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cvpr physiology 3 Flashcards

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1
Q

Pulmonary embolism features on ECG

A

May have S1Q3T3 abnormality on ECG

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2
Q

PE diagrams

A

pg 654

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3
Q

Flow-volume loops

A

Pg 655

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4
Q

RV in obstructive lung disease

A

↑

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5
Q

RV in restrictive lung disease

A

↓

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6
Q

FRC in obstructive lung disease

A

↑

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7
Q

FRC in restrictive lung disease

A

↓

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8
Q

TLC in obstructive lung disease

A

↑

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9
Q

TLC in restrictive lung disease

A

↓

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10
Q

FEV1 in obstructive lung disease

A

↓↓

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11
Q

FEV1 in restrictive lung disease

A

↓

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12
Q

FVC in obstructive lung disease

A

↓

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13
Q

FVC in restrictive lung disease

A

↓

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14
Q

FEV1/FVC in obstructive lung disease

A

↓

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15
Q

FEV1/FVC in restrictive lung disease

A

Normal or ↑ FEV1 decreased proportionately to FVC

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16
Q

Flow volume loops pg

A

655

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17
Q

Blue bloater disease

A

Chronic bronchitis

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18
Q

Pink puffer disease

A

Emphysema

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19
Q

Chronic bronchitis presentation

A
  • Wheezing
  • Crackles
  • Cyanosis (hypoxemia due to shunting)
  • Dyspnea
  • CO2 retention (respiratory acidosis)
  • 2° polycythemia
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20
Q

Pathology of chronic bronchitis

A

Hypertrophy and hyperplasia of mucus-secreting glands in bronchi → Reid index (thickness of mucosal gland layer to thickness of wall between epithelium and cartilage) > 50%

DLCO is usually normal

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21
Q

Diagnostic criteria of chronic bronchitis

A

Productive cough for > 3 months in a year for > 2 consecutive years

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22
Q

Emphysema presentation

A

Barrel-shaped chest

Exhalation through pursed lips (increases airway pressure and prevents airway collapse)

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23
Q

Pathology of emphysema

A
  • Centriacinar - associated with smoking Frequently in upper lobes (smoke rises up)
  • Panacinar - associated with α1-antitrypsin deficiency, frequently in the lower lobes
  • Enlargement of air spaces ↓ recoil, ↑ compliance, ↓ DLCO from the destruction of alveolar walls
  • Imbalance of proteases and antiproteases → ↑ elastase activity → ↑ loss of elastic fibers → ↑ lung compliance
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24
Q

