Quiz 4 Flashcards
What are the two different blood supplies of the lungs? Which provides blood supply for respiration and which provides supply for ventilation?
What is the difference in location of the pulmonary arteries in the hilum of both the R and L lung? What acronym is used to remember?
RALS
Right Anterior (to R primary bronchus)
Left Superior (to L primary bronchus)
Vd is dead space
What is the difference between anatomical and physiological dead space?
Anatomical dead space cannot participate in gas exchange by design.
Physiological dead space COULD participate in gas exchange, but often doesn’t
How much anatomical dead space does the average adult have?
150mL
What airway passages are considered anatomic dead space?
What is CaO2 in blood chemistry?
It is the arterial blood oxygen content
What is the equation for CaO2?
What is SaO2? How is it measured?
SaO2 is hemoblogin saturation
It is measured with pulse ox
What is considered the normal CaO2 level for a person (value, not range)?
20.1ml O2/dL of blood
What are the three methods by which CO2 can be transported in the blood?
1) Dissolved in plasma as a bicarbonate ion (80%)
2) Bound to hemoglobin (14%)
3) Dissolved in plasma as CO2 (6%)
Where in the systemic circulation is chloride content in RBCs the highest?
The right atrium
*Cl- ions diffuse into RBCs to balance the H+ generated from bicarbonate formation from carbonic acid
**Cl- will be highest in RA because that blood has maximal amounts of CO2 and has formed maximal amounts of HCO3-
How does the Bohr effect explain how increased pCO2 allows for increased delivery of oxygen to tissues?
Increases in pCO2 will cause an increase in bicarbonate formation which generates a proton as a byproduct
What is carbaminohemoglobin? What situations encourage more carbaminohemoglobin formation?
Carbon dioxide bound directly to the amino groups on hemoglobin
Deoxygenated hemoglobin has a higher affinity for CO2, so it will form more often at lower O2 saturation
How does the Haldane effect describe the increased removal of CO2 in an environment of increased pO2?
*The formation of which CO2 is able to be removed in the lungs
What are the five notable causes of hypoxemia?
Hypoventilation
Low FiO2
V/Q mismatch
Shunt
Diffusion impairment
Which of the 5 causes of hypoxemia will not respond to supplemental O2?
Shunts
Explain the following evaluation chart going over each box.
Good job!
What are the ABC’s (A-I) of reading a CXR?
What structure is indicated by the arrows? What type of interstitial lung disease is this commonly found in?
Fibroblastic foci
Idiopathic/Familial pulmonary fibrosis
What structure is indicated by the arrows? What disease process is it indicative of?
Asbestos body
Pneumoconiosis, specifically asbestosis
What types of interstial lung disease are likely to present with UIP (usual interstitial pneumonia) pattern?
1) Idiopathic pulmonary fibrosis
2) Familial pulmonary fibrosis
3) ILD associated with CTD (connective tissue disease)
Which ILD are associated with non-specific interstitial pneumonia (NSIP)? How can NSIP be differentiated from UIP?
ILD associated with CTD such as rheumatoid arthritis and scleroderma (both can also present with UIP)
NSP presents without fibroblastic foci
What are the two defining features of cryptogenic organizing pneumonia?
1) Cryptogenic meaning of no known cause
2) Plugging of the alveolar duct with loose fibroconnective tissue (varying degrees of plugging)
What is the main characterization of sarcoidosis? What findings would be indicative of sarcoidosis on BAL?
Non-necrotizing granulomatous deposition into tissues (commonly interstitial and hilar)
Increased CD4:CD8 ratio would be supportive of sarcoidosis
What findings are indicated by the arrows? What describes their most common location? What pathology is likely?
Granulomas
Distribution along brochovascular bundles and interlobular septa
Sarcoidosis
What describes the findings indicated by the arrows? What are they composed of? What pathology is most likely?
Granulomas
Composed of histiocytes and giant cells (typically well-formed)
Sarcoidosis
What is the treatment for sarcoidosis?
Many patients do not require treatment if asymptomatic
If critical organ dysfunction or severe constitutional symptoms (i.e. fatigue, hypercalcemia) can treat with corticosteroids
What finding is indicated by the black arrow? Is this finding indicative of sarcoidosis?
An ill-defined granuloma composed of giant cells and histiocytes and surrounded by lymphocytes
This is indicatie of hypersensitivity pneumonitis and can be contrasted with the well-differentiated granulomas seen in sarcoidosis
What are three notable history findings and one hallmark PE finding in ILD?
