Pulmonary Flashcards
What is COPD?
clinical term for lung disease characterized by chronic airway obstruction w/ increased resistance to air flow
What diseases are included in COPD?
chronic bronchitis, emphysema, bronchial asthma, bronchiectasis
What is the main cause of chronic bronchitis
smoking
cessation of smoking is associated with improvement of clinical sxs
What are the 2 types of pna?
alveolar pna
interstitial pna
Describe alveolar pna
intraavleolar inflammation, either as a bronchopna or lobar pna
Describe interstitial pna
primarily involves the alveolar septae, which includes viral pna
thickening of the alveolar sac
Which type of pna is caused by a bacterial infection?
alveolar
Alveolar pna may be…
focal or diffuse
Who is most likely to get alveolar pna?
debilitated elderly pts who are confined to be
What is bronchopneumonia?
pna limited to the segmental bronchi and surrounding parenchyma
What is known as “white out” of the lung
complete lobar pna, lobe is completely filled with pus
What is characteristic about lobar pna?
widespread or diffuse alveolar pna
causes total whiteout of an entire lobe/lobes on c xray
most common cause of community acquired pna?
strep pneumoniae
What is characteristic about interstitial pnas?
usually diffuse and often bilateral
usually caused by viruses
What happens if acute bacteria/viral pna are untreated or incompletely treated?
can become organizing pna (chronic pna)
resulting in interstitial fibrosis
What causes pna?
bacterial (75%), viral
less common: fungi, protozoa, parasites, aspiration
What is aspiration pna?
some ppl can loose gag reflex: alcoholics, higher neuro dysfunction (dementia), stroke pts, meningitis pts, trauma pts, high opiates
anything that is in the stomach can come up and go into the lungs, will see food surrounded by bacterial colonies in lungs
Most important bacteria causing pna?
Streptococcus
Staphylococcus
H. Infleunza
Where do the gram neg bacteria that cause pna come from?
bacteria are part of the enteric flora and can cause pna by contamination of the blood to the lungs
How do pathogens reach the lungs for infection?
- inhalation in air droplets (TB)
- aspiration of infected secretions from UR tract (strep/staph)
- Aspiration of infected particles in gastric contents
- hematogenous spread- via blood
pna is common in sepsis and may develop secondary to…
UTIs or GI tract infections
2 types of clinical pnas?
primary/community acquired: affects healthy ppl
secondary pna/hospital acquired (nosocomial): arise in ppl with preexisting illnesses
Sxs of pna?
fever, chills and prostration along with signs related to bronchial inflammation: cough and expectoration, SOB, dyspnea and tachypnea
What does the sputum look like in pna?
mucopurulent blood-tinged “rust-colored sputum”
strep pneumoniae
How is pna dx?
presumed dx clinically but need
- CXR
- bacteriologic studies of the sputum
- peripheral blood smears
- -bacterial: leukocytosis (neutrophilia)
- –viral: +/- lymphocytosis - blood gas analysis: may detect hypoxia or respiratory acidosis
Treatment for bacterial pna?
abx
Treatment for viral pna
supportive care
Who is the pneumococcus vaccine best for?
80-90% effect against most serotypes
high risk pts: sickle cell, multiple myeloma, DM, cancer, alcoholics, splenectomy pts, eldrly
What are feautres of atypical pna?
do not present with classic features, best ex. diffuse pna cause by mycoplasma pneumoniae
sxs are milderly
What are feautres of atypical pna?
do not present with classic features, best ex. diffuse pna cause by mycoplasma pneumoniae
sxs are milder
What is coccidioidomycosis?
a chronic necrotizing infx. that resembles TB
“valley fever”
in soil it forms hyphae with arthrospores that are very light and can be carried by the wind and be inhaled
How does coccidioidomycosis cause disease in the lungs?
arthrospores form spherules that are large vacuoles with a thick wall that are filled with endospores, upon rupture of walls endospores are released and spread via blood or by extension forming caseating granulomas
How pts with coccidioidomycosis present clinically?
