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575 Cards in this Set

  • Front
  • Back
What tumor-derived hormones are secreted in paraneoplastic syndrome associated with bronchogenic carcinoma?
Parathyroid-like polypeptide (hypercalcemia) ACTH-producing tumor (overstimulation of adrenals-->cushings syndrome) ADH-producing (water retention)
with age ------------ resp muscel strength ----------FEV1 and FVC
dec
in elderly-> inc residual volume and dec closing volume t or f
f- both inc
t or f in elderly chest wall stiffen and becomes more elastic
f chest wall stiffens and lose lung elastic recoil
t or f with elderly inc in clearance (pulmonary defense mechanism) and dec in pulmonary reserves
f-> dec in clearance and dec in pulmonary reserves
t or f dec in v/p perfustion mismatch
f
t or f pneumococcal and influenza vaccines are not recommended to the elderly
f
Warfarin or LMWH or UFH safe to use in pregnant women
LMWH & UFH
in elderly closing volume -> dec to RV
f-> inc to FRC
t or f in elderly-> TLV and RV inc
t
t or f PO2 decline per decade is 5 mm Hg
F decline is by 3 - 4 mm Hg
What are 2 suggestions to give to elderly pt?
excise and quite smoking
type of resp failure? Low PaO2 High PaCO2 Inadequate ventilation (­ PaCO2) and oxygenation. problems with: CNS Chest Wall Airways
Hypoxia with hypercarbia
type of resp failure? Low PaO2 PaCO2 does not rise (until “the end”) Problem: inability to get oxygen through the respiratory system and out to needy tissues. Types of problems: Circulatory & cardiac Hemoglobin Intrinsic lung disease ARDS (adult respiratory distress syndrome)
Hypoxemia Predominating
MOST COMMON cause for hypoxemia
Ventilation-Perfusion Mismatch
type of resp failure? -Signal to respiratory system from cns fails -malformation or injury to the structure of the chest wall ventilatory efforts are inadequate to remove CO2 and pull in adequate O2 -neuromuscular dsfxn in chest wall
Hypercapneic Respiratory Failure
Warfarin or LMWH or UFH effect extrinsic side of coagulation pathway
Warfarin
cannot be fully corrected with administration of oxygen
shunt
diffusion defect is primary cause of hypoxia T or F
f
caused by: pulm edema pulm emboli intrisnsic lung pathology
Primarily Hypoxemic Respiratory Failure
type of edema? caused by myocardial infarction or cardiomyopathies or left sided valvular heart disease.
Cardiogenic Pulmonary Edema
How is non-cardiogenic and cardiogenic edema differentiated?
By passing a balloon tipped catheter via a vein to the right side of the heart and out into the pulmonary circulation “wedging” the balloon in the pulmonary capillary bed Cardiogenic: the pulmonary capillary pressure is INCREASED due to the back pressure from the dysfunctional left heart. Noncardiogenic: the pulmonary capillary wedge pressure will be low to normal.
major cause of ARDS
sepsis
what test differentiates btwn hypoxemia and hypercarbia?
Arterial blood gases
pt with any of following require what action: Hypercarbia Acidosis Poor respiratory muscle strength Rapid respiratory rate (>40 breaths per minute) Signs of fatigue
mechanical ventilation
Type of ventilation? Respiratory rate is fixed (usually between 10 and 16 breaths per minute. Tidal volume is set at 6-8 ml per kg ideal body weight % oxygen is set
Controlled Mechanical Ventilation
Type of ventilation? Rate and tidal volume and % oxygen are set. Ventilator can sense patient efforts when he/she creates a negative pressure in the circuit Additional breaths by the patient are fully support by volume from the ventilator.
Assist Control Ventilation
-A valve is inserted in the expiratory side of the ventilator circuit to keep the pressure at end-expiration greater than zero. - assists with alveolar recruitment and helps avoid collapsing of alveoli & improving the ability to get oxygen to the patient. -often added to mechanical ventilation & especially in very hypoxic patients What is this?
PEEP (positive end expiratory pressure)
Type of mechincal vent complication?? Normal breathing is negative pressure The positive pressure on mechanical ventilation can lead to rupture of alveoli. Air can leak along the pulmonary interstitium track up the mediatinum into the pleural space and even into the subcutaneous tissues. Alveolar damage can be permanent. Pneumothorax can be fatal. Message: prevent it by monitoring pressure measurements and modifying ventilator settings as needed.
Barotrauma
Type of mechincal vent complication?? If very high intrathoracic pressures are created there can be compression of the veins returning to the heart. This leads to decreased ventricular filling (or lower pre-load) in the right ventricle. Less blood coming into the heart means less blood comes through the pulmonary circulation to the left ventricle so cardiac output can drop. Low cardiac ouput can lead to low blood pressure (hypotension).
Cardiovascular
Type of mechincal vent complication?? If inadequate time is allowed for exhalation & volume and pressure build up in the lung. This is particularly likely to happen in patients with obstructive lung diseases & who will need longer expiratory times. As pressure and volume build the cardiovascular complications occur. It would be best to avoid auto-PEEP If it occurs immediately pop the patient off the ventilator to relieve pressure. When resetting the ventilator to avoid auto-PEEP the most important change you can make is to decrease the respiratory rate. At a slower rate more time is available for expiration.
Dynamic Hyperinflation/Auto PEEP
In relation to lung cancer - what is this? -due to local growth of an apical lung tumor -invades pleural & chest wall & destroys bone -involvement of brachial plexus (C8 & T1-2 & sympathetic ganglion -Shoulder and back pain -->Pain & weakness and atrophy of arm -Ipsilateral Horner’s syndrome: (ptosis & miosis & loss of sweating)
Pancoast Syndrome
lung carcinoma that secretes PTH à hypercalcemia
squamous
what type of lung carcinoma is most associated with Paraneoplastic syndromes and Endocrinopathies?
oat cell; its precursor - the Kulchitsky cell - demonstrates APUD (Amine Precursor Uptake and Decarboxylation)
What determines therapy in lung carcinomas?
Histology -Major distinction: small cell vs. non-small cell -Small cell may respond to chemotherapy -Small cell most often has distant spread at diagnosis thus surgery cannot be curative Physiologic Status -Operability - will patient tolerate a resection and have adequate pulmonary function post-operatively? -->Pulmonary function tests Stage of Disease (local extent & distal spread)
type of lung carcinoma?? Histology shows large polygonal cells with keratinization or intercellular bridges
Squamous cell carcinoma
type of lung carcinoma?? Microscopy:  a) small cells with high nuclear:cytoplasmic ratio often extensive necrosis           b) nuclear "molding " is a characteristic feature in sputum cytology c) neurosecretory granules visible on electron microscopy -ne
Anaplastic Small Cell Carcinoma  (undifferentiated small cell ca small cell ca -> Oat cell ca)
Large cells so lacking features diagnostic of squamous cell ca or adenocarcinoma; variants include giant cell and carcinosarcoma (do not seem to behave differently) type of tummor?
Undifferentiated large cell carcinoma
-low grade tumors showing neuroendocrine differentiation (similar to small cell carcinoma) -middle age usually (median 50 yrs) -a tumor to think of in young patients with a lung nodule -etiology unknown (no smoking link) -surgery is usually curative but 5-10% metastasize and need chemotherapy type of cancer??
carcinoid tumors
Nicotine replacement therapy Nicotine gum & patch & lozenge & nasal spray & inhaler Psychotropics Sustained-release bupropion Partial nicotinic receptor agonist Varenicline
Three general classes of FDA-approved drugs for smoking cessation
NRT: Precautions
Patients with underlying cardiovascular disease Recent myocardial infarction Life-threatening arrhythmias Severe or worsening angina Patients with other underlying conditions Active temporomandibular joint disease (gum only) Pregnancy Lactation
major se of nicotine patch
psychotopic effect so take off before bed time
What drug for smoking cessation has the folllowing Contraindictions Patients with a seizure disorder Patients taking Wellbutrin & Wellbutrin SR & Wellbutrin XL MAO inhibitors in preceding 14 days Patients with a current or prior diagnosis of anorexia or bulimia nervosa Patients undergoing abrupt discontinuation of alcohol or sedatives (including benzodiazepines)
BUPROPION SR; Zyban (GlaxoSmithKline); generic
What drug used for smoking cessation has the following warning and precautions? Patients with a history of seizure Patients with a history of cranial trauma Patients taking medications that lower the seizure threshold (antipsychotics & antidepressants & theophylline & systemic steroids) Patients with severe hepatic cirrhosis
BUPROPION SR; Zyban (GlaxoSmithKline); generic
Type of mechincal vent complication?? Placing a cuffed endotracheal tube from the mouth through the vocal cords eliminates the normal upper airway defense mechanism. Additionally secretions can pool on top of the cuff and leak into the airways. Ventilated patients are in the ICU. The ICU is a hotbed of aggressive and highly antibiotic resistance bacteria so the resulting pneumonia is severe and hard to treat. Complicating things the patient is usually on a ventilator because they have a serious lung problem. It can be difficult to detect a new pneumonia either by exam or by xray. Prevention is simple: sit the patient up at a 45 degree angle with the bed; eveyone washes their hands between patients; use antibiotics judiciously not freely; avoid aspiration of gastric contents by closely monitoring any tube feeding given.
Ventilator Associated Pneumonia
Warfarin or LMWH or UFH Age is the most significant determining factor of dose. Elderly patients require 5mg or less per day. Young patients may require as high as 10mg per day. Drug dietary and disease interactions may further impact on dosing.
Warfarin
Warfarin or LMWH or UFH should not be used in ischemic stroke
none
What are key difference between CF and Immotile Cilia Syndromes?
CF -family hx -more organ involvement -malnutrtion -abnormal mucus Immotile Cilia Syndromes -Kartagener;s only: -->situs inversus and dextrocardia due to failure of organ rotation during dev’t. -dsfxn of flagella
These diseases mimic what lung diseass? Neoplasms Lymphangitic spread of cancer Bronchioloalveolar carcinoma Lymphoproliferative disorders Infections PCP CMV fungi viruses Pulmonary edema
Interstial Lung Disease (ILD)
The following are known caues of what disease? Pneumoconiosis– inorganic substances (silicosis and/or asbestosis) Toxins (oxides of nitrogen) Drugs (amiodaroneor bleomycin) Radiation Oxygen Hypersensitivity (farmer’s lung) organic substances
ILD
What are key characteristics of pulmonary circulation?
1.Low Pressure - RV systolic/diastolic 15-30/ 1-7 mm Hg - PA systolic/diastolic 15-30/ 5-13 mm Hg 2. Low Resistance - 2 to 6% of systemic 3. High Capacitance
What are key characteristics of systemic circulation
1. High Pressure - Systolic pressures range from 95-125 mm Hg 2. High Resistance 3. Low Capacitance
Type of Edema? -Pulmonary microvascular hydrostatic pressure increases due to failure of the left ventricle to pump forward adequately -Normal oncotic/lymphatic defenses are overwhelmed -Causes: myocardial infarction & cardiomyopathies & left sided valvular heart disease -the pulmonary capillary pressure is INCREASED due to the back pressure from the dysfunctional left heart. txmt?
Cardiogenic Pulmonary Edema ->Treat the cardiac problem and the edema will resolve.
What is a key feature of Cardiogenic pulmonary edema to dx pt w/o invasive procedure?
the pulmonary capillary pressure is INCREASED due to the back pressure from the dysfunctional left heart.
What is a key feature of non-cardiogenic pulmonary edema to dx pt w/o invasive procedure?
the pulmonary capillary wedge pressure will be low to normal.
causes of RV heart disease
-Higher pressures “seen” by the RV - r sided heart disease -Cardiac ?? Severe LV failure ?? Valvular heart disease -Pulmonary ?? Lung disease (hypoxemia - pulmonary HTN) - copd ?? Pulmonary vascular disease
Disease? -Percussion: dull -Breath sounds: bronchial -Fremitus: increased with bronchophony & egophony & whispered pectoriloquy -Added sounds: crackles
Consolidation
disease? -Percussion: resonant -Breath sounds: normal -Fremitus: normal -Added sounds: crackles &/or (wheezes)
Pulmonary Edema -swollen mucosa & sometimes -airway deflated
disease? -Percussion: resonant -Breath sounds: normal or prolonged expiration -Fremitus: normal -Added sounds: wheezes
Asthma/Bronchitis -broncial constriction -deflated airway
disease? -Percussion: hyperresonant -Breath sounds: decreased with prolonged expiration -Fremitus: decreased -Added sounds: wheezes
Emphysema/Hyperinflation -over inflated alveoli with destruction of wall
Disease? -Percussion: dull -Breath sounds: decreased to absent -Fremitus: decreased to absent -Added sounds: none
Pleural Effusion -pleural fluid or thinking
significance of S3?
