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Basic Pulmonary Physiology - M5 Board Review

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BASIC PULMONARY PHYSIOLOGY


This section complements the Respiratory Physiology section and the questions are more factual and less
clinical scenario based
Open All Answers: (+) | Close All Answers: (-)
Show Choices for #1: (+/-)
Which of the following muscles are not involved in inspiration:

Show Choices for #2: (+/-)


At the end of a passive expiration, the lung volume is:

Show Choices for #3: (+/-)


Airway resistance is primarily due to the:

Show Choices for #4: (+/-)


In the large conducting airways of an individual with high airway resistance, which of the following
will decrease resistance:

Show Choices for #5: (+/-)


An asthmatic patient has increased airway resistance, which of the following equations can explain
the mechanism for this:

Show Choices for #6: (+/-)


At which lung volume or capacity would pleural pressure be most negative (with spontaneous
breathing):

Show Choices for #7: (+/-)


Increasing altitude will result in which of the following:

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Show Choices for #8: (+/-)


Which of the following is not a cause of hyperventilation:
Show Choices for #9: (+/-)
The following graph describes CO2 responsiveness, with A being normal. Which of the following
would explain line C:

Show Choices for #10: (+/-)


Which of the following has the greatest dead space:

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Show Choices for #11: (+/-)


The following was the ventilation to perfusion ratio plotted by rib number on the x axis. What is
most likely true regarding point A:

Show Choices for #12: (+/-)


A patients end-tidal CO2 decrease while the paCO2 increase, which of the following is an explanation:
Show Choices for #13: (+/-)
After placing an otherwise healthy patient on mechanical ventilation, dead space:
Show Choices for #14: (+/-)
A patient has a paCO2 of 30 mm Hg and an TCO2 of 20 mm Hg, what is the percent dead space:

Show Choices for #15: (+/-)


Which of the following venous systems DO NOT contribute to anatomic shunt:
Show Choices for #16: (+/-)
Which of the following will result in the difference between the calculated A-a gradient utilizing

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.

Very low mixed venous saturation

D.

Mild anaemia

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See Explanation (+/-)


The correct answer is: C: Very low mixed venous saturation
This was a tricky one. The first thing you need to figure out is what is this question asking! The A-a gradient is the difference between the calculated oxygen tension in the alveoli and the arterial blood. The CcO2
is the difference between the blood that immediately leaves the (ventilated) alveoli and the arterial blood.
The theoretical CcO2 should be the same as the pAO2 (alveolar O2 tension). The difference between the
pAO2 or CcO2 and arterial O2 tension is due to shunt (as discussed in the next question). But this question is bringing up that the assumption that pAO2 and CcO2 being identical is not always the case, even assuming a normal ventilated alveoli. Lets discuss this further:

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.

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High FiO2

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15% answers

19% answers

Increased cardiac output

54% answers

Very low mixed venous saturation

Mild anaemia

11% answers

Show Choices for #17: (+/-)


A patient has an arterial haemoglobin saturation of 90% and a mixed venous saturation of 60%. Approximately, what is the shunt fraction:
A.
B.
C.
D.

20%
25%
30%
40%

See Explanation (+/-)


The correct answer is: B: 25%
Calculating shunt in clinical practice utilizing the physiologic shunt calculation is not easy. It utilizes the
content of oxygen in blood, which means you need to know the Hb, the saturation of Hb (Hbsat), and all the
variables of the alveolar gas equation:

Arterial content of blood (CaO2) = Hb X Hbsat X 1.34


Mixed venous content of blood (CmvO2)= Hb X Hbsat X 1.34

You also need to calculate the end capillary O2 content of blood (the blood just leaving the alveoli, which
uses the term CcO2.

CcO2 = Hb X Calculated Hbsat utilizing the alveolar gas equation X 1.34

In most cases the Hbsat utilizing the alveolar gas equation will be 100%. Above a PAO2 of, say 120, its safe
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to say that the Hb will have a near 100% saturation.

