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Pulmonary Flashcards

1
Q

Embryonic

A

weeks 4-7
lung bud –> trachea –> bronchial buds –> mainstem bronchi –> secondary bronchi –> tertiary bronchi
ERROR => tracheoesophageal fistula

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2
Q

Pseudoglandular

A

Weeks 5-17
endodermal tubules –> terminal bronchioles
surrounded by capillary network
RESPIRATION IMPOSSIBLE

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3
Q

Canalicular

A

Weeks 16-25
Terminal bronchioles –> respiratory bronchioles –> alveolar ducts
Surrounded by prominent capillary network
airways increase in diameter
Respiration at 25 weeks
Pneumocytes develop at 20 weeks

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4
Q

Saccular

A

week 26-birth

alveolar ducts –> terminal sacs (separated by sepate)

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5
Q

Alveolar

A

week 36- 8 years
Terminal sacs –> adult alveoli
in utero breathing via aspiration and expulsion of amniotic fluid –> increase vascular resistance
at birth fluid gets replaced with air –> decrease pulmonary vascular resistance

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6
Q

Pulmonary hypoplasia

A

poorly developed bronchial tree with abnormal histo

Associated with congenital diaphragmatic hernia (L side), bilateral renal agenesis (potter)

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7
Q

Bronchogenic cysts

A

caused by abnormal budding of the foregut and dilation of terminal/large bronchi
Discrete round, sharply defined fluid filled density on CXR
asymptomatic, drain poorly –> airway compression or recurrent respiratory infection

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8
Q

club cells

A

nonciliated low columnar/cuboidal with secretory granules
Located in bronchioles
Degrade toxins, secrete component of surfactant

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9
Q

Type 1 pneumocytes

A

squamous

thinly line alveoli for optimal gas exchange

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10
Q

Type 2 pneumocytes

A

cuboidal and clustered

stem cell for Type 1 and Type 2 pneumocytes and secrete surfactant.

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11
Q

Surfactant

A

decrease alveolar surface tension, decrease alveolar collapse, decrease lung recoil and increase compliance
Composed of lechithins (DPPC)
synthesis begins 20 weeks and achieves mature levels at week 35
CORTICOSTEROIDS –> surfactant

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12
Q

Alveolar macrophages

A

phagocytes
release cytokines and alveolar proteases
hemosiderin macrophages found in pulmonary edema or alveolar hemorrhage

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13
Q

Neonatal RDS

A

surfactant deficiency –> high surface tension –> alveolar collapse, ground glas
risk: premature, Maternal DM, C section
Tx: maternal steroids before birth, exogenous surfactant
Therapeutic O2 –> retinopathy, intraventricular hemorrhage, bronchopulmonary dysplasia
L/S >2 is healthy

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14
Q

Conducting zone of Respiratory tree

A

large airways consist of nose, pharynx, larynx, bronchi
airway resistance highest in large to medium bronchi
Warm, humidifies and filters air BUT NO GAS EXCHANGE
Cartilage and goblet cells extend to bronchi
Pseudostratified ciliated columnar cells= bronchus to beginning of terminal bronchioles then transition to cuboidal cells

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15
Q

Respiratory zone of respiratory tree

A

lung parenchyma (respiratory bronchioles, alveolar ducts, alveoli.
PARTICIPATE IN GAS EXCHANGE
cuboidal cells in respiratory bronchioles –> simple squamous
cilia terminate in respiratory bronchioles
alveolar macrophages clear debris

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16
Q

Lingula homologous to

A

right middle lobe

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17
Q

Relation of pulmonary artery to bronchus

A

Right anterior, Left superior

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18
Q

Carina position

A

posterior to ascending aorta and anteromedial to descending aorta

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19
Q

Most common site for inhaled foreign bodies

A

right lung
supine: superior segment of right lower lobe
lying on right side- right upper lobe
upright- enter right lower lobe

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20
Q

T8 Diaphragm

A

IVC

right phrenic N

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21
Q

T10 Diaphragm

A

esophagus

Vagus N

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22
Q

T12 Diaphragm

A

aorta
thoracic duct
azygous vein

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23
Q

Inspiratory reserve volume

A

air that can still be breathed in after normal inspiration

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24
Q

Tidal volume

A

air that moves into lung with each quiet inspiration (500)

