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108 Cards in this Set
- Front
- Back
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What types of organisms do you see with lobar pneumonia? bronchopneumonia? how about interstitial?
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Lobar: Pneumococcus most frequently; you see an intra-alveolar exudate with consolidation that may affect the whole lund
Bronchopneumonia: S. Aureus, H. flu, Klebsiella, S. pyogenes--> patchy distribution involving one or more lobes; infiltrate from the bronchioles into the adjacent alveoli Interstitial (atypical pneumonia): caused by viruses (RSV and Adenoviruses) Mycoplasma (walking pneumonia) legionella and chlamydia--> these is diffuse patchy inflammation, localized to the interstialy areas at alveaolar walls. Usually a more indolent course than bronchopneumona--X ray looks worse than the patient does |
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What are the H1 blockers?
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First generation: diphenhydramine, dimenhydrinate, chlorpheniramine--- these have sedating effects, used for allergy, motion sickness and as a sleep aid
Toxicity: sedation, antimuscarinic and anti-alpha adrenergic Second Generation: Loratidine, Fexodenadine, Desloratiadine, Cetirazine-- are much less sedating because of decreased entry into the CNS, still used for allergy |
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What are some asthma drugs used to treat prophylactically?
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Cromolyn, Nedocromil: prevents the release of mast cells; not effective in an acute attack
Zafirlukast and Montelukast: Block the Leukotriene (D4) receptor to prevent inflammatory mediators |
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How does theophylline (methylxanthine) work?
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It is a phosphodiesterase inhibitor that causes bronchodilation by inhibiting phosphodiesterase, causing a decrease in cAMP hydrolysis
narrow therapeutic index, cardio and neurotoxicity, cyt p450 metabolism |
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How does Ipratropium work?
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It is a competitive Muscarinic antagonist, which prevents bronchoconstriction
also used for COPD |
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what is first line therarpy for chronic asthma?
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Corticosteroids
beclomethasone and prednisone--> these inhibit the synthesis of all cytokines, inactivate NFKappaB which induces the production of TNF alpha |
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What are some expectorants?
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Guaifenesin (robitussin) which removes excess sputum, but a large dose is necessary--> does NOT suppress the cough reflex
N-acetylcysteine (Mucormyst) can loosen mucous plus in CF patients, and also used as an antidote for tyelenol overdose |
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why not give oxygen rapidly to a COPD patient?
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chronic hypercapnia causes hypoxia to be the main respiratory stimulus (whereas normal people use increase pCO2 as the stimulus) so, high doses of Oxgen quickily may cause respiratory failure
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How does one present with lung cancer?
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hemoptysis, bronchial obstruction, wheezing, pneumonic coin lesions on X-ray film
mets to the lung are most common (breast) presents with dyspnea primary in the lung presents with a cough |
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What are the complications associated with Lung Cancer?
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SPHERE
Superior Vena Cava Syndrome Pancoast's Tumor Horner's Syndrome Endocrine (paraneoplastic) Recurrent Laryngeal Symptoms (hoarseness) Effusions (pleural or pericardial) |
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What lung cancers occur centrally? peripherally?
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central: squamous and small cell (oat cell)
Peripheral: adenocarcinoma, large cell carcinoma |
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What lung cancer may lead to lambert eaton syndrome?
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Small Cell--> also often associated with ACTH or ADH release
Lambert Eaton: autoantibodies against Ca++ channels Small cell carcinoma: has kulchitsky cells--> small blue, dark cells |
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what does the FEV1/FEV look like in obstructive lung disease
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obstructive: less than 80%
restrictive: you'd see either normal (80%) or high (more than 80) FEV1/FEV |
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What are some obstructive lung diseases?
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chronic bronchitis, emphysema, asthma and bronchiectasis
you see a decreased FEV1/FVC ratio you have a hard time expiring-- remember you have super high compliance, making inspiration easy, but no recoil to expire, causing air trapping |
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What is responsible for surfactant production from the type II pneumocytes?
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Cortisol from both mom and baby, stimulates surfactant production
L:S ratio of more than 2 indicates fetal lung maturity |
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Clara Cells
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nonciliated columnar, with secretory granules. secrete component of surfactant; degrade toxins and act as reserve cells
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Where should you look if you've aspirated a peanut while sitting up? while laying down?
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upright, lower inferior lobe, right side
Supine, superior portion of right inferior lobe |
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What structures, and at what levels do they pierce the diaphragm?
