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306 Cards in this Set

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  • Back
What is the gold standard for diagnosing an acute pulmonary thromboembolism?
CT angiography
In pulmonary artery hypertension, which comes first: intimal proliferation or medial hypertrophy?
medial hypertrophy
What percentage of pulmonary artery hypertension is secondary to an identifiable underlying disease?
90%
Pulmonary emboli most often originate from where in the body?
venous thrombosis in lower extremities
Plexiform lesions within the pulmonary vasculature suggest which disease?
pulmonary arterial hypertension (advanced)
Multisystem necrotizing granulomatous vasculitis is the key pathological finding in which disease?
Wegener's Granulomatosis
Elevated levels of c-ANCA suggest what disease?
Wegener's Granulomatosis
What is first line therapy for Wegener's Granulomatosis?
steroids
Which histological stain is helpful in making a diagnosis of Wegener's Granulomatosis?
elastin stain
The pulmonary arteries carry (oxygenated/deoxygenated) blood, whie the pulmonary veins carry (oxygenated/deoxygenated) blood.
The pulmonary arteries carry (deoxygenated) blood, whie the pulmonary veins carry (oxygenated) blood.
Pulmonary arteries follow _____ to the level of the ___________.
airways; capillaries
Which is the only organ in the body that receives 100% of cardiac output?
lungs
How is blood in the bronchial veins returned to the heart?
Most of the blood in the bronchial veins is returned via the azygos vein on the R side, accessory hemiazygos (or left superior intercostal vein) on the L side. Some of the blood returns via the pulmonary veins.
What is normal pulmonary arterial pressure? Normal systemic blood pressure?
25/8; 120/80
The apices of the lungs receive better _______ while the bases of the lungs receive better ________.
The apices of the lungs receive better ventilation while the bases of the lungs receive better circulation.
Which two mechanism does the pulmonary vasculature have to increase flow?
1) recruit new vessels and 2) distend vessels
Pulmonary vascular resistance (PVR) = ?
(Mean PAP - Mean PCWP)/CO

PAP = pulmonary arterial pressure
PCWP = pulmonary capillary wedge pressure (left atrial pressure)
CO = cardiac output
What is the most common cause of secondary pulmonary hypertension?
COPD
Which instrument is used to measure pulmonary arterial pressure? How does it work?
Swan-Ganz catheter; inserted through R side of heart, emerges into pulmonary arteries, balloon inflates and occludes vessel and pressure is measured
In asthma, FEV1 is _______ and FEV1/FVC is ____________.
reduced, reduced
In emphysema, FEV1 is _________ and FEV1/FVC is __________.
reduced, reduced
In pulmonary fibrosis, FVC is __________.
reduced
Helium dilution may underestimate lung volume in which type of lung disease?
obstructive lung disease
What are two methods of calculating FRC?
helium dilution and body plethysmography
What are the three fluids that typically fill the lungs in disease states?
blood, pus, water
What are the four mechanisms of hypoxemia?
hypoventilation, V/Q mismatch, shunt, low inspired pO2
Minute ventilation =
tidal volume (liters/breath) x frequency (breaths/minute)
Ventilation of alveoli without perfusion is called __________.
dead space
V/Q = 0 is known as a _________.
shunt
V/Q >>1 is known as ________.
dead space
A "scooped out" expiratory phase on a flow-volume loop is suggestive of which type of respiratory disease?
obstructive (eg, emphysema)
Which method of measuring FRC may underestimate lung volume if airway obstruction is present?
the helium dilution method
What is an easy way to clinically differentiate between an absolute shunt and V/Q mismatch?
Administer 100% 02. If patient has a shunt, pO2 won't respond. If patient has V/Q mismatch, pO2 will increase.
Hypoxemia + Hypercapnea + normal (A-a)DO2 is most likely the result of?
hypoventilation
Hypoxemia + Hypercapnea + elevated (A-a)DO2
V/Q mismatch or shunt
DLCO will be increased in any respiratory disease where ________.
either the diffusing surface area is reduced (eg, emphysema) or the thickness is increased (eg, fibrosis)
COPD may have elements of __________ and/or __________.
chronic bronchitis; emphysema
Describe the "pink puffer" phenotype of COPD.
more emphysema, hyperventilate, use of accessory muscles, uncomfortable breathing, wasting
Describe the "blue bloater" phenotype of COPD.
more chronic bronchitis, cyanosis, PAH with cor pulmonale, edema
In COPD, how will these values present: FEV1, FEV1/FVC, MMFR, RV, TLC, FRC, IC
↓FEV1, FEV1/FVC < 0.7, ↓MMFR, ↑RV, ↑TLC, ↑FRC, ↓IC
COPD: Treatment
smoking cessation, bronchodilators, inhaled corticosteroids; long severe disease may need 100% 02, lung volume reduction surgery, CPAP or BiPAP
COPD is (reversible/irreversible)
irreversible
inflammatory airways disease characterized by airway hyperreactivity and hypersecretion of mucus
asthma
Why might B2-agonist therapy initially cause V/Q mismatch to worsen in treating asthma?
previously constricted pulmonary capillary beds serving underventilated parts of the lung may dilate in response to B2 therapy, causing an initial deterioration in V/Q mismatch
Curschmann's Spirals are associated with which disease? What are they?
asthma; mucus casts
Charcot-Leyden crystals are associated with which disease? What are they?
asthma; precipitated crystals of granular material from eosinophils
Creola bodies are associated with which disease? What are they?
asthma; desquaminated epithelium with BM
How will the following appear in asthma: FEV1, peak flow, RV, TLC, FRC?
