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Org Path Exam 2 > Resp I > Flashcards

Resp I Flashcards

1
Q

Even though the respiratory system has many defenses, are there still deaths from respiratory infections? What disease is the leading cause of death in elderly and children under 5 years?

A

Yes! Respiratory infections are common and one of the leading causes of death and disability

  • Pneumonia is a leading cause of death in the elderly and the chronically/terminally ill
  • Pneumonia is the leading cause of death in children under 5 years, worldwide
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2
Q

What are the protective mechanisms of the upper airway?

A
  • Humidifies air
  • Absorbs highly soluble gases
  • Removes particulates
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3
Q

What are the protective mechanisms of the lung?

A

Upper airway: Humidifies air, Absorbs highly soluble gases, Removes particulates

Airway reflexes: Cough, sneeze, gag, and bronchoconstrictor reflexes minimize aspiration and retention of foreign material

Mucociliary blanket and transport: moves mucus and impacted particles towards mouth

Anatomy:
Arrangement and size of branching airways prevent particles greater than 5 microns from reaching distal oxygen exchanging units and are usually removed by mucociliary blanket
-Inflammatory cells and mediators

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4
Q

What are the routes of pulmonary infection?

A

Inhalation
Aspiration
Bloodstream

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5
Q

What is the single most important cause of work absence?

A

Acute respiratory infections

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6
Q

Where is the lung sterile?

A

from the first bronchial division to the terminal lung units

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7
Q

How severe are acute lung infections?

A

-Most are mild and self-limiting
-Can be life threatening in:
Immunocompromised patients: transplant recipients, chemotherapy, AIDS
-Extremes of age, critically ill

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8
Q

What is acute bronchitis caused by? Describe the symptoms.

A
  • usually caused by a virus (RSV, H. influenzae, Strep. pneumonia)
  • symptoms are Cough, dyspnea, tachypnea, sputum
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9
Q

What is croup? What parts of the respiratory system are involved in it and what causes it/

A

-Croup=laryngotracheobronchitis
-When larynx, trachea, and lungs are involved
-Parainfluenza virus most common
(RSV, measles, adenovirus, influenza viruses)
-Severe in children
-Common in COPD

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10
Q

What is the clinical definition of chronic bronchitis and what is it?

A

Clinical Definition: Persistent productive cough for at least 3 CONSECUTIVE MONTHS for at least 2 CONSECUTIVE YEARS.

Clinical course: Cough and sputum, often without respiratory dysfunction
-Some patients develop COPD
-Complicated by recurrent infections, respiratory failure, cardiac failure
Pathogenesis: Hypersecretion of mucus
-Associated with cigarette smoking and air pollutants

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11
Q

What is primary bronchiolitis and its causes?

A
  • Acute respiratory distress, dyspnea, tachypnea
  • Caused by viruses (RSV in infants_
  • Resolves in a few days, may develop secondary pneumonia
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12
Q

What are the symptoms of Bronchiolitis Obliterans-Organizing Pneumonia (BOOP)? What causes it?

A
  • Acute onset with cough, shortness of breath, fever and malaise
  • Concentric fibrosis of submucosa of small bronchioles, resulting in obliteration of lumen
  • cause: Common response to infectious or inflammatory injury to lungs
  • Also associated with drugs, collagen vascular disease, graft-versus-host disease in bone marrow transplant patients
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13
Q

How do we classify pneumonias?

A

-First classified by anatomic changes, then
as etiologic agents were identified, a microbiologic classification
-Classification usually not possible at initial diagnosis
-X-rays led to a radiological classification
“-Atypical pneumonia” coined to distinguish some pneumonia
-NOW: Combined clinical classification:
factors such as age, risk factors for certain microorganisms, the presence of underlying lung disease/systemic disease, and whether the person has recently been hospitalized.

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14
Q

What are the clinical circumstance classifications of pneumonia?

A

Primary: in otherwise healthy person
Secondary: with local/systematic defects in defense

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15
Q

what are the etiologic agents causing pneumonia?

A

Bacteria: Strep. pneumoniae, Staphy. aureus, Mycobacterium tuberculosis

Viral: influenza, measles

Fungal: Cryptococcus, Candida, Asperillus

Other: Pneumocystis jirovecii, Mycoplasma, aspiration, lipid, eosinophilic

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16
Q

What are the type of host reactions we use to classify pneumonia?

