Final Test Flashcards

Question

*Describe the composition, synthesis, mechanism of action and function of lung surfactant.* What does the following describe? * This strongly interacts with phospholipids, is involved with adsorption and spreading of the surfactant on the surface of lungs, and prevents the collapse of the alveolus. Not required for life. 1. SP-A 2. SP-B 3. SP-C 4. SP-D 5. Both 1 and 2 6. Both 2 and 3

Answer 1

*Describe the composition, synthesis, mechanism of action and function of lung surfactant.* What does the following describe? * This strongly interacts with phospholipids, is involved with adsorption and spreading of the surfactant on the surface of lungs, and prevents the collapse of the alveolus. Not required for life. 1. SP-A 2. SP-B 3. **SP-C** 4. SP-D 5. Both 1 and 2 6. Both 2 and 3

Answer 2

*Discuss the etiology and treatment of infant respiratory distress syndrome.* * How does IRDS relate to neonatal mortality and premature births? * **The most common cause of neonatal mortality** * **High incidence in premies** * What is it caused by? * **It is caused by insufficient lung surfactant** * What are the 3 options for supportive care? 1. **Oxygenation** 2. **Ventilation aka CPAP** 3. **Surfactant replacement therapy**

Answer 3

*Identify types of pneumoconiosis and the compounds that initiate disease.* * What is ILD and what are the common causes? * The term “ILD” is generically used to describe a collection of diseases that involve diffuse scarring and/or inflammation of lung tissue. Common causes of ILD are as follows: * **Prolonged exposure to occupationally inhaled inorganic agents such as silicone, coal, asbestos, talc, mica, aluminum, and beryllium** * Idiopathic pulmonary fibrosis * Connective tissue disease (eg, Wegener granulomatosis, systemic lupus erythematosus, scleroderma, Sjögren disease) * **Sarcoidosis** * Hypersensitivity pneumonitis, such as “farmer’s lung” or “bird breeder's lung,” in which an immune reaction to organic dust induces a type III or type IV hypersensitivity reaction * Radiation-induced disease * Antitumor drugs (eg, bleomycin)

Answer 4

*Identify types of pneumoconiosis and the compounds that initiate disease.* **Chest XR finding: Pleural thickening, plaques, effusions, and Nodules in the LOWER zones** * State which pneumoconiosis is associated with the above Chest XR finding. Options are below 1. Silicosis 2. Coal workers’ pneumoconiosis 3. **Asbestosis**

Answer 5

*Identify types of pneumoconiosis and the compounds that initiate disease.* **Chest XR finding: Multiple small nodules in the UPPER zones and Hilar “eggshell” calcifications** * State which pneumoconiosis is associated with the above Chest XR finding. Options are below 1. **Silicosis** 2. Coal workers’ pneumoconiosis 3. Asbestosis

Answer 6

*Identify types of pneumoconiosis and the compounds that initiate disease.* **Chest XR finding: Large masses of dense fibrosis in the UPPER zones** * State which pneumoconiosis is associated with the above Chest XR finding. Options are below 1. Silicosis 2. **Coal workers’ pneumoconiosis** 3. Asbestosis

Answer 7

*Identify types of pneumoconiosis and the compounds that initiate disease.* * This pneumoconiosis is associated with increased susceptibility to tuberculosis. * **Silicosis** * Imaging shows fine nodularity in the upper zones of the lung. What do these nodules contain? * **The nodules demonstrate concentrically arranged (whorled) hyalinized collagen fibers surrounding an amorphous center.** * **Examination by polarized microscopy reveals weakly birefringent silica particles in the nodules.** * What eventually occurs as the nodules coalesce into hard, collagenous scars? * **Many patients develop progressive massive fibrosis aka PMF and further develop pulmonary HTN and cor pulmonale as a result of chronic hypoxia-induced vasoconstriction and parenchymal destruction.**

Answer 8

*Identify types of pneumoconiosis and the compounds that initiate disease.* * What is the difference between Simple coal worker's pneumoconiosis and Complicated coal worker's pneumoconiosis? * **Simple coal worker's pneumoconiosis (CWP)** * **Macrophages accumulate with little to no pulmonary dysfunction** * **Characterized by the presence of coal macules and larger coal nodules.** * **The coal macule consists of dust-laden macrophages and small amounts of collagen fibers.** * **The upper lobes and upper zones of the lower lobes are more heavily involved.** * **Complicated coal worker's pneumoconiosis** * **Progressive massive fibrosis (PMF)** * **Fibrosis is extensive and lung function is compromised (** * **Occurs on a background of simple CWP by coalescence of coal nodules and generally develops over many years** * **It is characterized by multiple, dark black scars larger than 2 cm and sometimes up to 10 cm in greatest diameter, that consist of dense collagen and pigment.** * What is Pulmonary anthracosis? * **The most innocuous coal-induced pulmonary lesion in coal miners, and also is commonly seen in urban dwellers and tobacco smokers.** * **Inhaled carbon pigment is engulfed by alveolar or interstitial macrophages, which then accumulate in the connective tissue along the pulmonary and pleural lymphatics and in draining lymph nodes.**

Answer 9

*Identify types of pneumoconiosis and the compounds that initiate disease.* * What is notable about where asbestosis starts in the lungs? * **In contrast with CWP and silicosis, asbestosis begins in the lower lobes and subpleurally, spreading to the middle and upper lobes as the fibrosis progresses.** * In asbestosis, contraction of the fibrous tissue distorts the normal architecture, creating enlarged air spaces enclosed within thick fibrous walls. What is the notable term used to describe the way the regions look? * **Honeycombing** * What is the most common manifestation of asbestos, and what are they made of /contain? * **Pleural plaques are the most common manifestation of asbestos exposure** and are well-circumscribed **plaques of dense collagen, often containing calcium.** * They develop most frequently on the anterior and posterolateral aspects of the parietal pleura and over the domes of the diaphragm. * What is shown in the image? * **Asbestos bodies** * **When asbestos fibers are inhaled, they become surrounded by alveolar macrophages and coated by a protein-iron complex, forming *_asbestos bodies._*** * **These bodies eventually undergo fibrosis, causing the lung tissue to become diffusely fibrotic and rigid and the airways to become distorted.** * How do patients with the asbestos present? * **Progressively worsening dyspnea appears 10 to 20 years after exposure.** * **It is usually accompanied by a cough and production of sputum.** * **The disease may remain static or progress to CHF, cor pulmonale, and death.**

