Witrak Pulmonary Pathology Flashcards
(255 cards)
1
Q
two principal metabolic functions of lung
A
- oxygenate blood
2. expire CO2
2
Q
PaO2 normal
SaO2 normal
A
PaO2 80-95mmHg
SaO2 >95%
3
Q
PaCO2 normal
A
PaCO2 35-45mmHg
4
Q
bronchiolitis
A
RSV in kids
5
Q
bronchitis commonest cause
A
cigarette smoke
6
Q
bronchiectasis
A
pertinent dilatation of bronchi:
infection of bronchi –> causes permanent deletation
7
Q
most fatal, common cancer is…
A
cigarette laden…lung cancer (loves to develop in bronchi)
8
Q
CHF
A
back pressure of venous system…hydrostatic pressure causes fluid to leave capillaries and oozes into alveolar spaces
9
Q
pulmonary arteries go along with…
A
bronchial tree
10
Q
22 week old fetus born prematurely risk of…
A
not enough surfactant –> alveoli cannot stay open = NEONATAL RESPIRATORY DISTRESS SYNDROME (NRDS)
11
Q
most common dramatic obstruction of pulmonary blood flow…
A
DVT –> PE
12
Q
commonest cause of pulmonary HTN…
A
hypoxemia
- low O2 –> vasospasm in pulmonary circulation
(chronic pulmonary diseases…emyphysema and interstitial fibrosis)
13
Q
sustained pulmonary HTN…
A
right heart failure
14
Q
isolated RHF due to pulmonary HTN is…
A
cor pulmonale
15
Q
commonest causes of hypoxemia –> vasospasm –> pul HTN:
A
emphysema and interstitial fibrosis
16
Q
Those with emphysema and interstitial fibrosis most commonly die from…
A
cor pulmonale
if pneumonia hasn’t set in
17
Q
Two commonest causes of shortness of breath (SOB)…
A
- asthma (respiratory)
2. CHF (LV failure - cardiac)
18
Q
“Never forget about ___ with shortness of breath”
A
blood hemoglobin level
19
Q
Multiple fractured ribs and chest cavity collapsing is called…
A
Flail chest
Tx: expand chest wall and canullize
20
Q
Obstructive disorders definition
A
expiratory airflow limitation
*typically smaller airways
21
Q
Obstructive disorders (and common associated age)
A
- ASTHMA (kids and adults)***
- COPD (adults, emphysema/chronic bronchitis)***
- bronchiectasis
- bronchiolitis (especially in kids, virally induced)
22
Q
How assess degree of obstruction
A
pulmonary function testing (common office spirometry): DECREASED FEV-1
23
Q
Restrictive diseases definition
A
- reduced total lung capacity (TLC) –> scarred, shrunken lungs
- reduced ventilatory elasticity –> chest wall poorly expansile
24
Q
Restrictive diseases
A
- diffuse parenchymal/interstitial lung disease –> idiopathic pulmonary fibrosis and occupational lung diseases
- chest wall/pleural disease
- massive obesity
- neuromuscular diseases
25
degree of restriction assessed by
pulmonary function testing: TLC
26
Major pulmonary disease
obstruction
| because of smoking
27
Most feared chronic pulmonary disease
idiopathic pulmonary fibrosis
| smoking disease and no good treatment
28
Pulmonary vascular diseases
* **affecting PROXIMAL/LARGER portion of pulmonary arterial tree:
- THROMBOEMBOLISM (from DVT)
- much less freq --> embolism of tumor, fat, air, amniotic fluid
* **SMALL pulmonary vessel disease:
- pulmonary HTN (secondary or idiopathic)
- pulmonary hemorrhage/vasculitis syndromes: Goodpastures with anti-GBM antibody, Wegener/ANCA vasculitis, SLE, idiopathic
29
The most immediate, acute, on-your-mind, common pulmonary disease that can cause death is...
PE
| from DVT
30
Biggest post-operative period risk...
DVT/PE
31
Diagnose DVT/PE...
D-dimer or just skip to invaluable chest CT angiogram*** = true pulmonary emboli
32
Treat DVT/PE with...
