Professional Documents
Culture Documents
11/12/15, 11:04 AM
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 1 of 22
11/12/15, 11:04 AM
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 2 of 22
11/12/15, 11:04 AM
Flagged
Question: 15
the alveolar gas equation and the actual post alveolar capillary (CcO2) to arterial PaO2 gradient to increase:
A.
B.
High FiO2
Increased cardiac output
C.
D.
Mild anaemia
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 3 of 22
11/12/15, 11:04 AM
Calculating the A-a gradient by using the alveolar gas equation (described in question 7) takes into account
the FiO2, barometric and water vapor pressure, the PaCO2, and the consumption of oxygen and formation
of CO2, but it doesnt tell you how desaturated the blood was as it approached the alveolus. You can imagine that the more desaturated the pre-alveolar blood is, the less likely it will be completely saturated when
it leaves the alveoli (although in most cases, even very desaturated blood is fully saturated, but this is picky
theoretical minutiae that has almost no bearing on clinical practice, hence the stuff the boards seem to focus on). Therefore when you use the alveolar gas equation to calculate how saturated the blood leaving the
lungs are, it assumes that all of the blood is maximally saturated. The difference between this theoretical
value and the actual PaO2 (A-a gradient) is typically thought to be a measure of the patients lung disease
(understanding that there will always be some level of shunt as discussed in Q15). But, in the setting of a
very low mixed venous saturation, even perfectly functioning lungs can (theoretically) have post alveolar
capillary blood that has an oxygen tension well below that which was calculated. Since these values will be
lower, the actual CcO2-a gradient (difference) will be smaller than what was calculated (A-a gradient). How
does this matter? In practice youll probably not worry about it and increase the FiO2 or recruit more alveoli by increasing PEEP.
Increased cardiac output, to some degree, it would seem, could theoretically be so high that it also would
not be fully oxygenated after leaving the alveoli, but this doesnt actually happen. Perhaps this is because at
high cardiac outputs the mixed venous saturation will be increased (if this doesnt make sense, see the ICU
section). Severe anaemia can be associated with very low mixed venous saturations, but this is rarely true
with mild anaemia.
The A-a gradient is an imperfect measure for judging lung disease as it varies with FiO2. The higher the
FiO2, the greater the normal gradient will be. In general, with plenty of exceptions, on room air a normal Aa gradient will be about 20 (or less) and on 100% FiO2 it should be under 100. People also use A/a or a/A
ratios, as these are not affected by FiO2 changes (the relative ratio stays the same). A normal a/A ratio is
around 0.8. Since this all requires some math, we now commonly use the P/F ratio, which is the paO2/FiO2.
A normal P/F ratio is above 300 (as youd expect at 100% FiO2 you should have a paO2 greater than 300).
Of all the indexes, this one has the most flaws, but its simple. ARDS is described in severity relative to P/F
ratios, for example.
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 4 of 22
High FiO2
11/12/15, 11:04 AM
15% answers
19% answers
54% answers
Mild anaemia
11% answers
20%
25%
30%
40%
You also need to calculate the end capillary O2 content of blood (the blood just leaving the alveoli, which
uses the term CcO2.
In most cases the Hbsat utilizing the alveolar gas equation will be 100%. Above a PAO2 of, say 120, its safe
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 5 of 22
11/12/15, 11:04 AM
The final physiologic shunt equation is (Q = flow, CmvO2 = content of mixed venous blood):
Qshunt/Qtotal = (CcO2-CaO2)/(CcO2-CmvO2)
Because the pAO2 is almost always at least 120 and nobody likes equations that are complex, you can substitute the value 100% for CcO2. Furthermore, because the Hb will be the same on the arterial and venous
side, you can get rid of the content equation and just use the Hb saturations. What your left with is something easy to calculate and actually clinically useful, which is the ventilation-perfusion ratio (or VQI as it is
usually called). Its a very simple calculation:
VQI = (1-SaO2)/(1-SmvO2)
Using the values from the stem: (1-0.9)/(1-0.6) = 0.1/0.4 = 25%. Shunt in a healthy individual is typically less
than 5%. For example a normal person has a 99% arterial saturation and a 75% venous saturation, therefore: (1-0.99)/(1-0.75) = 0.01/.25 = 4%.
13% answers
20%
25%
41% answers
30%
43% answers
3% answers
40%
10%
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 6 of 22
B.
20%
C.