Answer 10

*Contrast clinical findings in presentations of restrictive and obstructive lung processes.* * In obstructive lung diseases such as COPD * FEV-1 is **decreased** * Forced vital capacity (FVC) is near **normal or only slightly decreased** * FEV-1/FVC ratio is **\< 70% of predicted**

Answer 11

*Contrast clinical findings in presentations of restrictive and obstructive lung processes.* * In restrictive lung disease * **Decreased vital capacity** * **Decreased total lung capacity** * FEV1/FVC **ratio of \> 80%.**

Answer 12

Compare and contrast the lung capacity of restrictive versus obstructive lung diseases. * Which row shows obstructive lung disease and which shows restrictive?

Answer 13

Describe the differences between emphysema and bronchitis. * Both emphysema and bronchitis present with SOB. What are the other 2 main presentations for bronchitis?

Answer 14

* Describe the differences between emphysema and bronchitis.* * Does the following describe emphysema or **bronchitis**? _Mucous gland hypertrophy and hyperplasia with hypersecretion_

Answer 15

Describe the differences between emphysema and bronchitis. * Does the following describe **emphysema** or bronchitis? _Air space enlargement, alveolar wall destruction_

Answer 16

* Describe the differences between emphysema and bronchitis.* * Does the following describe **emphysema** or bronchitis? Defined by morphologic and radiologic features and affects the acinus

Answer 17

Describe the differences between emphysema and bronchitis. * Does the following describe emphysema or **bronchitis**? Defined by clinical features and initially involves the large airways

Answer 18

*Understand the differences between panacinar and centriacinar emphysema.* * Panacinar * Are the acini uniformly enlarged, or are only parts of them enlarged? * **Acini are uniformly enlarged, from the level of the respiratory bronchiole to the terminal blind alveoli.** * What lung zone is usually affected? * **It occurs more commonly in the lower lung zones,** * What protein are patients deficient in? What is the function of this protein? * **Patients have a α1-anti-trypsin deficiency** * **Normally present in serum, tissue fluids, and macrophages, is a major inhibitor of proteases (particularly elastase) secreted by neutrophils during inflammation. α1-anti-trypsin is encoded by a gene in the proteinase inhibitor (Pi) locus on chromosome 14.**

Answer 19

*Understand the differences between panacinar and centriacinar emphysema.* * Centracinar * Is this more common than Panacinar? Which one is associated more with smoking? * **Centracinar is more common and associated with smoking** * Does this affect all of the acini or only parts of it? * **Central or proximal parts of the acini, formed by respiratory bronchioles, are affected, while distal alveoli are spared.** * What lung zone are lesions most common in? * **Upper lobes**

Answer 20

*Describe the differences between emphysema and bronchitis.* Between the green and orange squares: * Which is associated with bronchitis and which is associated with emphysema? * CB= Chronic bronchitis=Green * Emphysema=Orange

Answer 21

*Describe the types of infection that can lead to bronchiectasis.* * What is bronchiectasis*?* * ****Bronchiectasis is a disease state in which bronchi become inflamed and dilated, causing obstructed airflow (wide airways impair laminar outlaw) and impaired clearance of secretions.** * **It is often associated with AIDS, cystic fibrosis, and Kartagener syndrome.** * What is seen on CT scans in bronchiectasis? * **In bronchiectasis, a “tree-in-bud” pattern is commonly seen on high-resolution CT scans**

Answer 22

*Describe the types of infection that can lead to bronchiectasis* * What bacteria can cause this? * **Necrotizing, or suppurative, pneumonia, will predispose affected patients to the development of bronchiectasis. Particularly with virulent organisms such as** * ***_Staphylococcus aureus_*** * ***_Klebsiella spp.,_*** * What viruses can cause this? * **HIV, or other viruses that induce an immunocompromised state**

Answer 23

*Identify the types of obstructions that can cause bronchiectasis.* * What conditions, aside from Infx, cause bronchiectasis*?* * ****Common causes are tumors, foreign bodies, and impaction of mucus.** * **Cystic fibrosis, in which widespread severe bronchiectasis results from obstruction caused by abnormally viscid mucus and secondary infections.** * **When bronchiectasis is associated with situs inversus and chronic rhinosinusitis, the triad of indings is referred to as Kartagener syndrome aka Primary ciliary dyskinesia (the immotile cilia syndrome)**

Answer 24

*Compare and contrast the causes of atopic (extrinsic) versus non-atopic (intrinsic) asthma.* * For Atopic * How common is this? * **The most common form of asthma** * What type of hypersensitivity is this, and what Ig molecule is it associated with? * **A classic example of type I IgE–mediated hypersensitivity reaction.** * When does it start in life? * **Childhood** * Does it have a genetic component? * **Yes, a positive family history of atopy and/or asthma is common** * What often precedes asthma attacks? * **Allergic rhinitis, urticaria, or eczema.** * What will a skin test show? * **Wheal and Flare Rxn**

Answer 25

Compare and contrast the causes of atopic (extrinsic) versus non-atopic (intrinsic) asthma. * Non-Atopic Asthma * What allergy history do patients have? * **Patients with nonatopic forms of asthma do not have evidence of allergen sensitization.** * Do patients usually have a positive skin test? * **Skin test results usually are negative.** * What type of air pollutants can cause this? * **Air pollutants (e.g., sulfur dioxide, ozone, nitrogen dioxide)** * What type of infections can cause this? What is thought to be the reason for this? * **Respiratory infections due to viruses (e.g., rhinovirus, parainfluenza virus)** * **It is thought that virus-induced inflammation of the respiratory mucosa lowers the threshold of the subepithelial vagal receptors to irritants.**

Answer 26

*Describe the changes in lung smooth muscle and cellular infiltrates associated with asthma.* * What are the 4 hallmarks of asthma? * **The hallmarks of asthma are** 1. **intermittent, reversible airway obstruction** 2. **chronic bronchial inflammation with eosinophils;** 3. **bronchial smooth muscle cell hypertrophy and hyperreactivity;** 4. **increased mucus secretion.**

