The Respiratory System at a Glance, 3rd Edition



The Respiratory System at a Glance





The Respiratory System at a Glance Jeremy P.T. Ward 3K' +HDG RI 'HSDUWPHQW RI 3K\VLRORJ\ DQG 3URIHVVRU RI 5HVSLUDWRU\ &HOO 3K\VLRORJ\ 'LYLVLRQ RI $VWKPD $OOHUJ\ DQG /XQJ %LRORJ\ .LQJ¶V &ROOHJH /RQGRQ /RQGRQ 8.

Jane Ward 0%&K% 3K' 6HQLRU /HFWXUHU 'HSDUWPHQW RI 3K\VLRORJ\ .LQJ¶V &ROOHJH /RQGRQ /RQGRQ 8.

Richard M. Leach 0' )5&3 &RQVXOWDQW 3K\VLFLDQ DQG +RQRUDU\ 6HQLRU /HFWXUHU *X\¶V DQG 6W 7KRPDV¶ +RVSLWDO 7UXVW DQG .LQJ¶V &ROOHJH /RQGRQ 6FKRRO RI 0HGLFLQH 6W 7KRPDV¶ +RVSLWDO /RQGRQ 8.

With contributions from

Charles M. Wiener 0' 3URIHVVRU RI 0HGLFLQH DQG 3K\VLRORJ\ 'HSDUWPHQW RI 0HGLFLQH -RKQV +RSNLQV 6FKRRO RI 0HGLFLQH %DOWLPRUH 0' 86$

Third edition

A John Wiley & Sons, Ltd., Publication



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Contents

5

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Preface to third edition

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R1 Water molecule Surfactant molecule ∴ When tap is opened the small bubble empties into the large

R2 < R1 but T2 < T1 because surface concentration of surfactant is higher when the alveolus is small The fall in R is more than offset by the fall in T, ∴ since P = 2T , P does not rise, but falls as the alveolus shrinks R

The Respiratory System at a Glance, 3e. By J.P.T. Ward, J. Ward, R.M. Leach. Published 2010 Blackwell Publishing Ltd.

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Lung mechanics: elastic forces

Structure and function

21

r

7

Lung mechanics: airway resistance (c) The effect of effort on inspiratory and expiratory airflow Effort dependent 6 A 600 Effort 5 independent

(a) Laminar and turbulent flow

4

Laminar flow

3

Airway smooth muscle

β-Adrenergic agonists (e.g. adrenaline and saltbutamol)

NANC nerves (inhibitory)

CO2

β2-Receptor

NO and VIP

Bronchodilation

(b) Main factors influencing bronchomotor tone

Expiration

Turbulent flow

0

1

1 2 3 4 5 6

300

TLC 600

Synapse

NANC nerves (excitatory)

Pulmonary stretch receptors (inhibit)

Airway irritant receptors (activate)

600

NO = Nitric oxide VIP = Vasoactive intestinal peptide SP = Substance P

ACh = Acetylcholine M3 = Muscarinic type 3 receptor

(d) Dynamic compression of airways

Expiration

Mast cells, eosinophil (Chapter 23)

= Nerve ending

(e) Maximum flow–volume loops

300

Vagal afferents = Receptor

RV

0

Inspiration

Brainstem (Chapter 12)

Histamine, Prostagladins Leukotrienes etc

Volume (L)

= Flow–volume curve for maximum effort from partly filled lungs A = Peak expiratory flow rate with lungs filled to total lung capacity B = Peak expiratory flow rate for partly filled lungs filled (RV + 3 L) TLC = Total lung capacity, RV = Residual volume

Airflow (L/min)

Vagal efferents

SP and neurokinins

Bronchoconstriction

ACh via M3 receptors

B 2

Inspiration

Airflow (L/min)

300

300

Intrathoracic airway Beginning of inspiration

Alveolus

6

0

0

0

Intrapleural space

During forced expiration

8.7

8 6

–0.5

4

0

+8.0 Numbers are pressures in kPa (1 kPa = 7.5 mmHg)

22

600

4 2 Lung volume (L)

0

Normal curve Obstructive airway disease of smaller airways. Note: • concave appearance of forced expiratory curve • forced inspiratory flow affected less than forced expiratory flow Upper airway obstruction (e.g. tracheal stenosis). Note: • flat topped flow–volume curve • forced inspiratory flow affected as much as expiratory flow Restrictive lung disease. Low peak flow rates are related to low volume. (Note: this figure is drawn to show the relationship between these traces by using absolute lung volume which cannot actually be obtained from a flow–volume loop alone).

