Pulm answers

Normal lung:

Fluid accumulation within the pleural space = _______________________ (effusion)

Transudates are caused by __________________________________ (starling forces) and 3 examples of causes of transudates in the pleural space are:

1.

2.

3.

CHF/cirrhosis/Nephrotic syndrome

If you collect fluid from the pleural space and it turns out to be an exudate what would you expect the fluid to be composed of? Name 3 causes of exudates:

1.

2.

3.

increase cellularity, protein concentration, LDH, cholesterol

infection, malignancy, rheumatologic

Obstructive lung diease

How is the severity of COPD assessed?

FEV1/FVC ratio and FEV1 decrease

What major diseases are within the category of COPD?

Chronic bronchitis, emphysea, bronchiectasis, asthma

All of the following are associated with COPD mortality except:

·         R-sided heart failure

·         Pneumothoraces

·         Infectious exacerbations

·         Respiratory alkalosis

Respiratory acidosis (not alkalosis) is associated with morbidity/mortality. Due to the decreased ability to exhale CO2 there is a build up in the body (H+ HCO2---H20 + CO2) which causes an accumulation of acid (left shift).

Why do people with emphysema have difficulty breathing?

decreased surface area for GE: airway wall destruction leads to enlargement of airspaces and a simplification of lung parenchyma

Which parts of the lung are involved in centriacinar emphysema?

Initially: proximal acinus, resp bronchiole (later may extend to alveolus)

·         Typically found in upper lobes of spokers

·         Lypmphoplasmcytic inflammatory infiltrate

Panlobulaar emphysema is associated with a deficiency in _________. The inheritance pattern is _____.  It is typically found in (upper/lower/all lobes). Patients may have associated illness in (name organ)_________.

·         Alpha-1-antitrypsin deficiency leads to low protease inhibitor

·         AR

·         Typically involves lower lobe (note: centriacinar involves upper)

·         Associated with hepatitis/cirrhosis of the liver

Paraseptal emphysema predisposes a patient to what complication (and why).

·         Paraseptal = distal destruction enlargement of alveoli

·         Usually upper lobe subpleural

·         Damage to this area predisposes to spontaneous pneumothorax

Why is smoking associated with emphysema?

·         Smoking increased PMN/macrophages activity  and increases  free radicalsà inhibit anti-protease activity

Clinically – how is chronic bronchitis defined?

·         Persistent cough + sputum that continues for 3+ months/yr over a 2+yr span

What is the pathophysiology of chronic bronchitis? Is there alveolar involvement as seen in emphysema

·         Proximal airway involvement w/o parenchymal injury (loss of GE) as seen in emphysema

·         Particulates/noxious chemicals inflame airways (many with mucous metaplasia) leading to mucopurulent exudates

What measurement is used to determine if there is increased mucus gland components seen with a histologic specimen of chronic bronchitis?

·         Reid index

·         Normal < 0.4

·         In chronic bronchitis can see 0.8

Why are people with chronic bronchitis prone to infections?

Mucus plugs create stasis – whenever there is stasis bacterial infections are more likely to occur (harder for immune cells to get to them, and they are not being cleared from the body as they normally would so they build up)

What changes to the airways are seen with bronchial asthma?

·         Hyper-responsiveness

·         Goblet cell metaplasia

·         Mucous gland hyperplasia

·         Airway muscular hypertrophy

What is the difference beyween extrinsic and intrinsic asthma?

·         Extrinsic (T1 HST to a defined allergen)

·         Intrinsic: reactive non-immune condition

If a patient is suspected of having type 1 asthma what type of testing maybe done to determine which allergen is responsible?

·         Skin testing to identify “wheal-and-flare- rxn

Bronchoconstriction is mediated by _______

·         Leukotrienes

Abnormally dilated airway due to rolonged detructive inflammation/infection og the airway + supporting structures is known as:

Bronchiectasis

This disorder is commonly seen in patients with what other diseases/disorders?

·         CF

·         Bronchial obstruction

·         Immunodeficiency disease

·         Necrotizing bronchoPNA

·         **damaged airways are permanent and result from congenital/hereditary condition—these enlarged airways are at risk for mucosal plugging and further destruction

Restrictive lung disease:

Occupational/environmental disease in which an inhalent leads to interstitial fibrosis is called__________________

Pneumoconiosis

If a patient presented with an intersitial lung disease what would you expect to see on PFTs?

Restrictive pattern: inflammatory and fibrosing processes lead to collagen deposition and thus scarring which leads to a shrunken hardened lung.

FEV1/FVC >80 but a decrease in both values

What causes the scarring seen in interstitial fibrosis?

