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148 Cards in this Set
- Front
- Back
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Normal MAP
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70-100 mmHg
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Normal MPAP
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10-18 mmHg
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BP needed for PH
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greater than 25 mmHg
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What can PAC measure?
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*Right side pressure
*PA pressure *RV pressure *PCWP *Mixed-venous Oxygen saturation |
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How will PCWP reflect the following?
1. PE 2. Mitral valve disease 3. ARDS 4. Left heart failure 5. PAH |
1. Normal
2. High 3. Normal 4. High 5. Normal |
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Reasons for Increased CO
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1. Thyrotoxicosis
2. Sepsis 3. Anaphylaxis 4. Exercise |
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How does PVR change in the following settings?
1. PAH 2. PE 3. Early mitral valve disease 4. Hypoxia 5. Left heart failure |
1. Increase
2. Increase 3. Normal 4. Increase 5. Normal |
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What are Left heart pressures like with PE?
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Normal
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Central Respiratory controllers modulate what?
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1. Increase in PaCO2
2. Decrease in pH (Increase in H+) |
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Peripheral respiratory controllers respond to what?
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Decrease in PaO2
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What is the threshold of PaO2 which stimulates peripheral chemoreceptors?
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60 mmHg
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What is the effect of decreased PCO2 on the threshold of PaO2?
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The threshold will be lower.
For example, if you increase PCO2, it will take less of a drop in PaO2 to stimulate the chemoreceptors. |
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What is the threshold of PaCO2 which stops stimulates chemoreceptors?
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30 mmHg
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What is Integral control?
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Ventilation matched to metabolic rate
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Ondine's Curse
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patients have no chemical drive to breath, so when they sleep, they will not breath.
When awake, have wakeful stimulus |
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Obesity Hypoventilation Syndrome
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Definition:An Obese person who doesn't breathe enough and so has hypercapnia and hypoxia
Cause: During sleep CO2 builds due to mechanical burden of obesity and low respiratory drive. Therefore they retain HCO3- to compensate during sleep, which blunts CO2 drive when awake. |
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Chronic hypoventilators
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Compensate with elevated bicarb. Therefore if there is acute hypercapnea, they will not respond.
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Respiratory failure in asthamatic presents with what kind of CO2
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Increased PCO2.
Normally they can hyperventilate to compensate for obstructed airways. This should lead to lower than normal PCO2. |
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Cheyne-Stokes Breathing
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Period of shallow breathing, that gets deeper, then shallow again. Then there is a period of apnea.
Commonly associated with Heart failure. More common during sleep than wakefullness. Carries with it bad prognosis. Due to slow moving blood, chemoreceptors are presented with low PCO2 blood from previous episode of hyperventilation, therefore maintaining apnea. |
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SIDS and Ondine's Curse are related to what brain structure?
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Medulla
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Dyspnea
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Respiratory controllers asking for more than you can give.