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25
Q

Expiratory reserve volume

A

air that can still be breathed out after normal expiration

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26
Q

Residual volume

A

air in lung after maximal expiration

RV and any lung capacity that includes RV cannot be measured by spirometry

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27
Q

Inspiratory Capacity

A

IRV+TV

air that be breathed in after normal exhalation

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28
Q

Functional residual capacity

A

RV + ERV

volume of gas in lungs after normal expiration

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29
Q

Vital capacity

A

TV + IRV + ERV

Maximum volume of gas that can be expired

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30
Q

Total Lung Capacity

A

IRV + TV + ERV + RV

volume of gas present in lungs after a maximal inspiration

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31
Q

Elastic recoil

A

Tendency of lungs to collapse inward and chest wall to spring outward
At FRC airway and alveolar pressure = Patm and intrapleural pressure is negative, PVR at minimum

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32
Q

Compliance

A

change in lung volume for a change in pressure
inversely proportional to wall stiffness and increased by surfactant
High compliance –> lung easy to fill (emphysema, aging)
Low compliance –> lung hard to fill (pulm fibrosis, pneumonia, ARDS, pulm edema)

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33
Q

Hysteresis

A

lung inflation follows a different pressure volume curve than lung deflation due to need to overcome surface tension forces in inflation.

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34
Q

Respiratory system changes in the elderly

A

TLC remains the same
increased compliance, RV, V/G mismatch, A-a gradient
Decreased chest wall compliance, FVC and FEV1, respiratory muscle strength, ventilatory response to hypoxia

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35
Q

CO poisoning

A

Normal Hb conc
low O2 sat Hb
Normal dissolved O2
low total O2

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36
Q

Anemia

A

Low Hb conc
Normal O2 sat Hb
Normal Dissolved O2
Low total O2

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37
Q

Polycythemia

A

High Hb concentration
Normal O2 sat Hb
Normal dissolved O2
High total O2 content

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38
Q

Methemoglobin

A

Iron in Hb is normally reduced (2+)
oxidized Iron (3+) does not bind O2 readily but has increased affinity to CN- –> tissue hypoxia from low O2 saturation and low O2 content
CYANOSIS AND CHOCOLATE COLORED BLOOD

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39
Q

Shift right on ODC

A 
low Hb affinity for O2 --> high P50
low pH
high PCO2
Exercise
high 2,3 BPG
High altitude
high temperature
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40
Q

Shift left on ODC

A 
low O2 unloading --> renal hypoxia --> high EPO synthesis --> compensatory erythrocytosis
basic
low PCO2
low 2,3 BPG
low temp
high CO
high MetHb
high HbF
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41
Q

CN- poisoning

A

Byproduct of combustion
Tx: hydrocobalamin, nitrites, sodium thiosulfate
Sx: breath has bitter almond odor, CV collapse
ODC normal

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42
Q

CO poisoning

A

odorless gas from fires, car exhaust or has heaters
Tx: 100% O2
Sx: HA, dizzy, bilateral globus pallidus lesions on MRI
Left shift in curve, bind competitively to Hb

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43
Q

Pulmonary circulation

A

Low resistance, high compliance

low PaO2 –> hypoxic vasoconstriction that shifts blood away from poorly ventilated region

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44
Q

Perfusion limited

A

O2, CO2, N2O

gas equilibrates early along the length of the capillary. Exchange can be high only if blood flow high

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45
Q

Diffusion limited

A

O2, CO

gases does not equilibrate by the time blood reaches the end of the capillary

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46
Q

Ventilation/ perfusion mismatch

A

High at apex and low at base

with exercise there is vasodilation of apical capillaries so ratio approaches 1

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47
Q

V/Q = 0

A

obstruction

100% O2 does not improve PaO2

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48
Q

V/Q = infinity

A

blood flow obstruction

100% O2 improves PaO2

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49
Q

Response to high altitude

A

low atmospheric oxygen–> low PaO2 –> high ventilation –> low PaCO2 –> respiratory alkalosis –>altitude sickness
increase EPO, 2,3 BPG, mitochondria, renal excretion of HCO3-
Vasoconstriction –> pulmonary HTN and RVH