D.
30%
40%
11/12/15, 11:04 AM
7% answers
10%
14% answers
20%
34% answers
30%
45% answers
40%
B.
C.
D.
Page 7 of 22
11/12/15, 11:04 AM
alveoli with normal tidal breathing. With normal tidal volumes, FRC is maintained and the ratio of ventilation to perfusion is unchanged during both inspiration and expiration (during tidal breathing). Now that
weve tied in shunt to lung volumes, lets talk about PFTs next.
14% answers
13% answers
21% answers
52% answers
For normal individuals, a persons FVC should be within 20% of predicted, so this patient could be normal.
People with mild obstructive lung disease generally have a preserved FVC, but with severe disease the FVC
can decrease significantly, although less so than restrictive lung disease. Therefore this patient could have
mild (likely not very severe) COPD or asthma. Restrictive lung disease is associated with significantly decreased total lung capacities and FVCs. Even mild restrictive lung disease should have an FVC less than
80%, therefore it can be concluded that the patient does not have restrictive lung disease.
10% answers
Page 8 of 22
11/12/15, 11:04 AM
43% answers
3% answers
45% answers
A.
B.
C.
A
B
C
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 9 of 22
11/12/15, 11:04 AM
Graph C has a severely reduced FVC and FEV1, but the FEV1/FVC ratio is preserved. Think of it this way,
with restrictive lung disease, the problem is more to do with inspiration (too small of breaths) and not expiration.
2% answers
95% answers
B
3% answers
A.
B.
C.
A
B
C
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 10 of 22
11/12/15, 11:04 AM
Obstructive disease has a scooped triangle for exhalation owing to the fact that there is an obstructive lesion during exhalation, whereas inhalation appears relatively normal. Graph A represents normal. In case it
ever comes up on an exam, a normal tidal volume will look like a circle, not a triangle with a rounded bottom
like the vital capacity breath does.
9% answers
3% answers
88% answers
A.
B.
C.
Page 11 of 22
11/12/15, 11:04 AM
coidosis, asbestosis, etc. In fact, most restrictive lung diseases (certainly all that are intrinsic to the lung)
will have a reduced DLCO. What you may not have known is that COPD can decrease DLCO as well, and
when it is as severe as in the above flow-volume loop, it certainly will. Recall that COPD will destroy the
alveolar-capillary interface, change alveolar geometry, and have associated loss of capillary beds and V/Q
mismatching. All of this will decrease DLCO. A couple other technical factors that will decrease DLCO test,
although not actually be due to lung disease is anaemia and elevated pCO2.
5% answers
25% answers
70% answers
It is effort independent
It is fairly variable within an individual
It is a late indicator of obstructive disease
D.
It is effort independent
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
18% answers
23% answers
45% answers
Page 12 of 22
11/12/15, 11:04 AM
14% answers
FEF25%-75%
FVC
C.
FEV1/FVC
D.
Productive cough
Patient factors which increase the incidence of perioperative pulmonary complications are COPD, asthma,
productive cough, smoking (especially >40 pack years), maybe obesity, exercise intolerance of less than one
flight of stairs, and age > 65 years. Surgical factors include upper abdominal surgery, thoracic surgery, and
length of surgery.
FEF25%-75%
5% answers
10% answers
FVC
FEV1/FVC
Productive cough
24% answers
61% answers
B.
C.
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 13 of 22
D.
11/12/15, 11:04 AM
2% answers
9% answers
84% answers
4% answers
Immediately post-op
B.
C.
12 hours post-op
24 hours post-op
D.
48 hours post-op
26% answers
Immediately post-op
52% answers
12 hours post-op
16% answers
24 hours post-op
48 hours post-op
6% answers
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 14 of 22
11/12/15, 11:04 AM
C.
D.
5% answers
9% answers
80% answers
6% answers
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 15 of 22
11/12/15, 11:04 AM
A.
B.
C.
Ciliary function does not improve until 8 weeks after smoking cessation
Sputum production decreases daily for the first two weeks
D.
