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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor=William J Gibson
|QuestionAuthor=William J Gibson (Reviewed by  {{YD}})
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Anatomy, Physiology
|MainCategory=Physiology
|SubCategory=Pulmonology
|SubCategory=Pulmonology
|MainCategory=Anatomy, Physiology
|MainCategory=Physiology
|SubCategory=Pulmonology
|SubCategory=Pulmonology
|MainCategory=Anatomy, Physiology
|MainCategory=Physiology
|SubCategory=Pulmonology
|SubCategory=Pulmonology
|MainCategory=Anatomy, Physiology
|MainCategory=Physiology
|MainCategory=Anatomy, Physiology
|MainCategory=Physiology
|MainCategory=Physiology
|SubCategory=Pulmonology
|SubCategory=Pulmonology
|MainCategory=Anatomy, Physiology
|MainCategory=Physiology
|SubCategory=Pulmonology
|SubCategory=Pulmonology
|MainCategory=Anatomy, Physiology
|MainCategory=Physiology
|SubCategory=Pulmonology
|SubCategory=Pulmonology
|MainCategory=Anatomy, Physiology
|MainCategory=Physiology
|SubCategory=Pulmonology
|SubCategory=Pulmonology
|MainCategory=Anatomy, Physiology
|MainCategory=Physiology
|MainCategory=Anatomy, Physiology
|MainCategory=Physiology
|SubCategory=Pulmonology
|SubCategory=Pulmonology
|Prompt=The Kayan tribe is a Burmese tribe known for a tradition in which the women gradually extend the length of their necks with coils. A 35-year-old Kayan woman presents to her local physician for shortness of breath that occurs when she travels to the farm. Before administering a methacholine challenge test, the physician makes some baseline measurements:
|Prompt=A 35-year-old female immigrant presents to the physician's for shortness of breath that occurs when she travels to the farm. Upon further questioning, the patient informs the physician that she belongs to the Kayan tribe of Burma that is known for a tradition in which the women gradually extend the length of their necks with coils. Prior to performing a methacholine challenge test, the physician obtains baseline measurements for the following:
* Tidal volume = 600mL


Tidal volume= 600mL
* PaCO {{sub|2}} = 40 mmHg


PaCO{{sub|2}}= 40 mmHg
* P {{sub|expired}} CO {{sub|2}} = 28 mmHg


P{{sub|expired}} CO{{sub|2}}= 28mL
* Respiratory Rate = 16/min
 
Respiratory Rate: 16/min


Which of the following represents the physiologic dead space in this patient?
Which of the following represents the physiologic dead space in this patient?
|Explanation=The patient in this vignette is being evaluated for asthma after reporting feeling pulmonary symptoms on exposure to a foreign stimulus (the farm).  In this case, the patient has a unique anatomy due to the tribe’s tradition of using series of coils to extend their necks.  Dead space is the volume of air which is inhaled that does not take part in the gas exchange, either because it remains in the conducting airways, or reaches alveoli that are not perfused or poorly perfused. We are asked to calculate the physiologic dead space in this patient. Just as dead space wastes a fraction of the inhaled breath, dead space dilutes alveolar air during exhalation. By quantifying this dilution it is possible to measure anatomical and alveolar dead space, employing the concept of mass balance, as expressed by Bohr equation (below).


|Explanation=The patient in this vignette is being evaluated for asthma after reporting feeling pulmonary symptoms on exposure to a foreign stimulus (the farm).  In this case, the patient has a unique anatomy due to the tribe’s tradition of using series of coils to extend their necks.  Dead space is the volume of air which is inhaled that does not take part in the gas exchange, either because it remains in the conducting airways, or reaches alveoli that are not perfused or poorly perfused. We are asked to calculate the physiologic dead space in this patient.
[[File:Bohr_equation.png]]
Just as dead space wastes a fraction of the inhaled breath, dead space dilutes alveolar air during exhalation. By quantifying this dilution it is possible to measure anatomical and alveolar dead space, employing the concept of mass balance, as expressed by Bohr equation.
 
An equation and example are provided below:
 
:<math> V_\mathrm{D} = V_\mathrm{T} \,\frac{P_\mathrm{a\,CO_2}-P_\mathrm{E\,CO_2}}{P_\mathrm{a\,CO_2}} </math>
 
:<math> V_\mathrm{D} = 0.5\,\frac{0.056-0.040}{0.056}  = 0.143 \ \mathrm{L} </math>


* ''V''<sub>D</sub> = dead space
* ''V''<sub>D</sub> = dead space
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In normal individuals, physiologic dead space is approximately 150mL.  However, plugging in the values given in the stem to the Bohr equation, we find that the  
In normal individuals, physiologic dead space is approximately 150mL.  However, when using the values given in the stem to the Bohr equation, the physiologic dead space in this patient is increased to 180 mL.
 
'''Educational Objective:'''  The physiologic dead space can be calculated by the dilution of alveolar CO2 as it is exhaled, using the Bohr equation.
 