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%

Show Choices for #18: (+/-)


Above which shunt fraction would supplemental oxygen not expect to increase the PaO2 by more
than 10 mm Hg:
A.

10%

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B.

20%

C.
D.

30%
40%

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See Explanation (+/-)


The correct answer is: D: 40%
Its important to have a general idea at which degree of shunt will supplemental O2 not have an effect on
increasing the arterial pO2. Different people will have different answers on this, but what is established is
that above 30% shunt youll get very little increase in pO2 with increased FiO2, and at 40% shunt raising
the FiO2 from 21% to 100% will have almost no effect on arterial pO2. This is a nomogram that youll see in
a lot of textbooks:

7% answers

10%

14% answers

20%

34% answers

30%

45% answers

40%

Show Choices for #19: (+/-)


Which of the following will increase venous admixture:
A.

Increased inspiratory reserve volume

B.
C.
D.

Decreased inspiratory reserve volume


Increased expiratory reserve volume
Decreased expiratory reserve volume

See Explanation (+/-)


The correct answer is: D: Decreased expiratory reserve volume
Decreased expiratory reserve volume (ERV) will in turn decrease functional reserve capacity (FRC), as FRC
= ERV + Residual volume (RV). FRC, as described in question 2, is the resting volume of the lung (post-exhalation), and at decreased volumes, less blood is being exposed to oxygenated alveoli, thus increasing the
shunt (also known as venous admixture, see question 15). Think of it this way, with reduced lung volumes
at end expiration it means that it will hold less oxygen for blood flow to pick upand that means the ration
of ventilation to perfusion will decrease (perfusion stays the same, ventilated alveoli decrease) and therefore shunt will worsen (increase). Decreasing inspiratory reserve volume (IRV) will decrease the largest
breath that one can take (total lung capacity) but will not affect the number of perfused but unventilated
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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.

Increased inspiratory reserve volume

14% answers

Decreased inspiratory reserve volume

13% answers

Increased expiratory reserve volume

21% answers

52% answers

Decreased expiratory reserve volume

Show Choices for #20: (+/-)


A patient has a forced vital capacity that is 90% predicted for his size, age, and gender. Which of the
following is true:
A.
B.
C.
D.

He does not have obstructive lung disease


He does not have restrictive lung disease
He does not have normal pulmonary function
None of the following conclusions can be made

See Explanation (+/-)


The correct answer is: B: He does not have restrictive lung disease
Forced vital capacity (FVC) is one of the most important tests we look at with pulmonary function tests. Essentially with an FVC, the patient takes a vital capacity breath and expires it as forcibly and rapidly as possible. By looking at the amount of air over time, one can look at the forced expiratory volume (FEV) at a given
time (most often we use the 1 second mark, or FEV1). The FVC to FEV1 ratio can be valuable in categorizing and grading lung disease. Additionally, we can look at different volume points during the FVC, such as
when 25% or 75% of the FVC volume has been exhaled (FEF25-75%, for example).

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.

He does not have obstructive lung disease


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10% answers

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43% answers

He does not have restrictive lung disease


He does not have normal pulmonary function

3% answers

None of the following conclusions can be made

45% answers

Show Choices for #21: (+/-)


Which of the following graphs represent obstructive lung disease:

A.
B.
C.

A
B
C

See Explanation (+/-)


The correct answer is: B: B
With severe obstructive disease notice two things. First the FVC is moderately reduced. Second, and far
more importantly, the FEV1 is significantly reduced, meaning that they have a descent sized breath, but it
takes a very long time to completely exhale and after 1 second (FEV1) a very small proportion of the FVC is
exhaled. Therefore, the FEV1/FVC ratio will be reduced. The FEV1/FVC ratio is an important tool for grading COPD, the smaller the ratio, the worse the disease. A normal FEV1/FVC is about 80%. Severe COPD is
associated with FEV1/FVC ratios below 50%. See Q28 in the other respiratory physiology section for more
detail on COPD grading.

