Respiratory Flashcards
1
Q
What intracellular signal is affected by beta adrenergic agonists?
A
Smooth muscle relaxes (from B2 stim) from increased cAMP
2
Q
Cause of hypoxemia with a normal A-a difference?
A
alveolar hypoventilation
OR
high altitude (less O2 in the air)
3
Q
trachea deviates toward normal lung
A
Pulmonary effusion
4
Q
Trachea deviates away from normal lung
A
atelectasis (collapsed lung)
5
Q
kerley B lines tell you
A
edema of interlobular septa
6
Q
flattened diaphragm on Xray
A
COPD
7
Q
ARDS causes
A
pneumonia
trauma
aspiration
sepsis
8
Q
Acute rejection of lung affects
A
pulmonary and bronchial circulation
9
Q
Chronic rejection of lungs affects
A
Small airways
10
Q
In healthy individuals, respiration is perfusion rather than diffusion limited (exercise, pulmonary embolism, etc).
Which is more affected in diffusion limitation, CO2 or O2 levels?
A
O2 levels. CO2 levels have a much higher diffusion capacity across the respiratory membrane. If you see VERY low pCO2 at the alveoli, this indicates a perfusion not a diffusion limitation
11
Q
How do you measure fetal lung maturity?
A
Lecithin/Sphingomyelin ratio. They are equal until 3rd trimester, when Type II pneumocytes start secreting surfactant
12
Q
Eggshell calcifications of hilar nodes and birefringent silica particles surrounded by fibrous tissue
A
silicosis
13
Q
fusiform rods seen with iron protein (prussian blue stain)
A
pulmonary asbestos. Will see an interstitial pattern on Xray
14
Q
Chloride shift in RBCs caused by
A
Carbonic anhydrase
- -CO2 carried in bicarb form predominantly
- -when bicarb leaves the RBC to dissolve in plasma, chloride enters the cell to maintain charge neutrality
15
Q
how does hemoglobin carry CO2
A
15% as carbamate Hb-NH-CO2
85% as HCO3 (carbonic anhydrase
16
Q
Which cancer causes SVC syndrome
A
small cell lung cancer. Causes headache, facial/upper extremity edema, and dilated veins
- -hoarseness: recurrent laryngeal
- -dysphagea: esoph. compression
17
Q
Sx of phrenic nerve irritation
A
- hiccups, SOB, elevation of hemidiaphragm on X ray
18
Q
Small airways
A
bronchioles and terminal bronchioles
–Large bronchi are part of the large airways
19
Q
What cells do you find in bronchi
A
cartilage
goblet cells
glands
20
Q
What do you find in the terminal bronchioles
A
pseudostratified ciliated columnar cells
–smooth muscles of airway walls(disappear after terminal bronchioles
21
Q
type of cell in respiratory bronchioles
A
cuboidal cells without cilia
22
Q
What secretes elastase
A
neutrophils and macrophages
23
Q
Where is there mixing of blood normally?
A
bronchial veins mix in
24
Q
Collapsing pressure=
A
2*T/R. This is the PRESSURE YOU NEED INSIDE THE BALLOON TO KEEP IT OPEN
25
what indicates fetal lung maturity?
lecithin: sphingomyelin ratio of 2
26
when are mature levels of pulmonary surfactant achieved?
Week 35. synthesis starts at week 26
27
When do alveoli tend to collapse
when radius is small (with expiration)
28
Which is the MOST important component of surfactant
dipalmitoylphosphatidylcholine
29
type II cells
cuboidal clustered cells that secrete pulmonary surfactant
30
clara cells
columnar cells that secrete component of surfactant and degrade toxins
31
Relation of pulmonary artery to bronchus
RALS
- Right PA anterior to bronchus
- Light PA superior to bronchus
32
Which lung are you more likely to inhale a foreign body into?
Right lung
33
What enters the diaphragm at T12?
Aorta
thoracic duct
azygous vein
34
Where should you do a thoracentesis?
