Resp Review Flashcards
Lung development
- weeks
- respiration capable when
Starting at week 4 –> birth
Week 25 viable
Bronchogenic cysts
Caused by abnormal budding of the forgut and dilation of terminal or large bronchi
Discrete, round, sharply defined, fluid filled densities on CXR
Club cells
- description
- location
- fxn (3)
Noncilated, low columnar/cuboidal with secretory granules
Located in small airways
Secrete components of surfactant
Degrades toxins
Act as reserve cells
Type I pneumocytes
- cell type
- fxn
Squamous, thin
Gas diffusion
Line alveoli
Type II pneumocyts
- cell type
- fxn
Cuboidal and clustered
Precursors to type I cells and other type II cells
Proliferate during lung damage
Secrete surfactant from lamellar bodies
–> decrease alveolar surface tension, prevents alveolar collapse –>
Decrease lung recoil and increase compliance
Pulmonary surfactant composed of
Mix of Lecithins
- Most important is dipalmitoylphosphatidylcholine (DPPC)
Screening test for fetal lung maturity
Lecithin-sphingomyelin ratio in amniotic fluid >2 is healthy
Persistently low O2 tension in newborn think
PDA
Infant, difficulty breathing, grunting
Bulging forhead
Intraventricular hemorrahge
- germinal matrix hemorrhages
- due to RDS
Cephalohematoma
rupture of subperiosteal blood
Due to forceps for birth
Location of ____ in respiratory tree
Pathway
1) Cartilage
2) Pseudostratified ciliated columnar
3) Smooth muscle
4) Goblet cells
5) Simple ciliated columnar
6) Club cells
7) Simple cuboidal epithelium
8) Simple cuboidal/ Squamous
Trachea –> Bronchi –> Bronchioles –> Terminal bronchioles –> Respiraotry bronchioles –> Alveolar sacs
1) Cartilage
- Trachea
- Bronchi
2) Pseudostratified ciliated columnar
- Trachea
- Bronchi
3) Smooth muscle
- Trachea –> Terminal bronchiles (Respiratory bronchioles sparse)
4) Goblet cells
- Trachea
- Bronchi
5) Simple ciliated columnar
- Bronchioles
6) Club cells
- Bronchioles
- Terminal bronchioles
- Respiratory bronchioles
7) Simple cuboidal epithelium, ciliated
- Terminal bronchioles
8) Simple cuboidal/ Squamous
- Respiratory bronchioles
9) Loss at cilia
- Respiraotry bronchioles
Common site for inhaled foreign bodies
Right lung
Right main stem bronchus wider and more vertical and shorter than left
Inhale peanut while upright
Basal segment of right lower lobe
Inhale peanut while supine
Enters posterior segment of right upper lobe
Pathologic dead space
When part of the respiratory zone becomes unable to perform gas exchange
Ventilated but not perfused
Compliance
High compliance
Low compliance
Complaint lungs comply (cooperate) and fill easily with air
High compliance
- Easier to fill
- emphysema, normal aging
Lower compliance
- lungs harder to fill
- pulmonary fibrosis, pneumonia
Surfactant effect on compliance
Increases compliance
Right sift in oxygen hemoglobin dissociation curve (6)
Increase
- Acid
- CO2
- Exercise
- 2,3 BPG
- Alititude
- Temperature
Resistance =
R= (P pulm artery - P L atrium ) / Cardiac output
R= Change P/ Q
Q= perfusion
V/Q at apex of lung
3
Wasted ventilation
V/Q at base of lungs
0.6 wasted perfusion
Rhinosinusitis most commonly from
S. pneumoniae
H. influenza
M catarrhalis
Epistaxis
- anterior vs posterior segment
Most commonly
- anterior
Life threatening
- posterior segment
- sphenopalatine artery, branch of maxillary artery
Test to rule out DVT
Diagnosis
Prophylaxis/ Acute management
Long term management
D-dimer lab test
- High sensitivity Low specificity
