1
Q
Cell Types in the following structures?
- Clara Cells
- Type I pneumocytes
- Type II pneumocytes
- Conducting Zone
- Respiratory Zone
A
- Clara Cells: non-ciliated columan with secretory granules
- Type I pneumocytes: simple squamous
- Type II pneumocytes: Cuboidal and clustered
- Conducting Zone: pseudostratified ciliaed columnar
- Respiratory Zone: cuboidal, which then switch to simple squamous in alveoli
2
Q
Structures extending into the end of the bronchi?
A
Cartilage and Goblet Cells
3
Q
Structures extending into the end of terminal bronchioles?
A
- pseudostratified ciliated columna cells
- smooth muscle of the airway
4
Q
Muscles of Inspiration and Expiration during quiet breathing?
A
INSPIRATION: diaphragm
EXPIRATION: passive!! ….no muscles here
5
Q
Muscles of Inspiration and Expiration during exercise?
A
INSPIRATION: -external intercostals
- sternocleidomastoid
- scaleneEXPIRATION: -internal intercostals
- rectus abdominis
- transverse abdominis
- internal and external obliques
6
Q
Processes that increase lung compliance?
-Name at least 2
A
- empysema
- normal aging
7
Q
Processes that decrease lung compliance?
Name at least 4
A
- pulmonary fibrosis
- scoliosis
- pulmonary edema
- pneumonia
8
Q
Factors that cause a right-ward shift of the Oxygen dissociation curve?
“Favoring the T-state” = TAUT
i.e decreasing oxygen binding affinity
-name 5
A
“C-BEAT” = mnemonic
- CO2
- 2,3 BPG
- Exercise (produce acid)
- Altitude
- Temperature
9
Q
Gases/Process that are diffusion-limited?
-name 4
A
CO (carbon monoxide)
- Oxygen under strenous exercise
- Fibrosis
- Emphysema
10
Q
Gases/Process that are perfusion-limited?
-name 3
A
- CO2 (carbon dioxide)
- N2O (nitrous oxide)
- O2 (oxygen under normal conditions)
11
Q
Factors that cause a left-ward shift of the Oxygen dissociation curve?
“Favoring the R-state”=RELAXED i.e increasing oxygen binding affinity
A
pH increase (usually happens in the lungs)
12
Q
Pulmonary artery vascular alterations in pulmonary hypertension?
-name 3
A
- arteriosclerosis
- medial hypertrophy
- intimal fibrosis
13
Q
prognosis for the two types of Pulmonary Hypertension?
A
PRIMARY: poor!
SECONDARY:
severe respiratory distress——–>cyanosis and RVH—->death from decompensated cor pulmonale
14
Q
Cause of primary Pulmonary Hypertension?
A
loss of function mutation in the BMPR2 gene (gene usually inhibits vascular smooth muscle proliferation)
–BMPR2 is a surface receptor that binds to many ligands in the TGF-Beta pathway
15
Q
Cause of secondary Pulmonary Hypertension?
-name 7
A
i. e. secondary to some other underlying condition:
- COPD
- Mitral Stenosis
- Recurrent Thromboemboli
- Autoimmune Disease
- L-to-Right shunt:
- sleep apnea
- living at high altitude
16
Q
Normal pulmonary artery pressures?
-systole and diastole?
A
10-14mmHg= diastole
25mmHg=systole …if greater = pulm HTN
17
Q
How does each of the causes of pulmonary hypertension lead to Pulm HTN?..i.e. what is the pathogenesis?
A
- COPD: destroys lung parenchyma—->increased resistance–increased pressure
- MITRAL STEOSIS: increase resistance and higher left-atrial pressure, then increases pressure
- RECURRENT THROMBOEMBOLI: decrease cross-sect area of pulm vascular bed—>increased resistance
- AUTOIMMUNE DISEASE: inflammation–intimal fibrosis—>medial hypertrophy
- L-to-RIGHT SHUNT: increased shear stress, then endothelial injury
- SLEEP APNEA: Hypoxic Vasoconstriction
- LIVING AT HIGH ALTITUDE: Hypoxic Vasoconstriction
18
Q
Causes of hypoxemia that have an elevated Aa gradient?
A
- V/Q mismatch
- R-to-L shunt
- Diffusion
19
Q
Causes of hypoxemia that have a normal Aa gradient?
-why is it normal?
A
- Increased altitude
- HyPOventilation
20
Q
Early onset physical exam findings in chronic bronchitis?
