Respiratory Flashcards
(362 cards)
1
Q
What disorder should you think about in a child with nasal polyps?
A
Cystic Fibrosis
2
Q
Why should you avoid aspirin in patients with nasal polyps?
A
Adults with nasal polyps and asthma are at a high likelihood of aspirin allergy (aspirin intolerant asthma).
3
Q
What subgroup is angiofibroma of the nasal mucosa most commonly seen in?
A
Adolescent males (almost exclusively)
4
Q
What virus can cause nasopharyngeal CA?
A
EBV
5
Q
What two demographics are at high risk for nasopharyngeal cancer from EBV?
A
African children, Chinese adults
6
Q
Describe the histology of nasopharyngeal carcinoma.
A
Pleomorphic keratin-positive epithelial cells in a background of lymphocytes
7
Q
What is the #1 cause of acute epiglottitis?
A
H. influenza b
8
Q
What viruses cause laryngeal papillomas?
A
HPV 6 and 11
9
Q
How many papillomas are seen in adults with laryngeal papillomas?
A
One
10
Q
How many papillomas are seen in children with laryngeal papillomas?
A
Multiple
11
Q
What are the two most common causes of lobar pneumonia?
A
S. pneumo and K. pneumoniae
12
Q
What are the 4 phases of lobar pneumonia?
A
Congestion, red hepatization (lots of RBCs), grey hepatization (RBCs broken down), resolution
13
Q
Which cells are stem cells of lungs that help regenerate the alveolar air sacs after lung damage?
A
Type II pneumocytes
14
Q
Grossly, how does bronchopneumonia appear?
A
Patchy (“shotgun”) appearance
15
Q
What is the #1 cause of bacterial pneumonia following a viral infection of the lung (influenza)?
A
S. aureus
16
Q
What are two major complications of staph aureus pneumonia?
A
Abscess, empyema
17
Q
What two bacteria are most commonly seen in patients with COPD?
A
H. influenzae, M. catarrhalis
18
Q
What stain is best to identify Legionella Pneumophila?
A
Silver stain
19
Q
What is the #1 cause of atypical pneumonia in infants?
A
RSV
20
Q
What is the classic location of aspiration pneumonia?
A
Right lower lobe
21
Q
Meningitis caused by TB classically presents in what location?
A
The base of the brain
22
Q
What happens to the FEV1/FVC ratio in COPD?
A
Decreases (Both FVC and FEV1 decrease, but FEV1 decreases more)
23
Q
What is the symptomatic time period necessary for a diagnosis of chronic bronchitis?
A
Productive cough lasting at least 3 months over a minimum of 2 years.
24
Q
What is the Reid index and what is its normal value?
A
Reid index- thickness of mucus glands in bronchi relative to the thickness of the entire wall. Normally <40%.
25
What is the Reid index in chronic bronchitis?
>50% (increased thickness of mucinous glands relative to the entire thickness of the bronchial wall).
26
A "blue bloater" has what disease?
Chronic bronchitis
27
What causes centriacinar emphysema?
Smoking (usually in upper lobes)
28
What causes panacinar emphysema?
Alpha 1 antitrypsin deficiency (destroy the entire acinus)
29
In which lobes is centriacinar emphysema usually found?
Upper (smoke travels up in the lungs)
30
In which lobes is panacinar emphysema usually found?
Lower lobes
31
Pink PAS positive globules on liver biopsy is indicative of...
Alpha 1 antitrypsin deficiency
32
What is the most common mutation seen in A1AT deficiency?
PiZ allele
33
Where does alpha-1 antitrypsin accumulate in individuals with A1ATD?
Endoplasmic reticulum
34
Explain the mechanism of wall collapse in emphysema.
Normally, recoil of alveoli serves to hold lower airways open during expiration. When their septa are destroyed in emphysema, they lose this ability, and the airways collapse.
35
Why do patients with emphysema breathe with pursed lips?
It creates back pressure to keep the small airways open (they would otherwise collapse in emphysema because of loss of recoil from alveoli to keep them open)
36
What disease does a "pink puffer" have?
Emphysema
37
What 3 cytokines do TH2 cells secrete?
IL-4, IL-5, IL-10
38
What does IL-4 do?
Promotes class switching to IgE/IgG
39
What cytokine is a key eosinophil activator?
IL-5
40
What are the two mechanisms that cause early inflammation in asthma?
Mast cell destabilization and release of preformed histamine. Production of LTC4, LTD4, LTE4
41
What are Curschmann spirals?
Twisted mucous plugs admixed with sloughed epithelium in asthma
42
What are Charcot-Leyden crystals?
Crystals in sputum formed from breakdown of eosinophils in sputum
43
What is bronchiectasis?
Permanent dilation of bronchioles and bronchi (large airways)
44
What are some causes of bronchiectasis?
Bronchial obstruction, Kartagener's syndrome (dysfunction of dynein arms of cilia), CF, allergic bronchopulmonary aspergillosis.
45
What is paraseptal (distal acinar) emphysema?
Emphysema of distal airway structures - associated with apical bullae that can rupture in tall, thin, male patients, creating a spontaneous pneumothorax.
46
What happens to the FEV1/FVC in restrictive diseases?
The ratio increases (Both FEV1 and FVC decrease, but FVC decreases more)
47
What induces fibrosis in idiopathic pulmonary fibrosis?
TGF-beta released from injured pneumocytes
48
What causes fibrosis in pneumoconiosis?
Alveolar macrophages responding to small particles
49
What is Caplan syndrome?
Black lung (coal worker pneumoconiosis) + rheumatoid arthritis
50
What is anthracosis?
A clinically insignificant anthracosis of the lung caused by mild exposure to carbon in pollutants.
51
What does silica do to alveolar macrophages?
