Respiratory System Part 3 For Radsci 350

Front 1

Neoplastic Disorders of the Lungs

Back 1

1. Bronchogenic Carcinoma
2. Pulmonary Metastases
3. Lymphoma

Front 2

Bronchogenic Carcinoma

Back 2

Arises from the mucosa of the bronchial tree.
- is the common malignant neoplasm.
- precise cause unknown but has been closely linked to smoking and to the inhalation of cancer-causing agents such as air pollution, exhaust gases and industrial fumes.

Front 3

Types of bronchogenic carcinoma

Back 3

- squamous carcinoma
- adenocarcinoma
- bronchiolar (alveolar cell) carcinoma
- small cell (oat cell) carcinoma

Front 4

Squamous Carcinoma

Back 4

typically arises in the major central bronchi and causes gradual narrowing of the bronchial lumen

Front 5

Adenocarcinomas

Back 5

Usually arise in the periphery of the lung rather than in the lareger central bronchi.

Front 6

Bronchiolar (alveolar cell) Carcinoma

Back 6

Lease common type of lung tumor.

Front 7

Small Cell (oat cell) Carcinomas

Back 7

Cause bulky enlargement of hilar lymph nodes, often bilaterally.

Front 8

Diagnosing Bronchogenic Carcinomas

Back 8

May be diagnosed by detection of cancer cells in teh sputum, but usually requires biopsy of the tumor during bronchoscopy or a needle biopsy.

Front 9

Radiographic Appearance of Bronchogenic Carcinomas

Back 9

These produce a broad spectrum of abnormalities that depend on the site of the tumor and its relationship to the bronchial tree. Two ways it might appear:
1. discrete mass
2. undetectable and identifiable only by secondary changes

Front 10

Airway obstruction and Bronchogenic Carcinomas

Back 10

Airway obstruction by bronchogenic carcinoma may cause atelectasis of a segment of lung and often leads to pneumonia that develops in the lung distal to the obstructed bronchus.

Front 11

Air Bronchogram Sign

Back 11

An important radiographic sign differentiating postobstructive pneumonia (bronchogenic carcinoma w/airway obstruction) from a simple inflammatory disease. An air bronchogram sign will not be visible in pneumonia caused by a bronchogenic carcinoma.

Front 12

Earliest sign of Bronchogenic Carcinoma

Back 12

A unilateral enlargement of the hilum is often the earliest sign of bronchogenic carcinoma. The enlarged hilum represents either a primary carcinoma arising in the major hilar bronchus or metastases to pulmonary lymph nodes from elsewhere in the lungs.

Front 13

Cavitation

Back 13

Cavitation often occurs in bronchogenic carcinoma. It represents central necrosis of the neoplasm.

Front 14

Treatment for Bronchogenic Carcinoma

Back 14

Most commonly treated with surgical resection of the lobe. Radiation therapy and chemotherapy may be used as a palliative measure.

Front 15

Progression of Bronchogenic Carcinomas

Back 15

The prognosis is poor due to direct lymphatic spread of the tumors. Distant metastases most often include the bones. Of all types, small cell carcinomas grow most quickly.

Front 16

Pulmonary Metastases

Back 16

1/3 of patients with cancer develop pulmonary metastases. It may develop from hematogenous or lymphatic spread from musculoskeletal sarcomas, myeloma, and carcinomas of the breast. Primary lung lesions may metastasize by spread through the bronchial tree.

Front 17

Radiographic Appearance of Pulmonary Metastases

Back 17

Hematogenous metastases - appear as multiple, relatively well-circumscribed, round or oval nodules throughout the lungs.
Lymphangitic metastases - appears as coarsened interstitial markings that have an irregular contour and are poorly defined. Found most prominently in the lower lobes and may cause pulmonary edema.

Front 18

Treatment of Pulmonary Metastases

Back 18

Treatment includes surgical resection, radiation therapy, and chemotherapy, but all are just palliative.

