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CRRAB II- FINAL > Pulmonary Path- Wittrak > Flashcards

Flashcards in Pulmonary Path- Wittrak Deck (88):
1

What is cor pulmonale?

Right heart failure due to chronic hypoxia-induced pulmonary hypertension

May see:
peripheral edema
Large/tender liver (passive congestion), increased JVP, cardiogenic shock

2

FEV1 less then what implies some sort of COPD?

Less than 80%

3

FEV1/FVC ratio needs to be less than what to imply COPD?

FEV1/FVC less than 70 %

4

What are COPD exacerbations usually caused by?

50% due to bacterial causes (pneumonia)

5

What are some common thing Bronchiectasis is associated with?

-Bronchial obstruction
-Poor ciliary motility (Kartagener syndrome)
-Cystic Fibrosis
-Allergic bronchopulmonary aspergillosis

6

What is bronchiectasis?

Chronic necrotizing infection of bronchi that lead to PERMANENTLY DILATED AIRWAYS

7

What is pathology of chronic bronchitis?

Hyperplasia of mucus-secreting glands in bronchi/ mucus plugging

8

Clinical diagnosis of chronic bronchitis?

Productive cough for > 3 month per year for > 2 years

9

What is the reid index? What will it be more than in chronic bronchitis?

Reid index = thickness of gland layer/ total thickness of bronchial wall

> 50% in chronic bronchitis

HIGHLY ASSOCIATED WITH SMOKING!

10

What is the pathology of emphysema?

Destruction of alveolar air sacs by neutrophils/ macrophages

Causes loss of elastic recoil and collapse of small airways during exhalation results in obstruction and air trapping

11

What are the two main causes of emphysema?

1. SMOKING
2. Alpha 1-anti trypsin deficiency

12

What type of emphysema does smoking cause? What part of the lobe is more severe?

-Centriacinar emphysema
-More severe in upper lobes

13

What type fo emphysema does alpha 1 anti-trypsin cause? What part of the lung is more severe?

-Panacinar emphysema
-More severe in lower lobes

14

Chronic bronchitis and emphysema both present with dyspnea and cough. How would you distinguish them clinically?

Chronic bronchitis:
-TONS OF MUCUS! Like cups of it!!!
- Blue bloater

Emphysema:
-minimal sputum
-Pink puffers
-Prolonged expiration with pursed lips

15

What is the general pathogenesis of asthma?

bronchial hyper responsiveness causes REVERSIBLE bronchoconstriction

16

What cytokines are produced by Th2 cells in asthma? And what do they do?

Th2 produce:

-IL-4 = induces class switching to IgE
-IL-5 = calls eosinophils!
-IL-10 = promotes Th2 subtypes of T helper cells

17

During re-exposure to an allergen in asthma.... what happens immediately?

-IgE-mediated activation of mast cells
-dumps PRE FORMED HISTAMINE GRANULES
-Histamine induces vasodilation in arterioles, and increased vascular permeability in the post-capillary venules

18

What is the second phase that perpetuates inflammation after re-exposure to an allergen in asthma?

Eosinophils produce leukotrienes C4, D4, and E4 which leads to bronchoconstriction, inflammation, and edema

19

What are some potential causes of nasal polyps?

-Chronic Rhinitis
-Cystic fibrosis (kids)
-Aspirin-intolerant asthma (adults)

20

What diagnosis asthma in regards to pulmonary function?

-Decreased FEV1 and FEV1/FCV
-Increases by 12% when inhaled B2 agonist or post-steroid trial

21

What are two complications of asthma?

Status asthmaticus- you die

Allergic Bronchopulmonary aspergillosis = allergic reaction to inhaled spores (can cause bronchiectasis_
-Treat with steroids and anti-fungal drugs

22

Rhonci

obstruction of medium-sized vessels

23

crackles

alveolar disease

24

Stridor

inspiratory wheeze--upper airway obstruction

25

How are the pulmonary function tests different between restrictive and obstructive diseases?

Obstructive lung disease have a decreased FEV1/FVC ratio

Restrictive have an increased FEV1/FVC ratio

FEV1 and FVC are decreased in both types... but in obstructive FEV1 is more dramatically reduced resulting in a decreased ratio

26

Decreased total lung capacity
Decreased FVC
Decreased FEV1
FEV1:FVC ratio is > 80%
What type of disease?

Restrictive disease!!!

Defined as FEV1/FVC ratio is greater than or equal to 80%

27

In what circumstance would a restrictive disease have a normal A-a gradient?

Poor breathing mechanics! Extrapulmonary, peripheral hypoventilation

Poor muscular effort = polio, myasthenia gravis

OR

Poor structural apparatus = scoliosis or morbid obesity

28

What circumstances would cause a restrictive disease to have an increased A-a gradient?

