RESPI

Anatomy

1. Functions of pleura
Parietal and visceral layer with pleural cavity in btw.
As it cling tightly to thorax wall, forced to expand n recoil passively during breathing.
Create a negative pressure to keep the lungs expanded always. (negative intrapleural pressure)

2. Difference between histology of Bronchus and bronchiole

Bronchus pseudostratified columnar ciliated cell ;complete rings of cartilage, presence of glands
Bronchiole simple columnar/cuboidal ciliated ;no cartilage or gland, only helical band of smooth muscle

3. Defense mechanism of Respi tract

i)Non-specific defense of lung:
Anatomical : nose hair, mucus, ciliated epithelium
Mechanical: cough, sneeze, swallowing reflex, turbulent flow, mucociliary escalator
Biochemical: cytokines, interferon, complement, lysozyeme, mucsus(buffering)
Cellular: macrophages (dust cells), lymphocytes, normal flora, dust cells
ii)Specific defence mechanism of lung :Ig A(neutralize/lyse/inhibit)
iii)Describe mucociliary escalator
Mucociliary escalator are present from larynx to terminal bronchioles.
Presence of ciliated epithelium & mucus
Particles adhere to mucus layer
Continous coordinated ciliary action upwards
Mucus and particles moved up the bronchial tree
Expelled thru swallowing/expectorated

Physiology
1. Explain how V/Q is varied in upper and lower region of normal lungs
Ventilation V of upper < lower (compliance) gravity also…
Perfusion Q of upper < lower ( gravity)
However the increase of Perfusion of lower is more than that of ventilation
V/Q of lower region< V/Q of upper region
2. Explain the difference between CO and CO2 in terms of binding sites and binding affinity
CO binds tightly but reversibly to Hb iron (HbCO) , affinity 200-250X of that O2
CO2 +H20 = H2CO3= H+ + HCO3-
H+ +Hb = HHb (DeoxyHb) OxyHb has lower CO2 affinity than DeoxyHb

3. Cough
i. Where is the location of cough receptors?
ii. afferent pathway: cough receptor on Trachea and bigger bronchi cough centre in medulla
(GLOSSAL PHARYNGEAL NERVE AND VAGUS NERVE)
iii. efferent pathyway
recurrent laryngeal nerve(vagus) –glottis
phrenic nerve – diaphragm
spinal nerve – intercostal, lattisimus dorsi
iv. Describe cough refleχ
Irritant trigger cough reflex.
Deep inspiration, epiglottis close. Vocal cord close tightly to trap air
Abdominal wall contract forcefully to push against diaphragm, strong contraction builds up
intrapulmonary pressure.
Forced expiration against the closed glottis due to increase pressure
Glottis sudden open, Air is expel together with the foreign particle
v. What happens to respiration during cough. Interrupted
 4. Describe the mechanics of forced breathing

Muscle involved
Inspiration Expiraton
Quiet Diaphragm, external intercostals Relaxation of the inspiratory muscle
Deep/forced Scalene, SCM, Quadratus Anterior abdominal wall (rectus abdominis), latissimus
lumborum, major/minor pectoralis dorsi, internal intercostal
Pressure decrease intrathoracic pressure Increase intrathoracic pressure
5.2 measures to control smoking
Nicotine patch, counseling/education, nicorrette, decrease advertising, increase taxing

MCQ: Lung physiology

Ventilation is greater at the base than the apex T
Perfusion is greater at the base than the apex T
Ventilation/perfusion ratio is greater at the base than the apex F

Pathology
Bronchiectasis

1. 2 differences between bronchiectasis and emphysema

Bronchiectasis: permanent dilation of bronchi & bronchioles caused by destruction of muscle
and elastic supporting tissue , infections…
Emphysema: permanent enlargement of air spaces to terminal bronchioles accompanied by
destruction of walls lost of alveolar attachment. Secondary to persistent infection and
obstruction. Parenchymal cells involvement, smoking…
2. 2 agents that can cause community acquired pneumonia
Viral: Influenza virus, Sars coronavirus
Bacteria: strep pneumonia, Haemophilus influenza
3. What are the multiple lesions seen on X ray of the pneumonic patient

dense white patch

Viral pneumonias typically produce faint, widely scattered white streaks or patches.
Some pneumonias can lead to a lung abscess which appears on the x-ray as a space filled with
fluid (pus).
There may be changes at the top of the lung, suggesting tuberculosis (coin lesions)
Therefore the multiple lesions could be TB Gohn focus Initial infection with
Mycobacterium. tuberculosis in an immunocompetent individual
usually occurs in an upper region of the lung producing a sub-pleural
lesion called a Ghon focus. Granulomatous involvement of
peribronchial and/or hilar lymph nodes is frequent in primary
tuberculosis due to lymphangitic spread from the Ghon focus.

