Respiratory Flashcards by Stephanie Escobar

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.

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In emphysema, Diffusing capacity of the lung for carbon monoxide (DLCO) is ________

decreased *due to emphysematous destruction of the alveolar-arterial membrane.

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How is a Normal A-a gradient clinically estimated?

(age/4) + 4

(ex: for a person <40 years old, gradient should be <14).

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hemorrhagic pleural effusion (exudative), nodular pleural thickening Psammoma bodies Desmosomes, Tono-filaments, long Microvilli

Mesothelioma

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Lung Malignancy not associated with smoking at all

Mesothelioma

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Calretinin + Cytokeratin 5/6+

Mesothelioma

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↑ CD4/CD8 ratio on BAL fluid ↓ PTH ↑ Calcium in serum Coarse Reticular Opacities

Sarcoidosis Also, ↑ ACE

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Non-Caseating Granulomas containing calcium + Protein Giant cell called what?

Schaumann bodies (Sarcoidosis)

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Non-Caseating Granulomas containing lipids/MQs in giant cell

Asteroid bodies (Sarcoidosis)

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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

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Neutrophils, macrophages, and _______ are the primary mediators of disease in chronic obstructive pulmonary disease.

CD8+ T lymphocytes

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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.

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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

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Prolonged, untreated obstructive sleep apnea can cause what complications (2)?

pulmonary hypertension

right heart failure

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BMPR2 gene mutations cause idiopathic ______

pulmonary hypertension

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What is seen here

Dilsted Air spaces

Emphysema

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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)

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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

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neutrophil elastase, that cause alveolar damage, reduced ciliary motion, and increased ______.

mucus secretion by goblet cells

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_______, a disease characterized by chronic airway inflammation, airway hyperresponsiveness, and intermittent, reversible bronchoconstriction.

Uncontrolled Asthma

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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)

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_________ 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

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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).

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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

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\_\_\_\_ 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 i**ncreased 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 ## Footnote **FRC**

Reserve volume + Expiratory Reserve Volume

Vital Capacity ## Footnote **VC**

TV + IRV + ERV

Total Lung Capacity ## Footnote **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

**% O₂sat 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?

↑ **A**cid H+ (↓pH) ↑ P**C**O₂ **E**xercise ↑ 2,3 **B**PG ↑ **A**ltitude ↑ **T**emperature **_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 P_AO2 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 altitud**e 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 o**f 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.**

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 f**ills up the terminal bronchioles and alveoli.** Electron microscopy of the substance shows **lamellar bodies.** What cells are bad?

Macrophages ## Footnote **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_)

Respiratory Flashcards

(103 cards)