Pulmonary Flashcards
1
Q
What is the extra lobe on the right side?
A
The middle lobe
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
3
Q
The lungs develop out of the _________
A
Gut tube
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
5
Q
The maximal force for the diaphragm is at ______ it’s resting length
A
130%
6
Q
How are compliance and elastance related?
A
They are inversely proportional
7
Q
At what fetal age is surfactant produced?
A
Fetal week 24
8
Q
The probability of tubulent flow is given by the ______
A
Reynolds number
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
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
11
Q
What is different about lungs in obstructive diseases?
A
Increased resistance
12
Q
What is the ratio between O2 in and CO2 out?
A
They are equal, so 1-1 ratio
13
Q
What are the lobes of the lung?
A
R = superior, middle, inferior L = superior, inferior
14
Q
What is the acinus?
A
The terminal bronchiole, alveolar ducts, alveoli - the region of lung supplied with air from a terminal bronchiole
15
Q
Which germ layer do the lungs develop from?
A
Embryonic endoderm
16
Q
Which week do lung buds develop at?
A
4
17
Q
Which branchial arches do the lungs develop between?
A
4th and 6th (remember there is no 5th)
18
Q
The formation of conducting airways is completed at the end of the _________ stage of lung development
A
Pseudoglandular
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
20
Q
What is an atresia?
A
When an orifice or passage in the body is abnormally closed/absent
21
Q
In lung development, the descent of the lungs is halted by the _________
A
Liver
22
Q
Is branching in the embryonic stage of lung development symmetrical?
A
No. More on the R
23
Q
Are most alveoli present at birth?
A
No. 90% of them develop after birth
24
Q
The pulmonary arteries develop from the __________ aortic arch
A
6th
25
```
What are the following lung volumes?
TGV
RV
TLC
FVC
FEV1
DLCO
```
```
Thoracic gas volume
Residual volume
Total lung capacity
Forced vital capacity in 1 second
Forced expiratory volume
uhh some measure of gas exchange
```
26
Is total ventilation affected by moderate disease conditions?
No. Generally, total ventilation is affected only by severe disease conditions
27
How does gravity affect ventilation and volume throughout the lung?
Ventilation of the top alveolus volume bottom
This is because of compliance - bottom alveolus in middle of PvsV curve; top alveolus is at top
28
What is compliance?
dV/dP
29
How do you calculate minute ventilation?
Tidal volume * breathing rate
Usually about 6 L
30
Our breathing rate/tidal volume is where it is because of the superposition of 2 types of work:
Resistance (increases with decreasing tidal volume b/c big breaths open airways)
Elastic (increases with increasing tidal volume)
Breathing parameters reduce total work
31
What are the 2 pleura?
Parietal - on inside of chest wall
| Visceral - on outside of lung
32
What are the cartilagenous air conduction pathways in the lung?
Trachea
Primary bronchi - 1R;1L
Secondary (lobar) bronchi - 3R;2L
Tertiary (segmental) bronchi - 10R;8L
33
Where are the pulmonary arteries? Where are the veins?
Arteries follow bronchial tree
| Veins are intersegmental
34
What is the blood supply of the bronchi? Where does it go?
Bronchial artery. Most of it anastomoses with the pulmonary supply and some goes back to the bronchial vein
35
What are 4 cell types in the bronchial epithelium?
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
36
What are 4 layers to the mucosa of the bronchus?
Epithelium
Basal lamina
Areolar connective tissue/lamina propria - loose connective tissue with capillaries an dleukocytes
Muscularis mucosa - agitate epithelium, helps submucosal glands excrete mucus
37
What are 3 layers to the submucosa of the bronchus?
Dense connective tissue
Cartilage plates with chondrocytes living in their lacunae
Adventitia - large blood vessels, nerves
38
___________________ connects to the points of the C-shaped cartilage rings in the trachea
Trachealis muscle
39
What are 2 cell types in the bronchiolar epithelium?
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
40
What are 2 cell types in the alveolar epithelium?
Type I pneumocyte - they chill
| Type II pneumocytes - secrete surfactant. Stem cell for type I and II pneumocytes
41
What is Dalton's Law?
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
42
What is the alveolar gas equation?
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
43
What is the rate-limiting step for removing CO2 from the blood in teh lungs?
Ventilation
| Diffusion is fast
44
What is the alveolar ventilation eqation?
PaCO2 = (rate VCO2/rate VA) * k
rate VCO2 = CO2 production in 1 minute
rate VA = alveolar ventilation in 1 minute
45
How is the length of the diaphragm affected in obstructive lung disease?
It is shorter b/c their lungs don't relax all the way.
As a consequence, force exerted by the diaphragm is less
46
Dras the lung pressure vs. volume curve
:)
47
What is lung compliance like in emphysema?
Increased, so elastic recoil of the lungs is decreased. Expiration is impaired.
48
3 causes of reduced chest wall compliance
Old age
Obesity
Scar tissue
49
3 affects of water surface tension on the lung if surfactant wasnt there
Wants to make the alveolus smaller -> collapse of alveoli, decreasing surface-volume ratio
Decreased lung compliance
Water accumulation in lung
50
Where in the lungs is the majority of airway resistance?
