Respiratory - Pathology Flashcards
1
Q
A patient presents with sudden-onset dyspnea one hour after suffering a femur fracture. He is found to have a ventilation/perfusion mismatch. What is your diagnosis?
A
Fat emboli
2
Q
Amniotic fluid emboli can lead to what dangerous hematologic condition in postpartum women?
A
Disseminated intravascular coagulation
3
Q
A patient presents with sudden chest pain, tachypnea, and dyspnea. What is the most likely diagnosis?
A
Pulmonary embolus
4
Q
Name the six most common causes of emboli to the lungs.
A
- Fat,
- Air,
- Thrombus,
- Bacteria,
- Amniotic fluid,
- Tumor
(remember: An embolus moves like a FAT BAT)
5
Q
What is the origin of the majority of emboli that become lodged in the lungs?
A
Deep leg veins
6
Q
Which three factors that promote blood coagulation are known as Virchow’s triad?
A
- Stasis
- hypercoagulability
- endothelial damage
7
Q
Describe Homan’s sign.
A
In Homan’s sign, dorsiflexion of the foot causes a tender calf muscle because of the presence of deep venous thromboses
8
Q
What medication is used to prevent deep venous thrombosis?
A
Heparin (or modified heparin molecules such as enoxaparin)
9
Q
What is the hallmark pulmonary function test finding in patients with obstructive lung disease?
A
Decreased forced expiratory volume1/forced vital capacity ratio
10
Q
List four types of obstructive lung disease.
A
- Chronic bronchitis
- Emphysema
- Asthma
- Bronchiectasis
11
Q
In obstructive lung disease, there is a(n) _____ (decrease/increase) in residual volume and a(n) ____ (decrease/increase) in functional vital capacity.
A
Increase; decrease
12
Q
What criteria must a patient meet to be considered to have chronic bronchitis?
A
A chronic productive cough at least three consecutive months in at least two years
13
Q
What histologic changes would be seen on lung biopsy in a patient with chronic bronchitis?
A
Hypertrophy of the mucus-secreting glands in the bronchioles
14
Q
The mucus gland hypertrophy seen in chronic bronchitis can be quantified using the _____ _____, which tends to be greater than what value in symptomatic patients?
A
Reid index; 50%
15
Q
How is the Reid index calculated?
A
Reid index = gland depth / total thickness of bronchial walls
16
Q
What clinical findings are auscultated in the lungs of patients with chronic bronchitis?
A
Usually wheezing and crackles
17
Q
What visible skin finding may be noted in patients with chronic bronchitis?
A
Cyanosis
18
Q
What pathologic changes are seen in the lungs of a patient with emphysema?
A
Enlargement of the air spaces; decrease in recoil resulting from the destruction of alveolar walls
19
Q
Smoking is associated with _____ (centriacinar/panacinar) -type emphysema, whereas α1-antitrypsin deficiency is associated with _____ (centriacinar/panacinar) -type emphysema.
A
Centriacinar; panacinar
20
Q
In addition to panacinar emphysema, α1-antitrypsin deficiency also causes what condition?
A
Liver cirrhosis
21
Q
A deficiency of α1-antitrypsin results in the increased activity of what enzyme?
A
Elastase; the enzyme degrades elastic fibers in the lungs
22
Q
What exam finding is often auscultated in the lungs of patients with emphysema?
A
Breath sounds are usually diminished with a decreased inspiratory/expiratory ratio
23
Q
In emphysemic lungs, there is a(n) (decrease/increase) _____ in recoil and, subsequently, a(n) _____ (decrease/increase) in compliance.
A
Decrease; increase
As a result, the residual volume of the lungs increases as the disease progresses
24
Q
In emphysema, the decrease in lung recoil is a result of destruction of alveolar walls by increased activity of which enzyme?
A
Elastase
25
Paraseptal emphysema is associated with bullae that can rupture and lead to _____ \_\_\_\_\_ in otherwise young healthy males.
