pulmonary 3 Flashcards
What drugs can cause restrictive lung disease?
bleomycin, busulfan, amiodarone, methotrexate
Always check drug history!
Describe Sarcoidosis.
“A GRUELING DISEASE”
A= ACE & ca2+ increase; G= granulomas (non-caseating); R= Rheumatoid Arthritis; U= uveitis; E= erythema nodosum; L= lymphadenopathy; I= idiopathic; N= non-caseating granuloma; G= gammaglobulinemia; V= Vitamin D increase.
What is idiopathic pulmonary fibrosis?ADD PICTURE OF HONEYCOMB
Repeated cycles of lung injury & wound healing with increased collagen deposition, “honey-comb” lung appearance & digital clubbing.
Antibody for Goodpasture Syndrome? What organ does this condition affect?
Anti Glomerular-BM antibodies
Affects the lung & kidney (glomerulonephritis).
What is found on histology for Pulmonary Langerhans cell histiocytosis? Risk factor for this disease?
Langerhan’s-like cells on histology with Birbeck granules inside (tennis racket shaped granules)
Smoking.
What direction does the Flow-Volume Loop go for Obstructive diseases?
Left.
What direction does the Flow-Volume Loop go for Restrictive diseases?
Right.
Describe FEV1 & FVC for obstructive & restrictive diseases.
FEV1 & FVC are decreased for both. However, FEV1 is more dramatically reduced compared to FVC, resulting in a decreased FEV1/FVC ratio.
What is the pathogenesis for Hypersensitivity pneumonitis?
Mixed type III/IV hypersensitivity reaction to environmental antigen leading to dyspnea, cough, chest tightness, headache.
Often seen in farmers & those exposed to birds.
What is the overall title for pneumoconioses?
“Environmental lung disease”
Chronic, fibrotic lung disease due to inhalation of environmental dust.
What do coal worker’s pneumoconiosis, silicosis & asbestosis increase the risk for?
Cor pulmonale, cancer & Caplan syndrome (rheumatoid arthritis & pneumoconioses with intrapulmonary nodules).
How is asbestosis transmitted?
Shipbuilding, roofing, plumbing.
What lobes does Asbestosis affect?
Lower lobes.
What does having Asbestosis increase the risk of getting?
1) Bronchogenic carcinoma > risk of mesothelioma; 2) pleural effusions.
How is Beryllioses transmitted?
Exposure to beryllium in aerospace & manufacturing industries.
What is seen on histology in Beryllioses?
Granulomatous (non-caseating granulomas via cell-mediated immunity induction)
Looks like Sarcoidosis.
What lobes are affected in Beryllioses?
Upper.
What will be seen on chest X-ray in silicosis and anthracosis?
“Eggshell” calcification of hilar lymph nodes.
How is Coal worker’s pneumoconiosis transmitted?
Prolonged coal dust exposure leading to macrophages laden with carbon, inflammation & fibrosis.
What is Coal worker’s pneumoconiosis also known as?
Black lung disease.
What lobes are affected in Coal worker’s pneumoconiosis?
Upper.
What is Anthracosis?
Asymptomatic condition found in many urban dwellers exposed to sooty air.
How is Silicosis transmitted?
Foundries, sandblasting, mines.
Pathogenesis of Silicosis?
Macrophages respond to silica & release fibrogenic factors, leading to fibrosis.
What is thought that Silica disrupts & what does this potentially cause?
Disrupt phagolysosomes & impair macrophages, increasing susceptibility to TB.
What lobes are affected in Silicosis?
Upper.
What is the only pneumoconioses that affects the lower lobes?
Asbestosis.
What is the only pneumoconioses that does not increase the risk for getting cancer?
Coal worker’s pneumoconiosis.
What will be seen histologically in asbestosis?
Hemosiderin-laden asbestos (ferruginous) bodies are golden-brown rods resembling dumbbells, found in alveolar septum sputum sample, visualized using Prussian Blue stain.
Aside from noncaseating granulomas, what will be seen histologically in sarcoidosis?
“Asteroid bodies:” stellate inclusions within giant cells of the granulomas.
What will be seen on CXR in asbestosis?
“Ivory white” calcified, supradiaphragmatic & pleural plaques but NOT precancerous.
