Respiratory - FA Patho p657 - 670 Flashcards
Most common cause of rhinosinusitis?
Most common acute cause is viral URI; may cause superimposed bacterial infection, most commonly S pneumoniae, H influenzae, M catarrhalis.
Most common location of epistaxis? When is epistaxis most dangerous?
Most commonly occurs in anterior segment of nostril (Kiesselbach plexus). Lifethreatening hemorrhages occur in posterior segment (sphenopalatine artery, a branch of maxillary artery).
Most common type of cancer in head and neck?
Mostly squamous cell carcinoma
Risk factors of Head and neck sq cell CA?
Risk factors include tobacco, alcohol, HPV-16 (oropharyngeal), EBV (nasopharyngeal)
DVT Virchow’s triad?
* Stasis (eg, post-op, long drive/flight) *Hypercoagulability (eg, defect in coagulation cascade proteins, such as factor V Leiden) * Endothelial damage (exposed collagen triggers clotting cascade)
What makes the d-dimer test a good test to rule out DVT?
High sensitivity, low specificity
Homan sign—? What is it, which disease?
dorsiflexion of foot –> calf pain. in DVT
Tx for DVT works on which intermediate of the clotting cascade? (Factor?) How are they administered?
Heparin, or LMWH work on Factor II & 10. Heparin is IV, and LMWH can be given subcutanoues
classic triad of hypoxemia, neurologic abnormalities, petechial rash. assoc with long bone fractures?
Fat embolli
What metabolic disturbances with PE?
V˙/Q˙ mismatch –> hypoxemia –> respiratory alkalosis
This patient has codominance inheritence disorder. He has jaundice, tender hepatomegaly, ascites, polycythemia, anorexia. He has problem breathing too. when he breathes, he tries to exhale through pursed lips. What does he have?
panacinar emphysema
Patient comes in with coughing with cupful of pus. He has CF. what is the cause of this cough?
Bronchiectasis
what happen to lung compliance in emphysema? why?
increased;
Imbalance of proteases and antiproteases –> inc elastase activity–> inc loss of elastic fibers –> inc lung compliance.
what other condition causes increased compliance?
normal aging
decreased lung compliance caused by
pul fibrosis, pneumonia, pul edema
CO2 retention is seen in emphysema or chronic bronchitis or both?
just chronic bronchitis
In chronic bronchitis –> mucus pug in terminal bronchioles –> huge V/Q mismatch (blue bloater)
In emphysema equal loss of V/Q–> no retention (pink puffer)
DLCO (diffusing capacity for CO) is normal/dec/inc for 1. chronic bronchitis 2. emphysema
- CB: normal 2. emphysema: decreased
Obstructive: please tell me FEV1/FVC ratio?
O is 80%
Rhinosinusitis typically affects which sinus?
Typically affects maxillary sinuses, which drain against gravity due to ostia located superomedially
Infections in sphenoid or ethmoid sinuses may extend to _________ _______ and cause complications
Infections in sphenoid or ethmoid sinuses may extend to cavernous sinus and cause complications (eg, cavernous sinus syndrome).
Common causes of epistaxis?
Common causes include foreign body, trauma, allergic rhinitis, and nasal angiofibromas (common in adolescent males).
Prophylaxis and Tx of DVT?
Use unfractionated heparin or low-molecularweight heparins (eg, enoxaparin) for prophylaxis and acute management.
Use oral anticoagulants (eg, warfarin, rivaroxaban) for treatment (long-term prevention).
Imaging test of choice for DVT?
Imaging test of choice is compression ultrasound with Dopple
interdigitating areas of pink (platelets, fibrin) and red (RBCs) found only in thrombi formed before death - what are they?
Lines of Zahn; help distinguish pre- and postmortem thrombi
Imaging test of choice for PE?
CT pulmonary angiography is imaging test of choice for PE (look for filling defects)
Premature kids with NRDS is treated with O2. What can it result in?
retinopathy of prematurity bronchopulmonary dysplasia intraventricular hemorrhage
ECG abnormalities in PE?