Ventricular failure: ->S3 heard (“Tennessee”) -Can come from left or right ventricle
significance of P2?
Pulmonary hypertension: -S2 is split due to delayed closure of pulmonic valve -Often referred to as P2 heart sound
Type of Edema? -Acute widespread injury to the pulmonary endothelium -Result: fluid leaks into the interstitium and alveoli. -Most common: Acute Respiratory Distress Syndrome (ARDS). -It is important to distinguish between cardiogenic and non cardiogenic pulmonary edema because of the difference in management approaches to the two types of edema. -By passing a balloon tipped catheter via a vein to the right side of the heart and out into the pulmonary circulation “wedging” the balloon in the pulmonary capillary bed we can usually distinguish between cardiogenic and noncardiogenic pulmonary edema
Non Cardiogenic Pulmonary Edema
T or F NTM always cause disease
F - MTb should always be considered a pathogen
Organism? Spread by droplet nuclei 1- 10 microns in size that are inhaled Larger particles impact on upper airway and are removed by mucus blanket and swallowed or coughed out
MTb
pathology of what disease? Inflammatory or exudative lesion Productive lesions (granulomas) Caseation necrosis Sclerosis and calcification Liquifaction cavitation
TB
ppd + 8mm - Patients with organ transplants
tx Consider 5 mm REACTION + HIV infection Close contacts of a TB case Persons with chest x-ray findings suggestive of previous TB not treated -> not active Patients with organ transplants Prednisone >15 mg/day > 1 month TNF-á antagonists (infliximab / etanercept / adalimumab
ppd + 15 mm - DM
tx A 10 mm REACTION IS + Other persons at high risk for infection Mycobacteriology lab personnel High risk populations (health care workers homes shelter clients/workers or prisoners or nursing home patients) Injection drug users Children & adolescents exposed to adults in high risk categories Recent (5 years) immigrants from endemic areas Clinical conditions: Silicosis or DM or ESRD or underweight or substance abuse or low dose corticosteroids or cancer head & neck Children <4 years old A 15 mm REACTION IS + Persons with no known risk factors Targeted skin testing is not recommended for this group
What are the key txmt rules for TB?
1. Prevent Resistance A small # of bacilli spontaneously mutate to be resistant to a single antibiotic. If that medication is used as a single drug then these resistant bacilli multiply. Never use a single agent for disease. Never add a single agent to a failing regimen. 2. Prevent Relapse Prolonged treatment Duration of treatment depends on the specific drugs used presence of drug resistance presence of cavities plus persistence of + cultures after 2 months (add 3 months) # doses taken within a given time frame 3. Assure compliance - directly observed therapy
T or F interpertation of ppd based on redness and induration
F - only on induration & bump feel
What is the most common mycobacterium isolated from individuals with HIV which presents as disseminated disease: High fevers + Blood cultures Occurs when CD4 count is severely reduced TB often precedes opportunistic diseases. TB usually precedes or coincides with the diagnosis of HIV?
MAC
disease? Primary TB often diagnosed. Infiltrates in any lung zone with lymphadenopathy. Extrapulmonary disease more common and often occurs with lung disease. Lymphatic and hematogenous disease common. Blood cultures can be +.
TB with HIV
TB drug? Hepatitis -More common in older patients & alcoholics and possibly in pregnancy -avoid alcohol Peripheral Neuropathy -Caused by Vitamin B6 defiency
INH
TB drug? -Colors secretions an orange like color -Causes cholestatic jaundice and occasional hepatitis -Potent Inducer of CYP P450 enzymes --Many many drug interactions
Rifampin
TB drug? MOA: inhibits arabinosyl transferases which is necessary in cell wall production
Ethambutol
TB Drug? Retrobulbar neuritis -Decreased visual acuity -Dose and duration dependent -Visual acuity tests should be done on patient needing long term ethambutol -Don’t use in young children unable to be tested
Ethambutol
TB drug? MOA: inhibit bacterial topoisomerase II (DNA gyrase) and IV
Fluoroquinolones -Levofloxacin and Moxifloxacin used most commonly
TB Drug? -Central nervous system toxicity: headaches & dizziness & insomnia & possibly seizures (these appear to be more common in the elderly) -Damage to growing cartilage (to date not seen in people but was seen in an animal model and quinolones should be avoided in children whenever possible) -Tendon rupture (rare)
Fluoroquinolones -Levofloxacin and Moxifloxacin used most commonly
TB drug? MOA: Inhibits RNA synthesis -Resistance can be seen with a single point mutation
Rifampin
What TB drug Reduced oral absorption when taken with divalent cations such as Ca & Mg and Fe?
Fluoroquinolones -Levofloxacin and Moxifloxacin used most commonly
TB drug? MOA: inhibits protein synthesis by binding to the 23S ribosonal RNA of the 50S subunit.
Linezolid - 2nd line agent
TB drug? MOA: Binds to the 30S-subunit of the ribosome causing DECREASED protein synthesis -Nephrotoxicity: somewhat common for a serious side effect reduced/delayed when the trough levels of the antibiotic (the level of drug at the end of the dosing interval) are low -Vestibular toxicity -Ototoxicity -Can prolong neuromuscular block caused by other drugs
Aminoglycosides - 2nd line agent
TB drug? MOA: Protein synthesis inhibitor -Side Effects include nephrotoxicity or ototoxicity or and vestibular toxicity
Capreomycin-2nd line agent
TB drug? MOA: inhibits mycolic acid production (related to INH) -Side effects: GI intolerance & hepatotoxicity and neuropathies
Ethionamide - 2nd line agent
TB drug? -MOA: inhibits alanine racemase -Frequent neurologic effects can be seen in the first 2 weeks -Usually toxicities get better with time - Headache & tremors & psychosis & convulsions and peripheral neuropathy -Pyridoxine is often given to prevent toxicities
Cycloserine- 2nd line agent
Why add PZA to TB regimen?
-allows for shorter courses of therapy (6 months in some circumstances) if continued for the first two months (56 doses)
A 46 year old male with pulmonary TB is started on a 4 drug regimen of INH & rifampin & PZA and ethambutol. Three weeks later he states that he is suffering from decreased visual acuity. Which of his medications is most likely the cause? A) INH B) rifampin C) PZA D) ethambutol
D) ethambutol
A 32 year old male with chronic hepatitis C but with no obvious complications from it is found to have pulmonary TB and is started on a standard 4 drug regimen. You council the patient to avoid alcohol consumption. He asks “can’t I just take Vitamin B6 like my friend did and still drink?” A) True B) False
B) False
Which statement is true? A. A child who inherits one CF gene mutation from each parent must have CF. B. A child with only one identified CF mutation cannot have CF. C. Blacks do not get CF. D. It is appropriate to consider a new diagnosis of CF in a 40 year old with compatible symptoms.
D
Which of the following is false? A. CFTR is a chloride channel. B. CFTR regulates other channels. C. Abnormal CFTR results in excess chloride secretion into the airway. D. Abnormal CFTR results in increased sodium absorption. E. abnormal CFTR and CF lead to decrease in surface liquid
C
What 4 drugs are used together iniate txmt for active TB?
RIPE-Rifampin & INH & PZA and Ethambutol is most often given daily -Streptomycin is sometimes used instead of ethambutol
TB drug? MOA: inhibits synthesis of mycolic acids which are components of the cell wall -Resistance is possible in all patients given the number of organisms present compared to the rate of spontaneous mutations
INH
TB drug? -Hepatitis -Polyarthragias -Hyperuricemia->Gout
Pyrazinamide (PZA)
ppd + 4mm - Children & adolescents exposed to adults in high risk categories
dont tx A 10 mm REACTION IS + Other persons at high risk for infection Mycobacteriology lab personnel High risk populations (health care workers & homes shelter clients/workers & prisoners & nursing home patients) Injection drug users Children & adolescents exposed to adults in high risk categories Recent (5 years) immigrants from endemic areas Other persons at high risk for disease Clinical conditions: Silicosis & DM & ESRD & underweight & substance abuse & low dose corticosteroids & cancer head & neck Children <4 years old
T or F NTM does always require treatment
F - applies to MTb
T or F NTM can sometimes contaminate water & clinical specimens and cause confusion between contamination and disease
T
T or F NTM can sometimes colonize the airways without causing disease and can cause confusion between colonoization and disease
T
T or F NTM are AFB negative
F - MTb and NTM are both AFB positive
T or F NTM are positive for tuberculin skin tests (cause cross-reactions with tuberculous antigens)
T
T or F NTM cause granulomas that - more often than MTb - are caseating
F -> non-caseating granulomas
Sarcoidosis can affect any organ but what does it affect especially according to lecture (according to carranza….blah blah blah)
Especially Lungs thoracic/neck lymph nodes & the skin & salivary glands & and lacrimal gland (dryness)
Which chronic lung disease is caused by inhalation of fumes & dust or particulate matter (inorganic)?
Pneumoconioses
What is usually the etiology of URTI's (common cold)?
Viruses (ie rhinoviruses or coronavirus or RSV or parainfluenza etc.
Chronic Hypersensitivity pneumonitis (asthma) is _______ ________ as opposed to acute which is mediated by antigen-antibody complexes (Type III -> hypersensitivity).
Cell mediated Type I hypersentitivity involving IgE -->IgE levels have been associated with developing both nonspecific airway hyperresponsive ness and asthma
What disease is associated with distended pus-containing fusiform or saccular dilatations of the bronchi with inflamed walls as well as adjacent lung tissue and pleura is frequently fibrous due to organized collapse and chronic inflammation ?
Bronchiectasis
What is this process: Airless lung parenchyma due to incomplete expansion of lungs or collapse of previously infiltrated lung
Atelectasis
Bacterial URTI's are not as common as viral but when present exhibit what characteristics?
PMN's and exudate formation; whitish yellow membranes in throat
T or F: a patient with latent TB is not infectious
TRUE
The type of emphysema caused by Alpha 1-antitrypsin deficiency is called _________ emphysema.
Panacinar
Dyspnea & Cachexia & Barrel Chest & Cor Pulmonale & Congestive Heart Failure are clinical signs of what disease?
Emphysema
Bronchitis & Emphysema or Both: Minimal Sputum
Emphysema
Bronchitis Emphysema or Both: Severe Dyspnea
Emphysema occurs early in disease (Puffer=dyspnea) Chronic bronchitis - dyspnea occurs later in diease
The _______ cavity is the space between viseral pleura and parietal pleura (separated by thin layer of fluid)
Pleural
Cor pulmonale causes _________ heart failure due to __________.
Right-sided; Pulmonary hypertension caused by lung disease
T or F: Chronic Bronchitis at times is not easily distinguished from Emphysema.
True; sometimes they go hand in hand
What is the most significant congenital respiratory disease occuring early in prenatal development( 4th week of prenatal development)?
Tracheo-esophageal fistula -failure of seperation of esophageal and lung buds from foregut -abdnormal connection btwn trachea and esophagus clinical problem: -neonatal feeding problem -coughing while feeding -aspiration while feeding = pneumonia
What is the most significant congenital respiratory disease occuring later in prenatal development( 4th - 8th week of prenatal development)?
Absence of lung or lobe -failure of airway budding into mesenchyme -usually not asymtomatic but has dec respiratory reserves with trauma surgery and infection
What are four examples of congenital respiratory diseases?
Tracheo-esophageal fistula & Bronchiogenic cysts & hypoplasia (absence of lung or lobe) & vascular anomalies
Type of Aspergillus infection? cough & dyspnea & fever and chills within 4 to 6 hours of exposure to spores. Responds to corticosteroids
Hypersensitivity pneumonitis/Extrinsic Allergic Alveolitis
Type of Aspergillus infection? in patients with long standing asthma; manifests as worsening of episodic airflow obstruction & eosinophilia & + skin test & + serology & elevated serum IgE & migratory CXR infiltrates & cough up brown plugs. Treat with steroids
Allergic Bronchopulmonary Aspergillosis (ABPA)
Type of Aspergillus infection? colonization of a pre-existing cavity (old TB etc.). Can cause bleeding due to erosion. May need to remove surgically.
Aspergilloma (fungus ball)
Type of Aspergillus infection? exclusively seen in the immunocompromised. Immunologic testing not of value. Culture it for diagnosis. May use more than one intravenous antifungal. Very high mortality.
