****A 13-year-old boy is brought to the emergency room by ambulance after collapsing

while playing at his school. The teacher states that while playing tag, the boy had difficulty
breathing, became tired, and fell to the ground without losing consciousness. While trying
to catch his breath, he made high-pitched inspiratory noises. On arrival at the hospital, the
boy appears lethargic and in moderate respiratory distress, with a respiratory rate of 30 per
minute. Physical examination of the chest reveals decreased breath sounds in all lung fields
with coarse rhonchi and wheezes throughout. An arterial blood gas on 50% oxygen is as
follows: pH = 7.34 PCO2 = 45 PO2 = 55 Bicarbonate = 14 Which of the following sets of
pulmonary function test results would most likely be obtained in this patient?
A. High FVC, high FEV-1, high TLC

B. High FVC, high FEV-1, low TLC

C. Low FVC, high FEV-1, low TLC

D. Low FVC, low FEV-1, high TLC

E. Low FVC, low FEV-1, low TLC

The correct answer is D. This patient is having an acute asthma attack. Asthma is an
obstructive lung disease primarily affecting air movement out of the lungs (exhalation).
The airways (especially the large bronchioles) are hypersensitive to irritating stimuli,
such as allergens and smoke. Local mast cell histamine release causes mucous secretion
and smooth muscle contraction leading to bronchoconstriction. Certain allergic "triggers"
(cats, pollen, hay, etc.) can precipitate attacks. Symptoms include coughing, difficulty
breathing, and wheezing. Physical examination of the lungs often reveals wheezes and
coarse lung sounds, although in severe cases one may hear only decreased breath sounds
and no wheezes due to very poor air flow. On pulmonary function tests asthmatics show
an obstructive pattern. Both the FEV-1 (maximum volume exhaled in one second) and the
FVC (maximum volume of air that can be exhaled in one breath) are decreased. The
hallmark of obstructive lung disease, however, is a decreased FEV-1/FVC ratio. The total
lung capacity (TLC) is often increased in acute asthma attacks as patients tend to
hyperinflate to obtain more oxygen while being unable to exhale efficiently. Thus, this
patient has a low FEV-1, a low FVC, and a high TLC.
 The
maximum expiratory flow-volume (MEFV) curves shown in the diagram above are from a
typical healthy individual (solid curve) and from a patient with pulmonary disease (dashed
curve). Which of the following is increased in the patient?
A. Airway diameter
B. Maximum expiratory flow rate

C. Radial traction of airways

D. Total lung capacity
E. Vital capacity

The correct answer is D. The dashed curve is typical of obstructive lung diseases such
as emphysema. The patient breathes at higher-than-normal lung volumes, as reflected by
the leftward shift of the dashed MEFV curve shown in the diagram. Note that the total
lung capacity (TLC) is 7 liters and the residual volume (RV) is about 3.5 liters in the
patient (dashed curve). The vital capacity (choice E), which is the difference between
TLC and RV is reduced to 3.5 liters with obstructive disease, compared to a normal value
of 5 liters (solid curve). (You should know that absolute lung volumes cannot be
determined from a MEFV test alone. An additional method is needed to measure residual
volume. However, the diagram above states that lung volumes are absolute, indicating
correct placement of the curves on the abscissa.)
The maximum expiratory flow rate (choice B) is reduced at any given lung volume in the
patient with obstructive disease (dashed curve) because the airway diameter (choice A) is
reduced. One factor that can lead to decreased airway diameter in emphysematous lungs
is the decrease in radial traction of the airways (choice C) which occurs when lung
elasticity is reduced.

***A 30-year-old otherwise healthy woman presents to her physician with complaints of
fatigue and dyspnea. Physical examination reveals normal breath sounds and the presence
of third and fourth heart sounds. Chest x-ray shows clear lung fields but right ventricular
enlargement, main pulmonary artery enlargement, and "pruning" of the peripheral
vasculature. Electrocardiogram shows right axis deviation and right ventricular
hypertrophy. Left ventricular function appears normal on echocardiography. Serologic
studies show antinuclear antibodies. Which of the following pathological findings would
this patient also show, either at autopsy or if an appropriate biopsy was taken?
A. Mural thrombus of the right atrium
B. Necrosis and scarring of the left ventricle

C. Plexogenic pulmonary vasculopathy

D. Pulmonary artery stenosis
E. Severe pulmonary fibrosis

The correct answer is C. The presentation described is classic for pulmonary

hypertension, and, more specifically, the primary idiopathic form of pulmonary
hypertension. This rare condition is suspected of being related to the collagen vascular
diseases, since up to 50% of patients have antinuclear antibodies (despite the absence of
frank presentation of other autoimmune disease). Also, a similar, known secondary form
of pulmonary hypertension is sometimes seen in patients with a wide variety of collagen
vascular diseases, including systemic lupus erythematosus, polymyositis,
dermatomyositis, systemic sclerosis, and adult and juvenile forms of rheumatoid arthritis.
A wide variety of other conditions have also been associated with secondary pulmonary
hypertension, including shunts, left atrial hypertension, chronic hypoxia, pulmonary
embolism, drug reaction, hepatic cirrhosis, and sickle cell disease. Both primary and
secondary forms of pulmonary hypertension are associated with prominent changes in the
pulmonary vasculature, which can include muscularization of smaller arterioles,
concentric hypertrophy of the intima ("onion skinning"), and a distinctive plexiform
lesion (plexogenic pulmonary vasculopathy) in which the smallest arterioles become
markedly dilated with lumens partially occluded by endothelial (or possibly
mesenchymal) cells and sometimes, thrombus. The prognosis of untreated pulmonary
hypertension is poor. However, the use of the vasodilator hydralazine with
anticoagulation can slow the course (fatal in about 3 years in untreated patients). If the
pulmonary hypertension is secondary, therapy of the primary disease can be helpful.

Unlike cor pulmonale, atrial fibrillation with mural thrombus (choice A) formation is
uncommon in primary pulmonary hypertension.

The absence of left ventricular findings on echocardiography tends to exclude myocardial

infarction as the source of the patient's findings (choice B).

The presence of enlargement of the main pulmonary artery excludes pulmonary artery
stenosis (choice D).

The clear lung fields exclude severe pulmonary fibrosis (choice E).

****A 23-year-old graduate student comes to the emergency room complaining of sudden
onset of shortness of breath while walking home from the library. He denies any significant
medical history and infrequently uses an inhaler when his asthma "acts up." He appears to
be in moderate distress and is breathing at a rate of 28/min.. On physical examination he is
afebrile and his breath sounds are normal on the right and decreased on the left. Percussion
of the left chest is hyperresonant. An anterior-posterior chest radiograph of this patient
would likely show which of the following?
A. An infiltrate in the left lower lobe
B. A radiolucency along the left chest wall
C. A wedge-shaped opacity in the left lung field

D. Fluid along the left costophrenic angle

E. Hyperinflation of both lung fields
The correct answer is B. This patient has suffered a spontaneous pneumothorax-an
accumulation of air within the pleural space often resulting in collapse of the lung.
Pneumothoraces are not uncommon. They are often caused by trauma but may also be
secondary to other lung pathology (i.e., tuberculosis, malignancy, emphysema,
pulmonary infarction, etc.). In this case, a pneumothorax has spontaneously arisen, most
likely from rupture of a bulla in the upper lung lobe. Spontaneous pneumothoraces occur
most often in young men (during the second or third decade) with a tall, slender body
habitus. Symptoms include pain and difficulty breathing. Diagnosis should be suspected
anytime there is absent or decreased breath sounds in an area that is hyperresonant to
percussion. A chest x-ray will show a radiolucency (dark area). In a large pneumothorax
with complete lung collapse, this area of radiolucency will be throughout the entire lung
field, but in a small pneumothorax it can be a long, narrow area corresponding to the
space between the chest wall and the partially collapsed lung.

A lobar infiltrate (choice A) could signify a lobar pneumonia, unlikely in this patient,
since he is afebrile and because of the sudden nature of the symptoms.

A wedge-shaped opacity (choice C) can sometimes be seen after a pulmonary infarction

from an embolus.

Fluid in the left lung field (choice D) would correlate with a pleural effusion (decreased
breath sounds, hyporesonance).

Hyperinflation of the lung fields (choice E) usually accompanies an obstructive disorder,

such as asthma (during an attack) or emphysema.

***A 65-year-old man presents with a productive cough and difficulty breathing. His
sputum culture is positive for encapsulated gram-positive cocci, which are often seen in
pairs. The patient's dyspnea is primarily due to which of the following mechanisms?
A. Inadequate perfusion
B. Inadequate ventilation
C. Increased airway resistance
 D. Increased lung compliance

E. Poor oxygen diffusion

The correct answer is E. The patient has pneumococcal pneumonia. In many bacterial
pneumonias, alveoli in large areas of the lungs fill with viscous fluid containing
proteinaceous debris and many neutrophils. This filling limits the rate at which oxygen
can diffuse into the capillary bed, and in many filled alveoli, may even completely block
oxygen diffusion into the bloodstream.

Inadequate ventilation (choice B) is not initially as important as poor diffusion.

Changes in perfusion (choice A), airway resistance (choice C), and lung compliance
(choice D) usually play lesser roles, although a perfusion/ventilation mismatch may also
develop as blood is shunted through poorly ventilated lung tissue.