Impairs phagolysosome formation, thus increasing risk for TB (only pneumoconiosis that increases TB risk)
52
In what lobe of the lung does silicosis typically occur?
Upper lobe (also increases the risk for TB, which preferentially infects upper lobe)
53
What category of patients are at risk for exposure to beryllium, and what does it cause?
Workers in the aerospace industry. Beryllium exposure causes noncaseating granulomas in the lung (similar to sarcoidosis) and increases risk of lung cancer.
54
What four general things can be caused by asbestos?
Fibrosis of the lung, fibrosis of the pleura, cancer of the lung, cancer of the pleura (mesothelioma).
55
What is the most common cancer that individuals exposed to asbestos get?
Lung cancer (bronchogenic) NOT mesothelioma!.
56
Patients in what occupation are at high risk for exposure to silica?
Sandblasters, miners.
57
What can cause "eggshell" calcifications of hilar lymph nodes?
Silicosis
58
What is the pathophysiology of idiopathic pulmonary fibrosis?
Repeated cycles of lung injury and healing with increased collagen deposition.
59
Where are non-caseating granulomas commonly seen in sarcoidosis?
Lung and hilar lymph nodes
60
What enzyme is commonly elevated in the blood of patients with sarcoidosis?
ACE
61
Why do patients with sarcoidosis have hypercalcemia?
Macrophages in non-caseating granulomas have 1-alpha hydroxylase activity and can activate vitamin D.
62
Explain the signs and symptoms of hypersensitivity pneumonitis.
Granulomatous reaction to inhaled organic antigens (pigeon feces, hay, etc.) with dyspnea, cough, chest tightness, etc. that GOES AWAY with removal of the stimulus. Can lead to interstitial fibrosis. Will see eosinophils in the tissue.
63
What is a plexiform lesion?
A tuft of capillaries resembling a primitive glomerulus seen in irreversible pulmonary hypertension.
64
What is normal pulmonary artery pressure?
10-14 mm Hg
65
What are some signs and symptoms of pulmonary hypertension?
Exertional dyspnea, right sided heart failure, RVH
66
What gene is inactivated in familial forms of primary pulmonary hypertension?
BMPR2
67
BMPR2 inactivation leads to...
Proliferation of vascular smooth muscle and pulmonary hypertension
68
What are some causes of secondary pulmonary hypertension?
Hypoxemia (COPD), increased volume in pulmonary circuit (left heart failure, mitral stenosis), recurrent pulmonary embolism.
69
What is a sequelae of recurrent pulmonary embolism?
Pulmonary hypertension secondary to thickening of the vascular wall due to repeated embolus deposition.
70
What is the microscopic hallmark of ARDS?
Formation of thickened hyaline membranes in alveoli.
71
What causes a diffuse "white out" of the lung on CXR?
ARDS
72
What cells are damaged in ARDS?
Type I and type II pneumocytes (injury to type II pneumocytes causes fibrosis upon recovery)
73
What is seen on CXR in newborns with neonatal ARDS?
Diffuse granularity
74
What test is used to screen for neonatal ARDS?
Lecithin:sphingomyelin ratio (lecithin increases as lungs mature). Ratio >2 = good.
75
What is the main component of surfactant?
Phosphatidylcholine (lecithin)
76
What are polycyclic aromatic hydrocarbons?
Extremely carcinogenic compounds found in cigarette smoke.
77
What two benign lesions can present as "coin lesions" on CXR or CT?
Granuloma and Bronchial hamartoma (Lung tissue and cartilage)
78
What types of tissue does a bronchial hamartoma contain?
Lung tissue and cartilage
79
Which type of lung cancer is not amenable to resection?
Small cell
80
What are some of the paraneoplastic syndromes that can be seen with small cell lung cancer?
Lambert-Eaton syndrome (antibodies against presynaptic calcium channels), ADH-producing tumor, ACTH-producing tumor
81
What are Kulchitsky cells?
Neuroendocrine cells (small, dark, blue cells) seen in small cell lung cancer.
82
What is the most common lung tumor in male smokers?
Squamous cell carcinoma
83
What are two major histologic characteristics of squamous cell carcinoma?
Intercellular bridging or keratin pearls
84
What is a common paraneoplastic syndrome seen with squamous cell carcinoma?
Hypercalcemia (tumor produces parathyroid-related peptide)
85
What lung tumor is cavitating?
Squamous cell carcinoma
86
What protein is released by squamous cell carcinoma to cause hypercalcemia?
Parathyroid hormone-related protein
87
What is the most common lung tumor in nonsmokers?
Adenocarcinoma
88
What is the most common lung tumor in female smokers?
Adenocarcinoma
89
What is the histologic characteristic of adenocarcinoma of the lung?
Glandular appearance with mucin production
90
Where (anatomically) is adenocarcinoma of the lung typically located?
In the periphery of the lung
91
Biopsy of a lung mass shows no evidence of intercellular bridging, keratin pearls, gland formation, or mucin. What is it?
Large cell carcinoma.
92
Bronchioloalveolar carcinoma is a cancer of which cells?
Clara cells
93
What is the hisologic appearance of bronchioloalveolar carcinoma?
Walls of alveolar air sacs replaced by columnar cells - apparent "thickening" of alveolar walls
94
What is the classic presentation of bronchioalveolar carcinoma on CXR?
Hazy infiltrates, similar to pneumonia
95
What is the prognosis of bronchioloalveolar carcinoma?
Excellent
96
Lung carcinoid tumor can be stained with..
Chromogranin
97
How can lung carcinoid tumor be differentiated from small cell carcinoma?
Both are neuroendocrine tumors. Small cell carcinoma is poorly differentiated, carcinoid tumor is well differentiated.