Interstitial lung diseases that decrease pulmonary diffusing capacity.......

Acute Respiratory Distress syndrome
Sarcoidosis
Pneumoconioses
Idiopathic Pulmonary Fibrosis
Goodpasture Syndrome
Wegeners
Hypersensitivity pneumonitis

29

Describe the pathogenesis of Idiopathic Pulmonary Fibrosis

Fibrosis of lung interstitium

Injury pneumocytes produce TGF-B that induces fibrosis/ abnormal alveolar healing response

Typically male smoker > 40 with progressive cough, dyspnea. Fibrosis on lung CT

Must rule out other causes of fibrosis like drugs and radiation therpay

30

Describe Pneumoconiosis what cell mediates this response?

Interstitial fibrosis due to occupational exposure mediated by MACROPHAGES

Requires chronic exposure to small particles that are fibrogenic

31

When would you see a shrunken, "black lung" that have antracosis? (collections of carbon-laden macrophages)

Coal Workers Pneumoconiosis

32

Which restrictive disease is the only one that increases your risk for TB?

Silicosis

33

You see multiple

Silicosis

34

How does silica impair the immune/inflammation response in the lungs?

Silica impairs phagolysosome formation by macrophages

35

Which pneumoconiosis is associated with increased incidence of lung cancer?

Asbestosis (and berylliosis?)

36

In which occupation would you see berylliosis?

Aerospace and manufacturing inductries

37

Which is the only pnumoconioses that affects the lower lobes?

Asbestiosis

38

What would you find histologically in asbestosis?

Asbestos/ Ferruginous bodies!

Golden brown dumbells found in alveolar septum

39

Non-caseating granulomas
Found in lungs in hilar lymph nodes
Skin Rash
Hypercalemia
Young African-American Female

SARCOIDOSIS!

40

Describe 5 indicators of sarcoidosis..

-Restrictive Disease (FEV1/FVC > 80%)
-Bilateral Hilar Lymphadenopathy
-Non-caseating granuloma
-Increased ACE
-Hypercalcemia (granulomas activate Vit. D.)

41

What types of granulomas are seen in sarcodosis?

Non-caseating granulomas

42

What occupation normally has hypersensitivity pneumonitis?

Farmers and those exposed to birds

43

What type of hypersensitivity is Hypersensitivity Pneumonitis?

Mixed type III/IV hypersensitivity reaction to environmental antigen

44

Pulmonary Hypertension is when MAP in the lung is greater than....

> 25 mmHg (normal is 10)

45

What are the 5 potential causes of pulmonary Hypertension?

1. Idiopathic PAH (heritable, associated with BMPR2 mutation)
2. Left Heart diseases
3. Lung disease or hypoxia
4. Thromoembolic (recurrent microthrombi decrease cross-sectional area of vascular bed)
5. Multifactorial (some combination)

46

Describe the pathogenesis of Acute Respiratory Distress Syndrome

Multiple causes

-Diffuse alveolar damage
-increased alveolar capillary permeability
-Protein-rich leakage into alveoli
-Non-cardiogenic pulmonary edema
-Results in intra-alveolar hyaline membranes
-Thickened diffusion barrier
-Decreased gas exchange

47

Give some potential causes of acute respiratory distress syndrome

Trauma
Sepsis
Shock
Gastric Aspiration
Uremia
Acute pancreatitis

48

How do you treat Acute Respiratory Distress Syndrome

30-40% mortality (that sucks)
Mechanical Ventilation
Address underlying cause!!

49

What causes neonatal respiratory distress syndrome?

Inadequate surfactant levels

50

What are the two most common things that causes massive hemoptysis?

Bronchogenic Caricoma
Bronchiectasis

51

What type of infections normally cause hemoptysis?

Bronchitis
Bacterial Pneumonia
TB

52

What are the three key risk factors for smoking?

Cigarette smoke
Radon
Asbestos

53

Aside from possible malignancy, what are two other benign causes of the classic "coin lesion"?

Granuloma - usually due to TB or fungus

Bronchial Hamartoma - contains lungs and CARTILAGE, often calcified on imaging

54

What are the two centrally located lung malignancies?

-Small cell carcinoma
-Squamous cell carcinoma

55

How would you treat small cell carcinoma?

Chemo!! Not responsive to surgical ressection

56

How do you treat non-small cell carcinomas?

Surgical resection!

57

What is the most common tumor in male smokers?

Squamous Cell carcinoma

58

Which lung cancer is associated with keratin pearls and intercellular bridges?

Squamous Cell Carcinoma

59

Which lung cancer is associated with glands and mucous production?