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50
Q

Response to exercise

A

High CO2 production, high O2 consumption
Right shift
high ventilation rate meet O2 demand
V/Q ratio from apex to base becomes more uniform
increase pulmonary blood flow due to increased cardiac output
low pH

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51
Q

Rhinosinusitis

A

obstruction of sinus drainage into nasal cavity –> inflammation and pain over are (Maxillary –> drain against gravity)
superior meatus- drain sphenoid, posterior ethmoid
middle meatus- drain frontal, maxillary and anterior ethmoid
inferior meatus0 drain nasolacrimal duct
VIRAL URI + H. influenz, S. pneumoniae, M. catarrhalis

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52
Q

Epistaxis

A

most common in anterior segment of nostril
life threatening in posterior segment
caused by foreign body, trauma, allergic rhinitis and nasal angiofibromas

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53
Q

Head and neck cancer

A

SCC
Risk: tobacco, alcohol, HPV 16, EBV
Field cancerization: carcinogen damages wide mucosal area –> multiple tumors that develop independently

54
Q

DVT

A

blood clot within deep vein –> swelling, redness, warmth, pain
predisposed: stasis, hypercoaguability, endothelial damage
D dimer –> rule out DVT
Imaging with compression US with Doppler
use unfractioned heparin or LMWH for acute management
oral anticoagulants for long term prevention

55
Q

Pulmonary emboli

A

V/Q mismatch, hypoxemia, respiratory alkalosis
sudden onset dyspnea, pleuritic chest pain, tachypnea
CT pulmonary angiography

56
Q

Lines of Zahn

A

platelets and fibrin- RBC streaks
ONLY IN THROMBI
postmortem finding

57
Q

Fat emboli

A

associated with long bone fractures and liposuction

hypoxemia, neuro abnormalities, petechial rash

58
Q

Air emboli

A

nitrogen bubbles precipitate in ascending divers. treat with hyperbaric O2

59
Q

Amniotic fluid emboli

A

during labor or postpartum
due to uterine trauma
lead to DIC

60
Q

Mediastinal mass anterior

A

Thyroid, thymic neoplasia, Teratoma, Lymphoma

61
Q

Mediastinal mass Middle

A

esophageal carcinoma, metastases, hiatal hernia, bronchogenic cysts

62
Q

Mediastinal mass Posterior

A

neurogenic tumor, multiple myeloma

63
Q

Mediastinitis

A

post op complication of cardiothoracic procedures, esophageal perforation, infection
fever tachy leukocytosis, chest pain, sternal wound drainage

64
Q

chronic mediastinitis

A

high proliferative connective tissue
Histoplasma capsulatum
fever tachy leukocytosis, chest pain, sternal wound drainage

65
Q

pneumomediastinum

A

presence of gas in mediastinum
via rupture of pulmonary bleb, trauma, Boerhaave syndrome
ruptured alveoli allow tracking of air into the mediastinum via peribronchial and perivascular sheaths
chest pain, dyspnea, voice change, subcutaneous emphysema, + Hamman sign

66
Q

Obstructive Lung Disease

A

Air trapping in lungs, airways close prematurely at high lung volumes
High RV, FRC, TLC
LOW FEV1, FVC, FEV1:FVC
V/Q mismatch, chronic hypoxic vasoconstriction can lead to cor pulmonale
COPD, chronic bronchitis, emphysema

67
Q

Restrictive lung disease

A

Low RV, FRC, TLC, FEV1, FVC

Normal or high FEV1: FVC

68
Q

Chronic bronchitis

A

wheezing, crackles, cyanosis, dyspnea CO2 retention, secondary polycythemia
Hypertrophy and hyperplasia of mucus secreting glands in bronchi
DLCO normal
Productive cough for > 3 months in a year for > 2 consecutive years