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T8: IVC
T10: esophagus, vagus T12: aorta, thoracic duct, azygous vein I ate 10 eggs at noon (12) |
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What are the muscles of respiration? During quiet breathing, during exercise?
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Quiet Breathing: inspiration is active (diaphragm), expiration is passive
Exercise: Inspiration: external intercostals, scalene muscle and sternomastoids Expiration: rectus abdominus, internal and external obliques, transversus abdominus, internal intercostals |
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Hypoxemia of Pulmonary Origin
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Increased A-a gradient
whereas extrapulmonary has normal A-a gradient |
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Calculation of A-a gradient
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PA02= Percent Oxygen (713) - arterial PCO2/.8
(.21)*713-(40*1.2)=100mmHg PA02 |
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What is the normal Pa02?
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95mmHg
so the normal A-a gradient is 100-95=5mmHg Medically significant A-a gradients are more greater than or equal to 30 |
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Medically significant A-a gradients?
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>30
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Causes of hypoxemia with an increased A-a gradient
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Ventilation Defect (airway collapse)
Perfusion Defect (PE) Diffusion Defect (Interstitial Fibrosis, or Edema) Right to Left Cardiac Shunts (Tetralogy of Fallot) |
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Nocturnal Cough
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GERD due to acid reflux into the bronchial tree at night or Bronchial Asthma: bronchoconstriction
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Productive Cough
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Chronic Bronchitis (smoking)
Bacterial Pneumonia Bronchiectasis |
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Drugs that cause a cough
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ACE inhibitors: inhibit the degradation of bradykinin causing mucosal swelling and irritation in the bronchial tree
Aspirin: causes an increase in LT-C-D-E4 (bronchoconstrictors) |
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What is the most common cause of hemopytis?
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Chronic Bronchitis
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What are some causes of hypoxemia with normal A-a gradients?
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respiratory depression (barbiturates or brain injury)
Paralyzed diaphragm or ALS (anterior horn degeneration) Upper airway blockage (food, epiglottisis (H. flu) Croup (parainfluenza) |
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What lung volumes and capactities cannot be measured by spirometry?
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Residual Volume, Total Lung Capacity and FRC
FRC: total amount of air in lungs after a normal expiration RV: volume of air in the lungs after a MAXIMAL expiration TLC: total amount of air in a fully expanded lung |
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what is tidal volume?
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The volume of air entering and leaving the lungs with normal breathing
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Forced Vital Capacity
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the total amount of air expelled after a maximal inspiration; normal is 5 liters
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FEV1
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normal is 4 Liters
FEV1/FVC is normally around 80% increased in restrictive diseases, decreased in obstructive |
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newborn turns blue when breastfeeding
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choanal atresia
unilateral or bilateral bony septum between the nose and the pharynx |
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Nasal Polyps in a child
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must rule out CF; order a sweat test--> nasal polyps are often associated with CF
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What are the most common types of polyps?
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Allergic Polyps--> most often seen in adults with a history of IgE mediated allergies
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What drugs are associated with nasal polyps?
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Aspirin and other NSAIDS
COX inhibititors leave the LOX open--> leukotrienes C, D, E4 are increased causing bronchoconstriction--> develop polyps |
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What complications are associated with OSA?
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Cor Pulmonale-- Right Ventricular Hypertrophy and pulmonary hypertension
See respiratory acidosis during apneaic episodes |
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Sinusitis
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Strep Pneumo is the most common pathogen causing sinusitis
maxillary: adults ethmoid: children sinusitis is most frequently caused by an URI; symptoms are caused by a blockage of drainage into the nasal cavity--> clinical findings include fever, pain over sinuses, nasal congestion |
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Nasopharyngeal Carcinoma
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assocaited with EBV, squamous cell carcinoma or undifferentiated cancer. Mets to cervical lymph nodes
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Laryngeal Carcinoma
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Smoking is the most common cause, though alcohol is synergistic with smoking
HPV (6 and 11) association, and the majority of the tumors are on the TRUE vocal cords keratinizing squamous cell carcinoma |
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Atelectasis
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Loss of lung volume due to inadequate expansion of the airways (collapse)
1. Resorption: airway obstruction (most common cause of fever 24-36 days after surgery) 2. Compression: tension pneumothorax or pleural effusion 3. Loss of surfactant |
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Surfactant production
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Cortisol and Thyroxine increase synthesis
Insulin inhibits synthesis Thus, Maternal Diabetes may cause RDS, along with C-section where you don't have the stress-induced increase in cortisol due to vaginal delivery |
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What are some causes, and ways to check on metabolic alkalosis?
