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Spring 2016 - CVPR > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

What is the extra lobe on the right side?

A

The middle lobe

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2
Q

How many generations of airway branches are there in humans? Which are the conducting ones?

A

23

The first 16 are conducting airways

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3
Q

The lungs develop out of the _________

A

Gut tube

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4
Q

What are the 5 stages of lung development?

A

Embryonic - foregut endoderm extends into surrounding mesenchyme. Branching occurs to level of subsegmental bronchi.

Pseudoglandular/terminal sac - branching to level of terminal bronchioles.

Canalicular - branching to level of respiratory bronchioles. Surfactant begins to be made. Fetal begins to practice breathing.

Saccular - terminal sacs form. Characterized by epithelial cell differentiation (type I and II pneumocytes)(

Alveolar (continues until age 3) - alveoli mature

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5
Q

The maximal force for the diaphragm is at ______ it’s resting length

A

130%

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6
Q

How are compliance and elastance related?

A

They are inversely proportional

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7
Q

At what fetal age is surfactant produced?

A

Fetal week 24

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8
Q

The probability of tubulent flow is given by the ______

A

Reynolds number

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9
Q

What are the 2 types of pulmonary ventilation?

A

Minute - volume of air that goes into or out of the lung in 1 minute

Alveolar - volume of air that flows into or out of the alveolar space in 1 minute

minute > alveolar b/c it encompasses more of the lung

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10
Q

What are the 2 dead spaces in the lung? What dead space do they combine to form?

A

Anatomic - air that remains in the conducting path
Alveolar - alveoli that are in unperfused areas in the lung

Physiologic dead space

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11
Q

What is different about lungs in obstructive diseases?

A

Increased resistance

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12
Q

What is the ratio between O2 in and CO2 out?

A

They are equal, so 1-1 ratio

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13
Q

What are the lobes of the lung?

A 
R = superior, middle, inferior
L = superior, inferior
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14
Q

What is the acinus?

A

The terminal bronchiole, alveolar ducts, alveoli - the region of lung supplied with air from a terminal bronchiole

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15
Q

Which germ layer do the lungs develop from?

A

Embryonic endoderm

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16
Q

Which week do lung buds develop at?

A

4

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17
Q

Which branchial arches do the lungs develop between?

A

4th and 6th (remember there is no 5th)

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18
Q

The formation of conducting airways is completed at the end of the _________ stage of lung development

A

Pseudoglandular

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19
Q

Do they pulmonary veins grow out of the LA or do they come to it?

A

They grow from the pulmonary vascular bed to the left atrium

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20
Q

What is an atresia?

A

When an orifice or passage in the body is abnormally closed/absent

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21
Q

In lung development, the descent of the lungs is halted by the _________

A

Liver

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22
Q

Is branching in the embryonic stage of lung development symmetrical?

A

No. More on the R

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23
Q

Are most alveoli present at birth?

A

No. 90% of them develop after birth

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24
Q

The pulmonary arteries develop from the __________ aortic arch

A

6th

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25
Q 
What are the following lung volumes?
TGV
RV
TLC
FVC
FEV1
DLCO
A 
Thoracic gas volume
Residual volume
Total lung capacity
Forced vital capacity in 1 second
Forced expiratory volume
uhh some measure of gas exchange
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26
Q

Is total ventilation affected by moderate disease conditions?

A

No. Generally, total ventilation is affected only by severe disease conditions

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27
Q

How does gravity affect ventilation and volume throughout the lung?

A

Ventilation of the top alveolus volume bottom

This is because of compliance - bottom alveolus in middle of PvsV curve; top alveolus is at top

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28
Q

What is compliance?

A

dV/dP

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29
Q

How do you calculate minute ventilation?

A

Tidal volume * breathing rate

Usually about 6 L

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30
Q

Our breathing rate/tidal volume is where it is because of the superposition of 2 types of work:

A

Resistance (increases with decreasing tidal volume b/c big breaths open airways)
Elastic (increases with increasing tidal volume)

Breathing parameters reduce total work

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31
Q

What are the 2 pleura?

A

Parietal - on inside of chest wall

Visceral - on outside of lung

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32
Q

What are the cartilagenous air conduction pathways in the lung?

A

Trachea
Primary bronchi - 1R;1L
Secondary (lobar) bronchi - 3R;2L
Tertiary (segmental) bronchi - 10R;8L

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33
Q

Where are the pulmonary arteries? Where are the veins?

A

Arteries follow bronchial tree

Veins are intersegmental

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34
Q

What is the blood supply of the bronchi? Where does it go?

A

Bronchial artery. Most of it anastomoses with the pulmonary supply and some goes back to the bronchial vein

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35
Q

What are 4 cell types in the bronchial epithelium?

A

Ciliated cells - move mucus up airway
Goblet cells - secrete mucus
Basal cells - stem cells for ciliated and goblet cells. These are shorter.
Neuroendocrine cells of varying types - reflexive control of airway diameter

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36
Q

What are 4 layers to the mucosa of the bronchus?

A

Epithelium
Basal lamina
Areolar connective tissue/lamina propria - loose connective tissue with capillaries an dleukocytes
Muscularis mucosa - agitate epithelium, helps submucosal glands excrete mucus

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37
Q

What are 3 layers to the submucosa of the bronchus?

A

Dense connective tissue
Cartilage plates with chondrocytes living in their lacunae
Adventitia - large blood vessels, nerves

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38
Q

___________________ connects to the points of the C-shaped cartilage rings in the trachea

A

Trachealis muscle

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39
Q

What are 2 cell types in the bronchiolar epithelium?

A

Club cells - secrete surface-active substances (like surfactant but not) that maintain patency of the bronchioles since the bronchioles don’t have cartilage plate support like bronchi do
Ciliated cells - move mucus up airway

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40
Q

What are 2 cell types in the alveolar epithelium?

A

Type I pneumocyte - they chill

Type II pneumocytes - secrete surfactant. Stem cell for type I and II pneumocytes

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41
Q

What is Dalton’s Law?

A

Inspired O2 = (atmospheric pressure - H2O partial pressure)* fraction oxygen being given

PiO2 = (760 Torr-47 Torr)*FO2

PB = barometric pressure
FO2 is 0.21 with normal breathing; 1 w/ 100% oxygen

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42
Q

What is the alveolar gas equation?

