A patient presents with sudden-onset dyspnea one hour after suffering a femur fracture. He is found to have a ventilation/perfusion mismatch. What is your diagnosis?
Amniotic fluid emboli can lead to what dangerous hematologic condition in postpartum women?
Disseminated intravascular coagulation
A patient presents with sudden chest pain, tachypnea, and dyspnea. What is the most likely diagnosis?
Name the six most common causes of emboli to the lungs.
- Amniotic fluid,
(remember: An embolus moves like a FAT BAT)
What is the origin of the majority of emboli that become lodged in the lungs?
Deep leg veins
Which three factors that promote blood coagulation are known as Virchow’s triad?
- endothelial damage
Describe Homan’s sign.
In Homan’s sign, dorsiflexion of the foot causes a tender calf muscle because of the presence of deep venous thromboses
What medication is used to prevent deep venous thrombosis?
Heparin (or modified heparin molecules such as enoxaparin)
What is the hallmark pulmonary function test finding in patients with obstructive lung disease?
Decreased forced expiratory volume1/forced vital capacity ratio
List four types of obstructive lung disease.
- Chronic bronchitis
In obstructive lung disease, there is a(n) _____ (decrease/increase) in residual volume and a(n) ____ (decrease/increase) in functional vital capacity.
What criteria must a patient meet to be considered to have chronic bronchitis?
A chronic productive cough at least three consecutive months in at least two years
What histologic changes would be seen on lung biopsy in a patient with chronic bronchitis?
Hypertrophy of the mucus-secreting glands in the bronchioles
The mucus gland hypertrophy seen in chronic bronchitis can be quantified using the _____ _____, which tends to be greater than what value in symptomatic patients?
Reid index; 50%
How is the Reid index calculated?
Reid index = gland depth / total thickness of bronchial walls
What clinical findings are auscultated in the lungs of patients with chronic bronchitis?
Usually wheezing and crackles
What visible skin finding may be noted in patients with chronic bronchitis?
What pathologic changes are seen in the lungs of a patient with emphysema?
Enlargement of the air spaces; decrease in recoil resulting from the destruction of alveolar walls
Smoking is associated with _____ (centriacinar/panacinar) -type emphysema, whereas α1-antitrypsin deficiency is associated with _____ (centriacinar/panacinar) -type emphysema.
In addition to panacinar emphysema, α1-antitrypsin deficiency also causes what condition?
A deficiency of α1-antitrypsin results in the increased activity of what enzyme?
Elastase; the enzyme degrades elastic fibers in the lungs
What exam finding is often auscultated in the lungs of patients with emphysema?
Breath sounds are usually diminished with a decreased inspiratory/expiratory ratio
In emphysemic lungs, there is a(n) (decrease/increase) _____ in recoil and, subsequently, a(n) _____ (decrease/increase) in compliance.
As a result, the residual volume of the lungs increases as the disease progresses
In emphysema, the decrease in lung recoil is a result of destruction of alveolar walls by increased activity of which enzyme?
Paraseptal emphysema is associated with bullae that can rupture and lead to _____ _____ in otherwise young healthy males.
Individuals with emphysema tend to exhale through pursed lips to increase _____ _____ and prevent _____ _____ during expiration.
Airway pressure; airway collapse
The definitive feature of the bronchoconstriction of asthma is that it is fully _____.
In patients with asthma, there is hyperresponsiveness of what lung segment?
While chronic bronchitis is a disease of the _____ (bronchi/bronchioles), asthma is a disease of _____ (bronchi/bronchioles).
Kartagener’s syndrome is associated with what types of lung disease?
Bronchiectasis and obstructive lung disease due to the failure of cilia to clear mucus from the lungs
Cough and wheezing are noted in patients with what two types of obstructive lung disease?
Asthma and chronic bronchitis
Tachypnea and pulsus paradoxus are noted in patients with what type of obstructive lung disease?
A child presents with cough, wheezing, dyspnea, tachypnea, hypoxemia, and mucus plugging. On exam, the patient also has a pulsus paradoxus. From what disease is this patient likely suffering?
What finding is commonly noted on pulmonary function testing of patients with asthma as well as those with emphysema?
