Respiratory System

Development of Face and Palate / Larynx and Phonation

1. Describe the role and fate of nasal prominences in the development of the face. (2%)

Frontonasal prominence – Forehead, nose bridge

Medial nasal : philtrum of upper lip, crest and tip of nose
Lateral nasal : alae of nose

2. Describe the role and fate of maxillary prominences in the development of the face. (2%)

Maxillary prominences : cheeks, lateral portion of upper lip

3. Describe the formation of the primary palate. (2%)

The merger of medial nasal prominences forms the intermaxillary segment consisting of the four
incisor teeth, the philtrum of the upper lip and the primary palate.

4. List the four elements of phonation and briefly describe them. (4%)

Expired air – air is blown out from the lungs.

Vibrators – vocal folds act as vibrators as air passes through them. The length and tension in the vocal
ligaments determine the pitch of the voice.
Resonators – air in pharynx, mouth and paranasal air sinuses give resonance to the voice.
Articulators – the lips, teeth, tongue and palate modify the sound into recognisable speech.

MCQ (T/F)

5. Regarding the development of face and palate:

A. The nasolacrimal duct drains into inferior meatus in the lateral wall of the nasal cavity.
B. Medial nasal prominences merge with each other to form intermaxiallary segment which gives rise to
secondary palate.
C. The maxillary prominences give rise to lower lip and lower jaw.
D. The frontonasal prominence forms the forehead and the dorsum and the apex of the nose.
E. Each lateral nasal prominence is separated from the maxillary prominences by nasolacrimal groove.

Answers: T F F T T
Medial nasal prominences merge with each other to form intermaxiallary segment which gives rise to
primary palate.
The maxillary prominences give rise to upper lip and upper jaw.

6. Regarding the larynx and phonation (state TRUE or FALSE)

A. Abduction of the vocal folds is mainly produced by posterior crico-arytenoid muscles.
B. Tension of the vocal cords is produced by cricothyroid muscles.
C. The fissure between the vestibular folds is called rima glottidis.
D. The paranasal sinuses act as vibrators to determine the pitch of the voice during phonation.
E. Upper half of larynx is supplied by the superior laryngeal artery which is a branch of superior thyroid
artery.

Answers: T T F F T
The fissure between the vestibular folds is called rima vestibule.
The vocal cord acts as vibrators to determine the pitch of the voice.
Respiratory tree

1. Goblet cells are present in these portions of the respiratory tract (State TRUE or FALSE).

a. Respiratory bronchioles
b. Small bronchi
c. Terminal bronchioles
d. Alveoli
e. Trachea
f. Nasopharynx
g. Larynx

FTFFTTT

2. State the different layers of the alveolo-capillary membrane.

a. Surfactant lining of the alveolar cells

b. Alveolar epithelium and its basement membrane
c. Capillary endothelium and its basement membrane
d. Tissue elements in the interalveolar septum

3. Define the boundaries of the trachea.***

a. Continuation of the larynx at the level of the 6th cervical vertebra and ends at about the
level of the 6th thoracic vertebra by dividing into the left and right main bronchi.

4. What is a broncho-pulmonary segment and how many of these segments are present in one lung?

a. The area of the lung supplied by a segmental bronchus

b. 10 such segments in each lung

5. What is the function of the pores of Kohn in the alveoli?

a. Equalize pressure between alveoli

Mechanics of Respiration 1
MCQ (T/F)

1. The following muscles are involved in deep inspiration

a. Scalene
b. Latissimus dorsi
c. Diaphragm
d. Quadratus lumborum
e. Sternocleidomastoid
f. Erectores spinae
g. Pectoralis major

ANS : TFFTTTF

Mechanics of Respiration 2

a) Give the definition of the following and its numerical value at rest.*** ( we are not required to
memorize resting values... i think, no one should need to memorize this)
(Given that atmospheric pressure is 760 mmHg)
i) Intra-alveolar pressure

Ans: Pressure present in the alveolus. 760 mmHg

ii) Intra-pleural pressure

Ans: Pressure in the pleural space between the visceral and pleural membrane. 756mmHg

iii) Transpulomonic pressure

Ans: Pressure gradient across the wall. 4mmHg

b) Give 2 instances when the compliance of the lung is

i) increased

Ans: As one ages, emphysema

ii) decreased

Ans: pulmonary venous pressure increases, lung remains unventilated for a long time, fibrosis of the lung

c) i) Why is surface tension present?***(this is a physics question)

Ans: It arises because the attractive forces between the adjacent molecules of water are much stronger
than those between the water and the gas.

ii) What cell is responsible for the production of pulmonary surfactant?

