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Pulmonology Flashcards

1
Q

At what week does the distal end of the respiratory diverticulum become the lung bud

A

4 weeks

Note - Error at this state (embryonic) leads to TE fistula

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2
Q 
Pulmonary hypoplasia (esp right lung)
Limb deformities
Facial anomalies
A

Potter sequence

Caused by oligohydramnios secondary to...
Bilateral renal agenesis
ARPKD
Obstructive uropathy
Chronic placental insufficiency
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3
Q

Chronic respiratory infections and discrete, round, sharply defined air-filled densities on CXR

A

BRONCHOGENIC CYST

Note - Caused by congenital dilation of large or terminal bronchioles

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4
Q

Cuboidal and clustered - secrete pulmonary surfactant made of phosphatidylcholine (lecithin; 30 wks) and phosphatidylglycerol (36 wks) to decrease lung recoil and increase compliance

A

TYPE II PNEUMOCYTES

Serve as precursors to Type I (squamous for gas exchange)

Note - Cover less surface area but are more plentiful than Type I pneumocytes

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5
Q

Nonciliated and cuboidal with secretory granules - degrade toxins

A

Club cells

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6
Q

Ground-glass appearance of lung fields with L/S < 1.5

Associated with…
Prematurity
Maternal diabetes (increased fetal insulin)
C-section (decreased fetal glucocorticoids)

Note - Fetal lungs mature when L/S > 2

A

NEONATAL RESPIRATORY DISTRESS SYNDROME

Treat with…
Maternal steroids
Artificial surfactants

May result in…
Metabolic acidosis
PDA (low O2 tension)
Necrotizing enterocolitis

Note - Retinopathy, IVH, and bronchopulmonary dysplasia if given supplemental O2

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7
Q

Includes cartilage, goblet cells, and pseudostratified columnar epithelium.

A

Bronchi

Note - Become serous fluid from club cells after this

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8
Q

Includes club cells and simple ciliated columnar epithelium.

A

Bronchioles

Note - Smooth muscle thickest here

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9
Q

Includes club cells and cuboidal ciliated cells

A

Respiratory bronchioles

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10
Q

Anatomic relationship of pulmonary artery to bronchus

“RALS”

A

Right anterior to bronchus

Left superior to bronchus

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11
Q

Vertebral levels of structures perforating diaphragm…

IVC
Esophagus/Vagus
Aorta, thoracic duct, azygous vein

A

T8 (directly enters RA)
T10
T12

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12
Q

Bifurcations of abdominal aorta, trachea, and common carotid

“rule of biFOURcation”

A

Abdominal aorta = L4
Trachea = T4
Common carotid = C4

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13
Q

Inspiratory capacity

A

IRV + TV

IRV = Room in lungs after normal inspiration
TV = Air in lungs after normal inspiration
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14
Q

Functional residual capacity - Volume of gas after normal expiration

A

ERV + RV

ERV = Air that can still be breathed out after normal expiration
RV = Air in lungs after maximal expiration
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15
Q

Vital capacity - Maximum volume of gas that can be expired after a maximal inspiration

A

IRV + TV + ERV

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16
Q

Total lung capacity - Maximum volume of gas present after a maximal inspiration

A

IRV + TV + ERV + RV

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17
Q

Physiologic dead space (VD)

(“Taco PAco PEco PAco”)

Note - Maximal alveolar dead space at lung apices

A

VT x [ (PaCO2 - PeCO2)/PaCO2 ]

VT = Tidal volume (normally around 500)
Pa = Arterial PCO2
Pe = Expired air PCO2

Note - Normally around 150

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18
Q

Ventilation without perfusion

A

Pathologic dead space

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19
Q

Minute ventilation (VE)

A

VT x RR

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20
Q

Alveolar ventilation (VA)

A

(VT - VD) x RR

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21
Q

At FRC…
Airway/alveolar pressures
IP pressure
PVR

A

0
Negative
Minimum

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22
Q

Lung inflation results in lower volume at same pressure compared to lung deflation - due to need to overcome surface tension in inflation

A

Hysteresis

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23
Q

Factors favoring taut hemoglobin - low O2 affinity shifts curve to the right (offloading)

