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Respiratory - SBAQ - 50
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Quezon J6 of 50
50 AQ: Physiology
Question 5 BA: # 1502G
Arterial blood gas ( interpretation: Store 0 of 1
A iG- year -old pat - ent with CORD presents with worse n ; ng breathiessness, he resuIcs of her areeda I blood
*
gas ( AEG) on air are shown below:
Report
this * pH: 7 25
pO : 3 . S kPa
question ^
PC 0 1 9.1 kPa
* ^
HCO.v : 34 nun o .t I
'
Which SINGLE statement regarding his ABG is true?
Answer Option Question Statistics
He has An acute exacerbation of A chronic metabolic Acidosis 1
X Ids lias A chronic compensated respiratory acidosis lejjfli )
He has an acute exacerbation of a chronic respiratoiy acidosis 1
He has an acute respiratory acidosis
]
He has an acute exacerbation of a chronic respiratory alkalosis
^
Explanation:
-
Artenal b ocd gas (AEG ) interpretation helps us with the assessment of a pot ent' s resp atory
gas exchange and a rid- base balance . The normal values on an ARG ran vary a little berweer
analysers but broadly speak ng are as follows;
Variable Range
FH 7.35 - 7.45
10 - 14 kPa
°
P :
PC02 4,5 - 6 kPa
HCO - , -
22 26 mmol/ l
Ease excess - 2 - 2 mmol / l
In this-cast; the patient ' s h story should concern you about a possible diagnosis of pifJ&ionary
embo - js. The pertirent ABG findings are as follows:
* Mild hypoxia ( type 2 respiratory failure )
* Low pH ( addaeniia)
* High FC02
* High bicarbonate
The combination of acidaemia.. a high PCG and a high bicarbonate ind . cates that this patient
^
has an acute exacerbation super imposeo on a chronic, compensated respiratory acidosis.
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Carbon monoxide ( CO )
SBAQ: Physiology
Question: SBAQ 2096
Carbon monoxide ( CO ):
^ Tag
Report A 21 - year- old student presents with confusion, headache, nausea and malaise. An arterial blood gas is
this performed and his carbon monoxide levels are found to be markedly elevated.
question
Which SINGLE statement regarding carbon monoxide is true?
Answer Option Question

Statistics
CO has no effect on oxygen transport
It causes the oxygen dissociation curve to shift to the right

J
>/ The P 02 of the blood in CO poisoning can be normal
It combines with haemoglobin to form carbaminohaemoglobin | |
It has approximately 25 times the affinity for haemoglobin that oxygen

does
Explanation:
Carbon monoxide ( CO) interferes with the oxygen transport function of the blood by combining with
haemoglobin to form carboxyhaemoglobin ( COHb ).
CO has approximately 240 times the affinity for haemoglobin that oxygen does and for that reason even
small amounts of CO can tie up a large proportion of the haemoglobin in the blood making it unavailable
for oxygen carriage. If this happens the P02 of the blood and haemoglobin concentration will be normal
but the oxygen concentration will be grossly reduced.
The presence of COHb also causes the oxygen dissociation curve to be shifted to the left, interfering with
the unloading of oxygen.
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Cor pulmonale
SBAQ: Physiology
Question: SBAQ 2346
Cor pulmonale:
^ Tag
Report A 70 - year- old woman with a known diagnosis of cor pulmonale secondary to COPD presents with a deterioration
this in her condition. You arrange for an ECG and a chest X - ray to be carried out.
question
Which SINGLE statement regarding cor pulmonale is true ?

Statistics
Mean pulmonary arterial pressure is usually greater than 20 mmHg )
It is caused by left ventricular hypertrophy

1 (Sgfr
J
There is reduced resistance to blood flow in the pulmonary circulation

1 J
Right bundle branch block on the ECG in suggestive of the diagnosis )
A dominant R wave in lead V4 is diagnostic
Explanation:
Cor pulmonale is the enlargement and failure of the right ventricle secondary to respiratory disease
that has caused increased resistance to blood flow in the pulmonary circulation.
For cor pulomale to occur the mean pulmonary arterial pressure is usually greater than 20 mmHg.
Complete right ventricular failure usually ensues if the mean pulmonary arterial pressure exceeds 40
mmHg.
The causes of cor pulmonale include:

• COPD and asthma
• Primary pulmonary hypertension
• Recurrent or massive pulmonary embolus
• Obstructive sleep apnoea
• Sarcoidosis
The diagnostic ECG criteria for right ventricular hypertrophy are as follows:
• Right axis deviation (> +110°)
• Dominant R wave in V1
• Deep S wave in V5 or V6 (> 7 mm deep)
• Normal QRS (excludes RBBB)
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Physiological dead space
Question: SBAQ 2161
Physiological dead space:
^ Tag
Report You have been asked to give a talk on lung volumes and gas exchange to a group of medical students. You are
this asked a question about the physiological dead space.
question
Which SINGLE statement regarding the physiological dead space is true?

Statistics
>/ It can account for up to 30% of the tidal volume
^ )
It can be measured by nitrogen washout test \ ]
Some gas exchange is possible within the physiological dead space

J
It is the total dead space minus the anatomical dead space
J
It is the sum of the volumes of those alveoli that have little or no blood
flowing through their adjacent capillaries
Explanation:
Dead space is defined as the volume of inhaled air that does not take part in gas exchange.
The dead space can be further classified into:

1. Anatomical dead space : The portion of the airways that conducts gas to the alveoli. No gas exchange is
possible in these spaces.
2. Alveolar dead space : The sum of the volumes of those alveoli that have little or no blood flowing
through their adjacent capillaries i.e the alveoli that are ventilated but not perfused. This is negligible in
healthy people but can increase considerably in individuals with lung disease that causes ventilation -
perfusion mismatch.
3. Physiological dead space : the sum of the anatomical and alveolar dead spaces. The physiological dead
space can account for up to 30% of the tidal volume.
The anatomical dead space can be measured by nitrogen washout test ( Fowler's method). The
physiological dead space can be measured by the Bohr equation.
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Quezon i $vf 50
50 AQ: Physiology
Question SBA: # 14S 5 G
Lung f un c E i on tests: Store 0 of 1
^ Tag
You review a 40- yeor - old patient with a h .story cf feeling breathless. He has the following lung function
test results :
13 Report
this
FEVV' FVC ratio = 96% predicted
question
* P/C = 58% predicted
• G a s transfer factor = reduced
Which of the following is the MOST likely cause for these resu Its? Select ONE answer only.
Anaemia
IS
X Pulmonary haemorrhage !
Pneumothorax ! jfta | )
Acute asthma
J
Chronic obstr uctive pulmonary disease ( COFDJ
Explanation:
i his patient is - - -
oreatoless with a rest : (Hive ventilatory defect a educed gas tronsfer facto .
1 fie gas transfer laclor is a measure of gas diffusion across the alveolae mernorane ,nto
capillaries . It is dependent uoon blood volume, blood flow, surface area of the membrane and
.
tlpp distribution of ventilation It is measured by the dlfftjslpri of carbon monoxide iTLCO) Tfie .
transfer coefficient (KCO) is the TLCC corrected for ung volume.
There arc numerous causes of a decreased transfer factor including:

• CORD
Acute asthma
• Interstfcial lung d ise se
^
Pulmonary oedema
• Pneumonia
• Pneumuthorax
• Pulmonary vascular disease
+ Pneumonectomy
Anaemia
Cl the causes listed in this quest on only a pneumothorax would cause both a restrictive lung
disease pattern and a reduced gas rmrsfer factor.
Normal vcnegatory function would be expected in anaemia, whilst CORD and acute asthma
would cause an obstructive lung disease pattern.
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Lung function tests
SBAQ: Physiology
Question: SBAQ 2057
Lung function tests:
^ Tag
Report You review a 60-year - old patient with a history of feeling breathless. He has the following lung function test
this results:
question
• FEV i- /FVC ratio = 95% predicted

• FVC = 92% predicted
• Gas transfer factor = reduced
Which of the following is the MOST likely cause for these results? Select ONE answer only .

Statistics
>/ Anaemia
^ j
Pneumothorax B ]
Chronic obstructive pulmonary disease ( COPD) B {Kfcfci )
Pulmonary oedema m* )
~
Polycythaemia
1 m i
Explanation:
This patient is breathless with a reduced gas transfer factor but has normal ventilatory function.
The gas transfer factor is a measure of gas diffusion across the alveolar membrane into capillaries. It is
dependent upon blood volume, blood flow, surface area of the membrane and the distribution of
ventilation. It is measured by the diffusion of carbon monoxide (TLCO). The transfer coefficient ( KCO) is the
TLCO corrected for lung volume.
There are numerous causes of a decreased transfer factor including:

• COPD
• Acute asthma
• Interstitial lung disease
• Pulmonary oedema
• Pneumonia
• Pneumothorax
• Pulmonary vascular disease
• Pneumonectomy
• Anaemia
Of the causes listed in this question only anaemia would cause a reduced gas transfer factor in the
presence of a normal FEVT /FVC ratio and.
COPD and would be expected to cause an obstructive lung disease pattern whilst pulmonary oedema and
a pneumothorax would be expected to cause a restrictive lung disease pattern.
Polycythaemia causes an increased gas transfer factor.
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Factors affecting the oxygen

dissociation curve
SBAQ: Physiology
Question: SBAQ 2089
Factors affecting the oxygen dissociation curve:
^ Tag
Report The oxygen dissociation curve, and the role of hemoglobin, are important clinically in understanding the
this relationship of arterial, oxygen saturation to the partial pressure of oxygen in arterial blood, particularly as it
question relates to disease.
An increase in which of the following factors will cause a LEFT SHIFT of the oxygen dissociation curve ? Select
ONE answer only.

Statistics
Increase in temperature
I »
Increase in carbon dioxide m
Presence of calcium
a
Presence of methaemoglobin
Increase in 2,3 - DPG

a
Explanation:
The oxygen dissociation curve can be shifted right or left by a variety of factors. A right shift indicates
decreased oxygen affinity of haemoglobin allowing more oxygen to be available to the tissues. A left shift
indicates increased oxygen affinity of haemoglobin allowing less oxygen to be available to the tissues.
1 . pH:
A decrease in the pH shifts the curve to the right, while an increase in pH shifts the curve to the left . This
occurs because a higher hydrogen ion concentration causes an alteration in amino acid residues that
stabilises deoxyhaemoglobin in a state (the T state ) that has a lower affinity for oxygen. This rightwards
shift is referred to as the Bohr effect .
2. Carbon dioxide ( C02):

A decrease in C 02 shifts the curve to the left, while an increase in C 02 shifts the curve to the right. C 02
affects the curve in two ways. Firstly, accumulation of C 02 causes carbamino compounds to be generated,
which bind to oxygen and form carbaminohaemoglobin. Carbaminohaemoglobin stabilizes
deoxyhaemoglobin in the T state. Secondly, accumulation of C 02 causes an increase in H+ ion
concentrations and a decrease in the pH, which will shift the curve to the right as explained above.
3 . Temperature:
An increase in temperature shifts the curve to the right, whilst a decrease in temperature shifts the curve
to the left . Increasing the temperature denatures the bond between oxygen and haemoglobin, which
increases the amount of oxygen and haemoglobin and decreases the concentration of oxyhaemoglobin.
Temperature does not have a dramatic effect but the effects are noticeable in cases of hypothermia and
hyperthermia .
4. Organic phosphates:
2,3 - Diphosphoglycerate (2,3- DPG) is the main primary organic phosphate. An increase in 2,3 - DPG shifts the
curve to the right, whilst a decrease in 2,3 - DPG shifts the curve to the left . 2,3 - DPG binds to haemoglobin
and rearranges it into the T state, which decreases its affinity for oxygen.
Methaemoglobin is an abnormal form of haemoglobin in which the normal ferrous form is converted to
the ferric state. Methaemoglobinaemia causes a left shift in the curve as methaemoglobin does not unload
oxygen from haemoglobin.
Calcium levels have no effect on the oxygen dissociation curve.
A table summarizing these effects is shown below:
Factor Decrease Increase

