Pathology Of The Respiratory System - Dr. Singh Flashcards
Alveoli walls
Thin walls + high vascularity
Epithelium is respiratory tract
Have cilia har sticking up
Mucous Blobs = goblet cells
Under respiratory epithelium is what
- SM and Submucosal glands
2. Cartilage is under that (chondrocytes)= holds open the trachea ridgedly
Type 1 pneumocytes do what
Gas exchange (they are very thin and line up with the capillary epithelial cells)
Type 2 pneumocytes do what
Make surfactant (also develop later in fetus) Replace type 1 pneumocytes (can become stem cells for type 1 cells)
Alveolar Pores of Kohn
Allow Air, bacteria, fluid, cells or travel between alveoli
Pulmonary Hypoplasia is what
Lungs dont stretch down to apex of heart
And dont grow as big = should be about x2 size of heart)
What can cause pulmonary hypoplasia
Diaphragmatic hernia
Low amniotic fluid levels in uterus ——> pulmonary hyperplasia + renal agenesis**
Airway malformation (tracheal stenosis)
Arthrocoposis (strictures preventing baby from expanding chest wall)
Immediate death from hypoplasia of lung happen at how many %
40 % or less lung weight compared to normal lung weight
Foregut cysts are what
Outpouching of foregut (respiratory—> ciliated epithelium , esophageal——> squamous epithelium, gastroenteric——> glandular epithelium)
= incidental outpouchings
Foregut cysts risks and complications
- rupture
- infection
- airway compression
Foregut cysts look like what on CT
Air-fluid level line inside it (shows there is fluid inside)
Congenital Pulmonary Airway Malformation (CPAM) Congenital Cystic Adenomatoid Malformation (CCAM)
What happens and types
*Arrested development* of pulmonary tissue + intrapulmonary cysts formation (the stage/type it arrests at is where it keeps cycling and forming a mass of that tissue instead of developing down to distal acinar) Type 0 : Trachebronchial Type 1 : Bronchial Type 2 : Bronchiolar Type 3 : Alveolar duct Type 4 : Distal acinar
Congenital Pulmonary Airway Malformation (CPAM) Congenital Cystic Adenomatoid Malformation (CCAM) some deatails about how it can be seen and how it communicates and risks
- Communicates with treachebronchal tree
- Fetal US detection
- Hydrops, pulmonary hypoplasia, infection later in life
Congenital Pulmonary Airway Malformation (CPAM) Congenital Cystic Adenomatoid Malformation (CCAM) TX
Remove before it gets infected of becomes a tumor = lobectomy DX inutero
Pulmonary Sequestration is what
An extra lobe is formed usually on the left side (non functioning lung tissue “Lung Bud”
= NO COMMUNICATION with treacheobronchial tree + independent arterial supply
Intralobar pulmonary sequestration is what
Extra lobe formed inside on of the lobes
= has its own blood supply
= not really connected to trachea or bronchus however can have its small own brachial branch however not enough O2 so INFECTIONS + abscess are easily formed
Intralobar pulmonary sequestration dx when
Usually hides and not until older children or adults
Extralobar pulmonary sequestration
Extra lobe forms outside the other lobes
= own blood supply and can have a small own airway attached + OWN PLEURA = abscess and infection easily
= you see mass lesion in chest or abd
Extralobular pulmonary sequestration dx when
Usually after birth with other congenital conditions
Other anomaly that can be present with a extralobular pulmonary sequestration
Diaphragmatic hernia
Atelectasis is what
Lung parenchyma cant expand and is acquired
Resorption Atelectasis
Airway obstruction (tumor, mucous,….) + gradual resorption of air = reducing lung expansion = most common = obstructive
Compression Atelectasis
Material accumulation in pleural cavity = compression of lung parenchyma
Contraction Atelectasis
Fibrotic or other restrictive process in pleura or peripheral lung = restricting lung expansion
= pleural fibrosis most common form
Pulmonary edema looks like what on histology
A lot of pink more then white, increase in epithelial cells = Left side HF since more P in the BVs + congestion
Pulmonary edema what causes it
- Left sided HF**, pulmonary V obstruction
- Hypoalbuminemia , nephrotic syndrome, liver disease = fluid leaks out
- Bacterial, sepsis, smoke, aspiration = alveolar wall injury
- high altitude + CNS injury
