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Flashcards in Respiratory Deck (340):
1

peculiar feature about newborn respiratory physiology

obligate nose breathers

2

RV vs. ERV

RV is the volume of air remaining after a maximal expiration. ERV is the volume remaining after normal expiration.

3

Characteristic of NRDS

Atelectasis. This is because without surfactant, the surface tension of the small alveoli collapse into the large aveoli.
- Lack of surfactant also decreases compliance.

4

When does surfactant appear?

Around week 24

5

Asthma physiology

Wheezing + tachypnea. Hypoxemia causes tachypnea, which drives PCO2 down.

6

What happens to intrapleural pressure with inspiration?

Becomes more negative than it is at rest or during expiration.

7

When airway pressure is equal to atmospheric pressure...

This is equilibrium and there is no airflow. ***Volume in the lungs = FRC.

8

What happens to alveolar PO2 with a PE?

Alveolar PO2 is equal to the PO2 in inspired air.

9

Blood flow in the systemic vs. pulmonary circulations...

Blood flow in the systemic and pulmonary circulations is nearly equal. Pulmonary flow is slightly less than the systemic flow because about 2% of systemic CO bypasses the lungs.

10

Resistance in pulmonary circulation

Resistance in the pulmonary circulation is lower than in the systemic circulation.

11

Compared with the apex of the lung, the base of the lung has...

a higher pulmonary capillary **PCO2

12

Mean arterial PO2 and PCO2 during exercise...

There is no change in mean arterial PO2 or PCO2. This is because ventilation rate increases to match the increased O2 consumption and CO2 production.
BUT venous pCO2 increases.

13

Central chemoreceptor location

Medulla. (medullary chemoreceptors).

14

Peripheral chemoreceptor location

Carotid and aortic bodies

15

If an area of the lung is not ventilated because of bronchial obstruction, the pulmonary capillary blood serving that area will have a PO2 that is...

Equal to mixed venous PO2. This is because pulmonary blood will NOT equilibriate with alveolar PO2 but will have a Po2 equal to that of mixed venous blood.

16

What happens with transporting CO2 from tissues to lungs?

CO2 is hydrated to form H+ and HCO3- in RBCs. H+ is buffered inside the RBCs by deoxyhemoglobin, which ACIDIFIES RBCs. HCO3- leaves RBCs in exchange for Cl- and is carried to the lungs in the plasma.

17

Carbonic anhydrase

Sits in RBCs and CO2 + H2O H2CO3.

18

What buffers H+ in RBCs?

Deoxyhemoglobin

19

hypoxemia

Decreased arterial PO2

20

Causes of hypoxemia

1) high altitude
2) hypoventilation
3) right to left cardiac shunt

21

Which cause of hypoxemia is associated with an increased AA gradient?

Right-to-left cardiac shunt. This is because the shunt "dilutes" the PO2 of the normally oxygenated blood thus decreasing the arterial O2.

22

Causes of hypoxemia with normal A-a gradient?

High altitude + hypoventilation

23

Causes of hypoxemia with increased A-a gradient?

1) V/Q mismatch
2) Diffusion limitation (fibrosis)
3) right-to-left shunt

24

Why is pH of venous blood only slightly more acidic than the pH of arterial blood?

H+ generated from CO2 and H2O is buffered by deoxyhemoglobin in venous blood.

25

Function of J (juxtacapillary) receptors

Receptors located in the alveolar walls, close to the capillaries. Engorgement of pulmonarry capillaries such as with left HF stimulates J receptors, which then cause rapid, shallow breathing.

26

How do you calculate dead space?

Tidal volume x ((arterial PCO2-expired PCO2)/arterial PCO2))

27

Initial development of lungs and when it happens

Lung bud buds off from distal end of respiratory diverticulum during week 4

28

embryonic stage events + timeframe

4-7 weeks
lung bud --> trachea --> mainstem bronchi --> secondary (lobar) bronchi --> tertiary (segmental) bronchi

29

what do errors in embryonic stage lead to?

TE fistula

30

pseudoglandular stage events + timeframe

5-16 weeks.
Endodermal tubules --> terminal bronchioles. Surrounded by modest capillary network.

31

Canalicular stage events + timeframe

16-26 weeks.
Terminal bronchioles --> respiratory bronchioles --> alveolar ducts. Surrounded by prominent capillary network.
*increase in airway diameter.

32

When is respiration possible?

