3 - Pulmonary Patho Flashcards
What is dyspnea?
Subjective experience of breathing discomfort
Normal tidal volume
400-800 ml
Kussmaul respirations are characterized by: (3)
increased RR
Very large tidal volume
No expiratory pause
Cheyne-Stokes Respiration
Alternating deep and shallow breathing patterns with 15-60 seconds apnea in between
What causes Cheyne Stokes?
Any condition that slows the blood flow to the brainstem or impairs conduction above the brainstem
It basically indicates a delayed reaction to chemoreceptors
Minute volume =
Tidal volume x RR
What causes peripheral cyanosis?
Centra cyanosis?
Poor blood delivery to the periphery, but normal PaO2
Decreased PaO2
What amount of unsaturated hemoglobin causes cyanosis?
5g of Hgb
How can you reverse clubbing?
You can’t, even if you restore normal oxygen levels
What probably causes clubbing?
Megakaryocytes and platelt clumps escape filtration in the pulmonary bed
They enter the systemic circulation
They lodge in the tissues and release platelet-derived growth factor at the nail bed
Can also happen 2/2 inflammatory cytokins and growth factors released during cancer
What do V and Q represent?
V = amount of air getting into the alveoli
Q = among of blood perfusing the capillary
What is a normal V/Q?
Why?
0.8-0.9
perfusion is usually somewhat greater than ventilation in the lung bases
AND
bronchial venous blood (non-participating) is shunted into peripheral circulation
What is alveolar dead space?
Alveoli are ventilated but not perfused
What does it mean if a V/Q is high?
Ventilation outstrips perfusion
What is the most common cause of a high V/Q?
PE
What is the definition of Acute Respiratory Failure?
PaO2 < 50
AND/OR
PaCO2 > 50 with pH <7.25
What are the four most common causes of postop resp failure?
atelectasis
pneumonia
pulmonary edema
pe
Who is most at risk for primary/spontaneous pneumothorax?
Young men, usually smokers
What is the cause of primary pneumothorax?
Blebs in the visceral pleura rupture and create a conduit for air to get into the pleural space
No clear cause, but almost everyone who has it has emphysema-like changes to their lung, whether they smoke or not
Autosomal dominant inheritance
What kind of Pneumothorax or COPD pts prone to?
Why?
Secondary/traumatic
they have large vesicles in their lungs that can rupture
What are other words for transudative?
Exudative?
watery
proteinaceous
What is the usual cause of transudative pleural effusion?
Cardiogenic
Hypoproteinemia from kidney or liver disease
What is the usual cause of exudative pleural effusion?
infection, inflammation, malignancy
Caused by anything that releases biochemical mediators and increased capillary permeability
What is the usual cause of empyema?
Detritus of infection d/t blocked lymph vessels
pneumonia, lung abscess, infected wounds
What is the usual cause of a chylothorax?
chyle dumped into plueral space by lymph instead of passing from the GI tract to the thoracic duct
Traumatic injury, injfection, disorder than disrupts lymph transport
What are parapneumonic effusions?
Occur in association with pneumonia
Physical examination of a patient with pleural effusion reveals:
Decreased breath sounds
dullness to percussion
pleural friction rub
In severe cases of empyema, what can be done?
Instillation of fibrinolytics and/or deoxyribonucelase
Deoxyribonuclease stimulates pleural fluid formation, which decreases the viscosity of the pus and makes it easier to drain
Restrictive Lung disorder are caused by _______
decreased compliance
A pulmonary function test in restrictive lung disease will show:
decreased FVC
Aspiration is restrictive or obstructive?
Restrictive
What are the three types of atelectasis?
Compression (tumor, fluid, air, abdominal distention)
Absorption (gradual absoprtion of air from obstructed or hypoventilated alveoli)
Surfactant Impairment
Is atelectasis restrictive or obstructive?
restrictive
The pore of Kohn only open during:
deep breathing
What does TCDB/IS improve atelectasis?
- promotes ciliary clearance
- redistributes surfactant
- Opens the pores of Kohn to allow collateral ventilation
What is bronchiectasis?
persistent abnormal dilation of the bronchi
What is cylindrical bronchiectasis? When is it typically seen?
symmetrically dilated bronchioles
seen after pneumonia and is reversible
What are some hallmark s/s of bronchiectasis?
chronic, productive cough that lasts from months to years
Hemoptysis
Cups and cups of foul-smelling purulent sputum
What is bronchiolitis?