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Loss of H ions (puking, NG suction)
Loss of Na+ followed by a loss of Cl- leading to reabsorption of HCO3- Increased Aldosterone Secretion (reabsorb Na+, excrete K, H and Cl- with a relative increase in HCO3-) Do a urine check of Cl- levels |
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What is the most common cause of pulmonary edema?
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Left heart failure
Starling Forces causing Pedema 1. Can see mitral stenosis, volume overload leading to increased hydrostatic pressure 2. or see decreased oncotic pressure with cirrhosis or nephrotic syndromes Injury 1. Infections (sepsis, pneumonia) 2. aspirations (drowning, gastric content) 3. Drugs (heroin) shock, massive trauma 4. High altitude |
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Pneumonia
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Community Acquired or Nosocomial
CA: majority are bacterial (strep pneumo) that are inhaled from an infected pateints, or aspiration of nasopharyngeal flora while sleeping Bronchopneumonia (acute bronchitis, and spreads locally to the lungs) or Lobar Pneumonia Signs: fever and productive cough, signs of consolidation Atypical CA-pneumonia often times mycoplasma pneumonia-- patchy interstitial pneumonia, NO signs of consolidation |
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How would you distinguish clinically signs of typical pneumonia from atypical pneumonia
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Atypical you don't see any signs of consolidation because it's generally interstitial, the alveolar are free of exudate
typical pneumonia (s. pnuemo) you have consolidation (dullness to percussion, increased vocal tactile fremitus, sound is better transmitted through consolidations |
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Nosocomial Pneumonia
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Epidemiology: severe underlying disease, antiobiotic therpay, immunosuppression. Most commonly comes from respirators
Pathogens are gram negative bacteria (pseudomonas aeruginosa--respirators) or E. Coli Gram Positive bacteria are Staph Aureus |
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pneumonia in immunocompromised patients
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CMV
Pneumocystisis Jiroveci Asperigillus Fumigatus you treat pneumocystis jiroveci with TMP-Sulfa for prophylacxis treatment |
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TB
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PPD does NOT distinguish an active from an inactive infection
kidneys are the most common extrapulmonary site of TB infection |
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Klebsiella Pneumonia
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Gram Negative fat Rod surrounded by a mucoid capsule
common cause of pneumonia in alcoholics, however s. pneumo is still the msot common pneumonia Currant Red sputum |
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psuedomonas aeruginosus
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green sputum (pyocyanin) gram negative fat rod covered with a capsule, water loving (most frequent cause of nosocomial pneumonia on respirators)
also most frequent cause of death to pneumonia in CF patients |
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Legionella Pneumophilia
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gram negative rod
water loving (water coolers, mists in the produce section, rainforests in zoos) may produce tubulointerstitial disease with destruction of the JGA leading to hypoaldosterone and hyporeninin |
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myocplasma
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military recruits, adolescents small confined areas
walking pneumonia insidious onset with low grade fever, may see cold agglutinins in the blood |
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Nonspecific beta agonists
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Isoproterenol: relaxes bronchial smooth muscle (beta 2) but adverse effect is tachycardia (b1)
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Beta 2 agonists
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Albuterol and Salmeterol: salmeterol is longer acting, whereas albuterol is used during an acute exacerbation
albuterol relaxes bronchial smooth muscle, salmeterol's adverse effects are tremor and arrhythmia |
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Theophylline
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INHIBITS PHOSPHODIESTERASE, thereby decreasing cAMP hydrolysis
usage is limited due to narrow therapeutic index (cardio and neurotoxicty) metabolized by P-450 |
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Ipratropium
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Competitive block of muscarinic receptors, preventing bronchoconstriction--> also used for COPD
iptratropium requires parasympathetics--> it is just blocking the constriction. So without a vagus nerve, you've got no working ipratropium |
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5-lipoxygenase inhibitor
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Zileuton
blocks conversion of arachianic acid into leukotrienes |
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Bosentan
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blocks endothelin, which is a potent vasoconstrictor that stimulates endothelial proliferation
used in the tx of primary pulmonary hypertension |
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hering breur reflex
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regulates lungs distension, affects the duration of inspiration and expiration, via the myelinated and unmyelinated C fibers in the lungs
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bronchial obstruction
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absent or decreased breath sounds of the affected area
the trachea will deviate TOWARD the side of the lesion decreased resonance and decreased fremitus |
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barrel shaped chest
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emphysema, where you have increased compliance, and less of a lung's tendency to collapse. Thus, the chest wall will have an increased tendency to expand--> higher FRC
Air trapping |
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What is vital capacity?