Canalicular stage, at 25 weeks

33

Saccular stage events + timeframe

Weeks 26-birth.
Alveolar ducts --> terminal sacs. Terminal sacs separated by primary septa. Pneumocytes develop.

34

Alveolar stage events + timeframe

Weeks 32-8 years.
Terminal sacs--> adult alveoli (due to secondary separation)

35

# of alveoli at birth and at 8 ye

At birth: 20-70 million
By 8 years: 300-400 million

36

How does breathing in utero work?

Aspiration and expulsion of amniotic fluid, which leads to increased vascular resistance.

37

Changes in pulmonary vascular resistance at birth.

At birth, fluid gets replaced with air, leading to decreased pulmonary vascular resistance.

38

Pulmonary hypoplasia

Poorly developed bronchial tree with abnormal histology.

39

Which lung does pulmonary hypoplasia usually involve?

Right lung

40

bronchogenic cysts

• Code: Jeep broncho in living room/bronchogenic cysts. Bronchi hanging overhead + guts hanging on top/caused by abnormal budding of the foregut (lung buds arise from the ventral foregut) and dilation of terminal or large bronchi. Metal railing around broncho + round cysts all over car + air tanks in back spraying air everywhere/discrete + round + sharply defined + air-filled densities on CXR. Chelsea on top with drains in her chest + bugs flying into mouth/Drain poorly and cause chronic infections.
• Location: Living room

41

Collapsing pressure equation

P = (2(surface tension))/radius

42

surfactant mechanism

decreases alveolar surface tension, preventing alveolar collapse, DECREASING lung recoil and increasing compliance.

43

Club cell histology

Conciliated; low-columnar/cuboidal with secretory granules.

44

Club cell function

1) Secrete component of surfactant.
2) Degrade toxins
3) Act as reserve cells

45

NRDS presentation on CXR

ground glass

46

L/S ratio predictive of NRDS

less than 1.5

47

Screening tests for fetal lung maturity

1) L/S ratio
2) Foam stability index test
3) surfactant-albumin ratio

48

Sequela of NRDS

1) PDA
2) metabolic acidosis
3) necrotizing enterocolitis

49

NRDS RF's

1) prematurity
2) maternal diabetes (due to increased fetal insulin)
3) C-section delivery

50

Why is C-section a risk factor for NRDS?

Decreased release of fetal glucocorticoids.

51

NRDS management

Maternal steroids before birth; artificial surfactant for infant.

52

Therapeutic O2 can cause...

RIB
Retinopathy of prematurity
Intraventricular hemorrhage
Bronchopulmonary dysplasia

53

Large airways

Nose --> bronchi

54

Small airways

Bronchioles --> terminal bronchioles

55

Function of conducting zone

Warm, humidify and filter airs but no gas exchange (dead space).

56

Extent of cartilage and goblet cells

End of bronchi

57

Epithelium of bronchus

psuedostratified ciliated columnar cells

58

Extent of psuedostratified ciliated columnar cells

Extend to beginning of terminal bronchioles, then transition to cuboidal cells

59

Extent of airway smooth muscle cells

End of terminal bronchioles.

60

Respiratory zone components

Lung parenchyma; respiratory bronchioles + alveolar ducts + alveoli.

61

Histology of respiratory bronchioles

Mostly cuboidal

62

Histology after respiratory bronchioles up to alveoli

simple squamous

63

When do cilia terminate?

Respiratory bronchioles

64

Relation of pulmonary artery to bronchus at each lung hilum

RALS -- Right Anterior; Left Superior

65

Lingula...

left lung

66

If you aspirate a peanut upright where will it end up?

Inferior segment of right inferior lobe.

67

If you aspirate a peanut while supine where will it end up?

superior segment of right inferior lobe

68

central tendon

big tendon in the diaphragm

69

Where does IVC perforate diaphragm?

T8

70

Where does vagus perforate diaphragm?

T10

71

Where does aorta perforate diaphragm?

T12

72

Where does esophagus perforate diaphragm?

T10

73

Where does thoracic duct perforate diaphragm?

T12

74

Where does azygos vein perforate diaphragm?

T12

75

Where does the trachea bifurcate?

T4 (bifourcate)

76

Where does the common carotid bifurcate?

C4 (bifourcate)

77

What innervates the diaphragm?