May have S1Q3T3 abnormality on ECG
Air emboli most commonly present in what patients?
nitrogen bubbles precipitate in ascending divers (caisson disease/decompression sickness); treat with hyperbaric O2; or, can be iatrogenic 2° to invasive procedures (eg, central line placement
Contents of mediastinim?
heart, thymus, lymph nodes, esophagus, and aorta
Which mediastinal masses are seen in the anterior compartment?
Anterior—4Ts: Thyroid, Thymic neoplasm, Teratoma, “Terrible” lymphoma
Which mediastinal masses are seen in the middle compartment?
Middle—esophageal carcinoma, metastases, hiatal hernia, bronchogenic cysts
Which mediastinal masses are seen in the post compartment?
Posterior—neurogenic tumor (eg, neurofibroma), multiple myeloma.
Common causes of mediastinitis?
Commonly due to :
- postoperative complications of cardiothoracic procedures (pathology ≤ 14 days),
- esophageal perforation
- contiguous spread of odontogenic/retropharyngeal infection
Common cause of chronic mediastinitis has what geographical association? pathomech of chronic mediastinitis?
Mississippi and Ohio River Valleys - Histoplasma capsulatum
Patho mech: fibrosing mediastinitis; due to inc formation of connective tissue in mediastinum
Sx of mediastinitis?
fever, tachycardia, leukocytosis, chest pain, and (especially with cardiac procedures) sternal wound drainage.
What is this a picture of?
Pneumomediastinum:
Presence of gas (usually air) in the mediastinum (black arrows show air around the aorta, red arrow shows air dissecting into the neck
Causes of pneumomediastinum?
Can either be spontaneous (due to rupture of pulmonary bleb) or 2° (eg, trauma, iatrogenic, Boerhaave syndrome).
Ruptured alveoli allow tracking of air into the mediastinum via peribronchial and perivascular sheaths
[Boerhaave - transmural, usually distal esophageal rupture due to violent retching.]
Sx of Pneumomediastinum
chest pain, dyspnea, voice change, subcutaneous emphysema, and Hamman Sign
What is ⊕ Hamman sign?
crepitus on cardiac auscultation
Sx of Chronic bronchitis?
Findings: wheezing, crackles, cyanosis (hypoxemia due to shunting), dyspnea, CO2 retention,
Chronic Bronchitis can lead to secondary _______?
polycythemia
What happens to Reid Index in chronic bronchitis and why? What is Reid Index?
Hypertrophy and hyperplasia of mucus-secreting glands in bronchi –> Reid index > 50%.
Reid Index = thickness of mucosal gland layer to thickness of wall between epithelium and cartilage
T or F DLCO is normal in chronic bronchitis
True
When do we a define a patient as having chronic bronchitis?
\ productive cough for > 3 months in a year for > 2 consecutive years.
Difference in location of Centriacinar vs Panacinar lesion in emphysema?
Centriacinar— Frequently in upper lobes
Panacinar— Frequently in lower lobes
Which form of emphysema is assoc with smoking?
Centriacinar
Diff in DLCO in emphysema is due to?
dec DLCO from destruction of alveolar walls
Signs on Xray for Emphysema?
Inc AP diameter, flattened diaphragm, inc lung field lucency
Sx of asthma?
: cough, wheezing, tachypnea, dyspnea, hypoxemia, dec inspiratory/ expiratory ratio, pulsus paradoxus, mucus plugging
Dx of Asthma done by?
spirometry
methacholine challenge
What are pictured here?
, Curschmann spirals F (shed epithelium forms whorled mucous plugs)
Charcot-Leyden crystals G (eosinophilic, hexagonal, double-pointed crystals formed from breakdown of eosinophils in sputum).
hyperresponsive bronchi in asthma lead to what pathological changes in the smooth musc?
Hyperresponsive bronchi –> reversible bronchoconstriction. Smooth muscle hypertrophy and hyperplasia
What happens in aspirin induced asthma?
Aspirin-induced asthma is a combination of COX inhibition (leukotriene overproduction –> airway constriction), chronic sinusitis with nasal polyps, and asthma symptoms
purulent sputum, recurrent infections, hemoptysis, digital clubbing are sx of ?
Bronchiectasis
Bronchiectasis is assoc with?
bronchial obstruction, poor ciliary motility (eg, smoking, Kartagener syndrome), cystic fibrosis, allergic bronchopulmonary aspergillosis.
