Respiratory Flashcards
What are symptoms of DVT?
Swollen foot/ankle (unilateral)
+/- pain, +/- Homan’s sign (pain with ankle dorsiflexion) +/- palpable cord
What causes elevated D-dimer? What is it?
Seen in DVT, PE
It is a fibrin degradation product that is elevated when plasmin is dissolving a clot
What are symptoms of PE
Pleuritic chest pain SOB Cough Fever Tachypnea Tachycardia Altered mental status/confusion
What are EKG changes seen in PE?
S1Q3T3
Wide S in lead 1
Large Q
Inverted T in lead 3
What are fat emboli associated with?
Long bone fractures
Liposuction
What is the classic triad of fat emboli?
Hypoxemia
Neurologic abnormalities
Petechial rash
What can amniotic fluid emboli cause?
DIC
How do you get air embolus?
With Caisson disease - the bends; decompression illness when you are scuba diving and come up too quickly
Could also be introduced from IV
How do you get bacterial embolus?
From bacterial endocarditis - shoots off clots all over body
What is pneumothorax?
Abnormal collection of air in the pleural space that interferes with normal breathing.
What are exam findings for pneumothorax?
Decreased breath sounds on affected side
CXR
CT scan
What is most concerning type of pneumothorax?
Tension pneumothorax - with every breath air escapes into pleural space and gets trapped (pushes organs of mediastinum to opposite side)
What is treatment for pneumothorax?
Need to get rid of air
Need a chest tube until lung has recovered
What is pathology in obstructive lung conditions?
There is obstruction of air flow resulting in air trapping the lungs (Can’t get rid of air very well); The airways close prematurely at high lung volumes and cause increased RV and total lung volume is increased.
What happens on pulmonary function test in COPD?
The FEV1 is greatly decreased and FVC is decreased also but the ratio of FEV1/FVC is decreased. THIS IS HALLMARK OF COPD
What happens in restrictive lung disease?
There is restricted lung expansion that causes decreased lung volumes
What happens on pulmonary function test in restrictive lung disease?
Both FEV1 and FVC ratio are decreased but ratio stays close to normal; the lung volumes are lower than normal
What are Curschmann spirals?
Whorled mucus plugs formed by shed epithelium in asthma
What are Charcot-Leyden crystals?
Eosinophilic, hexagonal, double pointed needle-like crystals formed from breakdown of eosinophils in sputum
What is differential for Eosinophilia?
Drugs Neoplasma Atopic disease (allergy, asthma, Churg-Strauss) Addison disease Acute interstitial nephritis Collagen vascular disease Parasites (Ascaria, Strongyloides,)
What is the pathophysiology of Chronic Bronchitis?
Hyperplasia of mucus-secreting glands in bronchi –> Reid index >50%
What is the Reid Index?
The thickness of the gland layer/total thickness of bronchial wall
How do you diagnose Chronic Bronchitis?
Productive cough for > 3 months per year for > 2 years
What are symptoms of Chronic Bronchitis?
Wheezing, crackles, cyanosis, late-onset dyspnea, CO2 retention, secondary polycythemia
What are blue bloaters?
-Hypoxemia, hypercapnia
Seen in chronic bronchitis; refers to the poor oxygenation and pulmonary hypertension that can sometimes occur
What is pathophysiology of emphysema?
Enlargement of air spaces, decreased recoil, increased compliance, decreased diffusing capacity for CO resulting from destruction of alveolar walls
What are the types of emphysema?
- Centracinar - associated with smoking - usually most prominent in upper lobes and superior segments of lower lobes
- Panacinar - associated with alpha1-antitrypsin deficiency
Where is destruction in centriacinar emphysema?
In the respiratory bronchioles
Where is destruction in panacinar emphysema?
Entire acinus - respiratory bronchioles, acinar ducts, acinus
What are signs of alpha 1 antitrypsin deficiency?
Early onset emphysema (increased elastase activity, loss of elastic fibers)
Early onset cirrhosis (builds up in liver)
What is Bronchiectasis? What is it associated with?
Destruction and dilation of bronchial walls –> causes chronic recurrent infections, purulent sputum, hemoptysis
-Associated with CF and Kartagener syndrome
What are pink puffers?
Dyspnea, hyperventilation
Most common cause of pulmonary HTN
COPD
Inhaled treatment of choice for chronic asthma
Inhaled steroid
Inhaled treatment of choice for acute asthma
Albuterol or Levalbuterol - NOT Salmeterol long acting
Narrow therapeutic index, drug of last resort for asthma
Theophylline
Inhibits mast cells release of mediators, only used for prophylaxis in asthma
Cromolyn
Inhaled treatment that blocks muscarinic receptors
Ipratroprium, Tiotropium
Blocks conversion of arachidonic acid to leukotriene
Zileuton
Inhaled long acting Beta agonist
Salmeterol
What medication for nasal decongestant can cause rebound congestion?
Pseudoephedrine, phenylephrine
What is the pathophysiology of interstitial lung diseases? How does it affect breathing mechanics?
They decrease pulmonary diffusing capacity and increase A-a gradient
What is sarcoidosis characterized by?
Immune-mediated, widespread non-caveating granuloma, elevated serum ACE levels and elevated CD4/CD8 ratio
What does sarcoidosis look like on X-ray?
Bilateral hilar adenopathy and reticular opacities
Who is sarcoidosis common in?
Black females
Erythema nodosum and bilateral adenopathy
Sarcoidosis
What is the mnemonic for Sarcoidosis?
A GRUELING Disease ACE increase Granuloma RA Uveitis Erythema nodosum Lymphadenopathy Idiopathic Noncaseating granuloma Gammaglobulinemia Vitamin D increase
What type of reaction is hypersensitivity pneumonitis?
