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cvpr physiology 3 Flashcards

1
Q

Pulmonary embolism features on ECG

A

May have S1Q3T3 abnormality on ECG

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2
Q

PE diagrams

A

pg 654

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3
Q

Flow-volume loops

A

Pg 655

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4
Q

RV in obstructive lung disease

A

↑

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5
Q

RV in restrictive lung disease

A

↓

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6
Q

FRC in obstructive lung disease

A

↑

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7
Q

FRC in restrictive lung disease

A

↓

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8
Q

TLC in obstructive lung disease

A

↑

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9
Q

TLC in restrictive lung disease

A

↓

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10
Q

FEV1 in obstructive lung disease

A

↓↓

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11
Q

FEV1 in restrictive lung disease

A

↓

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12
Q

FVC in obstructive lung disease

A

↓

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13
Q

FVC in restrictive lung disease

A

↓

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14
Q

FEV1/FVC in obstructive lung disease

A

↓

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15
Q

FEV1/FVC in restrictive lung disease

A

Normal or ↑ FEV1 decreased proportionately to FVC

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16
Q

Flow volume loops pg

A

655

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17
Q

Blue bloater disease

A

Chronic bronchitis

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18
Q

Pink puffer disease

A

Emphysema

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19
Q

Chronic bronchitis presentation

A
  • Wheezing
  • Crackles
  • Cyanosis (hypoxemia due to shunting)
  • Dyspnea
  • CO2 retention (respiratory acidosis)
  • 2° polycythemia
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20
Q

Pathology of chronic bronchitis

A

Hypertrophy and hyperplasia of mucus-secreting glands in bronchi → Reid index (thickness of mucosal gland layer to thickness of wall between epithelium and cartilage) > 50%

DLCO is usually normal

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21
Q

Diagnostic criteria of chronic bronchitis

A

Productive cough for > 3 months in a year for > 2 consecutive years

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22
Q

Emphysema presentation

A

Barrel-shaped chest

Exhalation through pursed lips (increases airway pressure and prevents airway collapse)

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23
Q

Pathology of emphysema

A
  • Centriacinar - associated with smoking Frequently in upper lobes (smoke rises up)
  • Panacinar - associated with α1-antitrypsin deficiency, frequently in the lower lobes
  • Enlargement of air spaces ↓ recoil, ↑ compliance, ↓ DLCO from the destruction of alveolar walls
  • Imbalance of proteases and antiproteases → ↑ elastase activity → ↑ loss of elastic fibers → ↑ lung compliance
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24
Q

Imaging of emphysema

A

CXR: ↑ AP diameter, flattened diaphragm, ↑ lung field lucency

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25
Q

Presentation of asthma

A
  • Cough
  • Wheezing
  • Tachypnea
  • Dyspnea
  • Hypoxemia
  • ↓ inspiratory/expiratory time ratio (expiratory time is increased)
  • Pulsus paradoxus
  • Mucous plugging
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26
Q

What is pulsus paradoxus

A

Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus.

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27
Q

Asthma triggers

A
  • Viral
  • URIs
  • Allergens
  • Stress
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28
Q

Dx of asthma

A
  • Spirometry
  • Methacholine challenge
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29
Q

Histology of asthma

A
  • Hyperresponsive bronchi → reversible bronchoconstriction
  • Smooth muscle hypertrophy and hyperplasia
  • Crurschman spirals (shed epithelium forms whorled mucous plugs)
  • Charcot-Lyden crystals (eosinophilic hexagonal, double-pointed crystals formed from breakdown of eosinophils in sputum
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30
Q

Asthma type of reaction

A

Type I hypersensitivity reaction

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31
Q

What is aspirin-induced asthma

A

Aspirin-induced asthma is a combination of:

  • COX inhibition (leukotriene overproduction → airway constriction)
  • Chronic sinusitis
  • Nasal polyps
  • Asthma symptoms
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32
Q

List of Obstructive lung diseases

A

Bronchiectasis

Chronic bronchitis

Emphysema

Asthma

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33
Q

List of restrictive lung diseases

A

Sarcoidosis

Inhalation injury and sequelae pneumoconiosis

Pulmonary fibrosis

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34
Q

Presentation of bronchiectasis

A
  • Purulent sputum
  • Recurrent infections
  • Hemoptysis
  • Digital clubbing
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35
Q

Pathology of bronchiectasis

A

Chronic necrotizing infection of bronchi or obstruction → permanently dilated airways

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36
Q

Bronchiectasis associated risks

A
  • Bronchial obstruction
  • poor ciliary motility (eg smoking, Kartagener syndrome)
  • Cystic fibrosis
  • Allergic bronchopulmonary aspergillosis
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37
Q

PFTs of restrictive lung diseases

A

↑ FEV1/FVC ratio Restricted lung expansion causes ↓ lung volumes (↓ FVC and TLC)

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38
Q

Breathing in restrictive lung diseases

A

Patients present with short shallow breaths

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39
Q

Categorical etiology of restrictive lung diseases

A
  • Poor breathing mechanics
  • Interstitial lung diseases
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40
Q

Restrictive lung diseases w/ a muscular etiology

A

Polio

Myasthenia gravis

Guillain-Barre syndrome

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41
Q

Restrictive lung diseases w/ poor structural apparatus

A

Scoliosis

Morbid obesity

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42
Q

List of restrictive lung diseases

A
  • Pneumoconioses
  • Sarcoidosis
  • Idiopathic pulmonary fibrosis
  • Good pasture syndrome
  • Granulomatosis with polyangiitis
  • Pulmonary langerhans cell histiocytosis
  • Hypersensitivty pneumonitis Drug toxicity
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43
Q

What is hypersensitivity pneumonitis

A

Mixed type III/IV hypersensitivity reaction to environmental antigen

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44
Q

Symptoms of hypersensitivity pneumonitis

4 listed

A
  • Dyspnea
  • Cough
  • Chest tightness
  • Headache
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45
Q

hypersensitivity pneumonitis most commonly occurs in?