Compression ultrasound with Doppler
Prophylaxis or acute management
- Heparin or low molecular weight heparins (enoxaparin)
Tx: Intravenous heparin drip
Long term prevention
- Warfarin
- rivaroxaban
Hypoxemia
Neurlogic abnormalities
Petechial rash
Fat emboli
Hypoexemia: low O2 in blood
Obstructive lung volumes
TLC FRC RV FEV1 FVC FEV1/FVC
Due to
Increased TLV
Increased FRC
Increased RV
Decreased FEV1 more than FVC
Decreased FEV1/FVC
Air trapping in lungs
Obstruction of air flow
COPD
Chronic bronchitis
Emphysema
Restrictive lung volumes
FEV1 FVC FEV1/FVC TLC FRC RV
Due to
FVC is more reduced or same as FEV1
Normal FEV1/FVC
Decreased TLV
Decreased FRC
Decreased RV
Pneumoconioses Sarcoidosis Pulmonary fibrosis Granulomatosis with polyangiitis Langerhans cell histocytosis Drug toxicity
Chronic bronchitis pathology
clinical presentation
Wheezing, crackles, cyanosis
Hypoxemia due to shunting
Dyspnea
Polycythemia (secondary)
Hypertrophy and hyperplasia of mucus secreting glands in bronchi
Emphysema
- two types
- pathology
- due to
- CXR
- clinical presentation (2)
Centriacinar
- assoc with smoking
- upper lobes
Panacinar:
- associated with alpha 1 antitrypsin
- Lower lobes
Enlargement of air spaces, decreased recoil, increased compliance
Increased elastase activity –> increase loss of elastic fibers –> increase lung compliance
CXR: increased AP diameter, flattened diaphragm, increase lung field lucency
Barrel shaped chest
Pursed lips breathing
Smooth muscle hypertrophy in lungs
Asthma
COPD increase in what cells
Neutrophils
Macrophages
CD8 T cells
Purulent sputum
Recurrent infections
Hemoptysis
Digital clubbing
- pathology
- assoc with
Bronchiectasis
Chronic necrotizing infections of bronchi –> permanently dilated airways
Kartagener syndrome
Cystic fibrosis
Aspergillosis
Asbestos affects what part of lungs
Lower lobes
Silica affects what part of lungs
Upper lobes
Coal affects what part of lungs
Upper lobes
Ivory white calcified plaques
what type of work
Asbestosis
Shipbuilding
Roofing
plumbing
Golden brown dumbbells on sputum sample
Asbestosis
Aerospace
Granulomatous on histology
Berylliosis
Fibrosis
Eggshell calcifications of hilar LN on CXR
Silicosis
Mesothelioma associated with
seen on histology
positive for
Asbestosis
Psammoma bodies on histology
+ Cytokeratin
+ calretinin
Pulmonary HTN value
> 25 mm Hg at rest
Physical findings pleural effusion
- Breath sounds
- Percussion
- Fremitus
- Tracheal deviation
Breath sounds= decreased
Percussion= Dull
Fremitus= Decreased
Tracheal deviation= None or away from side of lesion if large
Physical findings Atelectasis
- Breath sounds
- Percussion
- Fremitus
- Tracheal deviation
Bronchial obstruction
Breath sounds= decreased
Percussion= Dul
Fremitus= Decreased
Tracheal deviation= Toward side of lesion
Physical findings Simple pneumothorax
- Breath sounds
- Percussion
- Fremitus
- Tracheal deviation
Breath sounds= Decreased
Percussion= Hyperresonant
Fremitus= Decreased
Tracheal deviation = None
Physical findings Tension pneumothorax
- Breath sounds
- Percussion
- Fremitus
- Tracheal deviation
Breath sounds= Decreased
Percussion= Hyperresonant
Fremitus= Decreased
Tracheal deviation = Away from side of lesion
Physical findings of Consolidation (lobar pneumonia)
- Breath sounds
- Percussion
- Fremitus
- Tracheal deviation
Breath sounds= Bronchial breath sounds; late inspiratory crackles, egophony, bronchophony, whispered pectoriloquy
Percussion= Dull
Fremitus= Increased
Tracheal deviation = None