A
EARLY: -wheezing
- crackles
- cyanosis (hypoxemia due to shunting)
21
Q
Late onset physical exam findings in chronic bronchitis?
A
Dyspnea
22
Q
Potential triggers of asthma?
-name 3
A
- viral URI
- allergens
- stress
23
Q
Test used to diagnose asthma?
A
methacholine challenge (or alternatively: histamne challenge)
—in people with asthma, a very low dose of drug triggers exuberant bronchoconstriction
24
Q
Unique Histologic Findings on Asthma?
-name 2 and describes the composition of each
A
1) Curschmann’s Spirals: made up of shed epithelium that forms mucus plugs. They represent mucus casts of small airways.
2) Charcot-Leyden Crystals: formed from breakdown of eosinophils in sputum
25
Causes of broncoectasis?
| -name the major categories (3) and give corresponding examples
Bronchoectasis is chronic/recurrent infection of airways resulting in permanent dilation of the airways.
INFECTION:
- TB
- Pertussis
- allergic bronchopulmonary aspergillosis
OBSTRUCTION:
-tumor (usually)
Secondary to OTHER CONDITIONS:
- CF
- Kartagener's syndrome
26
Kartagener's syndrome
Can lead to Bronchoectasis.
- It is a defect in dynein, which results in cilia dysfunction, thereby preventing mucuous clearance
- --recurrent infections damage to walls of airways-> bronchoectasis
* **Other associated conditions:
- male infertiligy due to immotile sperm
- decreased female fertility
- recurrent sinusitis
27
What is the A-a gradient in Restrictive Lung Disease?
normal if extrapumonary
increased if interstial
28
Examples of interstitial restrictive lung disease?
- idiopathic pulmonary fibrosis
- sarcoidosis
- pulmonary hypertension
- Goodpasture's Sydrome
- Wegener's Vasculitis (GPA)
- ARDS
- NRDS
- Drug toxicity
- pneumoconioses
29
Examples of extrapulmonary restrictive lung disease?
CHEST WALL:
- obesity--> can result in Pickwickian Syndrome
- kyphoscoliosis
MUSCULAR:
- Guillaine Barre
- M.Gravis
- ALS
- Diaphragmatic disease
- Polyomyelitis
- MS
30
Classic histological findings in Acute Respiratory Distress Syndrome?
Hyaline membrane: which is composed of eosinophils and acellular material
31
Risk factors for Neonatal Respiratory Distress Syndrome? [NRDS]
-name 3
- premature delivery
- maternal diabetes (due to elevated fetal insulin)
- Cesarean delivery
32
Treatment for Neonatal R.D.S.?
| -name 2
1. maternal glucocorticoids
| 2. artificial surfactant
33
Classic/Hallmark histologic findings in Sarcoidosis
Non-caseating granulomas in multiple organs
Hypercalcemia (due to high levels of Vit. D, which result from increased alpha-hydroxylase activity of the granulomas...produced by macrophages )....manifest as
***Schaumann and Asteroid Bodies
NB: any non-caseating granuloma (e.g. Churg-Strauss, Berylliosis, or Silicsis) will akso have HYPERCALCEMIA because the granulomas activate Vit.D via alpha-1-hydroxylase activity
34
Drug toxicities leading to Restrictive Lung Disease
| -name 4 drugs
- Bleomycin
- Busulfan
- Amiodarone
- Methotrexate
35
Three main examples of pneumoconioses
- Silicosis
- Anthrcosis (coal-miner's lung)
- Asbestosis
36
What are the histologic/gross findings in each of the 3 examples of pneumoconioses?
- SILICOSIS:
- egg-shell calcifications of hilar lymph nodes
- concentric silicotic nodules...risk of TB
-ANTHRACOSIS:
-Dust cells with anthracotic pigment (black
macules)
- ASBESTOSIS:
- golden-brown fusiform rods resembling dumbbells
37
What is Virchow's Triad?
- Hypercoagulability
- Endothelial Dysfunction
- Stasis of Blood Flow
All three predispose to thrombus formation
38
Prophylaxis and acute treatment of DVT?
heparin
39
Long-term management/prevention of DVT?
Warfarin (Coumadin)
40
Sites of metastases of lung cancer?
| -name 4
- brain
- adrenals
- liver
- bone
41
Common causes of lung cancer? i.e. from other metastasis that lodge to the lung?
