Respiratory Path Flashcards

1
Q

Conducting Zone

A

Mouth/Nose, pharynx, trachea, bronchi to bronchioles

-Has squamous epithelium and progresses to Pseudostratified cliliated columnar epithelium with goblet cells

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2
Q

Bronchi

A

-Have cartilage and goblet cells. Below have smooth muscle and club cells

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3
Q

Bronchioles to terminal bronchioles

A
  • Smooth muscle with clara cells

- pseudostratified columnar epthelium

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4
Q

Respiratory zone

A
  • Respiratory bronchioles, alveolar ducts, alveoli

- Cuboidal cells in respiratory bronchioles and squamous cells in alveoli

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5
Q

Alveolar Macrophages

A

-Defense cells of alveoli

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6
Q

Type I pneumocytes

A
  • Thin simple squamous cells that participate in gas exchange
  • Comprise 97% of surface area
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7
Q

Type 2 pneuomcytes

A
  • Secrete surfactant to oppose surface tension
  • Serve as reserve cells during damage of type 1 cells
  • Contain lamellar bodies which are surfactant that will be secreted
  • Cuboidal cells
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8
Q

Clara/Club Cells

A
  • Located in the terminal bronchiole area and respiratory bronchiole.
  • Secrete defense proteins (IgA components, lysozyme, etc)
  • Chew up mucus that has been secreted and degrades surfactant
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9
Q

Collapsing pressure

A
  • Directly proportional to 2*surface tension and inversely proportional to radius.
  • Collapse is possible during exhalation.
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10
Q

Surfactant

A
  • Secreted by type 2 pneumocytes and breaks surface tension
  • Lecethin to sphingomyelin ratio of greater than 2:1 signals lung maturity
  • Doesn’t mature until week 35 (26-35)
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11
Q

Aspiration

A

-Most likely to occur in the right lower lobe

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12
Q

Diaphragm Structures

A
  • IVC at T8
  • Esophagus at T10
  • Aorta, azygous, thoracic duct at T12
  • Innervation by C3-5, inflammation may lead to referred pain to shoulder
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13
Q

Congenital Diaphragmatic Hernia

A

-Most commonly on left pleurodiaphragm leads to unilateral lung hypoplasia

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14
Q

Accessory Muscles of inspiration

A

-External intercostals - Pull up and out

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15
Q

Expiration

A

-Internal intercostals pull down and in

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16
Q

FRC

A
  • Expiratory reserve volume and residual volume

- The point at which the chest expansion and lung retraction are equalized and alveolar pressure is equal to atmospheric

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17
Q

Physiologic Dead Space

A
  • Anatomic plus functional dead space

- Arterial co2-expired CO2 over arterial co2

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18
Q

Hemoglobin A

A
  • Two alpha and 2 beta subunits
  • Taught state has low affinity for oxygen and is observed in a right shift.
  • Relaxed state has high affinity for oxygen and is seen in a left shift
  • Shift to taught with increase CO2, H+, temp, Cl, 2,3 BPG (increased metabolic activity)
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19
Q

Hgb F

A

Has two alpha and 2 gamma
-Has decreased affinity for 2,3 BPG meaning it has a higher affinity for oxygen. 2,3 BPG causes increased release in tissues.

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20
Q

Methemoglobin

A
  • Oxygen can only bind when Fe is reduced in the 2+ state.
  • If oxidized to 3+ can’t bind oxygen, pulse ox shows decreased saturation
  • Has higher affinity for Cyanide
  • Can be caused by nitrites, drugs, pyruvate kinase and G6PD
  • Cyanide poisoning treted with nitrates to form Fe3+ and take cyanide into hemoglobin and off cytochromes. Then give thisulfate to solubalize and methylene blue to reduce Fe
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21
Q

