1
Q
Arterial blood gas measure functions (3)
A
A method to assess oxygenation of blood plasma***, evaluate acid base status, and monitor therapy
2
Q
A-a gradient and how is it measured?
A
- Measure of lungs ability to transfer o2 from atmosphere to pulmonary circulation, if very high then not transferring (ventilating but not entering circulation), normal means it is.
- Measured normal = age/4
3
Q
Increased A-a gradient can indicate these 3 pathologies
A
- congestive heart failure
- adult respiratory distress syndrome
- lobar pneumonia
4
Q
Alveolar hypoventilation is often due to…
A
….interstitial lung disease
5
Q
Ways to attain ABG (2) and technique
A
- Radial artery stick
- Femoral artery stick (can’t be on any anticoag, need to put pressure on longer)
-use heparanized syringe, it fills passively, remove all air bubbles, transport on ice
6
Q
Allyn test in attaining ABG using radial artery stick
A
Used to assess ulnar radial artery anastomosis before acquiring specimen for ABG by occluding both radial and ulnar artery, having patient pump fingers, then release the ulnar and watch entire hand refill - ensures that the hand is dual perfused so ABG stick in radial artery doesn’t cut off supply
7
Q
PCO2 2 mech of removal from the body
A
- removal of bicarb
- exhalation of CO2
8
Q
A ___ mmHg change of PCO2 is equivalent to a ___ change in pH which is equivalent to a ___ MEQ change in base
A
12, .1, 6
9
Q
Strong vs weak acid/base
A
Completely dissolute in water while weak incompletely dissolute in water
10
Q
buffer
A
A weak acid/base combo that will resist change in pH, predominantly proteins intracellularly and predominantly NaHCO3 (bicarb) extracellularly (weak base)
11
Q
Treatment for respiratory acidosis
A
Increase ventilation to remove volatile acids from blood stream
12
Q
Postprandial alkaline tide
A
Refers to how upon eating a meal there can be a slight alkalosis that occurs in the blood stream because HCl is used in digestion and intracellular Bicarb is released into the plasma to compensate
13
Q
ABG stepwise approach (oh good lord 6 steps)
A
1) Is pH acidotic (<7.35) or alkalotic (>7.45) or normal? (May be normal in fully compensated condition)
2) Is PCO2 respiratory acidotic (>45), respiratory alkalotic (<35) or normal?
3) Is HCO3- metabolic acidotic (<22), metabolic alkalotic (>26), or normal?
4) Match the pCO2 and HCO3- with pH, find if the out of normal range one is going in same direction (High pCO2 with low pH and vise versa, low HCO3- with low pH)
5) If CO2 and HCO3- are going opposite direction of the pH, then this is compensation
6) Uncompensated pH is out of normal range, while partially compensated is 7.35-7.39 or 7.41-7.44
14
Q
Gold standard test to determine pH and oxygenation of the bloodstream
A
Arterial blood gas
15
Q
Hemoglobin and protein molecules in blood shift the physiologic pH of blood from ___ to ____ resting value
A
7, 7.35-7.45
16
Q
Difference between arterial blood gas and pulse oximetry
A
Pulseox measures % sat of hemoglobin molecule which isn’t good indicator of overall oxygenation of blood (cause you might only have 10 hemoglobin molecules), arterial blood gas measures partial pressure of free O2 dissolved in plasma
17
Q
Base excess
A
A positive or negative measure of how much base is needed to bring pH back to physiologic limits (i.e. -8 means we need 8 more units of base to return to physiologic normal, +8 means we need 8 fewer units of base), more accurate than HCO3- levels
18
Q
The anion gap and normal values
A
The difference between Na+ - (Cl- + HCO3-) and should normally be between 8-15 mEQ/L, but elevated levels indicate buildup of metabolic acids (metabolic acid)
19
Q
Only time IV bicarb is given is what condition?
A
Metabolic acidosis to drive K+ back into cells
20
Q
HCO3 is <24 in ____ acidosis or compensation for ____ alkalosis
A
metabolic, respiratory
21
Q
Issue with giving a patient to high of O2 levels
A
The nitrogen conc of air is important as surfactant to keep alveoli from collapsing and therefore if not a large enough portion of the air content can see atelectasis of alveoli
22
Q
30-60 rule and 60-90 rule
A
Refers to general rule that a PaO2 of 30=60% hemoglobin saturation, while a PaO2 of 60=90% saturation
23
Q
PaO2 levels interpretation and what does this indicate?
