Respiratory Pathology

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Alveolar-Arterial O2 Difference

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**Normal alveolar-arterial O2 difference:

[(A-a)DO2] < 10 mmHg

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Obstructive Lung Disease = COPD

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**Obstruction of air flow resulting in air trapping in the lungs

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PFT's will show:

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=DECREASED FEV1/FVC ratio

**HALLMARK**

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Types of Obstructive Lung Disease:

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1) Chronic Bronchitis
2) Emphysema
3) Asthma
4) Bronchiectasis

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Chronic Bronchitis

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**"Blue Bloater"**

=productive cough for >3 consecutive months in 2 or more years

**Hypertrophy of mucus-secreting glands in the bronchioles
=Reid index >50%

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What is the leading cause of chronic bronchitis?

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SMOKING

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Findings:

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=wheezing
=crackles
=cyanosis

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Emphysema

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**"Pink Puffer"**

**Enlargement of air spaces and DECREASED recoil resulting from destruction of alveolar walls

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Causes:

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**Smoking
=centriacinar emphysema

**alpha1-antitrypsin deficiency
=panacinar emphysema and liver cirrosis

**Both lead to an INCREASE in elastase activity

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Findings:

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1) Dyspnea
2) Decreased breath sounds
3) Tachycardia
4) Decreased I/E ratio

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Asthma

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**Bronchial hyperresponsiveness causes REVERSIBLE bronchoconstriction.

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Triggers?

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=viral URIs
=allergens
=stress

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Findings:

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=cough and wheezing
=dyspnea
=tachypnea
=hypoxemia
=decreased I/E ratio
=pulsus paradoxus

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Histological Findings?

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=Curschmann's spirals
=SM hypertrophy
=mucous plugging

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Bronchiectasis

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**Chronic necrotizing infection of bronchi --> leads to:

=dilated airways
=purulent sputum
=reccurent infections
=hemoptysis

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Associated with?

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1) Bronchial obstruction
2) CF
3) Poor ciliary motility
4) Kartagener's Syndrome

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Restrictive Lung Disease

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**Restricted lung expansion causes DECREASED lung volumes
=decreased VC and TLC

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PFT's:

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=FEV1/FVC ratio > 80%

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Types:

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1) Poor Breathing Mechanics
=EXTRApulmonary
2) Interstial Lung Diseases
=PULMONARY

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Poor Breathing Mechanics = EXTRApulmonary

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1) Poor muscular effort
=polio, MG

2) Poor structural apparatus
=scoliosis
=morbid obesity

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Interstitial Lung Diseases = PULMONARY

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1) Adult respiratory distress syndrome (ARDS)
2) Neonatal respiratory distress syndrome
=i.e. hyaline membrane disease
3) Pneumonconioses
=coal miner's silicosis
=asbestosis
4) Sarcoidosis

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Continued

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5) Idiopathic pulmonary fibrosis
6) Goodpasture's syndrome
7) Wegener's granulomatosis
8) Eosinophilic granuloma

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Comparing Obstructive vs. Restrictive Lung Disease

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**Obstructive lung volumes are > normal
=increased TLC, FRC, RV

**Restrictive lung volumes < normal

**In BOTH obstructive and restrictive, FEV1 and FVC are reduced, but in OBSTRUCTIVE, FEV1 is more dramatically reduced, resulting in a DECREASED FEV1/FVC ratio

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What is Kartagener's Syndrome?

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**Immotile cilia due to a dynein arm defect

**Associated w/ sinus inversus

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Results in:

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1) Male and female infertility
=sperm immotile
2) Bronchiectasis
3) Recurrent sinusitis
=bacteria and particles not pushed out

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Asbestosis

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**Diffuse pulmonary interstitial fibrosis caused by inhaled asbestos fibers

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What does this increase your risk of?