Answer 27

*Describe the changes in lung smooth muscle and cellular infiltrates associated with asthma.* * Which Ig molecule and which granulocyte are associated with asthma? * **IgE coats submucosal mast cells, which on exposure to allergen release their granule contents and secrete cytokines and other mediators.** * Describe the early and late phase of asthma-related reactions * **Mast cell-derived mediators produce two waves of reaction: an early (immediate) phase and a late phase.** * **The early-phase reaction** * **Dominated by bronchoconstriction, increased mucus production, and vasodilation.** * **Bronchoconstriction is triggered by mediators released from mast cells, including histamine, prostaglandin D2, and leukotrienes LTC4, D4, and E4, and by reflex neural pathways.** * **The late-phase reaction** * **Inflammatory in nature.** * **Inflammatory mediators stimulate epithelial cells to produce chemokines that promote the recruitment of TH2 cells, eosinophils, and other leukocytes, amplifying an inflammatory reaction initiated by resident immune cells.**

Answer 28

Describe the changes in lung smooth muscle and cellular infiltrates associated with asthma. * What leads to the structural changes in the bronchial wall? * **Repeated bouts of inflammation lead to structural changes in the bronchial wall referred to as airway remodeling.** * What kind of changes happen to the bronchial wall? * **These changes include hypertrophy of bronchial smooth muscle and mucus glands and increased vascularity and deposition of subepithelial collagen, which may occur as early as several years after initiation of symptoms.**

Answer 29

*Discover why lack of wheezes does not necessarily mean that a patient does not have asthma* * Does an extreme acute asthma attack have to have wheezing? * **No** * **During a most extreme asthma attack, wheezing may be absent because almost no air is passing through the airways** * If someone has asthma without wheezing, what symptom will they most likely have? * **Dry, non-productive cough. aka atypical asthma** * Why could someone have asthma without wheezing? * **Coughing may start after people are exposed to allergens, or when they are breathing in cold air. Coughing may also follow an upper respiratory infection.** * **A cough that begins after a person has begun taking beta-blockers is likely to be cough-variant asthma.** * **Think Drug-Induced Asthma or Occupational Asthma**

Answer 30

*Describe risk factors other than smoking that can lead to increased lung cancer risk.* * What are the common occupational exposures that have an increased risk of lung cancer? * **Uranium Mines** * **Work with asbestos** * **Inhalation of dust containing arsenic, chromium, nickel, or vinyl chloride.**

Answer 31

Adenocarcinoma

Answer 32

*Summarize the various presentations of different types of lung cancers.* * Adenocarcinoma * Who gets this more: men or women? Do non-smokers get this? * **Adenocarcinomas also are by far the most common primary tumors arising in women, in never-smokers, and in individuals younger than 45 years of age.** * Where do they usually occur? * **Adenocarcinomas are usually peripherally located, but also may occur closer to the hilum.** * Are they fast-growing or slow-growing? * **In general, adenocarcinomas grow slowly and form smaller masses than do the other subtypes, but they tend to metastasize widely at an early stage.** * What are the different growth patterns that this has? 1. **Acinar (gland- forming)** 2. **Papillary** 3. **Mucinous which is often multifocal and may manifest as pneumonia-like consolidation** 4. **Solid types.**

Answer 33

*Summarize the various presentations of different types of lung cancers.* * A subset of adenocarcinomas (about 10% in whites and 30% in Asians), particularly those arising in nonsmoking women, harbor mutations that activate what molecule? What does this molecule do and what growth pathways are associated with it? * **Epidermal growth factor receptor (EGFR)** * **A receptor tyrosine kinase that stimulates downstream pro-growth pathways involving RAS, PI3K, and other signaling molecules.** * What are these types of tumors sensitive to? * **These tumors are sensitive to drugs that inhibit EGFR signaling, although the response is often short-lived.**

Answer 34

*Summarize the various presentations of different types of lung cancers.* * Which 2 cancer types have the strongest association with smoking? * **Squamous cell and small cell carcinomas have the strongest association with smoking, but there is also an association with adenocarcinoma.**

Answer 35

*Summarize the various presentations of different types of lung cancers.* * Squamous cell carcinomas * Who gets this more: men or women? * **Men** * Where do they usually arise? Where do they often spread to? How is this different compared to other types? * **They tend to arise centrally in major bronchi and eventually spread to local hilar nodes, but they metastasize outside the thorax later than other histologic types.** * Large Squamous cell carcinomas may undergo central necrosis. What does this give rise to? * **Large SCCAs may undergo central necrosis, giving rise to cavitation.** * What often precedes the development of Squamous cell carcinoma? * **Squamous cell carcinomas often are preceded by the development, over years, of squamous metaplasia or dysplasia in the bronchial epithelium, which then transforms to carcinoma in situ, a phase that may last for several years.** * How would you describe what the tumor looks like and its location when patients reach the symptomatic stage? * **Eventually, when the neoplasm reaches the symptomatic stage, a well-defined tumor mass begins to obstruct the lumen of a major bronchus, often producing distal atelectasis and infection.**

Answer 36

*Summarize the various presentations of different types of lung cancers.* * Small cell lung carcinomas * Describe the shape/appearance of these tumors, as well as where they are located? * **Masses generally appear as pale gray, centrally located masses that extend into the lung parenchyma.** * **Masses are composed of relatively small tumor cells with a round to fusiform shape, scant cytoplasm, and finely granular chromatin with a salt and pepper appearance.** * Are these tumors very fragile or very hard? How do you know? * **Fragile** * **They often show fragmentation and “crush artifact” in small biopsy specimens.** * What is nuclear molding a result of? * **Nuclear molding results from close apposition of tumor cells that have scant cytoplasm** * What has usually occurred by the time this cancer has been diagnosed? * **By the time of diagnosis, most will have metastasized to hilar and mediastinal lymph nodes.** * What kind of markers are often seen with this cancer? * **Express a variety of neuroendocrine markers and may secrete polypeptide hormones that can result in paraneoplastic syndromes.**