What is ARDS?
Clinical syndrome characterized by acute onset respiratory failure, bilateral lung opacities, decreased PaO2/FIO2, no evidence of HF/fluid overload.
What are the causes of ARDS?
“SPARTAS”
S= sepsis; P= pancreatitis; pneumonia; A= aspiration; R= uRemia; T= trauma; A= amniotic fluid embolism; S= shock.
What is the main risk factor for ARDS?
Alcoholism.
What is the pathogenesis of ARDS?
Endothelial damage leads to increased alveolar capillary permeability, protein-rich leakage into alveoli, diffuse alveolar damage & noncardiogenic pulmonary edema.
What does ARDS result in the formation of?
Intra-alveolar hyaline membranes.
What is the damage in ARDS due to?
Initial damage due to release of neutrophilic substances toxic to alveolar wall, activation of coagulation cascade & O2-derived free radicals.
Management of ARDS?
Mechanical ventilation with low tidal volumes, address underlying cause.
What is sleep apnea?
Repeated cessation of breathing lasting 10 seconds or longer during sleep leading to disrupted sleep and daytime somnolence.
What happens to the PaO2 during the day to a patient with sleep apnea?
Normal.
Complications of sleep apnea?
Nocturnal hypoxia leading to systemic/pulmonary hypertension, arrhythmias, sudden death.
What is obstructive sleep apnea?
Respiratory effort against airway obstruction.
What is associated with obstructive sleep apnea?
Obesity & loud snoring.
What is obstructive sleep apnea caused by?
Excess pharyngeal tissue in adults, adenotonsillar hypertrophy in kids.
Tx for obstructive sleep apnea?
Weight loss, CPAP, surgery, stimulation of CN XII.
Complications of obstructive sleep apnea?
Lungs become hypoxic leading to vasoconstriction of lung vessels & pulmonary HTN, which may turn to cor pulmonale, arrhythmias & sudden cardiac death.
What is Central Sleep apnea?
No respiratory effort due to CNS injury/toxicity, HF, opioids.
Who is central sleep apnea common in?
Pre-mature infants (tx with caffeine).
What is obesity hypoventilation syndrome?
Obesity (BMI greater than or equal to 30) leading to hypoventilation, decreased PaO2 & increased PaCO2 during sleep.
What is the normal pressure of the pulmonary artery?
10-14 mmHg.
What levels of pressure indicate pulmonary HTN, both at rest and during exercise?
Rest: >25 mmHg; Exercise: >35 mmHg.
What is the characterization of pulmonary HTN?
Arteriolosclerosis, medial hypertrophy, & intimal fibrosis of the pulmonary arteries.
What is the course of disease for pulmonary HTN?
Severe respiratory distress leading to cyanosis and RVH, eventually death from decompensated COR PULMONALE.
What causes primary pulmonary HTN?
Inactivating mutation in the BMPR2 gene, classically seen in young females.
What is the normal function of the BMPR2 gene?
Inhibition of vascular smooth muscle proliferation.
What does this BMPR2 mutation lead to?
Decreased vessel radius, increased resistance, & increased pulmonary arterial pressure.
What are other causes of primary Pulmonary HTN?
Drugs (i.e. amphetamines, cocaine), connective tissue diseases, HIV, portal HTN, congenital heart disease, schistosomiasis.
What are the causes of secondary pulmonary HTN?
1) Left heart disease; 2) Lung disease or hypoxia; 3) Chronic thromboemboli; 4) Multifactorial.
What happens to the breath sounds, percussion, fremitus & tracheal deviation for a pleural effusion?
Breath sounds= decreased; percussion= dull; fremitus= decrease; tracheal deviation= none OR away from side of lesion.
What happens to the breath sounds, percussion, fremitus & tracheal deviation for atelectasis?
Breath sounds= decreased; percussion= dull; fremitus= decrease; tracheal deviation= toward side of lesion.
What happens to the breath sounds, percussion, fremitus & tracheal deviation for a simple pneumothorax?
Breath sounds= decreased; percussion= hyperresonant; fremitus= decrease; tracheal deviation= none.
What happens to the breath sounds, percussion, fremitus & tracheal deviation for a tension pneumothorax?