begins as focal asxs pneumonitis limited to lungs/regional lymph nodes… in immunocompromised granulomatous lesions can spread to virtually any organ
How pts with coccidioidomycosis present clinically?
begins as focal asxs pneumonitis limited to lungs/regional lymph nodes… in immunocompromised granulomatous lesions can spread to virtually any organ
some develop flu like sxs
What is pneumocystis carinii?
important cause of diffuse interstitial pna in immunocompromised pts
has characterisitics of both fungus and protozoan parasite
How is pneumocystis carinii transmitted?
via inhalation
- no disease in healthy pts
- pna in aids pts, leading cause of death
What is TB?
A chronic, bacterial infectious disease caused by Mycobacterium tuberculosis
What do we stain TB with? What does it look like?
AFB stain
magenta beaded rods
What does M. tuberculosis look like?
rod shaped bacterium with a waxy capsule. Acid fast.
it is an obligate aerobe whose cell wall contains mycolic acid, a complex lipid
What is reactivation/secondary TB? findings?
a reactivation of a dormant primary infection.
bacteria spreads to apex of lungs -> granulomatous pna -> confluent granulomas produce cavities -> hemoptysis
What is the spread of TB called?
miliary spread- GI tract if swallowed or spread to kidneys, brain or bones
What is the main complication of secondary TB?
Miliary spread
What type of lung carcinoma do non-smokers usually develop?
adenocarcinoma
Peak age in carincoma of lung? Gender difference?
60-70 yrs
male predominance but starting to even out due to increased smoking in women
How many ppl will die of lung cancer in US each year?
150,000
What is the only type of lung cancer that is receptive to chemo/radiation?
small cell carcinoma
Lung ca tumor may also extend into the esophagus causing…
dysphagia
What is chronic bronchitis?
chronic cough and production of sputum for a minimum of 3 months/yr for at least 2 consecutive years
Pathology of chronic bronchitis?
fibrous thickening of the walls of the bronchi and bronchiole with their lumens completely filled with thickened mucus
- due to hypertrophy of bronchial mucous and increase in # of goblet cells
What happens to the surface epithelium in chronic bronchitis?
may show focal ulcerations or metaplasia of columnar epithelium into stratified squamous epithelium
Sxs of chronic bronchitis due to increased mucus production?
prolonged coughing, thick tenacious/purulent sputum and dyspnea
Who are blue bloaters?
those with chronic bronchitis
hypoxia can be so bad during coughing that it causes cyanosis
How is the pulmonary vasculature affected by chronic bronchitis?
by peribronchial fibrosis, results in pulmonary HTN and chronic Cor Pulmonale (R HF)
Chronic bronchitis CXR?
increased bronchovascular markings and an enlarged heart
What is emphysema?
enlargement of the airspaces distal to the terminal bronchioles with destruction of the alveolar walls
rare in non-smokers, except in pts with genetic deficiency of Alpha-1 antitrypsin
Pathogenesis of emphysema
hypothesis: irritants in smoke cause influx of inflammatory cells into the alveoli-> proteolytic enzymes from the leukocytes destroy the alveolar walls causing enlargement of alveolar spaces
Gross pathology in emphysema>
lungs are enlarged, remain filled with air and do not collapse. Whiter than normal, billowy and touch in the chest midline
What are blebs?
sub pleural air-filled spaces formed by rupture alveoli which can rupture into the pleural cavity, causing a pneumothorax
What are bullae?
parenchymal air-filled spaces greater than 1 cm in diameter
blebs and bullae are seen in…
emphysema
Clinical features of emphysema
reduced respiratory surface so…compensatory tachypnea, barrel shaped chest. Often hunch forward to engage respiratory muscles
Who are pink puffers?
pts with emphysema, hyperventilate and are able to oxygenate blood adequately
Emphysema CXR?
clr lung fields with overinflation
What is bronchial asthma?
increased responsiveness of the bronchial tree to a variety of stimuli
attacks: expiratory wheeze, cough, dyspnea
What are the 2 major forms of asthma?
extrinsic asthma, intrinsic asthma
Describe extrinsic asthma
mediated by exposure to exogenous allergens (pollen, dander, mold)
typically affects children, often associated with all.