The Respiratory System at a Glance, 3e. By J.P.T. Ward, J. Ward, R.M. Leach. Published 2010 Blackwell Publishing Ltd.

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Lung mechanics: airway resistance

Structure and function

23

r

8

Carriage of oxygen

(a) Haemoglobin structure β

O2

O2

Haemoglobin is composed of four subunits, each containing a protein chain (globin) and a haem group. Normal adult haemoglobin, HbA, contains two identical α-chains composed of 141 amino acids and two β-chains composed of 146 amino acids. The haem group ( ) is attached to each chain at a histidine residue, and each has an iron atom in the ferrous form, which binds to an oxygen molecule. The haem groups lie in crevices in the crumpled ball of globin chains. The exact 3D (or quaternary) structure of haemoglobin can change and alter the accessibility of the oxygen-binding site. Each molecule of haemoglobin can bind up to four molecules of oxygen in a series of reactions which can be summarized as: Hb4 + 4O2 Hb4(O2)4

α O2

O2

75

150

50

25

a

pH, PCO2, temperature 2,3-DPG

200

Oxygen content (mL/L)

Oxygen saturation (%)

(b) The oxygen–haemoglobin 100 dissociation curve, haemoglobin concentration (150 g/L)

pH, PCO2, temperature 2,3-DPG

v

a = Normal arterial blood PO2 = 13.3 kPa (100 mmHg) O2 content = 200 mL/L O2 saturation = 97%

100

v = Resting mixed venous PO2 = 5.3 kPa (40 mmHg) O2 content = 150 mL/L O2 saturation = 75%

50 Dissolved oxygen

0

0

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 kPa PO2 0

(c) Anaemia and carbon monoxide poisoning

50

100

150 mmHg Note: For simplicity the Bohr shift is ignored

200

Oxygen content (mL/L)

Tissues remove 50 m L/L 150

100 Tissues remove 50 m L/L 50

0

0 0

24

Hb = 150 g/L Hb = 75 g/L Hb = 150 g/L COHb = 50%

C 2 20

B 4

A 6 40

8 PO2 60

10 80

12

14 100

16 kPa 120 mmHg

The Respiratory System at a Glance, 3e. By J.P.T. Ward, J. Ward, R.M. Leach. Published 2010 Blackwell Publishing Ltd.

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29

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Control of breathing I: chemical mechanisms

Effect of CO2 , pH and O2 on ventilation: Normal pH

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50

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10

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30

Groups of cells surrounded by fenestrated sinusoidal capillaries

(g)

Common carotid artery

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Carotid body (not part of sinus)

The Respiratory System at a Glance, 3e. By J.P.T. Ward, J. Ward, R.M. Leach. Published 2010 Blackwell Publishing Ltd.

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Control of breathing I: chemical mechanisms

Structure and function

31

r

12

Control of breathing II: neural mechanisms

Cortex

(g) Voluntary control of breathing via pyramidal tracts

Hypothalamus Emotion Temperature

Pons

Cut here No effect on breathing but loss of higher control

(a) Pneumotaxic centre Nucleus parabrachialis Kölliker-Fuse nucleus

Cut here Gasping (b) Dorsal respiratory group Nucleus tractus solitarius

Medulla

(f) Input from central and peripheral chemoreeceptors

(c) Ventral respiratory group Bötzinger complex Nucleus ambiguus and retro ambiguus

Cut here Abolition of breathing – apnoea

Respiratory muscles

Damage, inhaled irritants

(d) Descending respiratory motor neurones to diaphragm, intercostals and ancilliary respiratory muscles

Lung volume and muscle load

Spinal cord

(e) Lung receptors Stretch Proprioceptors Irritant Juxtapulmonary

32

The Respiratory System at a Glance, 3e. By J.P.T. Ward, J. Ward, R.M. Leach. Published 2010 Blackwell Publishing Ltd.