- breast
- colon
- prostate
- bladder
42
6 complications of Lunch Cancer?
| Hint: mnemonic = "SPHERE of complications"
```
S= Superior Vena Cava syndrome
H= Horner's Syndrome
P= Pancoast Tumor
E=Endocrine (paraneoplastic)
R=Recurrent Laryngeal symptoms (hoarseness)
E=Effusions (pleural or pericardial)
```
43
6 types of lung cancer?
- Squamous cell carcinorma
- Adenocarcinoma
- Mesothelioma
- Small Cell Carcinoma
- Large Cell Carcinoma
- Bronchial Carcinoid Tumor
44
Lung cancers that localize to the periphery?
- Adenocarcinoma
| - Large Cell carcinoma
45
Lung cancers that localize centrally (airways)
- Small Cell cancer (oat cell)
| - Squamous Cell Carcinoma
46
Lung cancers with a more diffuse pattern?
Bronchial Carcinoid tumor
**Has ground glass opacity similar to pneumonia
NB: Mesothelioma affects the pleura and prefers the lung bases usually
47
Unique Histological Findings for each of the 6 different types of lung cancers?
- Squamous cell carcinorma: Keratin Pearls and Intercellualr bridges
- Adenocarcinoma: the bronchialveolar subtype grows along alveolar septa--->gives apparent thickening of alveolar walls
- Mesothelioma: psammoma bodies (calcified pleural plaques are pathognomonic)
- Small Cell Carcinoma: Neoplasm of Kulchitsky cells whoch appear as small blue cells
- Large Cell Carcinoma: Pleomorphic Giant Cells
- Bronchial Carcinoid Tumor: Nests of Neuroendocrine cells, which are chromogranin positive
48
Homan's Sign?
Characteristic pf DVT:
| Happens when patirnt dorsiflects foot and there is calf pain
49
Imaging test of choice for a PE?
CT pulmonary Angiography
50
What is the Reid Index?
Thickness of gland layer/total thickness of bronchial wall.
| In bronchitis, this Index is greater than 50%
51
Which disease is characterized by apical cavitary lesions?
Cavitary Tuberculosis
-This is very typical in secondary TB which may be caused either by a) reinfection or b) reactivation
Primary TB is usually in the mid-zone of the lungs
52
Characteristic X-ray/histologic/serum findings in Sarcoidosis
-name 3 that are virtually pathognomonic
- Bilateral hilar adenopathy
- non-caseating granulomas
- elevated serum ACE levels
53
Gene mutation associated with Lung Adenocarcinoma?
K-RAS mutations are common
54
Gene mutation associated with Lung Small Cell Carcinoma?
L-myc (aplification of this oncogene is common)
NB: N-myc is amplified in neuroblastoma!!!!
55
What are the 5 adaptions to chronically living in high altitude areas?
--e.g. people who live in the Himalayan mountains?
1. Increased erythropoietin (EPO): which increases hematocrit and HgB...to carry more O2
2. Increased 2,3 BPG: favors the T-form of HgB by shifting the curve to the right and allowing more O2 to be offloaded
3. Increased Mitochondria???
4 Increased Renal Excretion of HCO3- to compensate for the respiratory alkalosis
5.Increased respiratory alkalosis (due to increase in hyperventilation)
56
Which drug is used to augment adaption to high altitude, and why?
Acetozolamide
-At high altitude, people hyperventilate due to low FIO2..but this results in respiratory alkalosis
--Normally, the kidney compensates for R.Alkalosis by eliminating more HCO3-...so by taking acetazolamide, you are augmenting this adaptation
57
What are the 5 adaptions/things that happen during exercise?
1. increased CO2 production
2. increased O2 consumption
3. increased alveolar ventilation ( to meet O2 usage)
4. Metabolic acidosis (from lactic acid)
5. increased pulmonary blood flow (due to increased CO)
NB: arterial PaO2 and PaCO2 are unchanged but venous PaO2 falls and PaCO2 increases
58
Causes of Lung abscess (localized pus collection in parenchyma)
-name 2
1. Bronchial obstruction e.g. cancer
| 2. aspiration of oropharyngeal contents (esp in epileptics or alcoholics or comatose pts)
59
Organisms responsible for lung abscess?
| -name 4
S. Aureus
| Anaerobes: (bacteriodes, fusobacterium, peptostreptococcus)
60
Which translocation is present in Burkitt's Lymphoma?
t(8:14)
The long arms of the c-myc gene(#8) translocates with the long arm of the heavy chain Ig-G gene (#14)
61
Classic cause of atypical pneumonia
mycoplasma pneumoniae
TREATMENT: macrolide (e.g. erythromycin) or fluoroquinolone
NB: Penicillin is NOT effective since mycoplasma does not have a cell wall.