Describe intrinsic asthma
precipitated by non-immune mechanisms: heat/cold, exercise, psychological stress
increased bronchi reactivity may be related to persistent inflammation of the bronchial mucosa
Pathology of bronchial asthma
bronchi show chronic inflammation and overabundance of mucus in lumen
nonspecific inflammatory cells, + several eosinophils
+/- whorls of shed epithelial cells (Curschmann spirals)
Histologic features of asthma
bronchial wall- bronchial gland hyperplasia with overproduction of mucus
increased # of smooth muscle cells and appear to be enlarged (freq. spasm)
Gross features of asthma
lungs are large, pink and touch in the midline (similar to emphysema)
overabundance of mucus plugs in lumen -> form casts
What is bronchiectasis?
permanent dilation of the bronchi (most common comp of chronic bronchitis)
recurrent pna common
adhesions btwn lobes may occur
What is pna?
inflammation of the lung
Etiology of an legionella infection?
can occur following inhalation of bacteria from humidifiers/AC units
What does pna sound like on auscultation?
rales, rhonchi and other signs of pulmonary consolidation
Clinical features of pneumococcus pna?
sudden onset chills, fever, pleuritic CP, cough and rust-colored sputum
What is characteristic about staph pna?
tends to produce multiple abscesses
What is characteristic about gram - pseudomonas pna?
most common hospital acquired pna, characterized by vascular lesions that cause infarcts/necrosis of the lung parenchyma
common source: contaminated ventilatory equipment.
mortality rate > 70%
What is characteristic about gram - klebsiella pneumoniae infx?
occurs in middle aged alcoholic males
thick currant red jelly sputum
What does Cryptococcus neoformans cause?
fungus which causes cryptococcosis, a systemic opportunistic mycosis which affects the meninges and lungs
Cryptococcus neoformans usually occurs only in which pt populations?
immunocompromised: AIDS, leukemia, lymphoma pts
Clinical presentation for P. carinii infx.
sudden onset fever, cough, dyspnea and tachypnea
bi rales/rhonchi
CXR: diffuse interstitial pna
How does P. carinii cause disease?
presence of cup/boat shaped cysts in the alveoli induce inflammatory response, resulting in a frothy, eosinophilic edema that blocks O2 exchange
How is TB transmitted?
person-person via respiratory aerosols, the initial site of infx is in the lungs
Where/what is the initial lung lesion in TB?
usually occurs in lower lobes, consists of a Ghon complex: peripheral parenchymal granuloma and prominent infected draining mediastinal (hilar) lymph node
What does the Ghon nodule look like grossly?
well circumscribed with central necrosis
in later stages: fibrotic and calcified
How do pts presents with primary TB?
90-95% asxs, lesion remains localized and heal with calcification than can be seen on CXR
What is progressive primary TB?
uncommonly, TB spreads to other parts of the lungs. Usually occurs in children/immunosuppressed.
initial lesion rapidly enlarges and there is an erosion of bronchi/bronchioles by the necrotic central liquefaction
What is Scrofula?
miliary spread of TB to neck supraclavicular lymph nodes
Complications of miliary spread?
contralateral pna, pleurtitis, intestinal TB, hemoptysis (erosion of small pulmonary aa)
Clinical features of TB?
begins with nonspecific sxs: fever, fatigue, night sweats, weight loss
secondary TB: nonproductive dry cough, low grade fever, loss of appetite, minor hemoptysis
Most common cause of cancer deaths worldwide
lung CA
How are carcinomas of the lungs classified?
according to histologic types of carcinoma: small cell v. non-small cell carcinoma
PATHOLOGIST makes this distinction
Etiology of lung CA?
chemicals in tobacco smoke- Polycyclic Hydrocarbons
genetics also involved
Mutated oncogenes in lung CA?