pH Right shift Left shift
CO2 Left shift Right shift
Temperature Left shift Right shift
2,3 - DPG Left shift Right shift
LEFT SHIFT
Decreased temp
100 r- Decreased 2- 3 DPG
Decreased [ H+]
90 CO
c
.2 80 /
/
(Q /
i
-
3 70 /
+( *
TJ
/
to /
60 /
/
50 / /
5
O /
O 40 /
O /
/
| 30 /
/
-
>X 20 / /
o /
10
///
0 10 20 30 40 50 60 70 80 90 100
P02 ( mmHg )
The oxygen dissociation curve and the factors affecting it. © Medical Exam Prep
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Fetal haemoglobin
SBAQ: Physiology
Question: SBAQ 2095
Fetal haemoglobin:
^ Tag
Report An arterial blood gas is taken from a 1- week - old baby with respiratory distress. A medical student is unsure of
this the relevance of the fetal haemoglobin levels and has asked if you can explain it to her.
question
Which SINGLE statement regarding fetal haemoglobin (HbF ) is true?

Statistics
The oxygen dissociation curve for fetal haemoglobin is shifted to the

left of that of adult haemoglobin
It has a higher affinity for oxygen than myoglobin |
It is composed of two alpha and two beta subunits 1 m i
It persists in the newborn until roughly 1 year of age

1 » )
It has a weaker affinity for oxygen than adult haemoglobin

U « ]
Explanation:
Fetal haemoglobin ( HbF) is the main oxygen transport protein in the human fetus during the last 7 months
of debvelopment. It persists in the newborn until roughly 6 months of age.
HbF has different globin chains to adult haemoglobin ( Hb). Whereas adult haemoglobin is composed of
two alpha and two beta subunits, fetal haemoglobin is composed of two alpha and two gamma subunits.
This change in the globin chain results in a greater affinity for oxygen and allows the fetus to extract blood
from the maternal circulation.
This increased affinity for oxygen means that the oxygen dissociation curve for fetal haemoglobin is shifted
to the left of that of adult haemoglobin.
The curve for myoglobin lies even further to the left than that of fetal haemoglobin and has a hyperbolic,
not sigmoidal, shape. Myoglobin has a very high affinity for oxygen and acts as an oxygen storage
molecule. It only releases oxygen when the partial pressure of oxygen has fallen considerably. The function
of myoglobin is to provide additional oxygen to muscles during periods of anaerobic respiration.
00
95.8
Fetal hemoglobin
Adult hemoglobin
*-
.2
7
50
7
c
J
7
o
0 19 26.8 40 80 120
Oxygen partial pressure (pOr mmllg )
Image sourced from Wikipedia

Courtesy of David Iberri CC BY-SA 3.0 &
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yL«?ftion 36 of 50
50 AQ: Physiology
Question 5 BA: #22526
Functions! residual capacity: 1 of 1
You review the notes of a 52 - year - old woman with chronic respiratory problems . Her ' ast 2 spirometry
tests are there , and you compare the resu ts to see hov; much her condition has deteriorated.
fQ Report
this
question
which SINGLE statement regarding Functional residual capacity is true?

Statistics
It can be calculated by spirometry
It is the volume of air present in the lungs afters maximum

expiration
The usual vo ums in a healthy male is 5 R 0 mL
v' It is reduced when lying in the supine position fcaaal
li is reduced by marked airway obstruction

S :
' .
Explanation:
The Functional residual capacity ( FRC) is Lhe volume oF air present in the lungs at the ehd oF a
.
normal expiration The usual volume in a healthy male is 2 , 0 L.
At FRC, the opposing elastic recoil forces of The lungs a nr : chest wall are in equilibrium a nr: there
-
is no exertion by the c .aphragm o other respiratory muscles.
The FRC is the sum of die expiratory reserve volume (ERV) and the residual volume (RV):
FRC = ERV + ;RV
The FRC cannot be estimated by spirometry as it includes the residual volume . In order to
measure the RV precisely ore of the following methods is needed:
Nitrogen washout [ Fowler 's method )
*
* Helium dilution technique
* Body plethysmography
The FRC is increased by the following:

* Me <ed airway obstruction (e.g. severe asthma and CORD )
* Loss of elastic recoil ( e.g. advanced age and emphysema )
The FRC is reduced by the following :

* Abnormally stiff,. a on-conn pliant lungs [ e .g. restrictive lung disorders such as pulmonary
fibrosis)
* Bilateral paralysis of the diaphragm
* Lying in the supine position
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Physiology - FRCEM SBAQ - 50
Question 27 of 50
SBAQ: Physiology
Question SBA: #14651
Lung function tests: Score 1 of 1
^ Tag You review a 60- year- old patient with a history of feeling breathless. His lung function tests have revealed
an increased gas transfer factor.
Report
this
question
Which of the following is the MOST likely cause for this result? Select ONE answer only .
Pulmonary oedema
Pneumonia
Pneumothorax ]
Pulmonary haemorrhage
Pulmonary hypertension I fliE

* I !
Explanation:
The gas transfer factor is a measure of gas diffusion across the alveolar membrane into
capillaries. It is dependent upon blood volume, blood flow, surface area of the membrane and the
distribution of ventilation. It is measured by the diffusion of carbon monoxide (TLCO ). The transfer
coefficient ( KCO) is the TLCO corrected for lung volume.
The causes of an increased gas transfer factor include:

• Exercise
• Polycythaemia
• Pulmonary haemorrhage
• Asthma ( not during acute attacks)
• Left-to- right shunts
All of the other causes listed in this question would cause a reduced gas transfer factor.
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J receptors
SBAQ: Physiology
Question: SBAQ 2391
J receptors:
^ Tag
Which of the following nerves is responsible for innervation of the J receptors? Select ONE answer only.
this
question

