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Hailey - CRRAB II > Witrak Pulmonary Pathology > Flashcards

Witrak Pulmonary Pathology Flashcards

1
Q

two principal metabolic functions of lung

A
  1. oxygenate blood

2. expire CO2

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2
Q

PaO2 normal

SaO2 normal

A

PaO2 80-95mmHg

SaO2 >95%

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3
Q

PaCO2 normal

A

PaCO2 35-45mmHg

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4
Q

bronchiolitis

A

RSV in kids

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5
Q

bronchitis commonest cause

A

cigarette smoke

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6
Q

bronchiectasis

A

pertinent dilatation of bronchi:

infection of bronchi –> causes permanent deletation

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7
Q

most fatal, common cancer is…

A

cigarette laden…lung cancer (loves to develop in bronchi)

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8
Q

CHF

A

back pressure of venous system…hydrostatic pressure causes fluid to leave capillaries and oozes into alveolar spaces

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9
Q

pulmonary arteries go along with…

A

bronchial tree

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10
Q

22 week old fetus born prematurely risk of…

A

not enough surfactant –> alveoli cannot stay open = NEONATAL RESPIRATORY DISTRESS SYNDROME (NRDS)

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11
Q

most common dramatic obstruction of pulmonary blood flow…

A

DVT –> PE

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12
Q

commonest cause of pulmonary HTN…

A

hypoxemia
- low O2 –> vasospasm in pulmonary circulation
(chronic pulmonary diseases…emyphysema and interstitial fibrosis)

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13
Q

sustained pulmonary HTN…

A

right heart failure

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14
Q

isolated RHF due to pulmonary HTN is…

A

cor pulmonale

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15
Q

commonest causes of hypoxemia –> vasospasm –> pul HTN:

A

emphysema and interstitial fibrosis

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16
Q

Those with emphysema and interstitial fibrosis most commonly die from…

A

cor pulmonale

if pneumonia hasn’t set in

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17
Q

Two commonest causes of shortness of breath (SOB)…

A
  1. asthma (respiratory)

2. CHF (LV failure - cardiac)

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18
Q

“Never forget about ___ with shortness of breath”

A

blood hemoglobin level

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19
Q

Multiple fractured ribs and chest cavity collapsing is called…

A

Flail chest

Tx: expand chest wall and canullize

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20
Q

Obstructive disorders definition

A

expiratory airflow limitation

*typically smaller airways

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21
Q

Obstructive disorders (and common associated age)

A
  • ASTHMA (kids and adults)***
  • COPD (adults, emphysema/chronic bronchitis)***
  • bronchiectasis
  • bronchiolitis (especially in kids, virally induced)
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22
Q

How assess degree of obstruction

A

pulmonary function testing (common office spirometry): DECREASED FEV-1

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23
Q

Restrictive diseases definition

A
  • reduced total lung capacity (TLC) –> scarred, shrunken lungs
  • reduced ventilatory elasticity –> chest wall poorly expansile
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24
Q

Restrictive diseases

A
  • diffuse parenchymal/interstitial lung disease –> idiopathic pulmonary fibrosis and occupational lung diseases
  • chest wall/pleural disease
  • massive obesity
  • neuromuscular diseases
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25
Q

degree of restriction assessed by

A

pulmonary function testing: TLC

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26
Q

Major pulmonary disease

A

obstruction

because of smoking

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27
Q

Most feared chronic pulmonary disease

A

idiopathic pulmonary fibrosis

smoking disease and no good treatment

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28
Q

Pulmonary vascular diseases

A
  • **affecting PROXIMAL/LARGER portion of pulmonary arterial tree:
  • THROMBOEMBOLISM (from DVT)
  • much less freq –> embolism of tumor, fat, air, amniotic fluid
  • **SMALL pulmonary vessel disease:
  • pulmonary HTN (secondary or idiopathic)
  • pulmonary hemorrhage/vasculitis syndromes: Goodpastures with anti-GBM antibody, Wegener/ANCA vasculitis, SLE, idiopathic
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29
Q

The most immediate, acute, on-your-mind, common pulmonary disease that can cause death is…

A

PE

from DVT

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30
Q

Biggest post-operative period risk…

A

DVT/PE

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31
Q

Diagnose DVT/PE…

A

D-dimer or just skip to invaluable chest CT angiogram*** = true pulmonary emboli

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32
Q

Treat DVT/PE with…

A

LMW heparin
Coumadin
newer anti-coagulants

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33
Q

Most pulmonary HTN is secondary to…

A

emphysema and pulmonary interstitial fibrosis

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34
Q

idiopathic pulmonary hypertension most commonly seen in

A

young women (

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35
Q

Cardiogenic causes of pulmonary edema

A
  • LEFT-SIDED CONGESTIVE HEART FAILURE
  • chronic CAD
  • MI
  • HTN heart disease
  • cardiomyopathies
  • aortic or mitral stenosis
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36
Q

Non-cardiogenic causes of pulmonary edema

A
  • ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) especially triggered by sepsis, trauma/shock –> microvascular/alveolar capillary injury
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37
Q

