Pulmonary Path- Wittrak Flashcards
What is cor pulmonale?
Right heart failure due to chronic hypoxia-induced pulmonary hypertension
May see:
peripheral edema
Large/tender liver (passive congestion), increased JVP, cardiogenic shock
FEV1 less then what implies some sort of COPD?
Less than 80%
FEV1/FVC ratio needs to be less than what to imply COPD?
FEV1/FVC less than 70 %
What are COPD exacerbations usually caused by?
50% due to bacterial causes (pneumonia)
What are some common thing Bronchiectasis is associated with?
- Bronchial obstruction
- Poor ciliary motility (Kartagener syndrome)
- Cystic Fibrosis
- Allergic bronchopulmonary aspergillosis
What is bronchiectasis?
Chronic necrotizing infection of bronchi that lead to PERMANENTLY DILATED AIRWAYS
What is pathology of chronic bronchitis?
Hyperplasia of mucus-secreting glands in bronchi/ mucus plugging
Clinical diagnosis of chronic bronchitis?
Productive cough for > 3 month per year for > 2 years
What is the reid index? What will it be more than in chronic bronchitis?
Reid index = thickness of gland layer/ total thickness of bronchial wall
> 50% in chronic bronchitis
HIGHLY ASSOCIATED WITH SMOKING!
What is the pathology of emphysema?
Destruction of alveolar air sacs by neutrophils/ macrophages
Causes loss of elastic recoil and collapse of small airways during exhalation results in obstruction and air trapping
What are the two main causes of emphysema?
- SMOKING
2. Alpha 1-anti trypsin deficiency
What type of emphysema does smoking cause? What part of the lobe is more severe?
- Centriacinar emphysema
- More severe in upper lobes
What type fo emphysema does alpha 1 anti-trypsin cause? What part of the lung is more severe?
- Panacinar emphysema
- More severe in lower lobes
Chronic bronchitis and emphysema both present with dyspnea and cough. How would you distinguish them clinically?
Chronic bronchitis:
- TONS OF MUCUS! Like cups of it!!!
- Blue bloater
Emphysema:
- minimal sputum
- Pink puffers
- Prolonged expiration with pursed lips
What is the general pathogenesis of asthma?
bronchial hyper responsiveness causes REVERSIBLE bronchoconstriction
What cytokines are produced by Th2 cells in asthma? And what do they do?
Th2 produce:
- IL-4 = induces class switching to IgE
- IL-5 = calls eosinophils!
- IL-10 = promotes Th2 subtypes of T helper cells
During re-exposure to an allergen in asthma…. what happens immediately?
- IgE-mediated activation of mast cells
- dumps PRE FORMED HISTAMINE GRANULES
- Histamine induces vasodilation in arterioles, and increased vascular permeability in the post-capillary venules
What is the second phase that perpetuates inflammation after re-exposure to an allergen in asthma?
Eosinophils produce leukotrienes C4, D4, and E4 which leads to bronchoconstriction, inflammation, and edema
What are some potential causes of nasal polyps?
- Chronic Rhinitis
- Cystic fibrosis (kids)
- Aspirin-intolerant asthma (adults)
What diagnosis asthma in regards to pulmonary function?
- Decreased FEV1 and FEV1/FCV
- Increases by 12% when inhaled B2 agonist or post-steroid trial
What are two complications of asthma?
Status asthmaticus- you die
Allergic Bronchopulmonary aspergillosis = allergic reaction to inhaled spores (can cause bronchiectasis_
-Treat with steroids and anti-fungal drugs
Rhonci
obstruction of medium-sized vessels
crackles
alveolar disease
Stridor
inspiratory wheeze–upper airway obstruction
How are the pulmonary function tests different between restrictive and obstructive diseases?
Obstructive lung disease have a decreased FEV1/FVC ratio
Restrictive have an increased FEV1/FVC ratio
FEV1 and FVC are decreased in both types… but in obstructive FEV1 is more dramatically reduced resulting in a decreased ratio
Decreased total lung capacity Decreased FVC Decreased FEV1 FEV1:FVC ratio is > 80% What type of disease?
Restrictive disease!!!
Defined as FEV1/FVC ratio is greater than or equal to 80%
In what circumstance would a restrictive disease have a normal A-a gradient?
Poor breathing mechanics! Extrapulmonary, peripheral hypoventilation
Poor muscular effort = polio, myasthenia gravis
OR
Poor structural apparatus = scoliosis or morbid obesity
What circumstances would cause a restrictive disease to have an increased A-a gradient?