TB pneumonia: caseating Lymph node, invade bronchus aspirating to another segment

4. Pathophysiology of Bronchiectasis
1. Obstruction chronic persistant infection  damage of wall obstruction  dilation.

5. Why is there hoarseness and dysphagia in this patient

 Compression of recurrent laryngeal nerve by lesion at the apex by TB lesion.

Emphysema
MCQ
1. Compliance increase T
2. Involve dilatation of the bronchioles F
3. Protease-antiprotease imbalance, the protease is inhibited by alpha1 antitrypsin T
4. Tobacco smoking cause Oxidant-antioxidant imbalance T

Asthma

Male Patient with bronchial asthma since 12 yo. He presented with dyspnoea. He inhaled salbutamol,
well-compliance.
1. Why is there airway obstruction in asthma
Acute: Direct stimulaton of subepithelial vagal (parasympathetic) receptors 
bronchoconstriction
Late phase: Major basic protein of eosinophils causes epithelial damage and airway constriction,
2. What does peak flow index indicate
Maximal forced expiration
3. Name 2 other tests to investigate lung function
Arterial blood gas and spirometry (FEV1/FVC)
*FEV1 is the forced expiratory volume for the 1 st sec ; FVC Forced Vital Capacity ( Forced
expiration into spirometer)
4. State Changes in FRC, ERV, FVC and FEV1/FVC for asthma patient
FRC and RV increase, ERV and VC may reduce
FEV1/FVC ratio decrease FEV1 decrease due to bronchoconstrictions. FVC unchanged
5. Definition and causes of wheezing
Wheezing(rhonchi) are musical sounds produce by passage of air thru narrowed bronchi. It
occurs on expiration due to bronchospasm. Causes: asthma, COPD (chronic bronchitis,
emphysema).
6. 2 occupations causing asthma
Pet show owner(dust), florist (pollen)
7. 3 risk factors (or pathogenesis?) causing airway obstruction in asthma
Allergens, NSAIDS (inhibit COX1-vasodilate), dust mite, exercise, stress
8. 2 occupation causing byssinosis
Cotton farmer, Factory workers, textile worker
9. 2 causes of chest pain : trauma, MI, AP, pleurisy. GERD

Behavioral science
What is the feeling of asthmatic patient
Anxiety, Fear , dependence, unpredictability
MCQ:
Pollen can cause extrinsic asthma

Chronic bronchitis

40yo man, He smokes 20 cigarettes/day. Have started coughing productive white copius sputum. He also
complains of SOB (it was a combined question with Stroke)
1i. What is the definition Chronic Bronchitis
persistent productive cough for at least 3 consecutive months in at least 2 consecutive years
ii. Pathogenesis of Chronic Bronchitis
causes: smoking, air pollution(city dweller)
hypertrophy of mucus secreting glands  hypersecretion of mucus
favour inflammatory cells infiltrations (inflammation)
cause epithelial layer ulceration and squamous cell metaplasia (columnar  squamous)
goblet cell metaplasia in all the way till bronchus..
fibrosis of bronchial wall  narrowing air flow limitation

2. Explain how the white sputum and cough are produced

Increase mucous glands hyperplasia bronchiole secretion due to irritation and accumulation of sputum
will trigger cough reflex

3i. Give 3 other defense mechanisms of respiratory tract other than cough reflex
Mucociliary escalator, Ig A, macrophage, dust cell ( alveolar macrophages) , sneeze reflex.etc

5. Explain how breathlessness occurs in chronic bronchitis

Ans:
-Greater muscular effort to overcome airway resistance due to bronchoconstriction and mucus
over production.
-Hypercapnia/hypoxaemia peripheral chemoreceptor  medullary respiratory centre 
increase respiraton.