Answer 37

Summarize the various presentations of different types of lung cancers. * Large cell carcinomas * Which cell layer do these tumors occur in? * **Large cell carcinomas are undifferentiated malignant *_epithelial_* tumors** * What cytologic features do these tumors lack? * **Cells lack the cytologic features of neuroendocrine carcinoma** * **Cells show no evidence of glandular or squamous differentiation.** * What is notable about the nuclei, nucleoli, and cytoplasm of this cancer type? * **The cells typically have large nuclei, prominent nucleoli, and moderate amounts of cytoplasm.**

Answer 38

*Summarize the various presentations of different types of lung cancers.* * Carcinoid Tumors * What is notable about the contents secretions of these cancer cells? * **These are malignant tumors composed of cells that contain dense-core neurosecretory granules in their cytoplasm and, rarely, may secrete hormonally active polypeptides.** * What is MEN syndrome? * **These tumors can occasionally occur as part of the multiple endocrine neoplasia (MEN) syndrome.** * **MEN Syndrome: Characterized by several endocrine glands develop noncancerous (benign) or cancerous (malignant) tumors or grow excessively without forming tumors.** * Who usually gets bronchial carcinoid tumors? * **Young Adults** * Compare and contrast the 2 classes of Carcinoid Tumors * **Think of these as low-grade neuroendocrine carcinomas. They are subclassified as typical or atypical; both are often resectable and curable.** * **Typical carcinoids** * **Like those in the intestinal tract, are composed of nests of uniform cells that have regular round nuclei with “salt-and-pepper” chromatin, absent/rare mitoses and little pleomorphism.** * **Atypical carcinoid tumors** * **Display a higher mitotic rate and small areas of necrosis.**

Answer 39

*Summarize the various presentations of different types of lung cancers.* * Carcinoid Tumors * Most masses originate in the main bronchi and follow 2 types of growth patterns. What are they? * **1. An obstructing polypoid, intraluminal mass** * **2. A mucosal plaque penetrating the bronchial wall, to fan out in the peribronchial tissue.** * Is metastasis at the time of diagnosis common? * **5 - 15% have metastasized to the hilar nodes at presentation, but distant metastases are rare.** * Whare the signs and symptoms of this cancer? * Most carcinoid tumors present with signs and symptoms related to their intraluminal growth. This include: * **Cough** * **Hemoptysis** * **Recurrent bronchial and pulmonary infections.** * What is carcinoid syndrome? * **Carcinoid syndrome is characterized by intermittent attacks of diarrhea, flushing, and cyanosis.** * **Only rarely do pulmonary carcinoids cause the carcinoid syndrome**

Answer 40

*Summarize the various presentations of different types of lung cancers.* * Malignant Mesothelioma * Where do these arise in the body? * **Usually in the parietal or visceral pleura** * **It also occurs much less commonly in the peritoneum and pericardium.** * How long is the latent period for this? * **The latent period for developing malignant mesothelioma after the initial exposure is long, often 25 to 40 years.** * What are the three morphologic appearances of this? 1. **Epithelial,** * **Cuboidal cells with small papillary buds line tubular and microcystic spaces;** 2. **Sarcomatous** * **Spindled, occasionally fibroblastic-appearing cells grow in sheets** 3. **Biphasic** * **Both sarcomatous and epithelial areas.** * What do signs/symptoms do patients present with? * **The presenting complaints are chest pain, dyspnea, and recurrent pleural effusions.** * **Concurrent pulmonary asbestosis is present in only 20% of individuals.** * Is metastasis common? * **The lung is invaded directly, and there is often metastatic spread to the hilar lymph nodes and, eventually/rarely, to the liver and other distant organs.** * What is seen when the lungs are examined at autopsy? * **At autopsy, the affected lung typically is ensheathed by a layer of yellow-white, firm, variably gelatinous tumor that obliterates the pleural space.** * How does asbestos relate to smoking? * **Exposure to asbestos in nonsmokers increases the risk for developing lung cancer 5-fold, while in heavy smokers exposed to asbestos the risk is increased approximately 55-fold.**

Answer 41

*Understand that secondary lung cancer (metastatic cancer from a distal site) is more common than primary lung cancer.* * What is the most common site of metastatic neoplasms? * **The lung is the most common site of metastatic neoplasms.** * How do these neoplasms get there? * **Both carcinomas and sarcomas arising anywhere in the body may spread to the lungs via** * **The blood** * **Lymphatics** * **Direct continuity** * What is a distinct feature seen in the parenchyma of this organ? * **Multiple discrete nodules (cannonball lesions) are scattered throughout all lobes, more at the periphery.**

Answer 42

*Be able to describe the pathogenesis, prevention, and therapies of diphtheria.* * Corynebacterium diphtheriae * What shape do these have? * **Clubbed or irregular shape** * **"Coryneforms"** * Are they gram negative or positive? * **Gram-Positive** * What does the Diphtheria toxin do to the epithelium of the upper respiratory tract? * **Causes a necrotic epithelium that becomes embedded with exuding fibrin, red, white cells** * What is usually seen on the tonsils, pharynx, and larynx? * **Grayish pseudomembrane**

Answer 43

Be able to describe the pathogenesis, prevention, and therapies of diphtheria. * Corynebacterium diphtheriae * Who is Infx by this prevented? * **There are four vaccines used to prevent diphtheria: DTaP, Tdap, DT, and Td.** * **Each of these vaccines prevents diphtheria and tetanus; DTaP and Tdap also help prevent pertussis (whooping cough).** * **Healthcare professionals give DTaP and DT to children younger than seven years old, while older children, teens, and adults get Tdap and Td.** * How is Infx by this treated? * See pic

Answer 44

*Understand and be able to discuss common bacterial pathogens responsible for upper respiratory tract infections, including those that present as sinusitis, pharyngitis, epiglottitis.* * Group A (Streptococcus pyogenes) * Is this gram negative or gram positive? * What shape does it have? * Describe the following virulence factors: * Hyaluronic acid capsule * **Resists phagocytosis** * **Binds to CD44 on epithelial cells which disrupts intercellular junctions allowing invasion of the epithelium.** * M Protein * **Major virulence factor** * **If absent, virulence is lost** * **Fimbriae** * **Inhibits complement** * **Maybe inhibits IgA** * What kind of hemolysis does this have? * **β-Hemolysis (Clear/Complete Hemolysis)**