Front 19

Bronchogenic Carcinoma Facts

Back 19

Squamous Cell - is centrally located, accounts for 80%, and is slow growing and slow to metastasize so it has the best prognosis. Is mostly what smokers get.
Pulmonary Adenocarcinoma - Has a faster growth rate so prognosis is worse (down to 15% survival rate). Usually non-smokers.
Small Cell Carcinoma - Create multiple lesions, is diffuse, so metastasizes very quickly. Prognosis is down to about 10% survival rate.

Front 20

Lymphoma

Back 20

A proliferation of abnormal lymph cells in the lymph system. Can be Hodgkins (pediatric) or Non-Hodgkins.

Front 21

Indicators of lymphoma

Back 21

Usually creates a "full" sensation in lungs and is found in the mediastinal area. Beginning Indicators:
1. Wide mediastinal area
2. White markings in lungs due to pressure creating retention of fluid.

Front 22

Hodgkins Lymphoma

Back 22

Pediatric lymphoma. Has Reed Steinberg cells which makes it more susceptable to chemo. Higher survival rate (up to 40%).

Front 23

Non-Hodgkins Lymphoma

Back 23

Not as susceptable to chemo so harder to treat. Usually found in 30-50 yr olds. Often involves other organs besides lymph nodes such as spleen and intestines.

Front 24

DISORDER: Bronchial Adenoma

Back 24

Location: Glandular structure of major/segmental bronchi
Radiographic Appearance: Peripheral atelectasis (obstruction) with obstructive pneumonia
Treatment: Surgical resection

Front 25

DISORDER: Bronchogenic Carcinoma

Back 25

Location: Lung parenchyma
Radiographic Appearance: Solitary lesion, ill-defined including atelectasis with obstruction, hilar enlargement, and cavitation in the upper lung.
Treatment: Surgical resection, radiation therapy, and chemo.

Front 26

DISORDER: Pulmonary Metastases

Back 26

Location: Throughout the lungs
Radiographic Appearance: Multiple nodules with sharp margins, Snowstorm nodules, solitary nodule, and coarsened interstitial markings
Treatment: All treatments are palliative only - surgical resection, radiation therapy, and chemo.

Front 27

Atelectasis

Back 27

A condition (not a disease) in which there is diminished air within the lung associated with reduced lung volume. Most commonly caused by bronchial obstruction. Air cannot enter that part of the lung supplied by the obstructed bronchus so air is trapped in the lung and then absorbed in the bloodstream so the lung collapses.

Front 28

Causes of Atelectasis

Back 28

Obstruction due to neoplasm, foreign body, or mucous plug, pneumothorax, pleural fluid, or lung abscess.

Front 29

Radiographic Appearance of Atelectasis

Back 29

Most common: local increase in density caused by the airless lung.
Direct sign: displacement of interlobar fissures which shift and become bowed, conforming to the contour of the collapsed segment.
Indirect Signs: elevation of the hemidiaphragm, displacement of the heart, mediastinum, and hilum toward the atelectatic segment, and compensatory overinflation of the rest of the lung.

Front 30

Treatment of Atelectasis

Back 30

Since it often looks like fluid, they will do a decubitus to make sure it is atelectasis.
To treat, they try to locate and fix the cause and then use spirometry to increase lung volume.

Front 31

Cystic Fibrosis

Back 31

Hereditary disease process of the 7th chromosome which affects mostly caucasians. Cystic Fibrosis is an endocrine disorder where mucous membranes make excessive mucous with high chloride and salt content. This creates an electrolyte imbalance that hardens the mucous in the lungs.

Front 32

Cystic Fibrosis environment

Back 32

Creates a good environment for bacteria to grow so the heavy mucous is hard to expel and bacterial infection and complications arise. Causes sclerosing of the bronchial passages. Also affects the pancreas and creates sterility in 90% of men who have it.

Front 33

Signs and Symptoms of Cystic Fibrosis

Back 33

SOB, chronic deep cough, difficulty breathing, lower oxygen sats, decreased growth, fatigue, digestive difficulty. Shortened life expectancy!

Front 34

Diagnosis of Cystic Fibrosis

Back 34

Diagnosed with the "sweat test" - it identifies excessive chloride and salt in sweat indicating cystic fibrosis. Then they know to look at the 7th chromosome.