Invasive aspergillosis
Bronchitis & Emphysema & or Both: Hypoxia & Cyanosis & polycythemia (increased rd blood cells)
Bronchitis
What 3 types of atelectasis are there?
Deficiency of surfactant; External compression of lung; resorption of air in lung & distal to an obstruction
What is the most common complication of chronic bronchitis?
Bronchiectasis
In obstructive lung disease --> Total lung capacity/forced vital capacity is _______ to ________.
Normal to Increased
What fungal infection is common in immunocompromised pt?
Aspergillus and Candida
What viral infection is common in immunocompromised pt --> esp in post-transplant pt?
CMV
What protozoan infection is common in immunocompromised pt?
pneumocystis carinii
T or F: Tumors can be associated with bronchiectasis
TRUE
T or F: Asthma is a reversible airway obstruction.
TRUE
In obstructive lung disease --> there is a _________ in expiratory flow rate.
Decrease
Cavitary lesions filled with pus. also air fluid seen
Lung Abscess
What fungal pneumonia involves a skin test which if positive have recent exposure and prognostic in that if did test at beginning of illness and then do the test again later in the illness then progronosis?
Cocciodiomycosis
When is serologic testing done for Cocciodiomycosis?
IgM Serologic testing: by Tube Precipitin or Latex Particle Agglutination: -->2-4 weeks of illness IgG Serologic testing: Complement Fixation; -->becomes + about 8 weeks after infection; results are diagnostic (+ = infected) and prognostic (very high titer = high chance of disseminated disease) --> up to 3 months to develop IgG
What fungal pneumonia does not have good skin or serologic testing and presents asymptomatic?
Histoplasmosis
What fungal infection in a COPD pt requires txmt if illness last for 8 weeks?
Histoplasmosis
What pt population is susceptible to Disseminated Histoplasmosis?
immunecompromised pt
What pediatric pulmonary disease is described as follows? 1. Insult within the first trimester 2. Ectopic lung tissue (supplied by the high pressure SYSTEMIC circulation). 3. No connection to the tracheobronchial tree. 4. Clinically very similar to cysts. 5. Surgery is more difficult because of the systemic blood supply.
Sequestrations
When is infant RSD highest?
earliest premature births --> 26 to 30 weeks and low birth weight
A neonate presents with the following: 1. Birth: cyanosis 2. Tachypnea & grunting & nasal flaring and chest wall retractions 3. Worsening oxygenation and respiratory acidosis over 24 hours. 4. Require supplemental oxygen/possibly mechanical ventilation HOw is this pt treated?
1. Oxygen 2. Mechanical ventilation a. Support until infant lung matures b. Positive pressure keeps lungs open 3. Other medical support (fluids & antibiotics & etc.) 4. Surfactant replacement a. Introduced intratracheally b. Results generally good
what are the organisms commonly causing lung abscess and how do they present on cxr?
Organisms: usually mixed flora (Fusobacterium & Bacteroides & Peptostreptococcus etc.) CXR: cavity with air-fluid level
T or F: Cystic fibrosis can be associated with bronchiectasis
TRUE
________ obstruction (in obstructive lung disease) is due to narrowing of airway (what disease) or loss of elastic recoil (what disease).
Expiratory; asthma; emphysema
What is the key element of the massive lung fibrosis that causes pneumoconioses?
Alveolar Macrophages
What caused traction on the lower lung by fibrosing upper lobes leading to retraction bullae at the base of the lung and later the great vessels (superior vena cava) leading to lack of adequate bood return to heart?
progressive massive fibrosis
What syndrome involves lung disease pt with silica exposure and who also has rheumatoid arthrititis?
Caplan's Syndrome
In restrictive lung disease -> total lung capacity is __________.
decreased
T or F: A patient with Bronchiectasis presents with bronchi (and/or bronchioli) filled with mucopurulent material; this mucous can be cleared by coughing.
First statement true -> second statement false
Restrictive lung disease is due primarily to either _________ abnormalities or __________ damage.
chest wall; parenchymal
Bronchitis & Emphysema & or Both: Weight loss
Emphysema (cachexia)
A particle that is less than ______ microns in size can enter alveoli -> contributing to what disease?
5; Pneumoconioses
What respiratory disease has bronchiolar walls thickened due to muscular hypertrophy & overgrowth of the mucous glands with thickening of basement membrane due to deposition of IgA and IgG and an infiltration with eosinophils as well as is stringy mucus in the lumen & together with eosinophils -> Charcot-Leyden crystals and Curschmann's spirals?
Asthma
What is the result of extensive desquamation of the cilia and epithelium and which impedes the removal of mucus?
status asthmaticus
What 2 components of the bronchial wall are primarily involved in asthma? (undergo hyperplasia)
Mucous glands (goblet cells); Smooth muscle
How is a pt with copd treated?
1. all copd pt must quit smoking 2. prevent and really txmt of infection --pneumocoocus vaccination --empiric antibiotics 3. oxygen if % Sat < 88% or PO2 < 55% 4. meds --bronchodilator--> long acting anti-chol (tiotropium) or B2-agonist (salmertorl or formoterol) now drug of choice for symptomatic relief of COPD 5. corticosteriods --systemic->use during copd exacerbations --local->inhaled steriod used in with moderate to severe chronic copd pt to improve quality of life
T or F: Chronic inflammation is part of asthma.
TRUE
T or F: Treatment of the inflammation will treat the bronchospasm but treatment of the bronchospasm will not treat the inflammation.
T
What Antibody is involved in extrinsic asthma?
IgE
T or F: Sarcoidosis can affect any organ -> not just the lungs.
TRUE
What is the most preferred drugs for prophylactic txmt of bronchial asthma?
inhaled corticosteriods -beclomethasone -budesonide -flunisolide -fluticasone -mometasone -tramcinolone
What should a pt using inhaled coriticosteroids be instructed to do and why?
rinse mouth after use to prevent orophyrengal candidiasis
When is a pt with interminant asthma considered not well controled?
when pt uses SABA >2 days a week for sx relief
what SABA causes less tachyphylasis?
levalbuterol
What ae is associated with long acting B2 agonists?
tachycardia tremor hyokalemia headache ***Prolonged QTc interval in OD
What is the MOA for B2 agonists?
cause smooth muscle relaxation: B2 agonist -> inc adenyl cyclase -> inc cAMP -> antagonism of bronchoconstriction
Is Asthma a restrictive or obstructive lung disease?
Usually Obstructive
Is asthma considered acute or chronic?
Acute (although the underlying process is more chronic)
What disease is associated with low grade fever & malaise & fatigue and clubbing of the fingers?
Bronchiectasis
What are unique pathologic features of bronchiectasis?
-permanent distortion of airway close to plural surface -walls fibrotic -unable to cleans self Key=>alot of metaplastic change ->squamous change =>horizontal ridging =>get lumps and bumps as go down airway circumferncial ridging
What is the Reid Index used for?
to measure the thickness of submucosa in chronic bronchitis. -inc in mucosa gland mass thickness of gland Layer / thickness of wall of airway if >40% = chronic broncitis
3 general types of lesions of the pleura:
Inflammatory & traumatic & neoplastic
What are the components of normal healthy trachea?
1. columnar cilated epithelium 2. mucous secreting goblet cells 3. brush cells with microvilli for absorption 4. basal or stem cells (multipotent) 5. Kulchitsky cells ->neuroendrocrine lineage
Where are bronchial glands located?
primarily in trachea and bronchi
what is the structure of bronchial glands?
branched tubular glands usually called acini in cross-section
What type of cells are seen in bronchial glands? and where?
see a mix of mucus and serous cells: ->mucus-secreting cells lie centrally and open into a wide lumen ->serous cells open into lumen which are extremely small and small canaliculi can be seen at the edge of the cells
What cell type is found in bronchial glands which are seen in Carcinoid tumors and Small (oat) cell carcinomas?
Kulchitsky (k) cells Carcinoid tumors -these cells secrete serotonin & kinin and bradykinin
What is the difference between Bronchials and Bronchi structure
Bronchi -large airway -supported by cartilage -include submucosal glands Bronchials -small airway <1cm in diameter -no cartilage -no submucosal gland
What are the cellular component of Terminal and Respiratory Bronchioles & Epithelium?
Single cuboidal cell layer • Non-ciliated Clara cells (secretory) • Primary epithelium of small bronchioles • Abundant cytochrome P-450 system • Protein-containing secretory granules • Serves as the Stem Cell for epithelial renewal • Secretion contributes to liquid lining layer of airways and alveoli • Ciliated cells • Almost no mucous cells in normal bronchiole
What are the componets of Primary Lobule (Acinus)?
• Terminal Bronchiole (single) – Non-cartilaginous support (alveoli) – No gas exchange – Conducts air to functional respiratory units • Respiratory bronchioles – 1-3 divisions; partial epithelial lining • Alveolar ducts & sacs and alveoli
What disease involves acinar damage?
emphysea
What cells line the alveoli and what is their fxn?
Type 1 cell epithelial cells • Component of air-blood barrier Type 2 cell epithelial cells • Surfactant synthesis • Stem cell for alveolar epithelium Alveolar macrophage • Derived from blood monocytes
What is the air-blood barrier and what is made up of?
Alveolar-Capillary Membrane • Surfactant lining alveoli • Alveolar epithelium (Type 1 cell) • Tissue elements of interstitial space – Basement lamina -> CT • Capillary endothelial cell ** Total thickness: 200-400 nm
What are pores of Kohn?
collateral ventilation -Openings in the intra-alveolar septa allowing movement of gas between adjacent alveoli
What are Lambert's sinus or canal?
collateral ventilation -Connections or anastomoses between alveolar ducts and terminal bronchioles.
What are the 2 Pulmonary Lymphatics networks?
• Two networks: –Pleural (superficial) plexus –Peribronchovascular (deep) plexus • Very permeable vessels –Endothelium is fenestrated and basement membrane is discontinuous – Intrapulmonary and hilar nodes receive flow from both systems
What is resistance?
resistance is directly related to pressure -if push harder inc resistance -inversely related to flow -> if resistance goes down -> flow will go up and vis versa
Where is resistance in respiratory system in series?
from nose to trachea->changes here have major changes on overall respiratory system resistance Series R = 80% total R ?? Increases add directly to total R ?? Consequences: ?? Nasal congestion -> etc. = big effect on R
Where does resistance in parallel occur in respiratory system and what effect does that have?
distal to trachea -changes can be big but not impact on respiratory system ?? Parallel R = 20% total R ?? Increases add reciprocally ?? Consequences: ?? Early lung disease = minimal effect on R
What is the fxn of Kulchitsky (k) cells?
found in bronchial glands -argentaffin-positive cells -contain neurosecretory granules
T or F: current use of systemic corticosteroids is a risk factor for asthma pts.
TRUE
Bronchitis & Emphysema or Both: Peribronchial fibrosis
Bronchitis
Sepsis & shock & trauma & pneumonia & toxic lung injury & aspiration of fluids and blood transfusions can all cause what disease?
Acute respiratory distress syndrome
What clinical factors affect airway resistance?
-Airway diameter -Mucosal: secretions & inflammation & edema & irritants->Asthma -Smooth muscle tone: CO2 & bronchoconstrictors & bronchodilators -Radial Traction on Airway ->lose radial traction with emphysema ->airways collapse
How is elastic work defined?
by compliance = change in volume/change in pressure
When does the lung have high compliance?
with emphysema -floppy lung -does not take much to change the volume
When does the lung have low compliance?
with fibrotic or scarring lung diseases -lung is stiff -takes large pressure to inflate a stiff balloon
How does surfactant play a role in surface tension and LaPlace's law?
- large alveoli volume -> st is high - at low alveolar volume ->st is low -small alveoli have smaller st and larger alveoli have larger st
What is FRC?
Functional Residual Capacity -balance pt btwn lung tendency to collapse and chest wall tendency to mov outward
Where is ventilation greatest in the lungs?
base of lungs -also where blood flow greatest so ventilation perfustion is 1:1
What four complications can long term use of corticosteroids have?
Osteoporosis & immunosuppression & addisonian crisis (secondary adrenal insufficiency) & diabetes
What fungal disease is widespread in the midwest and commonly associates with bird and bats?
Histoplasmosis
Increased responsiveness of bronchial tree to various stimuli is ________.
asthma
T or F: In Cor Pulmonale -> The Right Ventricle hypertrophies due to congestion in the lungs.
TRUE
What is closing volume and how does this relate to disease states?