The oxygen-hemoglobin dissociation curve shifts to the left under which of the following
circumstances?
A. Carbon monoxide poisoning

B. Decreased pH
C. Increased 2,3-DPG
D. Increased PCO2
E. Increased temperature

The correct answer is A. The loading of O2 is facilitated when the oxygen dissociation
curve shifts to the left, and the unloading of O2 is facilitated when the oxygen
dissociation curve shifts to the right. Carbon monoxide (CO) poisoning is extremely
dangerous for several reasons. CO left-shifts the oxygen dissociation curve, which
interferes with the unloading of O2. Also, CO, which has approximately 240 times the
affinity for hemoglobin than O2 does, preferentially binds to available sites on
hemoglobin.
The remaining answer choices all shift the oxygen-hemoglobin dissociation curve to the
right. A good way to remember the conditions that promote dissociation of O2 is to think
of exercising muscle, which has decreased pH (choice B) from lactic acid build-up and
increased PCO2 (choice D), increased 2,3-DPG (2,3-diphosphoglycerate; choice C)
because of increased glycolysis, and increased temperature (choice E).

A 62-year-old man with a 50-year-history of cigarette smoking has a complete work-up in

a pulmonary function laboratory. The table below shows pulmonary volumes and
capacities obtained using simple spirometry and helium washout techniques.

Lung Volumes Values

Functional residual capacity 5.0 L
Inspiratory reserve volume 1.5 L
Inspiratory reserve capacity 2.0 L
Vital capacity 3.5 L

What is the total lung capacity of this patient?

A. 6.5 L

B. 7.0 L

C. 7.5 L

D. 8.0 L

E. 8.5 L
The correct answer is B. The total lung capacity is the sum of the functional residual
capacity and inspiratory reserve capacity. The easiest approach to this type of question is
to construct a simple spirogram (see below) and fill in the values provided in the table.
This approach eliminates the need to memorize formulas. The missing volume or
capacity can be easily determined from the spirogram. The total lung capacity, functional
residual capacity, and residual volume are often increased in the emphysematous lungs of
patients with a long-term history of cigarette smoking.

A inspiratory reserve volume

B expiratory reserve volume
C inspiratory reserve capacity
D vital capacity
E residual volume
F functional residual capacity
G tidal volume
H total lung capacity

When watching a routine immunization injection being given to her 2-year-old brother, a
teenage girl suddenly complains of feeling faint and starts hyperventilating. A nurse has her
sit on the floor and gives her a paper bag. What is the rationale for this therapy?
 A. The higher CO2 content of the bag will correct the patient's compensated
respiratory acidosis
B. The higher CO2 content of the bag will correct the patient's compensated
respiratory alkalosis
C. The higher CO2 content of the bag will correct the patient's uncompensated
respiratory acidosis
D. The higher CO2 content of the bag will correct the patient's uncompensated
respiratory alkalosis
E. The paper bag is a placebo

The correct answer is D. Hyperventilation can be triggered by emotional stress, and the
resulting rapid breathing tends to "blow off" more CO2 from the lung than usual. Since
CO2 is carried in the serum principally as bicarbonate plus hydrogen ion, blowing off CO2
shifts the balance so that less bicarbonate and less hydrogen ion are present in the blood.
Less hydrogen ion translates to higher blood pH, i.e., alkalosis, which in this case is of
respiratory origin. It is an uncompensated respiratory alkalosis, since renal compensation
takes several days to occur. Re-breathing air, which is easily accomplished by breathing
into a paper bag, will slow the rate of CO2 loss and quickly correct the alkalosis. The
manifestations of the type of mild respiratory alkalosis seen in emotional hyperventilation
include light headaches, paresthesias, and sometimes, syncope. Severe respiratory
alkalosis (not seen in this setting) can also cause cramps, tetany, seizures, and cardiac
arrhythmias.
The volume-pressure curves shown above (TLC = total lung capacity) were obtained from
a normal subject and from a patient. Which of the following conditions best accounts for
the differences observed in the patient?
A. Asthma
B. Bronchospasm
C. Emphysema
D. Interstitial fibrosis

E. Old age

The correct answer is D. Hyperventilation can be triggered by emotional stress, and the
resulting rapid breathing tends to "blow off" more CO2 from the lung than usual. Since
CO2 is carried in the serum principally as bicarbonate plus hydrogen ion, blowing off CO2
shifts the balance so that less bicarbonate and less hydrogen ion are present in the blood.
Less hydrogen ion translates to higher blood pH, i.e., alkalosis, which in this case is of
respiratory origin. It is an uncompensated respiratory alkalosis, since renal compensation
takes several days to occur. Re-breathing air, which is easily accomplished by breathing
into a paper bag, will slow the rate of CO2 loss and quickly correct the alkalosis. The
manifestations of the type of mild respiratory alkalosis seen in emotional hyperventilation
include light headaches, paresthesias, and sometimes, syncope. Severe respiratory
alkalosis (not seen in this setting) can also cause cramps, tetany, seizures, and cardiac
arrhythmias.
 The diagram above
shows maximum expiratory flow-volume (MEFV) curves from a typical healthy individual
(solid curve) and from a patient with compromised pulmonary function (dashed curve).
Which of the following conditions is most likely represented by the dashed curve?
A. Asthma
B. Bronchospasm
C. Emphysema
D. Interstitial fibrosis

E. Old age

The correct answer is D. The maximum expiratory flow-volume (MEFV) curve is often
used as a diagnostic tool for identifying obstructive and restrictive lung diseases. In
restrictive lung diseases such as interstitial fibrosis, the MEFV curve begins and ends at
abnormally low lung volumes, and the flow rates are often higher than normal at any
given lung volume. Note on the diagram that the total lung capacity is ~3.2 liters and the
residual volume is ~0.8 liters in the patient (dashed curve). The residual volume cannot
be determined from a MEFV curve alone, so must be measured using a different
technique before the curves can be placed appropriately on the abscissa.

Lung volumes would expected to be higher than normal in asthma (choice A),
bronchospasm (choice B), emphysema (choice C), old age (choice E), and other
conditions involving narrowing of the airways or reduced radial traction of the airways,
allowing them to close more easily.
A patient with normal lungs overdoses on a secobarbital, causing hypoventilation. The
patient arrives at a hospital where the barometric pressure = 500 mmHg. Alveolar PCO2
rises to 80 mmHg and the respiratory exchange ratio is 1.0. Assuming that the patient's
condition remains unchanged, what percentage of inspired O2 will return the patient's
alveolar PO2 to normal (100 mmHg)?
A. 55

B. 40

C. 36

D. 28

E. 24

The correct answer is B. The patient is hypoventilating due to the effects of barbiturates
on respiration. This question requires use of the alveolar gas equation:

PAO2 = PIO2 – PACO2/R, where

PAO2 = the partial pressure of alveolar O2

PIO2 = the partial pressure of inspired O2

PACO2 = the partial pressure of alveolar CO2

R = respiratory exchange ratio

We know that PAO2 = 100 mmHg, PACO2 = 80 mmHg, and R = 1, so we can solve for
PIO2:
100 mmHg = PIO2 – 80 mmHg/1

PIO2 = 180 mmHg

PIO2= FO2 × (PB – PH2O), where FO2 is the fraction of inspired O2 and PB is the
barometric pressure. PH2O is the water vapor pressure in the airways and always remains
constant at 47 mmHg. Solving for FO2:

180 mmHg = FO2 × (500 mmHg - 47 mmHg)

FO2 is approximately .40.

In order for this patient to re-establish a normal value for alveolar PO2, a 40% oxygen
mixture must be inhaled. (The percent of oxygen present in the atmosphere is 21%.)

A 56-year-old woman with a 75-pack-year history of smoking cigarettes visits her

physician because of shortness of breath. The physician sends her to a pulmonary function
laboratory for a complete work-up. The table below shows pulmonary volumes and
capacities obtained using simple spirometry and helium washout techniques.

Lung volumes Amount

Functional residual capacity 4.5L
Inspiratory reserve volume 1.5L
Inspiratory reserve capacity 2.0L
Vital capacity 3.0L

What is the residual volume of this patient?

A. 1.5 L

B. 2.0 L

C. 2.5 L

D. 3.0 L

E. 3.5 L
 F. 4.0 L

The correct answer is E. Problems of this type are best approached by drawing a
spirogram (see below) and filling in the values provided in the table. This approach
eliminates the need to memorize formulas for the various pulmonary volumes and
capacities because these become obvious when the spirogram is examined. In this
particular problem, it is first necessary to calculate the total lung capacity (TLC) by
adding the functional residual capacity and inspiratory reserve capacity (TLC = 4.5 L +
2.0 L = 6.5 L). The residual volume is then calculated as the difference between TLC and
vital capacity, i.e., 6.5 L - 3.0 L = 3.5 L. The total lung capacity, functional residual
capacity, and residual volume are often increased in the emphysematous lungs of patients
with a long-term history of cigarette smoking.

A inspiratory reserve volume

B expiratory reserve volume
C inspiratory reserve capacity
D vital capacity
E residual volume
 F functional residual capacity
G tidal volume
H total lung capacity

A normal, healthy, 25-year-old man lives at the beach. His twin brother has been living in a
mountain cabin for the past 2 years. Which of the following indices would be expected to
be higher in the man living at sea level?
A. Diameter of pulmonary vessels
B. Erythropoietin production
C. Mitochondrial density in a muscle biopsy

D. Renal bicarbonate (HCO3-) excretion

E. Respiratory rate

The correct answer is A. A number of physiologic changes occur in a person living at

high altitude. The diminished barometric pressure at high altitude causes alveolar hypoxia
and arterial hypoxia. Pulmonary vasoconstriction occurs in response to alveolar hypoxia;
therefore, the diameter of the pulmonary vessels would be greater in the brother living at
sea level. All the other choices describe physiologic processes that would be enhanced by
living at high altitude.