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TV + IRV + ERV
so it's total lung capacity, minus the residual volume |
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What is tidal volume?
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about 500 ml, the air that moves in and out of the lung with each breath
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what are some important lung products?
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Surfactant
Prostaglandins Histamine ACE (which inactivates bradykinin, which explains why ACEInhibitors increase bradykinin and cause cough, angioedema) Kallikrein (which activates bradykinin) |
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Collapsing Pressure
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2 (tension)/ radius
tendency to collapse on expiration as radius decreases |
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What is the role of ACE and of kallikrein in the lung?
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ACE inactivates bradykinin and kallikrein activates it.
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What is the physiological dead space?
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Vd= Tidal Volume * (PaCO2-PeCO2)/PaCO2
so it's the anatomical dead space of the conducting airways plus the functional dead space in the alveoli--> the apex of healthy lungs are the biggest contributor to functional dead space |
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Hemoglobin
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2 alpha and 2 beta chains, existing in 2 forms
taut: not much affinity for O2 relaxed: high affinity for O2 |
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fetal hemoglobin
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has lower affinity for 2,3 BPG than adult hemoglobin, and thus higher affinity for O2
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Right shifting the Oxygen Dissociation Curve
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Increased temperature, Cl-, H+, 2,3 BPG, and CO2 all favor the taut form more so than the relaxed form--> which means there is a lower affinity for Oxygen, and it'll unload at the tissues
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methemoglobin
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has increased affinity for CN-
Iron in the Ferric State (Fe3+) Treat with metheylene blue |
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How do you treat Cyanide Poisoning?
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use nitrites to oxidize hemoglobin to methemoglobin (Fe3+), which binds cyanide, allowing cytochrome oxidase to function; Use thiosulfate to bind this cyanide, forming thiocyanate, which can be renally excreted
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What does altitude do to the oxygen dissociation curve?
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shifts it RIGHT
along with CO2, Acid, DPG, exercise and Temperature |
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In what conditions are the lungs diffusion limited?
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emphysema, fibrosis
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pulmonary hypertension
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normal pulmonary artery pressure is around 10-14 mmHg
In Pulmonary HTN: is more than 25 mmHg or 35 during exercise results in atherosclerosis, medial hypertrophy, intimal fiborsis of the pulmonary arteries PRIMARY: due to inactivating mutation in BMPR2 gene (normally functions to inhibit smooth muscle proliferation) |
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BMPR2
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gene mutated in primary pulmonary HTN
BMPR2 normally inhibits vascular smooth muscle proliferation |
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Secondary Pulmonary HTN
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due to COPD, mitral stenosis, recurrent thromboemboli, autoimmune disease, left to right shunt, or sleep apnea
the course: severe respiratory distress which leads to cyanosis and RVH and death from decompensated cor pulmonale |
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Coccidiodes Imitis
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Spherule filled with endospores
San Joaquin Valley-- or desert bumps, valley fever See erythema nodosum, or subcutaneous nodules, flu like symptoms |
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Narrow Based Buds
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Cryptococcus
seen with bat droppings |
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Broad Based Buds
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Blastomycosis
see skin and bone-- and the skin lesions simulate squamous cell carcinoma |
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What do you see with bat droppings?