62
Classic cause of atypical pneumonia in the elderly, smokers, or immunocompromised patients
Legionella Pneumophila
63
What is methenamine silver stain used to visualize?
Pneumocystis Jirovecii...it shows up as cysts and trophozites which don't stain with H&E
64
Classic presentation for TB?
| -name 4
- chronic productive cough
- weight loss
- night sweats and fever
- hemoptysis
65
Classic TB drugs in the first 6 months
- Isoniazid (INH)
- Rifampin
- Pyrazinamide
- Ethambutol
**mnemonc= RIPE***
66
What are nasal polyps characteristic of?
They are a consequence of repeated RHINITIS and when you have a child with Nasal Polyps---->think of CYSTIC FIBROSIS!!
67
Which bacteria is associated with acute epiglottitis, meningitis, otititis media and pneumonia in children?
H.Influenza Type B
68
Classic Presentation for acute epiglottitis in children?
Drooling with dysphagia, muffled voice, inspiratory stridor (distress),fever and sore throat
MNEMONIC= the 3 D's
69
What are the two key mediators of pain in pleauritic chest pain as that which results from penumonia presentation?
Bradykinin and Prostglandin E2 (PGE2)
70
Three Types of Pneumonia?
1. Lobar [mostly bacterial]
2. Bronchopneumonia [mostly bacterial]
3. Interstial Pneumonia..aka Atypical [mostly viral]
71
What is the stem cell of the lung which helps it regenerate in times of healing (e.g. resolution of lung after pneumonia infection)
Type II pneumocyte!!!! = stem cell of the lung
72
Potts' Disease?
Presence of TB in the lumba vertebrae as part of systemic spread of the 2ndary TB.
73
Which chronic obstructive disorder causes secondary amyloidosis
Bronchiectasis
74
Common drugs that induce Pulmonary Fibrosis?
- Bleomycin
- Amiodarone
- Busulfan (used in radiation therapy)
MNEMONIC: its hard to BlAB when you have pulmonary fibrosis
75
Which Pneumoconiosis mimics Sarcoidosis?
Berrylliosis
76
How does Recurrent Thrombembli lead to pulmonary HTN?
decrease in cross-sectional area of pulmonary vascular bed.
77
How does living at high altitude or sleep apnea lead to pulmonary HTN?
Chronic Hypoxemia causes hypoxic vasoconstriction.
78
How does L-to-R shunt lead to pulmonary HTN?
Increased shear stress---->causes endothelial injury
79
How does mitral stenosis lead to pulmonary HTN?
Increased resistance
80
How does autimmune disorder lead to pulmonary HTN?
Inflammation-->intimal fibrosis--->medial hypertrophy
81
What is the hallmark finding in Acute Respiratory Distress Syndrome?
Hyaline membrane formed by protein-rich fluid that has leaked into the alveolar wall.
82
Which three processes cause the damage in ARDS? i.e. what is the pathogenesis?
1. toxic substance from PMNs
2. coagulation cascade
3. oxygen-derived free radicals
83
Two functions of Type II pneumocytes?
1. surfactant prduction
| 2. stem cells for lung repair
84
What is the L:S ratio?
Lecithin-Sphingomyelin ratio....used to assess Neonatal Respiratory Distress Syndrme (NRDS)..if less than 1.5, then lung hasn't finished maturing.
NB: lecithin is a.k.a DIPAMYTOLPHOSPHATYDIL CHOLINE
85
What is the key difference in the treatment of small-cell carcinoma versus large-cell carcinoma?
SMALL CELL: inoperable by surgery, responsive to chemotherapy
LARGE CELL: removed by surgery, not responsive to chemotherapy
86
Most common lung tumor in male smokers
Small Cell Carcinoma
87
Most common lung tumor in female smokers
Adenocarcinoma
88
Most common lung tumor in non-smokers?
Adenocarcinoma
89
Which lab stain is usually positive for bronchial carcinoid tumor?
The cells are chromogranin positive because they are of neuroendocrine origin
90
To which side does the trachea deviate in the two major types of pneumothorax?
Spontaneous: TOWARDS the pneumothorax
Tension: AWAY from the pneumothorax
91
Which agent mostly causes bronchiolitis or pneumonia in infants and babies?