Increased erythropoietin production (choice B), caused by arterial hypoxia, leads to

increases in hematocrit in people living at high altitude.

Mitochondrial density increases (choice C) in people chronically exposed to the

hypoxemia caused by living at high altitude.

At high altitudes, the ventilation rate increases, causing a respiratory alkalosis. The
kidney then compensates by increasing the excretion of HCO3- (choice D).
Increasing the rate of respiration (choice E) is a very useful adaptation to the hypoxic
conditions of high altitude. The primary stimulus is the hypoxic stimulation of peripheral
chemoreceptors.

In the
maximum expiratory flow-volume (MEFV) curve shown above, at which point on the
curve does airway collapse limit maximum expiratory air flow?
A. Point A

B. Point B

C. Point C

D. Point D

E. Point E
The correct answer is D. The MEFV curve shown above is created when the patient
inhales as much air as possible (point A, the total lung capacity) and then expires with
maximum effort until no more air can be expired (point E, the residual volume). The
descending portion of the curve (indicated by the downward pointing arrow) represents
the maximum expiratory flow at each lung volume along the curve. This descending
portion of the curve is sometimes referred to as the "effort independent" portion of the
curve because the patient cannot increase expiratory flow rate further when greater effort
is expended. Increased effort alone cannot produce increases in the rate of air flow
because of a very powerful limiting factor called "dynamic compression" of the airways.
A given increase in expiratory effort produces equal increases in both the alveolar
pressure (which tends to increase air flow from the lungs) and the pressure outside the
airways which tends to cause them to collapse. Note from the curve that the maximum
expiratory flow rate is greater when the lungs are filled with a large volume of air
compared to when lung volume is lower. The main reason for this decrease in maximum
expiratory flow rate at the lower lung volumes is that the diameter of the various airways
becomes smaller and therefore easier to compress at lower lung volumes.

At point B, the patient has just begun to exhale with a maximum effort, and at point C,
the patient is still exhaling with a maximum effort and the air flow rate has nearly
reached its maximum value of ~400 liters/minute.

In which of the following conditions would oxygen therapy be most effective in alleviating
hypoxia?
A. Anemia due to blood loss
B. Edematous tissues
C. Emphysema
D. Localized circulatory deficiencies

E. Right-to-left cardiac shunts

The correct answer is C. Chronic pulmonary emphysema is characterized by distention

of small air spaces distal to the respiratory bronchioles and destruction of alveolar septa.
Long-term cigarette smoking is the usual cause. The marked loss of lung parenchyma
associated with emphysema leads to a decrease in the diffusion capacity of the lungs,
which reduces their ability to oxygenate blood and remove carbon dioxide. When arterial
hypoxemia is persistent and severe, oxygen therapy should therefore be considered.

Oxygen therapy is less effective for treating the hypoxia associated with anemia (choice
A), edematous tissues (choice B), localized circulatory deficiencies (choice D), and right-
to-left cardiac shunts (choice E), because in each case, there is already adequate oxygen
available in the alveoli. The problem in each of these situations is inadequate transport of
oxygen to the tissues, blunting the effects of increasing the oxygen tension of the inspired
air. Oxygen therapy will nonetheless increase the amount of dissolved oxygen carried in
the blood, which may be life-saving in some instances.

A 15-year-old boy is subject to recurrent attacks of asthma. A careful clinical history

reveals that the asthma attacks occur most frequently after aspirin administration. Which of
the following is the pathogenetic mechanism in this form of asthma?
A. Direct release of bronchoconstrictor mediators

B. Enhanced sensitivity to vagal stimulation

C. Inhibition of cyclooxygenase pathway
D. Type I hypersensitivity reaction
E. Type IV hypersensitivity reaction

The correct answer is C. Aspirin-induced asthma is an infrequent form of asthma. It is

related to the direct pharmacologic action of aspirin on the metabolism of arachidonic
acid. Aspirin inhibits the cyclooxygenase pathway without affecting the lipoxygenase
pathway, leading to a decreased ratio of prostaglandins (bronchodilators) to leukotrienes
(bronchoconstrictors). The disrupted balance between these two groups of arachidonic
acid metabolites leads to bronchoconstriction in predisposed patients.

Direct release of bronchoconstrictor substances (choice A) is one of several pathogenetic

mechanisms that may mediate occupational asthma, triggered by inhalation of a number
of chemicals, including epoxy resins, plastics, cotton fibers, toluene, formaldehyde, and
penicillin products.

Enhanced vagal stimulation (choice B) plays an essential role in non-atopic asthma. This
variety of asthma, AKA nonreaginic asthma, is initiated by viral infections of the upper
respiratory tract (e.g., common cold and flu), which appear to lower the threshold of
respiratory mucosa to parasympathetic (vagal) stimulation. Recall that vagal stimulation
exerts a bronchoconstrictor influence on the lungs.

Type I hypersensitivity reactions (choice D) are crucial in the pathogenesis of atopic

asthma following prior exposure to a number of allergens. T-cell activation instructs B
cells to produce IgE directed against a given allergen. On re-exposure, IgE on the surface
of mast cells binds the allergen and induces mast cell degranulation. The mediators
released from mast cells cause bronchospasm and recruit more inflammatory cells,
including eosinophils, lymphocytes, and basophils.

Type IV hypersensitivity reactions (choice E) do not occur in asthma.

A pulmonologist is testing a patient's lung volumes and capacities using simple spirometry.
Which of the following lung volumes or capacities cannot be measured directly using this
technique?
A. Expiratory reserve volume

B. Functional residual capacity

C. Inspiratory reserve volume

D. Tidal volume
E. Vital capacity

The correct answer is B. The functional residual capacity is the amount of air left in the
lungs after a normal expiration. Because this volume cannot be expired in its entirety, it
cannot be measured by spirometry. Essentially, lung volume that contains the residual
volume, which is the amount of air remaining after maximal expiration (e.g., functional
residual capacity and total lung capacity), cannot be measured by spirometry. These
volumes can be determined using helium dilution techniques coupled with spirometry or
body plethysmography.

The expiratory reserve volume (choice A) is the volume of air that can be expired after
expiration of a tidal volume.

The inspiratory reserve volume (choice C) is the volume of air that can be inspired after
inspiration of a tidal volume.

Tidal volume (choice D) is the amount of air inspired or expired with each normal breath.

Vital capacity (choice E) is the volume of air expired after a maximal inspiration.

A 25-year-old man has been living in a mountain cabin for the last 2 years. He has
developed an increase in ventilation rate and a muscle biopsy reveals increased numbers of
mitochondria. Which of the following physiological changes is also expected?
A. Decreased production of erythropoietin

B. Decreased 2,3-DPG
C. Increased renal excretion of H+ ions
D. Increased renal excretion of HCO3–
E. Pulmonary vasodilation

The correct answer is D. Compensation for high altitude includes an increase in the
renal excretion of bicarbonate. The diminished barometric pressure found at high altitude
causes arterial hypoxia, which is sensed by peripheral chemoreceptors. The ventilation
rate increases, thereby causing a respiratory alkalosis. The kidney then compensates by
increasing the excretion of HCO3–. Other adaptations to high altitude are increased 2,3-
DPG, which shifts the oxygen dissociation curve to the right. This facilitates the release
of O2 in the tissues. In addition, increased erythropoietin leads to an increased hematocrit.

Erythropoietin is increased, not decreased, in chronic hypoxia and at high altitude (choice
A).

2,3-DPG is increased (not decreased; choice B) at high altitudes, shifting the oxygen
dissociation curve to the right.

High altitude leads to respiratory alkalosis. The renal compensation is a metabolic

acidosis characterized by decreased H+ excretion and increased HCO3– excretion.
Respiratory acidosis is renally compensated with a metabolic alkalosis that would include
increases in H+ excretion (choice C).

Pulmonary vasoconstriction, not vasodilation (choice E) occurs in response to alveolar

hypoxia, such as would occur at high altitudes.

A patient comes in to the doctor because of a chronic cough. He notes occasional streaks of
blood in his sputum. Chest x-ray reveals multinodular, cavitating lesions in the apical
posterior segments of both lungs with evident satellite lesions. The condition described is
likely to occur in the apices of the lungs because they
A. are better perfused than the base
B. are more acidic than the base
C. contain more alveolar macrophages than the base

D. have a higher PO2 than the base

E. ventilate better than the base

The correct answer is D. The presentation is typical for reactivation pulmonary

tuberculosis. The patient may also note fever, malaise, and weight loss. The high PO2
found in the upper portion of the lungs provides a favorable environment for growth of
Mycobacterium tuberculosis, leading to reactivation tuberculosis. (In contrast, primary
tuberculosis tends to occur in the lower and middle lobes, where small infectious particles
are most likely to lodge after being inhaled.)

Ventilation increases from the top to the bottom of the lung, so choice E is wrong.
Perfusion increases even more rapidly than ventilation, so choice A is also wrong. As a
result, the ventilation-perfusion ratio decreases from the top to the bottom of the lung.
The higher ratio at the apex of the lung results in a relatively elevated PO2 at that
location.

The apex of the lung has a higher pH than the base, so choice B is wrong. Because the
ventilation-perfusion ratio is higher at the apex, PCO2 would be lower, thus increasing the
pH.

Regional differences in the density of alveolar macrophages (choice C) are not known to
cause the described predisposition.