Statistics
The subcostal nerve
The phrenic nerve
The glossopharyngeal nerve I

The vagus nerve
The oculomotor nerve
Explanation:
Juxtacapillary receptors (J receptors) are sensory cells that are located within the alveolar walls in
juxtaposition to the pulmonary capillaries of the lung.
The J receptors are innervated by the vagus nerve and are activated by physical engorgement of the
pulmonary capillaries or increased pulmonary interstitial volume, for example in the presence of
pulmonary oedema, pulmonary embolus, pneumonia and barotraumas. They may also be stimulated by
hyperinflation of the lung.
Stimulation of the J receptors causes a reflex increase in breathing rate, and is also thought to be involved
in the sensation of dyspnoea. The reflex response that is produced is apnoea, followed by rapid breathing,
bradycardia, and hypotension.
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Explanation:
In restrictive lung disease the FEV -| /FVC ratio is usually normal, i.e. > 0.7, and the FVC is reduced
to < 80% predicted normal.
In obstructive lung disease FEV i- is reduced to <80% of normal and FVC is usually reduced but to
a lesser extent than FEV The FEVT / FVC ratio is reduced to < 0.7.
^
According to the latest NICE guidelines ( 2010) airflow obstruction is defined as follows:
• Mild airflow obstruction = an FEV |- of >80% in the presence of symptoms
• Moderate airflow obstruction = FEV -| of 50-79%
• Severe airflow obstruction = FEVT of 30- 49%
• Very severe airflow obstruction = FEVT <30%.
Spirometry is a poor predictor of durability and quality of life in COPD but can be used as part of
the assessment of severity
COPD can only be diagnosed on spirometry if the FEVT is <80% and FEVT /FVC ratio is < 0.7
The NICE guidelines on COPD in over 16s can be viewed here: www.nice.org.ukc?
Lung function tests
SBAQ: Physiology
Question: SBAQ 2180
Lung function tests:
^ Tag
Report A 67 - year- old long-term smoker with presents with a gradually worsening history of breathlessness. Lung
this function tests are arranged.
question
Which of the following statements about lung function testing is FALSE? Select ONE answer only.

Statistics
Bronchiectasis is an example of an obstructive lung disease
Cystic fibrosis is an example of an obstructive lung disease

H m't )
Spirometry is the gold standard test for diagnosing and monitoring

COPD
V Spirometry is a good predictor of quality of life in COPD
Fibrosing alveolitis is an example of a restrictive lung disease | rtifr

( )
Explanation:
Spirometry is a useful and simple way to measure timed inspired and expired volumes. It is the gold
standard test for diagnosing and monitoring COPD, and is also similarly used in asthmatic patients.
Spirometry is not a good predictor of quality of life in COPD but can be used as part of the assessment of
severity. It is also useful for monitoring disease progression and reviewing response to treatments.
The forced vital capacity ( FVC ) is the volume of air in the lungs from a maximal inspiration to a forced
maximal expiration.
The forced expiratory volume in one second ( FEV is the volume of air that is expelled in the first second
of a forced expiration. ^
In obstructive lung disease FEV -] is reduced to <80% of normal and FVC is usually reduced but to a lesser
extent than FEV 1 with the resulting FEV -i /FVC ratio being reduced to <0.7. This occurs in conditions when
(
the airways are narrowed, causing obstruction, such as in asthma, COPD, cystic fibrosis and bronchiectasis.
In restrictive lung disease the FVC is reduced to <80% predicted normal and the FEV i- /FVC ratio is usually
normal, i.e. >0.7 . The FEVT is also reduced. This occurs in conditions when there is a reduced lung volume,
such as scoliosis and fibrosing alveolitis.
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Lung volumes in clinical practice
Question: SBAQ 2646
Lung volumes in clinical practice:
^ Tag
Report A patient with a history of moderate to severe chronic obstructive pulmonary disease ( COPD) has lung function
this testing carried out.
question
Which of the following lung volumes or capacities is most likely to be decreased in this case? Select ONE
answer only .

Statistics
Total lung capacity
\
>/ Vital capacity
Functional residual capacity
Residual volume 1 m
\
Residual volume / total lung capacity ratio
Explanation:
Obstructive lung disorders are characterised by airway obstruction. Many obstructive diseases of the
lung result from narrowing of the smaller bronchi and larger bronchioles, often because of excessive
contraction of the smooth muscle itself.
Types of obstructive lung disorders include:

• Chronic obstructive pulmonary disease (COPD)
• Asthma
• Bronchiectasis
The following table outlines the affects of obstructive lung disease on the various lung volumes and
capacities:
Decreased in obstructive lung

Increased in obstructive lung disease
disease
Total lung capacity (TLC) Vital capacity ( VC)
Residual volume ( RV) Inspiratory capacity ( 1 C )
Functional residual capacity ( FRC) Residual Inspiratory reserve volume ( IRV)
volume / total lung capacity ( RV /TLC) ratio Expiratory reserve volume ( ERV)
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Question 26 of 50
SBAQ: Physiology
Lung volumes: Score 1 of 1
^ Tag
Lung function testing is a valuable tool for evaluating the respiratory system, representing an important
adjunct to the patient history, various lung imaging studies, and invasive testing such as bronchoscopy.
Report When interpreting lung function tests it is important to have a good understanding of the various lung
this volumes.
question
Which of the following best describes the vital capacity? Select ONE answer only .