Spontaneous pneumothorax
26
Individuals with emphysema tend to exhale through pursed lips to increase _____ \_\_\_\_\_ and prevent _____ \_\_\_\_\_ during expiration.
Airway pressure; airway collapse
27
The definitive feature of the bronchoconstriction of asthma is that it is fully \_\_\_\_\_.
Reversible
28
In patients with asthma, there is hyperresponsiveness of what lung segment?
The bronchi
29
# Fill in the blank.
While chronic bronchitis is a disease of the _____ (bronchi/bronchioles), asthma is a disease of _____ (bronchi/bronchioles).
bronchi; bronchioles
30
Kartagener's syndrome is associated with what types of lung disease?
Bronchiectasis and obstructive lung disease due to the failure of cilia to clear mucus from the lungs
31
Cough and wheezing are noted in patients with what two types of obstructive lung disease?
Asthma and chronic bronchitis
32
Tachypnea and pulsus paradoxus are noted in patients with what type of obstructive lung disease?
Asthma
33
A child presents with cough, wheezing, dyspnea, tachypnea, hypoxemia, and mucus plugging. On exam, the patient also has a pulsus paradoxus. From what disease is this patient likely suffering?
Asthma
34
What finding is commonly noted on pulmonary function testing of patients with asthma as well as those with emphysema?
Decreased inspiratory/expiratory ratio; generally, obstructive diseases lengthen the expiratory phase
35
What blood pressure/pulse finding is often observed in patients with asthma?
Pulsus paradoxus
36
What are Curschmann's spirals?
Shed epithelium from mucous plugs associated with asthma
37
What two pathologic findings are associated with asthma?
Smooth muscle hypertrophy and mucous plugging
38
\_\_\_\_\_ is a chronic necrotizing infection of bronchi.
Bronchiectasis
39
In bronchiectasis, chronic necrotizing infection of the bronchi leads to what?
Permanent dilation of the airways
40
Patients with bronchiectasis often have a cough productive of what?
Blood and purulent sputum
41
Which two genetic diseases are associated with bronchiectasis?
Cystic fibrosis and Kartagener's syndrome
42
Individuals with bronchiectasis are prone to develop which fungal pulmonary infection?
Aspergillosis
43
What are three common triggers of asthma attacks?
Viral upper respiratory infections, allergens, and stress
44
Compare the onset of dyspnea and hypoxia in emphysema vs chronic bronchitis.
In emphysema, there is early-onset dyspnea and late-onset hypoxemia; in chronic bronchitis, there is early-onset hypoxemia and late-onset dyspnea
45
What causes late-onset hypoxemia in emphysema?
The eventual loss of capillary beds, which occurs with the loss of alveolar walls
46
What causes early-onset hypoxemia in chronic bronchitis?
Shunting
47
What two lung volumes are typically decreased in patients with restrictive lung disease?
Functional vital capacity and total lung capacity
48
Patients with restrictive lung disease typically have a forced expiratory volume1/forced vital capacity ratio within what range?
\>80% ; this differentiates restrictive from obstructive lung disease
49
What are the two general types of restrictive lung disease?
1. Poor breathing mechanics (caused by musculoskeletal or connective tissue disease)
2. Interstitial lung diseases
50
Extrapulmonary causes of restrictive lung disease are generally the result of what?
Poor breathing mechanics, usually as a result of muscular dysfunction (eg, polio) or structural difficulty (eg, scoliosis, morbid obesity)
51
Pulmonary causes of restrictive lung disease are generally the result of what category of diseases?
Interstitial lung diseases
52
What infectious disease can cause poor muscular effort and thereby lead to extrapulmonary restrictive lung disease?
Polio
53
What disease of the neuromuscular junction can cause poor muscular effort and thereby lead to extrapulmonary restrictive lung disease?
Myasthenia gravis
54
What is the mechanism of extrapulmonary restrictive lung disease in scoliosis?
The curvature of the spine distorts the breathing mechanics of the rib cage
55
Other than scoliosis and muscle diseases, what condition can lead to extrapulmonary restrictive lung disease?