The upper zones which received the nitrogen containing air from the conducting airways at the start of the inhalation of 100% oxygen) empty their high nitrogen gas causing the upslope. The point where this upslope occurs is called closing volume because lower zones are closed and not contributing to the expired gas. In disease states this point is reached nearer and nearer to FRV instead of near RV. Again this was tried as a clinical test to detect early lung disease.
for obstructive lung disease? what is FEV1 & FVC & FEV1/FVC?
FEV1 - dec FVC - dec or normal FEV1/FVC - dec
restrictive lung disease? what is FEV1 & FVC & FEV1/FVC?
FEV1 - dec or normal FVC - dec FEV1/FVC - normal or high
What disease state has dec TLC?
restrictive lung disease
What disease process has low DLCO? and why?
restrictive process suggests parenchymal disease
What is the A-a gradient equation?
PAO2 - PaO2 PAO2 = PIO2 - (PaCO2/R ) R = 0.8 & PaCO2 = 40mmHg & so PAO2 = 150 mmHg PIO2 = (FIO2)*(PB-PH2O) FIO2 = 0.21 -> room air PB = 750 mmHg -> at sea level PH2O = 47mmHg if all this correct -> PIO2 = 150 mmHg
What causes right shift in oxygen-hemoglobin dissociation curve?
increased PaCO2 (the Bohr effect) decreased pH (increased hydrogen ion concentration) elevated body temperature increased 2 -3-diphosphoglycerate (2 3-DPG
What causes left shift in oxygen-hemoglobin dissociation curve?
decreased PaCO2 (the Bohr effect) increased pH (decreased hydrogen ion concentration) decreased body temperature (hypothermia) decreased 2 3-DPG Alternative hemoglobins generally are left shifted. These include - fetal hemoglobin (HgF); -carboxyhemoglobin (generated by binding of carbon monoxide to the HgB); - methemoglobin (oxidation of the iron moiety from the ferrous to the ferric state; seen with congenital deficiencies or with oxidant drugs)
for Acute Resp acidosis: what is: pH pCO2 HCO3
pH < 7.35 pCO2 > 45 HCO3 btwn 23 and 26 -> kidneys have not had time to compensate -> takes 3 to 5 days to compensate -> so this occured with in last 2 days
Chronic Resp acidosis: what is: pH pCO2 HCO3
pH < 7.35 pCO2 > 45 HCO3 >27 -> kidneys has had time to compensate -> takes 3 to 5 days to compensate
Metabolic acidosis: what is: pH pCO2 HCO3
pH < 7.35 pCO2 < 35 HCO3 - not applicable
Chronic Resp alkalosis: what is: pH pCO2 HCO3
pH > 7.45 pCO2 <35 HCO3 < 23
Acute Resp alkalosis: what is: pH pCO2 HCO3
pH > 7.45 pCO2 < 35 HCO3 btwn 23 and 26 -> takes 3 to 5 days for kidney to compensate
Metabolic alkalosis: pH pCO2 HCO3
pH >7.45 pCO2 > 45 HCO3 - NA
What cells are involved in asthma?
Mast cell: leukotrienes & prostaglandins & histamine & platelet activating factor (PAF) Eosinophil: major basic protein & eosinophil cationic protein Macrophages: cytokines & lipid mediators & reactive oxygen species & PAF; also act as antigen presenting cells
What NS maintains bronchial smooth muscle tone; cholinergic stimulation (via the vagus) narrows the airway?
parasymp ns
What ns causes adrenergic stimulation relaxes airway smooth muscle; plays only small role in humans?
sympathetic ns
What controls local neural pathways that mediate smooth muscle tone through nt such as NO & VIP and Substance P?
Nonadrenergic noncholinergic (NANC) neural pathways
Pt presents with: -Sudden onset dyspnea & cough & wheezing -Chest tightness & feeling of suffocation -Symptom free periods -Family history for allergies or asthma frequently positive What does this pt have?
asthma
Pt presents with the following: -cough with sputum for 3 months or more per year for 2 or more consecutive years. Pathologically: -chronic bronchitis is associated with hypertrophy and hyperplasia of airway mucus glands -accumulation of mucus in small airways -narrowing and inflammation of the small airways -Excess secretions/mucous plugs What disease does this pt have?
chronic bronchitis
What disease process is descrbed as: enlargement of airspaces distal to the terminal bronchioles accompanied by destruction of the alveolar walls and loss of elastic recoil?
Emphysema
What are the three major chronic obstructive pulmonary diseases (COPD)?
Emphysema & Chronic Bronchitis & Bronchiectasis
T or F: Many times COPD is a combination of chronic bronchitis and emphysema -> not just pinned down to one systemic problem.
TRUE
Why do patients with bronchiectasis have clubbing of the fingers?
It is related to chronic hypoxia.
T or F: All patients affected with Acute Respiratory Distress Syndrome die during the acute stage.
False. 70% die during this stage -> but the remainder progress to a chronic stage -> where 10% may survive and 20% eventually die from interstitial fibrosis
T or F: COPD is a reversible condition
FALSE
T or F: Most histoplasmosis infections go on to become chronic.
False; most are acute and then resolve
Among patients with COPD in the US the vast majority have __________ (14 million) and the remainder have __________ (2 million)
Chronic Bronchitis; Emphysema
Name the 5 factors that are considered in susceptibility to Pneumoconioses.
1. Size/shape of particle (<5 microns); 2. Composition of particles; 3. Duration of exposure; 4. Patients clearance mechanism; 5. Other irritants (ie smoking)
What is the only acute restrictive lung disease?
Acute respiratory distress syndrome
Acute Respiratory Distress Syndrome is caused by a mechanism of either 1. Injury to the _________ _______ in pulmonary capillaries or 2. Injury to the ________ _________ _______.
1. Endothelial cells; 2. Alveolar epitheial lining cells
What disease: Enlargement of airspaces distal to terminal bronchioles; destruction of alveolar walls; loss of elastic recoil; collapse of unsupported enlarged air spaces on expiration; obstruction on expiration
Emphysema
T or F: Silicosis can lead to bronchogenic carcinoma (metastatic mesotheleomia).
TRUE
What is the characteristic difference of air sacs between healthy air sacs and air sacs with emphysema?
Emphysema: weakened and collapsed air sacs with Excess mucous
Bronchitis & Emphysema or Both: Pulmonary hypertension
Both
What disease presents with the following? Examination a.Wheezing especially on forced expiration; with prolongation of the expiratory phase. b. If hyperinflated increased anteroposterior diameter of the chest hyperresonant lung fields. c. If late in course signs of cor pulmonale: peripheral edema jugular venous distention. Testing a. PFTs: dec FEV1 normal or dec FVC -> Dec FEV1/FVC b. Chest X-ray: hyperinflation with small cardiac silhouette in emphysema; congestion & scattered infiltrates & possibly enlarged heart and prominent pulmonary vessels in chronic bronchitis c.Arterial blood gases: should be performed in outpatients if FEV1<40% or clinical signs of respiratory failure or right heart failure; and during exacerbations.
COPD
A pt presents with the following: -young age -obese -develops cor pulmonale early in disease -has prominent cor pulmonale (right heart failure) -develops hypercapnia early in disease -normal lung complinace -normal DLCO -moderate airway obstruction -inc hematocrit What disease state does this pt have?
chronic bronchitis = blue bloaters
A pt presents with the following: -older age -thin and tall -develop cor pulmonale late in the disease -has mild hypoxia -develops hypercapnia late in disease -inc lung compliance -sever dec in DLCO -sever airway obstruction -normal hematocrit What disease state does this pt have?
emphysema = pink puffer
What are the drugs of choice for COPD?
Long and short acting anti-cholenergics
What medication is used to treat COPD exacerbations?
corticosteriods
What is the major cause of emphysema?
Cigarettes
In extremely rare cases (1%) what can cause emphysema? and How are these pt treated?
hereditary alpha1-antitrypsin deficiency (which protect the tissue from leukocyte proteases) see in young pt with emphysema tx: alpha-1 proteinase inhibitors: prolastin or zemaira
What type of emphysema is proximal to terminal bronchi and is most associates with smoking?
Centrilobular (Centriancinar) emphysema
What type of emphysema is an upper long zone disease?
Centrilobular (Centriancinar) emphysema
What disease presents microscopically as follows? The major change is an increase in mucous glands in the submucosa with a variable chronic inflammatory cell infiltration and some increased fibrosis. The epithelium invariably shows marked increase in goblet cells and later may show loss of cilia and other metaplastic changes. Hyperplasia of mucous glands with marked increase in their volume is a prominent feature.
chronic bronchitis
What disease is a chronic irreversible dilation and distortion of bronchi caused by inflammatory destruction of the bronchial walls from necrotizing infection in the tracheobronchial walls and surrounding parenchyma?
bronchieactasis
What is a complication of Centrilobular (Centriancinar) emphysema?
Bullous Emphysema -upper zone thin sac which can suddenly rupture causing pneumothorax
What are common gross features shared btwn asthma and chronic bronchitis?
-airway filled with thick mucous plug -inflammatory inflitrate in alveolar walls - chronic - more leukocytes and plasma cells - narrowing of airway -edema key with chronic broncitis - inc in submucosal gland layer in alveolar wall
What type of emphysema is an lower long zone disease?
Panacinar or Panlobular
What type of emphysema is distal to terminal bronchi involving respiratory bronchi and distal alveoli has a lace like uniform appearance histologically?
Panacinar or Panlobular
How is Albuterol different from Levalbuterol?
Levalbuerol -more potent -less tachyphylaxisis -single isomer
Why are long acting B2 agonist have a longer duration of action vs. SABA?
The long acting beta-2 agonists are more lipophillic than the short acting beta-2 agonists therefore having a duration of effect lasting 12+ hours. Salmeterol: partial agonist Formoterol: full agonist more rapid onset of action. Otherwise equal efficacy. Long acting B2 agonists: Preferred adjunctive agent to inhaled corticosteroids. Useful for prevention of nighttime asthma symptoms.
Why is Tiotropium have a longer duration of action vs. Ipratropium?
Tiotropium blocks M1 – M3 receptors. Rapidly dissociates from M2 receptor but dislocates from M1 and M3 much slower conferring a long duration of action
What is key to use of metered-dose inhalers?
proper technique is key to ensure drug delivery to pt
What is the most common allele of CFTR gene causing CF?
delta F508
What is the specific problem in CF?
dsfxn in cAMP dependent chloride conductance channel
What links the physiologic consequences of mutant CFTR to lung disease?
Direct link to lung disease is still missing Decreased surface liquid volume results from excess Na+ absorption and decreased Cl - secretion Airway mucus is abnormal Mucociliary clearance is abnormal Airway obstruction occurs Bacterial infection is promoted Biofilms protecting communities of bacteria form Mucoid Pseudomonas aeruginosa Infections may be chronic impossible to eradicate Inflammation results from immune response Lung destruction bronchiectasis results (IMP)
What disease is treated as follows? Airway clearance techniques Percussion & postural drainage Active Cycle of Breathing techniques PEP (positive expiratory pressure) mask Autogenic drainage Oscillating Flutter Acapella device High Frequency Chest Compression (“vest”) Antibiotics for exacerbation TOBI - dont develop resistance because in lung only Agents to change viscosity of mucus -Hypertonic saline (7% NaCl by inhalation) - to loosen mucous Anti-Inflammatory medications High dose ibuprofen (inhibits neutrophil migration and release of lysosomal enzymes Zithromax (how this works in CF is not understood; the drug is not used in the usual way an antibiotic is used; evidence is good that it improves lung function and decreases exacerbations) Double lung transplantation
cf
What are other clinical manifestations seen in CF?
-sinus disease -nasal polyps -pancreatic disease -dm -obstuction of colon -male infertility
What are the criteria for CF dx?
One or more phenotypic features or CF in a sibling or + newborn screening test PLUS Evidence of CFTR dysfunction Elevated sweat chloride (> 60 meq/L by pilocarpine iontophoresis method. In children 40-60 “indeterminate.”) OR Abnormal nasal potential difference OR CF-causing CFTR mutations on both alleles
What are key endpt in CF study
-quality of life -improved lung fx NOT - mortality
In the Protease-antiprotease mechanism of emphysema what 2 things does smoking do?
1. Inhibits antielastase; 2. favors recruitment of leukocytes and release of elastase (causing elastic damage to the tissue)
-Alcoholic with rotten teeth -> what is he at risk for?
debility & malnutrition & depressed level of consciousness & poor ciliary function Klebsiella pneumoniae Occurs in alcoholics & diabetics & debilitated Bulging fissure on CXR & lobar pneumonia Sputum: plump gram - rod
Other than the protease-antiprotease mechanism -> what else does smoking do to cause emphysema?