A

alveolar PO2 = inspired PCO2 - arterial PO2/0.8

PAO2 = PIO2 - (PACO2/R)

R = respiratory exchange ration = CO2 produced/O2 consumed. Can vary depending on metabolite. Usually 0.8

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43
Q

What is the rate-limiting step for removing CO2 from the blood in teh lungs?

A

Ventilation

Diffusion is fast

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44
Q

What is the alveolar ventilation eqation?

A

PaCO2 = (rate VCO2/rate VA) * k

rate VCO2 = CO2 production in 1 minute
rate VA = alveolar ventilation in 1 minute

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45
Q

How is the length of the diaphragm affected in obstructive lung disease?

A

It is shorter b/c their lungs don’t relax all the way.

As a consequence, force exerted by the diaphragm is less

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46
Q

Dras the lung pressure vs. volume curve

A

:)

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47
Q

What is lung compliance like in emphysema?

A

Increased, so elastic recoil of the lungs is decreased. Expiration is impaired.

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48
Q

3 causes of reduced chest wall compliance

A

Old age
Obesity
Scar tissue

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49
Q

3 affects of water surface tension on the lung if surfactant wasnt there

A

Wants to make the alveolus smaller -> collapse of alveoli, decreasing surface-volume ratio

Decreased lung compliance

Water accumulation in lung

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50
Q

Where in the lungs is the majority of airway resistance?

A

Bronchioles

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51
Q

How do airway resistance and radius relate?

A

R oc 1/r^4

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52
Q

Where in the lungs can turbulent airflow be found?

A

The trachea (sometimes)

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53
Q

2 ways the body can induce bronchoconstriction

A

Parasympathetic input

Histamine

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54
Q

2 ways the body can induce bronchodilation

A

Sympathetic input

CO2 in bronchioles (which isn’t really the body doing something on purpose)

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55
Q

Why does higher lung volumes decrease resistance?

A

Increased radius of bronchioles

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56
Q

Why do patients with emphysema exhale through pursed ips?

A

Increases airway pressures, reducing airway collapse

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57
Q

3 factors that affect perfusion

A

O2 tension (hypoxic vaso-pulmonary constriction)
Capillary recruitment
Gravity

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58
Q

What is ventilation?

What is perfusion?

A

Ventilation (V) = air that reaches alveoli

Perfusion (Q) = blood that reaches the alveoli

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59
Q

How do V?Q ratios in the apex vs. base of lung compare?

A

The base of the lung has a lower V/Q ratio because ventilation and perfusion are increased at the base compared to the apex, but Q is more so

Apex of lung V/Q>1 ; wasted ventilation
Base of lung V/Q

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60
Q

Does V/Q mismatch affect arterial CO2 levels? What about O2?

A

No

Yes

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61
Q

2 ways the body corrects V/Q mismatch

A

Bronchodilation with high PCO2 in bronchiole

Vasoconstriction with low PO2 in blood

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62
Q

What is an area with perfusion but no ventilation?

A

Shunt

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63
Q

What is an area with ventilation but no perfusion?

A

Dead space

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64
Q

What is the most common mechanistic cause of hypoxemia?

A

V/Q mismatch

pneumonia, PE, COPD, etc

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65
Q

The conversion of CO2 to carbonic acid is catalyzed by _________ in _________

A

Carbonic anhydrase

Red blood cells

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66
Q

The effect of O2 binding reducing CO2 binding to hemoglobin and vice versa are the _____________ and _________ effects

A

Haldane (O2 binding reduces CO2 affinity for Hb)

Bohr (CO2 binding reduces O2 affinity for Hb)

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67
Q

What is the oxygen carrying capacity of the blood (definition)?

A

Maximal O2 that can be carried by a particular amount of Hb

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68
Q

What is the A-a gradient?

A

A measure of the difference between the Alveolar and arterial oxygen concentration (PAlvO2-PartO2)

We want it to be low

Helps find source of hypoxemia. If A-a is abnormal, problem is in the lungs

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69
Q

How is compliance in an alveolus with a large volume?

A

It is not so great compared to a smaller one (see pressure-volume curve)

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70
Q

How does FEV1/FVC compare between obstructive and restrictive lung disease?

A

Obstructive - less than normal b/c it is hard to exhale

Restrictive - greater than normal b/c lung volumes are reduced

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71
Q

What is the Henderson-Hasselbach equation

A

pH = pKa + log[A-]/[HA]

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72
Q

What is pH?

A

-log[H+]

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73
Q

3 intracellular buffers

A

organic phosphates
proteins
hemoglobin

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74
Q

4 extracellular buffers

A

proteins
albumin
phosphate
bicarbonate

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75
Q

3 stages of the bicarbonate buffering system

A

H2O + CO2 H2CO3 H+ + HCO3-

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76
Q

normal venous pH

A

7.4

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77
Q

How does pH of oxygenated and deoxygenated blood compare? Why?

A

Deoxyhemoglobin is a great buffer! venous pH is only slightly lower and venous pCO2 is only slightly higher than arterial blood despite there being much more CO2

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78
Q

What are the 2 compensation mechanisms for disturbed blood pH?

A

Lungs regulate CO2 levels (minutes)

Kidneys regulate bicarbonate (hours-days)

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79
Q

What is the most common cause of respiratory acidosis/alkalosis?

A

Changes in ventilation

Acidosis - too little ventilation
Alkalosis - too much ventilation

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80
Q

2 categories of metabolic acidosis. What are their causes?

A

Anion gap: Na+ - (Cl- and HCO3-). When Na»anions, indicates extra acid from somewhere being balanced by HCO3 reduction

Non-anion gap - from loss of bicarbonate

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81
Q

3 causes of non-anion gap metabolic acidosis

A

GI losses (like diarreha)
Renal losses
Too much IV saline (increases in Cl- with loss of bicarbonate)

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82
Q

8 causes of metabolic acidosis

A

MUD PILES

Methanol
Uremia
DKA (and other ketoacids like EtOH and starvation)
Propylene glycol
INH (isoniazid antibiotic)
Lactate
Ethylene glycol
Salicylates
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83
Q

5 causes of metabolic alkalosis

A

Loss of gastric acid (vomiting or NG tube suction)

Ingestion of a bicarbonate

Ingestion of an alkali

Hypovoluemia (contraction alkalosis)

Diuretics

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84
Q

What part of the brain contains motor neurons that control respiratory muscles?

A

Medulla

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85
Q

3 things that peripheral chemoreceptors look out for

A

Low arterial O2
High arterial PCO2
High arterial [H+]

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86
Q

Where are the peripheral chemoreceptors?