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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

Show Choices for #22: (+/-)


Which of the following flow volume loops represent obstructive lung disease:

A.
B.
C.

A
B
C

See Explanation (+/-)


The correct answer is: C: C
Flow volume loops are generated by plotting gas flow during forced exhalation, followed by forced inhalation (vital capacity). Restrictive and obstructive lung diseases have very characteristic patterns. Restrictive
lung disease maintains a general triangle shape during exhalation (remember restrictive disease has a relatively normal exhalatory pattern) but has very reduced flow during inspiration. Also note that the volumes
are also very reduced.

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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

Show Choices for #23: (+/-)


Regarding flow-volume loop C, which of the following is true regarding carbon monoxide diffusing
capacity (DLCO):

A.
B.
C.

DLCO will most likely be increased


DLCO will most likely be normal
DLCO will most likely be decreased

See Explanation (+/-)


The correct answer is: C: DLCO will most likely be decreased
The DLCO is a measurement of how well gas exchanges between the alveolus and capillary blood. Because
CO is has such a high affinity for Hb (200X more than O2) its a convenient test. Any disease process that
affects the alveolus will decrease the DLCO. Examples include disease states with junk that accumulates
inside the alveolus such as pulmonary oedema as well as diseases that affect the alveolus itself such as sarhttps://m5boardreview.com/review-topics/basic-pulmonary-physiology/

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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.

DLCO will most likely be increased

5% answers
25% answers

DLCO will most likely be normal

70% answers

DLCO will most likely be decreased

Show Choices for #24: (+/-)


Which of the following regarding the FEF25%-75% is false:
A.
B.
C.

It is effort independent
It is fairly variable within an individual
It is a late indicator of obstructive disease

D.

Decreased values indicate medium-sized airway obstruction

See Explanation (+/-)


The correct answer is: C: It is a late indicator of obstructive disease
The forced expiratory flow (FEF) is typically broken up into quarters: FEF25%, FEF50%, & FEF75%, which
means the exhaled volume at 25% of FVC, 50% of FVC, and 75% of FVC, respectively. Between the 25%
and 75% marks on the FVC curve is called the effort independent flow because it will theoretically not
change whether or not the patient is blowing at maximal effort. FVC and FEV1 will change significantly depending on effort. Unfortunately, the FEF FEF25%-75% is fairly variable when a patient blows for spirometery (the standard is at least three forced exhalations). The FEF25%-75% is an early indication of obstructive
disease and is often significantly reduced prior to the FEV1/FVC ratio decreasing. However, because of its
intra-individual variability and lack of significant evidence of being all that valuable clinically, its often noted but ultimately ignored. Therefore, it is a boards favorite! So what is FEF25%-75% actually telling us anyway? A decreased value is indicative of medium (some say small) airway disease. File this under a sensitive,
but not specific test.

It is effort independent

It is fairly variable within an individual

It is a late indicator of obstructive disease

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18% answers

23% answers

45% answers

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14% answers

Decreased values indicate medium-sized airway obstruction

Show Choices for #25: (+/-)


Which of the following is the best predictor of perioperative pulmonary complications:
A.
B.

FEF25%-75%
FVC

C.

FEV1/FVC

D.

Productive cough

See Explanation (+/-)


The correct answer is: D: Productive cough
Despite so much emphasis of PFTs on the boards, there is little evidence any of it makes a big difference or
predicts perioperative pulmonary complications. Sorting through the data is a bit of challenge, so let me
put it this way: interpreting a PFT to predict perioperative pulmonary complications is of very low utility,
therefore there is little reason for an anesthesiologist to order one. The one exception is a pneumonectomy, which the reason for this is discussed in the question 5 of the cardiac respiratory & vascular surgery
section (advanced exam topic).

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

Show Choices for #26: (+/-)


Which of the following patients would an ABG be most indicated preoperatively for a patient with
COPD?
A.

Na 140, K 4.5, Cl 110, CO2 24, Cr 1.0, BUN 26

B.

Na 120, K 4.5, Cl 85, CO2 25, Cr 1.5, BUN 26

C.