Restrictive lung diseases have two major causes - what are they?
- Poor breathing mechanics :
- Poor muscular effort—polio, myasthenia gravis, Guillain-Barré syndrome
- Poor structural apparatus—scoliosis, morbid obesity
- Interstitial lung diseases
What are the differences between poor breathing mechanics and interstitial lung disease in terms of a) location, b) DLCO, and c) A-a gradient?
Poor breathing mechanics
extrapulmonary, normal DLCO, normal A-a gradient)
Interstitial lung diseases
pulmonary, dec DLCO, inc A-a gradient
Ex of interstitial lung diseases?
- Pneumoconioses (eg, coal workers’ pneumoconiosis, silicosis, asbestosis)
- Sarcoidosis
- Idiopathic pulmonary fibrosis
- Goodpasture syndrome
- Granulomatosis with polyangiitis (Wegener)
- Pulmonary Langerhans cell histiocytosis (eosinophilic granuloma)
- Hypersensitivity pneumonitis
- Drug toxicity
4 drugs that can lead to restrictive lung disease?
(bleomycin, busulfan, amiodarone, methotrexate)
Hypersensitivity pneumonitis is what type of HS?
—mixed type III/IV hypersensitivity reaction to environmental antigen.
Asbestosis assoc with which occupations?
Associated with shipbuilding, roofing, plumbing
Pathognomic lesion of asbestosis?
supradiaphragmatic and pleural plaques are pathognomonic of asbestosis.
Which cancer is more common with asbestosis? Which lung cancer has the highest association with asbestosis?
a) Bronchogenic CA
b) mesothelioma
I.e. if you have asbestosis, you are likely to get bronchogenic CA, but if you have mesothelioma, then you most likely had asbestosis
Asbestosis looks like what histologically?
golden-brown fusiform rods resembling dumbbells , found in alveolar sputum sample, visualized using Prussian blue stain, often obtained by bronchoalveolar lavage.
Of all the pneumoconioses, which effect upper and which affect lower lobes
All affect upper lobes except Asbestosis, which affects lower lobes.
Which occupation is assoc with Berylliosis?
Associated with exposure to beryllium in aerospace and manufacturing industries
Berylliosis inc risk of what diseases?
cancer and cor pulmonale
What is Caplan syndrome and which pneumoconioses inc risk for developing it?
Patients with rheumatoid arthritis develop lung nodules after being exposed to things like silica and coal dust -
inc risk with asbestosis, Coal workers pneumoconiosis and silicosis, but not berylliosis
Silicosis is assoc with which occupations?
Associated with sandblasting, foundries, mines
CXR signs of Silicosis
“Eggshell” calcification of hilar lymph nodes on CXR
What marker is positive in mesothelioma?
Calretinin ⊕ in almost all mesotheliomas, ⊝ in most carcinomas
Patho features of mesothelioma?
May result in hemorrhagic pleural effusion (exudative), pleural thickening
Histological sign seen in Mesothelioma?
Psammoma bodies
Hyaline membrane of ARDS
Pathomech of ARDS
Alveolar insult –> release of pro-inflammatory cytokines –>neutrophil recruitment, activation, and release of toxic mediators (eg, reactive oxygen species, proteases, etc) –> capillary endothelial damage and inc vessel permeability –> leakage of protein-rich fluid into alveoli –> formation of intra-alveolar hyaline membranes and noncardiogenic pulmonary edema
Most common cause of ARDS? Other causes?
Sepsis is most common cause. Other causes: aspiration, pneumonia, trauma, pancreatitis
How to Dx ARDS?
- Abnormal chest X-ray (bilateral lung opacities)
- Respiratory failure within 1 week of alveolar insult
- Decreased Pao2/Fio2 (ratio < 300, hypoxemia due to intrapulmonary shunting and diffusion abnormalities)
- Symptoms of respiratory failure are not due to HF/fluid overload
T or F ARDS presents with normal PCWP
true, Pulm edema is non cardiogenic
Definition of sleep apnea
Repeated cessation of breathing > 10 seconds during sleep –>disrupted sleep –>daytime somnolence. Diagnosis confirmed by sleep study.
