RESP Block

TBL-11-During PFT the FEV1:

A-is difficult to perform
B-is unaffected by dynamic compression of airways
C-is reduced in patients with fibrosis
D-can be used to assess the efficacy of bronchodilator therapy
E-increases with age
*both answers are correct*
2-the FEV1 in a patient with COPD is reduced due to
A-early air way collapse
B-increase in the number of small airways
C-incrseased elastic recoil of the lung
D-hypertrophy of the diaphragm
3-Which PFT parameter is greatly increased in emphysema
A-TLC
B-FEV1
C-FEV1/FVC
4-a medical resident is reviewing the case history of a 45-year-old man
suffering from thoracic outlet syndrome. In a clinical context, which of the
following is the correct definition of the thoracic outlet?
A-Gap between the sternal and costal origins of the diaphragm
B-the upper opening of the thoracic cage
5- Which of the following is the function of serous glands in the mucosa of
upper respiratory tract?

A-filtration
B-humidification

6- Which of the following indices cannot be measured directly by

spirometry?
A- VC
B- FEV1
C- RV
D- TLC
7-The FEV1 and FVC are measured in a patient with pulmonary fibrosis
and we expect
A- FEV1
B- FVC
C- FEV1/FVC

8-cillia in the respiratory epithelium extend up to which of the following

segments?
A-Alveolar Ducts
B-respiratory bronchioles
C-terminal bronchioles
9- The head of the sixth rib articulates with:
A-the inf. articular facet of T5 and sup. Articular facet of T6
B- The inf. articular demi facet of T5 and sup. Articular facet of T6
C-The inf. articular demi facet of T5 and the sup articular demi facet of T6
10- The sternal angle is a land mark for locating level of the:
A-costal margin
B- Jugular notch
C-second costal rib

*medical scenario:
During one of your hospital rotations you observe a resident performing pleural
tap to obtain a sample of pleural fluid. The resident inserts the needle near the
lower border of 8th rib at the right ant. Axillary line and withdraws small
quantity of pleural fluid. The next day, during your rounds, the patient
complains of tingling and numbness of the skin of his chest from the level on 8th
rib down toward the umbilicus of the right side.
Q1: what specific structure was likely to be damaged by the needle?
Intercostal nerve
Q2: list two other structures that may also be damaged?
Intercostal vein and artery
Q3: these structures are running in which muscle layers?
Q4: name the safe place where the resident should insert the needle to avoid
damaging these structures?
*the rule says we should insert the needle superior to the inferior rib* so the
resident has to insert the needle superior to the 9th rib.
Scenario2
Q5-7 are related to this clinical vignette.
A 65-year-old male resident of Riyadh visited the ER of a hospital, complaining
of difficulty in breathing and chest tightness for the past year. He is a heavy
smoker and have chorionic cough, producing several tablespoons of white
sputum each morning. He has no known cardiac disease but he is worried that
he may have pulmonary disease. The physician ordered spirometry tests. Test
results are shown below before and after the administration of an inhaled
bronchodilator
PFT
FVC (L)
FEV1 (L)
FEV1/FVC%
FEF 25%
75% (L/S)

Before Bronchodilator
Actual value
%predicted

After Bronchodilator
Actual value
%Change

4
2.4
60
2

4.2
2.9
68
2.4

103
80
51

5
20
20

Q5: what type of pulmonary disease is present? Restricted or

obstructed? Obstructive

Q6: which two PFT results support your answer? EV/FVC is low 2) both
FEV and FVC are low (FEF Is low)
Q7: what is your diagnosis? Asthma
__________________________________________________

TBL2
1-Which of the following occurs during normal quiet breathing?
A-respiratory gasps
B- Phrenic Motoneurons fire once every minute
C-firing of the phrenic motoneurons is rhythmic
2-early air way collapse during expiration in obstructive disease leads to
air trapping. What would you expect to see in that patient?
A-increased PaO2
B-increased PACO2
C- Increased FEV1
3-in spinal cord and central nervous system injuries
A-injury is below C5 level, quiet breathing is not affected
B- Injury is above C3 level, quiet breathing is not affected
C- Injury is above C2 level, quiet breathing is not affected
4-which of the conditions would produce the greatest stimulation of the
chemosensitive area in the medulla
A- Increase in arterial PO2
B- Increase in arterial H+
C- Increase in arterial PCO2