MCL: 5-7th rib
Mid axillay: 7-9th rib
paravertebral: 9th-11th rib
35
Muscles of inspiration during exercise
scalene
sternocleidomastoids
external intercostals
36
IRV
amount of air that can still be breathed in after normal inspiration
37
FRC+IC
TLC
38
Inspiratory capacity
IRV+TV
| how much more can you breathe in after a normal breath
39
FRC
ERV+RV
TLC-IC
how much more can you breathe out after a normal breath
40
TLC
IRV+TV+ERV+RV
41
Dead space calcuation
Vt x (Paco2-Peco2)/Paco2
42
Which part of the lungs is the biggest contributor to functional dead space?
apex of lungs
43
Taut vs relaxed forms of hemoglobin (2alpha + 2beta)
Taut: low affinity for O2
Relaxed: high affinity for O2
44
What factors cause taut form to dominate?
increased chloride, 2,3 BPG, H+, and CO2
45
how do you treat methemoglobinemia?
methylene blue
46
How do nitrites cause poisoning?
Convert Fe2+ to Fe3+
47
fetal hemoglobin has a lower affinity for
2,3-BPG
48
How do you treat cyanide poisoning?
Nitrites--make methemoglobin which can bind cyanide.
| Also give thiosulfate to bind cyanideq
49
how does CO shift the oxygen hemoblogin curve?
LEFT shift. Decreased maximum bound and loss of sigmoidal shape
Increased affinity for O2, less unloading
50
When hemoglobin curve shifts to the right
decreased affinity for O2 (more unloading, at tissue level)
51
Causes of right shift
```
C-BEAT
CO2
BPG
Exercise
Acid/altitude
Temperature
```
52
Pulmonary vascular resistance is lowest at
FRC
| --increased lung volume: compresses alveolar vessels, but less resistance in extra-alveolar vessels
53
are you perfusion or diffusion limited during exercise?
perfusion limited. Still able to reach normal PA at the end of the capillary
54
When might you be diffusion limited?
Emphysema (decreased surface area)
| Fibrosis (increased thickness)
55
Normal pulmonary artery pressure
10-14 mmHg
56
Cause of primary pulmonary HTN
BMPR2
57
Cause of secondary pulmonary HTN
```
COPD
Mitral stenosis
Recurrent emboli
autoimmune dz like systemic sclerosis
sleep apnea
high altitude
```
58
How do you calculated pulmonary vascular resistance?
PVR= (Ppa-Pla)/CO
Resistance=deltaP/Q
59
Diffusion calculation
Vgas=A/T x Dk(P1-P2)
60
PAO2=
150-PaCo2/0.8
61
When do you see an increased Aa gradient
Shunting
V/Q mismatch
Fibrosis
62
cause of hypoxemia with a normal Aa gradient
high altitude
| hypoventilation
63
V/Q ratio at apex of lung
3 (wasted ventilation)
64
V/Q ratio at the base of lung
0.6 (wasted perfusion)
65
are ventilation/perfusion greater at the lung base or apex?
both are greater at the base than the apex
66
VQ ratio during exercise
1-->apical arteries expand
67
V/Q=0
SHUNT. Lots of blood flow, no ventilation. Airway obstruction!
68
V/Q=infinity
DEAD SPACE. Lots of airflow, no blood. pulmonary embolism
69
Who would benefit from high flow 100% O2?
Person with Deadspace. We assume there are some areas of the lung that are still getting blood.
Shunt does NOT improve with 100% oxygen because the air is not even reaching the blood!
70
Most of CO2 is transported in what form?
bicarbonate in the plasma
71
Haldane effect
oxygenation of Hb promotes dissociation of H+ from Hb within the RBC
--H+ binds HCO3 and forms free CO2 with carbonic anhydrase
72
How else is CO2 transported?
- carbaminohemoglobin (CO2 bound to the N terminus of hemoglobin)
- dissolve CO2
73
Bohr effect
H+ in peripheral tissues causes shift to the right=unloading O2
74
Changes at high altitude
```
Increased 2,3-BPG
Increased mitochondria
Decreased PO2 and PCO2
Increased renal excretion of bicarbonate (increase this with acetazolamide)
-->Watch out for cor pulmonale
```
75
Changes in the lungs with exercise
V/Q ratio -->1
decreased pH
No change in PaO2 and PaCO2!!