Major cause of SOB

A

pulmonary edema

–> from LHF (cardiogenic) or ARDS (non-cardiogenic)

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38
Q

Pulmonary infectious diseases

A
  • infection of the distal/alveolar lung –> pneumonia/lung abscess
  • infection of the airways –> epiglottitis, laryngitis, tracheobronchitis, bronchiolitis
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39
Q

commonest infectious disease leading to hospital admission and death in USA
= “by far the commonest way to leave this planet”

A

pneumonia

alveolar

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40
Q

pneumonia diagnosis requires:

A

pulmonary infiltrate(s) seen on either CXR or CT

  • don’t always need to have fever, but need to have an infiltrate
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41
Q

types of pneumonia pathogenesis:

A
  • CAP (pneumococcus)
  • nosocomial (pseudomonas)
  • immunosuppressed (bugs that would not normally hurt healthy individual)
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42
Q

pneumonia can lead to…

A

lung abscess

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43
Q

types of pneumonia (physiologically):

A
  • alveolar***most life threatening

- interstitial: atypical microorganisms

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44
Q

big fork in the ER with URIs is…

A

when do I get a chest xray

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45
Q

Another way to impair respiration…

A

pleural fluid and air disease

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46
Q

Pleural fluid and air disease definition:

A

space occupying effect: restricting lung expansion or causing lung collapse (atelectasis)

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47
Q

Types pleural fluid and air disease

A

EFFUSIONS:

  • TRANSUDATES (eg. CHF),
  • EXUDATES (eg. para-penumoic/empyema, malignant)
  • HEMOTHORAX (eg. trauma, aortic aneurysm or dissection rupture)
  • CHYLOUS (eg. lymphatic/thoracic duct obstruction)

PTX: spontaneous or tension

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48
Q

PTX definition

A

visceral pleural air leak secondary to underlying lung pathology (trauma vs. many chronic lung diseases)

  • spontaneous
  • tension PTX
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49
Q

lung collapse

A

atelectasis

  • can be segment, lobe or entire lung
  • usually due to OBSTRUCTED BRONCHUS or pleural effusion
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50
Q

when atelectasis –>

A

lung cannot ventilate normally –> respiratory distress –> potential death

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51
Q

most serious/bad pleural fluid…

A

exudate**

can be cancer

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52
Q

which chest cavity has the section most likely to rupture

A

left chest (almost exclusively)

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53
Q

chylous pleural fluid

A

trauma or cancer

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54
Q

any chronic lung disease can lead to…

A

spontaneous PTX (bleb rupture)

-> put in chest tube (displace air)

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55
Q

unrelieved atelectasis:

A

risk of pneumonia

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56
Q

bronchiectasis definition

A
  • chronic infection/inflammation fo larger airways: IRREVERSIBLE bronchial DILATATION
  • chronic mucopurulent sputum production
  • eventual bronchial collapse/obstructive symptoms
  • not therapized –> can cause total lung failure
  • unrelated to cigarette smoking***
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57
Q

If you obstruct a bronchus, the lung will… (and associated risk)

A

If you obstruct a bronchus, the lung will absorb air behind it and cause that area to collapse.
This poorly ventilated, collapsed area is a perfect set up for pneumonia.

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58
Q

Commonest cause of bronchiole obstruction is…

A

mucus plugging

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59
Q

Commonest cause of cancer death:

A

lung cancer (carcinoma)

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60
Q

Pulmonary/pleural neoplasia types:

A
  • small cell (VERY BAD)
  • non-small cell (USUALLY BAD)
  • low-grade neuroendocrine (carcinoid) tumors (NOT SO BAD)
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61
Q

METS to lung

A

from any cancer

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62
Q

Primary pleural neoplasms

A
  • malignant mesothelioma (REALLY BAD) (asbestos)

- solitary fibrous tumor (USUALLY BENIGN)

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63
Q

rare respiratory cancer

A

cancer of trachea

*trachea usually is not affected by cancer as other parts of respiratory system are

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64
Q

drinker and smoker cancer risk…

A

esophageal cancer

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65
Q

“one of the worst cancers on earth”

A

small cell lung carcinoma

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66
Q

“If can choose a malignancy in the lung, you want…”

A

a carcinoid tumor

  • low grade
  • slow growing
  • usually curable with surgery
  • related to smoking
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67
Q

Congenital/neonatal lung associations…

A

Associated with any:

  • perinatal death (in utero)
  • neonatal respiratory distress with variable survival (neonatal)
  • delayed symptoms/discovery into adulthood possibly (adult)
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68
Q

Congenital/neonatal lung diseases

A
  • congenital pulmonary airway malformation
  • lung agenesis/hypoplasia
  • tracheal/bronchial anomalies
  • congenital lobar overinflation
  • pulmonary sequestration
  • foregut cysts
  • arteriovenous alformation
  • NRDS
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69
Q

Commonest congenital/neonatal lung disease

A

congenital pulmonary airway malformation

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70
Q

Commonest symptoms of lung disease

A
  • dyspnea
  • cough
  • sputum production
  • wheezing
  • chest pain
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71
Q

MOA dyspnea associated with lung dz

A

decreased respiratory system compliance OR increased resistance to air flow OR impaired gas exchange OR not enough alveoli –> increased work of breathing –> SOB

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72
Q

types of cough and what it indicates

A

non-productive: less likely to be infectious process, likely diffuse parenchymal/interstitial lung disease

productive: likely to be infectious

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73
Q

productive cough quality

A
  • clear/mucoid: asthma
  • purulent: infection
  • bloody: 1) in adult smoker, malignant 2) pneumonia
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74
Q

_____ in adult smoker is malignancy until proven otherwise

A

hemoptysis

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75
Q

what part of the airway produces wheezing?