5 . Give 2 pediatric effects in mothers who are smokers

Postnatal
Birth weight/size:
Still birth, premature birth, low birth weight (IUFGR intrauterine fetal growth retardation)
Due to deprivation of fetus from supply of oxygen.
Nicotine narrowing of blood vessels, Carbon monoxide reduce Oxygen capacity of Hb (HbCO)

Infantile
Lung: prematureDelayed lung development, Vulnerable to asthma, risk of Sudden infant death
syndrome SIDS
Premature: deficiency of surfactant , infant respiratory distress syndrome IRDS
Brain function : Nicotine  learning disorder, future addiction

Acute Bronchitis
Cause by virus: influenza, common cold virus, adenovirus, measles virus
May have superimposed bacterial infections ( Strept pneumonia, H.influenza, Moraxella catarrhalis)

Asbestosis/Lung Cancer

1. Describe pathology feature of asbestosis

Asbestos bodies found in lungs of patient (golden brown)
Macrophages ingest asbestos  release cytokines reticulin formation… accumulate around
bronchiole and alveoli.. collagen replacement then fibrosis…
2. Name 4 occupation that are related to asbestosis
Manufacturing workers for roofing materials, clutch casing, brake lining, workers who laid
down the roofing, fire fighting suits
3. Name the asbestos and smoking related lung ca
Squamous cell carcinoma (bronchogenic carcinoma)
4. Name 2 other occupational lung diseases and occupation causing them
 Coal worker pneumoconiosis: coal Miner
Bsyssinosis: Cotton farmer
Silicosis: stone cutter, quarrying
5. FEV1/FVC reduced. Why?
FEV1 reduce maybe due to obstruction at the bronchus. Or bronchiectasis as the Cx.. both
decrease…
6. Besides from pleurisy, name 2 pulmonary causes of chest pain: pleural effusion, tension
pneumothorax, acute bronchitis, TB, trauma on chest ,frail chest…
7. Describe the different mechanism of how cigarette smoking causes cough
Irritants .. irritate the airways increase the mucus secretion
8. 2 risk factor of lung cancer. 2 environmental cause:
Heavy metal exposure (nickel, chromium, arsenic, smoking, asbestos)
2nd hand smoker
9. Investigation for lung Ca : sputum cytology, bronchoscopy, FNAC, CXR
10. What is the oncogene causing lung cancer:
Oncogene: K ras , c-myc
Tumour: p53, APC
Carcinogen will mutate the protooncogene that affect cell division and cell growth
11. Palliative care
12. Describe TNM staging
T: Tumor grading size – mitotic figure
N: Lymph node involvement
M: Metastasis

Pharmocology
MOA of drugs for cough
mucolytics: beak disulphide bond of glycoprotein of mucus (viscous  liquid) eg Acetylcarbocysteine,
meta cysteine
antitussive: opioid analogue, decrease bronchial secretion, thicken sputum. For unproductive cough.
(not for productive cough) eg Codeine
Expectorant: increase fluidity (bronchial secretions) and increase productive cough eg. Volatile oil,
iodides, chlorides
Demulcents: sooth airway . decrease stimuli fr throat, larynx, trachea eg linctus, methol,eucalypus
Decongestant: sympathomimetics (vasoncon) eg pseudoephedrine

MOA of asthmatic drugs

B2 adrenoceptor agonist (salbutamol) :selective B2 agonist bronchodilation (SE: tremor, tachycardia)
Anitmuscarinic(Ipratropium) : useful as adjunct to B2
Cromoglycate: stabilize mast cell, inhibit histamine releases (SE: hypersensitivity)
Nedocromil sodium: prevent lung anaphylaxis, eosinophilia and SO2 induced bronchocon
Xanthine(theophylline): relax brochial smooth muscle by
i) Adenosine antagonist Prevent inhibition of AC + cAMP  + [Ca]i  inhibit contractile
ii) Phosphodiesterase inhibitor  prevent cAMP breakdown
SE: small therapeutic index. Seizure, cardiac dysrythmia.
Glucocorticoids: multi mechanism, - mucus, antagonize histamine rxn (SE: imunocom oral
candidiasis)
Antihistamine : prophylactic, eg COX inhibitor, Leukotriene synthase inhibitor

MCQ
i. palpitation is common in salbutamol T
ii. cromoglycate can cause tremor F (salbutamol cause tremor)
iii. Xanthine has narrow therapeutic index T
iv. Ipratropium has adverse side effects and poorly tolerated F
v. steroid inhalers can cause oral candidiasis T