A 
Increased...
pH (H+ buffer)
CO2
Exercise
2,3-BPG
Altitude
Temperature

Note - Results in renal hypoxia and increased EPO (erythrocytosis)

Note - 2,3-BPG is increased in hypoxia as its role is to bind Hb and enhance release

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24
Q

Mechanism of placental O2 transfer

A

HbF (2a, 2y) has a higher affinity for O2 due to decreased affinity of 2,3-BPG - drives oxygen across placenta to fetus

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25
Q

Mechanism of Methylene blue therapy for Methemoglobinemia

A

Methylene blue picks up electron from NADPH MetHb reductase and transfers it to MetHb - reduces Fe3+ back to Fe2+

Note - Do not give in G6PD deficiency (no NADPH)

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26
Q

Mechanism of CO induced left shift in Hb curve

A

CO binds with great affinity than O2, and therefore decreases offloading due to positive cooperativity

Note - On a blood oxygen content (not saturation) graph the result is a shift down

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27
Q

Normal Hb concentration
Decreased O2 sat
Normal PaO2 (dissolved O2)
Decreased total O2 content

A

CO POISONING

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28
Q

Decreased Hb concentration
Normal O2 sat
Normal PaO2 (dissolved O2)
Decreased total O2 content

A

ANEMIA

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29
Q

Increased Hb concentration
Normal O2 sat
Normal PaO2 (dissolved O2)
Increased total O2 content

A

POLYCYTHEMIA

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30
Q

Pa equilibrates with PA early along capillary - diffusion can only be increased by increasing blood flow

A

PERFUSION LIMITED GAS

Includes O2 in a healthy adult (high DLCO), CO2, N2O

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31
Q

Pa does not equilibrate fully with PA by the time blood reaches the end of the capillary

A

DIFFUSION LIMITED GAS (LOW DLCO)

Includes O2 in emphysema (decreased area), fibrosis (increased thickness), CO

Note - Exercise results in similar situation but DLCO is not decreased

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32
Q

PVR equation

A

[ P(pulm artery) - P(LA) ]/CO

Note - R = dP/Q

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33
Q

Alveolar gas equation - used for A-a gradient

A

PAO2 = 150 - (PaCO2/0.8)

Note - Normal A-a gradient = 10-15

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34
Q

Area of lung with highest and lowest V/Q

A

V/Q highest at apex (3; wasted ventilation)
Lowest at base (< 1; wasted perfusion)

Note - Both V and Q are maximal at the base and minimal at the apex, but Q drops more rapidly than V as you approach apex

Note - Apex ratio approaches 1 during exercise due to increased CO

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35
Q

V/Q = 0

A

SHUNT

Ventilation is 0 so O2 does not improve PaO2 (e.g. aspiration)

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36
Q

V/Q = infinity

A

DEAD SPACE

Perfusion is 0 so O2 does improve PaO2 (e.g. PE)

In a PE perfusion is distributed to nearby inflamed regions (poor ventilation) resulting in a R to L shunt (hypoxia) - Hyperventilation lowers CO2 but cannot raise O2

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37
Q

Causes of hypoxemia by normal and elevated A-a gradient

A

Normal:
High altitude
Hypoventilation

Elevated:
V/Q mismatch
Low DLCO
R to L shunt

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38
Q

Methods (3) of CO2 transport

A

HCO3- (90%)

Binding at N-terminus of globin (not heme and forming HbCO2 - favors taut form

Dissolved CO2

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39
Q

Haldane effect

A

In lungs oxygenation of Hb promotes H+ and CO2 offloading

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40
Q

Bohr effect

A

In tissue elevated PCO2 and H+ promote O2 offloading

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41
Q

Enzyme responsible for converting CO2 to H2CO3 - generates an H+ to bind Hb

Note - HCO3- is secreted from the cell via a HCO3-Cl antiporter

A

CARBONIC ANHYDRASE

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42
Q

Mechanism of RVH in high altitudes

A

Chronic hypoxic pulmonary vasoconstriction resulting in pulmonary hypertension

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43
Q

Risk factors for head and neck cancer

A

Alcohol
Tobacco
HPV-16 (oropharyngeal)
EBV (nasopharyngeal)

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44
Q

Acute and long term management of DVT

A

Acutely Heparin or LMWH (e. Enoxaparin)

