Respiratory Flashcards
In COPD, the fraction of air in the lungs that is not involved in respiration, the RV/TLC ratio, is ______
increased *A high RV/TLC ratio correlates with poor outcomes in patients with COPD.
In emphysema, Diffusing capacity of the lung for carbon monoxide (DLCO) is ________
decreased *due to emphysematous destruction of the alveolar-arterial membrane.
How is a Normal A-a gradient clinically estimated?
(age/4) + 4
(ex: for a person <40 years old, gradient should be <14).
hemorrhagic pleural effusion (exudative), nodular pleural thickening Psammoma bodies Desmosomes, Tono-filaments, long Microvilli
Mesothelioma
Lung Malignancy not associated with smoking at all
Mesothelioma
Calretinin + Cytokeratin 5/6+
Mesothelioma
↑ CD4/CD8 ratio on BAL fluid ↓ PTH ↑ Calcium in serum Coarse Reticular Opacities
Sarcoidosis Also, ↑ ACE
Non-Caseating Granulomas containing calcium + Protein Giant cell called what?
Schaumann bodies (Sarcoidosis)
Non-Caseating Granulomas containing lipids/MQs in giant cell
Asteroid bodies (Sarcoidosis)
Constitutional symptoms Cough, dyspnea & chest pain Extrapulmonary findings
Anterior/posterior uveitis
Löfgren syndrome
Parotid gland swelling
Erythema Nodosum
migratory polyarthritis
Sarcoidosis
Lofgren syndrome → a classic triad of fever, erythema nodosum, and bilateral hilar adenopathy; however, this characteristic triad is not always present and has also been associated with migratory polyarthritis, especially involving ankles
Neutrophils, macrophages, and _______ are the primary mediators of disease in chronic obstructive pulmonary disease.
CD8+ T lymphocytes
Can Acetaminophen exacerbate Asthma symptoms?
No, Acetaminophen is only a weak inhibitor of cyclooxygenase. Aspirin and other nonsteroidal anti-inflammatory drugs that inhibit cyclooxygenase can precipitate asthma attacks due to leukotriene overproduction in the airways.
Expiratory airflow rates are reduced in COPD due to inflammatory and _________ of the bronchi in chronic bronchitis
and decreased alveolar elastic recoil in emphysema.
fibrotic narrowing
Prolonged, untreated obstructive sleep apnea can cause what complications (2)?
pulmonary hypertension
right heart failure
BMPR2 gene mutations cause idiopathic ______
pulmonary hypertension
What is seen here
Dilsted Air spaces
Emphysema
Farthest Left graph is normal what causes the other two?
Middle:
Increased elastic resistance | Restrictive Lung Disease
WOB is minimized when the tidal volume is low. To compensate for low lung volumes, rapid, shallow breathing is favored
Right:
Increased airflow resistance | COPD
WOB is minimized with lower respiratory rates and higher tidal volumes (ie, relatively slow, deep breathing)
Patients with severe emphysema typically have chronic _____ leading to chronic respiratory acidosis
with metabolic compensation (high bicarbonate, slightly acidic pH),
often accompanied by hypoxemia
(PaO2<75 mm Hg on room air).
CO2 retention
neutrophil elastase, that cause alveolar damage, reduced ciliary motion, and increased ______.
mucus secretion by goblet cells
_______, a disease characterized by chronic airway inflammation, airway hyperresponsiveness, and intermittent, reversible bronchoconstriction.
Uncontrolled Asthma
Uncontrolled asthma causes chronic inflammation, composed mainly of eosinophils, helper T cells, and mast cells, which cause ____ & increased smooth muscle which further worsens airway obstruction and symptoms.
bronchial wall thickening
*& increased smooth muscle
(airway remodeling)
_________ inhibit the production of inflammatory mediators (cytokines, prostaglandins, leukotrienes), reduce leukocyte extravasation into the respiratory epithelium, and induce apoptosis of inflammatory cells.
In addition, they decrease smooth muscle proliferation and mucus production by goblet cells.
(Asthma)
inhaled corticosteroids (ex: fluticasone)
reduce the frequency and severity of exacerbations
used for long-term asthma control
Histologic findings of idiopathic pulmonary fibrosis include
- patchy lymphoplasmacytic infiltrates,
- focal fibroblastic proliferation with dense fibrosis,
- honeycombing
- hyperplasia of type 2 pneumocytes
Therapies are directed at slowing the progression of fibrosis by…..
inhibiting TGF ß
and
other fibrogenic growth factors (PDGF, FGF, and VEGF).
for any given lung volume the transpulmonary pressure will be significantly increased
is called what and in what is it a hallmark of?
