Step 1 Pulmonology

Front 1

If you are checking phospholipids on amnio, you are checking for what?

Back 1

Fetal lung maturity!

Front 2

What id dipalmitoyl phosphatidylcholine?

Back 2

Lecithin (component of surfactant)! Marker of fetal lung maturity

Front 3

Where is the superior sulcus of the lung?

Back 3

At the apex (site of pancoast tumors)

Front 4

Pancoast tumors damage what part of the brachial plexus?

Back 4

Lower trunk (C8-T2)

Front 5

What 2 things do Type II pneumocytes do?

Back 5

1) Produce surfactant 2) regenerate pneumocytes that are damaged

Front 6

What do Clara cells do? Do they have cilia?

Back 6

No cilia. They secrete Clara cell secretory protein (CCSP) which inhibits neutrophil recruitment/activation and neutrophil mucin production. Might have something to do with surfactant also.

Front 7

What 3 things are present in the respiratory tract only to the bronchi and above?

Back 7

Cartiledge, goblet cells, and mucous/serous glands

Front 8

Waht kinds of cells line the bronchioles for the most part?

Back 8

Simple cuboidal ciliated epithelium

Front 9

What kinds of cells line the respiratory tract up until the bronchioles?

Back 9

Pseudostratified columnar

Front 10

Do alveoli have cilia?

Back 10

Nope!

Front 11

a-1-antitrypsin vs COPD. Which is panacinar vs centriacinar, which is upper vs lower lobe predominant?

Back 11

a-1-antirypsin: panacinar, lower lobe predominant. COPD: centriacinar, upper lobe predominant

Front 12

What can vitamin A deficiency do to epitheliums?

Back 12

Can cause squamous metaplasia with keratinization (vit A is important in maintaining orderly differentiation of special epithelia, like mucous secreted columnar epithelia)

Front 13

What kind of gating does the dysfunctional transmembrane protein in CF have?

Back 13

ATP. Pumps chloride against concentration gradient (dragging Na and water with it)

Front 14

How should bicarb change in acute vs chornic setting for changes in CO2?

Back 14

Acute increase in CO2 by 10: HCO3 1 if acute, 3 if chronic. Acute decrease in CO2 by 10: 2 if acute, 4 if chronic

Front 15

Do you get heart failure cells acutely?

Back 15

Nope! Chronic change

Front 16

At FRC, what is the intrapleural pressure?

Back 16

-5cm H2O

Front 17

Is lung compliance normal or abnormal in ARDS?

Back 17

Abnormal! Decreased.

Front 18

What is NORMAL in ARDS?

Back 18

PCWP

Front 19

Initial problem in ARDS?

Back 19

Increased capillary permeability -> exudative leakage into alveoli -> formation of intra alveolar hyaline membranes. Release of neutrophilic substances toxic to alveolar wall, activation of coag cascade, free radicals.

Front 20

Effect of COPD on TLC, RV, FVC and FEV1/FVC?

Back 20

Increased TLC and RV, decreased FVC and FEV1/FVC

Front 21

Can FEV1/FVC be increased in restrictive lung dz?

Back 21

Yes!

Front 22

Type I pneumocytes are what kind of cell? What is their function?

Back 22

Squamous, thin. Gas exchange! 97% of alveolar surfaces!

Front 23

Where is airway resistence the highest in the bronchial tree?

Back 23

The 2nd-5th generations of bronchi (airways >2m in diameter). Then falls off because total area of bronchi goes up!

Front 24

Pts with asthma - better to avoid allergens or cold air?

Back 24

Allergens!

Front 25

What rxn does carbonic anhydrase catalyze?

Back 25

CO2 + H20 -> H2CO3 (and backwards)

Front 26

What is the RBC "chloride shift"?

Back 26

After H2CO3 spontaneously converts to HCO3 and H+, HCO3 diffuses out of the cell into the plasma, and to keep electrical neutrality, Cl- diffuses into the cell. Cause of high Cl- content of venous RBCs

Front 27

Top 2 most common causes of SVC syndrome? Tumor spread where to cause syndrome?

Back 27

1) Bronchogenic carcinoma 2) NHL. Mediastinum > pancoast tumor

Front 28

Are perfusion and ventilation greater at the base or apex of the lung?

Back 28

Base!

Front 29

V/Q at apex vs base?

Back 29

Apex = 3, base = 0.6

Front 30

Relative alveolar, arterial and venous pressure in zones 1-3 of the lung?

Back 30

Zone 1 (apex): PA>Pa>Pv. Zone 2: Pa>PA>Pv. Zone 3 (base): Pa>Pv>PA

Front 31

What does it mean that PA>Pa in the apex of the lung?