Bronchioles
51
How do airway resistance and radius relate?
R oc 1/r^4
52
Where in the lungs can turbulent airflow be found?
The trachea (sometimes)
53
2 ways the body can induce bronchoconstriction
Parasympathetic input
| Histamine
54
2 ways the body can induce bronchodilation
Sympathetic input
| CO2 in bronchioles (which isn't really the body doing something on purpose)
55
Why does higher lung volumes decrease resistance?
Increased radius of bronchioles
56
Why do patients with emphysema exhale through pursed ips?
Increases airway pressures, reducing airway collapse
57
3 factors that affect perfusion
O2 tension (hypoxic vaso-pulmonary constriction)
Capillary recruitment
Gravity
58
What is ventilation?
| What is perfusion?
Ventilation (V) = air that reaches alveoli
| Perfusion (Q) = blood that reaches the alveoli
59
How do V?Q ratios in the apex vs. base of lung compare?
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
60
Does V/Q mismatch affect arterial CO2 levels? What about O2?
No
| Yes
61
2 ways the body corrects V/Q mismatch
Bronchodilation with high PCO2 in bronchiole
Vasoconstriction with low PO2 in blood
62
What is an area with perfusion but no ventilation?
Shunt
63
What is an area with ventilation but no perfusion?
Dead space
64
What is the most common mechanistic cause of hypoxemia?
V/Q mismatch
pneumonia, PE, COPD, etc
65
The conversion of CO2 to carbonic acid is catalyzed by _________ in _________
Carbonic anhydrase
| Red blood cells
66
The effect of O2 binding reducing CO2 binding to hemoglobin and vice versa are the _____________ and _________ effects
Haldane (O2 binding reduces CO2 affinity for Hb)
Bohr (CO2 binding reduces O2 affinity for Hb)
67
What is the oxygen carrying capacity of the blood (definition)?
Maximal O2 that can be carried by a particular amount of Hb
68
What is the A-a gradient?
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
69
How is compliance in an alveolus with a large volume?
It is not so great compared to a smaller one (see pressure-volume curve)
70
How does FEV1/FVC compare between obstructive and restrictive lung disease?
Obstructive - less than normal b/c it is hard to exhale
Restrictive - greater than normal b/c lung volumes are reduced
71
What is the Henderson-Hasselbach equation
pH = pKa + log[A-]/[HA]
72
What is pH?
-log[H+]
73
3 intracellular buffers
organic phosphates
proteins
hemoglobin
74
4 extracellular buffers
proteins
albumin
phosphate
bicarbonate
75
3 stages of the bicarbonate buffering system
H2O + CO2 H2CO3 H+ + HCO3-
76
normal venous pH
7.4
77
How does pH of oxygenated and deoxygenated blood compare? Why?
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
78
What are the 2 compensation mechanisms for disturbed blood pH?
Lungs regulate CO2 levels (minutes)
| Kidneys regulate bicarbonate (hours-days)
79
What is the most common cause of respiratory acidosis/alkalosis?
Changes in ventilation
Acidosis - too little ventilation
Alkalosis - too much ventilation
80
2 categories of metabolic acidosis. What are their causes?
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
81
3 causes of non-anion gap metabolic acidosis
GI losses (like diarreha)
Renal losses
Too much IV saline (increases in Cl- with loss of bicarbonate)
82
8 causes of metabolic acidosis
MUD PILES
```
Methanol
Uremia
DKA (and other ketoacids like EtOH and starvation)
Propylene glycol
INH (isoniazid antibiotic)
Lactate
Ethylene glycol
Salicylates
```
83
5 causes of metabolic alkalosis
Loss of gastric acid (vomiting or NG tube suction)
Ingestion of a bicarbonate
Ingestion of an alkali
Hypovoluemia (contraction alkalosis)
Diuretics
84
What part of the brain contains motor neurons that control respiratory muscles?
Medulla
85
3 things that peripheral chemoreceptors look out for
Low arterial O2
High arterial PCO2
High arterial [H+]
86
Where are the peripheral chemoreceptors?
Carotid bodies
87
Where are central chemoreceptors?
ventral surface of medulla
88
What do central chemoreceptors sense?
Protons in CSF, which correlates with arterial CO2
89
Do the peripheral or central chemoreceptors have more power to mediate the ventilatory response?
Central
90
How does the kidney control pH?
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
91
What are the 3 different types of normal breath sounds?
Vesicular
Bronchovesicular
Bronchial
Bronchiovesicular and bronchial sounds heard over the periphery of the lung are abnormal
92
Rales sound like ______
Velcro
93
Are wheezes more commonly heard on inspiration or expiration?
Expiration
94
Rhonchi sound like _____
Rumbles
95
What is the difference between a lung volume and a lung capacity?
Capacities are the sums of at least 2 volumes
96
Can you directly measure lung residual volume?
No
97
What is functional residual capacity?
The volume of gas remaining in lung at end of a tidal expiration
ERV + RV
Expiratory reserve volume + residual volume
98
At which volume is the lung system in equilibrium?
end of a tidal breath - functional reserve capacity
99
What is inspiratory capacity
Volume of gas that can be maximally inspired from a normal exhale
TV + IRV
100
What is vital capacity?
