1. ________ __________ of the respiratory system is the sum of the pressures from the lung curve and the chest wall curve.
    Transmural Pressure
  2. Transmural pressure of the lungs is referred to as what, which represents the stored energy that enables passive deflation of the lungs.
    Lung Elastic Recoil Pressure (Pel)
  3. How is transmural pressure of the lung determined?
    Alveolar Pressure (PA) minus Pleural Pressure (Ppl)
  4. How is transmural pressure of the chest wall determined?
    Pleural pressure (Ppl) minus body surface (barometric) pressure
  5. In order to determine transmural pressures, a subject inspires maximally, exhales a preset volume into a spirometer, then relaxes against a closed airway with glottis open. PA is estimated by the pressure at the ________ and Ppl is estimated by the _________ pressure.
    • Mouth
    • Esophageal
  6. The respiratory system curve flattens near TLC and RV. The increased stiffness near TLC is mainly due to __________, and the increased stiffness near RV is due to the ___________.
    • Elastic Recoil
    • Chest Wall
  7. The relaxed volume of the chest wall is about _____% of TLC.
  8. The relaxed volume of the lung is below ______.
  9. ______ is the point which outward recoil of the chest wall equals the inward recoil of the lungs.
  10. What happens to elastic recoil and compliance when there is destruction of alveolar walls, such as happens with smokers (emphysema)?
    • Decreased Elastic Recoil
    • Increased Compliance
  11. What happens to elastic recoil when there is interstitial or infiltrative lung disease (pulmonary fibrosis)?
    • Increased Elastic Recoil
    • "Lung Shrinkage" by loss of alveolar units
  12. What would be the predicted effect of Pulmonary Fibrosis on TLC and transmural pressures?
    • Decreased predicted TLC
    • Higher transmural pressures
  13. What would be the predicted effect of Emphysema on TLC and transmural pressure?
    • Higher TLC -- can be over 100%
    • Decreased transmural pressure
  14. Near TLC, the expiratory flow increases with each increase in effort. At lower lung volumes, however, greater muscular effort increases expiratory flow up to a limiting value. This limit cannot be exceeded by increasing effort, so we have _______-_________ over the last _____ of VC.
    • Effort-Independence
    • 3/4
  15. What two things can decrease maximum expiratory flow?
    • Increased resistance of the upstream segment
    • Decreased elastic recoil
  16. In which type of disease, obstructive or restrictive, is the FEV1 to FEV ratio reduced?
  17. What does the flow volume loop of a person with an obstructive lung disease look like, compared to normal?
    It's concave -- same volume as normal, but can't exhale as fast
  18. What does the flow volume loop of a person with a restrictive lung disease look like, compared to normal?
    Push the loop to the right -- same slope, just smaller volume
  19. With reversible lung obstruction, a patient's flow volume loop will look normal after the patient has been given what?
  20. When giving patients positive-pressure ventilation, what happens to airway opening pressure? What is the effect on pleural pressure?
    • Increases with inhalation
    • Less negative
  21. What two factors are required for a bronchodilator to produce a significant change in a patient?
    200 cc and 12% change
  22. Ideally, the A-a gradient would be equal to 0. In reality, it is around _____, due to a small amount of shunting and ventilation perfusion mismatching.
    10 mm Hg
  23. When the A-a ratio is increased to greater than _____, it indicates a parenchymal disease of the lung.
  24. What are the four factors that cause a decreased P50 (increased affinity) on the oxyhemoglobin dissociation curve?
    • Decreased Temp
    • Decreased PCO2
    • Decreased 2-3-DPG
    • Increased pH
  25. What are the four factors that cause an increase in P50 (decreased affinity) on the oxyhemoglobin dissociation curve?
    • Increased Temp
    • Increased PCO2
    • Increased 2-3-DPG
    • Decreased pH
  26. What are the four possible causes of hypoxemia? Which is most common?
    • Hypoventilation
    • Low ventilation to perfusion ratios (V/Q)**
    • Shunt
    • Diffusion Impairment
  27. What is the effect of hypoventilation on the A-a gradient? What is the effect of giving supplemental oxygen? What is the effect on PaCO2?
    • A-a gradient is normal
    • O2 supplementation corrects the hypoxemia, but not the hypoventilation
    • PaCO2 is increased
  28. What is the effect of a shunt on the A-a gradient? What is the effect of giving supplemental oxygen? What is the effect on PaCO2?
