Pulmonary Flashcards
Right shift in oxygen-hemoglobin dissociation curve
ACE BATs right handed
Acid CO2 Exercise 2,3-BPG Altitude Temperature
Rhinosinusitis
Obstruction of sinus drainage into nasal cavity leading to inflammation and pain over affected area
usually maxillary sinus in adults
Most common acute cause is viral URI - my cause superimposed bacterial infection (Strep pneumo, H flu, M catarrhalis)
Epistaxis
Nose bleed
Most commonly occurs in anterior segment of nostril (Kiesselbach plexus).
Life-threatening hemorrhage occurs in posterior segment (sphenopalatine artery, a branch of maxillary artery)
Deep venous thrombosis
Blood clot within a deep vein leading to swelling, redness, warmth, and pain. Predisposed by Virchow Triad (SHE)
Stasis Hypercoagulability (defect in coagulation cascade proteins, such as factor V Leiden) Endothelial damage (exposed collagen triggers clotting cascade)
Approx 95% of pulmonary emboli arise from proximal deep veins of lower extremity
Homan sign - dorsiflexion of foot leads to calf pain
use unfractionated heparins (enoxaparin) for prophylaxis and acute management
Use oral anticoagulants (warfarin, rivaroxaban) for treatment (long-term prevention)
Chronic Bronchitis
An obstructive lung disease
Hyperplasia of mucus-secreting glands in bronchi leads to Reid index (thickness of gland layer/total thickness of bronchial wall) of more than 50%
Productive cough for more than 3 months per year (not necessarily consecutive) for more than 2 years
Findings: Wheezing, crackles, cyanosis (early onset hypoxemia due to shunting), late onset dyspnea, CO2 retention (hypercapnia), secondary polycythemia
Blue Bloater
Emphysema
An obstructive lung disease
Enlargement of air spaces, reduced recoil, more compliance, low diffusing capacity for CO resulting from destruction of alveolar walls. Two types:
1) Centriacinar - associated with smoking
2) Panacinar - associated with alpha1-antitrypsin deficiency
Increased elastase activity leads to loss of elastic fibers leading to increased lung compliance
Exhalation through pursed lips to increased airway pressure and prevent airway collapse during respiration
Barrel-shaped chest
Pink Puffer
Asthma
An obstructive lung disease
Bronchial hyperresponsiveness causes reversible bronchoconstriction. Smooth muscle hypertrophy, Curschmann spirals (shed epithelium forms whorled mucus plugs) and Charcot-Leyden crystals (eosinophilic, hexagonal, double-pointed, needle-like crystals formed from breakdown of eosinophils in sputum)
Can be triggered by viral URIs, allergens, stress.
Test with methacholine challenge
Findings: cough, wheezing, tachypnea, dyspnea, hypoxemia, low inspiratory/expiratory ratio, pulsus paradoxus, mucus plugging
Bronchiectasis
Chronic necrotizing infection of bronchi leads to permanently dilated airways, purulent sputum, recurrent infections, hemoptysis
Associated with bronchial obstruction, poor ciliary motility (smoking, Kartagener syndrome), cystic fibrosis, allergic bronchopulmonary aspergillosis
Restrictive lung diseases
Restricted lung expansion causes lower lung volume (low FVC and TLC). PFTS: FEV1/FVC ratio higher than 80%
Types of restrictive lung diseases and examples
1) Poor breathing mechanics (extrapulmonary, peripheral hypoventilation, normal A-a gradient):
- Poor muscular effort (polio, myasthenia gravis)
- Poor structural apparatus (scoliosis, morbid obesity)
2) Interstitial lung diseases (pulmonary lower diffusion capacity, high A-a gradient) - 10
- ARDS
- Neonatal respiratory distress NRDS (hyaline membrane disease)
- Pneumoconioses (anthracosis, silicosis, asbestosis)
- Sarcoidosis: bilateral hilar lymphadenopathy, noncaseating granulomas; high ACE and high Ca
- Idiopathic pulmonary fibrosis (repeated cycles of lung injury and wound healing with high collagen deposition)
- Goodpasture
- Granulomatosis with polyangiitis (Wegener)
- Langerhans Cell Histiocytosis (Eosinophilic granuloma)
- Hypersenstivity pneumonitis
- Drug toxicity (bleomycin, busulfan, amiodarone, methotrexate)
Hypersensitivity pneumonitis
Mixed type III/IV hypersensitivity reaction to environmental antigen leads to dyspnea, cough, chest tightness, headache.
Often seen in farmers and those exposed to birds
Pneumoconioses
Coal worker’s pneumoconiosism silicosis, and asbestosis
Higher risk of Cor Pulmonale and Caplan Syndrome (RA + pneumoconioses + intrapulmonary nodules)
Asbestosis
A pneumoconiosis
Associated with shipbuilding, roofing, plumbing
“Ivory white” calcified, supradiaphragmatic and pleural plaques are pathognomonic of asbestosis.