Ans: Type II alveolar epithelial cells

iii) Pulmonary surfactant is manufactured from fatty acids from 2 places. Name them.***(very vague,
candidate will not know whether you're asking for 2 places where pulmonary surfactant is produced or
where fatty acids are manufactured. Even after seeing the answer i'm not sure what the question is
supposed to mean)

Ans: Blood, lung.

iv) Give 2 physiological functions of pulmonary surfactant.

Ans: Lowers the surface tension, promotes the stability of the alveoli, keeps the alveoli dry, prevents the
transudations of fluid

d) State whether bronchoconstriction (C) or bronchodilation (D) occurs in the following.

Adrenergic sympathetic stimulation

Activation of alpha receptors
Chemoreceptor stimulation
Histamine
Increase in carbon dioxide

Ans: DCCCD

e) In assessing expiratory airway resistance, FEV1/ FVC is assessed. State whether there is an increase or
a decrease in the following as compared to that of a normal person.

A person with obstructive disease

A person with restrictive disease

Ans : Decrease, increase

Pulmonary Ventilation

a) Give the definitions of the following lung capacities:

Functional Residual Capacity

- Volume of gas remaining in the lungs at the end of a normal tidal expiration.
Inspiratory Capacity
- Volume of air that is inhaled into the lungs during maximal inspiratory effort that begins at the end
Of a normal tidal expiration
Vital Capacity
- Volume of air expelled from the lungs during a maximal forced expiration starting after a maximal
forced inspiration
Total Lung Capacity
- Volume of air in the lungs after a maximal inspiratory effort

b) Define the following.

i) Anatomical dead space
ii) Alveolar dead space
iii) Physiologic dead space
iv) Minute ventilation
v) Alveolar ventilation

Ans: The volume of gas that enters the respiratory passage where there is no gas exchange per breath
The volume of gas that enters unperfused alveoli per breath
The volume of gas that enters the lungs that is not subject to gas exchange ( i would prefer the
formula alveolar dead space + anatomical dead space
Volume of air inspired or expired per minute
Volume of air that reaches the alveoli per minute

c) State whether it is the upper or lower zones of the lungs for the following.

Better ventilated
Subjected to greater distending pressure
More compliant
Less negative intrapleural pressure
(in comparison to the other zone)

Ans: Lower zones, Upper zones, Lower zones, Lower zones

Defense mechanisms of the respiratory tract

1. Give 2 examples for each of the following:

1. Anatomical/ physical barriers:

2. mechanical barriers:
3. Biochemical/ humoral defenses:
4. Cellular defense mechanisms:
5. microbiological defense mechanism:

a. ciliated epithelium, mucus secretion, nasal hairs.

b. turbulence in air flow, cough reflex, sneezing, swallowing reflex, mucocilliary escalator.
c. mucus, lysozyme, cytokines, interferon, complement.
d. macrophages, lymphocytes, neutrophils, rapid mucosa regeneration.
e. streptococci, staphylococci, diphteroids

2. how does the normal flora of the respi tract interfere with the colonization of pathogens? Give 2
methods.

Occupies receptor sites, competition for nutrients, secretion of metabolic toxins, cross reacting antibody
production stimulated.

3. List 2 factors that may impair the defenses of the respi tract.

Air pollution, alcohol, bacterial/viral infections, immunosuppression, respi tract diseases (asthma,
emphysema, cystic fibrosis)

4. What is the primary Ig in the secretions of the respi tract?

Ig A
Drugs used for cough

1. what is the main function of the cough reflex?

To prevent foreign material from entering the lower respi tract, to clear foreign material and excessive
secretions from the lower respi tract.

2. Antitussives are cough suppressants - increasing the threshold of the cough centre in the brainstem.
Give an example of an antitussive and its main use.

Codeine, dextromethorphan, pholcodine. Used for dry unproductive cough to minimize damage to the
respi tract, and allow healing of surgery or wounds to the abdomen and eyes

3. How do mucolytics work? Give an example of a mucolytic.

Mucolytics break the disulphide bonds in mucus glycoprotein, reducing the viscosity to allow easier
expectoration. Acetylcysteine, methylcysteine, carbocysteine.

4. how do expectorants such as iodide and ipecacuanha function?

By irritating the bronchial mucosa, they increase amount and fluidity of secretions and promote productive
cough.

5. Oxymetazoline is a topical decongestant used in the treatment of rhinorrhea of the common cold and
allergies. How does it work?