Breath sounds= decreased; percussion= hyperresonant; fremitus= decrease; tracheal deviation= away from side of lesion.
What happens to the breath sounds, percussion, fremitus & tracheal deviation for consolidation?
Breath sounds= bronchial breath sounds; percussion= dull; fremitus= increase; tracheal deviation= none.
What is a pleural effusion?
Excess accumulation of fluid between pleural layers leading to restricted lung expansion during inspiration.
How to treat a pleural effusion?
Thoracentesis to remove fluid.
What is a transudate pleural effusion?
Decreased protein content due to increased hydrostatic pressure or decreased oncotic pressure.
What is an exudate pleural effusion?
Increased protein content, cloudy due to malignancy, pneumonia, collagen vascular disease, trauma.
What is a lymphatic pleural effusion?
AKA chylothorax, due to thoracic duct injury from trauma or malignancy.
What is a pneumothorax?
Accumulation of air in the pleural space.
Effects of a pneumothorax?
Unilateral chest pain & dyspnea, unilateral chest expansion, decreased tactile fremitus, hyperresonance, diminished breath sounds, all on the affected side.
What is a primary spontaneous pneumothorax?
Due to rupture of atypical sub-pleural bleb or cysts, occurs in tall, thin young males.
What is a primary secondary pneumothorax?
Due to diseased lung or mechanical ventilation with use of high pressures.
What is a traumatic pneumothorax?
Caused by blunt or penetrating trauma.
What is a tension pneumothorax?
Air enters the pleural space but cannot exit, leading to trachea deviating away from affected lung.
Tx for tension pneumothorax?
Immediate needle decompression & chest tube placement.
Symptoms for a tension pneumothorax?
SOB, chest pain, tachypnea, tachycardia.
What is pneumonia?
Inflammation of alveoli.
What is lobar pneumonia caused by?
S. pneumoniae most commonly, also Legionella, Klebsiella.
What are the characteristics of lobar pneumonia?
Intra-alveolar exudate leading to consolidation.
What is bronchopneumonia pneumonia caused by?
S. pneumoniae, S. aureus, H. influenzae, Klebsiella.
What are the characteristics of bronchopneumonia pneumonia?
Acute inflammatory infiltrates from bronchioles into adjacent alveoli.
Another name for interstitial (atypical) pneumonia?
Walking pneumonia.
What is interstitial (atypical) pneumonia caused by?
Mycoplasma, Chlamydia, Legionella, viruses.
What are the characteristics of interstitial (atypical) pneumonia?
Diffuse patchy inflammation localized to interstitial areas at alveolar walls.
What is a lung abscess?
Localized collection of pus within parenchyma.
What is a lung abscess caused by?
Aspiration of oropharyngeal contents or bronchial obstruction.
Tx for lung abscess?
Clindamycin.
What is seen on CXR of a lung abscess?
Air-fluid levels.
What is the cavitation due to?
Anaerobes (i.e. Bacteroides, Fusobacterium, Peptostreptococcus).
What is a mesothelioma?
Malignancy of the pleura associated with asbestosis.
What is the treatment for lung abscess?
Clindamycin
What is seen on CXR of a lung abscess?
Air-fluid levels
Fluid levels are common in cavities (presence suggests cavitation).
What is the cavitation in a lung abscess due to?
Anaerobes (i.e. Bacteroides, Fusobacterium, Peptostreptococcus)
What is a mesothelioma?
Malignancy of the pleura (outer linings of the lungs) associated with asbestosis.
What is seen on histology for a mesothelioma?
Psammoma bodies (round collection of Ca2+)
What is positive in most mesotheliomas and negative in most carcinomas?
Cytokeratin & calretinin
Is smoking a risk factor for mesothelioma?
No
Where else can a mesothelioma arise?
Peritoneum, pericardium, tunica vaginalis (testes sac)
What is another name for a Pancoast tumor?
Superior Sulcus Tumor
Where is the location of a Pancoast tumor?
Apex of lung
What can a Pancoast tumor cause by compression of various structures?
Recurrent laryngeal nerve -> hoarseness
Superior cervical ganglion -> Horner Syndrome (ipsilateral ptosis, miosis, anhydrosis)
SVC -> SVC syndrome
Sensorimotor deficit
Shoulder pain radiating toward axilla & scapula
Upper extremity edema d/t subclavian vessel compression
Spinal cord compression/paraplegia
What causes SVC syndrome?