A

Carotid bodies

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87
Q

Where are central chemoreceptors?

A

ventral surface of medulla

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88
Q

What do central chemoreceptors sense?

A

Protons in CSF, which correlates with arterial CO2

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89
Q

Do the peripheral or central chemoreceptors have more power to mediate the ventilatory response?

A

Central

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90
Q

How does the kidney control pH?

A

By altering amount of H+ secretion, which is proportional to bicarbonate (HCO3-) reabsorption

so, the kidney decreases bicarbonate reabsorption in alkalosis so it can keep more H+ ions

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91
Q

What are the 3 different types of normal breath sounds?

A

Vesicular
Bronchovesicular
Bronchial

Bronchiovesicular and bronchial sounds heard over the periphery of the lung are abnormal

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92
Q

Rales sound like ______

A

Velcro

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93
Q

Are wheezes more commonly heard on inspiration or expiration?

A

Expiration

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94
Q

Rhonchi sound like _____

A

Rumbles

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95
Q

What is the difference between a lung volume and a lung capacity?

A

Capacities are the sums of at least 2 volumes

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96
Q

Can you directly measure lung residual volume?

A

No

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97
Q

What is functional residual capacity?

A

The volume of gas remaining in lung at end of a tidal expiration

ERV + RV
Expiratory reserve volume + residual volume

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98
Q

At which volume is the lung system in equilibrium?

A

end of a tidal breath - functional reserve capacity

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99
Q

What is inspiratory capacity

A

Volume of gas that can be maximally inspired from a normal exhale

TV + IRV

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100
Q

What is vital capacity?

A

ERV + TV + IRV

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101
Q

What is total lung capacity?

A

RV + ERV + TV + IRV

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102
Q

Can you diagnose restrictive disease with spirometry?

A

No

the FEV1/FVC can be normal!

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103
Q

Draw the flow-volume loop of the lung

A

Mrr

Inspiration is symmetric
Expiratory limb has an increase in airflow at the beginning

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104
Q

Draw the flow-volume loops of fixed, variable intrathoracic, and variable extrathoracic obstructions

A

:)

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105
Q

2 ways to measure lung volumes

A

Dilution w/ gas that won’t be readily absorbed like helium - requires uniform diffusion of gas

Plethysmography - uses Boyle’s law and pressure changes in a small volume to look at lung volume

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106
Q

What is boyle’s law

A

P1V1 = P2V2

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107
Q

How do we measure DCLO?

A

Transfer of a known (but small) amt of CO to blood

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108
Q

What do you need to correct for in DLCO testing?

A

Alveolar volume

DLCO/VA

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109
Q

What are 2 terms used to describe respiratory muscle strength?

A

PiMax
PeMax

Inspiration/expiration against a closed valve

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110
Q

3 reasons the bicarbonate buffer is so important

A

High concentration
Blood pH is close to pK (where curve is steepest)
Can be affected by both kidneys and lungs (most effect)

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111
Q

FRC and ________ are equivalent terms

A

TGV (toral gas volume)

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112
Q

At what lung capacity are elastic and resistance work minimized?

A

FRC (functional residual capacity)

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113
Q

How do you calculate minute ventilation? Alveolar ventilation?

A

Vm = Vt*RR

Va = (Vt-Vd)*RR

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114
Q

How do you calculate pulmonary vascular resistance?

A

R = dP/CO

CO is in L/min so is flow

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115
Q

4 categories of obstructive lung disease

A

Chronic bronchitis
Emphysema
Asthma
Bronchiectasis

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116
Q

Why is the lamina propria important?

A

It allows leukocytes to wander around in it

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117
Q

4 causes of hypoxemia (4 for the 2nd one)

A

Altitude
Hypoventilation (obesity, central, neuromuscular, drugs)
Diffusion limitation (exercize, interstitial lung diseae)
Low V/Q or shunt

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118
Q

Thromboxane is a vaso______

A

Constrictor

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119
Q

Prostacyclin is a vaso_______

A

Dilator

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120
Q

6 inflammatory cells found in asthmatic airways

A 
Mast cells
Eosinophils
Th2
Dendritic cells
Macrophages
Neutrophils
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121
Q

3 structural airway changes in asthma

A

Increase in airway SMCs
Increase in blood vessels
Increase in mucus secretion form increased goblet cells and size of submucosal glands

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122
Q

Do sympathetic neurons have much power in ditermining airway diameter?

A

Nope. It’s mostly parasympathetic neurons

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123
Q

What element do we use to treat asthma?

A

Magnesium in life threatning exacerbation

Bronchodilates maybe due to inhibition of calcium influx into SMC

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124
Q

4 short-acting beta-adrenergic agonists (SABAs)

A

Albuterol
Terbutaline
Pirbuterol
Levabuterol

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125
Q

2 long-acting beta-adrenergic agonists (LABAs)

A

Salmeterol

Formoterol

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126
Q

Are anticholinergics used in COPD or asthma? What is their suffix? What do they do?

A

COPD
-tropium
Bonchodilate via SMC relaxation
Inhibit production of respiratory secretions

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127
Q

What are the actions of systemic glucocorticoids?

What respiratory issue are they given for?

A

Inhibit phospholipase -> inhibit cytokine synthesis
-> anti-nflammatory, vasoconstrict (reducing edema)

Use to treat acute exacerbations of asthma

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128
Q

Can you use LABAs by themselves for asthma treatment?

A

No - can increase deaths

Should be combined with an inhaled corticosteroid to control inflammation

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129
Q

What do leukotriene modifiers due?

A

Inhibit 5-lipoxygenase
Bronchodilate
Anti-inflammatory due to leukotriene blocking

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130
Q

What is omalizumab?

What is it used for?

A

Anti-IgE

Allergic asthma

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131
Q

What is mepolizumab?

A

Anti-IL-5, which is a cytokine

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132
Q

Why is lung infacrtion uncommon?

A

Collateral circulation from bronchial arteries

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133
Q

What is the source of most bleeding in the lung?

A

Bronchial circulation (not pulmonary)

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134
Q

How does the compliance of pulmonary vessels compare to systemic ones? What are 2 results of this?

A

Much more compliance

-> low resistance, high volume vascular bed

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135
Q

Does lung resistance go up when cardiac output increases? 2 reasons

A

No

Lung vessels are highly distensible
The number of perfused vessels increases

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136
Q

What are the 3 West zones of the lung?