20

A 62-year-old woman complains to her physician that she is chronically tired. She has lost
several pounds in the past few months without a change in her diet. Blood tests indicate
she has severe anemia (Hb < 7 g/dL). Further testing shows the presence of blood products
in her stool and a large malignant tumor in her ascending colon. Which of the following is
likely to be decreased in this woman?
A. Arterial O2 content

B. Arterial O2 saturation

C. Arterial PO2
D. Cardiac output
E. Heart rate
F. Stroke volume
The correct answer is A. A decrease in the hemoglobin concentration of the blood
causes a proportional decrease in the oxygen carrying capacity of the blood. Each gram
of hemoglobin can normally carry a total of 1.34 g oxygen. Thus, each 100 mL of arterial
blood can normally carry about 20 mL oxygen at a normal hemoglobin concentration of
15 g/dL blood. With a hemoglobin concentration of 7 g/100 mL, each 100 mL of blood
can carry only 9.4 mL oxygen. The oxygen saturation of hemoglobin in the arterial blood
(choice B) and the arterial PO2 (choice C) are virtually unaffected by the hemoglobin
concentration of the blood.

The reduced oxygen-carrying capacity of the severely anemic patient is associated with a
compensatory increase in cardiac output during resting conditions, and especially during
exercise. The elevation in cardiac output helps to maintain oxygen delivery to the tissues
at an adequate level. The increase in cardiac output (choice D) is caused by an increase in
heart rate (choice E) and stroke volume (choice F).

A medical student volunteers to have his lung volumes and capacities measured for his
organ physiology laboratory class. He is connected to a spirometer containing a known
concentration of helium. He is instructed to breathe several times until the helium has
equilibrated between the spirometer and his lungs. He is then instructed to exhale as much
air as he possibly can. Calculations are made to determine the amount of air remaining in
his lungs, which is called the
A. expiratory reserve volume

B. functional residual capacity

C. inspiratory capacity
D. inspiratory reserve volume

E. residual volume
F. tidal volume
G. vital capacity
The correct answer is E. There are two ways to arrive at the correct answer to this
question. The first is to simply remember the definition of residual volume (RV): the
amount of air remaining in the lungs after maximal exhalation. The second way is to
recall that the helium dilution technique described above is used to measure functional
residual capacity (FRC) and RV, which narrows the reasonable option choices to B and E
only. All of the other volumes and capacities can be directly measured with spirometry
because they are blown into the spirometer. Only FRC and RV represent amounts of air
that remain in the lungs.

Expiratory reserve volume (choice A) is the volume expelled by an active expiratory

effort after passive expiration.

Functional residual capacity (choice B) is defined as the amount of air remaining in the
lungs after passive expiration.

Inspiratory capacity (choice C) is the maximal amount of air inspired after a passive
expiration.

Inspiratory reserve volume (choice D) is the amount of air inspired with a maximal
inspiratory effort over and above the tidal volume.

Tidal volume (choice F) is the amount of air that is inspired (or expired) with each
normal breath.

Vital capacity (choice G) is the largest amount of air that can be expired after a maximal
inspiratory effort.

Carbon dioxide is transported in blood by a variety of mechanisms. Which of the following

is quantitatively the most important method for transporting CO2?
A. As carbaminohemoglobin
B. As CO2 in gas bubbles
C. As CO2 in physical solution
D. As sodium bicarbonate in red cells

E. As sodium bicarbonate in serum

The correct answer is E. Red blood cells (and many other blood cells) contain the
enzyme carbonic anhydrase, which catalyzes the intracellular conversion of CO2 to
bicarbonate and H+ ion. Most of the bicarbonate in the red cell is exchanged across the
plasmalemma for chloride ion. This means that while the bulk of the production of
bicarbonate occurs in the red cell (choice D), the bulk of the actual transport occurs in
serum as bicarbonate. Carbonic anhydrase is not present in serum. Bicarbonate can also
be produced in serum by nonenzymatic means, but the process is slow.

CO2 is also carried as carbaminohemoglobin (choice A), which forms when CO2 binds to
an NH2 side group of the hemoglobin protein, rather than to the heme iron (Fe2+), as with
carbon monoxide and oxygen.

CO2 is not transported in the form of bubbles (choice B), which is a good thing, because
gas bubbles are effectively emboli, which can lead to considerable morbidity or death.

Some CO2 is carried directly dissolved in blood (choice C). It is 20 times more soluble in
blood than is O2.

A native to the Peruvian Andes is being studied at his home elevation of 15,000 ft. He is
found to have an arterial PO2 of 40 mm Hg, an O2 saturation of 75% , and an arterial O2
content of 20 mL O2/dL blood. An increase in which of the following makes it possible for
the arterial O2 content to be "normal" even though the arterial PO2 and O2 saturation are far
below the typical values for a person living at sea level?
A. Capillary density
B. Hematocrit
C. Hyperventilation
D. Pulmonary diffusion capacity
E. Ratio of ventilatory capacity to body mass
The correct answer is B. In full acclimatization to hypoxia, the hematocrit can increase
from a normal, sea level value of 45% to an average of 60% to 65% with a proportional
increase in blood hemoglobin levels. This increased level of hemoglobin in the blood
makes it possible to carry normal amounts of oxygen even though the arterial PO2 and
oxygen saturation are far lower than the sea level normal. Each gram of hemoglobin can
carry 1.34 mL O2. With a normal blood hemoglobin concentration of 15 g/dL and an O2
saturation of 97%, the arterial O2 content would be 15 x 1.34 x 0.97 = 19.5 mL O2/dL (not
counting dissolved oxygen). In the acclimatized Andean native with a blood hemoglobin
concentration of 20 g/dL and oxygen saturation of 75%, the O2 content would be 20 x
1.34 x 0.75 = 20.1 mL O2/dL (not counting dissolved oxygen).

A high capillary density (choice A) facilitates the exchange of nutrients (which includes
oxygen) and metabolites between the blood and tissue spaces via diffusion, but does not
affect arterial O2 content.

Hyperventilation (choice C) can lower alveolar PCO2 and therefore raise the alveolar
PO2. This is a powerful mechanism for raising the arterial PO2, but it does not affect the
O2 content at a given PO2.

The pulmonary diffusion capacity (choice D) increases at high altitude, which ensures
equilibrium of PO2 between alveolar air and pulmonary capillary blood despite the lower-
than-normal oxygen pressure gradient. However, this increase in pulmonary diffusion
capacity does not affect the O2 content at a given PO2.

Andean natives have a large chest in proportion to body size, giving a high ratio of
ventilatory capacity to body mass (choice E). The large lungs of Andean natives can
reduce the physical effort required to maintain adequate oxygenation, but this is
independent of the oxygen-carrying capacity of their blood.

A term neonate is born after a long, difficult delivery. The baby has an APGAR score of 3,
so arterial blood is drawn for blood gas studies 3 minutes after delivery. Arterial blood gas
studies show a PO2 of 10 mm Hg, PCO2 of 27 mm Hg, and pH of 7.09. Which of the
following is the best interpretation of these studies?
A. Markedly decreased PCO2, suggesting hyperventilation

B. Markedly decreased pH, suggesting acidosis

C. Markedly decreased PO2, suggesting respiratory failure
 D. Markedly increased pH, suggesting alkalosis
E. Within normal limits

The correct answer E. This is something of a trick question, but it is included to

illustrate a specific point of which you should be aware. The biochemistries of neonates,
especially in the first minutes to hours of life, can be strikingly different from those of
adults. Specifically, the normal range of arterial blood pH at birth is 7.11 to 7.36; the
normal range of PO2 at birth is the strikingly low 8 to 24 mm Hg; and the normal range of
PCO2 at birth is the low 27 to 40 mm Hg.

PCO2 (choice A) is normally lower for infants than adults.

pH (choices B and D) may vary over the first few hours of life in infants who
subsequently do well from 7.09 to 7.50 (a range broader than reported "normals" in the
question stem, but still not necessarily clinically significant).

PO2 (choice C) can be very low at birth but comes up during the first day of life, when it
may still normally be as low as 54 mm Hg.

A healthy 42-year-old woman with a history of anxiety attacks sits in the hospital waiting
room as her 3-year-old daughter undergoes open heart surgery for a septal malformation.
The woman experiences a feeling of suffocation and is obviously hyperventilating. She
informs her husband that she feels faint and has blurred vision. Which of the following is
most likely to relieve the symptoms caused by hyperventilation?
A. Breathing a 10% oxygen/90% nitrogen mixture

B. Breathing 100% nitrogen

C. Breathing in and out of a plastic bag
 D. Intravenous administration of bicarbonate
E. Lying down

The correct answer is C. Hyperventilation associated with states of anxiety can lead to
feelings of faintness, suffocation, tightness in the chest, and blurred vision. Individuals
undergoing such an attack may not be aware of overbreathing. The anxious,
hyperventilating woman is "blowing off" carbon dioxide, which lowers her arterial PCO2.
Many of the symptoms associated with anxiety attacks are probably caused by a decrease
in cerebral blood flow secondary to low arterial PCO2. Recall that carbon dioxide is a
major regulator of cerebral blood flow, i.e., carbon dioxide dilates the brain vasculature,
and conversely, the vasculature constricts when carbon dioxide levels are low. The
decrease in cerebral blood flow leads to cerebral hypoxia, which is probably responsible
for the fainting and blurred vision. An attack may be terminated by breathing in and out
of a plastic bag because this can increase carbon dioxide levels in the blood. Inhaling a
5% carbon dioxide mixture would also be effective.

Breathing a mixture of 10% oxygen/90% nitrogen (choice A) or 100% nitrogen (choice

B) can decrease oxygen delivery to the brain and thereby worsen the symptoms caused by
hyperventilation.

Hyperventilation results in hypocapnia (low PCO2), which causes alkalosis (high blood
pH). Bicarbonate (choice D) should not be administered to an alkalotic patient.