Decreased Compliance
Pulmonary Fibrosis
____ stimulates bronchodilation via blockade of the binding of acetylcholine (a neurotransmitter) to muscarinic receptors. Inhaled form is more commonly used for chronic obstructive pulmonary disease
Ipratropium
At high altitude, the low partial pressure of inspired oxygen (PiO2) leads to hypoxemia with consequent hyperventilation and ______.
respiratory alkalosis
Lithium-induced _____ is the result of lithium’s antagonizing effect on the action of vasopressin on principal cells within the collecting duct system.
diabetes insipidus
Beta-adrenergic activity increases the activity of the Na-K-ATPase pump;
therefore, both endogenous catecholamines and therapeutic beta-2 agonists (eg, albuterol, dobutamine) can cause transient hypokalemia due to
increased transport of potassium intracellularly
via
Na-K-ATPase pump
Increased urinary concentrations of calcium, oxalate, and uric acid promote salt crystallization,
whereas increased urinary _____ concentration and high fluid intake prevent calculi formation.
citrate
Because low Cl- impairs renal excretion of ____________, total body chloride depletion often plays an important role in the pathogenesis of ___________.
HCO3-
metabolic alkalosis
The work of breathing is minimized when the tidal volume is ___ in Restrictive Lung Disease
low
*due to Increased elastic resistance
The work of breathing is minimized with ___ respiratory rates and ___ tidal volumes in COPD
lower
higher
*due to Increased airflow resistance
Uncontrolled asthma causes chronic inflammation, composed mainly of eosinophils, helper T cells, and mast cells, which cause bronchial wall thickening & _____ which further worsens airway obstruction and symptoms.
increased smooth muscle
What is seen here
Honeycombing
(pulmonary Interstitial fibrosis)
*hyperechoic outlines and really tiny bubbles seen as opposed to lighter outlines and bigger bubbles seen in emphysema
Inhaled corticostroids (Fluticasone)
inhibit the production of inflammatory mediators
(cytokines, prostaglandins, leukotrienes),
reduce leukocyte extravasation into the respiratory epithelium, and induce _____ of inflammatory cells.
In addition, they decrease smooth muscle proliferation and mucus production by goblet cells.
(Treats Asthma)
apoptosis
Inhaled corticostroids (Fluticasone)
inhibit the production of inflammatory mediators
(cytokines, prostaglandins, leukotrienes),
reduce leukocyte _____ into the respiratory epithelium, and induce apoptosis of inflammatory cells.
In addition, they decrease smooth muscle proliferation and
______
(Treats Asthma)
Extravasation
mucus production by goblet cells.
Inhaled corticostroids (Fluticasone)
inhibit the production of inflammatory mediators
(cytokines, prostaglandins, leukotrienes),
reduce leukocyte extravasation into the respiratory epithelium, and induce apoptosis of inflammatory cells.
In addition, they decrease ______ and
mucus production by goblet cells.
(Treats Asthma)
smooth muscle proliferation
Functional Residual Capacity
FRC
Reserve volume
+
Expiratory Reserve Volume
Vital Capacity
VC
TV
+
IRV
+
ERV
Total Lung Capacity
TLC
TV + IRV + ERV + RV
Minute Ventilation
Tital Volume x Resp Rate
Alveolar Ventilation
Tital Volume – Dead Space
x
Respiratory Rate
*Dead space = 150 usually
Equation to determine Physiological dead space
Tidal Volume
x
(PaCO – PeCO/ PaCO)
*PeCO = expired Carbon Dioxide
Compliance is increased by ___ & decreased by wall stiffness
Surfactant
Aging is associated with decreased
lung compliance
FVC & FEV1
Ventilatory response to hypoxia/hypercapnia
What remains the same though?
TLC
Hemoglobin concentration in:
CO poisoning
Anemia
Polycythemia
Normal
Decrease
Increase
Total O2 content in:
CO poisoning
Anemia
Polycythemia
Decreased
Decreased
Increased
*PaO2 remians normal for all 3
% O2 sat of Hemoglobin in:
CO poisoning
Anemia
Polycythemia
Decreased
Normal
Normal
Ferric
Ferous
Fe 3+
Fe 2+
*Iron in Hemoglobin needs to be Ferous to bind
___ Hb has more affinity for Cyanide than oxygen
Ferric (Fe3+)
Chocolate blood
Cyanosis
Methemeglobinemia
(Cyanide poisoning)
*treat with Methelyne blue/ Vit. C
What factors cause a right shift in the Oxygen hemoglobin dissociation curve?