Physical findings of pulmonary edema
- Breath sounds
- Percussion
- Fremitus
- Tracheal deviation
Consolidation
Breath sounds= Bronchial breath sounds; late inspiratory crackles, egophony, bronchophony, whispered pectoriloquy
Percussion= Dull
Fremitus= Increased
Tracheal deviation = None
Pleural effusions are
Excess accumulation of fluid between pleural layers –> restricted lung expansion during inspiration
Lobar pneumonia
- organism
- characteristics
S pneumonia (more frequently )
Legionella
Klebsiella
Consolidation
Interstitial (atypical) pneumonia
- organism
- characteristics
Mycoplasma Chlamydophila pneumoniae Chlamydia psittaci legionella Viruses (RSV, CMV, influenza, adenovirus)
DIffuse patchy inflammation localized to interstitial areas at alveolar walls
Diffuse more than 1 lung
Tx Lung abscess
Clindamycin
Lung abscess organisms
Due to anaerobes
- Bacteroides
- Fusobacterium
- Peptostreptococcus
S. Aureus
Carcinoma in apex of lung
- type
- does what
- symptoms
Pancoast tumor (superior sulcus tumor)
Invades cervical sympathetic chain
Compression of locoregional structures
- Recurrent laryngeal n= hoarseness
- Stellate ganglion= Horner syndrome**
(ispl ptosis, miosis, anhidrosis)
- Superior vena cava= SVC syndrome
- Brachiocephalic vein= brachiocephalic syn
- Brachial plexus= sensormotor deficits
SVC syndrome
Obstruction of SVC impairs blood drain from head
Facial plethora (red face) - blanches with poking
JVD
Upper extremity edema
Increased risk fo aneurysm
Coin lesion on CXR
Lung cancer
Small cell carcinoma
- Location
- Prognosis
- Produce
- Key feature
- Amplication of
- Cels
- Positive for
Central
Very aggressive
Product
- ACTH
- SIADH
- Ab against Ca channel
High nucleus to cytoplasm ratio
Amplification of myc oncogenes (nyc)
Abbrevations in TP53, Rb
Neuroendocrine Kulchitsky cells –> small dark blue cells
+ Chromogranin A
+ Neuron-specfiic enolase
A 71-year-old man is brought to the emergency department by ambulance after he was found by his neighbor walking around his garden confused and unable to answer questions. He is confused and oriented only to person. His temperature is 37.6° C (99.7° F), heart rate is 110/min, respiratory rate is 20/min, and blood pressure is 130/92 mm Hg. While in the emergency department the patient has a seizure. Laboratory tests show a serum sodium level of 115 mEq/L, potassium of 3.8 mEq/L, glucose of 100 mg/dL, and osmolality of 250 mOsm/ kg. Urine electrolyte testing show a urine osmolality of 500 mOsm/kg. X-ray of the chest shows a mass in the lung. Which of the following is the most likely etiology of the mass? (A) Foreign body aspiration (B) Metastatic brain cancer (C) Prostate cancer (D) Small cell carcinoma (E) Tuberculosis
D. Small cell carcinoma
Adenocarcinoma
- location
- most common in
- mutation
- physical feature
- CXR
- Histology
- positive for
Peripheral
Most common lung cancer in nonsmokers and overall
Mutations “MARKER”
- MET, ALK, RET, KRAS, EGFR, ROS
Hypertrophic osteoarthropathy (clubbing)
CXR: hazy infiltrates similar to pneumonia; better prognosis
Glandular pattern on histology
+ Mucin
Squamous cell carcioma
- location
- description
- produces
- risk
- histology
Central
Hilar mass arising from bronchus
Cavitation
Cigarattes
Hypercalcemia (PTHrP)
Keratin pearls and intercellular bridges
Large cell carcinoma
- Location
- Prognosis
- Associated with
- Histology
Peripheral
Highly anaplastic undifferentiated tumor
Poor prognosis
Smoking
Pleomorphic GIANT cells