C3,C4,C5 (Phrenic nerve, C3,C4C5 keeps the diaphragm alive). This explains why pain can be referred to shoulder (C5) and trapezius ridge (C3,4)

78

Typical tidal volume

500 mL

79

What can you not measure by spirometry

1) RV
2) FRC
3) *TLC

80

Dead space equation

FA 633

81

physiologic dead space

anatomic dead space + alveolar dead space

82

Largest contributor to alveolar dead space

Apex of lung

83

anatomic dead space

dead space of conducting airways

84

Pathologic dead space

ventilated but not perfused

85

Minute ventilation equation

Vt x RR

86

alveolar ventilation

VA = (Vt-Vd) x RR

87

Normal dead space volume

150 mL/breath

88

Why is system pressure atmospheric at FRC?

Inward pull of lung is balanced by outward pull of chest wall.

89

When is PVR at minimum?

FRC

90

When is alveolar pressure at FRC?

0

91

compliance expression

deltaV/deltaP. Change in lung volume for a change in pressure.

92

When is compliance increased?

1) emphysema
2) normal aging
*surfactant increases compliance.

93

Hysteresis

Concept that lung inflation curve follows a different curve than lung deflation curve due to need to overcome surface tension forces in inflation.

94

Taut form of hemoglobin

Deoxygenated; low affinity for O2, thus promoting release/unloading.

95

Relaxed form of hemoglobin

High affinity for O2 (300x). Hb exhibits positive cooperatively and negative allostery.

96

Cl affect of hemoglobin

Favors taut form over relaxed form.

97

Fetal Hb structure

2alpha and 2gamma

98

Why does fetal Hb have higher O2 affinity?

Decreased affinity of HbF for 2,3BPG

99

Oxidized Hb

decreased O2 affinity but increased cyanide affinity

100

What do you use to induce methemoglobinemia?

Nitrites, followed by thiosulfate.

101

Other things that can cause methemoglobin

benzocaine

102

carboxyhemoglobin

Hb bound to CO

103

left shift vs. right shift

Right shift = decreased affinity
Left shift = increased affinity

104

CO poisoning management

100% O2 + hyperbaric O2

105

O2 content of blood equation

= (1.34 x Hb x SaO2) + (0.003 x PaO2

106

normal Hb amount in blood

15 g/dL

107

normally 1 g Hb can bind...

1.34 mL O2

108

O2 binding capacity =

20.1 mL O2/dL blood

109

physiologic effects of decreased Hb on
1) arterial O2 content
2) O2 saturation
3) PaO2

1) decreased
2) no change
3) no change

110

Calculating O2 delivery to tissues

= CO x O2 content of blood

111

CO poisoning effect on total O2 content

Decreased

112

Anemia effect on...
1) Hb concentration
2) %O2 sat of Hb
3) dissolved O2 (PaO2)
4) total O2 content

1) decreased
2) normal
3) normal
4) decreased

113

Polycythemia effect on
1) Hb concentration
2) %O2 sat of Hb
3) dissolved O2 (PaO2)
4) total O2 content

1) increased
2) normal
3) normal
4) increased

114

V/Q mismatch

Either shunt physiology or dead space.

115

Examples of low V/Q

1) chronic bronchitis
2) asthma
3) hepatopulmonary syndrome
4) acute pulmonary edema

116

Perfusion limited gases

1) O2 (normal health)
2) CO2
3) N2O

117

Perfusion limited gas characteristics

1) Gas equilibrates early along the length of the capillary.
2) Diffusion can only be increased if blood flow increases.

118

Diffusion limited gases

1) O2 (emphysema, fibrosis)
2) CO

119

Diffusion limited gas graph + characteristic

Linear. Gas does not equilibrate by the time blood reaches the end of the capillary.

120

Diffusion equation

FA 613

121

What is the underlying diffusion problem with emphysema?

Decreased area for diffusion

122

DLCO

Extent to which oxygen passes from air sacs of lungs into blood.

123

Hypoxia

Decreased O2 delivery to tissue

124

Causes of hypoxia

1) decreased CO
2) hypoxemia
3) anemia
4) CO poisoning

125

Causes of ischemia

1) impeded arterial flow
2) decreased venous drainage

126

V/Q at apex of lung

3 (wasted ventilation), both perfusion and ventilation are reduced, but perfusion is reduced to a greater extent

127

Lung zones

Zone 1 is apex, 2 is middle lobe, 3 is base

128

V/Q at base of lung

0.6 (wasted perfusion)

129

When is ventilation greatest?

base of the lung

130

When is perfusion greatest?

base of the lung

131

Pa,PA,PV in Zone 1

PA greater than Pa greater than Pv

132

Pa,PA,PV in Zone 2

Pa greater than PA greater than PV

133

Pa,PA,PV in Zone 3

Pa greater than Pv greater than PA

134

What happens to V/Q with exercise?