A

Often seen in farmers and those exposed to birds

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46
Q

Reversibility of hypersensitivity pneumonitis

A

Reversible in early stages if stimulus is avoided

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47
Q

Histological and lab test features of sarcoidosis

A
  • Characterized by immune-mediated, wide-spread noncaseating granulomas
  • Elevated serum ACE levels
  • elevated CD4/CD8 ratio in bronchoalveolar lavage fluid
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48
Q

Sarcoidosis most commonly occurs in?

A

African-American females

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49
Q

Symptoms of sarcoidosis

A

Often asymptomatic except for enlarged lymph nodes

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50
Q

Imaging of sarcoidosis

A
  • CXR of bilateral hilar adenopathy and coarse reticular opacities
  • CT of chest better demonstrates the extensive hilar and mediastinal adenopathy
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51
Q

Sarcoidosis associations

A
  • A facial droop is UGLIER
  • Bell palsy
  • Uveitis
  • Granulomas (epithelioid, containing microscopic Schaumann and asteroid bodies)
  • Lupus pernio (skin lesions on face resembling lupus)
  • Interstitial fibrosis (restrictive lung disease)
  • Erythema nodosum
  • Rheumatoid arthritis-like arthropathy
  • Hypercalcemia (due to ↑ 1α-hydroxylase-mediated vitamin D activation in macrophages)
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52
Q

Describe granulomas in sarcoidosis

A

(epithelioid, containing microscopic Schaumann and asteroid bodies)

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53
Q

Describe lupus pernio

A

(skin lesions on face resembling lupus)

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54
Q

What is Erythema nodosum?

A
  • Is a type of skin inflammation that is located in a part of the fatty layer of skin
  • Erythema nodosum results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees.
  • The tender lumps, or nodules, of erythema nodosum range in size from a dime to a quarter.
  • Associated with sarcoidosis
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55
Q

Treatment of sarcoidosis

A

Steroids (if symptomatic)

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56
Q

What is inhalation injury and sequelae

A

Complication of smoke inhalation from fires or other noxious substances

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57
Q

Common causes of inhalation injury and sequelae

A

Caused by heat particulates (< 1µm diameter) or irritants (eg NH3) → chemical tracheobronchitis, edema, pneumonia, ARDS

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58
Q

Associations of inhalation injury and sequelae

A

Many patients present 2° to burns and also

  • CO inhalation
  • Cyanide poisoning
  • Arsenic poisoning
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59
Q

Common physical exam finding in inhalation injury and sequelae

A

Singed nasal hairs common on exam

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60
Q

Bronchoscopy in inhalation injury and sequelae

A

Shows severe

  • Edema
  • Congestion of bronchus
  • Soot deposition
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61
Q

Pictures of inhalation injury and sequelae

A

658

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62
Q

Pneumoconiosis Mnemonic

A

Asbestos is from the roof, (was common in insulation), but affects the base (lower lobes) Silica and coal are from the base (earth), but affect the roof (upper lobes)

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63
Q

Asbestosis is associated with

A

Shipbuilding Roofing Plumbing

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64
Q

Histological features of asbestosis

A

Ivory white calcified supradiaphragmatic and pleural plaques are pathognomonic of asbestosis

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65
Q

Risks associated with asbestos

A

Bronchogenic carcinoma > risk of mesothelioma

↑ risk of pleural effusions

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66
Q

In what part of the lung does asbestosis occur?

A

Affects lower lobes

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67
Q

Histological features of asbestosis

A

Asbestos (ferruginous) bodies are golden-brown fusiform rods resembling dumbbells, found in alveolar sputum sample obtained by bronchoalveolar lavage

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68
Q

Asbestos stain

A

Prussian blue stain

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69
Q

Berylliosis associated with

A

Associated with exposure to beryllium in aerospace and manufacturing industries

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70
Q

Histological features of Berylliosis

A

Granulomatous (noncaseating) on histology and therefore occasionally responsive to steroids

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71
Q

Berylliosis associated risks

A

↑ risk of cancer and cor pulmonale

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72
Q

In what part of the lung does berylliosis occur?

A

Affects upper lobes

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73
Q

Common causes of coal workers pneumoconiosis

A

Prolonged coal dust exposure → macrophages laden with carbon → inflammation and fibrosis

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74
Q

Coal workers pneumoconiosis AKA

A

Black lung

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75
Q

coal workers pneumoconiosis associated risks

A

↑ risk for Caplan syndrome (rheumatoid arthritis and pneumoconioses with intrapulmonary nodules)

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76
Q

Location of the lung affected in coal workers pneumoconiosis

A

Affects upper lobes

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77
Q

Imaging of coal workers pneumoconiosis

A

Small, rounded nodular opacities seen on imaging

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78
Q

What is anthracosis?