Na 140, K 3.5, Cl 85, CO2 45, Cr 1.0, BUN 15

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D.

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Na 155, K 4.5, Cl 120, CO2 25, Cr 1.0, BUN 26

See Explanation (+/-)


The correct answer is: C: Na 140, K 3.5, Cl 85, CO2 45, Cr 1.0, BUN 15
The worst of the worst of COPDers are the CO2 retainers, and these are people you will have a hard time
keeping extubated after surgery. CO2 retention classically has compensated elevated bicarb (CO2 on the
chem 7), and choice C describes such a patient.

Na 140, K 4.5, Cl 110, CO2 24, Cr 1.0, BUN 26


Na 120, K 4.5, Cl 85, CO2 25, Cr 1.5, BUN 26

2% answers
9% answers

84% answers

Na 140, K 3.5, Cl 85, CO2 45, Cr 1.0, BUN 15


Na 155, K 4.5, Cl 120, CO2 25, Cr 1.0, BUN 26

4% answers

Show Choices for #27: (+/-)


Following an abdominal operation, at what time would the FRC be expected to be the lowest:
A.

Immediately post-op

B.
C.

12 hours post-op
24 hours post-op

D.

48 hours post-op

See Explanation (+/-)


The correct answer is: B: 12 hours post-op
FRC is affected by position, anesthesia, and operations. Following an operation FRC is classically the lowest
12 hours following an operation. This is due to splinting, atelectasis, residual affects of anesthesia (including analgesics for post-op pain control), and post-operative positioning. Lets talk about this a bit more in
the next question.

26% answers

Immediately post-op

52% answers

12 hours post-op

16% answers

24 hours post-op
48 hours post-op

6% answers

Show Choices for #28: (+/-)

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Which of the following will decrease the FRC the least:


A.
B.

Changing from upright to supine position


Volatile anesthesia

C.
D.

Changing from supine to prone position


Changing from upright to prone position

See Explanation (+/-)


The correct answer is: C: Changing from supine to prone position
This one is a bit of a poorly worded question, as if you realize that changing from a supine to prone position
will actually increase FRC in many cases, can you still say that it will decrease the FRC the least? I did not
revise this questions stem to illustrate the ambiguity and poor wording of questions youll come across.
Now with the basic exam at the end of the CA-1 year, you can see exactly what I mean!
Heres the deal with FRC and positioning: FRC will decrease in a healthy adult by 15% just by changing from
an upright to supine position (from a loss of ERVbut you already knew thatright?). Changing from an
upright to prone position will also drop the FRC quite a bit, but less so. Changing from supine to prone position has pretty mild effects, unless youre paralyzed, mechanically ventilated, and obese, in which case it
improves FRC significantly.
General anesthesia will decrease FRC by about 10-20%* (above that caused by position differences) and
the greatest decrease is 10 minutes after induction.
What can you do to increase FRC. Hmmm, lets seeyou can raise the head of the bed, you can get them
out of bed early, and you can give them PEEP (or CPAP post-operatively).

*Closer to 50% reduction in very obese individuals!

Changing from upright to supine position


Volatile anesthesia

5% answers
9% answers

80% answers

Changing from supine to prone position


Changing from upright to prone position

6% answers

Show Choices for #29: (+/-)


Regarding smoking cessation:

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A.

It will take 72 hours for carboxyhaemoglobin levels to fall to normal levels

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

See Explanation (+/-)


The correct answer is: D: Pulmonary complications decrease if cessation occurs 8 weeks prior to surgery but not
24 hours
Smoking cessation is actually a mildly controversial subject for anesthesiologists in regard to its effects on
perioperative respiratory function and complications. Smoking is associated with decreased ciliary function, increased sputum, up-regulation of destructive enzymes and reactive metabolites that lead to development of COPD, immunologic dysregulation , changed surfactant, small airway reactivity, and epithelial
permeability. After a list like that, what could the controversy be?!?

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.