5-which of embryonic structure get rise to the epithelium of

respiratory system?
A- Ectoderm
B- Endoderm
C- Mesoderm

6-a 49-year-old woman has a neoplasm is the hilum of the left

lung, anterior to the primary bronchus. Which of the following
structures in the surrounding area is most likely to be compressed
if the neoplasm were to continue to grow in the anterior direction
A-azygos vein
B-esophagus
C-phrenic nerve
7-which cell type covers most of alveolar surface area
A-alveolar type II
B-columnar
C-squamous
8-47 year-old man is diagnosed with bronchogenic carcinoma of
upper lobe of the left lung. X-ray shows paralysis of the diaphragm
on the ipslateral side.damage to which of the following structures
is most likely the cause of this paralysis.
A-phrenic nerve
B-anterior cervical ganglion
C-recurrent laryngeal nerve
9- A 60 year-old man has had pain in the lateral side of his
stomach for the 2 past months. Which of the following nerves most
likely carries the pain sensation from affected side?
A-vagus
B-phrenic
C-intercostal

10-identfy the structure

A-alveolus
B-bronchus
D-trachea

Medical scenario
A 67-year-old developed a worsening cough over several months and when the
septum began to show streaks of blood, he consulted a physician, the patient gave a
history of smoking cigarettes for 40 years and recently had noticed that his voice
had become hoarse. An x-ray of the chest revealed an irregularly shaped density in
the hilar region of the left lung.
Q1-how might the hoarseness relate to the location of the density?
Affected the recurrent laryngeal nerve causing hoarseness.
Q2-list 2 structures situated in the vicinity of hailer region of the lung?
Pulmonary A. pulmonary V.
Q3-what is the nerve supply of mediastinal pleura against which the density lies?
Phrenic N.
Q4- if density obstructed the left upper lobe bronchus, what would the affect be the
lung would collapse

*Scenario2
During a road traffic accident (RTA) a 25-year-old driver hit his head against a
wind screen. On arrival at the ER department of nearby hospital his pulse was 60
bpm and respiratory rate was 8 breaths per minute. His breathing was deep and his
blood labored. He also had brain edema.
His blood gases revealed:

PaCO2= 50mm Hg (normal 35-45)

PaO2= 70 mm Hg (normal 80-100)
Q5: what is the cause of his respiratory depression? The brain edema applied
pressure and caused the respiratory center to be inhibited
Q6: what would the response be on the two types of chemoreceptors? The central
chemoreceptors would sense the high blood co2 and high H+ in the CSF,
the peripheral chemoreceptors will sense the decrease in O2 and both will
cause increase in respiration
Q7: based on your physiological knowledge of regulation of respiration list two
interventions needed in this patient?
Diuretics (to decrease edema) and mechanical ventilator

______________________________________________________

TBL3
1-hypoxic vasoconstriction in the lung will result as a consequence of which of the
following physiological changes below?
A- Increased PAO2
B- Decreased PACO2
C- Increased PH
D- Decreased PAO2
2-which condition below will lead to a rise in pulmonary wedge pressure (PCWP)
A- A rise in right atrial pressure
B- A rise in left atrial pressure
C- A drop in pulmonary capillary pressure
D- A drop in left atria pressure
3-which of the following changes below will enhance the diffusion of a gas
exchange into the blood
A-decreased solubility (S) of the gas
B-increased diffusion distance
C-increased pressure differential