A
Normal 80-106
mild hypoxia 60-79
mod hypoxia 40-59
severe hypoxia <39
Determines need of oxygen therapy
24
Q
Immediate treatment for carbon monoxide poisoning
A
Extreme O2 supplementation or use of a dive chamber
25
Net result of left shift and right shift in oxy hemoglobin dissociation curve
- More O2 taken up by HGB but less released
- Less O2 taken up by HGB but more released at tissues
26
In patients with respiratory acidosis or alkalosis, we often do not see ___ because they are often COPD or other obstructive dz patients
Respiratory compensation
27
Respiratory and renal compensation
- Respiratory is achieved rapidly by elimination or retention of CO2 via hyper or hypoventilation
- Renal is achieved slowly by secretion or reabsorption of H+ and HCO3-
28
metabolic acidosis 2 subgroups
- Increased anion gap due to metabolic biproduct buildup
- normal anion gap seen with excessive bicarb loss
29
Metabolic alkalosis 2 subgroups
- Excessive gain of bicarb often thru ingestion
- Excessive H+ loss often from vomiting or hypokalemia
30
Standard in treatment of metabolic alkalosis
KCl and saline
31
Respiratory acidosis 3 subgroups
- depression of respiratory centers
- lung disease
- disorders of respiratory muscles
32
Respiratory acidosis treatment
Improve ventilation sometimes mechanically
33
respiratory alkalosis is usually caused by...
...anxiety or psychogenic source
34
Respiratory zone of the respiratory system includes these 3 structures and is the site of gas exchange from air to body
- respiratory bronchioles
- alveolar ducts
- alveolar sacs
35
Sympathetic vs parasympathetic innervation to the trachea
Sympathetic activates B receptors leading to relaxation and dilation of airways, parasympathetic activates muscarinic receptors leading to contraction and constriction of the airways
36
Type I vs type II pneumocytes
Type I are the site of gas exchange, type II produce and secrete surfactant
37
Blood flow to the lungs is influenced by...
...gravity, with standing causing flow to be lowest at apex and highest at the bases of the lungs
38
Tidal volume definition and normal value
Normal quiet breathing volume moved in and out in respiration, approx 500mL
39
Inspiratory reserve volume and normal value
Maximum inspiratory volume beyond normal tidal volume, approx 3000mL
40
Expiratory reserve volume and normal value
Maximum expiratory volume beyond normal tidal volume, approx 1,200mL
41
Tidal volume + inspiratory reserve volume = ___ (also what is the value normally?)
inspiratory capacity (amount of air that can be inhaled after end of normal respiration) (3500mL)
42
Expiratory reserve volume + residual volume = ___ (also what is the value normally?)
Functional residual capacity (amount of air in lungs at end of tidal volume breath) (2400mL)
43
Inspiratory capacity + expiratory reserve volume =___ (also what is the value normally?)
Vital capacity (maximum air exhaled after maximum inhalation) (4700mL)
44
Vital capacity + residual volume = ___ (what is the value normally?)
Total lung capacity (volume of air in lungs at end of max inspiration) (6000mL)
45
Residual volume definition, value, and calculation
Volume of gas remaining in lungs after forced max expiration, 1,200mL, calculated by total lung capacity - (tidal vol + expiratory reserve volume)
46
a1 antitrypsin deficiency
Inherited disease that may cause lung disease in patients where first signs and symptoms develop in 20-50's causing emphysema
47
Subcutaneous emphysema
A potential pathologic finding that may indicate pneumothorax presence, indicated by characteristic crackling under the skin upon touch that in itself is harmless
48
Consolidation vs effusion
Consolidation is fluid in the lung that amplifies sound, while effusion is fluid around the lung that insulates sound transmission
49
Crackles are also known as...
...rales
50
Hyperresonance upon percussion is due to ____ in the thorax characteristic of these 2 pathologies
excessive air, emphysema or pneumothorax
51
Consolidation vs effusion
Consolidation is fluid in the lung that amplifies sound, while effusion is fluid around the lung that insulates sound transmission
52
Hyperresonance upon percussion is due to ____ in the thorax characteristic of these 2 pathologies
excessive air, emphysema or pneumothorax
53
2 functions of the sinuses and how do we learn to breath first?