LMW heparin
Coumadin
newer anti-coagulants
33
Most pulmonary HTN is secondary to...
emphysema and pulmonary interstitial fibrosis
34
idiopathic pulmonary hypertension most commonly seen in
young women (
35
Cardiogenic causes of pulmonary edema
- LEFT-SIDED CONGESTIVE HEART FAILURE
- chronic CAD
- MI
- HTN heart disease
- cardiomyopathies
- aortic or mitral stenosis
36
Non-cardiogenic causes of pulmonary edema
- ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) especially triggered by sepsis, trauma/shock --> microvascular/alveolar capillary injury
37
Major cause of SOB
pulmonary edema
--> from LHF (cardiogenic) or ARDS (non-cardiogenic)
38
Pulmonary infectious diseases
- infection of the distal/alveolar lung --> pneumonia/lung abscess
- infection of the airways --> epiglottitis, laryngitis, tracheobronchitis, bronchiolitis
39
commonest infectious disease leading to hospital admission and death in USA
= "by far the commonest way to leave this planet"
pneumonia
| alveolar
40
pneumonia diagnosis requires:
pulmonary infiltrate(s) seen on either CXR or CT
- don't always need to have fever, but need to have an infiltrate
41
types of pneumonia pathogenesis:
- CAP (pneumococcus)
- nosocomial (pseudomonas)
- immunosuppressed (bugs that would not normally hurt healthy individual)
42
pneumonia can lead to...
lung abscess
43
types of pneumonia (physiologically):
- alveolar***most life threatening
| - interstitial: atypical microorganisms
44
big fork in the ER with URIs is...
when do I get a chest xray
45
Another way to impair respiration...
pleural fluid and air disease
46
Pleural fluid and air disease definition:
space occupying effect: restricting lung expansion or causing lung collapse (atelectasis)
47
Types pleural fluid and air disease
EFFUSIONS:
- TRANSUDATES (eg. CHF),
- EXUDATES (eg. para-penumoic/empyema, malignant)
- HEMOTHORAX (eg. trauma, aortic aneurysm or dissection rupture)
- CHYLOUS (eg. lymphatic/thoracic duct obstruction)
PTX: spontaneous or tension
48
PTX definition
visceral pleural air leak secondary to underlying lung pathology (trauma vs. many chronic lung diseases)
- spontaneous
- tension PTX
49
lung collapse
atelectasis
- can be segment, lobe or entire lung
- usually due to OBSTRUCTED BRONCHUS or pleural effusion
50
when atelectasis -->
lung cannot ventilate normally --> respiratory distress --> potential death
51
most serious/bad pleural fluid...
exudate**
| can be cancer
52
which chest cavity has the section most likely to rupture
left chest (almost exclusively)
53
chylous pleural fluid
trauma or cancer
54
any chronic lung disease can lead to...
spontaneous PTX (bleb rupture)
-> put in chest tube (displace air)
55
unrelieved atelectasis:
risk of pneumonia
56
bronchiectasis definition
- chronic infection/inflammation fo larger airways: IRREVERSIBLE bronchial DILATATION
- chronic mucopurulent sputum production
- eventual bronchial collapse/obstructive symptoms
- not therapized --> can cause total lung failure
- unrelated to cigarette smoking***
57
If you obstruct a bronchus, the lung will... (and associated risk)
If you obstruct a bronchus, the lung will absorb air behind it and cause that area to collapse.
This poorly ventilated, collapsed area is a perfect set up for pneumonia.
58
Commonest cause of bronchiole obstruction is...
mucus plugging
59
Commonest cause of cancer death:
lung cancer (carcinoma)
60
Pulmonary/pleural neoplasia types:
- small cell (VERY BAD)
- non-small cell (USUALLY BAD)
- low-grade neuroendocrine (carcinoid) tumors (NOT SO BAD)
61
METS to lung
from any cancer
62
Primary pleural neoplasms
- malignant mesothelioma (REALLY BAD) (asbestos)
| - solitary fibrous tumor (USUALLY BENIGN)
63
rare respiratory cancer
cancer of trachea
| *trachea usually is not affected by cancer as other parts of respiratory system are
64
drinker and smoker cancer risk...
esophageal cancer
65
"one of the worst cancers on earth"
small cell lung carcinoma
66
"If can choose a malignancy in the lung, you want..."
a carcinoid tumor
- low grade
- slow growing
- usually curable with surgery
- related to smoking
67
Congenital/neonatal lung associations...