Morbid obesity
56
What category of interstitial lung diseases has a clear association with an environmental exposure?
Pneumoconioses
57
What disease is associated with repeated cycles of lung injury and wound healing with increased collagen deposition?
Idiopathic pulmonary fibrosis
58
Name three pneumoconioses that can cause restrictive lung disease.
1. Coal miner's disease
2. Silicosis
3. Asbestosis
59
What nongranulomatous disease that commonly affects the renal and pulmonary systems can cause interstitial lung disease?
Goodpasture's syndrome
60
What disease can cause restrictive lung disease due to eosinophilic granulomas in the lungs?
Histiocytosis X
61
Name three drugs that can cause interstitial lung disease.
1. Bleomycin
2. Busulfan
3. Amiodarone
62
What processes cause restrictive lung disease due to poor muscular effort?
Polio and myasthenia gravis
63
What processes cause restrictive lung disease due to poor structural breathing mechanics?
Scoliosis and morbid obesity
64
What processes cause restrictive lung disease due to interstitial lung pathology?
Acute respiratory distress syndrome, neonatal respiratory distress syndrome, pneumoconioses, sarcoidosis, idiopathic pulmonary fibrosis, Goodpasture's syndrome, Wegener's granulomatosis, histiocytosis X, and certain drug toxicities
65
Which lobe of the lung is most affected in coal miner's disease?
Upper lobes
66
Coal miner's disease can be associated with what two additional pathologic conditions?
Cor pulmonale or Caplan's syndrome (the combination of pneumoconiosis and rheumatoid arthritis)
67
Patients with silicosis likely worked in what three fields?
Foundries, sandblasting, and mining
68
What cell type is responsible for the fibrosis induced by silica inhalation?
Macrophages
69
Silicosis increases the risk of what infectious disease?
Tuberculosis
70
What lobe of the lung is most affected by silicosis?
Upper lobes
71
The finding of eggshell calcification on chest x-ray would increase suspicion of what disease?
Silicosis
72
What substance, used for such things as shipbuilding and insulation, can result in a diffuse pulmonary interstitial fibrosis?
Asbestos
73
Patients with asbestosis are at increased risk of what two cancers?
Mesothelioma and bronchogenic carcinoma
74
What gross pathologic finding can be found on the pleura of patients who have been exposed to asbestos?
Ivory white pleural plaques
75
Asbestosis is most commonly seen in practitioners of what professions?
Shipbuilders, plumbers, and roofers
76
Asbestosis mainly affects the ____ (lower/upper) lung lobes, while coal worker's lung affects the _____ (lower/upper) lobes.
Lower; upper
77
What are asbestos bodies and where are they located?
Golden-brown fusiform rods found in macrophages
78
In neonatal respiratory distress syndrome, there is a deficiency of what chemical?
Surfactant
79
How does the lack of surfactant in neonatal respiratory distress syndrome impair gas exchange in the lungs?
Surfactant deficiency leads to an increase in surface tension, resulting in collapse of the alveoli
80
What cells make surfactant?
Type II pneumocytes
81
Surfactant is made most abundantly during which period of neonatal gestation?
After the 35th week
82
What ratio is used as a measure of lung maturity in neonates? How is it tested?
The lecithin/sphingomyelin ratio. In the amniotic fluid
83
In neonatal respiratory distress syndrome, the lecithin-to-sphingomyelin ratio is usually within what range?
\<1.5
84
Medical treatment for neonatal respiratory distress syndrome includes what treatment for the mother before birth?
Maternal steroids
85
What vascular pathology is associated with persistently low oxygen tension due to neonatal respiratory distress syndrome?
Patent ductus arteriosus
## Footnote
patent ductus arteriosus can cause pulmonary hypertension if not corrected medically or surgically
86
What are three risk factors for neonatal respiratory distress syndrome?
Prematurity, maternal diabetes (due to elevated insulin), and cesarean delivery (due to decreased release of fetal glucocorticoids)
87
How can neonates be treated for respiratory distress syndrome after birth?
With artificial surfactant
88
Use of supplemental oxygen in neonates can lead to what ocular pathology?