A

Zone 1: Palveolar > P arterial > Ppulmonary veins
Minimal blood flow
At apex

Zone 2: Parterial>Palveolar>Pvenous
Intermittent blood flow
At middle

Zone 3: Parterial > Pvenous > P alveolar
Constant blood flow
At base

Locations can change with position, but in upright individual are like this

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137
Q

4 safety factors to prevent pulmonary edema

A

Decreased interstitial oncotic pressure
Increased interstitial hydrostatic pressure
Increased plasma oncotic pressure
Lymphatic reserve system

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138
Q

2 mechanisms for pulmonary edema

2 ways you can destinguish

A

Hemodynamic (or hydrostatic or cardiogenic) from increased pulmonary hydrostatic pressure

Permiability (or non-hydrostatic or non-cardiogenic) from acute widespread injury to microvascular circulation

History/exam
left atrial pressure (from pulmonary capillary wedge pressure). If it is low, this means it is not hemodynamic

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139
Q

What are the 5 categories of pulmonary hypertension?

What are the 2 other ways to categorize pulmonary hypertension?

A 
Pulmonary arterial
Due to left heart disease
Due to lung disease/hypoxia
Thromboembolic
Idiopathic/unclear/multifactorial

Pre-capillary (arterial)
Post-capillary (venous)

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140
Q

Which gorup of people does idiopathic pulmonary arterial hypertension tend to affect?

A

Younger women

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141
Q

4 targeted pathways for medical management of pulmonary arterial hypertension

A

Endothelin pathway - endothelin receptor antagonists (endothelin is a vasoconstrictor)

Nitric oxide pathway - inhibiting phosphodiesterase (braks down NO)

Prostacyclin pathway - prostacyclins vasodilate

Calcium channel blockers - for those with an acute reponse to a pulmonary vasodilator (5% of the time)

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142
Q

The pulmonary vasodilating effects of nitric oxide are mediated through its second messenger, ______________

A

cGMP (grump)

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143
Q

_______________ degrades cGMP

A

Phosphodiesterase

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144
Q

Prostacyclins upregulate ______________

A

cAMP

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145
Q

4 drug categories to reduce airway tone in asthma

A

Beta-agonists
Anti-cholinergics
Leukotriene inhibitors
Methylxanthines (theophylline) - phosphodiesterase inhibitors that increase intracellular cAMP

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146
Q

3 drug categories to reduce inflammation in asthma

A 
Corticosteroids
Mast cell stabilizers
Leukortriene inhibitors
Anti-IgE (omalizumab)
Anti-IL5 (mepolizumab)
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147
Q

What defines COPD?

A

Irreversible airflow limitation

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148
Q

What defines chronic bronchitis?

A

Productive cough present for 3 months/year over a 2-year period without another identified medical cause

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149
Q

What defines emphysema?

A

Abnormal, permanent enlargement of air spaces distal to terminal bronchioles
+
Destruction of alveolar walls w/o obvious fibrosis

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150
Q

2 subtypes of emphysema. What causes each?

A

Centriacinar - smoking
Scarring and focal dilation of broncioles and adjacent alveoli

Panacinar - alpha1 anti-trypsin deficiency (autosomal recessive)
Bronchioles down to alveoli involved

151
Q

What is bronchiectasis?

A

Abnormal dilation of proximal medium-sized bronchi due to destruction of muscular and elastic components of their walls

They produce shit-tons of sputum

152
Q

Cystic fibrosis is a mutation in what gene?

A

Cystic fibrosis trans-membrane regulator

153
Q

The ascultatory hallmark of bronchiolotis is _____

A

Inspiratory squeak

154
Q

2 major causes of airflow obstruction

A

Airway narrowing (bronchospasm, plugging, inflammation)

Floppy airways (decreased radial tethering or decreased airway integrity)

155
Q

2 types of asthma. Which one tends to be more chronic/persistent?

A

Extrinsic (allergic)

Intrinsic (nonallergic). More chronic/persistent

156
Q

What is bronchoprovocation? What is it for?

A

Give methacholine/histamine and test FEV1

Can detect occult asthma

157
Q

What is the PV curve like in acute asthma?

A

Above (higher volumes) but same shape (no change in tissue properties)

158
Q

How do you differentiate vocal cord dysfunction from asthma? (3)

A

Sounds on inspiration (stridor)
Fiberoptic laryngoscopy
Bronchoprovacation may worsen VCD, but does not change FEV1 or PC20

159
Q

What is vocal cord dysfunction (in pulmonary setting)

A

Inappropriate vocal cord motion results in airflow obstruction

160
Q

How many people have COPD after 50 years of smoking?

A

20

161
Q

What is the mechanism of dynamic airway collapse in emphysema?

A

Reduced elasticity of tissue around airways so can’t withstand pleural pressure

162
Q

What is the PV curve like in emphysema?

A 
High volume
Steeper curve (because more compliant/less elastic)
163
Q

5 causes of death from COPD

A 
Respiratory failure
Right ventricular failure
Pneumonia
Spontaneous pneumothorax
Pulmonary embolism
164
Q

How do you get bronchiectasis?

A

A combination of:
Infectious/inflammatory insult

Impaired drainage/obstruction/immunodeficiency

165
Q

3 parts to management of bronchiectasis

A

Airway clearance to remove secretions
Antibiotics
Treatment of reactive airways disease

166
Q 
Well controlled asthma frequency:
Daytime symptoms
Nighttime symptoms
SABA
Peak flow
Oral steroid
Urgent care visit
A 
2x/week
2x/month
2x/week
Normal
1x/yr
1x/yr
167
Q

What is tiotripium for?

A

A long-acting anticholinergic for asthma in ppl >12

168
Q

What does cromolyn/nedocromil do?

A

Inhibit mast cell mediator release

Preventative therapy for exercise-induced or allergen-induced asthma

169
Q

What does theophylline do?

A

Inhibits phosphodiesterase

-> bronchodilation and some anti-inflammatory activity

170
Q

What are the effects of particle size on drug inhalation?

A

> 5um deposit in pharynx and larger airways

171
Q

What has the greatest capacity to influence the natural history of COPD?

A

Smoking - so everybody should stop

172
Q

Is physical activity recommended in COPD?

A

Yes! Exercise is important

173
Q

What is the pressure difference across the lung?

A

Pulmonary artery pressure - left atrial pressure

174
Q

Where are the lymphatic vessels in the lungs?

A

Intralobular, with the veins

175
Q

What causes hydrostatic pulmonary edema?

