RESPIRATORY Flashcards
1
Q
Where do the small airways technically begin?
A
bronchioles and end at terminal bronchioles
2
Q
Give a description of what the “anatomic dead space” is (no equation)
A
This is the air that is in the conducting zone of the respiratory system
3
Q
Which structures are no longer found after the bronchi (2)? Which are no longer found after the terminal bronchioles?
A
Cartilage and Goblet cells; Pseudostratified ciliated epithelium and smooth muscle (it is sparse beyond here)
4
Q
Which “bronchioles” are present in the respiratory zone?
A
Respiratory bronchioles; terminal bronchioles are the last structures of the conducting zone
5
Q
What is the epithelium of the conducting zone? The Respiratory zone?
A
Conducting zone = pseudostratified columnar; Respiratory zone = Cuboidal in respiratory bronchioles and then simple squamous
6
Q
Histology of Type I pneumocyte
A
Simple squamous
7
Q
Why are alveoli most likely to collapse in expiration?
A
The Collapsing pressure = 2(surface tension)/Radius? Since the radius decreases in expiration, the pressure to collapse is greatly increased
8
Q
What is the significance of the lecithin to sphingomyelin ratio?
A
indicates fetal lung maturity? >2 is adequate
9
Q
How do type II pneumocytes decrease the collapsing pressure?
A
P = 2(surface tension)/R? By decreasing surface tesnion, surfactant decreases the numerator leading to lower collapsing pressure
10
Q
When does surfactant synthesis begin? When are lungs mature? What ratio do you use?
A
26, 35, Lecithin:sphingomyelin >2
11
Q
What is the homologue of the right lung middle lobe in the left lung?
A
Lingula
12
Q
Where will a peanut go if aspirated when upright? When supine?
A
Upright = lower portion of right inferior lobe; Supine = superior portion of right inferior lobe
13
Q
Discuss the relation of the right and left pulmonary arteries with respect to the right and left mainstem bronchi
A
Right pulmonary artery is anterior to right bronchus; Left pulmonary artery is superior to left bronchus
14
Q
What 2 structures pierce the diaphragm at T10?
A
Esophagus and Vagal trunks
15
Q
What 3 structures pierce the diaphragm at T12?
A
Aorta, Thoracic duct, Azygos vein
16
Q
Air that can still be breathed in after normal inspiration
A
Inspiratory reserve volume (IRV)
17
Q
Air that moves into lung with each quiet inspiration (typically 500 mL)
A
Tidal volume (TV)
18
Q
Air that can still be breathed out after normal inspiration
A
Expiratory reserve volume (ERV)
19
Q
Air in lung after maximal expiration and cannot be measured on spirometry
A
Residual volume
20
Q
IRV + TV
A
Inspiratory capacity
21
Q
RV + ERV (volume in lungs after normal expiration)
A
Functional Residual capacity
22
Q
TV + IRV + ERV (maximum volume of gas that be expired after maximal inspiration)
A
Vital Capacity
23
Q
IRV + TV + ERV + RV
A
TLC (volume of gas in lungs after a maximal inspiration)
24
Q
What is the inspiratory reserve volume?
A
Air that can be breathed in after a normal inspiration
25
What is the tidal volume?
Normal amount of air moving into lung with each inspiration (500 mL)
26
What is the expiratory reserve volume?
Air that can still be breathed out after normal expiration
27
What is the residual volume?
The amount of air in the lung after a maximal expiration
28
What is the inspiratory capacity?
IRV + TV (That is the normal amount inspired plus that which can be inspired on top of it)
29
What is the Functional residual capacity?
RV +ERV (volume in lungs after normal expiration? So the amount of air that can be breathed out after a normal expiration (ERV) plus that which remains after that (RV))
30
What is the vital capacity?
TV + IRV + ERV (maximum volume of gas that can be expired after a maximal inspiration)
31
What is the total lung capacity?
IRV + TV + ERV + RV (volume of gas in lungs after maximal inspiration)
32
How do you calculate Physiologic dead space?
Vd = Vt [(PaCo2 - PeCO2)/PaCO2]
33
What is the physiological deadspace? Explain in words
It is the anatomic deadspace plus the functional deadspace in alveoli
34
What part of the healthy lung is the largest contributor of functional deadspace?
Apex of lung
35
Regarding the physiology of the lung and chest wall, what is the significance of FRC?