Retinopathy of prematurity
89
In acute respiratory distress syndrome, acute alveolar damage leads to a(n) _____ (decrease/increase) in alveolar capillary permeability.
Increase
90
Despite many etiologies, what pathophysiology is seen in all cases of acute respiratory distress syndrome?
Fluid leakage into alveoli causing hyaline membrane formation on the inside of the alveolus thus impeding gas exchange
91
Name seven conditions known to cause acute respiratory distress syndrome.
Trauma, sepsis, shock, gastric aspiration, acute pancreatitis, amniotic fluid embolism, uremia
92
What obstetric complication can result in adult respiratory distress syndrome?
Amniotic fluid embolism
93
A chronic alcoholic suffering from acute pancreatitis is experiencing difficulty breathing and oxygen desaturation. From what pulmonary complication of acute pancreatitis may she be suffering?
Acute respiratory distress syndrome
94
Name three molecular mechanisms that contribute to the initial damage to the alveoli in acute respiratory distress syndrome.
1. Neutrophilic toxins
2. Activation of the coagulation cascade
3. Oxygen-derived free radicals
95
The forced expiratory volume1:forced vital capacity is what percent in normal lungs; in obstructive lung disease; in and restrictive lung disease?
Approximately 80%; \<80%; \>80%
96
Forced expiratory volume1 and forced vital capacity are reduced in both obstructive and restrictive pulmonary diseases; however, forced expiratory volume1 is more dramatically reduced in ____ (obstructive/restrictive) pulmonary disease.
Obstructive
97
In ____ (obstructive/restrictive) pulmonary disease, forced expiratory volume1/forced vital capacity \<80% and lung volumes are increased.
Obstructive
98
In _____ (obstructive/restrictive) pulmonary disease, forced expiratory volume1/forced vital capacity \>80% and lung volumes are decreased.
Restrictive
99
How do total lung volumes in obstructive lung disease compare with normal lung volumes?
Lung volumes in chronic obstructive pulmonary disease are greater than normal lung volumes
100
Is residual volume decreased, increased, or normal in obstructive lung disease?
Increased
101
How do total lung volumes in restrictive lung disease compare with normal lung volumes?
Lung volumes are less than normal in restrictive lung disease
102
In which type of lung disease, obstructive or restrictive, is the forced expiratory volume1/forced vital capacity ratio more dramatically reduced?
Obstructive
103
Define sleep apnea.
The condition that occurs when a person repeatedly stops breathing for at least 10 seconds during sleep
104
Define central sleep apnea.
Sleep apnea due to a lack of respiratory effort
105
Define obstructive sleep apnea.
Sleep apnea with which there is a drive to breathe but mechanical airway obstruction (usually obesity) prevents respiration
106
An obese man complains of chronic fatigue. His wife says he is an especially loud snorer. What condition may be contributing to this patient's fatigue?
Sleep apnea
107
Name three treatments of sleep apnea.
1. Weight loss
2. Continuous positive airway pressure
3. Surgery
108
Name five conditions potentially associated with sleep apnea.
1. Obesity
2. Loud snoring
3. Pulmonary hypertension
4. Arrhythmias
5. Possible sudden death
109
In the case of bronchial obstruction, what happens to the breath sounds over the affected area?
They are decreased or absent
110
What are the physical exam findings in a patient with bronchial obstruction?
Hyporesonance to percussion, decreased fremitus, and if there is tracheal deviation, it is towards the side of the lesion
111
What are the physical exam findings in a patient with pleural effusion?
Decreased breath sounds, dullness to percussion, decreased fremitus
112
What are the physical exam findings in a patient with lobar pneumonia?
Bronchial breath sounds, dullness to percussion, increased fremitus, no tracheal deviation
113
What are the physical exam findings in a patient with pneumothorax?
Decreased breath sounds, hyperresonance, absent fremitus, and tracheal deviation away from the lesion
114
Pleural effusions cause a(n) _____ (decrease/increase) in fremitus, whereas pneumonia causes a(n) _____ (decrease/increase) in fremitus.
