Term
| Branching and Respiratory zones in the lungs |
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Definition
| First 16 branches are conduction zones and no gas exchange occurs. 17-19 are respiratory bronchioles, 20-22 are alveolar ducts and the alveolar sacs are the 23 branch. 17 and up there is gas exchange. |
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Term
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Definition
| structure distal to terminal bronchioles consisting of the respiratory zone. |
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Term
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Definition
| Total Lung Capacity - Volume at maximal inspiration. Does not change much with age. TLC = RV + ERV + VT + IRV |
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Term
|
Definition
| Residual volume = Air remaining after maximal expiration. Cannot be directly measured by a spirometer. Increases with age. |
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Term
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Definition
| Vital Capacity - Volume between Max in and Max out. Decreases w age as RV increases. VC = TLC - RV |
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Term
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Definition
| Functional Residual Capacity - Volume in lungs at the end of normal expiration. Increases with age. |
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Term
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Definition
| Inspiratory capacity - volume from relaxed (FRC) to maximum inspiration. Decreases with age. IC = TLC - FRC |
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Term
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Definition
| Expiratory reserve volume - volume expired from FRC to RV |
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Term
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Definition
| Tidal Volume - Change in lung volume during any one complete respiratory cycle |
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Term
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Definition
| Inspiratory Reserve Volume - volume entering lungs going from normal tidal inspiration to maximal forced inspiration. |
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Term
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Definition
| Forced Vital Capacity - When expiration is performed as forcefully as possible. |
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Term
|
Definition
| Forced Expiratory volume - volume forcibly exhaled in 1 sec. usually 80% of FVC |
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Term
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Definition
| Forced expiratory flow rate - represents flow rate ove rhte middle half of FVC .25 - .75 sec. Greatest sensitivity for detecting early air flow obstruction. |
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Term
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Definition
| Diaphragm, External intercostal (only during exercise) and scalene / sternocleidomastoid (maximal breathing, obstruction and paralysis of other insp. muscles.) |
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Term
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Definition
| Usually passive. Abdominals and internal intercostals |
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Term
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Definition
| Slope of pressure volume curve. Not a straight line, changes with Transpulmonary pressure. |
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Term
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Definition
| Aveolar pressure - equal to atmosphere at end-insp and end-expi, flow rate is zero. Greater then atmosphere during expiration and less then during inspiration |
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Term
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Definition
| Transpulmonary pressure - Pa - Ppl, pressure difference acting to distend lungs and keep airways open |
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Term
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Definition
| Pleural pressure - oppositely directed elastic forces of the lungs and chest wall that create a negative pressure that becomes more negative as lung volume increases |
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Term
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Definition
| Slope of plot Change in Vol over Change in pressure measured with no air flow. |
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Term
| Lung compliance and elastance |
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Definition
| Cl (compliance) is a measure of distensibility, elastance 1/Cl is a measure oflung stiffness |
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Term
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Definition
| Takes into account different lung sizes and obtained by dividing compliance by FRC |
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Term
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Definition
| Change in volume over pressure measured during air flow |
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Term
| Frequency dependence of compliance |
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Definition
| Cdyn declines at higher frequency in states of increased airway resistance i.e. asthma, edema, excess mucous. |
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Term
| What two properties of the lung give rise to the pressure volume curve |
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Definition
| Elastic and surface tension |
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Term
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Definition
| Structures (collagen net) in the lungs act to equalize alveolar inflation |
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Term
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Definition
| Decreases surface tension so less pressure is needed to fill the lungs. Surface tension increases as alveolar surface area increases (keeps lungs from over inflating). |
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Term
| What indicates mature levels of surfactant in the amniotic fluid |
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Definition
| Lecithin:Sphingomyelin ratio greater than 2:1. In the fetus surfactant appears between week 24 and 35. |
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Term
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Definition
| During inspiration flow is effort dependent at all lung volumes. However, during expiration flow is effort dependent at high volumes but becomes effort independent at moderate and low lung volumes. |
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Term
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Definition
Deep slow breaths - High Elastic work but low resistance work
Rapid Shallow breaths - High resistance but low elastic work |
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Term
| Time Constant of Alveolar filling |
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Definition
| = to resistance X Compliance. Time alveolus requires to fill is proportional to this constant |
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Term
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Definition
| Amount of gas expired or inspired in one minute. Tidal Volume X Frequency. Usually about 6 L or 1 TLC. |
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Term
|
Definition
| Oxygen Consumption = Minute Ventilation i X (Fraction of O2 inhaled - Fraction of O2 exhaled) |
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Term
|
Definition
| = VCO2/VO2. Usually around .82. 1 for all carb diet, .7 for all fat diet. |
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Term
|
Definition
| Va = f(Vt - Vd), where f is frequncy of breaths, Vt is tidal volume and Vd is anatomical dead space (air in conducting part of lungs where gas exchange is not occuring). another eq is Va = (VCO2 X K)/PACO2 |
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Term
| Alveolar gas equation (Must memorize and know how to use.) |
|
Definition
PaO2 + PaCO2/R = PiO2, PaO2 is the partial pressure of Oxygen in the alveolus, PaCO2 is the partial pressure of CO2 in the Alveolus, R is the Respirtory Quotient (usually assumed to be .8) and PiO2 is the partial pressure of O2 in inspired air. The Eq can alos be written PaO2 = FiO2(Pb-47) - PaCO2/.8
, where FiO2 is the fraction of O2 in the Air, Pb is the atmospheric pressure, 47 is water vapor pressure in the lungs? (I think, either way it's constant) |
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Term
| Conversion of BTPS(Lung gas Volume, = body temp, baro press, saturated with water vapor) to STPD (Blood gas = Stand temp. press dry) |
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Definition
|
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Term
|
Definition
| = Anatomic dead space + alveolar dead space. Alveolar dead space is gas in alveoli that is not being perfused by blood (embolism or hemorrhage will increase it.) |
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Term
| Bohr equation to measure Physiologic dead space |
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Definition
| Vd/Vt = (PaCO2 - PeCO2)/PaCO2, where Vd is volume of dead space, Vt is tidal volume, PaCO2 is alveolar CO2 pressure and PeCO2 is Expired CO2 pressure |
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Term
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Definition
| Normal PaCO2 but low PvO2, inadequate blood flow to tissue i.e. Shock, heart failure, local obstruction |
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Term
|
Definition
| PO2 of arterial blood is low, Hypoxemia, i.e. COPD, Emphysema, high altitude. |
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Term
|
Definition
| Reduced ability of tissue to utilize O2. Cyanide poisoning |
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Term
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Definition
| Not enough Hb in blood to deliver O2 at the required rate. Anemia, CO poisoning |
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Term
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Definition
| Ventilation perfusion ratio. Va = alveolar ventilation and Q = Blood flow throught the lung. Usually about .8 but increases as you move to the apex of the lung. |
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Term
| What are the four main respiratory centers? |
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Definition
| DRG, VRG, PRG, Botzinger complex |
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Term
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Definition
| Dorsal Respirating group, located in the nucleus tractus solitaris of the medulla. Mainly inspiratory, Main pattern generator |
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Term
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Definition
| Ventral Respiratory Group. Inspiratory and expiratory neurons |
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Term
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Definition
| Pontine respirating group. includes pneumotaxic and Apneustic Centers. Inspiration and expiration, modulate rate and depth of breathing. |
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Term
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Definition
| In medulla, entirely expiratory neurons, inhibits inspiratory neurons of DRG and VRG. |
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Term
| What plays a role in determing respiratory response to exercise |
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Definition
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Term
| What helps alter respiratory response to altered emotional states |
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Definition
| Limbic system and hypothalamus |
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Term
| Volitional control of respiration |
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Definition
|
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Term
|
Definition
| (vagus nerve) interacts w respiratory centers to coordinate breathing and circulation |
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Term
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Definition
| About 75% of the ventilation response to hypercapnea. Slower then peripheral receptors and is involved in longer term regulation i.e. asthma, altitude, exercise and COPD. Located on the ventrolateral medulla near CN XII. Drop in CSF pH appears to be the main stimulus. |
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Term
| Peripheral Chemoreceptors |
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Definition
| In the carotid body and arch of aorta. Fast, about 25% of ventilation response. detects PaCO2, PaO2 and pH, but responds best to PaCO2. Asphyxia detector |
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Term
| Stretch receptors in lung |
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Definition
| Tonic (non-adapting). Play a role in terminating inspiration and expiration |
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Term
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Definition
| Rapidly adapting. Stimuli include rapid inflation, noxious gas, smoke, dust and cold air. Play a role in bronchoconstriction and may contribute to asthma because histamine is believed to stimulate them. |
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Term
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Definition
| Juxta-capillary, fast adapting. Stimulation results in rapid shallow breathing. Stimuli include engorgement of pulmonary capillaries, increases interstitial fluid volume. Maybe cause feeling of dyspnea in patients with heart failure |
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Term
Which of the following concerning average lung volumes and capacities of a person at rest is TRUE?
