Obstructive Diseases

Question 1

What is a DDx based on these problems?

Wheezing and nighttime breathing problem

Cough productive sputum

Leg edema

Progressive dyspnea

Significant Smoking history (>70 pyhx)

Some hobby and occupational exposures (limited) to respiratory irritants

Answer 1

• COPD
• Asthma
• CHF
• Lung cancer
• Tracheomalacia
• Pericardial effusion
• Pulmonary embolism

Question 2

Pt comes in with symtpoms suggestive of obstuctive lung disease, what tests would you order?

Answer 2

• Chest X-ray • EKG
• CBC
• BNP

• Pulmonary Function studies

• Arterial Blood gases
• Echo

Question 3

What do you see in this image?

Answer 3

HYperlucency, Hyperinflated lung, flattened diaphram

will see increased retrosternal space on side view

Question 4

Spirometry for obstructed lung disease

Answer 4

Scalloped with normal inspiratory and decreased expiratory

Question 5

These are all examples of:

• Emphysema
• Chronic Bronchitis
• Bronchiectasis
• Chronic persistent asthma (FEV1 remains abnormal after therapy)

Answer 5

COPD

Question 6

Three key determinant of diffusion in lungs

Answer 6

The surface area of the lung with contact to diffusing alveoli (VA - Alveolar Volume)

the thickness of the alveolar- capillary membrane (Dm - Membrane Diffusion)

the volume of blood available in the capillary bed of the lung (Vc - Capillary Blood Volume).

Question 7

What effect does these diseases have on Diffusing capacity?

• Asthma
• Alveolar hemorrhage (acute)
• Intracardiac shunt (left to right)

• Erthyrocytosis

Answer 7

Elevation of DLCO

Question 8

What causes decrease of DLCO

Answer 8

– Significant Anemia

– Loss of parenchyma in diseases like emphysema.

– Diseases that scar the lung such as pulmonary fibrosis, or sarcoidosis

– Swelling of lung tissue (pulmonary edema) due to heart failure, or due to an acute inflammatory response to allergens (acute interstitial pneumonitis).

– Diseases of the circulation in the lung, such as pulmonary vasculitis or pulmonary hypertension.

Question 9

Amount of air left in the lungs after a normal expiration. This is a sum of the residual volume which r_equires indirect measurement_ with helium diluation or with body plethysmography)

Answer 9

FRC

Question 10

____ is the amount of air that can be expired after expiratoin of a tidal volume

____ amount that can be inspired after inspiration of a normal tidal volume

Answer 10

ERV

IRV

Question 11

___ amount of air inhaled or exhaled in a normal breath

___ the amount of air expired after a maximal inspiration

Answer 11

TV

VC

Question 12

How do you calculate forced vital capacity

Answer 12

Take TLC - RV

Question 13

This pt has restrictive lung disease. What is true of their functional residual capacity?

what about maximum flow rate or total volume exhaled?

Answer 13

Decreased functional residual capacity by plethysmography

Decreased maximum flow rate and decreased total lung volume exhaled

Question 14

What is true of the FEV1 and FVC as well as the ratio in restrictive lung disease?

Answer 14

In restrictive disease the FEV1 and FVC are reduced but the ratio is normal. A decreased ratio is found in obstructive lung disease.

Question 15

With advanced restrictive disease the _____ level will fall and the _____will rise.

Answer 15

arterial oxygen

carbon dioxide

Question 16

What happens to antatomic dead space and compliance in restrictive lung disease?

Answer 16

Anatomic dead space remains relatively constant at different lung inflations

The increased elastic recoil of the lung in restrictive lung disease decrease compliance

Question 17

52 yo man reports worsening productive cough. Present for over 4 years but worsened over last 6 months. Smoked 2 ppd of cigarettes for last 30 years. An increased number of which of the following cell types best accounts for these symptoms?

Answer 17

Goblet cells

Question 18

Chronic cough with copious sputum for at least 3 months in 2 consecutive years. Smoking and inhalation of irritating substances including smog are usually associated.

Answer 18

Chronic Bronchitis

Question 19

What happens to submucosal glands and goblet cells in chronic bronchitis?

Answer 19

Early excess mucus from hypertrophy of submucosal glands in the larger bronchi but later in the course of the disease goblet cell metaplasia of bronchioles and small bronchi also contribute.

Question 20

What are some other microscopic changes we see in pt with chronic bronchitis?

Answer 20

infections infiltration of small airways by alveolar macrophages and fibrosis of bronchiolar walls (even obliteration of the lumina

Question 21

What happens to larger bronchi in pt with chornic bronchitis?

Answer 21

Smooth muscle hypertrophy can be seen in larger airways related to increased effort to clear bronchi of the mucus but is not the source of the excess mucus

Question 22

What causes increased risk of lung cancer in pts with chronic bronchitis?