A

the smaller airways

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76
Q

cardiac asthma

A

CHF: edema surrounding small airways

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77
Q

wheezing respiratory diseases

A
  • asthma

- emphysema

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78
Q

what causes pain in the chest?

A

parietal pleura*** (not interstitium)

  • pleuritis
  • pneumonia
  • PE infarcting pleura
  • PTX
  • chest wall injury
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79
Q

MOA dyspnea

A

respiratory control center is sensing not sufficient oxygen –> work harder to get normal oxygen –> dyspnea

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80
Q

most common cause of dyspnea in primary care setting

A

33% asthma

30% heart failure

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81
Q

fatigue, dyspnea…don’t forget about _____

A

ANEMIA

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82
Q

ACUTE/sudden changes of dyspnea/fatal

A

= HOSPITAL ADMISSION

  • laryngeal edema/anaphylaxis
  • bronchospasm
  • MI
  • large PE
  • inhaled toxic substance (chlorine gas/NO)
  • massive hemorrhage
  • massive hemolysis
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83
Q

expiratory wheezing, think…

A

asthma

including cardiac asthma: peribronchial edema due to CHF

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84
Q

acute cough with sputum production + fever and chills ==>

A

pneumonia

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85
Q

misc. causes of cough

A
  • GERD
  • cardiac
  • psychogenic
  • medication-related (lisinopril)
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86
Q

only sputum worth examining in lab

A

deep tracheobronchial specimen

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87
Q

smoker + terrible arm/shoulder pain –>

A

Horner Syndrome = cancer into brachial plexus

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88
Q

pulmonary docs smart their consult with _____

A

smoking status

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89
Q

Patient history clues:

A
  1. smoking/COPD/lung CA/IPF
  2. inhalation exposures
  3. travel history
  4. CT disease
  5. cancer hx
  6. cytotoxic chemo hx
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90
Q

“Are you a splunker? Do you like to crawl through caves with bat shit all over the place?”

A

histoplasmosis exposure

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91
Q

“Are you a guy who loves to ATV up in the north woods and wrestle with your black lab in rotting wood piles?”

A

blastomycosis exposure

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92
Q

“Are you a snow bird in New Mexico who loves to shovel sand?”

A

coccidioidomycosis exposure

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93
Q

SLE, RA can produce ____

A

interstitial fibrosis and pleuritis

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94
Q

barrel chest classic for…

A

emphysema

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95
Q

kyphoscoliosis

A

can’t expand lungs

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96
Q

stridor (inspiratory wheeze) common with…

A

upper airway obstruction

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97
Q

crackles/rales

A

ALVEOLAR DZ:

  • pneumonia
  • pulmonary edema
  • interstitial/fibrosing disease
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98
Q

decreased lung sounds

A
  • emphysema
  • PTX
  • pleural effusion
  • pulmonary consolidation (lobar pneumonia)
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99
Q

CT scan is a poor man’s auscultation

A

captain morgan stance chuckle

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100
Q

clubbing of fingers

A

***sign of serious underlying dz

Associated with:

  • IPF
  • asbestosis
  • CF
  • cyanotic CHD
  • malignancy of lungs/pleura
  • pulmonary AV malformation
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101
Q

5th vital sign

A

pulse oximetry

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102
Q

in what chronic disease state do you get CO2 retention

A

emphysema or chronic bronchitis (COPD)

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103
Q 
***arterial blood gases sample norm
PaO2
PaCO2
pH 
HCO3 
SaO2
A 
PaO2: 80-95 mmHg
PaCO2: 35-45 mmHg
pH: 7.35-7.45
HCO3: 22-28 meq/L
SaO2: 95-100%

arterial sample

104
Q

***CXR

A
  • pulmonary or pleural dz
  • cardiac enlargement
  • mediastinal pathology
105
Q

NOTE: CXR won’t pick up…

A

larger airways disease, pulmonary vascular disease, asthma

will be normal CXR

106
Q

cardiac disease assessment throwback

A
  • EKG
  • ECHO
  • troponin (increased in MI)
  • BNP (increased in HF)
107
Q

***Pulmonary Function Testing (PFT) indicators

108
Q

***Atelectasis

A

collapse of LOSS OF LUNG VOLUME:
- segmental, lobar, or entire lung

CXR: showing volume loss plus poulmonary OPACIFICATION

109
Q

Primary atelectasis (neonatal)