Decreased inspiratory/expiratory ratio; generally, obstructive diseases lengthen the expiratory phase
What blood pressure/pulse finding is often observed in patients with asthma?
What are Curschmann’s spirals?
Shed epithelium from mucous plugs associated with asthma
What two pathologic findings are associated with asthma?
Smooth muscle hypertrophy and mucous plugging
_____ is a chronic necrotizing infection of bronchi.
In bronchiectasis, chronic necrotizing infection of the bronchi leads to what?
Permanent dilation of the airways
Patients with bronchiectasis often have a cough productive of what?
Blood and purulent sputum
Which two genetic diseases are associated with bronchiectasis?
Cystic fibrosis and Kartagener’s syndrome
Individuals with bronchiectasis are prone to develop which fungal pulmonary infection?
What are three common triggers of asthma attacks?
Viral upper respiratory infections, allergens, and stress
Compare the onset of dyspnea and hypoxia in emphysema vs chronic bronchitis.
In emphysema, there is early-onset dyspnea and late-onset hypoxemia; in chronic bronchitis, there is early-onset hypoxemia and late-onset dyspnea
What causes late-onset hypoxemia in emphysema?
The eventual loss of capillary beds, which occurs with the loss of alveolar walls
What causes early-onset hypoxemia in chronic bronchitis?
What two lung volumes are typically decreased in patients with restrictive lung disease?
Functional vital capacity and total lung capacity
Patients with restrictive lung disease typically have a forced expiratory volume1/forced vital capacity ratio within what range?
>80% ; this differentiates restrictive from obstructive lung disease
What are the two general types of restrictive lung disease?
- Poor breathing mechanics (caused by musculoskeletal or connective tissue disease)
- Interstitial lung diseases
Extrapulmonary causes of restrictive lung disease are generally the result of what?
Poor breathing mechanics, usually as a result of muscular dysfunction (eg, polio) or structural difficulty (eg, scoliosis, morbid obesity)
Pulmonary causes of restrictive lung disease are generally the result of what category of diseases?
Interstitial lung diseases
What infectious disease can cause poor muscular effort and thereby lead to extrapulmonary restrictive lung disease?
What disease of the neuromuscular junction can cause poor muscular effort and thereby lead to extrapulmonary restrictive lung disease?
What is the mechanism of extrapulmonary restrictive lung disease in scoliosis?
The curvature of the spine distorts the breathing mechanics of the rib cage
Other than scoliosis and muscle diseases, what condition can lead to extrapulmonary restrictive lung disease?
What category of interstitial lung diseases has a clear association with an environmental exposure?
What disease is associated with repeated cycles of lung injury and wound healing with increased collagen deposition?
Idiopathic pulmonary fibrosis
Name three pneumoconioses that can cause restrictive lung disease.
- Coal miner’s disease
What nongranulomatous disease that commonly affects the renal and pulmonary systems can cause interstitial lung disease?
What disease can cause restrictive lung disease due to eosinophilic granulomas in the lungs?
Name three drugs that can cause interstitial lung disease.
What processes cause restrictive lung disease due to poor muscular effort?
Polio and myasthenia gravis
What processes cause restrictive lung disease due to poor structural breathing mechanics?
Scoliosis and morbid obesity
What processes cause restrictive lung disease due to interstitial lung pathology?
Acute respiratory distress syndrome, neonatal respiratory distress syndrome, pneumoconioses, sarcoidosis, idiopathic pulmonary fibrosis, Goodpasture’s syndrome, Wegener’s granulomatosis, histiocytosis X, and certain drug toxicities
Which lobe of the lung is most affected in coal miner’s disease?
Coal miner’s disease can be associated with what two additional pathologic conditions?
Cor pulmonale or Caplan’s syndrome (the combination of pneumoconiosis and rheumatoid arthritis)
Patients with silicosis likely worked in what three fields?
Foundries, sandblasting, and mining
What cell type is responsible for the fibrosis induced by silica inhalation?
Silicosis increases the risk of what infectious disease?
What lobe of the lung is most affected by silicosis?
The finding of eggshell calcification on chest x-ray would increase suspicion of what disease?
