question

muscles of normal breathing

answer

inspiration: internal/external intercostals elevate ribs; diaphragm descends to create vacuum expiration: passive recoil

question

muscles of forced breathing

answer

inspiration: sternocleidomastoid elevates the sternum; scalenes elevates the ribs; pec minor elevates the ribs expiration: internal intercostals pull ribs down; abdominals pulls ribs down and diaphram up; quadratus lumborum pulls last rib down

question

type I pneumocytes

answer

97% of alveolar surface squamous THIN for gas exchange

question

type II pneumocytes

answer

secrete surfactant via calcium channel dependent fusion of lamellar body membranes with cell membrane --exocytosis stem cells for type I and II pneymocytes; proliferate during damage

question

trachibronchial tree: conducting zone

answer

trachea is covered in C-shaped hyaline cartilage and smooth muscle; pseudostratified ciliated columnar cells with goblet, basal, and club/ clara cells; divides into two mainstem bonchi at the level of the sternal angle, T4/5 right branch is more vertical, and wider --thus aspiration almost always goes to the right right branch --three lobar bronchi left branch --two lobar bronchi; bronchi have circular shaped hyalin cartilage and smooth muscle cartilage ceases at the bronchioles and terminal bronchioles, which still have smooth muscle but simple ciliated columnar epithelium

question

where does the trachea divide ?

answer

T4/T5; level of the sternal angle right mainstem bronchi is more vertical and wider

question

where along the respiratory tree does hyalin cartilage cease?

answer

at the level of the bronchioles, which still have smooth muscle

question

respiratory zone

answer

made of the respiratory and terminal bronchioles: cuboidal ciliated cells, club cells, and smooth muscle alveolar sacs: simple squamous layer of pneumocytes, alveolar macrophages and capillaries

question

particle passage through lung:

answer

large particles stuck in mucus at the trachea, bronchi, or bronchioles are swept up and out by cilia small particles wi the respiratory bronchioles and alveoli are eaten by macrophages

question

structures passing through diaphragm

answer

IVC: T8 esophagus and vagus: T10 aorta: T12 i ate ten eggs at twelve

question

aspiration from standing

answer

base of the R lower lobe

question

aspiration from supine

answer

posterior R upper lobe or R lower lobe

question

tracheal histo

answer

pseudostratified ciliated columnar epithelium 16-20 C shaped hyaline cartilage rings with the opening facing posteriorly smooth muscle clara cells secrete surfactant-like lecethin goblet cells and basal cells

question

bronchial histo

answer

pseudostratified ciliated columnar epithelium O shaped hyaline cartilage rings smooth muscle clara cells secrete surfactant-like lecethin goblet cells and basal cells

question

goblet cells

answer

mucus producing cells found at the trachea and bronchi but not bronchioles

question

clara club cells

answer

secrete a surfactant like substance w high IgA which protects the lining most abundant at the terminal bronchioles

question

bronchioles and terminal bronchioles histo

answer

conducting zone: simple ciliated columnar epithelium with club/clara cells and smooth muscle no hyalin cartilage

question

respiratory bronchioles histo

answer

cuboidal ciliated cells with club/clara cells epithelium some smooth muscles but no cartilage

question

alveolar sacs

answer

NON CILIATED respiratory epithelium of pneumocytes and alveolar macrophages capillaries some smooth muscles but no cartilage

question

tidal volume

answer

tidal volume inspiratory reserve volume expiratory reserve volume residual volume

question

functional residual capacity

answer

residual vol+ expiratory reserve vol

question

inspiratory capacity

answer

tidal vol + inspiratory reserve vol

question

vital capacity

answer

inspiratory capacity + expiratory reserve vol (inspiratory reserve vol+tidal vol+expiratory reserve vol)

question

total lung capacity

answer

vital capacity + residual vol inspiratory capacity + functional residual capacity inspiratory reserve vol + tidal vol + expiratory reserve vol + residual vol

question

high altitude

answer

hypoxemia due to reduction in partial pressure of oxygen hyperventilation --respiratory alkalosis (blowing off acid) renal compensation --mild metabolic acidosis increased excretion of HCO3

question

prolonged altitude stats

answer

1. hypoxemia pO2 lower than 76 2. respiratory alkalosis LOW pCO2 below 33 3. ALKALOTIC pH above 7.45 4. compensatory metabolic acidosis, loss of HCO3 below 22