Long-term oral anticoagulants (e.g. Warfarin, Rivaroxaban)

45
Q

Hypoxemia
Neurologic abnormalities
Petechial rash (neck, axilla)
Thrombocytopenia

A

FAT EMBOLISM

46
Q 
Air trapping resulting in...
Decreased FEV1/FVC (< 70%)
Markedly decreased FEV1
Decreased FVC
Increased RV (and FRC, TLC)
Increased expiratory phase

Flow-volume loop…
Shifts to the left (larger volumes)
Decreases in size (reduced FEV and FVC)

A

OBSTRUCTIVE LUNG DISEASE

Includes COPD, asthma, and bronchiectasis

Note - Slow, deep breaths to decrease work of breathing against airway resistance

47
Q

Interdigitating areas of pink (platelets, fibrin) and red (RBCs) found only in thrombi formed before death

A

LINES OF ZAHN

48
Q 
Productive cough for > 3 m/yr for > 2 yrs
Wheezing
Crackles
Early hypoxemia (shunt) - elevated EPO
Eventually hypercarbia
Reid index > 40%
Normal DLCO

Note - Reid index measures mucus gland enlargement

A

CHRONIC BRONCHITIS

Blue bloater - Hyperplasia of mucus-secreting glands in bronchi, inflammatory infiltrates, and squamous metaplasia

49
Q

Two types of emphysema

A

Centriacinar - Upper lobes in smokers

Panacinar - Lower lobes in A1AT deficiency (+cirrhosis)

50
Q

Mechanism of emphysema

A

Increased elastase (macrophage, neutrophils) activity
Increased compliance (inspiration)
Decreased recoil (expiration)
Hyperinflation
Dynamic airway obstruction during expiration
Decreased DLCO

Note - “Puffing” is to keep airway pressure elevated and prevent airway collapse during respiration

51
Q

Shed epithelium forming whorled mucous plugs in asthma patients

A

Curschmann spirals

52
Q

Eosinophilic, hexagonal needle-like crystals in sputum of asthma patients

A

CHARCOT-LEYDEN CRYSTALS

Formed from breakdown of eosinophils

53
Q 
Purulent sputum
Recurrent infections
Hemopytisis
Digital clubbing
Permanently dilated airways on CT
A

BRONCHIECTASIS

Chronic necrotizing infection of bronchi associated with…
Obstruction
Poor ciliary motility (smoking, Kartagener)
Cystic fibrosis
Allergic bronchopulmonary aspergillosis (CF, Asthma)

54
Q

FEV1/FVC > 80
Decreased FEV1
Decreased FVC
Decreased TLC

Flow-volume loop…
Shifts to the right (smaller volumes)
Decreases in size (reduced FEV and FVC)

A

RESTRICTIVE LUNG DISEASE

Fast, shallow breaths to decrease work against elastic resistance of lungs

Increased FEV1/FVC due to increased radial traction increasing diameter of airways

Includes…

Idiopathic pulmonary fibrosis
Poor breaching mechanics (normal DLCO, A-a gradient)
ARDS
NRDS/hyaline membrane disease
Pneumoconioses
Hypersensitivity pneumonitis
Sarcoidosis
55
Q 
Bilateral hilar lymphadenopathy
Noncaseating granulomas
Asteroid bodies ("centriole-like")
Schaumann body (calcium in giant cells)
Uveitis
Cutaneous nodules
Increased ACE
Hypercalcemia due to increased ACE and 1,25 vit D
A

SARCOIDOSIS

Note - CD4+ predominance which drives granuloma formation

56
Q

Honeycomb CT
Lower lobe reticulonodular opacities on CXR
Digital clubbing
Restrictive PFTs

A

IDIOPATHIC PULMONARY FIBROSIS

Repetitive cycles of lung injury and TGF-b mediated healing resulting in increased collagen deposition - Neutrophil predominance

57
Q 
Farmer or birdkeeper with...
Dyspnea
Cough
Chest tightness
Granulomatous inflammation with eosinophils
A

HYPERSENSITIVITY PNEUMONITIS

Mixed Type III/IV hypersensitivity reaction to thermophilic Actinomyces - CD8+ predominance