Carboxyhemoglobin

A
  • Hemoglobin has higher affinity for CO and demonstrates as non-sigmoidal curve
  • Causes shift to the left and down in oxygen binding capacity
  • Pulse ox often shows normal, need to get a carboxyhemoglobin level
  • Symptoms are red color, headache, vommiting, altered mental status
  • Treat with hyperbaric oxygen
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22
Q

Pulmonary circulation

A
  • High compliance low resistance circuit

- elevated CO2 causes contsritcion and O2 causes dilation

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23
Q

Perfusion limited

A
  • Normal physiologic conditions all gases are perfusion limited except CO
  • Equilibration along length
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24
Q

Diffusion Limited

A
  • Equilibration doesn’t occur and gases are limited by their diffusing capacity
  • Diffusion proportional to pressure difference and area and inversely proportional to thickness
  • Emphysema causes a loss of area and fibrosis causes and increase in thickness both leading to diffusion limiting
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25
Q

Primary Pulmonary Hypertension

A

-Defect in BMPR2 leads to smooth muscle proliferation and constricion, poor prognosis

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26
Q

Secondary Pulmonary Hypertension

A
  • Caused by anything that decreases oxygenation or increases CO2 levels leading to vasoconstriction
  • Sleep Apnea, Altitude, Multiple Thromboemboli, Right to Left cardiac shunt, systemic sclerosis (scleroderma), Mitral stenosis, COPD
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27
Q

Cyanosis

A
  • Occurs with elevated deoxyhemoglobin, not necessarily decreased oxygen levels
  • Content is in bound to Hgb and unbound fractions
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28
Q

Alveolar Gas Equation

A
  • PAo2= PIo2-PCO2/.8

- Alveolar oxygen is equiivlent to space not occupied by CO2

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29
Q

A-a Gradient

A
  • Pressure gradient for oxygen to flow from alveoli to capillaries
  • Will be increased in diffusion problems, V/Q mismatches, Shunting
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30
Q

Hypoxemia with normal A-a

A
  • Means there is decreased alveolar oxygen

- Hypoventilation or altitude

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31
Q

Hypoxemia with increased A-a

A
  • There is impaired blood flow/oxygen extraction

- Diffusion, V/Q mismatches, R to L shunt (decreased a of returning blood)

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32
Q

Hypoxia

A

-Decreased oxygen Delivery to tissues: Decreased CO, anemia, CO poisoning, hypoxemia

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33
Q

Ischemia

A
  • Decreased blood flow to tissues

- Arterial block or venous congestion

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34
Q

V/Q mismatches

A
  • Apex Ventilation 3 times perfusion Zone 1 (wasted ventilaton)
  • Zone 2, middle: Ventilation almost equal to perfusion
  • Zone 3, base: Ventilation less than perfusion: Physiologic dead space
  • Ventialation and perfusion are both the greatest at the base of the lung, but perfusion is proportionally greater.
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35
Q

Exercise

A

-Capillaries open because of increased perfusion pressures leads to increased perfusion in apex

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36
Q

V/Q is 0

A

Airway obstruction, supplemental oxygen will not help

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37
Q

V/Q is infinite

A
  • perfusion defect due to embolization etc.

- Leads to shunt and therefore oxygen will help

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38
Q

CO2 Transport

A
  • Majority dissolved in bicarbonate. CA speeds up reaction. Turns to CO2 at lungs and is blown off
  • 5% as CO2 bound to N terminus of Hgb, increases liklihiood of tught state and offloading in tissues
  • 5% dissolved
  • H+ offloaded in lungs increases affinity for O2 and H+ comes on in tissues, decreases affinity
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39
Q

High Altitude

A
  • Acute hyperventiltion leads to alkalosis
  • Respond: EPO, Elevated HCO3 excretion (Acetazolamide augments), Elevated 2,3 BPG (Stressed), Increased cellular mitochondria,
  • Acute hypoxic vasoconstriction can lead to pulmonary edema
  • Chronic hypoxic vasoconstriction can lead to RVH
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40
Q