Back 31

Blood flows only in a pulsatile fasion with heart beats, when artierial pressure is able to overcome alveolar pressure.

Front 32

Describe the breathing pattern in Cheyne-Stokes. What conditions is it seen in?

Back 32

Periods of apnea followed by gradually increasing tidal volumes and then gradually decreasing tidal volumes, then followed by another apenic period. Seen in CHF and neuro diseases?

Front 33

Difference in breathing pattern in Cheyne-Stokes vs OSA?

Back 33

No cyclic variation in tidal volume in OSA.

Front 34

Peptostreptococcus, fusobacterium and bacteriodes are found in the lung. How did they get there?

Back 34

Aspiration! These are normal oral flora.

Front 35

Irritation to whcih parts of the parietal pleura will cause pain to referred to the shoulder?

Back 35

Diaphragmatic or mediastinal

Front 36

Which is shorter, the R or L main bronchus?

Back 36

R! Why things go down there more. Also straighter and wider.

Front 37

Which one is bringing oxygenated blood to the fetus, the umbilical artery or vein?

Back 37

VEIN!

Front 38

What vessel has the highest oxygen content in the fetal circulation?

Back 38

Umbilical vein!

Front 39

From what vessels do the fetal umbilical arteries originate from?

Back 39

Internal illiac arteries

Front 40

Stab wounds to the L chest at or lateral to the midclavicular line will hit the RV or the lung?

Back 40

Lung! Will hit RV if deep enough (remember, lung covers part of heart on both sides)

Front 41

What is FRC equal to?

Back 41

Expiratory reserve volume (ERV) + residual volume (RV)

Front 42

When is PVR the lowest in the breathing cycle?

Back 42

At FRC. With inspiration, pressure placed on vessels by expanding alveoli. With expiration, pressure placed on vessel by collapsing positive pressure.

Front 43

Alveolar elastase is secreted by what cell type?

Back 43

Alveolar macrophages

Front 44

Is the rate of blood flow in the pulmonary and systemic cirulations the same or different?

Back 44

The same! Always! or else the heart would either empty of overflow!

Front 45

Normally which is higher, pulmonary or systemic vascular resistence?

Back 45

Systemic! Pulm vasculature is a low resistence, high slow system.

Front 46

Does pulmonary blood pressure increase significnatly during exercise?

Back 46

Nope! only by 2-3 points!

Front 47

Most common cause of meconium ileus?

Back 47

CF!

Front 48

How does the concentration of eccrine sweat change as it travels down the eccrine duct?

Back 48

Starts out isotonic with ECF, then CFTR resorbs NaCl, making hypotonic

Front 49

Elevated serum tryptase indicated what?

Back 49

Released from degranulating mast cells along with histamine -> anaphylaxis!

Front 50

Where are the chemoreceptors that respond to low O2 to increase respiratory drive located?

Back 50

Carotid and aortic bodies.

Front 51

At an O2 level below what does the hypoxic drive to breath kick in?

Back 51

PaO2 <60

Front 52

What are central chemoreceptors for breathing sensitive to?

Back 52

Directly to pH and indirectly to CO2

Front 53

What is a normal A-a gradient?

Back 53

10-15mm Hg

Front 54

What is the alveolar gas equation?

Back 54

At sea level: PAO2 = 150 - PaCO2/0.8. Remember, multiple PaCO2 by 5/4 for easier math!

Front 55

Sputum sample showing granule containing cells and crystalloid masses. What are they, and what condition is it?

Back 55

Eos and Charcot Leyden crystals (contain eosinophil membrane protein). Atopic allergic asthma.

Front 56

What cytokine is invovled in the growth and differentiation of eosinophils? Who releases it?

Back 56

IL-5. TH2 cells.

Front 57

What is the Reid index? What is it a prognostic factor for? What is a normal value?

Back 57

Used in CB. Ratio of thickness of mucous gland layer to total thickenss of bronchial wall from epithelium to top of cartilage layer. Normal = 0.4.

Front 58

Blockage of what 2 types of receptors would relieved rthe bronchoconstriction of asthma? 2 examples of each?

Back 58

Muscarinic (ipratropium and tiotropium) and leukotriene (montelukast, zafirlukast)

Front 59

Pleural thickening and calcificaitons along lower lung fields and diaphragm - what is it?

Back 59

Asbestosis!

Front 60

"Egg-shell calcifications of the hilar nodes" what condition?

Back 60

Pulmonary silicosis

Front 61

Pulmonary presentation of beriliosis is similar to what?

Back 61

Sarcoid.

Front 62

Complete opacification of a lung with tracheal deviation to that side. What is it?