A
  • rare

- incomplete expansion of lung/lungs at birth –> includes INADEQUATE SURFACTANT

110
Q

***Secondary subtypes atelectasis

A
  • > 99% atelectasis cases

- obstructive: MUCUS PLUGGING –> resorpted alveolar gas distal to plug

111
Q

***Commonest cause of atelectasis in children

A

mucus plugging

especially in asthma, CF (RML syndrome)

112
Q

kid + chronic cough + atelectasis is ____ until proven otherwise

A

foreign body aspiration

113
Q

***three main physiologic causes of atelectasis

A

RESORPTIVE

COMPRESSION

CONTRACTION

114
Q

RESORPTIVE atelectasis

A
  • alveolar collapse bc pneumonia or poor lung vent
    *post-general anesthesia
    = accumulated mucus secretions
115
Q

COMPRESSION atelectasis

A
  • pulmonary collapse due to mass effect from pleural effusion, PTX, tumor etc.
116
Q

CONTRACTION atelectasis

A
  • pulmonary shrinkage due to pleural fibrosis or fibrotic interstitial dz
117
Q

Failure to relieve atelectasis

A

increased risk pneumonia

118
Q

significant cause of cough and atelectasis in a two year old

A

foreign body inhalation

119
Q

aspiration pneumonitis

A

nun died suddenly from inhaling hard boiled egg

120
Q

***obstructive pulmonary diseases

A
  • ASTHMA**
  • COPD (emphysema**/chronic bronchitis)
  • bronchiectasis
  • bronchiolitis
121
Q

“airway hyper-responsiveness”

A

bronchochonstriction

122
Q

asthma ____ airflow obstruction

A

REVERSIBLE

123
Q

***How common is asthma

A

EXTEREMLY common
300 million people worldwide (11% adults, 15% of children)

*more poverty: more asthma in children

124
Q

90% of asthma cases are…

A

triggered by ALLERGIC/ATOPIC DZ (IgE mediated)

125
Q

10% of asthma cases are…

A

NONATOPIC/”INTRINSIC”
(often more adult-onset/more severe dz, triggered by:
ASA, other rx, exercise, cold air, sterss, inhaled irritants)

126
Q

***symptoms of asthma

A
  • episodic wheezing
  • dyspnea
  • cough

*kids: predominantly have cough

127
Q

***diagnosis of asthma

A
  • symptom based
  • variable/intermittent airways obstruction
  • no CXR findings
  • PET/spirometry: decreased FEV1
    >12% FEV1 increase with inhaled BETA 2 AGONIST***
128
Q

Of note: COPD and asthma relationship

A

10% of COPD patients have asthma features

with response to corticosteroids, probably both dz present

129
Q

asthma histology

A

mucosal/submucosal inflammation:

  • eosinophils/T lymphocytes
  • mucosal EDEMA
  • MUCUS HYPERSECRETION/PLUGGING
  • goblet cell hyperplasia
  • hypertrohied bronchial smooth muscle
130
Q

***targets of therapy of asthma

A
  1. relief of bronchoconstriction with BETA 2 AGONIST
  2. inflammation control/suppression: ICS
  3. refer for persistent
131
Q

***complications of asthma

A
  • status asthmaticus
  • allergic broncopulmonary aspergillosis
  • chronic eosinophilic pneumonia
132
Q

status asthmaticus

A
  • acute/severe
  • sustained bronchoconstriction
  • DEATH if not reversed
133
Q

allergic bronchopulmonary aspergillosis

A

allergic reaction to inhaled aspegillus spores:
- lung infiltrates with eosinophils/mucoid bronchial plugging –> can cause bronchiectasis***

Rx: steroids and antifungals

134
Q

COPD***stats

A
  • 4th leading cause of US death
  • 80-90% associated with cigarette smokers
  • at least 15-20% of chronic smokers develop COPD
135
Q

COPD pathophys

A
  • expiratory airflow obstruction that is NOT reversible
  • overlaps with adult asthma
  • slowly progressive/persistent dz
  • periodic acute exacerbations often due to respiratory infection
136
Q

COPD etiology

A
  • abnormal inflammatory response to noxious gases/particles
  • cigarette smoke has toxic effects on trachea/bronchi: submucosal glandular hyperplasia with ABUNDANT MUCUS PRODUCTION/COUGH = CHRONIC BRONCHITIS
137
Q

why alveoli destroyed by cigarette smoke

A
  • neutrophils/macrophages release ELASTOLYTIC PROTEINASES –> degrade natural anti-proteinase protection –> PROGRESSIVE ACINAR DESTRUCTION with PERMANENT AIR SPACE ENLARGEMENT = emphysema
138
Q

centriacinar emphysema

A

*majority of cases

predominantly affecting UPPER lobes

139
Q

panacinar emphysema

A

upper AND lower lung field involvement of equal severity

- advanced common emphysema OR A1AT DEFICIENCY (associated liver disease)