ERV + TV + IRV
101
What is total lung capacity?
RV + ERV + TV + IRV
102
Can you diagnose restrictive disease with spirometry?
No
| the FEV1/FVC can be normal!
103
Draw the flow-volume loop of the lung
Mrr
Inspiration is symmetric
Expiratory limb has an increase in airflow at the beginning
104
Draw the flow-volume loops of fixed, variable intrathoracic, and variable extrathoracic obstructions
:)
105
2 ways to measure lung volumes
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
106
What is boyle's law
P1V1 = P2V2
107
How do we measure DCLO?
Transfer of a known (but small) amt of CO to blood
108
What do you need to correct for in DLCO testing?
Alveolar volume
DLCO/VA
109
What are 2 terms used to describe respiratory muscle strength?
PiMax
PeMax
Inspiration/expiration against a closed valve
110
3 reasons the bicarbonate buffer is so important
High concentration
Blood pH is close to pK (where curve is steepest)
Can be affected by both kidneys and lungs (most effect)
111
FRC and ________ are equivalent terms
TGV (toral gas volume)
112
At what lung capacity are elastic and resistance work minimized?
FRC (functional residual capacity)
113
How do you calculate minute ventilation? Alveolar ventilation?
Vm = Vt*RR
Va = (Vt-Vd)*RR
114
How do you calculate pulmonary vascular resistance?
R = dP/CO
CO is in L/min so is flow
115
4 categories of obstructive lung disease
Chronic bronchitis
Emphysema
Asthma
Bronchiectasis
116
Why is the lamina propria important?
It allows leukocytes to wander around in it
117
4 causes of hypoxemia (4 for the 2nd one)
Altitude
Hypoventilation (obesity, central, neuromuscular, drugs)
Diffusion limitation (exercize, interstitial lung diseae)
Low V/Q or shunt
118
Thromboxane is a vaso______
Constrictor
119
Prostacyclin is a vaso_______
Dilator
120
6 inflammatory cells found in asthmatic airways
```
Mast cells
Eosinophils
Th2
Dendritic cells
Macrophages
Neutrophils
```
121
3 structural airway changes in asthma
Increase in airway SMCs
Increase in blood vessels
Increase in mucus secretion form increased goblet cells and size of submucosal glands
122
Do sympathetic neurons have much power in ditermining airway diameter?
Nope. It's mostly parasympathetic neurons
123
What element do we use to treat asthma?
Magnesium in life threatning exacerbation
| Bronchodilates maybe due to inhibition of calcium influx into SMC
124
4 short-acting beta-adrenergic agonists (SABAs)
Albuterol
Terbutaline
Pirbuterol
Levabuterol
125
2 long-acting beta-adrenergic agonists (LABAs)
Salmeterol
| Formoterol
126
Are anticholinergics used in COPD or asthma? What is their suffix? What do they do?
COPD
-tropium
Bonchodilate via SMC relaxation
Inhibit production of respiratory secretions
127
What are the actions of systemic glucocorticoids?
| What respiratory issue are they given for?
Inhibit phospholipase -> inhibit cytokine synthesis
-> anti-nflammatory, vasoconstrict (reducing edema)
Use to treat acute exacerbations of asthma
128
Can you use LABAs by themselves for asthma treatment?
No - can increase deaths
| Should be combined with an inhaled corticosteroid to control inflammation
129
What do leukotriene modifiers due?
Inhibit 5-lipoxygenase
Bronchodilate
Anti-inflammatory due to leukotriene blocking
130
What is omalizumab?
| What is it used for?
Anti-IgE
| Allergic asthma
131
What is mepolizumab?
Anti-IL-5, which is a cytokine
132
Why is lung infacrtion uncommon?
Collateral circulation from bronchial arteries
133
What is the source of most bleeding in the lung?
Bronchial circulation (not pulmonary)
134
How does the compliance of pulmonary vessels compare to systemic ones? What are 2 results of this?
Much more compliance
-> low resistance, high volume vascular bed
135
Does lung resistance go up when cardiac output increases? 2 reasons
No
Lung vessels are highly distensible
The number of perfused vessels increases
136
What are the 3 West zones of the lung?
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
137
4 safety factors to prevent pulmonary edema
Decreased interstitial oncotic pressure
Increased interstitial hydrostatic pressure
Increased plasma oncotic pressure
Lymphatic reserve system
138
2 mechanisms for pulmonary edema
| 2 ways you can destinguish
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
139
What are the 5 categories of pulmonary hypertension?
What are the 2 other ways to categorize pulmonary hypertension?
```
Pulmonary arterial
Due to left heart disease
Due to lung disease/hypoxia
Thromboembolic
Idiopathic/unclear/multifactorial
```
Pre-capillary (arterial)
Post-capillary (venous)
140
Which gorup of people does idiopathic pulmonary arterial hypertension tend to affect?