↓FEV1, ↓Peak Flow, ↑RV, ↑TLC, ↑FRC
Describe treatment for asthma
First line therapy: short acting B2 agonist (albuterol) + inhaled corticosteroid
Supplemental: long term B2 agonist (eg salmeterol), anti-IgE (omalizumab), anti-leukotrienes (montelukast), theophylline (not in US)
What is intrinsic asthma?
adult onset, no allergic hx, typically after severe resp illness, perennial sx, ↑ refractory to treatment
What is extrinsic asthma?
young onset, family hx of allergies, hx of specific allergies, atopic and inhalation responses
What is the mechanism behind aspirin sensitivity in asthma?
aspirin blocks synthesis of prostaglandin and thromboxane by inhibiting COX; this is thought to upregulate the other ass'd pathway to leukotriene synthesis
Bronchiectasis is (reversible/irreversible).
irreversible
What particular disease process is seen in both CF and PCD?
bronchiectasis
How does smoking cause emphysema?
smoking upregulates elastase production and simultaneously downregulates anti-elastases (like alpha1-antitrypsin)
Describe panacinar emphysema. Which lobes of the lung does it preferentially affect? What is it associated with?
relatively uniform throughout acinus, including respiratory bronchioles, alveolar ducts, alveolar sacs; relatively diffuse damage; lower lobes typically more involved; ass’d with α1-antitrypsin deficiency
Describe centroacinar emphysema. Which lobes of the lung does it preferentially affect? What is it associated with?
proximal part (respiratory bronchiole) of acinus is involved; typically ass'd with smoking; upper lobes typically more involved
What are the pathological findings in BOOP?
fibromyxoid plugs in distal bronchioles and alveoli +/- endogenous lipid pneumonia
What is the treatment for BOOP?
steroids
Describe the components of this image.
Alveolar septae, alveolar macrophages, capillary
What type of cells form the visceral pleura?
mesotheliomal cells
What type of cells line the bronchi?
ciliated columnar epithelial cells
Peribronchial inflammation and organization leading irreversible bronchial dilation as seen in CF and PCD is called _________.
bronchiectasis
What disease is this?
bronchiectasis
This is a histological sample from which disease?
bronchiectasis (note the dilated bronchus, muco-purulent debris in lumen of airway)
The most common structural ciliary defect in PCD is ________.
lack of dynein arms
What are these and in which respiratory disease are they found?
These are Charcot-Leyden crystals, precipitated crystals from eosinophils granule material; these are found in asthma
What are these and in which disease are they found?
These are Curschmann's spirals (thin casts of mucin) that are found in asthma
Asthma (H&E stain). What are the bright red cells?
eosinophils
What is the clinical definition of chronic bronchitis?
productive cough >3 months/year x >2 years
Patchy fibromyxoid plugs in distal bronchioles and alveoli. What disease is this?
BOOP (the bronchiolitis obliterans part)
Patchy fibromyxoid plugs in distal bronchioles and alveoli. What disease is this?
BOOP (the organizing pneumonia part)
What is this? What disease is it associated with?
Creola body (denuded epithelium and basement membrane); seen in asthma
+ culture of which two organisms in particular is associated with a worse prognosis in CF?
pseudomonas aeruginosa and burkholderia cepacia
Name some of the extrapulmonary complications of CF.
CFRD, gallbladder disease, osteopenia/osteoporosis, arthopathy/vasculitis, nephrolithiasis, female infertility
Sarcoidosis is particularly prevalent in which population?
AA women
A granuloma is a focal accumulation of _________.
epitheloid histiocytes
AA F presents with dyspnea. CXR reveals hilar adenopathy. What disease is this? What is the major histological feature?
sarcoidosis; non-caseating granulomas
Histiocytes such as those seen in sarcoidosis have a (high/low) N/C ratio?
low N/C ratio - lots of cytoplasm
A farmer or air conditioning repair man presents with dyspnea, cough, and fatigue. CXR reveals bilateral interstitial pattern and pathology reveals patch peri-bronchiolar inflammation with loosely formed granulomata. What is the likely diagnosis?
hypersensitivity pneumonia (due to exposure to organic dusts) - note the peri-bronchial expansion
75yo male, former shipyard worker, presents with dyspnea. Pathology shows this. What is the likely diagnosis?
asbestosis; note the patchy subpleural infiltrate
What is this? What is the likely diagnosis?
A ferruginous body with a couple macrophages that have tried to digest it. This is seen in asbestosis.
What is the etiology of Usual Interstitial Pneumonia (UIP)?
This is a trick question. The cause of UIP is idiopathic. In fact, UIP = IPF (Idiopathic pulmonary fibrosis)
65yo male presents with dyspnea. CXR and CT reveal patchy subpleural infiltrates. Pathology reveals temporally heterogenous interstitial inflammation and fibrosis. What is the likely diagnosis?
UIP (IPF)
This gross lung specimen most likely came from someone who died from what disease?
UIP (IPF); note the sub-pleural fibrosis and characteristic honeycomb change adjacent to normal lung (temporally heterogenous)
Diffuse alveolar damage (DAD) is the pathological finding in which disease?
ARDS (Acute Respiratory Distress Syndrome)
In newborn, ARDS is known as ______.
hilar membrane disease (HMD)
Contrast fibroblast activity in BOOP and DAD.
In BOOP, fibroblasts are confined to the airspaces. In DAD, fibroblasts invade the interstitium.j
Vital capacity (VC) is...
volume expired when going from TLC → RV
Total lung capacity (TLC) is....
volume in lungs after max inspiration
Residual volume (RV) is......
volume in lungs remaining after max expiration
Functional Residual Capacity (FRC) is.....
volume in lungs at end of expiration during tidal breathing
When calculating the alveolar-arterial O2 difference, the arterial O2 level is obtained by_________ while the alveolar O2 level is obtained by __________.
arterial O2 is measured as part of an ABG; alveolar O2 is calculated using the alveolar gas equation
What kind of chest wall abnormalities can cause restrictive lung disease?
fibrothorax, kyphoscoliosis, morbid obesity
Myasthenia gravis and ALS can cause restrictive lung disease by causing _________.
weakness of respiratory muscles
Interstitial Lung Disease (ILD) is also known as _________.