Decongestants are sympathomimetics that activate alpha-1-adrenergic receptors on blood vessels, causing
vasoconstriction which causes bronchodilation
Hemoglobin and Gas transport

a. What is the importance of NADH in RBCs? (1mark)

The enzyme NADH-cytochrome b5 reductase uses NADH to reduce methemoglobin to hemoglobin.

b. What are the physiological advantages of the Bohr effect in oxygen transport? (2marks)

In the lungs where the pH is highest, the oxygen-hemoglobin curve shifts to the
left indicating that Hb has a higher affinity for oxygen. This favours oxygen
uptake by Hb in the lungs.
In peripheral tissues where acid metabolites (e.g lactic acid) are produced, pH
is lower. The curve shifts o the right indicating a decreased affinity of Hb for
oxygen. Oxygen is therefore released rapidly in the periphery.

*The change in Hb-O2 affinity caused by changes in blood pH is referred to as

the BOHR EFFECT.

c. In what condition is 2,3-BPG concentration raised? (1mark)

Chronic hypoxia (In pulmonary emphysema, high altitudes)/

Chronic anemia.

d. Why does HbF bind weakly to 2,3-BPG compared to HbA? (1mark)***

HbF has γ-globin chains which lack some of he positively charged amino
Acids found in the β-chains that are responsible for binding 2,3-BPG.

e. Name 2 ways in which CO2 is transported in the blood. (2marks)

As bicarbonate ions (main pathway)/

Bound to the globin chain of Hb/
Dissolved in plasma.

f. Give a physiological advantage of the Haldane effect. (1mark)

In tissue capillaries, the Haldane effect causes increased pick up of CO2

because of O2 removal from the Hb/
In the lungs, there is increased release of CO2 because of O2 pick up by the Hb.

*The amount of CO2 transported in the blood is markedly influenced by the degree
of oxygenation of the blood. This is the HALDANE EFFECT.

g. Why are O2, H+ (hydrogen ion), CO2 and 2,3-BPG collectively called allosteric
effectors? (1mark)***

Their interaction at one site on the Hb moleculeaffects the binding of O2 to heme

groups at different locations on the molecule.
Benign and Malignant Neoplasia of URT

A 54 year old man went to see his family doctor complaining of difficulty in swallowing which started 2
months ago and had gotten worse over the past 1 month. He cannot eat solid foods now only semi-solid
and liquid foods. He also complained of severe pain associated with his difficulty in swallowing. His voice
has been persistently hoarse for the past 1 month. On further inquiry, he claimed to have lost weight over
the past 1 month. However, he did not suffer from cough or hemoptysis. He smokes 20 cigarettes a day for
the past 30 years. He also drinks alcohol, about 7 pints of beer a week.

a. Give a probable diagnosis for this patient. (1mark)***

Laryngeal carcinoma.

*Cough is the most common symptom of a bronchogenic carcinoma. Its absence in this case would
probably be more indicative of laryngeal carcinoma than bronchogenic/lung cancer.

b. Name two groups of this carcinoma that respond well to voice saving surgery. (2marks)***

Glottic and Supraglottic carcinoma.

c. Morphologically, what is the most common type of this lesion? (1mark)

Squamous cell carcinoma.

d. Which pattern of nasopharyngeal carcinoma shows the strongest association with EBV?
(1mk)***

Undifferentiated carcinoma.

*This is also the most common.

e. What is the treatment of choice for this type of Nasopharyngeal carcinoma (NPC)? (1mark)

Radiotherapy.

*The keratinized type of NPC is radio-resistant. It is treated by surgically resection.

f. Where do reactive nodules/ vocal cord polyps usually develop? Which group of
individuals are most at risk of developing them? (2marks)

Location- anterior one third of vocal cords

Group most at risk- heavy smokers/ individuals who impose great strain on their
vocal cords (singers’ nodules)/ individuals who suffer from stomach acid reflux.
g. Describe the histology of a nasopharyngeal angiofibroma. (1mark)

It consists of blood vessels arranged in fibrous tissue.

*This benign tumor is locally invasive and capable of eroding bone.

h. What are nasal polyps? (1mark)

They are focal protrusions of the mucosa associated with inflammation, allergy,
Mucoviscidosis/ cystic fibrosis.

*They are not true neoplasms. Histologically, a nasal polyp appears to have an
edematous mucosa with loose stroma and lots of inflammatory cells (mostly
eosinophils).
Allergic Rhinitis & Anti- asthmatic drugs.