Answer 22

Squamous cell metaplasia is a reaction to irritation in the larger bronchi and increases risk of lung cancer

Question 23

_____ are normal flat lining cells of alveoli

______ produce surfactant not mucus. The can be increased in a reaction to damage to the lung but does not cause excess mucus.

Answer 23

Type 1 pneumocytes

Type 2 pneumocytes

Question 24

What clinical findings are associated with Chronic Bronchitis

Answer 24

– Productive cough and dyspnea
– Cyanosis (due to decreased O2 saturation from hypoxemia)

– Expiratory wheezing and rhonchi
– Corpul monale
– clubbing

Question 25

What do we see on CXR in pts with chornic bronchitis

Answer 25

– Enlarged heart,horizontally oriented – Increased bronchial markings

Question 26

51 yo male smoker comes to you with a fevers and productive cough of green yellow sputum up to 1⁄2 cup a day. Also with morning cough the past 5 years. Which of the following findings would be most likely in the patient.

Answer 26

increased Reid Index

Question 27

What is an increased REID index mean?

Answer 27

Ratio of the thickness of the mucous gland layer to the thickness of the wall between the epithelium and cartilage (Normal is \<0.4 ). The ratio of the gland depth to the total thickness of the bronchial wall is the REID INDEX.

Question 28

Apical cavitary lesions would be seen in \_\_\_\_\_\_. Not associated with excessive mucus production.

Answer 28

tuberculosis

Question 29

Enlarged hilar lymph nodes suggests

Answer 29

sarcoidosis or bronchogenic carcinoma.

Question 30

Elevated sodium chloride level in the sweat is seen in

Answer 30

cystic fibrosis

Question 31

37 yo man with SOB and RUQ abdominal pain. DOE with 2 flights of stairs. Smoked 1⁄2 PPH for 10 years. Exam Temp 98.7, RR 22, HR 72. Clubbing. Sclera yellow. Hepatomegaly. Lungs diminished BS bilaterally. Labs. Alk Poh 86, ALT 220, AST 200, T bili 3.8, T bili 3.0. Biopsy of the liver fibrosis in the portal triads, intracellular globular inclusions with eosinophilic material that is PAS stain positive. Which of the following pulmonary findings would be most likely in this patient?

Answer 31

Destruction of alveolar walls : anti-trypsin 1 deficiency

Question 32

Where do we see alveolar desctruction in alpha 1 AT deficiency? what about smoking?

Answer 32

Panacinar Centriacinar

Question 33

Pathophys behind alpha1 antitripsin defiency

Answer 33

This is a protease inhibitor which counterbalances substances such as elastase. The normal phenotype is considered PiMM with alpha-1 antitrypsin deficiency a protease antiprotease imbalance leads to unchecked inflammation with neutrophils migrating into alveolar spaces. stimulated cells release elastase from their granules and creates oxygen free radicals which inactive the alpha1 antitrypsin

Question 34

The combination of high elastase activity and increased oxygen free radicals from tobacco smoking in these with low antiprotease activity causes

Answer 34

accelerated destruction of the lung tissue.

Question 35

Person presents with symptoms of emphysema and they are 30 with no smking history

Answer 35

alpha 1 AT defiency

Question 36

how does alpha 1 antitrypsin defiency cause liver issues?

Answer 36

The eosinophilic globular cytoplasmic inclusions are collection of nonfunctional alpha1 antrypsin that accumulates in the hepatocytes and causes hepatic dysfunction and fibrosis leading to cirrhosis and hepatic failure.

Question 37

Interstitial lymphocytic infiltrate are associated with

Answer 37

viral infections, myplasma pneumonia and autoimmune conditions.

Question 38

A 16 yo boy presents with earache. He has a history of Recurrent otitis media, ongoing sinus issues, recurrent bronchitis. Exam demonstrates nasal mucosa pale and swollen with yellow to green secretions. Retracted Tympanic membrane and absent mobility with a middle ear effusion. A sweat chloride test is performed and results both times are normal. Microscopic analysis of the boys semen reveals immobile spermatozoa. A defect in which of the following is the most likely for this patient’s condition.

Answer 38

Kartageners

Question 39

What is Kartageners

Answer 39

is genetic illness as result of immobile cilia (ciliopathy). The cytoskeletal structure of the ciliary and specifically the **dynein** cellular motors axon the macrotublar doublets at the periphery of the ciliary axoneme.

Question 40

Classic symptoms of Kartageners

Answer 40

As a result defects in mucociliary clearance lead to chronic upper and lower respiratory tract disease. Males also demonstrate infertility as a result of immobile spermatozoa.

Question 41

CF is due to CFTR in chrom 7; what GI and pulmonary associations do we see?

Answer 41

Respiratory tract disease – (over 90%), recurrent infections and bronchiectasis with most eventual respiratory failure by age 30-50 GI tract– meconium ileus, malabsorption, pancreatic insufficiency