A

asymptomatic condition found in many urban dwellers exposed to sooty air

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79
Q

Silicosis is commonly caused by?

A

Sandblasting Foundries Mines

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80
Q

Macrophages respond to silica and release fibrogenic factors leading to fibrosis

A

It is thought that silica may disrupt phagolysosomes and impair macrophages, increasing susceptibility to TB ↑ risk of cancer, cor pulmonale and Caplan syndrome

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81
Q

What part of the lung does silicosis affect?

A

Affects upper lobes

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82
Q

Imaging of silicosis

A

Eggshell calcification of hilar lymph nodes on CXR

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83
Q

Silicosis mnemonic

A

The silly egg sandwich I found is mine Histology: Eggshell calcification of hilar lymph nodes on CXR Causes: Sandblasting, Foundries, Mines

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84
Q

Pictures of pneumoconiosis

A

659

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85
Q

What is mesothelioma?

A

Malignancy of the pleura associated with asbestosis

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86
Q

Complications of mesothelioma

A

May result in:

hemorrhagic pleural effusion (exudative)

Pleural thickening

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87
Q

Histological features of mesothelioma

A

Psammoma bodies seen on histology

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88
Q

How to distinguish mesothelioma vs carcinoma

A

Calretinin (+) in almost all mesotheliomas, (-) in most carcinomas

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89
Q

Smoking in mesothelioma

A

Smoking is not a risk factor

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90
Q

ARDS AKA

A

Acute Respiratory Distress Syndrome

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91
Q

What is ARDS

A

Acute respiratory distress syndrome. Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood. Infants can also have respiratory distress syndrome.

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92
Q

Pathophysiology of acute respiratory distress syndrome

A

Alveolar insult → release of pro-inflammatory cytokines → neutrophil recruitment, activation and release of toxic mediators (eg, reactive oxygen species, proteases, etc) → capillary endothelial damage and ↑ vessel permeability → leakage of protein-rich fluid into alveoli → formation of intra-alveolar hyaline membranes and noncardiogenic pulmonary edema (normal PCWP)

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93
Q

PCWP in Acute Respiratory Distress Syndrome

A

Normal intra-alveolar hyaline membranes and noncardiogenic pulmonary edema (normal PCWP)

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94
Q

Most common cause of ARDS

A

Sepsis

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95
Q

Common causes of ARDS

A

Sepsis (most common)

Aspiration Pneumonia

Trauma

Pancreatitis

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96
Q

Dx of ARDS

A

A diagnosis of exclusion with the following criteria (ARDS)

Abnormal CXR (bilateral lung opacities)

Respiratory failure within 1 week of alveolar insult

Decreased PaO2/FiO2 (ratio < 300, hypoxemia due to ↑ intrapulmonary shunting and diffusion abnormalities)

Symptoms of respiratory failure are not due to HF/fluid overload

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97
Q

Consequences of ARDS

A

Impaired gas exchange

↓ lung compliance

Pulmonary HTN

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98
Q

Management of ARDS

A

Treat the underlying cause

Mechanical ventilation: ↓ Tidal Volumes, ↑PEEP

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99
Q

What is PEEP?

A

positive end-expiratory pressure

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100
Q

Photos of ARDS

A

Pg 660

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101
Q

What is sleep apnea?

A

Repeated cessation of breathing > 10 seconds during sleep → disrupted sleep → daytime somnolence

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102
Q

Dx of sleep apnea

A

Sleep study Normal PaO2 during the day

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103
Q

Sleep Apnea complications

A
  • Hypoxia → ↑ EPO release →↑erythropoiesis
  • Nocturnal hypoxia → systemic/pulmonary hypertension, arrhythmias (atrial fibrillation/flutter),
  • Sudden death
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104
Q

What is obstructive sleep apnea?

A

Respiratory effort against airway obstruction

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105
Q

obstructive sleep apnea common causes

A

Associated with obesity, loud snoring, daytime sleepiness

Caused by excess parapharyngeal tissue in adults, adenotonsillar hypertrophy in children

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106
Q

Treatment of obstructive sleep apnea

A

Weight loss CPAP Surgery

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107
Q

What is central sleep apnea

A

Impaired respiratory effort due to CNS injury/toxicity, HF, opioids

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108
Q

What causes central sleep apnea?

A

May be associated with Cheyne-Stokes respirations (oscillations between apnea and hypernea)

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109
Q

Treatment of central sleep apnea

A

Treat with positive airway pressure

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110
Q

What is obesity hypoventilation syndrome?