98
What lung tumor presents as a polyp-like mass in the bronchus?
Carcinoid tumor
99
What is the classic appearance of metastasis to the lungs?
Cannonball appearance - multiple nodules
100
What is a unique place that lung cancer likes to metastasize?
Adrenal gland
101
Which primary lung tumor will most commonly affect the pleura?
Adenocarcinoma (grows on the periphery of the lung and can cause pleural puckering)
102
What are the signs and symptoms of SVC syndrome?
Distended head and neck veins with edema and blue discoloration of the arms and face.
103
What thoracic tumor shows psammoma bodies on histology?
Mesothelioma
104
What lung cancer results from a k-ras mutation?
Adenocarcinoma
105
What is lepidic spread?
Cancer spreading along alveolar septa like a picket fence. Seen in bronchioloalveolar carcinoma.
106
What lung tumor will have nodular growth with central necrosis and cavitations?
Squamous cell
107
Biopsy of a lung tumor shows cells with salt and pepper chromatin with nuclear molding. Dx?
Small cell carcinoma
108
What lung tumor is associated with peripheral leukocytosis/eosinophilis?
Large cell
109
What lung tumor is associated with amplification of myc oncogenes?
Small cell carcinoma
110
To what side does the trachea shift in a spontaneous pneumothorax?
The side of the collapsed lung
111
What is the most common cause of spontaneous pneumothorax?
Rupture of apical blebs (seen in tall, thin males)
112
To what side does the trachea shift in a tension pneumothorax?
Away from the lesion
113
What are the three types of atelectasis?
Resorption (obstructive), compression, contraction
114
What causes resorption atelectasis?
Complete obstruction of airway (asthma, chronic bronchitis, bronchiectasis, foreign bodies)
115
To which side does the mediastinum shift with resorption atelectasis?
Toward the atelectatic lung
116
Explain the pathophysiology of resorption atelectasis.
Complete obstruction of the airway causes diminished lung volume. As a result, the mediastinum shifts TOWARDS the atelectatic lung.
117
How do you treat resorption atelectasis?
Remove the obstruction (it is also known as obstructive atelectasis)
118
To what side does the mediastinum shift in a compression atelectasis?
AWAY from the atelectatic lung (an example is a tension pneumothorax)
119
Explain the pathophysiology of compression atelectasis.
Something in the pleural cavity (air, fluid, tumor, etc.) causes compression of the lung, pushing the mediastinum AWAY from the atelectatic lung.
120
Which form of atelectasis is irreversible?
Contraction
121
What causes contraction atelectasis?
Fibrotic changes of the lung and/or pleura, preventing full expansion.
122
What are the 3 most common causes of otitis media?
Strep pneumo, H. influenza, Moraxella catarrhalis (gram - diplococci)
123
What serotypes of C. trachomatis cause neonatal conjunctivits?
D-K (from mom having an STD)
124
What are the two causes of neonatal conjunctivitis?
C. trachomatis (D-K), N. gonorrheae
125
What causes trachoma?
C. trachomatis A-C subtypes
126
What are the 3 F's of trachoma?
Fomites, flies, fingers (all 3 spread the disease)
127
How does trachoma cause blindness?
Repeated infection with C. trachomatis types A-C results in scarring and inversion of the eyelid. The eyelashes abrade the cornea, causing blindness. The disease is spread by the 3 F's: fingers, flies, fomites.
128
What is the most common cause of otitis externa?
Pseudomonas
129
What is the most common cause of viral conjunctivits?
Adenovirus (non-enveloped DNA virus) - swimming pool conjunctivitis.
130
What is the #1 cause of retinitis in AIDS patients?
CMV (herpesvirus - enveloped DS DNA)
131
What agar grows Fusarium?
Sabourad dextrose
132
What is Fusarium, what does it cause, and how do you get it?
Fusarium is a fungus (grows on sabourad dextrose) acquired through homemade contact lens solutions or trauma. It can cause keratitis of the eye and blindness.
133
What is Acanthamoeba, what does it do to your eyes, and how do you get it?
Acanthamoeba is a parasite acquired from deep water in lakes (association with contact lenses and swimming) that causes keratitis and blindness.
134
Explain the correlation between toxoplasmosis and blindness.
Mother is exposed (changing cat litter or eating contaminated food) during pregnancy, toxo crosses the placenta, and causes irreversible blindness to the child in the child's teens or 20s.
135
What receptor does rhinovirus use to enter cells?
ICAM-1 (zinc blocks ICAM-1, hence ZICAM)
136
What are some signs and symptoms of epiglottitis and in what patient population are you concerned about it?
Fever, sore throat, drooling, "catchers-stance", hoarsness, dysphagia. Concerned in unvaccinated individuals because it is caused by Hib.
137
What causes the green color of sputum?
Myeloperoxidase
138
After a lung transplant, what is most commonly attacked in a chronic rejection?
Small airways (bronchioles - bronchiolitis obliterans)
139
What is asbestosis?
Formation of fibrocalcific plaques on the parietal pleura with subsequent thickening and fibrosis of the lower lung.
140
What are ferruginous bodies?
Asbestos covered with a protein-iron matrix.
141
Which parts of the respiratory tree are within the conducting zone?
Large airways: nose, pharynx, trachea and bronchi
| small airways: bronchioles and terminal bronchioles
142
Where in the respiratory tree does cartilage and goblet cells extend to?
The end of bronchi
143
What is the purpose of the anatomic dead space of the respiratory tree?
The conducting zone warms, humidifies and filters the air
144
What is the epithelial lining to the end of the terminal bronchioles before you get into the respiratory zone?
pseudostratified ciliated columnar cells to beat mucus up and out of the lungs
145
what is included in the respiratory zone?
respiratory bronchioles, alveolar ducts, and alveoli
146
what is the epithelial lining in the respiratory bronchioles?