Imaging of emphysema

A

CXR: ↑ AP diameter, flattened diaphragm, ↑ lung field lucency

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25
Presentation of asthma
* Cough * Wheezing * Tachypnea * Dyspnea * Hypoxemia * ↓ inspiratory/expiratory time ratio (expiratory time is increased) * Pulsus paradoxus * Mucous plugging
26
What is pulsus paradoxus
Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus.
27
Asthma triggers
* Viral * URIs * Allergens * Stress
28
Dx of asthma
* Spirometry * Methacholine challenge
29
Histology of asthma
* Hyperresponsive bronchi → reversible bronchoconstriction * Smooth muscle hypertrophy and hyperplasia * Crurschman spirals (shed epithelium forms whorled mucous plugs) * Charcot-Lyden crystals (eosinophilic hexagonal, double-pointed crystals formed from breakdown of eosinophils in sputum
30
Asthma type of reaction
Type I hypersensitivity reaction
31
What is aspirin-induced asthma
Aspirin-induced asthma is a combination of: * COX inhibition (leukotriene overproduction → airway constriction) * Chronic sinusitis * Nasal polyps * Asthma symptoms
32
List of Obstructive lung diseases
Bronchiectasis Chronic bronchitis Emphysema Asthma
33
List of restrictive lung diseases
Sarcoidosis Inhalation injury and sequelae pneumoconiosis Pulmonary fibrosis
34
Presentation of bronchiectasis
* Purulent sputum * Recurrent infections * Hemoptysis * Digital clubbing
35
Pathology of bronchiectasis
Chronic necrotizing infection of bronchi or obstruction → permanently dilated airways
36
Bronchiectasis associated risks
* Bronchial obstruction * poor ciliary motility (eg smoking, Kartagener syndrome) * Cystic fibrosis * Allergic bronchopulmonary aspergillosis
37
PFTs of restrictive lung diseases
↑ FEV1/FVC ratio Restricted lung expansion causes ↓ lung volumes (↓ FVC and TLC)
38
Breathing in restrictive lung diseases
Patients present with short shallow breaths
39
Categorical etiology of restrictive lung diseases
* Poor breathing mechanics * Interstitial lung diseases
40
Restrictive lung diseases w/ a muscular etiology
Polio Myasthenia gravis Guillain-Barre syndrome
41
Restrictive lung diseases w/ poor structural apparatus
Scoliosis Morbid obesity
42
List of restrictive lung diseases
* Pneumoconioses * Sarcoidosis * Idiopathic pulmonary fibrosis * Good pasture syndrome * Granulomatosis with polyangiitis * Pulmonary langerhans cell histiocytosis * Hypersensitivty pneumonitis Drug toxicity
43
What is hypersensitivity pneumonitis
Mixed type III/IV hypersensitivity reaction to environmental antigen
44
Symptoms of hypersensitivity pneumonitis 4 listed
* Dyspnea * Cough * Chest tightness * Headache
45
hypersensitivity pneumonitis most commonly occurs in?
Often seen in farmers and those exposed to birds
46
Reversibility of hypersensitivity pneumonitis
Reversible in early stages if stimulus is avoided
47
Histological and lab test features of sarcoidosis
* Characterized by immune-mediated, wide-spread noncaseating granulomas * Elevated serum ACE levels * elevated CD4/CD8 ratio in bronchoalveolar lavage fluid
48
Sarcoidosis most commonly occurs in?
African-American females
49
Symptoms of sarcoidosis
Often asymptomatic except for enlarged lymph nodes
50
Imaging of sarcoidosis
* CXR of bilateral hilar adenopathy and coarse reticular opacities * CT of chest better demonstrates the extensive hilar and mediastinal adenopathy
51
Sarcoidosis associations
* A facial droop is UGLIER * Bell palsy * Uveitis * Granulomas (epithelioid, containing microscopic Schaumann and asteroid bodies) * Lupus pernio (skin lesions on face resembling lupus) * Interstitial fibrosis (restrictive lung disease) * Erythema nodosum * Rheumatoid arthritis-like arthropathy * Hypercalcemia (due to ↑ 1α-hydroxylase-mediated vitamin D activation in macrophages)
52
Describe granulomas in sarcoidosis
(epithelioid, containing microscopic Schaumann and asteroid bodies)
53
Describe lupus pernio
(skin lesions on face resembling lupus)
54
What is Erythema nodosum?
* Is a type of skin inflammation that is located in a part of the fatty layer of skin * Erythema nodosum results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees. * The tender lumps, or nodules, of erythema nodosum range in size from a dime to a quarter. * Associated with sarcoidosis
55
Treatment of sarcoidosis
Steroids (if symptomatic)
56
What is inhalation injury and sequelae
Complication of smoke inhalation from fires or other noxious substances
57
Common causes of inhalation injury and sequelae
Caused by heat particulates (\< 1µm diameter) or irritants (eg NH3) → chemical tracheobronchitis, edema, pneumonia, ARDS
58
Associations of inhalation injury and sequelae
Many patients present 2° to burns and also * CO inhalation * Cyanide poisoning * Arsenic poisoning
59
Common physical exam finding in inhalation injury and sequelae
Singed nasal hairs common on exam
60
Bronchoscopy in inhalation injury and sequelae
Shows severe * Edema * Congestion of bronchus * Soot deposition
61
Pictures of inhalation injury and sequelae
658
62
Pneumoconiosis Mnemonic
Asbestos is from the roof, (was common in insulation), but affects the base (lower lobes) Silica and coal are from the base (earth), but affect the roof (upper lobes)
63
Asbestosis is associated with
Shipbuilding Roofing Plumbing
64
Histological features of asbestosis