Younger women
141
4 targeted pathways for medical management of pulmonary arterial hypertension
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)
142
The pulmonary vasodilating effects of nitric oxide are mediated through its second messenger, ______________
cGMP (grump)
143
_______________ degrades cGMP
Phosphodiesterase
144
Prostacyclins upregulate ______________
cAMP
145
4 drug categories to reduce airway tone in asthma
Beta-agonists
Anti-cholinergics
Leukotriene inhibitors
Methylxanthines (theophylline) - phosphodiesterase inhibitors that increase intracellular cAMP
146
3 drug categories to reduce inflammation in asthma
```
Corticosteroids
Mast cell stabilizers
Leukortriene inhibitors
Anti-IgE (omalizumab)
Anti-IL5 (mepolizumab)
```
147
What defines COPD?
Irreversible airflow limitation
148
What defines chronic bronchitis?
Productive cough present for 3 months/year over a 2-year period without another identified medical cause
149
What defines emphysema?
Abnormal, permanent enlargement of air spaces distal to terminal bronchioles
+
Destruction of alveolar walls w/o obvious fibrosis
150
2 subtypes of emphysema. What causes each?
Centriacinar - smoking
Scarring and focal dilation of broncioles and adjacent alveoli
Panacinar - alpha1 anti-trypsin deficiency (autosomal recessive)
Bronchioles down to alveoli involved
151
What is bronchiectasis?
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
Cystic fibrosis is a mutation in what gene?
Cystic fibrosis trans-membrane regulator
153
The ascultatory hallmark of bronchiolotis is _____
Inspiratory squeak
154
2 major causes of airflow obstruction
Airway narrowing (bronchospasm, plugging, inflammation)
Floppy airways (decreased radial tethering or decreased airway integrity)
155
2 types of asthma. Which one tends to be more chronic/persistent?
Extrinsic (allergic)
| Intrinsic (nonallergic). More chronic/persistent
156
What is bronchoprovocation? What is it for?
Give methacholine/histamine and test FEV1
| Can detect occult asthma
157
What is the PV curve like in acute asthma?
Above (higher volumes) but same shape (no change in tissue properties)
158
How do you differentiate vocal cord dysfunction from asthma? (3)
Sounds on inspiration (stridor)
Fiberoptic laryngoscopy
Bronchoprovacation may worsen VCD, but does not change FEV1 or PC20
159
What is vocal cord dysfunction (in pulmonary setting)
Inappropriate vocal cord motion results in airflow obstruction
160
How many people have COPD after 50 years of smoking?
20
161
What is the mechanism of dynamic airway collapse in emphysema?
Reduced elasticity of tissue around airways so can't withstand pleural pressure
162
What is the PV curve like in emphysema?
```
High volume
Steeper curve (because more compliant/less elastic)
```
163
5 causes of death from COPD
```
Respiratory failure
Right ventricular failure
Pneumonia
Spontaneous pneumothorax
Pulmonary embolism
```
164
How do you get bronchiectasis?
A combination of:
Infectious/inflammatory insult
Impaired drainage/obstruction/immunodeficiency
165
3 parts to management of bronchiectasis
Airway clearance to remove secretions
Antibiotics
Treatment of reactive airways disease
166
```
Well controlled asthma frequency:
Daytime symptoms
Nighttime symptoms
SABA
Peak flow
Oral steroid
Urgent care visit
```
```
2x/week
2x/month
2x/week
Normal
1x/yr
1x/yr
```
167
What is tiotripium for?
A long-acting anticholinergic for asthma in ppl >12
168
What does cromolyn/nedocromil do?
Inhibit mast cell mediator release
| Preventative therapy for exercise-induced or allergen-induced asthma
169
What does theophylline do?
Inhibits phosphodiesterase
| -> bronchodilation and some anti-inflammatory activity
170
What are the effects of particle size on drug inhalation?
>5um deposit in pharynx and larger airways
171
What has the greatest capacity to influence the natural history of COPD?
Smoking - so everybody should stop
172
Is physical activity recommended in COPD?
Yes! Exercise is important
173
What is the pressure difference across the lung?
Pulmonary artery pressure - left atrial pressure
174
Where are the lymphatic vessels in the lungs?
Intralobular, with the veins
175
What causes hydrostatic pulmonary edema?
Increased pulmonary capillary wedge pressure
176
What pressure defines pulmonary hypertension?
Mean pulmonary artery pressure >25 mmHg
177
What is V=IR for the lungs?
Pulmonary arterial pressure = CO * resistance
178
What is the gold standard diagnostic for pulmonary embolism?
Angiogram
| Rarely performed though
179
In which chest Xray projection can the heart appear enlarged?
AP
180
What does the silhouette sign show on Xray?
2 structures of similar density in contact (like lung-heart border)
181
What is atelectasis?
Regions of lung collapse
182
What is the spine sign on CR?
Spine becomes less radiolucent as we move downswards because th elung is filled with something more dense instead of air.
183
How does the P-V curve change in restrictive lung disease?
It decreases, because compliance is decreased
Note that if cause of restriction isn't lung tissue itself, compliance won't chnage
184
What 2 things characterize interstitial lung disease?
Inflammation
+
Scarring
185
5 treatment options for interstitial lung disease
```
Remove offending expore (if possible)
Immunosupression (if necessary)
Drugs (nintedanib, pirfenidone for idiopathic pulmonary fibrosis)
Oxygen
Transplantation
```
186
What is idiopathic pulmonary fibrosis?
A scarring lung disease with pattern of injury of usual interstitial pneumonia
So IPF if clinical
UIP is from pathology
187
Where in the lung is idiopathic pulmonary fibrosis usually?