Associated with higher incidence of lung cancer (bronchogenic carcinoma > mesothelioma)
Affects lower lobes
Asbestos (ferruginous) bodes are golden-brown fusiform rods resembling dumbbells, found in alveolar sputum
Berylliosis
A pneumoconiosis
Associated with exposure to beryllium in aerospace and manufacturing industries
Granulomatous on histology and therefore occasionally responsive to steroids
Affects upper lobes
Coal workers’ pneumoconiosis
A pneumoconiosis
Prolonged coal dust exposure leads to macrophages laden with carbon leading to inflammation and fibrosis
AKA Black Lung Disease
Affects upper lobes
Anthracosis - asymptomatic condition found in many urban dwellers exposed to sooty air
Silicosis
A pneumoconiosis
Associated with foundries, sandblasting, mines.
Macrophages respond to silica and release fibrinogenic factors, leading to fibrosis
It is thought that silica disrupt phagolysosomes and impair macrophages, increasing susceptibility to TB.
Also higher risk of bronchogenic carcinoma
Affects upper lobes
“eggshell” calcification of hilar lymph nodes.
Asbestos is from the roof (was common in insulation) but affects the base (lower lobes)
Silica and coal are from the base (earth) and affect the roof (upper lobes)
Physical findings for Pleural Effusion
Decreased breath sounds
Dull to percussion
Decreased fremitus
No tracheal deviation or away from side of lesion (if large)
Atelectasis (bronchial obstruction) on physical exam
Decreased breath sounds
Dull to percussion
Decreased fremitus
Tracheal deviation away from side of lesion
Simple pneumothorax on physical exam
Decreased breath sounds
Hyperresonant
Decreased fremitus
No tracheal deviation
Tension pneumothorax on physical exam
Decreased breath sounds
Hyperresonant
Decreased fremitus
Tracheal deviation away from side of lesion
Consolidation (lobar pneumonia, PE) on physical exam
Bronchial breath sounds; late inspiratory crackles
Dull to percussion
Increased fremitus
No tracheal deviation
Lobar pneumonia
Organisms:
Strep pneumo (#1)
Legionella
Klebsiella
Features:
Intra-alveolar exudate leads to consolidation
May involve either lobe or lung
Bronchopneumonia
Organisms:
Strep pneumo
Staph aureus
H flu
Klebsiella
Features:
Acute inflammatory infiltrates from bronchioles into adjacent alveoli
Patchy distribution involving 1 or more lobes
Interstitial (atypical) pneumonia
Organisms:
Viruses (influenza, CMV, RSV, adenoviruses)
Mycoplasma
Legionella
Chlamydia
Features:
Diffuse patchy inflammation localized to interstitial areas at alveolar walls; diffuse distribution involving at least 1 lobe
Generally follows a more indolent course (“walking” pneumonia)
Small cell (oat cell) carcinoma
Lung cancer
Central location
Can be undifferentiated to very aggressive.
May produce ACTH (Cushing syndrome), SIADH, or antibodies against presynaptic Ca channels (Lambert-Eaton myasthenic syndrome) or neurons (paraneoplastic myelitis/encephalitis). Amplification of myc oncogenes common. Inoperable; treat with chemotherapy
Histology:
Neoplasm of neuroendocrine Kulchitsky cells (small dark blue cells)
Chromogranin A (+)
Adenocarcinoma
A non-small cell lung cancer
Peripheral location
Most common lung cancer in nonsmokers and overall (except for metastases). Activation mutations include KRAS, EGFR, and ALK. Associated with hypertrophic osteoarthropathy (clubbing)
Bronchioloalveolar subtype (adenocarcinoma in situ): CXR often shows hazy infiltrates similar to pneumonia; excellent prognosis
Histology :
- Glandular pattern on histology, often stains mucin (+)
- Bronchoalveolar subtype: grows along alveolar septa leading to apparent thickening of alveolar walls
Squamous cell carcinoma
A non-small cell lung cancer
Central location
Hilar mass arising from bronchus; cavitation; cigarettes; hypercalcemia (produces PTHrP)
Histo:
Keratin pearls and intercellular bridges
Large cell carcinoma
A non-small cell lung cancer
Peripheral location
Highly anaplastic undifferentiated tumor; poor prognosis. Less responsive to chemo; removed surgically
Histo:
Pleomorphic giant cells. Can secrete B-hCG
Bronchial carcinoid tumor
A non-small cell lung cancer
No lung location
Excellent prognosis; metastasis rare.
Symptoms usually due to mass effect; occasionally carcinoid syndrome (5-HT secretion leads to flushing, diarrhea, wheezing)
Histo:
Nests of neuroendocrine cells; chromagranin A (+)