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**Pleural MESOTHELIOMA and bronchogenic carcinoma

**Asbestosis and smoking GREATLY increase your risk of bronchogenic cancer
=smoking NOT additive w/ mesothelioma

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Who do we see these in?

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**Shipbuilders and plumbers

**LONG LATENCY

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What do we seen in the lung?

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**Ferruginous bodies in the lung
=asbestos fibers coated w/ hemosiderin

**Ivory-white pleural plaques

COLOR IMAGE 42

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Neonatal Respiratory Distress Syndrome

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**Surfactant deficiency leading to INCREASED surface tension --> resulting in alveolar collapse

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More about surfactant:

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**Made by type II pneumocytes--in the greatest volume after the 35th week of gestation

**Surfactant = dipalmitoyl phosphatidylcholine

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What is the lecithin-to-sphingomyelin ratio?

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**The ratio in amniotic fluid can be used as a measure of fetal lung maturity

=it is usually <1.5 in neonatal respiratory distress syndrome

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Treatment:

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**Maternal steroids before birth

**Artifical surfactant for the infant

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Lung Cancer

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**LEADING CAUSE OF CANCER DEATH!

1) Bronchogenic Carcinoma
2) Carcinoid Tumor
3) Metastases

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Bronchogenic Carcinoma

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1) Tumors that arise CENTRALLY:
=Squamous Cell Carcinoma
=Small Cell Carcinoma

2) Tumors that arise PERIPHERALLY:
=Adenocarcinoma
=Bronchioalveolar carcinoma
=Large cell carcinoma

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Squamous Cell Carcinoma

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**Clear link to SMOKING

=ectopic PTH-related peptide production

COLOR IMAGE 36, Image 118

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Small Cell Carcinoma

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**Clear link to SMOKING

=associated with ectopic hormone production--ADH, ACTH

**May lead to Lambert-Eaton Syndrome

COLOR IMAGE 37

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Adenocarcinoma

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MOST common

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Bronchioalveolar Carcinoma

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Probably NOT related to smoking

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Large cell carcinoma

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UNDIFFERENTIATED

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How does lung cancer typically present?

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=Cough
=Hemoptysis
=Bronchial obstruction
=Wheezing
=Pneumonic "coin" lesion on X-ray

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Carcinoid Tumor

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**Can cause Carcinoid Syndrome
=flushing
=diarrhea
=wheezing
=salivation

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Lung cancer has a SPHERE of complications:

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**SPHERE**
=Superior vena cava syndrome
=Pancoast's tumor
=Horner's syndrome
=Endocrine (paraneoplastic)
=Reccurent laryngeal symptoms (hoarseness)
=Effusions (pleural or pericardial)

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Metastases

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VERY COMMON

1) Brain
=epilepsy
2) Bone
=Pathologic fracture
3) Liver
=Jaundice, hepatomeagaly

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Pancoast's Tumor

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**Carcinoma that occurs in the APEX of the lung --> may thus affect the cervial sympathetic plexus --> causing HORNER'S SYNDROME

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Recall the symptoms of Horner's Syndrome:

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1) Ptosis
2) Miosis
3) Anhidrosis

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Pneumonia

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1) Lobar
2) Bronchopneumonia
3) Interstitial (=atypical) pneumonia

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Lobar Pneumonia--Organism?

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Pneumococcus

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Features:

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**Intra-alveolar exudate --> consolidation

**May involve the entire lung

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Bronchopneumonia--organisms?

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**S. aureus
**H. flu
**Klebsiella
**S. pyogenes

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Features:

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**Acute inflammatory infiltrates from bronchioles into adjacent alveoli

**Pathy distribution involving 1 or more lobes

IMAGE 116

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Interstitial (=atypical) Pneumonia--Organisms?

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**Viruses
=RSV
=Adenoviruses

**Mycoplasma

**Legionella

**Chlamydia

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Features:

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**Diffuse patchy inflammation localized to interstitial areas at alveolar walls

**Distribution involving 1 or more lobes

**Image 119