58
Q

Lower lobe pleural plaques
Pleural effusion
Golden-brown fusiform rods resembling dumbbells visualized with Prussian blue

A

ASBESTOSIS

59
Q

Noncaseating granulomatous in upper lobes with hilar nodes - common in aerospace and manufacturing workers

A

BERYLLIOSIS

May respond to steroids

60
Q

Macrophages laden with carbon in upper lobes - inflammation and fibrosis

A

COAL WORKERS PNEUMOCONIOSIS

Histologically similar to Anthracosis - asymptomatic in urban dwellers

61
Q

Eggshell calcification of hilar lymph nodes affecting upper lobes - Common in foundries and mines

A

SILICOSIS

Silica disrupts phagolysosomes increasing risk for TB

62
Q

Causes of (“SPPARTAS”)…

Impaired alveolar gas exchange and respiratory failure
Acute onset respiratory failure
No evidence of HF/fluid overload
Decreased PaO2/FiO2 (< 200)
Bilateral lung opacities (white out) on CXR
Can get waxy hyaline membrane

Caused by...
Sepsis
Pancreatitis ( large release of cytokines and enzymes cause activation of neutrophils in alveolar tissues)
Pneumonia
Aspiration
uRemia
Trauma
Amniotic fluid embolism
Shock
A

ACUTE RESPIRATORY DISTRESS SYNDROME

Trauma that results in bilateral pulmonary contusions or fat embolism following long bone fractures

cause INJURY TO ALVEOLAR PNEUMOCYTES and the PULMONARY ENDOTHELIUM –> release of inflammatory cytokines –> recruit neutrophils to the lung –> inflammatory mediators are released and cause further inflammation and alveolar endothelial damage causing:

1) increased pulmonary capillary permeability and fluid entry into the alveoli
2) decreased surfactant production causing alveolar collapse
3) protein rich fluid and necrotic debris causing hyaline membrane formation

63
Q

Treatment of ARDS

A

Mechanical ventilation with low TV

64
Q

Mechanism of ARDS

A

Endothelial damage (neutrophils, ROS, coagulation)
Increased alveolar capillary permeability
Protein-rich leakage into alveoli (hyaline membranes)
Diffuse alveolar damage
Non-cardiogenic pulmonary edema (normal PCWP)

65
Q

Mechanism of pulmonary arterial hypertension - Presents as loud S2, systolic ejection murmur, right ventricular heave

Note - Defined as > 25 mmHg

A

Autosomal dominant BMPR2 mutation
Endothelial dysfunction
Medial hypertrophy and intimal fibrosis (onion skinning)
Plexiform capillary formation

66
Q

Group I pulmonary hypertension

A

PULMONARY ARTERIAL HYPERTENSION (PAH)

Idiopathic
Heritable (BMPR2 mutation causing smooth muscle proliferation)
Drugs
Connective tissue disease
HIV
Portal hypertension
Congenital heart disease
Schistosomiasis
67
Q

Group II pulmonary hypertension

A

LEFT HEART DISEASE

68
Q

Group III pulmonary hypertension

A

LUNG DISEASE/HYPOXIA

69
Q

Group IV pulmonary hypertension

A

CHRONIC THROMBOEMBOLIC

70
Q

Difference between pleural effusion and atelectasis (bronchial obstruction) on physical exam

A

Tracheal deviation is towards side of lesion in atelectasis

Note - Both have decreased breath sounds, dullness to percussion, and decreased fremitus

71
Q

Light’s criteria

A

Exudative if…

Pleural/serum protein >0.5
Pleural/serum LDH >0.6
Pleural LDH > 2/3 upper limit for serum LDH

72
Q

Common causes of exudative pleural effusion

A

Malignancy
Pneumonia
Collagen vascular disease
Trauma

Note - Increases risk of empyema

73
Q

Thin, tall, young male with sudden onset chest pain

A

PRIMARY SPONTANEOUS PNEUMOTHORAX

Due to rupture of apical subpleural blebs or cysts

Note - Secondary due to diseased lung (e.g. bullae in emphysema, infections) or barotrauma (mechanical ventilation)

74
Q

CXR appearance of…
Lobar pneumonia
Bronchopneumonia
Atypical pneumonia

A

Consolidation restricted to one lobe or lung
Patchy consolidation within a lobe or lung
Diffuse distribution along alveolar walls