Gas exchange in Pulmonary edema
Alveolar spaces = lower O2 exchange
Heart failure cells
After a while of Pulmonary edema , microhemorrhage in alveoli = M accumulate (hemosiderin-laden) ——-> look brown
= in HF and CHF chronic
ALI (Acute Lung Injury)
Acute hypoxemia, bilateral infiltrates (PaO2/FiO2 < 300)
= no cardiac failure
ARDS
= acute respiratory distress, bilateral infiltrates
= worsening hypoxia ( PaO2/FiO2 < 200)**
= no cardiac problems
DAD (Diffuse Alveolar Damage)
The histologically findings of ARDS
What can cause ARDS
- Sepsis
- Diffuse pulmonary infections
- Gastric aspirations
- Trauma injury (including head)
- Pancreatitis
- Toxins (like E cigs)
What happens in ARDS from cellular level
Edema in alveoli = from damage at endothelial cells of alveoli + capillaries (from Blood circulation)
= N activation and come inside alveoli = kill type 1 cells
= fluid + hyaline membranes form** from alveolar damage
= NOT from lung itself
Hyaline membrane form as from what
Edema+ Fibrin + cellular debri
= DAD (diffuse Alveolar Damage)
= ventilation - perfusion mismatch
ARDS can lead to what
Fibrosis (irreversible) or resolution
ARDS death rate
40 % die in exudate stage (edema and hyaline membrane ) before the proliferation stage (fibroblasts and pneumonia, early fibrosis)
= Fibrotic stage is last and if reached can never be reversed
Neonatal RDS
= reduced surfactant
= hypoxemia
= pulmonary hypoperfusion —> endothelial damage
= you can see Hyaline membranes *****
Restrictive Lung Disease is what and pulmonary function test you see what
Restriction in expanding = V restriction
= FEV1/FVC normal
= FVC reduced
= TLC decreased
Obstructive Lung Disease is what and PFT you see what
Exhalation problem = decreased air flow = Low FEV1/FVC = TLC increase = FEV1 decreased
Restrictive Lung Disease also called
Interstitial lung disease (disease between alveoli)
3 common Obstructive Lung Diseases
- COPD (chronic bronchitis)
- Emphysema
- Asthma
What happens to cause COPD
- Toxins causing more mucous to form to protect airway and get rid of it
- Thickening of the muscle around airway + mucous buildup = narrowing of tract
- This irritates and damages the airway, inflammation
Chronic Bronchitis is defined as what
Cough + sputum production for 3 months in 2 consecutive years
= mucous gland hyperplasia ——> damages the airway
Reed index
How hick the submucosal layer is in the respiratory epithelium
= to see if there is chronic bronchitis
What neoplasm can form from chronic bronchitis
Squamous metaplasia ——> dysplasia ——> carcinoma
Emphysema is what location
Irreversible airspace enlargement distal to terminal bronchiole
Centrilubular emphysema is seen when
Smoking
Panlobular emphysema is seen in when
A1-antitrypsin deficiency
Chronic bronchitis can cause what in smokers
Damages the alveolar walls + alveoli collapse due to contraction upstream = air trapping = centrilobular
= chronic bronchitis traveling down from the bronchus
Reason smokers have contrilobular emphysema
Started at terminal bronchus (constricted with mucous)——> dilation starts at respiratory bronchiole and travels down
CXR and physical look of emphysema
Black lungs
= barrel chest ( square like chest)
Auscultation of emphysema
Exaltation wheezing
= flow graph shows (chair looking graph)
Blue Bloaters
CHRONIC BRONCHITIS
- Productive cough
- Elevated Hb (from CO in smoke causing less O2 delivery)
- Peripheral edema and higher BMI
- Rhonchi + wheezing
- Cyanotic
Pink Puffers
EMPHYSEMA
- Older, thin
- Severe dyspnea
- Quite chest (not as much wheezing due to expanded air spaces)
- Air hunger. Pursed lips, tripod posture
A1- antirtypsin deficiency what happens
- Liver making A1- AT does not make or transport out it right = lever damage
- Also A1-AT needed in lungs to protect it from Neutrophilic Elastase (during infection or when N are needed they secrete Elastase that damage the respiratory tract walls, only A1-AT can protect the walls from this)
A1-AT deficiency what do you see in location
Emphysema is panlobar (starting at the alveoli level), moving up to respiratory bronchus eventually
= also more in the lower lobes
(Where more BF is)
Spontaneous Pneumothorax location
Distal acinar (only Alvoli)
A1- AT deficiency hesitance and gene