In respiratory bronchioles it's cuboidal cells then squamous cells up to the alveoli
147
which cell types in the lung participate in gas exchange?
Type 1 pneumocytes - squamous cells that line the alveoli
148
Which cell types secrete surfactant?
Type 2 pneumocytes - cuboidal cells that are clustered
149
What are Clara cells?
Nonciliated, columnar cells with secretory granules. Secrete components of surfactant, degrade toxins and act as reserve cells
150
Which lung cancer arises from Clara cells?
Bronchoalveolar caricinoma
151
how many lobes does the right lung have? the left lung?
Right - 3
| left - 2 (and lingula)
152
If a patient aspirates a peanut - no matter the position they are in where will it most likely go?
Via the right main stem bronchus into the inferior Right lobe
153
If a patient aspirate a peanut while upright - where will it go?
Via the right main stem bronchus into the lower portion of the inferior Right lobe
154
If a patient aspirate a peanut while supine- where will it go?
Via the right main stem bronchus into the superior portion of the inferior Right lobe
155
Describe the relation of the pulmonary artery to the bronchus at each lung hilus...
RALS
Right - Anterior
Left - Superior
156
What type of epithelium lines the trachea? How does this change in a smoker?
Ciliated columnar epithelium
| Smoker - squamous metaplasia
157
What is the mnemonic for the structures perforating the diaphragm and what are they?
I ate ten eggs at twelve
I ate - IVC 8
ten eggs - 10 esophagus (also the vagus)
at twelve - aorta 12 (also the thoracic duct and azygous vein)
158
Name 3 muscles you use for inspiration during exercise
External intercostals, scalenes, SCM
159
Name 5 muscles you use for expiration during exercise
rectus abdominus, internal and external obliques, transversus abdominus, internal intercostals
160
Where is the location of the largest amount of functional dead space?
In a health person - the apex of the lung
161
What is the equation for determining physiological dead space?
Vd = Vt x ((PaCO2 - PECO2)/PaCO2)
162
what is the lungs compliance?
The lungs ability to stretch during inspiration (change in lung volume for a given change in pressure)
163
What is FRC?
Functional residual capacity - the point at which the inward pull of the lung is balanced by the outward pull of the chest wall.
At this point - the airway and alveolar pressures are 0 and the intrapleural pressure is negative (preventing a pneumothorax)
164
Is FRC decreased or increased in emphysema?
FRC is increased in emphysema - The lungs are more compliant - barrel chested patients
165
Is FRC decreased or increased in patients with pulmonary fibrosis or edema?
FRC is decreased in pulmonary fibrosis or edema - these patients have decreased lung compliance, the total lung volume is decreased
166
Name 3 situations where you would see decreased lung compliance?
decreased in pulmonary fibrosis, pneumonia, and pulmonary edema
167
Name 2 situations where you would see increased lung compliance?
normal aging, emphysema
168
What is mean by the taut and relaxed forms of hemoglobin?
T = Taut = Tissue, taut form has low affinity for O2 to give it away to the tissue
R = Relaxed = Respiratory, Relaxed form has higher affinity for O2
169
Does hemoglobin exhibit positive or negative allostery?
Negative
but positive cooperativity
170
What side of the dissociation curve favors the taut form?
a right shift - Increased Chloride, increased H+, CO2, 2,3 BPG and increased temperature
171
Is the dissociation curve shifted to the right or left for fetal hemoglobin?
Fetal hemoglobin has lower affinity for 2,3 BPG and therefore higher affinity for O2 so it is shifted to the left
172
What's wrong with methemoglobin?
This is the oxidized form of hemoglobin (Fe 3+ ferric) that does not bind O2 as readily but has increased affinity for cyanide
173
What causes methemoglobin?
```
Nitrates/nitrites
anti-malarial drugs
dapsone
sulfonamides
metoclopramide
local anesthetics
```
174
What drug is known to gradually lower methemoglobin?
Cimetidine
175
How do I know the difference between Fe3+ and Fe2+
```
Ferric = 3+ = abC
Ferrous = 2+ = Ferrou2 - binds to O2 better
```
176
How do you treat methemoglobinemia?
Methylene blue + Vitamin C
177
How do you traet cyanide poisoning?
use nitrates to oxidze hemoglobin to methemoglobin which will bind up the cyanide - then use thiosulfate to bind this cyanide forming thiocyanide which is renally excreted
178
How is cyanide toxic?
It uncouples the electron transport chain by binding to cytochrome C
179
What's wrong with carboxyhemoglobin?
This form of hemoglobin is bound to CO instead of O2
180
What does hemoglobin bound to CO instead of O2 do to the dissociation curve?
It causes a left shift with a decreased in oxygen binding capacity - you get decreased oxygen unloading in tissues
181
How do you measure PO2?
Measured as a dissolved gas (arterial blood gas)
182
why doesn't myoglobin show the positive cooperativity that hemoglobin does?
Myoglobin is monomeric unlike hemoglobin which is a tetramer
183
if the dissociation curve shifts to the right - does that mean you have increased or decreased affinity for O2?
Decreased affinity for O2 - unload at the tissue
184
An increased in all factors, except pH, causes a shift of the curve to which way?
To the right - decreased affinity
185
What's the mnemonic for a right shift of the dissociation curve?
C-BEAT
CO2, BPG, Exercise, Acid/Altitude, Temperature
186
what is the progression that's seen in a patient with constant hypoxemia?
Low alveolar O2 --> chronic vasoconstriction --> pulmonary HTN --> cor pulmonale and subsequent RV failure
187
Name 3 conditions that exhibit a perfusion limited gas exchange limitation?