A

Obesity (BMI ≥30 Kg/m2) → hypoventilation → ↑ PaCO2 during waking hours (retention);↓ PaO2 and ↑PaCO2 during sleep

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111
Q

Pickwickian syndrome AKA

A

obesity hypoventilation syndrome

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112
Q

obesity hypoventilation syndrome AKA

A

Pickwickian syndrome

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113
Q

What is pulmonary hypertension

A

Pulmonary hypertension = ≥ 25 mmHg at rest

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114
Q

Consequences of pulmonary hypertension

A
  • Arteriosclerosis
  • Medial hypertrophy
  • Intimal fibrosis of pulmonary arteries
  • Plexiform lesions
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115
Q

Describe the course of pulmonary hypertension

A

Severe respiratory distress → cyanosis and RVH → death from decompensated cor pulmonale

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116
Q

Types of Pulmonary hypertension

A
  1. PAH
  2. LHD
  3. Lung disease or hypoxia
  4. Chronic thromboembolic
  5. Multifactorial​
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117
Q

What is PAH

A

Type I pulmonary hypertension: pulmonary arterial hypertension

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118
Q

Most common causes of PAH

A

Often idiopathic

Heritable PAH can be due to an inactivating mutation in BMPR2 gene (normally inhibits vascular smooth muscle proliferation) = Poor prognosis

Other causes include:

drugs (amphetamines, cocaine)

Connective tissue disease

HIV

Portal hypertension

Congenital heart disease

Schistosomiasis

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119
Q

Mechanism of PAH

A

Pulmonary vasculature endothelial dysfunction results in ↑ vasoconstrictors (eg endothelin) and ↓ vasodilators (eg NO and prostacyclins)

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120
Q

Drugs that can cause PAH

A

(amphetamines, cocaine)

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121
Q

Type 2 pulmonary hypertension AKA

A

Left heart disease

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122
Q

Type 2 pulmonary hypertension causes

A

Systolic/diastolic dysfunction Valvular disease

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123
Q

Type 3 pulmonary hypertension AKA

A

Lung diseases or hypoxia

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124
Q

Causes of Type 3 pulmonary hypertension

A

Destruction of lung parenchyma (eg, COPD) Lung inflammation/fibrosis (eg, interstitial lung diseases) Hypoxemic vasoconstriction (eg, obstructive sleep apnea, living in high-altitude)

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125
Q

Type 4 pulmonary hypertension AKA

A

Chronic thromboembolic

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126
Q

Causes of Type 4 pulmonary hypertension

A

Recurrent microthrombi → ↓ cross-sectional area of pulmonary vascular bed

127
Q

Type 5 pulmonary hypertension AKA

A

Multifactorial pulmonary HTN

128
Q

Causes of Type 5 pulmonary hypertension

A

Hematologic disorders

Systemic disorders

Metabolic disorders

Compression of the pulmonary vasculature by a tumor

129
Q

What is a Pleural effusion

A

Excess accumulation of fluid between the pleural layers → restricted lung expansion during inspiration

130
Q

Treatment of pleural effusion

A

Thoracentesis to remove/reduce fluid

131
Q

Breath sounds of pleural effusion

132
Q

Percussion in of pleural effusion

133
Q

Fremitus in pleural effusion

134
Q

Tracheal deviation in pleural effusion

A

None if small Away from side of lesion if large

135
Q

Types of pleural effusions

A
  • Transudate
  • Exudate
  • Lymphatic
136
Q

Describe transudate pleural effusion

A

↓ protein content

Due to ↑ hydrostatic pressure (eg, HF) or ↓ oncotic pressure (eg, nephrotic syndrome, cirrhosis)

137
Q

Describe exudate pleural effusion

A

↑ protein content

Cloudy Due to; malignancy, pneumonia, collagen vascular disease, trauma (occurs in states of ↑ vascular permeability)

Must be drained due to the risk of infection

138
Q

Describe lymphatic pleural effusion

A

Due to thoracic duct injury from trauma or malignancy Milky-appearing fluid; ↑ TGs

139
Q

lymphatic pleural effusion AKA

A

Chylothorax

140
Q

Pictures of pleural effusion

141
Q

What is atelectasis?

A

atelectasis is collapse of lung tissue with loss of volume.

142
Q

Breath sounds in atelectasis/bronchial obstruction

143
Q

Percussion in atelectasis/bronchial obstruction

144
Q

Fremitus in atelectasis/bronchial obstruction

145
Q

Tracheal deviation in atelectasis/bronchial obstruction

A

Toward the side of lesion

146
Q

What is a pneumothorax?

A

pneumothorax refers to a condition in which the space between the wall of the chest cavity and the lung itself fills with air, causing all or a portion of the lung to collapse. Air usually enters this space, called the pleural space, through an injury to the chest wall or a hole in the lung.

147
Q

Breath sounds in simple pneumothorax

148
Q

Percussion in simple pneumothorax

A

Hyperresonant

149
Q

Fremitus in simple pneumothorax

150
Q

Tracheal deviation in simple pneumothorax

151
Q

What is a tension pneumothorax?

A

Tension pneumothorax is the progressive build-up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return. Positive pressure ventilation may exacerbate this ‘one-way-valve’ effect.

152
Q

Breath sounds in tension pneumothorax

153
Q

Percussion in tension pneumothorax

A

Hyperresonant

154
Q

Fremitus in tension pneumothorax

155
Q

Tracheal deviation in tension pneumothorax

A

Away from the side of the lesion

156
Q

What is pulmonary consolidation?

A

A pulmonary consolidation is a region of normally compressible lung tissue that has filled with liquid instead of air. The condition is marked by induration (swelling or hardening of normally soft tissue) of a normally aerated lung. It is considered a radiologic sign.

