Pathology Flashcards
Asthma
Chronic inflammatory condition due to episodic exacerbations of bronchoconstriction by triggers
Sx - episodic, worse at night, dry cough, wheeze and shortness of breath,
Ix - ECG, peak flow, Blood gasses
Mx - SABA first line when exacerbated sx
- ICS each day to prevent sx
*If failing to resound to treatment in life threatening - BiPAP
**In kids - trial 8-12 weeks of 2 puffs low dose ICS and salbutamol
Acute attack - oxygen given
- Salbutamol and ipratropium bromide by nebuliser
- Hydrocortisone IV
IV Aminophilline if sever attack
Acute asthma diagnosis
- Rapid deterioration in symptoms
- Moderate - PEFR 50-75% predicted
- Severe “ 33-50% predicted, resp rate >25, HR>110, unable to complete sentences
- Life-threatening - PEFR<33%, sats <92%, becoming tired, no wheeze (airways so tight), haemodynamically unstable
Emphysema
Lots of air in the lungs caused by a loss of elastic fibres of alveoli
Cx - Smoking and A1 anti trypsin defect
Sx - SOB
Ix - CT, bloods, lung function tests
Mx - bronchodilators, ICS, antibiotics
- When elastic fibres are removed, leads to increased lung compliance, greater airway space and so greater resistance leading to increased work of breathing, decreasing transfer factor
Pulmonary fibrosis
Replacement of elastic fibres with collagen fibres in alveoli walls leading to stiff walls and reduced lung compliance
Cx - Infections, allergy, toxins, irritants, CT diseases
Sx - shortness of breath, exercise intolerance, dry cough, loss of appetite and weight loss
*Inspiratory reps
Ix - breathing and blood test - restrictive defect with reduced TLCO
CT
Mx - Lifestyle changes
- pirfenidone to slow progression sand reduce collagen growth
Bronchiectasis
- Very large airways, become blocked, inflammation across whole bronchi tube, poor clearance of secretions, (obstructive defect)
- Haemophlious influenza most common
Cx - Infections, cystic fibrosis, cilia not functioning, gamma globulin deficiency
Sx - cough with a lot of sputum, occasional haemoptysis, coarse crepitations, clubbing in fingers
Ix - HRCT 1st choice showing bronchial wall dilation and lack of bronchial wall tapering
- coarse crepitations at base
- Feature of Kartagenrs syndrome
Gamma globulins
IgG - most common, in blood and fluid helping to protect from bacterial and viral infections
IgE - Small amount in blood, increase due to parasites and allergy (Type 1 sensitivity reactions)
IgM - In blood and lymph, first made after infection (Type 2 hypersensitivity reaction)
IgA - Lining respiratory tract, saliva,
IgD - Not fully understood
Pulmonary chondroma
- Benign tumour of cartilage
- More likely to be females
- More likely to be peripheral
- Associated with Carnery’s triad
Pulmonary hamartoma
- Disordered proliferation of mature cartilage, fat and smooth muscle
- More likely males than females
- More likely to be central
- Solitary
TNM grading system
T - Tumour size (1-4)
N - Nodes spread (0-2)
M - Metastases (0-2) - No lungs or liver, just lungs, both
Adenocarcinoma
- Develop more peripherally in the lung
- Associated with areas of fibrous scarring
- Glandular epithelium malignancy
- Most common tumour
Lung cancers
- 3rd most common cancer behind breast and prostate
*80% of cases are smokers
> Non small-cell (80%)
Adenocarcinoma - 40% - non smokers (cavity lesions)
squamous cell carcinoma - 20% - smokers (cavity lesions)
large cell carcinoma - 10%
Mesothelioma - around the lining of an organ
> Small cell (20%)
* cells contain neurosecretory granules that can release neuroendocrine hormones - responsible for multiple paraneoplastic syndromes
Sx - SOB, cough, haemoptysis, finger clubbing, recurrent Pneumonia, weight loss, lymphadenopathy (supraclavicular are often first)
Ix - Chest x-ray, CT
- biopsy of lung tissue
**Raised platelets
Mx - surgery
- radio, chemo or immunotherpy
Mesothelioma