Decrease; increase
115
Bronchial obstructions may cause tracheal deviation _____ (away from/toward) the lesion, whereas pneumothoraces result in deviation _____ (away from/toward) the lesion.
Toward; away from
116
In what area of the lungs does squamous cell carcinomas typically arise?
Central
117
In what area of the lungs does small cell carcinoma typically arise?
Central
118
In what area of the lungs does adenocarcinoma typically arise?
Peripheral
119
In what area of the lungs does large cell carcinoma typically arise?
Peripheral
120
List the two lung cancers that have a link to smoking.
1. Squamous cell carcinoma
2. Small cell carcinoma
121
Squamous cell carcinoma of the lungs is known for the ectopic production of what substance?
Parathyroid hormone-related peptide, the release of which causes hypercalcemia
122
List three forms of bronchogenic carcinoma that tend to arise peripherally in the lungs.
1. Adenocarcinoma
2. Bronchioalveolar carcinoma
3. Large-cell carcinoma
123
What is the most common type of lung cancer in non-smokers?
Adenocarcinoma
124
What peripherally arising form of bronchogenic carcinoma is most anaplastic or undifferentiated?
Large-cell carcinoma
125
What are the classic symptoms of carcinoid syndrome and what is the cause?
Flushing, diarrhea, wheezing, salivation; the symptoms are caused by serotonin secretion into the bloodstream
126
Are metastases from primary lung cancers very rare, rare, common, or very common and to what three sites do they occur?
Very common; brain, bone, and liver.
127
In association with a primary lung cancer, what finding suggests brain metastases?
Seizures
128
In association with a primary lung cancer, what finding suggests bone metastases?
Pathologic fractures
129
In association with a primary lung cancer, what two findings suggest liver metastases?
Jaundice and hepatomegaly
130
What type of cancer is the leading cause of cancer death?
Lung cancer
131
Lung cancer can present with what incidental radiologic finding?
Pulmonary "coin" lesions
132
How can the voice of a patient with lung cancer change?
Hoarseness; due to compression of the recurrent laryngeal nerve
133
Which potential spaces can develop effusions as a result of lung cancer?
Pleural and pericardial effusions
134
How does the mnemonic **SPHERE** help one to remember common complications associated with lung cancer?
**SPHERE** stands for **S**uperior vena cava syndrome, **P**ancoast's tumor, **H**orner's syndrome, **E**ndocrine (paraneoplastic) complications, **R**ecurrent laryngeal symptoms, and **E**ffusions
135
A cavitary hilar mass arising from the bronchus of a long-time smoker may suggest which disease process?
Squamous cell carcinoma
136
Histologically, which lung carcinoma forms keratin pearls and intercellular bridges?
Squamous cell carcinoma
137
Which lung carcinoma may develop in sites of prior pulmonary inflammation or injury and is the most common lung cancer in nonsmokers and females?
Bronchial adenocarcinoma
138
Which of the following is more common on x-ray of the chest in lung adenocarcinoma, a single lesion or multiple densities?
Multiple densities
139
Clara cells differentiate into type II pneumocytes in which type of lung cancer?
Adenocarcinoma (bronchial and bronchioloalveolar)
140
Which cells are the precursors to small-cell lung cancer?
Neuroendocrine Kulchitsky cells
141
Name three possible paraneoplastic syndromes associated with small cell carcinoma of the lung.
Adrenocorticotropic hormone syndrome, the syndrome of inappropriate antidiuretic hormone secretion, and Lambert-Eaton syndrome
142
What is Lambert-Eaton syndrome?
A paraneoplastic syndrome associated with small cell carcinoma of the lung in which autoantibodies form against presynaptic calcium channels, leading to muscle weakness
143
What is the usual approach to the treatment of large cell carcinoma of the lung?
Remove surgically (poorly responsive to chemotherapy)
144
Histologically, which lung cancer is associated with pleomorphic giant cells with leukocyte fragments in the cytoplasm?