Peripheral and basilar
188
What is the difference between usual interstitial pneumonia and nonspecific interstitial pneumonia on pathology?
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
What are the 2 smoking-related ILDs that are on a spectrum? How do you treat them?
Respiratory bronchiolitis
Desquamative interstitial pneumonia
Stop smoking
190
What characterizes pulmonary langerhans cell histiocytosis? Who gets it? How do you treat it?
New smokers
Cysts and nodules mostly in upper lobe
Stop smoking
191
What characterizes organizing pneumonia?
Plugs of granulation tissue and fibrosis distal to bronchioles
Imaging: ground glass and consolidation that may be migratory
192
How do you treat organizing pneumonia?
6-12 months of steroids
193
How do you treat acute and chronic eosinophilic pneumonia?
Steroids
194
What causes lymphangioleiomyomatosis (LAM)? What characterizes it?
Mutation in tuberous sclerosis genes
Get cysts and nodules, peribronchovascular proliferation of SMCs
195
What characterizes sarcoidosis?
Systemic noncaseating granulomatous disease
196
What are the 2 parts of the physiologic state of anxiety? What parts of the brain are involved in each?
Conscious feeling - mediated by cortex, cingulate cortex, frontal lobes
Emotional states - mediated by autonomic, endocrine, somatic responses involving the amygdala, mypothalamus, brainstem
197
What are the 2 components of anxiety?
Cognitive
| Physiologic state of hyper-arousal
198
What 2 things are the biological basis of panic disorder?
Dysregulation in the noradrenergic system/excess norepinephtine
Dysregulation of GABA
199
3 hypotheses for panic dosorder
CO2 + lactate hypersensitivity due to chronic hyperventilation
False suffocation alarm - brainstem alarm is too sensitive
Hypersensitive limbinc system
200
2 changes in chronic bronchitis. What is the primary involved cell?
```
Squamous metaplasia (allow epithelium to be tougher)
Mucus gland hypertrophy
```
201
At what point do you say something is bronchiectasis?
When airway diameter > vessel diameter
202
What happens in constrictive/obliterative bronchitis?
Airways scar shut
203
What defines diffuse alveolar damage?
Inflammation of alveolar septa
204
How do you tell if a hemorrhage is not from biopsy? (3)
More blood
Iron-containing macrophages in airspaces
Fibrous ribbons of septa
205
Where are neutrophils in acute bronchitis?
In wall and airway
206
Nonnecrotizing granuloma menas what 2 diseases?
Sarcoid/beryllium
207
What is the difference in location between smoking and alpha-1-antitrypsin deficiency emphysema?
Smoking - upper lobes, around airways
Alpha-1-antitrypsin - lower lobes, panlobular
208
3 symptoms of B cell tumors
Fever
Weight loss
Drenching night sweats
209
3 risk factors for primary spontaneous pneumothorax
Men
Smokers
Familyhistory
210
6 symptoms of pneumothorax
```
Acute onset chest pain
Dyspnea
Cough
Anxiety
Cyanosis
Respiratory distres
```
Somehow these are different than PE
211
What is the difference between a bulla and a bleb?
Bulla - enlargement of lung tissue
| Bleb - enlargement of visceral pleura
212
What is a tension pneumothorax
Intrapleura pressure > atmospheric pressure at least during expiration (sometimes inspiration in addition)
Decreases venous return, limits cardiac output
Medical emergency
213
What do you do in event of a tension pneumothorax?
Do not wait for a CXR
| Insert a chest tube to deflate
214
What's the difference between transudate and exudate?
Transudate - from increased hydrostatic pressure
Exudate - from increased permeability. So has more proteins, LHD, cells
215
3 drugs used for smoking cessation
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
How do you measure the pressure volume curve clnically?
Insertion of an esophageal pressure monitor. This is a surrogate for pleural pressure
217
What serum value is increased in sarcoidosis?
ACE
218
What is dysphonia?
| Where is the defect?
Alteration of voice quality. Usually a laryngeal source
219
What is dysarthria?
| Where is the defect?
Alteration of rhyrhm, enunciation, articularion
Neurological or muscular source
220
What is stertor?
| Where is the defect?
A snoring sound from nose, nasopharynx, throat
221
When should a patient see an otolaryngologist?
If hoarseness last longer than 2 or 3 weeks
222
2 materials vocal fold cysts can be made out of
Blood
| Mucus
223
2 materials vocal fold polyps can be made out of
Blood
| Fibrous tissue
224
How do you treat vocal fold hemorrhage and tears?
Strict voice rest
225
Does COPD risk and lung cancer risk correlate?
Yes!
| As COPD worsens, lung cancer risk is increased
226
What are the 3 subtypes of non small call lunc cancer?
Squamous cell carcinoma - bronchial epithelium
Adenocarcinoma - mucus glands
Large cell carcinoma (like the others)
227
What is the cellular origin of small cell carcinoma?
Bronchi
228
4 symptoms of undiagnosed lung cancer
Cough
Anorexia
Weakness
Weight loss
229
How do you typically treat small cell lung cancer?
Drugs: cisplatin, etopiside
230
How do you typically treat non-small cell lung cancer?