The feelings of faintness and blurred vision resulting from hyperventilation are not
relieved by lying down (choice E).
 Arterial oxyhemoglobin 97%
Arterial partial pressure of oxygen 100 mm Hg
Arterial oxygen content 97 mL oxygen/L blood
Mixed venous oxyhemoglobin 50%
Mixed venous partial pressure of oxygen 35 mm Hg
Mixed venous oxygen content 47 mL oxygen/L blood
Cardiac output 6 L/min

Arterial oxyhemoglobin 97%

arterial partial pressure of oxygen 100mm Hg

Arterial oxygen content 97 mL oxygen/L blood

Mixed venous oxyhemoglobin 50%

mixed venous partial pressure of oxgen 35 mm Hg

Mixed venous oxygen content 47 mL oxygen/L blood

cardiac output 6 L/min

A 25-year-old man weighing 150 pounds has lost both kidneys to renal disease and
undergoes hemodialysis therapy 3 days each week. He becomes severely anemic
(hemoglobin = 7.0 g/dL) because his kidneys are no longer producing erythropoietin. The
data above were obtained from the patient during resting conditions. What is his resting
oxygen consumption?
A. 100 mL/min

B. 150 mL/min

C. 200 mL/min

D. 250 mL/min

E. 300 mL/min
The correct answer is E. Oxygen consumption can be calculated using the Fick equation
as follows: oxygen consumption = cardiac output x (arterial O2 content - venous O2
content). Therefore, oxygen consumption = 6 L/min x (97 mL O2/L - 47 mL O2 /L) = 6
L/min x (50 mL O2/L) = 300 mL O2 /min. Note that each liter of blood loses 50 mL of
oxygen as it passes through the tissues. Because 6 liters of blood pass through the tissues
each minute, and because each liter of this blood loses 50 mL of oxygen, a total of 300
mL of oxygen are used by the tissues each minute.

A couple presents to a clinic for work-up of infertility after 5 years of unprotected

intercourse. The wife denies any medical problems and notes regular menstrual cycles. The
husband states that he has had chronic sinusitis and lower respiratory tract infections.
Physical examination of the woman is unremarkable. Examination of the man is
remarkable for dextrocardia. Further work-up of the husband will most likely reveal
A. azoospermia
B. germinal cell aplasia
C. immotile sperm
D. isolated gonadotropin deficiency

E. varicocele

The correct answer is C. The husband is suffering from Kartagener's syndrome, an

autosomal recessive disorder characterized by infertility, situs inversus, chronic sinusitis,
and bronchiectasis. The underlying cause of these varied manifestations are defects in the
dynein arms, spokes of microtubule doublets of cilia in the airways and the reproductive
tract. Since sperm motility is dependent on the functioning of cilia, infertility frequently
accompanies this disorder. Situs inversus occurs because ciliary function is necessary for
cell migration during embryonic development.

Azoospermia (choice A) is not a feature of Kartagener's syndrome, as sperm production

or survival is not affected in this disorder.

Germinal cell aplasia (choice B), also known as Sertoli only syndrome, is characterized
by oligospermia or azoospermia.

Isolated gonadotropin deficiency (choice D) is characterized by delayed or incomplete

pubertal maturation.

Varicocele (choice E) results in an increased testicular temperature, decreasing the count

of normal, viable sperm.

Under normal conditions, the main drive for respiration is

A. arterial PCO2 acting through central chemoreceptors
B. arterial PCO2 acting through peripheral chemoreceptors

C. arterial pH acting through central chemoreceptors

D. arterial pH acting through peripheral chemoreceptors

E. arterial PO2 acting through central chemoreceptors

F. arterial PO2 acting through peripheral chemoreceptors

G. Hering-Breuer reflex

The correct answer is A. The most important factor in the control of minute-to-minute
ventilation is arterial PCO2, which influences chemoreceptors located near the ventral
surface of the medulla. As arterial PCO2 rises, CO2 diffuses from cerebral blood vessels
into the cerebrospinal fluid. Carbonic acid is formed and dissociates into bicarbonate and
protons. Protons directly stimulate these central chemoreceptors, resulting in
hyperventilation. Hyperventilating reduces the PCO2 in the arterial blood and
subsequently in the CSF.
Peripheral chemoreceptors located in the carotid and aortic bodies respond to increases in
PCO2 (choice B), but are less important than the central chemoreceptors. It is estimated
that when a normal subject hyperventilates in response to inhalation of CO2, less than
20% of the response can be attributed to the peripheral receptors. However, they respond
more quickly than their central counterparts, and are thought to play a role in regulating
ventilation after abrupt changes in PCO2.

There are no known central chemoreceptors that respond to arterial pH (choice C).

Carotid chemoreceptors (choice D) cause hyperventilation in response to decreases in

arterial pH. However, the CO2 acting through central chemoreceptors is the most
important regulator of ventilation under normal conditions.

There are no known central chemoreceptors that respond to arterial PO2 (choice E).

Peripheral chemoreceptors located in the carotid and aortic bodies respond to decreases in
PO2 (choice F) and are solely responsible for the increase in ventilation due to arterial
hypoxemia. However, the CO2 acting through central chemoreceptors is the most
important regulator of ventilation under normal conditions.

There are two types of Hering-Breuer reflexes (choice G). The Hering-Breuer inflation
reflex increases the duration of expiration after steady lung inflation. The Hering-Breuer
deflation reflex causes a decrease in the duration of expiration produced by substantial
deflation of the lung. The degree of lung inflation is sensed by pulmonary stretch
receptors thought to reside within the smooth muscle of the airways. This reflex was once
thought to be an extremely important mechanism for regulation of ventilation. However,
it is now known that this reflex does not become active unless tidal volumes exceed one
liter (as in exercise). This reflex may also be important in newborns.

A 72-year-old man visits his physician because of a cough that has persisted for several
months. The man thinks he was exposed to asbestos for 4 years in his late fifties at an
insulation factory. A chest X-ray shows mottling. The table below shows pulmonary
volumes and capacities obtained using simple spirometry and helium washout techniques.

Lung volumes Amount

Functional residual capacity 2.0L
Inspiratory reserve volume 1.5L
Inspiratory reserve capacity 2.0L
 Vital capacity 3.3L
Tidal volume 0.5L

What is the total lung capacity of this patient?

A. 2.0 L

B. 3.0 L

C. 4.0 L

D. 5.0 L

E. 6.0 L

The correct answer is C. The total lung capacity is the sum of the functional residual
capacity and inspiratory reserve capacity. Problems of this type are best approached by
drawing a spirogram (see below) and filling in all values provided in the table. This
approach eliminates the need to memorize formulas for the various pulmonary volumes
and capacities because these become obvious when the spirogram is examined.

The presence of asbestos in the lungs can cause an interstitial process that slowly
develops into diffuse pulmonary fibrosis after a long latent period. Pulmonary fibrosis
decreases lung compliance and increases the elasticity of the lungs. Patients with
asbestosis usually have a decrease in total lung capacity, functional residual capacity, and
residual volume.
A - inspiratory reserve volume; B - expiratory reserve volume; C- inspiratory reserve
capacity; D - vital capacity; E - residual volume; F - functional residual capacity; G - tidal
volume; H - total lung capacity.

The
maximum expiratory flow-volume curve shown above was obtained from a normal,
healthy volunteer. Which point on the curve represents residual volume?
A. Point A

B. Point B

C. Point C

D. Point D

E. Point E
The correct answer is E. The maximum expiratory flow-volume (MEFV) curve is
created when the patient inhales as much air as possible and then expires with maximum
effort until no more air can be expired. The amount of air that remains in the lungs after
maximal expiration is the residual volume, and is depicted by point E. Note that the
absolute value of the residual volume cannot be determined from a MEFV curve alone.
Additional studies, such as helium dilution, are needed to determine the absolute value.

Choice A is the lung volume at the total lung capacity; however, absolute lung volumes
cannot be determined from a MEFV curve without additional methods. The other points
on the curve correspond to the following:

At choice B, the patient has just begun to exhale with a maximum effort at this point.

At choice C, the patient is exhaling with a maximum effort and the rate of air flow has
reached its maximum value of nearly 400 liters/minute at this high lung volume.

The descending portion of the curve (choice D) represents the maximum expiratory flow
at each lung volume along the curve. This portion of the curve is sometimes referred to as
the "effort-independent" portion of the curve because the patient cannot increase
expiratory flow rate further by expending greater effort.

A 12-year-old girl has been severely anemic (Hb = 6.0 g/dL) for several months. Which of
the following is most likely to be decreased during resting conditions?
A. 2,3-diphosphoglycerate
B. Arterial PO2
C. Cardiac output
D. Mixed venous PO2
E. Red blood cell H+ concentration
The correct answer is D. Oxygen delivery to the tissues is approximately equal to
cardiac output x hemoglobin concentration x the amount of oxygen extracted from the
blood (oxygen extraction = arterial oxygen content - venous oxygen content). Some of
the compensatory mechanisms that come into play in an anemic person with a low
hemoglobin content include the following: increased levels of 2,3 diphosphoglycerate
(2,3-DPG; choice A), increased cardiac output (choice C), and increased red blood cell
H+ concentration (choice E). The increase in 2,3-DPG and red blood cell H+
concentration cause the oxygen-hemoglobin dissociation curve to shift to the right, which
facilitates unloading of oxygen in the tissues.