Ivory white calcified supradiaphragmatic and pleural plaques are pathognomonic of asbestosis
65
Risks associated with asbestos
Bronchogenic carcinoma \> risk of mesothelioma ↑ risk of pleural effusions
66
In what part of the lung does asbestosis occur?
Affects lower lobes
67
Histological features of asbestosis
Asbestos (ferruginous) bodies are golden-brown fusiform rods resembling dumbbells, found in alveolar sputum sample obtained by bronchoalveolar lavage
68
Asbestos stain
Prussian blue stain
69
Berylliosis associated with
Associated with exposure to beryllium in aerospace and manufacturing industries
70
Histological features of Berylliosis
Granulomatous (noncaseating) on histology and therefore occasionally responsive to steroids
71
Berylliosis associated risks
↑ risk of cancer and cor pulmonale
72
In what part of the lung does berylliosis occur?
Affects upper lobes
73
Common causes of coal workers pneumoconiosis
Prolonged coal dust exposure → macrophages laden with carbon → inflammation and fibrosis
74
Coal workers pneumoconiosis AKA
Black lung
75
coal workers pneumoconiosis associated risks
↑ risk for Caplan syndrome (rheumatoid arthritis and pneumoconioses with intrapulmonary nodules)
76
Location of the lung affected in coal workers pneumoconiosis
Affects upper lobes
77
Imaging of coal workers pneumoconiosis
Small, rounded nodular opacities seen on imaging
78
What is anthracosis?
asymptomatic condition found in many urban dwellers exposed to sooty air
79
Silicosis is commonly caused by?
Sandblasting Foundries Mines
80
Macrophages respond to silica and release fibrogenic factors leading to fibrosis
It is thought that silica may disrupt phagolysosomes and impair macrophages, increasing susceptibility to TB ↑ risk of cancer, cor pulmonale and Caplan syndrome
81
What part of the lung does silicosis affect?
Affects upper lobes
82
Imaging of silicosis
Eggshell calcification of hilar lymph nodes on CXR
83
Silicosis mnemonic
The silly egg sandwich I found is mine Histology: Eggshell calcification of hilar lymph nodes on CXR Causes: Sandblasting, Foundries, Mines
84
Pictures of pneumoconiosis
659
85
What is mesothelioma?
Malignancy of the pleura associated with asbestosis
86
Complications of mesothelioma
May result in: hemorrhagic pleural effusion (exudative) Pleural thickening
87
Histological features of mesothelioma
Psammoma bodies seen on histology
88
How to distinguish mesothelioma vs carcinoma
Calretinin (+) in almost all mesotheliomas, (-) in most carcinomas
89
Smoking in mesothelioma
Smoking is not a risk factor
90
ARDS AKA
Acute Respiratory Distress Syndrome
91
What is ARDS
Acute respiratory distress syndrome. Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood. Infants can also have respiratory distress syndrome.
92
Pathophysiology of acute respiratory distress syndrome
Alveolar insult → release of pro-inflammatory cytokines → neutrophil recruitment, activation and release of toxic mediators (eg, reactive oxygen species, proteases, etc) → capillary endothelial damage and ↑ vessel permeability → leakage of protein-rich fluid into alveoli → formation of intra-alveolar hyaline membranes and noncardiogenic pulmonary edema (normal PCWP)
93
PCWP in Acute Respiratory Distress Syndrome
Normal intra-alveolar hyaline membranes and noncardiogenic pulmonary edema (normal PCWP)
94
Most common cause of ARDS
Sepsis
95
Common causes of ARDS
Sepsis (most common) Aspiration Pneumonia Trauma Pancreatitis
96
Dx of ARDS
A diagnosis of exclusion with the following criteria (ARDS) Abnormal CXR (bilateral lung opacities) Respiratory failure within 1 week of alveolar insult Decreased PaO2/FiO2 (ratio \< 300, hypoxemia due to ↑ intrapulmonary shunting and diffusion abnormalities) Symptoms of respiratory failure are not due to HF/fluid overload
97
Consequences of ARDS
Impaired gas exchange ↓ lung compliance Pulmonary HTN
98
Management of ARDS
Treat the underlying cause Mechanical ventilation: ↓ Tidal Volumes, ↑PEEP
99
What is PEEP?
positive end-expiratory pressure
100
Photos of ARDS
Pg 660
101
What is sleep apnea?
Repeated cessation of breathing \> 10 seconds during sleep → disrupted sleep → daytime somnolence
102
Dx of sleep apnea
Sleep study Normal PaO2 during the day
103
Sleep Apnea complications
* Hypoxia → ↑ EPO release →↑erythropoiesis * Nocturnal hypoxia → systemic/pulmonary hypertension, arrhythmias (atrial fibrillation/flutter), * Sudden death
104
What is obstructive sleep apnea?
Respiratory effort against airway obstruction
105
obstructive sleep apnea common causes
Associated with obesity, loud snoring, daytime sleepiness Caused by excess parapharyngeal tissue in adults, adenotonsillar hypertrophy in children
106
Treatment of obstructive sleep apnea
Weight loss CPAP Surgery
107
What is central sleep apnea
Impaired respiratory effort due to CNS injury/toxicity, HF, opioids
108
What causes central sleep apnea?
May be associated with Cheyne-Stokes respirations (oscillations between apnea and hypernea)
109
Treatment of central sleep apnea
Treat with positive airway pressure
110
What is obesity hypoventilation syndrome?
Obesity (BMI ≥30 Kg/m2) → hypoventilation → ↑ PaCO2 during waking hours (retention);↓ PaO2 and ↑PaCO2 during sleep
111
Pickwickian syndrome AKA
obesity hypoventilation syndrome
112
obesity hypoventilation syndrome AKA
Pickwickian syndrome
113