A. TLC>IRV>RV>ERV>TV
B. TLC>IRV>ERV>RV>TV
C. TLC>ER>IRV>RV>TV
D. TLC>ER>RV>IRV>TV |
|
Definition
| TLC>IRV>RV>ERV>TV Answer A |
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Term
| Which of the following represents the pressure difference that acts to distend the lungs? |
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Definition
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Term
| An asthma sufferer finds she has to breathe at twice her normal rate. How does that affect her dynamic compliance? |
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Definition
| It decreases. With higher breathing frequency and increased airway resistance, there is insufficient time for filling and emptying of the lung. |
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Term
| ABout what percent of TLC is FRC |
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Definition
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|
Term
| Effect of resistance of acini on total resistance |
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Definition
| The acini do have very high resistance, but there are so many of them that they have little effect on the total air flow resistance. |
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Term
Which of the following does NOT apply to the alveoli at the base of the lungs?
A. They are less elastic than the alveoli at the apex.
B. The pleural pressure is lower.
C. At FRC they aere les inflated than the alveoli at the apex.
D. They are closed at RV.
E. They have a greater volume change than alveoli at the apex during inspiration from FRC. |
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Definition
| The elastic properties of lung tissue are the same at the base as the apex. A |
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Term
| To which of the following is alveolar PCO2 directly proportional? |
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Definition
| Rate of CO2 production and rate of O2 consumption. PCO2 is inversely proportional to alveolar ventilation |
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Term
Which of the following is FALSE concerning the ventilation and perfusion of different regions of the lung?
A. Alveoli at the top of the lung have a smaller dynamic compliance.
B. The Hb at the base of the lung is less saturated than that at the apex of the lung.
C. PAO2 at the apex of the lung is higher than that at the base of the lung.
D. Regional variation in ventilation-perfusion is more efficient for oxygenating blood than is uniform ventilation-perfusion.
E. Variation of the ventilation/perfusion ratio in the lungs only becomes significant when lung function begins to degrade. |
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Definition
| Uniform is more efficient than regional variation. D |
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Term
If the blood moved slower than normal through the alveolar capillaries, which of the following would have an increased uptake?
A. Carbon dioxide.
B. Carbon monoxide.
C. Oxygen
D. None of the above. |
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Definition
| CO is diffusion limited which means that the more time for diffusion, the more CO that will diffuse across. B |
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Term
Which of the following pairs is INCORRECT concerning central nervous systems and a factor they respond to by affecting respiration?
A. Cerebellum: Mechanoreceptor input
B. Limbic system: emotional states
C. Cerebral cortex: voluntary control
D. Cerebral motor cortex: exercise |
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Definition
| The cerebellum can affect respiration by responding to exercise, but the mechanoreceptor input is mostly coordinated by the medullary respiratory centers. A |
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Term
|
Definition
atypical pneumonia, is little or no
sputum production and a modest WBC count elevation, Half of patients have cold agglutinins. It is often
diagnosed empirically by a high cold agglutinin titer and by a response to erythromycin. |
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Term
|
Definition
| pneumonia tends not to cause a productive cough; the inflammation is mostly interstitial and lymphocytic. Common organisms include influenza, respiratory syncytial virus (may be epidemic in children), adenovirus, parainfluenza, and others. Cytomegalovirus pneumonia occurs in immunocompromised patients (AIDS, transplants ...). Infected cells have abundant cytoplasm and large intranuclear “owl’s eyes” inclusions. Adeno virus - smudge nuclear inclusions. Hanta Virus - location plus hemorrhagic fevers that produce fever, myalgia, cough, and headache with rapid onset respiratory failure. |
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Term
|
Definition
| This is as an initial infection, in children or adults. The initial focus of infection is a small peripheral granuloma with hilar lymph node involvement. Together, these make up the Ghon complex. Almost always, these granulomas resolve without further spread. |
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Term
|
Definition
| This is seen mostly in adults. It can be reactivation of prior infection, particularly when health status declines (as in alcoholics, AIDS...). However, most cases probably result from reinfection. The granulomatous inflammation is much more florid and widespread. Typically, the upper lung lobes are most affected, and cavitation can occur. |
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Term
|
Definition
| An aggressive variant of secondary TB occurs when resistance to infection is very poor. myriad of small millet seed (1-3 mm) sized granulomas, either in lung or in other organs. inflammation is granulomatous, with epithelioid macrophages and Langhans’ giant cells along with lymphocytes, plasma cells, maybe a few neutrophils, fibroblasts with collagen, and characteristic caseous necrosis in the center. An acid-fast stain will show the organisms. Culture should be done to determine drug sensitivities. The inflammatory response is a type IV hypersensitivity reaction. |
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Term
| M. avium-intracellulare (MAI) |
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Definition
often seen in AIDS, but is usually not as a pulmonary infection. It instead is usually found systemically in organs of
the mononuclear phagocyte system (lymph nodes, liver, spleen, bone marrow, and intestine). |
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Term
|
Definition
| filamentous bacteria. Actinomyces grow in clusters or clumps, causing a chronic abscessing bronchopneumonia. Nocardia is weakly acid fast. Both are more common in immunocompromised patients. |
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Term
|
Definition
| are more common in immunocompromised or severely ill patients |
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Term
|
Definition
| may not be distinguishable from bacterial bronchopneumonias, although localized infection or even poorly formed granulomas are possible. Severely neutropenic patients are at risk. |
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Term
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Definition
Several dimorphic fungi have a limited geographic distribution (Mississippi and Ohio river valleys for Histo, desert southwest for Cocci). Cryptococcus is particularly common in AIDS. The major dimorphic fungi are:
Cryptococcosis (Cryptococcus neoformans)
Histoplasmosis (Histoplasma capsulatum)
Coccidioidomycosis (Coccidioides immitis)
Blastomycosis (Blastomyces dermatitidis) |
|
|
Term
| What stain do you use for Fungi |
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Definition
| Gomori methenamine silver (GMS) or a PAS stains |
|
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Term
|
Definition
| often follows other chronic inflammatory or destructive processes and is more common in immunocompromised hosts, particularly those who are neutropenic. Aspergillus often invades blood vessels, causing hemorrhage and infarction. |
|
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Term
| Pneumocystis jiroveci pneumonia (formerly Pneumocystis carinii, PCP) |
|
Definition
| About a third of AIDS patients die of it, Prophylaxis with Bactrim or pentamidine is very useful. produces an extensive pneumonia with a foamy exudate filling alveoli. Fever, cough, and dyspnea are the major presenting signs and symptoms. The usual diagnostic method is bronchoalveolar lavage (BAL). Use GMS stain. Does not culture well. |
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Term
|
Definition
Lipid pneumonias are not infectious but can mimic other pneumonias, sometimes appearing as areas of consolidation.
Exogenous lipid pneumonia - occurs when oily foreign material (like mineral oil) is inhaled. This causes a foreign body reaction with giant cells in and near bronchi.
Endogenous lipid pneumonia - occurs with obstruction, like a bronchus-obstructing tumor. Distal to the bronchus, secretions build up. Macrophages phagocytose the debris & become foamy. The lung has a gold-yellow appearance (“golden” pneumonia). |
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Term
| Two basic causes of restrictive lung disease |
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Definition
Chest wall disorders with normal lungs (i.e. neuromuscular diseases such as polio, severe obesity, pleural disease, and kyphoscoliosis).
Interstitial & infiltrative diseases (i.e. adult respiratory distress syndrome, pneumoconioses,
idiopathic pulmonary fibrosis, other interstitial lung diseases). |
|
|
Term
ACUTE RESTRICTIVE LUNG DISEASE:
Diffuse Alveolar Damage / Adult Respiratory Distress Syndrome (ARDS). |
|
Definition
This is caused by a toxic agent or factor that triggers release of mediators damaging the alveolar endothelium, epithelium or both. This causes exudation of edema, protein, and inflammatory cells with cell necrosis and digestion of the lung matrix.