Exercise

A
  • Elevated CO2 production and O2 usage
  • PaCO2 and PaO2 are normal but there will be a drop in the venous content of oxygen and increase in CO2
  • VQ equalizes in lung by opening of unused capilaries.
41
Q

DVT

A

-Thrombosis in deep veins of leg, caused by stasis, hypercoagulability, endothelial damage

42
Q

Hypercoagulability

A
  • Estogen Use, smoking
  • Factor V Lieden
  • Protein C or S deficency (S is cofactor for protein C inactiavtion of V and VII)
  • Prothrombin 2010 ( mutation in 3’ UTR that leads to increased stability of mRNA and elevated prothrombine levels)
  • Antiphospholipid (B2)
  • PNH
  • Cancer (adenocarcinoma)
  • Nephrotic leads to ATIII loss (heparin increses activity. Activates serine proteases 2,7,9,10,11, also complement proteins.)
  • Dysfibrinogenemia (increase clotting risk)
43
Q

Sympotoms

A

-Positive Homan sign with pain on dorsiflexion

44
Q

Pulmonary Embolism

A
  • If small can reorganize and cause pulmonary hypertension due to scarring and fibrosis
  • Saddle: RVH block leading to mechanical-electrical dissociation, JVD, parasternal heave and increased P2
  • Pleuritic chest pain with hemoptysis
  • Dx with spiral CT (CT angio)
45
Q

Fat Embolism

A
  • Post trauma, fracture of long bone leads to fat

- Chest pain, neurologic signs and petichiae on chest

46
Q

Gas embolus

A
  • Diving/decompression sickness

- Caissons disease

47
Q

DVT Thrombus

A

See above

48
Q

Amniotic

A
  • Contains pro-clotting tissue factor and lipid

- Seen during pregnancy and also often with DIC

49
Q

Obstructive Lung Disease

A
  • Characterized by elevated FRC, and TLC due to air trapping.
  • There will be a decresed FEV1 and slightly decreased FVC. The FEV1/FVC ratio will be decreased
  • V/Q mismatches are common
50
Q

Chronic Bronchitis

A
  • Inflammation and irritation cause hyperplasia of the mucous glands and serrous glands to account for more than 50% of the wall diameter
  • Pts will have productive cough, dyspnea, wheeze
  • Decreased PaO2 and increased PaCO2
  • small airway disease
51
Q

Centriacinar emphysema

A

-Irritation and inflammation due to smoking leads to increased protease activity from alveolar macrophages. This leads to destruction of the center of the accinus. Respiratory bronchiole etc.

52
Q

Panacinar Emphysema

A
  • Alpha 1 antitrypsin deficency due to misfolded protein from liver.
  • Accumulation in liver leads to PAS positive staining of eosinophilic bodies in the ER of hepatocytes
  • Leads to panacinar emphysema as there is little opposition to elastase
  • PiM is normal allele and PiZ is abnormal PiZM has increased susceptability to emphysema with smoking, PiZZ has panacinar emphysema
  • May cause chirrosis in liver
53
Q

Emphysema

A
  • Cough without spututum. Wheezes will be present
  • There will be hyperlucency of lung fields
  • Pink puffers. Pursed lips allow for positive end expiratory pressure leading and keeps airways from collapsing
54
Q

Asthma

A
  • Type 1 hypersensitivity characterized by TH2 release of IL-4 (switch to IgE) IL-5 (Eosinophils) IL-10 (Suprress TH1 and increase TH2)
  • IgE crosslinked on mast cells causes release of histamine causing vasodilation in arterioles and leakage in post capillary venules
  • Late phase characterized by eosinophilic infiltrate and MBP release inflammation
  • Leukotrienes C-E cause bronchocontriction
  • (Leukotriene B4 is chemotactic to neutrophils and not involved in this process)
  • Charcot-Leyden crystals (MBP from neutrophils)
  • Crushman’s spirals are epithelial cells that are shed.
  • Wheezing, dyspnea, pulsus paradoxus, mucous plug.
55
Q