Associated with any:
- perinatal death (in utero)
- neonatal respiratory distress with variable survival (neonatal)
- delayed symptoms/discovery into adulthood possibly (adult)
68
Congenital/neonatal lung diseases
- congenital pulmonary airway malformation
- lung agenesis/hypoplasia
- tracheal/bronchial anomalies
- congenital lobar overinflation
- pulmonary sequestration
- foregut cysts
- arteriovenous alformation
- NRDS
69
Commonest congenital/neonatal lung disease
congenital pulmonary airway malformation
70
Commonest symptoms of lung disease
- dyspnea
- cough
- sputum production
- wheezing
- chest pain
71
MOA dyspnea associated with lung dz
decreased respiratory system compliance OR increased resistance to air flow OR impaired gas exchange OR not enough alveoli --> increased work of breathing --> SOB
72
types of cough and what it indicates
non-productive: less likely to be infectious process, likely diffuse parenchymal/interstitial lung disease
productive: likely to be infectious
73
productive cough quality
- clear/mucoid: asthma
- purulent: infection
- bloody: 1) in adult smoker, malignant 2) pneumonia
74
_____ in adult smoker is malignancy until proven otherwise
hemoptysis
75
what part of the airway produces wheezing?
the smaller airways
76
cardiac asthma
CHF: edema surrounding small airways
77
wheezing respiratory diseases
- asthma
| - emphysema
78
what causes pain in the chest?
parietal pleura*** (not interstitium)
- pleuritis
- pneumonia
- PE infarcting pleura
- PTX
- chest wall injury
79
MOA dyspnea
respiratory control center is sensing not sufficient oxygen --> work harder to get normal oxygen --> dyspnea
80
most common cause of dyspnea in primary care setting
33% asthma
| 30% heart failure
81
fatigue, dyspnea...don't forget about _____
ANEMIA
82
ACUTE/sudden changes of dyspnea/fatal
= HOSPITAL ADMISSION
- laryngeal edema/anaphylaxis
- bronchospasm
- MI
- large PE
- inhaled toxic substance (chlorine gas/NO)
- massive hemorrhage
- massive hemolysis
83
expiratory wheezing, think...
asthma
| including cardiac asthma: peribronchial edema due to CHF
84
acute cough with sputum production + fever and chills ==>
pneumonia
85
misc. causes of cough
- GERD
- cardiac
- psychogenic
- medication-related (lisinopril)
86
only sputum worth examining in lab
deep tracheobronchial specimen
87
smoker + terrible arm/shoulder pain -->
Horner Syndrome = cancer into brachial plexus
88
pulmonary docs smart their consult with _____
smoking status
89
Patient history clues:
1. smoking/COPD/lung CA/IPF
2. inhalation exposures
3. travel history
4. CT disease
5. cancer hx
6. cytotoxic chemo hx
90
"Are you a splunker? Do you like to crawl through caves with bat shit all over the place?"
histoplasmosis exposure
91
"Are you a guy who loves to ATV up in the north woods and wrestle with your black lab in rotting wood piles?"
blastomycosis exposure
92
"Are you a snow bird in New Mexico who loves to shovel sand?"
coccidioidomycosis exposure
93
SLE, RA can produce ____
interstitial fibrosis and pleuritis
94
barrel chest classic for...
emphysema
95
kyphoscoliosis
can't expand lungs
96
stridor (inspiratory wheeze) common with...
upper airway obstruction
97
crackles/rales
ALVEOLAR DZ:
- pneumonia
- pulmonary edema
- interstitial/fibrosing disease
98
decreased lung sounds
- emphysema
- PTX
- pleural effusion
- pulmonary consolidation (lobar pneumonia)
99
CT scan is a poor man's auscultation
*captain morgan stance chuckle*
100
clubbing of fingers
***sign of serious underlying dz
Associated with:
- IPF
- asbestosis
- CF
- cyanotic CHD
- malignancy of lungs/pleura
- pulmonary AV malformation
101
5th vital sign
pulse oximetry
102
in what chronic disease state do you get CO2 retention
emphysema or chronic bronchitis (COPD)
103
```
***arterial blood gases sample norm
PaO2
PaCO2
pH
HCO3
SaO2
```
```
PaO2: 80-95 mmHg
PaCO2: 35-45 mmHg
pH: 7.35-7.45
HCO3: 22-28 meq/L
SaO2: 95-100%
```
arterial sample
104
***CXR
- pulmonary or pleural dz
- cardiac enlargement
- mediastinal pathology
105
NOTE: CXR won't pick up...
