Restrictive (Interstitial) Lung Diseases Flashcards
What is the interstitium of the lung?
The connective tissue space around the airways and the vessels and the space between the basement membranes of the alveolar walls
Features of restrictive, diffuse interstitial lung disease
Reduced lung compliance - stiff lungs
Low FEV1 and Low FVC but FEV1/FVC normal ratio
Reduced gas transfer (diffusion abnormality)
Ventilation/perfusion imbalance
Presentation of diffuse lung disease
Discovery on abnormal CXR
SOB on exertion or rest
Type I resp failure
HF
Pathology of parenchymal (interstitial) lung injury
Acute response - diffuse alveolar damage (DAD) Chronic response - Usual interstitial pneumonitis (UIP) - granulomatous responses (sarcoidosis, hypersensitivity pneumonitis) - other patterns Fibrosis or end stage honeycomb lung
What is diffuse alveolar damage associated with?
Major trauma Chemical injury / toxic inhalation Circulatory shock Drugs Infection Autoimmune disease Radiation Idiopathic
What does idiopathic mean?
Without a known cause
Evolution of DAD
Exudative stage ( up to 7 days following the injury) - oedema - hyaline membranes damage Proliferative stage (7 days onwards) - interstitial inflammation - interstitial fibrosis
What does DAD stand for?
Diffuse alveolar damage
Histological features of DADs
Protein rich oedema Fibrin Hyaline membranes Denuded basement membranes Epithelial proliferation Fibroblast proliferation Scarring; interstitium and lung spaces
What is sarcoidosis?
A multisystem granulomatous disorder of unknown aetiology
Histology of sarcoidosis
Epithelioid and giant cell granulomas
Necrosis/caseation very unusual
Little lymphoid infiltrate
Variable associated fibrosis
Who gets sarcoidosis?
Young adults
F > M
Organ involvement in sarcoidosis
Lymph nodes Lung Spleen Liver Skin, eyes, skeletal muscle Bone marrow Salivary glands
Presentation of sarcoidosis
Acute arthralgia (polyarthralgia) Erythema nodosoum Bilateral hilar lymphadenopathy Swinging fever Asymptomatic - accidental abnormal CXR SOB Cough Lupus pernio Hypercalcaemia
Treatment of sarcoidosis
Corticosteriods
Diagnosis of sarcoidosis
Clinical findings Imaging Serum calcium +++ and ACE CXR PFTs Biopsy Bloods / urinalysis / ECG/ Eye exam Bronchoscpy including biopsies Kveim test Tuberculin test
Antigens in hypersensitivity pneumonitis
Thermophilic actinomycetes
- micropolyspora faeni
- thermoactinomyces vulgaris
Presentation of hypersensitivity pneumonitis
Acute presentation - fever - dry cough - myalgia - chills 4 - 9 hours after Ag exposure - crackles - tachypnoea - wheeze Chronic presentation - insidious - malaise - SOB - cough - low grade illness - crackles and some wheeze
Does acute hypersensitivity pneumonitis have a precipitating antibody?
Yes
What can hypersensitivity pneumonitis lead to?
Resp failure
Gas transfer low
Pathology / histology of hypersensitivity pneumonitis
Immune complex mediated combined Type III and Type IV hypersensivity reaction Soft centraacinar epitheliod granulomata Interstitial pneumonitis Foamy histocytes Bronchiolitis obliterans Upper zone disease
What may unusual interstitial pneumonitis (UIP) be seen in?
Connective tissue diseases; especially scleroderma and rheumatoid disease
Drug reaction
Post infection
Asbestos exposure
Cryptogenic or idiopathic (idiopathic pulmonary fibrosis (IPF) and cryptogenic fibrosing alveolitis (CFA)
Histology of UIP
Patchy interstitial chronic inflammation
Type II pneumocyte hyperplasia
Smooth muscle and vascular proliferation
Evidence of old and recent injury
- temporal heterogenicity
- spatital heterogenicity
Proliferating fibroblastic foci
Presentation of idiopathic pulmonary fibrosis
Clinical syndrome SOB (chronic) Cough (chronic) Basal crackles Cyanosis Pneumonitis Clubbed or crackles Progressive disease; most dead within 5 years Restrictive PFT and reduced gas transfer
Who gets idiopathic pulmonary fibrosis?
60 - 70 y/o
M > F
What would a CXR of idiopathic pulmonary fibrosis show?
Basal / posterior
diffuse infiltrates
Cysts
“Ground glass”
Prognosis of idiopathic pulmonary fibrosis
Poor
- some fulminant
- some steroid response
What happens beyond the terminal bronchiole?
Diffusion
Normal Pa02
10.5 - 13.5 kPa
Normal PaCO2
4.8 - 6.0 kPa
What is type I Resp failure?
PaO2 < 8kPa (PaCO2 normal or low)
What is type II resp failure?
PaCO2 > 6.5kPa (Pa02 usually low)
What are the 4 abnormal states Assosiated with hypoxaemia?
Alveolar hypoventilation
Shunt
Ventilation/perfusion imbalance (V/Q)
Diffusion impairment
Pathology of alveolar hypoventilation
Hypoventilation increases PaCO2 and thus increases PaCO2
Increased in PaCO2 decreases Pa02 which causes Pa02 to fall
Fall in PaO2 due to hypoventilation is corrected by raising FIO2.
What is FIO2?
Fraction of inspired air which is oxygen