Bronchiectasis

A
  • Necrotizing infection of the lower airways leading to dilation and obstructive lung disease
  • Recurrent infections, hemoptysis, foul smelling sputum
  • Irreversible
  • S Aureus, Pseudomons, BPA
  • Karterenger, CF
56
Q

Bronchiolitis Obliterans

A
  • Formation of poorly healing scar fibrosis and epihelial debris in small airways of lungs.
  • Presents with obstructive pattern with increased FRC and decreased FEV1/FVC.
  • Most commonly seen in lung transplants and in GVHD in stem cell transplants
57
Q

Restrictive Lung Disease

A
  • Decreased FRC and increased FEV1/FVC
  • Mechanical: Normal A-a (expiration is passive)
  • INterstitial: Elevated A-a (Diffusion Barrier)
58
Q

Mechanical Restriction

A
  • Motor dysfunction: Myasthenia Gravis, Polio, ALS

- Structural: Scoliosis, Obesity

59
Q

ARDS

A
  • Many causes
  • All classified by endothelial and epithelial damage leading to cytokine release and recruitment of neutrophils and T cells
  • Inflammation and exudation leading to hyaline membrane formation, leads to diffusion barrier and increased A-a gradient
  • Destruction of type 1 and type 2 pneumocytes leads to decrease in durfactant and widespread atelectasis, may be treated with PEEP
  • Loss of type 2 can lead to scarring rather than repair with further problems
  • Atlectasis causes shunt leading to increased A-a gradient
  • CXR will show diffuse white-out appearance
60
Q

Neonatal Respiratory Distress

A
  • Decreased Lecethin:Sphingomyelin ratio leads to increase surface tension and diffuse alveolar collapse
  • Hypoxemia and cyanosis
  • Increased risk in premature (lungs don’t develop until 36 weeks), C-Section (No cortisol release, cortisol stimulates maturation), Diabetic Mothers (insulin is inhibitory to lung maturation)
  • Can treat by giving mother steroids intrapartum/prepartum and also giving surfactant to baby
  • Tx: PEEP oxygen until lungs mature.
  • Long term O2 risks retinopathy of prematurity (blindness by free radicals) and Bronchopulmonary dysplasia (necrotizing bronchitis and fibrosis (mechanical and free radical))
  • Low oxygen tension can keep PDA open
61
Q

Anthracosis

A
  • Coal miners lung
  • Diffuse black infiltrate in macrophages causes fibrosis
  • Patients may also have RA associated
62
Q

Silicosis

A
  • Sand blasters and miners
  • Generally in upper lobes with fibrosis
  • Impairs phagolysosome fusion leading to increased risk of TB infection
63
Q

Berryliosis

A
  • Aerospace

- Noncasseating granulomas (sarcoidosis look a like) increase risk for carcinoma

64
Q

Asbestos

A
  • Macrophages consume asbestos and becomes Fe bound ferruginous bodies
  • Increased risk for Lung cancer and mesothelioma
  • Generally subpleural
65
Q

Sarcoidosis

A
  • Generally effects young adult/middle aged african american females
  • Noncasseating granulomas most commonly effect the lungs, but can effect anywhere
  • Asteroid bodies and shumman bodies (Ca inside giant cells)
  • Granulomas make ACE and also alpha 1 hydroxylase leading to elevated vitamin D and elevated Ca
  • May present anywhere in the body: Erythema multiforme, uveitis, sjoggrens syndrome like
66
Q

Systemic Sclerosis

A

-Can also show interstitial fibrosis with restrictive lung pattern

67
Q

Idiopathic Pulmonary Fibrosis

A
  • Repeated cycles of injury and fibrosis lead to eventual progression to honeycomb lung and often need transplant
  • Related to tgf-B and collagen production
68
Q