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Control of breathing II: neural mechanisms

Structure and function

33

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Pulmonary circulation and anatomical right-to-left shunts

(b) The initial effects of a 20% right-to-left shunt on arterial O2 and C02 contents and partial pressures

(a) Pulmonary and systemic circulation and normal anatomical right-to-left shunts

Bronchial artery Pulmonary capillary pressure: Arterial end Venous end 14 mmHg 8 mmHg

O2 content = 200mL/L CO2 content = 480mL/L

80%

Alveoli *O2 content = 150 mL/L *CO2 content = 520 mL/L

Pulmonary artery pressure: 24/9, mean 15 mmHg LA

RA

Arterial O2 content = Arterial CO2 content =

Aorta RV

80 20 x 200 + x 15 = 190mL/L 100 100 80 20 x 480 + x 520 = 488m L/L 100 100

LV VCM

Systemic capillary pressure: Venous end Arterial end 10 mmHg 30 mmHg

Aortic pressure: 120/70, mean 90 mmHg

*Note: The mixed venous contents used are normal values. In fact, the abnormal arterial contents would lead to abnormal mixed venous contents so this simple analysis underestimates the effects on arterial contents.

The PO2 and PCO2 that result from these O2 and CO2 contents can be found from the O2 and CO2 dissociation curves:

Tissue 700

O2 and CO2 dissociation curves

VCM = venae cordis minimae (thebesian veins)

Normal O2 and CO2 pressures and contents O2 and CO2 pressures and contents following mixing 20% mixed venous blood with 80% blood undergoing normal gas exchange

O2 and CO2 content (mL/L)

600 CO2 500 400 300 O2

200 100 0 –1

34

1

3

5

7 9 PO2/PCO2 (kPa)

The Respiratory System at a Glance, 3e. By J.P.T. Ward, J. Ward, R.M. Leach. Published 2010 Blackwell Publishing Ltd.

11

13

15

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Pulmonary circulation and anatomical right-to-left shunts

Structure and function

35

r

14

Ventilation–perfusion mismatching

(a) Different types of VA/Q r egions

Q = Normal VA/Q = Normal (close to 1)

Dead space

Dead-space effect

Shunt effect

True/anatomical shunt

VA = Normal

VA = Low

VA = 0

VA = Normal Q=0

Q = Low

VA/Q = ∞

VA/Q = High

Q = Normal

Q = Normal

VA/Q = Low

VA/Q = 0

Ventilation, VA , perfusion, Q (arbitrary units per unit lung volume) and ventilation–perfusion ratio, VA/Q

Normal VA = Normal

(b) Variation of ventilation, VA , perfusion, Q and ventilation–perfusion ratio, VA/Q with vertical height in the upright lung 3

Q

2

VA

1 VA/Q 0

Base

Apex

PO2 and O2 contents of blood from these regions breathing air and oxygen 02 content (mL/L) 200

200 0

0

0

10 20 PO2 kPa

02 content (mL/L) 02 content (mL/L) 02 content (mL/L) 200 200

0

10 20 PO2 kPa

O2 content of blood draining the region breathing air ( Normal Unchanged

No blood draining this region

0

0

10 20 PO2 kPa

VA = 4 Q=1

VA = 5 VA/Q = 0.3 Q = 15

36

0

10 20 PO2 kPa

) and breathing O2-enriched air (

Normal Unchanged

Low Increased

(c) The effect of a mixture of high and low VA/Q regions on arterial blood gases

VA/Q = 4

0

):

Low Unchanged

Alveoli at start and end of breath

Blood vessels at different heights

(d) Alveolar air equation This predicts the PO2 in the functioning or ‘ideal’ alveoli

Small flow with: High PO2 Normal O2 content Low PCO2 Low CO2 content

Peripheral and central chemoreceptors PA O2 =~ PΙO2 – PaCO2 R

Combined to give: Low O2 content High CO2 content Low PO2 Slightly high PCO2

Ventilation R = The respiratory gas exchange ratio = CO2 production O2 consumption

Large flow with: Low PO2 Low O2 content High PCO2 High CO2 content

Final picture: Low O2 content Normal or low CO2 content Low PO2 Normal or low PCO2

(R is usually about 0.8)

PΙO2 = Inspired O2 partial pressure PaCO2 = Arterial CO2 partial pressure (≈ alveolar)

The Respiratory System at a Glance, 3e. By J.P.T. Ward, J. Ward, R.M. Leach. Published 2010 Blackwell Publishing Ltd.