Causes: 1. Shock (trauma)
5. Uremia
2. Oxygen toxicity
6. Infections
3. Drugs (Chemotherapy)
7. Other
4. Toxic inhalation |
|
|
Term
| two phases of diffuse alveolar damage |
|
Definition
| The acute phase has interstitial edema, alveolar epithelial cell necrosis, and hyaline membranes. In the organizing phase, most of the hyaline membranes are gone. Instead, the interstitium is diffusely expanded by a proliferation of myofibroblasts. The alveolar septae are lined by plump, regenerating type II pneumocytes. Often the two phases (acute and organizing) coexist. |
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Term
| CHRONIC RESTRICTIVE LUNG DISEASES |
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Definition
| A group of disorders with interstitial (alveolar) fibrosis with no known etiology. There is often severe pulmonary disease. |
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Term
| Idiopathic pulmonary fibrosis |
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Definition
| Type of Chronic restricitve. with progressive, diffuse interstitial fibrosis. It is also called Usual Interstitial Pneumonitis (UIP). The mechanism is unclear. The eventual outcome is end-stage honeycomb lung. The average time course is 5 years. The lungs are heavy and stiff. The pleural surface is nodular and firm. Microscopically, there are areas of scarring with cysts lined by metaplastic bronchial epithelium (honeycomb lung) admixed with areas of less affected and relatively normal lung. |
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Term
| Other variants of chronic restrictive lung disease |
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Definition
| non-specific interstitial pneumonitis (NSIP, lacks the patchiness of UIP and has a better prognosis), respiratory bronchiolitis, and desquamative interstitial pneumonia (DIP). |
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Term
| NON INFECTIOUS GRANULOMATOUS DISEASES |
|
Definition
| Sarcoidosis, Berylliosis, Hypersensitivity pneumonitis |
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Term
|
Definition
| multisystem disease of uncertain etiology characterized by multiple "non-caseating" granulomas which occur mostly in the lung and hilar lymph nodes but can also be found in the spleen, bone marrow, skin, and eye. most common in African-Americans and in Caucasians of Northern European descent. African-Americans have 10 times higher incidence than the general US population. More common in females. Etiology is unknown, but it is likely immunologic. |
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Term
| Clincal course of sarcoidosis |
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Definition
| patients may be asymptomatic, but shortness of breath, fever, fatigue, weight loss, anorexia, and night sweats can occur. On chest films, there is often prominent hilar adenopathy. There can also be lymphadenopathy, skin, and eye involvement (iridocyclitis). The clinical course is unpredictable; 60 - 70% of patients recover with minimal or no residual disease; 20% have permanent loss of lung function, and 10% die of progressive pulmonary fibrosis and cor pulmonale; may respond to corticosteroid therapy. There is cutaneous anergy. |
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Term
|
Definition
| biopsies show non-necrotizing granulomas. There are no identifiable microorganisms on special stains. The granulomas are found both in mediastinal lymph nodes and in pulmonary parenchyma. In the lung, the granulomas are usually along bronchovascular bundles and adjacent to the pleura. Sarcoidosis can cause end-stage pulmonary fibrosis. |
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Term
|
Definition
| multiple non-caseating granulomas in the lung and looks very similar to sarcoidosis. It is a type of pneumoconiosis (see below). A good clinical history is needed to distinguish these two entities.affects approximately 2% of people who have occupational exposure to beryllium (aerospace workers, nuclear industry). |
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|
Term
| Hypersensitivity pneumonitis |
|
Definition
| An immune mediated inflammatory lung disease caused by inhaling an antigen or antigens. Typically, it may be seen in people exposed to and who have an allergy to molds, animal proteins, or certain types of bacteria. A number of terms have been used to describe situations in which this disease occurs including farmer’s lung, pigeon breeder’s lung, humidifier lung, bird fancier’s disease, etc. Hypersensitivity pneumonitis may present acutely with fever, cough or dyspnea, or chronically with an insidious onset of dyspnea. Histologically, there is a patchy chronic interstitial inflammatory infiltrate associated with ill-defined interstitial granulomas. The main treatment is to avoid exposure to the antigen causing the reaction. If there is continued exposure, progressive fibrosis and end-stage honeycomb fibrosis may develop. |
|
|
Term
| List the PNEUMOCONIOSES - OCCUPATIONAL LUNG DISEASES |
|
Definition
| Asbestosis, Coal workers' pneumoconiosis, Silicosis, Berylliosis |
|
|
Term
|
Definition
| pathologic hallmarks are pulmonary fibrosis associated with the presence of asbestos bodies, also causes pleural plaques. Pleural plaques are well-circumscribed plaques of dense collagen which develop most often on the anterior and posterior aspects of the parietal pleura. causes rare malignancy of the pleura called malignant mesothelioma. Asbestos bodies are golden brown beaded rods with a translucent center on tissue sections. They consist of asbestos fibers coated with iron and protein. When stained with an iron stain, they are called ferruginous bodies. |
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Term
| Coal workers' pneumoconiosis |
|
Definition
| caused by inhaling coal dust. manifested by coal dust macules (1-2 mm) and coal nodules (larger). macule consists of an accumulation of dust-filled macrophages in the interstitium surrounding dilated respiratory bronchioles. nodules are palpable lesions less than 1 cm in size. They are accumulations of dust-filled macrophages like the coal dust macules, but are larger and often with fibrous bands. Patients with complicated coal worker's pneumoconiosis have developed large black fibrous scars or nodules greater than 2 to 3 cm. Pathologically, this is called progressive massive fibrosis. |
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Term
|
Definition
| reaction to inhaled crystalline silica (i.e. quartz). Sandblasters are commonly affected. Pathologically, there are numerous small nodules, mostly in the upper lung fields. Histologically, the nodules are concentric lamellated hyaline and collagen bands. Often, birefringent small particles are identified in the nodules. The nodules can fuse to form larger (>1 cm) masses and are then termed conglomerate nodules. If fibrosis continues, progressive massive fibrosis can occur. |
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|
Term
| IATROGENIC CAUSES OF PULMONARY FIBROSIS |
|
Definition
Drugs: Many chemotherapeutic agents and some other types of drugs may cause interstitial fibrosis. Some drugs most associated with pulmonary fibrosis are busulfan and bleomycin.
Radiation: Radiation-induced interstitial fibrosis (radiation pneumonitis) can occur after radiation of a part of the lung - usually as treatment for cancer. Histologically, it causes organizing diffuse alveolar damage or later, end-stage fibrosis. |
|
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Term
| COLLAGEN VASCULAR DISEASE |
|
Definition
| Pulmonary fibrosis is a main complication of collagen vascular disease, especially rheumatoid arthritis and systemic sclerosis (scleroderma), but rarely with lupus. Histologically, it is indistinguishable from idiopathic pulmonary fibrosis. The prognosis is equally poor. |
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|
Term
| Pulmonary eosinophilic granuloma |
|
Definition
occurs in adults between 17 and 60 years of age with a mean age of 30. It is almost always smoking associated.
Clinically, patients have cough and dyspnea and the chest X-ray shows multiple small nodules distributed throughout the lungs with a predilection for the upper lobes.
Microscopically, there are nodular aggregates of Langerhans cells admixed with histiocytes, eosinophils, plasma cells and lymphocytes associated with stellate fibrosis. The lesions are centered around bronchioles. Over time, more cellular lesions progress to scars. Finding the Langerhans cells are the key to the diagnosis. They have an irregular indented nucleus and pale, pink cytoplasm. Their identity can be confirmed by immunostaining or electron microscopy. Usually, this disease will resolve and the patient will do well if they stop smoking. In a few cases, however, it progresses to end-stage lung disease. |
|
|
Term
| Diagnosis of Pulmonary Embolism (PE) |
|
Definition
The symptoms of PE are notoriously unreliable and non-specific, but the sudden onset of dyspnea and/or hyperventilation should alert to the possibility of PE. Pleuritic chest pain and hemoptysis occur late, after infarction and hemorrhage, and are relatively infrequent.
The single most consistent finding is tachycardia. Only with massive embolism is there a right ventricular gallop, a palpable “lift” over the right side of the heart, or a loud pulmonary closure sound on auscultation. Detection of deep venous thrombosis by venography is an excellent clue to the diagnosis of PE, but its absence does not rule it out. Physical findings of lower leg deep venous thrombosis include: swelling, tenderness, warmth, and pain on raising the leg.
The blood gases may show hypoxia, hypocapnia, and respiratory alkalosis. Lung ventilation/perfusion scan with comparison of ventilation and perfusion may contribute to the diagnosis, but are not entirely reliable. The only definitive test is the pulmonary angiogram, which is not often performed. The classical finding is abrupt cut-off of a vessel; however, filling defects are more common. |
|
|
Term
|
Definition
usually secondary to cardiovascular conditions as well as COPD, recurrent thromboemboli, autoimmune diseases (especially scleroderma), fen-phen diet pills, cocaine, cirrhosis, and HIV infection. Initially there is increased muscular thickness of arterioles and small arteries with intimal fibrosis. At this point, the morphologic changes in the lung are considered reversible.
With continued pulmonary vascular resistance, plexiform lesions develop. Plexiform lesions are an aneurysmal expansion in the vessel wall containing a distinctive proliferation of vascular channels lined by endothelial-like cells. When this happens, the pulmonary morphologic changes are irreversible. May also cause an irreversible vasculitis if very severe. |
|
|
Term
| Primary pulmonary hypertension |
|
Definition
rare condition, usually in child-bearing age women, with clinical and morphologic features of pulmonary hypertension in which secondary causes (i.e. heart defects, COPD ...) have been excluded. About 20% of cases are familial. Half the familial cases and a few sporadic cases have a mutated BMPR2 gene (autosomal dominant).
Symptoms of pulmonary hypertension are dyspnea, fatigue, and sometimes chest pain. Although treatable, over time right ventricular failure can develop and causes death. |
|
|
Term
| PULMONARY VASCULITIDES AND HEMORRHAGE SYNDROMES |
|
Definition
| The alveoli are filled by hemorrhage and hemosiderin-laden macrophages. These conditions are due to vascular or alveolar septal capillary damage which may or may not be found histologically. i.e. Goodpasture’s syndrome, Wegener’s granulomatosis, Collagen vascular disease (esp SLE) |
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|
Term
|
Definition
| Biopsy of the kidney rather than lung is preferred. Goodpasture's is a rare disease; Wegener's and related ANCA-associated vasculitis (see below) is the most common cause of a pulmonary-renal syndrome. Other vasculitis syndromes, autoimmune diseases like lupus, and infections must also be considered |
|
|
Term
|
Definition
a multisystem disorder with necrotizing granulomas predominantly affecting the upper and lower respiratory tracts and the kidneys, although any organ may be involved. In the lungs, the disease usually consists of multiple bilateral nodules. Histologically, the nodules consist of necrotizing granulomas, often with neutrophils infiltrating among the macrophages. A key histologic finding is a necrotizing vasculitis which may affect small arteries, veins, and/or capillaries. c-ANCAs recognize proteinase 3, a serine protease found in the lysosomal granules and plasma membranes of neutrophils and monocytes. Wegener’s granulomatosis is most often manifested by c-ANCA.
p-ANCAs recognize myeloperoxidase. p-ANCA is associated with other vasculitic and autoimmune conditions. Neither are sensitive or specific |
|
|
Term
| Restrictive pattern (spirometry) |
|
Definition
| reduced vital capacity with relatively normal flow rates (FEV1/FVC > 0.70). A spirogram showing a restrictive defect resembles a normal spirogram except that all volumes are proportionally reduced. |
|
|
Term
| Diseases causing a restrictive pattern |
|
Definition
| idiopathic pulmonary fibrosis, pulmonary embolus, atelectasis, pneumothorax, muscular or neurologic disease (muscular dystrophy, myasthenia gravis, ...), heart failure, pneumonia |
|
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Term
|
Definition
| slowed air flow with airway obstruction. The FEV1 is reduced more than the FVC, such that FEV1/FVC < 0.7. Patients with this pattern chronically have, by definition, chronic obstructive pulmonary disease (COPD). |
|
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Term
|
Definition
Most common clinical disease. Dyspnea, particularly on exertion, with decreased FEV1 and FEV1/FVC (< 0.7).