It will take 72 hours for carboxyhaemoglobin levels to fall


to normal levels

7% answers

13% answers

Ciliary function does not improve until 8 weeks after


smoking cessation
Sputum production decreases daily for the first two
weeks

3% answers

Pulmonary complications decrease if cessation occurs 8


weeks prior to surgery but not 24 hours

77% answers

Show Choices for #30: (+/-)


A patient with COPD underwent a preoperative ECG. Which of the following is most likely to be
present:
A.

Inverted t-waves in a coronary specific pattern

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B.

Left bundle branch block

C.
D.

Poor R-wave progression


Accelerated junctional rhythm

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See Explanation (+/-)


The correct answer is: C: Poor R-wave progression
COPD puts strain on the right heart and can lead to right heart failure. Classic findings on the ECG are
signs of right heart strain, such as poor R-wave progression, enlarged P-waves (P pulmonale), R waves
greater than S waves in V1, RBBB, and right axis deviation. Also present, on exams, are low voltage ECGs
because of dynamic lung hyperinflation. Likewise, classic for exams is increased incidence of multifocal atrial tachycardia (MAT), which will present with at least three different distinct wandering P waves and an irregular rhythm.

Inverted t-waves in a coronary specific pattern

4% answers

Left bundle branch block

5% answers

84% answers

Poor R-wave progression


Accelerated junctional rhythm

8% answers

Show Choices for #31: (+/-)


Following upper abdominal surgery:
A.
B.

Residual volume (RV) increases by 10%


Expiratory reserve volume (ERV) increases by 25%

C.

Vital capacity (VC) is typically preserved

D.

Tidal volume (TV) decreases by 75%

See Explanation (+/-)


The correct answer is: A: Residual volume (RV) increases by 10%
Abdominal surgery is very injurious to the respiratory system, and if youre asked about this, good chance
youll be asked in relation to lung volumes. The main take away clinically is that abdominal surgery decreases FRC, which decreases lung compliance and increases shunting and hypoxia. The decrease in FRC is due
to a 25% loss in ERV. Interestingly, following abdominal surgery RV increases by a little over 10%. TV decreases moderately (~20%) as does total lung volume, following surgery. These effects are usually worst
12 to 24 hours after surgery* and are back to baseline in 2 weeks.

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*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

Residual volume (RV) increases by 10%

Expiratory reserve volume (ERV) increases by 25%

9% answers

17% answers

Vital capacity (VC) is typically preserved

39% answers

Tidal volume (TV) decreases by 75%

Show Choices for #32: (+/-)


Which of the following is the best anatomic estimate for the level of the carina:
A.

3rd thoracic vertebrae

B.
C.

Sternal angle
Nipple line

D.

One finger breadth below the sternal notch

See Explanation (+/-)


The correct answer is: B: Sternal angle
This is an important reference point.
13% answers

3rd thoracic vertebrae

60% answers

Sternal angle
Nipple line

8% answers

One finger breadth below the sternal notch

19% answers

Show Choices for #33: (+/-)


Which of the following is the best marker for dynamic compliance:
A.
B.

Plateau pressure
Peak pressure

C.

Peak pressure plateau pressure

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Basic Pulmonary Physiology - M5 Board Review

D.

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Transpulmonary pressure

See Explanation (+/-)


The correct answer is: B: Peak pressure
Understanding peak and plateau pressure is important and it is discussed ad nauseam in the advanced cardiopulmonary ICU section. In this section, lets just concentrate on the basics. Plateau pressure is measured
with an inspiratory hold so that there is time for airflow from the ventilator to the alveoli to equilibrate (in
other words the net movement from the higher pressure ETT to the lower pressure alveoli equilibrate and
all airflow stops). This means the pressure you are measuring is the equivalent pressure that the alveoli are
experiencing. Furthermore, this is the pressure that is needed to keep the lungs inflated at the given volume. This is what is called static compliance. It is measured by the following simple equation:

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
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18% answers

54% answers

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20% answers

Peak pressure plateau pressure


Transpulmonary pressure

8% answers

Show Choices for #34: (+/-)


Which of the following will most likely increase peak pressure without an increase in plateau pressure:
A.