With increased CO, apical capillaries vasodilator, V/Q approaches 1.

135

Relative forms of CO2 transport

1) HCO3- (90%)
2) carbaminohemoglobin (HbCO2) (5%)
3) dissolved CO2 (5%)

136

carbaminohemoglobin

CO2 bound to Hb at N-terminus of globin (not heme)

137

Haldane effect

In lungs, oxygenation of Hb promotes dissociation of H+ from Hb. This shifts equilibrium toward CO2 formation; therefore, CO2 is released from RBCs. (shifts equation to the left)

138

Bohr effect

In peripheral tissue, increased H+ from tissue metabolism shifts curve to right, unloading O2.

139

Pulmonary vasculature response to high altitude

Chronic hypoxic pulmonary vasoconstriction results in pulmonary HTN + RVH.

140

Renal response to high altitude

Increased renal excretion of HCO3- to compensate for respiratory alkalosis (this is why acetazolamide is also given for altitude sickness).

141

Rhinosinusitis pathophys

Obstruction of sinus drainage into the nasal cavity, leading to inflammation and pain over affected area

142

Sinuses typically affected in rhinosusitis and drainage

Maxillary sinuses, which drain into the middle meatus.

143

Common bacterial causes of rhinosinusits

S Pneumonia + H influenza + M cattarhalis

144

Most common area for epistaxis

Anterior segment of nostril (Kiesselach plexus)

145

Life-threatening hemorrhages location?

Posterior segment (sphenopalatine artery)

146

Sphenopalatine branches from...

Maxillary artery

147

Field cancerization

Carcinogen damages wide mucosal area leading to multiple tumors

148

Virchow triad

Stasis + hyper coagulability + endothelial damage

149

Endothelial damage and thrombosis mechanism

Exposed collagen triggers clotting cascade

150

D-dimer characteristics as a test

High sensitivity, low specificity

151

Homan sign

Sign of DVT. Dorsiflexion of foot --> calf pain.

152

Acute management of DVTs

unfractionated heparin or low-molecular weight heparins

153

DVT prophylaxis

unfractionated heparin or low-molecular weight heparins

154

DVT long-term prevention

warfarin + rivaroxaban

155

Imaging test of choice for DVTs

compression ultrasound

156

acid-base disturbance with PEs

Respiratory alkalosis (tachypnic)

157

What composes lines of Zahn?

areas of pink = platelets, fibrin
red = RBCs

158

Fat emboli triad

hypoxemia + neurologic abnormalities + petechial rash

159

amniotic fluid emboli association

DIC

160

Imaging test of choice for PE

CT pulmonary angiography

161

Cardiac sequela of obstructive lung disease

Chronic hypoxic pulmonary vasoconstriction can lead to cur pulmonale

162

Reid index

Thickness of mucosal gland layer to thickness of war between epithelium and cartilage. (NOT just surface area ratio)

163

Chronic bronchitis diagnosis

Productive cough for greater than 3 months (don't need to consecutive) for over 2 consecutive years.

164

CXR in chronic bronchitis

Normal (mucus buildup is etiology)

165

Centriacinar vs. panacinar emphysema location

centriacinar usually in upper lobes, panacinar frequently in lower lobes.

166

emphysema pathophys

Increased elastase activity leads to loss of elastic fibers leading to increased lung compliance.

167

Breathing pattern in emphysema

Exhalation through pursed lips to increase airway pressure and prevent airway collapse.

168

recoil and compliance in emphysema

Increased compliance, decreased recoil

169

CXR finding in asthma

Peribronchial cuffing

170

Inspiratory/expiratory ratio in asthma

Decreased

171

Bronchiectasis pathophys + presentation

Chronic necrotizing infection of bronchi leading to permanently dilated airways + purulent sputum + recurrent infections + hemoptysis + digital clubbing

172

FEV1/FVC in restrictive lung disease

greater than or equal to 80%

173

ILD characteristics

Decreased diffusing capacity + increased A-a gradient

174

Pulmonary langerhans cell histiocytosis (eosinophilic granuloma)

...