The main types of COPD are emphysema and chronic bronchitis, which are irreversible, and asthma, in which there is bronchial constriction that is relieved by bronchodilators. Both emphysema and chronic bronchitis are usually due to smoking, and they are often mixed together to varying degrees. Bronchiectasis (scarred, irregularly dilated bronchi from chronic infection), which is rare except in cystic fibrosis patients, can also cause an obstructive pattern. 4th leading cause of death. onset is insidious, and progression to death is slow, often taking about 30 years. The exception to this is asthma, which has a more obvious onset and can kill abruptly. |
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Term
|
Definition
abnormal permanent enlargement of airspaces distal to the terminal bronchiole, due to destruction of their walls, without obvious fibrosis.
The main cause is smoking, but α-1-antitrypsin deficiency and air pollution also contribute to emphysema. |
|
|
Term
| Clinical appearance of emphysema |
|
Definition
| appear when about 1/3 of the functioning alveolar parenchyma is lost. Typically, there is dyspnea with coughing and wheezing. The chest is enlarged, the patient is thin and has lost weight. On physical exam, the patient has increased AP diameter of his chest (emphysema is more common in men, probably since they are more likely to smoke). He will lean forward and has obviously prolonged and difficult exhalation. There are abnormal breath sounds with wheezing. The lungs are hyperresonant by percussion, with decreased fremitus. Accessory respiratory muscles such as the sternocleidomastoids and abdominals can be used. Blood gases and oxygen saturation are relatively normal. They overventilate but appear well oxygenated, and thus are called "pink puffers." |
|
|
Term
| pathologic features of emphysema |
|
Definition
| best noted grossly in lung tissue that has been fixed while inflated. The main finding is loss of alveolar walls instead of homogeneous parenchyma with alveolar spaces too small to individually see. There are obvious larger air spaces as in a sponge. The septae, small bronchi, and blood vessels can appear almost free floating, unconnected to the parenchyma |
|
|
Term
| Centrilobular emphysema (also called centriacinar) |
|
Definition
| in which the damage is near respiratory bronchioles (where the anthracotic pigment is seen). Damage is worst in the upper lung fields. This is by far the most common pattern. It is seen with smoking. |
|
|
Term
| Panacinar emphysema (also called panlobular) |
|
Definition
| loss of alveoli is diffuse. This rare pattern is typical of α-1-antitrypsin deficiency. |
|
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Term
|
Definition
| large air spaces, more than 1 cm in diameter |
|
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Term
|
Definition
smaller cystic space, more than 5 mm in diameter. Blebs and bullae can be seen with any form of emphysema. If close enough to the pleura, they can rupture into it causing spontaneous
pneumothorax. Emphysema, whatever the
cause or pattern, with bullae is called bullous emphysema.
Bullae can happen in young people with otherwise normal lungs. These are often subpleural near the apex, and can rupture without cause or warning, causing spontaneous pneumothorax. This pattern is called localized or paraseptal emphysema. |
|
|
Term
Perifocal emphysema (also called
paracicatricial emphysema) |
|
Definition
| emphysema near focal scars, tumors, or other lesions. These lesions are usually asymptomatic, but can impair pulmonary function if numerous and widespread. |
|
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Term
|
Definition
persistent cough with sputum production for at least 3 months in at least 2 consecutive years. It is caused by smoking and air pollution. There is hypersecretion of mucus into the large airways, with hyperplasia of the bronchial glands.
Inflammation, fibrosis and squamos metaplasia can occur. Blood gases show decreased oxygen saturation (hypoxia) and increased carbon dioxide (hypercapnia). This causes respiratory acidosis, increased cardiac output, polycythemia, pulmonary vasoconstriction, pulmonary hypertension, and cor pulmonale. The combination of poor oxygenation and right-sided heart failure from cor pulmonale means these patients appear as "blue bloaters." |
|
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Term
|
Definition
| ratio of mucous gland layer to entire mucosa. Normal is less then 0.4 |
|
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Term
|
Definition
| blockage of small bronchi / bronchioles, usually in combination with large airway disease, particularly chronic bronchitis. In chronic bronchitis there is goblet cell metaplasia with mucous plugging in bronchioles, peribronchiolar inflammation and fibrosis. In severe cases, there can even be obliteration of the lumen (obliterative bronchiolitis) |
|
|
Term
|
Definition
chronic necrotizing infection of bronchial walls, causing destruction of the wall with saccular dilation. Causes for this uncommon condition include:
1. Congenital / hereditary conditions (congenital bronchiectasis, cystic fibrosis, immunodeficiency, immotile cilia / Kartagener's syndrome, intralobar sequestration). Kartagener's syndrome is the combination of situs inversus, sinusitis, and bronchiectasis. There is defective ciliary motility with structurally abnormal cilia, often absent or irregular dynein arms.
2. Bronchial obstruction (foreign body, tumor)
3. Necrotizing pneumonia, most often tuberculosis, Staphylococcus, or mixed infections |
|
|
Term
| Pathology of bronchiectasis |
|
Definition
| The airways are markedly and often irregularly dilated. If there is active infection and inflammation, there will be acute and chronic inflammation in the bronchial walls with loss of the respiratory mucosa, ulcers, and even necrosis. There will also be scarring of the wall, often with loss of the bronchial cartilage. |
|
|
Term
| Symptoms of bronchiectasis |
|
Definition
| Severe persistent cough, with expectoration of foul-smelling, sometimes bloody sputum. After getting up in the morning, the patient may have paroxysms of coughing as collected pools of pus drain into bronchi. There will also be obstructive ventilatory insufficiency, which can cause marked dyspnea, orthopnea, cyanosis, and less frequently, cor pulmonale, metastatic brain abscesses, and amyloidosis. |
|
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Term
|
Definition
| most common, with allergies, usually starts in childhood. It is a type I hypersensitivity reaction. |
|
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Term
|
Definition
| nonimmune cause (aspirin/drugs, lung infection, cold, inhaled irritants, stress, & exercise), often onset in adulthood. Prognosis is worse than extrinsic asthma. often coexists with or has similarities to chronic bronchitis. |
|
|
Term
|
Definition
| Lungs are overinflated. Bronchi and bronchioles are occluded by thick mucous plugs. The mucous plugs can contain whorls of shed epithelium, causing the well-known Curschmann's spirals. There is hyperplasia of the bronchial glands and thickening of the bronchial smooth muscle and basement membranes. Eosinophils can be abundant |
|
|
Term
| most common cause of a solitary lung nodule |
|
Definition
|
|
Term
|
Definition
T1 <3 cm.
T2 >3 cm.
T3 Through pleura to potentially resectable tissue (chest wall, diaphragm) or in main bronchus.
T4 Through pleura to unresectable tissue (heart, great vessels, esophagus …).
N0 no nodal metastases.
N1 ipsilateral hilar or peribronchial lymph node metastases.
N2 ipsilateral mediastinal or subcarinal lymph node metastases.
N3 contralateral mediastinal or supraclavicular lymph node metastases.
Stage:
1 T1N0 or T2N0 60-70% 5-year survival with resection, sometimes adjuvant chemo.
2 T1 or 2N1 or T3N 30-55% 5-year survival with resection, adjuvant chemo.
3 Any T or N, but M0 10-35% 5-year survival with chemo, then surgery if resectable.
4 Any T and N, M1 <5% 5-year survival with chemo, sometimes with local therapy. |
|
|
Term
| Superior vena cava (SVC) syndrome |
|
Definition
| Tumor compression or invasion of SVC. Causes swelling & flushing of face, head, and arms with dilated veins. This is a life-threatening emergency |
|
|
Term
| Apical tumors (usually non-small cell tumors) |
|
Definition
Pancoast tumor: Tumor invades nerves in or near brachial plexus, causes pain & weakness of arm & hand.
Horner syndrome: Tumor invades sympathetic chain or cervical stellate ganglion, causes ipsilateral ptosis (droopy eyelid), miosis (abnormal pupil constriction), enophthalmos (eye recedes in orbit), and anhydrosis (lack of sweating in affected side of face / arm).