·         Damage to alveoli/ducts causes an accumulation of inflammatory cells which secrete cytokines and inflammatory mediators which damage the alveolar epithelium and induce collagen deposition/fibrinogenesis

·         Interstitium expands from the vast cellularity

Match AIP, UIP, NSIP, RBILD, DIP for each of the following

·         Patchy interstitial fibrosis (UIP)

·         Best Rx is to quit smoking + steroids (RBILD)

·         AKA hamman-rich syndrome (AIP)

·         Homogenous chronic interstitial PNA (NSIP)

·         Which has the best outcome (NSIP)

·         Diffuse interstitial infiltrates on xray leading to pulmonary fibrosis, systic changes, diffuse scarring (AIP)

·         Respiratory failure occurs over 2-5 years and ultimately progresses to honeycomb lung (UIP)

·         Involvement of alveolar units with desquamted alveolar pneumocytes and macrophages (DIP)

All of the following are true concerning sarcoidosis except:

a.       Non-caseating granulomas can be found in different organ systems including the heart, lung, brain, skin

b.      Pulmonary involvement starts with the lung then progresses to mediastinal and hilar LAD

c.       CD4 t cells activate macrophages to become epithelioid histioytes (T4 HST)

d.      Increased CD4:CD8 ratio

b. LAD proceeds lung involvement

match the following: silicosis, asbestosis, berylliosis

·         Birefringent (silica)

·         May present with pleural effusion/plaques (asbestos)

·         Interstitial granulomatous reaction (berylliosis – presents like sarcoidosis)

·         Interstitial fibrosis (asbestosis)

·         Sclerotic nodule (silicosis)

·         Commonly seen in brake mechanics (asbestosis)

Farmers lung is an example of what type of  pneumonitis?

HST – type ¾

Vascular lung disease:

Transudates result from _______________________ starling forces

3 causes of transudates are _____________________ _____________________ ________________

CHF/nephritic/cirrhosis

Describe what would be found in a chest tube that drained an exudate? Elevated cellularity, proteins, cholesterol, LDH

3 causes: ____________ _________________ ______________ cancer, infection, rheumatoid

What causes respiratory failure in ARDS (pathogenesis)?

Acute injury to alveolar/capillary unit leads to increased permeability and exudation of plasma protein/inflammatory cells which form an exudate  hyaline fibrous membrane

Can you treat ARDS with supplemental O2?

No – due to vascular shunting, V/Q mismatch, and increased lung stiffness

Pulmonary infections:

What 3 patterns of PNA may be seen on x-ray? Describe each:

·         Broncho-pneumonia – most common

o   Patchy consilidation

·         Lobar

o   Bacterial infection of confluent area or entire lobe

o   Most common cause = strep pneumo

·         Interstital

o   Atypicals

What are the bodies defense mechanisms for the following:

·         >several microns: trapped in nasal and tracheobronchial clearance

·         approx micron: phagocytosis by macrophages in respiratory bronchiole/alveola duct pathways

·         <micron: remain in air current = exhale

Name 3+ complications of PNA

·         lung abscess

·         empyema: pus in pleural sace

·         bacteremia

·         sepsis

·         fibrinoblastic organzation w/ scarring

Which types of PNA are being described below?

·         phagocytosing macrophages + giant cells: Aspiration PNA

·         patchy, neutrophilic fibrinopurulent exudate in distal airways/alveoli: BronchoPNA

·         goes through stages (congestion à red hepatization à grey hepatization à resolution): lobar PNA

List some of the unique pulmonary infections AIDS patients are suseptable to due to their low T cell count:

·         PCP

·         CMV

·         Fungal: histoplasmosis, cociodiomycosis, cryptococcosis

All of the following about TB is true except

·         Caseating granulomas

·         Ghon lesion is a localized infection that drains to hilar LN (Ghon complex)

·         Tuberculoma is an upper lobe cavitation

·         If a patient becomes immunocomprosed they can have a reactivation = secondary TB

Tuberculoma is a fibro-caseous/calcific mass

Post pneumonic abscesses commonly result from which 2 organisms?

Staph aureus + klebsiella

Foul smelling purulent material is associated with what type of pneumonia? What type of bacteria would be seen in their abscess?

Aspiration pneumonia *mixed anaerobes/aerobes

Fungal disease: match the following: histoplasmosis, coccidoides, cryptococcous, aspergillus, zucor

·         Found in ohio river valley: histoplasma

·         Found in san jauquin area of SW: coccidioides

·         Budding yeast with prominent polysaccharide coat: Cryptococcus

·         Endospores: coccidiodes

·         Right angle branching: zucor

·         Maybe associated with hypersensitivity allergic pattern: aspergillis

·         Identified as budding yeast on silver stain: histo

·         Maybe found in TB cavitary lesion: aspergillis

Lung cancer:

Most lung cancers are bronchogenic carcinoma: what are the major subtypes (most commonà least)?

·         Adenocarcinoma

·         Squamous cell

·         Small cell

·         Large cell

What type of bronchogenic carcinoma is being described below?

·         Cytoplasmic keratin + intercellular brideges are seen histologically – sq.

·         Can be associated with hyponatremia – small cell (ADH paraneoplastc)

·         Arise peripherally and produce a desmoplastic stromal response: adenocarcinoma

·         Maybe associated with hypercalcemia (Sq – Parathyroid related hormone)

·         Arise peripherally and often has malignant giant cells: large cell

Tumors may produce local injury and tissue damage. Name 3+ examples:

·         Pleural effusion

·         SVC syndrome

·         Nerve damageà hoarseness

·         Airway obstruction à PNA/abscess

·         Horners

·         Pancoast syndrome

How are bronchogenic lung cancers staged?

All use TNM staging except Small cell undifferentiated which commonly presents with advanced disease/distant mets so it is staged as “localized or disseminated”

Which form of bronchogenic lung cancer is not treated surgically

Small cell