O2 (normal health), CO2, N2O
188
What is perfusion limitation?
Gas equilibrates early along the length of the capillary. Diffusion can be increased only if the blood flow is increased
189
Name 3 conditions that exhibit a diffusion limited gas exchange limitation?
O2 - emphysema, fibrosis, CO
190
What is a diffusion limitation?
Gas doesn't equilibrate by the time the blood reaches the end of the capillary
You get a decreased in area in emphysema and you get an increase in thickness in pulmonary fibrosis
191
At what pressure does a patient have pulmonary hypertension?
≥ 25mm Hg normal or ≥35 mm Hg during exercise
192
what's seen histiologically with pulmonary hypertension?
Arteriosclerosis, medial hypertrophy and intimal fibrosis of the pulmonary arteries
193
what is primary pulmonary hypertension?
BMPR2 gene inactivating mutation (bone morphogenic protein receptor 2)
194
What is the function of BMPR2 when it's working correctly?
inhibits vascular smooth muscle proliferation
195
Name some things that can cause secondary pulmonary hypertension?
```
COPD
Mitral stenosis
recurrent thromboemboli
autoimmune disease
left to right shunt
sleep apnea
living at high altitude (hypoxic vasoconstriction)
```
196
What is the equation for pulmonary vascular resistance?
PVR = (P in pulmonary artery - P in L atrium) / Cardiac output
197
A patient presents with normal Pa O2, decreased SaO2 and decreased O2 content - what might they have?
CO poisoning
198
What is SaO2?
% saturation
199
A patient presents with normal PaO2, normal SaO2 and decreased O2 content - what might this be?
Anemia - low Hb
200
A patient presents with normal PaO2, normal SaO2 and increased O2 content - what might this be?
Polycythemia - increased Hb
201
What is the O2 content of the blood?
O2 content = (O2 binding capacity x O2 saturation) + dissolved O2
202
what causes O2 content of the blood to decrease without changing the O2 saturation or arterial PO2?
decreased hemoglobin
203
What is the equation for oxygen delivery to tissues?
Oxygen deliver to tissues = cardiac output x oxygen content of the blood
204
What is the alveolar gas equation?
PAO2 = 150 - PaCO2/0.8
205
what occurs as you increased alveolar PCO2?
alveolar PO2 decreases
206
what is the value for a normal A-a gradient?
A-a gradient = PAO2 - PaO2 = 10-15 mmHg
207
What can cause an increased A-a gradient?
Hypoxemia
| causes include R to L shunting, V/Q mismatch, or fibrosis (diffusion limitation)
208
What causes hypoxemia but still has a normal A-a gradient?
High altitude or hypoventilation
209
What is normal value of PaO2/FiO2?
normally 300 - 500
| < 200 = severe hypoxia (like in ARDS)
210
A patient inhaled a piece of food - what are going to see on V/Q?
This is an airway obstruction = SHUNT
V/Q = 0; in a shunt, 100% O2 will not improve PO2
you have low ventilation and high perfusion
211
A patient gets a PE - what are you doing to see on V/Q?
This is a blood flow obstruction = PHYSIOLOGICAL DEAD SPACE
| V/Q = infinity; assuming s not being perfused
212
Does V/Q increased or decreased during exercise?
V/Q decreases during exercise because you get vasodilation in the lungs
This leads to increased perfusion in the apices so you're not wasting as much ventilation
213
Describe what's happening at the apex of the lung in terms of ventilation and perfusion
Apex has decreased perfusion over all (increased V and decreased Q)
so V/Q = >1, it's wasted ventilation -- physiologic dead space
214
What is V/Q at the apex of the lung?
```
Apex = top of the lung
V/Q = >1
```
215
why does TB prefer the apices of the lung upon reactivation?
more oxygen
216
Describe what's happening at the base of the lung in terms of ventilation and perfusion
The base has increased perfusion over all
V/Q = <1
This is a form of shunting - the blood leaves the lungs without being adequately oxygenated
Gravity pulls more blood down tot he bases so perfusion is better in the base of the lung than the apex
217
What are the pressures in Zone 1 of the lung?
Zone 1 = apex
| PA>Pa>PV
218
What are the pressures in Zone 2 of the lung?
Zone 2 = middle
| Pa>PA>PV
219
What are the pressures in Zone 3 of the lung?
Zone 3 = base
| Pa>Pv>PA
220
How is CO2 transported in the lungs?
Bicarbonate (90%)
Carbaminohemoglobin of HbCO2 (5%)
Dissolved CO2 (5%)
221
What is the Haldane effect?
In the lungs, the oxygenated of Hb promotes dissociation of H+ from Hb. this shifts equilibrium toward CO2 formation - therefore, CO2 is released from the RBCs
222
What is the Bohr effect?
In peripheral tissues, Increased H+ from tissue metabolism shifts the dissociation curve tot he right resulting in unloading of O2
223
A person climbs a bajillion feet to the top of a mountain and they decide they want to live there. They are ventilating - what is your kidney going to start to excrete more of?
Bicarb - this compensates for the respiratory alkalosis due to hyperventilating.
224
What drug can you use to help with high altitudes?
Acetazolamide - gets rid of XS bicarb
225
what is Virchow's triad?
1. stasis
2. hypercoagulability (defect in coag cascade proteins - most commonly factor V leiden) or xs estrogen, sickle cell, polycythemia
3. endothelial damage (exposed collagen triggers clotting cascade)
226
A patient presents after hip surgery with calf pain and a positive homans sign - and a palpable cord in their leg - how should you treat them?
This is a DVT
You want to acutely manage with heparin (should have been given to prevent it) and use warfarin for long term prevention of DVT recurrence
227
What's the concern with a DVT?
can lead to a pulmonary embolus
228
What is Homan's sign?