larger airways disease, pulmonary vascular disease, asthma
| will be normal CXR
106
cardiac disease assessment throwback
- EKG
- ECHO
- troponin (increased in MI)
- BNP (increased in HF)
107
***Pulmonary Function Testing (PFT) indicators
FEV1/FVC
108
***Atelectasis
collapse of LOSS OF LUNG VOLUME:
- segmental, lobar, or entire lung
CXR: showing volume loss plus poulmonary OPACIFICATION
109
Primary atelectasis (neonatal)
* rare
| - incomplete expansion of lung/lungs at birth --> includes INADEQUATE SURFACTANT
110
***Secondary subtypes atelectasis
* >99% atelectasis cases
| - obstructive: MUCUS PLUGGING --> resorpted alveolar gas distal to plug
111
***Commonest cause of atelectasis in children
mucus plugging
especially in asthma, CF (RML syndrome)
112
kid + chronic cough + atelectasis is ____ until proven otherwise
foreign body aspiration
113
***three main physiologic causes of atelectasis
RESORPTIVE
COMPRESSION
CONTRACTION
114
RESORPTIVE atelectasis
- alveolar collapse bc pneumonia or poor lung vent
*post-general anesthesia
= accumulated mucus secretions
115
COMPRESSION atelectasis
- pulmonary collapse due to mass effect from pleural effusion, PTX, tumor etc.
116
CONTRACTION atelectasis
- pulmonary shrinkage due to pleural fibrosis or fibrotic interstitial dz
117
Failure to relieve atelectasis
increased risk pneumonia
118
significant cause of cough and atelectasis in a two year old
foreign body inhalation
119
aspiration pneumonitis
nun died suddenly from inhaling hard boiled egg
120
***obstructive pulmonary diseases
- ASTHMA**
- COPD (emphysema**/chronic bronchitis)
- bronchiectasis
- bronchiolitis
121
"airway hyper-responsiveness"
bronchochonstriction
122
asthma ____ airflow obstruction
REVERSIBLE
123
***How common is asthma
EXTEREMLY common
300 million people worldwide (11% adults, 15% of children)
*more poverty: more asthma in children
124
90% of asthma cases are...
triggered by ALLERGIC/ATOPIC DZ (IgE mediated)
125
10% of asthma cases are...
NONATOPIC/"INTRINSIC"
(often more adult-onset/more severe dz, triggered by:
ASA, other rx, exercise, cold air, sterss, inhaled irritants)
126
***symptoms of asthma
- episodic wheezing
- dyspnea
- cough
*kids: predominantly have cough
127
***diagnosis of asthma
- symptom based
- variable/intermittent airways obstruction
- no CXR findings
- PET/spirometry: decreased FEV1
>12% FEV1 increase with inhaled BETA 2 AGONIST***
128
Of note: COPD and asthma relationship
10% of COPD patients have asthma features
| with response to corticosteroids, probably both dz present
129
asthma histology
mucosal/submucosal inflammation:
- eosinophils/T lymphocytes
- mucosal EDEMA
- MUCUS HYPERSECRETION/PLUGGING
- goblet cell hyperplasia
- hypertrohied bronchial smooth muscle
130
***targets of therapy of asthma
1. relief of bronchoconstriction with BETA 2 AGONIST
2. inflammation control/suppression: ICS
3. refer for persistent
131
***complications of asthma
- status asthmaticus
- allergic broncopulmonary aspergillosis
- chronic eosinophilic pneumonia
132
status asthmaticus
- acute/severe
- sustained bronchoconstriction
- DEATH if not reversed
133
allergic bronchopulmonary aspergillosis
allergic reaction to inhaled aspegillus spores:
- lung infiltrates with eosinophils/mucoid bronchial plugging --> can cause bronchiectasis***
Rx: steroids and antifungals
134
COPD***stats
- 4th leading cause of US death
- 80-90% associated with cigarette smokers
- at least 15-20% of chronic smokers develop COPD
135
COPD pathophys
- expiratory airflow obstruction that is NOT reversible
- overlaps with adult asthma
- slowly progressive/persistent dz
- periodic acute exacerbations often due to respiratory infection
136
COPD etiology
- abnormal inflammatory response to noxious gases/particles
- cigarette smoke has toxic effects on trachea/bronchi: submucosal glandular hyperplasia with ABUNDANT MUCUS PRODUCTION/COUGH = CHRONIC BRONCHITIS
137
why alveoli destroyed by cigarette smoke
- neutrophils/macrophages release ELASTOLYTIC PROTEINASES --> degrade natural anti-proteinase protection --> PROGRESSIVE ACINAR DESTRUCTION with PERMANENT AIR SPACE ENLARGEMENT = emphysema
138
centriacinar emphysema
*majority of cases
| predominantly affecting UPPER lobes
139
panacinar emphysema
upper AND lower lung field involvement of equal severity
| - advanced common emphysema OR A1AT DEFICIENCY (associated liver disease)
140
risk of emphysematous blebs
PTX
141
COPD mechanisms of airflow obstrux
- if predominant BRONCHITIS = mucus PLUGGING