The arterial PO2 (choice B) and arterial oxygen saturation of hemoglobin are independent
of hemoglobin concentration. However, a decrease in the hemoglobin concentration of
the blood causes a proportionate decrease in the oxygen-carrying capacity of the blood.
(Think of a glass beaker containing a solution of hemoglobin. If a gas having a PO2 of
100 mm Hg is bubbled through the solution, the PO2 of the solution will be 100 mm Hg
regardless of the hemoglobin concentration. However, if the concentration of hemoglobin
in the beaker is doubled, the beaker will now contain twice as much oxygen.) Because
each gram of hemoglobin can normally carry a total of 1.34 g oxygen, the arterial oxygen
content of this patient can be calculated as follows: 1.34 mL O2/g Hb x 6.0 g Hb/dL blood
= 8.04 mL O2/dL blood (normal = 20 mL O2/dL blood). When the oxygen content of the
arterial blood is decreased to only 8 mL O2 /dL, the loss of oxygen to the tissues will
cause the venous oxygen tension to fall to lower-than-normal levels during rest and to
very low levels whenever exercise is attempted.

A 51-year-old male smoker presents with fever and a cough productive of greenish-yellow
sputum. The patient states that he has had a morning cough with excessive mucus
production for the past 5 years. Which of the following abnormalities would most likely be
found in this patient?
A. Apical cavitary lesions on x-ray
B. Curschmann spirals in his sputum
C. Elevated salt levels in his sweat
D. Enlarged hilar lymph nodes on x-ray

E. Increased Reid index

The correct answer is E. This patient presents with symptoms suggestive of acute
infection (elevated temperature, greenish-yellow sputum) on a background of chronic
bronchitis, which is common in smokers. Hyperplasia and hypertrophy of mucous glands
in chronic bronchitis causes them to be present at deeper levels in the bronchial wall than
usual. The ratio of the gland depth to the total thickness of the bronchial wall is termed
the Reid index, which would be increased in this patient.

Apical cavitary lesions (choice A) might be indicative of cavitary tuberculosis. This

condition is not associated with excessive mucus production. Hemoptysis and weight loss
might also be expected as clinical findings.

Curschmann spirals (choice B) are found in asthmatic patients and represent mucus casts
of small airways. This patient does not have the typical episodic history of acute
asthmatic attacks with acute dyspnea as the major clinical problem.

Elevated sodium chloride levels in sweat (choice C) are present in cystic fibrosis. This
condition has an onset in early life and is associated with excessive production of thick
mucus, which predisposes to infection of the airways and permanent damage.

Enlarged hilar lymph nodes (choice D) might suggest bronchogenic carcinoma or a

granulomatous process, which would be less likely than chronic bronchitis. In addition,
patients with carcinoma often present with hemoptysis and weight loss, rather than
excessive mucus production.
 The volume-
pressure curves shown above were obtained from a normal subject and a patient. Which of
the following abnormalities is most likely in this patient?
A. Adult respiratory distress syndrome

B. Asbestosis
C. Emphysema
D. Pulmonary edema
E. Sarcoidosis

The correct answer is C. Histological examination of the emphysematous lung shows

loss of alveolar walls with destruction of associated capillary beds. This loss of lung
tissue reduces the elastic recoil of the lung and increases the pulmonary compliance, i.e.,
increases the distensibility of the lungs. [Recall that compliance = volume/pressure.] Note
that the volume-pressure curve of the patient is displaced to the left and has a steeper
slope compared to normal. The increase in compliance associated with emphysema is not
reversible.
Adult respiratory distress syndrome (choice A), asbestosis (choice B), and sarcoidosis
(choice E) all cause decreased pulmonary compliance.

Pulmonary edema (choice D), e.g., from congestive heart failure or valvular disease,
decreases pulmonary compliance.

A 21-year-old woman attempted suicide by taking an overdose of barbiturates. On arrival

in the emergency department, her blood pressure is 95/65 and her pulse is 105 per minute.
The physician in the intensive care unit orders arterial blood gases. Which of the following
values would you expect in this patient?
A. PO2 = 45, PCO2 = 45, pH = 7.45

B. PO2 = 55, PCO2 = 70, pH = 7.50

C. PO2 = 65, PCO2 = 35, pH = 7.45

D. PO2 = 75, PCO2 = 60, pH = 7.30

E. PO2 = 98, PCO2 = 60, pH = 7.20

The correct answer is D. Barbiturate overdose causes respiratory depression, resulting in

carbon dioxide retention (producing increased PCO2 and decreased pH) and hypoxemia
(decreased PO2). In other words, the patient has respiratory acidosis. You should look for
a low PCO2, high CO2, and acidotic pH. Choices A, B, C, and E do not fulfill these
requirements. Note that choice C might be expected in a patient who is hyperventilating
to the point of respiratory alkalosis: diminished O2 (the usual drive for hyperventilation in
nonpsychiatric hyperventilation), diminished CO2, and mildly alkalotic pH.
A medical student, whose baseline alveolar PCO2 level was 40 mm Hg, begins to
voluntarily hyperventilate for an experiment during his respiratory physiology laboratory.
If his alveolar ventilation quadruples and his CO2 production remains constant,
approximately what will be his alveolar PCO2?
A. 4 mm Hg

B. 10 mm Hg

C. 20 mm Hg

D. 80 mm Hg

E. 160 mm Hg

The correct answer is B. When you hyperventilate, CO2 is blown off. The amount of
CO2 blown off is inversely proportional to alveolar ventilation. This is shown by the
alveolar ventilation equation:

VA = VCO2/PACO2, where

VA = alveolar ventilation

VCO2 = CO2 production

PACO2 = alveolar PCO2

So, if VCO2 remains the same, and VA quadruples, PACO2 must decrease by 4 fold; 40
mm Hg decreases to 10 mm Hg.

Which of the following cells play a crucial role in the pathogenesis of alveolar-capillary
damage in adult respiratory distress syndrome (ARDS)?
A. CD4-positive lymphocytes
 B. CD8-positive lymphocytes

C. Eosinophils
D. Mast cells
E. Neutrophils

The correct answer is E. ARDS, pathologically referred to as diffuse alveolar damage, is

a clinical syndrome of acute respiratory failure resulting from diffuse injury to the
alveolar/capillary barrier. Such injury may be caused by a great variety of initiating
insults, the most frequent of which are shock, severe trauma, sepsis, and gastric
aspiration. All these different forms of injury result in recruitment of neutrophils within
the alveolar capillaries. Neutrophils release chemokines that attract histiocytes and
produce oxygen radicals, prostaglandins, and proteases that damage alveolar epithelium.
Formation of hyaline membranes is due to a combination of plasma fluid extravasation
and alveolar cell necrosis.

CD4+ (helper) lymphocytes (choice A), CD8+ (cytotoxic) lymphocytes (choice B),
eosinophils (choice C), and mast cells (choice D) have been implicated in a number of
pulmonary diseases, but not in diffuse alveolar damage.

A 55-year-old man walks into clinic, breathing heavily and complaining of dyspnea and
constant fatigue. On physical examination, the physician observes a "barrel chest"
(expanded, with increased anteroposterior diameter) and hypertrophy of the accessory
respiratory muscles. No cyanosis is evident. The man states that he has been smoking two
packs of cigarettes/day for 30 years. Occasionally, he develops episodes of nonproductive
cough, each lasting a few days, but he denies asthma attacks. Blood gas analysis shows
minimal hypoxemia and normal CO2. Respiratory volumes are characterized by reduced
forced expiratory volume/second (FEV1), markedly increased residual volume, and
increased total lung capacity. Which of the following underlying pathogenetic mechanisms
is most likely responsible for this patient's condition?
A. Airway obstruction

B. Bronchospasm
C. Chest wall deformity

D. Interstitial infiltration

E. Loss of elastic recoil

The correct answer is E. This patient is the classic pink puffer with chronic obstructive
pulmonary disease (COPD). COPD is an umbrella term that refers to overlapping clinical
conditions resulting from a combination of emphysema, asthma, bronchiectasis, and
chronic bronchitis. If emphysema is predominant, patients with COPD have severe
dyspnea (puffers), scanty sputum production, and nearly normal O2 arterial pressure, and
thus no cyanosis (pink). Loss of elastic recoil is characteristic of emphysema, which is
due to destruction of alveolar walls and enlargement of airspaces distal to terminal
bronchioles. Destruction of the pulmonary elastic fibers brings about increased resistance
to airflow, which is reflected by an increased FEV1. The lungs become overexpanded;
while total pulmonary capacity increases, the functioning lung parenchyma decreases.

Airway obstruction (choice A) is prevalent in patients who have COPD with predominant
chronic bronchitis, ie, blue bloaters. Decreased PaO2 manifests with cyanosis (blue), and
bronchitis causes abundant sputum production. Pulmonary hypertension and right
ventricular overload produce peripheral edema (bloaters). The patient in this case does
not fit this description.

Bronchospasm (choice B) is associated with asthma, a frequent component of COPD.

Attacks of asthma are due to spasm of bronchiolar smooth muscles, resulting in increased
resistance to expiration. The clinical history clearly rules out bronchospasm as the
fundamental mechanism of this patient's condition.

Chest wall deformity (choice C), such as severe kyphoscoliosis and obesity, and
interstitial infiltration (choice D), usually due to interstitial fibrosis, are responsible for
restrictive pulmonary disease. Restrictive pulmonary disease leads to decreased lung
compliance and reduction in all respiratory volumes. The barrel-chest deformity of this
patient is a consequence, not a cause, of the underlying pathologic change, ie,
overexpansion of lungs.

A 60-year-old nursing home patient is transferred to the hospital in respiratory distress.