Increase in venous CO2 content and decrease in venous O2 content
76
dorsiflexion of foot causes calf pain
Homan's sign, think DVT
77
Treatment for acute DVT
heparin
78
Treatment for long-term prevention of DVT
warfarin
79
hypoxemia
neuro changes
petechial rash
Think pulmonary emboli!
80
What is bronchiolitis obliterans pneumonia?
Formation of granulation tissue with pneumonia. Causes obstruction of airways
81
How od you treat bronchiolitis obliterans pneumonia?
Corticosteroids
82
How do you tell whether a patient died because of a pulmonary embolism or if the thromboembolism formed after death?
Lines of Zahn
83
Reid index
Tells you thickness of glandular layer compared to bronchial wall
--Over 50% in patients with bronchitis
84
Cause of chronic bronchitis
Hypertrophy of mucus secreting glands
85
Cause of emphysema
enlargement of airspaces and decreased recoil with destroyed alveolar walls
86
breathing through pursed lips
emphysema. Increased airway presure and prevent airway collapse resulting from increased compliance
87
centriacinar emphysema, upper lobes
Smoking
88
panacinar emphysema, lower lobes
a1-antitrypsin
89
Cause of asthma
bronchial hyperresponsiveness
90
Histology of asthma
smooth muscle hypertrophy
Curschmann's spirals (mucus plugs)
Charcot-leyden crystals (breakdown of eosinophils)
91
pulsus paradoxus seen in
asthma
| obstructive sleep apnea
92
bronchiectasis
necrotizing infection of bronchi causing dilated airways, purulent sputum, infections, and hemoptysis
93
bronchiectasis associated with
smoking (ciliary motility)
kartagener's
cystic fibrosis
bronchopulmonary aspergillosis
94
Cause of restrictive lung disease with an abnormal A-a gradient
Interstitial lung diseases
- ARDS
- pneumoconioses
- sarcoidosis
- idiopathic pulmonary fibrosis
- goodpasteur's
- wegener's
- hypersensitivity pneumonitis
95
which drugs can cause interstitial lung disease?
bleomycin
busulfan
amiodarone
methotrexate
96
coal miner's lung
anthracosis
97
sandblasting, mines, foundries
silicosis
98
pathogenesis of silicosis
macrophages release fibrinogenic factors in response to silica
99
pts with silicosis are susceptible to
TB and bronchogenic carcinoma
100
eggshell calcifications of hilar lymph nodes
silicosis
101
shipbuilding, roofing, plumbing
asbestosis
102
affects upper lobes
anthracosis silicosis
103
affects lower lobes
asbestosis
104
golden brown fusiform dumbbells
asbestosis
105
Ivory white calcified pleural plaques
asbestos exposure! But they do not indicate precancerous lesion
106
Asbestos associated with
mesothelioma and bronchogenic carcinoma
107
neonatal respiratory distress syndrome caused by:
surfactant deficiency.
Lecithin: sphingomyelin ratio will be less than 1.5
108
What is your other concern with neonatal respiratory distress syndrome?
Low O2 tension could lead to a PDA
109
You decide to administer supplemental O2 to a neonate with respiratory distress. What are some complications?
retinopathy of prematurity
| bronchopulmonary dysplasia
110
Treatment for neonatal respiratory distress syndrome
maternal steroids before birth
| artificial surfactant for baby
111
Risk factors for neonatal respiratory distress syndrome
prematurity
materal diabetes
cesarean delivery (less CRH)
112
Causes of ARDS
```
sepsis, shock, trauma,
--gastric aspiration
uremia
pancreatitis
amniotic fluid embolism
```
113
Pathophysiology of ARDS
diffuse alveolar damage
- capillary permeability
- protein rich leakage into alveoli
- intra-alveolar hyaline membrane
114
what causes the initial damage precipitating ARDS?
neutrophil toxins
coagulation cascade
oxygen derived free radicals
115
What hormone might be elevated in sleep apnea?