    • A-a gradient is increased
    • Supplemental oxygen has little effect
    • PaCO2 is normal or decreased
  29. What is the ventilation to perfusion ratio (V/Q) of the overall lung, normally?
  30. What is the effect of a V/Q mismatch on the A-a gradient? What is the effect of giving supplemental oxygen? What is the effect on PaCO2?
    • A-a gradient is increased
    • Responds very well to small increases in oxygen
    • PaCO2 may be normal, increased, or decreased
  31. What are the three most common causes of hypoxemia in a V/Q mismatch?
    • Asthma
    • Pneumonia
    • Acute Respiratory Distress Syndrome
  32. What is characteristic of diffusion impairment?
    A fall in PaO2 during exercise
  33. A significant diffusion abnormality will cause low ______ at rest. Will supplemental oxygen help?
    • PaO2
    • Yes
  34. What is the effect of a diffusion abnormality on the A-a gradient? What is the effect on PaCO2?
    • A-a gradient is increased
    • PaCO2 in normal or low
  35. Pleural diseases consist of an abnormal accumulation of what?
    Air, fluid, or blood
  36. What are the three types of pleural diseases?
    • Pneumothorax
    • Pleural Effusion
    • Hemothorax
  37. What is it called when there is a spontaneous rupture of weak areas on the surface of the lung, allowing air to leak into the pleural space?
  38. What are the three classifications for a pneumothorax?
    • Spontaneous Pneumothorax: primary (no underlying lung disease) & secondary (h/o parenchymal lung disease)
    • Traumatic Pneumothorax: penetrating or blunt trauma to the chest
    • Iatrogenic Pneumothorax: central line, pacemaker, etc
  39. What two things are seen in a primary spontaneous pneumothorax?
    Subpleural Bullae & Airway Inflammation
  40. What is the most common cause of a secondary pneumothorax?
  41. What is the difference between a bullae and a bleb?
    Bullae are connected with airways; blebs are not necessarily, but are within the visceral pleura itself
  42. What four symptoms are associated with the clinical presentation of a Pneumothorax?
    • Sudden onset pleuritic chest pain
    • Dyspnea
    • Tachycardia
    • Diminished breath sounds
  43. What is the decreased PO2 due to in a pneumothorax?
    V/Q mismatch
  44. What are the two main things seen in the pathophysiology of a pneumothorax?
    • Hypoxemia
    • Acute Respiratory Alkalosis
  45. What are the two goals in the management of a pneumothorax?
    • Remove air from the pleural space
    • Decrease the likelihood of a recurrence
  46. What is an agent that inflames and causes attachment of the visceral and parietal pleuras to obliterate the pleural space called?
  47. If a pneumothorax is small, primary, and asymptomatic, what is the rate of pleural air absorption? How is this typically treated?
    • 1.25% per day
    • High flow oxygen for 6 hours; repeat CXR -- if no bigger, discharge and return in 24 hours for reassessment
  48. With a primary pneumothorax of greater than 15% in a patient that is hemodynamically stable, what treatment method is used?
    • Aspiration
    • F/u CXR in 6 hours
  49. What is a life-threatening emergency characterized by more air being ingested into the pleural space with each breath a patient takes? This can push the mediastinum over, causing a decrease in venous return to the heart, as the IVC and SVC can be constricted and misplaced anatomically.
    Tension Pneumothorax
  50. What are the following signs and symptoms characteristic of?
    Tachycardia, low blood pressure (due to decreased venous return), decreased lung sounds, tracheal deviation, increasing difficulty breathing, and jugular vein distention
    Tension Pneumothorax
  51. What is the treatment for a tension pneumothorax?
    Needle Decompression
  52. What are the pleurodesis agents?
    • **Talc: risk of ARDS
    • Doxycycline: very painful
    • Bleomycine: very expensive
  53. What is VATS? What is it used to treat?
    • Video Assisted Thoracic Surgery
    • Pneumothorax
  54. In which type of pneumothorax, primary or secondary, are symptoms more severe as there is less pulmonary reserve? Air leaks are more common and tend to persist longer.
    Secondary Spontaneous Pneumothorax
  55. What is the treatment for a Secondary Spontaneous Pneumothorax?
    • Admit
    • Chest Tube
    • Suction if persistent air leak or failure to reexpand with underwater seal
    • Pleurodesis to prevent recurrence
    • Possible surgey
  56. What are the two most useful evaluation methods for differentiating between a transudate or exudate pleural effusion?