Bronchial carcinoid tumor
- Prognosis
- Symptoms
- Histology
- Positive for
Excellent prognosis; metastasis rare
Symptoms due to mass effect or carcinoid syndrome
- Flushing, diarrhea, wheezing
Nests of neuroendocrine cells
+ Chromogranin A
Decrease of alveolar oxygen in lungs
–> Vasoconstriction –> reduce perfusion of lung, shunting of blood toward well-ventilated regions of lung
COPD –> Low alveolar oxygen –> chronic vasoconstriction –> pulmonary HTN –> Cor pulmonale
Perfusion
How much blood to an area
Tx Pulmonary HTN
Competitive antagonist for endothelium 1 receptors –> decrease pulmonary vascular resistance
- Bosentan
- Ambrisentan
Prostaglandin analog
(dilate vessel like pulmonary arteries)
- Iloprost
- Epoprostenol
Sildenafil
- phosphodiesterase inhibitor that causes vasodilation
Nifedipine
- dihydropyridine Ca channel blocker
Tx for SEVERE primary pulmonary htn
Inhaled nitric oxide
Primary pulmonary hypertension
- assoc with
Associated with abnormalities in BMPR2: bone morphogenic protein receptor type II
BMPR2 protein prevents proliferation of vascular smooth muscle
Mutation leads to excessive vascular smooth muscle proliferation –> reduced vessel radius, increased resistance and increased pulmonary arterial pressure
Defective tyrosine kinase gene
Bruton agammaglobulinemia
Hypoxemia
Hypoxia
Hypoxemia: low oxygen in blood
Hypoxia: body or region deprived of oxygen
High A-a gradient indicates
Shunting of blood
Diffusion limitation (pulmonary fibrosis)
V/Q mismatch
Advanced age
Oxygenation in Anemia
Hemoglobin decreases –> oxygen content decreases
Decrease total O2 content
No change in O2 saturation
No change in arterial PO2 (amount dissolved in blood)
V/Q at apex and base
Apex
V/Q > 1
Base
V/Q <1
Exercise on V/Q ratio
V/Q ratio goes down towards one
Vasodilation of capillaries in apex
Perfusion increases
V/Q –> zero
Low ventilation (outside body --> alveoli) High perfusion
Airway obstruction
- pneumonia
- pulmonary edema
- lung cancer
Supplemental O2 ineffective
V/Q –> infinity
High ventilation, low perfusion
Blood flow obstruction or physiologic dead space
Supplemental O2 effective
Response to exercise
Increase O2 consumption
Increase CO2 production
V/Q more uniform
Increase pulmonary blood flow due to increase CO
Decrease pH
No change in arterial PO2 and PCO2
Increased venous CO2 levels
Acute motion sickness clinical presentation
Headache
Fatigue
Extreme
- Acute cerebral edema due to hypoxia induced vasodilation
- Acute pulmonary edema
Response to high altitudes (6)
Increase ventilation Increased erythropoietin Increase 2,3 BPG Increase meitochondria Increase efficiency of O2 utililzation Increased renal excretion bicarb
Physiologic changes in chronic mountain sickness
Increase RBC mass and hematocrit Increased blood viscosity Decreased tissue blood flow Elevated pulmonary artery pressure (constricts due to hypoxia) Right sided heart enlargement Peripheral artery pressure falls Congestive heart failure
Positive G force does a visual “ blackout” occur
- due to
4-6 G
Due to insufficient blood return to heart
Insufficient pumping of blood to brain
How is body affected at zero gravity (5)
Decreased blood volume Decreased RBC mass Decreased muscle strength/ work capacity Decreased maximum and cardiac output Loss of calcium and phosphate resulting in loss of bone mass
The BENDS
Breathing problems
Extremity pain
Neurologic changes
Death
Elevated D dimer Pleuritic chest pain SOB Tachypnea High A-a gradient
- CXR?