Statistics
The volume of air in the lungs at the end of a maximal inspiration
The volume of air present in the lungs at the end of a normal

expiration
The maximum volume of air that can be breathed out following a

maximal inspiration
1 feiaii . 1
The maximum volume of air that can be breathed out during maximal
expiration
fe 1
The maximum volume of air that can be breathed in during maximal Q*
inspiration
Explanation:
It is important to have an understanding of lung volumes and definitions of these volumes in

adults.
The tidal volume (TV) is the volume of air drawn in and out of the lungs during normal breathing.
The usual volume in a healthy male is 0.5 L.
The vital capacity ( VC) is the maximum volume of air that can be breathed out following a
maximal inspiration. The usual volume in a healthy male is 4.5 L.
The residual volume ( RV ) is the volume of air in the lungs after a maximum expiration. The usual
volume in a healthy male is 1.0 L.
The inspiratory reserve volume ( IRV) is the maximum volume of air that can be breathed in at the
end of a normal tidal inspiration. The usual volume in a healthy male is 3.0 L.
The expiratory reserve volume ( ERV) is the maximum volume of air that can be breathed out at
the end of a normal tidal expiration. The usual volume in a healthy male is 1.0 L.
Total lung capacity (TLC) is the volume of air in the lungs at the end of a maximal inspiration. TLC
= RV+VC. The usual volume in a healthy male is 5.5 L.
Functional residual capacity ( FRC) is the volume of air present in the lungs at the end of a normal
expiration. FRC = ERV + RV. The usual volume in a healthy male is 2.0 L.
80
Inspiratory
Reserve
Voume
( IRV ) Inspiratory
Capacity
(1C )
U)
Vital
| 37
Tidal
Capacity
( VC )
Total
Lung
<u Volume Capacity
E 30
( TV or VT ) ( TLC )
§ Expiratory
Reserve
Volume
( ERV Functional
Residual
15 Capacity
( FRC )
Residual Residual
Volume Volume
( RV ) ( RV )
Image sourced from Wikipedia C?

Courtesy of Wikimedia Commons CC BY -SA 3.0 C?
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Lung volumes in clinical practice
SBAQ: Physiology
Question: SBAQ 2655
Lung volumes in clinical practice:
^ Tag
Report A patient with a history of worsening chronic worsening breathlessness undergoes lung function testing. The
this results demonstrate that both the FEV1 and FVC are reduced and the FEV1 /FVC ratio is greater than 80%.
question
Which of the following is the most likely diagnosis? Select ONE answer only.

Statistics
Chronic bronchitis
a
Asthma
>/ Pulmonary oedema | qg& |
Bronchiectasis
Emphysema
Explanation:
Obstructive lung disorders are characterised by airway obstruction. Many obstructive diseases of the
lung result from narrowing of the smaller bronchi and larger bronchioles, often because of excessive
contraction of the smooth muscle itself.
In obstructive lung disorders the FEV 1 is generally reduced and the FEV 1 /FVC ratio is less than 0.7.
Types of obstructive lung disorders include:

• Chronic obstructive pulmonary disease (COPD )
• Asthma
• Bronchiectasis
Restrictive lung disorders are characterised by restricted lung expansion . They result in a decreased
lung volume, increased work of breathing, and inadequate ventilation and / or oxygenation.
In restrictive lung disorders there is a reduction in the FVC and the FEV 1 . The decline in the FVC is
greater than that of the FEV 1, resulting in preservation of the FEV 1 /FVC ratio (> 80% ).
Types of restrictive lung disorders include:

• Pulmonary fibrosis
• Sarcoidosis
• Pulmonary oedema
• Adult respiratory distress syndrome ( ARDS)
• Neuromuscular diseases e.g. muscular dystrophy
• Anatomical e.g. obesity, scoliosis
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Question }3 of 50
Question SBA: # 14801
The oxygen dissociation curve: Sc re 1 >f 1

° *
^ Tag
The oxygen dissociation curve, and the role of hemoglobin, are important clinically in understanding the
relationship of arterial, oxygen saturation to the partial pressure of oxygen in arterial blood, particularly as
Report
it relates to disease .
this
question
Which SINGLE statement regarding the oxygen dissociation curve is FALSE?

Statistics
&r
~
The oxygen dissociation curve has a sigmoid shape
>/ A decrease in C02 shifts the curve to the right
Each gram of haemoglobin can combine with 1.34 mL of oxygen
The p50 value Is the value that tells us the partial pressure of oxygen at (:
which the red blood cells are 50% saturated with oxygen
At high partial pressures of oxygen haemoglobin binds to oxygen

oxyhaemoglobin
to form
£
Explanation:
The oxygen dissociation curve is a graph that plots the proportion of haemoglobin in its
oxygen -laden saturated form on the vertical axis against the partial pressure of oxygen on the
horizontal axis. The curve is a valuable aid in understanding how the blood carries and releases
oxygen.
At high partial pressures of oxygen, haemoglobin binds to oxygen to form oxyhaemoglobin .

All of the red blood cells are in the form of oxyhaemoglobin when the blood is fully saturated
.
with oxygen Each gram of haemoglobin can combine with 1.34 mL of oxygen
..
At low partial pressures of oxygen (e g within tissues that are deprived of oxygen),
oxyhaemoglobin releases the oxygen to form haemoglobin.
The oxygen dissociation curve has a sigmoid shape because of the co- operative binding of
oxygen to the 4 polypeptide chains . Co- operative binding means that haemoglobin has a
greater ability to bind oxygen after a subunit has already bound oxygen Haemoglobin is .
therefore most attracted to oxygen when 3 of the 4 polypeptide chains are bound to oxygen.
There is often a P50 value expressed on the curve, which is the value that tells us the partial
pressure of oxygen at which the red blood cells are 50% saturated with oxygen At an oxygen .
saturation of 50% the PaO? is approximately 25 mmHg (3.5k Pa).
LEFT SHIFT
Decreased temp
100 Decreased 2- 3 DPG
Decreased [H+l
X CO
E 70
/
/
S / /
/ /
50 / /
3 / /
g 40
/
£ 30 /
I /
20 /
S /
/
10
0 10 20 30 40 SO 60 70 80 90 100
p 02 (mmHg)
Factors affecting the oxygen dissociation curve include:
The oxygen dissociation curve can be shifted right or left by a variety of factors . A right shift
Indicates decreased oxygen affinity of haemoglobin allowing more oxygen to be available to the
tissues . A left shift indicates increased oxygen affinity of haemoglobin allowing less oxygen to be
available to the tissues .
1. pH:
A decrease in the pH shifts the curve to the right , while an increase in pH shifts the curve to the
left. This occurs because a higher hydrogen ion concentration causes an alteration in amino acid
residues that stabilises deoxyhaemoglobin in a state ( the T state) that has a lower affinity for
oxygen. This rightwards shift is referred to as the Bohr effect.
2 . Carbon dioxide ( C02):