Positive in a DVT - dorsiflexion of the foot leads to calf pain
229
Name the emboli: Long bone fracture and liposuction
Fat embolus
230
Name the emboli: Caisson disease - decompression illness from rising too quickly while diving
Air embolus
231
If you have a defect in the perfusion phase when you check a V/Q scan - what should you think?
Possible PE
232
A patient presents with a sudden-onset of dyspnea, chest pain, tachypnea. They have hypoxemia, neurologic abnormalities and a petechial rash - what is happening?
PE
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A patient gets a PE and develops DIC - what most likely happened?
They probably just delivered a baby and got an amniotic fluid emboli
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What is the imaging test of choice for a PE?
CT pulmonary angiography
235
What will you see on an EKG with a PE?
most PE's are minor so you will see non-specific ST segment and T wave changes
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What will you see on an EKG with a MASSSIVEEE like patient is freaking out vitals all over the place PE?
S1 Q3 T3 - wide S in lead 1, large Q and inverted T in lead 3
due to increased pressure and volume to RV
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What will you see the A-a gradient do when a patient has PE?
A-a gradient will be increased
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Where will a particle between 10-15 um get trapped?
URT
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Where will a particle between 2.5 - 10 um get trapped?
particles enter trachea and bronchi but are cleared by mucocilliary transport
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Where will a particle less than 2 um get trapped?
will reach terminal bronchiole and alveoli and get phagocytosed by alveolar macrophage
241
what are the lines of Zahn?
Interdigitating areas of pink and red found in thrombi formed BEFORE death = pre-mortem PE
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Name the 4 types of Obstructive lung diseases
Chronic bronchitis, emphysema, asthma and bronchiectasis
243
Name some times of restrictive lung diseases?
poor breathing mechanics due to poor effort or poor structural
interstitial lung diseases - ARDS, pneumoconiosis, Sarcoidosis, idiopathic pulmonary fibrosis, goodpastures, Wegener's, langerhans histiocytosis, hypersensitivity pneumonitis, drug toxicity
244
why do you have to be careful when you supplement O2 to COPD patients?
hypoxia drives their respiratory function - whereas in normal patients the PCO2 mediates respiratory drive - in patients with longstanding COPD - O2 supplementation can lead to respiratory suppression and coma
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What is the main problem with COPD?
Obstruction - obstructed from getting are OUT of the lung
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What is the main problem in restrictive diseases?
Can't fill the lung
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COPD is a disease of the....
small airways
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A patient presents with wheezing, crackles, cyanosis (early onset hypoxemia due to shunting) and late onset dyspnea
Chronic bronchitis
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How do you determine a patient has chronic bronchitis?
Productive cough for > 3 months per year (not necessarily consecutive) for >2 years
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Name the disease: Hypertrophy of mucus-secreting glands in the bronchi leading to in Reid index of >50%
Chronic bronchitis
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What leisurely activity do patients with chronic bronchitis most likely partake?
smoking
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Why does air get trapped in patients with obstructive lung diseases?
Airways close prematurely at high lung volumes
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A patient has an increased RV, decreased FVC and they have a decreased FEV1/FVC ratio
Obstructive lung disease
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A patient has enlarged air spaces and decreased recoil due to a loss of elastic fibers
Emphysema
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Emphysema associated with smoking
Centriacinar
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Emphysema associated with alpha 1 anti-trypisin deficiency
panacinar
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What other organ is typically involved with panacinar emphysema?
The liver
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A patient presents with a barrel chest, hyperinflated lungs with flattening of the diaphragm and blunting of the costophrenic angles, they are very thin and breath through pursed lips - what is this and why do they do this?
Emphysema - they need to increased airway pressure to prevent airway collapse during respiration
259
What is a Hoover sign?
Seen in emphysema
Hyperexpansion of the lungs due to air trapping causes the diaphragm to flatten, which causes it to contract inward instead of down - thereby paradoxically pulling the inferior ribs inwards during inspiration
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Name the disease: bronchial hyperresponsiveness causes reversible bronchoconstriction leading to smooth muscle hypertrophy
Asthma
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What will you see on histology of a patient with asthma?
Curschmann's spirals, Charcot Leyden crystals,
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What are Curschmann's spirals?
Seen in asthma, shed epithelium forms mucus plugs
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What are Charcot Leyden crystals?
Seen in asthma, formed from breakdown of eosinophils in sputum
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How can you test Asthma?
Methacholine challenge
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A patient presents with coughing, wheezing, tachypnea, dyspnea, hypoxemia, decreased inspiratory/expiratory ratio, pulsus paradoxus and mucus plugging
Asthma attack
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What is Bronchiectasis?
Obstructive lung disease
Chronic necrotizing infection of bronchi leading to permanently dilated airways, purulent sputum, recurrent infections, hemoptysis
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What are some conditions that can be associated with Bronchiectasis?
Bronchial obstruction, poor ciliary motility (smoking), Kartagener's, cystic fibrosis, allergic bronchopulonary aspergillosis
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What can you see in the brain due to COPD?
Decreased cerebral vascular resistance...
A patient with long standing COPD is likely to have hypoxia and hypercapnea - the hypercapnia produces cerebral vasodilation via a decreased in cerebral vascular resistance - so you get increased cerebral blood flow
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a patient has decreased TLC but they have an increased FEV1/FVC ratio - what is this?
Restrictive lung disease
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In what type of restrictive lung disease will you still have a normal A-a gradient?
Poor muscular effort or poor structural apparatus leading to poor breathing mechanics
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In what type of restrictive lung disease will you see an increased A-a gradient?