157
Q

Examples of diseases where consolidation occurs

A

Lobar pneumonia

Pulmonary edema

158
Q

Breath sounds in consolidation (lobar pneumonia, pulmonary edema)

A
  • Bronchial breath sounds
  • Late inspiratory crackles
  • Egophony
  • Whispered pectoriloquy
159
Q

Percussion in consolidation (lobar pneumonia, pulmonary edema)

160
Q

Fremitus in consolidation (lobar pneumonia, pulmonary edema)

161
Q

Tracheal deviation in consolidation (lobar pneumonia, pulmonary edema)

162
Q

What is pneumothorax

A

Accumulation of air in pleural space

163
Q

Signs of pneumothorax

6 listed

A
  • Dyspnea
  • Uneven chest expansion
  • Chest pain
  • ↓ tactile fremitus
  • Hyperresonance
  • Diminshed breath sounds

ALL ON THE AFFECTED SIDE

164
Q

Types of pneumothorax

A

Primary spontaneous pneumothorax Secondary spontaneous pneumothorax Traumatic pneumothorax Tension pneumothorax

165
Q

What is a primary spontaneous pneumothorax?

A

Due to rupture of apical subpleural bleb or cysts

166
Q

Primary spontaneous pneumothorax occurs most commonly in?

A

Tall, thin, young males Smokers

167
Q

What is a secondary spontaneous pneumothorax

A

Due to diseased lung (eg, bullae in emphysema, infections) Mechanical ventilation with use of high pressures → barotrauma

168
Q

What is traumatic pneumothorax

A

Caused by blunt (eg, rib fracture) penetrating (eg, gunshot), or iatrogenic (eg, central line placement, lung biopsy, barotrauma due to mechanical ventilation) trauma

169
Q

What is Tension pneumothorax

A

Can be caused by any form primary, secondary or traumatic Air enters the pleural space but cannot exit; Increasing trapped air → tension pneumothorax

170
Q

Special considerations of a tension pneumothorax

A
  • Trachea deviates away from the affected lung
  • Needs immediate needle decompression and chest tube placement
  • May lead to ↑ intrathoracic pressure →↓ venous return →↓ cardiac function
171
Q

Pneumothorax photos

172
Q

Types of pneumonia

4 listed

A
  • Lobar pneumonia
  • Bronchopneumonia
  • Interstitial pneumonia
  • Cryptogenic organizing pneumonia
173
Q

Organisms of lobar pneumonia

A
  • S pneumoniae (most frequent)
  • Legionella
  • Kliebsella
174
Q

Organisms of Bronchopneumonia

A
  • S pneumoniae
  • S aureus
  • H influenzae
  • Kliebsella
175
Q

Organisms of interstitial pneumonia

A
  • Mycoplasma
  • Chlamydophila pneumoniae
  • Chlamydophila psittaci
  • Legionella Viruses (RSV, CMV, Influenza, adenovirus)
176
Q

Organisms of cryptyogenic organizing pneumonia

A
  • Etiology unknown
  • Secondary organizing pneumonia caused by chronic inflammatory diseases (eg, rheumatoid arthritis) or medication side effects (eg, amiodarone)
  • (-) sputum and blood cultures
  • No response to antibiotics
177
Q

Characteristics of lobar pneumonia

A

Intra-alveolar exudate → consolidation and may involve the entire lobe or the whole lung

178
Q

Characteristics of bronchopneumonia

A
  • Acute inflammatory infiltrates from bronchioles into adjacent alveoli
  • Patchy distribution involving ≥ 1 lobe
179
Q

Intersititial pneumonia AKA

A

Walking Pneumonia Or Atypical pneumonia

180
Q

Walking pneumonia AKA

A

Interstitial pneumonia Or atypical pneumonia

181
Q

Characteristics of interstitial pneumonia

A
  • Diffuse patchy inflammation localized to interstitial areas at alveolar walls
  • Diffuse distribution involving ≥ 1 lobe
  • Generally follows a more indolent course (“walking” pneumonia)
182
Q

Cryptogenic organizing Pneumonia was known as?

A

Formerly known as bronchiolitis obliterans organizing pneumonia (BOOP)

183
Q

Characteristics of Cryptogenic organizing pneumonia

A

Formerly known as bronchiolitis obliterans organizing pneumonia (BOOP) Noninfectious pneumonia characterized by inflammation of bronchioles and surrounding structures

184
Q

Days 1-2 of lobar pneumonia

A
  • “Congestion” Red-purple, partial consolidation of parenchyma
  • Exudate mostly bacteria
185
Q

Days 3-4 of lobar pneumonia

A
  • “Red hepatization” Red-brown, consolidated
  • Exudate with fibrin, bacteria, RBCs and WBCs
186
Q

Days 5-7 of lobar pneumonia

A

“Gray hepatization” Uniformly gray Exudate full of WBCs, lysed RBCs and fibrin

187
Q

Day 8 of lobar pneumonia

A

“resolution” Enzymes digest components of exudate

188
Q

Lung cancer mortality

A

Leading cause of cancer death

189
Q

Lung cancer presentation

A
  • Cough
  • hemoptysis
  • Bronchial obstruction
  • Wheezing
  • "coin” lesion on CXR or non-calcified nodule on CT
190
Q

Sites of metastases from lung cancer

A
  • Adrenals
  • Brain
  • Bone (pathologic fracture)
  • Liver (jaundice, hepatomegaly)
191
Q

Types of cancer metastases to the lungs

A

Usually, multiple lesions and are more common than primary neoplasms

Most often from

  • Breast
  • Colon
  • Prostate
  • Bladder
192
Q

Mnemonic of lung cancer complications

A

SPHERE

  • Superior vena cava/thoracic outlet syndromes
  • Pancoast tumor
  • Horner syndrome
  • Endocrine (paraneoplastic)
  • Recurrent laryngeal nerve compression (hoarseness)
  • Effusions (pleural or pericardial)
193
Q