Large-cell carcinoma
145
What is the approach to treatment of small-cell lung cancer?
This inoperable cancer is treated with chemotherapy
146
Patients with metastases to the lung present with symptoms of _____ (cough/dyspnea) and patients with primary lung cancer present with symptoms of _____ (cough/dyspnea).
Dyspnea; cough
147
Bronchioloalveolar adenocarcinoma can present similarly to which other non-cancer pathological lung disease?
Pneumonia
148
A long-time shipbuilder presents with difficulty breathing. X-ray demonstrates an effusion. On tap, the fluid is bloody. A biopsy shows psammoma bodies. What is the disease process?
Mesothelioma secondary to asbestos exposure
149
Small-cell carcinoma is associated with the production of what two hormones?
Adrenocorticotropic hormone or antidiuretic hormone
150
In what region of the lung does Pancoast's tumor occur?
The apex
151
Because of its location, Pancoast's tumor may affect what neurologic structure?
The cervical sympathetic plexus
152
When Pancoast's tumor disrupts the cervical sympathetic plexus, it can result in what condition?
Horner's syndrome
153
Horner's syndrome includes what three findings?
Ptosis, miosis, and anhidrosis
154
Lobar pneumonia is most frequently the result of infection with what organism?
*Streptococcus pneumoniae*
155
Which type of pneumonia is most often caused by viruses?
Interstitial (atypical) pneumonia
156
List two viruses that commonly cause interstitial pneumonia.
Respiratory syncytial virus and adenoviruses
157
In which type of pneumonia does an intra-alveolar exudate lead to consolidation?
Lobar pneumonia
158
Which type of pneumonia characteristically shows diffuse, patchy inflammation?
Interstitial (atypical) pneumonia
159
Interstitial pneumonia characteristically shows diffuse, patchy inflammation that is localized to what areas of the lung?
Interstitial areas at the alveolar walls
160
The distribution of interstitial pneumonia characteristically involves how many lobes?
At least one, usually more
161
Which type of category of pneumonia typically has a less acute presentation?
Interstitial pneumonia
162
List four bacterial etiologies of bronchopneumonia.
1. *Staphylococcus aureus*
2. *Haemophilus influenzae*
3. *Klebsiella*
4. *Streptococcus pyogenes*
163
List three bacterial causes of interstitial pneumonia.
1. *Mycoplasma*
2. *Legionella*
3. *Chlamydia*
164
What is a lung abscess?
A localized collection of pus in the lung parenchyma
165
What two conditions can predispose a patient to lung abscesses?
Bronchial obstruction (usually by a tumor) or the aspiration of gastric contents (often after seizures or heavy alcohol use)
166
What type of individuals are predisposed to developing lung abscesses, even in the absence of preexisting pulmonary disease?
Patients who are prone to loss of consciousness like alcoholics and epileptics; they are at increased risk of aspiration of gastric contents
167
Name two organisms (or classes of organisms) most commonly implicated in the development of lung abscesses.
1. *Staphylococcus aureus*
2. Anaerobes
168
In terms of pleural effusions, transudates have _____ (less/more) protein than exudates.
Less
169
In terms of pleural effusions, exudates have _____ (less/more) protein than transudates.
More
170
What are three common causes of transudative pulmonary effusions?
1. Congestive heart failure
2. Nephrotic syndrome
3. Hepatic cirrhosis
171
Name four causes of exudative pulmonary effusions.
1. Malignancy
2. Pneumonia
3. Collagen vascular disease
4. Trauma
172
What makes an exudate cloudy?
Exudates are cloudy because of their higher protein content
173
Name the three types of pleural effusions.
1. Transudative
2. Exudative
3. Lymphatic
174
Are pleural effusions that are secondary to trauma usually transudates or exudates?
Exudates, due to increased vascular permeability in the setting of trauma
175
Which type of pleural effusion consists of high levels of triglycerides and has a milky appearance grossly?
Lymphatic
176
For what reason does an exudative pleural effusion require drainage?
Exudates have a high infection risk; they can progress to empyema, which requires surgery