Oxidant/antioxidant imbalance (free radicals released -> induce cell damage)
What pulmonary infection is a pt with CHF at risk for?
What is the most common bacterial cause of pneumonia -> may be found in the oropharynx of healthy people and still has an appreciable mortality despite antibiotics?
What disease presents as follows? -Acute onset of a shaking chill -May follow an upper respiratory infection -Fever & dyspnea & pleuritic chest pain -Cough & rusty sputum -Leukocytosis -Signs of consolidation on exam -CXR: lobar consolidation -Gram stain: gram + lancet shaped diplococci & intracellular
classic pneumonia
What are signs in a pt with pneumonia of a poor outcome?
Bacteremia Hematogenous spread (meningitis & endocarditis & arthritis) More than 1 lobe involved Type 3 serotype (more virulent) Very young or very old
The type of emphysema caused by smokers is called _________ emphysema.
Centrilobular
What type of pneumonia is lethal and have the following risk factors? immunosuppression & smoking & COPD & advanced age & male & cardiac disease and present as follows: High fever & recurrent chills & cough GI involvement (diarrhea \) common “relative bradycardia” for degree of fever Hyponatremia & hypophosphatemia May have a fulminant systemic course CXR: varied patterns Gram stain doesn’t show it; silver stain or DFA stain Cultured on selective media Serology
Legionella
An elderly pt suffers from the flu gets better then soon after get worse -> what organism is involved? What other population are susceptible to this organism?
Staphylococcus aureus IV drug users
Which type of bronchogenic carcinoma has the worst prognosis -> most aggressive and not usually amenable to surgery?
Small Cell (oat cell)
Bronchitis & Emphysema or Both: Frequent Upper Respiratory infections
Bronchitis
Name the types of Pleural Lesions:
Mesothelioma & Pleural effusions and plueritis & Pneumothorax & Hemothorax & Chylothorax
What disease: Excessive production of tracheobronchial mucous causing cough.
Chronic Bronchitis
What 3 diseases included in COPD (chronic obstructive pulmonary disease)?
Emphysema & Chronic Bronchitis & Bronchiectasis (just a reminder)
What disease: erodes bronchial wall & eric-smelling sputum & chest pain & weight loss & chronic cough & fever & clubbing of fingers and toes
Lung Abscess *note -> bronchiectasis also has clubbing of toes--the difference here is eroding of bronchial wall. Bronchiectasis is permanent dilatation of bronchial wall.
Anthracosis & Silicosis or Asbestosis -> all three or none: Increased risk of TB
Anthracosis and Silicosis
_____ % of Chronic Bronchitis cases are caused by _________.
90%; Smoking (I know we all love percentages)
Bronchitis & Emphysema or Both: Acute disease
Neither (trick question!)
What are the risk factors for contracting histoplasmosis (other than living in this hell hole we call omaha….j/k)
exposure to soil contaminated with bird poo & preexisting COPD & compromised immunity
What disease: Thickening of bronchial walls mucous gland hyperplasia chronic inflammation & fibrosis & mucous plugging.
Chronic Bronchitis
The presence of transudate in the pleural space is called ________
hydrothorax; caused by CHF and Left-sided heart failure especially
T or F: Chronic Bronchitis results in Restriction.
False; leads to obstruction
What are the main differences in the pathways for chronic bronchitis and emphysema?
Bronchitis: bronchiolar injury & hypersecretion of mucous; emphysema: destruction of alveolar walls early (bronchitis does it later)
Which acute disease exhibits severe dyspnea & cyanosis & and hypoxia?
Acute respiratory distress syndrome
One of the main characteristics (underlined in the notes) of chronic Bronchitis is ________.
Fibrosis
Anthracosis & Silicosis & or Asbestosis & all three & or none: Can lead to mesothelioma
Asbestosis (this is the #1 characteristic of asbestosis)
What disease: Permanent dilatation of bronchi -> can be secondary to persisting infection or obstruction
Bronchiectasis
T or F: Asthma is more common in females.
FALSE (males 2:1)
What process takes place in pulmonary fibrosis or tuberculosis?
Cavitation
What is the first step in treatment for bronchitis and emphysema?
Quit smoking
________ occurs as a result of an exudate (protein rich)
Pleuritis
The two chronic restrictive lung diseases caused by occupational/environmental exposure are: 1.____ -> 2._________
Hypersensitivity Pneumonitis; Pneumoconioses (ie asbestosis)
In this disease fibrin is deposited along damaged alveolar lining -> which leads to diffuse alveolar damage.
What is Acute respiratory distress syndrome? (jeopardy style baby)
Anthracosis & Silicosis or Asbestosis -> all three or none: increases risk of cancer 5 fold
Asbestosis
Chronic Restrictive lung diseases are diseases of _________ ________.
Lung parenchyma
Anthracosis & Silicosis or Asbestosis -> all three or none: runs a benign course
Anthracosis
What term means: Labored Breathing
Dyspnea
90% of all lung cancers are caused by smoking (150 000 deaths/yr). What are the other 10% caused by? (hint-variety of things)
Radon (radioactive gas=2nd leading cause--.20 000 deaths/yr); Air pollution; Radiation exposure; Asbestos exposure; Nickel and chromate exposure
The end result of chronic restrictive lung diseases is _________.
Diffuse pulmonary fibrosis
Anthracosis & Silicosis or Asbestosis -> all three or none: shows pleural plaques
Asbestosis
T or F: Chronic Bronchitis gives you the "pink puffer"
False; gives you "Blue Bloater" (B for Bronchitis -> Blue Bloater)
Anthracosis & Silicosis or Asbestosis -> all three or none: Leads to Fibrosis
All Three
What causes pleural effusion?
Microbial infection & cancer & pulmonary infarction & viral pleuritis
Which chronic restrictive lung disease has no known cause?
Idiopathic pulmonary fibrosis
Histoplasmosis infection symptoms include: fever & chills & weight loss & cough (with/without) mucus or pus
WITH
In asbestosis -> what sets off a fibrogenic reaction?
Macrophages ingesting an asbestos fiber
What immune cells are primarily involved in asthma?
mast cells
Neutrophil/complement defects (humoral defects) result in increased incidence of ___________ ________.
Bacterial pneumonia
What disease invovles extrinsic allergic alveolitis caused by exposure to organic dust?
Hypersensitivity Pneumonitis
Cell-mediated immune defects result in increased incidence of (intracellular/extracelluar) ___________.
Intracellular parasites (ie TB & HSV & pneumocystis carinii)
What ways can pneumonia be spread?
Inhalation of pathogens & aspiration of infection & aspiration of gastric contents & hematongenous spread (IV & septic emboli)
What disease: Multi-system granulomatous disease of unknown etiology (presumably immune mediated)
Sarcoidosis
What are the possible complications of pneumonia?
Abscess formation; Plueritis & empyema (collection of pus); fibrosis--> chronic Dx
T or F: in a patient older than age 40 in the absence of systemic infection lung complications should be assumed it is cancer until proven otherwise.
TRUE
What term means: Physican wasting with loss of weight and musche mass caused by disease
Cachexia
T or F: Emphysema gives you the "pink puffer"
True (emphysema=pink puffer)
What is the definition of Pneumonia?
Any infection in the lung (acute or chronic)
Pneumonia is of Bacterial or viral or fungal origin?
Any of the above.
In Asthma -> which is more difficult -> expiration or inspiration?
Expiration
T or F: Pneumoconioses is caused by exposure to organic dust particles.
False; inorganic particles (organic--Hypersensitivity Pneumonitis)
What are the 2 main subclasses of pneumonia?
Lobar Pneumonia and Bronchopneumonia
Bronchopneumonia or Lobar Pneumonia: Consolidation of multiple respiratory units surrounding individual bronchial branches
Bronchopneumonia
Bronchopneumonia or Lobar Pneumonia: Consolidation of entire Lobe of Lung
Lobar Pneumonia
What are the 2 main pathways of pathogenesis for Acute Respiratory Distress Syndrome?
Damage to alveolar lining cells or damage to alveolar capillary endothelium--leads to interstitial edema -> high protein exudation (hyaline membranes)
What treatment difference is there for bronchitis?
Use bronchodilators and antibiotics.
What organisms cause community acquired acute pneumonias?
Haemophilus Influenzae; Moraxella catarrhalis; Staph Aureus; Klebsiella Pneumoniae; Legionella Pneumoniae
What organism causes Pneumococcus?
Streptococcus pneumoniae
How can histoplasosis be diagnosed?
sputum test & chest x-ray & biopsy of granulomatous tissue & complement fixation & urinary antigen test & immunodiffusion test
What organisms cause community acquired atypical pneumonias?
Mycoplasma Pneumoniae & Chlamidia sp. & Viruses
What is associated with Type I hypersenistivity & allergens & atopic dermatitis and hay fever?
asthma
T or F: Hypersensitivity pneumonitis is only an acute disease.
False. It can also be a chronic disease.
Give an example of a community acquired atypical pneumonia caused by a virus.
SARS
What immune related chronic restrictive lung disease affects blacks 10:1 and women 2:1?
Sarcoidosis
What organism causes nosocomial pneumonia (according to lecture notes)?
Pseudomonas Aeruginosa
What is the primary cause for aspiration pneumonia?
Markedly debilitated; unconscious patients; abscesses frequent
Fibrothorax & Pneumothorax & Empyema & Hemothorax or chylothorax: encasement of lungs with fibrous tissue that obliterates pleural cavity.
Fibrothorax
T or F: Lung cancer usually has a poor prognosis with a 5 yr survival rate of 10-15%.
TRUE
Cytomegalovirus primarily affects who?
Immunosuppressed (AIDS) & bone marrow transplant
Pneumocystis pneumonia affects who?
Immunosuppressed (AIDS)
What organism causes tuberculosis?
Mycobacteria Tuberculosis (causes chronic bacterial infection)
What chronic lung disease is associated with caseating granulomatous inflammation?
Tuberculosis
What chronic lung disease is associated with non-caseating (necrotic) granulomatous inflammation?
Sarcodosis
T or F: Anthracosis usually leads to bronchogenic carcinoma.
False; Most=benign course
What types of cells are associated with TB?
epitheliod macrophages & multinucleated giant cells & lymphocytes
What disease: purulent cough & dyspnea & hypoxia & cyanosis & peribronchial fibrosis & pulmonary hypertension & cor pulmonale & congestive heart failure.
Chronic Bronchitis
Fibrothorax & Pneumothorax & Empyema & Hemothorax & or chylothorax: Entry of air or gas into pleural cavity; may cause atelectasis & compression & collapse of lung.
Pneumothorax (spontaneous vs trauma)
What is the "Ghon Complex"?
associated with localized lung inflammation in primary tuberculosis
Acute hypersensitivity pneumonitis is of _______ onset and is mediated (or affected) by _________ ________.
Sudden; antigen-antibody Complexes
T or F: Primary TB usually heals spontaneously
TRUE
Define Consolidation as it refers to the lungs.
Process of becoming solid (ie when lung becomes firm as air spaces are filled with exudate in pneumonia)
What treatment is there for the rare form of emphysema?
alpha 1-antitrypsin infusion
T or F: In primary TB -> viable organisms can still persist after healing and calcification
TRUE
The "ghon Complex" forms in which part of the lung and enlarges which lymph nodes?
lower part of upper lobe & upper part of lower lobe (right in the middle); enlarges hilar lymph nodes
T or F: Sarcoidosis exhibits caseating granulomas
False; exhibit non-caseating granulomas
Anthracosis & Silicosis or Asbestosis -> all three or none: Increased risk of bronchogenic carcinoma
Silicosis (maybe asbestosis too but mesothelioma is the characteristic sign of asbestosis
Granulomas in TB can produce cavities in the lungs which can cause hemoptysis. What is hemoptysis?
coughing up blood
T or F: The primary TB infection is more damaging than the secondary infection.
False (other way around)
What disease: non-specific mild pulmonary disease & low grade fever & 95% undiagnosed & ghon complex
Primary TB
What disease: Non-productive cough & low grade fever & malaise & night sweats & weight loss & hemoptysis
Secondary TB
What can be seen in a sputum test for TB?
Acid fast bacilli - cell wall rich in lipids
Name 2 Middle Respiratory Tract Tumor?
SCCA (squamous cell carcinoma) of Larynx small cell (oat) cell carcinoma
What are 3 specific examples of Pneumoconioses?
1. Coal worker's lung (anthracosis); 2. Silicosis; 3. Asbestosis
T or F: the erythema around the indurated area of a PPD test is measured.