A

Increased pulmonary capillary wedge pressure

176
Q

What pressure defines pulmonary hypertension?

A

Mean pulmonary artery pressure >25 mmHg

177
Q

What is V=IR for the lungs?

A

Pulmonary arterial pressure = CO * resistance

178
Q

What is the gold standard diagnostic for pulmonary embolism?

A

Angiogram

Rarely performed though

179
Q

In which chest Xray projection can the heart appear enlarged?

A

AP

180
Q

What does the silhouette sign show on Xray?

A

2 structures of similar density in contact (like lung-heart border)

181
Q

What is atelectasis?

A

Regions of lung collapse

182
Q

What is the spine sign on CR?

A

Spine becomes less radiolucent as we move downswards because th elung is filled with something more dense instead of air.

183
Q

How does the P-V curve change in restrictive lung disease?

A

It decreases, because compliance is decreased

Note that if cause of restriction isn’t lung tissue itself, compliance won’t chnage

184
Q

What 2 things characterize interstitial lung disease?

A

Inflammation
+
Scarring

185
Q

5 treatment options for interstitial lung disease

A 
Remove offending expore (if possible)
Immunosupression (if necessary)
Drugs (nintedanib, pirfenidone for idiopathic pulmonary fibrosis)
Oxygen
Transplantation
186
Q

What is idiopathic pulmonary fibrosis?

A

A scarring lung disease with pattern of injury of usual interstitial pneumonia

So IPF if clinical
UIP is from pathology

187
Q

Where in the lung is idiopathic pulmonary fibrosis usually?

A

Peripheral and basilar

188
Q

What is the difference between usual interstitial pneumonia and nonspecific interstitial pneumonia on pathology?

A

IPF: spatially and temporally heterogeneous fibrosis w/ fibroblasts. Fibrotic and normal lung are seen right next to each other

NIP: temporally homogenous fibrosis with varying degrees of inflammation and fibrosis

189
Q

What are the 2 smoking-related ILDs that are on a spectrum? How do you treat them?

A

Respiratory bronchiolitis
Desquamative interstitial pneumonia

Stop smoking

190
Q

What characterizes pulmonary langerhans cell histiocytosis? Who gets it? How do you treat it?

A

New smokers
Cysts and nodules mostly in upper lobe
Stop smoking

191
Q

What characterizes organizing pneumonia?

A

Plugs of granulation tissue and fibrosis distal to bronchioles

Imaging: ground glass and consolidation that may be migratory

192
Q

How do you treat organizing pneumonia?

A

6-12 months of steroids

193
Q

How do you treat acute and chronic eosinophilic pneumonia?

A

Steroids

194
Q

What causes lymphangioleiomyomatosis (LAM)? What characterizes it?

A

Mutation in tuberous sclerosis genes

Get cysts and nodules, peribronchovascular proliferation of SMCs

195
Q

What characterizes sarcoidosis?

A

Systemic noncaseating granulomatous disease

196
Q

What are the 2 parts of the physiologic state of anxiety? What parts of the brain are involved in each?

A

Conscious feeling - mediated by cortex, cingulate cortex, frontal lobes

Emotional states - mediated by autonomic, endocrine, somatic responses involving the amygdala, mypothalamus, brainstem

197
Q

What are the 2 components of anxiety?

A

Cognitive

Physiologic state of hyper-arousal

198
Q

What 2 things are the biological basis of panic disorder?

A

Dysregulation in the noradrenergic system/excess norepinephtine

Dysregulation of GABA

199
Q

3 hypotheses for panic dosorder

A

CO2 + lactate hypersensitivity due to chronic hyperventilation

False suffocation alarm - brainstem alarm is too sensitive

Hypersensitive limbinc system

200
Q

2 changes in chronic bronchitis. What is the primary involved cell?

A 
Squamous metaplasia (allow epithelium to be tougher)
Mucus gland hypertrophy
201
Q

At what point do you say something is bronchiectasis?

A

When airway diameter > vessel diameter

202
Q

What happens in constrictive/obliterative bronchitis?

A

Airways scar shut

203
Q

What defines diffuse alveolar damage?

A

Inflammation of alveolar septa

204
Q

How do you tell if a hemorrhage is not from biopsy? (3)

A

More blood
Iron-containing macrophages in airspaces
Fibrous ribbons of septa

205
Q

Where are neutrophils in acute bronchitis?

A

In wall and airway

206
Q

Nonnecrotizing granuloma menas what 2 diseases?

A

Sarcoid/beryllium

207
Q

What is the difference in location between smoking and alpha-1-antitrypsin deficiency emphysema?

A

Smoking - upper lobes, around airways

Alpha-1-antitrypsin - lower lobes, panlobular

208
Q

3 symptoms of B cell tumors

A

Fever
Weight loss
Drenching night sweats

209
Q

3 risk factors for primary spontaneous pneumothorax

A

Men
Smokers
Familyhistory

210
Q

6 symptoms of pneumothorax

A 
Acute onset chest pain
Dyspnea
Cough
Anxiety
Cyanosis
Respiratory distres

Somehow these are different than PE

211
Q

What is the difference between a bulla and a bleb?

A

Bulla - enlargement of lung tissue

Bleb - enlargement of visceral pleura

212
Q

What is a tension pneumothorax

A

Intrapleura pressure > atmospheric pressure at least during expiration (sometimes inspiration in addition)

Decreases venous return, limits cardiac output

Medical emergency

213
Q

What do you do in event of a tension pneumothorax?

A

Do not wait for a CXR

Insert a chest tube to deflate

214
Q

What’s the difference between transudate and exudate?

A

Transudate - from increased hydrostatic pressure

Exudate - from increased permeability. So has more proteins, LHD, cells

215
Q

3 drugs used for smoking cessation

A

Nicotine
Bupropion (Wellbutrin) - inhibits reuptake of dopamine and norepinephirine, reduces weight gain, reduces depression
Varenicline - partial agonist at nicotine receptor; also blocks nicotine binding

216
Q

How do you measure the pressure volume curve clnically?

A

Insertion of an esophageal pressure monitor. This is a surrogate for pleural pressure

217
Q

What serum value is increased in sarcoidosis?

A

ACE

218
Q

What is dysphonia?

Where is the defect?

A

Alteration of voice quality. Usually a laryngeal source

219
Q

What is dysarthria?

Where is the defect?

A

Alteration of rhyrhm, enunciation, articularion

Neurological or muscular source

220
Q

What is stertor?