1. A 12 year old boy visited a clinic complaining of a runny nose and sneezing that occurs, according
to his mother, especially when he plays with the family dog. Upon further questioning, it is
discovered that he has had this problem for a few years now and has been to see doctors at other
clinics before who told his mother that he is suffering from allergic rhinitis.

a) Explain briefly what is allergic rhinitis. (2marks)

Initiated by a hypersensitivity reaction to allergens (pollens, fungi, animal allergens, dust mites). It
is an immunoglobulin – mediated immune reaction. Also known as Hay fever.

b) List 3 common features of this condition. (3marks)

Marked mucosal edema, redness, mucus secretion, accompanying leukocytic infiltration.

c) If you were the doctor at the clinic, what would be your advice to this boy and his mother?
(2marks)

Advice : Stay away from situations that would lead the boy to be exposed to allergens as well
making sure conditions at home are as dust free as possible.

d) State 3 differences between asthma and allergic rhinitis. (3marks)

certain types of asthma do not require the presence of common allergens (pollen) to occur.
Asthma leads to reversible bronchoconstriction of the airways.
Little or no shedding of airway epithelium in rhinitis

2. a) Explain briefly the pathogenesis of asthma. (2marks)

Inhalled allergen interacts with IgE that is bound to the surface of mast cells interspersed among
the epithelial cells of the bronchial mucosa. The mast cells degranulate and release mediators that
produce the effects characteristic of asthma.

The body of a 20 year old woman was brought to the forensics department. Upon autopsy of the body, the
coroner’s report states that she died due to an asthmatic attack.

b) State 3 probable morphological features that the coroner has most likely seen in the lungs to have come
to the conclusion that he did. (3marks)

Curshmann spirals, Charcot – leyden crystals, thick mucous plugs occluding bronchi and bronchioles,
hypertrophy of bronchial smooth muscle.
c) Match the conditions below that contraindicate the usage of the drugs in the table. The conditions may
be used once, more than once or not at all. (3marks)

A - Diabetes

B - Children

C – Female patients

Drug Contraindications
Salbutamol A
Theophylline B
Prednisolone A

e) List 2 side effects of the usage of glucocorticoids in the treatment of asthma. (2marks)

osteoporosis, HPT, diabetes, thrush, cataract.

Tobacco and Health

1.Give 3 examples of respiratory diseases linked to tobacco. (3 marks)

(Just about everything you can think of =P) Tuberculosis, pneumonia, influenza, chronic bronchitis,
asthma, chronic airway obstruction, emphysema, lung cancer

2.Give 4 examples of cardiovascular diseases related to tobacco. (4 marks)

IHD, Hypertension, Cerebrovascular diseases, pulmonary heart disease, atherosclerosis, aortic aneurysm,
(any other cvs disease you can think of)

3.Give an example of paediatric diseases linked to tobacco. (1 mark)

Low birth weight, respiratory distress syndrome, sudden infant death syndrome.

4.What is ETS? What is its significance with reference to respiratory disease? (4 marks)

ETS is Environmental Tobacco Smoke. It contains the same carcinogens which are present in tobacco
smoke. Prolonged exposure to ETS increases risks of developing lung cancer,
asthma, bronchitis, pneumonia. It causes eye and nasal irritation. Children are the most adversely affected.

5.How can tobacco be controlled? Give 3 examples. (3 marks)

(There's a list of 9 in the notes. -_-;;)

tax tobacco heavily, prevent children from being addicted, using the taxes for control programs, eliminate
smoking among medical staff, use laws to eliminate ETS, eliminate advertising, print health warnings on
boxes, promote economic alternatives to growing tobacco, eliminate incentives that promote tobacco use.
Occupational respiratory diseases

1.What are possible allergic sensitizers in occupational rhinitis and laryngitis? Name three. (3 marks)

dusts and mites, fungi from flour; dusts from animal feed and grain; chemicals in adhesives; latex on
granules on latex gloves; pollen and mold spores; proteins from lab animals

2.What size of particles cause pneumoconioses? What happens to bigger particles? (4 marks)***

Particles up to 1 micron reach the alveoli - these are ingested by macrophages and are either cleared by
lymphatics or cause fibrosis. Bigger particles get trapped in the mucus in the upper airways.