Answer 45

*Understand and be able to discuss common bacterial pathogens responsible for upper respiratory tract infections, including those that present as sinusitis, pharyngitis, epiglottitis.* * Group A (Streptococcus pyogenes) * What can patients with a URI from this present with? * **Intense acute pharyngitis** * **Glomerulonephritis** * **Tonsillitis** * **Redness and edema of mucus membranes** * **Purulent exudate** * List and describe the 3 conditions that can happen if this is untreated? 1. ***_Scarlet fever_*** * **- High fever \> 38.30C** * **Sandpaper rash** * **Strawberry tongue** * **Circumoral palor** 2. ***_Rheumatic fever and Rheumatic heart disease_*** * **Antibodies to M protein and other cell wall components also bind human cardiac sarcolemma** 3. ***_Post-Strep Glomerulonephritis_*** * **1-5 weeks after acute pharyngitis or streptococcal skin infection** * **Blood and protein in urine, edema, hypertension, renal insufficiency, oliguria** * **Deposition of immune complexes in the kidneys** * **Majority of patients recover but it can be fatal or develop into chronic disease in rare cases.**

Answer 46

Understand and be able to discuss common bacterial pathogens responsible for upper respiratory tract infections, including those that present as sinusitis, pharyngitis, epiglottitis. * Bordatella pertussis AKA Whooping Cough * Are these gram negative or positive? * **Gram-negative** * What shape do they have? * **Coccobacilli** * Are these bacteria encapsulated? * **Encapsulated** * Describe the test results for * **Oxidase and catalase positive** * **Think oxygen = positive** * **Nitrate, citrate and urea negative**

Answer 47

*Understand and be able to discuss common bacterial pathogens responsible for upper respiratory tract infections, including those that present as sinusitis, pharyngitis, epiglottitis.* * Bordatella pertussis AKA Whooping Cough * Describe the catarrhal stage * **2 week incubation** * **Mild disease if anything but highly infectious** * Describe the paroxysmal stage * **After two weeks.** * **Explosive whooping cough** * **Whoop upon inhalation leading to rapid exhaustion -** * **Associated with vomiting, cyanosis, convulsions** * **Dangerous complications in infants** * **Rarely can lead to seizures and encephalopathy.** * When is the initiation of treatment pointless? * **Treatment initiated after the start of the paroxysmal stage rarely alters the clinical**

Answer 48

*Understand and be able to discuss common bacterial pathogens responsible for upper respiratory tract infections, including those that present as sinusitis, pharyngitis, epiglottitis.* * Haemophilus influenzae * Are these gram negative or positive? * **Gram-negative** * What shape do they have? * **Rods** * Are they encapsulated? * **Yes** * What emergency situation is this the most common cause of? * ***_Epiglottitis_* due to Hib is rare BUT it remains the most common cause in both immunized and unimmunized individuals in the absence of trauma.** * Does this have hemolysis? * **No (gamma)**

Answer 49

*Understand and be able to discuss common bacterial pathogens responsible for upper respiratory tract infections, including those that present as sinusitis, pharyngitis, epiglottitis.* * Neisseria gonorrhoeae * Are these gram negative or positive? * **Gram-Negative** * What shape do these have? * **Diplococci** * What kind of URI's do patients present with? * ***_Pharyngitis_*** * **Tonsillitis** * **Most cases resolve spontaneously** * What is unique about the identification of these bacteria? * **Thayer-martin media with 5% sheep blood** * **Selective for Neisseria spp**

Answer 50

*Understand and be able to discuss common bacterial pathogens responsible for upper respiratory tract infections, including those that present as sinusitis, pharyngitis, epiglottitis.* * Chlamydia pneumoniae * Is this gram negative or positive? * **Gram-Negative** * Where does this bacterium live? * **Obligate intracellular bacterium** * What URI's are common? * **Mild URI's** * **Pharyngitis, otitis media, rhinitis, low fever, laryngitis** * How do you Dx this as the causative pathogen? * **Microimmunofluorescence or ELISA using species- specific antigens**

Answer 51

*Describe how virulence factors impact the pathogenesis of bacterial pneumonia.* * What is a virulence factor? * **Virulence factors are molecules produced by bacteria, viruses, fungi, and protozoa that add to their effectiveness**

Answer 52

* VAP: Ventilator-Associated Pneumonia (≥ 48hrs after endotracheal intubation)

Answer 53

*Discuss the clinical presentation, mechanisms of pathogenicity, diagnosis, prevention/treatment and epidemiology of the following bacterial respiratory pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Legionella pneumophila, Mycoplasma pneumoniae, Klebsiella pneumoniae .* * Streptococcus pneumoniae * Are these gram positive or negative? * **Gram-positive** * What shape does it have? * **Diplococci** * What 3 main virulence factors does it have? * **Capsule** * **Hyaluronidase** * **Pneumolysin** * What is notable about the spit of patients? * **Rusty sputum** * What tests are used to Dx this? * **Alpha-hemolytic** * **Optochin sensitive** * **Catalase negative** * What are the 3 vaccines and who is each one suited for? * **PPSV23: over 65 or immunocompromised** * **PCV13: over 65, immunocompromised** * **PCV7: pediatric** * What factors are associated with an increased incidence of pneumococcal pneumonia? * **Primary viral infection** * **Alcohol or drug intoxication can reduce phagocytosis and depress the cough reflex** * **Abnormal circulatory dynamics** * **Malnutrition, age, complement deficiency**

Answer 54

*Discuss the clinical presentation, mechanisms of pathogenicity, diagnosis, prevention/treatment and epidemiology of the following bacterial respiratory pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Legionella pneumophila, Mycoplasma pneumoniae, Klebsiella pneumoniae .* * Haemophilus influenzae * What gram stain does this have? * **Gram-Negative** * What shape does this have? * **Rod** * Is it encapsulated? * **Yes** * What do patients present with? * **Epiglottitis, meningitis, otitis media, pneumonia** * How do you dx this specific pathogen? * **Growth on chocolate agar with factors V and X** * **No hemolysis** * What vaccine exits? * **Vaccine that uses a type B capsular antigen**