Recurrent nocturnal hypoxia due to sleep apnea lead to which consequences?
systemic/pulmonary hypertension, arrhythmias (atrial fibrillation/flutter), sudden death
Central sleep apnea due to?
Impaired respiratory effort due to CNS injury/toxicity, HF, opioids. May be associated with Cheyne-Stokes respirations (oscillations between apnea and hyperpnea). Think 3 C’s: Congestive HF, CNS toxicity, Cheyne-Stokes respiration
Normal pulm artery pressure? Pulm HTN?
Normal mean pulmonary artery pressure = 10–14 mm Hg; pulmonary hypertension ≥ 25 mm Hg at rest.
Pulm HTN - patho consequences?
Results in arteriosclerosis, medial hypertrophy, intimal fibrosis of pulmonary arteries, plexiform lesions
heritable PAH is due __________ mutation in _____ gene?
Heritable PAH can be due to an inactivating mutation in BMPR2 gene (normally inhibits vascular smooth muscle proliferation)
Other non heritable causes of PAH?
drugs (eg, amphetamines, cocaine), connective tissue disease, HIV infection, portal hypertension, congenital heart disease, schistosomiasis.
4 types of atelectasis
Obstructive, Compressive, Contraction, Adhesive
Explain 4 types of atelectasis and give ex of cause for each one?
- Obstructive—airway obstruction prevents new air from reaching distal airways, old air is resorbed (eg, foreign body, mucous plug, tumor)
- Compressive—external compression on lung decreases lung volumes (eg, space-occupying lesion, pleural effusion)
- Contraction (cicatrization)—scarring of lung parenchyma that distorts alveoli (eg, sarcoidosis)
- Adhesive—due to lack of surfactant (eg, NRDS in premature babies)
name 4 types of pneumothorax
primary spontaneous
secondary spontaneous
traumatic
tension
clinical symptoms of pneumothorax?
all on affected side
unilateral chest pain
dyspnea
unilateral chest expansion
dec tactile fremitus
hyperresonancy
diminished breath sounds
what type of pneumothorax is due to rupture of apical blebs or cysts? patient pop?
primary spontaneous; usually tall, thin young males and smokers
what type of pleural effusion is also known as chylothorax?
lymphatic pleural effusion
2 causes of lymphatic (chylothorax) effusions?
thoracic duct injury from trauma, malignancy
what content is high in chylothorax?
TGs
Diff between transudate and exudative pleural effusion? causes?
Transudate - dec protein content.
Due to inc hydrostatic pressure (eg, HF) or dec oncotic pressure (eg, nephrotic syndrome, cirrhosis).
Exudate - inc protein content, cloudy.
Due to malignancy, pneumonia, collagen vascular disease, trauma (occurs in states of inc vascular permeability). Must be drained due to risk of infection.
Light criteria
Pleural fluid
Pleural fluid is exudative if ≥ 1 of the following criteria is met:
Pleural fluid protein/serum protein ratio > 0.5
Pleural fluid LDH/serum LDH ratio > 0.6
Pleural fluid LDH > 2⁄3 of the upper limit of normal for serum LDH
Exudate = Excess protein and LDH
name 3 bugs that cause lobar pneumonia
S. pneumoniae (95%) Legionella Klebsiella
what is bronochopneumonia?
acute inflammatory infiltrates from bronchioles into adjacent alveoli, patchy distribution involving more than 1 lobe
4 bugs that cause bronchopneumonia?
S. pneumoniae S. aureus H. influenza Klebsiella
name 7 agents that cause interstitial (atypical) pneumonia
Viruses influenza, CMV, RSV, adenoviruses Mycoplasma, Legionella, Chlamydia
What type of pneumonia is seen here?
Interstitial (atypical pneumonia)
Diffuse patchy inflammation localized to interstitial areas at alveolar walls; CXR shows bilateral multifocal opacities
List the 4 phases of lobar pneumonia, and how many days each one takes?
Congestion 1-2 d
Red hepatization 3-4 d
Gray hepatization 5-7d
Resolution 8+
How does the lung look in each phase of lobar pneumonia and contents?