Back 62

Probably a mainstem bronchus lesion inhibiting ventilation of that side -> lung volume collapse

Front 63

Lower lobe fibrotic lung lesion and ipsilateral calcified hilar adenopathy - what is it?

Back 63

Primary TB with Ghon complex (lower lobe)

Front 64

What happens in an individual during the first week after exposure to active TB?

Back 64

Intracellular (alveolar macrophages) bacterial proliferation

Front 65

Does TB infect the lower lung fields or the lymph nodes first? When does the Th1 response start?

Back 65

Infect lower lung fields first, then eventually migrate to the lymph nodes (after 2-4 weeks). At THIS point in the lymph nodes, Th1 response initiated.

Front 66

What is seen histologically in asbestosis?

Back 66

Interstitial lung fibrosis and asbestos bodies (asbestos fibers coated in protein iron matrix). Look like golden brown fusiform rods resembling dumbells

Front 67

Cell type that invades in CB vs asthma?

Back 67

CB = neutrophils. Asthma: eos and mast cells

Front 68

Calcified hilar lymph nodes and birefringent particles surrounded by dense collagen - what is it?

Back 68

Silicosis

Front 69

What are ferruginous bodies? What stain shows them best?

Back 69

Asbestos bodies (translucent asbestos center). Prussian blue shows best.

Front 70

"Perilymphatic accumulations of coal dust laden macrophages" what is it?

Back 70

Coal miner's lung

Front 71

Stab wound immediately above the clavicle and to the R of the manubrium - what is punctured?

Back 71

Lung! Goes above the clavicle.

Front 72

Pathogenesis CREST and systemic sclerosis? Cytokine involved?

Back 72

Increased collagen deposition in tissues stimulated by TGF-B release from monoclonal T cell that accumulate in tissues

Front 73

A patient has a metabolic alkalosis. What lab should you check to determine the cause?

Back 73

Urine chloride! Low in chloride responsive (2/2 vomitting, diuretics) high in chloride non-responsive: hyperaldosteronism.

Front 74

What happens to lung compliance in pulmonary fibrosis?

Back 74

Decreased!

Front 75

Does OSA result in pulm HTN, systemic HTN, or both?

Back 75

Both!

Front 76

How does pulmonary edema affect lung compliance?

Back 76

Decreases it!

Front 77

What 3 conditions cause decreased pulmonary compliance?

Back 77

Pulmonary fibrosis, pulmonary edema, insufficient surfactant

Front 78

What happens to pH, O2, CO2, and HCO3 at high altitude?

Back 78

Get hypoxic (O2 ~60), which stimulated resp drive to breath. Increse vintillation leads to decreased CO2, with some metabolic compensation, but with an increased pH nontheless. EPO kicks things back to normal in ~2 weeks.

Front 79

When is PO2 in the LA slightly lower than in the pulm capillaries?

Back 79

Mixes with deoxygenated blood from bronchial arteries (that gets returned via pulmonary veins)

Front 80

What is normal PaO2?

Back 80

80-95

Front 81

Normal PAO2 is what?

Back 81

104

Front 82

What happens to the A-a gradient in V/Q mismatch?

Back 82

Increased! PA stays the same but Pa decreases.

Front 83

What does a R to L shunt do to the A-a gradient?

Back 83

Increases!

Front 84

What are the causes of hypoxemia? Which have increased A-a gradient?

Back 84

High altitude, hypoventilation, V/Q mismatch, diffusion limitation, R to L shunt. High altitude and hypoventilation DO NOT have an increased A-a gradient.

Front 85

Why do you see high expiratory flow RATES in restrictive lung dz despite low lung volumes?

Back 85

Increased radial traction on airways (increasing their diameter) 2/2 pull from firboitc lung tissue

Front 86

What are the rib levels of the lower borders of the pleura and lungs on each side at the midclavicular, axillary and paravertebrals?

Back 86

R and L the same: Lung always ends two ribs above the pleura. Midclavicular: 7, midaxillary: 10, paravertebral: 12.

Front 87

Vein, artery and nerve are where relative to the rib?

Back 87

Just below

Front 88

In all exocrine glands EXCEPT sweat glands, the CFTR protein usually does what? Inhibition results in what change to the transepithelial potential?

Back 88

Normally secretes Cl- into lumen and inhibits reabsorption of Na+ and water (to hydrate lumen). Damaged CFTR results in less Cl- secreted and more Na+ and water reabsorbed -> more NEGATIVE transepithelial potentail

Front 89

What is a Ghon complex?

Back 89

A Ghon focus + hilar lymphadenopathy

Front 90

Pleural cells with long, slender micro villi and abundant tonofilaments - what is it?