- gold standard
- ECG changes
Pulmonary embolism
CXR: normal
Pulmonary angiogram
S1Q3T3 deep S in lead I large Q and inverted T in lead III
Ankle pain with dorsiflexion
Homan’s sign
DVT
Primary spontaneous pneumothorax due to
Apical blebs
Tall and thin
Charcott Leyden crystals
Asthma
Drop in systolic pressure by 10 mm/Hg during inspiration
- Disease
- what happens
- seen in
Pulsus Paradoxus
Decreased intrathoracic pressure –> increased right ventricle blood return
Right ventricle pushed into left ventricle –> poor cardiac output and drop in systolic pressure
Cardiac tamponade
Asthma
Pulmonary embolism (severe)
Cyprohepatadine
- type
- use
Antihistamine
Use: Appetite stimulant
Antidote for serotonin syndrome
Promethazine
- type
- use
Antihistamine
Use: Nausea, vomiting
Hydroxyzine
- type
- use
Antihistamine
Use: Sedation itching
Meclizine
- type
- use
Antihistamine
Vertigo
Formoterol
- type
- use
- risk
Long Acting beta agonist
Mainstay of COPD tx
For asthma must also be on inhaled corticosteriod
Increased risk when used alone
Muscarinic Antagonists used in COPD asthma
- MOA
Ipratropium (short acting)
Tiotropium ( long acting)
Decrease overall vagal or parasympathetic tone in lungs
Zileuton
- type
- MOA
5-lipoxygenase inhibitor
Blocks conversion of arachidonic acid into leukotrienes
Salmeterol
- type
- Use
- risk
Long Acting beta agonist
Mainstay of COPD tx
For asthma must also be on inhaled corticosteriod
Increased risk when used alone
Steroids
- examples
- MOA
Fluticasone
Budesnoide
Beclomethasone
Inhibit cytokine synthesis
Inhibit TNF-alpha production
Cromolyn
- MOA
Prevents release of histamines from mast cells
Prevents bronchoconstriction and inflammation
Montelukast
- MOA
- Use
Prevents bronchogenic and chemotactic effects of leukotriene D4
Aspirin and allergy induced asthma
COPD tx
Long Acting beta agonist
Formoterol
Salmeterol
Theophylline
- type
- MOA
- characteristic
- side effect
Methylxanthines
Can cause bronchiodilation by inhibiting phosphodiesterase
- Increase cAMP
- decrease hydrolysis
Narrow therapeutic index
Side effects
- Tremor
- Tachycardia
- Can cause seizure
Guaifenesin
- type
- Fxn
- Does not do what
Expectorant
Thin mucus
Does not suppress cough
+ dextromethorphan to suppress cough
Omalizumab
- type
- use
- MOA
- reduces
Anti IgE monoclonal Ab
Severe asthma with allergic component
Binds IgE in serum and blocks receptor
Reduces exacerbation and use of rescue inhaler
Diphenhydramine
- type
- others
- effects
- Uses
- Toxicity
1st generation H1 blockers
Diphenhydramine
Dimenhydrinate
Chlorpheniramine
Very sedating
Antimuscarinic and anti-alpha adrenergic effects
Uses:
- Allergies
- Motion sickness
- Sleep aids
Toxicity
- Sedation
- Dry mouth
- Delirum in elderly
N- acetylcysteine
- type
- uses
- MOA
Expectorant
Tylenol overdose
Use for contrast induce nephropathy
Mucolytic that breaks disfulide bonds in patients with obstructive lung disease
2nd Generation H1 blockers
- examples
- use
Loratadine
Fexofenadine
Desloratadine
Cetirizine
Allergy
Much less sedating
Phenylephrine Pseudoephedrine - type - Use - MOA - Reduces - Adverse
Nasal decongestant
Works as alpha adrenergic agonist
Constrict dilated arterioles in nasal mucosa
Reduce airway resistance, swelling and nasal congestion
Adverse
- Long term use can cause rebound congestion
Epoprostenol iloprost
- MOA
- Use
- Side effects
Works by directly vasodilating the pulmonary vascular beds
Reducing the pressures in both systems
Pulmonary HTN
Side effects
- Jaw pain
- Flushing
Bosentan
- type
- use
- side effect
Antagonizing endothelial receptor 1
Pulmonary HTN
Side effect: hepatotoxicity
Sarcoidosis
A GRUELING Disease
ACE enzyme increase Gammaglobulinemia Rheumatoid factor Uveitis Erythema nodosum Lymphadenopathy (bilateral, hilar) Idiopathic Noncaseating Granulomas vitamin D increase