175

Hypersensitivity pneumonitis hypersensitivity type

Mixed type III/IV

176

Hypersensitivity pneumonitis presentation

Dyspnea + cough + chest tightness + headache

177

Pneumoconioses cardiac sequela

Increased risk of cor pulmonale

178

asbestosis professional RF's

Shipbuilding + roofing + plumbing

179

Pathognomonic finding of asbestosis

"Ivory white" calcified, supra diaphragmatic and pleural plaques.

180

asbestosis association

Increased risk of pleural effusions

181

Lung region affected in asbestosis

Lower lobes

182

Lung region affected in asbestosis in berylliosis

Upper lobes

183

Potential treatment for berylliosis

Occasionally responsive to steroids (granulomatous)

184

Coal workers' pneumoconiosis findings

inflammation + fibrosis

185

Coal workers' pneumoconiosis lung region affected

Upper lobes

186

Silicosis professional RF's

Foundries + sandblasting + mines

187

Silicosis pathophys

Macrophages respond to silica and release fibrogenic factors, leading to fibrosis

188

Silicosis and increased TB risk pathophys

Silica disrupts phagolysosomes and impairs macrophages, thus increasing susceptibility to TB.

189

Silicosis lung region affected

Upper lobes

190

PaO2/FIO2 in ARDS

decreased

191

ARDS and fluid overload

no evidence of HF or fluid overload

192

ARDS associations

SPARTAS: Sepsis, Pancreatitis, Pneumonia, Aspiration, uRemia, Trauma, Amniotic fluid embolism, Shock

193

ARDS pathophys

endothelial damage leads to increased alveolar capillary permeability, leading to protein-rich leakage into alveoli, leading to diffuse alveolar damage and noncardiogenic pulmonary edema.

194

ARDS management

Mechanical ventilation with low tidal volumes, address underlying cause.

195

Initial ARDS damage pathophys

Release of neutrophilic substances toxic to alveolar wall --> activation of coagulation cascade --> oxygen derived free radicals

196

PaO2 in sleep apnea

Decreased at night, normal during day

197

Sleep apnea definition

Repeated cessation of breathing greater than 10 seconds during sleep.

198

Sudden death in sleep apnea pathophys

Nocturnal hypoxia --> systemic/pulmonary HTN --> arrhythmias (atrial fibrillation/fluter)

199

OSA etiology in adults and kids

Adults --> excess paraparyngeal tissue.
Kids --> adenotonsillar hypertrophy

200

Central sleep apnea

No respiratory effort due to CNS injury/toxicity, HF, opioids

201

Obesity hypoventilation syndrome labs

Decreased PaO2 and increased PaCO2 during sleep; increased PaCO2 during waking hours (retention).

202

Normal mean pulmonary artery pressure

10-14 mm Hg

203

Pulmonary HTN defined as..

greater than 35 mm Hg at rest

204

Arterial sequela of pulmonary HTN

Pulmonary arteries..
1) Arteriosclerosis
2) medial hypertrophy
3) intimal fibrosis

205

Heritable PAH genetics

Inactivating mutation in BMPR2 gene

206

BMPR2 gene function

normally inhibits vascular smooth muscle proliferation

207

Other causes of PAH

1) Amphetamines + cocaine
2) connective tissue disease
3) HIV infection
4) portal HTN
5) congenital heart disease
6) schistosomiasis

208

ID associated with PAH...

schistosomiasis

209

Microthrombi and pulmonary HTN mechanism

recurrent micro thrombi lead to decreased cross-sectional area of pulmonary vascular bed

210

fremitus

Vibratory sensation transmitted through the lungs.

211

Fremitus
1) Increased pathophys
2) decreased pathophys

1) Denser or inflamed lung tissue, eg pneumonia
2) air or fluid in pleural spaces, eg COPD or asthma

212

tracheal deviation with atelectasis (bronchial obstruction)

Toward side of lesion

213

Simple pneumo
1) breath sounds
2) percussion
3) fremitus

1) decreased
2) hyperresonant
3) decreased

214

tracheal deviation in simple pneumo

None

215

tracheal deviation in tension pneumo

Away from side of lesion

216

Simple pneumo
1) breath sounds
2) percussion
3) fremitus

1) decreased
2) hyper resonant
3) decreased

217

Consolidation (lobar pneumonia, pulmonary edema)
1) breath sounds
2) percussion
3) fremitus

1) bronchial breath sounds; late inspiratory crackles
2) dull
3) ***increased

218

typical organisms in lobar pneumonia

1) s pneumo most frequently
2) legionella
3) klebsiella

219

Lobar pneumonia characteristics

Intra-alveolar exudate leading to consolidation; may involve entire lobe or lung.