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Case studies: answers

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Chapter 21: Chest imaging and bronchoscopy 21.1 A routine screening chest X-ray (CXR) D DOZD\V LQFOXGHV D ODWHUDO &;5 E LV SHUIRUPHG DW IXOO H[SLUDWLRQ F DOORZV YLVXDOL]DWLRQ RI WKH PHGLDVWLQXP G ZLWK DQWHULRU±SRVWHULRU $3 ILOP DOORZ D GHWDLOHG YLHZ RI OXQJ SDUHQFK\PD 21.2 Which of the following is NOT normally an indication for computed tomography? D SOHXUDO GLVHDVH E SXOPRQDU\ YDVFXOLWLV F SXOPRQDU\ HPEROL G SDUHQFK\PDO GLVHDVH 21.3 What is the gold standard for diagnosing pulmonary emboli? D YHQWLODWLRQ±SHUIXVLRQ VFDQV E +LJKUHVROXWLRQ FRPSXWHG WRPRJUDSK\ F SRVLWURQ HPLVVLRQ WRPRJUDSK\ G SXOPRQDU\ DQJLRJUDSK\ 112

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Chapter 22: Public health and smoking 22.1 Respiratory disease D DFFRXQWV IRU  RI DOO GHDWKV LQ WKH 8. E DFFRXQWV IRU  RI HPHUJHQF\ KRVSLWDO DGPLVVLRQV F GXH WR HPSK\VHPD FDXVHV UHGXFHG H[HUFLVH WROHUDQFH LQ  PLOOLRQ SHRSOH LQ WKH 86$ G DFFRXQWV IRU ∼  KRVSLWDO DGPLVVLRQV SHU \HDU LQ WKH 8. 22.2 Smoking-related disease D DFFRXQWV IRU ∼ RI DOO GHDWKV LQ WKH 8. E LV WKH VHFRQG JUHDWHVW FDXVH RI SUHYHQWDEOH LOOQHVV DQG PRU WDOLW\ ZRUOGZLGH F LV ODUJHO\ UHVWULFWHG WR UHVSLUDWRU\ SUREOHPV G LV GHFUHDVLQJ ZRUOGZLGH 22.3 Progressive decline in lung function (FEV1 ) D FHDVHV RQ VWRSSLQJ VPRNLQJ E GRHV QRW RFFXU LQ KHDOWK\ QRQVPRNHUV F FDXVHV GLVDELOLW\ ZKHQ WKH )(9 IDOOV WR DERXW  RI WKDW DW  \HDUV ROG G LV VWURQJO\ DFFHOHUDWHG LQ DOO VPRNHUV 22.4 Smoking cessation D UHGXFHV WKH ULVN RI OXQJ FDQFHU WR WKDW LQ QRQVPRNHUV E FDXVHV DQ LQFUHDVH LQ EUDLQ GRSDPLQH F UDWHV DUH LPSURYHG PRVW E\ WUHDWPHQW ZLWK EXSURSLRQ G UDWHV DUH LPSURYHG E\ GHFUHDVLQJ WKH UHZDUG HIIHFWV ZLWK SDU WLDO DJRQLVWV RI QLFRWLQLF DFHW\OFKROLQH UHFHSWRUV