A decrease in CO? shifts the curve to the left, while an increase in CO? shifts the curve to the
right . CO? affects the curve in two ways. Firstly, accumulation of CO? causes carbamino
compounds to be generated, which bind to oxygen and form carbaminohaemoglobin.
Carbaminohaemoglobin stabilizes deoxyhaemoglobin in the T state . Secondly, accumulation of
CO 2 causes an increase in H + ion concentrations and a decrease in the pH, which will shift the
curve to the right as explained above.
3 . Temperature:
An increase in temperature shifts the curve to the right, whilst a decrease in temperature shifts
the curve to the left . Increasing the temperature denatures the bond between oxygen and
haemoglobin, which increases the amount of oxygen and haemoglobin and decreases the
.
concentration of oxyhaemoglobin Temperature does not have a dramatic effect but the effects
are noticeable in cases of hypothermia and hyperthermia.
4. Organic phosphates:
2,3- Diphosphoglycerate (2, 3 - DPG) is the main primary organic phosphate . An increase in 2, 3 -
-
DPG shifts the curve to the right , whilst a decrease In 2, 3 DPG shifts the curve to the left . 2,3-
DPG binds to haemoglobin and rearranges it into the T state, which decreases its affinity for
oxygen.
A table summarizing these effects is shown below :

CO , Left shift Rit>ht shift
2,3- DPG Left shift Right shift
Next question
FRCEMExamPrep.co.uk
Question 46 of 50
SBAQ: Physiology
Factors affecting the oxygen dissociation curve: Score 1 of 1
^ Tag The oxygen dissociation curve, and the role of hemoglobin, are important clinically in understanding the
relationship of arterial, oxygen saturation to the partial pressure of oxygen in arterial blood, particularly as it
Report relates to disease.
this
question
An increase in which of the following factors will cause a LEFT SHIFT of the oxygen dissociation curve?
Select ONE answer only.
Presence of calcium
Increase in carbon dioxide
Increase in 2,3 - DPG
Increase in temperature
V Presence of methaemoglobin
Explanation:
The oxygen dissociation curve can be shifted right or left by a variety of factors. A right shift
indicates decreased oxygen affinity of haemoglobin allowing more oxygen to be available to the
tissues. A left shift indicates increased oxygen affinity of haemoglobin allowing less oxygen to be
available to the tissues.
1. pH:
A decrease in the pH shifts the curve to the right, while an increase in pH shifts the curve to the
left . This occurs because a higher hydrogen ion concentration causes an alteration in amino acid
residues that stabilises deoxyhaemoglobin in a state ( the T state ) that has a lower affinity for
oxygen. This rightwards shift is referred to as the Bohr effect .
2. Carbon dioxide ( C02):

A decrease in C 02 shifts the curve to the left, while an increase in C 02 shifts the curve to the
right. C 02 affects the curve in two ways. Firstly, accumulation of C 02 causes carbamino
compounds to be generated, which bind to oxygen and form carbaminohaemoglobin.
Carbaminohaemoglobin stabilizes deoxyhaemoglobin in the T state. Secondly, accumulation of
C 02 causes an increase in H+ ion concentrations and a decrease in the pH, which will shift the
curve to the right as explained above.
3 . Temperature :
An increase in temperature shifts the curve to the right, whilst a decrease in temperature shifts
the curve to the left . Increasing the temperature denatures the bond between oxygen and
haemoglobin, which increases the amount of oxygen and haemoglobin and decreases the
concentration of oxyhaemoglobin. Temperature does not have a dramatic effect but the effects
are noticeable in cases of hypothermia and hyperthermia .
4 . Organic phosphates:
2,3 - Diphosphoglycerate (2,3- DPG) is the main primary organic phosphate. An increase in 2,3 - DPG
shifts the curve to the right, whilst a decrease in 2,3- DPG shifts the curve to the left. 2,3 -DPG
binds to haemoglobin and rearranges it into the T state, which decreases its affinity for oxygen.
Methaemoglobin is an abnormal form of haemoglobin in which the normal ferrous form is

converted to the ferric state. Methaemoglobinaemia causes a left shift in the curve as
methaemoglobin does not unload oxygen from haemoglobin.
Calcium levels have no effect on the oxygen dissociation curve.
A table summarizing these effects is shown below:

C 02 Left shift Right shift
2,3 - DPG Left shift Right shift
LEFT SHIFT
Decreased temp
100 r Decreased 2- 3 DPG
Decreased [H+]
90 CO
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C
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10
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0 10 20 30 40 50 60 70 80 90 100
P02 ( mmHg )
Next question
Pre- oxygenation
SBAQ: Physiology
Question: SBAQ 2658
Pre- oxygenation:
^ Tag
Report Your consultant performs pre - oxygenation prior to intubation with the aim of replacing nitrogen in the lungs
this with oxygen.
question
Which of the following combinations of lung volumes or capacities is most important in this process? Select
ONE answer only.

Statistics
Tidal volume plus inspiratory reserve volume B iCfEfr 1
Tidal volume plus expiratory reserve volume B SEfr - ]
Residual volume plus expiratory reserve volume
Residual volume plus inspiratory reserve volume 1 ]
Inspiratory reserve volume plus expiratory reserve volume | (jEfo )
Explanation:
Pre-oxygenation is the administration of oxygen to a patient prior to intubation. It helps to extend the
'safe apnoea time'. The 'safe apnoea time' is defined as the duration of time following cessation of
breathing/ventilation that elapses until arterial desaturation occurs ( Sa 02 reaches < 90%).
The primary mechanism by which pre-oxygenation works is by 'denitrogenation' of the lungs, however
maximal pre-oxygenation is achieved when the alveolar, arterial, venous and tissue compartments are all
filled with oxygen. Denitrogenation is achieved using oxygen to wash out the nitrogen contained in the
lungs after breathing room air, resulting in a larger alveolar oxygen reservoir.
The functional residual capacity ( FRC ) is the volume of gas that remains in the lungs after a normal
tidal expiration . It is the sum of the residual volume ( RV) and the expiratory reserve volume ( ERV). One
method of measuring the FRC is the nitrogen washout technique.
The FRC is the most important store of oxygen in the body . The greater the FRC, the longer apnoea can
be tolerated before critical hypoxia develops. Patients with reduced FRC ( e.g. lung disease, kyphoscoliosis,
pregnancy, and obesity) reach critical hypoxia more rapidly. The aim of pre-oxygenation is to replace
nitrogen in the FRC with oxygen.
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The pulmonary circulation
SBAQ: Physiology
Question: SBAQ 2386
The pulmonary circulation:
^ Tag
Report A 19 - year- old student is brought in by ambulance after being rescued from a house fire. You check her oxygen
this saturations and find that they are 89% on air. You immediately commence high - flow oxygen becuase of this.
question
Which statement best describes the effect of hypoxia on pulmonary blood flow ?