- Tumour of tissue surrounding an organ
- Almost always due to asbestosis exposure
- development of the mesothelioma is usually 20 or more years from the time of exposure
Sx - Chest pain, SOB, weight loss, persistent cough, tiredness
* spread into lung, pleural cavity, hilar lymph nodes usually
Ix - Chest X ray - pleural plaques present (benign)
- thoracoscopy and histology
Mx - surgery
- chemo, radio and immunotherapy
Extra-pulmonary manifestations of lung cancer
> Invasion of local structures
- SVC blocked due to tumour co impression leading to raised JVP
- Recurrent laryngeal nerve compression leading to hoarseness
- Phrenic nerve compression leading to elevation of the hemi diaphragm
- Cushing’s syndrome by ectopic ACTH secretion
- Pancoast tumour at apex of the lung causing Horner’s syndrome
Pancoast tumour
- Growing tumour usually in the apex of the lung that can cause suppression on SVC leading to raised JVP
- Can compress sympathetic plexus resulting in Horner’s syndrome
- Can compress recurrent laryngeal nerve causing a coarse voice
Hypertrophic osteoarthropathy
- Prominent with squamous cell lung cancers
- Clubbing and inflammation of the membrane (periostitis) of joint, especially DIJ
Sx - Swelling of ankles, knees wrists and elbows MC joints and finger clubbing
Transfer/perfusion defect
Transfer/perfusion - Flow of blood to alveolar capillaries (need PaCO2)
Defect - Determines alveolar capillary gas transfer (reduced PaCO2)
Cystic fibrosis
Mutation in Phe508del causing mutation in CFTR gene,C7, leading to a chloride channel defect, affecting mucus secreting cells
Sx - Thick sticky mucus, plugging airways and pancreas, persistent cough, repeated lung infections, wheezing, inflamed nasal passage, failure to thrive, loose greasy stools
*can cause delayed puberty
Ix - newborn blood spot test
Mx - bronchodilators, steroids
- prophylactic antibiotics
Restrictive defect
- Due to stiff alveolar walls, reducing lung compliance (alveolar walls aren’t able to expand)
FEV1 <80% predicted
FVC <80% predicted
FEV1/FVC ratio >70% normal
Obstructive defect
- Airways become narrowed due to inflammation from secretions
FEV1 <80% predicted
FVC = normal or low
FEV1/FVC ratio <70% predicted
Ventilation defect
Ventilation - Flow of air into alveoli
Defect - Reduced flow of air into alveoli due to increase PaCO2 (respiratory acidosis)
Surfactant deficiency
- Type II pneumocytes that secrete surfactant have not yet differentiated to secrete surfactant
- Leads to increased surface tension, reduced lung volume and increased work of breathing
Pneumothorax
- Collapsed lung due to air in pleural cavity pushing on the lung causing it to collapse
Sx - Sudden chest pain and shortness of breath, reduced breath sounds on affected side, hyper resonant on percussion
Cx - injury such as car accident or assault, lung disease such as COPD,
Tension pneumothorax - Air held in pleural cavity under positive pressure causing a mediastinal shift to the opposite side
1st spontaneous - No underlying trauma or conditions (tall people with Marfan’s syndrome for example)
2nd spontaneous - Underlying disease present but no trauma (those with cystic fibrosis)
Iatrogenic - lung biopsy, mechanical ventilation, central line insertion
Ix - CXR - if symptoms obvious no need for scan
Mx - needle aspiration 2nd ICS
- chest drain into triangle ff safety if aspiration doesn’t work
**If secondary pneumothorax and is >2cm and/or SOB, patients should be treated with a chest drain 1st line
Pleural effusions
Blood, lymph or chly in the pleural cavity
Cx - Penetrating injury to lung, heart and great vessels, cancer, infection, heart failure
Sx - reduced expansion, dull percussion, diminished breath sounds at the affected side, sudden shortness of breath, sudden chest pain, tracheal shift to opposite site
Ix - CXR then CT chest
- Protien level>30 =exudative