Less common complications: constrictive pericarditis or tamponade, esophageal symptoms |
|
|
Term
| Paraneoplastic syndromes Hypercalcemia |
|
Definition
| due to bone mets or PTHRP from squamous carcinoma; more on this in the endocrine block. |
|
|
Term
| Paraneoplastic syndromes SIADH |
|
Definition
| water retention and sodium loss with hyponatremia, due to small-cell carcinoma. |
|
|
Term
| Paraneoplastic syndromes Finger clubbing |
|
Definition
| often with large-cell carcinoma |
|
|
Term
| Paraneoplastic syndromes Trousseau syndrome |
|
Definition
| migratory thrombophlebitis |
|
|
Term
| Paraneoplastic syndromes Cushing syndrome |
|
Definition
| ACTH production, usually by a small-cell carcinoma |
|
|
Term
| Paraneoplastic syndromes Hypocalcemia |
|
Definition
| usually due to calcitonin secretion by a squamous carcinoma |
|
|
Term
| Paraneoplastic syndromes Lambert-Eaton syndrome |
|
Definition
| myasthenia gravis-like symptoms, except weakness does not involve (or is less severe in) muscles of respiration and of the face, and strength often improves with continued effort. Often seen with small-cell carcinoma, sometimes other tumors; up to half are idiopathic. There are other neurologic / neuromuscular paraneoplastic syndromes. |
|
|
Term
|
Definition
| most common benign neoplasm in the lung. most common in older men |
|
|
Term
| four main kinds of lung carcinoma |
|
Definition
| squamous carcinoma, adenocarcinoma, large cell undifferentiated carcinoma, and small cell carcinoma. From a practical standpoint, one can lump squamous cell carcinoma, adenocarcinoma and large cell carcinomas together as "non small cell carcinomas" which have roughly similar but not identical clinical behavior and are treated the same way. Small cell carcinomas are highly malignant, rapidly growing, and more responsive to chemotherapy. They are treated very differently from other lung carcinomas. |
|
|
Term
|
Definition
| keratin pearl formation, cytoplasmic keratin, or at least intercellular bridges, (well, moderately, or poorly differentiated). About 90% of squamous cell carcinomas arise in segmental or larger bronchi. Chest X-ray often shows a large cavitary hilar mass, have both endobronchial and invasive growth into the peribronchial soft tissue, lung and adjacent lymph nodes. |
|
|
Term
|
Definition
| composed of malignant glandular or papillary elements, often with mucin production, more peripherally located, near the pleura, and can cause pleural effusions. the majority of adenocarcinomas are in smokers, it is the tumor type most often found in non-smokers. Must consider it a possible metastasis as opposed to primary. A minority of adenocarcinomas contain abundant epidermal growth factor receptors (EGFR) and many of those with EGFR respond to certain new, specific chemotherapies. EGFR-containing tumors are more common in Asians, women, and non-smokers |
|
|
Term
| Bronchioloalveolar carcinoma |
|
Definition
| distinctive subtype of adenocarcinoma the malignant cells grow along the preexisting alveolar framework. These tumors may present as a single nodule, multiple nodules, or in a pattern which looks like a pneumonia. These tumors often differentiate like Clara cells (non-ciliated peg-like cells in the terminal bronchiole), type II pneumocytes, goblet cells, or a combination of them. subdivided into mucinous and non-mucinous varieties. The mucinous carcinomas have well differentiated tall columnar cells with basally located nuclei. The nonmucinous ones have central nuclei, no mucin, and hobnail-shaped tumor cells. Although the nonmucinous ones have more nuclear atypia, they actually have a better prognosis than the mucinous ones. On the other hand, the stage is the best way to determine the prognosis |
|
|
Term
|
Definition
| are composed of sheets of poorly differentiated malignant cells without glandular or squamous differentiation by light microscopy. Grossly they are bulky soft grey, tan or pink masses with extensive necrosis. Half arise in subsegmental or larger bronchi; the other half are peripheral and subpleural in location. worst prognosis among the non-small cell carcinomas |
|
|
Term
| Small cell undifferentiated carcinoma |
|
Definition
| composed of clusters or cords of small cells with scanty cytoplasm often spindled without squamous or glandular differentiation, most have have neuroendocrine differentiation. tend to be hilar or central in location (in major bronchi). most frequent type of lung cancer associated with ectopic hormone production (paraneoplastic syndromes). 99% occur in smokers. |
|
|
Term
|
Definition
| also called grade 1 neuroendocrine carcinomas, histologically resemble carcinoids of the GI tract, with solid or ribbon-like areas and less cytologic atypia than carcinomas. not associated with smoking and have a favorable prognosis, but a minority do metastasize (10-year survival 70-94%). |
|
|
Term
|
Definition
| Most lung cancers have multiple differentiation by EM but one predominates by light Microscopy. particularly unfortunate to have is a combined small cell and non-small cell carcinoma. These tumors tend not to respond to either conventional therapy for a non-small cell carcinoma, or the chemotherapy given for small cell carcinoma. |
|
|
Term
|
Definition
| About 25-30% of adenocarcinomas and 16% of squamous cell carcinomas are associated with scar tissue. Once thought that the scar caused the cancer, now though that the scar is a reaction of the normal host to the cancer (i.e. a “desmoplastic response") |
|
|
Term
| METASTATIC TUMORS TO THE LUNG |
|
Definition
| commonest lung tumor of all, The most common sites of origin include lung, breast, and ovary. |
|
|
Term
|
Definition
Solitary fibrous tumor of pleura is an uncommon, slow-growing, localized tumor of fibroblast-like cells. Histologically, there is a varied pattern with bland spindle cells admixed with large fibrous areas. It immunostains with CD34. It is not related to asbestos exposure.
Malignant mesothelioma diffusely involves the pleura and can be bilateral, asbestos exposure, sarcomatoid epithelial or biphasic. EM or immunostaining can differentiate epithelial or biphasic from an adenocarcinoma. Mesotheliomas tend to stain with calretinin but not CEA, CD15, TTF-1. By electron microscopy, mesotheliomas have distinctive long, slightly curving microvilli on their surfaces |
|
|
Term
| Respiratory Distress Syndrome (RDS) / Hyaline Membrane Disease |
|
Definition
| occurs with prematurity, when the lung is too immature to make sufficient surfactant. Mature at 36 weeks, 60-80% at 28 weeks. Production is retarded in diabetic mothers. Tests can be done to know, An L:S ratio >2 is good. Other useful tests are lamellar body count and fluorescence polarization (f-pol). The f-pol has a high sensitivity. Corticosteroids, given to the mother prior to delivery, speed up surfactant production. serious long-term complication of RDS is bronchopulmonary dysplasia (BPD), in which the lung does not mature normally and becomes fibrotic with bronchiolar metaplasia and cysts. |
|
|
Term
| Sudden Infant Death Syndrome (SIDS) |
|
Definition
| In SIDS, the child is essentially normal, but dies suddenly while sleeping, and autopsy reveals normal gross and microscopic appearances of all organs. SIDS is most common in young mothers who smoke and who are poor and poorly educated. It is also more common in premature or low birth weight infants. The incidence of SIDS is greatly reduced by placing the baby on its back to sleep. |
|
|
Term
|
Definition
| a few of these are large enough to compress the adjacent lung |
|
|
Term
|
Definition
| portion of lung that lacks a normal connection to the airways and is supplied by blood from the systemic circulation; it is not functional and can become infected or compress remaining normal lung. |
|
|
Term
|
Definition
| this is usually due to oligohydramnios, diaphragmatic hernia, or other identifiable cause. |
|
|
Term
| Trachea-esophageal fistula |
|
Definition
| aspiration is a common, serious complication of this problem |
|
|
Term
| Congenital cystic adenomatoid malformation |
|
Definition
| rare - a mass of benign cystic and stromal tissues, predominantly bronchioles, that compresses normal lung. |
|
|
Term
| Abnormal number of lobes / pulmonary agenesis |
|
Definition
| this often accompanies other anomalies |
|
|
Term
|
Definition
| gene frequency is 2 – 4% for Caucasian populations; about 2/3 of cases are due to a single gene defect (ΔF508) of the CFTR gene, a chloride channel. This causes abnormally thick secretions in various sites, including the respiratory tract. It occurs in about 1 in 2,500 Caucasians but is far less common in other racial groups. The diagnosis is made by detecting an elevated sweat chloride or by genetic testing. Lung problems develop over time, bronchiectasis with recurrent infections, particularly with Pseudomonas (aeruginosa and cepacia species) and S. aureus. |
|
|
Term
| Reasons to do sputum cytology |
|
Definition
| detect and characterize malignancy, most commonly in patients who are either high risk (mainly smokers) and exhibit pulmonary symptoms but have no obvious mass lesion by radiographic studies, or in patients with radiographic evidence of a mass lesion, whether symptomatic or not. |
|
|
Term
| Advantages of sputum cytology |
|
Definition
• It is the easiest and cheapest method of sampling the pulmonary tree
• It can be performed as often as necessary, requiring no surgical intervention
• It is safe
• The area sampled is large, which can be particularly important in occult lesions |
|
|
Term
| Disadvantages to sputum cytology |
|
Definition
•It is significantly less sensitive
•Inflammatory and degenerative changes can render cellular material in the sputum un-interpretable or can cause morphologic artifacts which falsely simulate malignancy. |
|
|
Term
| The adequacy of a sputum specimen is determined primarily by |
|
Definition
| presence of alveolar macrophages, indicating that the specimen obtained is a deep cough specimen producing material from the lower airways. In addition, the specimen should not be obscured by oral or upper airway contaminants. |
|
|
Term
| Sputum cytology and characterization of malignancy |
|
Definition
| While sputum cytology is good for detecting malignancy, the characterization of malignant cells as squamous carcinoma, adenocarcinoma, small cell carcinoma or other is less accurate. For purposes of patient management, the distinction between small cell cancer and non-small cell cancer is most often all that is necessary, and this is easily achievable if malignant cells are identified in the sputum. |
|
|
Term
|
Definition
•Surgery does not need to be performed
•An answer can often be given within two hours of the procedure
•The technique is highly sensitive and specific for identification of Pneumocystis, CMV, Herpes, and bacterial agents, including acid-fast bacilli.