EPO
116
decreased breath sounds, dullness to percussion and decreased fremitus
pleural effusion
117
decreased breath sounds, dullness to percussion, decreased fremitus and tracheal deviation towards lesion
atelectasis
118
decreased breath sounds, hyperresonance, and decreased fremitus with tracheal deviation toward lesion
spontaneous pneumothorax
119
decreased breath sounds, hyperresonance, and decreased fremitus and deviation away from lesion
tension pneumothorax
120
bronchial breath sounds with crackles, dullness to percussion, and increased fremitus
consolidation (lobar pneumonia or pulmonary edema)
121
alpha1 antitryptase is synthesize in
the liver
122
Which TB drug does not affect hepatic fxn
ethambutol
123
histology: chronic lung rejection
lymphocytic infiltrate
bronchiolitis obliterans
necrosis
FIBROSIS
124
histology: acute lung rejection
perivascular mononuclear infiltrate
125
Common complications of lung cancer
SPHERE
- superior vena cava
- pancoast
- horner's
- endocrine
- recurrent laryngeal compression
- effusions (pleural/pericardial)
126
cough, hemoptysis, bronchial obstruction, coin lesion on x ray or nodule
lung cancer
127
most common cause of lung cancer
metastates
128
Where do lung cancer metastasize from?
breast
colon
prostate
bladder
129
Where to lung cancers metastasize to?
adrenals
brain
bone
liver
130
Which lung cancers are NOT associated with smoking?
bronchioloalveolar
| bronchial carcinoid
131
kras
adenocarcinoma
132
myc
small cell carcinoma
133
Most common cause of lung cancer in nonsmokers and women
adenocarcinoma
134
which cancer is associated with clubbing?
adenocarcinoma
135
What subtype of adenocarcinoma shows hazy infiltrates and shows thickening of alveolar walls?
bronchioloalveolar subtype
136
prognosis of bronchioloalveolar subtype adenocarcinoma
excellent
137
Which cancers are found centrally?
squamous and small cell
138
Which cancers are found peripherally?
adenocarcinoma and large cell carcinoma
139
hilar mass with keratin pearls located centrally
squamous cell
140
features of squamous cell carcinoma
cavitation
cigarettes
hypercalcemia
141
Histology of small cell carcinoma
undifferentiated with small dark blue cells
142
paraneoplastic syndrome of small cell carcinoma
ACTH
ADH
lambert eaton
143
the small cell carcinoma cells are derived from
neuroendocrine cells of kulchisky
144
which kind of cancer can you NOT operate on?
small cell carcinoma
145
histology of large cell carcinoma
pleomorphic giant cells that are highly anaplastic
146
how do you treat large cell carcinoma?
remove surgically! chemotherapy is less effective
147
lung tumor that shows nests of neuroendocrine cells that are chromogranin positive
bronchial carcinoid tumor
148
Sx of bronchial carcinoid tumor
mass effect, sometimes carcinoid syndrome with serotonin secretion=flushing, diarrhea, wheezing
149
Pancoast tumor
carcinoma in the apex of the lung that can affect cervical sympathetics and cause horner's syndrome
150
psamomma bodies in lung cancer located in the pleura with pleural effusions and pleural thickening
mesothelioma
151
Which cancers show psamomma bodies?
papillary thyroid cancer
serous cystadenoma of the ovary
meningioma
mesothelioma
152
Causes of bronchopneumonia
Strep pneumo
S aureus
H flu
Klebsiella
153
Causes of Lobar pneumonia
S pneumo
| Klebsiella
154
What is hypersensitivity pneumonitis
mixed type III/IV hypersensitivity rxn to environmental antigens
155
who is predisposed to hypersensitivity pneumonitis?
farmers and birds
156
bronchopneumonia characteristics
inflammation from bronchioles to adjacent alveoli
| --patchy distribution involving more than 1 lobe
157
Cause of a spontaneous pneumothorax
apical blebs
| --tall, thin, males
158
Cause of tension pneumothorax
trauma or lung infection
159
Name the first generation H1 blockers
diphenhydramine
dimenhydrinate
chlorpheniramine
160
Name the second generation H2 blockers
```
loratadine
fexofenadine
desloratadine
cetirizine
-ADINE
```
161
What are the additional benefits of H2 blockers?