Portable chest x-ray demonstrates a heavy shadowing of the right middle and right lower
lobes. Gram's stain of sputum shows large numbers of lancet-shaped, gram-positive
diplococci. Arterial blood gases reveal a P02 of 50 mm Hg. Which of the following
mechanisms most likely accounts for this patient's hypoxia?
A. Decreased surface area of alveolar capillary membranes

B. Decrease of P02 in inspired air

C. Hypoventilation of central origin
D. Hypoventilation of peripheral origin
E. Inequalities of ventilation and perfusion

The correct answer is E. The patient has lobar pneumococcal pneumonia of the right
middle and right lower lobes. Respiratory distress in lobar pneumonia is predominately
due to inequalities of ventilation and perfusion, since the dilated vessels of the involved
lobes transmit a higher-than-usual percentage of the blood passing through the lungs at
the same time that the alveolar fluid prevents normal ventilation of the affected areas.
Inequalities of ventilation and perfusion also can contribute to hypoxemia in chronic
obstructive pulmonary disease, atelectasis, pulmonary infarction, tumors, and
granulomatous diseases.

Decreased surface area of alveolar capillary membranes (choice A) is seen following lung
resection and in diseases such as emphysema.

Decrease of P02 in inspired air (choice B) is seen at high altitude and during artificial
ventilation if the fractional O2 content setting is incorrect.
Hypoventilation of central origin (choice C) is seen with morphine and barbiturate
overdose.

Hypoventilation of peripheral origin (choice D) is seen with acute poliomyelitis, chest

trauma, suffocation, drowning, phrenic nerve paralysis, and Pickwickian syndrome.

A three-year-old child is brought to the emergency room after inhaling a peanut. The
peanut has lodged in the right mainstem bronchus, largely occluding it. The child is
cyanotic, and non-invasive transcutaneous monitoring reveals a PO2 of 60 mm Hg. Which
of the following mechanisms best accounts for the child's hypoxemia?
A. Decreased capacity of pulmonary diffusion

B. Decreased PO2 in inspired air

C. Hypoventilation of central origin
D. Hypoventilation of peripheral origin
E. Inequalities of ventilation and perfusion

The correct answer is E. Inequalities of ventilation and perfusion contribute to hypoxia

in many settings. In this case, blood goes to both lungs (perfusion), but air is prevented
from entering one of the lungs (ventilation). Because the right lung is being perfused, but
not ventilated, hypoxemia ensues when the deoxygenated blood from the right lung
mixes with oxygenated blood from the left lung. If the inadequate ventilation of the lung
persists long enough, the lung tissue itself can be damaged, causing a secondary local
dilation of arterioles, making the problem even worse. Peanuts are notorious for
producing this type of problem in young children because of their size and shape, which
allows them to lodge in the trachea or main bronchus after aspiration.

Decreased diffusion capacity (choice A) can occur when the blood-gas barrier is
thickened (e.g., diffuse interstitial fibrosis, sarcoidosis, asbestosis, respiratory distress
syndrome), when the surface area of the blood-gas barrier is reduced (e.g.,
pneumonectomy, emphysema), or when less hemoglobin is available to carry oxygen
(e.g., anemia, pulmonary embolism).

Decreased PO2 in inspired air (choice B) is seen at high altitudes and when the settings
are wrong during artificial ventilation.

Hypoventilation of central origin (choice C) is seen in morphine and barbiturate

overdose.

Hypoventilation of peripheral origin (choice D) is seen in poliomyelitis and chest trauma.

40

The
maximum expiratory flow-volume curve shown above is created when the patient inhales
as much air as possible and then expires with maximum effort until no more air can be
expired. What is the forced vital capacity of this patient?
 A. 1.5 Liters

B. 2.5 Liters

C. 3.5 Liters

D. 4.5 Liters

E. 6.0 Liters

The correct answer is D. The forced vital capacity (FVC) is the difference in volume
between the total lung capacity (TLC) and the residual volume (RV). The TLC and RV
are represented on the diagram as the points of intersection between the abscissa and
flow-volume curve: TLC = 6 L and RV = 1.5 L. Therefore, FVC = 6 - 1.5 = 4.5 Liters.
Although the diagram shows absolute lung volumes, these cannot be obtained from a
forced expiration without first determining the residual volume using other methods (for
the same reason that TLC and RV cannot be determined using a spirometer). However, it
is still possible to determine FVC because this is the difference between TLC and RV, and
differences in volume can be determined from a forced expiration diagram.

Which of the following would shift the oxygen-hemoglobin dissociation curve to the right?
A. Carbon monoxide poisoning

B. Decreased PCO2
C. Decreased pH
D. Decreased temperature
E. Decreased 2,3-DPG
The correct answer is C. The loading of O2 is facilitated when the oxygen dissociation
curve shifts to the left, and the unloading of O2 is facilitated when the oxygen
dissociation curve shifts to the right. A good way to remember the conditions that
promote dissociation of O2 is to think of exercising muscle, which has decreased pH
(choice C) because of the accumulation of lactic acid, increased PCO2 (compare with
choice B) because of the increased rate of aerobic metabolism, increased temperature
(compare with choice D), and increased 2,3-DPG (2,3-diphosphoglycerate; compare with
choice E) because of increased glycolysis.

Carbon monoxide poisoning (choice A) left-shifts the oxygen dissociation curve, which
interferes with the unloading of O2. Carbon monoxide also strongly binds to available
sites on hemoglobin.

The maximum
expiratory flow-volume (MEFV) curves shown in the diagram above are from a typical
healthy individual (solid curve) and from a patient with pulmonary disease (dashed curve).
Which of the following is increased in the patient?
A. Pulmonary compliance
B. Radial traction of airways

C. Residual volume
D. Total lung capacity
E. Vital capacity

The correct answer is B. Because the airways are tethered to the lung parenchyma,
radial traction of the airways decreases when lung volume decreases, causing the airway
diameter to decrease with each decrease in lung volume. The dashed curve is typical of a
patient with restrictive lung disease such as interstitial fibrosis. The airways are tethered
more strongly to the lung parenchyma in interstitial fibrosis (and the overall elasticity of
the lung is increased), which causes the airways to be held open to a greater extent at
each lung volume (i.e., radial traction is greater). This increase in radial traction and
subsequent increase in airway diameter causes the maximum expiratory flow rate to be
higher at any given lung volume, as shown by the dashed curve in the diagram. The
increase in fibrous material in the lung causes the pulmonary compliance (choice A) to
decrease.

The MEFV curve in restrictive lung disease (dashed curve) begins and ends at
abnormally low lung volumes, and the flow rates are often higher than normal at a given
lung volume. Note that the total lung capacity (TLC, choice D) is ~3.2 liters and the
residual volume (RV, choice C) is ~0.8 liters in the patient (dashed curve). The vital
capacity (choice E), which is the difference between TLC and RV thus is reduced to ~2.4
liters in the patient, compared to a value of 5 liters in the healthy individual (solid curve).
Note that absolute lung volumes cannot be determined from a MEFV test alone. An
additional method is needed to measure residual volume. However, the diagram above
states that lung volumes are absolute, indicating correct placement of the curves on the
abscissa.
An emphysema patient is breathing quickly and shallowly. A friend tells the patient that he
is breathing too fast, and suggests the patient instead breathe deeply and slowly. The
patient complies, then begins to turn blue. What happened?
A. The decreased compliance of the alveoli collapses them
B. The decreased compliance of the large airways collapses them
C. The increased compliance of the alveoli collapses them
D. The increased compliance of the large airways collapses them
E. Changes in compliance play no role in the observed pathophysiology

The correct answer is D. In emphysema, the compliance of both the lung parenchyma
and the weakened bronchi is markedly increased. This change in compliance can create
the paradoxical situation that forced expiration may compress the larger airways
(dynamic compression), trapping air in the alveoli, rather than allowing air exchange.
Thus, the best breathing strategy for these patients is taking short, rapid breaths that do
not cause collapse of airways.

Changes in alveolar compliance (choices A and C) are not implicated in this

phenomenon.

Decreased compliance of the large airways (choice B) would make dynamic compression
less likely to occur.

Choice E is incorrect, as changes in airway compliance are fundamental to the observed

pathophysiology.

A patient is placed on a ventilator in the intensive care unit. The patient has an anatomic
dead space of 150 ml. If the ventilator has a dead space of 350 ml and a rate of 20/min,
what tidal volume should be selected for the ventilator to provide an alveolar ventilation of
6 liters/minute?
A. 1200 ml

B. 1000 ml
 C. 800 ml

D. 600 ml

E. 400 ml

The correct answer is C. Recall that total ventilation is equal to alveolar ventilation plus
dead space ventilation. This can be expressed mathematically as: VT × n = VA × n + VD×
n, where

VT = tidal volume

VA = the volume of alveolar gas in the tidal volume

VD = dead space

n = respiratory frequency

All you have to do to calculate the answer to this question is to plug the given values into
this equation and solve for VT. Realize also that the dead space is the combined dead
space of the patient and the ventilator: 150 ml + 350 ml = 500 ml. Do not forget to check
your units–you need to convert 6 l/min to 6000 ml/min.

(VT) × (20/min) = (6000 ml/min) + (500 ml) × (20/min)

(VT) × (20/min) = 16,000 ml/min

VT = 800 ml
A medical student volunteers to have his lung volumes and capacities measured for his
organ physiology laboratory class. He is connected to a spirometer containing a known
concentration of helium. He is instructed to breathe several times until the helium has
equilibrated between the spirometer and his lungs. He is then instructed to exhale as much
air as he possibly can. Calculations are made to determine the amount of air remaining in
his lungs. This quantity is known as the
A. expiratory reserve volume

B. functional residual capacity

C. inspiratory capacity
D. inspiratory reserve volume

E. residual volume
F. tidal volume
G. vital capacity

The correct answer is E. There are two ways to arrive at the correct answer to this
question. The first is to simply remember the definition of residual volume (RV): the
amount of air remaining in the lungs after maximal exhalation. The second way is to
recall that the helium dilution technique described above is used to measure functional
residual capacity (FRC) and RV, which narrows the reasonable option choices to only B
and E. All of the other volumes and capacities listed in the question options can be
directly measured with spirometry. Only FRC and RV represent amounts of air that
remains in the lungs.
Expiratory reserve volume (choice A) is the volume expelled by an active expiratory
effort after passive expiration.