'''References:'''  First Aid 2014 page 596.
|AnswerA=150 mL
|AnswerA=150 mL
|AnswerAExp='''Incorrect:''' 150mL is approximately the normal physiologic dead space, but the dead space in this patient is increased as the volume can be determined by the Bohr equation to be 190mL.
|AnswerAExp=150mL is approximately the normal physiologic dead space, but the dead space in this patient is increased as the volume can be determined by the Bohr equation to be 180 mL.
|AnswerB=175 mL
|AnswerB=175 mL
 
|AnswerBExp=The dead space in this patient is increased as the volume can be determined by the Bohr equation to be 180 mL.
|AnswerBExp='''Incorrect:'''  Inserting the values given above into the Bohr equation shows that the physiologic dead space in this patient is 180 mL.
|AnswerC=180 mL
|AnswerC=180 mL
 
|AnswerCExp=Although the approximately normal physiologic dead space is 150 mL, the patient has an unusual anatomy that may increase the volume of her physiologic dead space. The dead space in this patient is increased as the volume can be determined by the Bohr equation to be 180 mL.
|AnswerCExp='''Correct:'''  Inserting the values given above into the Bohr equation shows that the physiologic dead space in this patient is 180 mL.
|AnswerD=190 mL
|AnswerD=190 mL
|AnswerDExp=The dead space in this patient is increased as the volume can be determined by the Bohr equation to be 180 mL.
|AnswerE=225 mL
|AnswerEExp=The dead space in this patient is increased as the volume can be determined by the Bohr equation to be 180 mL.
|EducationalObjectives=The physiologic dead space can be calculated with the Bohr equation, which quantifies the using the dilution of alveolar CO2 as it is exhaled.<br>
[[File:Bohr_equation.png]]


|AnswerDExp='''Incorrect:'''  Inserting the values given above into the Bohr equation shows that the physiologic dead space in this patient is 180 mL.
* ''V''<sub>D</sub> = dead space
 
* ''V''<sub>T</sub> = [[tidal volume]]
|AnswerE=225 mL
* ''P<sub>aCO<sub>2</sub></sub> = [[partial pressure]] of [[carbon dioxide]] in [[arteries]]
|AnswerEExp='''Incorrect:'''  Inserting the values given above into the Bohr equation shows that the physiologic dead space in this patient is 180 mL.
* ''P<sub>ECO<sub>2</sub></sub> = partial pressure of carbon dioxide in exhaled air
|References=First Aid 2015 page 602<br>
First Aid 2014 page 596
|RightAnswer=C
|RightAnswer=C
|WBRKeyword=Lung, Lung volume, Dead space, Pulmonology
|WBRKeyword=Lung, Lung volume, Dead space, Pulmonology, Physiology, Respiratory physiology
|Approved=Yes
|Approved=Yes
}}
}}

Latest revision as of 02:37, 28 October 2020

 
Author [[PageAuthor::William J Gibson (Reviewed by Yazan Daaboul, M.D.)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Physiology
Sub Category SubCategory::Pulmonology
Prompt [[Prompt::A 35-year-old female immigrant presents to the physician's for shortness of breath that occurs when she travels to the farm. Upon further questioning, the patient informs the physician that she belongs to the Kayan tribe of Burma that is known for a tradition in which the women gradually extend the length of their necks with coils. Prior to performing a methacholine challenge test, the physician obtains baseline measurements for the following:
  • Tidal volume = 600mL
  • PaCO 2 = 40 mmHg
  • P expired CO 2 = 28 mmHg
  • Respiratory Rate = 16/min

Which of the following represents the physiologic dead space in this patient?]]

Answer A AnswerA::150 mL
Answer A Explanation AnswerAExp::150mL is approximately the normal physiologic dead space, but the dead space in this patient is increased as the volume can be determined by the Bohr equation to be 180 mL.
Answer B AnswerB::175 mL
Answer B Explanation AnswerBExp::The dead space in this patient is increased as the volume can be determined by the Bohr equation to be 180 mL.
Answer C AnswerC::180 mL
Answer C Explanation [[AnswerCExp::Although the approximately normal physiologic dead space is 150 mL, the patient has an unusual anatomy that may increase the volume of her physiologic dead space. The dead space in this patient is increased as the volume can be determined by the Bohr equation to be 180 mL.]]
Answer D AnswerD::190 mL
Answer D Explanation AnswerDExp::The dead space in this patient is increased as the volume can be determined by the Bohr equation to be 180 mL.
Answer E AnswerE::225 mL
Answer E Explanation AnswerEExp::The dead space in this patient is increased as the volume can be determined by the Bohr equation to be 180 mL.
Right Answer RightAnswer::C
Explanation [[Explanation::The patient in this vignette is being evaluated for asthma after reporting feeling pulmonary symptoms on exposure to a foreign stimulus (the farm). In this case, the patient has a unique anatomy due to the tribe’s tradition of using series of coils to extend their necks. Dead space is the volume of air which is inhaled that does not take part in the gas exchange, either because it remains in the conducting airways, or reaches alveoli that are not perfused or poorly perfused. We are asked to calculate the physiologic dead space in this patient. Just as dead space wastes a fraction of the inhaled breath, dead space dilutes alveolar air during exhalation. By quantifying this dilution it is possible to measure anatomical and alveolar dead space, employing the concept of mass balance, as expressed by Bohr equation (below).


In normal individuals, physiologic dead space is approximately 150mL. However, when using the values given in the stem to the Bohr equation, the physiologic dead space in this patient is increased to 180 mL.
Educational Objective: The physiologic dead space can be calculated with the Bohr equation, which quantifies the using the dilution of alveolar CO2 as it is exhaled.

References: First Aid 2015 page 602
First Aid 2014 page 596]]

Approved Approved::Yes
Keyword WBRKeyword::Lung, WBRKeyword::Lung volume, WBRKeyword::Dead space, WBRKeyword::Pulmonology, WBRKeyword::Physiology, WBRKeyword::Respiratory physiology
Linked Question Linked::
Order in Linked Questions LinkedOrder::