- Lighten the weight of the head
- Moisten and filter air
-through the nose
54
Functions of PFT's (3)
- add to diagnosis of disease (pulmonary and cardiac)
- monitor progression of disease and effectiveness of treatment
- aid in pre op assessment of certain patients
55
Different components of PFTs (8)
- spirometry
- flow volume loop
- bronchodilator response
- lung volumes
- diffusion capacity (DLCO)
- bronchoprovocation testing
- max respiratory pressures
- simple and complex cardiopulmonary exercise testing
56
6 min walk test
Test to evaluate physical function or assess therapeutic response in COPD and pulmonary fibrosis patients, considered positive if oxygen saturation falls by >4% ending below 93% after 6 minutes of walking and indicates need for confirmatory ABG's
57
Indications for PFTs (6)
- Signs and symptoms of pulmonary distress
- screening at risk population (smokers current or former >45 years of age)
- monitoring drug toxicity
- abnormal study such as CXR or EKG
- environmental exposure monitoring
- preoperative assessment and risk stratification
58
Steps to performance of an FVC maneuver in spirometry
- Prep patient (results are VERY effort dependent)
- cover nose with clip
- elevate chin slightly and extend neck slightly
- put mouthpiece in mouth after inhaling and then exhale hard and fast as possible
- need to avoid coughing, variable flow, or early termination
59
Spirometry's goal is to measure ____, it cannot (directly) measure ____
Vital capacity, residual volume
60
Body plethysmography
Used to measure total lung capacity by placing patient in a small airtight room while taking measurements to determine residual volume and total lung capacity
61
Flow (flow volume loop) definition
Volume of a substance moved thru a structure or space over a period of time in L/s
62
Flow volume loop, what is it sometimes referred to as?
- A measurement of flow during pulmonary function testing that should have a rounded inhalation and a sharp spike in expiration (this height should represent 90% of what can be exhaled) followed by continuous drop straight line
- also referred to as a spirogram
63
Volume time loop
A measurement of flow during pulmonary function testing that determines FEV1 and should have 90% of the volume (in L) released in the first second before quickly tapering off to a flat line
64
Lung properties that affect spirometry (2)
- mechanical properties (compliance and elastic recoil)
- resistive properties (affected by airway diameter predominantly)
65
% predicted in spirometry
What a patient performed based on what is predicted based on age, gender, height, weight, ethnicity to determine some fraction value which is then interpreted (low % is worse for the patient)
66
Spirometry % FVC predicted value interpretation
80-120% normal
70-79% mild reduction
50-69% moderate reduction
<50% severe reduction
67
Spirometry % FEV1 predicted value interpretation
>75% normal
60-75% mild obstruction
50-59% moderate obstruction
<49% severe
68
Spirometry % FEF 25-75% predicted value interpretation
>60% normal
40-60% mild
20-40% moderate
<10% severe
69
Obstructive disease pattern loss with spirometry % predicted values
- FEF 25-75 decreased
- FEV1 decreased
- FVC normal to decreased in late stage (last thing to go)
- FEV1/FVC <70% predicted
70
Obstructive lung disease list (5)
- asthma (reversible obstructive dz)
- COPD (chronic bronchitis and emphysema)
- bronchiectasis
- bronchiolitis
- upper airway obstruction
71
Restrictive disease pattern loss with spirometry % predicted values
- TLC decreased
- FVC decreased
- Normal or increased FEV1/FVC ratio
72
Restrictive lung disease list (4)
- Parenchymal disease (interstitial lung disease)
- pleural disease
- chest wall disease
- neuromuscular disease
73
Scooped out vs witch's hat on volume/flow diagram
Scooped out is characteristic of obstructive disease, witch's hat is characteristic of restrictive disease
74
Bronchodilator response spirometry
Test done on patients with obstructive pattern on spirometry to determine degree to which FEV1 improves with inhaled bronchodilator to document reversible airflow obstruction, significant if FEV1 increases by 12% and 200mL or greater
75
Fixed upper airway obstruction pattern on flow volume loop (such as a tumor in larynx) vs variable extrathoracic obstruction vs variable intrathoracic obstruction
- Rounded shape with equal expiratory (+) and inspiratory (-) values
- Rounded shape with greater expiratory (+) and lower inspiratory (-) flow
- Rounded shape with lower expiratory (+) and greater inspiratory (-) flow
76
- Methods for measuring lung volumes (3)
- Indications for a lung volume measurement (2)
- Helium, nitrogen washout, body plethsmography
- diagnose restrictive component, differentiate between chronic bronchitis from emphysema
77
Carbon monoxide diffusion capacity (DLCO), what does a decreased and increased value mean?