Length tension inappropriateness. |
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Signs of Shock
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1. Tachypnea
2. Tachycardia 3. Hypotension 4. Skin changes (cyanosis, mottling, white/gray) 5. Confusion 6. Oliguria |
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Cardiogenic Shock
(CO, Filling pressures, SVR) |
CO = Decreased
Filling pressures = pressure backs up behind pump SVR = Increased due to vasoconstrict |
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Cardiogenic Shock Characteristics
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Hx: Cardiac disease, acute chest pain
Physical: Tachycardia or bradycardia, hypotension * Murmur or gallops * Cool, clammy skin *Crackles in lungs, dyspnea, sitting upright CXR: Pulmonary edema - venous congestion and pleural effusions |
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Hypovolemic Shock
(CO, Filling pressures, SVR) |
CO: Dec
Filling pressure: Dec (CVP & PCWP) SVR: Inc |
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Hypovolemic Shock
Characteristics |
Hx: Vomitting/diarrhea, blood stool, trauma
Physical: Cool clammy skin Tachycardia, dry membranes, hypotension Poor skin turgor Labs: Low Hgb, high BUN/creatinine |
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Distributive Shock
(CO, Filling pressures, SVR) |
CO: Increased
Filling pressure: Low to normal PCWP SVR: Low (abnormal vasodilation) |
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Distributive Shock
Mechanisms |
*Direct AV connection: Macro or micro
*Mitochondrial poisoning ie. cyanide poisoning or thiamine deficiency *Abnormal oxygen release at capillary |
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Systemic Inflammatory Response Syndrome
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2 or more of the following
1. Temp greater than 38 C or less than 36 C 2. RR > 20 breaths/min or PaCO2 <32 mmHg 3. WBC >12,000/mm3 or > 10% bands 4. HR >90 beats/min |
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MODS
Primary vs. Secondary |
Primary: Directly attributed to insult itself
Secondary: Consequence of host response |
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Distributive Shock
Characteristics |
Hx: Fever, confusion, abdominal pain
Physical: Warm extremities, flushed Hypotension, tachycardia, tachypnea Widened pulse pressure, low diastolic pressure Hyper- or hypothermic Labs: WBC high Lactate out of proportion to BP Respiratory alkalosis |
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Obstructive Shock
(CO, Filling pressures, SVR) |
CO: Dec
Filling pressure: Increase, pressure backs up behind the pump SVR: Increase There is a mechanical restriction to filling or emptying. |
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Obstructive Shock
Causes |
*Tension pneumothorax
* PA obstruction (PE) * Mechanical valve stuck closed *Pericardial disease |
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Which has more of an effect on pulmonary microvascular fluid balance?
Protein Osmotic pressure or Permeability |
Permeability
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CPWP in:
1. Cardiogenic 2. ARDS |
Cardiogenic --> Increased
ARDS --> Normal or low |
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What is ARDS?
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Acute respiratory failure with:
1. Hypoxemia, refractory to supplemental O2 2. Diffuse pulmonary infiltrates, b/l 3. Pulm edema with absence of cardiogenic cause 4. Reduced pulmonary compliance (Dec FRC) |
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ARDS
Risk Factors |
*Sepsis
*Multiple fractures (long bones, pelvis) *Drugs *Aspiration of gastric contents *Massive blood transfusions *Prolonged hypotension *AIDS *Acute pancreatitis *Pneumonia *Inhaltion of smoke or toxic gases *Organ transplatns, esp allogenic bone marro recip |
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ARDS
Pathology |
* Injured pulmonary vascular endothelium/epithelium
* Pulm edema, first insterstial, then alveolar flooding *Hyaline membranes (made of albumin and fibrinogen) - from protein exudate * Sequestration of granuloctyes * Alveolar hemorrhage, lung hepatization * Hyperplasia of Type II cells |
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ARDS
Chest X-ray |
Whiting-out
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ARDS
Major Cause of people with ARDS |
MODS
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MODS
Organ Dysfxn Assement takes into account what systems? |
*CNS (glasgow)
*Pulmonary (PaO2/FiO2) *Renal (creatine) *Cardiovascular (BP) *Coagulation (platelets) *Hepatic (bilirubin) |
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What does PEEP do?
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Increases alveolar volume and improves arterial and tissue oxygenation
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PEEP: side effects
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1. Barotrauma - Dec Venous return and CO. Pneumothorax, pneumomediastinum
2. Volutrauma - Distension of lung induces or exacerbates ALI |
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Which position do you have a higher FRC, supine or standing?
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Standing, because abdominal contents are out of the way.
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What is abdominal paradox?
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Abdomen pushes in during inspiration.
Due to b/l phrenic nerve damage. |
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What body parts are needed for coughing?
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Rectus sheath
Glottis |
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Compliance =
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change in volume/change in pressure
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P=
(related to tension and radius) |
P=2T/r
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Cell mediators of:
1. COPD 2. Asthma |
1. macrophages and neutrophils
2. macrophages and eosinophils |
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Bronchiectasis
Sx Causes |
Permanent Dilation of bronchi and bronchioles
Sx: Clubbing, coughing up phlegm, hemoptysis, dyspnea, cor pulmonale, febrile exacerpations Causes: Infeciton, airway obstruction Bronchial secretions: CF, ABPA, Primary ciliary dyskinesia |
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What is Varenicline?