3.The severity of lung disease caused by dust is dependent on what factors? (3 marks)

nature and properties of the dust, amount of dust retained in the lung (inhaled dose and duration of
exposure), individual reactivity of the dust

4.What are the pathologic changes seen in a lung affected by pneumoconiosis? (4 marks)

destruction of alveoli and capillaries, with fibrotic replacement fibrous cysts seen, giving a honeycomb
appearance, fibrotic thickening of respiratory bronchioles, alveolar ducts and alveoli, fibrotic thickening
and calcification of the pleura, plaques, bronchogenic carcinoma

5.What kind of granulomas, if present, are most commonly found in pneumoconioses? (1 mark)

foreign body granulomas

Obstructive and Restrictive Lung Diseases

Question 1
Define and give 2 examples each for obstructive and restrictive lung diseases.

Obstructive: ↑resistance to airflow due to partial/complete obstruction at any level of the bronchial tree.
E.g. chronic bronchitis, emphysema, asthma, bronchiectasis, bronchiolitis obliterans.
Restrictive: ↓expansion of lung parenchyma with ↓total lung capacity. E.g. Kyphoscoliosis, pleural
disease, poliomyelitis, obesity,ARDS, pneumoconiosis, sarcoidosis, extrinsic allergic alveolitis,
cryptogenic fibrosing alveolitis, lymphangitis carcinomatosis.

Question 2
Define chronic bronchitis, emphysema, asthma and bronchiectasis.

Chronic bronchitis : cough productive of sputum most days in at least 3 consecutive months for at least
2-3 consecutive years.
Emphysema : ↑beyond the normal size of airspaces distal to terminal bronchiole due to destruction of
alveoli
Asthma : chronic inflammatory disease of the airways causing ↑in airway hyperresponsiveness. This
leads to recurrent, reversible episodes of wheezing, breathlessness, chest tightness and coughing.
Bronchiectasis : permanent dilation of bronchi and bronchioles caused by destruction of muscle and
elastic supporting tissue, secondary to persisting infection/obstruction

Question 3
a. Describe the pathogenesis of ARDS

Injury to alveolar epithelium and alveolar capillary endothelium->leaky lung capillary bed->exudates
pours into interstitium, then alveolar spaces->fibrosis

b. What is hypersensitivity pneumonitis?

Hypersensitivity reaction (type III & IV) to inhaled organic antigens->formation of circulating immune
complexes->non-caseating granulomas.

c. How do you manage a patient with hypersensitivity pneumonitis?

Mainly prevention. If affected, removal of offending Ag is important, followed by high-does steroids in

initial stages. After that it’s just supportive and compensative treatment.

Question 4
a. What is pneumoconiosis?
Diffuse, usually fibrotic lung reaction to inhaled inorganic Ags.

b. List 3 types of pneumoconiosis.

Silicosis, berylliosis, asbestosis, siderosis, byssinosis

c. List 2 causes of COPD.

Smoking, α1-antitrypsin deficiency, atmospheric pollution, occupational dust exposure, repeated

bronchopulmonary infections.

d. Give 3 microscopic signs of chronic bronchitis

Hypertrophy of mucus-secreting glands, inflammatory cell infiltration, epithelial layer destruction,

squamous cell metaplasia, fibrosis of bronchial wall.

Question 5

a. What are the 3 main types of emphysema?

Centriacinar, panacinar, paraseptal(distal acinar)

b. Why is there hypoxemia in COPD?

Airway obstruction, loss of alveolar surface area, ventilation-perfusion mismatch, reduced respiratory
drive.

c. Give 3 complications of COPD

Infections, pneumothorax, cor pulmonale, secondary polycythemia, respiratory failure.

d. List 2 types of management for COPD.

Stop smoking, antibiotics(for infections), bronchodilators(β2-agonists), corticosteroids

Tuberculosis

Question 1

a. Why is TB a re-emerging disease?

Partnership with HIV – HIV weakens the immune system making it easier for (re)infection to occur. Also
there are multidrug resistant strains.

b. List 3 risk factors for TB.

Poor socioeconomic status, occupation – health care workers/miners, smoking, alcoholics, predisposing
medical conditions, geographical (↑in wet, cold climates like UK)

Question 2

a. What are the etiological agents for TB?

Mycobacterium tuberculosis, M. bovis, M. kansasii, M. avium

b. What are the 3 main categories of TB?

Primary TB, Postprimary/Secondary TB, Disseminated TB

Question 3

a. Describe the pathogenesis of Primary TB

inhaled bacteria->upper part of lower lobe/lower part of upper lobe->macrophages phagocytose bacteria
and become epitheloids->granuloma surrounded by lymphocytes and fibroblasts->necrosis of epitheloids-
>caseation. Some epitheloids become giant cells.

b. Describe the pathogenesis of postprimary TB.