Adenocarcinoma

60

Which to lung cancers are neoplasms of neuroendocrine cells, thus chromogranin A +?

-Small cell carcinoma
-Bronchial carcinoid Tumor

61

Describe the characteristics of small cell carcinoma

Poorly differentiated
Very aggressive
Centrally located
Paraneoplastic Syndromes: Cushing syndrome, SIADH, Lambert Eaton myasthenic syndrome = Ab against Ca+ channels)

62

What are the SPHERE of complications associated with lung cancers?

Superior vena cava syndrome
Pancoast tumor
Horner Syndrome
Endocrine (paraneoplastic)
Recurrent laryngeal nerve compression (hoarsness)
Effusions (pleural or pericardial)

63

What is a pancoast tumor?

Carcinoma that occurs in the apex of the lung

May causes Pancoast syndrome by invading the cervical sympathetic chain:

Horner's Syndrome
SVC syndrome
Sensorimotor deficits
Hoarseness

64

Which lung cancer is composed of well-differentiated neuroendocrine cells?

Carcinoid Tumor

*Chromogranin +!!!

65

If you see an elevated diaphragm in a lung cancer patient, what should you think?

Phrenic nerve involvement = diaphragmatic paralysis

66

Which lung cancer presents like pneumonia but with not respond to antibiotics?

Bronchioalveolar carcinoma

67

What two metastases sites may indicate the first sign of lung cancer?

Bone - pathologic fracture
Brain - seizure or focal neurologic deficit

68

What are the 4 common sites of metastasis of lung cancer?

Liver
Bone
Adrenals
Brain

69

Why is hypercalcemia common in lung cancer?

-Could be due to bone metastases

-Or tumor production of PTHrP or calcitriol (Vit D) - especially is squamous cell!

70

Which lung neoplasm is associated with Lambert-Eaton syndrome? What is that?

Associated with small cell carcinoma

LE syndrome = antibodies against presynaptic Ca2+ channels

71

Which lung neoplasm is associated with Cushing syndrome? What is that?

Increased ACTH secretion, associated with small cell carcinoma

72

What is a hamartoma composed of?

Lung tissue + CARTILAGE!

73

How would you distinguish a lung meastasis from a primary lung tumor?

Metastases are typically multiple and bilateral!!!

Lungs are common site for metastatic neoplasmas

74

What is a pleural effusion? How do you treat it?

Excess accumulation of fluid between pleural layers

Restricted lung expansion during inspiration

Treat with thoracentesis to remove fluid

75

What type of fluid will a non-inflammatory pleural effusion contain? What causes it?

TRANSUDATE

Due to increased hydrostatic pressure (like in CHF) or

Decreased osmotic pressure (like nephrotic syndrome)

76

What type of fluid will an inflammatory pleural effusion contain? What can cause it?

EXUDATE

Increased protein content

Can be due to:
Bacterial pneumonia
Lung Abscess
Viral Infection
Pulmonary Embolism
Esophageal rupture

77

What are some chronic sequale of pleural inflammation?

Adhesions to chest wall

Empyema can cause thick pleural rind requiring surgical decrotication for lung expansion

78

What is a chylothorax? What causes it?

Pleural effusion due to decreased lymphatic resorption

Caused by throacic duct injury from trauma or malignancy.

79

What color is the fluid in a chylothorax?

Milking appearing fluid high in triglycerides

80

What are the two most common causes of a transudative effusion?

1. Left ventricular heart failure

2. Cirrhosis

81

What are the most common causes of exudative effusions?

1. Bacterial pneumonia
2. Malignancy
3. Viral infection
4. Pulmonary Embolism

82

What should you suspect if there is low pleural fluid glucose (

Associated with parapneumonic effusion/ empyema like bacterial pneumonia, lung abscess, viral infection, etc

Implies need for extended chest tube drainage proceedure

83

How should you treat recurrent pleural effusions that are compromising pulmonary function?

Treat by pleural space obliteration/ talc pleurodesis

84

What is the typical causes of a primary spontaneous pneumothorax?

Small subpleural bleb rupture

Usually seen in young adults with no apparent lung disease

85

What is the typical causes of a secondary spontaneous pneumothorax?

Air leak from underlying lung disease (emphysema, asthma, CF, TB pneumonia, neoplasia, etc)

86

What defines a tension pneumothorax?

Air enters pleural space but cannot exit.

Everytime patient breathes in air, results in increased amount of air in pleural space

Pushes trachea to OPPOSITE SIDE

87

Which way does the trachea deviate in a tension pnuemothorax?

It deviates to the OPPOSITE of the pneumothorax

88

-Unilateral chest pain
-Dyspnea
-Decreased tactile fremitus
-Hyperresonance
-Diminished breath sounds

Pneumothorax