Surgery
Also chemotherapy/radiation with surgery - adjuvant and neoadjuvant therapy
231
What are the 2 types of apnea?
Central - respiratory effeorts are absent
| Obstructive
232
In pneumonia what does infectious agent sputum indicate? Minimal sputum?
Bacteria
| Atypical bacteria or viral
233
All patients with suspected pneumonia should have which 4 diagnostic tests?
CXR
CBC
Complete metabolic panel
Blood gas/pulse oximetry
234
________ is produced by parynchymal cells in response to bacterial toxins
Procalcitonin
Indicates there is an infection in lung or intestine, where the parynchemal cells live
235
4 groups who shoud get pneumococcal vaccine
Immuncompromised people
>65
Chronic illness
Asplenia
236
What are the 3 main subtypes of afferent nerves within the vagus nerve that regulate cough?
Rapidly adapting receptors
Slowly adapting stretch receptors
C-fibers
RARs, SARs respond to mechanical stretch
C-fibers respond to chemical stimuli
237
4 phases of the cough reflex
Inspiratory phase (glottis open)
Compressive phase (glottis closed)
Expiratory phase
Relaxation phase
238
Time frame for acute, subacute, chronic cough
8 weeks
239
5 causes of chronic cough in adults
```
Upper airway cough syndrome
Asthma
GERD
Non-asthmatic eosinophilic bronchitis
Neuropathic cough
```
240
What is the mechanism of upper airway cough syndrome?
Cough receptors stimulated by secretions from nose or sinuses
241
What is non-asthmatic eosinophilic bronchitis?
Eosinophilic airway inflammation like asthma but without variable airflow limiatation or airway hyperresponsiveness
242
Antagonists of which 3 bronchial smooth muscle receptors cause bronchoconstriction?
Muscarinic
Leukotriene
Histamine
243
What is the main drug you give for anaphylaxis
Epinephrine
244
The common cold's symptoms are mostly explained by release of ________ inflammatory mediators
Bradykinin
245
3 effects of muscarinic receptor block
Sedation
Prevention of nausea and vomiting
Block of secretions
246
4 organisms that cause atypical pneumonia
Legionella
M. Pneumoniae
C. Pneumoniae
C. psittaci
247
What 7 things can fill the alveoli?
Poor funny boy can't piss for crap
Pus, fluid, blood, cells/cancer, protein, fat, calcium
248
Influenzavirus variation is due to 2 types of envelope glycoproteins:
Hemagglutinin
| Neurominidase
249
2 classes of antivirals we use to treat influenza and 2 examples of each
Neurominidase inhibitors (oseltamivir, zanamivir)
Adamantanes (amantadine, rimantidine)
250
3 defenses against upper airway collapse
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
What is cheyne-stokes respiration?
Hypercapneic respiratory drive results in overshooting of PaCO2 below apneic threshold
So, an oscillatory pattern of apnea and hyperpnea
252
3 most common mutations in adenocarcinoma
KRAS
EGFRT
EML4-ALK
253
Which 2 nerves go to the larynx? Where does it come from?
Superior laryngeal nerve
Recurrent laryngeal nerve
From vagus nerve
254
What are the 2 parts of the superior laryngeal nerve?
Internal - sensatibon
| External - motor (to upper crycothyroid)
255
Which respiratory phase is stridor heard in?
Inspiratory
Expiratory
Biphasic
256
What is the mechanism of croup?
Subglottic narorowing
257
Reinke's edema is seen in what patient population?
Female smokers
258
How long does it take for an ACE-inhibitor cough to stop after the drug is stopped?
1-7 days usually
| But up to month
259
How do you calculate the A-a gradient?
What is PalveolarO2 usually?
Palveolar O2 - P arterial O2
P alveolar O2 is about 102 mmHg if ventilation is good
260
How do you tell if respiratory pH changes are acute or chronic?
For every 10 mmm change in PaCO2
0. 08 pH change in acute
0. 03 pH change in chronic
261
What is winters formula?
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
How do you determine if there is not additional nonanion gap acidosis?
18+(normal bicarb + observed bicarb) = 22-26
OR the difference is between 4 and 8?
263
Do antihistamines reduce inflammation?
Apparently not
264
How do degcongestants work?
Stimulation of alpha1-adrenergic receptors
| -> constriciton of nasal blood vessels
265
What are 3 topical decongestants?
Pheynylephrine
Oxymetolazine
Xylometolazine
266
3 drugs you give in combo to reduce symptoms of the common cold
1st gen antihistamine
Decongestant
Naproxen - blocks inflammation
267
What is more helpful than taking expectorants?
Increasing fluid intake
| Using a cool mist/steam vaporizer
268
What is the expectorant we care about? What does it do?
Guaifenesin
| Decreases viscocity of respiratory tract secretions
269
What is the defect in primary ciliary dyskinesia (immotile ciliary syndrome)?
Dyenin arms
270
What is the most common immune cell in the pulmonary airspace?
macrophages (90-95%)
271
Smoking increases which immune cell in the lung?
Macrophages
272
Which signalling molecule suppresses inflammation of macrophages in the absence of PAMPs? What binds it?