FRC (i.e. the volume of air in the lungs after normal expiration (RV +ERV)) is the point at which the outward pull of the chest wall is balanced by the inward pull of the lungs
36
What forms of Hb (T and R) have high and low affinity for O2?
Taut form has low affinity for O2, relaxed form has high affinity for O2
37
Chloride, H, CO2, temperature, and 2,3-DPG favor (T or R) form of Hb?
Taut (i.e. the low affinity form) this way, Hb gives off O2
38
What 5 factors favor the taut form of Hb over the relaxed form?
Chloride, CO2, H, temperature, and 2,3-DPG
39
Which form of hemoglobin has the lowest affinity for 2,3 DPG?
Fetal Hb (allows it to be left-shifted and therfore to have higher affinity for O2 than mom leading to fetal oxygenation)
40
Which tissues have taut Hb and relaxed Hb?
Taut is in (peripheral) tissues; R (relaxed) form is in respiratory tissues
41
Why does fetal Hb have a higher affinity for O2 than adult?
Because fetal Hb has a lower affinity for 2,3, DPG which normally causes a right shift
42
EXPLAIN the treatment of cyanide poisoning (2 aspects)
Nitrites oxidize hemoglobin to methemoglobin which will bind up the cyanide, this allows cytochrome oxidase (complex IV) to function; Thiosulfate is given to bind up the cyanide to form thiocyanate which is renally excreted
43
How do you treat methemoglobinemia?
Methylene blue
44
Why are nitrites toxic to Hb? This is exploited in the Tx of what?
They oxidize Fe2 to Fe3 (methemoglobin); This is exploited in cyanide poisoning because Fe3 (methemoglobin) will bind to cyanide which allows cytochrome oxidase to fxn
45
What is the shift in O2 binding curve when carboxyhemoglobin is present?
Left shift (this is carbon monoxide poisoning)
46
Why does the myoglobin-O2 curve lack a sigmoidal shape?
Myoglobin is a monomer and thus, cannot display cooperativity with its subunits like Hb
47
What would alkaline blood do to the HbO2 curve?
It would cause a left shift, (Haldane effect)
48
When is gas equilibration with capillary diffusion limited? Perfusion limited?
Diffusion limited in fibrosis and emphysema; perfusion limited in normal health
49
What does perfusion limited gas equilibration mean?
It means more gas can diffuse into the bloodstream only if there is an increase in perfusion to the lung
50
What does diffusion limited gas equilibration mean?
it means that the gas has not equilibrated by the time it reaches the end of the capillary, more perfusion will not help!
51
How do you know if someone ahs pulmonary HTN?
\>25 mmHg resting or \>35 exercising
52
An activating mutation of the BMPR2 gene is likely to cause \_\_\_\_\_\_\_\_\_\_
Primary pulmonary HTN (normally funtions to inhibit smooth muscle proliferation)
53
What is the genetic basis of primary pulmonary HTN?
Activating mutation of BMPR2 (normally functions to inhibit smooth muscle proliferation)
54
Why do recurrent PE's lead to pulmonary HTN?
it decreases the cross-sectional area of the pulmonary vascular bed
55
How do you calculate pulmonary vascular resistance?
PVR = (Ppulm artery - P left atrium)/CO
56
How much O2 can be bound by 1g of Hb?
1.34 mL O2
57
How do you calculate O2 content?
O2 content = (O2 binding capacity x %sat) + dissolved O2
58
How do you approximate the alveolar gas equation?
PAO2 = 150 - (PaCO2/0.8)
59
What would increase the A-a gradient?
This is how much more O2 is in the alveoli than the blood; shunting, V/Q mismatch, and fibrosis (impairs diffusion)
60
What are 2 causes of normal A-a gradient hypoxemia?
Hypoventilation and High altitude
61
What is V/Q at the apex? What is V/Q at the base?
Apex V/Q = 3; Base V/Q = 0.6 (Apex has wasted ventilation, ideal for TB; Base has wasted perfusion!)
62
What is greater at the base of the lung? Ventilation or perfusion?
BOTH! But V/Q ratio is greater at the apex
63
What happens to the V/Q ratio at the apex of the lung in exercise?
Decreases because Q is increasing!
64
What happens to V/Q in a shunt?
Approaches 0 (airway obstruction)
65
What happens to V/Q in a blood flow obstruction?
Approaches infinity, i.e. physiologic dead space increases
66
What are the 3 forms that CO2 is transported from tissues to lungs?