A

Fibrinous and suppurative, according to the dominant exudate

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17
Q

What anatomical patterns do we use when classifying pneumonia?

A

Bronchopneumonia

Lobar pneumonia

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18
Q

What is the difference between typical and atypical pneumonia?

A

typical pneumonia: Classic bacterial pneumonia caused by Strep. pneumoniae

Atypical pneumonia: Not caused by traditional pathogens
-Caused by a variety of microorganisms

Distinction between atypical and typical pneumonia is medically insufficient

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19
Q

What is the point of a combined clinical classification of pneumonia? What are the types?

A
  • Attempts to ID a patient’s risk factors when s/he first presents to medical attention
  • Advantage: can guide appropriate initial treatment before the microbiologic agent is identified
  • Community-acquired pneumonia (CAP)
  • Healthcare-associated pneumonia: patients living outside the hospital who have recently been in close contact with the health care system
  • Hospital-acquired pneumonia (HAP)
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20
Q

What is community acquired pneumonia (CAP)?

A

-Infectious pneumonia in a person who has NOT recently been hospitalized
***Most common type of pneumonia
Causes vary with age
S. pneumoniae, viruses, atypical bacteria, H influenzae

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21
Q

What is the most common type of pneumonia?

A

CAP

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22
Q

What is hospital acquired pneumonia? What percentage of admitted patients get it?

A
  • 5% of admitted patients
  • Acquired during or after hospitalization for another illness or procedure
  • the Causes, microbiology, treatment, and prognosis are different than CAP
  • MRSA, Pseudomonas, Enterobacter, Serratia
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23
Q

What is the difference between bronchopneumonia and lobar pneumonia?

A

Bronchopneumonia: focal inflammation centered on the airways; often bilateral

Lobar pneumonia: diffuse inflammation affecting the entire lobe or segment. Pleural exudate is common

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24
Q

What are the symptoms and causes of bronchopneumonia? How do you treat it?

A
  • Common in: infancy or elderly
  • patients with debilitating disease or chronic pulmonary disease
  • Patients often become septicemic
  • Multifocal, patchy consolidation
  • Tends to involve several lobes, basal, bilateral
  • Centered on bronchioles or bronchi with subsequent spread to surrounding alveoli

Typical agents: Staph, Strep, H. influenzae

  • Resolves with treatment
  • May heal by organization with scarring
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25
Q

How do people usually aquire an H. influenza infection and what does it cause?

A
  • from endogenous aspiration and reduced protective mechanisms
  • Often pre-existing COPD or viral infections
  • *Usually causes bronchopneumonia
  • May develop bronchiolitis or bronchiectasis as complications
26
Q

What is lobar pneumonia and what causes it?

A
  • Uncommon in infancy and old age
  • Streptococcus pneumoniae most common
  • Affects otherwise healthy adults 20-50 yrs.
  • Except Klebsiella pneumoniae in elderly, diabetics, alcoholics
  • Diffuse consolidation
  • Uniformly affects anatomically delineated segment(s) or entire lobe(s)
27
Q

What are the symptoms of lobar pneumonia?

A

cough, fever, rigors, pleuritic chest pain, difficulty breathing, purulent (green/yellow) sputum; may contain flecks of blood

Demonstrated by dullness to percussion with bronchial breathing

CXR: Well-defined, homogenous opacity observed in the right middle lobe (arrow)

28
Q

What is the most common way to get lobar pneumonia and how do we treat it?

A
  • Strep. pneumoniae (pneumococcus)
  • Antibiotics decreased the mortality to 10%, but NO EFFECT on the incidence
  • Often a post-viral infection (i.e., host mechanisms impaired)
  • Route of infection: inhalation
  • Gram-positive diplococci
29
Q

What does Klebsiella pneumonia cause regarding respiratory infections? Where?

A
  • pneumonia in right upper lobe
  • Common in elderly men, alcoholics, patients with diabetes mellitus, malignancies, and heart disease
  • Abscess formation common;25% develop empyemas
  • Mortality approaches 30%
  • Klebsiella is part of normal GI flora
  • Gram-negative rod
30
Q

What does Enterobacteriaceae (e.g., E. coli) cause in the respiratory system?

A
  • Frequently from blood-borne dissemination to the lungs
  • Usually no preceding upper respiratory infection
  • High mortality rates
  • Associated with sepsis, diabetes mellitus, pyelonephritis, and heart disease
  • Gram-negative rods
31
Q

What does Staph. aureus cause in the respiratory system?