K-ras
Myc
mutation in tumor suppressor genes in lung CA
p53
Rb (retinoblastoma gene)
chromosomal abnormality associated with lung cancer?
deletion in the short arm of chromosome 3 (3p)
cellular adaptions before lung CA
metaplasia of bronchial epithelium from pseudostratified columnar epithelium into stratified squamous epithelium
(can be restored to normal if smoker quits)
What is “undifferentiated large cell carcinoma”
malignant transformation of the stem cells of the bronchial epithelium- become anaplastic before differentiation
What are tumors of neuroendocrine cells called
small or oat cell carcinoma
What are tumors of mucous producing cells of the bronchioles called?
adenocarcinomas, form irregular glands
What is the only lung CA that will produce hormones?
small cell carcinoma
Where is small cell carcinoma located?
centrally
only lung CA highly response to chemo/radiation
small cell carcinoma (if caught early)
What is the only lung CA that is 95% peripherally located?
adenocarcinoma of the lung
Which lung cancer is also known as scar carcinoma?
adenocarcinoma
What is characteristic about squamous cell carcinomas?
30% all lung CA
always associated with smoking
most centrally located
How do squamous cell carcinomas appear grossly?
firm, gray-white ulcerative masses which extent through bronchial wall into the adjacent parenchyma
Are most squamous cell carcinomas usually invasive at dx?
2/3 are.
But this is the lung CA with the best prognosis out of the 4 due to slower metastasis
Squamous cell carcinoma presentation?
cough, dyspnea, hemoptysis, CP, +/- pna with pleural effusion
How do adenocarcinomas of the lung appear grossly?
irregular masses, gray-white, soft and glistening
What is bronchioalveolar carcinoma?
distinctive subtype of adenocarcinoma that grows along preexisting alveolar walls
copious mucin in sputum
CXR: single peripheral nodule OR multiple nodules OR diffuse infiltrate indistinguishable from lobar pna
Histology of bronchioalveolar carcinoma?
2/3 nonmucinous
1/3 mucinous tumors feat. increased goblet cells
Which of the 4 types of lung CAs grows and metastasizes the fastest?
small cell carcinoma (aka oat cell carcinoma)
What is unique to small cell carcinomas?
it produces a variety of paraneoplastic syndromes which are distinctive: diabetes insipidus due to ADH production, ectopic ACTH or parathorome production
How does small cell carcinoma appear grossly?
as a perihilar (central) mass, freq. with extensive lymph node metastases. Soft and white but with extensive hemorrhage and necrosis
How does small cell carcinoma look histologically?
sheets of small, round, oval or spindle-shaped cells
scant cytoplasm with finely granular nuclear chromatin (large nucleus, dark purple)
What is characteristic of large cell carcinoma? how do they look histologically?
dx of exclusion in poorly undifferentiated non-small cell carcinoma
cells are large and irregular, ample cytoplasm. nuclei freq. show prominent nucleoli and vesicular chromatin
Where do all lung CAs typically metastasize to?
to regional lymph nodes, particularly the mediastinal and hilar lymph nodes
Most common extranodal site: adrenal gland. then brain, bone, liver.
Clinical presentation for most lung CAs
10-15% asxs, discover incidentally on CXR
30%: local effects (bronchial obstruction, atelectasis, sxs of lung infx)
30% sxs pertaining to distant metastasis (liver=hepatomegaly, brain= seizures, bone= fractures, etc.)
30% nonspecific (weight loss, night sweats, malaise)
Most successful technique in dx of squamous cell carcinoma?
bronchoscopy with biopsy (if centrally located)
FNA and cytology can also be useful
5 year survival rate for most lung CAs
10-15%
What is malignant mesothelioma?
neoplasm of mesothelial cells, most common in the pleura
80% of pts have exposure to asbestos, latency period 20-30yrs
pleural mesotheliomas encases and compresses the lung
Mesothelioma is also called…
rind tumor
Presentation of malignant mesothelioma
age ~60yrs
pleural effusion/pleural mass, CP, weight loss, malaise
spreads locally first then mets to liver, bones, peritoneum and adrenals
Tx for malignant mesothelioma
ineffective, prognosis poor