•A BAL is a fairly easy way of sampling widely. The fluid obtained is representative of a wide area of lung and has less sampling error than a biopsy alone.
•A BAL carries a low rate of morbidity and can be used for patients who are very ill and cannot undergo a biopsy procedure. |
|
|
Term
| Fine Needle Aspiration Cytology |
|
Definition
advantages:
•Direct sampling of a lesion without surgery, particularly in a patient who cannot handle surgery
•Is specific enough to provide the basis for definitive treatment in most instances
•Cheaper, safer and less time consuming than surgery
•Specimen can be evaluated at the bedside to determine specimen adequacy
There are several disadvantages to FNA:
•Development of pneumothorax (20 to 40% of patients), because the needle does cross the pleural space, although the majority of these do not require chest tube placement
•Significant hemorrhage may also occur, although this complication is rare
•Difficulty sampling due to anatomic considerations (ribs, spinal column, and mediastinal organs) |
|
|
Term
|
Definition
It would be uncommon to identify malignant cells in the pleural fluid of a serous effusion. Both benign inflammatory and malignant processes affecting the mesothelium will present most commonly as an exudate.
A benign inflammatory process will commonly have a greater number of inflammatory cells than a malignant process, and a malignant process will more commonly be bloody than a benign process, although neither of these findings is very specific.
Exudates are usually related to infections. The vast majority of malignant lesions affecting the pleura which can be detected in the pleural fluid are either metastatic carcinoma (most commonly breast), or extension of a primary lung carcinoma to the pleura. |
|
|
Term
| Spontaneous pnuemothorax in an otherwise health person |
|
Definition
| Paraseptal emphysema is not common, but does account for a significant number of cases of spontaneous pneumothorax in young persons. It is not related to smoking. There are subpleural bullae that can burst with minimal trauma. |
|
|
Term
|
Definition
| (A1AT) is produced in the liver, and one of its functions is to protect the lungs from the neutrophil elastase enzyme, which can disrupt connective tissue. Deficient patients are likely to develop panacinar emphysema at a young age; 50% of these patients will develop liver cirrhosis, because the A1AT is not secreted properly and instead accumulates in the liver. |
|
|
Term
| Mechanisms of hypoxemia with an increased A-a gradient |
|
Definition
1. Shunt
2. Ventilation/perfusion (V/Q) mismatch
3. Diffusion |
|
|
Term
| Mechanisms of hypoxemia with an normal A-a gradient |
|
Definition
1. Decreased PiO2 (hypoxic gas mix or altitude)
2. Hypoventilation |
|
|
Term
|
Definition
| (Hb x 1.39 x SaO2)+ (0.003 x PaO2) |
|
|
Term
Oxygen delivery to the
peripheral tissues |
|
Definition
Delivery is content multiplied by rate of supply
or
DaO2 = CaO2 x cardiac output |
|
|
Term
| Relationship between Cardiac output and SvO2 |
|
Definition
| CO ~ SvO2. Mixed venous saturation(SvO2) reflects the global balance between oxygen delivery and oxygen consumption |
|
|
Term
| Bronchiectasis: Airway Clearance methods and results for CF and non-CF patients |
|
Definition
• Methods
– Chest Percussion and Postural Drainage
– Mechanical vibration devices
– Positive expiratory pressure devices
• Results
– Non-CF: unclear
– CF: improved lung function, reduced bacteria |
|
|
Term
| Bronchiectasis: Inhaled Antibiotics, drugs and results |
|
Definition
• Tobramycin for CF
– Improved pulmonary function and decreased exacerbations
– Small increase in tobramycin resistance.
• Non-CF
– Tobramycin reduces bacteria density.
– Gentamicin
• Reduced sputum myeloperoxidase, sputum production, nocturnal desaturations
• Improved Borg Scale and six minute walk |
|
|
Term
| Bronchiectasis: inhaled rhDNAase |
|
Definition
• CF
– Improved lung function and decreased hospital days
– Hemoptysis possibly increased
• Non-CF
– Large study: 349 adults, 23 centers, 24 weeks
– Decreased lung function and increased exacerbations |
|
|
Term
| Bronchiectasis: inhaled steroids |
|
Definition
• CF
– Neither benefit nor harm
• Non-CF
– Reduced sputum
– Improved lung function
– Reduced markers of inflammation |
|
|
Term
| Bronchiectasis: Oral antibiotics |
|
Definition
• Azithromycin in CF
– Improved lung function
– Decreased hospitalizations
• Erythromycin in non-CF
– Reduction in sputum production
– Improved lung function
– No effect on inflammatory markers |
|
|
Term
| Bronchiectasis: Hypertonic saline |
|
Definition
• Randomized clinical trial in CF
– 164 patients, 48 weeks
– Improved FEV1 and FVC
– Decreased pulmonary exacerbations
– Treatment time long but cost low
• Anecdotal(unreliable) evidence of effect in non-CF |
|
|
Term
| Bronchiectasis: IV antibiotics |
|
Definition
• Acute Exacerbation
– Increased symptoms: cough, sputum
production, dyspnea
– Objective findings: physical exam findings,
drop in lung function, weight loss, fever, CXR
changes
• Target cultured bacteria
• Target Pseudomonas aeruginosa
• Use combination antibiotics |
|
|
Term
| Bronchiectasis: hemoptysis |
|
Definition
• Less than massive
– Consider increasing intensity of baseline
treatments
– Consider IV antibiotics
• Massive hemoptysis (>200 mL)
– Stabilize the airway with intubation
– Bronchial artery embolization
– Surgical resection
– Transplantation |
|
|
Term
| Bronchiectasis: When to and not to do a lung transplantation |
|
Definition
• CF
– Adults with 5-year predicted survival <30%
– Patients on ventilators
– Hesitate for patients with B cepacia
– Hesitate for children
• Non-CF
– For intractable hemoptysis
– For low prognosis
– May have equivalent outcomes |
|
|
Term
| Summary of antihistamine metabolism |
|
Definition
H1 antagonists eliminated more rapidly by children than by adults. counterindicated in children
Many antihistamines are metabolized by CYPs; therefore, inhibition of CYP activity (ex. macrolide antibiotics or imidazole antifungals) can increase antihistamine levels and lead to toxicity.
Newer antihistamines cetirizine, fexofenadine are not subject to these drug interactions (loratadine is metabolized by CYPs) |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| Prevents autocoid release |
|
Definition
| cromolyn sodium, nedocromil sodium |
|
|
Term
|
Definition
|
|
Term
|
Definition
| beclomethasone dipropionate, fluticasone, triamcinolone acetonide, flunisolide, budesonide. |
|
|
Term
|
Definition
|
|
Term
|
Definition
| ipratropium bromide, tiotropium |
|
|
Term
| Combinations asthma drugs |
|
Definition
| fluticasone + salmeterol (Advair) formoterol + budesonide (Symbicort) |
|
|
Term
| Clinical uses of H1-receptor antagonists |
|
Definition
Symptomatic relief of seasonal allergic rhinitis
(hayfever & urticaria), where histamine is the primary mediator.
H1-receptor antagonists relieve:
Sneezing & itching, by inhibiting histamine-inducted activation of sensory nerves
Acute runny nose (rhinorrhea), by inhibiting secretion from mucus glands
Acute congestion by inhibiting leakage of post-capillary venules
Allergic dermatoses, acute uticaria, and pruritus |
|
|
Term
| First-generation antihistamines |
|
Definition
| diphenhydramine, dimenhydrinate, chlorpheniramine, promethazine, cyclizine |
|
|
Term
| Second-generation antihistamines |
|
Definition
| fexofenadine, loratadine, cetirizine, desloratadine |
|
|
Term
| The mechanism of hypoxia in pulmonary edema is... |
|
Definition
| V/Q mismatch. Alveolar edema causes hypoxemia chiefly because of blood flow to unventilated units. V/Q mismatch |
|
|
Term
| Diagnosing sleep apnea: oximetry vs polysomnography |
|
Definition
Oximetry: Relatively good specificity but poor sensitivity and Negative Predictive Value
i.e. will be normal in people with significant disease. Never let a normal oximeter dissuade you from a diagnosis.
• Overnight polysomnography is the gold
standard. |
|
|
Term
| RML Atelectasis Chest X ray finding |
|
Definition
| Obscure border of right side of heart |
|
|
Term
|
Definition
involves the brachial plexus
• Pancoast or superior sulcus tumors arise from the apex of the upper lobe
– Affecting the 8th cervical nerve to the second thoracic nerve roots
– Pain, temperature change and muscle wasting (along nerve root dermatomal distribution) |
|
|
Term
Pleural effusion:
Transudate vs. exudate |
|
Definition
• Light’s criteria
• If any one of the following is met the
effusion is an exudate
– Pleural fluid protein/serum protein ratio greater than 0.5.