Interstitial lung diseases that decrease pulmonary diffusing capacity…….
Acute Respiratory Distress syndrome Sarcoidosis Pneumoconioses Idiopathic Pulmonary Fibrosis Goodpasture Syndrome Wegeners Hypersensitivity pneumonitis
Describe the pathogenesis of Idiopathic Pulmonary Fibrosis
Fibrosis of lung interstitium
Injury pneumocytes produce TGF-B that induces fibrosis/ abnormal alveolar healing response
Typically male smoker > 40 with progressive cough, dyspnea. Fibrosis on lung CT
Must rule out other causes of fibrosis like drugs and radiation therpay
Describe Pneumoconiosis what cell mediates this response?
Interstitial fibrosis due to occupational exposure mediated by MACROPHAGES
Requires chronic exposure to small particles that are fibrogenic
When would you see a shrunken, “black lung” that have antracosis? (collections of carbon-laden macrophages)
Coal Workers Pneumoconiosis
Which restrictive disease is the only one that increases your risk for TB?
Silicosis
You see multiple
Silicosis
How does silica impair the immune/inflammation response in the lungs?
Silica impairs phagolysosome formation by macrophages
Which pneumoconiosis is associated with increased incidence of lung cancer?
Asbestosis (and berylliosis?)
In which occupation would you see berylliosis?
Aerospace and manufacturing inductries
Which is the only pnumoconioses that affects the lower lobes?
Asbestiosis
What would you find histologically in asbestosis?
Asbestos/ Ferruginous bodies!
Golden brown dumbells found in alveolar septum
Non-caseating granulomas Found in lungs in hilar lymph nodes Skin Rash Hypercalemia Young African-American Female
SARCOIDOSIS!
Describe 5 indicators of sarcoidosis..
- Restrictive Disease (FEV1/FVC > 80%)
- Bilateral Hilar Lymphadenopathy
- Non-caseating granuloma
- Increased ACE
- Hypercalcemia (granulomas activate Vit. D.)
What types of granulomas are seen in sarcodosis?
Non-caseating granulomas
What occupation normally has hypersensitivity pneumonitis?
Farmers and those exposed to birds
What type of hypersensitivity is Hypersensitivity Pneumonitis?
Mixed type III/IV hypersensitivity reaction to environmental antigen
Pulmonary Hypertension is when MAP in the lung is greater than….
> 25 mmHg (normal is 10)
What are the 5 potential causes of pulmonary Hypertension?
- Idiopathic PAH (heritable, associated with BMPR2 mutation)
- Left Heart diseases
- Lung disease or hypoxia
- Thromoembolic (recurrent microthrombi decrease cross-sectional area of vascular bed)
- Multifactorial (some combination)
Describe the pathogenesis of Acute Respiratory Distress Syndrome
Multiple causes
- Diffuse alveolar damage
- increased alveolar capillary permeability
- Protein-rich leakage into alveoli
- Non-cardiogenic pulmonary edema
- Results in intra-alveolar hyaline membranes
- Thickened diffusion barrier
- Decreased gas exchange
Give some potential causes of acute respiratory distress syndrome
Trauma Sepsis Shock Gastric Aspiration Uremia Acute pancreatitis
How do you treat Acute Respiratory Distress Syndrome
30-40% mortality (that sucks)
Mechanical Ventilation
Address underlying cause!!
What causes neonatal respiratory distress syndrome?
Inadequate surfactant levels
What are the two most common things that causes massive hemoptysis?
Bronchogenic Caricoma
Bronchiectasis
What type of infections normally cause hemoptysis?
Bronchitis
Bacterial Pneumonia
TB
What are the three key risk factors for smoking?
Cigarette smoke
Radon
Asbestos
Aside from possible malignancy, what are two other benign causes of the classic “coin lesion”?
Granuloma - usually due to TB or fungus
Bronchial Hamartoma - contains lungs and CARTILAGE, often calcified on imaging
What are the two centrally located lung malignancies?
- Small cell carcinoma
- Squamous cell carcinoma
How would you treat small cell carcinoma?
Chemo!! Not responsive to surgical ressection
How do you treat non-small cell carcinomas?
Surgical resection!
What is the most common tumor in male smokers?
Squamous Cell carcinoma
Which lung cancer is associated with keratin pearls and intercellular bridges?
Squamous Cell Carcinoma
Which lung cancer is associated with glands and mucous production?
Adenocarcinoma
Which to lung cancers are neoplasms of neuroendocrine cells, thus chromogranin A +?