Far less sedating than first generation blockers because less entry into the CNS--> good for old people!
162
What else can you use H1 blockers for?
sleep aid
| motion sickness
163
formoterol
long acting B2 agonist
164
side effect of salmeterol, formoterol
tremor and arrhythmia
165
theophylline=category?
methylxanthine
166
theophylline mechanism
inhibits phosphodiesterase
| -decreases cAMP
167
tox: theophylline
cardiotoxicity, neurotoxicity
168
theophylline blocks action of
adenosine
169
which drug is metabolized by p450?
theophylline
170
Mech: iptratropium
competitively blocks muscarainic receptors, preventing bronchoconstriction
171
iptratropium uses
asthma, COPD
172
category: beclomethasone
corticosteroid
173
category: fluticasone
corticosteroid
174
corticosteroid mechanism
inhibits synthesis of all cytokines.
- -Inactivates NF-kB
- -inhibits TNF-a production
175
What is the first line therapy for chronic asthma?
corticosteroids beclomethasone and fluticasone
176
omazlizumab
monoclonal IgE antibody
177
inications for omalizumab
allergic asthma resistant to inhaled steroids and b2 agonists
178
good for aspirin induced asthma
montelukast zafirlukast
179
mechanism of montelukast zafirlukast
Block leukotriene receptors
180
mechanism zileuton
5-lipoxygenase pathway inhibitor
181
B2 agonist mechanism
increases cAMP causing bronchodilation
182
effect of Ach and adenosine on bronchi
Both cause bronchoconstriction
183
Expectorants
guaifenesin
| N-acetylcysteine
184
Guaifenesin mechanism
thins secretions
185
N-acetylcystein mechanism
loosens mucous plugs in CF
186
Bosentan
Used for pulmonary arterial hypertension:
| Antagonizes endothelin 1 receptors to decrease PVR
187
Mechanism dextromethorphan
Decreases cough reflex by antagonizing NMDA glutatmate receptor. Has mild opioid effect when used in excess (give naloxone)
188
mechanism methacholine
Muscarinic agonist
189
side effects of pseudoephedrine/phenylephrine
Hypertension
| -CNS stimulation/anxiety
190
Nasal polyps caused by
repeated bouts of rhinitis
| Aspirin intolerant asthma
191
Child with nasal polyps
CF
192
Angiofibromas occur in
in adolexcent males. continued nose bleeds
193
naspharyngeal carcinoma associated with
EBV--Naspharyngeal carcinoma and AA.
194
pleomorphic keratin-positive epithelial cells in a background of lymphocytes
`nasopharyngeal carcinoma
195
fever, drooling, muffled voice, and inspiratory stridor in a kid
epiglottitis caused by Hflu
196
cause of bilateral vocal cord nodule
excessive use (singers)
- -presents with hoarseness, resolves with rest.
- -composed of myxoid CT
197
laryngeal papilloma caused by
HPV 6 and 11
198
laryngeal carcinoma
alcohol and tobacco. presents with hoarseness, cough, stridor
199
thick mucoid capsule bug
klebsiella. usually aspiration pneumonia
200
Four phases of lobar pneumonia
congestion
red hepatization
grey hepatization (RBCs broken down)
resolution
201
causes of bronchopneumonia
```
Staph aureus
-Haemophilus
pseudomonas
moraxella
legionella
```
202
most common cause of secondary pneumonia
staph aureus
203
pneumonia in COPD
Haemophilus or moraxella
204
complication of mycoplasma pneumonia
autoimmune hemolytic anemia
205
pneumonia in farmers and veterinarians with high fever
Q fever
- -cattle spores
- -no vector
- -no skin rash
206
where can TB spread to?
1. meninges
2. cervical lymph
3. kidney=sterile pyuria
4. lumbar vertebrae=potts
207
ABG of someone with pulmonary embolism
```
hypoxemia
respiratory alkalosis (blowing off all your CO2)
```
208
Clubbing is associated with
Prolonged hypoxia:
- lung cancer
- CF
- TB
- empyema, bronchiectasis, lung abscess
- OR cyanotic congential heart disease