Chapter 23: Respiratory failure 23.1 Hypercapnia is in inevitable when the cause of hypoxia is D YHQWLODWLRQ±SHUIXVLRQ PLVPDWFKLQJ E GLIIXVLRQ LPSDLUPHQW F K\SRYHQWLODWLRQ G ORZ LQVSLUHG P2 23.2 Respiratory failure D LV SUHVHQW DQG NQRZQ DV µW\SH ¶ LQ D SDWLHQW ZLWK DQ DUWHULDO P2 RI  N3D  PP+J DQG D Pco RI  N3D  PP+J E LV SUHVHQW LQ D SDWLHQW GLVDEOHG E\ EUHDWKOHVVQHVV DW UHVW ZLWK DQ DUWHULDO P2 RI  N3D F LV FODVVHG DV W\SH  LI PD co LV KLJK EXW P2 LV QRUPDO G QHDUO\ DOZD\V UHTXLUHV VRPH NLQG RI PHFKDQLFDO YHQWLODWRU\ VXSSRUW 23.3 Typical symptoms and signs caused by a high Pa co2 include D FROG SDOH VNLQ E ZHDN SXOVH F KHDGDFKH ZKLFK LV RIWHQ ZRUVH IROORZLQJ VOHHS G FHQWUDO F\DQRVLV 23.4 Chronic arterial hypoxia combined with chronic arterial hypercapnia D LV RIWHQ DVVRFLDWHG ZLWK DQDHPLD E FRXOG H[SODLQ DQ DUWHULDO S+ RI  EHFDXVH RI WKH KLJK DUWHULDO Pco

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Chapter 24: Asthma: pathophysiology 24.1 Which of the following is NOT a characteristic of asthma? D LQFUHDVH LQ ,J* LPPXQRJOREXOLQV E DLUZD\ K\SHUUHVSRQVLYHQHVV F LQILOWUDWLR RI HRVLQRSKLOV LQWR WKH DLUZD\V G LQFUHDVHG PXFXV SURGXFWLRQ 24.2 The most common allergens associated with asthma in the UK are (in order of importance) D SROOHQV KRXVH GXVW PLWH IXQJDO VSRUHV E KRXVH GXVW PLWH SROOHQV DQLPDO GDQGHU F KRXVH GXVW PLWH SROOHQV IXQJDO VSRUHV G KRXVH GXVW PLWH DQLPDO GDQGHU SROOHQV 24.3 The immediate response of asthma involves D PDVW FHOO GHJUDQXODWLRQ E ELQGLQJ RI DQWLJHQ WR ,J( RQ PDFURSKDJHV F UHOHDVH RI F\WRNLQHV VXFK DV ,/ G DFWLYDWLRQ RI FKROLQHUJLF QHUYHV 24.4 Chronic asthma is associated with: D DFWLYDWLRQ RI HRVLQRSKLOV E DFWLYDWLRQ RI 7+ O\PSKRF\WHV F UHGXFHG IXQFWLRQ RI JREOHW FHOOV G GHFUHDVHG SHUPHDELOLW\ RI VXEPXFRVDO FDSLOODULHV

Chapter 25: Asthma: treatment 25.1 Which test is NOT used during diagnosis or monitoring of asthma? D GLIIXVLQJ FDSDFLW\ E SHDN H[SLUDWRU\ IO Z UDWH F EURQFKLDO FKDOOHQJH WHVW G VNLQ SULFN WHVW 25.2 Which drug is the most commonly prescribed preventer therapy in asthma? D β DGUHQRUHFHSWRU DJRQLVWV E [DQWKLQHV VXFK DV WKHRSK\OOLQH F PXVFDULQLF UHFHSWRU DQWDJRQLVWV G LQKDOHG VWHURLGV 25.3 Long-acting β2 -adrenoreptor agonists D ZRUN E\ LQFUHDVLQJ F*03 LQ DLUZD\ VPRRWK PXVFOH E PD\ EHFRPH OHVV HIILFDFLRX GXH WR WROHUDQFH DIWHU ORQJWHUP XVH F FDQ EH XVHG DV WKH VROH WKHUDS\ LQ DVWKPD G DUH WKH I UVW FKRLFH IRU D UHOLHYHU WKHUDS\ 25.4 Which of the following is NOT a common adverse effect of low-dose inhaled steroids? D FRXJK E ZHLJKW JDLQ F RUDO FDQGLGLDVLV G KRDUVHQHVV