Answer 55

*Discuss the clinical presentation, mechanisms of pathogenicity, diagnosis, prevention/treatment and epidemiology of the following bacterial respiratory pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Legionella pneumophila, Mycoplasma pneumoniae, Klebsiella pneumoniae .* * Legionella pneumophila * What gram stain does this have? * **Gram-negative** * Is it aerobic or anaerobic? * **aerobic** * Is it extracellular or intracellular? * **intracellular** * What locations have common infection rates? * **Hot tubs, Air conditioning, Showers** * What Virulence factors does it have? * **Major secretory protein: *_metalloprotease_*** * **DNase, Rnase** * **Lipase, phosphatase** * **Inhibits phago-lysosome fusion** * What do patients present with? * **Diarrhea** * **Hemolytic Anemia** * **Severe pneumonia with little or no inflammation of bronchioles or upper airways** * **Pontiac Fever: less severe, fever and muscle aches over 2-5 days, self-limiting** * What tests are used to dx this? * ***_Urinary antigen test_* or rapid microagglutination test** * **Slow growth on *_BCYE_***

Answer 56

*Discuss the clinical presentation, mechanisms of pathogenicity, diagnosis, prevention/treatment and epidemiology of the following bacterial respiratory pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Legionella pneumophila, Mycoplasma pneumoniae, Klebsiella pneumoniae .* * Mycoplasma pneumoniae * What conditions can prolonged infection cause? * **Steven Johnson Syndrome** * **Hemolytic Anemia** * What tests are used to diagnose this? * **Complement fixation test (CFT)** * **IgM by latex agglutination or ELISA**

Answer 57

*Discuss the clinical presentation, mechanisms of pathogenicity, diagnosis, prevention/treatment and epidemiology of the following bacterial respiratory pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Legionella pneumophila, Mycoplasma pneumoniae, Klebsiella pneumoniae .* * Klebsiella pneumoniae * Are these gram negative or positive? * **Gram-negative** * What shape do they have? * **rod** * Are they aerobic or anaerobic? * **anaerobic** * What 2 populations are this common in, and what is notable about the spit of patients? * **Alcoholics and diabetics** * **"Currant jelly” sputum (Blood and mucus)**

Answer 58

*Recall and be able to perform the major components of the lung exam (inspection, palpation, percussion and auscultation).* * What order do you perform a lung exam in? * **Order Of Exam:** * **1. Look** * **2. Feel** * **3. Listen (Includes percuss)**

Answer 59

* "Feel" * A minor aspect of the exam and clinically not extremely useful * Can feel for tactile fremitus * Percuss

Answer 60

Cheyne Stokes

Answer 61

* Kussmaul

Answer 62

3 options * A macrolide * Usually clarithromycin * Azithromycin * Doxycycline

Answer 63

* Options * Fluoroquinolone * Beta-Lactam * Amoxicillin * Amoxicillin/Clavulanate * Alternatives * Cephalosporin + macrolide

Answer 64

* Aspiration pneumonia * Includes Anaerobes and gram-negative bacteria * Usually polymicrobial pathogens isolated! R sided lobar infiltrates, but can also present bilateral and diffuse/interstitial pattern.

Answer 65

* Influenza virus * Higher risk of secondary bacterial pneumonia with Staph/MRSA) * Tx: Neuraminidase inhibitor (oseltamivir) within 48-72hrs or combined with for hospitalized: secondary bacterial pneumonia.

Answer 66

* Legionella * Remember to consider travel history * Diarrhea and most areas

Answer 67

* Pneumocystis jirovecii (PCP) * Fungal pathogens, parasites, and less common: cytomegalovirus

Answer 68

* Coccidiomycosis- Southwestern US * Histoplasmosis- Ohio River valley; Mississippi

Answer 69

* Usually upper lobe- apical consolidates with cavitation) * Exposures or secondary due to immunosuppression therapies (anti-TNF agents for RA)

Answer 70

* Typical * Generally Lobar pattern, classic presentation, “typical” pathogens * Atypical * Generally Interstitial pattern, atypical presentation, “atypical” pathogens (no growth on standard culture media, nothing seen on Gram’s stain), Viral

Answer 71

* Symptoms of Bacterial Pneumonia * Productive cough * SOB * Trouble Swallowing * Fever, Fatigue * Tachycardia * Increased RR * Signs of Pneumonia * Egophony * Dull to percussion * Accessory Muscle * Sputum

Answer 72

* Tests * Cultures * Lab/Test Results * Gram’s Stain and Culture of Blood and/or Sputum * Typical pathogens * Urinary Antigen Tests (UAT): * Legionella, Pneumococcal * PCR ($$) * Atypical pathogens (16 viral + Legionella species, Mycoplasma pneumoniae, Chlamydia pneumoniae, and mycobacteria)

Answer 73

*Identify and discuss diagnostic considerations for evaluating pneumonia.* * What pattern do you see on an X-ray for: * Nosocomial (hospital(VAP), or hospital-acquired(HAP)) * **Bronchopneumonia pattern** * Bacterial CAP * **Lobar pattern:** * Viral and PCP (immune suppressed patients) * **Interstitial patterns**

Answer 74

*Describe the initial treatment of a patient presenting to the emergency department with a critical respiratory illness.* * What is respiratory failure defined as? * **Defined as an inadequate gas exchange due to malfunction of one or more components of the respiratory system** * What are the two main types of respiratory failure * **Two main types: hypoxemic and hypercapnic/hypercarbic** * **BOTH can be present in a patient** * What are the signs of respiratory failure? * **Mental status changes, fatigue, retractions, ineffective chest wall movements, cyanosis**

Answer 75

*Describe the initial treatment of a patient presenting to the emergency department with a critical respiratory illness.* * HYPOXEMIC RESPIRATORY FAILURE * What O2 saturation is associated with this? * **Hypoxemia, inability to oxygenate, arterial oxygen saturation less than 90% while receiving increased inspired oxygen fraction** * What is characterized by, relative to the alveolar membrane? * **Impaired alveolar diffusion, inflammation or fluid affecting diffusion across alveolar membrane** * What are the causes of this? * **Pneumonia, ARDS, pulmonary embolism, pulmonary edema, alveolar hemorrhage** * **Ventilation-perfusion mismatch and intrapulmonary shunting**