Diffuse inflammation of the small airways or bronchioles
Bronchiolitis is most common in _________
children
What are some hallmark symptoms of bronchiolitis?
nonproductive,d ry cough
hyperinflated chest
rapid RR and accessory muscle use
low grade fever
What is BOOP?
Bronchiolitis Obliterans Organizing Pneumonia
Complication of Bronchiolitis obliterans
alveoli and bronchioles become filled with plugs of connective tissue
What is Bronchiolitis Obliterans Syndrome?
inflammatory, fibrotic deposits of connective tissue in lung
Occurs as a complication of lung transplant
What are the top three causes of pulmonary fibrosis?
- Remodeling from an active disease
- Autoimmune (SLE, sarcoidosis, RA)
- Inhalation of harmful substances (Coal dust and asbestos especially)
What is the survival rate for idiopathic pulmonary fibrosis?
2-5 years after diagnosis
What is the primary presenting symptom of idiopathic pulmonary fibrosis?
dyspnea on exertion
What is oxygen toxicity?
Prolonged exposure to high FiO2 at normal atmospheric pressure causes severe inflammation d/t free radicals
Leads to cellular necrosis or apoptosis, damage to alveolocapillary membrane, disruption of surfactant
What is pneumoconiosis?
lung changes d/t inhalation of dust particles
usually asbestos, silica, coal dust
What are the three phases of ARDS?
Exudative (within 72 hours)
Proliferative (1-3 weeks)
Fibrotic (2-3 weeks)
What happens during the exudative phase of ARDS?
Inflammatory cytokins are released
They active macrophages, which release more cytokines
Neutrophils release ROS and Arachidonic acid metabolites
metabolites turn into prostaglandins, thromboxanes, and leukotrines
Vessel walls get annihilated
What happens during the proliferative phase of ARDS?
fibroblasts, myofibroblasts, type II pneumocytes begin the recovery
What happens during the fibrotic phase of ARDS?
remodeling and fibrosis,
oblierates the alveoli, respiratory bronchioles and insterstitium
Decreased FRC and V/Q mismatch
Severe right to left shunt and respiratory failure
In obstructive pulmonary disease, airway obstruction is worsened during ________
expiration
What are the unifying signs and symptoms of obstructive pulmonary disease?
symptom: dyspnea
sign: wheezing
What spirometry metric is primarily effected by obstructive lung disease?
FEV1
The amount of air that is expelled during the first second of expiration
What are the most common obstructive lung disease?
asthma and COPD
Asthmas causes:
hyperresponsiveness of mucosa
constriction of the airway
variable airflow obstruction that is reversible
Asthma prevalence is ________ and death rates are highest for:
increasing
adult females, blacks, adults over 65
What is the early asthmatic response?
reaches a maximum within the first thirty minutes and resolves within 1-3 hours
bronchospasm, tenacious mucus, narrowing of airways and obstruction to airflow
What is the late asthmatic response?
develops 4-8 hours after early response
increased hyperresponsiveness
What is the normal PaCO2 progression during asthma?
Usually low at first due to hyperventilation
Eventually will elevate as airways close off
Respiratory acidosis is a sign of impending respiratory failure
When is an asthma attack considered status asthmaticus?
When it fails to respond to normal measures
What are the two phenotypes of COPD?
Chronic bronchitis
Emphysema
In chronic bronchitis, inhalation of irritants causes:
bronchial inflammation and edema
increase size and number of goblet cells
hypertrophied smooth muscle/fibrosis
narrowed airways
More mucus, and no cilia to move it out
Emphysema is characterized by:
destruction of alveoli through breakdown of elastin
There’s an imbalance between proteases and antiproteases, which leads to oxidative stress and apoptosis
What causes primary emphysema?
alpha 1 antitrypsin
Alpha 1 normally inhibits the action of proteolytic enzymes, so when it’s absent, there’s an imbalance between proteases and antiprotease
Thats when emphysema happens
What is universally true of COPD, whether chronic bronchitis or emphysema?