Diffuse Parenchymal Lung Disease (DPLD)
Decreased lung compliance, like that found in restrictive lung disease, causes what changes in FEV1, FVC, and the FEV1/FVC ratio?
reduced FEV1, reduced FVC, and high FEV1/FVC ratio (>0.7)
Decreased lung compliance like that seen in restrictive lung diseases has what effect on lung volumes (TLC, FRC, RV)?
TLC, FRC, and RV are all reduced
Isolated weakness in the muscles of respiration (as in restrictive lung disease caused by ALS or myasthenia gravis) has what effect on the following lung volumes: TLC, FRC, RV?
TLC is decreased; FRC in normal; RV is increased
Morbid obesity as an isolated cause of restrictive lung disease has what effect on the following lung volumes: TLC, FRC, RV?
FRC is decreased, TLC and RV are normal
Why does interstitial fibrosis typically only cause dyspnea on exertion?
Thickening of the alveolar-capillary interface leads to impaired diffusion. An RBC spend 0.75 sec transiting a capillary, and it only take 0.25 sec (normally) for O2 to diffuse across. So at rest there is plenty of "pad." On exertion, transit time is shorter than the impaired diffusion time.
Lofgren's syndrome is one of the most common presentations of ______. What does it involve?
sarcoidosis; fever, bilateral hilar lymphadenopathy, polyarthritis
Two cutaneous lesions are commonly associated with sarcoidosis. What are they?
erythema nodosum (raised, red, tender bumps or nodules on the anterior aspect of the legs) and lupus pernio (indurated plaques and discoloration of the nose, cheeks, lips and ears)
Sarcoidosis is diagnosed by ______.
tissue biopsy (bronchoscopy with transbronchial biopsy)
Patient presents with fever and raised, red tender bumps on her legs.CXR is above. Tissue biopsy reveals peri-bronchial non-caseating granulomas. Patient has no evidence of TB or cancer. What is the likely diagnosis?
sarcoidosis
How is sarcoidosis treated?
steroids are first-line treatment; hydroxychloroquine may also be used (changes intravesicular pH thus interfering with MHC binding to peptide antigen in vesicle)
UIP is the histological manifestation of _________.
Idiopathic pulmonary fibrosis (IPF)
60yo male presents with progressive dyspnea, nonproductive cough. PE reveals clubbing and bibasilar crackles. Further tests show reduced lung volumes, reduced expiratory flows, and decreased DLCO. A-a gradient is increased. CXR is above. Biopsy shows heterogenous fibrosis. What is the likely diagnosis?
IPF (Idiopathic pulmonary fibrosis)
How is Idiopathic Pulmonary Fibrosis treated?
IPF is almost uniformly fatal, but treatment includes: O2, immunosuppressive therapy (prednisone, azathioprine), anti-fibrotics, and potentially lung transplant
A failure of gas exchange manifests as (hypoxemia/hypercapnea) while a failure of the respiratory pump manifests as (hypoxemia/hypercapnea).
A failure of gas exchange manifests as (hypoxemia) while a failure of the respiratory pump manifests as (hypercapnea).
Generally speaking, a defect in O2 diffusion leads to dyspnea in only what setting?
exertion/exercise
What is the most common cause of hypoxemia in pulmonary fibrosis?
V/Q mismatch is the most common cause (not diffusion impairment, which is often seen)
An increase in dead space or a decrease in minute ventilation will ultimately cause_________.
hypercapnea
An ABG of 7.32/54/58/28 is indicative of__________.
respiratory acidosis
An ABG of 7.34/32/58/18 is indicative of__________.
metabolic acidosis
Why is it dangerous to give a patient with chronic hypercapnea 100% O2?
Patients with chronic hypercapnea as a result of hypoventilation will essentially turn off their central chemoreceptors in response to CO2 overload and their peripheral chemoreceptors will take over. A sudden increase in O2 will cause the central receptors to slow breathing (in the patient who is already hypoventilating).
An ineffective cough is a clinical sign of ________.
respiratory muscle weakness
In the pleural cavity, hydrostatic pressure favors the movement of fluid (into/out of) the pleural space.
In the pleural cavity, hydrostatic pressure favors the movement of fluid (into) the pleural space.
In the pleural cavity, oncotic pressure favors the movement of fluid (into/out of) the pleural space.
In the pleural cavity, oncotic pressure favors the movement of fluid (out of) the pleural space.
Normal pleural fluid is bicarbonate-(rich/poor) and protein-(rich/poor).
Normal pleural fluid is bicarbonate-(rich) and protein-(poor).
Pleural fluid originates from capillaries within the (parietal/visceral) pleura and is reabsorbed by lymphatics located in the (parietal/visceral) pleura.
Pleural fluid originates from capillaries within the (parietal) pleura and is reabsorbed by lymphatics located in the (parietal) pleura.
What are the two most common causes of ARDS?
pneumonia (direct lung injury) and sepsis (indirect lung injury)
What are the mechanisms by which Activated Protein C can mitigate the pathological procresses that cause ARDS?
APC inactivates factors Va and VIIIa (antithrombotic effect), inhibits cytokine formation (anti-inflammatory effect), and inhibits PAI-1 (profibrinolytic effect)
High cardiac output hypotension is suggestive of what kind of shock?
septic shock
A patient with a wide pulse pressure, brisk capillary refill, oliguria, lactic acidosis, and a hyperdynamic chest most likely is in what kind of shock?
septic shock
Describe the pathogenesis of ARDS.
In ARDS, there is injury to the pulmonary vasculature epithelium (either a direct insult like trauma or an indirect insult like sepsis) which causes an increase in permeability. Protein-rich exudate leaks into the interstitium and alveolar spaces. The result is hypoxemia and decreased lung compliance, all of which cause rapid onset of respiratory failure.