Risk factors for lung cancer

FHx

A
  • Smoking/second hand smoke
  • Radon
  • Asbestos
  • Family history
194
Q

Mnemonic of lung cancer location and cause

A

Squamous and Small cell carcinomas are Sentral (central) and often caused by Smoking

195
Q

Common location of small cell carcinoma

196
Q

Common location of adenocarcinoma

A

Peripheral

197
Q

Common location of squamous cell carcinoma

198
Q

Common location of large cell carcinoma

A

Peripheral

199
Q

Common location of Bronchial carcinoid tumor

A

Central or Peripheral

200
Q

Characteristics of small cell carcinoma

A
  • Undifferentiated → very aggressive
  • May produce ACTH (Cushing Syndrome),
  • SIADH
  • Antibodies against presynaptic Ca channels (Lambert-Eaton myasthenic syndrome)
  • or neurons (paraneoplastic myelitis, encephalitis, subacute cerebellar degeneration

Amplification of MYC oncogenes common

201
Q

Management of small cell carcinoma

A

Chemotherapy +/- radiation

202
Q

Histology of small cell carcinoma

A

Neoplasm of endocrine Kulchitsky cells → small dark blue cells

203
Q

Characteristics of Adenocarcinoma

A

Most common 1° lung cancer

More common in women than men

  • Most common lung cancer to arise in non-smokers
  • Associated with hypertrophic osteoarthropathy (clubbing)
  • Bronchioloalveolar subtype (adenocarcinoma in situ)
  • Bronchial carcinoid and bronchioalveolar cell carcinoma have a lesser association with smoking
204
Q

Histological features of Adenocarcinoma

A
  • Glandular pattern on histology
  • often stains (+) mucin
  • Bronchioalveolar subtype grows along alveolar septa → apparent “thickening” of alveolar walls tall columnar cells containing mucus
205
Q

Characteristics of squamous cell carcinoma

A
  • Hilar mass arising from the bronchus
  • Cavitation
  • Cigarettes
  • Hypercalcemia (produces PTHrP)
206
Q

Histological features of squamous cell carcinoma

A

Keratin pearls and intercellular bridges

207
Q

Characteristics of large cell carcinoma

A
  • Highly anaplastic undifferentiated tumor;
  • Less responsive to chemotherapy;
  • remove surgically
  • Strong association with smoking
208
Q

Histological features of large cell carcinoma

A

Pleomorphic giant cells

209
Q

Characteristics of bronchial carcinoid tumor

A
  • Excellent prognosis
  • Metastasis rare
  • Symptoms due to mass effect or carcinoid syndrome (flushing, diarrhea, wheezing)
210
Q

Histological features of bronchial carcinoid tumor

A
  • Nests of neuroendocrine cells
  • Chromogranin A (+)
211
Q

Photos of lung cancers

212
Q

What is a lung abscess?

A

A localized collection of pus within parenchyma

213
Q

Treatment of lung abscess

A

Antibiotics

214
Q

Imaging of lung abscess

A
  • Air-fluid levels often seen on CXR
  • Fluid levels common in cavities
  • Presence suggests cavitation due to anaerobes (eg, Bacteroides, Fusobacterium, Peptostreptococcus) or S aureus
  • Lung abscess 2° to aspiration is most often found in right lung
  • Location depends on patients position during aspiration
215
Q

Pancoast tumor AKA

A

Superior sulcus tumor

216
Q

Superior sulcus tumor AKA

A

Pancoast tumor

217
Q

What is Pancoast tumor?

A

Carcinoma that occurs in the apex of the lung may cause Pancoast syndrome by invading cervical sympathetic chain

218
Q

Pancoast tumor symptoms

A

Compression of locoregional structures may cause array of findings

  • Recurrent laryngeal nerve → hoarseness
  • Stellate ganglion → Horner syndrome (ipsilateral ptosis, miosis, anhidrosis)
  • Superior Vena Cava → SVC syndrome
  • Brachiocephalic vein → brachiocephalic syndrome Brachial plexus → sensorimotor deficits
219
Q

What is Superior Vena Cava syndrome?

A

An obstruction of the SVC that impairs blood drainage from the head (“facial plethora”; note blanching after fingertipp pressure in neck (jugular venous distension) and upper extremities (edema)

220
Q

Common causes of Superior Vena Cava Syndrome

A
  • Malignancy (eg, mediastinal mass, Pancoast tumor)
  • Thrombosis from indwelling catheters
221
Q

Treatment of Superior Vena Cava Syndrome

A
  • Medical emergency
  • Can raise intracranial pressure (if obstruction is severe) → headaches, dizziness, ↑ risk of aneurysm/rupture of intracranial arteries
222
Q

Picture of SVC syndrome

223
Q

List of 1st-gen histamine-1 blockers

A

Names contain “-en/-ine or “-en/-ate”

  • Diphenhydramine
  • Dimenhydrinate
  • Chlorpheniramine
224
Q

List of 2nd-gen histamine-1 blockers

A

Names usually end in “-adine”