Front 35

Treatment of Cystic Fibrosis

Back 35

Treated with bronchodilators, chest physiotherapy (tapping on chest), and prophylactic antibiotics.

Front 36

Radiographic Appearance of Cystic Fibrosis

Back 36

Irregular thickening of linear markings throughout the lungs and invariable hyperinflation of the lungs.

Front 37

ARDS

Back 37

Stands for Adult (or Acute) Respiratory Distress Syndrome - not a disease process! Is severe, acute onset, unexpected, life-threatening respiratory distress in people with no underlying lung disorder. Often called "shock lung".

Front 38

What happens in ARDS

Back 38

The structure of the lung completely breaks down leading to massive leakage of cells and fluid into the interstitial and alveolar spaces. The structural breakdown results in sever hypoxemia caused by pronounced respiratory impairment in the ability to oxygenate blood.

Front 39

Radiographic Appearance of ARDS

Back 39

Patchy, ill-defined areas of alveolar consolidation scattered throughout both lungs (bilateral infiltrates - meaning white markings). Can look like pulmonary edema, but unlike PE, the heart remains normal size and there is no evidence of redistribution of blood to upper zones.

Front 40

Treatment of ARDS

Back 40

Diuretics to decrease fluid load. Oxygen therapy and ventilation to help breathing. May treat with steroids or epinephrine (antihistamine) to decrease inflammation.

Front 41

Mediastinal Emphysema

Back 41

A rupture in the mediastinal area which traps air in the mediastinum. Can cause damage to the lung tissue because it is pushing the lungs away from the vascular area.

Front 42

Radiographic Appearance of Mediastinal Emphysema

Back 42

Frontal Chest Radiographs: Lateral displacement of the mediastinal pleura which appears as a long, linear opacity that runs parallel to the heart border but is separted by the air.
Lateral Projection: Air collecting behind the sternum, extending in streaks downward and anterior to the heart.

Front 43

Subcutaneous Emphysema

Back 43

Caused by penetrating or blunt injuries that disrupt the lung and parietal pleura and force air into the tissues of the chest wall. Can hear crepitation (crackling) when papating the skin of the chest.

Front 44

Radiographic Appearance of Subcutaneous Emphysema

Back 44

Streaks of lucency outlining muscle bundles.

Front 45

Treatment of Mediastinal and Subcutaneous Emphysema

Back 45

If emphysema is minimal and does not progress then no treatment is needed. If the air does not absorb and increases, surgical resiction to block off the source of air may be required.

Front 46

DISORDER: Atelectasis

Back 46

Location: Obstruction of segment/lobe or lung collapse
Radiographic Appearance: Local increased density, platelike streaks
Treatment: Positioning of the patient with incentive spirometry

Front 47

DISORDER: ARDS

Back 47

Location: Lung structure breakdown
Radiographic Appearance: Patchy, ill-defined areas of consolidation
Treatment: Diuretics to decrease fluid build up and oxygen therapy and ventilation

Front 48

DISORDER: Mediastinal Emphysema

Back 48

Location: Air in bronchovascular sheath
Radiographic Appearance: Radiolucency running parallel to heart border
Treatment: If minimal, none...Surgical resection to prevent more air escape

Front 49

DISORDER: Subcutaneous Emphysema

Back 49

Location: Air in surrounding muscle bundles
Radiographic Appearance: Air streaks in muscle bundles
Treatment: If minimal, none...Surgical resection to prevent more air escape.

Front 50

Pleural Disorders

Back 50

1. Pneumothorax
2. Pleural Effusion
3. Empyema

Front 51

Pneumothorax

Back 51

The presence of air in the pleural cavity resulting in partial or complete collapse of the lung. The increased air in the pleural cavity compresses the lung, causing it to collapse. Caused by rupture from emphysema or spontaneous rupture, trauma, or iatrogenic causes.

Front 52

Symptoms of Pneumothorax

Back 52

Sudden, severe chest pain and dyspnea.