220

typical organisms in bronchopneumonia

1) s pneumo
2) s aureus
3) H flu
4) klebsiella

221

bronchopneumonia characteristics

1) Acute inflammatory infiltrates from bronchioles into adjacent alveoli
2) patchy distribution involving more than 1 lobe

222

typical organisms in interstitial (atypical) pneumonia

1) mycoplasma
2) chlamydia
3) legionella
4) RSV
5) CMV
6) influenza
7) adenovirus

223

interstitial (atypical) pneumonia characteristics

Diffuse patchy inflammation localized to interstitial areas at alveolar walls; diffuse distribution involving one or more than one lobe.

224

lung abscess etiology

1) aspiration
2) bronchial obstruction (eg cancer)

225

lung abscess treatment

Clindamycin

226

Location of aspiration when upright

Basal segments of right lower lobe

227

Location of aspiration when supine

Posterior segments of right upper lobe or superior segment of right lower lobe

228

Sequela of mesothelioma

1) hemorrhagic pleural effusion (exudative)
2) pleural thickening

229

caveat about mesothelioma

Smoking is not a risk factor

230

mesothelioma markers

Cytokeratin + calretinin positive

231

area affected in Horner syndrome

Superior cervical ganglion

232

pan coast tumor associations

1) hoarseness
2) horner's
3) SVC syndrome
4) sensorimotor deficit

233

Physical exam findings in SVC syndrome

1) facial plethora
2) blanching after fingertip pressure
3) JVD
4) upper extremity edema

234

SVC syndrome etiology

1) Pancoast tumor
2) thrombosis from indwelling catheter

235

SVC syndrome sequela pathophys

Raised ICP --> headaches, dizziness + increased risk of aneurysm/rupture of intracranial arteries.

236

Coin lesion on CXR...

lung cancer

237

non calcified nodule on CXR...

lung cancer

238

lung cancer mets

adrenals + brain + bone + liver

239

most common mets to lung

Breast, colon, prostate, bladder

240

lung cancer caveat

mets more common than primary neoplasms

241

small cell management

chemo +/- radiation

242

small cell origin

neoplasm of neuroendocrine Kulchitsky cells

243

adenocarcinoma genetics

Activating mutations in KRAS + EGFR + ALK.

244

adenocarcinoma association

Hypertrophic osteoarthropathy

245

CXR of adenocarcinoma in situ

hazy infiltrates similar to pneumonia.

246

adenocarcinoma in situ also known as...

bronchioloalveolar subtype

247

SCC location

hilar mass arising from bronchus

248

large cell carcinoma management

Less responsive to chemo; surgery.

249

large cell carcinoma marker

Can secrete beta-hCG

250

bronchial carcinoid tumor prognosis

Excellent; mets rare

251

bronchial carcinoid presentation

Symptoms due to mass effect or carcinoid syndrome (flushing, diarrhea, wheezing).

252

bronchial histology

Nests of neuroendocrine cells + chromogranin A positive.

253

First generation antihistamines

1) Diphenhydramine
2) dimenhydrinate
3) chlorpheniramine

254

Second generation antihistamines

1) Loratadine
2) fexofenadine
3) desloratadine
4) cetirizine

255

Guaifenesin caveat

just thins respiratory secretions; doesn't suppress cough reflex.

256

N-acetylcysteine MOA

disrupts disulfide bonds

257

N-acetylcysteine use

Liquefying mucus in COPD

258

Dextromethorphan mechanism

1) antagonizes NMDA glutamate receptors
2) synthetic codeine analog

259

abuse potential of dextromethorphan?

Mild

260

pseudoephedrine mechanism

alpha-adrenergic agonist

261

pseudoephedrine SE's

HTN + CNS stimulation/anxiety

262

Pulmonary HTN drugs

1) bosentan
2) sildenafil
3) epoprostenol, iloprost

263

Bosnian mechanism

Competitively antagonizes endothelin-e receptors

264

How can sildenafil be used for pulmonary HTN?

By inhibiting cGMP, prolongs vasodilatory effect of NO.