69
Q

Sarcoidosis

A

immune mediated widespread noncaseating granulomas
high ACE levels, high CD4/CD8 ratio
enlarged LN
bilateral adenopathy and coarse reticular opacities
Associated Bells Palsy, Uveitis, granulomas, Lupus pernio, Intersititial fibrosis, erythema nodosum, RA like, high Ca
Tx steroids

70
Q

Inhalation injury sequelae

A

chemical tracheobronchitis, edema, pneumonia, ARDS
secondary to burns, CO, CN, arsenic
singed nasal hairs or soot
severe edema, congestion of bronchus and soot deposition

71
Q

Asbestosis

A

Shipbuilding, roofing, plumbing
ivory white calcified supradiaphragmatic and pleural plaques
Bronchogenic carcinoma > mesothelioma, increase risk of Caplan syndrome
LOWER LOBES
ferruginous bodes are golden brown fusiform rods resembling dumb ells
increase risk pleural effusion

72
Q

Berylliosis

A

aerospace and manufacturing industry
granulomatous
increase risk of cancer and cor pulmonale
UPPER LOBES

73
Q

Coal Workers

A

macrophages with carbon –> inflammation and fibrosis
increase risk of Caplan
UPPER LOBES
small rounded nodular opacities

74
Q

Caplan Syndrome

A

RA, pneumoconioses with intrapulmonary nodules

75
Q

silicosis

A

sandblasint, foundries, mines
macrophages release fibrinogenic factors –> fibrosis
increase susceptibility to Tb, increase risk of cancer, cor pulmonale, Caplan syndrome
UPPER LOBES
eggshell calcifications of hilar LN

76
Q

Mesothelioma

A

malignancy of pleura associated with asbestosis
may result in hemorrhagic pleural effusion, pleural thickening
Psammoma bodies
Calretinin and cytokertain +

77
Q

ARDS

A

alveolar insult –> pro inflammatory cytokines –> neutrophils –> endothelial damage and increasesed permeability –> hyaline membranes
Loss of surfactant –> alveolar collapse
via sepsis, aspiration, pneumonia, trauma, pancreatitis
Dx: bilateral lung opacities, resp failure, low PaO2/FiO2, hypoxemia, not HF issues
impaired gas exchange, low lung compliance, pum HTN

78
Q

Sleep apnea

A

repeated cessation of breathing > 10 seconds during sleep –> disrupted sleep –> daytime somnolence
Dx sleep study
Nocturnal hypoxia –> systemic/ pulm HTN, arrhythmias, sudden death
Hypoxia –> increase EPO –> increase erythropoiesis

79
Q

Obstructive sleep apnea

A

respiratory effort against airway obstruction
Normal PaO2during the day
Associated with obesity, loud snoring, daytime sleepiness
caused by parapharyngeal tissue in adults, adenotonsillar hypertrophy in children.
Tx weight loss, CPAP, dental device

80
Q

Central sleep apnea

A

impaired respiratory effot due to CNS injury, HF, opioids

Associated wtih Cheyne Stokes respirations

81
Q

Obesity hypoventilation syndrome

A

obesity –> hypoventilation –> high PaCO2 during waking hours, low PaO2 and high PaCO2 during sleep
Pickwickian syndrome

82
Q

Pulm HTN

A

normal 10-14
HTN >25 at rest
results in arteriosclerosis, medial hypertrophy, intimal fibrosis of pulmonary A, plexiform lesions
severe resp distress –> cyanosis and RVH –> death from decompensated cor pulmonale

83
Q

Pulm A HTN

A

Heritable can be due to inactivation of BMPR2 gene
poor prognosis
increase vasoconstrictors and decrease vasodilators

84
Q

Left Heart Disease

A

caused by systolic/ diastolic dysfunction and valvular disease

85
Q

Lung diseases or hypoxia

A

destruction of lung parenchyma, lung inflammation/ fibrosis, hypoxemic vasoconstriction

86
Q

Chronic thromboembolic

A

recurrent microthrombi –> decreased cross sectional area of pulmonary vascular bed

87
Q

Multifactorial pulm HTN

A

hematologic, systemic, metabolic disorders, compression of pulmonary vasculature by a tumor