Front 53

Radiographic Appearance of Pneumothorax

Back 53

Hyperlucent area in which all pulmonary markings are absent. The radiographic hallmark of pneumothorax is the demonstration of the visceral pleural line which is outlined centrally by air within the lung and peripherally by air within the pleural space. May do a decub to identify.

Front 54

Treatment of Pneumothorax

Back 54

If large, then a chest tube drainage with suction is used to remove the air and prevent recurrence. It reates a negative pressure again to "reinflate" the lung.

Front 55

Tension Pneumothorax

Back 55

Emergency in which air continues to enter the pleural space but cannot exit. Causes complete collapse of the lung and depression of the hemidiaphragm. The heart and mediastinal structures shift towards the opposite side. Can be fatal.

Front 56

Pleural Effusion

Back 56

The accumulation of fluid (plasma) in the pleural space. Most common causes: CHF, PE, infection such as TB, pleurisy, neoplastic disease, and connective tissue disorders. BASICALLY, a vascular obstruction of some sort causing fluid to move into the pleural space.

Front 57

Radiographic Appearance of Pleural Effusion

Back 57

Blunting of the costophrenic angle and upward concave border of the fluid level. Small pleural effusions are seen best on laterals. Larger amounts of fluid produce a homogeneous radiolucency (whiteness) that may obscure the diaphragm and borders of the heart. Massive effusions may compress the adjacent lung and displace the heart and mediastinum to the opposite side.

Front 58

Treatment of Pleural Effusion

Back 58

Thoracentesis to remove fluid and finding the cause and fixing it.

Front 59

Back 59

Anatomy of the Heart

Front 60

Circulation of Blood Through the Heart and Lungs

Back 60

Oxygen-poor blood from the body enters the Right Atrium via the IVC and SVC. This blood flows from the Right Atrium into the Right Ventricle via the Tricuspid valve. The blood leaves the Right Ventricle via the Pulmonary valve and goes to the lungs via the pulmonary artery . Oxygen is exchanged in the capillary beds and then returns to the heart via the pulmonary vein. Oxygen-rich blood enters the left atrium, goes to the left ventricle via the bicuspid (or mitral) valve. It leaves the left atrium via the Aorta valve into the aorta and out to the body.

Front 61

Pulmonary Embolism

Back 61

Blood clots in the vasculature (pulmonary arteries) of the lungs, usually in the lower lobes due to preferential blood flow to these regions.

Front 62

Radiographic Appearance of Pulmonary Embolism

Back 62

Cardinal sign of a Pulmonary Embolism is a white "pie-shaped" wedge. The bigger the wedge, the bigger the embolism and therefore it is in a bigger vessel. May be accompanied by edema.

Front 63

Diagnosis of Pulmonary Embolism

Back 63

To diagnose, the patient is sent to Nuc Med (least invasive) for a perfusion/ventilation scan, to CT to use contrast to see the vasculature (large amount of contrast makes reaction probability high) or to angio, but this is most invasive.

Front 64

Treatment of Pulmonary Embolism

Back 64

Anticoagulant therapy and thrombolytics.

Front 65

Pulmonary AV Malformations

Back 65

An abnormal vascular communication from a pulmonary artery to a pulmonary vein. Can cause shunting of blood from arteries to veins so proper oxygen exchange does not occur and this can lead to cyanosis. Common in congenital hemolytic disorders or in trauma.

Front 66

Radiographic Appearance of AV Malformations

Back 66

Round or oval lobulated soft tissue mass most commonly situated in the lower lobes.

Front 67

Treatment of AV Malformations

Back 67

A pulmonary angiogram can be done before surgical intervention to prove the diagnosis. A detachable balloon can be placed to block teh flow of blood through the connection.

Front 68

Acquired Heart Disease

Back 68

1. Coronary Artery Disease
2. Congestive Heart Failure
3. Pulmonary Edema

Front 69

Coronary Artery Disease

Back 69

Narrowing of the coronary arteries causes oxygen deprivation of the myocardium and ischemic heart disease. Narrowing of the lumen is usually due to the deposition of fatty material on the inner arterial wall. Damage to the cell wall (tunica intima) causes platelets to come in to fix it, then cholesterol (LDL) catches on the platelets causing sclerosing of the wall.