  • Loratadine
  • Fexofenadine
  • Desloratadine
  • Cetrizine
225
Q

Clinical uses of 1st-gen histamine-1 blockers

A
  • Allergy
  • Motion sickness
  • Sleep aid
226
Q

Clinical uses of 2nd-gen histamine-1 blockers

227
Q

Adverse effects of 1st-gen histamine-1 blockers

A
  • Sedation
  • Antimuscarinic
  • Anti-α-adrenergic
228
Q

Adverse effects of 2nd-gen histamine-1 blockers

A

Far less sedating than 1st generation because of ↓ entry into CNS

229
Q

What is Guaifenesin

A
  • Expectorant
  • thins respiratory secretions
  • Does not suppress cough reflex
230
Q

What is N-acetylcysteine

A

Mucolytic

  • liquifies mucus in chronic bronchopulmonary diseases (COPD, CF) by disrupting disulfide bonds
  • Also, used as an antidote for acetaminophen overdose
231
Q

What is Dextromethorphan?

A

Antitussive (antagonizes NMDA glutamate receptors)

  • Synthetic codeine analog
  • Has mild opiod effect when used in excess
  • Naloxone can be given for OD
  • Mild abuse potential
  • May cause serotonin syndrome if combined with other serotonergics
232
Q

Pseudoephedrine MOA

A

α-adrenergic agonist

233
Q

Phenylephrine MOA

A

α-adrenergic agonist

234
Q

Clinical uses of Pseudoephedrine

A
  • Used as nasal decongestants
  • Reduce hyperemia, edema, nasal congestion
  • Open obstructed eustachian tubes
235
Q

Adverse effects of Pseudoephedrine

A
  • HTN
  • Rebound congestion if used for more than 4-6 days
  • Can also cause CNS stimulation/anxiety
236
Q

Clinical uses of Phenylephrine

A
  • Used as nasal decongestants
  • Reduce hyperemia, edema, nasal congestion
  • Open obstructed eustachian tubes
237
Q

Adverse effects of Phenylephrine

A
  • HTN
  • Rebound congestion if used for more than 4-6 days
238
Q

pHTN AKA

A

Pulmonary hypertension

239
Q

List of drug classes to treat pHTN

A
  • Endothelin receptor antagonists
  • PDE-5 inhibitors
  • Prostacyclin analogs
240
Q

Endothelin receptor antagonists MOA

A

Competitively antagonizes endothelin-1 receptors (ETA and ETB) → ↓pulmonary vascular resistance

241
Q

Considerations of Endothelin receptor antagonists

A

Monitor LFTs

242
Q

Examples of Endothelin receptor antagonists

243
Q

PDE-5 inhibitors MOA

A

Inhibits PDE-5 → ↑cGMP → prolonged vasodilatory effect of NO

244
Q

Considerations of PDE-5 inhibitors

A

Also used to treat erectile dysfunction

245
Q

PDE-5 inhibitors are contraindicated with

A

Taking nitroglycerin or other nitrates

246
Q

Examples of PDE-5 inhibitors

A

Sildenafil

247
Q

What is PGI2

A

Prostacyclin

248
Q

Prostacyclin analogs MOA

A

PGI2 (prostacyclin) with direct vasodilatory effects on pulmonary and systemic arterial vascular beds Inhibits platelet aggregation

249
Q

Side effects of Prostacyclin analogs

A

Flushing Jaw pain

250
Q

Examples of Prostacyclin analogs

A
  • Epoprostenol
  • Iloprost
251
Q

Asthma drugs target what systems in the body

A

Bronchoconstriction is mediated by

  1. inflammatory processes
  2. parasympathetic tone

Therapy targets these 2 pathways

252
Q

Examples of β2-agonists

3 listed

A
  • Albuterol
  • Salmeterol
  • Formoterol
253
Q

Albuterol mechanism

A

Relaxes bronchial smooth muscle (short acting β2-agonist)

254
Q

Albuterol clinical uses

A

Used during acute exacerbations of asthma

255
Q

Salmeterol mechanism

A

Long-acting agents for prophylaxis

256
Q

Adverse effects of Salmeterol

A
  • Tremor
  • Arrhythmia
257
Q

Formoterol mechanism

A

Long-acting agents for prophylaxis

258
Q

Adverse effects of Formoterol

A
  • Tremor
  • Arrhythmia
259
Q

List some inhaled corticosteroids

A
  • Fluticasone
  • Budesonide
260
Q

Fluticasone MOA

A
  • Inhibit the synthesis of virtually all cytokines
  • Inactivate NF-κB, the transcription factor that induces the production of TNF-α and other inflammatory agents
261
Q

Clinical uses of Fluticasone

A

1st line therapy for chronic asthma

262
Q

Special considerations when using Fluticasone

A

Use a spacer or rinse mouth after use to prevent oral thrush

263
Q

Budesonide MOA

A
  • Inhibit the synthesis of virtually all cytokines
  • Inactivate NF-κB, the transcription factor that induces the production of TNF-α and other inflammatory agents
264
Q