Functional residual capacity (choice B) is defined as the amount of air remaining in the
lungs after passive expiration.

Inspiratory capacity (choice C) is the maximal amount of air inspired after a passive
expiration.

Inspiratory reserve volume (choice D) is the amount of air inspired with a maximal
inspiratory effort over and above the tidal volume.

Tidal volume (choice F) is the amount of air that is inspired (or expired) with each
normal breath.

Vital capacity (choice G) is the largest amount of air that can be expired after a maximal
inspiratory effort.

Blood stored in a blood bank tends, with time, to become relatively depleted of 2,3-
diphosphoglycerate. What effect does this have on the hemoglobin-oxygen dissociation
curve?
A. Shifts the curve to the left, so that the hemoglobin has a decreased oxygen
affinity
 B. Shifts the curve to the left, so that the hemoglobin has an increased oxygen
affinity
C. Shifts the curve to the right, so that the hemoglobin has a decreased oxygen
affinity
D. Shifts the curve to the right, so that the hemoglobin has an increased oxygen
affinity
E. Does not change the dissociation curve

The correct answer is B. 2,3-diphosphoglycerate (2,3-DPG) is produced in red cells by a

variation on the glycolytic pathway, and levels diminish when glycolysis by the red cells
slows. The depletion of 2,3-DPG in stored blood causes the hemoglobin dissociation
curve to shift to the left, leading to an increase in oxygen affinity. This increase is helpful
in the picking up of oxygen by hemoglobin in the lungs, but can be very problematic in
the release of oxygen from the blood in tissues. This is not just a theoretical point:
considerable effort has been expended in developing improved solutions for storing
packed red cells and methods for "restoring" older stored cells so that the 2,3-DPG levels
are adequate. In practice, in otherwise reasonably healthy patients, older transfused blood
will quickly regenerate 2,3-DPG when placed in the glucose-containing environment of
the serum, but even transiently decreased 2,3-DPG levels in a severely compromised
patient can be dangerous.

A patient's airway pressure is being measured while he is breathing into a spirometer.

Which of the following lung volumes would be associated with an airway pressure of +30
cm H2O?
A. Functional residual capacity

B. Minimal volume
C. Residual volume
D. Tidal volume
E. Total lung capacity
The correct answer is E. For this question, you need not worry about the actual value of
the airway pressure. There is only one listed answer that would produce a positive airway
pressure, and that is total lung capacity. To measure the airway pressure, a patient inspires
or expires from a spirometer, and then relaxes while his airway pressure is measured. It is
easy to determine whether the airway pressure would be negative or positive by
practicing on yourself. Inhale to total lung capacity and relax. You will feel the sensation
of wanting to blow air out--this creates a positive pressure in your airways. Any volume
above functional residual capacity (FRC) will create a positive airway pressure, and any
volume below FRC will create a negative airway pressure.

The functional residual capacity (choice A) is the volume of air that remains in the lung
after a normal expiration. The FRC is the equilibrium volume when the elastic recoil of
the lungs is balanced by the tendency of the chest to spring out. Because this is the
volume when the patient is "at rest," the airway pressure is zero. Breathe out normally (to
reach FRC) and notice that there is no pressure in your airways.

Minimal volume (choice B) can only be achieved with an excised lung. It is the volume
of air remaining in an excised lung that is maximally deflated. It is smaller than the
residual volume because the chest wall is not there to help draw the lung open.

The residual volume (choice C) is the volume of air remaining in the lungs after maximal
expiration. At volumes less than FRC, like residual volume, the airway pressure would be
less than 0 cm H2O. Exhale all the way (to residual volume), and relax--you will feel the
sensation of wanting to draw air in--this creates a negative pressure in your airways (like
a vacuum).

Tidal volume (choice D) is the volume of air that is inhaled or exhaled with each normal
breath.

A 32-year-old female with gradually worsening dyspnea and fatigue, anginal chest pain,
and two documented episodes of pulmonary thromboemboli over the last year receives a
heart-lung transplant. Her native heart shows massive right ventricular hypertrophy. The
lungs show numerous thromboemboli, and the vasculature shows marked medial smooth
muscle hypertrophy, web-like endothelial proliferations filling several arterioles, and
atherosclerotic plaques on the main pulmonary arteries. With which of the following
diagnoses are these findings most consistent?
A. Adult respiratory distress syndrome
 B. Atopic asthma
C. Goodpasture's disease
D. Pulmonary hypertension
E. Sarcoidosis

The correct answer is D. Normally, the pulmonary circulation is a low-pressure system,

eliciting very little endothelial or medial response. Conversely, pulmonary hypertension
leads to medial hypertrophy, arterial fibrosis, and marked narrowing of the arterial
lumina, predisposing to arterial thrombosis. Tufts of endothelial proliferations (producing
so-called plexogenic pulmonary arteriopathy) is prominent in primary pulmonary
hypertension.

Adult respiratory distress syndrome (ARDS; choice A) is a clinical term for rapid onset
of respiratory insufficiency secondary to diffuse alveolar damage. The lungs show alveoli
filled with proteinaceous debris and desquamated alveolar lining cells and alveolar septae
lined by hyaline membranes. The heart and pulmonary vasculature show no specific
changes in ARDS.

Atopic asthma (choice B) is characterized by chronic airway inflammation and bronchial

hyperresponsiveness. No cardiovascular changes are found in atopic asthma; instead
there are copious mucus plugs, numerous bronchial neutrophils and eosinophils,
thickening of the bronchial basement membrane, and hypertrophy of bronchial smooth
muscle and submucous glands.

Goodpasture's disease (choice C) is a necrotizing and hemorrhagic pneumonitis

accompanied by rapidly progressive glomerulonephritis. The lungs would be filled with
fresh hemorrhage and hemosiderin-laden macrophages.

Sarcoidosis (choice E) is an interstitial pneumonitis that produces non-caseating giant

cell granulomas. It typically produces nodules in the lungs and hilar lymph nodes; arterial
and cardiac involvement by sarcoidosis is very uncommon.

A heroin addict is found unconscious in an alley with an empty syringe beside him. When
his blood gases are checked, which of the following would be expected?
A. Metabolic acidosis

B. Metabolic alkalosis
 C. Normal pH balance

D. Respiratory acidosis

E. Respiratory alkalosis

The correct answer is D. Opioids, such as heroin, depress respiration centrally by

reducing the responsiveness of brainstem respiratory centers to CO2. The resulting
hypoventilation leads to CO2 retention because of the inability of the patient to "blow off"
the CO2. This increases the production of carbonic acid (H2CO3) by carbonic anhydrase
present in red blood cells (which converts CO2 to carbonic acid). Dissociation of carbonic
acid to bicarbonate (HCO3–) and protons produces a respiratory acidosis.

Metabolic acidosis (choice A) is caused by a primary decrease in HCO3–, which can occur
after tissue hypoxia (which increases levels of lactic acid) or in uncontrolled diabetes
mellitus.

Metabolic alkalosis (choice B) is caused by an increase in HCO3–, which can occur

subsequent to ingestion of alkali or a loss of gastric acid (vomiting).

Normal pH balance (choice C) might be anticipated if the respiratory acidosis persists,

allowing time for the kidneys to compensate for the altered pH by conserving HCO3–.
However, renal compensation takes several days (this patient suffered from an acute
heroin overdose), and is rarely complete.

Respiratory alkalosis (choice E) is caused by a decrease in PCO2, which can occur with
hyperventilation.
 T
he diagram above shows spirographic tracings of forced expirations from two different individuals.
Trace X was obtained from a person with healthy lungs. Which of the following is most likely
represented by trace Y?
A. Asthma
B. Bronchospasm
C. Emphysema
D. Interstitial fibrosis

E. Old age

The correct answer is D. A forced expiration is the simplest test of lung function. The
individual breathes in as much air as the lungs can hold and then expels the air as rapidly
and as far as possible. The forced vital capacity (FVC) is the vital capacity measured with
a forced expiration (FVC = 3 L for patient Y). The forced expiratory volume in one
second (FEV1) is the amount of air that can be expelled from the lungs during the first
second of a forced expiration (FEV1 = 2.7 L for patient Y). The FEV1/FVC ratio has
diagnostic value for differentiating between normal, obstructive, and restrictive patterns
of a forced expiration. The FEV1/FVC ratio for the healthy individual (X) is 4 L/5 L =
80% and the FEV1/FVC for patient Y is 2.7/3.0 = 90%.

FEV1/FVC is a function of airway resistance. Increases in airway resistance associated

with asthma (choice A), bronchospasm (choice B), emphysema (choice C), and old age
(choice E) tend to decrease the FEV1/FVC ratio below its typical normal value of 80%.
FEV1/FVC is often increased with interstitial fibrosis because of increased radial traction
of the airways, i.e., the airways are held open to a greater extent at any given lung
volume, reducing their resistance to air flow. The increase in elastic recoil also makes it
difficult to breathe deeply, which decreases FVC. This combination of decreased FVC
along with normal or slightly increased FEV1/FVC is characteristic of fibrotic lung
disease.