265

epoprostenol, iloprost SE's

flushing + jaw pain

266

epoprostenol, iloprost MOA

PGI2 (prostacyclin)

267

formoterol

like salmeterol

268

salmeterol, formoterol AE's

tremor + arrhythmia

269

1st line for chronic asthma

fluticasone, budesonide (inhaled corticosteroids0

270

fluticasone, budesonide MOA

1) inhibit synthesis of virtually all cytokines
2) inactivate NF-kappaB

271

NF-kappaB

TF that induces production of TNF-alpha and other proinflammatory agents

272

tiotropium vs. ipratropium

tiotropium is long acting

273

methacoline receptor

M3 agonist

274

best treatment for aspirin-induced asthma

Montelukast, zafirlukast

275

Montelukast, zafirlukast mechanism

block leukotriene receptors (CysLT1)

276

Zileuton SE

hepatotoxic

277

Zileuton MOA

5-lipoxygenase inhibitor

278

Omalizumab clinical use

allergic asthma with increased IgE levels resistant to inhaled steroids and LABAs

279

theophylline MOA

bronchodilator via phosphodiesterase inhibition, leading to increased cAMP levels due to decreased cAMP hydrolysis

280

theophylline caveats

1) limited usage due to narrow therapeutic index (cardiotoxic + neurotoxic)
2) adenosine

281

Phosphodiesterase (PDE)

cAMP --> AMP

282

cAMP respiratory mechanism

bronchodilator

283

molecules that cause bronchoconstriction

1) ACh
2) adenosine

284

Phospholipase A2 in arachidonic acid pathway

Converts membrane phospholipids to arachidonic acids

285

What activates COX-2?

NF-kB

286

5-lipoxygenase

Arachidonic acid --> 5-HPETE (eicosanoid)

287

COX-1 action in arachidonic acid pathway

arachidonic acid --> cyclic endoperoxides

288

arachidonic acid pathway

1) membrane phospholipids --> arachidonic acid --> 5-HPETE --> Leukotrienes
2) membrane phospholipids --> arachidonic acid --> cyclic endoperoxides --> prostacyclin + PGs + thromboxane

289

Leukotrienes that increase bronchial tone

1) LTC4
2) LTD4
3) LTE4

290

Dinoprostone

PGE2

291

Alprostadil

PGE1

292

Carboprost

PGF2alpha

293

thromboxane actions

1) increase platelet aggregation
2) increase vascular tone

294

PGE1 actions

Decreases vascular tone

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PGE2 actions

Increases uterine tone

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PGF2alpha actions

Increases uterine tone

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Prostacyclin (PGI2) action

1) decreases platelet aggregation
2) decreases vascular tone

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Pulmonary hypertension characteristic finding

Coronary sinus dilation is a characteristic finding (coronary sinus contains venous blood and communicates freely with the RA and therefore may become dilated secondary to any factor that causes right atrial dilatation).

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Causes of transudate

1) increased hydrostatic pressure
2) decreased oncotic pressure

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examples of transudate

1) nephrotic syndrome
2) cirrhosis

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Conditions that cause exudate

1) malignancy
2) pneumonia
3) collagen vascular disease
4) trauma
*states of increased vascular permeability.

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chylothorax

AKA lymphatic effusion

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Cause of lymphatic effusion

thoracic duct injury from trauma or malignancy

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lymphatic effusion presentation

1) Milky-appearing fluid
2) increased TGs

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Pneumothorax
1) breath sounds
2) percussion
3) fremitus

1) diminished
2) hyperresonant
3) decreased

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Cause of secondary spontaneous pneumo

1) Diseased lung (eg bullae in emphysema, infections).
2) mechanical ventilation with use of high pressures leading to barotrauma.

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Tension pneumothorax

Can be any of other types. Air enters pleural space but cannot exit. Increased trapped air leads to tension pneumothorax.

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tension pneumo management

Immediate needle decompression + chest tube placement.

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tracheal deviation in tension pneumo

Trachea deviates away from affected lung.

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Phases of lobar pneumonia

 Hippo with cold in lawn chair/congestion. Red lungs + covered in blood vessels + francis’s climbing all over it/1) congestion (first 24 hrs): red, heavy and boggy lobe + vascular dilation + alveolar exudate contains mostly bacteria.
 red hippo in lawn chair/red hepatization. Red lungs + newts crawling around everywhere + big RBCs on the ground + lawn chair covered in fibrin/2) red hepatization (2-3 days): red, firm lobe (liver-like consistency + alveolar exudate contains erythrocytes + neutrophils + fibrin.
 Grey hippo in lawn chair/grey hepatization. Grey lobe + disintegrating RBCs on ground + lawn chair covered in fibrin + newts crawling around/3) grey hepatization (4-6 days): gray-brown firm lobe + RBCs disintegrate + alveolar exudate contains neutrophils and fibrin.
 Hippo dancing around/4) resolution: restoration of normal architecture + enzymatic digestion of the exudate.