SIRP-a
Collectins
273
Surfactants are also called ________ because of their immune responsibilities in the lung
Collectins
274
3 types of secreted pattern recognition receptors in the lungs that serve as bridges between PAMPs and their spcific receptors
Collectins
Complement
Pentraxins
275
3 types of cellular pattern recognition receptors
Toll-like receptors
Svacenger receptors
C-type lectin receptors (lectins are carb PAMPs)
276
How does collectin binding change during inflammation in the presence of pAMPs?
It goes from binding SIP-a to binding PAMPs directly and this allows them to bind inflammatory receptors (instead of inhibitory receptors)
277
What cell type does mycobacterium tuberculosis live in?
Macrophages
278
What is the calcified lung nodule marking the initial site of TB infection called?
Ghon complex
279
What is a Ranke comples?
A Ghon complex + calcified regional lymph nodes
280
How do you read a TB skin test?
After 48-72 hours, measure the diameter of induration (not erythema)
281
What are the 3 groups of criteria for a positive TB skin test?
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
What populaitons do tuberculosis skin test false-negatives occur in?
T-cell depleted people
AIDS
Immunosuppression
Chemo
Old people
283
What 2 populations does tuberculosis skin test calse positivity occur in?
BCG vaccinated
| People infected with envirionmental mycobacteria
284
How do TB blood tests work?
Take blood
Add TB antigens
Measure amount of IFN-Y
Quantiferon measures this with ELISA
T-spot measures this with antibodies
285
Why might immigrants get active TB well after moving? What are 2 advantages they lose?
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
2 drugs we use to treat latent TB infection
isoniazid
Rifampin
Combined for 3 months
OR isioniazid for 9 months
OR rifampin for 4 months
287
Major side effect of isonizaid
Hepatitis
| So don't use in people with liver problems
288
4 causes of hypoxemia
V/Q mismatch
Impaired diffusion
Alveolar hypoventilation
Low inhaled O2 (high altitude, other)
289
3 things to always do inevaluation of respiratory failure
PHysical exam
Chest imaging (first CXR)
Arterial blood gas
290
What is FIO2 at room air?
0.21
291
What is barometric pressure at sea level or denver
760
| 630
292
What is PH2O
47
293
Without positive end expiratory pressure on a ventilaro, what can happen?
Atelectasis b/c lungs can keep deflating since the glottis doesn't close like in normal breathing
294
Can ARDS be explained by cardiac failure or fluid overload?
Not fully
295
What is the time frame for ARDS development?
Occurs within 1 week of known clinical insult or worsening in respiratory symptoms
296
What part of the lung is inflamed in ARDS?
Alveoli
297
How do you describe alveolar edema in ARDS?
Proteinaceous
298
What sort of deposit forms in ARDS?
Hyaline membrane (from protein deposition)
299
What is the ONLY therapeutic intervention that improves survival in ARDS?
Ventilator
But important to limit pressure
Allow hypercapnea
Consider putting patients prone
300
3 major determinants of site and severity of occupational lung disease
Dose (duration*concentration)
Solubility
Particle size
301
Rounded atelectasis is from _____
Asbestos exposure
302
How does acetoazolamide reduce altitude sickness?
Increases bicarbonate loss
303
3 things in treatment of HACE
Oxygen
Descent
IV dexamethosone
304
Do people with HAPE also get AMS?
Sometimes - predispositions are different
305
What causes HAPE?
Pulmonary hypertension in response to acute hypoxia44An overexuberant response
306
What 3 drugs are given for HAPE?
Pulmonary vasodilators: nifedipiene, tadalafil
| Increases clearance of water out of alveoli - salmeterol
307
How is airflow afected in diving?
Resistance and distance b/c of of tubing and outhpiece increases-> increase in work of breathing
308
What causes nitrogen narcosis?
Breathing of compressed air at >100 ft
B/c nitrogen acts as a narcotic
309
What is the biggest risk foractor for tuberculosis activation?
HIV
310
2 basic types of ARDS
Hypercapneic (too much CO2)
| Hypoxic (too littoe O2)
311
What are the 4 variable parameters on a ventilator?
Oxygenation:
FIO2
PEEP (positive end-expiratory pressure)
Ventilation:
Respiratory rate
Tidal volume
312
What 4 things are altered in ARDS?
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
5 most common causes of ARDS
```
Sepsis
Pancreatitis
Trauma
Aspiration
Transfusion
```
314
Is ventilator use better prone or supine?
Prone, apparently
315
What is pneumonconiosis?
Dust-related lung disease leading to inflammation and scarring
316
_____ is the most common cause of occupational asthma
Isocyanates
317
If you see adult onset asthma, you should look for_________
An occupational source
318
Isocyanates are associated with what behavior?
Paints
319
If you see pleural plaques you should think _________
Asbestos exposure
320
Which 2 lung cancers are central?
Squamous cell carcinoma
| Small cell carcinoma
321
What color is small cell carcinoma on H&E?
Blue
322
If you see a lung that looks kind of like millet, you should think_____
Active TB
323
Are kids nose or mouth breathers?
Nose (so congestion is a big problem!)
324
Irritant asthma is also known as ______
RADS 9(reactive airways dysfunction syndrome)
325
What are the 2 types of asthma caused by occupational exposures?