↑ Acid H+ (↓pH)
↑ PCO2
Exercise
↑ 2,3 BPG
↑ Altitude
↑ Temperature
ACE BAT
What factors cause a left shift in the Oxygen hemoglobin dissociation curve?
↓ H+ (↑pH)
↓ PCO2
↓ 2-3 BPG
↓ Temperature
↑ Carbon Monoxide
↑ Myoglobin
↑ Fetal Hemoglobin
Left or right shift in the Hb-O2 curve?
↑ Myoglobin
↑ Fetal Hemoglobin
Left
Left or right shift in the Hb-O2 curve?
↑ Carbon Monoxide
Left
Almond odor breath
Cyanide poisoning
Classically associated with bilateral globus pallidus lesions on MRI
Carbon Monoxide poisoning
Inhibit aerobic metabolism via inhibition of complex IV (cytochrome-c) causing hypoxia that does not correct with O2
Cyanide
Low PAO2 causes a hypoxic ______ of the blood vessels
vasoconstriction
*shunts blood to well ventilated areas
Both ventilation and perfusion are greater at the ____ of the lung
Base
V/Q = infinity
indicates a ____ obstruction
Blood Flow
(Pulmonary embolism)
Oxygen supplementation helps
V/Q = zero
indicates a ____ obstruction
airway
(aspiration)
Oxygen supplementation does not help
V/Q mismatch
Diffusion limitation (fibrosis/ emphysema)
Right to Left Shunt (Terrible Ts)
__ A-a gradient
Increase
V/Q = 3 at apex of lung
wasted ventilation or perfusion?
ventilation
V/Q = 0.6 at base of lung
wasted ventilation or perfusion?
perfusion
(3V.6P)
In response to high altitude there is a chronic INCREASE in (2)
ventilation
Mitochondria
Patients with ____can develop interstitial lung diseases, both from the pulmonary manifestations of the disease itself and from certain therapies (methotrexate, cyclophosphamide, sulfasalazine).
rheumatoid arthritis
Subpleural areas of dense collagen deposition, lymphocyte infiltration, and fibroblast proliferation intermixed with areas of normal lung tissue. Diagnosis?
Idiopathic Lung Fibrosis
Microscopy may show fibrosis and honeycombing.
Presence of brown, beaded rods coated with iron-containing material and inorganic particles with a similar ferrous material. Calcified pleural plaques are also common.
Asbestosis
Asbestos bodies (brown, beaded rods coated with iron-containing material)
Ferruginous bodies (inorganic particles with a similar ferrous material)
Histologic findings include noncaseating granulomas, peribronchiolar fibrosis, and patchy lymphocytic infiltrates.
Chronic hypersensitivity pneumonitis
Women with dry cough and dyspnea
Diagnosis?
Sarcoidosis
Diagnosis
Mesothelioma
(Shipbuilding, insulation, asbestos exposure)
internalized ___ particles impair macrophage function by disrupting phagocytosis and promoting apoptosis. This increases the risk of mycobacteria infection (particularly M tuberculosis).
silica
(Silicosis)
Just review
Sarcoidosis
Fever, Night sweats, Weight loss, Cough
biopsy would typically show caseating granulomas and acid-fast bacilli.
TB
Dry cough + exertional Dyspnea
BAL shows increased neutrophils and characteristic lipid-laden macrophages that result from
GERD causing
micro-aspiration
Dry cough + Exertional Dyspnea
Bronchoalveolar lavage shows high lymphocyte count
Hypersensitivity Pneumonitis
(restrictive lung disease)
Chest x-ray: diffuse reticular interstitial opacities
suggests?
interstitial fibrosis
(Restrictive lung diseases like sarcoidosis, Hypersensitive pneumonitis etc.)
BAL in ______ often demonstrates hemosiderin-laden macrophages
cardiogenic pulmonary edema
*From elevated pulmonary capillary hydrostatic pressure leading to extravasation of red blood cells into the alveoli. Leukocyte percentages are not significantly affected.
Th1, IL-2, IFN - ɣ
mediators of what lung disease?
Sarcoidosis
IFN-γ activates _____ and promotes granuloma formation. Activated macrophages and T cells also produce _____, further assisting in leukocyte recruitment and granuloma maintenance.
macrophages
tumor necrosis factor-alpha
Cytokines involved with ___ include IL-4 and IL-5, which are secreted by Th2 cells.
asthma
What are those????