What are the two stages of ARDS?
the exudative phase, followed by the proliferative stage
Is ARDS reversible?
yes
Why is mortality in ARDS not related to the degree of hypoxemia?
it is rare that patients with ARDS actually die of hypoxemia; they typically die of complications (pneumonia from being on a ventilator, etc)
What are some of the indications for ventilator therapy in treating ARDS?
Want to use Positive End Expiratory Pressure (PEEP) and lower tidal volumes. We don't want to "pop" open wet alveoli because it will eventually cause fibrosis. Similarly, some of the alveoli will remain closed and some alveoli will receive most of the tidal volume - we don't want the tidal volume to be too high or we will again cause fibrosis.
Physical limitations after recovery from ARDS caused by sepsis are typically due to_______.
permanent neuromuscular-skeletal injury
What is transudate?
non-inflammatory fluid with a low protein content
An increase in capillary hydrostatic pressure or decrease in plasma oncotic pressure will cause what kind of pleural effusion?
a transudate
What is exudate?
inflammatory, proteinaceous fluid
What effect will a pneumonia have on tactile fremitus?
pneumonia will cause fremitus to be increased because sound travels faster through liquid than air
What effect will a pleural effusion or pneumothorax have on tactile fremitus?
a pleural effusion or pneumothorax will cause fremitus to be absent because of the liquid/air layer between the chest wall and pleura
60yo female presents with dyspnea, cough. CXR is above. What is the likely cause for her dyspnea?
R sided pleural effusion; note the meniscus
72yo male presents with dyspnea, cough. CXR in lateral decubitus position is above. Pleural effusion of ~5mm of fluid is suspected. Is thoracentesis indicated?
Diagnostic thoracentesis should NOT be attempted unless the thickness of pleural fluid is > 10mm
How much pleural fluid can be safely removed by thoracentesis? What is the risk of removing more?
Up to 1500 cc's can be removed. If you remove more you run the risk of expansionary pulmonary edema.
In diagnostic thoracentesis, what studies can be done to differentiate between transudate and exudate?
LDH, total protein, albumin
What are Light's criteria for identifying an pleural exudate? Do all of them have to be satisfied?
pleural fluid protein/serum protein > 0.5
pleural fluid LDH/serum LDH > 0.6
pleural fluid LDH > 2/3 upper limit of normal for serum LDH (or 163IU/L)

the presence of any one of these criteria identifies an exudate
What is the most common cause of pleural effusion? Are they most often unilateral or bilateral?
CHF; bilateral transudate
Why are pleural effusions so common in cirrhosis (2 mechanisms)? Are they typically bilateral or unilateral?
cirrhosis decreases protein production, thus reducing plasma oncotic pressure; ascites secondary to cirrhosis can leak fluid through small diaphragmatic defects; typically R sided (67%) transudate
Thoracentesis is performed on a patient with a R side pleural effusion. The fluid is > 50% lymphocyes. What should you be thinking of?
cancer or TB
Thoracentesis is performed on a patient with a R side pleural effusion. The fluid is > 10% basophils. What should you be thinking of?
leukemic infiltration
What is the definition of the hemothorax?
pleural fluid Hct/blood Hct > 50%
What is on the differential when elevated levels of amylase are found in fluid removed from a pleural effusion?
pancreatitis, esophageal rupture, malignant effusion
What is an empyema? How is it different from an abscess?
Active bacterial infection within the pleural space with presence of gross pus. This differs from an abscess in that an abscess is formed in an area where there is no natural cavity.
What are the criteria for a complicated parapneumonic pleural effusion?
pH < 7.1 or glucose <40
What are some of the indications for drainage of a pleural effusion?
pus, + gram stain or culture, glucose < 40, pH < 7.0, high LDH, loculation
The lower the pH and glucose in a malignant pleural effusion, the (higher/lower) the tumor burden.
The lower the pH and glucose in a malignant pleural effusion, the (higher) the tumor burden.
What is a chylothorax? How is it diagnosed?
a chylothorax is pleural fluid accumulation due to disruption of the thoracic duct (trauma, tumor); diagnosed using pleural triglyceride levels (definite if > 110)
What is a chyliform effusion?
a chyliform effusion is often mistaken for a chylothorax; a chyliform effusion is a pleural effusion that appears milky because of high cholesterol levels (not TG's) and it implies a long-standing effusion with cellular debris; it is often seen in TB and rheumatoid effusion
What is pleuritis?
pleuritis is any inflammatory process that involves the parietal pleura; AKA pleurisy
A pneumothorax can result from in a tear of either the ____ or _______.
lung; chest wall
How is a pneumothorax treated?
tube thoracostomy in the 2nd anterior space, mid clavicular line
Routine CXR of a 24yo male shows a solitary nodule with calcification in the periphery of the RLL. Biopsy shows normal tissues in excess and disarray. What is the likely diagnosis? Is it malignant?
hamartoma; it is benign
Name the three major non-small cell carcinomas of the lung.
Adenocarcinoma, Squamous cell carcinoma, large cell undifferentiated carcinoma
What is the relationship between the number of cigarettes smoked and the risk of developing lung cancer?
The risk of developing lung cancer is directly related to the number of cigarettes smoked
Which two types of lung cancer are more often associated with smoking?
squamous cell carcinoma and small cell carcinoma
Which two types of lung cancer are more likely to present centrally?
squamous cell carcinoma and small cell carcinoma
Which two types of lung cancer are more likely to present peripherally?
adenocarcinoma and large cell undifferentiated carcinoma
Which type of lung carcinoma is ass'd with secreting PTH-like hormone? What are related findings?
squamous cell carcinoma; "stones, bones, and groans" (kidney stones, depletion of calcium salts and thus bone weakness, and groans from the aches)
Keratin pearls and desmosomes (intracellular bridges) are pathological findings in which type of lung carcinoma?
squamous cell carcinoma
This is a biopsy of the respiratory mucosa. What type of cancer is this? How would you describe the abnormalities?