Immunologic - latency
| Irritant/RADS - no latency
326
What is the difference in mechanisms caused high and low molecular weight compounds in by occupational immunologic asthma?
MW - specific IgE reaction
| LMW - combine with endogenous proteins to create new antigenic determinants
327
How do pulmonary pressures change with hypoxia?
Increase from vasoconstriction
328
Is HACE part of AMS?
Yes. It is severe AMS with significant brain problems
329
3 drugs used for AMS
Dexamethosone - decreases brain edema
Acetazolamide - bicarb wasting ->metabolic acidosis -> hyperventilation
Ibuprofen
First 2 are used to TREAT AMS
330
3 signs of respiratory distress in infants
Lethargy
Poor feeding (b/c it's the most active thing they do)
Grunting
331
Signs and symptoms of upper airway obstruction. 1 regular airway obstruction, 3 severe
Stridor
Drooling
Dysphagia
Dyspnea/distress
332
What is the most comon cause of chronic stridor?
Laryngomalacia
When the epiglottis blocks the airway
333
What is malacia?
Abnormal tissue sofening
| In terms of pulmonology, it means collapse of part of the airway
334
What is clinically associated with a recurrent wheeze, a hoarse cough, and recurrent illnesses?
Tracheobronchomalacia
335
What is the narrowest point in the airway of adults? Children?
Glottis (vocal cord part)
| Cricoid
336
5 things for Ddx of acute stridor
```
Croup (laryngotracheobronchitis)
Bacterial tracheitis
Epiglottiitis
Laryngeal foreign body
Scalding
```
337
What is the most common form of acute airway obstruction in children?
Croup
338
What does bronchioloitis sound like on ascultation?
Polyphonic wheezes in lung fields
339
2 results of bronchopulmonary dysplasia
Decreased surface area
| Thickened interstitium
340
What 3 things does the H1 histamine receptor do?
Vasodilation
Increased capillary permeability
Cramping of gut smooth muscle
341
What is the difference between 1st and 2nd generations of antihistamines?
1st - H1 and other receptors
| 2nd - pretty selective for H1
342
What is the difference between NE and epi's actions on blood vessels?
NE - vasodilation
| Epi - vasoconstriction
343
4 side effects of antihistamines
Sedation
Antimuscarinic action - dry mouth, urinary retention, constipation
Paradoxical exitation
Postural hypotension
344
Topical decongestants stimulate which receptors?
Alpha-1
345
Does dextromethorphan depress respiration or predispose to addition?
No
346
Which drug is for robotripping? Which receptor does it act on?
Dextromethorphan
| NMDA glutamate receptors
347
Where is inspiration on the PV hysteresis curve? Expiration?
Inspiration - right
| Expiration - left
348
Catbon dioxide is a broncho______ and a vaso______
Bronchodilator
| Vasoconstrictor
349
Medical intervention for stridor at rest due to croup?
Epinephrine nebs
350
Medical intervention for epiglottitis?
Intubation - it is a medical emergency
351
What are 3 differences between child and adult chest walls?
```
Weak intercostal muscles
Horizontal ribs (no bicket handle)
Diaphragm is flat
```
352
At what age can children perform spirometry?
6 usually
353
Which children are not likely to grow out of asthma by age 12? (2)
Allergic
| Family history of asthma
354
What is empyema?
Purulent pleural effusion
355
Bronchopulmonary dysplasia represents the consequences of lung injury caused by what 3 things on the susceptible, immature lung?
Oxygen toxicity
Barotrauma
Inflammation
356
What is the newborn screening test for cystic fibrosis?
Immunoreactive trypsin levels (elevated in newborns with CF)
357
Which 3 blood vessel receptors cause vasodilation?
Muscarnic
Histamine H1
Bradykinin
358
Which receptor suppresses the cough reflex?
Mu opioid
359
Which 2 receptors result in pain?
Bradykinin
| Histamine H1
360
What drug class is Loratidine?
Second generation antihistamine
361
2 receptors you can block to reduce motion sickness
| How do they work in pregnancy?
H1
Muscarinic
They are safe to use in pregnant people
362
What is the mechanism of action of mucolytics?
Split disulfide linkages between mucopriteins, decreasing their viscocity
Also antioxidants
363
What chemical are mucolytics?
N-acetyl cysteine
364
Where is the cough reflex controlled in teh brain?
Medulla
365
What effect does low fluid volume have on pH?
Alkalosis
366
What is the mechanism of action of zyleutin?
It is a methylzanthine for treating asthma
| Inhibits 5-lipoxegenase -> leukotriene block -> bronchodilation
367
What is the main toxicity of zyleutin?
Hepatotoxicity
368
Is sarcoidosis restrictive or obstructive?
Restrictive
369
What is the difference between redand grey pneumonia?
Red - looks like a liver on CT. Has RBCs, fibroblasts, neutrophils.
Frey - when RBCs start dying
370
What drug class is diphenhydramine?
First generation antihistamine
Benadryl!
371
Does histamine have much of a role in colds?
No
| Mast cell mediators have a minor role in viral respiratory infections
372
What is a side effect of phenylephrine?
Irritation
373
What drug class do you use to treat upper airway cough syndrome?
1st generation antihistamine