Chapter 26: Chronic obstructive pulmonary disease 26.1 Which of the following is NOT normally associated with chronic bronchitis? D LQFUHDVHG WRWDO OXQJ FDSDFLW\ E &R UHWHQWLRQ

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Chapter 27: Pulmonary hypertension 27.1 Pulmonary hypertension is defined as D D PHDQ SXOPRQDU\ DUWHU\ SUHVVXUH 3$3 > PP+J GXULQJ H[HUFLVH E D PHDQ 3$3 ∼ PP+J DW UHVW WKDW LQFUHDVHV WR > PP+J GXULQJ H[HUFLVH F D PHDQ 3$3 > PP+J DW UHVW RU > PP+J GXULQJ H[HUFLVH G D PHDQ 3$3 >  PP+J DW UHVW RU >  PP+J GXULQJ H[HUFLVH 27.2 The most common cause of pulmonary hypertension is D K\SR[DHPLD VHFRQGDU\ WR UHVSLUDWRU\ GLVHDVHV E OHIW KHDUW IDLOXUH F SXOPRQDU\ HPEROLVP G JHQHWLF GHIHFWV 27.3 Idiopathic pulmonary arterial hypertension D FRPPRQO\ FDXVHV SXOPRQDU\ RHGHPD E LV PRVW SUHYDOHQW LQ ZRPHQ DJHG  \HDUV RU PRUH F KDV D PHDQ VXUYLYDO ZLWKRXW WUHDWPHQW RI  \HDUV G RFFXUV LQ  SHU   SRSXODWLRQ 27.4 Which of the following drugs is NOT used for treatment of pulmonary hypertension? D VLOGHQDIL W\SH  SKRVSKRGLHVWHUDVH LQKLELWRU E ERVHQWDQ HQGRWKHOLQ UHFHSWRU DQWDJRQLVW F SURVWDF\FOLQ DQDORJXHV LQFUHDVHV F$03 G IHQIOXUDPLQ PRGXODWHV VHURWRQLQ XSWDNH DQG UHOHDVH

Chapter 28: Venous thromboembolism and pulmonary embolism 28.1 Deep vein thrombosis D SURSDJDWLQJ LQWR WKH IHPRUDO DQG LOLDF YHLQV KDV D  FKDQFH RI FDXVLQJ SXOPRQDU\ HPEROLVP E RFFXUV LQ  RI SDWLHQWV XQGHUJRLQJ KLS RU NQHH UHSODFHPHQW VXUJHU\ LQ WKH DEVHQFH RI SURSK\ODFWLF WKHUDS\ Self-assessment questions

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Chapter 29: Pulmonary vasculitis 29.1 Pulmonary vasculitis D UDUHO\ LQYROYHV RWKHU YDVFXODU EHGV E LV SULPDULO\ DVVRFLDWHG ZLWK LQIODPPDWLR DQG QHFURVLV RI WKH EORRG YHVVHOV F LV WKH PRVW FRPPRQ PDQLIHVWDWLRQ RI UKHXPDWRLG DUWKULWLV LQ WKH OXQJ G LV PRVWO\ FDXVHG E\ LQIHFWLRQ 29.2 Which of the following is NOT a primary vasculitides? D &KXUJ±6WUDXVV V\QGURPH E :HJHQHU¶V JUDQXORPDWRVLV F *RRGSDVWXUH¶V V\QGURPH G V\VWHPLF OXSXV HU\WKHPDWRVXV 29.3 Which of the following is NOT normally associated with vasculitides? D ,QFUHDVHG DQWLQHXWURSKLO F\WRSODVPLF DQWLERGLHV $1&$ E FDSLOODU\ UXSWXUH DQG DOYHRODU KDHPRUUKDJH F K\SR[DHPLD G LQILOWUDWLR RI HRVLQRSKLOV 29.4 What is the most common therapy for pulmonary vasculitis? D LQKDOHG ORZGRVH FRUWLFRVWHURLGV E FKHPRWKHUDS\ F RUDO FRUWLFRVWHURLGV G SODVPDSKHUHVLV