- if predominant EMPHYSEMA = decreased elastic/avlevolar "TETHERING" of respiratory bronchioles --> airway collapse during expieration with alveolar AIR TRAPPING --> loss of elastic recoil --> HYPERINFLATION
* often mixed
142
COPD predominant bronchitis think
BLUE BLOATERS
MUCUS PLUGGING
143
COPD preominant emphysema think
PINK PUFFERS
AIR TRAPPING/HYPERINFLATION
144
COPD clinical presentations
- sedentary lifestyle (avoiding exertional dyspnea)
- progressive dyspnea
- evolving cough with sputum (mucoid or purulent)
- acute chest illness
145
what is acute chest illness (acute COPD exacerbation) ER
- increased cough
- purulent sputum
- wheezing/dyspnea (episodic)
*may resemble asthma, CHF, bronchiectasis
(acute COPD exacerbation) ER
146
COPD physical exam with severe dz
- systemic wasting
- hyperinflated lungs
- decreased breath sounds
- use of accessory musces
- cyanosis
- right HR (cor pulmonale)
147
COPD diagnosis
PFT: FEV1/FVC
148
ABGs with COPD
mild: hypoexemia without hypercarbia
severe: worsening HYPOXEMIA WITH HYPERCARBIA
= more severe, the higher the CO2 will be
149
hemogram with COPD
if POLYCYTHEMIA --> implies CHRONIC HYPOXEMIA
*kidney senses hypoxemia
has to do with CARBON MONOXIDE** ? GAH
150
COPD clinical course
- slowly progressive sx
| - periodic acute exacerbations --> puts them in the ICU
151
COPD prognosis
> 65 yo IF ADMITTED TO ICU: 15-30% mortality rate (60% at 12 months)
152
***bronchiectasis
permanently dilated bronchi/bronchioles
153
causes significant hemopysis
- cancer
- TB
- bronchiectasis
- rare pulmonary hemorrhage syndromes
154
biggest culprit of bronchiectasis
- CF
- aspiration
- airway obstruction: foreign body or tumor
155
rare cause bronchiectasis
- Kartagener's syndrome (primary ciliary dyskinesia)
- prior pulmonary inf
- CT dz: RA, Sjogrens
- immune deficiencies
- unknown: 25-50% cases
156
main Kartagener syndrome defect
missing dynein arms
157
***Respiratoy Tract Infection: commonest infection...
URI, tracheitis/bronchitis/bronchiolitis, PNEUMONIA
158
Commonest lethal adult infection
pulmonary alveolar pneumonia
*if require admission: 30 day mortality rate is 20%
159
pneumonia Sx
Acute/rapidly evolving:
- cough
- fever
- pleuritic chest pain
- dyspnea
- sputum
- plus/minus chills/rigors
* elderly esp: mental status changes
- maybe GI changes, NVD
160
pneumonia physical exam
- audible RALES on chest auscultation
| - PULMONARY CONSOLIDATION on CXR
161
pneumonia pathology
- alveolar exudative (NEUTROPHILIC) inflammation (bacterial)
- interstitial/alveolar wall inflammation: LYMPHOCYTIC type (atypical pneumonia...mycoplasma, chlamydophylia, virus)
- necrotizing granulomas (fungi or mycobacteria)
162
lobar pneumonia in otherwise healthy person, have to think...
streptococcus pneumoniae (pneumococcus)
163
Diagnosis: marked, bilateral pulmonary infiltrates.
| So, differential:
- severe bilateral pneumonia
- severe CHF
- severe ARDS
164
bugs of pneumonia that like to become abscesses...
staph
| entero
165
empyema
- pleura leaks pus (space occupying rind develops in pleural space)
166
ancillary studies of pneumonia***
- pulse ox (desaturation)
- leukocytosis (usually neutrophilic)
- ESR (increased)
- CRP (increased)
- deep sputum gram stain
- urinary antigen testing (pneumococcus)
167
Why pneumonia?
- infection requires:
1. defect in host defenses and/or pre-existing acute or chornic lung disease
2. marked virulent organism
3. overwhelming infection
168
Predisposing factors to penumonia ***
1. extremes of age
2. altered consciousness (aspiration risk)
3. cigarette smoking
4. COPD
5. pulmonary edema
6. malnutrition
7. immunosuppression (acquired or congenital)
169
predisposing factors continued ***
8. CF
9. immotile cilia syndrome
10. bronchial obstruction
11. viral respiratory tract inf with secondary bacterial pneumonia
170
most common fear of someone diagnosed with influenza A and B + other risk factors
secondary bacterial pneumonia
171
clinical classification of pneumonia
1. CAP (treat empirically)
2. nosocomial (ventilated)
3. immunocompromised (cancer)
4. chronic pneumonia (TB or fungi, failure to respond to empiric)
172
Valley Fever
coccidiomycosis
173
***atypical pneumonia
mycoplasma
chlamydophilia
viuses
- often milder than bacterial, BUT symptom overlaps do not allow reliable clinical separation
174
Percentage of pneumonia patients who may be afebrile
20%
| especially elderly
175
Even with overwhelming pneumonia infection, _____ may occur, especially in ______.