Statistics
Metabolic demand has a greater influence on pulmonary blood

distribution than hypoxia
The response to hypoxia is attenuated in acidosis a® j
>/ The maximal response to hypoxia occurs at a pA 02 of 70mmHg % )
Hypoxia causes localised vasodilation

M gfe )
The sympathetic nervous system has a greater influence on pulmonary

blood distribution than hypoxia
Explanation:
The main intrinsic regulator of pulmonary blood flow is the local partial pressure of alveolar oxygen ( pA 02).
A low pA 02 causes vasoconstriction of arterioles and visa versa. This is the Hypoxic Pulmonary
Vasoconstriction ( HPV) reflex and it facilitates the diversion of blood flow away from poorly ventilated
alveoli and towards well-ventilated alveoli to maximise gaseous exchange. The maximal hypoxic
vasoconstriction occurs at a pA 02 of 70mmHg ( at a normal pH). HPV is unique to the pulmonary
circulation. In the systemic circulation hypoxia and hypercarbia cause localised vasodilation and increased
local blood flow.
The mechanism underlying HPV is not fully known but is thought to involve depolarisation via 02- sensitive
K channels in the vascular smooth muscle membrane, with resultant calcium influx and smooth muscle
contraction.
A raised pC02 will also cause localised vasoconstriction. This is a separate mechanism to HPV, which is
independent of pC02. Acidosis enhances HPV; for a given level of hypoxia, HPV will be greater for a lower
pH.
The sympathetic nervous system has no major role in controlling pulmonary blood flow. Metabolic
demand also has no role in regulating pulmonary blood flow as alveolar perfusion vastly exceeds
metabolic requirements.
Hide Correct Answer

Explanation:
This patient has a history of worsening breathlessness and lung function tests that reveal a
restrictive lung disease pattern. In restrictive lung disease the FEV |- /FVC ratio is usually normal,
i.e. 70% predicted, and the FVC is reduced to < 80% predicted. The FEVT /FVC ratio is generally
normal both the FVC and FEVT are reduced. The ratio can also be elevated if the FVC is reduced
to a greater degree.
Of the options listed in this question only idiopathic pulmonary fibrosis could produce a
restrictive lung disease pattern.
Smoking is a risk factor for the development of idiopathic pulmonary fibrosis, especially if there
is a greater than 20- pack -year history.
Explanation:
The residual volume ( RV) is the volume of air in the lungs after a maximum expiration. The usual
volume in a healthy male is 1.0 L. The residual volume tends to increase with age.
Emphysema is an obstructive airways disease which will result in an increased residual volume
due to the air trapping that occurs.
The respiratory system in infants
Question: SBAQ 2275
The respiratory system in infants:
^ Tag
Report You review an 8 - month - old infant with a respiratory tract infection.
this
question
Which SINGLE statement regarding the differences in the respiratory systems of infants and adults is true?

Statistics
One millimeter of oedema can narrow a baby's airway by as much as | Qjgj

60%
Infants have lower oxygen consumption than adults | m )
The chest wall is less compliant in infants than in adults H )
The oxygen dissociation curve for fetal haemoglobin is shifted to the )

right of that of adult haemoglobin
The airway is narrowest at the level of the thyroid cartilage in infants mm 1
Explanation:
The infant has a greater metabolic rate and greater oxygen consumption than the adult. This partly
explains the fact that infants and children have higher respiratory rates than adults.
Neonates preferentially breathe through their nose and their narrow nasal passages are easily blocked by
secretions and may be damaged by a nasogastric tube or a nasally placed endotracheal tube. 50% of
airway resistance in neonates is from the nasal passages.
The airway is funnel shaped and narrowest at the level of the cricoid cartilage. Here, the epithelium is
loosely bound to the underlying tissue. Trauma to the airway easily results in oedema and one millimetre
of oedema can narrow a baby's airway by as much as 60%.
In the adult, the lung and chest wall contribute equally to the total compliance. In the newborn, most of the
impedance to expansion is due to the lung alone, and this is dependent upon the presence of pulmonary
surfactant. Pulmonary surfactant is a mixture if lipids and proteins that is formed and secreted by type II
alveolar pneumocytes. The principal function of pulmonary surfactant is to reduce the surface tension at
the air - water interface in the lung. The lung compliance increases over the first few weeks of life as fluid is
removed from the lung.
The chest wall is significantly more compliant in infants than it is in adults. As a consequence of this the
functional residual capacity ( FRC) in infants is relatively low compared to adults. The compliance of the
infants chest wall leads to prominent sternal recession when the airways become obstructed or lung
compliance decreases.
The combination of a high metabolic rate and high oxygen consumption with lower lung volumes and
limited respiratory reserve means that infants, and to a lesser degree children, desaturate much more
rapidly than adults. This is a very important consideration during airway procedures, such as endotracheal
intubation.
Fetal haemoglobin ( HbF) is the main oxygen transport protein in the human fetus during the last 7 months
of development . It persists in the newborn until roughly 6 months of age. HbF has different globin chains
to adult haemoglobin ( Hb). Whereas adult haemoglobin is composed of two alpha and two beta subunits,
fetal haemoglobin is composed of two alpha and two gamma subunits. This change in the globin chain
results in a greater affinity for oxygen and allows the fetus to extract blood from the maternal circulation.
This increased affinity for oxygen means that the oxygen dissociation curve for fetal haemoglobin is shifted
to the left of that of adult haemoglobin.
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Quezon J of 50
50 AQ: Physiology
Question 5 BA: # 2B31fi
Lung volumes in dinkal practice : Srore 1 of 1
A patient with, a known history of pulmonary fibrosis undergoes lung function testing .
lp3 Report
this
quest ori Which of the following is most likely to be present on lung function testing? Select ONE answer only .
V Decreased Functional residual capacity
Increased vita capacity