    • Protein (fluid and serum)
    • LDH (fluid and serum)
  57. In a transudate pleural effusion, what is the F/S protein number, the LDH, and the F/S LDH?
    • F/S Protein: < 0.6
    • LDH: < 2/3
    • F/S LDH: < 0.5
  58. In an exudate pleural effusion, what is the F/S protein, the LDH, and the F/S LDH?
    • F/S Protein: > or = to 0.6
    • LDH: > 2/3
    • F/S LDH: > or = to 0.5
  59. What is the most common cause of a transudate pleural effusion?
    Congestive Heart Failure
  60. What are the two most common causes of an exudate pleural effusion?
    Infections and Malignancies
  61. What is the treatment method for a transudate pleural effusion?
    • Treat the underlying problem
    • Diurese
  62. What is the treatment method for an exudate pleural effusion?
    • Treat the underlying problem
    • Specific therapy -- pneumonia, malignancy
  63. What is pus in the pleural space called?
  64. How is a chronic empyema treated?
    Treat like an abscess -- surgical decortication, open drainage (rib resection)
  65. How is a malignant pleural effusion managed?
    • Repeat therapeutic thoracentesis -- very short life expectancy and slow reaccumulation
    • Chemo-responsive tumors may require occasional tapping
  66. What are the complications associated with pleurodesis?
    • Pain, fever, and infection
    • Rare fatal pneumonitis with Talc
  67. In general, which is superior for treating pneumothorax, VATS or pleurodesis?
    VATS -- superior with less recurrences
  68. What is the most common cause of cancer mortality in the US and worldwide?
    Lung Cancer
  69. What are the four major types of Lung Cancer?
    • Non-Small Cell -- Squamous, Adenocarcinoma, Large Cell
    • Small Cell
  70. What is the main difference between Non-Small Cell and Small Cell Carcinoma?
    • Non-Small Cell is surgically resectable
    • Small Cell is treated with chemo and radiation
  71. Which two types of lung cancer are more common in women? Which type is more common in males?
    • Women: Adenocarcinoma and Small Cell
    • Men: Squamous
  72. What are the following symptoms indicative of?

    Cough, Dyspnea, Hemoptysis, Chest Pain, Unilateral Wheezing/Stridor, Hoarseness, Dysphagia, Weakness, Weight Loss, Fever, SVC Syndrome, Brachial Plexus Involvement, Bone Pain, Neurological Symptoms
    Lung Cancer
  73. What syndrome, associated with lung cancer, is due to the production of biologically active substances? Hypercalcemia is associated with squamous cell. SIADH, ectopic ACTH production, gynecomastia, and hypertrophic pulmonary osteoarthropathy can also be associated with this sydrome.
    Paraneoplastic Syndromes
  74. Which type of lung cancer tends to cavitate?
    Squamous Cell Carcinoma
  75. Which type of lung cancer is often peripherally located?
  76. What are spiculations, or finger-like projections off a tumor, indicative of?
  77. What method is used to diagnose malignancy, lung transplant rejection, or sarcoidosis?
    Transbronchial Biopsies
  78. What is used to diagnose mediastinal lymphadenopathy, as well as being useful in staging lung cnncer?
    Endobronchial Ultrasound (EBUS)
  79. How is small cell carcinoma staged?
    • Limited Disease (1/3)
    • Extensive Disease (2/3)
  80. How is non-small cell carcinoma staged?
    • TMN System
    • T: Primary Tumor
    • N: Lymph Node Involvement
    • M: Distant Metastasis
  81. What is the main treatment for small cell carcinoma?
  82. How is Stage I Non-Small Cell Carcinoma treated?
    • Surgical Resection
    • Radiation therapy for patients who are not surgical candidates
  83. How is Stage II Non-Small Cell Carcinoma treated?
    • Surgical Resection
    • Radiation therapy for patients who are not surgical candidates
  84. How is Stage III A Non-Small Cell Carcinoma treated?
    • Surgical Resection if possible
    • Cisplatin based induction chemo followed by surgery appears to improve survival
  85. How is Stage III B Non-Small Cell Carcinoma treated?
    • Radiation therapy considered the standard of care
    • Newer radiation techniques may be superior
    • Addition of platinum based chemo appears to have a modest survival benefit
  86. How is Stage IV Non-Small Cell Carcinoma treated?
    Chemotherapy -- platinum based combination
  87. What are two contraindications for lung resection?
    • Hypoxemia ( < 60 mm Hg)
    • Hypercapnea ( > 45 mm Hg)