Leukopenia may occur with overwhelming infection,
| especially infants and elderly
176
***empiric antibiotics effective in ___% of CAP patients
>95%
177
microbiological diagnosis approach regarding penumonia
- etiology discoverable in only 50-60% of patients
| - MOST ADMITTED PT CAP RX'D EMPIRICALLY* w/o bug ID
178
respiratory secretions methods of diagnosis
- SPUTUM (deep cough)
- tracheal aspiration
- bronchoscopy with washing/bronchoalveolar lavage
- quick bug stains (GRAM)
- culture or PCR*
179
***how can diagnose pneumonia
1. respiratory secretions
2. blood culture
3. culture of PLEURAL/EMPYEMA FLUID or ABSCESS
4. urinary antigen testing: PNEUMOCOCCUS or Legionella
5. LUNG BX (esp mycobacteria and fungi)
6. serology
7. emerging serum test: PROCALCITONIN (increased in bacterial infection but not viral dz)
180
***most CAP bugs:
- strep pneumonia
- myscoplasma penumoniae
- chlamydophilia pneumonia
- Legionella
- respiratory viruses
181
***commonest cause of non-epidemic pneumonia
BACTERIAL PNEUMOCOCCUS
182
Associate patients iwth prior influenza, abx rx, COPD with increased risk of pneumonia due to:
- s. aurea
- enterobacteriaceae
- pesudomonas
183
Associate patients with ICU admission with pneumonia due to:
- s. pneumonia
- entereic gram - bacilli
- s. aureus
- legionella
- h. influenzae
- respiratory viruses
- immunosuppressed
184
Associate immunosuppressed with pneumonia due to:
- PNEUMOCYSTIS jirovecii
- CMV
- fungal
185
Commonest cause of CAP VIRAL pneumonia in adults
INFLUENZA (a, b, avian)
186
CAP depending on travel andendemic risk...never forget
- TB (immigrant populations)
| - FUNGAL DZ (USA): histoplasmosis, blastomycosis, coccidioidomycosis
187
general infectious disease mantra
"NEVER FORGET MYCOBACTERIUM TUBERCULOSIS"
188
Most feared, common pneumonia
pneumococcus
189
splenectomized patients at risk for
overwhelming pneumococcus sepsis
190
mycoplasma pneumonia key points
- bacterium without cell wall
- up to 15% of CAP
- can have URI Sx***
191
chlamydophilia pneumonia key points
- intracellular bacterium
- 5-10% of CAP (elderlyi)
- can have URI Sx***
192
Legionella pneumphilia key points
- 2-9% CAP
- associated URI Sx***
- aerosolized water droplets from water reservoirs
- epidemic outbreaks
- patients with predisposing chronic dz
- fatality rates up to 50%
- urinary antigen test
193
gram negative bacilli key points
- serious underlying disease (CF)
- nosocomial
- mechanically ventilated patients
- KLEBSIELLA
- PSEUDOMONAS AERUGINOSA
- MORAXELLA CATARRHALIS
- MISC
194
Can group A streptococcus cuase pneumonia?
Yes.
Can cause fulminant pneumonia with early empyema in young/IC patients.
195
Anaeorbic bacteria causing pneumonia are typically associated with _______
aspiration of gastric contents.
ASPIRATION PNEUMONIA
196
Why is aspiration pneumonia especially bad?
- usually MIXED ANAEROBIC/AEROBIC inf
- CHEMICAL INJURY by acidic gastric contents
- frequent ABSCESS formation
197
How is viral pneumonia different?
- infects interstitium instead of alveoli
| - typically sets up shop for secondary bacterial
198
Non-influenza viruses of pneumonia
- RSV (babies)
- parainfluenzae (IC)
- human metapneumovirus
- SARS
199
Commonest cuase of lower respiratory tract infection (bronchiolitis) in kids
RSV
| types A and B
200
"Don't sleep in a campsite full of rats and rodents because of..."