Front 70

What Coronary Artery Disease Does

Back 70

Occlusion of a coronary artery deprives an area of myocardium of its blood supply and leads to the death of muscke cells (mycardial infarction) in the area of vascular distribution. Can lead to CHF and be fatal.

Front 71

Radiographic Appearance of Coronary Artery Disease

Back 71

Chest radiographs mostly look normal so people are sent to have radionuclide perfusion,intravascular ultrasound, or CT. Definitive test is coronary arteriography.

Front 72

Treatment of Coronary Artery Disease

Back 72

Angioplasty and stent placement, cholesterol lowering through meds or diet, blood thinners, exercise, and open heart (bypass) surgery.

Front 73

Congestive Heart Failure

Back 73

CHF refers to the inability of the heart to propel blood at a rate and volume sufficient to provide an adequate supply to the tissues. Cause include cardiac abnormalities, hypertension, or any obstructive process that abnormally increases the peripheral resistance to blood flow.

Front 74

Radiographic Appearance of Left-Sided Congestive Heart Failure

Back 74

Left-sided heart failure produces an appearance of cardiac enlargement, redistribution of pulmonary venous blood flow (enlarged superior pulmonary veins and decreased caliber of the veins draining teh lower lungs, interstitial edema, alveolar edema (irregular, poorly defined patchy densities) and pleural effusions.
Causes include: coronary heart disease, valvular disease, and hypertension.

Front 75

Radiographic Appearance of Right-Sided Congestive Heart Failure

Back 75

Dilation of teh right ventricle and right atrium is present. Increased pressure may cause dilation of the SVC, widening of the right superior mediastinum, and edema of the lower extremeties. Also, elevation of the right hemidiaphragm due to enlargement of congested liver.
Common causes: pulmonary valvular stenosis, emphysema, and pulmonary hypertension from pulmonary emboli.

Front 76

Cardinal Sign of Congestive Heart Failure

Back 76

For both right and left-sided CHF, cardiomegaly is a cardinal sign due to insufficient cardiac output.

Front 77

Treatment of Congestive Heart Failure

Back 77

Pull off excess fluid with drugs such as lasix. Low salt diet, no overexertion, and plethora of drugs for comfort measures such as diuretics, beta-blockers, antithrombotic therapy, digitalis, etc...

Front 78

Pulmonary Edema

Back 78

Abnormal accumulation of fluid in the extravascular pulmonary tissues. Most common cause is an elevation of the pulmonary venous pressure often due to left-sided heart failure.

Front 79

Pulmonary Edema Cardinal Sign and Radiographic Appearance

Back 79

"Bat Wing" sign - also called a perihilar haze due to the guazy look. It is a diffuse, bilaterally symmetric, fan-shaped infiltration that is most prominent in the central portion of the lungs and fades toward the periphery.

Front 80

Treatment of Pulmonary Edema

Back 80

Is the same as treatment for congestive heart failure.

Front 81

Congenital Heart Disease

Back 81

1. Ventricular Hypertrophy
2. Septal Defects
3. Aortic Disorders

Front 82

Ventricular Hypertrophy

Back 82

Enlargement of the right ventricle due to the atrial septal defect which is the failure of the foramen ovale to close after birth. Because the left atrial pressure is usually higher than the pressure in the right atrium, the shunting of blood between the atria from left to right causes increased pulmonary blood flow and overloading of the right ventricle. The right atrium is also enlarged.

Front 83

Atrial Septal Defect

Back 83

See card on Ventricular Hypertrophy

Front 84

Ventricular Septal Defect

Back 84

Hole between the two ventricles. Causes increased pulmonary blood flow and increased pulmonary venous return. This leads to diastolic overloading and enlargement of the left atrium and left ventricle.