Congestion: Red-purple, partial consolidation of parenchyma Exudate with mostly bacteria
Red hepatization:
Red-brown, consolidated Exudate with fibrin, bacteria, RBCs, and WBC
Gray hepatization:
Uniformly gray Exudate full of WBCs, lysed RBCs, and fibrin
Resolution:
Enzymes digest components of exudate
5 risk factors for lung cancer
smoking, second hand smoking, radon, asbestos, family hx
name 5 complications of lung cancer
SPHERE of complications:
- Superior vena cava/thoracic outlet syndromes
- Pancoast tumor
- Horner syndrome
- Endocrine (paraneoplastic)
- Recurrent laryngeal nerve compression (hoarseness)
- Effusions (pleural or pericardial)
what lung cancer is associated with kulchitsky cells?
small cell carcinoma
what lung cancers are + chromogranin A? Other markers for same disease?
small cell bronchial carcinoid tumor;
Chromogranin A ⊕, neuron-specific enolase ⊕, synaptophysin ⊕.
what lung cancer is associated with myc oncogene amplification?
small cell
small cell carcinoma of the lung can produce 2 types of antibodies, what are they?
- Ab against presynaptic (P/Q type) Ca2+ (Lambert Eaton)
- Ab against neuron that can lead to paraneoplastic myelitis/encephalitis (anti-Hu)
List Paraneoplastic manifestations of small cell lung cancer?
- Ab against presynaptic (P/Q type) Ca2+ (Lambert Eaton)
- Ab against neuron that can lead to paraneoplastic myelitis/encephalitis (vs purkinke cells anti-Hu)
- Opsoclonus - myoclonus ataxia
- Inc ADH —> hyponatremia, Cushings (inc ACTH)
Cancer dx assoc with KRAS, EGFR, and ALK.
adenocarinoma
Cancer Dx assoc with apparent “thickening” of alveolar walls. Tall, columnar cells containing mucus.
Bronchioalveolar subtype of adenocarcinoma
A woman with hypertrophic osteoarthropathy is likely to have which type of lung cancer?
adenocarcinoma
Marker assoc with adenocarcinoma
Mucin (+)
Lung cancer dx assoc with keratin pearls and intercellular bridges?
Sq. cell carcinoma
Why does Squamous cell carcinoma lead to hypercalcemia?
produces PTHrP
Assoc with pleomorphic giant cells?
Large cell CA
Which lung cancer is more likely in nonsmokers vs smokers?
Nonsmokers - adenocarcinoma
Smokers - large cell carcinoma, squamous cell , small cell
Which lung cancers are located central vs peripheral?
Central - small cell, squamous cell and bronchial carcinoid
Peripheral - adenocarcinoma, large cell, and broncial carcinoid
Marker of bronchial carcinoid ?
chromogranin A
what type of cells are seen in carcinoid tumor?
neuroendocrine
Bact causes of lung abscess?
Due to anaerobes (eg, Bacteroides, Fusobacterium, Peptostreptococcus) or S aureus.
Lung abscess will form where if due to aspiration - if upright vs supine?
RLL if upright, RUL or RML if recumbent.
What lung lesion is assoc with hoarseness or Horner syndrome? why?
Pancoast tumor
Compression of:
Recurrent laryngeal nerve –> hoarseness
Stellate ganglion –> Horner syndrome (ipsilateral ptosis, miosis, anhidrosis)
What other structures (3) can be compressed by pancoast tumor? consequences?
Superior vena cava –> SVC syndrome
Brachiocephalic vein –> brachiocephalic syndrome (unilateral symptoms)
Brachial plexus –> sensorimotor deficits
Sx of SVC syndrome
(“facial plethora”; note blanching after fingertip pressure in A), neck (jugular venous distention), and upper extremities (edema).
Causes of SVC syndrome?
Commonly caused by malignancy (eg, mediastinal mass, Pancoast tumor) and thrombosis from indwelling catheters
An infant comes in with bulging anterior fontanelle, hypotension, decerebrate posturing, tonic-clonic seizures, irregular respirations. Could it be child abuse?
germinal matrix immature –> intraventircular hemorrhage
if child abuse: Subdural hemorrhage and retinal hemorrhge