What is pulmonary hypertension
Pulmonary hypertension = ≥ 25 mmHg at rest
114
Consequences of pulmonary hypertension
* Arteriosclerosis * Medial hypertrophy * Intimal fibrosis of pulmonary arteries * Plexiform lesions
115
Describe the course of pulmonary hypertension
Severe respiratory distress → cyanosis and RVH → death from decompensated cor pulmonale
116
Types of Pulmonary hypertension
1. PAH 2. LHD 3. Lung disease or hypoxia 4. Chronic thromboembolic 5. Multifactorial​
117
What is PAH
Type I pulmonary hypertension: pulmonary arterial hypertension
118
Most common causes of PAH
Often idiopathic Heritable PAH can be due to an inactivating mutation in BMPR2 gene (normally inhibits vascular smooth muscle proliferation) = Poor prognosis Other causes include: drugs (amphetamines, cocaine) Connective tissue disease HIV Portal hypertension Congenital heart disease Schistosomiasis
119
Mechanism of PAH
Pulmonary vasculature endothelial dysfunction results in ↑ vasoconstrictors (eg endothelin) and ↓ vasodilators (eg NO and prostacyclins)
120
Drugs that can cause PAH
(amphetamines, cocaine)
121
Type 2 pulmonary hypertension AKA
Left heart disease
122
Type 2 pulmonary hypertension causes
Systolic/diastolic dysfunction Valvular disease
123
Type 3 pulmonary hypertension AKA
Lung diseases or hypoxia
124
Causes of Type 3 pulmonary hypertension
Destruction of lung parenchyma (eg, COPD) Lung inflammation/fibrosis (eg, interstitial lung diseases) Hypoxemic vasoconstriction (eg, obstructive sleep apnea, living in high-altitude)
125
Type 4 pulmonary hypertension AKA
Chronic thromboembolic
126
Causes of Type 4 pulmonary hypertension
Recurrent microthrombi → ↓ cross-sectional area of pulmonary vascular bed
127
Type 5 pulmonary hypertension AKA
Multifactorial pulmonary HTN
128
Causes of Type 5 pulmonary hypertension
Hematologic disorders Systemic disorders Metabolic disorders Compression of the pulmonary vasculature by a tumor
129
What is a Pleural effusion
Excess accumulation of fluid between the pleural layers → restricted lung expansion during inspiration
130
Treatment of pleural effusion
Thoracentesis to remove/reduce fluid
131
Breath sounds of pleural effusion
↓
132
Percussion in of pleural effusion
Dull
133
Fremitus in pleural effusion
↓
134
Tracheal deviation in pleural effusion
None if small Away from side of lesion if large
135
Types of pleural effusions
* Transudate * Exudate * Lymphatic
136
Describe transudate pleural effusion
↓ protein content Due to ↑ hydrostatic pressure (eg, HF) or ↓ oncotic pressure (eg, nephrotic syndrome, cirrhosis)
137
Describe exudate pleural effusion
↑ protein content Cloudy Due to; malignancy, pneumonia, collagen vascular disease, trauma (occurs in states of ↑ vascular permeability) **Must be drained** due to the risk of infection
138
Describe lymphatic pleural effusion
Due to thoracic duct injury from trauma or malignancy Milky-appearing fluid; ↑ TGs
139
lymphatic pleural effusion AKA
Chylothorax
140
Pictures of pleural effusion
662
141
What is atelectasis?
atelectasis is collapse of lung tissue with loss of volume.
142
Breath sounds in atelectasis/bronchial obstruction
↓
143
Percussion in atelectasis/bronchial obstruction
Dull
144
Fremitus in atelectasis/bronchial obstruction
↓
145
Tracheal deviation in atelectasis/bronchial obstruction
Toward the side of lesion
146
What is a pneumothorax?
pneumothorax refers to a condition in which the space between the wall of the chest cavity and the lung itself fills with air, causing all or a portion of the lung to collapse. Air usually enters this space, called the pleural space, through an injury to the chest wall or a hole in the lung.
147
Breath sounds in simple pneumothorax
↓
148
Percussion in simple pneumothorax
Hyperresonant
149
Fremitus in simple pneumothorax
↓
150
Tracheal deviation in simple pneumothorax
None
151
What is a tension pneumothorax?
Tension pneumothorax is the progressive build-up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return. Positive pressure ventilation may exacerbate this 'one-way-valve' effect.
152
Breath sounds in tension pneumothorax
↓
153
Percussion in tension pneumothorax
Hyperresonant
154
Fremitus in tension pneumothorax
↓
155
Tracheal deviation in tension pneumothorax
Away from the side of the lesion
156
What is pulmonary consolidation?
A pulmonary consolidation is a region of normally compressible lung tissue that has filled with liquid instead of air. The condition is marked by induration (swelling or hardening of normally soft tissue) of a normally aerated lung. It is considered a radiologic sign.
157
Examples of diseases where consolidation occurs
Lobar pneumonia Pulmonary edema
158
Breath sounds in consolidation (lobar pneumonia, pulmonary edema)
* Bronchial breath sounds * Late inspiratory crackles * Egophony * Whispered pectoriloquy
159
Percussion in consolidation (lobar pneumonia, pulmonary edema)
Dull
160
Fremitus in consolidation (lobar pneumonia, pulmonary edema)
↑
161
Tracheal deviation in consolidation (lobar pneumonia, pulmonary edema)
None
162
What is pneumothorax
Accumulation of air in pleural space
163
Signs of pneumothorax 6 listed
* Dyspnea * Uneven chest expansion * Chest pain * ↓ tactile fremitus * Hyperresonance * Diminshed breath sounds ALL ON THE AFFECTED SIDE
164
Types of pneumothorax