Interstitial lung diseases
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Name 4 types of Pneumoconioses
Anthracosis
Silicosis
Asbestosis
Berylliosis
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Name the Pneumoconioses: Associated with coal mines - affects the upper lobes, is not associated with smoking and there's no increased risk of lung cancer
Anthracosis
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What is Caplan syndrome?
Coal worker's pneumoconioses + rheumatoid arthritis
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Name the Pneumoconioses: associated with foundries, sandblasting, and mines
Silicosis
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Name the Pneumoconioses: Macrophages eat the particles but phagolysome formation is impaired
Silicosis
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Name the Pneumoconioses: INCREASED risk of infection with TB
Silicosis
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Name the Pneumoconioses: Increased risk of bronchogenic carcinoma
Silicosis
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Name the Pneumoconioses: Affects upper lobes and causes an "egg shell" calcification of the hilar lymph nodes
Silicosis
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Name the Pneumoconioses: Associated with shipbuilding, roofing and plumbing
Asbestosis
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Name the Pneumoconioses: Ivory white clacified pleural plaques are pathonomonic of this - are NOT precancerous
Asbestosis
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Name the Pneumoconioses: Associated with in increased incidence of bronchogenic carcinoma and mesothelioma
Asbestosis
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Name the Pneumoconioses: Affects the lower lobes and has dumbbell shaped golden brown rods
Asbestosis
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Name the Pneumoconioses: Seen in mining and people that work in aerospace indusrty
Berylliosis
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Name the Pneumoconioses: Noncaseating granulomas in the lung, hilar lymph nodes and systemic organs and have an increased risk of cancer. Seen in mining and people that work in aerospace indusrty
Berylliosis
286
What causes neonatal respiratory distress syndrome?
Premature birth with a lecithin:sphingomyelin ratio <1.5
287
Why can maternal diabetes lead to neonatal respiratory distress syndrome?
The mom's excess glucose leads to increased insulin in the baby which leads to decreased surfactant production
288
What's the concern with giving O2 for neonatal respiratory distress syndrome?
may result in blindness due to hyperoxemia because oxygen free radicals can damage the retinal arteries
289
what is normal FEV1/FVC ratio?
80%
290
what is a potential late finding seen in acute respiratory distress syndrome?
a progressive interstitial fibrosis = restrictive lung disease
due to repair of the lungs
291
In what situations do you see hyaline membrane deposition in the alveoli?
ARDS and Neonatal RDS
292
what progression can be seen in sleep apnea?
Hypoxia --> increased EPO released --> increased erythropoiesis
293
What's the lung abnormality: Decreased breath sounds, dull percussion, decreased fremitus
Pleural effusion
294
What's the lung abnormality: Decreased breath sounds, dull percussion, decreased fremitus and tracheal deviation toward the side of problem
Atelectasis (bronchial obstruction)
295
What's the lung abnormality: Decreased breath sounds, hyperresonant percussion, decreased fremitus and tracheal deviation toward the side of problem
Spontaneous pneumothorax
296
What's the lung abnormality: Decreased breath sounds, hyperresonant percussion, decreased fremitus and tracheal deviation AWAY from the side of problem
Tension pneumothorax
297
What's the lung abnormality: bronchial breath sounds with late inspiratory crackles, dull percussion and increased fremitus
Consolidation (like in lobar pneumonia or pulmonary edema)
298
What type of breathing is commonly seen in congestive heart failure or in increased intracranial pressure?
Cheyne-Stokes Respirations
299
What is the most common cause of cancer?
Metastatic! from breast, colon, prostate and bladder
300
Where does lung cancer like to go?
Adrenals, brain, bone, liver
301
Name the lung cancer: Located peripherally, is CEA + and is associated with k-ras activating mutation
Adenocarcinoma
302
Name the lung cancer: most common lung cancer in nonsmokers and in smoking females
Adenocarcinoma
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Name the lung cancer: contains glands or mucin and is located peripherally
Adenocarcinoma
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Name the lung cancer: CXR shows hazy infiltrates like a pneumonia because the tumor cells are columnar cells that grow along bronchioles and alveoli
Bronchioalveolar carcinoma
305
Name the lung cancer: is a subtype of Adenocarcinoma
Bronchioalveolar carcinoma
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Name the lung cancer: grows along alveolar septa leading to apparent "thickening" of alveolar walls, has a very good prognosis
Bronchioalveolar carcinoma
307
Name the lung cancer: Centrally located, Hilar mass arising from the proximal bronchus, associated with smoking and cavitary lesion, also produces PTHrP leading to hypercalcemia and low PTH levels
Squamous cell carcinoma
308
Name the lung cancer: Keratin pearly and intercellular bridging
Squamous cell carcinoma
309
Name the lung cancer: Undifferentiated and very aggressive, located centrally and commonly has amplification of myc oncogenes
Small cell carcinoma
310
Name the lung cancer: Neoplasm of neuroendocrine Kulchitsky cells leading to small dark blue cells
Small cell carcinoma
311
Name the lung cancer: May produce ACTH, ADH or antibodies against presynaptic calcium channels
Small cell carcinoma
312
Name the lung cancer: Inoperable tumor that is treated with chemotherapy
Small cell carcinoma
"too small for the surgeons to see"
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Name the lung cancer: Peripheral highly anaplastic undifferentiated tumor with a poor prognosis that gets removed surgically because it doesn't really respond to chemo
Large cell carcinoma
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Name the lung cancer: Excellent prognosis, has nests of neuroendocrine cells that are chromogranin positive
Bronchial carcinoid tumor
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Name the lung cancer: Symptoms are usually due to a mass effect, you may see a carcinoid syndrome with serotonin secretion leading to flushing, diarrhea and wheezing
Bronchial carcinoid tumor
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Name the lung cancer: Psammoma bodies within the pleura results in hemorrhagic pleural effusions and pleural thckening
Mesothelioma
317
Where else can you see a mesothelioma besides the pleura?
in peritoneum, pericardium and tunica vaginalis
318
What are the most common causes of lobar pneumonia?