This is squamous cell carcinoma in situ. Note the hyperchromasia (inc staining), pleomorphism (morphologically different), and architectural disarray (abnormal maturational progression)
Is the presence of squamous cell carcinoma in the lung likely to be a primary or secondary (metastatic) process?
Squamous cell carcinoma in the lung of a non-smoker is very very unlikely to be primary lung cancer. It is much more likely to be metastatic from another source.
Which primary carcinoma of the lung is the most common in non-smokers?
adenocarcinoma
The presence of glands and mucus production in a primary carcinoma of the lung suggests what type of carcinoma? Where is it more likely to be found (eg peripherally or centrally)?
adenocarcinoma; peripherally
What kind of primary lung cancer is this?
adenocarcinoma (note the gland formation)
What stain is used to detect mucin in a lung tissue sample thought to be adenocarcinoma?
PASd stain
Bronchoalveolar carcinoma (BAC) is a subset of what type of lung cancer? Is it associated with smoking?
adenocarcinoma; not associated with smoking
Bronchoalveolar carcinoma (BAC) typically presents (peripherally/centrally) and with a (nodular/multifocal) appearance.
Bronchoalveolar carcinoma (BAC) typically presents (peripherally) and with a (multifocal) appearance.
What type of primary lung cancer presents similarly to adenocarcinoma but doesn't feature glands or mucin formation?
large cell undifferentiated carcinoma
What is the major prognostic factor for non-small cell lung cancer? What are some other prognostic factors?
STAGE is the major prognostic factor; other factors include performance status and weight loss
Which type of primary lung cancer is associated with ectopic ADH and ACTH production?
small cell lung cancer
Which type of primary lung cancer is notorious for presenting at late stage?
small cell lung cancer
Which type of primary lung cancer is associated with an Eaton-Lambert finding or Cushing's syndrome?
small cell lung cancer
Is small cell lung carcinoma responsive to treatment? What is the caveat?
yes, small cell lung cancer is generally very responsive to chemo; that said, it almost always recurs (very low 5 year survival)
What kind of primary lung cancer is this? What are the key histological findings?
this is small cell lung carcinoma; high N/C ratio, high mitotic rate, ghost cells are admixed, nuclear molding
What kind of primary lung cancer is this? What are the key histological findings?
this is small cell lung carcinoma; high N/C ratio, high mitotic rate, ghost cells are admixed, nuclear molding
74yo male with hx of working on brake pads at a Ford plant. CT above. What is the likely diagnosis?
mesothelioma
What is the most common malignant neoplasm that affects the lung?
metastatic neoplasms
What are the most common metastatic neoplasms that affect the lung?
breast adenoC, GI adenoC, renal adenoC, head/neck squamous cell C
This metastatic cancer of the lung is most likely to be from what organ?
This is metastatic renal cell carcinoma. >80% of metastatic renal cancer is of the clear cell variety.
Metastatic cancer from the bone is called ______.
osteosarcoma
Metastatic cancer from the skin is called ________ and is typically caused by excessive ______.
melanoma; sun exposure
What is the most common form of cancer causing death in men in the USA? How about women?
lung cancer; lung cancer! (NOTE: lung cancer is the 2nd most common cancer in the USA; rate in men has been dropping off, while the rate in women seems to have plateaued but is not dropping)
Lung cancer is particularly common in (white/AA)(men/women).
Lung cancer is particularly common in (AA)(men).
Does the risk for lung cancer in a smoker after cessation ever drop to the level of a non-smoker?
NO
Is clubbing a normal finding in COPD?
NO; it is a common finding in lung cancer (only the non small cell carcinomas)
Frothy sputum production is most often related to which type of primary lung carcinoma?
Bronchoalveolar carcinoma (a subset of adenocarcinoma)
Which type of lung carcinoma is the only one associated with cavitation? Who gets it?
squamous cell carcinoma? this is a disease of smokers
Which type of lung carcinoma is associated with hypercalcemia? What are the effects of hypercalcemia?
squamous cell carcinoma (weakness, dehydration, mental status changes)
Clubbing is associated with which of the lung carcinomas?
the non-small cell carcinomas (adenocarcinoma, squamous cell carcinoma, large cell undifferentiated carcinoma)
Small cell lung carcinoma is associated with which paraneoplastic syndrome(s)?
SIADH (low Na associated with mental status changes) and ACTH production
What kind of radiologic exam is of particular use in staging lung carcinoma?
CT PET scan
What paraneoplastic syndromes are associated with small cell lung carcinoma?
SIADH (hyponatremia), Cushing's, neuro syndromes (Lambert-Eaton, peripheral neuropathy, cortical cerebellar degeneration)
How is lung cancer definitively diagnosed?
sputum cytology (especially useful for patients with hemoptysis), bronchoscopy with transbronchial needle biopsy (good for central lesions, high diagnostic yield), transthoracic needle biopsy (for peripheral lesions, done with CT guidance), thoracentesis
How is non small cell lung cancer staged? How is small cell lung cancer staged?
NSCLC is staged using the TNM system; SCLC is staged as either limited (confined to hemithorax that can be targeted in a radiation port) or extensive (not encompassed by by a radiation port)
What is standard treatment for early (eg N=0 and M=0) stage NSCLC?
surgical resection +/- adjuvant chemo
At what stage is the majority of NSCLC diagnosed? How is it treated at this stage?
stage IV (47%); mainly palliative care
What is standard treatment for limited stage small cell lung carcinoma?
chemo + XRT and prophylactic cranial radiation
What is the major drawback in using low dose spiral CT to screen for lung cancer?
high false positive rate
99% of lobar pneumonias are caused by which organism?
Strep. pneumoniae
What are the principal organisms that cause community acquired pneumoniae?
strep pneumoniae, klebsiella, hemophilus, S. aureus, other streptococci
In pneumococcal pneumonia, red hepatization describes the (early/late) stage while gray hepatization describes the (early/late) stage.