Primary spontaneous pneumothorax Secondary spontaneous pneumothorax Traumatic pneumothorax Tension pneumothorax
165
What is a primary spontaneous pneumothorax?
Due to rupture of apical subpleural bleb or cysts
166
Primary spontaneous pneumothorax occurs most commonly in?
Tall, thin, young males Smokers
167
What is a secondary spontaneous pneumothorax
Due to diseased lung (eg, bullae in emphysema, infections) Mechanical ventilation with use of high pressures → barotrauma
168
What is traumatic pneumothorax
Caused by blunt (eg, rib fracture) penetrating (eg, gunshot), or iatrogenic (eg, central line placement, lung biopsy, barotrauma due to mechanical ventilation) trauma
169
What is Tension pneumothorax
Can be caused by any form primary, secondary or traumatic Air enters the pleural space but cannot exit; Increasing trapped air → tension pneumothorax
170
Special considerations of a tension pneumothorax
* Trachea deviates away from the affected lung * Needs immediate needle decompression and chest tube placement * May lead to ↑ intrathoracic pressure →↓ venous return →↓ cardiac function
171
Pneumothorax photos
663
172
Types of pneumonia 4 listed
* Lobar pneumonia * Bronchopneumonia * Interstitial pneumonia * Cryptogenic organizing pneumonia
173
Organisms of lobar pneumonia
* S pneumoniae (most frequent) * Legionella * Kliebsella
174
Organisms of Bronchopneumonia
* S pneumoniae * S aureus * H influenzae * Kliebsella
175
Organisms of interstitial pneumonia
* Mycoplasma * Chlamydophila pneumoniae * Chlamydophila psittaci * Legionella Viruses (RSV, CMV, Influenza, adenovirus)
176
Organisms of cryptyogenic organizing pneumonia
* Etiology unknown * Secondary organizing pneumonia caused by chronic inflammatory diseases (eg, rheumatoid arthritis) or medication side effects (eg, amiodarone) * (-) sputum and blood cultures * No response to antibiotics
177
Characteristics of lobar pneumonia
Intra-alveolar exudate → consolidation and may involve the entire lobe or the whole lung
178
Characteristics of bronchopneumonia
* Acute inflammatory infiltrates from bronchioles into adjacent alveoli * Patchy distribution involving ≥ 1 lobe
179
Intersititial pneumonia AKA
Walking Pneumonia Or Atypical pneumonia
180
Walking pneumonia AKA
Interstitial pneumonia Or atypical pneumonia
181
Characteristics of interstitial pneumonia
* Diffuse patchy inflammation localized to interstitial areas at alveolar walls * Diffuse distribution involving ≥ 1 lobe * Generally follows a more indolent course ("walking" pneumonia)
182
Cryptogenic organizing Pneumonia was known as?
Formerly known as bronchiolitis obliterans organizing pneumonia (BOOP)
183
Characteristics of Cryptogenic organizing pneumonia
Formerly known as bronchiolitis obliterans organizing pneumonia (BOOP) Noninfectious pneumonia characterized by inflammation of bronchioles and surrounding structures
184
Days 1-2 of lobar pneumonia
* "Congestion" Red-purple, partial consolidation of parenchyma * Exudate mostly bacteria
185
Days 3-4 of lobar pneumonia
* "Red hepatization" Red-brown, consolidated * Exudate with fibrin, bacteria, RBCs and WBCs
186
Days 5-7 of lobar pneumonia
"Gray hepatization" Uniformly gray Exudate full of WBCs, lysed RBCs and fibrin
187
Day 8 of lobar pneumonia
"resolution" Enzymes digest components of exudate
188
Lung cancer mortality
Leading cause of cancer death
189
Lung cancer presentation
* Cough * hemoptysis * Bronchial obstruction * Wheezing * \"coin" lesion on CXR or non-calcified nodule on CT
190
Sites of metastases from lung cancer
* Adrenals * Brain * Bone (pathologic fracture) * Liver (jaundice, hepatomegaly)
191
Types of cancer metastases to the lungs
Usually, multiple lesions and are more common than primary neoplasms Most often from * Breast * Colon * Prostate * Bladder
192
Mnemonic of lung cancer complications
SPHERE * Superior vena cava/thoracic outlet syndromes * Pancoast tumor * Horner syndrome * Endocrine (paraneoplastic) * Recurrent laryngeal nerve compression (hoarseness) * Effusions (pleural or pericardial)
193
Risk factors for lung cancer FHx
* Smoking/second hand smoke * Radon * Asbestos * Family history
194
Mnemonic of lung cancer location and cause
**S**quamous and **S**mall cell carcinomas are **S**entral (central) and often caused by **S**moking
195
Common location of small cell carcinoma
Central
196
Common location of adenocarcinoma
Peripheral
197
Common location of squamous cell carcinoma
Central
198
Common location of large cell carcinoma
Peripheral
199
Common location of Bronchial carcinoid tumor
Central or Peripheral
200
Characteristics of small cell carcinoma
* Undifferentiated → very aggressive * May produce ACTH (Cushing Syndrome), * SIADH * Antibodies against presynaptic Ca channels (Lambert-Eaton myasthenic syndrome) * or neurons (paraneoplastic myelitis, encephalitis, subacute cerebellar degeneration ## Footnote **Amplification of MYC oncogenes common**
201
Management of small cell carcinoma
Chemotherapy +/- radiation
202
Histology of small cell carcinoma
Neoplasm of endocrine Kulchitsky cells → small dark blue cells
203
Characteristics of Adenocarcinoma
Most common 1° lung cancer More common in women than men * Most common lung cancer to arise in non-smokers * Associated with hypertrophic osteoarthropathy (clubbing) * Bronchioloalveolar subtype (adenocarcinoma in situ) * Bronchial carcinoid and bronchioalveolar cell carcinoma have a lesser association with smoking