Where is the defect?

A

A snoring sound from nose, nasopharynx, throat

221
Q

When should a patient see an otolaryngologist?

A

If hoarseness last longer than 2 or 3 weeks

222
Q

2 materials vocal fold cysts can be made out of

A

Blood

Mucus

223
Q

2 materials vocal fold polyps can be made out of

A

Blood

Fibrous tissue

224
Q

How do you treat vocal fold hemorrhage and tears?

A

Strict voice rest

225
Q

Does COPD risk and lung cancer risk correlate?

A

Yes!

As COPD worsens, lung cancer risk is increased

226
Q

What are the 3 subtypes of non small call lunc cancer?

A

Squamous cell carcinoma - bronchial epithelium
Adenocarcinoma - mucus glands
Large cell carcinoma (like the others)

227
Q

What is the cellular origin of small cell carcinoma?

A

Bronchi

228
Q

4 symptoms of undiagnosed lung cancer

A

Cough
Anorexia
Weakness
Weight loss

229
Q

How do you typically treat small cell lung cancer?

A

Drugs: cisplatin, etopiside

230
Q

How do you typically treat non-small cell lung cancer?

A

Surgery

Also chemotherapy/radiation with surgery - adjuvant and neoadjuvant therapy

231
Q

What are the 2 types of apnea?

A

Central - respiratory effeorts are absent

Obstructive

232
Q

In pneumonia what does infectious agent sputum indicate? Minimal sputum?

A

Bacteria

Atypical bacteria or viral

233
Q

All patients with suspected pneumonia should have which 4 diagnostic tests?

A

CXR
CBC
Complete metabolic panel
Blood gas/pulse oximetry

234
Q

________ is produced by parynchymal cells in response to bacterial toxins

A

Procalcitonin

Indicates there is an infection in lung or intestine, where the parynchemal cells live

235
Q

4 groups who shoud get pneumococcal vaccine

A

Immuncompromised people
>65
Chronic illness
Asplenia

236
Q

What are the 3 main subtypes of afferent nerves within the vagus nerve that regulate cough?

A

Rapidly adapting receptors
Slowly adapting stretch receptors
C-fibers

RARs, SARs respond to mechanical stretch
C-fibers respond to chemical stimuli

237
Q

4 phases of the cough reflex

A

Inspiratory phase (glottis open)
Compressive phase (glottis closed)
Expiratory phase
Relaxation phase

238
Q

Time frame for acute, subacute, chronic cough

A

8 weeks

239
Q

5 causes of chronic cough in adults

A 
Upper airway cough syndrome
Asthma
GERD
Non-asthmatic eosinophilic bronchitis
Neuropathic cough
240
Q

What is the mechanism of upper airway cough syndrome?

A

Cough receptors stimulated by secretions from nose or sinuses

241
Q

What is non-asthmatic eosinophilic bronchitis?

A

Eosinophilic airway inflammation like asthma but without variable airflow limiatation or airway hyperresponsiveness

242
Q

Antagonists of which 3 bronchial smooth muscle receptors cause bronchoconstriction?

A

Muscarinic
Leukotriene
Histamine

243
Q

What is the main drug you give for anaphylaxis

A

Epinephrine

244
Q

The common cold’s symptoms are mostly explained by release of ________ inflammatory mediators

A

Bradykinin

245
Q

3 effects of muscarinic receptor block

A

Sedation
Prevention of nausea and vomiting
Block of secretions

246
Q

4 organisms that cause atypical pneumonia

A

Legionella
M. Pneumoniae
C. Pneumoniae
C. psittaci

247
Q

What 7 things can fill the alveoli?

A

Poor funny boy can’t piss for crap

Pus, fluid, blood, cells/cancer, protein, fat, calcium

248
Q

Influenzavirus variation is due to 2 types of envelope glycoproteins:

A

Hemagglutinin

Neurominidase

249
Q

2 classes of antivirals we use to treat influenza and 2 examples of each

A

Neurominidase inhibitors (oseltamivir, zanamivir)

Adamantanes (amantadine, rimantidine)

250
Q

3 defenses against upper airway collapse

A

Upper airway recruitment threshold (stimuli needed for upper airway dilator muscle response)

Loop gain (amt of ventilatory response to stimuli)

Arousal threshold (for negative pressure)

251
Q

What is cheyne-stokes respiration?

A

Hypercapneic respiratory drive results in overshooting of PaCO2 below apneic threshold
So, an oscillatory pattern of apnea and hyperpnea

252
Q

3 most common mutations in adenocarcinoma

A

KRAS
EGFRT
EML4-ALK

253
Q

Which 2 nerves go to the larynx? Where does it come from?

A

Superior laryngeal nerve
Recurrent laryngeal nerve
From vagus nerve

254
Q

What are the 2 parts of the superior laryngeal nerve?

A

Internal - sensatibon

External - motor (to upper crycothyroid)

255
Q

Which respiratory phase is stridor heard in?

A

Inspiratory
Expiratory
Biphasic

256
Q

What is the mechanism of croup?

A

Subglottic narorowing

257
Q

Reinke’s edema is seen in what patient population?

A

Female smokers

258
Q

How long does it take for an ACE-inhibitor cough to stop after the drug is stopped?

A

1-7 days usually

But up to month

259
Q

How do you calculate the A-a gradient?

What is PalveolarO2 usually?

A

Palveolar O2 - P arterial O2

P alveolar O2 is about 102 mmHg if ventilation is good

260
Q

How do you tell if respiratory pH changes are acute or chronic?

A

For every 10 mmm change in PaCO2

  1. 08 pH change in acute
  2. 03 pH change in chronic
261
Q

What is winters formula?

A

1.5*bicarb + 8 +-2 = expected pCO2

This is how you can tell if the person is appropriately responding to a metabolic pH change

262
Q

How do you determine if there is not additional nonanion gap acidosis?

A

18+(normal bicarb + observed bicarb) = 22-26

OR the difference is between 4 and 8?

263
Q

Do antihistamines reduce inflammation?

A

Apparently not

264
Q

How do degcongestants work?

A

Stimulation of alpha1-adrenergic receptors

-> constriciton of nasal blood vessels

265
Q

What are 3 topical decongestants?

A

Pheynylephrine
Oxymetolazine
Xylometolazine

266
Q

3 drugs you give in combo to reduce symptoms of the common cold

A

1st gen antihistamine
Decongestant
Naproxen - blocks inflammation

267
Q

What is more helpful than taking expectorants?