Chapters 30 and 31: Diffuse parenchymal (interstitial) lung diseases/Sarcoidosis 30.1 The most common form of DPLD is D RFFXSDWLRQDO OXQJ GLVHDVH E VDUFRLGRVLV F LGLRSDWKLF LQWHUVWLWLDO SQHXPRQLWLV G GUXJ LQGXFHG 30.2 DPLD is commonly associated with D LQFUHDVHG OXQJ FRPSOLDQFH E DQ REVWUXFWLYH GHIHFW F GHFUHDVHG D/ co G LQFUHDVHG UHVLGXDO YROXPH 30.3 The most frequent form of non-usual interstitial pneumonitis is D QRQVSHFLIL LQWHUVWLWLDO SQHXPRQLWLV 16,3 E FU\SWRJHQLF RUJDQL]LQJ SQHXPRQLD &23 114

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Chapter 32: Pleural diseases 32.1 Pleurisy D LV D FRPPRQ WHUP XVHG IRU DOO GLVHDVHV RI WKH SOHXUD E LV GXH WR LQIODPPDWLR RI WKH SOHXUD F LV PDGH ZRUVH E\ GHHS LQVSLUDWLRQ G LV QRW SUHVHQW LQ SQHXPRWKRUD[ 32.2 The fluid between the parietal and visceral pleurae D LV QRUPDOO\ SURWHLQULFK E LV SULPDULO\ GUDLQHG E\ WKH YLVFHUDO O\PSKDWLFV F LV IRUPHG E\ QHW ILOWUDWLR RI D WUDQVXGDWLYH IOXL G KDV D YROXPH RI > P/ 32.3 Exudative pleural effusions D DUH SURWHLQSRRU E DUH DOZD\V DVVRFLDWHG ZLWK LQIHFWLRQ F DUH PRVWO\ FRPPRQO\ FDXVHG E\ FRQJHVWLYH KHDUW IDLOXUH G RIWHQ KDYH UDLVHG ODFWDWH GHK\GURJHQDVH 32.4 Mesothelioma D KDV D PHGLDQ VXUYLYDO RI > \HDUV E PRVW FRPPRQO\ RFFXUV ± \HDUV DIWHU DVEHVWRV H[SRVXUH F LV LQYDULDEO\ IDWDO G FDQ EH WUHDWHG ZLWK VWHURLGV

Chapter 33: Occupational and environmental-related lung disease 33.1 The most common form of occupational and environmental lung disease D LV GXH WR DWPRVSKHULF SROOXWLRQ DQG VHFRQGDU\ VPRNLQJ E FDXVHV OXQJ ILEURVL F LV WULJJHUHG DV D UHVXOW RI ZRUNSODFH VXEVWDQFHV LQ   SHRSOH LQ WKH 8. SHU \HDU G LV DVWKPD 33.2 Which of the following statements about inhaled irritants is UNTRUE? D +LJKO\ VROXEOH DJHQWV HJ DPPRQLD IDYRXU GDPDJH WR WKH DOYHRODU HSLWKHOLXP E ([WHQVLYH H[SRVXUH FDQ OHDG WR EURQFKLROLWLV REOLWHUDQV DIWHU ± ZHHNV F $FWLYDWLRQ RI LUULWDQW UHFHSWRUV OHDGV WR G\VSQRHD G 'LHVHO SDUWLFXODWHV LQFUHDVH PRUWDOLW\ SDUWLFXODUO\ LQ WKH HO GHUO\ 33.3 Pneumoconiosis D LV FDXVHG E\ LQKDODWLRQ RI RUJDQLF PDWHULDOV E FDQ LQ VRPH FDVHV GHYHORS LQWR SURJUHVVLYH PDVVLYH ILEURVL F WHQGV WR UHVXOW LQ UHYHUVLEOH DLUZD\V REVWUXFWLRQ G GRHV QRW LQFOXGH DVEHVWRVLV 33.4 Which of the following statements about Farmer’s lung is UNTRUE? D ,W LV WKH PRVW FRPPRQ H[DPSOH RI H[WULQVLF DOOHUJLF DOYHROLWLV E ,W LV GXH WR FRQWDPLQDWLRQ ZLWK WKHUPRSKLOLF DFWLQRP\FHWHV EDFWHULD