204
Histological features of Adenocarcinoma
* Glandular pattern on histology * often stains (+) mucin * Bronchioalveolar subtype grows along alveolar septa → apparent "thickening" of alveolar walls tall columnar cells containing mucus
205
Characteristics of squamous cell carcinoma
* Hilar mass arising from the bronchus * Cavitation * Cigarettes * Hypercalcemia (produces PTHrP)
206
Histological features of squamous cell carcinoma
Keratin pearls and intercellular bridges
207
Characteristics of large cell carcinoma
* Highly anaplastic undifferentiated tumor; * Less responsive to chemotherapy; * remove surgically * Strong association with smoking
208
Histological features of large cell carcinoma
Pleomorphic giant cells
209
Characteristics of bronchial carcinoid tumor
* Excellent prognosis * Metastasis rare * Symptoms due to mass effect or carcinoid syndrome (flushing, diarrhea, wheezing)
210
Histological features of bronchial carcinoid tumor
* Nests of neuroendocrine cells * Chromogranin A (+)
211
Photos of lung cancers
665
212
What is a lung abscess?
A localized collection of pus within parenchyma
213
Treatment of lung abscess
Antibiotics
214
Imaging of lung abscess
* Air-fluid levels often seen on CXR * Fluid levels common in cavities * Presence suggests cavitation due to anaerobes (eg, Bacteroides, Fusobacterium, Peptostreptococcus) or S aureus * Lung abscess 2° to aspiration is most often found in right lung * Location depends on patients position during aspiration
215
Pancoast tumor AKA
Superior sulcus tumor
216
Superior sulcus tumor AKA
Pancoast tumor
217
What is Pancoast tumor?
Carcinoma that occurs in the apex of the lung may cause Pancoast syndrome by invading cervical sympathetic chain
218
Pancoast tumor symptoms
Compression of locoregional structures may cause array of findings * Recurrent laryngeal nerve → hoarseness * Stellate ganglion → Horner syndrome (ipsilateral ptosis, miosis, anhidrosis) * Superior Vena Cava → SVC syndrome * Brachiocephalic vein → brachiocephalic syndrome Brachial plexus → sensorimotor deficits
219
What is Superior Vena Cava syndrome?
An obstruction of the SVC that impairs blood drainage from the head ("facial plethora"; note blanching after fingertipp pressure in neck (jugular venous distension) and upper extremities (edema)
220
Common causes of Superior Vena Cava Syndrome
* Malignancy (eg, mediastinal mass, Pancoast tumor) * Thrombosis from indwelling catheters
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Treatment of Superior Vena Cava Syndrome
* Medical emergency * Can raise intracranial pressure (if obstruction is severe) → headaches, dizziness, ↑ risk of aneurysm/rupture of intracranial arteries
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Picture of SVC syndrome
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List of 1st-gen histamine-1 blockers
Names contain "-en/-ine or "-en/-ate" * Diphenhydramine * Dimenhydrinate * Chlorpheniramine
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List of 2nd-gen histamine-1 blockers
Names usually end in "-adine" * Loratadine * Fexofenadine * Desloratadine * Cetrizine
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Clinical uses of 1st-gen histamine-1 blockers
* Allergy * Motion sickness * Sleep aid
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Clinical uses of 2nd-gen histamine-1 blockers
allergy
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Adverse effects of 1st-gen histamine-1 blockers
* Sedation * Antimuscarinic * Anti-α-adrenergic
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Adverse effects of 2nd-gen histamine-1 blockers
Far less sedating than 1st generation because of ↓ entry into CNS
229
What is Guaifenesin
* Expectorant * thins respiratory secretions * Does not suppress cough reflex
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What is N-acetylcysteine
**Mucolytic** * liquifies mucus in chronic bronchopulmonary diseases (COPD, CF) by disrupting disulfide bonds * Also, used as an antidote for acetaminophen overdose
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What is Dextromethorphan?
Antitussive (antagonizes NMDA glutamate receptors) * Synthetic codeine analog * Has mild opiod effect when used in excess * Naloxone can be given for OD * Mild abuse potential * May cause serotonin syndrome if combined with other serotonergics
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Pseudoephedrine MOA
α-adrenergic agonist
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Phenylephrine MOA
α-adrenergic agonist
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Clinical uses of Pseudoephedrine
* Used as nasal decongestants * Reduce hyperemia, edema, nasal congestion * Open obstructed eustachian tubes
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Adverse effects of Pseudoephedrine
* HTN * Rebound congestion if used for more than 4-6 days * Can also cause CNS stimulation/anxiety
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Clinical uses of Phenylephrine
* Used as nasal decongestants * Reduce hyperemia, edema, nasal congestion * Open obstructed eustachian tubes
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Adverse effects of Phenylephrine
* HTN * Rebound congestion if used for more than 4-6 days
