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CRRAB II- FINAL > Pulmonary Path- Wittrak > Flashcards

Pulmonary Path- Wittrak Flashcards

1
Q

What is cor pulmonale?

A

Right heart failure due to chronic hypoxia-induced pulmonary hypertension

May see:
peripheral edema
Large/tender liver (passive congestion), increased JVP, cardiogenic shock

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2
Q

FEV1 less then what implies some sort of COPD?

A

Less than 80%

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3
Q

FEV1/FVC ratio needs to be less than what to imply COPD?

A

FEV1/FVC less than 70 %

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4
Q

What are COPD exacerbations usually caused by?

A

50% due to bacterial causes (pneumonia)

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5
Q

What are some common thing Bronchiectasis is associated with?

A
  • Bronchial obstruction
  • Poor ciliary motility (Kartagener syndrome)
  • Cystic Fibrosis
  • Allergic bronchopulmonary aspergillosis
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6
Q

What is bronchiectasis?

A

Chronic necrotizing infection of bronchi that lead to PERMANENTLY DILATED AIRWAYS

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7
Q

What is pathology of chronic bronchitis?

A

Hyperplasia of mucus-secreting glands in bronchi/ mucus plugging

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8
Q

Clinical diagnosis of chronic bronchitis?

A

Productive cough for > 3 month per year for > 2 years

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9
Q

What is the reid index? What will it be more than in chronic bronchitis?

A

Reid index = thickness of gland layer/ total thickness of bronchial wall

> 50% in chronic bronchitis

HIGHLY ASSOCIATED WITH SMOKING!

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10
Q

What is the pathology of emphysema?

A

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

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11
Q

What are the two main causes of emphysema?

A
  1. SMOKING

2. Alpha 1-anti trypsin deficiency

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12
Q

What type of emphysema does smoking cause? What part of the lobe is more severe?

A
  • Centriacinar emphysema

- More severe in upper lobes

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13
Q

What type fo emphysema does alpha 1 anti-trypsin cause? What part of the lung is more severe?

A
  • Panacinar emphysema

- More severe in lower lobes

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14
Q

Chronic bronchitis and emphysema both present with dyspnea and cough. How would you distinguish them clinically?

A

Chronic bronchitis:

  • TONS OF MUCUS! Like cups of it!!!
  • Blue bloater

Emphysema:

  • minimal sputum
  • Pink puffers
  • Prolonged expiration with pursed lips
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15
Q

What is the general pathogenesis of asthma?

A

bronchial hyper responsiveness causes REVERSIBLE bronchoconstriction

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16
Q

What cytokines are produced by Th2 cells in asthma? And what do they do?

A

Th2 produce:

  • IL-4 = induces class switching to IgE
  • IL-5 = calls eosinophils!
  • IL-10 = promotes Th2 subtypes of T helper cells
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17
Q

During re-exposure to an allergen in asthma…. what happens immediately?

A
  • 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
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18
Q

What is the second phase that perpetuates inflammation after re-exposure to an allergen in asthma?

A

Eosinophils produce leukotrienes C4, D4, and E4 which leads to bronchoconstriction, inflammation, and edema

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19
Q

What are some potential causes of nasal polyps?

A
  • Chronic Rhinitis
  • Cystic fibrosis (kids)
  • Aspirin-intolerant asthma (adults)
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20
Q

What diagnosis asthma in regards to pulmonary function?

A
  • Decreased FEV1 and FEV1/FCV

- Increases by 12% when inhaled B2 agonist or post-steroid trial

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21
Q

What are two complications of asthma?

A

Status asthmaticus- you die

Allergic Bronchopulmonary aspergillosis = allergic reaction to inhaled spores (can cause bronchiectasis_
-Treat with steroids and anti-fungal drugs

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22
Q

Rhonci

A

obstruction of medium-sized vessels

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23
Q

crackles

A

alveolar disease

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24
Q

Stridor

A

inspiratory wheeze–upper airway obstruction

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25
Q

How are the pulmonary function tests different between restrictive and obstructive diseases?

A

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

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26
Q 
Decreased total lung capacity
Decreased FVC
Decreased FEV1
FEV1:FVC ratio is > 80%
What type of disease?
A

Restrictive disease!!!

Defined as FEV1/FVC ratio is greater than or equal to 80%

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27
Q

In what circumstance would a restrictive disease have a normal A-a gradient?

A

Poor breathing mechanics! Extrapulmonary, peripheral hypoventilation

Poor muscular effort = polio, myasthenia gravis

OR

Poor structural apparatus = scoliosis or morbid obesity

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28
Q

What circumstances would cause a restrictive disease to have an increased A-a gradient?