In pneumococcal pneumonia, red hepatization describes the (early) stage while gray hepatization describes the (late) stage.
Which patient populations are at increased risk of a pneumonia caused by aspiration of anaerobic organisms?
patients under anesthesia, alcoholics, those with siezures
Foul smelling sputum in a pneumonia is most commonly associated with what kind of organism?
anaerobic organism (bacteroides, streptococci, fusobacteria)
What are the major complications of a pneumonia?
abscess, bacteremia, pyothorax or empyema
Mycoplasma pneumonia is highly transmissible by way of........
airborn droplets
A Ghon complex is defined as.....
a Ghon focus (focus of granulomatous inflammation) + an involved hilar lymph node
The difference between a Ghon focus and a Ghon complex is.......
a Ghon focus is a focus of granulomatous inflammation and may be found peripherally while a Ghon complex is a Ghon focus found centrally in association with an involved hilar lymph node
In contrast with sarcoidosis, granulomas in TB are (caseating/non-caseating).
granulomas in TB are caseating, whereas granulomas in sarcoidosis are non-caseating
The Ziehl-Neelsen stain is used to identify.....
the acid-fast bacilli of mycobacterium tuberculosis
TB typically involves the (lower/upper) lobes of the lung.
TB typically involves the (upper) lobes of the lung.
How is secondary TB defined? What is the outcome?
a new TB infection in a previously sensitized patient or a reactivation of a primary TB infection; the granulomas may be confined (as before in the case of primary infection) or the organisms will disseminate
Is cavitation a feature of TB?
Cavitation can occur in TB.
What is miliary TB?
miliary TB is TB that has disseminated to other organs and is defined by the presence of multiple small granulomas
Which histological stain is used to detect cryptococcus?
mucicarmine stain
Which fungus forms caseating granulomas that are virtually indistinguishable from TB without special stains? Where is this fungus found?
histoplasmosis; found in Ohio and Mississippi River Valleys in bird droppings
Which fungus is associated with "San Joaquin Valley Fever"?
coccidioides immitis
What is the defining histological feature of aspergillus?
septate hyphae with 45 deg angle branching
What three types of pulmonary disease does aspergillus cause?
invasive aspergillosis, aspergilloma (fungus ball), and allergic bronchopulmonary aspergillosis
Which patient population is susceptible to invasive aspergillosis?
immunocompromised patients (HIV, leukemia, chemotherapy)
Which fungus is known to be angiocentric?
aspergillus
Which special histological stain is used to identify aspergillus?
silver stain
This is a silver stain of a lung tissue biopsy. What is this?
aspergillus (note the septate hyphae with 45 deg branching)
Eosinophils are associated with which type of aspergillosis?
allergic bronchopulmonary aspergillosis
Pneumocystis jiroveci (PCP) is a (bacteria/virus/fungus) that infects which patient population?
Pneumocystis jiroveci (PCP) is a (fungus) that infects the immunosuppressed, particularly HIV patients.
A poorly managed 36yo HIV patient with low CD4 count complains of fever and cough. Bronchial lavage is performed, and a silver stain is applied to histological specimen. What is the likely diagnosis? What is bronchoalveolar lavage so useful in this case?
Pneumocystis jiroveci (PCP) - note the cup shaped organisms; PCP causes the alveoli to fill with a proteinaceous frothy exudate that is easy to sample with bronchoalveolar lavage
What is the defining histological feature of a viral pneumonia?
interstitial lymphocytes
Histological specimen from an infant with a viral pneumonia. What is the likely etiology?
CMV (note the large cells with nuclear inclusions, characteristic "owls eye")
18yo male develops an acute pneumonia with non productive cough and low grade fever. What is the likely etiology? How should it be treated?
mycoplasma pneumoniae (note the inflammation and denuding of the bronchiole) - treat with a macrolide (eg, azithromycin)
What are the three most common ways to get a lung infection? What is the most common in CAP? In HAP?
aspiration, inhalation, and hematogenous; aspiration is by far and away the most common in both CAP and HAP
Which organism is most associated with hematogenous lung infections? What are some risk factors?
Staph aureus; IVDA and endocarditis are predisposing factors
Are most lung infections caused by aspiration characterized as low- or high- volume aspiration?
low volume aspiration
Which CAP-causing organism is most associated with alcoholism?
Klebsiella pneumonaie
Which CAP-causing organism is most associated with COPD?
Haemophilus influenzae
Which organism is the most common cause of pneumonia, both CAP and HAP?
Strep. pneumoniae
Which cause of lung infection is associated with an infected water supply.
Legionella
Describe the symptoms of an "atypical" pneumonia. Is this delineation predictive of the specific pathogen involved?
indolent onset, generally less ill, low grade fever, headache, dry cough, rales without consolidation, negative cultures, patchy/interstitial infiltrates; this delineation is NOT highly predictive of a specific pathogen
What special kind of test can be used to identify Legionella as the cause of a pneumonia? What is the major drawback?
a urinary antigen immunoassay; this test only detects 1 serotype
Under what conditions is a sputum gram state helpful in identifying the causative agent of a pneumonia?
a sputum gram stain is really only useful to do on a lower airway specimen (single morphology, lots of PMN's, few squamous epithelial cells) before the patient has received antibiotics
Name some of the reasons why a sputum gram stain or culture may not be useful in identifying the cause of a pneumonia.
misinterpret normal colonizers of the oropharynx as the pathogen, dry cough, poor specimen handling, prior antibiotic administration, doesn't help identify legionella, mycoplasma, chlamydia, etc
26yo male with 4 week hx of cough, low grade fever, night sweats, and undesirable 10 lb weight loss. CXR is above. What is the likely dx?