– Pleural fluid LDH/serum LDH ratio greater than 0.6.
– Pleural fluid LDH greater than two thirds the upper limits of normal of the serum LDH. |
|
|
Term
|
Definition
| orally active inhibitor of 5-lipoxygenase, and thus inhibits leukotrienes (LTB4, LTC4, LTD4, and LTE4) formation. Zileuton is used for the maintenance treatment of asthma |
|
|
Term
| By what mechanism do the cephalosporins work and name a few |
|
Definition
| Cell wall synthesis inhibitors. Ceftriaxone, Ceftazidime, Cefapime |
|
|
Term
| What groups of drugs are protein synthesis inhibitors? |
|
Definition
Aminoglycosides:Tobramycin,Gentamicin.
Macrolides:Clarithromycin,Azithromycin.
And one synthetic antibiotic Linezolid |
|
|
Term
|
Definition
| Used for serious gram positive hospital acquired infections. Inhibits protein synthesis by interfering with initiation. |
|
|
Term
|
Definition
| DNA synthesis inhibitor, blocks topoisomerase II. Treats gram negative (also effective against gram positive) UTI, RTI, Bacterial diarrhea, gonnococcal and atypical pneumonia. Treat psuedomonas, H. Influenza and Neisseria. May cause tendon rupture. Contraindicated in pregnancy. |
|
|
Term
|
Definition
| Fluorquinolone with extended spectrum against gram positive bacteria. Has about the same adverse effects as ciprofloxacin |
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Term
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Definition
| Ceftriaxone and Ceftazidime(3rd gen), Cefapime(4th gen). MOA blocks peptidoglycan cross linking. 3rd gen. are used for serious gram negative infection, 4th gen have extended gram pos spectrum. Hypersensitivity reaction, disulfiram like effect, nephrotoxicity. |
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Term
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Definition
| Imipenem, Meropenem. Blocks cell wall synthesis. Treats broad spectrum of Gr + and - infections including psuedomonas. May cause serizures at high levels. |
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Term
| Aminoglycosides: use and toxicity |
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Definition
| Tobramycin, Gentamicin. Bind 30S. Used for severe gram - infections. Nephro and ototoxicity |
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Term
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Definition
| Clarithromycin, Azithromycin. Bind 50S, inhibits translocation of aminoacyl peptide. Used to treat CAP and atypical pneumonia, Chlamydia and diptheria. Side effects include GI upset, rash , hepatitis |
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Term
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Definition
| Anti-Tubercular Drugs, inhibits mycolic acid synthesis. Used for treatment and prophylaxis. SE: peripheral neuropathy(Vit B6 can prevent it), Lupus, hepatitis, G6PD deficient patients have hemolytic anemia. |
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Term
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Definition
| Anti-Tubercular Drug, Inhibits bacterial DNA-dependent RNA polymerase. Used for active TB or leprosy or as prophylaxis for contacts of patients with menningococcal meningitis or H. Influenza type B. SE: Hepatitis, nephritis and turns urine sweat and tears orange. |
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Definition
Ethambutol: inhibits mycobacterial cell wall synthesis. SE: retrobulbar neuritis resulting in decreased visual acuity and red green color blindness.
Pyrazinamide: MOA unknown. SE: Hyperuricemia (gout), fever, GI intolerance, hepatotoxicity. |
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Term
empiric antimicrobial therapy is recommended for outpatient
management of community-acquired pneumonia in a previously healthy adult with no antibiotics in the past 3 months? |
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Definition
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Term
| CAP with comorbidities or antibiotics in the lst 3 months |
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Definition
| fluoroquinolone, Amoxicillin/ampicillin, or a 3rd gen cephalosporin + macrolide |
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Term
| Inpatients non-ICU and ICU |
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Definition
| about the same as outpatients with comorbidities except it can be given IV |
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Term
| Pneumonia when psuedomonas is a concern |
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Definition
| piperacillin/tazobactam, cefepime, imipenem, meropenem plus either ciprofloxacin or levofloxacin. Consider combos with aminoglycosides. |
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Term
| Pneumonia if CA-MRSA is a consideration |
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Definition
| Add linezolid, or vancomycin |
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Term
| What beta-lactam antibiotics have anti-pseudomonal activity |
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Definition
| Cefepime, meropenem, ciprofloxacin, levofloxacin, piperacillin/tazobactam |
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Term
| What effect does rifampin have on hepatic microsomal enzymes? |
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Definition
| potent inducer of the hepatic microsomal enzymes and thereby decreases the half-life of a number of drugs, including digoxin, warfarin, prednisone, cyclosporine, methadone, oral contraceptives, clarithromycin, the HIVprotease inhibitors, the HIV nonnucleoside reverse transcriptase inhibitors, and quinidine |
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Term
| How should pyrazinamide associated polyarthralgia be managed? How should pyrazinamide associated gout be managed? |
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Definition
| • Hyperuricemia is a common adverse effect of pyrazinamide therapy; the incidence is probably reduced by concurrent rifampin therapy. Clinical gout is seen only rarely. Polyarthralgias are encountered fairly commonly but are not related to the hyperuricemia. |
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Term
| Which drug should be given for prophylaxis of TB |
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Definition
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Term
| Arterial oxygen content - CaO2 |
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Definition
| CaO2 = (Hb x 1.39 x SaO2) + (0.003 x PaO2) |
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Term
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Definition
| DaO2 = CaO2 x cardiac output |
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Term
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Definition
Cardiac Output = VO2/(CaO2 - CvO2)
VO2: O2 consumption
CaO2:arterial O2 content
CvO2: mixed venous O2 content.
If CO decreses so does CvO2 |
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Term
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Definition
| Improves QOL but not survival |
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Term
| Pneumonia is what type of diagnosis |
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Definition
| Chest X-ray. Micro studies only help! Nursing home is considered hospital acquired. |
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Term
A 45 year old male has increasing dyspnea. A chest radiograph reveals large bilateral pleural effusions. A right thoracentesis is performed, and 500 cc of bloody fluid is obtained. These findings are LEAST often associated with:
A Congestive heart failure
B Tuberculosis
C Metastatic carcinoma
D Bronchogenic carcinoma
E Pulmonary infarction |
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Definition
| The effusions seen with CHF are typically serous in nature and not serosanguineous. |
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Term
| Which lung cancer is more associated with hypercalcemia |
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Definition
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Term
A 30 year old woman has smoked 1 pack of cigarettes per day for the past 13 years. Currently, her pulmonary function studies are normal. Aside from occasional bouts of coughing, she has no major problems. In order to provide motivation for her to quit smoking, you advise her that she can expect to benefit from all of the following EXCEPT:
A Diminshed risk for lung cancer
B Reversal of emphysematous changes
C Abatement of chronic bronchitis
D Lower risk for lung infections
E Decreased risk for lung cancer in close family members |
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Definition
| Once alveoli are destroyed, they cannot be restored. However, quitting will halt the ongoing destruction |
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Term
A 48 year old female with a 5 kg weight loss with malaise and increasing dyspnea for the past month has a chest radiograph that reveals a large right pleural effusion. A thoracentesis is performed, and 650 cc of milky white fluid is obtained. The most probable cause for this finding is:
A Mediastinal malignant lymphoma
B Penetrating chest trauma
C Tuberculosis
D Congestive heart failure
E Systemic lupus erythematosus |
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Definition
| There is obstruction of the thoracic duct and/or major lymph channels in the chest cavity with leakage of chylous fluid to produce a chylothorax. This is the rarest form of pleural effusion.A |
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Term
A 52-year-old transit authority employee presents with shortness of breath and dry cough which have been worsening over several months. He is unable to pinpoint the exact onset of these symptoms. Which of the following is most important for diagnosis of a treatable etiology for his symptoms:
A Physical examination
B Pulmonary function tests
C Chest x-ray
D History
E Transbronchial biopsy |
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Definition
| The history could point to specific pathogens or environmental causes for his disease. |
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Term
A 31 year old male is involved in a motor vehicle accident with laceration of the brachial artery. When paramedics arrive on the seen, he has cold, pale skin and a barely obtainable blood pressure. On admission to the hospital, he has a hematocrit of 15% and is given 4 units of packed red blood cells. Over the next few days he develops decreasing oxygen saturations measured by arterial blood gases. He is intubated, but requires increasing ventilatory pressures with increasing FIO2. Two weeks following the accident, his chest radiograph shows increasing infiltrates. He remains afebrile. Which of the following findings best typifies the probable microscopic appearance of his pulmonary parenchyma at this point in time:
A Proliferation of type II pneumonocytes
B Honeycomb lung
C Hyaline membranes
D Intra-alveolar edema
E Vascular thrombosis |
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Definition
| He has adult respiratory distress syndrome (ARDS) which is described pathologically by the term diffuse alveolar damage (DAD). DAD has three phases. The second phase of DAD is characterized by cellular proliferation, particularly many alveolar macrophages. A. CDE are all early findings and B is a late finding. |
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Term