140
Q

risk of emphysematous blebs

141
Q

COPD mechanisms of airflow obstrux

A
  • if predominant BRONCHITIS = mucus PLUGGING
  • if predominant EMPHYSEMA = decreased elastic/avlevolar “TETHERING” of respiratory bronchioles –> airway collapse during expieration with alveolar AIR TRAPPING –> loss of elastic recoil –> HYPERINFLATION
  • often mixed
142
Q

COPD predominant bronchitis think

A

BLUE BLOATERS

MUCUS PLUGGING

143
Q

COPD preominant emphysema think

A

PINK PUFFERS

AIR TRAPPING/HYPERINFLATION

144
Q

COPD clinical presentations

A
  • sedentary lifestyle (avoiding exertional dyspnea)
  • progressive dyspnea
  • evolving cough with sputum (mucoid or purulent)
  • acute chest illness
145
Q

what is acute chest illness (acute COPD exacerbation) ER

A
  • increased cough
  • purulent sputum
  • wheezing/dyspnea (episodic)

*may resemble asthma, CHF, bronchiectasis

(acute COPD exacerbation) ER

146
Q

COPD physical exam with severe dz

A
  • systemic wasting
  • hyperinflated lungs
  • decreased breath sounds
  • use of accessory musces
  • cyanosis
  • right HR (cor pulmonale)
147
Q

COPD diagnosis

A

PFT: FEV1/FVC

148
Q

ABGs with COPD

A

mild: hypoexemia without hypercarbia
severe: worsening HYPOXEMIA WITH HYPERCARBIA

= more severe, the higher the CO2 will be

149
Q

hemogram with COPD

A

if POLYCYTHEMIA –> implies CHRONIC HYPOXEMIA

*kidney senses hypoxemia
has to do with CARBON MONOXIDE** ? GAH

150
Q

COPD clinical course

A
  • slowly progressive sx

- periodic acute exacerbations –> puts them in the ICU

151
Q

COPD prognosis

A

> 65 yo IF ADMITTED TO ICU: 15-30% mortality rate (60% at 12 months)

152
Q

***bronchiectasis

A

permanently dilated bronchi/bronchioles

153
Q

causes significant hemopysis

A
  • cancer
  • TB
  • bronchiectasis
  • rare pulmonary hemorrhage syndromes
154
Q

biggest culprit of bronchiectasis

A
  • CF
  • aspiration
  • airway obstruction: foreign body or tumor
155
Q

rare cause bronchiectasis

A
  • Kartagener’s syndrome (primary ciliary dyskinesia)
  • prior pulmonary inf
  • CT dz: RA, Sjogrens
  • immune deficiencies
  • unknown: 25-50% cases
156
Q

main Kartagener syndrome defect

A

missing dynein arms

157
Q

***Respiratoy Tract Infection: commonest infection…

A

URI, tracheitis/bronchitis/bronchiolitis, PNEUMONIA

158
Q

Commonest lethal adult infection

A

pulmonary alveolar pneumonia

*if require admission: 30 day mortality rate is 20%

159
Q

pneumonia Sx

A

Acute/rapidly evolving:

  • cough
  • fever
  • pleuritic chest pain
  • dyspnea
  • sputum
  • plus/minus chills/rigors
  • elderly esp: mental status changes
  • maybe GI changes, NVD
160
Q

pneumonia physical exam

A
  • audible RALES on chest auscultation

- PULMONARY CONSOLIDATION on CXR

161
Q

pneumonia pathology

A
  • alveolar exudative (NEUTROPHILIC) inflammation (bacterial)
  • interstitial/alveolar wall inflammation: LYMPHOCYTIC type (atypical pneumonia…mycoplasma, chlamydophylia, virus)
  • necrotizing granulomas (fungi or mycobacteria)
162
Q

lobar pneumonia in otherwise healthy person, have to think…

A

streptococcus pneumoniae (pneumococcus)

163
Q

Diagnosis: marked, bilateral pulmonary infiltrates.

So, differential:

A
  • severe bilateral pneumonia
  • severe CHF
  • severe ARDS
164
Q

bugs of pneumonia that like to become abscesses…

A

staph

entero

165
Q

empyema

A
  • pleura leaks pus (space occupying rind develops in pleural space)
166
Q

ancillary studies of pneumonia***

A
  • pulse ox (desaturation)
  • leukocytosis (usually neutrophilic)
  • ESR (increased)
  • CRP (increased)
  • deep sputum gram stain
  • urinary antigen testing (pneumococcus)
167
Q

Why pneumonia?