Goodpastures

A

-Collagen 4 type 2 hypersentivity

69
Q

Wegners

A

-c-anca

70
Q

Langerhans Cell Histiocytosis

A

-Bierbeck granules and many other systemic symptoms

71
Q

Hypersensitivity Pneumonitis

A
  • Type 3 and type 4 hyperssensitivities related to environmental exposure
  • Poorly formed granulomas, can have systemic symptoms
  • Occupational exposure, farmers are classic example
  • Inflammation and fibrosis progress to restrictive presentation
72
Q

Drugs

A

Bleomycin and Buslfan for chemo

  • Methotrexate
  • Amiodarone
73
Q

Central Sleep Apnea

A

-Loss of respiratory drive in the medulla

74
Q

Obstructive sleep apnea

A
  • Blockage of breathing during night
  • Hypoventilation leads to decreased O2 and mildly elevated CO2
  • Can cause switch to oxygen mediated respiratory drive
  • Present with fatigue and may present with depression like symptoms. Rule out hypothyroid
  • Can cause pulmnary hypertension, arrythmias, death
  • Also commonly see polycythemia
75
Q

Spontaneous Pneumothorax

A
  • Rupture of emphysematous bled, generally in hypervetilated upper lobes
  • Commonly presents in tall, marfanoid young men
  • Hyperresonant with absent breath sounds. Trache deviated towards
76
Q

Tension Pneumothorax

A
  • Trauma induced sucking chest wound causing increase pressure and tracheal deviatoin opposite of injury.
  • Emergenty thoracocentesis is necessary.
77
Q

Lung Cancer Presentation

A
  • Presents late as a coin lesion on CXR
  • Differentiate from histo/TB with biopsy
  • Often presents with cachexia or with paraneoplastic syndrome
  • Poor prognosis
  • Smoking and radon are main risk factors
  • May caues wheezing, obstruction, and hemptysis
78
Q

Lung Cancer metastasizes from

A
  • Most commonly the breast

- Also bladder, prostate, colon

79
Q

Metastasizes to

A
  • The most common is adrenals causing addisons like syndrome. By far most common met to adrenals
  • Bone, brain, liver
80
Q

Superior Vena Cava syndrome

A
  • Tumor obstruction of the superior vena cava leads to backup into face and upper extremeties
  • Facial edema, headache, arm pain
  • Emergency because can raise intracranial pressure and increase risk of anyeurism
81
Q

Pancoast Tumor

A

Tumor in the upper lobe of the lung that can compress local structures

  • Horners syndrome
  • Laryngeal nerve compression leading to hoarsness
  • Brachiocephalic, phrenic, subclavian compresion
82
Q

Horners Syndrome

A
  • Compression of the sympathetic chain and superior ganglia leading to: Anhidrosis, miosis, ptosis
  • Compression of second order neuron
  • Primary from hypothalamus (post) to IML
  • Secondary (presynaptic) exit chord and run to ganglion
  • Third from ganglion along carotid to long cilliary nerves
83
Q

Effusions

A

Possible pericardial or pleural effusions

84
Q

Adenocarcinoma

A
  • Most common subtype worldwide
  • Arises in women and in nonsmoker
  • Peripheral location
  • k-ras or EGFR (non-smoker, may be treated with her2-neu) mutation
  • Relatively good prognosis
  • Not associated with any paraneoplastic
  • Clubbing possible
85
Q

Bronchoalveolar carcinoma

A
  • Tumor of cuboidal cells that runs along the inerstitum of alveoli and bronchus
  • May appear like an interstitial pneumonia on CXR
  • Relatively good prognosis
86
Q