A

Increasing fluid intake

Using a cool mist/steam vaporizer

268
Q

What is the expectorant we care about? What does it do?

A

Guaifenesin

Decreases viscocity of respiratory tract secretions

269
Q

What is the defect in primary ciliary dyskinesia (immotile ciliary syndrome)?

A

Dyenin arms

270
Q

What is the most common immune cell in the pulmonary airspace?

A

macrophages (90-95%)

271
Q

Smoking increases which immune cell in the lung?

A

Macrophages

272
Q

Which signalling molecule suppresses inflammation of macrophages in the absence of PAMPs? What binds it?

A

SIRP-a

Collectins

273
Q

Surfactants are also called ________ because of their immune responsibilities in the lung

A

Collectins

274
Q

3 types of secreted pattern recognition receptors in the lungs that serve as bridges between PAMPs and their spcific receptors

A

Collectins
Complement
Pentraxins

275
Q

3 types of cellular pattern recognition receptors

A

Toll-like receptors
Svacenger receptors
C-type lectin receptors (lectins are carb PAMPs)

276
Q

How does collectin binding change during inflammation in the presence of pAMPs?

A

It goes from binding SIP-a to binding PAMPs directly and this allows them to bind inflammatory receptors (instead of inhibitory receptors)

277
Q

What cell type does mycobacterium tuberculosis live in?

A

Macrophages

278
Q

What is the calcified lung nodule marking the initial site of TB infection called?

A

Ghon complex

279
Q

What is a Ranke comples?

A

A Ghon complex + calcified regional lymph nodes

280
Q

How do you read a TB skin test?

A

After 48-72 hours, measure the diameter of induration (not erythema)

281
Q

What are the 3 groups of criteria for a positive TB skin test?

A

Depends on risk for TB reactivation

> =5 mm Immunocompromised, old TB, recent contact with active TB

> =10 mm Immigrants from certain places, homeless, diabetes, dialysis, etc

> =15 mm all low-risk people

282
Q

What populaitons do tuberculosis skin test false-negatives occur in?

A

T-cell depleted people

AIDS
Immunosuppression
Chemo
Old people

283
Q

What 2 populations does tuberculosis skin test calse positivity occur in?

A

BCG vaccinated

People infected with envirionmental mycobacteria

284
Q

How do TB blood tests work?

A

Take blood
Add TB antigens
Measure amount of IFN-Y

Quantiferon measures this with ELISA
T-spot measures this with antibodies

285
Q

Why might immigrants get active TB well after moving? What are 2 advantages they lose?

A

Reduced vitamin D b/c lots of people go to dark places

Vitamin D suppresses growth of TB in macrophages
Induces expression of cathelicidins, which can kill TB

286
Q

2 drugs we use to treat latent TB infection

A

isoniazid
Rifampin

Combined for 3 months
OR isioniazid for 9 months
OR rifampin for 4 months

287
Q

Major side effect of isonizaid

A

Hepatitis

So don’t use in people with liver problems

288
Q

4 causes of hypoxemia

A

V/Q mismatch
Impaired diffusion
Alveolar hypoventilation
Low inhaled O2 (high altitude, other)

289
Q

3 things to always do inevaluation of respiratory failure

A

PHysical exam
Chest imaging (first CXR)
Arterial blood gas

290
Q

What is FIO2 at room air?

A

0.21

291
Q

What is barometric pressure at sea level or denver

A

760

630

292
Q

What is PH2O

A

47

293
Q

Without positive end expiratory pressure on a ventilaro, what can happen?

A

Atelectasis b/c lungs can keep deflating since the glottis doesn’t close like in normal breathing

294
Q

Can ARDS be explained by cardiac failure or fluid overload?

A

Not fully

295
Q

What is the time frame for ARDS development?

A

Occurs within 1 week of known clinical insult or worsening in respiratory symptoms

296
Q

What part of the lung is inflamed in ARDS?

A

Alveoli

297
Q

How do you describe alveolar edema in ARDS?

A

Proteinaceous

298
Q

What sort of deposit forms in ARDS?

A

Hyaline membrane (from protein deposition)

299
Q

What is the ONLY therapeutic intervention that improves survival in ARDS?

A

Ventilator

But important to limit pressure
Allow hypercapnea
Consider putting patients prone

300
Q

3 major determinants of site and severity of occupational lung disease

A

Dose (duration*concentration)
Solubility
Particle size

301
Q

Rounded atelectasis is from _____

A

Asbestos exposure

302
Q

How does acetoazolamide reduce altitude sickness?

A

Increases bicarbonate loss

303
Q

3 things in treatment of HACE

A

Oxygen
Descent
IV dexamethosone

304
Q

Do people with HAPE also get AMS?

A

Sometimes - predispositions are different

305
Q

What causes HAPE?

A

Pulmonary hypertension in response to acute hypoxia44An overexuberant response

306
Q

What 3 drugs are given for HAPE?

A

Pulmonary vasodilators: nifedipiene, tadalafil

Increases clearance of water out of alveoli - salmeterol

307
Q

How is airflow afected in diving?

A

Resistance and distance b/c of of tubing and outhpiece increases-> increase in work of breathing

308
Q

What causes nitrogen narcosis?

A

Breathing of compressed air at >100 ft

B/c nitrogen acts as a narcotic

309
Q

What is the biggest risk foractor for tuberculosis activation?

A

HIV

310
Q

2 basic types of ARDS

A

Hypercapneic (too much CO2)

Hypoxic (too littoe O2)

311
Q

What are the 4 variable parameters on a ventilator?

A

Oxygenation:
FIO2
PEEP (positive end-expiratory pressure)

Ventilation:
Respiratory rate
Tidal volume

312
Q

What 4 things are altered in ARDS?

A

Timing within 1 week of a known clinical insult or new/worsening respiratory symptoms

CXR bilateral opacities not explained by other causes

Origin of edema not fully explained by cardiac failure/fluid overload

Decreased oxygenation

313
Q

5 most common causes of ARDS

A 
Sepsis
Pancreatitis
Trauma
Aspiration
Transfusion
314
Q

Is ventilator use better prone or supine?

A

Prone, apparently

315
Q

What is pneumonconiosis?

A

Dust-related lung disease leading to inflammation and scarring

316
Q

_____ is the most common cause of occupational asthma

A

Isocyanates

317
Q

If you see adult onset asthma, you should look for_________

A

An occupational source

318
Q

Isocyanates are associated with what behavior?