A
  • infection requires:
    1. defect in host defenses and/or pre-existing acute or chornic lung disease
    2. marked virulent organism
    3. overwhelming infection
168
Q

Predisposing factors to penumonia ***

A
  1. extremes of age
  2. altered consciousness (aspiration risk)
  3. cigarette smoking
  4. COPD
  5. pulmonary edema
  6. malnutrition
  7. immunosuppression (acquired or congenital)
169
Q

predisposing factors continued ***

A
  1. CF
  2. immotile cilia syndrome
  3. bronchial obstruction
  4. viral respiratory tract inf with secondary bacterial pneumonia
170
Q

most common fear of someone diagnosed with influenza A and B + other risk factors

A

secondary bacterial pneumonia

171
Q

clinical classification of pneumonia

A
  1. CAP (treat empirically)
  2. nosocomial (ventilated)
  3. immunocompromised (cancer)
  4. chronic pneumonia (TB or fungi, failure to respond to empiric)
172
Q

Valley Fever

A

coccidiomycosis

173
Q

***atypical pneumonia

A

mycoplasma
chlamydophilia
viuses

  • often milder than bacterial, BUT symptom overlaps do not allow reliable clinical separation
174
Q

Percentage of pneumonia patients who may be afebrile

A

20%

especially elderly

175
Q

Even with overwhelming pneumonia infection, _____ may occur, especially in ______.

A

Leukopenia may occur with overwhelming infection,

especially infants and elderly

176
Q

***empiric antibiotics effective in ___% of CAP patients

177
Q

microbiological diagnosis approach regarding penumonia

A
  • etiology discoverable in only 50-60% of patients

- MOST ADMITTED PT CAP RX’D EMPIRICALLY* w/o bug ID

178
Q

respiratory secretions methods of diagnosis

A
  • SPUTUM (deep cough)
  • tracheal aspiration
  • bronchoscopy with washing/bronchoalveolar lavage
  • quick bug stains (GRAM)
  • culture or PCR*
179
Q

***how can diagnose pneumonia

A
  1. respiratory secretions
  2. blood culture
  3. culture of PLEURAL/EMPYEMA FLUID or ABSCESS
  4. urinary antigen testing: PNEUMOCOCCUS or Legionella
  5. LUNG BX (esp mycobacteria and fungi)
  6. serology
  7. emerging serum test: PROCALCITONIN (increased in bacterial infection but not viral dz)
180
Q

***most CAP bugs:

A
  • strep pneumonia
  • myscoplasma penumoniae
  • chlamydophilia pneumonia
  • Legionella
  • respiratory viruses
181
Q

***commonest cause of non-epidemic pneumonia

A

BACTERIAL PNEUMOCOCCUS

182
Q

Associate patients iwth prior influenza, abx rx, COPD with increased risk of pneumonia due to:

A
  • s. aurea
  • enterobacteriaceae
  • pesudomonas
183
Q

Associate patients with ICU admission with pneumonia due to:

A
  • s. pneumonia
  • entereic gram - bacilli
  • s. aureus
  • legionella
  • h. influenzae
  • respiratory viruses
  • immunosuppressed
184
Q

Associate immunosuppressed with pneumonia due to:

A
  • PNEUMOCYSTIS jirovecii
  • CMV
  • fungal
185
Q

Commonest cause of CAP VIRAL pneumonia in adults

A

INFLUENZA (a, b, avian)

186
Q

CAP depending on travel andendemic risk…never forget

A
  • TB (immigrant populations)

- FUNGAL DZ (USA): histoplasmosis, blastomycosis, coccidioidomycosis

187
Q

general infectious disease mantra

A

“NEVER FORGET MYCOBACTERIUM TUBERCULOSIS”

188
Q

Most feared, common pneumonia

A

pneumococcus

189
Q

splenectomized patients at risk for

A

overwhelming pneumococcus sepsis

190
Q

mycoplasma pneumonia key points

A
  • bacterium without cell wall
  • up to 15% of CAP
  • can have URI Sx***
191
Q

chlamydophilia pneumonia key points

A
  • intracellular bacterium
  • 5-10% of CAP (elderlyi)
  • can have URI Sx***
192
Q

Legionella pneumphilia key points

A
  • 2-9% CAP
  • associated URI Sx***
  • aerosolized water droplets from water reservoirs
  • epidemic outbreaks
  • patients with predisposing chronic dz
  • fatality rates up to 50%
  • urinary antigen test
193
Q

gram negative bacilli key points

A
  • serious underlying disease (CF)
  • nosocomial
  • mechanically ventilated patients
  • KLEBSIELLA
  • PSEUDOMONAS AERUGINOSA
  • MORAXELLA CATARRHALIS
  • MISC
194
Q

Can group A streptococcus cuase pneumonia?

A

Yes.

Can cause fulminant pneumonia with early empyema in young/IC patients.

195
Q

Anaeorbic bacteria causing pneumonia are typically associated with _______

A

aspiration of gastric contents.

ASPIRATION PNEUMONIA

196
Q

Why is aspiration pneumonia especially bad?

A
  • usually MIXED ANAEROBIC/AEROBIC inf
  • CHEMICAL INJURY by acidic gastric contents
  • frequent ABSCESS formation
197
Q

How is viral pneumonia different?