Reinfection/reactivation of dormant bacteria in granuloma, usually in host with weakened immunity

c. What causes the ‘coin lesions’ in the X-rays of patients with postprimary TB?

TB granuloma becomes liquefied->contents of granuloma coughed out leaving behind a cavity, which is
seen on X-ray as coin lesion.
Question 4

a. What causes disseminated TB?

Erosion of granuloma into alveolar capillary->TB bacilli disseminated throughout body

b. Where does the hematogenous spread of TB usually occur?

Usually to organs with high O2 tension e.g. kidneys, ends of long bones, brain, meninges, lungs, lymph
nodes, spleen, vertebra

c. What is Miliary TB?

Occurs when large numbers of TB bacilli are released into bloodstream->pulmonary venous return to
heart->numerous small tubercles are scattered throughout body.

Question 5

a. List 3 different confirmatory tests to detect TB

Tuberculin test, sputum smear, CSF for meninges, FNAC of LN, biopsy of LN

b. Give 3 types of management for TB.

Bacillus Calmette-Guerin (BCG) vaccine protects against disseminated & miliary TB. DOTs, multidrug
therapy

c. Name the drugs used in TB therapy.

Isoniazid (INH), Ethambutol (EMB), Rifampicin (RIF), Pyrazinamide (PZA), Streptomycin (SM)
Anti-TB Drugs

1. Explain the mechanism of action of rifampicin, & give one possible side effect. (3 marks)

- Inhibits RNA synthesis, kills intracellular microbes.

- Liver damage with jaundice, pseudomembranous colitis, nausea, fever, ?orange tinge to body fluids.

2. Give 3 other example of 1st-line anti-TB drugs other than rifampicin. (3 marks)

- Ethambutol, streptomycin, pyrazinamide, isoniazid.

3. What are the indications for the usage of 2nd-line anti-TB drugs? (2 marks)

- Resistance to 1st-line drugs, avoidance of adverse effects of 1st-line drugs.

4. Give 2 examples of atypical mycobacteria. (2 marks)

Mycobacterium kansasii, M. marinum, M. scrofulaceum, M. avium.

Microbiology of Respiratory Infection

1. Match the following: -

a) The virus family for SARS. B

b) A very prevalent viral infection that is D
seasonal in nature.
c) Gram negative bacteria which colonies A
exhibits "hockey puck" sign.
d) Gram postivive cocci that forms beta- E
haemolytic colonies of blood agar,
e) An atypical pathogen of bacterial G
community-acquired pneumonia.

A. Moxarella catarrhalis B. Coronovirus C. Orthomyxovirus

D. Common cold E. Streptococcus pyogenes
F. Chronic bronchitis G. Legionella pneumophilia
Pathology of non-TB infective disease of the lung

1. Give 2 examples that may predispose a person to pulmonary infections. (2 marks)

- cigarette smoking, aspiration of nasopharyngeal flora, COPD etc.

2. Give 2 complications of pneumonia. (2 marks)

- lung consolidation, empyema, lung abscess, bactermic dissemination.

3. What are the laboratory tests that can be performed to confirm a diagnosis of a patient that is suspected
of having pneumonia? (3 marks)

- sputum test, blood culture, chest X-rays.

4. What are the unique microscopic morphology of a pneumocystis pneumonia, & what is the stain used?
(3 marks)

- “cotton candy” exudates, septa thickened by oedema, minimal mononuclear infiltrate in intra-alveolar
spaces.
- silver/ GIEMSA stains.
Control of Breathing

1. Define the functions of the following:- (6 marks)

(a) Inspiratory center – responsible for basic rhythm of respiration, caused by its intrinsic periodic firing.
- initiates inspiratory ramp signals.

(b) Pneumotaxic center – control the inspiratory center.

- inhibits inspiratory ramp  decreases duration of inspiration  increases
respiratory rate.

(c) Apneustic center – accelerates the depth of inspiration.

- increases the duration of inspiration with short expiratory gasps.

2. Explain how does increased PCO2 in the blood stimulates the central chemoreceptors. (2 marks)

- Increase PCO2, CO2 enters brain and cerebral spinal fluid (blood brain barrier impermeable to H+ ions).
- CO2 then hydrated into H2CO3, which then dissociates into H+ ions, which stimulates the central
chemoreceptors.

3. What is the medical condition behind Ondine’s curse? (2 marks)

- Lost of automatic control of breathing with intact voluntary control.