A
  • 5 – 10% of all pneumonias
  • High mortality rate
  • Classically FOLLOWS influenza infection
  • 20 – 40 % of normal adults carry the organism in the nares
  • Causes suppurative and ulcerative bronchiolitis with necrosis of bronchiolar wall
  • Septic infarction and abscess formation are complications (Patients with Staph. endocarditis can seed lungs with septic emboli –> pulmonary infarcts and abscess formation)
32
Q

What does pseudomonas aeroginosa cause int eh respiratory tract?

A
  • hospital-acquired pneumonia
  • Burn patients, Patients on mechanical ventilation, Patients on antibiotics, Cystic fibrosis patients
  • Gram-negative rod
33
Q

What does Serratia marcescens cause in the respiratory tract?

A
  • Hospital-acquired and rare
  • Associated with instrumentation (intubation, bronchoscopy) and COPD
  • Gram-negative rod
34
Q

What are the four stages of lobar pneumonia?

A
  • it is a classic acute inflammatory response
    1. Edema and congestion: 12-14 hours
  • Vascular engorgement (congestion)
  • Intra-alveolar fluid (proteinaceous exudate)
  • Lung is heavy, edematous, red
    2. Red hepatization: 1-3 days
  • Neutrophils accumulate in alveoli (and lymphocytes and macrophages)
  • Extravasation of red blood cells
  • Fibrinous exudate on pleura
  • Lung is red, solid and airless. Resembles fresh liver
    3. Gray hepatization 3-4 days
  • more fibrin in alveoli
  • disintegrated inflammatory cells
  • Lung is grey-brown and solid
    4. Resolution8-10 days (untreated)
  • Resorption of exudate
  • Enzymatic digestion of inflammatory debris with preservation of alveolar architecture
35
Q

How to lung abscesses form? What causes them?

A
  • Same as non-pulmonary abcesses
  • Thick fibrous wall with inflammatory cells
  • Core (center) has inflammatory debris
  • Radiology—cavitary mass may look like malignancy

Arises from:

  • Pneumonia (Staphylococcus, coliforms, anaerobes)
  • Aspiration
  • Bronchial obstruction proximal to abscess
  • Infected pulmonary infarct
  • Septic embolus from another site
36
Q

What are some complications of bacterial pneumonia?

A

Lots of them
-Respiratory and circulatory failure
-Sepsis
-Pleural effusion
-Empyema (suppurative material in pleural space)
-Lung abscess (Tissue destruction and necrosis; Common with S. pneumoniae, Klebsiella, S. aureus)
Pleuritis, pericarditis, endocarditis, meningitis, arthritis (Dissemination of infection)
Septic embolus into systemic artery
Lung scar (Organization of exudate culminating in solid fibrous tissue)
Bronchiectasis
Antibiotic adverse effects

37
Q

What are “atypical” pneumonias? What causes it

A

-Patients with symptoms that are not classic for bacterial pneumonia, i.e., minimal or nonproductive cough, headache; chest X-ray shows no consolidation
Agents responsible:
-Viruses: Parainfluenza, RSV, adenovirus, Epstein-Barr virus
-Mycoplasma
-Legionella pneumophila
-Chlamydia (Follows contact with birds after inhalation of dried bird excretion and/or handling contaminated birds)
-Rickettsia (Vector (usually tick) obligate intracellular bacteria; causes widespread vasculitis)
-Histology shows interstitial inflammation and fibrinous exudate

38
Q

What is interstitial pneumonia?

A
  • Alveolar wall inflammation
  • Lymphocytes, plasma cells, and macrophages
  • Alveoli free of cellular exudate, may have fibrinous exudate and hyaline membranes
  • Associated with viruses, Rickettsia or Mycoplasma
  • Diffuse alveolar injury is usually present (ARDS)
  • Not always bilateral and symmetrical – 50% are unilateral
  • interstitial pneumonia can also refer to a noninfectious pneumonia
39
Q

What are viral pneumonias and how do we diagnose them?

A

-Diagnosis of exclusion
-Common cause of pneumonia in children
-Caused by influenza virus, respiratory syncytial virus (RSV), common cold viruses (parainfluenza, adenovirus), human metapneumovirus and herpes or varicella viruses
-General histologic features:
interstitial inflammation
lymphocytic infiltrates
nuclear and cytoplasmic inclusion bodies
cell necrosis

40
Q

What is RSV?