False. Only the induration is measured (normal = &lt;10 mm)
Bronchitis & Emphysema or Both: Productive cough
Bronchitis
What disease: widespread hematogenous seeding of bacteria; numerous granulomas in lungs or other organs (ie spleen)
Miliary TB
T or F: Sarcoidosis is typically a fatal disease.
False; 10% mortality & 70% spontaneous recovery & 50% asymptomatic
T or F: Disseminated TB can cause granulomas on pluera (causing pleuritis) and extrapulmonary TB
TRUE
Where are the most common sites of metastasis of lung cancers?
Brain and Liver mostly -> occasionaly bone (mandible) -> rarely oral soft tissue
Premature infants commonly have respiratory problems due to insufficient pulmonary __________. When does the fetus begin to produce this prenatally?
surfactant after 25 wk
What is the main cause of SCCA of the larynx?
Smoking and chronic alcohol use
Two of the common causes of Hypersensitivity Pneumonitis are: __________ Lung and _______ _________ Lung.
Farmer's Lung (moldy hay/grain); Pigeon Breeder's Lung (pigeon serum protein in droppings)
Fibrothorax & Pneumothorax & Empyema & Hemothorax or chylothorax: Collection of blood in space between chest wall and lung (pleural cavity).
Hemothorax (trauma vs. rupture of intrathoracic aortic aneurysm)
List the 4 types of Bronchiogenic carcinomas.
1. SCCA (30%) 2. Adenocarcinoma (30%) 3. Large Cell undifferentiated (10%) 4. Small Cell (oat cell-20%)
Coccidiomycosis or Aspergillosis or Zygomycosis: Southwest
Coccidiomycosis
What collagen vasuclar diseases are associated with IPF
Rheumatoid Arthritis Scleroderma (Progressive Systemic Sclerosis) Systemic Lupus Erythematosis
what key organ is involved with IPF?
lung
What ILD involves multiple organs including Lung & Eye and Heart tissue?
sacrodosis
Which is least likely to indicate an interstitial lung disease? A. Diffuse pulmonary infiltrates on chest x-ray B. Acute fever & chills and rust-colored sputum C. Progressive dyspnea over months and crackles on physical exam D. Rheumatoid arthritis with progressive dyspnea and infiltrates on chest x-ray
B
What disease presents as follows? -Progressive dyspnea on exertion Paroxysmal cough & usually nonproductive Abnormal breath sounds on chest auscultation Bibasilar fine inspiratory (Velcro) crackles Tachypnea Clubbing - 25-50% Abnormal chest x-ray or high resolution CT scan (HRCT) Restrictive pulmonary physiology with reduced lung volumes and DLCO and wide p(A-a)O2 difference
Idiopathic Pulmonary Fibrosis (IPF)
What disease has the following diagonistic criteria that must be met before dx? (w/0 sugical lung biopsy) Major Criteria: Exclude other causes of ILD PFTs show restrictive pattern or abnormal gas exchange Bibasilar reticular shadows w/ little ground glass opacity Alternative diagnosis not suggested by bronchoscopic studies Minor Criteria Age >50 Insidious onset otherwise unexplained dyspnea Duration of illness >3 months Bibasilar Velcro crackles
IPF
What disease presents with the following high resolution CT scan findings? Irregular reticular (net-like)densities Sub-pleural & posterior & lower lobe location Sub-pleural honecombing Traction bronchiectasis Mildly enlarged lymph nodes
IPF
What is the Treatment & Prognosis for IPF?
No known effective treatment. Prognosis poor with progressive lung destruction. Periods of acute deterioration. Median survival about 3 years after diagnosis. 5-year survival 20-40%
Which statement is true about IPF? A. This is a non-specific lung disease diagnosed by finding fibrosis on biopsy B. A lung biopsy is sufficient to diagnose IPF C. A uniform distribution of radiologic and histopathologic abnormalities makes non-specific pulmonary fibrosis (NSIP) more likely than IPF D. A low FEV1 / FVC is typical of IPF
c
What disease shows accumulation of activated T (CD4) cells and macrophages at sites of ongoing inflammation?
Sarcoidosis
What ILD effects the eye and can lead to blindness?
Sarcoidosis
What are key PFT for sarcoidosis?
Restrictive & low DLCO May be obstructive or mixed obstructive and restrictive Lesions may be endobronchial Mixed FEV1/FVC reduced TLC reduced
What disease is diagnosed with the following citerias? Compatible clinical picture Granulomas on biopsy Bronchoscopy has high yield Exclusion of other entities Infectious – TB & fungi (histoplasmosis) & NTM Occupational disease (Beriliosis) Neoplasm Lymphoma
Sarcoidosis
IPF and Sarcoidosis share which characteristic? A. Granulomas are typical findings on biopsy B. Disease is limited to the lungs C. Reduced FEV 1 & FVC & Total Lung Capacity & and DLCO are typical D. Prognosis is poor
C
When is it necessary to tx a pt with sarcoidosis?
Treatment only for serious symptoms or organ involvement – corticosteroids. Effect on mortality unclear.
What disease presents with the following pathology? interstitial lymphocytes patchy involvement with areas of marked fibrosis and areas of less fibrosis and more inflammation bibasilar and subpleural accentuation often progresses to end stage or "honeycomb" lung
USUAL INTERSTITIAL PNEUMONITIS (UIP) (aka idiopathic pulmonary fibrosis or IPF)
What disease has this key pathologic feature? "HONEYCOMB LUNG" end stage scarred & retracted & shrunken & lung dilated air spaces from destroyed lung alternate with fibrous scars pleura is "hobnailed" (bumpy) due to interstitial retraction.
USUAL INTERSTITIAL PNEUMONITIS (UIP) (aka idiopathic pulmonary fibrosis or IPF)
What disease presents with the following pathology? large numbers of alveolar macrophages interstitial lymphocytes mild interstitial fibrosis progresses to honeycomb lung less commonly than UIP.
DESQUAMATIVE INTERSTITIAL PNEUMONITIS (DIP)
What disease presents with the following pathologic findings? interstitial lymphocytes relatively mild interstitial fibrosis interstitial granulomas (in about 2/3 of cases) often peribronchiolar inflammation can produce small airway obstruction ("bronchiolitis obliterans- organizing pneumonia" or "BOOP" ) only rarely progresses to honeycomb lung
HYPERSENSITIVITY PNEUMONITIS
What disease presents with the following pathologic findings? systemic non-necrotizing granulomatous inflammation (nodes & lung & eyes & liver & spleen & skin....) diffuse pulmonary interstitial granulomas and fibrosis often with nodule formation perilymphangitic pattern (bronchial biopsy often +) and regional nodes commonly involved (? inhaled antigen draining through lymphatics) variable clinical course & can progress to end stage fibrosis must exclude infection (mycobacteria & fungi mainly)
SARCOIDOSIS
T or F: A non-caseating granulomas are only seen in Sarcoidosis.
F -> early TB granulomas may present as noncaseating granulomas need other features to make that dx
What disease is characterised with infiltration of involved tissues by Langerhans cells and Birbeck granules (CD1a antigen on cell surface )?
EOSINOPHILIC GRANULOMA (Langerhans Cell Histiocytosis; Pulmonary Histiocytosis X)
A pt is exposed to any of the following: Aluminum Iron (red macules) Antimony Rare earths Barium Tin (gray macules) Chromium Titanium (white) Urban pollution & cigarette smoking (black) T or F: This pt has no clinical symptoms and no abnormal PFT but does have a chx some small densities the pt will evetually develop a lung disease.
F - the pt has dust macules in the lung which do not progress to lung disease.
What disease is associated with eggshell calcifications of hilar lymph nodes?
silicosis
What disease cause a pt with TB to have a 4 to 6 fold inc risk of active TB?
silicosis
What is the size of the ppd test result for a pt with silicosis and TB to treat the pt?
10mm
What disease is associated with: - Pleural plaques -->thickened pleural in patches along lateral chest walls and/or diaphragm and/or mediastinal pleural. Often calcified and appear as hard white areas on CXR -Cycle of inflammation and fibrosis. -Generally appears most prominent at the lung bases. -The “shaggy heart” border on CXR is common. -Symptoms: dry cough & crackles on exam & exertional dsypnea -PFTs: restrictive process with low lung volumes. -Can result in clubbing & cor pulmonale & respiratory failure.
Asbestosis
Where is signs of asbestosis NOT found?
Apeces of lung and costal-phrengal angle
What are 3 clinical patterns of asbestos exposure?
Pleural Disease Asbestosis (fibrotic lung disease) Malignancies -Bronchogenic (lung) disease -Malignant mesothelioma
What causes the following effects? ->5 fold increase in risk for lung cancer ->90 fold increased risk for lung cancer in pt that smoke
asbestos
What disease has the following presentation? Symptoms occur 4 to 8 hours after exposure to organic dust from animals or hay. Most common in the spring when the hay has been molding in the silo all winter and is then forked out. Fever & chills & sweating & cough and dyspnea – which sounds a lot like acute pneumonia! On exam: tachypnea & crackles over the lungs CXR: bilateral reticulonodular infiltrates Will resolve spontaneously within 18 to 24 hours. Repeated exposures lead to progressively more severe attacks. If continued exposure is not avoided can lead to restrictive lung disease.
Hypersensitivity pneumonitis (also called extrinsic allergic alveolitis)
What disease has the following presentation? -Wheezing & cough & shortness of breath worsening in the work place. -Can perform spirometry before and after a work shift to aid diagnosis. -One in 5 individuals will have asthmatic reactions. -Does respond to bronchodilators but avoiding exposure is the true treatment.
Occupational asthma
A pt is exposed to oxides of nitrogen from fresh cut hay (yellow brown gas seen overlying the hay). He comes to the ED with severe shortness of breath. CXR: bilateral diffuse lung infiltrates. Pathology report is non specific: ARDS type picture/diffuse alveolar damage and/or bronchiolitis obliterans Pt also has hypoxemia. What is this pt suffering from? How should he be treated?
Treatment is oxygen and respiratory support; corticosteroids.
What disease is a combination of type III (immune complex) and type IV (cell mediated) reactions?
HYPERSENSITIVITY PNEUMONITIS
What type of lung cancer arises from the terminal bronchioles?
Bronchioalveolar cancer
What is a type of lung cancer that is a neuroendocrine tumor of low malignancy?
Carcinoid
What type of lung cancer is associated with asbestos exposure & takes 25-40 yrs to develop & is pluera-derived and has a poor prognosis?
Mesothelioma
What disease: persisten hoarseness & change in voice stridor (high pitched crowing sound) & rare under age 40
SCCA of larynx
Bronchitis & Emphysema or Both: Cor Pulmonale
Both
What do small (oat) cells arise from?
Neuroendocrine cells - kulchitsky cells found in bronchial glands
What type of hormones do small (oat) cell (bronchogenic carcinoma) express?
polypeptide hormones
What chronic lung disease is associated with elevated ACE?
Sarcoidosis
What type of pneumonia causes necrosis with scaring and patching distribution of inlfammatory infiltrage in alveolar wall?
broncial pnuemonia
What disease? Internuclar and/or intercytoplasmic inclustions monocytes in interstial wall area of alveoli
viral pulmary infections
What fungus grows as hyphea in lung?
aspergillius and Mucour
What fungus grows as yeast in lung?
carplasto & histio & coxididies
lamenar & concentricl concentration of collegen with aceullar center
silicosis
What is the disease associated inhaled toxic fumes or gas causing necrosis of the airway and leackage of protien into airway leading to hyaline membranes in alveolar ducts and collapse of alveolar parenchyma?
Diffuse alveolar damage (DAD) the pathologic equivalent of adult respiratory distress syndrome (ARDS)
acute BO secondary to fume inhalation are caused by oxides of nitrogen
silo-filler's disease
defined as the accumulation of coal dust in the lungs and the tissues' reaction to its presence. -diagnosis of requires a history of exposure to coal dust -usually at least 10 years underground -and certain relatively characteristic abnormalities on the chest radiograph. What is this disease?
Coal Workers Pneumoconiosis
What is BOOP?