Note - Bronchopneumonia is acute inflammatory infiltrate in alveoli from adjacent bronchioles

75
Q

Bacterial etiology and treatment of air-fluid level in right lung

Note - Typically follows aspiration pneumonia

A

LUNG ABSCESS

Anaerobes (Bacteroides, Fusobacterium, Peptostreptococcus) or S. aureus

Treat with Clindamycin

Note - If upright will be right base, if supine will be superior segment of right lower lobe or posterior segment of upperlobes

76
Q

Cancer with…
Psammoma bodies
Cytokeratin
Calretinin

A

Mesothelioma

77
Q

Hoarseness (recurrent laryngeal)
Horner (superior cervical ganglion)
SVC syndrome
Sensorimotor deficit/arm pain (C8-T2)

A

PANCOAST SYNDROME

78
Q 
Smoker with...
Undifferentiated central neoplasm 
Neuroendocrine origin
Kulchitsky cells - small, dark blue cells
Chromogranin A+
Neuron-specific enolase+
Myc oncogene
Stain via neuro cell adhesion molecule (NCAM or CD56)
May cause...
Cushing's
SIADH
Lambert-Eaton
CNS dysfunction
A

SMALL CELL CANCER

Chemotherapy/Radiation

79
Q 
Non-smoker with...
Peripheral glandular neoplasm
Mucin+
KRAS
EGFR
ALK
May cause...
Hypertrophic osteoarthropathy (clubbing)
A

ADENOCARCINOMA

Subtypes

Note - Most common form overall

80
Q

Adenocarcinoma caused by growth along alveolar septa - thickening of alveolar wall with hazy infiltrates on CXR

Note - Better prognosis

A

BRONCHOALVEOLAR ADENOCARCINOMA (ADENOCARCINOMA IN SITU)

81
Q

Smoker with…
Central hilar mass arising from the bronchus
Cavitation
Keratin pearls and intercellular bridges

May cause…
Hypercalcemia

A

SQUAMOUS CELL CARCINOMA

82
Q

Peripheral highly anaplastic undifferentiated tumor
Pleomorphic giant cells

Elevated b-hCG
Gynecomastia
Galactorrhea

A

LARGE CELL CARCINOMA

Less responsive to chemotherapy so poor prognosis - remove surgically

83
Q

Non-smoker with…
Pulmonary nest of neuroendocrine cells
Chromogranin A+

May cause…
Carcinoid syndrome

A

BRONCHIAL CARCINOID TUMOR

Excellent prognosis

84
Q

Relationship of chest and lung compliance at FRC

A

Negative transmural pressure by chest wall (perpetually expanding) is balanced by positive transmural pressure by lung (perpetually collapsing)

Results in a resting airway pressure of 0 and intrapleural pressure of -5

85
Q

Nerve under the piriform recess - damage leads to decreased supraglottic sensation and decreased cough reflex

A

INTERNAL SUPERIOR LARYNGEAL NERVE

Sensory afferent fibers (X) of the cough reflex (larynx, epiglottis) - efferents by motor portion of X

86
Q 
Markedly decreased ERV
Normal RV
Decreased FRC (ERV + RV)
Decreased TLC
Decreased FEV1 (< 80%)
Decreased FVC (< 80%)
A

OBESITY-RELATED RESTRICTIVE LUNG DISEASE

87
Q

Location of inferior border of lung/visceral pleura and parietal pleura…

Mid-axillary
Mid-clavicular
Paravertebral

A

6th rib and 8th rib
8th rib and 10th rib
10th rib and 12th rib

Note - Potential space between these two pleura is the costodiaphragmatic recess

Note - Always enter above a rib to avoid damaging intercostals lying underneath rib

88
Q

Mechanism of decreased cerebral blood flow in hyperventilation (e.g. panic attack)

A

Decreased CO2 - potent cerebral vasodilator

89
Q

Mechanism for minimum pulmonary vascular resistance at FRC

A

Inspiration stretches alveolar capillaries increasing their length and reducing their diameter, increasing their resistance

Expiration reduces tenting of extra-alveolar vessels and increases intrathoracic pressure on them, increasing their resistance

