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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
Mechanism of Methylene blue therapy for Methemoglobinemia
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)
26
Mechanism of CO induced left shift in Hb curve
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
27
Normal Hb concentration Decreased O2 sat Normal PaO2 (dissolved O2) Decreased total O2 content
CO POISONING
28
Decreased Hb concentration Normal O2 sat Normal PaO2 (dissolved O2) Decreased total O2 content
ANEMIA
29
Increased Hb concentration Normal O2 sat Normal PaO2 (dissolved O2) Increased total O2 content
POLYCYTHEMIA
30
Pa equilibrates with PA early along capillary - diffusion can only be increased by increasing blood flow
PERFUSION LIMITED GAS Includes O2 in a healthy adult (high DLCO), CO2, N2O
31
Pa does not equilibrate fully with PA by the time blood reaches the end of the capillary
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
32
PVR equation
[ P(pulm artery) - P(LA) ]/CO Note - R = dP/Q
33
Alveolar gas equation - used for A-a gradient
PAO2 = 150 - (PaCO2/0.8) Note - Normal A-a gradient = 10-15
34
Area of lung with highest and lowest V/Q
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
35
V/Q = 0
SHUNT Ventilation is 0 so O2 does not improve PaO2 (e.g. aspiration)
36
V/Q = infinity
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
37
Causes of hypoxemia by normal and elevated A-a gradient
Normal: High altitude Hypoventilation Elevated: V/Q mismatch Low DLCO R to L shunt
38
Methods (3) of CO2 transport
HCO3- (90%) Binding at N-terminus of globin (not heme and forming HbCO2 - favors taut form Dissolved CO2
39
Haldane effect
In lungs oxygenation of Hb promotes H+ and CO2 offloading
40
Bohr effect
In tissue elevated PCO2 and H+ promote O2 offloading
41
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
CARBONIC ANHYDRASE
42
Mechanism of RVH in high altitudes
Chronic hypoxic pulmonary vasoconstriction resulting in pulmonary hypertension
43
Risk factors for head and neck cancer
Alcohol Tobacco HPV-16 (oropharyngeal) EBV (nasopharyngeal)
44
Acute and long term management of DVT
Acutely Heparin or LMWH (e. Enoxaparin) Long-term oral anticoagulants (e.g. Warfarin, Rivaroxaban)
45
Hypoxemia Neurologic abnormalities Petechial rash (neck, axilla) Thrombocytopenia
FAT EMBOLISM
46
``` 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)
OBSTRUCTIVE LUNG DISEASE Includes COPD, asthma, and bronchiectasis Note - Slow, deep breaths to decrease work of breathing against airway resistance
47
Interdigitating areas of pink (platelets, fibrin) and red (RBCs) found only in thrombi formed before death
LINES OF ZAHN
48
``` 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
CHRONIC BRONCHITIS Blue bloater - Hyperplasia of mucus-secreting glands in bronchi, inflammatory infiltrates, and squamous metaplasia
49
Two types of emphysema
Centriacinar - Upper lobes in smokers | Panacinar - Lower lobes in A1AT deficiency (+cirrhosis)
50
Mechanism of emphysema
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
Shed epithelium forming whorled mucous plugs in asthma patients
Curschmann spirals
52
Eosinophilic, hexagonal needle-like crystals in sputum of asthma patients
CHARCOT-LEYDEN CRYSTALS Formed from breakdown of eosinophils
53
``` Purulent sputum Recurrent infections Hemopytisis Digital clubbing Permanently dilated airways on CT ```
BRONCHIECTASIS Chronic necrotizing infection of bronchi associated with... Obstruction Poor ciliary motility (smoking, Kartagener) Cystic fibrosis Allergic bronchopulmonary aspergillosis (CF, Asthma)
54
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)
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
``` 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 ```
SARCOIDOSIS Note - CD4+ predominance which drives granuloma formation
56
Honeycomb CT Lower lobe reticulonodular opacities on CXR Digital clubbing Restrictive PFTs