Hx
-Dyspnea (usually on exertion, at rest in severe)
-Very slow progression (months)
-Little/no sputum
PE
-High-pitched end-inspiratory crackles (rales) at lung bases
What are the four main injury patterns for ILD?
1) Usual interstitial pneumonia (UIP)
2) Nonspecific interstitial pneumonia (NSIP)
3) Organizing pneumonia (OP)
4) Granulomas
What are three notable histopathological features of UIP in ILD?
What are three notable histopathological features of NSIP in ILD?
What is the notable histopathological feature of OP in ILD?
What are three notable histopathological features of granulomas in ILD?
What histopathologic features are shown here? What class of ILD histology is it?
What histopathologic features are shown here? What class of ILD histology is it?
What histopathologic features are shown here? What class of ILD histology is it?
What histopathologic features are shown here? What class of ILD histology is it?
What are the differences between a collagenized nodule and a granuloma?
What are three notable histology findings in hypersensitivity pneumonitis?
What is on the differential for causes of UIP in ILD?
What is on the differential for causes of NSIP in ILD?
What is on the differential for causes of OP in ILD?
What is on the differential for causes of granulomas in ILD?
Which volume and two capacities can not be determined by spirometry?
1) RV
2) FRC
3) TLC
From left to right, which flow volume loops are normal, restrictive, and obstructive?
What Flow-volume pattern is displayed here? What is the pathology that is occuring?
Variable Intrathoracic Obstruction
What Flow-volume pattern is displayed here? What is the pathology that is occuring?
Variable Extrathoracic Obstruction
What Flow-volume pattern is displayed here? What is the pathology that is occuring?
Fixed Airway Obstruction
What are the ranges of FEV1 Z- scores for mild, moderate, and severe respiratory obstruction?
What is a bronchodilator test?
A patient presenting with obstruction is adminstered a bronchidilator preceding spirometry in order to measure if there is improvement
What is the criteria that a bronchodilator test must meet to demonstrate reversible airflow obstruction?
At what point during a methacholine test is the test terminated and conisdered postitive for airway hyper-reactivity?
Does a normal FEV1/FVC with reduced FVC garauntee restrictive disease of the lungs?
What should be done if a reduced FVC is found on spirometry in order to evaluate for restrictive diseases?
Evaluate TLC with plethysmography (gas dilution is sometimes used)
What are four causes of low DLCO?
Why does emphysema cause a reduced DLCO?
Explain the changes from normal seen in chronic bronchitis using this diagram:
Good job!
What are the expected results in DLCO for asthma, emphysema, chronic bronchitis and bronchiectasis?
Normal: Asthma, Chronic bronchitis, Bronchiectasis
Reduced: Emphysema
How is a diagnosis of pneumonia made in CR&R?
Clinical history + radiographic opacity
Can pneumonia by diagnosed by H&P findings alone?
What are the five criteria in the CURB-65 (used to decide on admission to ER/hospital)?
What CURB-65 scores are used to determine where a patient should be treated (Outpatient, inpatient, ICU)? Where are CURB-65 scores mostly used?
They are mostly used in the ER
What treatments are appropriate for uncomplicated CAP? What treatments could be used for complicated CAP?
What is the most common pathogen causing CAP for patients being admitted to inpatient care?
Staphylococcus aureus/gram-negative bacilli
How should Non-ICU inpatient pneumonia be treated? How should atypical pneumonia be treated?
How should ICU pneumonia be treated?
Compare transudative vs. exudative pleural effusion as well as common causes of each:
Will a transudative or exudative effusion present with pleural liquid high in LDH and protein?
Exudative pleural effusion
What are the two functions of thoracentesis in management of a pleural effusion?
What does Light’s criteria evaluate? What are the criteria?
When is chest tube drainage used in pleural effusion treatment?
What would be the expected pressure at FRC of the following in a pneumothorax: Alveoli, Intrapulmonary pressure, TPP
All would be 0 due to lung collapse
What four treatments can be implemented for pneumothorax?
Are these gross findings more consistant with centriacinar or panacinar emphysema?
Centrilobular (centriacinar) emphysema
*Note the large holes in the upper lung and interspersed areas of normal lung
Are these gross findings more consistant with centriacinar or panacinar emphysema?
Panacinar emphysema
*Note the diffuse distribution
What criteria are used to evlauate COPD after spirometry? What are the four grades?