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Partial nAChR agonist
Relives craving and withdrawl |
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How to glucocorticoids exert their effect?
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1. Dec cytokines release and production
2. Dec mucous production 3. Dec airway hyperresponsiveness Trying to reduce inflammation |
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Mixed venous PO2
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40 mmHg
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4 key points on oxygen-dissociation curve
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1. 27, 50%
2. 40, 75% 3. 60, 90% 4. 100, 97% |
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Oxygen consumption =
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O2 consumed = oxygen delivered - oxygen leaving
O2 consumed = CO*CaO2 - CO*CvO2 |
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Cancer often associated with PE
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Pancreatic
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Pulmonary Emoblism
Chest X-Ray |
* Pleural effusion
* Dilated PA * Hyperlucency * Atelactasis *Often normal |
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Pneumothorax
Clinical presentation |
Chest pain
Dyspnea can have cough |
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Tension pneumothorax
Clinical presentation |
Dec VR
Tachycardia Hypotension Hypoxemia Death |
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Pleural Effusion
Clinical presentation |
Dyspnea
Chest pain |
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Pleural Effusion
Physical Exam |
Dec breath sounds
Dullness to percussion Egophony at upper level Reduced excursion of diaphragm |
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IPF
Clinical Presentation |
Hx: Insidious onset, 50-70 y/o
Physical: Velcro crackles, clubbing, loud P2, edema CXR: Reticulonodular shadows, lower lobes, traction bronchiectasis, little ground glass, end stage honey-combing Outcome: Poor prognosis |
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UIP CXR
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End stage honeycombing
Very little ground glass Traction bronchiectasis Patchy reticular densities at lung bases |
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BOOP
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CT plugs at terminal airways
Fume expsosures, viral infection, CT dz Subacute onset of dyspnea and cough CXR: Patchy consolidations Good response to corticosteroids |
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Chronic eosinophilic pneumonia
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Clinical presentation: Fever, weight loss, cough
NOT IgE mediated Biopsy: Tissue infiltrate with eosinophils CXR: Negative image of pulmonary Edema Treatment: good response to corticosteroids DDx: Ascaris, allergic granulomatosis, angitis, Nitrofurantoin, sulfa, carbamazepine |
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Sarcoidosis
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Young black females and Scandinavians
Non-caseating granuloma CXR: b/l hilar and mediastinal adenopathy |
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Sarcoidosis
Systems Affected |
Lung: interstitial infiltrates and b/l hilar and mediastinal LNs
Nerves: bells palsy and peripheral neuropathy Eye: anterior uveitis Heart: Cardiomyopathy and AV block Liver: cholestatic defect Joints: diffuse arthralgias Skin: erythema nodosum Granulomata: hypercalcemia |
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Churg Strauss Vasculitis
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1. Prodromal phase: Asthma; paranasal sinus disease
2. Blood eosinophilia: GI tract and lungs 3. Vasculitis: Lung: Granulomatous vasculitis Heart: pericarditis and coronary vasculitis Neuro: Mononeuritis mulitplex Skin: palpable purpura, ulcers, nodules p-ANCA association 50% of time |
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Goodpasture's Syndrome
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Clinical presentation: Acute lung hemorrhage and hematuria
Often follows influenza or exposure to toxic hydrocarbon |
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Muscles of Inspiration
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Diaphragm
External Intercostals Sternocleidomastoid Scalenes Pectoralis |
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Emphysema has airflow obstruction during inhalation or exhalation
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Exhalation
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Why does abdominal paradox occur?
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Neg pleural pressure due to the accessory muscles pull diaphragm up and this causes the abdomen to sink in
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Ways to damage phrenic nerve
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MVA (C3,4 5)
Mediastinal mass (cancer) Neck trauma (carotid surgery) |
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Whats the main problem for quadriplegics?
