Pathology: Diffuse alveolar damage results in increased alveolar capillary permeability and protein leak into alveoli. Causes noncardiogenic pulmonary edema with normal PCWP. Formation of intra-alveolar hyaline membranes.

Treatment: mechanical ventilation with low tidal volume

39
Q

Drugs that cause pulmonary hypertension

A

Amphetamines, cocaine

40
Q

Pathology of pulmonary hypertension

A

pulmonary artery pressure greater than 25 mmHg at rest

Arteriolosclerosis, medial hypertrophy, intimal fibrosis of pulmonary arteries

41
Q

Tracheal deviation in different respiratory conditions

A

pleural effusion: none or away from side of lesion
atelectasis: toward side of lesion
tension pneumo: away from side of lesion
simple pneumo: none

42
Q

Types of pleural effusion

A

Transudate: due to disruption of starling forces (increased hydrostatic pressure, decreased oncotic pressure) due to HF, nephrotic syndrome, hepatic cirrhosis. Low protein

Exudate: High protein. Due to malignancy, pneumonia, collagen vascular disease, trauma

Lymphatic: High TGs. Due to thoracic duct injury by trauma or malignancy

43
Q

Types of pneumothorax

A

Primary spontaneous: rupture of apical blebs or cysts in tall thin young male

Secondary spontaneous: due to diseased lung or high pressure mechanical vent

Traumatic: blunt or penetrating trauma

Tension: Air enters pleural space but can’t get out. Causes trachea to deviate away from affected lung

44
Q

Lobar pneumonia

A

Organisms: S pneumo, Legionella, Klebsiella

Pathology: consolidation due to exudate, involves entire lobe or lung

45
Q

Bronchopneumonia

A

Organisms: S pneumo, S aureus, H flu, Klebsiella

Pathology: inflammation from bronchioles into adjacent alveoli, patchy distribution

46
Q

Interstitial pneumonia

A

Organisms: viruses, mycoplasma, legionella, chlamydia

Pathology: diffuse patchy involvement involving interstial areas

47
Q

Lung abscesses

A

Clinical: Classically seen in patients with loss of consciousness and aspiration of oropharyngeal contents or bronchial obstruction

Pathology: Local collection of pus in parenchyma. Due to anaerobes

Imaging: Air-fluid levels

Treatment: Clindamycin

48
Q

Pancoast tumor

A

Carcinoma in apex of lung. Can invade cervical sympathetic chain and cause Horner syndrome, SVC syndrome, sensorimotor defects, hoarsness

49
Q

SVC syndrome

A

Obstruction of SVC by malignancy or thrombosis preventing blood drainage from head, neck, and upper extremities. Causes facial plethora, JVD, and edema. Can raise intracranial pressure if obstruction severe.

50
Q

Sites of metastasis for lung cancers

A

Adrenals, brain, bone, liver

51
Q

Cancers that metastasize to lung

A

Breast, colon, prostate, bladder

52
Q

Small cell carcinoma of lung

A

Location: central

Pathology: Undifferentiated neuroendocrine cells that appear as small dark blue cells. Chromogranin A+, amplificiation of myc genes

Clinical: Very aggressive. Can made ACTH, cause SIADH, cause myasthenic syndrome, cause paraneoplastic encephtalitis

53
Q

Adenocarcinoma of lung

A

Location: peripheral

Clinical: most common lung cancer in nonsmokers, and overall. Clubbing.

Pathology: mutations in KRAS, EGFR, ALK. Glandular pattern. Mucin +

54
Q

Squamous cell carcinoma of lung

A

Location: central

Clinical: can cause hypercalcemia through a paraneoplastic syndrome

Pathology: Hilar mass, cavitation, keratin pearls

55
Q

Large cell carcinoma of lung

A

Location: peripheral

Clinical: Poor prognosis

Pathology: Highly anaplastic and undifferentiated, pleomorphic giant cells, can secrete beta hcG

56
Q

Bronchial carcinoid tumor

A

Pathology: neuroendocrine cell nests; chromogranin A +

Clinical: escellent prognosis, presents with symptoms of mass effect, occasionally cuases carcinoid syndrome

57
Q

meconium ileus

A

obstruction of distal ileum by dehydrated meconium. Most commonly cuased by cystic fibrosis. Often is the presenting symptom at birth of CF.