Bicarb (most), Carbaminohemoglobin (HBCO2)? CO2 bound to N-terminis of GLOBIN not heme, and dissolved CO2
67
Where on Hb does CO2 bind?
to N-terminis of the GLOBIN (carbaminohemoglobin)
68
What is the Haldane effect?
This is when oxygenation in the lungs promotes H dissociation from Hb leading to CO2 formation
69
Why could living at a high altitude lead to RVH?
Since there is a low PO2, there is chronic hypoxic pulmonary vasoconstriction that leads to increased resistance
70
What is the most common cause of hypercoagulability?
Factor V Leiden
71
What is a likely cancer to cause a tumor pulmonary embolus?
Renal Cell CA
72
What increase in Reid index is observed in Chronic bronchitis?
greater than 50%
73
What airways are affected by chronic brochitis?
Small airways
74
What is the timeline for chronic bronchitis?
Productive cough for \> 3 months (doesnt have to be consecutive) for over 2 years
75
Why do emphysema pts exhale through pursed lips?
increases airway pressure to prevent airway collapse during expiration
76
What is the main association with centriacinar emphysema?
smoking
77
What is a Curschmann spiral?
Shed epithelium in mucus plugs
78
What is a Charcot Leyden crystal
breakdown product of eosinophil membrane protein
79
What test is used for asthma?
Methacholine challenge test
80
Which obstructive airway disease involves smooth muscle hypertrophy?
Asthma
81
Which colonizing disease can cause bronchiectasis?
Allergic Bronchopulmonary Aspergillosis
82
What are 2 causes of poor breathing due to structural abnormalities?
Scoliosis and morbid obesity
83
4 drugs that can cause restrictive lung disease
Methotrexate, Busulfan, Bleomycin, and Amiodarone
84
Which interstitial lung disease is associated with pathologic fractures?
Langerhans histiocytosis (Eosinophilic granuloma)
85
What is the cause of idiopathic pulmonary fibrosis?
repeated cycles of lung injury with wound healing and collagen deposition in interstitium
86
Which pneumoconiosis increases susceptibilities to TB and why?
Silicosis because silica may inhibit phagolysosomal fusion
87
What causes "Eggshell" calcifications of hilar lymph nodes?
Silicosis
88
Silicosis increases risk for what 2 things?
Bronchogenic carcinoma and TB
89
Which pneumoconioses affect the upper lobes? Lower lobes?
Upper lobes = Silicosis and Anthracosis; Lower lobes = Asbestosis
90
Ivory white calcified pleural plaques
pathognomonic feature of asbestos exposure, NOT precancerous
91
Which pneumoconisosis is associated with shipbuilding, roofing, and plumbing?
Asbestosis
92
What lecithin:sphingomyelin ratio is predictive of neonatal RDS?
2 is normal
93
What are 2 untoward effects of giving supplemental O2 to neonatal respiratory distress syndrome
Retinopathy of prematurity; Bronchopulmonary dysplasia
94
3 risk factors for neonatal RDS
Prematurity (not enough surfactant); maternal diabetes (too much fetal insulin); cesarian delivery = not enough glucocorticoids from stress of birth which causes development of surfactant
95
What are 2 ways to treat neonatal RDS?
Can give artificial surfactant but can also give maternal steroids before birth
96
What is the hallmark of ARDS?
DIFFUSE ALVEOLAR DAMAGE with formation of intra-alveolar hyaline membrane
97
Where is the tracheal deviation in 1) Atelectasis from bronchial obstruction 2) Spontaneous pneumothorax 3) Tension pneumothorax
1) toward 2) toward 3) away
98
Which peripherally located lung cancer bares a poor prognosis?
Large cell carcinoma
99
What is a Kulchitsky cell?
A neuroendocrine cell in small cell carcinoma (chromogranin positive)
100
What is the most common thing to see on Xray of lung CA?
Calcified Coin lesion
101
What is the most common cause of metastasis to adrenals?
lung cancer
102
What lung cancer is associated with k-ras activating mutations? Which amplifies myc oncogenes?
k-ras = adenocarcinoma; L-myc = small cell carcinoma
103
What would be a likely V/Q in lung cancer?
0; airway obstruction
104
Which lung cancer is associated with hypertrophic osteoarthropathy?
adenocarcinoma
105
What mutation is seen in adenocarcinoma of the lung? What other type of cancer displays this?
K-ras; also seen in colorectal carcinoma
106
Which type of lung cancer looks most similar to pneumonia?