IDIOPATHIC PULMONARY FIBROSIS Repetitive cycles of lung injury and TGF-b mediated healing resulting in increased collagen deposition - Neutrophil predominance
57
``` Farmer or birdkeeper with... Dyspnea Cough Chest tightness Granulomatous inflammation with eosinophils ```
HYPERSENSITIVITY PNEUMONITIS Mixed Type III/IV hypersensitivity reaction to thermophilic Actinomyces - CD8+ predominance
58
Lower lobe pleural plaques Pleural effusion Golden-brown fusiform rods resembling dumbbells visualized with Prussian blue
ASBESTOSIS
59
Noncaseating granulomatous in upper lobes with hilar nodes - common in aerospace and manufacturing workers
BERYLLIOSIS May respond to steroids
60
Macrophages laden with carbon in upper lobes - inflammation and fibrosis
COAL WORKERS PNEUMOCONIOSIS Histologically similar to Anthracosis - asymptomatic in urban dwellers
61
Eggshell calcification of hilar lymph nodes affecting upper lobes - Common in foundries and mines
SILICOSIS Silica disrupts phagolysosomes increasing risk for TB
62
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 ```
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
Treatment of ARDS
Mechanical ventilation with low TV
64
Mechanism of ARDS
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
Mechanism of pulmonary arterial hypertension - Presents as loud S2, systolic ejection murmur, right ventricular heave Note - Defined as > 25 mmHg
Autosomal dominant BMPR2 mutation Endothelial dysfunction Medial hypertrophy and intimal fibrosis (onion skinning) Plexiform capillary formation
66
Group I pulmonary hypertension
PULMONARY ARTERIAL HYPERTENSION (PAH) ``` Idiopathic Heritable (BMPR2 mutation causing smooth muscle proliferation) Drugs Connective tissue disease HIV Portal hypertension Congenital heart disease Schistosomiasis ```
67
Group II pulmonary hypertension
LEFT HEART DISEASE
68
Group III pulmonary hypertension
LUNG DISEASE/HYPOXIA
69
Group IV pulmonary hypertension
CHRONIC THROMBOEMBOLIC
70
Difference between pleural effusion and atelectasis (bronchial obstruction) on physical exam
Tracheal deviation is towards side of lesion in atelectasis Note - Both have decreased breath sounds, dullness to percussion, and decreased fremitus
71
Light's criteria
Exudative if... Pleural/serum protein >0.5 Pleural/serum LDH >0.6 Pleural LDH > 2/3 upper limit for serum LDH
72
Common causes of exudative pleural effusion
Malignancy Pneumonia Collagen vascular disease Trauma Note - Increases risk of empyema
73
Thin, tall, young male with sudden onset chest pain
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
CXR appearance of... Lobar pneumonia Bronchopneumonia Atypical pneumonia
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
Bacterial etiology and treatment of air-fluid level in right lung Note - Typically follows aspiration pneumonia
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
Cancer with... Psammoma bodies Cytokeratin Calretinin
Mesothelioma
77
Hoarseness (recurrent laryngeal) Horner (superior cervical ganglion) SVC syndrome Sensorimotor deficit/arm pain (C8-T2)
PANCOAST SYNDROME
78
``` 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 ```
SMALL CELL CANCER Chemotherapy/Radiation
79
``` Non-smoker with... Peripheral glandular neoplasm Mucin+ KRAS EGFR ALK ``` ``` May cause... Hypertrophic osteoarthropathy (clubbing) ```
ADENOCARCINOMA Subtypes Note - Most common form overall
80
Adenocarcinoma caused by growth along alveolar septa - thickening of alveolar wall with hazy infiltrates on CXR Note - Better prognosis
BRONCHOALVEOLAR ADENOCARCINOMA (ADENOCARCINOMA IN SITU)
81
Smoker with... Central hilar mass arising from the bronchus Cavitation Keratin pearls and intercellular bridges May cause... Hypercalcemia
SQUAMOUS CELL CARCINOMA
82
Peripheral highly anaplastic undifferentiated tumor Pleomorphic giant cells Elevated b-hCG Gynecomastia Galactorrhea
LARGE CELL CARCINOMA Less responsive to chemotherapy so poor prognosis - remove surgically
83
Non-smoker with... Pulmonary nest of neuroendocrine cells Chromogranin A+ May cause... Carcinoid syndrome