S. pneumonia most frequently, klebsiella
319
What are the most frequent causes of Bronchopneumonia?
S pneumo, S aureus, H flu, Klebsiella
320
Which pneumonia has acute inflammatory infiltrates with patchy distribution in 1 or more lobes?
Bronchopneumonia
321
Which pneumonia involves patchy inflammation localized to interstitial areas at alveolar walls only?
interstitial atypical pneumonia
322
What causes interstitial pneumonia
viruses (RSV, adenovirus, influenza), mycoplasma, legionella, chlamydia
323
what are the gross phases of lobar pneumonia?
congestion
red hepatization
gray hepatization
resolution
324
what are the most common bacteria seen in aspiration pneumonia leading to a lung abscess?
anaerobes: fusobacterium, bacteroides, peptostreptococcus
| also S aureus
325
What type of hypersensitivity is seen in hypersensitivity pneumonitis?
Mixed type III/IV HS reaction to environmental antigen
326
Name the pleural effusion: decreased protein content, due to CHF, nephrotic syndrome or hepatic cirrhosis
Transudate
Transudate = transparent
327
Name the pleural effusion: increased protein content, cloudy. Due to malignancy, pneumonira, collagen vascular disease, trauma
Exudate
must be drained in light of risk of infection
328
Name the pleural effusion: due to thoracic duct injury from trauma, malignancy, milky-appearance, has increased triglycerides
Lymphatic aka chylothorax
329
What's the leading cause of a chylothorax?
lymphoma
330
A patient presents with a unilateral chest pain and dyspnea. they have unilateral chest expansion, decreased tactile fremitus, hyperresonance and diminished breath sounds - what's happening?
pneumothorax
331
What type of pneumothorax has an accumulation of air in the pleural space, occurs most frequently in tall, thin, young males due to rupture of apical blebs and causes the trachea to deviate toward the affected lung?
Spontaneous pneumothorax
332
What type of pneumothorax usually occurs in a setting of trauma or lung infection and leads to air entering the pleural space but not able to exit and leads to the trachea deviating away from the affected lung?
Tension pneumothorax
333
what is the gold standard treatment for tension pneumothorax?
chest tube at midaxillay 4th intercostal space
334
What is the rough and dirt job for treating tension pneumothorax?
needle thoracostomy is immediate and life saving in someone with dropping vital signs - this is midclavicular needle insertion at the 2nd intercostal space
335
Name 3 first generation H1 blockers
Diphenhydramine, dimenhydrinate, chlorpheniramine
336
Name 4 2nd generation H1 blockers
Loratadine, fexofenadine, desloratadine, cetirizine
337
What drug relaxes bronchial smooth muscle via Beta 2 and is used during acute exacerbation of asthma
Albuterol
338
What drug is long acting agent beta 2 agonist used for prophylaxis
Salmeterol, formoterol
339
What are the adverse side effects of Salmeterol and formoterol?
tremor and arrhythmia
340
What drug is a methyxanthing?
Thophylline
341
How does theophylline work?
likely causes bronchodilation by inhibiting phosphodiesterase leading to increased cAMP levels due to decreased cAMP hydrolysis
342
What drug does theophylline block?
denosine
343
Why do you use theophylline?
TX COPD or asthma
344
Name two muscarinic antagonists for treating bronchoconstriction and COPD
Ipratropium and tiotropium
345
What are the side effects of Ipratropium and tiotropium?
metallic taste and a cough
346
What corticosteroids are first line therapy for chronic asthma?
Beclomethasone, fluticasone
347
How do Beclomethasone and fluticasone work?
Inhibit synthesis of cytokines - inactivates NF-kB which is the transcription factor that induces the production of TNF-alpha
348
Which antileukotrienes block the leukotriene receptor?
Montelukast and zafirlukast
349
What antileukotrienes are good for aspirin induced asthma?
Montelukast and zafirlukast
350
How does Zileuton work?
5-lipoxygenase pathway inhibitor - blocks conversion of arachidonic acid to leukotrienes
351
How does Omalizumab work?
Monoclonal anti-IgE antibody that binds mostly unbound serum IgE
352
When would you use Omalizumab?
Used in allergic asthma resistant to inhaled steroids and long acting beta 2 agonists
353
What is Guaifenesin?
Expectorant - thins respiratory secretions but does NOT suppress the cough reflex - would want to give a cough suppressant with it
354
How is N-acetylcysteine a mucolytic?
Loosens mucous plugs in CF patients by cleaving disulfide bonds within mucous glycoprotein
355
What is Bosentan use to traet?
pulmonary arterial hypertension
356
how does Bosentan work?
competitively antagonizes endothelin-1 receptors, decreasing pulmonary vascular resistance
357
What is dextromethorphan?
Antitussive that antagonizes NMDA glutamate receptors.
358
What is dextromethorphan an analog of?
Synthetic analog of codeine - has mild opioid effect when used in XS and has mild abuse potential
Naloxone can be given for overdose
359
How do pseudoephedrine and phenylephrine work?
sympathomimetic alpha agonistic nonprescription nasal decongestants
360
What would you use pseudoephedrine and phenylephrine for?
reduces hyperemia, edema and nasal congestion; open obstructed Eustachian tubes
pseudoephedrine is also used as a stimulant
361
What is the toxicity seen with pseudoephedrine and phenylephrine?
Hypertension
pseudoephedrine can also cause CNS stimulation/anxiety
362
What is Methacholine?
Muscarinic receptor agonist - used in asthma challenge testing