- Measures the lungs diffusing capacity to transport inhaled gas from alveoli to pulmonary capillaries using a small amount of carbon monoxide
- <80% predicted indicates obstructive lung disease or anemia, >120% predicted indicates asthma or polycythemia
78
7 barriers to o2 transport in the alveoli according to walt
- alveolar epithelium
- tissue interstitum
- capillary epithelium
- plasma layer
- red cell membrane
- red cell cytoplasm
- hemoglobin binding forces and type of hemoglobin
79
Bronchoprovocation testing, what is a positive result?
Use of methacholine, histamine, or exercise stress test in an attempt to induce bronchospasm useful in diagnosis of asthma and diagnostic if >20% decrease in FEV1
80
Obstructive pattern evaluation of FVC. FEV1, FEV1/FVC, FV loop shape, DLCO, TLC/RV, responsiveness to bronchodilator
- FVC normal or decreased
- FEV1 decreased
- FEV1/FVC decreased <70%
- scooped loop
- DLCO decreased in emphysema or normal in crhonic bronchitis
- TLC/RV increased
- positive response to bronchodilator
81
Restrictive pattern evaluation of FVC, FEV1, FEV1/FVC, FV loop shape, DLCO, TLC/RV
- FVC decreased
- FEV1 decreased or normal
- FEV1/FVC normal
- witch's hat loop
- DLCO decreased
- TLC/RV decreased
82
DLCO will be ___ in emphysema but ___ in chronic bronchitis because ____
Decreased, normal, chronic bronchitis affects proximal airways where gas exchange is not taking place
83
Acinus
The anatomic unit of the lung supplied by the terminal bronchiole where gas exchange in the respiratory system occurs
84
The 4 volumes of the lung
- Inspiratory reserve
- tidal
- expiratory reserve
- residual
85
The 4 capacities of the lung
(2 or more volumes comprise a capacity)
- vital
- inspiratory
- functional residual
- total lung
86
FEV1
Forced expiratory volume in 1 second, a very beneficial measurement taken by spirometry
87
FVC
Forced vital capacity, a very beneficial measurement taken by spirometry
88
FEV1/FVC%
The forced expiratory volume in one second divided by the total forced vital capacity, should be 90% in a healthy lung, a very beneficial measurement taken by spirometry
89
____ spirometry measurement is used to track severity of COPD over time
FEV1
90
Normal lungs have ___ flow rate and ___ lung volume
Restrictive lungs have ___ flow rate and ___ lung volume
Obstructive lungs have ___ flow rate and ___ lung volume
- High, high
- High, low
- Low, high
91
COPD is the ___ leading cause of death, and its mortality rates are not ____
4th, decreasing
92
Leading cause of COPD
Smoking
93
COPD risk with age, gender, and socioeconomic status
Increases with age, equal between genders, low socioeconomic status associated with higher risk
94
Asthma COPD Overlap syndrome
Refers to fact that patients with asthma have 10-30 fold increased risk of developing COPD as well resulting in features associated with asthma and COPD both in a patient
95
COPD development younger than 40 years old could indicate....
....alpha 1 anti-trypsin deficiency
96
Pack year
Clinical quantification of cigarette smoking used to determine exposure to tobacco and assess risk of developing pathology related to smoking, calculated by (cigs avg. smoked per day/20cigs/pack)*#YEARS smoked
97
COPD pathophysiology
Chronic irritation and air inflow limitation resulting in gas exchange abnormalities resulting in acidotic status (retention of CO2) that can see mucus hypersecretion, pulmonary vascular changes and scarring, and systemic effects such as osteopenia or anxiety
98
Patients with COPD that have ____ have a higher mortality rate
acute exacerbations
99
3 types of COPD
- Emphysema
- chronic bronchitis
- non reversible asthma (asthma COPD overlap syndrome)
100
Chronic bronchitis defining characteristic
-Increased mucus and inflammation in terminal bronchioles
101
Emphysema defining characteristic
-A loss of lung elasticity and destruction of lung parenchyma that sees destruction and enlargement of alvelolar sacs distal to terminal bronchioles that leads to acidotic state due to CO2 buildup
102
Chronic bronchitis diagnosis
Clinical diagnosis of a productive cough lasting at least 3 months in 2 consecutive years for which other causes have been excluded, irreversible condition where patients see hyperplasia and hypertrophy of goblet cells and mucus glands causing sputum buildup and narrowing of airways limiting airflow
103
Most patients have what type of COPD?