RSV
Treatment = ribavirin
*page 160 in FA
92
Roughly spherical structures (cysts) that stain with silver stains in lungs?
Pneumocystis.
stain is methenamine
93
What molecule inhibits the fusion of phaglysosome fusion in mycobacterium pneumonia
Sulfatides!
-they allow the m.tuberculosis to survive in macrophages
94
Which diseases do each of the 4 mycobacterium cause?
M. Tuberculosis: TB
M.Avium-Intracellulare: common in HIV patients and causes disseminated non-TB symptoms. Prophylaxis with Azithromycin
M.Leprae: Leprosy (Hansen's Disease)
M.Kansaii: Pulmonary TB-like symptoms
****By far, M. Tuberculosis is the common cause of TB, even in HIV patients
95
Which lung cancer is associated with SIADH?
-Small cell carcinoma can cause ectopic ADH secretion leading to increased sodium loss, resulting in hyponatremia (can cause seizure) and high urine osmolarity>serum osmolarity
96
Most common cause of lung abscess?
S. Aureus
97
What is the main cause of pneumonia in CF patients?
Pseudomona Aeruginosa....virulence is due to polysaccharide formation
98
Which syndrome is induced by bronchial carcinoid tumor?
| -what are the features of the syndrome?
Carcinoid Syndrome!!
- serotonin secretion
- Flushing (e.g. turning red after drinking alcohol)
- Diarrhea
- Wheezing (some sort of asthma attack)
99
What type of virus is RSV?
a Paramyxoviridae
-negative-sense si`ngle-stranded RNA viruses that are non-segmented, helical, and enveloped
100
Owl's eye inclusion is typical of what disease/infection entity?
CMV
-common in imunocompromised patients, e.g. HIV or transplant recipients
101
What is increased or decreased in each of the three different types of pleural effussions?
TRANSUDATE: reduced protein
EXUDATE: increased protein content
CHYLOTHORAX (LYMPHATIC): increased triglycerides
102
What causes each of the 3 different types of Pleural Effusion?
TRANSUDATE:
- CHF
- nephrotic syndrome
- hepatic cirrhosis
- protein-losing enteropathy
EXUDATE: ***must be drained to prevent infection**
-malignancy
-pneumonia
-collagen vascular disease
-trauma (in states of increased vascular
permeability)
CHYLOTHORAX (LYMPHATIC):
- thoracic duct injury from trauma
- malignancy
103
What is the color of each type of pleural effusion?
TRANSUDATE:
EXUDATE: cloudy
CHYLOTHORAX (LYMPHATIC): milky-appearing fluid
104
What is a unilateral pleural effusion most indicative of?
Bacterial cause!!
| ___but this is certainly not ALWAYS the case___
105
What is hypernia?
--increases breathing out with a corresponding increase in CO2 production rate e.g. exercise
106
Two types of sleep apnea and the main driver for each kind?
CENTRAL:
- brain doesn't send proper signal to your respiratory muscles to breathe
OBSTRUCTIVE:
-respiratory skeletal muscles are too relaxed to support breathing
107
Treatment for sleep apnea?
- Weight Loss
- CPAP (Mask)
- Surgery
108
What causes ARDS (diffuse alveolar lung injury)
| -name 7
-sepsis
-trauma
-shock
-gastric aspiration (stomach acid damages the
alveoli)
-uremia
-acute pancreatitis
-amniotic fluid embolism
109
Treatment for RSV
Ribavirin in babies
-palivizumab
110
What is the classic triad for a fat emboli?
- neurological abnormalities
- hypoxemia
- petechial rash
NB: fat emboli usually happens with long bone fractures or liposuction
111
What type of a hypersensitivity reaction is Sarcoidosis?
Type IV HSR (since it's T-cell mediated inflammation)
-To diagnose the disease, you ONLY need presence of activated Macrophages...which are activated by IFN-gamma which is produced by Th1
112
A patient presents with cyanosis and SOB. PMH is significant for mild anemia and menorrhagia. Duringan ABG, you notice that her blood is chocolate-colored...what treatment will you give and why?
Give the patient methylene blue. It reverses Fe3+ to Fe3+
Diagnosis: She has methemoglobin, in which her HgB iron is oxidized from Fe2+ to Fe3+
--Fe3+ has a low affinity for oxygen and a higher affinity for cyanide.
Common causes of methemoglobin are nitrites antibiotics, anesthetics, dyes or it cold be congenital.
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