Ferruginous bodies
(asbestosis)
Chest x-ray reveals bilateral midalveolar and lower alveolar opacities.
Transbronchial lung biopsy reveals lipoproteinaceousmaterial that is positive on periodic acid–Schiff stain and fills up the terminal bronchioles and alveoli.
Electron microscopy of the substance shows lamellar bodies.
What cells are bad?
Macrophages
Pulmonary alveolar proteinosis
a rare condition characterized by progressive respiratory dysfunction due to the accumulation of surfactant
(PAS positive material forming lamellar bodies) within the alveolar spaces.
The condition occurs most often due to the impaired clearance of surfactant by alveolar macrophages (decreased GM-CSF signaling).
Pulmonary alveolar proteinosis is
histology demonstrates nodules composed of whorled collagen fibers and dust-laden macrophages. Imaging demonstrates innumerable upper lobe–predominant nodes within the pulmonary parenchyma.
silicosis
composed of a thick, fibrinous exudate and pus
Typically occurs when bacteria infect the pleural space (typically from an associated pneumonia).
Patients often present with fever, chills, and (occasionally) sepsis, not months of weight loss and dyspnea.
Empyema
Review
Histologically, mesothelioma can appear as cuboidal or flattened cells (epithelium-like) or spindle cells (stromal-like).
Pirfenidone is an antifibrotic agent that inhibits ____ used to treat Idiopathic Pulmonary Fibrosis
No drug is curative, but slow progressive fibrosis in patients with IPF.
TGF-β
another treatment option is nintedanib, a tyrosine kinase inhibitor that inhibits PDGF, FGF, and VEGF.
Histologic findings of _____ include patchy lymphoplasmacytic infiltrates, focal fibroblastic proliferation with dense fibrosis, honeycombing, and hyperplasia of type 2 pneumocytes.
idiopathic pulmonary fibrosis
Interstitial lung disease is associated with:
decreased lung volumes
increased lung elastic recoil (b/c fibrotic tissue)
*NOT AN INCREASE FEV1, Steph
increased elastic recoil results in increased ______ on the airways, leading to increased expiratory flow rates when corrected for the low lung volume.
(Restrictive lung disease)
radial traction (outward pulling)
*NOT an INCREASED FEV1
Thickening of the bronchioles, which occurs in ___ , leads to narrowing of the airways.
Although reduced airway radius leads to local increase in airflow velocity, overall the increased resistance causes a decrease in expiratory flow rates.
Asthma
is defined as the change in lung volume for a given change in pressure.
Lung compliance
*Increased compliance means that the lung tissue stretches and expands more in response to increased pressure. Restrictive lung diseases cause decreased lung compliance
Chronic disease presents with gradually progressive cough, dyspnea, fatigue, and weight loss
Lung biopsy reveals lymphocytic infiltrate, poorly formed noncaseating granulomas, and alveolar septal fibrosis
x-ray reveals reticular densities in both lung fields
Hypersensitivity Pneumonitis
Idiopathic Pulmonary Fibrosis effects on
Type 1 pneumocytes
Type 2 pneumocytes
Basement Membrane
Fibroblast
↓
↑
Abnormal
↑
*focally repairs by fibroblast proliferation/collagen deposition instead of normal restoration via type 2 pneumocyte differentiation
Review
Restrictive lung disease has
DECREASED compliance
Obstructive is INCREASED compliance
Restrictive or Obstructive disease?
Restrictive
Graph shows lowered FEV1
*The black curve (normal PFT) results with an FEV1 of 4 liters, an FVC of 5 liters, and an FEV1/FVC ratio of 80%.
Red curve shows a reduced FEV1 of 3 liters, a reduced FVC of 3.5 liters, and a slightly increased FEV1/FVC ratio of 86%.
FVC/ FEV-1 ratio is ____
decreased
ARDS due to inhalational injury
what cell type is most damaged?
Type 1 pneumocyte
(Alveolar epithelial lining for gas exchange)
Surfactant production
Stem cell reservoir for pneumocytes
Type 2 pneumocyte
Hyaline membrane disease of prematurity
What cell type is disfunctional?
Type 2 pneumocyte
In
Ciliary dyskinesia (Kartagener syndrome)
Cystic fibrosis: airway desiccation
What cell type has a disfunction?
Ciliated airway epithelial cell
( FXN: Mucociliary escalator, Salt, water & moisture homeostasis)