A
  • infects interstitium instead of alveoli

- typically sets up shop for secondary bacterial

198
Q

Non-influenza viruses of pneumonia

A
  • RSV (babies)
  • parainfluenzae (IC)
  • human metapneumovirus
  • SARS
199
Q

Commonest cuase of lower respiratory tract infection (bronchiolitis) in kids

A

RSV

types A and B

200
Q

“Don’t sleep in a campsite full of rats and rodents because of…”

A

Hanta virus

  • infected mice/SW USA
  • flu-like symptoms, non-cardiogenic pulmonary edema (ARDS)
201
Q

Most frequent complication of varicella infection in healthy adults and its mortality rate

A

varicella pneumonia

10-30% mortality

202
Q

Fungal pneumonia***in healthy people transmitted by

A

INHALATION OF SPORES

–> pulmonary infection +/- systemic spread

203
Q

Fungal pneumonia in health people caused by…

A

histoplasmosis
blastomycosis
coccidioidomycosis

204
Q

Those who come in with pneumonia –> give empiric Rx –> they come back in 10 days and have pertinient social/travel history…work up for

A

fungal pneumonia

205
Q

Pathology of fungal pneumonia

A

necrotizing granulomas

**can mimic TB and Wegener’s granulomatosis

206
Q

Upon CT exam, solitary pulmonary nodule with calcification, think…

A

GRANULOMA –> FUNGAL

lung cancer is too aggressive and rapidly evolving –> does NOT calcify

207
Q

Innumerable granulomas peppering the lung

A

milliary infectious process

  • TB
  • fungal in miliary pattern
208
Q

Anytime see necrotizing granulomas, it is ______ until proven otherwise.

A

INFECTIOUS

fungal vs. mycobacterium

209
Q

***fungal pneumonia biographies: Ohio/Mississippi

A

HISTOPLASMOSIS

210
Q

HISTOPLASMOSIS

A
  • bats***/bird
  • persistent pulmonary infiltrates
  • respiratory secretions***
  • tissue/LN bx***
211
Q 
RI
pulmonary nodule
mediastinal complications
calcifications of spleen (old granulomas)
erythema nodosum
arthritis
A

HISTOPLASMOSIS

212
Q

***fungal pneumonia biographies: central/SW USA/Great Lakes region

A

North American BLASTOMYCOSIS

213
Q

BLASTOMYCOSIS

A
  • spore inhalation from ROTTING WOOD
  • dogs commonly infected too
  • bloodstream dissemination
  • respiratory secretions***
  • tissue/LN bx***
214
Q

persistent pulmonary infiltrate
black lab hunter dog
skin lesions/tumor/erythema

A

BLASTOMYCOSIS

215
Q

***fungal penumonia biographies: SW USA/semi-desert/”Valley Fever”

A

COCCIDIOMYCOSIS

216
Q

COCCIDIOIDOMYCOSIS

A
  • CAP or flu-like sx
  • skin, bone/joints like blastomycosis
  • INHALATION of spores
  • respiratory secretions***
  • tissue bx***
217
Q

Tx of active pulmonary fungal dz

A

antifungal -AZOLES (occasionally amphotericin B)

218
Q

Define immunocompromised:

A

defect in cellular or humor immunity, phagocytosis or with severe neutropenia

219
Q

Almost all cases of pneumonia in immunocompromised patients are due to _____ deficiencies such as:

A

ACQUIRED

  • HIV/AIDS
  • chronic immunosuppression
  • chemo
  • transplant
220
Q

Bugs seen in IC patients

A
  • PNEUMOCYSTIS (HIV/AIDS)
  • CMV
  • norcariosis
221
Q

pneumocystis jirovecii pearls

A
  • HIV/AIDS patients
  • dyspnea
  • cough
  • maked hypoxemia
  • MINIMAL CXR CHANGES
  • CT to see bilateral infiltrates
  • neumocystis
222
Q

other IC pneumonia bugs

A
  • herpes virus (VZV)
  • atypical mycobacteria (MAI)
  • invasicve fungal: candidiasis, cryptococcosis, aspergillus, mucormycosis
  • parasites (toxo, strongyloidiasis)
223
Q

key point regarding immunocompromised patient with new pulmonary/febrile symptoms…

A

MULTIPLE different causative organisms possible

224
Q

***definition of pulmonary edema

A

movement of FLUID INTO ALVEOLAR SPACES (alveolar flooding)

225
Q

vast majority of pulmonary edema is ______

A

cardiogenic

226
Q

causes noncardiogenic pulmonary edema

A

Alveolar microvascular injury:

  • ARDS***/acute lung injury (TOTALLY HAPPENSTANCE)
  • high altitude pul edema
  • neurogenic pul edema
227
Q

pulmonary edema with mixed cardiogenic/ARDS features

228
Q

cardiogenic pulmonary edema mechanism

A

increased alveolar capillary pressure due to increased pulmonary venous pressure –> increased pulmonary interstitial fluid formation –> alveolar flooding

229
Q

clinical presentation of cardiogenic pulmonary edema EITHER:

A
  1. ACUTE DYSPNEA with anxiety, diaphoresis, hypoxia (eg. MI)
  2. MORE GRADUAL (over 24 hours) ONSET OF DYSPNEA on exertion, orthopnea, paroxysmal nocturnal dyspnea with cough +/- pink/frothy sputum
    * chest pain think MI
230
Q

cardiogenic pulmonary edema physical exam

A
  • tachypnea
  • tachycardia
  • hypertension (adrenaline) OR hypotension (cardiogenic shock)
  • cook extremities if poor peripheral perfusion
  • RALES +/- RHONCHI/WHEEZES
  • CARDIAC MURMURS (S3)
  • JVD
231
Q