A

-Significant cause of pneumonia in children and infants (Mortality Virus culture shows syncytia
Necrotizing bronchiolitis and interstitial pneumonia, infrequent cytoplasmic inclusion bodies

41
Q

What is CMV?

A
  • Immunocompromised people
  • Often associated with Pneumocystis jirovecii pneumonia
  • Leading cause of death in allogeneic bone marrow transplant recipients
  • Herpes-type virus
  • Diagnostic hallmark: cellular enlargement with intranuclear and intracytoplasmic inclusions
  • Diffuse interstitial pneumonia common feature
42
Q

What is varicella zoster regarding the respiratory system?

A
  • Pneumonia occurs in approximately 5% of patients with chickenpox (mostly adults)
  • Greater severity in immunosuppressed
  • Herpes-type virus
  • Histology is typical interstitial pneumonia
  • Intranuclear inclusion may be found in alveolar lining cells
43
Q

What is Mycoplasma pneumoniae? What does it cause?

A
  • common cause of community-acquired pneumonia
  • Prolonged gradual onset and resolution
  • Resolves without complications in almost all cases; may be severe in children
  • Small bacterium that lacks a cell wall
  • Free-living – doesn’t require host cell for replication
  • Doesn’t Gram stain and difficult to culture
  • High cold agglutinins, but not diagnostically useful; DNA probes available
  • Histology is typical interstitial pneumonia
44
Q

What is Legionella pneumophila? What does it cause?

A

-Community- or hospital- acquired
-Aerosol of contaminated water
Humidifiers, respiratory therapy equipment, whirlpool spas, showers, etc.
2 clinical syndromes:
1) Legionnaires’ disease: Severe pneumonia and multisystemic disease
2) Pontiac fever: acute febrile self-limited viral-like illness
-High mortality in elderly and infants

45
Q

What is the difference between pathogenic and opportunistic fungi?

A

Pathogenic: Superficial, Deep, Systemic
Opportunistic: Reactivation of dormant systemic mycosis
-Pulmonary entry of opportunistic pathogen (e.g., Aspergillus, zygomycetes)
-GI or GU entry; hematogenous spread

46
Q

What is Histoplasma capsulatum?

A

-Histoplasmosis is a common pulmonary fungal infection
-May disseminate (extrapulmonary)
-Endemic in Ohio River and lower Mississippi River valleys
-Inhalation of spores from soil near bird and bat guano
-Most asymptomatic; Mimics a flu-like illness; self-limited
-Chronic in some: cough, weight loss, fevers, cavitary lesions
-Disseminated in immunocompromised
Studies
-Chest X-ray: coin lesions
-Culture and serological testing
Pathology; Granulomas plus caseation; heal with fibrosis and calcification
-Narrow-necked budding yeasts (2-5 µm)

47
Q

What is Blastomyces dermatitidis?

A

-Pulmonary fungal infection
-May disseminate
-Endemic in central and South Eastern U.S.
-Inhalation of conidia from soil
-50% asymptomatic, pulmonary symptoms vary
-Resembles influenza, bacterial pneumonia, chronic TB, or ARDS
Studies: Chest X-ray: infiltrates or mass-like nodules; Serologic testing

Pathology: Granulomas with necrosis and variable neutrophilic response
Heals with apparent fibrous scar without calcifications
Large (8-15 µm) broad-based budding yeast; thick, refractile cell walls

48
Q

What is Coccidioides immitis?

A

-Coccidiomycosis in the southwest; Endemic to CA, AZ, NV, NM, TX, UT
-San Joaquin Valley Fever
I-nhalation of spores from soil
-Usually mild, flu-like symptoms, rashes
-May develop pneumonia, lung nodules, disseminated disease. May be fatal
Studies:
Chest X-ray: coin lesions
Culture, serology, PCR, DNA probes
Pathology similar to TB
Necrotizing granulomas and neutrophils
Heal by fibrosis with +/- calcifications
Large spherules with small endospores

49
Q

How does Candida albincans cause a respiratory infection?

A

Immunocompromised host
Most common fungemic/invasive fungus
Bronchopneumonia (Hematogenous spread or aspiration, instrumentation)
0Chest X-ray non-specific
-Culture interpretation difficult because of oral contamination
-Normal oral and GI commensal
-Histopathology is diagnostic
-Invasive budding yeast, pseudohyphae; neutrophils
Other Candida species too

50
Q

What does asperilligus cause?