88
Q

Pleural effusion

A 
Excess accumulation of fluid between pleural layers --> restricted lung expansion during inspiration
decreased breath sounds
dull to percussion 
decreased fremitus
Tracheal deviation none
89
Q

Atelectasis

A 
Alveolar collapse
decreased breath sounds
dull to percussion
decreased fremitus
trachea deviate to side of lesion
90
Q

Simple pneumothorax

A 
accumulation of air in pleural space
Sx dyspnea, uneven chest expansion, chest pain
decreased breath sounds
hyperresonant
decreased fremitus
91
Q

Tension pneumothorax

A

air enters pleural space but cannot exit. Increasing trapped air
decreased breath sounds
Hyperresonant
decreased fremitus
Tracheal deviation away from side of lesion –> mediastinal displacement –> kinking IVC –> decrease venous return –> decreased cardiac output

92
Q

Consolidation

A

bronchial breath sounds, late respiratory crackles, egophony
dull to percussion
increased fremitus

93
Q

Causes of atelectasis

A

obstructive: prevent new air reaching distal airways, old air resorbed
Compressive: external compression on lung decreases lung volumes
Contraction: scarring of lung parenchyma that distorts alveoli
Adhesive: due to lack of surfactant

94
Q

Lymphatic Pleural effusion

A

thoracic duct injury from trauma or malignancy

Milky appearing fluid high TG

95
Q

Exudate pleural effusion

A

high protein content, cloudy
due to malignancy, inflammation, trauma
MUST BE DRAINED DUE TO RISK OF INFECTION

96
Q

Transudate effusion

A

low protein, clear

via increased hydrostatic pressure or decreased oncotic pressure

97
Q

Primary spontaneous pneumothorax

A

due to rupture of apical subpleural bleb or cyst

in tall thin young males and smokers

98
Q

Secondary spontaneous pneumothorax

A

due to diseased lung, mechanical ventilation with use of high pressure

99
Q

Traumatic pneumothorax

A

blunt, penetrating or iatrogenic trauma

100
Q

Lobar Pneumonia

A

S. pneumoniae, Legionella, Klebsiella

intra alveolar exudate

101
Q

Bronchopneumonia

A

S. pneumoniae, S. aureus, H. influenzae, Klebsiella
acute inflammatory infiltrates from bronchioles into adjacent alveoli
Patchy distribution in >1 lobe

102
Q

interstitial pneumonia

A

Mycoplasma, chlamydophila pneumoniae, chlamydophila psittai, Legionella, viruses
diffuse patchy infiltrate localized to interstitial areas of alveolar wall
bilateral multifocal opacities
Indolent

103
Q

Cryptogenic organizing pneumonia

A

chronic inflammatory diseases or medication (amiodarone) - sputum culture
Noninfectious with inflammation of bronchioles and surrounding structures

104
Q

Lung cancer

A

cough, hemoptysis, bronchial obstruction, wheezing, coin lesion
Metastasize to liver, adrenals, bone, brain,
Metastasis from breast, colon, prostate, bladder
Complications: SVC syndrome, pancoast tumor, Horner syndrome, endocrine, recurrent laryngeal N compression, effusions
Risk factors: smoking, radon, asbestos, fam hx

105
Q

Small cell carcinoma of the lung

A 
Central location
undifferentiated (very aggressive)
May produce ACTH, ADH, Lambert Eaton
Amplification of myc oncogenes
Neoplasm of neuroendocrine Kulchitsky cells
Chromogranin A +
Neuron specific enolase +
synaptophysin +
106
Q

Adenocarcinoma of the lung

A 
Peripheral location
nonsmoking women
activate KRAS, EGFR, ALK
associated with clubbing
glandular pattern on histo
mucin +
Bronchioalveolar subtype grows along alveolar septa --> thickening of alveolar walls. Tall, columnar cells containing mucus
107
Q

Squamous cell carcinoma of the lung

A

Central location
Hilar mass arising from the bronchus
cavitation, cigarettes, hypercalcemia
keratin pearls and intracellular bridges