They will have prolonged expiration
More than 90% of bronchitis infections are caused by _______
viruses
How can you tell the difference between bronchitis and pneumonia?
chest x ray
bronchitis will not have infiltrates
Patients with bacterial bronchitis usually have these three symptoms:
productive cough
fever
pain behind the sternum that is aggravated by coughing
Bacterial bronchitis is rare and usually only happens to people who:
have had a viral bronchitis
have COPD
What pathogens are found in HCAP but rarely in CAP?
Psuedomonas aeruginosa
Klebsiella pneumoniae
Enterobacter
What is normally the cause of legionella, viral, and mycobacterial outbreaks?
inhalation of organisms that are released by coughs/sneezes
OR
aerosolized water, like in contaminated RT equipment
What is the #1 guardian of the lower respiratory tract?
The alveolar macrophage
What is the most common cause of bacterial pneumonia?
pneumococcal (streptococcus pneumoniae)
What happens when S. Pneumoniae is treated with antibiotics?
Rapidly lysed
Releases intracellular bacterial proteins that are toxic (namely pneumolysin)
Why do some patients with pneumonia get worse after initiating antibiotic treatment?
the massive release of pneumolysin causes massive inflammation and edema, which creates a pungent medium for more bacterial growth and spread
How severe is viral pneumonia?
Usually seasonal, mild, and self-limiting
most dangerous when followed by an opportunistic bacterial pathogen
What disease can reactivate a dormant TB infection
Biggest and most concerning is HIV
cancer, diabetes, immunosuppressants, poor nutritional status, renal failure
What kind of necrosis is involved in TB?
caseous necrosis
cheeselike material that lays inside tubercles
An abscess is a type of _______necrosis
liquefactive
Abscess formation follows ______
consolidation of the lung
What types of pneumonia are most likely to form abscesses?
klebsiella and Staphylococcus
When a patient with a known abscess develops a cough with copiuos amounts of foul smelling sputum and/or blood, what might that indicate?
Abscess communication with a bronchus
What is the most common cause of PE?
EMbolization of a DVT
What genetic mutations result in hypercoaguability?
Protein C and S deficiency
Factor V Leiden
How is Troponin level useful in PE management?
can indicate how serious things are
Elevated troponin indicates RV dysfunction and the possibility of serious adverse events
The #1 cause of laryngeal cancer is:
smoking, especially with alcohol consumption
Primary lung cancers are also called ________ and arise from the _________
bronchogenic cancer
epithelium of the respiratory tract
What are the two major categories of bronchogenic lung cancer?
Nonsmall Cell Lung Cancer
Neuroendocrine tumors
What are the three types of Nonsmall Cell Lung Cancer?
Squamous cell (30%)
Adenocarcinoma (35-40%)
Large Cell (10%)
What are the two types of neuroendocrine lung tumors?
Small Cell lung carcinomas (15% of cases, but 25% of deaths)
Bronchial Carcinoid Tumors (1%)
Which lung cancers are associated with smoking?
Which are not?
Small cell and Squamous cell
Adenocarcinoma and bronchial carcinoid
How aggressive is mesothelioma?
Extremely fast to metastasize, but their metastases are usually slow growing
Usually live 10-15 years after diagnosis
What is the TNM classification system?
Used for staging
T: Extent of the tumor
N: Nodal involvement
M: Extent of metastasis
What is functional residual capacity?
resting lung volume
balance between elastic recoil of the lungs and elastic recoil of the chest
Infants up to _______ are obligate nose breathers
2-3 months
Surfactant is produced by _______ cells
Type II alveolar
Surfactant is produced by ______ weeks and secreted into the lungs by ______ weeks
20-24
30
What’s the old name for respiratory distress syndrome in neonates?
Hyaline membrane disease
Is chest wall compliance higher or lower in infants?
Higher
hasn’t totally ossified
M 1203
How do infants maintain FRC with increased chest wall compliance?
To keep airways from closing, have muscular “braking” of expiration
Caused either by active glottic narrowing or increased action of external intercostals
How long do placentally transferred IgG levels last in neonates?
A few months (half life 21 days)
Which immune antibody types are transferred in breast milk?