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pHTN AKA
Pulmonary hypertension
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List of drug classes to treat pHTN
* Endothelin receptor antagonists * PDE-5 inhibitors * Prostacyclin analogs
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Endothelin receptor antagonists MOA
Competitively antagonizes endothelin-1 receptors (ETA and ETB) → ↓pulmonary vascular resistance
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Considerations of Endothelin receptor antagonists
Monitor LFTs
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Examples of Endothelin receptor antagonists
Bosentan
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PDE-5 inhibitors MOA
Inhibits PDE-5 → ↑cGMP → prolonged vasodilatory effect of NO
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Considerations of PDE-5 inhibitors
Also used to treat erectile dysfunction
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PDE-5 inhibitors are contraindicated with
Taking nitroglycerin or other nitrates
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Examples of PDE-5 inhibitors
Sildenafil
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What is PGI2
Prostacyclin
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Prostacyclin analogs MOA
PGI2 (prostacyclin) with direct vasodilatory effects on pulmonary and systemic arterial vascular beds Inhibits platelet aggregation
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Side effects of Prostacyclin analogs
Flushing Jaw pain
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Examples of Prostacyclin analogs
* Epoprostenol * Iloprost
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Asthma drugs target what systems in the body
Bronchoconstriction is mediated by 1. inflammatory processes 2. parasympathetic tone Therapy targets these 2 pathways
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Examples of β2-agonists 3 listed
* Albuterol * Salmeterol * Formoterol
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Albuterol mechanism
Relaxes bronchial smooth muscle (short acting β2-agonist)
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Albuterol clinical uses
Used during acute exacerbations of asthma
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Salmeterol mechanism
Long-acting agents for prophylaxis
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Adverse effects of Salmeterol
* Tremor * Arrhythmia
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Formoterol mechanism
Long-acting agents for prophylaxis
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Adverse effects of Formoterol
* Tremor * Arrhythmia
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List some inhaled corticosteroids
* Fluticasone * Budesonide
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Fluticasone MOA
* Inhibit the synthesis of virtually all cytokines * Inactivate NF-κB, the transcription factor that induces the production of TNF-α and other inflammatory agents
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Clinical uses of Fluticasone
1st line therapy for chronic asthma
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Special considerations when using Fluticasone
Use a spacer or rinse mouth after use to prevent oral thrush
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Budesonide MOA
* Inhibit the synthesis of virtually all cytokines * Inactivate NF-κB, the transcription factor that induces the production of TNF-α and other inflammatory agents
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Clinical uses of Budesonide
1st line therapy for chronic asthma
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Special considerations when using Budesonide
Use a spacer or rinse mouth after use to prevent oral thrush
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List prototypes of muscarinic antagonists for treating asthma 2 listed
* Tiotropium * Ipratropium
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Tiotropium MOA
Completely block muscarinic receptors preventing bronchoconstriction
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Clinical uses of Tiotropium
* Asthma * COPD
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Duration of action of Tiotropium
Long-acting
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Ipratropium MOA
Completely block muscarinic receptors preventing bronchoconstriction
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Clinical uses of Ipratropium
Asthma COPD
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Classes of drugs used to treat asthma 8 listed
* β2-agonists * Inhaled corticosteroids * Muscarinic antagonists * Antileukotrienes * Anti-IgE monoclonal therapy * Methylxanthines * Mast cell stabilizers * Methacholine (challenge?)
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List prototypes of Antileukotrienes 3 listed
* Montelukast * Zafirlukast * Zileuton
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Montelukast MOA
Block leukotriene receptors (CysLTI1)
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Montelukast Clinical uses
Especially good for aspirin-induced and exercise-induced asthma
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Zileuton MOA
* 5-lipoxygenase pathway inhibitor * Blocks conversion of arachidonic acid to leukotrienes