Bronchiolitis obliterans and Organizing Pneumonia necrosis of the airway epithelium & bronchiolitis obliterans (BO) & and occasionally bronchiectasis
What disease can present with any of the following? Macules Nodules Massive fibrosis Caplan's lesions Interstitial fibrosis
Coal Workers Pneumoconiosis
What can cause PAP -> pulmonary alverolar protienosis? How does it manifest and treated?
acute expose to silica -> sandblaster -large amount of surfactant is released in to air way -tx: lavage pt lung
What disease presents with nodules that are round & hard and often blue to green in color & microscopically are well demarkated and round and a whorled collagenous center with a more or less prominent infiltrate of dust laden macrophages around the periphery? round & hard and typically blue to green but may have other colors if other dusts are present. By microscopy they have fairly sharply demarcated round borders and a whorled collagenous center with a more or less prominent infiltrate of dust laden macrophages around the periphery. Hilar lymph nodes in silicosis are frequently enlarged and extremely fibrotic. They may calcify in an egg shell pattern which is visible roentgenographically
Silicosis
What disease has hilar lymph notes often enlarged and extremely fibrotic and may calcify in an egg shell pattern which is visible roentgenographically?
Silicosis
Where is asbestosis usually found in the lung?
lower lung field
What disease can progress in the following way: Macules Silicotic nodules Progressive massive fibrosis Silica proteinosis Mixed dust fibrosis Diffuse interstitial fibrosis ? Lung cancer
silicosis
What disease has the pathological characteristic of ferruginous body that is mineral particle with iron-protein coats?
Asbestosis
What disease can present as any of the following? -Benign parenchymal lesions - fibrosis of airways & narrowing parenchymal disese - thinken and collagenation of alveolar wall -Benign pleural lesions -Neoplasms
asbestosis
What disease has the following gross and microscopic apperance? -gross: lung looks alot like consolidated & lobar pnuemonia white dense apperance -microscopically: alveolar wall thickening see dense collegen accumulate in lower lobe on plueral surface
asbestosis
What disease presents with pleural plaques & pleural fibrosis & pleural effusions and pleural pseudotumors that do not necesssary develop into malignacies?
asbestosis
What is EAA (extrinsic allergic alveolitis)?
Extrinsic allergic alveolitis (EAA) is a hypersensitivity response to the inhalation of a variety of organic dusts. Allergic Alveolitis the type III hypersensitivity reaction results in interstitial changes with physiological impairment typical of restrictive disease. The existence of granulomas suggests a type IV delayed hypersensitivity.
What disease presents with the following? ->Schaumann bodies (old calcified concretions representing the site of previous granulomas) may be found and provide an important clue to the diagnosis.
EAA
REM sleep is characterized by which of the following sleep spindles high amplitude slow waves muscle atonia K complexes
C
Which of the following is a characteristic change in sleep architecture with aging? decreased REM sleep decreased sleep efficiency increased slow wave sleep decreased cycling time between NREM and REM sleep
B
How is sleep characterized in children?
longer total sleep time increased slow wave and REM sleep
How is sleep characterized in the elderly?
-decreased sleep efficiency -daytime napping -decreased slow wave sleep -rem sleep fragmented and dec rem sleep
How do the following relate to sleep? -Develop regular sleep habits -Slow down and unwind before bedtime. -Bedroom should be dark & cool and quiet. -Daily exercise & best performed late afternoon. -Light snack before bedtime
The “Do’s” of Good Sleep Hygiene
How do the following relate to sleep? -Napping during the day. -Forcing your self to sleep. -Taking problems to bed. -Strenuous mental and physical activities just before bedtime. -Use of caffeine or alcohol or tobacco just before bedtime. -Reading or eating or watching TV in bed.
The “Don’ts” of Good Sleep Hygiene
How are sleep disorders classified?
A. Insomnias: B. Sleep-related breathing disorders: C. Hypersomnias not related to a breathing disorder: D. Circadian rhythm disorders: E. Parasomnias: F. Sleep-related movement disorders:
What sleep disorder manifest as follows? these disorders manifest as either difficulty initiating or maintaining sleep; adjustment sleep disorder or psychophysiologic insomnia or limit-setting sleep disorder or sleep-onset association disorder. or excessive sleepiness; they are not secondary to other medical/psychiatric disorders.
Insomnias
What sleep disorder is characterized by abnormal breathing at night; obstructive sleep apnea; central sleep apnea?
Sleep-related breathing disorders
What sleep disorder is characterized by excessive daytime sleepiness without evidence of a breathing disorder; narcolepsy or insufficient sleep syndrome?
Hypersomnias not related to a breathing disorder
What sleep disorder is characterized by misalignment between the patient’s sleep pattern and that which is desired or regarded as the societal norm; shift work sleep disorder or time zone change syndrome --> delayed sleep phase syndrome?
Circadian rhythm disorders
What sleep disorder is characterized as clinical disorders that are undesirable phenomena that occur predominately during sleep. They are often more disruptive to a bed partner than to the patient. Many of them are more predominant in childhood. Examples include: 1. Arousal disorders: sleep walking & night terrors 2. Associated with REM sleep: nightmares & sleep paralysis & REM behavior disorder 3. Other: sleep enuresis (bedwetting)
Parasomnias
What sleep disorder is characterized by abnormal movements during sleep; restless leg syndrome?
Sleep-related movement disorders
What is a Polysomnography?
refers to an overnight study during which multiple body functions are monitored simultaneously (sleep study)
How are sleep disorders dx?
1st -->Screening for sleep disorders begins with the primary care physician. All patients should be asked the following during the review of systems: (part of history taking) How many hours of sleep do you get at night? Do you have trouble falling asleep or staying asleep during the night? Are you excessively sleepy during the day? Do you snore? 2nd--?Many patients referred to a sleep center will undergo polysomnography (sleep study)
Type of insomina? usually <1 week; precipitated by anxiety/emotion producing life event
Transient insomnia (adjustment sleep disorder)
Type of insomina? up to several weeks; temporary stressful experiences or inability to adjust sleep-wake cycle to new needs
Short-term insomnia
Type of Insomnia? months to years; many possible causes
Chronic insomnia
What are common causes of chronic insomina?
1. Sleep-related disorders a. Inadequate sleep hygiene b. Disruptive or irregular sleep-wake schedule c. Obstructive sleep apnea d. Restless leg syndrome 2. Medication/drug-related: extended use of sleep medications or other medications that interfere with sleep or excessive use of alcohol and other drugs of abuse. 3. Medical disorders: chronic pain syndromes & GERD & asthma 4. Psychiatric disorders: particularly mood and anxiety disorders
What sleep disorder is characterized with feeling sleepy in times other than after lunch or early evening or during times requiring alertness such as in a meeting or while driving?
Excessive Daytime Sleepiness (EDS)
What are determinants of physiological sleepiness?
1. Quantity of sleep 2. Quality of sleep 3. Circadian rhythms 4. Drugs 5. Central nervous system
What is the Consequences of EDS?
1. Problems in vigilance cognitive function & memory/concentration and mood. 2. These problems lead to deterioration in: a. School/job performance b. Social relationships/family life c. Driving skills
How is EDS dx?
Multiple Sleep Latency Test (MSLT): an objective test of sleepiness. Measures the tendency to fall asleep while lying in a quiet & dark bedroom at 4 times during the day. a. Based upon assumption that sleepiness is a physiological need that leads to a tendency to fall asleep. b. Normal daytime sleep latency is >15 min in well-rested adults; there should be no REM sleep during the 20 minute nap. -->True disease seen if pt falls aspleep within 5 min
What is the key factor in the effect of NREM sleep on ventalation?
Loss of wakefulness stimulus to breathe
What are characteristic effects of NREM sleep on ventalation in normal/healthy individual?
dec TV -->slight inc in PCO2 reduced airway activity -> muscles are not maintaining dilation -more narrow -> so inc resistance -dec alveolar ventiation
When is ventilation becomes dependent on chemorecepter and mechanorecepter stimulus?
NREM SLEEP
What effects does NREM sleep have on PO2 and PCO2?
PO2 - stays the same PCO2 - slight inc
How is sleep apnea defined?
-cessation of airflow for > 10 seconds -classified as obstructive or central or or mixed
type of apnea? - Mainly in stages 1 and 2 - Related to hypocapnic inhibition and fluctuations in sleep state - Common in congestive heart failure (Cheyne-Stokes respiration). - 45% of patients with stable congestive heart failure have sleep apnea mostly central in etiology
central apnea
How does central apnea present on a polysomnogram?
-No airflow for > 10 sec. - NO FLOW -No respiratory effort.. - NO EFFORT -SAO2 desaturation
How does obstructive apnea present on a polysomnogram?
• No airflow for > 10 sec. - NO FLOW • respiratory effort. - SEE EFFORT • SAO2 desaturation
Type of Apnea?? The occurrence of upper airway obstruction during sleep requires three components: (1) A susceptible upper airway in terms of dimensions and compliance (2) Decrease "tone" in the upper airway (3) A collapsing transmural pressure is required for upper airway closure to occur
Obstructive Apnea
obstructive or central or mixed: which is clinically significant?
obstructive
What symptoms are seen with sleep apnea while sleeping?
- Gasping or snorting - Witnessed apneas - Sudden or jerky body movements - Restless sleep
When are the following symptoms seen in a pt suffering from sleep apnea? - Wake up feeling non-refreshed - Morning headache dry or sore throat - Personality changes > problems with memory/concentration -day time sleepiness
These are sx seen while awake
How do the following relate to sleep? - Sleep-related breathing disorders - Narcolepsy - Idiopathic CNS hypersomnolence - Psychiatric disorders - Periodic limb movements of sleep - Chronic use of drugs or alcohol - Other medical disorders - Periodic hypersomnias - Insufficient sleep - Sleep-wake cycle disorder - Long sleeper
These are causes of excessive daytime sleep
What are the cardiac consequenses of Obstructive Sleep Apnea (OSA)?
a. Nocturnal arrhythmias - PVCs correlate with O2 desaturation if O2 sat reaches below 60% - Bradycardia b. Decreased SV and CI during apneic events. c. Systemic hypertension -->VERY IMP CONSQ OF SLEEP APNEA*** - Higher incidence of OSA in patients with essential HTN - Higher urinary catecholamine levels - Systemic hypertension is more common in patients with sleep apnea/hypopnea independent of age gender and body weight. - Sleep apnea may be a cause of "idiopathic" hypertension. d. Cor pulmonale - Only in patients with lung disease and daytime hypoxemia
What is an important cardiac consequense of sleep apnea?
systemic HTN
Why would a pt with obstructive sleep apnea develop cor pulmonale?
pt may also have lung disease and daytime hypoxemia
What are these risk factors associated with? Previous history of venous thromboembolism Heart disease: CHF atrial arrhythmias Malignancy-especially adenocarcinoma Trauma or major surgery Pregnancy or puerperium Estrogens: exogenous intake Paralysis or profound immobility Increasing age Congenital or acquired clotting abnormalities Obesity (relative risk 2.9) Hypertension (relative risk 1.9) Cigarette smoking 25 to 34 cig/day-relative risk 1.9 >35 cig/day- 3.3 relative risk
pulmonary embolism and DVT
When does a pt develop RV failure in relation to the pulmonary vascular bed?
Occlusion of more than 75% of the pulmonary vascular bed also local mediator release and hypoxic pulmonary vasoconstriction may add to the effects of mechanical occlusion
What gas exchange abnormalities are seen in a pulmonary embolism?
Increased dead space ventilation Hypoxemia Increased (a-A) CO2 gradient and increased VD/VT. Increased dead space is typical of PE but not specific Patients with PE typically hyperventilate Low PaCO2 Hypoxemia- can be very mild.
When do the following clinical sx present? Dyspnea Tachycardia Pleuritc Pain Cough CXR non-specific and may present with: Atelectasis or parenchymal density Pleural Effusion Pleural based opacity Elevated diaphragm
PE
What respiratory change causes the following? Atelectasis Localized bronchoconstriction Post-embolic pulmonary edema Intracardiac shunt if PA pressures are very high
Low V/D leading to hypoxia due to pathophysiologic effects of PE
What is the first test that should be done if PE suspected?
Measurement of D-dimer in the Blood A fibrin degradation product Produced by plasmin-mediated proteolysis of cross linked fibrin Elevated levels usually occur with thromboembolic disease Non-specific (e.g. increased by aging & inflammation & cancer) Abnormal result has a low positive predictive value. Sensitivity is influenced by clinical probability Low D-dimer + low clinical likelihood are highly sensitive for VTE A negative test can exclude pulmonary embolism if clinical probability is low Cannot exclude the diagnosis if clinical probability is high
When suspecious of PE -> what test is used to visualizes the perfusion of the lung?
Ventilation Perfusion Scan
Why is Contrast Venography no longer used in the of PE?
expensive invasive phlebitis & dye reactions & venous access may be inadequate.
When is a echocardiogram used in a pt with PE?
To assess extent of pulmonary outflow obstruction and pt prognosis
What respiratory measures are made duing a polysomnography?