108
Q

Large cell carcinoma of the lung

A 
Peripheral location
highly anaplastic undifferentiated tumor
poor prognosis
less responsive to chemo
STRONG ASSOCIATION WITH SMOKING
pleomorphic giant cells
109
Q

Bronchial carcinoid tumor

A 
central or peripheral
excellent prognosis
mass effect or carcinoid syndrome
nests of neuroendocrine cells
chromogranin A +
110
Q

Lung abscess

A

pus within parenchyma
caused by aspiration of oropharyngeal contents or bronchial obstruction
Air fluid levels seen on CXR
Due to anaerobes

111
Q

Pancoast tumor

A

apex of the lung

can compress recurrent laryngeal N, stellate ganglion, SVC, brachiocephalic V, brachial plexus, phrenic N

112
Q

SVC syndrome

A

impair blood drainage from the head, neck, upper extremities.
Caused by malignancy and thrombosis
MEDICAL EMERGENCY
can rain intracranial pressure –> HA dizzy, increased risk of aneurysm

113
Q

Histamine 1 blockers first generation

A

Diphenhydramine,dimenhydrinate, chlorpheniramine, doxylamine
used for allergy, motion sickness, sleep aid
adverse: sedation, antimuscarinic, anti a adrenergic

114
Q

Histamine 1 blockers second generation

A

-adine
used for allergy
Adverse: far less sedating than 1st generation because of low entry into CNS

115
Q

Guaifenesin

A

thins respiratory secretions, does not suppress cough reflex

116
Q

N acetylcysteine

A

liquifies mucus in chronic bronchopulmonary diseases by disrupting disulfide bonds

117
Q

Dextromethorphan

A

antagonize NMDA glutamate receptors
Has mild opioid effect when used in excess
Naloxone can be given for overdose
mild abuse potential
May cause 5HT syndrome if combined with other serotonerigic agents

118
Q

Pseudoephedrine, phenylephrine

A

a adrenergic agonists
used to reduce hyperemia, edema, open obstructed eustachian tubes
Adverse: HTN. rebound congestion if used more than 4-6 days
Can also cause CNS stimulation, anxiety

119
Q

Endothelin receptor antagonists

A

decrease pulmonary vascular resistance
Hepatotox
treat pulm HTN

120
Q

PDE5 inhibitors

A

increase cGMP –> prolonged vasodilatory effect of NO
treat pulm HTN and erectile dysfunction
don’t use nitro

121
Q

Prostacyclin analogs

A

inhibit platelet aggregation
treat pulm HTN
side effects: flushing, jaw pain

122
Q

Albuterol

A

B2 agonist
relax bronchial smooth M
acute exacerbation of asthma
can cause tremor arrhythmia

123
Q

Salmeterol, formoterol

A

B2 agonist for asthma
long acting agents for prophylaxis
cause tremor arrhythmias

124
Q

Fluticasone, budesonide

A

inhaled corticosteroids for asthma
inhibit synthesis of all cytokines
Inactivate NFkB
1st line therapy for chronic asthma

125
Q

Tiotropium, ipratropium

A

muscarinic antagonist for asthma
prevent bronchoconstriction
used for COPD

126
Q

Montelukast, zafirlukast

A

block leukotriene receptors (CysLT1)

good for aspirin induced and exercise induced asthma

127
Q

Zileuton

A

5 lipoxygenase pathway inhibitor
blocks conversion of arachidonic acid to leukotrienes
Hepatoxic

128
Q

Omalizumab

A

anti IgE monoclonal therapy
bind unbound IgE and blocks binding to FceRI
used in allergic asthma with high IgE levels resistant to inhaled steroids and long acting B2 agonists

129
Q

Theophylline

A

methylxanthines for astma
likely causes bronchodilation by inhibiting phosphodiesterase –> high cAMP due to low cAMP hydrolysis
limited use due to narrow therapeutic index
cardiotox, neurotox
block actions of adenosine

130
Q

Anti IL5 monoclonal therapy

A

prevent eosinophil differentiation maturation, activation and survival mediated by IL5 stimulation.
Mepolizumab, reslizumab –> against IL5
Benralizumab –> against IL5 receptor a

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