Bronchioloalveolar because follows the bronchioles
107
What genetic mutation is implicated in small cell carcinoma?
myc oncogene amplification
108
What is the eponym for the malignant cells of small cell CA?
Kulitschky cells
109
Where do lung carcinoid tumors occur?
In bronchi
110
What can be seen on the histology of mesothelioma?
Psammoma body (keratin pearls are eosinophilic, psammoma bodies are basophilic)
111
What is facial plethora?
impaired blood drainage from the head (SVC syndrome)
112
3 populations at risk for aspiration pneumonia (Abscess)? Bugs involved?
Epileptics; alcoholics, diabetics (gastroparesis), also stroke pts with bulbar probs (nucleus ambiguus)--bacteroides, fusobacterium, peptostreptococcus
113
What kind of hypersensitivity is hypersensitivity pneumonitis?
a mixed III/IV
114
What situation leads to increased tactile fremitus?
pneumonia (consolidation)
115
Rhinovirus receptor
ICAM-1
116
Name 2 diseases associated with nasal polyps
Aspirin intolerant asthma and Cystic fibrosis
117
Who is the most likely to have a nasal angiofibroma?
Adolescent male
118
Pleomorphic keratin-positive epithelial cells in a background of lymphocytes
Nasopharyngeal carcinoma (Asians with EBV); classically also involves cervical lymph nodes
119
Why is acute epiglottitis a medical emergency?
it risks airway obstruction
120
How do you treat a vocal cord nodule?
rest the voice
121
What is a vocal cord nodule composed of? 2 other diseases with this?
Degenerative myxoid tissue; atrial myxoma, mitral valve prolapse
122
What will you see on the biopsy of nasopharyngeal carcinoma?
pleomorphic keratin-positive epithelial cells in a background of lymphocytes
123
Another name for croup
laryngotracheobronchitis
124
What causes a laryngeal papilloma?
HPV 6 and 11 (koilocytic change)
125
What are the risk factors for laryngeal carcinoma?
Tobacco and alcohol; rarely from a laryngeal papilloma (HPV 6 and 11 are low risk)
126
What are the 3 major patterns of pneumonia?
Lobar pneumonia; Bronchopneumonia; Interstitial pneumonia
127
What causes grey hepatization of a lung with pneumonia?
Follows red hepatization and is when the RBCs breakdown
128
What is a pneumonia that follows the bronchioles?
Bronchopneumonia
129
What would happen if you lost type II pneumocytes?
pathcy atelectasis (loss of surfactant)
130
CXR worse than clinical presentation?
interstitial pneumonia
131
What is infected in interstitial pneumonia?
Literally, the interstices? i.e. the alveolar septae etc.
132
What is the most common cause of secondary pneumonia?
S. pneumo! i.e. following a viral infection with influenza
133
What complication may arise in K. pneumo pneumonia?
abscess formation (it is an aspirated pneumonia)
134
What causes empyema?
S. aureus
135
What pneumonia often leads to an exacerbation of COPD?
H. influenzae, M. catarrhalis, L. pneumophila
136
Best way to visualize Legionella? 2 others?
Silver stain; H. pylori and P. jiroveci
137
2 complications of mycoplasma pneumoniae?
Cold autoimmune hemolytic anemia; erythema multiforme
138
Most common cause of atypical pneumonia in infants
RSV
139
What are 3 ways that Coxiella is different from other Rickettsial organisms?
1) causes pneumonia 2) DOES NOT REQUIRE ARTHROPOD VECTOR 3) no skin rash
140
Discuss primary TB
goes to lower lobe and hilar lymph node forming caseating granulomas and a calcified lesion = Gohn complex? USUALLY ASYMPTOMATIC
141
Why would miliary TB cause sterile pyuria?
it is acid fast, wouldn?t show up
142
Where does tuberculous meningitis tend to occur?
base of the brain
143
Name 3 stains for TB
Auramine rhodamine, Ziehl Neehlsen, AFB
144
What is a normal FEV1:FVC ratio?
0.8
145
If mucus plugs trap CO2, what happens to O2?
PO2 drops, that is a general principle
146
Which lobes are most affected in centriacinar emphysema? Why?
This is caused by smoking, since V/Q is highest in upper lobes they are the best ventilated
147
Where does mutant A1AT accumulate?
endoplasmic reticulum of hepatocytes
148
What is the normal allele for A1AT? Mutant Allele? What is the inheritance pattern?