The Gold criteria
What is the model for treatment (Groups A-D) for patients with stable COPD?
*mMRC scale of 2+ indicates dyspnea with even mild exertion (more severe)
What are 5 notable features of Potter sequence?
What is an Extralobuar sequestration (pulmonary)?
What is the embryological origin of a pulmonry extralobar sequestration? By what age is it usually identified? What are 3 symptoms seen in an affected infant?
What pathology is shown here?
What is an intralobar sequestration (pulmonary)?
What is the etiolgoy of an intralobar sequestration? In what patient population is it seen (rarely)? What are 3 notable symptoms?
*Rarely seen before 5 years, often diagnosed before 20yo
What is indicated by a score of 25 on the ACT (asthma control test)? Of less than 19? Less than 15?
What are the three classes of RF for VTE?
What is the usefulness of D-dimer testing for suspected PE/DVT?
What are four other sources of emboli besides DVT?
What acid-base disturbance is expected with a PE?
Respiratory alkalosis
Hypoxemia -> respiratory drive -> Increased breathing removes too much CO2
What are the five classes of the Pulmonary Embolism Severity Index (PESI)? What is the relative risk of mortality associated with each class?
For which PESI risk classes should outpatient treatment be considered?
Of intermediate to high-risk PE cases, what is used to differentiate admission to the MICU vs. the medical floor?
What is Ohm’s law in the pulmonary vasculate?
What are normal values for the following:
mPAP
PCWP
CO
PVR
What does pulmonary capillary wedge pressure (PCWP) estimate?
Left ventricular end-diastolic pressure (LVEDP)
What are the five WHO classifications for pulmonary hypertension?
What value of mPAP defines pulmonary hypertension? What is the difference in PCWP and PVR in pre vs. post capillary pulmonary hypertension?
BONUS: Using the diagram, explain why PCWP and PVR values are altered in pre vs. post capillary PH
What is the gold standard for diagnosing pulmonary hypertension?
Right heart catheterization (RHC)
What is the most common cause of pulmonary hypertension?
Left heart disease
How does lung disease cause pre-capillary hemodynamics in pulmonary hypertension?
Hypoxemic pulmonary vasoconstriction
What EKG findings would be expected in pulmonary hypertension?
Right atrial enlargement
Mediastinal fullness
What is the difference between pulmonary hypertension and pulmonary arterial hypertension (PAH)?
PAH is a subtype of pulmonary hypertension involving narrowing of the pulmonary arteries (excludes capillaries and veins)
Recall the following information in the chart:
Which WHO pulmonary hypertension group is notable for a post-capillary cause of PH?
Left-heart disease
Which WHO pulmonary hypertension group is notable for a pre, post or combined capillary etiology for PH?
Group 5; multisystem or unknown
Which WHO pulmonary hypertension group is notable for a normal PVR?
Left heart disease
What treatments are appropriate for each WHO pulmonary hypertension group?
How is fluid obtained through thoracentesis evaluated for the liklihood of a transudative or exudative effusion? What are the three criteria?
What are the four main types of pneumoconiosis?
Coal
Silica
Asbestos
Beryllium
The finding in this biopsy is most consistent with what type of pneumoconiosis? Why?
Silicosis
*The silicotic nodule is composed mostly of bundles of interlacing pink collagen
What type of pneumoconiosis is indicated here? What findings are consistant with this?
What cell type is instrumental in the fibrogenic response of silicosis?
Macrophages
Can silicosis and coal worker’s pneumoconiosis (CWP) coexist?
Yes, called mixed-dust pneumoconiosis
What type of pneumoconiosis is indicated here? What findings are significant?
Coal worker’s pneumoconiosis (CWP)
*The coal macule is visible in the interstitium, note they is more common in the upper lung zones
What are the findings seen here on the left (A) and right (B)? What type of pneumoconiosis do they suggest?
A: Coal macule
B: Coal nodule
CWP
What histological pattern is associated with berylliosis?
Sarcoid (up to 6% of sarcoid dx may actually be berylliosis)
In what three trades is beryllium used signifcantly?
-Nuclear weapons manufacturing
-Aerospace industry
-Metal machining, scrap reclaimation
What is the most common CFTR mutation? What is one other notable mutation?
What type of CFTR modulators are used to treat Class II mutations? Which are used for class III-IV mutations? Name two drug examples of each type