A

Paints

319
Q

If you see pleural plaques you should think _________

A

Asbestos exposure

320
Q

Which 2 lung cancers are central?

A

Squamous cell carcinoma

Small cell carcinoma

321
Q

What color is small cell carcinoma on H&E?

A

Blue

322
Q

If you see a lung that looks kind of like millet, you should think_____

A

Active TB

323
Q

Are kids nose or mouth breathers?

A

Nose (so congestion is a big problem!)

324
Q

Irritant asthma is also known as ______

A

RADS 9(reactive airways dysfunction syndrome)

325
Q

What are the 2 types of asthma caused by occupational exposures?

A

Immunologic - latency

Irritant/RADS - no latency

326
Q

What is the difference in mechanisms caused high and low molecular weight compounds in by occupational immunologic asthma?

A

MW - specific IgE reaction

LMW - combine with endogenous proteins to create new antigenic determinants

327
Q

How do pulmonary pressures change with hypoxia?

A

Increase from vasoconstriction

328
Q

Is HACE part of AMS?

A

Yes. It is severe AMS with significant brain problems

329
Q

3 drugs used for AMS

A

Dexamethosone - decreases brain edema

Acetazolamide - bicarb wasting ->metabolic acidosis -> hyperventilation

Ibuprofen

First 2 are used to TREAT AMS

330
Q

3 signs of respiratory distress in infants

A

Lethargy
Poor feeding (b/c it’s the most active thing they do)
Grunting

331
Q

Signs and symptoms of upper airway obstruction. 1 regular airway obstruction, 3 severe

A

Stridor
Drooling
Dysphagia
Dyspnea/distress

332
Q

What is the most comon cause of chronic stridor?

A

Laryngomalacia

When the epiglottis blocks the airway

333
Q

What is malacia?

A

Abnormal tissue sofening

In terms of pulmonology, it means collapse of part of the airway

334
Q

What is clinically associated with a recurrent wheeze, a hoarse cough, and recurrent illnesses?

A

Tracheobronchomalacia

335
Q

What is the narrowest point in the airway of adults? Children?

A

Glottis (vocal cord part)

Cricoid

336
Q

5 things for Ddx of acute stridor

A 
Croup (laryngotracheobronchitis)
Bacterial tracheitis
Epiglottiitis
Laryngeal foreign body
Scalding
337
Q

What is the most common form of acute airway obstruction in children?

A

Croup

338
Q

What does bronchioloitis sound like on ascultation?

A

Polyphonic wheezes in lung fields

339
Q

2 results of bronchopulmonary dysplasia

A

Decreased surface area

Thickened interstitium

340
Q

What 3 things does the H1 histamine receptor do?

A

Vasodilation
Increased capillary permeability
Cramping of gut smooth muscle

341
Q

What is the difference between 1st and 2nd generations of antihistamines?

A

1st - H1 and other receptors

2nd - pretty selective for H1

342
Q

What is the difference between NE and epi’s actions on blood vessels?

A

NE - vasodilation

Epi - vasoconstriction

343
Q

4 side effects of antihistamines

A

Sedation
Antimuscarinic action - dry mouth, urinary retention, constipation
Paradoxical exitation
Postural hypotension

344
Q

Topical decongestants stimulate which receptors?

A

Alpha-1

345
Q

Does dextromethorphan depress respiration or predispose to addition?

A

No

346
Q

Which drug is for robotripping? Which receptor does it act on?

A

Dextromethorphan

NMDA glutamate receptors

347
Q

Where is inspiration on the PV hysteresis curve? Expiration?

A

Inspiration - right

Expiration - left

348
Q

Catbon dioxide is a broncho______ and a vaso______

A

Bronchodilator

Vasoconstrictor

349
Q

Medical intervention for stridor at rest due to croup?

A

Epinephrine nebs

350
Q

Medical intervention for epiglottitis?

A

Intubation - it is a medical emergency

351
Q

What are 3 differences between child and adult chest walls?

A 
Weak intercostal muscles
Horizontal ribs (no bicket handle)
Diaphragm is flat
352
Q

At what age can children perform spirometry?

A

6 usually

353
Q

Which children are not likely to grow out of asthma by age 12? (2)

A

Allergic

Family history of asthma

354
Q

What is empyema?

A

Purulent pleural effusion

355
Q

Bronchopulmonary dysplasia represents the consequences of lung injury caused by what 3 things on the susceptible, immature lung?

A

Oxygen toxicity
Barotrauma
Inflammation

356
Q

What is the newborn screening test for cystic fibrosis?

A

Immunoreactive trypsin levels (elevated in newborns with CF)

357
Q

Which 3 blood vessel receptors cause vasodilation?

A

Muscarnic
Histamine H1
Bradykinin

358
Q

Which receptor suppresses the cough reflex?

A

Mu opioid

359
Q

Which 2 receptors result in pain?

A

Bradykinin

Histamine H1

360
Q

What drug class is Loratidine?

A

Second generation antihistamine

361
Q

2 receptors you can block to reduce motion sickness

How do they work in pregnancy?

A

H1
Muscarinic

They are safe to use in pregnant people

362
Q

What is the mechanism of action of mucolytics?

A

Split disulfide linkages between mucopriteins, decreasing their viscocity
Also antioxidants

363
Q

What chemical are mucolytics?

A

N-acetyl cysteine

364
Q

Where is the cough reflex controlled in teh brain?

A

Medulla

365
Q

What effect does low fluid volume have on pH?

A

Alkalosis

366
Q

What is the mechanism of action of zyleutin?

A

It is a methylzanthine for treating asthma

Inhibits 5-lipoxegenase -> leukotriene block -> bronchodilation

367
Q

What is the main toxicity of zyleutin?

A

Hepatotoxicity

368
Q

Is sarcoidosis restrictive or obstructive?

A

Restrictive

369
Q

What is the difference between redand grey pneumonia?

A

Red - looks like a liver on CT. Has RBCs, fibroblasts, neutrophils.

Frey - when RBCs start dying

370
Q

What drug class is diphenhydramine?

A

First generation antihistamine

Benadryl!

371
Q

Does histamine have much of a role in colds?

A

No

Mast cell mediators have a minor role in viral respiratory infections

372
Q

What is a side effect of phenylephrine?

A

Irritation

373
Q

What drug class do you use to treat upper airway cough syndrome?

A

1st generation antihistamine

Spring 2016 - CVPR (4 decks)

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