PiM, PiZ; it is codominant so PiMZ is less serious unless they smoke and PiZZ is serious
149
Why are ppl with emphysema usually skinny?
They need to do more "exercise" to get the air out
150
Why does COPD lead to cor pulmonale?
Hypoxic vasoconstriction increases pulmonary resistance
151
What is the usual cause of airway obstruction in asthma?
allergic stimuli
152
Explain the pathogenesis of asthma (the immunology of)
allergens stimulate CD4 to differentiate into Th2 which produce IL-4, IL-5, and IL-10? The IgE produced from IL-4 induced class-switching will sensitize mast cells
153
What interleukin is directly responsible for charcot-leyden crystals?
IL-5 attracts eosinophils (however, IL-4 causes IgE production which sensitizes mast cells and they release eosinophil chemotactic factor)
154
What do leukotrienes C4, D4, and E4 do in asthma?
bronchoconstriction
155
Most severe sequela of asthma
status asthmaticus
156
Tx of aspirin induced asthma
montelukast
157
What 2 populations are most likely to get allergic bronchopulmonary aspergillosis?
Asthmatics and Cystic fibrosis
158
What kind of amyloidosis would develop in ABPA?
Secondary amyloidosis i.e. SAA --\> AA from chronic infection (anemia of chronic disease is also likely)
159
What cells are responsible for fibrosis in idiopathic intersitial fibrosis?
TGF-B from type II pneumocytes leads to activation of fibroblasts
160
Where does fibrosis usually begin in idiopathic pulmonary fibrosis? What is the end-stage?
subpleural; honeycomb lung
161
What cells are responsible for fibrosis in pneumoconioses?
MO because they engulf antigen and cause fibrosis
162
What pneumoconiosis can cause non-caseating granulomas?
Berryliosis; assoc. with aerospace stuff? Be sure to differentiate from sarcoidosis
163
What inclusions are seen in sarcoidosis?
asteroid bodies
164
Dermatologic finding in sarcoidosis
erythema nodosum
165
What is coal workers pneumoconiosis with rheumatoid arthritis?
Caplan syndrome
166
Who gets silicosis?
sandblasters and silica miners (increase risk of TB)
167
What kind of inflammation occurs in hypersensitivity pneumonitis?
granulomatous
168
What is seen on microscopy in severe, long-standing pulmonary HTN?
plexiform lesions (tufts of capillaries blown out from the artery)
169
Diffuse alveolar damage characterizes
ARDS (along with hyaline membranes)
170
What causes the formation of hyaline membranes in ARDS?
There is diffuse alveolar damage, the leakage of proteins into the necrotic mix causes hyaline membranes to form
171
White out on CXR
ARDS
172
The fact that ARDS can be complicated by fibrosis is a testament to the loss of which cell?
Type II pneumocyte (the basal cell of the lung)
173
What is the point of PEEP in ARDS?
Their lungs collapse easily due to the damage. So Positive END EXPIRATORY pressure keeps them open a bit when finishing the expiration
174
What is the difference between ARDS and neonatal RDS?
ARDS = diffuse alveolar damage; neonatal RDS = lack of surfactant so has patchy atelectasis; however, hyaline membranes can still form
175
Diffuse granularity (ground glass) CXR of newborn
neonatal RDS
176
What is the most likely cause of bronchopulmonary dysplasia in an infant?
Tx with supplemental O2 for neonatal RDS (other AE = retinopathy of prematurity)
177
Why would someones basement give them lung cancer?
If there is radon it can decay to uranium leading to ionizing radiation of the lungs
178
What is a benign tumor in the lung composed of lung tissue and cartilage?
bronchial hamartoma
179
Most common tumor in male smokers
SCC of lung
180
Where does bronchioloalveolar carcinoma come from?
Clara cells
181
Lung cancer arising from Clara cells?
Bronchioloalveolar carcinoma (lepidic growth pattern, good prognosis)
182
Which lung tumor is chromogranin positive?
Carcinoid tumor (bronchial polyp) NOTE there is another card in here that says small cell CA is, I am not sure if that is true, ignore
183
What are the intercellular bridges of SCC of lung?
desmosomes
184
Benign bronchial polypoid lesion; malignant? Stain?
Bronchial hamartoma; Carcinoid (chromogranin)
185
Unique site of lung cancer metastasis
adrenal gland
186
Which cancer is a primary pleural cancer? A metastasis to it?
mesothelioma; adenocarcinoma