Answer 76

*Describe the initial treatment of a patient presenting to the emergency department with a critical respiratory illness.* * HYPERCAPNIC RESPIRATORY FAILURE * What happens to serum CO2? * **Increases** * What is wrong with ventilation? * **Unable to VENTILATE alveoli, problem with the air pump** * What the reading for PaCO2? * **Under 45** * Respiratory acidosis: What is the rule of thumb for pH changes and PaCO2? * **Every change of 10 in the PaCO2, pH changes by 0.08** * **As PaCO2 decreases, pH increases.**

Answer 77

obstructive

Answer 78

restrictive

Answer 79

obstructive

Answer 80

restrictive

Answer 81

obstructive

Answer 82

restrictive

Answer 83

*Describe the viral pathogens, physical exam, and pharmacologic interventions of croup.* * What is croup? * **Most common infection of the middle respiratory tract** * **Disproportionally affects children** * **Mucosal edema and inflammation exponentially increases airway resistance and the work of breathing** * **Viral infection of the glottic and subglottic regions** * What are the common patients/infection characteristics? * **Infx rates peak in fall and early winter** * **Most common in children 3 months to 5 years** * **Spread by secretions** * **Males \> females** * What pathogens cause this? * **Parainfluenza virus 1,2,3,4 (most common)** * **Respiratory syncytial virus** * **Influenza Adenovirus** * **Enteroviruses** * **Human metapneumovirus** * What are the signs/symptoms of this? * **Cough-barky or brassy, seal like** * **Hoarseness** * **Low grade fever** * **Occasional respiratory distress with retractions** * **Sometimes can have Stridor** * **Inspiratory sound when calm** * **Walls of subglottic space are drawn together making an obstruction that causes the sound** * **Turbulent airflow is usually inspiratory but may be biphasic**

Answer 84

*Describe the viral pathogens, physical exam, and pharmacologic interventions of croup.* * How do patients present? * **Most patients have an upper respiratory infection with some combination of rhinorrhea, pharyngitis, mild cough, and low grade fever for 1-3 days before signs of upper airway obstruction become apparent.** * **Child then develops the classic “barking” cough, hoarseness, and inspiratory stridor.** * **Fever can reach 39-40 degrees C (102.2-104 F), some are afebrile** * **Symptoms are worse at night and recur for several days.** * **Lasts about 5 days with the 3rd night being the worst** * What is the home treatment for it? * **Warm humidified air is helpful to decrease the swelling of the subglottis, this can be done in a closed bathroom with the hot shower running** * **If warm mist fails, breathe cool air by standing near an open refrigerator or freezer. You can also go outside with the child if weather is cold** * What is the Rx treatment for it? * **Best: Dexamethasone phosphate (0.6 mg/kg) orally x 1 dose. Can be given intramuscularly if child will not take the oral medication** * **Alternative: Prednisilone 2mg/kg per day orally in 2 divided doses/day for 3 days** * What do you use for significant airway compromise? * **Racemic epinephrine reduces subglottic edema. Because of rebound, this should be administered in an Emergency Department** * **An inhaled alpha adrenergic agent that decreases subglottic edema** * **Takes effect in 10-30 minutes and fades within 60-90 minutes** * **Under age 4 yrs - 0.05 mL/kg/dose up to max dose of 0.5mL/dose diluted with 3mL NS via nebulizer over 15 min** * **Over 4 years - 0.5mL/dose diluted with 3mL NS via nebulizer over 15 min** * **Rebound effect may occur, with worsening of symptoms as the effect of the drug dissipates.** * **Aerosol treatment may be repeated every 20 minutes for 1-2 hours in severe cases** * What sign will you see on x-ray?

Answer 85

*Discuss the pathophysiology, clinical presentation and treatment of bronchiolitis.* * What is bronchiolitis? * **It is a disease of the small bronchioles with increased mucus production and occasional bronchospasm, sometimes leading to airway obstruction** * **Hand carriage is the most frequent method of transmission** * What are the common patients/infection characteristics? * **Most common in infants and young children first 2 years of life** * **Males to females 1.5 :1** * **Most severe in young infants** * **100,000-126,000 infants are hospitalized yearly with Bronchiolitis** * **More common in winter and early spring** * What pathogens cause this? * **#1 Respiratory Syncytial Virus** * **Human metapneumovirus** * **Parainfluenza** * **Influenza** * **Adenoviruses** * **Rhinoviruses** * **Coronaviruses** * What is the pathogenesis of this? * **RSV has an incubation period of 4-6 days** * **Bronchiolitis presents as a progressive respiratory illness** * **Presents similarly to a common cold in the early phase with cough and rhinorrhea** * **Progresses over 3-7 days to noisy, raspy breathing and audible wheezing** * Describe severe RSV Infx. * **1 to 2 out of 100 children younger than 6 months of age with RSV infection may need to be hospitalized** * **They may require oxygen, intubation, and/or mechanical ventilation** * **Most improve in 2-5 days but cough can linger up to 21-30 days** * **1-2% mortality rate**

Answer 86

*Discuss the pathophysiology, clinical presentation and treatment of bronchiolitis.* * What are the signs/symptoms of bronchiolitis? * **Low grade fever** * **Irritability** * **Increased work of breathing** * **Very young infants may not have a prodrome, may have apnea as the first sign of infection** * **Prolonged expiratory phase** * **Nasal flaring** * **Intercostal retractions (Sometimes)** * **Suprasternal retractions (Sometimes)** * **Air trapping with hyper-expansion of the lungs** * How do you Dx this? * **Laboratory studies are not required but quick test in office is easily done** * **Pulse oximetry is adequate for monitoring oxygenation** * **Frequent regular assessments of cardiorespiratory status is necessary** * **Infants may develop respiratory failure quickly if they are very tired** * How do you treat this? * **Hospitalize if respiratory distress, hypoxia, under 4 months of age** * **Supportive care includes:** * **Cool, humidified oxygen** * **Nasopharyngeal suctioning** * **Chest physiotherapy** * **Elevate head of bed** * **IV fluids if unable to take oral feeds** * What complications arise? * **Short Term** * **Dehydration (water loss due to increased respiratory rate)** * **Acidosis** * **Late Term** * **Asthma later in childhood** * **Recurrence is common, tends to be mild, treatment same as the first episode** * How do you prevent bronchiolitis? * **Palivizumab (RSV monoclonal antibody) Initiate just before onset of RSV season** * **Monthly injections, 15mg/kg per dose** * **Indicated for those under 2 years with chronic lung disease, very low birth weight, hemodynamically significant cyanotic and cyanotic heart disease** * **Immunization with influenza vaccine over 6 months**