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methemoglobinemia presentation

dizziness + dyspnea + confusion + seizures + coma

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Complication of nitric oxide administered for pulmonary HTN disease of newborn

methemoglobinemia

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Systemic mastocytosis

o Code: Scott Massed: huge cat spewing acid from its mouth behind him/mast cell proliferation in the bone marrow and in other organs, resulting in increased histamine secretion gastric acid hypersecretion. Scott looking like below + flushed face + itching himself intensely + booting everywhere/presentation = pruritis + rash + flushing + GI symptoms (abdominal cramps, nausea, vomiting). Huge nests at top of all the sail boat masts + intestines in the nests/small bowel biopsy = nests of mast cells within the mucosa.
o Location: Boat yard, end of dock near exit from Royal River

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Worsening SOB + malaise + continued respiratory symptoms in a patient with pneumonia

pulmonary effusion

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CXR of pulmonary effusion

blunting of costophrenic angle + air fluid level.

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Physical exam findings of pleural effusion

pleural friction rub on auscultation.

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Characteristic finding in severe PAH

Lesions can progress to form plexiform lesions (interlacing tufts os mall vascular channels)

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presentation of IPF

insidious onset of dyspnea on exertion + dry cough present for more than 3 months + bibasilar rales clubbing + diffuse reticular opacities.

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inflammatory mediators of chronic bronchitis

monocytes + CD8+ T cells + neutrophil infiltration

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cough productive of yellow sputum...

chronic bronchitis

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common pathogen in smokers with chronic bronchitis

H flu

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sputum findings in bronchial asthma

Luke in corner and it’s hailing on him + eoss goddesses wrapped around all the hanging spiral/sputum findings = **eosinophils, which are recruited and activated by IL-5 secreted by TH2 type helper T-cells.

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bronchiectasis association

hypertrophic osteoarthropathy (HOA)

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leukocoria

White reflex

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leukocoria associations

1) retinoblastoma
2) congenital cataracts

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ARDS on CXR

bilateral radiographic opacities

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Brain abscess RF's

endocarditis + bronchiectasis + IV drug use

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lung abscess presentato

indolent + fever + night sweats + weight loss + cough productive of foul-smelling sputum (indicative of anaerobes).

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How do enteric bacteria (e coli + klebsiella + enterococci) cause hepatic abscesses?

Ascend biliary tract

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other route of infection to hepatic abscess

portal vein pyemia

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How does staph aureus cause hepatic abscesses?

Francis with a blow dart gun shooting seeds at liver/another route of infection = hematogenous seeding of the liver with staph aureus.

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pneumoconiosis associated with insulation...

asbestosis/mesothelioma

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Mesothelioma histology

tumor cells with long, slender microvilli + abundant tonofilaments

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typical pneumonia

♣ Code: Margaret Lawrence: she’s sweating profusely + coughing up sputum all over her chest/presentation = high fever + lobar consolidation + productive sputum. Newts crawling around floor everywhere/these symptoms result from the primary responding immune cell, the neutrophil, which enters area, releases pyrogenic products (fever), causes innocent bystander damage to lung, and creates abscesses (lobar consolidation). /usually EXTRACELLULAR organisms, gram-negatives (1) s. pneumo + 2) H. influ + 3) M. cattarhalis + 4) S. aureus). /lobar infiltrate. Steph in a track suit flashing her tits + prostitutes sitting at table/treatment = empirical ceftriaxone + azithromycine.
♣ Location: Conference room in library first floor

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typical pneumonia treatment

ceftriaxone + azithromycine

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neonatal atypical pneumonia presentation

crackles + wheeze

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cold agglutinins

antibodies (usually IgM) produced in response to certain kinds of infection such as m. pneumoniae.

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Relation between lung volume and pulmonary vascular resistance

o Code: huge massive U/graph is U shaped. /This is because high lung volumes (eg following inspiration) increase PVR due to the longitudinal stretching of alveolar capillaries by the expanding alveoli. Decreased lung volumes also increase PVR due to decreased radial traction from adjacent tissues on the large extra-alveolar vessels. /thus, PVR is lowest at the FRC.
o Location: Above DIA

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What can you use to measure FRC and RV?

helium dilution technique

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Lamellar body or granule

Phospholipids are stored in lamellar bodies and serve as pulmonary surfactant.