D-increased the molecular weight

4-which relationship between alveolar pressure (PAV) and pulmonary capillary
pressure (PCP) below is representative for zone2 in the upright lung during the
diastolic phase of the cardiac cycle?
A- PALV=PCP
B- PALV< PCP
C- PALV>PCP
D- PCP>PALV
5-in obstruction of the superior or inferior vena cava, venous blood is returned to
heart by an alternate route via the azygous vein, which becomes dilated in the
process. Which of the following structures might be compressed as a result
A- Trachea
B- Root of left lungs
C- Thoracic duct
6-70 year old male with pneumonia complains of difficulty in breathing. Physical
examination indicates decreased lung expansion and breath sounds over the right
side of the chest. The physician suspects the presence of pleural effusion. Which of
the following locations is the initial site for pleural effusion?
a. Costomediastinal recess
b. Suprapleural membrane
c. Pulmonary ligament
d. Pericardiophrenic recess
e. Costodiaphragmatic recess
7-Aortic opening in diaphragm which one of the following structures
A- Arch of aorta
B- Right phrenic nerve
C- Azygous vein

8-the third anterior intercostal vein drains into

A-azygous vein
B-hemiazygous vein
C-musculophrenic vein

D-internal thoracic vein

9-which of the following conditions below will lead to pulmonary edema?
A-decreased fluid filtration from the pulmonary capillaries
B-Enhanced or increased lymphatic drainage
C-interstitial pressure becomes slightly more negative.
D-left-sided heart failure
10-left bronchial arteries are branches:
A-left 3rd post. Intercostal
B-left 5th post, intercostal
C-descending thoracic aorta
*Clinical Scenario
A 6 year old boy was found to have high blood pressure during a physical
examination at school. He
Was referred to a GP, who verified the high blood pressure and noted that femoral
pulses were weak
In comparison to radial and carotid pulses. His feet were cold and he had to wear
warm socks in summer. A chest radiograph was showing irregular notches along
the lower borders of several ribs
On both sides of the chest except the first two ribs.
Q6: what is the reason of high blood pressure?
Coarctation of the aorta
Q7: Which vessels caused the notching along the ribs?
The intercostal arteries
Q8: Why was notching absent at first two ribs?
Because they are supplied posteriorly by the costocervical trunk
Q9: In which direction was the blood flowing?
Anterior to posterior
Q10: What will be the auscultation findings in this case?
Additional sounds on surface of chest bruit

Scenario 2

A 57 year old man who has smoked two packed of cigarettes daily for the past 30
years present to the ER with a substernal pressure radiating down his left arm and
feeling of indigestion. The pain lasted 30 min and was accompanied by shortness
of breath. He has an intermittent cough that occasionally is productive of teaspoon
of septum in the morning.
In the emergency room the patient appears to be in moderate respiratory distress
and is complaining of chest tightness. His blood pressure is 140/90 mm Hg. His
pulse is 110 bpm, and his respiration are 30 breaths per min. the patient is
dyspneic. Examination of the chest reveals rales at both bases. His blood gases
while breathing room air reveal:
PaCO2= 32 mm Hg (normal 35-45)
PaO2= 60mm Hg (normal 80-100)
PH=7.47
His white blood cell count is 15,600 per mm (4300- 10,800)
Hb 14.3 (normal 13.5- 17.5)
The patient is admitted to the intensive care unit and the following pressure is
measured:
Pulmonary artery occlusion pressure (PAOP) or pulmonary capillary wedge
pressure (PCWP): 28 mm Hg (8-12 mm Hg)
Q1: list three possible causes of dyspnea in this patient?
1) Accumulation of mucus and fluid 2) smoking history 3) low oxygen
Q2: what does the present of rales tell you?
It indicates the presence of fluid in the cavity
Q3: list two causes of hypoxemia?
1) A low V/Q
2) The mucus/fluid barrier preventing o2 diffusion

Q4: what is his pack-year smoking history?

(Multiply the number of packs per day by number of years) 230 = 60

Q5: based on the above observations, what is your diagnosis and what treatment
can you think of?
Chronic bronchitis and left heart failure (so this is cardiogenic)
Treatment: diuretics to release fluids, oral steroids and oxygen.

Good Luck =)
Done by:
Asmaa Dalhi