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Zileuton adverse effects
Hepatotoxic
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Zafirlukast MOA
Block leukotriene receptors (CysLTI1)
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Zafirlukast clinical uses
Especially good for aspirin-induced and exercise induced asthma
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List prototypes of Anti-IgE monoclonal therapy
Omalizmab
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Omalizmab drug class
Anti-IgE monoclonal therapy
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Omalizumab MOA
Binds mostly to unbound serum IgE and blocks binding to FeεRI
283
Clinical uses of Omalizumab
Used in allergic asthma with ↑IgE levels resistant to inhaled steroids or long-acting β2-agonists
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List prototypes of Methylxanthines
Theophylline
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Theophylline drug class
Methylxanthines
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Theophylline MOA
Likely causes bronchodilation by inhibiting phophodiesterase → ↑ cAMP levels due to ↓ cAMP hydrolysis
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Special considerations of Theophylline
* Usage is limited because of the narrow therapeutic index * Metabolized by CYP-450 * Blocks actions of adenosine
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Theophylline adverse effects
Usage is limited because of narrow therapeutic index Cardiotoxicity Neurotoxicity
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List prototypes of mast cell stabilizers
* Cromolyn * Nedocromil
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Cromolyn MOA
Prevent release of inflammatory mediators from mast cells
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Cromolyn clinical uses
Used for prevention of bronchospasm not for acute bronchodilation
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Nedocromil MOA
Prevent release of inflammatory mediators from mast cells
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Nedocromil clinical uses
Used for prevention of bronchospasm not for acute bronchodilation
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Pathways on
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Methacholine MOA
Nonselective muscarinic receptor (M3) agonist
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Metacholine Clinical uses
Used in bronchial challenge (methacholine challenge) test to help diagnose asthma
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DLCO in emphysema
decreased
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DLCO in asthma
DLCO normal or ↑
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What is ARDS
Acute respiratory distress syndrome (ARDS) is a rapidly progressive disease occurring in critically ill patients. The main complication in ARDS is that fluid leaks into the lungs making breathing difficult or impossible
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Histological markers of small cell carcinoma
Chromogranin A (+) Neuron-specific enolase (+) Synaptophysin (+)
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Adenocarcinoma prevalence
* Most common 1° lung cancer * More common in women than men * Most common lung cancer to arise in non-smokers
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DLCO in chronic bronchitis
DLCO is usually normal
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Lung cancers with strong association with smoking
* Large cell carcinoma
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Prognosis of large cell carcinoma
poor prognosis
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large cell carcinoma association with smoking
strong association with smoking
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prognosis of bronchial carcinoid tumor
* Excellent prognosis * metastasis rare
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Causes of lung abscess
Caused by aspiration of oropharyngeal contents (especially in patients predisposed to loss of consciousness [eg, alcoholics, epileptics]) or bronchial obstruction (eg, Cancer)
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What is Pancoast Syndrome?
typically results when a malignant neoplasm of the superior sulcus of the lung (lung cancer) leads to destructive lesions of the thoracic inlet and involvement of the brachial plexus and cervical sympathetic nerves (stellate ganglion)
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Causes of central sleep apnea
* CNS injury/toxicity * HF * opioids
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Findings in inhalation injury and sequelae
* chemical tracheobronchitis * edema * pneumonia * ARDS
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Mutations of adenocarcinoma
Activating mutations include KRAS, EGFR, and ALK
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Most common lung cancer to arise in non-smokers
Adenocarcinoma
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Adenocarcinoma CXR
hazy infiltrates similar to pneumonia; better prognosis
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Small cell carcinoma activating mutations
Amplification of MYC oncogenes common
CVPR
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