58
Q

Influenza vaccine

A

Inactivated vaccine: Induce antibodies against hemagglutinin antigen which inhiibin bindings ot hemagglutinin to host cell receptors, prevneting virus from entering cells.q

59
Q

Minute ventilation vs alveolar ventilation

A

Minute ventilation is total volume of new air that enters resp pathways per minute

Alveolar ventilation is only volume of new air reaching gas exchange areas per minute - doesn’t include dead space

60
Q

piriform recess

A

Cavities on either side of laryngeal orifice. During swallowing, food diverted into piriform recesses and then into esophagus by epiglottis. Food can get stuck in it and damage the internal laryngeal nerve, which serves as the afferent limb of the cough reflex

61
Q

DHR flow cytometry

A

Tests for neutrophil superoxide production to diagnose CGD. Preferred to NBT testing.

62
Q

First vs second generation H1 blockers

A

First gen: end in “ine” or “ate” - diphenhydramine, dimenhydrinate, chlorpheniramine

Second gen: end in “adine” - loratadine, fexofenadine, desloratadine, cetirizine

63
Q

N-acetylcysteine

A

Mucolytic agent used to loosen mucus plugs in CF patients by disrupting disulfide bonds.

Also is antidote for acetaminophen OD

64
Q

Dextromethorphan

A

Synthetic codeine. Antagonizes NMDA glutamate receptors

65
Q

Nasal decongestants

A

Names: Pseudophedrine, phenylephrine

MOA: alpha1 agonists, constrict nasal vessels to reduce edema and congestion

ADRs: HTN, CNS stimulation/anxiety

66
Q

Bosentan

A

MOA: endothelin-1 receptor antagonist - decreases pulmonary vascular resistance

Use: pulm htn

ADRs: hepatotoxicity

67
Q

Sildenafil

A

MOA: Inhibits PDE-5 leading to vasodilation

Use:pulm HTN, ED

68
Q

Prostacyclin agonists

A

Names: epoprostenol, iloprost

MOA: vasodilatory effect, inhibits platelet aggregation

ADRs: flushing, jaw pain

Use: pulm htn

69
Q

Ipratropium

A

MOA: muscarinic antagonist - prevents bronchoconstriction

Use: asthma, COPD; tiotropium is long acting form

70
Q

Anti-leukotriene agents

A

Montelukast and zafirlukast: block leukotriene receptors, good for aspirin-induced asthma

Zileuton: 5-lipoxygenase pathway inhibitor, blocks conversion of AA to leukotrienes

71
Q

Omalizumab

A

monoclonal anti-IgE antibody

used in allergic asthma resistant to steroids and B2 agonists

72
Q

theophylline

A

MOA: inhibits phosphodiesterase, increasing cAMP and causing bronchodilation

Use: narrow therapeutic index limits use for asthma

73
Q

Metacholine

A

MOA: M3 agonist

Use: metacholine challenge to diagnose asthma

74
Q

Cryptococcus neoformans

A

Budding yeast with thick capsule. Opportunistic pathogen. Most commonly causes meningoencephalitis. Lung infection usually occurs first but is usually asymptomatic

75
Q

Normal A-a gradient

A

Less than 10-15 mmHg

76
Q

Pancoast syndrome

A

Caused by tumor at lung apex, often in superior sulcus.

Presents with shoulder pain, Horner syndrome, spinal cord compression

77
Q

Fat embolism syndrome

A

Acute onset neurologic abnormalities, hypoxemia, petechial rash

USMLE (17 decks)

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