-Airflow at nose and/or mouth: used to diagnose hypopneas/apneas -Respiratory movements: allow differentiation of apneas into subtype -Pulse oximetry: to measure oxygen saturation during the night
What are 2 key ways to prevent PE and DVT?
Low dose of anticoagulation is effective in reducing the risk Mechanical devices such as pneumatic compression devices
T or F -> Anticoagulation does influence the existing clot; handled by the patient’s fibrinolytic system.
F
T or F -> Heparin is the prototype anticoagulant -> followed by coumadin
T
T or F -> Fibrinolysis may be used if hemodynamic compromise is present.
T
When anticoagulants and fibrolytics are contraindicated what other measure is taken to avoid DVT/PE?
mesh filter is placed in the inferior vena cava to prevent clot migration to the pulmonary vascular bed
Measurement of physiologic sleep tendency is best performed in which of the following situations? in a dark quiet room listening to a lecture driving a car during attending rounds
A
The propensity for sleep is highest during which portion of the day? 6am – 12pm 12pm - 6pm 6pm – 12am 12am – 6am
D
Which of the following elements of a patient history is critical for determining the etiology of daytime sleepiness? medication history tobacco history surgical history family history
A
The following are refered to collectively as what term? a. Homeostatic sleep drive b. Biologic clock - set at 25hr c. Social/external factors i. Sleeping environment: noise & light & safety ii. Emotional: fear & anxiety & stress & elation & sadness iii. Effects of others: co-sleepers & infants/children iv. Drgus/medications d. Intrinsic illness i. Psychiatric disorders: depression ii. Neurologic disorders: dementia iii. Medical disorders: pain & asthma & GERD & heart failure
Determinants of sleep
Why is the capillary bed able to increase its volume 2-2.5 times?
The system also has a high capacitance -> so that an increase in C.O. results in recruitment and distension of capillaries rather than a large increase in pressure.
T or F: The normal pulmonary circulation is low pressure -> low resistance system -> and high capacitiance with minimal vascular musculature when compared with systemic vessels.
T
What is the only cause of cor pulmonale?
hypoxia NOT CHF
What structural dysfxn in heart can lead to PH?
Mitral stenosis Initial passive increase in PA pressure can lead to vasoconstriction and remodeling and persistent pulmonary hypertension
What illnesses can most effect sleep?
Psychiatric disorders: depression Neurologic disorders: dementia Medical disorders: pain & asthma & GERD & heart failure
When are "tumorlets" due to endothelial cell dysfxn seen?
in primary htn seen in young women -also known as Pulmonary arterial hypertension may be idiopathic and sporadic (IPAH) -rare
What is the characteristic pathologic finding in Idiopathic pulmonary arterial hypertension -> formerly called “primary htn”?
plexogenic lesions are seen in the vessels -The narrowing or obliteration of vessels leads to increased resistance and increased pulmonary pressures.
Which of the following for Pleural Effusion is false? A. Increase in hydrostatic pressure: congestive heart failure B. Increase in oncotic pressure: nephrotic syndrome C. Decrease in pressure in pleural space: lung collapse or lobar atelectasis D. Increased permeability of the microvascular circulation due to inflammatory mediators: pneumonia
B
What disease presents as follows? Symptoms: dyspnea and pleuritic chest pain Signs: dullness to percussion & absence of fremitus & diminished/absent breath sounds & friction rub
Pleural Effusions
When is thoracentesis indicated?
-to establish the etiology of a pleural effusion -relief of symptoms due to large pleural effusions -drainage of infected fluid
When is a pleural biopsy?
an exudate effusion of unknown etiology -> particularly if malignancy or TB suspected
When is a thoracentesis done on a pt possibly with pleural effusion?
when there is a substancial amt of pleural fluid & > 10mm thick
Transudate .or. Exudate? when systemic factors influence the formation and absorption of pleural fluid are altered. Examples: congestive heart failure & cirrhosis.
Transudate
Transudate .or. Exudate? when local factors that influence the formation and absorption of pleural fluid are altered. Examples: pneumonia malignancy.
Exudate
Transudate .or. Exudate? Pleural fluid protein to serum protein ratio =0.5 and/or Pleural fluid LDH to serum LDH =0.6 and/or Total pleural fluid LDH > 2/3 the upper limit of normal for serum LDH if no serum values available: Pleural fluid LDH > 45% of serum upper limit of normal and/or Pleural fluid cholesterol > 45 mg/dL and/or Pleural fluid protein > 2.9 g/dL
Exudate
Transudate is due to CHF & Cirrohsis or Nephrotic Syndrome. T or F
T
If pH < 7.20 in exudate -> what could be the possible causes of the pleural effusion?
:complicated parapneumonic effusion or empyema & malignancy & rheumatoid arthritis
What type of effusion presents with the following values and how is it tx? pH 7.0 – 7.20 & glucose = 40 mg/dL LDH =1000 IU/L; negative Gram stain/culture
Borderline parapneumonic effusion: treatment is repeat thoracentesis in 6-12 hours: -if no change/improvement in pH can treat as a typical parapneumonic effusion; -if pH or glucose are worse -> treat as complicated parapneumonic effusion
What type of effusion presents with the following values and how is it tx? pH =7.20 & glucose =40 mg/dL & Gram stain/culture negative;
Typical parapneumonic effusion: generally not associated with loculation; -treatment is continuance of antibiotics alone
What type of effusion presents with the following values and how is it tx? pH <7.0 & glucose <40 mg/dL & Gram stain/culture positive
Complicated parapneumonic effusion: can become loculated; treatment includes placement of a chest tube ± thrombolytics
What type of effusion presents with frank pus obtained at thoracentesis and how is it tx?
Empyema: ; needs chest tube ± thrombolytics; often needs surgical decortication after healing
What disease whould you suspect if exudate with lymphocytosis?
TB
If excudate obtained from thoracentesis has Triglyceride level >110 mg/dL -> what is suspected?
chylothorax
If excudate obtained from thoracentesis has : presence of blood in the pleural space -> what is suspected?
hemothorax
consequence of a diagnostic of therapeutic procedures; most common causes are central line placement & thoracentesis and bronchoscopy.
Iatrogenic pneumothorax
result of penetrating or nonpenetrating injury to the chest
Traumatic pneumothorax
acute chest pain and dyspnea. may have decreased breath sounds on effected side in tall & thin body habitus; tobacco abuse type of pnemothorax cause tx
Primary spontaneous pneumothorax Usually due to rupture of apical pleural blebs or cystic spaces which lie within or immediately under the visceral pleura Treatment is needle aspiration of air
type of pneumothorax most commonly caused by COPD & pneumocystis carinii pneumonia in AIDS pt
Secondary spontaneous pneumothorax
type of pneumothorax with symptoms of dyspnea & tachycardia & tachypnea & distended neck veins and hypotension. Decreased breaths sounds on effected side. Trachea is deviated. See most often in mechanically ventilated pts how is it treated
Tension pneumothorax: Medical emergency: if diagnosis suspected -> proceed directly to placing a large-bore needle into the pleural space through the second anterior intercostal space.
What type of pnuemothorax is considered to be a Medical emergency?
Tension pneumothorax
What anti-coag binds to AT and has a long polysaccride chain/tail that binds to thrombin?
UFH
What is the neg effect of long polysaccride chain/tail in UFH?
complex with factor 4 - thrombin which lead to drop in plates and anti-coaguation
LMWH OR UFH -Can be given SC for therapeutic purposes and therefore can be used for outpatient treatment and peri-procedural bridge therapy. -Slightly lower incidence of heparin-induced thrombocytopenia -No need to monitor PTT useful if blood draws are not possible -Alternative to warfarin when INR cannot be routinely obtained or warfarin is contraindicated (e.g. pregnancy)
LMWH
Warfarin or LMWH OR UFH dosing based on weight?
LMWH & UFH
Warfarin or LMWH OR UFH Does not dissolve the clot but prevent its propagation and growth
LMWH & UFH
Warfarin or LMWH OR UFH Completely neutralized by protamine
UFH
Warfarin or LMWH OR UFH renally eliminated
LMWH
In an exudate what could be the cause of the following values? Neutrophils: if >50% Lymphocytes: if >50% Eosinophils: if >10% LDH: LDH >500:
Neutrophils: if >50% acute process including parapneumonic effusion pulmonary embolus & pancreatitis Lymphocytes: if >50% chronic process including tuberculosis and malignancy Eosinophils: if >10% blood or air in pleural space or drugs or Churg-Strauss LDH: LDH >500: complicated parapneumonic effusion & malignancy & rheumatoid arthritis
Warfarin or LMWH OR UFH Inhibits the synthesis of vitamin k dependent clotting factors II / VII / IX / and X.
Warfarin
Warfarin or LMWH OR UFH develop skin necrosis in pt with protien C and S deficiency
Warfarin
Warfarin or LMWH OR UFH desired INR range in a patient is 2-3.
Warfarin
Warfarin or LMWH OR UFH antagonized by green leafy veg and Enteral supplements contain soy protein
Warfarin
Warfarin or LMWH OR UFH rx with Sulfamethoxazole-trimethoprim to increase INR
Warfarin
How is PH defined?
mean PA pressure greater than 25 mm Hg at rest or greater than 30 mm Hg on exertion normal = 12 to 16 mm Hg
Sarcoidosis & histiocytosis X & lymphangiomatosis can lead to vascular inflamation and pulmonary hypertension. T or F
T
Smooth muscle membrane changes and release of endothelial factors can both cause what condition leading what condition?
hypoxia
What is the main reason why COPD pt develops PH?
hypoxia
What is the most powerful and most common stimulus for pulmonary vasoconstriction?
hypoxia
What part of sleep is charactes with the following? -decreased metabolic rate with reduced minute ventilation -reduced tidal volume -no change breathing frequency -decreased heart rate (parasympathetic predominance) -dec blood pressure -normal thermoregulation
NREM (Non-Rapid Eye Movement)
What stage of sleep is characterized by transition between wakefulness and sleep; often perceive that you are still awake?
NREM (Non-Rapid Eye Movement) sleep Stage N1
What stage of sleep is characterized by true sleep in that thoughts now are short fragmented?
NREM (Non-Rapid Eye Movement) sleep Stage N2
What stage of sleep is also known as slow wave sleep; little or no mentation?
NREM (Non-Rapid Eye Movement) sleep Stage N3
What waves characteristics are seen in EEG when first starting to sleep?
waves at high freq and low amplitude
What waves characteristics are seen in EEG when moving from N1 stage to N3 stage in sleep?
waves get taller and slower
What part of sleep is associated with unstable cardiopulmonary system & variable ventilation & heart rate and blood pressure as well as loss of thermal regulation (Poikilothermic state)?
REM (Rapid Eye Movement) Sleep
What stage of sleep is characterized with sleep spindles and K complexes?
Stage 2
What stage of sleep is associated with waves that are of high amplitude and low frequency?
Stage 3 or Delta sleep
What stage of sleep has EEG characteristics with being awake with sawtooth waves?
REM sleep
What is sleep architecure?
refers to the overall structure of the sleep stages during the night. -starts with Stage 1 and 2 predominate during the night and are the first stages seen during the night -Slow wave sleep predominates in the early part of the night; the amount of slow wave sleep during the night decreases with age. -REM sleep first appears about 90-110 minutes after sleep onset. The first REM period is short. REM periods then cycle with NREM periods approximately every 90 minutes. The REM periods become longer during the later part of sleep.
LMWH or UFH or Warfarin true steady state reached in 12 to 14 days
Warfarin
bind directly to thrombin and inhibit its action.
Direct Thrombin Inhibitors (DTI): Lepirudin and argatroban
indicated for anticoagulation in patients with HIT.
Lepirudin and argatroban
Lepirudin or argatroban hepatically metabolized by liver -> safe to use in pt with renal dysfxn
argatroban
A pentasaccharide that selectively inhibits factor Xa activity
Fondaparinux
-renal elimination -Approved for treatment of deep venous thrombosis (DVT) pulmonary embolism (PE) and prophylaxis of DVT/PE in major orthopedic surgery. -safe in pt with HIT
Fondaparinux
Lyse thrombi by catalyzing the formation of plasmin from its precursor plasminogen. Plasmin lyses clot by breaking down the fibrinogen and fibrin contained in a clot.
Fibrinolytic (thrombolytic) Agents tissue plasminogen activator (TPA) or Alteplase; Reteplase; Tenecteplase.
Use in patients with confirmed PE and systemic hypotension is widely advocated.
Fibrinolytic (thrombolytic) Agents
Intracerebral hemorrhage is the most feared bleeding complication. Risk increases with age.
Fibrinolytic (thrombolytic) Agents