Chr 14 Pi gene = normal
Pizz (homozygous for it)
Autosomal Recessive
Asthma what happens
Reversible with bronchodilator
Inflammation + hyper-responsiveness
= muscle constriction
= mucous hypersecreation
Atopic Asthma is from what
Extrinsic
- 2/3 pts
- Childhood + any age
- high IgE (type 1 hypersensitivity)
- E, Mast cells, Lymphocytes - Allergens cause this
- FH link
non-Atopic Asthma
Intrinsic
1/3 pts
= older pts
= normal IgE levels so not allergy induced
= cold and exercise and infection can cause it
Steps of how Asthma comes on
- Allergen = exaggerated Th2 cells response
- IL4 and IL5 secreted and tells B cells to make IgE
- Mast cells secrete IL5
- Eosinophils come —> release granules (on second exposure)
Leukotrines do what
- Bronchoconstrict (also uses PGE, Ach, Histamine)
- Mucous secretion
- Increase vascular permeability
Interleukins do what
Recruit inflammatory cells
When you go to doctor and the pt has asthma what do they need to do
Take asthma control test
= to see if asthma is controlled or not
= important because if not controlled then there are many long term effects
Asthma uncontrolled effects
- Airway remodeling (fibrosis, SM hyperplasia, increased goblet cells + submucosal glands)
= bronchodilators and corticosteroids stop working on these pts
Status Asthmaticus what is it and what do you see
- Asthma attack that does not stop, mucous completely obstruction airway,
= fatal asthma attack - Curschmann spirals (coiled thick mucous plugs), Charcot Leyden crystals (E granules and breakdown products)
Genetics + environment associated with atopic Asthma
- seasonal allergies
- eczema
= pollution
= X allergen exposure at early age
= early infections
Aspirin Sensitive Asthma
BLOCKED COX 1 + 2 = Arachidonic Acid goes towards 5-Lipoxygenase pathway which increases leukotreins
= increased bronchospasm
= increased chemotaxis
= SAMTERS TRIAD
SAMTERS Triad
- Nasal polyps
- Recurrent rhinitis
- Aspirin sensitive Asthma
Bronchiectasis
Chronic inflammation causing destruction of proximal bronchi = permanently dilated airways
- Dilated diameter
- More mucous
- Destroyed airway wall
- Loss of cilia
What can cause Bronchiectasis
- Allergic Bronchopulmonary Aspergillosis (ABPA)
- CF
- TB
- Primary Ciliary dyskinesia
CF in lung
CL- not leaving
= Na and H2O goes into cells
= mucous is dehydrated and thick and bacteria easily infects it, sticks to everything, cant be cleared
Bronchiectasis what do you see on the lung
The bronchioles are so dilated they go all the way to the periphery of the lungs
Kartageners Syndrome
Primary Ciliary Dyskinesia
= dynein arm not working (in microtubules ——> X flagella and cilia) = X cilia in respiratory tract
Kartageners Syndrome TRIAD
- Sinusitis
- Bronchiectasis
- Situs inversus (heart is on right side , gastric bubble on right side = which should be on left done by cilia in fetus)
= often male infertility is also another problem
CF infertility
X vas deferons
Allergic Bronchopulmonary Aspergillosis
= lives in airspace’s ——> exagggerated hypersensitivity response
= IgE is made and try to destroy it
= usually in pts with asthma or CF
= thick dark mucous in bronchi ——> bronchiectasis in advanced disease
Allergic Bronchopulmonary Aspergillosis DX
+ skin test
Septal hyphae with acute angle (like a tree)
(Aspergillosis does many more things like fungal ball)
what causes Bronchiectasis
- CF
- Allergic Bronchopulmonary Aspergillosis
- Primary Ciliary Dyskinesia
Idiopathic Pulmonary Fibrosis
- Waves in inflammation
2. Usual Interstitial Pneumonia * pattern in histology , normal + inflammation + organizing pneumonia + fibrosis areas
4 things seen in usual Interstitial Pneumonia
- Normal areas
- Inflammation
- Fibroblast foci (fibrosis) (pink)
- Peripheral honeycombing (circular thing looking)
Factors that lead to Idiopathic Pulmonary Fibrosis
- Smoking, industrial societies
- Genetics
- Over 50yo (with increasing dyspnea)
Idiopathic Pulmonary Fibrosis DX and type of lung disease
RESTRICTIVE LUNG DISEASE
= biopsy and see the usual Interstitial Pneumonia pattern
= CT scan
Idiopathic Pulmonary Fibrosis SX
- Velcro- like crackles (both inspiratory and expiratory)
- SOB
- PFT restrictive pattern (decreased FEV1 and TPV, normal FEV1/FCV)
- Honeycomb lung from basilar infiltrates **