Hanta virus
- infected mice/SW USA
- flu-like symptoms, non-cardiogenic pulmonary edema (ARDS)
201
Most frequent complication of varicella infection in healthy adults and its mortality rate
varicella pneumonia
| 10-30% mortality
202
Fungal pneumonia***in healthy people transmitted by
INHALATION OF SPORES
| --> pulmonary infection +/- systemic spread
203
Fungal pneumonia in health people caused by...
histoplasmosis
blastomycosis
coccidioidomycosis
204
Those who come in with pneumonia --> give empiric Rx --> they come back in 10 days and have pertinient social/travel history...work up for
fungal pneumonia
205
Pathology of fungal pneumonia
necrotizing granulomas
| **can mimic TB and Wegener's granulomatosis
206
Upon CT exam, solitary pulmonary nodule with calcification, think...
GRANULOMA --> FUNGAL
| lung cancer is too aggressive and rapidly evolving --> does NOT calcify
207
Innumerable granulomas peppering the lung
milliary infectious process
- TB
- fungal in miliary pattern
208
Anytime see necrotizing granulomas, it is ______ until proven otherwise.
INFECTIOUS
| fungal vs. mycobacterium
209
***fungal pneumonia biographies: Ohio/Mississippi
HISTOPLASMOSIS
210
HISTOPLASMOSIS
- bats***/bird
- persistent pulmonary infiltrates
- respiratory secretions***
- tissue/LN bx***
211
```
RI
pulmonary nodule
mediastinal complications
calcifications of spleen (old granulomas)
erythema nodosum
arthritis
```
HISTOPLASMOSIS
212
***fungal pneumonia biographies: central/SW USA/Great Lakes region
North American BLASTOMYCOSIS
213
BLASTOMYCOSIS
- spore inhalation from ROTTING WOOD
- dogs commonly infected too
- bloodstream dissemination
- respiratory secretions***
- tissue/LN bx***
214
persistent pulmonary infiltrate
black lab hunter dog
skin lesions/tumor/erythema
BLASTOMYCOSIS
215
***fungal penumonia biographies: SW USA/semi-desert/"Valley Fever"
COCCIDIOMYCOSIS
216
COCCIDIOIDOMYCOSIS
- CAP or flu-like sx
- skin, bone/joints like blastomycosis
- INHALATION of spores
- respiratory secretions***
- tissue bx***
217
Tx of active pulmonary fungal dz
antifungal -AZOLES (occasionally amphotericin B)
218
Define immunocompromised:
defect in cellular or humor immunity, phagocytosis or with severe neutropenia
219
Almost all cases of pneumonia in immunocompromised patients are due to _____ deficiencies such as:
ACQUIRED
- HIV/AIDS
- chronic immunosuppression
- chemo
- transplant
220
Bugs seen in IC patients
- PNEUMOCYSTIS (HIV/AIDS)
- CMV
- norcariosis
221
pneumocystis jirovecii pearls
- HIV/AIDS patients
- dyspnea
- cough
- maked hypoxemia
- MINIMAL CXR CHANGES
- CT to see bilateral infiltrates
- neumocystis
222
other IC pneumonia bugs
- herpes virus (VZV)
- atypical mycobacteria (MAI)
- invasicve fungal: candidiasis, cryptococcosis, aspergillus, mucormycosis
- parasites (toxo, strongyloidiasis)
223
key point regarding immunocompromised patient with new pulmonary/febrile symptoms...
MULTIPLE different causative organisms possible
224
***definition of pulmonary edema
movement of FLUID INTO ALVEOLAR SPACES (alveolar flooding)
225
vast majority of pulmonary edema is ______
cardiogenic
226
causes noncardiogenic pulmonary edema
Alveolar microvascular injury:
- ARDS***/acute lung injury (TOTALLY HAPPENSTANCE)
- high altitude pul edema
- neurogenic pul edema
227
pulmonary edema with mixed cardiogenic/ARDS features
sepsis
228
cardiogenic pulmonary edema mechanism
increased alveolar capillary pressure due to increased pulmonary venous pressure --> increased pulmonary interstitial fluid formation --> alveolar flooding
229
clinical presentation of cardiogenic pulmonary edema EITHER:
1. ACUTE DYSPNEA with anxiety, diaphoresis, hypoxia (eg. MI)
2. MORE GRADUAL (over 24 hours) ONSET OF DYSPNEA on exertion, orthopnea, paroxysmal nocturnal dyspnea with cough +/- pink/frothy sputum
* chest pain think MI
230
cardiogenic pulmonary edema physical exam
- tachypnea
- tachycardia
- hypertension (adrenaline) OR hypotension (cardiogenic shock)
- cook extremities if poor peripheral perfusion
- RALES +/- RHONCHI/WHEEZES
- CARDIAC MURMURS (S3)
- JVD
231
CHF suspected...order:
BNP***
serum B-natriuretic peptide
(secreted by VENTRICLES secondary to stretching or increased wall tension)***
232
cardiogenic pulmonary edema on CXR
bilateral basilar interstitial/alveolar infiltrates +/- cardiomegaly
233
CXR: bilateral basilar interstitial/alveolar infiltrates DIFFERENTIAL***
- HF severe pulmonary edema
- bilateral pneumonia
- noncardiogenic ARDS
234
***non-cardiogenic pulmonary edema is usually...
Acute Respiratory distress syndrome (ARDS)/ Acute lung injury (ALI)
235
ARDS SYNDROME characterized by:
- dyspnea
- hypoxemia
- diffuse pulmonary infiltrates on CXR
236
ARDS path
Diffuse alveolar damage (DAD) with alveolar HYALINE MEMBRANES evolving to granulation tissue/organizing phase***resolution or pulmonary fibrosis/death
237
ARDS mech
some sort of process in bloodstream/sepsis --> causes pathologic migration of activated angry neutrophils to alveolar space --> proteolytic changes --> chew up normal alveolar space lining --> capilary leakage --> fibrin --> airspace compromise
238
clinical diagnosis with no lab value to measure
ARDS
239
clinical definition of ARDS
secondary to a PRECIPITATING INSULT WITHIN PREVIOUS 2-3 DAYS
- sepsis***
- pulmonary infection
- general trauma***/head injury "SHOCK LUNG"
- inhaled irritants
- drug overdoses/near drowning
- transfusion
- gastric aspiration
UNPREDICTABLE
240
ARDS pathophysicology
poorly understood
| alveolar capillary injury
241
ARDS tx
mechanical ventilation***
| treat underlying intiating event
242
ARDS mortality rate
30-40%
243
Acute lung injury definition
(acute interstitial pneumonia)
acute respiratory failure WITHOUT clear precipitating etiology
- similar to ARDS
- organizing DAD
244
ALI mortality rate
HIGH MORTALITY
| 30-70%
245
***Intersitital/Diffuse Parenchymal lung disease definition
(ILD)
non-infectious inflammation of pulmonary capillary wall of INTERSTITIUM +/- involvement of alveolar spaces and distal airways
defined on causality
RESTRICTIVE not obstructive
246
interstitial lung disease pathology
chronic interstitial inflammation (+/- granulomatous change) with risk of PULMONARY FIBROSIS
247
difference between COPD and ILD
COPD: obstructive
ILD: restrictive
248
ILD clinical sx
- onset varies
- USUALLY CHRONIC/PROGRESSIVE DYSPNEA
- persistent NON-PRODUCTIVE COUGH
249
severe ILD clinical sx
- hypoxemia at rest
- chronic pulmonary HTN
- eventual cor pulmonale (due to hypoxemic vasocnx) = COD
250
ILD on CXR
- can simulate pulmonary infection***
- reticular/reticulonodular infiltrates**** +/- alveolar filling pattern
- STREAKY FIBROTIC LINES on CXR
251
Ddx of chronic pulmonary infiltrates:
1. fungal*, mycobacterial, other bug
2. neoplasm* simulating pneumonia or ILD
3. ILD with known cause
4. idiopathic ILD (subtype?)
252
ILD with known causes:
1. inhalation exposure
2. drug-induced pulmonary toxicity
3. radiation-induced lung injury
4. ARDS
5. smoking related Pulmonary Langerhans Cell Histiocytosis PLCH***, Desquamative InterstitialPneumoniaDIP***/RespiratoryBronchiolitis-ILD RB-ILD***, Idiopathic Pulmonary Fibrosis IPF***
6. familial risk
253
most feared interstitial lung disease on the planet
idiopathic pulmonary fibrosis
| most occur in smokers, 70%
254
ILD with idiopathic/poorly understood causes:
1. SARCOIDOSIS
(common in African Americans)
2. AIP
USUAL INTERSISTIAL PNEUMONIA (UIP/IPF)***
non-specific IP, etc.etc.
3. ILD associated with CT disease (SLE, RA, scerloderma)
4. diffuse pulmonary hemorrhage syndromes (goodpastures, ANCA)
5. alveolar preoteinosis
6. eosinophilic pneumonia
7. granulomatuous/vasculitic Wegener's
8. Lymphangioleiomyomatosis (LAM) FEMALES**
9. MISC
255
eleven syllable ILD
lymphangioleiomyomatosis (LAM) females**