A

-Aspiration of ubiquitous fungus
-Aspergilloma, invasive aspergillosis in immunocompromised host
-Allergic bronchopulmonary aspergillosis, –hypersensitivity pneumonia in asthma, cystic fibrosis
-May cause colonization of lung abscess
-Studies: chest X-ray, culture
Histopathology:
Septated hyphae branching at 45°
Often invades vessels, may cause infarction, hemorrhage, necrosis

51
Q

What does Pneumocystis jirovecii cause?

A

-Formerly Pneumocystis carinii (species in rats, not humans)
-Causes PCP (pneumocystis pneumonia)
-Opportunistic pathogen in immunosuppressed
-Fever, non-productive cough, SOB, hypoxia, pneumothorax
-Chest X-ray: diffuse pulmonary infiltrates
Diagnose by BAL or biopsy
Cup or boat-shaped cysts in alveoli with pink exudate (crushed ping pong balls)

52
Q

What are some epidemiological statistics of TB?

A
  • Approximately 1/3 of world infected with mycobacterium TB; 10% get disease
  • Approximately 30,000 cases per year in US with 2,000-3,000 fatalities
  • Resurgence of disease aided by immunocompromised state (HIV/AIDS) and drug-resistant strains
  • Most cases are Mycobacterium tuberculosis
  • Acid-fast bacilli (AFB)
  • Gram stain is unreliable for ID
53
Q

How does mycobacterium cause TB?

A
  • airborne droplets; implants in the lower lung fields
  • multiples slowly: one division/24 hours
  • After 3-10 weeks, may spread through lymphatic and hematogenous channels to nodes and organs/ tissues prior to cell-mediated immunity
  • Lymphohematogenous dissemination probably occurs in most cases, setting the stage for reactivation
  • Reactivation occurs commonly in the elderly and immunocompromised as the balance between host resistance and pathogenicity of bacteria tips in favor of the organism
54
Q

What are the three types of pulmonary tuberculosis?

A

1) Primary: small mid-zone lung lesion with hilar lymph node involvement
2) secondary: the lesions are usually apical and bilateral
3) miliary: the lungs and other organs contain numerous small granulomas

55
Q

What is primary tuberculosis?

A
  • Associated with a small inflammatory lesion and hilar lymphadenitis
  • Usually asymptomatic and becomes latent
  • Classic symptoms are a chronic cough with blood-tinged sputum, fever, night sweats, and weight loss
56
Q

What is a Ghon Complex?

A

Focus of primary infection
Granuloma with central caseous necrosis
Organizes leaving a fibrocalcific nodule often with persisting viable tuberculosis

57
Q

How is TB diagnosed?

A

Diagnosed by chest X-ray, tuberculin skin test, sputum culture, histopathology

58
Q

What is secondary TB?

A

-reinfection (primary) or reactivation
-Reactivation of dormant primary lesions many decades later
~10% of latent infections reactivate
-Risk of reactivation increases with immunosuppression and age
Apices of one or both upper lobes
Histopathology:
Granulomas with central caseous necrosis
Most lesions converted to fibrocalcific scars
Many complications can ensue, i.e., progressive pulmonary disease and/or dissemination to pleura and organs

59
Q

What are the complications of TB?

A

Primary progressive
Tuberculous pneumonia
Non-reactive tuberculosis
Hematogenous dissemination
Tuberculous pleuritis; pericarditis
Scrofula (tuberculosis affecting lymph nodes of the neck)
Death due to: progressive pulmonary insufficiency, pulmonary hemorrhage due to erosion of major pulmonary artery, miliary tuberculosis, and tuberculous meningitis

60
Q

What is bronchiectasis?

A

-Permanent abnormal dilatation of the bronchi and bronchioles
-Symptoms: chronic cough, dyspnea, hemoptysis, infected sputum production
Pathogenesis:
-Arises in various lung conditions
-Chronic infection, cystic fibrosis, immotile cilia, radiotherapy, chronic aspiration, etc.
-Results from pulmonary inflammation and scarring 2o infection, obstruction, lung fibrosis
-Airways dilate when fibrosis contracts
-Recurrent infection/inflammation damages airways
-Can be idiopathic
-Complications
-Pneumonia, lung abscess, emphysema, remote abscesses, amyloid, pulmonary fibrosis, cor pulmonale

Org Path Exam 2 (8 decks)

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