Front 85

Patent Ductus Arteriosus Defect

Back 85

The ductus arteriosus is a vessel that extends from the bifurcation of the pulmonary artery to join the aorta just distal to the left subclavian artery. It is supposed to close soon after birth. Due to blood flow from the high pressure aorta to the pulmonary artery, there is increased pulmonary blood flow and excess volume of blood returned to the left atrium and left ventricle. On a radiograph you see enlargement of the left atrium and left ventricle, as well as the central pulmonary arteries. You also see a prominent aortic knob.

Front 86

Treatment of Septal Defects

Back 86

Small defects may resolve on their own. Larger defects may be treated by the use of prostoglandin synthetase inhibitors to achieve closure. Surgery may be needed to close holes.

Front 87

Tetralogy of Fallot (Blue-baby syndrome)

Back 87

Four abnormalities:
1. High ventricular septal defect
2. Pulmonary stenosis
3. Overriding of the aortic orifice above the ventricular defect
4. Right ventricular hypertrophy

Front 88

Radiographic Appearance of Tetralogy of Fallot

Back 88

Cardinal Sign is "boot-like" appearance of heart called coeur en sabot which indicates upward and lateral displacement of the apex of the heart.

Front 89

Treatment of Tetralogy of Fallot

Back 89

Surgical - must repair the ventricular septal defect to repair all of the other problems.

Front 90

Coarctation of the Aorta

Back 90

A narrowing or constriction of the aorta that most commonly occurs just beyond the branching of the blood vessels to the head and arms.

Front 91

Radiographic Appearance of Coarctation of the Aorta

Back 91

Rib notching from pressure erosion and missing aortic bulb on chest radiograph.

Front 92

Treatment of Coarctation of the Aorta

Back 92

Surgical repair to include one of the following three choices:
end-to-end anastomosis, patch aortoplasty, and left subclavian flap aortoplasty.

Front 93

Aortic Aneurysm

Back 93

When the vessel stays dilated and this weakens the walls. Can be caused by high blood pressure. Treatment can be to put a stent in, but also to find the cause and fix it. Visualized as an enlarged aortic bulb.

Front 94

Dissecting Aneurysm

Back 94

When the tunica intima pulls away from the tunica media. Creates a false lumen between the two tunicas.

Front 95

Radiographic Appearance of Dissection of the Aorta

Back 95

Due to the blood entering the wall of the aorta and separating the layers, we see a progressive widening of the aortic shadow with an irregular or wavy border. Often seen in those with Marfan's syndrome.

Front 96

Treatment of Dissection of the Aorta

Back 96

These are fatal if not treated immediately with surgery (grafts) or stents.

Front 97

Aortic Stenosis

Back 97

Narrowing of the aorta due to plaque formation.

Front 98

Infectious Disorders of the Heart

Back 98

1. Rheumatic Heart Disease
2. Pericardial Effusion
3. Pericarditis

Front 99

Rheumatic Heart Disease

Back 99

Rheumatic fever is an autoimmune disease that results from a reaction of the patients antibodies against antigens from a previous streptococcal infection. If left untreated, the major damage of the fever is to the valves of the heart (mitral and aortic). The allergic response causes inflammation of the valves. Small nodules develop around the valves and the thickened valves stick together rather than opening properly.

Front 100

Treatment of Rheumatic Heart Disease

Back 100

Prevention by treating the strep infection is the best approach. Once someone has rheumatic heart disease, it is treated with antibiotics, antiinflammatories, and restricted activity.

Front 101

Pericardial Effusion

Back 101

The accumulation of fluid within the pericarial space surrounding the heart. May result from bacteria, viruses, or neoplastic involvement.

Front 102

Radiographic Appearance of Pericardial Effusion

Back 102

Seen as an enlargement of the cardiac silhouette. However, since over 200 ml of fluid must have accumulated to see this, echocardiography is better suited for seeing pericardial effusion.

Front 103

Treatment of pericardial effusion

Back 103

Treatment depends on the cause. Pericardiocentesis is performed to remove the fluid buildup and a drain may be inserted.

Front 104

Pericarditis

Back 104

Infection of fluid around the pericardial sac. Use a needle to drain the fluid and antibiotics or antivirals.