90
Q

Profuse epistaxis in an adolescent male

A

Angiofibroma

91
Q

Pleomorphic epithelial cells
Keratin+
Lymphocytic infiltration
Cervical adenopathy

A

Nasopharyngeal carcinoma

92
Q

Hoarseness
Single vocal cord nodule in adults, multiple in children

Associated with HPV 6, 11

A

Laryngeal papilloma

Rarely may progress to laryngeal carcinoma - associated with alcohol and smoking

93
Q

Four stages of lobar pneumonia

Note - Most common S. Pneumo, Klebsiella

A

Congestion
Red hepatization (neutrophils, RBCs)
Grey hepatization
Resolution (TII pneumocytes)

94
Q

Most common causes (5) of bronchopneumonia…

Secondary, abscess, empyema
Secondary, COPD
CF
Community, COPD
Community, COPD, immunocompromised
A 
S. aureus
HIB
Pseudomonas
Moraxella
Legionella
95
Q

Most common causes (6) of atypical pneumonia…

Young adults (2)
Infants
Post-transplant
Elderly
Vet/Farmer with high fever
A 
Mycoplasma (IgM hemolytic anemia), Chlamydia
RSV
CMV
Influenza
Coxiella (Q fever)
96
Q

Timeline of TB infection

A

Hilar nodes, lower lobe Ghon focus with primary infection
Calcified Ranke’s complex with healing
Apical caseating granulomas (central necrosis, Langerhans giant cells) with secondary activation

97
Q

Most common locations for miliary TB

A

Basal meningitis
Cervical lymph nodes
Sterile pyuria
Pott’s

98
Q

Unilateral sided facial swelling
Unilateral sided arm swelling
Unilaterally distended jugular vein

A

BRACHIOCEPHALIC OBSTRUCTION

Unilateral unlike SVC syndrome which is bilateral

Note - Brachiocephalic also receives right lymphatic duct

99
Q

Acidosis
High PCO2
Normal HCO3-

A

ACUTE RESPIRATORY ACIDOSIS

Renal compensation does not occur until after at least 24-48 hours of respiratory derangement

100
Q

Mechanism of oxygen-induced hypercapnia

A

Pulmonary vasodilation increases dead space ventilation

Decreased chemoreceptor activity decreases minute ventilation

Decreased Hgb affinity for CO2 (Haldane effect) increases pCO2 levels

101
Q

Anterior mediastinal masses

A

Thymoma
Teratoma
Thyroid cancer
Lymphoma

102
Q

Respiratory quotient

A

CO2 produced/O2 consumed

Note - Typically around 0.8

103
Q

Laplace’s law and surfactant

A

Distention pressure is the pressure needed to prevent collapse…

DP = 2T/r so as radius decreases DP increases - Surfactant decreases T with r to prevent an increase in DP

104
Q

Resistance vessels of lower airway

A

Maximum resistance at medium sized bronchioles - Resistance lowers down the tree with increasing surface area

105
Q

Differentiating hemithorax opacification by obstruction from pleural effusion

A

Obstruction - Mediastinal shift towards collapsed lung

Effusion - Mediastinal shift away from effusion

106
Q

Collateral circulation of the lung

A

Bronchial arteries supply the bronchioles and then rejoin the pulmonary vein - This slightly lowers the PO2 in the outgoing pulmonary veins

Note - Collateral circulation results in hemorrhagic infarction rather than ischemic infarction in PE

107
Q

Relationship of Palv, Part, Pv in zones of the lung

Zone 1 - Collapsed capillary (pathologic; apex)
Zone 2 - Pulsatile flow
Zone 3 - Continuous flow

A

Zone 1 - Palv > Part > Pv
Zone 2 - Part > Palv > Pv
Zone 3 - Part > Pv > Palv

Note - In supine position entire lung is zone 3

108
Q

Sweat of a CF patient

Intestinal/Resp

A

higher Na and Cl ( due to CFTR and ENaC, diminished salt resorption)

Low Na and Cl ( decreased Cl secretion and increased Na absorption)

109
Q

Eosinophils and mast cells

leukotrienes C4,D4,E4

A

bronchial asthma

induce bronchospasm and increasing bronchial mucus secretion

Step 1 (17 decks)

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