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Chapter 34: Cystic fibrosis and bronchiectasis 34.1 Cystic fibrosis is D DQ DXWRVRPDO GRPLQDQW WUDLW E GXH WR WKH ) PXWDWLRQ LQ PLQ E DJH > \HDUV F PHDQ EORRG SUHVVXUH > PP+J G XUHD > PPRO/

Chapter 38: Pulmonary tuberculosis 38.1 Which statement is INCORRECT concerning TB? D ,QIHFWLRQ ZLWK 7% LV YLD LQKDODWLRQ E 6XVFHSWLELOLW\ WR 7% LV JUHDWHU LQ WKH HOGHUO\ F ,QIHFWLRQ UHVXOWV LQ IRUPDWLRQ RI D JUDQXORPD G 7KH *KRQ IRFXV LV NQRZQ DV WKH SULPDU\ FRPSOH[ 38.2 Investigations of TB D WKH 0DQWRX[ WHVW LV RIWHQ QHJDWLYH LQ 0LOLDU\ 7% E WKH +HDI WHVW LV WKH PRVW FRPPRQO\ XVHG WHVW F 0LOLDU\ 7% LV HDVLO\ GHWHFWHG E\ XSSHU OREH VKDGRZLQJ LQ &;5 G Mycobacterium tuberculosis EDFLOOL DUH DFLGIDVW DQG JURZ UDSLGO\ 38.3 Which of the following is NOT a common feature of TB? D HU\WKHPD QRGRVXP E SOHXUDO HIIXVLRQV F SXOPRQDU\ RHGHPD G EURQFKLHFWDVLV 38.4 Treatment of TB D FRUWLFRVWHURLGV DUH SUHVFULEHG WR DOO SDWLHQWV E DQ LPSRUWDQW IDFWRU LV SDWLHQW FRPSOLDQFH ZLWK WKHUDS\ F GUXJ WUHDWPHQW LV PDLQWDLQHG IRU  PRQWKV LQ XQFRPSOLFDWHG FDVHV G 3\ULGR[LQH LV JLYHQ ZLWK LVRQLD]LG WR OLPLW OLYHU G\VIXQFWLRQ

Chapter 39: The immunocompromised host 39.1 Which of the following is NOT normally associated with immunosuppression? D GLDEHWHV E WUHDWPHQW ZLWK VWHURLGV F VPRNLQJ G PDOQXWULWLRQ Self-assessment questions

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39.2 Which of the following is NOT a consequence of chemotherapy? D QHXWURSDHQLD E LPSDLUHG 7FHOO IXQFWLRQ F FRPSOHPHQW GHILFLHQ \ G LQFUHDVHG VXVFHSWLELOLW\ WR IXQJDO LQIHFWLRQV 39.3 The HIV-positive patient D +,9 FDXVHV GHSOHWLRQ RI &' 7O\PSKRF\WHV E WKH FRPPRQHVW FKHVW LQIHFWLRQ LV 3&3 Pneumocystis jirovecii pneumonia F LQ WKH 8.  RI FDVHV ZLWK P\FREDFWHULXP WXEHUFXORVLV DUH FRLQIHFWHG ZLWK +,9 G Cytomegalovirus &09 LQIHFWLRQ LV UDUH LQ +,9 39.4 Which statement is NOT true concerning identification of respiratory infections in the Immunocompromised host? D &KHVW FRPSXWHG WRPRJUDSK\ FDQ EH GLDJQRVWLF IRU DVSHUJLOOR VLV E (DUO\ EURQFKRDOYHRODU ODYDJH FDQ DLG GLDJQRVLV LQ ∼ RI FDVHV F 3OHXUDO IOXL LV UDUHO\ LQYHVWLJDWHG LQ VXFK SDWLHQWV G &;5 PD\ VKRZ GLIIXVH LQILOWUDWH EXW EH RWKHUZLVH QRQ VSHFLILF

Chapter 40: Lung cancer 40.1 Lung cancer D KDV DQ RYHUDOO \HDU VXUYLYDO RI