End stage Idiopathic Pulmonary Fibrosis is seen how
Basilar infiltrates = honeycomb fibrosis (spaces with thick areas around them)
Idiopathic Pulmonary Fibrosis TX
TGF-B inhibitors
Lung transplant
(3-5 years)
Non-Specific Interstitial Pneumonia compare to UIP
Only uniform infiltrates no fibrosis (higher prognosis then UIP)
Also idiopathic
Non-Specific Interstitial Pneumonia histology
Uniform pattern
Fibrosis and inflammation = thickening spaces between alveoli (plasma cells and lymphocytes)
Non-Specific Interstitial Pneumonia risks
Can go on and become more fibrotic = harder to treat
Otherwise just treat with steroids and ant inflammatory agents
Cryptogenic Organizing Pneumonia what happens
Called bronchiolitis obliterans organizing pneumonia
= from a previous infection or inflammatory process
Cryptogenic Organizing Pneumonia SX
- Pneumonia like consolidation
2. 5th and 6th decade in life
Histology of Cryptogenic Organizing Pneumonia
- White loose fibro-CT tissue plugs = circular fibroblasic foci (MASSON BODIES)
= one component of UIP
Cryptogenic Organizing Pneumonia can be confused with what
You see the Masson bodies and that is what you see in infection, tumor, drug/toxin induced lung injury
= however rule this out by seeing no inflammation and widespread fibroblastic foci areas
Cryptogenic Organizing Pneumonia to
Oral steroids cures it
Autoimmune lung disease is in what category
CT disease (Interstitial lung disease)
- RA
- Systemic sclerosis
- SLE
Sarcoidosis histology
Non-caseating non-necrotising granulomata
Sarcoidosis
Histiocytes making granulomas
= multinucleated giant cells
How to you see Sarcoidosis in CXR
- Hilar lymphadenopathy (white consolidation next to the branching of the lobes)
- There can also be in pulmonary infiltration also
Sarcoidosis risk
Stage 4 pulmonary fibrosis
Sarcoidosis histology
- Granulomas + giant cells
- Asteroid Body (pink fuzz ball inside the Giant cell) = debri
- Schaumann body (purplish blob inside the giant cell) = calcification
Sarcoidosis prevalence
- under 40yo
- AA
- involves lungs usually
- elevated ACE levels
Sarcoidosis development
Not in stages (some are progressive to fibrosis)
Hypersensitivity Pneumonitis histology
- A bunch of inflammation everywhere (purple dots all over)
Hypersensitivity Pneumonitis is what
- Immune reaction to inhaling Ag
- Pigeon -breeder lung (bird poop protein)
- Farmers lung (Actinomycetes spores)
- Hot tub lung (MAC reaction)
= not infection, hypersensitivity
(Vape, hairspray, work inhalants, wind instrument bagpipes)
Hypersensitivity Pneumonitis causes
Airway centered granulomata associated with lymphocytes
4 smoking related lung diseases
- Idiopathic Pulmonary Fibrosis
- Desquamative Interstitial Pneumonia
- Respiratory Bronchiolitis - Interstitial Pneumonia
- Langerhans Cell Histiocytosis
Desquamative Interstitial Pneumonia Histology and type of lung disease
RESTRICTIVE 1. Stuffed alveolar spaces 2. Alveoli FULL OF M cells = plug the alveoli = 5th-6th decade = from smoking
Desquamative Interstitial Pneumonia TX
Corticosteroids
Stop smoking
Good prognosis (survive at 5years)
RB-ILD (Respiratory Bronchiolitis Interstitial Lung Disease) is what
3rd -4th decade in life
= smoking related
= baby part of DSIP less symptomatic
RB-ILD (Respiratory Bronchiolitis Interstitial Lung Disease)DX
CT scan = early interstitial lung disease seen
- M some
- Peribronchial metaplasia (abnormally located ciliated cells)
- Some fibrosis if advanced
RB-ILD (Respiratory Bronchiolitis Interstitial Lung Disease)TX
Stop smoking + steroids
Langerhans Cell Histocytosis is what
= Stellate lung lesions *****
= scarring ——> big many cysts that can rupture and cause pneumothorax
Langerhans Cell Histocytosis histology
- E*
- Langerhans cells*
- Fibrosis and cysts
= stain with S-100 and CD1a+ **
Langerhans Cell Histocytosis TX
Stop smoking
Pulmonary Alveolar Proteinosis what happens
= X surfactant metabolism = defected granulocyte-M colony stimulating factor (GM-CSF)
= autoimmune, secondary, hereditary
= surfactant Protein accumulates throughout the alveoli and airspaces
Pulmonary Alveolar Proteinosis prevalence
Young -mileage female autoimmune prone
Pulmonary Alveolar Proteinosis TX
GM- CSF given SubQ