CHF suspected…order:

A

BNP*
serum B-natriuretic peptide
(secreted by VENTRICLES secondary to stretching or increased wall tension)*

232
Q

cardiogenic pulmonary edema on CXR

A

bilateral basilar interstitial/alveolar infiltrates +/- cardiomegaly

233
Q

CXR: bilateral basilar interstitial/alveolar infiltrates DIFFERENTIAL***

A
  • HF severe pulmonary edema
  • bilateral pneumonia
  • noncardiogenic ARDS
234
Q

***non-cardiogenic pulmonary edema is usually…

A

Acute Respiratory distress syndrome (ARDS)/ Acute lung injury (ALI)

235
Q

ARDS SYNDROME characterized by:

A
  • dyspnea
  • hypoxemia
  • diffuse pulmonary infiltrates on CXR
236
Q

ARDS path

A

Diffuse alveolar damage (DAD) with alveolar HYALINE MEMBRANES evolving to granulation tissue/organizing phase***resolution or pulmonary fibrosis/death

237
Q

ARDS mech

A

some sort of process in bloodstream/sepsis –> causes pathologic migration of activated angry neutrophils to alveolar space –> proteolytic changes –> chew up normal alveolar space lining –> capilary leakage –> fibrin –> airspace compromise

238
Q

clinical diagnosis with no lab value to measure

239
Q

clinical definition of ARDS

A

secondary to a PRECIPITATING INSULT WITHIN PREVIOUS 2-3 DAYS

  • sepsis***
  • pulmonary infection
  • general trauma***/head injury “SHOCK LUNG”
  • inhaled irritants
  • drug overdoses/near drowning
  • transfusion
  • gastric aspiration

UNPREDICTABLE

240
Q

ARDS pathophysicology

A

poorly understood

alveolar capillary injury

241
Q

ARDS tx

A

mechanical ventilation***

treat underlying intiating event

242
Q

ARDS mortality rate

243
Q

Acute lung injury definition

A

(acute interstitial pneumonia)

acute respiratory failure WITHOUT clear precipitating etiology

  • similar to ARDS
  • organizing DAD
244
Q

ALI mortality rate

A

HIGH MORTALITY

30-70%

245
Q

***Intersitital/Diffuse Parenchymal lung disease definition

A

(ILD)

non-infectious inflammation of pulmonary capillary wall of INTERSTITIUM +/- involvement of alveolar spaces and distal airways

defined on causality
RESTRICTIVE not obstructive

246
Q

interstitial lung disease pathology

A

chronic interstitial inflammation (+/- granulomatous change) with risk of PULMONARY FIBROSIS

247
Q

difference between COPD and ILD

A

COPD: obstructive
ILD: restrictive

248
Q

ILD clinical sx

A
  • onset varies
  • USUALLY CHRONIC/PROGRESSIVE DYSPNEA
  • persistent NON-PRODUCTIVE COUGH
249
Q

severe ILD clinical sx

A
  • hypoxemia at rest
  • chronic pulmonary HTN
  • eventual cor pulmonale (due to hypoxemic vasocnx) = COD
250
Q

ILD on CXR

A
  • can simulate pulmonary infection***
  • reticular/reticulonodular infiltrates** +/- alveolar filling pattern
  • STREAKY FIBROTIC LINES on CXR
251
Q

Ddx of chronic pulmonary infiltrates:

A
  1. fungal*, mycobacterial, other bug
  2. neoplasm* simulating pneumonia or ILD
  3. ILD with known cause
  4. idiopathic ILD (subtype?)
252
Q

ILD with known causes:

A
  1. inhalation exposure
  2. drug-induced pulmonary toxicity
  3. radiation-induced lung injury
  4. ARDS
  5. smoking related Pulmonary Langerhans Cell Histiocytosis PLCH, Desquamative InterstitialPneumoniaDIP/RespiratoryBronchiolitis-ILD RB-ILD, Idiopathic Pulmonary Fibrosis IPF
  6. familial risk
253
Q

most feared interstitial lung disease on the planet

A

idiopathic pulmonary fibrosis

most occur in smokers, 70%

254
Q

ILD with idiopathic/poorly understood causes:

A
  1. SARCOIDOSIS
    (common in African Americans)
  2. AIP
    USUAL INTERSISTIAL PNEUMONIA (UIP/IPF)***
    non-specific IP, etc.etc.
  3. ILD associated with CT disease (SLE, RA, scerloderma)
  4. diffuse pulmonary hemorrhage syndromes (goodpastures, ANCA)
  5. alveolar preoteinosis
  6. eosinophilic pneumonia
  7. granulomatuous/vasculitic Wegener’s
  8. Lymphangioleiomyomatosis (LAM) FEMALES**
  9. MISC
255
Q

eleven syllable ILD

A

lymphangioleiomyomatosis (LAM) females**

Hailey - CRRAB II (6 decks)

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