A

Interstitial lung diseases that decrease pulmonary diffusing capacity…….

Acute Respiratory Distress syndrome
Sarcoidosis
Pneumoconioses
Idiopathic Pulmonary Fibrosis
Goodpasture Syndrome
Wegeners
Hypersensitivity pneumonitis
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29
Q

Describe the pathogenesis of Idiopathic Pulmonary Fibrosis

A

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

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30
Q

Describe Pneumoconiosis what cell mediates this response?

A

Interstitial fibrosis due to occupational exposure mediated by MACROPHAGES

Requires chronic exposure to small particles that are fibrogenic

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31
Q

When would you see a shrunken, “black lung” that have antracosis? (collections of carbon-laden macrophages)

A

Coal Workers Pneumoconiosis

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32
Q

Which restrictive disease is the only one that increases your risk for TB?

A

Silicosis

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33
Q

You see multiple

A

Silicosis

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34
Q

How does silica impair the immune/inflammation response in the lungs?

A

Silica impairs phagolysosome formation by macrophages

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35
Q

Which pneumoconiosis is associated with increased incidence of lung cancer?

A

Asbestosis (and berylliosis?)

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36
Q

In which occupation would you see berylliosis?

A

Aerospace and manufacturing inductries

37
Q

Which is the only pnumoconioses that affects the lower lobes?

A

Asbestiosis

38
Q

What would you find histologically in asbestosis?

A

Asbestos/ Ferruginous bodies!

Golden brown dumbells found in alveolar septum

39
Q 
Non-caseating granulomas
Found in lungs in hilar lymph nodes
Skin Rash
Hypercalemia
Young African-American Female
A

SARCOIDOSIS!

40
Q

Describe 5 indicators of sarcoidosis..

A
  • Restrictive Disease (FEV1/FVC > 80%)
  • Bilateral Hilar Lymphadenopathy
  • Non-caseating granuloma
  • Increased ACE
  • Hypercalcemia (granulomas activate Vit. D.)
41
Q

What types of granulomas are seen in sarcodosis?

A

Non-caseating granulomas

42
Q

What occupation normally has hypersensitivity pneumonitis?

A

Farmers and those exposed to birds

43
Q

What type of hypersensitivity is Hypersensitivity Pneumonitis?

A

Mixed type III/IV hypersensitivity reaction to environmental antigen

44
Q

Pulmonary Hypertension is when MAP in the lung is greater than….

A

> 25 mmHg (normal is 10)

45
Q

What are the 5 potential causes of pulmonary Hypertension?

A
  1. Idiopathic PAH (heritable, associated with BMPR2 mutation)
  2. Left Heart diseases
  3. Lung disease or hypoxia
  4. Thromoembolic (recurrent microthrombi decrease cross-sectional area of vascular bed)
  5. Multifactorial (some combination)
46
Q

Describe the pathogenesis of Acute Respiratory Distress Syndrome

A

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
47
Q

Give some potential causes of acute respiratory distress syndrome

A 
Trauma
Sepsis
Shock
Gastric Aspiration
Uremia
Acute pancreatitis
48
Q

How do you treat Acute Respiratory Distress Syndrome

A

30-40% mortality (that sucks)
Mechanical Ventilation
Address underlying cause!!

49
Q

What causes neonatal respiratory distress syndrome?

A

Inadequate surfactant levels

50
Q

What are the two most common things that causes massive hemoptysis?

A

Bronchogenic Caricoma

Bronchiectasis

51
Q

What type of infections normally cause hemoptysis?

A

Bronchitis
Bacterial Pneumonia
TB

52
Q

What are the three key risk factors for smoking?

A

Cigarette smoke
Radon
Asbestos

53
Q

Aside from possible malignancy, what are two other benign causes of the classic “coin lesion”?

A

Granuloma - usually due to TB or fungus

Bronchial Hamartoma - contains lungs and CARTILAGE, often calcified on imaging

54
Q

What are the two centrally located lung malignancies?

A
  • Small cell carcinoma

- Squamous cell carcinoma

55
Q

How would you treat small cell carcinoma?

A

Chemo!! Not responsive to surgical ressection

56
Q

How do you treat non-small cell carcinomas?

A

Surgical resection!

57
Q

What is the most common tumor in male smokers?

A

Squamous Cell carcinoma

58
Q

Which lung cancer is associated with keratin pearls and intercellular bridges?

A

Squamous Cell Carcinoma

59
Q

Which lung cancer is associated with glands and mucous production?

A

Adenocarcinoma

60
Q

Which to lung cancers are neoplasms of neuroendocrine cells, thus chromogranin A +?