Back 90

Mesothelioma!

Front 91

Cells that stain positive for chromogranin and synaptophysin indicated what?

Back 91

Neuroendocrine!

Front 92

Lung cancer at the periphery of the lung with distribution along the alveolar septum (arising from alveolar septum)? Tall columnar cells that do not invade stroma or vasculature?

Back 92

BAC (a subtype of adenocarcinoma)

Front 93

Silicosis increases risk of what lung infection?

Back 93

TB!

Front 94

What kind of cells make up the true vocal folds (vocal chords)

Back 94

Stratified squamous epithelium - the reason why HPV might attack!

Front 95

What structure forms most of the R border of the heart on CXR?

Back 95

Right atrium!

Front 96

In COPD there is excess elastase, which is secreted by what two cell types?

Back 96

Neutrophils and alveolar macrophages

Front 97

Is the methecholine challenge test more useful for ruling in or out asthma?

Back 97

Ruling out (very specific, but not so sensitive)

Front 98

How do you distinguish relative from absolute erythrocytosis?

Back 98

Measure RBC mass - normal means relative, increased means absolute

Front 99

Secondary erythrocytosis can be stimulated by hypoxia at what SaO2 and PaO2 levels?

Back 99

SaO2<92, PaO2<65

Front 100

Does chronic lung rejection after transplant involve obliteration of blood vessels or bronchioles? What about acute rejection?

Back 100

Acute = blood vessels chronic = bronchioles

Front 101

"Subpleural cystic airspace enlargement" honeycomb lung - what disorder?

Back 101

Idiopathic pulmonary fibrosis

Front 102

Pathogenesis of lung abcess formation?

Back 102

Release of lysosomal enzymes from macrophages and neutrophils

Front 103

Do arterial blood PO2, PCO2 and pH change during exercise? Do venous?

Back 103

Arterial no - homeostatic mechanisms keep constant. Venous - yes!

Front 104

For what type of lung cancer, even when localized, is surgery never the treatment?

Back 104

Small cell.

Front 105

What two pulmonary effects does parasympathetic stimulation have?

Back 105

Increased bronchiolar constriction (NOT vascular) and increased mucus production. Increases airway resistence and WOB.

Front 106

What is the formula for minute ventilation? For alveolar ventilation?

Back 106

Minute: Tidal volume x RR. Alveolar: (Tidal volume - dead space) x RR (only the air involved in gas exchange)

Front 107

Exudation and alveolar hepatization occur in what condition?

Back 107

Lobar pneumonia (ex: strep pneumo)

Front 108

In patients with decreased lung compliance vs increased airway resistence (COPD, asthma), what tidal volume/RR combination is favored? Why?

Back 108

In general, more breaths means more work against airway resistence, larger tidal volume means more work against elastic recoil. Decreased lung compliance: favor fast RR with small tidal volumes, increased airway resistence opposite: favor slower RR with larger tidal volumes.

Front 109

Is acute pancreatitis a risk factor for ARDS?

Back 109

Yes!

Front 110

Particle <2um are cleared at what part of the respiratory system? By what? What does this then cause?

Back 110

Alveoli, by macrophages! Become activated and secrete cytokines that lead toinflammation, injury, collagen formation and fibrosis (pneoconiosis (asbestos, silicosis, etc)

Front 111

What does PaO2 represent?

Back 111

Amount of )2 dissolved in plasma

Front 112

What does SaO2 represent?

Back 112

% saturation of Hgb molecules

Front 113

Normal PaO2 and SaO2 but decreased O2 content - what is it?

Back 113

Anemia!

Front 114

What lung cancer is most common in women and non-smokers?

Back 114

Adenocarcinoma (not BAC).

Front 115

Peripherally located lung tumor consisting of glandular or papillary structures?

Back 115

Adenocarcinoma!

Front 116

What lung tumor is associated with gynecomastia and galactorrhea?

Back 116

Large cell

Front 117

What are the 3 main cytokines that mediate systemic inflammatory response?

Back 117

IL-1, IL-6, TNF-alpha

Front 118

Histologic difference between grey and red hepatization during lobar pneumonia?

Back 118

Red: whole RBCs, liver is grossly red. Grey: dissintegrated RBCs, liver is grossly pale. Both contain neutrophils and fibrin.

Front 119

What does major basic protein do? (2)

Back 119

Kills helminths and damages bronchial epithelium

Front 120

What is the most common benign lung tumor?

Back 120

Hamartoma!

Front 121

Solitary lung nodule with "popcorn calcifications"?

Back 121

Hamartoma!