Squamous Cell Carcinoma

A
  • Most common in male smokers
  • Centrally located lesion arising from squamous cells of bronchus (Metaplasia due to irritation)
  • Poor prognosis but resection is attemptable
  • Keratin perals and intercellular (desmosome) bridges
  • Associated with PTHrP and often causes hypercalcemia
  • May also cause local mass effect problems leading to respiratory compromise, atelectasis and infection in involved bronchus
87
Q

Small Cell Carcinoma

A
  • Centerally located and most common in male smokers
  • Neuroendocrine origin with chromogranin and synaptophysin stain
  • Aggressive with early metastasis, no surgery possible
  • SIADH
  • ACTH leading to cushings
  • Lambert Eaton
  • Myc oncogene often involved
88
Q

Large Cell Carcinoma

A
  • Poorly differentiated anaplastic pleiomorphic giant cells
  • Located in periphery (Diff from adenocarcinoma)
  • Poor prognosis
  • Surgical resection may be attempted.
89
Q

Bronchial Carcinoid Tumor

A
  • Tumor of well differentiated neuroendocrine cells (synatophysin and chromogranin)
  • Located in bronchus and has good prognosis, rarely metastaszes and can be resected
  • May rarely cause carcinoid syndrome
  • Mass effect with respiratory obstruction is common
90
Q

Mesothelioma

A
  • Rare tumor of pleural fluid producing mesothelial cells
  • Associated with asbestos (although lung cancer more common)
  • Malignant with poor prognosis, grows around encasing lungs leading to respiratory compromise
  • Often is calcified and may have psammoma bodies
  • Hemorrhagic effusions.
91
Q

Lobar Pneumonia

A
  • CXR shows lobar involvment
  • Massive exudate into alveolar lumen
  • Most common is strep Pneumo then klebsiella (Aspiration of GI, not gastric contents)
  • Congestion: Bacterial infiltration, edema, hyperemia
  • Red hepatization: Transudate RBC, neutrophils show up and fibrin deposits
  • Grey Hepatization: Degredation of fibrin and RBC
  • Recovery: Type 2 pneumocytes proliferate and debris removed, coughing
92
Q

Bronchopneumonia

A
  • CXR shows patchy infiltrate often involving multiple areas
  • Bacterial and neutrophil exudate into bronchioles and nearby alveoli
  • S Aureus
  • S Pneumo
  • H Flu (following influenza)
  • Klebsiella
93
Q

Interstitial (atypical) Pneumonia

A
  • Inflamation of interstitium with relative sparing of exudate into alveolar spaces
  • Generally leads to a more indolent course and CXR will show large areas of opacification without focal opacities
  • Viral (RSV in Kids, Flu in elderly, adenovirus in recruits)
  • Mycoplasma is most common, no gram stain and IgM cold agglutinins
  • Chlamydia is second most common and can infect infants born to infected mothers
  • Legionella: Intracellular silver stain, water resivoir, fever and GI often accompany, SIADH
  • CMV high risk in post transplant and AIDS
  • Coxiella: Q fever, ricketsia that forms a spore, inhaled by vets/farmers. High spiking fevers
  • Candida
94
Q

Lung Abcess

A
  • Collection of pus and necrotic debris in lung parenchyma
  • Generally occurs secondary to blockage of bronchus/bronchile
  • Cancer SCC may be a cause, but more likely to be infectous
  • S Aureus is most common
  • Can be oropharyngeal anaerobes (peptococcus, fusobacterium, bacteroides)
  • Klebsiella also possible
  • Pseudomonas, candida also possible
95
Q

Empyema

A
  • Collection of pus in the pleural space
  • Usually secondary to pneumonia
  • Must drain or else could harden and permanently damage lung parenchyma
96
Q

Transudate

A
  • Low protein count

- CHF, nephrotic syndrome, cirrhosis

97
Q

Exudate

A
  • High protein count
  • Malignany, infection, trauma
  • Can be a nidus for infection and should be drained
98
Q

Chylothorax

A
  • Disruption of the thoracic duct

- Secondary to trauma or lymphoma.