TB - not the upper lobe involvement, fissure skewed upward
45yo hunter presents to ER with 3 day history of flu-like illness. CXR is above. What fungal pathogen should be on the differential?
blastomycosis
A patient with structural lung disease (eg, CF) develops a pneumonia. What is the likely etiology?
Pseudomonas aeruginosa
A patient with no prior medical record or risk factors presents to the ER and is diagnosed with pneumonia. What do you prescribe him?
advanced generation macrolide (azithromycin or clarithromycin) OR an antipneumococcal flouroquinolone (levofloxacin or moxifloxacin)
A patient with no prior hospitalizations but a history of COPD and suspected alcohol abuse is diagnosed with a pneumonia. What do you prescribe him? What bugs beyond the normal possibilities are you concerned about?
antipneumococcal flouriquinolone (levofloxacin or moxifloxacin) OR a 2nd/3rd generation cephalosporin + macrolide; here we are concerned about the possibility of anaerobic GN bacilli (from aspiration due to EtOH abuse) and DRSP (due to his hx of COPD for which he may have received antibiotics for a prior infection)
A patient presents to the ER with a pneumonia. He is sick enough that the ER staff decides to admit him to a regular ward (not ICU). What should he be treated with? What bug in particular are you worried about that could make him this sick?
IV 3rd generation cephalosporin + macrolide OR an IV antipneumococcal flouroquinolone; in addition to the usual suspects, you are worried about legionella
A inpatient at your hospital develops a pneumonia and is deemed sick enough to be transferred to the ICU. How should he be treated? What bugs should you be worried about?
Should be worrying about Pseudomonas aeruginosa and Staph aureus. Treat him with an IV 3rd generation cephalosporin + macrolide OR IV antipneumococcal flouroquinolone; also consider vancomycin or an antipseudomonal B lactam + cipro
When treating a community-acquired pneumonia, how many days should it take for symptoms to improve if you have prescribed the appropriate therapy? How long will it take for the CXR to improve.
2 days for symptoms to improve. may take up to three weeks for the CXR to clear
What is the most likely cause for a bacterial pneumonia in a symptomatic HIV patient?
Strep pneumonia
What is the most likely cause of an abnormal CXR in a symptomatic HIV+ person?
a bacterial pneumonia (no matter what the CD4 count)
What is first-line therapy for PCP in an AIDS patient?
Trimethoprim-Sulfamethoxazole, IV pentamidine, corticosteroids (if respiratory failure is suspected)
The dependent regions of the lung receive a greater proportion of (blood flow/ventilation) as a result of gravity.
The dependent regions of the lung receive a greater proportion of (blood flow) as a result of gravity.
"Obliterative" mechanisms of pulmonary artery hypertension include.....
emphysema, ILD, vasculitis, sarcoidosis
This patient has pulmonary arterial hypertension. At this stage is his disease reversible?
Yes, it is reversible. Here we see medial hypertrophy, but no plexiform lesions which would indicate a more advanced, irreversible stage.
What three pathways are utilized pharmacologically to treat pulmonary arterial hypertension?
endothelin (vasoconstrictor), prostacyclin (vasodilator), and nitric oxide (vasodilator) pathways
A patient is diagnosed with pulmonary artery hypertension and treated with an acute vasodilator, to which he responds. What should be the next step in treatment?
calcium channel blocker
A patient is diagnosed with pulmonary artery hypertension and treated with an acute vasodilator, to which he doesn't respond. What should be the next step in treatment?
treat with either an endothelin antagonist (bosentan, ambrisentan), NO upregulator (sildenafil), or prostacyclin agonist (iloprost, treprostanil, epoprostanol)
What are the two proteins that are most important for determining blood oncotic pressure?
albumin and globulin
How is fluid removed from the interstitium of the lung?
the peribronchovascular interstitium has lower hydrostatic pressure due to the elastic recoil of adjacent structures (especially during inhalation), so fluid tracks from the alveolar-capillary interstitium along interstitial planes to the hilar regions of the lung, which are rich in valved lymphatics that clear the fluid
Kerley lines, peribronchial cuffing, and a perihilar butterfly pattern are all radiological findings suggestive of.........
pulmonary edema secondary to CHF
How do you treat someone with high pressure pulmonary edema (HPPE)? How quickly do you see a result?
Loop diuretic (furosemide), B1 agonist to increase CO (dobutamine), positive pressure (CPAP); the results are typically dramatic and relatively rapid
In the Starling Equation
Jv = Kf x [(HPcap – HPis) – σ (OPcap – OPis)]

What does σ stand for?
reflection coefficient of proteins across the capillary wall from 0 (fully permeable) to 1 (impermeable), normally about 0.6
Jv = Kf x [(HPcap – HPis) – σ (OPcap – OPis)]

In cardiogenic (eg, high pressure pulmonary edema), the Starling Equation is (greater than/less than) the normal value of Kf(~7).
Jv = Kf (much greater than ~7) in HPPE
Jv = Kf x [(HPcap – HPis) – σ (OPcap – OPis)]

During the resolution of HPPE, the Starling Equation is (greater than/less than) the normal value of Kf(~7).
Jv = Kf (less than ~7) in the resolution phase
In contrast to the resolution of CHF-related pulmonary edema, the resolution of ARDS is signicantly slower because.....
ARDS stems from a breakdown in capillary membrane permeability while CHF-related edema stems from an increase in capillary hydrostatic pressure; in CHF-related edema, the protein-poor transudate can rapidly be removed from the alveolar spaces; in ARDS a protein rich exudate fills the alveoli, and this is much more difficult to get out of the alveolar spaces
The predominant ion transport mechanism in the alveoli is ion channels, the most important of which is _______.
ENaC
Maximal alveolar fluid transport is associated with (lower/higher) mortality in ARDS.
lower
Which drug has been shown to increase levels of ion channel conductance and enhance fluid clearance in ARDS?
albuterol, a B2-agonist
In the perinatal period there is upregulation of ______ in order to dry out alveoli in preparation for the first breath.