Compression of the SVC
What are the effects of SVC syndrome?
Impaired blood drainage from head (facial plethora = blanching after fingertip pressure), neck (JVD), & upper extremities (edema)
What are the most common causes of SVC syndrome?
Pancoast tumor & thrombosis from indwelling catheter
Is SVC syndrome a medical emergency?
Yes -> can raise ICP -> headaches, dizziness, increase risk of aneurysm/rupture of intracranial arteries
What does CXR show for pulmonary edema?
Bilateral, fluffy infiltrate
What does CXR show for interstitial lung disease?
Bilateral reticular markings
What does CXR show for pneumothorax?
Increased lucency
What does CXR show for pleural effusion?
Complete hemithorax opacification
What does CXR show for pulmonary embolism?
Normal
Describe what happens to your body when you have a pneumothorax?
Air accumulates in the pleural space causing it to expand & compress the underlying lung which may collapse.
What are the details of a spontaneous pneumothorax?
Passage of air into the pleural sac from an abnormal connection between pleura & the bronchial system as a result of bullous emphysema or some other lung disease.
What are the symptoms of a spontaneous pneumothorax?
Sharp pain on one side of chest & SOB. Trachea deviates toward affected lung.
What are the details of a tension pneumothorax?
Can result from trauma, lung infection or medical procedures. Air becomes trapped in the pleural space & cannot escape -> air & pressure accumulating within the chest each time the patient inhales. The lung on the affected side collapses & the mediastinum is pushed towards the contralateral side compressing the other lung -> impaired venous return, decreased CO, decreased BP, LOC -> shock & death.
What are the symptoms for typical pneumonia?
Fever, cough, malaise, purulent sputum, chest pain, SOB. CXR shows a lobar infiltrate that ‘whites out’ the image.
What is lobar infiltrate?
Well-defined lung consolidation
What is a lung consolidation?
Region of lung tissue filled with liquid.
What are the symptoms for atypical pneumonia?
Less severe symptoms, non-productive cough, headache, fatigue. CXR shows diffuse, patchy infiltrate.
What does a CXR for a main stem bronchus lesion look like?
Completely opacified (‘white-out’ d/t decrease of radiolucent air) hemithorax on affected side.
What does hemithorax mean?
1/2 of the chest.
What symptoms does a patient with a main stem bronchus lesion exhibit?
Decreased breath sounds & deviation of trachea to the affected side suggestive of lung collapse (atelectasis).
What is a main stem bronchus lesion caused by?
Lung tumor that obstructs the main stem bronchus.
Why does the lung collapse in a main stem bronchus lesion?
No new air is getting in.
What is the leading cause of cancer death?
Lung cancer.
What are the symptoms of lung cancer?
Cough, hemoptysis, bronchial obstruction, wheezing, pneumonic ‘coin’ lesion on CXR or noncalcified nodule on CT, weight loss, night sweats.
What are the risk factors for lung cancer?
Smoking, second-hand smoke, radon, asbestos, family history.
What is radon?
Heavy gas that settles down into coal mines. Grows along alveolar septa -> apparent ‘thickening’ of alveolar walls.
What are the characteristics of a large cell carcinoma?
Prognosis & metastasis for a bronchial carcinoid tumor are good & rare.
What are the symptoms of a bronchial carcinoid tumor?
Due to mass effect or carcinoid syndrome (flushing, wheezing & diarrhea).
‘B-FDR’
B = bronchospasm & wheezing
F = flushing
D = diarrhea
R = right sided heart lesions (i.e. valve, murmur)
What is the histology for a bronchial carcinoid tumor?
Nests of neuroendocrine cells. Chromogranin A positive.
Which lung carcinomas have some relationship with smoking?
Small cell, adenocarcinoma, squamous cell, large cell.
What are the 2 lung carcinomas most likely seen in non-smokers?
Adenocarcinoma & bronchial carcinoid tumor.
When will you see an increased CEA marker?
‘P-CLUBS’ cancer
P = pancreas
C = colon
LU = lungs
B = breast
S = stomach.