A 29 year old woman has a positive double stranded DNA test along with myalgias and arthralgias. A urinalysis reveals red blood cell casts in urine. Her serum urea nitrogen is 52 mg/dL with creatinine of 7.1 mg/dL. She is treated with corticosteroid therapy. A month later, she became febrile. She again has cough with production of a small amount of blood-streaked whitish sputum. A chest radiograph now showed multiple 1 to 2 cm pulmonary nodules. A CBC shows Hgb 12.2 g/dL, Hct 36%, MCV 89 fL, platelet count 215,000/microliter, and WBC count 2,200/microliter with differential count of 40 segs, 5 bands, 35 lymphs, 15 monos, 3 eosinophils, and 2 basophils. Which of the following infectious agents is most likely to be producing the second chest radiographic pattern:
A Staphylococcus aureus
B Aspergillus flavus
C Pneumocystis carinii
D Adenovirus
E Mycobacterium avium-complex |
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Definition
| She has systemic lupus erythematosus with lupus nephritis. SLE can be associated with cytopenias, and corticosteroid therapy produces immune suppression. The result is leukopenia, particularly neutropenia, that puts her at risk for pulmonary fungal infection with Aspergillus. Aspergillosis typically produces nodular lesions. Vascular invasion is common. |
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Term
Hemoptysis for several weeks results in a workup for a 70 year old man, a non-smoker, that reveals a 6 cm left perihilar cavitary mass by chest CT scan. Sputum cytologic examination reveals atypical cells present consistent with squamous cell carcinoma. A mediastinoscopy is performed, and the mass appears to extend into the the mediastinum, but not to the opposite lung. Sampling of enlarged hilar and scalene lymph nodes reveals metastatic squamous cell carcinoma. He most likely has a:
A Resectable lesion
B Stage of T1
C Probable 5 year survival of 80%
D History of radon gas exposure
E Positive antinuclear antibody test |
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Definition
| This is a large, unresectable cancer with a poor prognosis because distant nodes are involved. The second most common cause for lung cancer is probably radon gas (if passive smoking is included with smoking as a risk). |
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Term
A 35-year-old HIV positive male has had a previous bout of Pneumocystis carinii pneumonia and now has a CD4 lymphocyte count of 69/microliter. He is at LEAST risk for a pulmonary infection with:
A Respiratory syncytial virus
B Mycobacterium avium-complex
C Staphylococcus aureus
D Aspergillus fumigatus
E Mycobacterium tuberculosis |
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Definition
| RSV is most often an infection of children. In general, pulmonary viral infections are not increased significantly with AIDS. |
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Term
Two years following orthotopic cardiac transplantation, a 44-year-old male develops fever and cough after his immunosuppressive therapy was increased to treat acute rejection. His symptoms do not improve after several months. Chest radiograph reveals right middle lobe infiltrates with abscess formation. A bronchoalveolar lavage is most likely to yield:
A Acid fast bacilli
B Clusters of gram positive cocci
C Gram negative rods
D Long filamentous gram positive organisms
E Large cells with intranuclear inclusions |
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Definition
| Nocardia can produce a chronic abscessing pneumonia. It occurs more frequently in immunocompromised patients.D |
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Term
(104) A 35 year old male is involved in a motor vehicle accident and sustains injuries including blunt trauma to the chest and abdomen, right ischial fracture, right femoral fracture, and left tibial fracture. He is taken to surgery and the fractures are stabilized. Postoperatively he is doing well until two days after admission, when he suddenly develops severe dyspnea. Despite resuscitative measures, he dies. What special stain performed on a section of the lung at autopsy would most help to elucidate the probable cause for these findings:
(105) A 35 year old woman has dyspnea worsening over the past two weeks. She is coughing up large amounts of sputum that resemble thick, gelatinous cream. She had a similar episode a year ago. A chest radiograph shows diffuse pulmonary opacification. A lung biopsy is performed, and microscopically every alveolus is filled with an acellular exudate. Lung lavage is performed and she recovers. Which of the following special stains performed on the biopsy will be most useful to demonstrate the nature of this exudate and the underlying disease:
A Acid fast stain
B Gomori methenamine silver (GMS) stain
C Periodic acid-Schiff (PAS) stain
D Oil red O stain |
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Definition
(D) Match on 104. Fat embolism syndrome typically includes fat droplets in pulmonary and brain vasculature. The ORO stain helps to highlight them.
(C) Match with 105. The alveolar exudates of pulmonary alveolar proteinosis, an uncommon idiopathic disease, are PAS positive. |
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Term
(109) A 42 year old male received an orthotopic cardiac transplant two months ago and has had mild acute rejection treated with increasing immunosuppressive therapy. He has developed a cough with fever and headache. A chest radiograph reveals consolidation involving most of the right mid-lung. A bronchoalveolar lavage reveals long, filamentous, gram positive organisms to be present.
A Acute abscessing bronchopneumonia
B Chronic abscessing pneumonia
C Interstitial pneumonitis
D Lobar pneumonia
E Miliary granulomata |
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Definition
| Nocardia asteroides and Actinomyces israeli tend to produce chronic abscessing pneumonias, particularly in immunocompromised patients. |
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Term
| A 2-year-old child has croup. |
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Definition
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Term
A 33 year old female complains of a cough for several months, along with shortness of breath. A chest radiograph demonstrates multiple small nodules distributed throughout all lung fields, but more numerous in the upper lobes. A transbronchial biopsy is performed, and examination of the tissue reveals nodular aggregates of Langerhans cells with eosinophils, lymphocytes, plasma cells, and some fibroblasts with collagenization. These findings are most characteristic for:
A Wegener's granulomatosis
B Hypersensitivity pneumonitis
C Pulmonary eosinophilic granuloma
D Goodpasture's syndrome
E Bronchial asthma |
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Definition
| Eosinophilic granuloma is a localized lesion that is part of the spectrum of Langerhans cell histiocytosis, seen in children as histiocytosis X. In adults, the lesions tend to form small scars and resolve with time. This uncommon condition has a mean age of 30, with a 2:1 F:M predominance. The Langerhans cells are the key to the diagnosis. |
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Term
A 55 year old male with a long history of smoking has recently experienced an episode of hemoptysis along with his usual cough. He has a sputum cytology examination performed that demonstrates the presence of atypical cells with hyperchromatic nuclei and orange-pink cytoplasm. A chest radiograph is most likely to reveal a(an):
A Large hilar mass
B Pneumonia-like consolidation
C Peripheral nodule
D Carinal mass
E Left pleural thickening |
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Definition
| Both squamous cell and oat cell carcinomas tend to be central in location.A |
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Term
A 41 year old man with a 10 kg weight loss over the past 3 months now has had worsening fever, non-productive cough, and dyspnea for several days. A chest radiograph shows some patchy infiltrates in both lungs. He has a CBC that shows a WBC count of 3250/microliter with differential of 78 segs, 3 bands, 5 lymphs, 11 monos, 2 eosinophils, and 1 basophil, Hgb 13.8 g/dL, Hct 41.4%, MCV 91 fL, and platelet count 317,000/microliter. His CD4 lymphocyte count is 79/microliter. Cryptosporidium organisms are found in a stool specimen. A bronchoalveolar lavage is performed, yielding fluid that microscopically demonstrates pink, foamy exudate with little inflammation. Which of the following additional findings on microscopic examination is he most likely to have:
A Acid fast bacilli
B Branching septate hyphae
C Multiple cysts with GMS stain
D Hemosiderin-laden macrophages
E Short gram positive rods |
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Definition
| He is most likely to have Pneumocystis carinii pneumonia in association with the acquired immunodeficiency syndrome. PCP has an exudate composed of the Pneumocystis cysts and trophozoites with little accompanying inflammation. The clinical findings in this case are typical as well.C |
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Term
If the equal pressure point during expiration is in the lobar bronchi, which of the following is TRUE?
A. Expiratory flow would be effort dependent.
B. Expiratory flow would be effort independent.
C. The bronchi beyond the equal pressure point would compress.
D. This situation would only occur during medium and low lung volumes. |
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Definition
| These airways are rigid and non-collapsible, which does not limit expiratory flow like it would if the equal pressure point were in the alveoli.A |
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Term
Which of the following does NOT apply to the alveoli at the base of the lungs?
A. They are less elastic than the alveoli at the apex.
B. The pleural pressure is lower.
C. At FRC they aere les inflated than the alveoli at the apex.
D. They are closed at RV.
E. They have a greater volume change than alveoli at the apex during inspiration from FRC. |
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Definition
| The elastic properties of lung tissue are the same at the base as the apex. A |
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Term
In which situation would the response to hypoxia be limited?
A. In a patient with obstructed airways.
B. When hypoxia is accompanied by hypercapnea.
C. In the hypoxia induced by high altitude.
D. During hypoventilation. |
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Definition
| In high altitude there is hypoxia, but no hypercapnea, so the respiratory systems does not respond as strongly. C |
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Term
Pulmonary atelectasis is seen by chest radiography to involve all of the right lung of a 44 year old male who had the sudden onset of severe dyspnea. This is most likely to have resulted from:
A Aspiration of a foreign body
B Pulmonary embolism
C Squamous cell carcinoma
D Penetrating chest trauma
E Bronchiectasis |
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Definition
| This would lead to pneumothorax with lung collapse. Such trauma is not infrequent, particularly in auto accidents.D |
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Definition
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