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cryptococcus neoforms and histoplasmosis
crypto: narrow based buds Histo: yeast filled macrophages |
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Dimorphic Fungi
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mold in soil
yeast in tisuue Histo, Blasto, Paracoccidio Coccidio: is not a yeast in tissue, but rather a spherule all of these may cause pneumonia, and may disseminate treatment: fluconazole or ketoconazole for local infections, and amphotericin B for systemic infections |
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Mycoplasma Pneumonia
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Walking Pneumonia--> insidious onset, nonproductive cough, diffuse interstitial infiltrate
X ray looks worse than the picture; high titers of cold agglutinin (IgM) NO cell wall, not seen on gram stain; it's the only bacterial membrane containing cholesterol treat: tetracycline or erythromycin mycoplasma is penicillin resistant because they don't have a cell wall mycoplasma is grown on Eaton's Agar |
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Opportunistic Fungal Infections
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Asperigillus (45 degree branching hyphae (colonizing, invasive and allergic)
Candida: yeast with pseudohyphae in culture at 20, germ tube formation at 37 is diagnostic (tx candida with nystatin for superficial, and amphotecerin B for disseminated) Cryptococcus Neoformans (narrow based buds, NOT dimorphic) latex agglutination detects polysaccaride capsule, soap bubble in brain Mucor and Rhizopus--> these are mold with irregular septae with wide branching angles, seen in DKA and leukemic patients |
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Wide-branching angle of irregular septae
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Mucor and Rhizopus Species
this is mold with irregular septae, seen in Leukemics and DKA. fungi may proliferate in blood vessels, causing infarction--> rhinocerebral frontal lobe abscess |
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Pneumocystis Jirovecii
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Causes diffuse interstitial pneumonia, most are aymptomatic unless immunocompromised. Diffuse bilateral CXR appearance
Dx: methenamine silver stain of the lung tissue Tx: TMP-SMX, pentamidine, dapsone Start prophylactic treatment when CD4 counts drop below 200 cells in HIV patients cysts look like crushed ping pong balls-- NEED silver stain |
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How do you treat sporothrix schenckii
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-- Cigar shaped budding yeast are visible in the pus
Treat with potassium Iodide (KI) or Itraconozaole |
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Lab Findings with Pulmonary Infarction
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Respiratory Alkalosis (arterial PCO2 is less than 33)
PaO2 is less than 80 mm Hg A-a gradient is INCREASED in all cases Abnormal Perfusion radionuclide Scan-- where the ventilation is normal, but the perfusion scan is abnormal Positive D-Dimers |
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What clinical signs are consistent with pulmonary hypertension
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Accentuated P2
Progressive Dyspnea and Chest Pain with exertion Left parasternal heave indicative of RVH Right Sided Failure due to Cor Pulmonale |
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Goodpasture's Syndrome
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Pulmonary Hemorrage with hemoptysis generally precede renal failure
you will see a linear pattern on EM of the kidney-- it's an anti-body against the noncollagenous alpha 3 chain of Collagen IV (type II hypersensitivity) |
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Interstitial Lung Diseases
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Pneumoconioses
Goodpasture's ARDS Sarcoidosis Hyaline Membrane Disease Wegener's Eosinophilic Granuloma (histiocytosis X) Drug Toxicity (bleomycin, amiodarone, busulfan) |
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Silicosis
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Most common occupational disease in the world
Quartz (crystalline silicone dioxide) most often implicated Foundries, Sandblsting, working in mines quartz is highly fibrogenic, deposits in the upper lungs--> quartz activates |
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How do you calculate the PAO2?
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150-Pco2/0.8
.8 is the respiratory quotient |
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What are some causes of hypoxemia with increased A-a gradient
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they are intrapulmonary problems
ventilation defect perfusion defect diffusion defect Right to Left shunt |
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Hypoxemia with a normal A-a gradient
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Respiratory Depression or Upper airway obstruction
Chest Dysfunction |
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resorption atelectasis
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airway obstruction prevents air from reaching alveoli
generally from mucous plug after surgery, aspiration of foreign material, or centrally located bronchogenic carcinoma clinical findings: fever and dyspnea, absent breath sounds and focal fremitus, ipsilateral elevation of the diaphragm and tracheal deviation-> inspiratory lag |
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Compression atelectasis
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Increased pressure causes the lung to collapse
tension pneumothorax and pleural effusion trachea will deviate away from the collapsed lung |
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typical community acquired pneumonia
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due to strep pneumo
alpha hemolytic, optochin sensitive--> strep pneumo is also a competent bacteria capable of taking up DNA from other bacteria that have died |
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patchy areas of consolidation in the lungs full of neutrophils in the alveoli and bronchi
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Bronchopneumonia
begins as an acute bronchitis, and then spreads locally into the lungs |
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What is the most common cause of atypical pneumonia?
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mycoplasm pneumonia
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What causes nosocomial pneumonia; contracted from respirators?
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Pseudomonas Aeruginosus
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what is the most frequent cause pulmonary thromboembolism?
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femoral veins--> 95%
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Restrictive Lung Disease
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Decrease of ALL lung volumes and capacities
decreased FEV1, but decreased FVC leads to an increased ratio often have the FVC the same as the FEV1 due to the increased lung elasticity |
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Silicosis
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quartz is most often implicated
in the upper lobes of the lung, it is highly fibrogenic. See eggshell calcifications and birefrigent particles surrounded by fibrous tissue |
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What complications are you at risk for in devloping pneumoconiosis?
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TB and lung cancer. Cor pulmonale and caplan syndrome (RA nodules in the lung + a pneumoconiosis)
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unexplained pleural effusion in a young woman?
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SLE until proven otherwise
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