- Patient must remember to breathe consciously in order to survive.
Respiratory Epidemiology and Prevention

1. Name 5 risk factors in respiratory tract infections? (5 marks)

Malnutrition, low birth weight, poor housing and over crowding, indoor air pollution, outdoor air
pollution, environmental tobacco smoke, educational level of mother.

2. a) What is pneumonia and state the most common bacteria that cause pneumonia. (3 marks)

Pneumonia is an inflammatory process affecting alveoli and airways leading to consolidation of lung
parenchyma secondary to bacterial, viral or fungal infection. Streptococcus pneumonia.

(b) Name three risk factors for the above bacteria (3 marks)

old people, post viral infection, impaired immune system-malnutrition, diabetes mellitus, rheumatoid
arthritis, renal disease, leukaemia, alcoholics, cirrhosis.

3. (a) Why women and children are the most people who has chronic respiratory disease. (3 marks)
***

This is due to indoor air pollution. Air pollution indoor is 1000 times more easily affecting the
lungs than outdoor due to biomass fuel used in cooking and heating. They are those who stay in
house relatively longer than men do, who are the breadwinner in the family.

(b) Name two diseases that caused by ambient air pollution. (2 marks)***

Ambient air pollution is outdoor air pollution. Bronchitis, emphysema, pneumonia, COPD, lung
cancer, Asthma, acute respiratory disease.

(c) State what do you understand about rule 1000. (2 marks)***

It is pertaining to indoor air pollution where air pollution released indoor is 1000 times more likely
to reach people's lung.

4. Name three primary prevention methods to reduce the incident of lung cancer caused by tobacco
smoking. (3 marks)
Health promotion by preventing non-smokers from addiction to nicotine, aimed primarily at children <
10. create smoke free environment, increase cigarette prices.
Pulmonary adjustment to various activities

1. (a) What are the differences between physiological stresses in exercises and in high altitude? (3
marks)

Exercise: Increase O2 demand and Co2 production.

High altitude: decreases PO2.

(b) Why does the fractional concentration of Oxygen does not change in high altitude? (4
marks)***

The fractional concentration of O2 is not changed because the amount of oxygen is still the same
in high altitudes. That means, the fraction of oxygen in the world is 21percent and it still stays true
even in high altitude where people have difficulty in breathing. The difference is because of the
pressure, po2. It differs according to the level form the sea. Hence, in high altitude, the pressure is
lower than at the sea level. Hence, PO2 in high altitude is lower.

(c) Fill in the blanks (5 marks)

Early adaptive Chronic
Minute ventilation Increase Increase
Tidal volume Increase Increase
Arterial PO2 Decrease Decrease
Arterial PCO2 Decrease Decrease
Arterial pH Increase, no change Increase, no change
Arterial HCO3 Decrease Decrease

(d) How is the Oxygen delivery to the tissues increase in exercise? (2 marks)

Increased effect of local pH, pCo2, and temperature.

Increased ability of muscle to utilise O2

(e) Why does the pulmonary blood flow increases in exercise? (2 marks)

Increased CO – increased venous return by deeper inspiratory effect and extravascular

compression by the active muscles.
Decreased pulmonary vascular resistance which is due to recruitment of pulmonary blood vessels
in the apex and distention of pulmonary vessels.

(f) Why is there cerebral edema in high altitudes? (4 marks)

Cerebral edema is caused by increased intravascular hydrostatic pressure. Hypocapnia is a strong

cerebral vasoconstriction and results in reduced blood flow. Hypoxia, which is dominant, causes
cerebral vasodilatation. Hence, there is hyperperfusion and distension of cerebral blood vessels
leads to HACE.

(g) What are the compensation mechanisms in high altitudes? (3 marks)***

Renal compensation, which occurs within a day where excretion of base is

Increased and H, are conserved. Erythropoiesis and increased 2,3- DPG.
Pulmonary Circulation and Pulmonary Vascular Diseases

1. Give 3 differences between the systemic circulation and pulmonary circulation.

Systemic Pulmonary
high pressure system low pressure system
Arteries – oxygenated blood arteries – deoxygenated blood
veins – deoxygenated blood veins – oxygenated blood
well developed smooth muscle in vessel walls poorly developed smooth muscle in vessel walls
tissue fluid formation NO tissue fluid formation
neural and humoral regulation regulated by hypoxia and gravity
gravity effects negligible affected by gravity.