Clinical uses of Budesonide

A

1st line therapy for chronic asthma

265
Q

Special considerations when using Budesonide

A

Use a spacer or rinse mouth after use to prevent oral thrush

266
Q

List prototypes of muscarinic antagonists for treating asthma

2 listed

A
  • Tiotropium
  • Ipratropium
267
Q

Tiotropium MOA

A

Completely block muscarinic receptors preventing bronchoconstriction

268
Q

Clinical uses of Tiotropium

A
  • Asthma
  • COPD
269
Q

Duration of action of Tiotropium

A

Long-acting

270
Q

Ipratropium MOA

A

Completely block muscarinic receptors preventing bronchoconstriction

271
Q

Clinical uses of Ipratropium

A

Asthma

COPD

272
Q

Classes of drugs used to treat asthma

8 listed

A
  • β2-agonists
  • Inhaled corticosteroids
  • Muscarinic antagonists
  • Antileukotrienes
  • Anti-IgE monoclonal therapy
  • Methylxanthines
  • Mast cell stabilizers
  • Methacholine (challenge?)
273
Q

List prototypes of Antileukotrienes

3 listed

A
  • Montelukast
  • Zafirlukast
  • Zileuton
274
Q

Montelukast MOA

A

Block leukotriene receptors (CysLTI1)

275
Q

Montelukast Clinical uses

A

Especially good for aspirin-induced and exercise-induced asthma

276
Q

Zileuton MOA

A
  • 5-lipoxygenase pathway inhibitor
  • Blocks conversion of arachidonic acid to leukotrienes
277
Q

Zileuton adverse effects

A

Hepatotoxic

278
Q

Zafirlukast MOA

A

Block leukotriene receptors (CysLTI1)

279
Q

Zafirlukast clinical uses

A

Especially good for aspirin-induced and exercise induced asthma

280
Q

List prototypes of Anti-IgE monoclonal therapy

281
Q

Omalizmab drug class

A

Anti-IgE monoclonal therapy

282
Q

Omalizumab MOA

A

Binds mostly to unbound serum IgE and blocks binding to FeεRI

283
Q

Clinical uses of Omalizumab

A

Used in allergic asthma with ↑IgE levels resistant to inhaled steroids or long-acting β2-agonists

284
Q

List prototypes of Methylxanthines

A

Theophylline

285
Q

Theophylline drug class

A

Methylxanthines

286
Q

Theophylline MOA

A

Likely causes bronchodilation by inhibiting phophodiesterase → ↑ cAMP levels due to ↓ cAMP hydrolysis

287
Q

Special considerations of Theophylline

A
  • Usage is limited because of the narrow therapeutic index
  • Metabolized by CYP-450
  • Blocks actions of adenosine
288
Q

Theophylline adverse effects

A

Usage is limited because of narrow therapeutic index

Cardiotoxicity

Neurotoxicity

289
Q

List prototypes of mast cell stabilizers

A
  • Cromolyn
  • Nedocromil
290
Q

Cromolyn MOA

A

Prevent release of inflammatory mediators from mast cells

291
Q

Cromolyn clinical uses

A

Used for prevention of bronchospasm not for acute bronchodilation

292
Q

Nedocromil MOA

A

Prevent release of inflammatory mediators from mast cells

293
Q

Nedocromil clinical uses

A

Used for prevention of bronchospasm not for acute bronchodilation

294
Q

Pathways on

295
Q

Methacholine MOA

A

Nonselective muscarinic receptor (M3) agonist

296
Q

Metacholine Clinical uses

A

Used in bronchial challenge (methacholine challenge) test to help diagnose asthma

297
Q

DLCO in emphysema

298
Q

DLCO in asthma

A

DLCO normal or ↑

299
Q

What is ARDS

A

Acute respiratory distress syndrome (ARDS) is a rapidly progressive disease occurring in critically ill patients. The main complication in ARDS is that fluid leaks into the lungs making breathing difficult or impossible

300
Q

Histological markers of small cell carcinoma

A

Chromogranin A (+)

Neuron-specific enolase (+)

Synaptophysin (+)

301
Q

Adenocarcinoma prevalence

A
  • Most common 1° lung cancer
  • More common in women than men
  • Most common lung cancer to arise in non-smokers
302
Q

DLCO in chronic bronchitis

A

DLCO is usually normal

303
Q

Lung cancers with strong association with smoking

A
  • Large cell carcinoma
304
Q

Prognosis of large cell carcinoma

A

poor prognosis

305
Q

large cell carcinoma association with smoking

A

strong association with smoking

306
Q

prognosis of bronchial carcinoid tumor

A
  • Excellent prognosis
  • metastasis rare
307
Q

Causes of lung abscess

A

Caused by aspiration of oropharyngeal contents (especially in patients predisposed to loss of consciousness [eg, alcoholics, epileptics]) or bronchial obstruction (eg, Cancer)

308
Q

What is Pancoast Syndrome?

A

typically results when a malignant neoplasm of the superior sulcus of the lung (lung cancer) leads to destructive lesions of the thoracic inlet and involvement of the brachial plexus and cervical sympathetic nerves (stellate ganglion)

309
Q

Causes of central sleep apnea

A
  • CNS injury/toxicity
  • HF
  • opioids
310
Q

Findings in inhalation injury and sequelae

A
  • chemical tracheobronchitis
  • edema
  • pneumonia
  • ARDS
311
Q

Mutations of adenocarcinoma

A

Activating mutations include KRAS, EGFR, and ALK

312
Q

Most common lung cancer to arise in non-smokers

A

Adenocarcinoma

313
Q

Adenocarcinoma CXR

A

hazy infiltrates similar to pneumonia; better prognosis

314
Q

Small cell carcinoma activating mutations

A

Amplification of MYC oncogenes common

CVPR (93 decks)

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