Pulmonary complications decrease if cessation occurs 8 weeks prior to surgery but not 24 hours
Following cessation of smoking it takes about 2-4 weeks for ciliary function to return to normal. Immediately following cessation of smoking, sputum production actually increases, if the patient stops smoking
just before surgery, they will still have impaired ciliary function and even more increased sputum production. Even a day of not smoking will significantly decrease levels of carboxyhaemoglobin back to normal values, which will increase oxygen carrying capacity (DO2). Because there is an increased risk with quitting
smoking just before surgery and no significant benefit if they smoked within the past few weeks, some
anesthesiologists argue that patients who cannot quit at least a month or two prior to surgery should be
told to smoke up until the day of surgery as the only benefit is a decreased carboxyhaemoglobin. This of
course, in my humble opinion, is asinine, as other effects of cigarette smoking include wound healing and
infection. Maximal benefit from smoking cessation is realized when smoking has been stopped for 8 weeks
or more.
7% answers
13% answers
3% answers
77% answers
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 16 of 22
B.
C.
D.
11/12/15, 11:04 AM
4% answers
5% answers
84% answers
8% answers
C.
D.
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 17 of 22
11/12/15, 11:04 AM
*It would appear that upper abdominal surgery may decrease FRC more than most other types of surgery,
have its maximal decrease later, and recover slower.
35% answers
9% answers
17% answers
39% answers
B.
C.
Sternal angle
Nipple line
D.
60% answers
Sternal angle
Nipple line
8% answers
19% answers
Plateau pressure
Peak pressure
C.
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 18 of 22
D.
11/12/15, 11:04 AM
Transpulmonary pressure
Static compliance = Volume/ Pressure = Tidal volume delivered/ (Plateau pressure PEEP).
The next subject is dynamic compliance. Dynamic compliance is the compliance of the respiratory system
during inspiration. This means that the pressure is taking into account not only the static compliance (the
pressure needed to keep the lungs inflated, but also the pressure needed to overcome the intrinsic airway
resistance to deliver the air to the alveoli). Its equation is also simple:
Dynamic compliance = Volume/ Pressure = Tidal volume delivered/ (Peak pressure PEEP).
The difference between the peak and plateau represents the resistance flow. This means that it is the
pressure needed to overcome the resistance to flow within the airways (remember from question 3 that
most of this occurs in the conducting airways). Other terms you will come across is calling the peak pressure the airway pressure and the plateau pressure the alveolar pressure.
Transpulmonary pressure is another important concept. It is the alveolar (plateau pressure) minus the
pleural (esophageal) pressure. It represents the actual pressure across the lungs. This is also discussed in
the advanced ICU section, but it has a lot of relevance to daily anesthetic delivery as well so check out
question 36.
Plateau pressure
Peak pressure
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
18% answers
54% answers
Page 19 of 22
11/12/15, 11:04 AM
20% answers
8% answers
Kinked ETT
B.
C.
ARDS
Pleural effusion
D.
Trendelenburg position
94% answers
Kinked ETT
ARDS
2% answers
Pleural effusion
1% answers
Trendelenburg position
4% answers
Page 20 of 22
11/12/15, 11:04 AM
ference:
A.
B.
C.
Asthma exacerbation
D.
66% answers
Pneumothorax
12% answers
Asthma exacerbation
Foreign body aspiration
7% answers
B.
C.
D.
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 21 of 22
11/12/15, 11:04 AM
Again, this subject is discussed in more detail in the ICU sections, but lets introduce it here in case you do
not complete the ICU advanced cardiopulmonary section in preparation for the basic exam (which I think
would not be a bad idea, but the ICU principles section is an absolute must, as oxygen utilization and transport are huge topics on the boards as well as the basics of mechanical ventilation strategies. Above a
plateau pressure of 30 cm H20, the risk of barotrauma (air dissecting out of the lungs into places it should
not be such as pneumothorax, pneumomediastinum, pneumopericardium, etc) increases greatly, therefore
we want to keep the plateau pressures less than that, even if we significantly limit tidal volumes. In obese
people, because of large abdomens and noncompliant chests, their static compliance of the respiratory system is very low, meaning that a plateau pressure above 30 cm H20 is very likelyBUT, this doesnt mean
they are at risk for barotrauma. Why? Barotrauma really occurs when the transpulmonary pressure (remember it is alveolar pressure minus pleural pressure) is high. Patients with low compliant thoracic cavities
will have a high pleural pressure, and we measure that with the esophageal pressure. Therefore, this patients transpulmonary pressure is only 35 20 = 15! Thats nothing.
19% answers
64% answers
SAVE
2% answers
SUBMIT
https://m5boardreview.com/review-topics/basic-pulmonary-physiology/
Page 22 of 22