Mixed type II/IV reaction to environmental antigen –> dyspnea, cough, chest tightness, headache
What are the different types of Pneumoconiosis
Anthracosis Asbestosis Coal worker's lung Silicosis Berylliosis
a. What is Asbestosis associated with?
b. What are characteristic lung findings?
c. Affects which part of lung?
d. Increased risk of cancer?
a. Associated with shipbuilding, roofing, plumbing
b. Ivory white, calcified, supra diaphragmatic and pleural plaques; Asbestos (Ferruginous bodies) are golden brown fusiform rods resembling dumbbells found in alveolar septum
c. Affects lower lobes
d. Increased risk of bronchogenic carcinoma > mesothelioma
What is damage from in pneumoconiosis disease?
From the macrophages
a. the other name for Coal workers’ pneumoconiosis
b. Caused by:
c. Affects which part of lung?
d. Increased risk of cancer?
a. Anthracosis
b. prolonged coal dust exposure –> macrophages become laden with carbon and cause inflammation/fibrosis (black lung disease)
c. Affects UPPER lobes
d. No risk of cancer
a. What is Silicosis associated with?
b. Characteristic lung findings?
c. Affects which part of the lung?
d. Increased risk of?
a. Foundries, sandblasting, mines
b. Macrophages respond to silica and release fibrogenic factors that cause fibrosis
c. Affects UPPER lobes
d. Increased susceptibility to TB (because silica disrupts phagolysosomes and impairs macrophages) Also increased risk of bronchogenic carcinoma
a. What is Berylliosis associated with?
b. Lung pathology?
c. Affects which part of lung?
d. Increased risk of?
a. Aerospace and manufacturing industries
b. Granulomas on histology
c. Upper lobes
d. Increased risk of carcinoma
Golden-brown fusiform rods resembling dumbbells
Ferruginous asbestos bodies
Lung findings in silicosis
Eggshell calcification of hilar lymph nodes
What is the pathophysiology of ARDS?
Shock, infection, toxic gas inhalation, aspiration, high [O2], pancreatitis –> inflammatory cells/mediators and oxygen free radicals –> damage to endothelial or alveolar epithelial (type I) cells –> diffuse alveolar damage and hyaline membrane disease
What is Hyaline membrane disease?
Seen in ARDS
Initial damage due to macrophage substances
What is cause of neonatal RDS?
Surfactant deficiency –> increased surface tension –> alveolar collapse
What is treatment of neonatal RDS?
Maternal steroids 24-48 hours before birth, artificial surfactant for infant
Which ratio is predictive of neonatal RDS?
Lecithin:Sphingomyelin ratio <1.5 in amniotic fluid
What are risk factors for neonatal RDS?
Prematurity
Maternal diabetes
C section
What is lung finding in neonatal RDS?
air space and interstitial opacities - ground glass appearance
Bilateral hilar adenopathy, uveitis
Sarcoidosis
Vasculitis and glomerulonephritis
Wegeners, Goodpastures
Anti-glomerular basement membrane antibodies
Goodpastures
Honeycomb lung on x-ray
Interstitial fibrosis
Tennis racket shaped cytoplasmic organelles
Birbeck granules
Iron-containing nodules in the alveolar septum
Ferruginous bodies - suggest Asbestosis
Cough, hemoptysis, bronchial obstruction, wheezing, pneumonic “coin” lesion on CXR or non-calcified nodule on CT
Lung cancer
Complications of lung cancer
SPHERE of complications
Superior vena cava syndrome Pancoast tumor Horner syndrome Endocrine (paraneoplastic) Recurrent laryngeal nerve compression Effusions (pleural or pericardial)
What does non-small cell carcinoma (oat cell) include?
Large cell
Squamous cell
Adenocarcinoma
Adenocarcinoma
a. Location
b. Characteristics
c. Histology
MOST COMMON TYPE
a. Peripheral
b. Most common lung cancer in NON Smokers but also associated with smoking; CEA positive, activating mutations include KRAS, EGFR, ALK.
c. Glandular pattern on histology, often stains mucin +.
What is Bronchioalveolar carcinoma? Characteristics?
Subtype of adenocarcinoma
CXR often shows hazy infiltrates similar to pneumonia (excellent prognosis)
Grows along alveolar septa –> thickens alveolar walls
Large cell Carcinoma
a. Location
b. Characteristics
c. Histology
a. Peripheral
b. Highly anapestic undifferentiated tumor; poor prognosis; Strongly associated with smoking
c. Giant cells, secretes bHCG
Squamous cell Carcinoma
a. location
b. charactersistics
c. histology
a. Central
b. hilar mass arising from bronchus; Cavitation, Cigarettes, hyperCALCEMIA (PTHrP produced)
c. Keratin pearls! and intracellular bridges
Small cell carcinoma
a. location
b. characteristics
c. histology
a. Central
b. N:C ratio is very high; produces ACTH, ADH or antibodies against presynaptic Ca channels (Lambert Eaton); amplification of myc oncogenes
c. Neoplasm of neuroendocrine Kulchitsky cells –> small dark blue cells; Chromogranin A
S MMnemonic for lung cancer
Squamous cell Small cell Smoking Central Secreting
What do you seen microscopically for Mesothelioma?
Psammoma bodies
Most common locations of lung cancer metastasis?
Brain
Bone
Liver
Adrenal
How is small cell carcinoma treated?
Chemotherapy; not amenable to surgical resection
What is FEV1/FVC ratio in obstructive disease? restrictive disease?
obstructive - decreased ratio; FEV1 decreases more than FVC
restrictive - greater than normal; FVC decreases more than FEV1
Why do you see hypercalcemia in sarcoidosis?
In the macrophages of the granuloma there is increased 1alpha hydroxyase that activates Vitamin D