What substance, used for such things as shipbuilding and insulation, can result in a diffuse pulmonary interstitial fibrosis?
Patients with asbestosis are at increased risk of what two cancers?
Mesothelioma and bronchogenic carcinoma
What gross pathologic finding can be found on the pleura of patients who have been exposed to asbestos?
Ivory white pleural plaques
Asbestosis is most commonly seen in practitioners of what professions?
Shipbuilders, plumbers, and roofers
Asbestosis mainly affects the ____ (lower/upper) lung lobes, while coal worker’s lung affects the _____ (lower/upper) lobes.
What are asbestos bodies and where are they located?
Golden-brown fusiform rods found in macrophages
In neonatal respiratory distress syndrome, there is a deficiency of what chemical?
How does the lack of surfactant in neonatal respiratory distress syndrome impair gas exchange in the lungs?
Surfactant deficiency leads to an increase in surface tension, resulting in collapse of the alveoli
What cells make surfactant?
Type II pneumocytes
Surfactant is made most abundantly during which period of neonatal gestation?
After the 35th week
What ratio is used as a measure of lung maturity in neonates? How is it tested?
The lecithin/sphingomyelin ratio. In the amniotic fluid
In neonatal respiratory distress syndrome, the lecithin-to-sphingomyelin ratio is usually within what range?
Medical treatment for neonatal respiratory distress syndrome includes what treatment for the mother before birth?
What vascular pathology is associated with persistently low oxygen tension due to neonatal respiratory distress syndrome?
Patent ductus arteriosus
patent ductus arteriosus can cause pulmonary hypertension if not corrected medically or surgically
What are three risk factors for neonatal respiratory distress syndrome?
Prematurity, maternal diabetes (due to elevated insulin), and cesarean delivery (due to decreased release of fetal glucocorticoids)
How can neonates be treated for respiratory distress syndrome after birth?
With artificial surfactant
Use of supplemental oxygen in neonates can lead to what ocular pathology?
Retinopathy of prematurity
In acute respiratory distress syndrome, acute alveolar damage leads to a(n) _____ (decrease/increase) in alveolar capillary permeability.
Despite many etiologies, what pathophysiology is seen in all cases of acute respiratory distress syndrome?
Fluid leakage into alveoli causing hyaline membrane formation on the inside of the alveolus thus impeding gas exchange
Name seven conditions known to cause acute respiratory distress syndrome.
Trauma, sepsis, shock, gastric aspiration, acute pancreatitis, amniotic fluid embolism, uremia
What obstetric complication can result in adult respiratory distress syndrome?
Amniotic fluid embolism
A chronic alcoholic suffering from acute pancreatitis is experiencing difficulty breathing and oxygen desaturation. From what pulmonary complication of acute pancreatitis may she be suffering?
Acute respiratory distress syndrome
Name three molecular mechanisms that contribute to the initial damage to the alveoli in acute respiratory distress syndrome.
- Neutrophilic toxins
- Activation of the coagulation cascade
- Oxygen-derived free radicals
The forced expiratory volume1:forced vital capacity is what percent in normal lungs; in obstructive lung disease; in and restrictive lung disease?
Approximately 80%; <80%; >80%
Forced expiratory volume1 and forced vital capacity are reduced in both obstructive and restrictive pulmonary diseases; however, forced expiratory volume1 is more dramatically reduced in ____ (obstructive/restrictive) pulmonary disease.
In ____ (obstructive/restrictive) pulmonary disease, forced expiratory volume1/forced vital capacity <80% and lung volumes are increased.
In _____ (obstructive/restrictive) pulmonary disease, forced expiratory volume1/forced vital capacity >80% and lung volumes are decreased.
How do total lung volumes in obstructive lung disease compare with normal lung volumes?
Lung volumes in chronic obstructive pulmonary disease are greater than normal lung volumes
Is residual volume decreased, increased, or normal in obstructive lung disease?
How do total lung volumes in restrictive lung disease compare with normal lung volumes?
Lung volumes are less than normal in restrictive lung disease
In which type of lung disease, obstructive or restrictive, is the forced expiratory volume1/forced vital capacity ratio more dramatically reduced?
Define sleep apnea.