question

ventilation V

answer

air through the alveoli

question

perfusion Q

answer

blood coursing by the alveoli

question

the four major causes of hypoxemia

answer

alveolar hypoventilation VQ mismatch diffusion impairment right-left shunting

question

MCC VQ mismatch

answer

PE --where ventilation continues but there is no perfusion V>Q thus HIGH V/Q

question

VQ zones

answer

zone I apex: V>Q high V/Q (like a PE) zone II midd: V~Q zone III base: V<Q low V/Q (airway obstruction, atelectasis)

question

VQ zone I

answer

apex: V>Q more ventilation than perfusion bc gravity high V/Q (like PE)

question

VQ zone III

answer

base: V<Q more perfusion than ventilation bc gravity low V/Q (like airway obstruction, atelectasis)

question

Hg dissociation curve: right shift

answer

increased metabolic demand: decreased pH, BPG increase, temp increase MCC: lactic acidosis

question

Aa gradient

answer

A: alveolar a: arteriolar normally around 10-12 mmHg wide Aa suggests hypoxemia be O2 not getting from Alveoli to arteriorles

question

MCC wide Aa

answer

PE pt. w tachypnea, history of DVT or risk factors

question

Alveolar gas equation

answer

[150mmHg/pO2 in air] - [paCO2/.8]

question

hyperventilation

answer

blowing off CO2 causes respiratory alkalosis

question

hypoventilation

answer

retaining CO2 causes respiratory acidosis

question

cerebral blood flow is mostly determined via

answer

pCO2: high CO2 causes higher cerebral blood flow once pO2 drops below 50mmHg, cerebral blood flow determined by pO2

question

hypercapnia

answer

high CO2 levels ie patients w COPD, will tend to have higher cerebral plasma flow

question

carotid bodies

answer

chemoreceptor and baroreceptor measures pO2, pCO2, H+, and stretch transmission via glossopharyngial (IX) and solitary nucleus of medulla

question

aortic bodies

answer

chemoreceptor measures pCO2 and H+ transmission via vagus (X) and solitary nucleus of medulla

question

chemoreceptors

answer

peripheral: carotid and aortic bodies; stimulated by drop on PO2 (below 60), increase in PCO2, and decrease of pH central: stimulated by drop on pCO2 wi brain interstitial fluid

question

baroreceptors

answer

carotid bodies: stimulated with drop in arteriolar pressure or decreased stretch to increase efferent sympathetic firing, and decrease efferent parasympathetic firing thus increasing vasoconstriction, HR, and contractility via glossy (IX) which synapses at the solitary nucleus of medulla

question

chronic COPD pt and oxygen supplementation

answer

the chronic COPD pt. is perpetually hypercapnic, due to air trapping thus their peripheral chemoreceptors have been desensitized to high CO2 and low O2 thus when given extra O2, the chemoreceptors think there is plenty of oxygen, and thus the pt. might stop breathing

question

breathing centers of the brain

answer

apneustic center detects hypoxia (low O2) pneumotactic center detects hypercapnia (high CO2) both at the pons, blood from superior cerebellar, AICA, and basilar

question

apneustic breathing

answer

lesion to the pneumotactic center of the pons leads to long inhalations and short exhalations assoc. w chronic COPD bc pneumotactic is desensitized to pCO2

question

medullary breathing

answer

the medulla has a respiratory rate of about 16 --faster than usual

question

Cheyne Stokes breathing

answer

faster faster faster drop. increased speed in breathing followed by apnea MCC brain stem leasion or increased ICP

question

Biots breathing

answer

gasps and short pauses, characteristic of severe meningitis, head trauma, or active dying

question

Kussmaul's breathing

answer

compensatory tachypnea and hyperpnea --fast deep breaths compensatory with metabolic acidosis, DKA, renal failure

question

Juxtacapillary J receptors

answer

within the lung interstitum increase respiratory rate in response to pulm edema, PE, or consolidation

question

slow adapting lung receptors

answer

found at the sternocostal junction stimulated w stretch and inflation responsible for exhalation

question

pulsus paradoxus

answer

exaggerated drop in BP or pulse of more than 10 on inspiration MCC: pericardial tamponade, pneumothorax

question

Kussmaul sign

answer

increased jvd on inspiration MCC pneumothorax

question

retinopathy of prematurity

answer

premies are on 100% O2, when taken off, the body things its hypoxic and increases VEGF leading to increased neovascularization creating friable wee arteries