Steroids or IVIG
Pulmonary Alveolar Proteinosis histology
Alveoli full of surfactant protein (light pink stuff) looking like edema
Pulmonary Alveolar Proteinosis DX
Bronchioloalveolar lavage is done and pulling out a bunch of milky looking surfactant and protein from it fluid, from the alveolar spaces
Pneumoconiosis happens from what
- Occupational exposure (in this case I have to find out all who have been exposed)
- Air pollution
= some pts have more exaggerated response
Pneumoconiosis is worse in who
Smokers (ciliary clearance)
Smaller particles
High and repetitive exposure to toxins
Coal Workers Pneumoconiosis 3 conditions that these patients can get
- Anthracosis (accumulation of coal pigment)
- Coal Macules / Nodules
- Progressive Massive Fibrosis (advanced and fatal stage, usually does not progress there unless Smokey Coal to heat cabins and homes DO PROGRESS)
Silicosis comes from what
Inhaling silicon dioxide (mining , concrete repair, demolition) = HIGH CHANCE CANCER
Silicosis what happens
SLOW progressive (even after exposure is gone) fibrosis = silica deposits in collagenous nodules* + calcification (EGGSHELL CALCIFICATIONS)*
Silicosis on CXR or CT
Circles at the hilum are seen = eggshell calcifications
CT : rings white that are seen in the fibrotic area
Silicosis location
Fibrosis is more upper lobular location
Coal miner pneumoconiosis and cancer
No link unless bituminous coal
Asbestosis caused by what
Inhaling asbestos fibers = Insulation workers = shipyard navy workers = paper mill workers = Oil or chemical refinery worker
Asbestosis diseases it causes
- Pleural fibrosis, effusion, mesothelioma
- Lung interstitial fibrosis, carcinoma
- Other cancers (like liver)
Asbestos fibers are dangerous for hat reason and histology
They are thin and straight = easy to travel down and are nerves removed
= Asbestos Bodies (FERRUGINOUS BODIES)
= look like brown straight lines with some beads on it (M that is the beading on it)
Pleural plaque formation happens in what condition and what does it look like on histology
Asbestos
= Candlewax dripping on pleura , hyalinized collagen
Mesothelioma associated with what
Asbestos even after decades after exposure
= cancer in the lungs
= can come from the pleural plaques
What does a PE look like in the CXR
- Wedge shaped lesion that’s white = small PE
Or a red infect that’s also wedged shaped - Saddle PE = fatal right HF from big PE
Lines of Zahn
How you can tell if pt died from coagulation from death or if it was the cause of death
= IF CAUSE OF DEATH ——> lines of alternating red (RBCs) and white (plt, fibrin)
Angiography of PE
Contrast does not go down all the way to the smallest vessels only in big branches
BM emboli
Cause PE from trauma or chest compressions (you see fat and lymph cells)
Talc Embolism
Drugs takes by IV can cause a shiny looking PE
Septic emboli
Can happen form IV drug use Can also happen from endocarditis = infective material ABSCESSES in blood ——> PE = valve vegetation ——> PE 1. Jane way lesions 2. Roth spots 3. Splinter hemorrhages
Pulmonary HTN is what
Pulmonary Artery P > 20mmHg
Pulmonary HTN happens when
- More genetic young pts primary vascular disease
- Left HF
- . hypoxia or Chronic Pulmonary parenchymal disease
- From PE
Pulmonary HTN histology
- Knotted BVs = PLEXIFORM LESION
2. Medial hypertrophy (SM in vessels)
3 Pulmonary Hemorrhage Syndromes
- Goodpasture Syndrome
- Granulomatosis with Polyangitis (Wagner granulomatosis)
- Idiopathic Pulmonary Hemosiderosis
Pulmonary Hemorrhage Syndrome histology
Hemosiderine stained M in lungs and blood hemorrhaging
Goodpasture Syndrome what happens and histology
ABs attacking collagen4 on BM = linear immunofluorescence study
+ you see the RBCs around the linear staining in histology
= TYPE 2 hypersensitivity
Goodpasture Syndrome prevalence
Male younger age 2nd-3rd decade
= AB against collagen 4 on BM
Goodpasture Syndrome attacks what organs
Lungs and Kidneys
Granulomatosis With Polyangiitis
Wagners Disease
= granulomatous inflammation that can hemorrhage (can look like pneumonia)
= a lot of bleeding in the lung
= BV necrotizing granuloma
Granulomatosis With Polyangiitis prevalence
Male over 40yo
= ANCA +
= saddle nose necrotizing granulomatous
= bleeding in lung alveoli