The condition that occurs when a person repeatedly stops breathing for at least 10 seconds during sleep
Define central sleep apnea.
Sleep apnea due to a lack of respiratory effort
Define obstructive sleep apnea.
Sleep apnea with which there is a drive to breathe but mechanical airway obstruction (usually obesity) prevents respiration
An obese man complains of chronic fatigue. His wife says he is an especially loud snorer. What condition may be contributing to this patient’s fatigue?
Name three treatments of sleep apnea.
- Weight loss
- Continuous positive airway pressure
Name five conditions potentially associated with sleep apnea.
- Loud snoring
- Pulmonary hypertension
- Possible sudden death
In the case of bronchial obstruction, what happens to the breath sounds over the affected area?
They are decreased or absent
What are the physical exam findings in a patient with bronchial obstruction?
Hyporesonance to percussion, decreased fremitus, and if there is tracheal deviation, it is towards the side of the lesion
What are the physical exam findings in a patient with pleural effusion?
Decreased breath sounds, dullness to percussion, decreased fremitus
What are the physical exam findings in a patient with lobar pneumonia?
Bronchial breath sounds, dullness to percussion, increased fremitus, no tracheal deviation
What are the physical exam findings in a patient with pneumothorax?
Decreased breath sounds, hyperresonance, absent fremitus, and tracheal deviation away from the lesion
Pleural effusions cause a(n) _____ (decrease/increase) in fremitus, whereas pneumonia causes a(n) _____ (decrease/increase) in fremitus.
Bronchial obstructions may cause tracheal deviation _____ (away from/toward) the lesion, whereas pneumothoraces result in deviation _____ (away from/toward) the lesion.
Toward; away from
In what area of the lungs does squamous cell carcinomas typically arise?
In what area of the lungs does small cell carcinoma typically arise?
In what area of the lungs does adenocarcinoma typically arise?
In what area of the lungs does large cell carcinoma typically arise?
List the two lung cancers that have a link to smoking.
- Squamous cell carcinoma
- Small cell carcinoma
Squamous cell carcinoma of the lungs is known for the ectopic production of what substance?
Parathyroid hormone-related peptide, the release of which causes hypercalcemia
List three forms of bronchogenic carcinoma that tend to arise peripherally in the lungs.
- Bronchioalveolar carcinoma
- Large-cell carcinoma
What is the most common type of lung cancer in non-smokers?
What peripherally arising form of bronchogenic carcinoma is most anaplastic or undifferentiated?
What are the classic symptoms of carcinoid syndrome and what is the cause?
Flushing, diarrhea, wheezing, salivation; the symptoms are caused by serotonin secretion into the bloodstream
Are metastases from primary lung cancers very rare, rare, common, or very common and to what three sites do they occur?
Very common; brain, bone, and liver
In association with a primary lung cancer, what finding suggests brain metastases?
In association with a primary lung cancer, what finding suggests bone metastases?
In association with a primary lung cancer, what two findings suggest liver metastases?
Jaundice and hepatomegaly
What type of cancer is the leading cause of cancer death?
Lung cancer can present with what incidental radiologic finding?
Pulmonary “coin” lesions
How can the voice of a patient with lung cancer change?
Hoarseness; due to compression of the recurrent laryngeal nerve
Which potential spaces can develop effusions as a result of lung cancer?
Pleural and pericardial effusions
How does the mnemonic SPHERE help one to remember common complications associated with lung cancer?
SPHERE stands for Superior vena cava syndrome, Pancoast’s tumor, Horner’s syndrome, Endocrine (paraneoplastic) complications, Recurrent laryngeal symptoms, and Effusions
A cavitary hilar mass arising from the bronchus of a long-time smoker may suggest which disease process?
Squamous cell carcinoma
Histologically, which lung carcinoma forms keratin pearls and intercellular bridges?
Squamous cell carcinoma
Which lung carcinoma may develop in sites of prior pulmonary inflammation or injury and is the most common lung cancer in nonsmokers and females?
Which of the following is more common on x-ray of the chest in lung adenocarcinoma, a single lesion or multiple densities?
Clara cells differentiate into type II pneumocytes in which type of lung cancer?