!»
Increased F EV 1
&
Decreased FEVjyFVC ratio
Increased residual voknrie
Explanation:
Restrictive lung disorders are characterised by restricted lung expansion. They result in a
decreased lung volume, increased work of breaching, and inadequate vent - ation and / cr
oxygenation .
Types of restrictive lung disorders include:

Pulmonaiyfibrosis
* Sarcoidosis
* Pulmonary oedema
* Adult respiratory distress syndrome ( ARDS)
* Neuromuscu ar diseases e .g. muscular dystrophy
* Anatomical e .g. obesity, scoliosis
Ln restrictive lung disorders there is a reduction in the forced vital capacity (FVc.) and the
forced expiratory volume in one second { FEV 1 }. The decline in the FVC is greater than that of
the F1EV1, resulting in preservation of the FEV1VFVC ratio {> 8Q%).
In restrictive lung disorders the following lung volumes and capacities are reduced :
* Vital capacity {VQ
* Total lung capacity {TLC )
* Inspiratory capacity ( IC)
* Residual volume ( RV)
* Functional residual capacity { FRC}
Next question
Pulmonary surfactant
SBAQ: Physiology
Question: SBAQ 2007
Pulmonary surfactant:
^ Tag
Report A pre -term infant develops respiratory distress syndrome after birth. She is deficient in pulmonary surfactant.
this
question
Which of the following is NOT a function of pulmonary surfactant? Select ONE answer only.

Statistics
~
Maintaining alveolar size | (m )
v' Decreasing pulmonary compliance 1 mh
Reduce surface tension at the air -water interface in the lung

1 *
Contributing to innate immunity B )
Preventing atelectasis
Explanation:
Pulmonary surfactant is a mixture if lipids and proteins that is formed and secreted by type II alveolar
pneumocytes .
The principal function of pulmonary surfactant is to reduce the surface tension at the air - water interface
in the lung. The proteins and lipids that make up the surfactant have both hydrophilic and hydrophobic
regions. By adsorbing to the air - water interface, with the hydrophobic tails facing towards the air and the
hydrophilic heads facing towards the air and, the main lipid component of surfactant,
dipalmitoylphosphatidylcholine ( DPPC ), reduces surface tension.
In addition to reducing surface tension pulmonary surfactant is also important for:

• Maintaining structural integrity and alveolar size
• Increasing pulmonary compliance
• Preventing atelectasis
• Keeping the alveoli dry
• Contributing to innate immunity
Hide Correct Answer

Tidal volume
SBAQ: Physiology
Question: SBAQ 2140
Tidal volume:
^ Tag
Report The anaesthetic team are called to the resus area of your Emergency Department to ingubate a trauma patient.
this His age is unknown but he appears to be an average sized man in his early 20 s. Following successfully intubating
question the patient they set up the ventilator and prepare to transfer him to ICU.
What is the approximate tidal volume in an average sized, healthy young male? Select ONE answer only .

Statistics
10 ml / kg body mass | ii» 1
14 ml / kg body mass | « 1
20 ml / kg body mass | m 1
4 ml /kg body mass | m 1
7 ml /kg body mass | aaa 1
Explanation:
The tidal volume is the volume of air displaced between normal inhalation and exhalation when extra
effort is not applied. In a healthy, young adult male tidal volume is approximately 500 ml per inspiration or
7 ml / kg of body mass.
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View Take Results Statistics

Arterial blood gas ( interpretation: Store 0 of 1

Which SINGLE statement regarding his ABG is true?

Answer Option Question Statistics

He has An acute exacerbation of A chronic metabolic Acidosis 1

X Ids lias A chronic compensated respiratory acidosis lejjfli )

He has an acute exacerbation of a chronic respiratoiy acidosis 1

He has an acute respiratory acidosis

Main Menu User Menu =

Which SINGLE statement regarding carbon monoxide is true?

Answer Option Question

CO has no effect on oxygen transport

It causes the oxygen dissociation curve to shift to the right

It combines with haemoglobin to form carbaminohaemoglobin | |

It has approximately 25 times the affinity for haemoglobin that oxygen

Hide Correct Answer

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Which SINGLE statement regarding cor pulmonale is true ?

Answer Option Question

Mean pulmonary arterial pressure is usually greater than 20 mmHg )

It is caused by left ventricular hypertrophy

There is reduced resistance to blood flow in the pulmonary circulation

Right bundle branch block on the ECG in suggestive of the diagnosis )

A dominant R wave in lead V4 is diagnostic

The causes of cor pulmonale include:

Hide Correct Answer

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Physiological dead space

Question: SBAQ 2161

Physiological dead space:

Which SINGLE statement regarding the physiological dead space is true?

Answer Option Question

>/ It can account for up to 30% of the tidal volume

It can be measured by nitrogen washout test \ ]

Some gas exchange is possible within the physiological dead space

The dead space can be further classified into:

Hide Correct Answer

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View Take Results Statistics

Lung f un c E i on tests: Store 0 of 1

Answer Option Question Statistics

Chronic obstr uctive pulmonary disease ( COFDJ

There arc numerous causes of a decreased transfer factor including:

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Lung function tests

Lung function tests:

• FEV i- /FVC ratio = 95% predicted

Answer Option Question

Chronic obstructive pulmonary disease ( COPD) B {Kfcfci )

There are numerous causes of a decreased transfer factor including:

Polycythaemia causes an increased gas transfer factor.

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Factors affecting the oxygen

Factors affecting the oxygen dissociation curve:

Answer Option Question

Increase in carbon dioxide m

Increase in 2,3 - DPG