ENaC
Which drug is given to preterm neonates to accelerate ENaC upregulation and to thus mature their lungs?
dexamethasone (a steroid)
Air bronchograms are indicative of what kind of filling pattern?
alveolar filling pattern
Which cells make up the bulk of the alveolar wall? Which cells replaces the aforementioned cells when the aforementioned cells die?
Type I pneumocytes have long processes and make up the majority of the alveolar wall. If the alveolar wall is damaged, Type II pneumocytes become hyperplastic and turn into Type I pneumocytes.
7 days after admission for a motorcyle accident, a patient develops dyspnea and hypoxemia. CXR shows a diffuse alveolar filling pattern with air bronchograms. What is the likely diagnosis? What is pink material in this histological specimen?
this is classic Acute Respiratory Distress Syndrome (ARDS); the pink material lining the alveoli is hyaline, the product of a proteinaceous exudate leaking into the alveolar spaces
Contrast the mechanisms of ARDS and Respiratory Distress of the Newborn (aka Hyaline Membrane Disease or HMD)
In ARDS, there is damage to the capillary endothelium and/or the Type I pneumocytes leading to a proteinaceous exudate filling the alveolar spaces and deposition of hyaline. In HMD, a lack of adequate surfactant production in the neonatal lung leads to atelectasis, hypoxia/acidosis, and eventual necrosis resulting in hyaline formation.
Name the disease.
This is Hyaline Membrane Disease, or Respiratory Distress of the Newborn. Note the thick hyaline deposit and the profound atelectasis of the surrounding lung parenchyma due to lack of adequate surfactant production.
A 22yo male presents with dyspnea and hemoptysis. Labs indicate compromised renal function. Anti-GBM IgG is detected in his serum. A histological specimen from his lung is above. What is the diagnosis?
Goodpasture's Syndrome (IgG antibody to capillary basement membrane, involves both lung and kidney); note the RBC's spilling into the alveolar spaces
Elevated serum levels of ANA or anti-dsDNA antibody in a young female with a CXR showing a diffuse alveolar filling pattern is likely to be what disease?
Acute Lupus Pneumonitis (a component of SLE)
Focal lung infections from aspiration tend to occur in which part of the lung?
typically the RLL
What type of pneumonia occurs distal to an obstruction? What is the classic histological finding? What is the only other potential cause of this kind of pneumonia?
Endogenous lipoid pneumonia (aka post obstructive pneumonia or golden pneumonia); the classic histological finding is foamy macrophages in the alveolar spaces; the only other thing that can cause this is amiodarone (the antiarrhythmic agent)
What is the most primary, innate mechanism of airway clearance?
cough
What mechanism of airway clearance is compromised in PCD and CF?
mucociliary clearance
In the conducting airways _____ is the most important mechanism of airway defense while in the alveolar space the most important mechanism of defense is __________.
mucociliary clearance; alveolar macrophages
What other major anatomical abnormality is seen in 50% of PCD patients? Why is this?
situs inversus/dextrocardia; cilia play an essential role in determining organ asymmetry during embryological development
Which antimicrobials are found in the periciliary layer of the airways?
lysozyme, lactoferrin, secretory IgG and IgM
What protein plays an essential role in host airway defense by accompanying secretory IgG and IgM to the apical surface of epithelial cells?
secretory component
Is IgA deficiency a cause of chronic respiratory infection? Why or why not?
It may be, but is it more likely that IgA is a marker for more important determinants like IgG-2 and IgG-4
What role do neutrophils play in airways defense.
Neutrophils are a secondary defense mechanism throughout the lung and are bacteriocidal. Primary defense in the proximal airways is mucociliary clearance and in the distal airways is alveolar macrophages.
What is the reason that most infarcts in the lung are "red" infarcts?
Dual blood supply (pulmonary arteries + bronchial arteries)
Jugular venous distension, accentuated S2, RV heave, right sided gallop, and peripheral edema are all signs of........
pulmonary arterial hypertension
Patients with Idiopathic Pulmonary Arterial Hypertension (IPAH) have high levels of which protein circulating in their plasma?
Endothelin-1, a potent vasoconstrictor
56yo male presents to ER with acute onset of dyspnea and hemoptysis. He is apprehensive and breathing fast. He says he came straight from the airport where he just landed after coming back from LA overnight. His symptoms started shortly after getting off the plane. CT angio is performed. What is the diagnosis?
Pulmonary Embolism.
Compared to the awake state, the body's reponse to hypoxemia and/or hypercapnea in the sleep state is (elevated/depressed).
Compared to the awake state, the body's reponse to hypoxemia when asleep is (depressed).
In which stage of sleep is the body the least responsive to hypoxemia / hypercapnea?
REM sleep
During which stage of sleep is breathing the most irregular?
REM Phasic stage (NOTE: this is not the stage of REM where rapid eye movements occur - that is the preceeding REM Tonic phase)
Repetitive episodes of diminished air flow associated with oxygen desaturation or arousal during sleep is termed....
sleep apnea
The 10 year mortality of a person diagnosed with obstructive sleep apnea is (low/high).
The 10 year mortality of a person diagnosed with obstructive sleep apnea is (high 40-56%).
Snoring is a common feature of (obstructive/central) sleep apnea.
Snoring is a common feature of (obstructive) sleep apnea.
A common cause of central sleep apnea is lesions to which part(s) of the brain?
the medulla and/or pons
A potential cause of central sleep apnea is low gain loop (lack of response to elevated CO2 levels). Low gain loops are often associated with.........
narcotics use
Sleep-Related Hypoventilation is often seen in what kind of people?
obese people (diaphragm can't push against a huge belly)
What causes Cheyne-Stokes respiration?
CNS problems or heart failure
Cheyne-Stokes breathing is a (hypo/hyper)ventilatory state?
hyperventilatory state