Kinked ETT

B.
C.

ARDS
Pleural effusion

D.

Trendelenburg position

See Explanation (+/-)


The correct answer is: A: Kinked ETT
This is about as classic of a simple boards question as it gets. I supplied you with easy choices. There are
some similar questions to this throughout the M5, and the point is not to just retell the same question over
and over, but emphasize this point, which is so high yield, its just shy of guaranteed. Remember that peak
pressure measures airway compliance (pressure) and plateau pressure measures alveolar pressure (respiratory system compliance). With a kinked ETT there will be increased resistance to deliver the air to the
alveoli (peak pressure high) but the actual alveoli themselves will not be affected (plateau normal). With
ARDS, or any type of pulmonary oedema, the alveoli are filled with fluid (as well as a surfactant deficiency,
etc, etc, etc) and it takes much more pressure to open those alveoli, therefore plateau pressure will increase. Now, when plateau pressure increases, peak pressure will also increase, but the difference between
peak and plateau will remain about the same (if peak pressure was 8 cm H20 above plateau without a disease that only affects the alveoli, lets imagine that it will stay the same after the alveoli are affected). In reality ARDS will increase both (plateau more, but lets keep in basic, right!). With a pleural effusion, the lung
will have a decreased space in which to inflate, which means that plateau will be increased but the peakplateau difference will remain the same (in theory, for illustrationagain nothing is actually that simple).
Obesity and trendelenburg will have the same effect.

94% answers

Kinked ETT
ARDS

2% answers

Pleural effusion

1% answers

Trendelenburg position

4% answers

Show Choices for #35: (+/-)


Which of the following will increase the plateau pressure without increasing the peak-plateau difhttps://m5boardreview.com/review-topics/basic-pulmonary-physiology/

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ference:
A.
B.

Negative pressure pulmonary oedema


Pneumothorax

C.

Asthma exacerbation

D.

Foreign body aspiration

See Explanation (+/-)


The correct answer is: A: Negative pressure pulmonary oedema
All pulmonary oedema will increase plateau pressures, and in most cases, the peak-plateau difference will
be less affected. Cardiogenic pulmonary oedema and ARDS are diseases which have many affects and can
lead to swelling of airways, vascular congestion causing obstruction of conducting airways (cardiac asthma), plugging, etc. Negative pressure pulmonary oedema, on the other hand is about as clean as pulmonary oedema gets, as it occurs typically in strong, young people inspiring forcefully against a closed glottis (laryngospasm, etc) with a net movement of water from the pulmonary circulation into the alveoli and
little affect on the conducting airways. Therefore, youd expect an increase in plateau pressure and an unchanged peak to plateau pressure difference. Pneumothorax will increase both peak and plateau, but in
general one would expect the peak to be increased more. Asthma will primarily increase peak pressures (increased airway resistance), but can raise plateau pressures in severe disease through dynamic hyperinflation (se the advanced ICU section). Foreign body aspiration may have localized hyperinflation distal to the
foreign body or lung collapse. Whatever the case, the most noticeable change will be an increased airway
resistance and increased peak pressure.

66% answers

Negative pressure pulmonary oedema


15% answers

Pneumothorax

12% answers

Asthma exacerbation
Foreign body aspiration

7% answers

Show Choices for #36: (+/-)


A morbidly obese patient is anesthetized and mechanically ventilated. The plateau pressure is measured at 35 cm H20 and has an esophageal pressure of 20 cm H20. Which of the following are true:
A.

The patient is at very high risk of barotrauma

B.
C.

The patient has an acceptable transpulmonary pressure


The tidal volume should be reduced

D.

A chest tube should be placed

See Explanation (+/-)


The correct answer is: B: The patient has an acceptable transpulmonary pressure

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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

The patient is at very high risk of barotrauma

64% answers

The patient has an acceptable transpulmonary pressure


15% answers

The tidal volume should be reduced


A chest tube should be placed

SAVE

2% answers

SUBMIT

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