question

hyalin membranes

answer

RDS: respiratory distress syndrome

question

ARDS

answer

widespread pulmonary microvascular endothelum damage causes leaky capillaries, increased cytokine damage, and alveolar edema compensatory goblet cell hyperplasia leads to increased REID index, exacerbating hypoxia intra-alveolar edema, inflammation, hyalin membranes with normal pulmonary capillary wedge pressure (bc not a cardiogenic prob)

question

Obstructive pulmonary disease findings

answer

air trapping !! increased compliance and increased stretch normal to increased lung capacity normal forced vital capacity DECREASED FEV1 DECREASED FEV1/FVC

question

decreased FEV1

answer

obstructive

question

decreased FEV1/FVC

answer

obstructive

question

Restrictive pulmonary disease findings

answer

reduced expansion/elasticity decreased lung capacity decreased forced vital capacity normal to low FEV1 normal FEV1/FVC (bc both are lowered together)

question

normal FEV1/FVC

answer

restrictive -both are lowered together

question

chronic bronchitis dx details

answer

obstructive lung volumes productive cough for more than three mos (not necessarily consecutive) per year for more than two years cyanotic due to shunting dyspnea due to hypercapnia wheezing and crackles

question

chronic complications of chronic bronchitis

answer

recurrent bacterial infections, increased PMS and inflammation secondary polycythemia pulmonary htn and cor pulmonale

question

chronic bronchitis pathophys

answer

hyperplasia of mucus secreting glands of the bronchi (goblet cells) with patchy squamous metaplasia thickened walls w Reid index ;50%

question

asthma pathology

answer

eosinophilic mediated: Il5 released recruits eosinophils curshmann spirals: shed epithelum leading to whorled mucus plugs charcot-leyden crystals: eosinophil bkdwn product increased sensitivity leads to muscle hypertrophy

question

Curshmann spirals

answer

epithelial slophing into whorled mucus plugs seen with asthma

question

Charcot-Leyden crystals

answer

eosinophilic hexagonal double pointed needle like crystals from excessive breakdown of eosinophils in sputum

question

Panacinar emphysema

answer

assoc w a1 antitrypsin deficiency

question

Centriacinar emphysema

answer

assoc. w smokers

question

PAS staining

answer

periodic acid schiff stains for glycoproteins positive stain assoc. a1 antitrypsin deficiency (RE ALL also PAS +)

question

expiratory wheeze

answer

caused by constriction assoc. w asthma bronchoconstriction

question

inspiratory wheeze

answer

stridor caused by obstruction assoc. w croup (paramyxoid virus)

question

bronchiolitis

answer

RSV

question

epiglottitis

answer

H. flu drooling, leaning forward, w stridor

question

croup, laryngotracheitis

answer

paramyxovirus, cornybacterium diptheria inspiratory seal like stridor

question

rust colored sputum

answer

strep pneumo due to extravasation of RBC

question

green sputum

answer

CAP: from myeloperoxidase released from PMN teen CF: pseudamona pyocyanin (re babe CF s.aureus)

question

currant jelly sputum

answer

klebsiella due to extravasation of RBC

question

pneumonia after flu

answer

staph aureus

question

foul smelling sputum

answer

anarobes -pseudamona esp assoc. w alcoholics and homeless tx w clindamycin

question

legionellosis

answer

pontiac fever: acute self-limiting flu like symptoms pneumonia GI upset, diarrhea bradycardia, confusion, headache hyponatremia sputum gram stain w high PMNs but no bacteria (doesnt gram stain)

question

hyponatremia w flu-like symptoms, GI upset, pneumonia

answer

legionarres also assoc: bradycardia, headache, confusion

question

anthracosis

answer

coal miners lung coal laden macrophages and pleural thickening with calcifications NO increase in cancer risk restrictive lung pattern and exertional dyspnea

question

asbestosis

answer

shipyard, old buildings restrictive lung pattern w increased risk of cancer calcified pleural plaques and ferruginous bodies

question

ferruginous bodies

answer

asbestosis restrictive lung disease

question

silicosis

answer

sand and glass impairs macrophages, thus increased susceptibility to Tb egg shell calcifications and restrictive lung pattern

question

egg shell calcifications

answer

silicosis

question

idiopathic pulmonary fibrosis

answer

restrictive lung pattern with honeycombing of the lungs repeated cycles of lung injury and wound healing with increased collagen deposition assoc. digital clubbing

question

honey combing of the lungs

answer

diffuse small reticulonodular opacities more pronounced at the lower lobes on CXR IDIOPATHIC pulmonary fibrosis