BRONCHIAL CARCINOID TUMOR Excellent prognosis
84
Relationship of chest and lung compliance at FRC
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
Nerve under the piriform recess - damage leads to decreased supraglottic sensation and decreased cough reflex
INTERNAL SUPERIOR LARYNGEAL NERVE Sensory afferent fibers (X) of the cough reflex (larynx, epiglottis) - efferents by motor portion of X
86
``` Markedly decreased ERV Normal RV Decreased FRC (ERV + RV) Decreased TLC Decreased FEV1 (< 80%) Decreased FVC (< 80%) ```
OBESITY-RELATED RESTRICTIVE LUNG DISEASE
87
Location of inferior border of lung/visceral pleura and parietal pleura... Mid-axillary Mid-clavicular Paravertebral
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
Mechanism of decreased cerebral blood flow in hyperventilation (e.g. panic attack)
Decreased CO2 - potent cerebral vasodilator
89
Mechanism for minimum pulmonary vascular resistance at FRC
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
Profuse epistaxis in an adolescent male
Angiofibroma
91
Pleomorphic epithelial cells Keratin+ Lymphocytic infiltration Cervical adenopathy
Nasopharyngeal carcinoma
92
Hoarseness Single vocal cord nodule in adults, multiple in children Associated with HPV 6, 11
Laryngeal papilloma Rarely may progress to laryngeal carcinoma - associated with alcohol and smoking
93
Four stages of lobar pneumonia Note - Most common S. Pneumo, Klebsiella
Congestion Red hepatization (neutrophils, RBCs) Grey hepatization Resolution (TII pneumocytes)
94
Most common causes (5) of bronchopneumonia... ``` Secondary, abscess, empyema Secondary, COPD CF Community, COPD Community, COPD, immunocompromised ```
``` S. aureus HIB Pseudomonas Moraxella Legionella ```
95
Most common causes (6) of atypical pneumonia... ``` Young adults (2) Infants Post-transplant Elderly Vet/Farmer with high fever ```
``` Mycoplasma (IgM hemolytic anemia), Chlamydia RSV CMV Influenza Coxiella (Q fever) ```
96
Timeline of TB infection
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
Most common locations for miliary TB
Basal meningitis Cervical lymph nodes Sterile pyuria Pott's
98
Unilateral sided facial swelling Unilateral sided arm swelling Unilaterally distended jugular vein
BRACHIOCEPHALIC OBSTRUCTION Unilateral unlike SVC syndrome which is bilateral Note - Brachiocephalic also receives right lymphatic duct
99
Acidosis High PCO2 Normal HCO3-
ACUTE RESPIRATORY ACIDOSIS Renal compensation does not occur until after at least 24-48 hours of respiratory derangement
100
Mechanism of oxygen-induced hypercapnia
Pulmonary vasodilation increases dead space ventilation Decreased chemoreceptor activity decreases minute ventilation Decreased Hgb affinity for CO2 (Haldane effect) increases pCO2 levels
101
Anterior mediastinal masses
Thymoma Teratoma Thyroid cancer Lymphoma
102
Respiratory quotient
CO2 produced/O2 consumed Note - Typically around 0.8
103
Laplace's law and surfactant
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
Resistance vessels of lower airway
Maximum resistance at medium sized bronchioles - Resistance lowers down the tree with increasing surface area
105
Differentiating hemithorax opacification by obstruction from pleural effusion
Obstruction - Mediastinal shift towards collapsed lung | Effusion - Mediastinal shift away from effusion
106
Collateral circulation of the lung
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
Relationship of Palv, Part, Pv in zones of the lung Zone 1 - Collapsed capillary (pathologic; apex) Zone 2 - Pulsatile flow Zone 3 - Continuous flow
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
Sweat of a CF patient | Intestinal/Resp
higher Na and Cl ( due to CFTR and ENaC, diminished salt resorption) Low Na and Cl ( decreased Cl secretion and increased Na absorption)
109
Eosinophils and mast cells | leukotrienes C4,D4,E4
bronchial asthma induce bronchospasm and increasing bronchial mucus secretion

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