Mx - Insert chest drain into safe triangle in axilla region - can affect long thoracic nerve and cause winged scapula
‘safe triangle’: Lateral border of pec major, lateral border of latissimus dorsi and horizontal line from the nipple going laterally
Transudative and exudative causes of pleural effusions
Exudative - inflammation, high protein
- lung cancer, pneumonia, rheumatoid arthritis, tuberculosis
Transudative - Fluid shifting, low protein
- congestive cardiac failure, hypoalbuminaemia, hypothyroidism
02 dissociation curve
Acidosis = shift right
- Reduced oxygen affinity but increased delivery of oxygen to tissues
Cx - Low pH or high temperature
Alkalosis = shift left (lots of air)
- Increased oxygen affinity but reduced delivery of oxygen to tissues
Cx - high pH or low temperature
Investigations into neuromuscular disorder
FEV1 and FVC restrictive pattern but FEV1/FVC ratio can also be increase….>100%
E.g. Myasthenia gravis (restrictive pattern of lung disease)
Kartagener’s syndrome
Autosomal recessive cilia disorder (microtubules)
Comprising: Bronchiectasis, situs inversus and chronic sinusitis
Sx - Recurrent chest infections, infertility, defective movement of cilia, ear/nose/throat symptoms
COPD
- Umbrella term - Non reversible, long term deterioration in air flow through lungs caused by damage to lung tissues
- Usually always a smoker
- Chronic bronchitis - productive cough for 3 months in the last 2 years
Sx - Productive cough, shortness of breath, infective exacerbations, coarse crepitations and wheeze
Ix - Bloods - Deficient in A1 anti trypsin protein
- Lung function tests
- CXR showing hyper inflated lungs
Mx - SABA or SAMA 1st line
- if not working give LABA and LAMA/ICS
- exacerbation (most commonly harm influenza)- with purulent sputum or pneumonia - give amoxicillin or clarithromycin
2nd line - doxycycline
* Acute exacerbation - 5 days oral prednisone
- if max treatment not working - BiPAP
**Repet esxacerbations give prophylactic azithromycin
Acute COPD exacerbations
Mx -
Nebulised salbutamol and ipratropium
Oral or IV steroids
IV theophylline if not responsive to nebs
5 day course of oral pre
type I respiratory failure
hypoxia (PaO2<8Kpa) with normal or low PaCO2
Cx - Ventilation perfusion missmatch
Type II respiratory failure
Hypoxia (PaO <8kPa) with hypercapnia (PaCO2 >6kPa)
Cx - alveolar hypoventilation with or without V/Q mismatch
Pneumonia
- An acute lower respiratory tract infection causing consolidation of alveoli due to build up of secretions in sacs
Sx - Fever, rigors, malaise, anorexia, shortness of breath, coughing purulent sputum, haemoptysis, pleuritic chest pain
Ix - Chest x ray or CT
- Blood for organism causing
- Reduced/bronchial/harsh breath sounds, dull percussion, coarse crackles in the lungs
Mx - amoxicillin or clarithromycin 5 days 1st line if mild
- Amoxicillin and clarithromycin 7-10 days if severe
- repeat CXR in 6 weeks**
- usually streptococcus pneumonia or haemophilus influenza
Lung tumour associations
Small cell - SIADH ,^ ACTH causing hypertension, hyperglycaemia, hypokalaemia, Lambert eaton syndrome
Squamous cell - PTHrp causing hypercalcaemia, HPOA, clubbing, hyperthyroidism
Adenocarcinoma - Gynaecomastia and HPOA
Pulmonary embolism
Clot (usually from DVT) travels to the pulmonary arteries. Leads to reduced blood flow to the lung tissues and create strain on the right side of the heart
Risk factors - immobility, long flights, pregnancy, malignancy…
Sx - SOB, cough with or without blood, pleuritic chest pain, hypoxia, tachycardia, raised resp rate, haemodynamically unstable
Ix - Initial - D dimer, CXR (wedge shaped)
- CTPA for diagnosis
- If CT negative, check lower limb proximal US
Mx - 1st Apixiban or enoxoparin (3 months if provoked and 6 if unprovoked)
* Massive PE and unstable - thrombi-lysis first line - altaplaze
**Repeat PE - consider IVC filters
Pulmonary hypertension