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Cannot expire
W/o rectus abdominis cannot generate positive pleural pressure |
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Required to cough
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Rectus sheath
Glottis |
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At what level does cartilage disappear?
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Bronchioles
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why do things preferentially go to the right?
where in the right? |
Right is more aligned with the trachea.
Wider Upright - posterobasal segment of right lower lobe Supine - superior portion of right lower lobe Right side - right middle lobe or psoterior segment of RUL |
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Why do the small ariways contrible little to total airway resistance
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aligned in parallel
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At FRC, pressure in pleural space is...
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negative
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compliance =
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Change in volume/change in pressure
measure of distensibility |
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Pal during expiration
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Positive
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Types of work in resp system
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Elastic work to overcome recoil pressure of chest wall and lung
-this is higher at higher lung volumes Resistive work to overcome resistance to airflow -higher during exhalation and low lung volumes |
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DLCO depends on
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Hb present
Functioning alveolar capillary surface area |
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DLCO of emphysema
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decreased
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DLCO of chronic bronchitis
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normal
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DLCO of asthma
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normal or increased
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Asthma classification
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Intermittent
• Sx less than 2/wk Persistent • Mild o Sx >2x /week o Night sx >2x/mt • Moderate o Daily sx & Bagonist use o >1x/wk night time • Severe o Continuous sx o Frequent night sx |
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Cytokines important in asthma
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IL-4 isotype switching
IL-5 make and activate eosinophils |
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Most common arterial blood gas in asthmatics
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low po2 due to v/q mismatch
low pco2 due to hyperventilation respiratory alkalosis |
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Histology of Asthma
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Curschmann spirals --> mucuous plugs with shed epithelial cells. This is a pathologic effect of the major basic proteins and cationic proteins produced by eosinophils. They damage epithelium, leading to shed cells.
Charcot-leyden crystals: crystalline granules in eosinophils |
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Samter's syndrome
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Aspirin
Nasal polyps Asthma |
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Stages of COPD
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• Mild
o FEV1 >80% • Moderate o FEV1 50-80% • Severe o FEV1 30-50% • Very Severe o Fev1<30 or <50 plus chronic resp failure |
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What is first line COPD treatment
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Short acting Anticholinergics
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Nutritional requirements for COPD
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Vit A, C, E and coenzyme Q
Selenium Adaquate Carbs |
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Most effective anti asthma drug
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ICS
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Main risk factor for TB
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Unventilated Air
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How long does it take for PPD to become positive after infection
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2-3 weeks
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% cases negative PPD:
miliary newly active disease pleural cases |
miliary -- 50%
newly active case --20 pleuarl cases - 30% |
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What part of the PPD determines result?
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Size of induration. The risk factors determine cut off for size.
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How to treat latent TB?
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INH
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conditions that increase risk of progression to TB disease
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HIV
ESRD Diabetes mellitus substance abuse Corticosteroids Recent infection with MTB |
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TB pleural disease
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Follows primary infection
Unilateral Exudate |
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Where does TB reactivate
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Apical posterior secion upper lobe
Superior segment of lower lobes |
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Ghon complex
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caseous necrosis in hilar lymph nodes
**Calcified focus of infeciton + associated lymph node |
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Pott's Disease
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TB in vertebra
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Extrapulm sites of TB infection
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Adrenal - Addisons disease
Cervical lymph nodes --> Crofula Vertebra --> potts diseaes Meningeal - meningitis kidney is most common |
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What kind of people get MOTT
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People with underlying lung disease or immuno comproised
Can have skin involvement |
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Bronchitis
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Inflammation of the bronchial tree (no evidence of alveolar space infection)
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3 most common resp infections by aspiration
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Viral infections, TB, legionella
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What kind of people are more at risk for H. influenzae?
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COPD and alcoholics
CXR often shows pleural effusion |
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When deprived of sleep, the first things to recover are...