Honeycomb lung on CT
- disease
- Genetic mutation
- CT
Idiopathic pulmonary fibrosis
Genetic mutation: telomerase, mucin MUC5B
Patchy interstitial fibrosis
What medications cause restrictive lung disease
Bleomycin
- Pneumonitis with infiltrates
Busulfan
- Acute lung injury
- Chronic interstitial fibrosis
- Alveolar hemorrhage
Amiodarone
- Pulmonary fibrosis
Methotrexate
- Hypersensitivity like lung reaction
Tx Langerhans Cell Histiocytosis
Quit smoking
Bilateral hilar adenopathy
Uveitis
Sarcoidosis
Lung metastasis to
Brain
Bone
Liver
Adrenal glands
Pontiac fever
Legionella pneumophilia
Causes of transudate pleural effusion
Low protein high electrolyte
Increased hydrostatic pressure
Decreased oncotic pressure
CHF
Cirrhosis
Nephrotic syndrome
Fluid overload
Causes of Exudate pleural effusion
High protein
Results from pleural and lung inflammation –> increased membrane permeabililty
Cancer
Pneumonia, infections, TB
Uremia
Connective tissue disease
Obstructive sleep apnea medication
Modafinil
- Wake up during day
Salicylate intoxication what occurs
Respiratory alkalosis
- immediately
Anion gap metabolic acidosis
- after 12 hrs
Cystic fibrosis pathogenesis
CFTR gene mutation
3 base pair deletion of phnylalanine at amino acid position 508.
Mutations causes impaired post-translational processing (improper folding and glycosylation) of CFTR
Inhaled anesthetic
Large arteriovenous concentration gradient
Difference between the concentration of gas anesthetic in arterial and venous blood
If tissue solubility is high, results in large amount of anesthetic taken up from arterial blood and low venous concentration
Need more anesthetic to replace what was absorbed by tissues
Blood saturation takes longer
Brain saturation also delayed
Pain sensation in anterior tongue
Mandibular division of trigeminal nerve
Progressive weakness
Gets better as day goes on
Dry mouth and episodic double vision
Difficulty with erections even though good libido
Decreased strength of hip flexors and diminished knee reflexes, repeat shows normalization of strength and reflexes
Condition
Due to
Lambert Eaton
Ab to voltage gated calcium channel
Small cell lung cancer
Achondroplasia abnormality involving
Chondrocytes
AD
Point mutation
FGFR3
Vomiting from chemotherapy is due to what region
Chemoreceptor trigger zone (CTZ) located on dorsal surface of the medulla at the caudal end of the fourth ventricle
known as area postrema
Cells with eye glasses
Tx
malaria
plasmodium falciparum
Trophozoites
African species are chloroquine resistant
Tx Chloroquine
Tx Atovaquone-proguanil or artemisinin
P. Vivax and P ovale
Tx primaquine addition
Diabetes medication
Weight loss
- Type
- Examples
- MOA
- Adverse
GLP-1 agonist
- Exenatide
- Liraglutide
Increase glucose dependent insulin secretion
Decrease glucagon secretion
Delay gastric emptying
Pancreatitis
Vaccine to C. tetani how does it prevent symptoms
Circulating ab that neutralize bacterial products
Black neurotoxic exotoxin called tetanospasmin
Child
Language regression
Tantrums
Hemoglobin 9
Due to
Inhibition of
Anemia
Regression
Lead toxicity
Inhibition of ferrochelatase
delta-aminolevulinic acid
Accident
Bleeding complications oozing from catheters and venipuncture sites
DIC
HSV
Tx
MOA
Acyclovir
Incorporation into newly replicating viral DNA
2 day hx reduced sensation in legs Fatigue especially with exercise Six months ago visual blurring Psoriasis hx Glucocorticoid use Decreased pain and light tough below level of umbilicus Bilateral spasticity
Brain lesion?
Multiple sclerosis
Perivenular inflammatory cells made up of autoreactive T lymphocytes and macrophages directly against myelin components