A
  • Small cell carcinoma

- Bronchial carcinoid Tumor

61
Q

Describe the characteristics of small cell carcinoma

A

Poorly differentiated
Very aggressive
Centrally located
Paraneoplastic Syndromes: Cushing syndrome, SIADH, Lambert Eaton myasthenic syndrome = Ab against Ca+ channels)

62
Q

What are the SPHERE of complications associated with lung cancers?

A 
Superior vena cava syndrome
Pancoast tumor
Horner Syndrome
Endocrine (paraneoplastic)
Recurrent laryngeal nerve compression (hoarsness)
Effusions (pleural or pericardial)
63
Q

What is a pancoast tumor?

A

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

64
Q

Which lung cancer is composed of well-differentiated neuroendocrine cells?

A

Carcinoid Tumor

*Chromogranin +!!!

65
Q

If you see an elevated diaphragm in a lung cancer patient, what should you think?

A

Phrenic nerve involvement = diaphragmatic paralysis

66
Q

Which lung cancer presents like pneumonia but with not respond to antibiotics?

A

Bronchioalveolar carcinoma

67
Q

What two metastases sites may indicate the first sign of lung cancer?

A

Bone - pathologic fracture

Brain - seizure or focal neurologic deficit

68
Q

What are the 4 common sites of metastasis of lung cancer?

A

Liver
Bone
Adrenals
Brain

69
Q

Why is hypercalcemia common in lung cancer?

A
  • Could be due to bone metastases

- Or tumor production of PTHrP or calcitriol (Vit D) - especially is squamous cell!

70
Q

Which lung neoplasm is associated with Lambert-Eaton syndrome? What is that?

A

Associated with small cell carcinoma

LE syndrome = antibodies against presynaptic Ca2+ channels

71
Q

Which lung neoplasm is associated with Cushing syndrome? What is that?

A

Increased ACTH secretion, associated with small cell carcinoma

72
Q

What is a hamartoma composed of?

A

Lung tissue + CARTILAGE!

73
Q

How would you distinguish a lung meastasis from a primary lung tumor?

A

Metastases are typically multiple and bilateral!!!

Lungs are common site for metastatic neoplasmas

74
Q

What is a pleural effusion? How do you treat it?

A

Excess accumulation of fluid between pleural layers

Restricted lung expansion during inspiration

Treat with thoracentesis to remove fluid

75
Q

What type of fluid will a non-inflammatory pleural effusion contain? What causes it?

A

TRANSUDATE

Due to increased hydrostatic pressure (like in CHF) or

Decreased osmotic pressure (like nephrotic syndrome)

76
Q

What type of fluid will an inflammatory pleural effusion contain? What can cause it?

A

EXUDATE

Increased protein content

Can be due to:
Bacterial pneumonia
Lung Abscess
Viral Infection
Pulmonary Embolism
Esophageal rupture
77
Q

What are some chronic sequale of pleural inflammation?

A

Adhesions to chest wall

Empyema can cause thick pleural rind requiring surgical decrotication for lung expansion

78
Q

What is a chylothorax? What causes it?

A

Pleural effusion due to decreased lymphatic resorption

Caused by throacic duct injury from trauma or malignancy.

79
Q

What color is the fluid in a chylothorax?

A

Milking appearing fluid high in triglycerides

80
Q

What are the two most common causes of a transudative effusion?

A
  1. Left ventricular heart failure

2. Cirrhosis

81
Q

What are the most common causes of exudative effusions?

A
  1. Bacterial pneumonia
  2. Malignancy
  3. Viral infection
  4. Pulmonary Embolism
82
Q

What should you suspect if there is low pleural fluid glucose (

A

Associated with parapneumonic effusion/ empyema like bacterial pneumonia, lung abscess, viral infection, etc

Implies need for extended chest tube drainage proceedure

83
Q

How should you treat recurrent pleural effusions that are compromising pulmonary function?

A

Treat by pleural space obliteration/ talc pleurodesis

84
Q

What is the typical causes of a primary spontaneous pneumothorax?

A

Small subpleural bleb rupture

Usually seen in young adults with no apparent lung disease

85
Q

What is the typical causes of a secondary spontaneous pneumothorax?

A

Air leak from underlying lung disease (emphysema, asthma, CF, TB pneumonia, neoplasia, etc)

86
Q

What defines a tension pneumothorax?

A

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

87
Q

Which way does the trachea deviate in a tension pnuemothorax?

A

It deviates to the OPPOSITE of the pneumothorax

88
Q
  • Unilateral chest pain
  • Dyspnea
  • Decreased tactile fremitus
  • Hyperresonance
  • Diminished breath sounds
A

Pneumothorax

CRRAB II- FINAL (20 decks)

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