IgA
IgG
IgM
Infants have an exaggerated apneic response to ________
laryngeal stimulation
Most common causes of acute onset Upper Airway Obstruction in peds
infection
foreign body
angioedema
OSA
trauma
Most common causes of chronic Upper Airway Obstruction in peds
congenital malformations
subglottic stenosis
catilaginous weakness
vocal cord paralysis
Agitation in infants should be regarded as _______
a sign of hypoxemai or obstruction
You should never attempt examination of the pharynx in a kid if:
any suspicion of epiglottitis or retropharyngeal abscess
Any stimulation could precipitate acute obstruction
In peds a loud gasping snore indicates
enlarged tonsils/adenoids
In peds stridor during inspiration suggests
airway compromise in the eiglottis, arytenoids, vocal cords, glottis
In peds expiratory stridor or wheeze results from
narrowing or collapse of the lower trachea or bronchi
in peds airway noise during inspiration and expiration indicates
a fixed obstruction of the vocal cords or subglottic space
If a peds cough is croupy or low pitched, you should suspect
tracheal pathology
What is the most common cause of croup?
viral (laryngotracheitis)
and recurrent (spasmodic croup)
Croup illnesses are characterized by _____ and ______
infection
UAO
Kids are most likely to get croup at what age?
2 years average
(6mo to 5 years)
What causes croup?
subglottic edema or obstruction
In moderate to severe croup, ____ and____ should be given for treatment
steroids
neb of racemic epi (to help until steroids kick in)
What pathogen historically caused acute epiglottitis?
Hib
Haemophilus infuenzae type B
Now we vaccinate against it
Acute epiglottitis is associated with what signs and symptoms?
Hot potato voice
insp stridor
severe respiratory distress
tripod positioning
drooling and dysphagia
Most common cause of peritonsilar abscess
GABHS tonsillitis
Treatment for peritonsillar abscess
must be drained! if it spontaneously ruptures it can kill the child
What is the most common, potentially life threatening upper airway infection in children?
Bacterial tracheitis (psuedomembranous croup)
What is the treatment for bacterial tracheitis?
intubation
IV antibiotics
Angioedema is usually caused by:
mast cell mediated allergies (peanuts, milk, eggs)
What is laryngomalacia?
abnormally soft laryngeal cartilage
most common cause of chronic stridor in infants
What happens in laryngomalacia?
epiglottis or arytenoids fold inward with inspiration, partially covering the glottis
What is tracheomalacia?
tracheobronchial cartilages are flaccid and tend to collapse
What are the most common causes of stridor in children?
Tracheomalacia
Vocal Cord Paralysis
What is subglottic stenosis?
subglottic airway diameter of < 4 mm at the cricoid in full term infant, < 3 in premie
What is choanal atresia?
unilateral or bilateral lack of patency in the nasal cavity
lifethreatening in newborns
What is laryngeal atresia?
failure of larynx to recanalize during embryogenesis
What are some symptoms of OSA in children (besides snoring)?
FTT
labored breathing
restlessness
sweating during sleep
nocturnal enuresis
Untreated pediatric OSA can cause:
cardiovascular disease
insulin resistance
What is bronchopulmonary dysplasia?
chronic lung disease of prematurity
Aside from RDS, what increases the risk of bronchopulmonary dysplasia?
antenatal chorioamnionitis
preeclampsia
inflammation and postnatal sepsis
PDA
hyperoxia
genetics
What is the canalicular stage of fetal lung development?
When does it occur?
type II epithelial cells appear
capillaries grow into alveolar regions
16-28 weeks
What is the saccular stage of fetal lung development?
When does it occur?
septation and formation of alveoli and respiratory units
26-28 weeks
Which pathogen most commonly causes bronchiolitis?
RSV
Nasal swabs positive for RSV in 70% of cases
Having childhood bronchiolitis is a risk factor for ______
developing asthma
______ pneumonia is 2-3x more common in children than adults
viral
What is bronchiolitis obliterans?
fibrotic obstruction of the respiratory bronchioles and alveolar ducts d/t inflammation
very rare in kids
Asthma diagnosis depends on testing using spirometry, which can only be done after age:
5-6 years
The most common manifestations of cystic fibrosis involve which two systems
resp and GI
The incidence of SIDS is low during ______
the first month of life
increases sharply in the second month
peaks at 2-4 months
unlikely after 6 months
which blade should be used to intubate peds?
Miller easier than Mac