Increase pressure in the pulmonary arteries, causing strain on right side of the heart - leads to back pressure on systemic circulation
Cx - connective tissue disease, left sided HF, COPD, PE, sarcoidosis
Sx - SOB, syncope, tachycardia, raised JVP, hepatomegaly, peripheral oedema
Ix - right ventricular hypertrophy and increased BNP
Sarcoidosis
- Small nodules of granuloma tissue (macrophages) forming around your Body - lungs, eyes, joints, skin and lymph nodes
- 2 spikes (early adulthood and around 60)
*black females affected most
Cx - immune system overdrive, attacking its tissues and organs
Sx - tender bumps on the skin (erythema nodusum), SOB, persistent dry cough, lymphadenopathy , fever, fatigue, weigh loss, night sweats
Ix - Bloods - raised ACE, hypercalcaemia, raised Ig, raised CRP, LFT, urine test for kidneys, reduced ejection fraction
- ECG or EKG
- lung function tests
- eye exam
- Chest x ray - bilateral hilar lymohadenopahty
- biopsy nodules
Mx - Conservative
- steroids if: - stage2/3, high ca, heart, eye or neuro involvement…
Tuberculosis
*Infection spread through inhaling tiny droplets from coughs or sneezes from an infected person
Cx - mycobacterium tuberculosis
Sx - persistent cough with mucous and possibly blood, weight loss, night sweats, high temperature, loss of appetite and swelling in the neck
Ix - CXR - paint sprinkled
- CT and ultrasound for other areas of the body
- Unilateral hilar lymphadenopathy
- granulomas with caseous necrosis
Mx - Long course of antibiotics - rifampicin
- vaccination
*If giving biologics (infliximab), TB status must be checked first
- most common in Africa and Asia
** Associated with aspergilloma
Atelectasis
- Common post op condition where basal alveolar collapse can lead to resp difficulties
Cx - when airways become clogged with bronchial secretions
Sx - dyspnoea and hypoxia around 72hrs post surgery
Mx - upright position
- chest physio - breathing exercises
TCLO measurement
Measurement of gas transfer from alveoli to blood
high - asthma, haem, l-r shunts, polycythaemia
low - everything else
Acute respiratory distress syndrome (ARDS)
- Increased permeability of alveolar capillaries leading to fluid accumulation
*Mortality of 40%
Cx - infection, trauma, transfusion, cardio pulmonary bypass, pancreatitis
Sx - dyspnoea, bilateral lung crackles, low sats
Ix - CXR, ABG
Mx - oxygenation/ventilation prone position, antibiotics
Obstructive sleep apnoea
- Episodes where the person stops breathing during sleep
Sx - snoring, day time sleeping, tiredness,
Ix - sleep studies (Polysomnography)
Mx - CPAP
- lifestyle factors - weight, alcohol and smoking
*DVLA informed if causing excessive daytime sleepiness
(Idiopathic) pulmonary fibrosis
- Progressive chronic lung condition where there is fibrosis of the interstitial lung
RF - 50-70yo
- male
Cx - idiopathic, asbestosis, medications like amiodaropne lupus, toxins
Sx - clubbing, SOB, progressive,
***Inspiratory bibasal crackles
Ix - - Spirometry showing restrictive picture
- Impaired gas exchange TlCO
CXR - ground glass appears of opacities
CT - investigation of diagnosis
Mx - pulmonary rehab
- poor prognosis
- oxygen
- Pirfenidone (anti fibrotic)
Acute bronchitis
- Inflammation of trachaea and main bronchias
- Axs with large airways and lots of sputum
Sx - cough, sore throat, runny nose, wheeze
- some may have low grade fever
* Different from pneumonia due to multiple symptoms and norma examination of chest
Ix - Clinical
Mx - fluids, analgesia…
- doxy first line - CRP>100 give instantly, if b between 20-100 give delayed prescription
* Doxy not given in pregnancy or children
* Amoxicillin 2nd line
Lung fibrosis
Upper
- allergic alveolitis
- coal workers pneumococis
- silicosis
- sarcoidosis
- Ank spond
- TB
- Radiation
Lower
- IPF
- CT disorder SLE
- Amiodarone, methotrexate
- asbestosis