2. State 2 physiologic functions of the pulmonary circulation.

Gas exchange, nutrient supply to the alveolar ducts and alveoli, a filter to trap thrombi and other emboli,
angiotensin converting enzyme (ACE) released by the pulmonary capillaries.

3. List 3 causes of pulmonary edema.

Increased vascular hydrostatic pressure (LV failure),

reduced plasma oncotic pressure (hypoalbuminemia),
increased membrane permeability (acute respiratory distress syndrome),
drugs (narcotics, salicylates),
pulmonary infection (Influenza, TB),
inhalation injury (aspiration, smoke),
pulmonary emboli,
neurogenic (head injury, seizures…)

4. Define what a physiologic shunt is. Give an example of a physiologic shunt.

The mixing of deoxygenated blood with oxygenated blood. (?)

Anastomoses between the bronchial capillaries and pulmonary capillaries and veins.
Blood flow from the coronary arteries into the chambers of the left heart.
Blood passing through non-ventilated areas of the lung.

5. Give 2 possible symptoms you might come across in a patient with pulmonary hypertension.

Dyspnea, fatigue, syncope, peripheral edema, chest pain.

Chest Trauma
(Source: Chest Trauma lecture, R. Loh: 29/03/2005)

a) Define ‘de-acceleration’ injury. (2m)

Ans: - The thoracic cage stops but the internal viscera still moves on impact. The
internal viscera then stops suddenly.
- This causes the hollow viscera to tear away from its fixation, and spills its
contents into the body’s cavity

b) A man was admitted into the A & E department for a deep stab wound located 2cm above his left
nipple.

ii. List at least 2 pleural complications of a stab wound. (2m)

Ans: (Choose any 2) – Tension pneumothorax/ Haemothorax/ Haemopneumothorax/

Hydrothorax/ Pyopneumothorax

iii. Based on chest X-rays, it was found that the man had trapped air in his thorax.
What would his treatment be? (1m)

Ans: - Drain the air using a water seal

c) Match the following with the correct answers. (5m)

No. Statement Answer

i. Blood accumulates in the pericardial sac, leading to reduced C
ventricular filling with shock
ii. Seen in children with blunt chest injuries, due to the transmitted B
force of de-acceleration
iii. One of the pleural complications due to penetrating wounds D
iv. Lungs flap in at inspiration and flap out at expiration***(dun see A
how lung can flap)
v. Occurs when there is trauma to the lower chest or upper abdomen E

Flail chest –A
Splenic rupture –B
Cardiac temponade –C
Tension pneumothorax –D
Diaphragmatic rupture –E
Hyperventilation & Mass Sociogenic Illness (MSI)
(Source: Hyperventilation & Mass Sociogenic Illness (MSI) lecture, PJ: ?)

QUESTION 8 (10m):

a) Define mass sociogenic illness (MSI). (2m)

Ans: - A constellation of symptoms suggestive of an organic illness, but without

an identifiable cause
- Occurs among 2 or more persons who share beliefs related to the
symptoms

b) It is discovered that MSI outbreaks share several characteristics. State at least 4 characteristics of
MSI. (4m)

Ans: (Choose any four)

2 Primarily seen among adolescents/ pre-adolescents
3 More common in females
4 Transmission of MSI is by sight or audiovisual cues
5 There is no illness among other groups of people who share the same
environment with the group which has MSI
6 There is evidence of unusual physical or mental stress among those who
have MSI
7 There is no clinical or lab evidence of illness
8 Hyperventilation seen among those affected
9 There are relapses if MSI in the setting of original outbreak
10 Rapid spread and rapid resolution of the outbreak

c) Cite 3 symptoms of hyperventilating syndrome. (3m)

Ans: (Choose any 3):

1. Respiratory system 2. GI system
- Breathlessness - Sickness
- Tightness of the chest - Abdominal pain
- Sighing

3. CNS 4. CVS
- Dizziness - Tachycardia
- Feeling faint - Palpitations
- Headache
- Blurred vision

5. Tingling of the: 6. General:

- Arms - Tension
- Fingers - Panic
- Mouth - Anaemia
- Fatigue
d) A young woman panicked and was hyperventilating after she found out that
her father had a heart attack and was taken to the hospital. She now feels
dizzy, breathless, and her vision is getting blurred. What should she do to overcome her
hyperventilating attacks immediately? (1m)

Ans: - She must breathe quietly into a small paperbag for about 5 minutes
(the “brown paper-bag treatment”)

[NOTE: This treatment is used during violent hyperventilating attacks. The ‘brown paper-bag
treatment’ is done to increase the carbon dioxide levels in her blood.]