Front 122

Lung cancer that appears on CXR as a penuomnia like calcification?

Back 122

BAC (a subtype of adenocarcinoma)

Front 123

What is normal alveolar PCO2?

Back 123

40

Front 124

If alveolar air is not at its equilibrium levels (O2 104, CO2 40), what is most likely the problem?

Back 124

Poor alveolar perfusion (could be diffusion problem, ie shunting, but this is less likely since CO2 diffuses SUPER fast, and would probably still be able to diffuse to some degree).

Front 125

What makes sputum in bacterial infections green?

Back 125

Myeloperoxidase release from neutrophils during oxidative BURST

Front 126

What does myeloperoxidase do?

Back 126

Part of neutrophil oxidative burst to kill bacteria. Catalyzes formation of HOCl from chloride and hydrogen peroxide. Is a heme containing molecule.

Front 127

Mena pulmonary artery systolic pressure great than what is considered pulmonary HTN?

Back 127

>25 at rest

Front 128

What 4 things does prostacyclin affect?

Back 128

Decreases the following: platelet aggregation, vascular tone, bronchial tone, uterine tone

Front 129

What 3 things does TxA2 affect?

Back 129

Increases: platelet aggregation, vascular tone, bronchial tone

Front 130

Pathogenesis primary pulm HTN?

Back 130

Two hits hypothesis: abnormal BMPR2 gene predisposes, then second insult (many possibilites) leads to increased vascular smooth muscle

Front 131

Acute bronchiolitis in an infant is due to what bug? What treatment if severe?

Back 131

RSV! Ribavirin.

Front 132

Ribavirin is used for what two bugs?

Back 132

RSV and HCV

Front 133

MoA Isoniazid? What compound is it chemically similar to?

Back 133

Inhibits mycolic acid (a long branched chain fatty acid used in mycobacterium cell walls) synthesis. Structurally similar to B6

Front 134

MoA caspofungin?

Back 134

Inhibit fungal cell wall synthesis (by inhibiting glucan synthesis)

Front 135

How do the -azole antifungals work?

Back 135

Inhibit cell membrane synthesis (by inhibiting ergosterol synthesis)

Front 136

Isoniazid must be processed by what to work?

Back 136

Myocobacterial catalase peroxidase.

Front 137

What asthma treatment drug has the strongest and most predictable anti-inflammatory action?

Back 137

Glucocorticoids (fluticasone)

Front 138

What is Zileuton?

Back 138

Leukotriene blocker, used in asthma

Front 139

MoA amphotericin B and nystatin?

Back 139

Bind ergosterols and create deadly PORES

Front 140

What anti TB agent causes visual changes?

Back 140

Ethambutol (optic neuritis)

Front 141

MoA ethambutol? What is it used to treat?

Back 141

TB! Inhibits carbohydrate polymerization (part of cell wall)

Front 142

What kind of drug is streptomycin?

Back 142

Aminoglycoside!

Front 143

MoA rifampin?

Back 143

Blocks DNA dependent RNA polymerase, thus blocks mRNA synthesis.

Front 144

MAC prophylaxis in HIV pts?

Back 144

Azithromycin

Front 145

MoA Cromolyn and nedocromil in asthma treatment?

Back 145

Inhibit mast cell degranulation

Front 146

MoA N-acetylcysteine in CF?

Back 146

Mucolytic; cleaves disulfide bridges within glycoproteins

Front 147

What are the two major concerns with theophylline intoxication? How do you treat?

Back 147

Seizures and cardiac arrythmias. Treat with BBs (cardiac. hard to treat seizures)

Front 148

What is an example of a methylxanthine?

Back 148

Theophylline!

Front 149

MoA theophylline?

Back 149

Decrease phosphdiesterase activaty -> increase cAMP -> bronchial relaxation

Front 150

What is bosentan used in the treatment of? MoA?

Back 150

PPH. Vasodilates by blocking endothin receptors

Front 151

Isoniazid induced peripheral neuropathy is due to what?

Back 151

B6 deficiency!

Front 152

Which of the 1st line TB agents requires an acidic environment to work?

Back 152

Pyrazinamide - works in macrophage phagolysosome (acidic!)

Front 153

What are the 5 first line TB drugs?

Back 153

Isoniazid, Rifampin, Ethambutol, pyrazinamide (and streptomycin)

Front 154

What is omalizumab?

Back 154

Monoclonal IgE antibody that binds IgE in serum -> used in asthma treatment

Front 155

Why do 2nd generation antihistamines have fewer side effects?

Back 155

No CNS entry

Front 156

An anti histamine ends in -adine -> is it first or second generation?

Back 156

Second!