Adenocarcinoma (bronchial and bronchioloalveolar)
Which cells are the precursors to small-cell lung cancer?
Neuroendocrine Kulchitsky cells
Name three possible paraneoplastic syndromes associated with small cell carcinoma of the lung.
Adrenocorticotropic hormone syndrome, the syndrome of inappropriate antidiuretic hormone secretion, and Lambert-Eaton syndrome
What is Lambert-Eaton syndrome?
A paraneoplastic syndrome associated with small cell carcinoma of the lung in which autoantibodies form against presynaptic calcium channels, leading to muscle weakness
What is the usual approach to the treatment of large cell carcinoma of the lung?
Remove surgically (poorly responsive to chemotherapy)
Histologically, which lung cancer is associated with pleomorphic giant cells with leukocyte fragments in the cytoplasm?
What is the approach to treatment of small-cell lung cancer?
This inoperable cancer is treated with chemotherapy
Patients with metastases to the lung present with symptoms of _____ (cough/dyspnea) and patients with primary lung cancer present with symptoms of _____ (cough/dyspnea).
Bronchioloalveolar adenocarcinoma can present similarly to which other non-cancer pathological lung disease?
A long-time shipbuilder presents with difficulty breathing. X-ray demonstrates an effusion. On tap, the fluid is bloody. A biopsy shows psammoma bodies. What is the disease process?
Mesothelioma secondary to asbestos exposure
Small-cell carcinoma is associated with the production of what two hormones?
Adrenocorticotropic hormone or antidiuretic hormone
In what region of the lung does Pancoast’s tumor occur?
Because of its location, Pancoast’s tumor may affect what neurologic structure?
The cervical sympathetic plexus
When Pancoast’s tumor disrupts the cervical sympathetic plexus, it can result in what condition?
Horner’s syndrome includes what three findings?
Ptosis, miosis, and anhidrosis
Lobar pneumonia is most frequently the result of infection with what organism?
Which type of pneumonia is most often caused by viruses?
Interstitial (atypical) pneumonia
List two viruses that commonly cause interstitial pneumonia.
Respiratory syncytial virus and adenoviruses
In which type of pneumonia does an intra-alveolar exudate lead to consolidation?
Which type of pneumonia characteristically shows diffuse, patchy inflammation?
Interstitial (atypical) pneumonia
Interstitial pneumonia characteristically shows diffuse, patchy inflammation that is localized to what areas of the lung?
Interstitial areas at the alveolar walls
The distribution of interstitial pneumonia characteristically involves how many lobes?
At least one, usually more
Which type of category of pneumonia typically has a less acute presentation?
List four bacterial etiologies of bronchopneumonia.
- Staphylococcus aureus
- Haemophilus influenzae
- Streptococcus pyogenes
List three bacterial causes of interstitial pneumonia.
What is a lung abscess?
A localized collection of pus in the lung parenchyma
What two conditions can predispose a patient to lung abscesses?
Bronchial obstruction (usually by a tumor) or the aspiration of gastric contents (often after seizures or heavy alcohol use)
What type of individuals are predisposed to developing lung abscesses, even in the absence of preexisting pulmonary disease?
Patients who are prone to loss of consciousness like alcoholics and epileptics; they are at increased risk of aspiration of gastric contents
Name two organisms (or classes of organisms) most commonly implicated in the development of lung abscesses.
- Staphylococcus aureus
In terms of pleural effusions, transudates have _____ (less/more) protein than exudates.
In terms of pleural effusions, exudates have _____ (less/more) protein than transudates.
What are three common causes of transudative pulmonary effusions?
- Congestive heart failure
- Nephrotic syndrome
- Hepatic cirrhosis
Name four causes of exudative pulmonary effusions.
- Collagen vascular disease
What makes an exudate cloudy?
Exudates are cloudy because of their higher protein content
Name the three types of pleural effusions.
Are pleural effusions that are secondary to trauma usually transudates or exudates?
Exudates, due to increased vascular permeability in the setting of trauma
Which type of pleural effusion consists of high levels of triglycerides and has a milky appearance grossly?
For what reason does an exudative pleural effusion require drainage?
Exudates have a high infection risk; they can progress to empyema, which requires surgery