Overlap of emphysema and chronic bronchitis
104
Blue bloater syndrome
Refers to how chronic bronchitis patients often present, as overweight and cyanotic
105
Pink puffer syndrome
Refers to how emphysema patients often present, thin due to weight loss and muscle wasting and flattened diaphragm as they puff air and develop a reddish complexion
106
4 classic symptoms of COPD
- Chronic cough
- sputum production
- Dyspnea on exertion
- fatigue
107
Supplementary signs/symptoms of COPD (3)
- Increased AP diameter
- prolonged expiratory phase of respiration
- hyperresonance pattern on chest
108
Characteristics of late stage COPD (4)
- skeletal muscle wasting
- JVD and peripheral edema due to right sided heart failure (cor pulmonale) and resultant pulmonary hypertension
- tripoding
- polycythemia (measured CBC with diff)
109
2 common comorbid conditions in COPD patients
- depression
- Heart failure
110
PE findings of COPD (note that a PE for COPD is rarely diagnostic in itself) (4)
- shallow rapid breathing
- barrel shaped chest
- hyperresonance on percussion
- diminished breath sounds
111
Confirmatory diagnostic test to diagnose suspected COPD
Spirometry, most important value is FEV1/FVC ratio less than .70 is diagnostic***, performed pre and post bronchodilator to rule out asthma (minimally changes in COPD)
112
"Half moon" pattern on a PFT volume/flow graph is associated with....
...Obstructive lung disease such as COPD
113
Other labs for COPD (5)
- CXR
- ABG
- a1 antitrypsin indicated for all COPD patients at least once
- BNP
- CBC
114
Fundamental principle goals of COPD treatment (3)
- prevent progression
- reduce exacerbations
- treat complications
115
Common 4 meds used in COPD
- inhaled short acting bronchodilators
- long acting bronchodilators
- inhaled glucocorticoids
- theophyline (oral bronchodilator more side effects used in refractory cases)
116
What only 2 treatments have been shown to improve survival of COPD patients? What are pharmacological treatments considered?
- Smoking cessation and o2 therapy
- relief of symptoms (palliative)
117
Inhaled bronchodilators for COPD
Bring short acting relief of symptoms in all stages of COPD and act either as a anticholinergic or B2 agonist
118
Inhaled corticosteroids for COPD and what is one side effect?
- Treatment for 3rd stage or more severe COPD alongside short and long acting bronchodilators
- can often cause oral thrush as a side effect
119
When is pulmonary rehab recommended for COPD patients?
For symptomatic patients with FEV1 <50% predicted (class 3 or higher COPD)
120
Oxygen therapy for COPD patients
Used in severe COPD or exacerbations either continuously, during exercise, or to relieve acute dyspnea
121
COPD exacerbations
Episodic increase in frequency and severity of cough, increase in volume production and changes in character, and dyspnea increasing most often due to acute bacterial infections (up to 10% fatal due to already impaired functioning at rest)
122
Regardless of mild or severe COPD exacerbations, these 4 things are indicated
- Antibiotics (culture and amoxicillin)
- bronchodilators
- inhaled corticosteroids
- potentially o2 therapy
123
Lung parenchyma definition
The respiratory bronchioles, alveolar ducts, and sacs (areas of the lung involved in its primary function of gas exchange)
124
Emphysema effects the _____, different from chronic bronchitis
Lung parenchyma
125
Surgical intervention for COPD patients is recommended for what group?
Younger patients with a life expectancy <2 years without the intervention
126
Lung volume reduction surgery function
Remove damaged parts of the lung to reduce hyperinflation and improve effectiveness of respiratory muscles and elastic recoil ability of lungs
127
____ is the most common chronic illness in children
Asthma
128
Asthma is more common in ____ women than men, ____ than adults, and ____ race
How has the rate of asthma changed in the past 20 years?
- adult, children, african americans
- It has nearly doubled
129
Obstructive asthma pathophysiology
A complex, often reversible disease derived from heredity and environment that due to many causes that see inflammation with recurring episodes of airflow obstruction (cannot get air out of small airways), bronchial hyperresponsiveness, and underlying inflammation triggered by some source
130
Factors that play a role in causing of asthma (4)
- viral infection (RSV under age 1)
- genetics
- allergens
- poor air quality
131
Asthma is better treated if ____ can be identified and avoided
Triggers
132
In uncontrolled chronic asthma, can see....