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S3/S4 of NREM
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Two key changes in sleep as we age:
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Increase in Wakefulness after sleep onset
Ded in SWS |
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75% sat O2 = x mmHg
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40 mmHg
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Definitions:
Hypoxia Hypoxemia |
Hypoxia - lack of o2 supply to tissues
Hypoxemia - Dec PO2 or SO2 in the blood |
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50% sat O2 = x mmHg
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27 mmHg
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Causes of Hypoxia w/o hypoxemia
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Anemia (blood is saturated, just Hb isnt)
Abnormal tissue demand |
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Hypoxia w/ hypoxemia
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Low PiO2
Shunt Diseases of the lungs or chest bellows |
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Physiologic dead space equation
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Vd/Vt =(PaCO2-PeCO2)/PaCO2
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90% sat = x mmHg
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60 mmHg
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97% sat = x mmHg
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1100
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Right shift of Hb dissociation curve
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Inc temperature
Decreased pH Inc 2,3 DPG |
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tissue oxygen delivery =
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O2content ml/dl x CO dl/min
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Effects of Anemia on:
oxygen content aterial po2 o2 sat |
Dec oxygen content (b/c dec in Hb amount conc)
Aterial PO2 normal O2 sat is normal |
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Effects of CO on:
oxygen content aterial po2 o2 sat |
oxygen content: dec
aterial po2: normal o2 sat: normal |
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Most common people to get iPH
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young, healthy, women
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Most common cause of PH
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Autoregulation causing vasoconstriciton
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Bone morphometric protein receptor related to...
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iPH
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Levels of various things in PH:
NO, thromboxane, Prostcyclin, endothelin |
NO dec (normally vasodilates)
Prostacyclin dec (protects against vascrular injury) Endothelin inc (mitogen that contributes to vasoconstrion and clel prolif) Thromboxane Inc |
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Treatment for Pulm HTN
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Endothelin antagonists
NO Prostacyclin analogues Diuretics Calcium channel blockers |
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Progressive systemic sclerosis
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ANA
Interstitial fibrosis Raynauds phenomena pursing of lips |
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Common organisms causing bronchiectasis
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H influenzae
MTb Staphylococcus aureus Adenovirus |
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Size restriciton of particles that can enter resp tract
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>10 microns --> nasopharynx
5-10 microns --> trachea <4 microns --> terminal bronchi |
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Percent of cells that are macrophages in normal BAL
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85% (10% lymphs)
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Master switch for immune response in the lung
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NK-kB; due to LPS, IL-1, or TNF
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What is the action of IL-10
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Inhibits actions of activated T cells
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Chemo/luekemia predisposes to what infecitons
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Candida
S aureus gram neg |
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Lupus or CML predisposes to what lung infections
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punemococcus or H flu
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HIV, Hodgkins, Sarcoid --> T cell defects predispose to what infections
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PCP, HSV, candida, crypto, TB, MAI, varicella, aspergillus, VZ, listeria
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B cell defects mimic what sort of defect?
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Asplenia. cannot make Abs to target encapsulated organisms
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Common molds include:
These appear with B or T cell defects |
Aspergillus
Candida B cell defects |
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Where can candida spread to systemically?
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Urine, eye
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Clinical presentation of Histo
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Flu like syndrome
Hilar adenopathy Nodular inflitrates in upper lobes fibrosisng mediastinits |
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Blastomycoses presentation
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75% are just lung
Can have skin, bone, prostate involvement as well Diffue infiltrates, fibronodular or mass infiltrates, cavitaiton |
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Predispose to disseminated coccidoies disease
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Immunosuppresed
Diabetes black HIV |
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HIV viral load and related risks of diseases
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CD4 >500: TB and bacteria
CD4 200-500: oral thrush, zoster, hairy leukoplakia 100-200: PCP less than 100, toxo, crypto less than 50 CMV, AI, PML |
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how does PCP patient present
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Fever, wasting, cough, dyspnea
CXR: diffuse interstital and bilateral infiltrates |
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Bacteria that is increasing in prevalance in nosocomial pneumonia
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Acenitobacgter
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most common cause of bronchiectasis worldwide
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TB
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