  88. What is the M:F ratio for lung cancer?
    2.7 : 1
  89. In US men, what is now the most frequent form of lung cancer?
  90. There is a ____ - _____% increased risk of lung cancer in non-smokers exposed to "second-hand" cigarette smoke.
  91. What are the common genetic changes seen in lung cancer?
    • TP53 Gene Mutations
    • Inactivation of pathway controlling RB1 (retinoblastoma gene, 13q11)
    • Loss of heterozygosity (LOH) on chromosome 3p
  92. What is the most common type of lung tumors?
    Epithelial Tumors
  93. What are the two types of benign epithelial tumors of the lung?
    • Papilloma
    • Adenoma
  94. What are the five types of malignant epithelial tumors?
    • Squamous
    • Adeno
    • Small Cell
    • Large Cell
    • Carcinoid
  95. Identify the carcinoma:
    A malignant epithelial tumor showing keratinization and/or intercellular bridges that arises from bronchial epithelium
    >90% occur in cigarette smokers
    Majority arise centrally in the mainstem, lobar, or segmental bronchi but may occur peripherally
    Gross appearance: white to gray; may form intraluminal masses; may occlude bronchial lumen; often undergoes cavitary necrosis
    Squamous Cell Carcinoma
  96. Is the survival rate better for a squamous cell or adenocarcinoma of the same stage?
    Squamous Cell Carcinoma
  97. Identify the tumor type:
    A malignant epithelial tumor with glandular differentiation and/or mucin production
    Most cases seen in smokers but also develops more frequently than other histological types in never smokers (especially women)
    Most located peripherally but may grow endobronchially or diffusely in lung
    Gross Appearance: either well-circumscribed or stellate; may show hemorrhage, necrosis, or cavitation; may cause pleural retraction or puckering; may appear gelatinous due to mucin production; may be solitary or multiple
  98. What is a specific type of adenocarcinoma that grows along alveolar septa in a non-invasive fashion leading to pulmonary consolidation resembling pneumonia; often multifocal and bilateral
    Bronchioloalveolar Carcinoma (BAC)
  99. Identify the tumor type:
    A malignant neuroendocrine tumor composed of relatively small cells with scant cytoplasm, fine nuclear chromatin, nuclear molding, necrosis, and high mitotic rate
    About 20% of all lung cancers
    Usually located centrally with invasion of mediastinum and lymph node involvement
    Gross Appearance: white-tan, soft mass with extensive necrosis, peribronchial growth, and lymphangitic spread
    Small Cell Carcinoma
  100. Identify the tumor type:
    An undifferentiated non-small cell carcinoma that lacks features of either glandular or squamous differentiation
    About 9% of all lung cancers
    Most tumors located peripherally
    Gross Appearance: large peripheral masses that often invade visceral pleura, chest wall, or adjacent structures
    Large Cell Carcinoma
  101. What is a distinctive subset of epithelial tumors that share many morphologic features including the presence of neurosecretory granules? What are the four types?
    Neuroendocrine Tumors: Carcinoid, Atypical Carcinoid, Large Cell Neuroendocrine Carcinoma, Small Cell Carcinoma
  102. What is the most common type of pleural tumors?
    Malignant Mesothelioma
  103. What are malignant mesotheliomas most commonly due to? What is their latency period? What is the most common fiber type?
    • Asbestos Exposure
    • 30-40 years
    • Crocidolite
  104. What are the following symptoms characteristic of?

    Lungs become shrunken and stiff; oxygen uptake is impaired; hypoxemia worsens with exercise; hypoxemia is readily corrected with oxygen supplementation; carbon dioxide excretion is relatively preserved; cardiac output is limited
    Interstitial Lung Disease
  105. Infiltration in interstitial lung disease can impair diffusion. How does this result in hypoxemia?
    Because CO2 diffuses easier than oxygen
  106. What is the most common interstital lung disease of unknown etiology?
    Idiopathic Interstitial Pneumonia
  107. Which has a worse prognosis, usual interstitial pneumonia or non-specific interstitial pneumonia?
    Usual Interstitial Pneumonia
  108. Bronchiolitis Obliterans Organizing Pneumonia (BOOP) is a disease with an unknown etiology. How is it diagnosed? How is it treated?
    • Biopsy
    • Responds well to corticosteroids
  109. What is the ventilatory pattern in interstital lung disease?
    Rapid Shallow Breathing
  110. What is the effect of interstitial lung disease on vital capacity (VC)?
  111. What is the effect of interstitial lung disease on expiratory flow FEV1?
    Relatively Normal
  112. What is the effect of interstitial lung disease on the FEV1:FVC ratio?
    Normal or Increased
  113. What is the confirmatory measurement in interstitial lung disease?
    Decreased Total Lung Capacity
  114. What is the primary cause of resting hypoxemia in interstitial lung disease?
    Ventilation/Perfusion Mismatching
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