....persistent changes in airway structure (i.e. bronchodilator PFTs not showing the improvement it should) including fibrosis, epithelial injury, smooth muscle hypertrophy, etc. That's why its important to control it to limit this from occurring
133
Strongest predisposing factor to development of asthma
Atopy - propensity for IgE response to environmental antigen
134
Common history findings of asthma (5)
- family history of asthma especially mother
- cig smoke exposure
- coughs at night
- cough or wheeze after exercise
- colds take long time to resolve
135
When (timing of respiratory cycle) is wheezing most often found on physical exam of asthmatic patient?
-End expiratory phase
136
Physical exam findings of asthma (5)
- Wheezing end expiratory
- allergic shiners
- nasal drainage
- mucosal swelling
- nasal polyps
137
Provocation test for diagnosis of asthma
Inducing asthma attack thru exercise or pharmacologic means (methylcholine commonly) to determine presence of asthma due to hyperreactive response to the testing compared to a normal patient who will not be very effected
138
Differential diagnosis of asthma (5)
- COPD
- CHF
- ACEI induced cough
- PE
- foreign body obstruction
139
Important principle: ____ of asthma determines initial treatment, and ____ determines changes in therapy throughout life
severity, control
140
(4) categories of severity of asthma in patients 12 and older
- Intermittent
- Persistent mild
- persistent moderate
- persistent severe
141
Asthma action plan
Usage of peak expiratory flow rate device and asthma medication to determine "zones" off baseline measures the patient falls in and needs to follow using proper individualized treatment protocol often using color coordination in order to control their asthma (example is adding a daily claritin if falling in the yellow zone)
142
Stepwise therapy
Very important treatment principle of asthma to use recommendations for 3 different age groups with daily long term care for persistent treatment and therapy being altered as necessary when not controlled (stepped up) or when controlled for 2-3 month period (stepped down)
143
Every asthma patient requires....
....short acting B agonist (SABA, albuterol typically) in the form of a rescue inhaler to treat acute symptoms, for some patients this is all they need
144
In asthma, you will never prescribe solely a...
....long acting B agonist, only in combo with inhaled corticosteroids (alongside the SABA that all patients already get) in stepping up therapy, they have a black box warning of increased asthma related deaths and should be stepped down if controlled
145
Rule of 2's
Asthma treatment rule that if a patient is experiencing symptoms more often than 2 times per week during the day or twice a month at night, treatment regiment needs to be stepped up, while if there have been no exacerbations in the past 2 (or 3) months with no impairment with exercise or seasonal change, may step down
146
Sampter's triad
Triad that detects patient that undergoes asthma exacerbation within minutes of taking aspirin
- ASA sensitivity
- asthma
- nasal polyps
147
Common asthma triggers (4)
- cold air
- exercise
- allergens
- fumes
148
Patients who are considered high suspicion for asthma
3 or more wheezing episodes in past 12 months or 2 episodes in past 6, that required an oral corticosteroid, plus presence of 1 major or 2 minor criteria
149
Daily long term care is recommended for all asthma's that are classified as ____ (persistent or intermittent?)
Persistent
150
Cromolyn and nedocromil drug class
Mast cell stabilizer
151
Examples of leukotriene modifiers used to treat asthma (3)
- Singulair (montelukast)
- accolate (zafirlukast)
- zyflo (zileuton)
Professional Development
flashcards
Decks in class (62)
# Cards
-
Part 1122
-
Part 2123
-
Part 3120
-
Part 4150
-
Part 5124
-
Part 6125
-
Part 7148
-
Part 8160
-
Part 9198
-
Part 10119
-
Part 11131
-
Part 12119
-
Part 13126
-
Part 14123
-
Part 15133
-
Part 16142
-
Part 17124
-
Part 18135
-
Part 19127
-
Part 20108
-
Part 21160
-
Part 22125
-
Part 23145
-
Part 24160
-
Part 25170
-
Part 26120
-
Part 27130
-
Part 28153
-
Part 29124
-
Part 30144
-
Part 31181
-
Part 32121
-
Part 33165
-
Part 34133
-
Part 35116
-
Part 36175
-
Part 37170
-
Part 38191
-
Part 39222
-
Part 40150
-
Part 41124
-
Part 42154
-
Part 43183
-
Part 44132
-
Part 45103
-
Part 46125
-
Part 47165
-
Part 48126
-
Part 49114
-
Part 50155
-
Part 51151
-
Part 52101
-
Part 53128
-
Part 54151
-
Part 55130
-
Part 56132
-
Part 57149
-
Part 58131
-
Part 59151
-
Part 60151
-
Part 61136
-
Part 62111