Answer 87

* **Acute Pulmonary exacerbation** * • Increase in cough * • Fever * • Change in sputum * • Decreased activity, lethargy * • Hemoptysis * **Chronic Pulmonary Clinical Complications** * • Recurrent pulmonary infections * • Sinusitis * • Pneumonia * ***_• Bronchiectasis_*** * **Exocrine Clinical complications** * • Pancreatic insufficiency * • Pancreatitis * • Malabsorption of fat-soluble vitamins * • 30% develop diabetes mellitus * • Failure to thrive * **GI Clinical complications** * • Meconium ileus in newborns * • Malabsorption with steatorrhea of fat-soluble vitamins * • Rectal prolapse * • Prolonged neonatal jaundice * **Reproductive Clinical Complications** * • 99% of males struggle with fertility * • Increased difficulties with fertility for females * **Integumentary Clinical Complications** * • “salty” skin * • clubbing of fingers

Answer 88

*Explain clinical presentation and diagnosis of cystic fibrosis.* * How do you Dx cystic fibrosis? * ***_Clinical symptoms_*** * ***_Family history_*** * ***_Immunoreactive trypsinogen_*** * ***_Sweat test_*** * ***_Genetic testing_***

Answer 89

* ARDS severity is defined by the ratio, PaO2/FiO2 * Mild, PaO2/FiO2 \>200 but \<300 mmHg * Moderate, PaO2/FiO2 \>100 but \<200 mmHg * Severe, PaO2/FiO2 \<100 mmHg

Answer 90

* What causes the damage: Direct injury * • Alveoli are directly injured * • Release of proinflammatory cytokines which include tumor necrosis factor and interleukin * • Cytokines recruit neutrophils that release toxic mediators – destructive enzymes and O2 free radicals * • Results in damage to the capillary endothelium and alveolar epithelium

Answer 91

* What causes the damage: Indirect injury * • can involve some type of systemic problem (sepsis) * • release of a substance into the circulation (fat emboli from fracture) * • some type of stress, burns or multiple trauma • antigens from a blood transfusion * • common pathway for both direct and indirect causes of ARDS seems to involve an inflammatory response that causes damage to the alveoli

Answer 92

*Discuss the pathophysiology of ARDS and contrast the three phases of ARDS.* * In ARDS, what happens to the alveoli and hyaline membrane? * **The result of ARDs is diffuse alveolar damage and hyaline membrane disease** * What does this lead to? * **Hypoxemia and respiratory failure**

Answer 93

* What are the 2 most common causes of ARDS? * Pneumonia * Sepsis

Answer 94

Discuss the signs, symptoms and pathophysiology of pulmonary embolism. * Where do most PE's come from? * PE is most commonly a thrombus (blood clot), but can be other things * **80% come from DVT in the lower extremities** * **15% from the pelvis** * **Rest from other sources (fat, air, amniotic fluid, foreign body such at talc, septic emboli, tumor emboli)** * What is Virchow's triad? * **Endothelial injury - surgery (most common risk), injury, infection** * **Stasis or turbulent flow - varicosities, edema/CHF, immobility (travel, bed rest, obstruction), pregnancy** * **Hypercoagulable state - cancer, smoking, hemophilias (protein C/S and antithrombin deficiency), ?pregnancy (PE typical in the weeks After delivery)**

Answer 95

*Discuss the signs, symptoms and pathophysiology of pulmonary embolism.* * What are the common signs/symptoms of PE? * **Prolonged Sitting** * **Nothing makes it better** * **DOE, SOB, and cough, LE swelling and calf pain (Homan’s positive).** * What do 20% of patients present with? * **• Classic triad of pleuritic CP, SOB and hemoptysis is present in \<20%** * **• 4% present with syncope and 2% present with new seizure** * Why do strokes occur? * **Increase pulmonary pressure due to PE. 20% of people have a PFO.** * **Can send thrombotic material back into the LA and LV and into the carotid circulation** * **Paroxysmal embolism syndrome** * What cardiac and respiratory symptoms occur? * **Tachycardia is common; fever occurs in 10%, but only 2% are above 102.5** * **Resp - typically clear but can hear: wheezes, crackles bilaterally** * **Card - new RBBB; can have atrial fibrillation or if massive PE can have cardiac arrest and arrhythmias (PEA, asystole)**

Answer 96

* PAH is Mean pulmonary artery pressure \> 25 mm Hg at REST * Sequelae * ▸ Athersclerotic vascular disease * ▸ Arterial narrowing and hypertension * ▸ Right heart strain * ▸ Respiratory compromise * ▸ Hypertrophy * ▸ Cor pulmonale

Answer 97

* Definition OSA aka Obstructive sleep apnea * recurrent nocturnal cessation of breathing \>10 seconds * Sublcass is OHS (obesity hypoventilation syndrome), OHS = Pickwickian Syndrome

Answer 98

* Polysomnography, also called a sleep study, * a test used to diagnose sleep disorders. * Polysomnography records your brain waves, the oxygen level in your blood, heart rate and breathing, as well as eye and leg movements during the study. * Chronic Hypoxemia can cause: * ▸ Pulmonary vasoconstriction * ▸ 2 ̊ polycythemia * ▸ Systemic hypertension * ▸ Cardiac arrhythmias * ▸ Sudden death * Sleep Apnea Classes * Obstructive (OSA) * Obese * Hypoxic * Hypercapneic * Excess parapharyngeal tissue = adults who snore loudly * Adenotonsillar hypertrophy = children who snore loudly * Central * Toxic (opiates/sedatives) * Trauma/infection/stroke * Advanced HF

Answer 99

Risk factors: BMI, neck circumference, congenital, HTN

Final Test Flashcards

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