question

interstitial pneumonia bugs

answer

mycoplasma, chlamydia, legionella RSV, CMV

question

stages of a lobar pneumonia

answer

day 1. congestion w vascular dilation; alveolar exudate of bacteria day 2-3: red hepatization: alveolar exudate of PMNs, fibrin, erythrocytes with a red liver like consistency day 4-6: grey hepatization: RBC disintegrate, alveolar exudate of PMNs and fibrin; lobe grey and brown resolution: enzymatic digestion of infiltrate; restored architecture

question

red hepatization of the lungs

answer

day 2-3 of lobar pneumonia alveolar exudate of PMNs, fibrin, erythrocytes

question

grey hepatization of the lungs

answer

days 4-6 of lobar pneumonia RBC disintegrate, alveolar exudate of PMNs and fibrin

question

resolution of lobar pneumonia

answer

enzymatic digestion of intiltrate w restored architecture

question

Mesothelioma histopath

answer

malignancy of pleura assoc. w asbestosis psammoma bodies and epitheliod papillary projections lined with mesothelial cells cytokeratin+ and calretinin +

question

psammoma bodies

answer

mesolemioma meningioma papillary carcinoma of the thyroid serous papillary cystadenocarcinoma of ovary

question

Pancoast superior sulcus tumor

answer

at the apex of the lung compression syndromes recurrent laryngeal: hoarseness superior cervical ganglia: horners ipsi ptosis, miosis, anhidrosis shoulder pain due to brachial plexus irritation SVC syndrome possible but rare assoc. w non small cell

question

SVC syndrome

answer

impaired venous return from the upper part of the body, manifesting as persistent cough, dyspnea, facial edema, elevated ICP, elevated JVP assoc. w mediastinum mass

question

Small cell lung cancer

answer

aggressive and widely metastatic centrally located syndromes: cushings due to increased ACTH, SIADH, labert eaton presynaptic Ca channel abs

question

Small cell lung cancer histopath

answer

Kulchitsky cells: undifferentiated small blue cells cytokeratin+ synaptophysin+ chromogranin+ neuroenolase+

question

Kulchitsky cells

answer

poorly differentiated, dark blue cells with salt and pepper nucleus neuroendocrine origin cytokeratin+ synaptophysin+ chromogranin+ neuroenolase+

question

Adenocarcinoma of the lung

answer

located peripherally most common lung cancer in nonsmokers and womyn assoc. w finger clubbing, KRAS, EGFR, ALK activating mutations hazy infiltrates on CXR resemble pneumonia thickening of alveolar walls

question

Adenocarcinoma of the lung histopath

answer

glandular pattern w mucin+ stain thickening of alveolar walls

question

Squamous cell carc lung

answer

hilar mass arising from bronchus w central necrosis or cavitation high assoc. smoking: squamous metaplasia of respiratory epithelium secondary to chronic irritation (re similar to barrets) produces PTH causing hypercalcemia --Keratin pearls on histo

question

Squamous cell carc lung histopath

answer

keratin pearls (re hypercalcemia) due to squamous metaplasia secondary to smoking (similar to barrets)

question

Large cell carcinoma of lung

answer

peripherally located highly anaplastic undifferentiated tumor secrete BhCG causing gynecomastia and galactorrea

question

Bronchial carcinoid tumor

answer

low grade, epithelial origin secrete seretonin causing flushing, diarrhea, wheezing nests of neuroendocrine cells, chromogranin A+

question

Large cell carcinoma of the lung histopath

answer

pleomorphic giant cells +BhCG

question

digital clubbing

answer

assoc w large cell lung cancer, adenocarcinoma of the lung, ideopathic pulmonary fibrosis, bronchiectasis, end stage COPD, CF re anemia is spooning

question

Ghon complex

answer

caseating granulomas at hilar nodes, and the ghon focus ie lower lobe classic assoc. primary TB infection

question

primary vs reactive tb

answer

primary lesions at lower of middle lobes of lungs reactive lesions at apex of lungs primary tb is asymptomatic

question

hilar node lesions

answer

silicosis: egg shell primary Tb: granulomas sarcoidosis: lymphadenopathy squamous cell carcinoma: mass

question

coin lesion

answer

on CXR primary lung cancer re: mets have multiple lesions

question

highest fetal oxygenated blood

answer

ductus venosum which bypasses the liver from the umbilical vein to the IVC

question

where does a fish bone get stuck ?

answer

piriform recess by the vocal cords close proximity to laryngeal nerve of X (cough reflex)

question

asbestosis cancer assoc.

answer

malignant mesothelioma vv rare bronchogenic carcinoma

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