- Small cell carcinoma
- Bronchial carcinoid Tumor
Describe the characteristics of small cell carcinoma
Poorly differentiated
Very aggressive
Centrally located
Paraneoplastic Syndromes: Cushing syndrome, SIADH, Lambert Eaton myasthenic syndrome = Ab against Ca+ channels)
What are the SPHERE of complications associated with lung cancers?
Superior vena cava syndrome Pancoast tumor Horner Syndrome Endocrine (paraneoplastic) Recurrent laryngeal nerve compression (hoarsness) Effusions (pleural or pericardial)
What is a pancoast tumor?
Carcinoma that occurs in the apex of the lung
May causes Pancoast syndrome by invading the cervical sympathetic chain:
Horner’s Syndrome
SVC syndrome
Sensorimotor deficits
Hoarseness
Which lung cancer is composed of well-differentiated neuroendocrine cells?
Carcinoid Tumor
*Chromogranin +!!!
If you see an elevated diaphragm in a lung cancer patient, what should you think?
Phrenic nerve involvement = diaphragmatic paralysis
Which lung cancer presents like pneumonia but with not respond to antibiotics?
Bronchioalveolar carcinoma
What two metastases sites may indicate the first sign of lung cancer?
Bone - pathologic fracture
Brain - seizure or focal neurologic deficit
What are the 4 common sites of metastasis of lung cancer?
Liver
Bone
Adrenals
Brain
Why is hypercalcemia common in lung cancer?
- Could be due to bone metastases
- Or tumor production of PTHrP or calcitriol (Vit D) - especially is squamous cell!
Which lung neoplasm is associated with Lambert-Eaton syndrome? What is that?
Associated with small cell carcinoma
LE syndrome = antibodies against presynaptic Ca2+ channels
Which lung neoplasm is associated with Cushing syndrome? What is that?
Increased ACTH secretion, associated with small cell carcinoma
What is a hamartoma composed of?
Lung tissue + CARTILAGE!
How would you distinguish a lung meastasis from a primary lung tumor?
Metastases are typically multiple and bilateral!!!
Lungs are common site for metastatic neoplasmas
What is a pleural effusion? How do you treat it?
Excess accumulation of fluid between pleural layers
Restricted lung expansion during inspiration
Treat with thoracentesis to remove fluid
What type of fluid will a non-inflammatory pleural effusion contain? What causes it?
TRANSUDATE
Due to increased hydrostatic pressure (like in CHF) or
Decreased osmotic pressure (like nephrotic syndrome)
What type of fluid will an inflammatory pleural effusion contain? What can cause it?
EXUDATE
Increased protein content
Can be due to: Bacterial pneumonia Lung Abscess Viral Infection Pulmonary Embolism Esophageal rupture
What are some chronic sequale of pleural inflammation?
Adhesions to chest wall
Empyema can cause thick pleural rind requiring surgical decrotication for lung expansion
What is a chylothorax? What causes it?
Pleural effusion due to decreased lymphatic resorption
Caused by throacic duct injury from trauma or malignancy.
What color is the fluid in a chylothorax?
Milking appearing fluid high in triglycerides
What are the two most common causes of a transudative effusion?
- Left ventricular heart failure
2. Cirrhosis
What are the most common causes of exudative effusions?
- Bacterial pneumonia
- Malignancy
- Viral infection
- Pulmonary Embolism
What should you suspect if there is low pleural fluid glucose (
Associated with parapneumonic effusion/ empyema like bacterial pneumonia, lung abscess, viral infection, etc
Implies need for extended chest tube drainage proceedure
How should you treat recurrent pleural effusions that are compromising pulmonary function?
Treat by pleural space obliteration/ talc pleurodesis
What is the typical causes of a primary spontaneous pneumothorax?
Small subpleural bleb rupture
Usually seen in young adults with no apparent lung disease
What is the typical causes of a secondary spontaneous pneumothorax?
Air leak from underlying lung disease (emphysema, asthma, CF, TB pneumonia, neoplasia, etc)
What defines a tension pneumothorax?
Air enters pleural space but cannot exit.
Everytime patient breathes in air, results in increased amount of air in pleural space
Pushes trachea to OPPOSITE SIDE
Which way does the trachea deviate in a tension pnuemothorax?
It deviates to the OPPOSITE of the pneumothorax
- Unilateral chest pain
- Dyspnea
- Decreased tactile fremitus
- Hyperresonance
- Diminished breath sounds
Pneumothorax
