Obstructive Lung Dz - University of Kentucky



Obstructive Lung Dz

(COPD)

| +Dec. FEV1/FVC

+Obstruction of air flow

(air trapped in lungs |1. Chronic Bronchitis

2. Emphysema |3. Asthma

4. Bronchiectasis | | |

|Chronic Bronchitis |=productive cough > 3 consecutive months in |--hypertorphy of mucus-secreting glands in |--recurrent infections perpetuate dz( acute |*Reid index= |

|“Blue bloater” |two+ years |bronchioles (*Reid index >50%) |exacerbations: H.inf, S. viridians, S. |thickness of gland layer |

| |Clinical: wheezing, crackles, cyanosis, |--mcc= smoking |pneumo |thickness of bronchial wall |

| |rhonchi, cor pulmonale, resp failure |chronic irritation: |--mucus plugging, inflamm, edema, fibrosis, | |

| | |air pollution, etc. |sm. muscle atrophy | |

|Emphysema |Clinical: barrel chest d/t hyperinflation, |--caused by smoking, (centriacinar) & α1 |Centrilobular—central, proximal lobule; |Paraseptal—distal acinus (alveoli), |

|“pink puffer” |cor pulmonale, pursed lips, (breath sounds, |anti-trypsin defic (panacinar & liver |upper lobes |pleura, septae, lobule edge, spontaneous|

| |(TF, dyspnea, tachycardia, (I/E ratio, |cirrhosis)( |Inflamm: bronchi, bronchioles, alveolar |PTX, confluent air spaces |

| |hyperresonance |(elastase activity, (anti-elastase activ OR ( |ducts (distal alv NOT involved) |Irregular—d/t scarring |

| |--enlargement of air spaces and (recoil from|cilia d/t smoke( alveolar mucus plugging( |Panacinar—uniform, enlargement of lobules, |Bullous—lg, peripheral “balloons” PTX |

| |destruction of alveolar walls |overinflation( vessel damage/ischemia( |bronhioles, distal alveoli; lower lobes, α1 |Interstitial—alveolar tear( air into CT |

| | |destruction |anti-trypsin deficiency |stroma |

|Asthma |Clinical: Cough, wheezing, dyspnea, |Extrinsic: atopy, typeI hypersensitivity |Intrinsic: often follows viral nfection, |Hyperinflated lungs w/ mucus plugs |

| |tachypnea, hypoxemia, ( I/E ratio, pulsus |(IgE-mediated), airway narrowing + |no family hx, no (IgE |(Curschmann’s spirals |

| |paradoxus |(permeability |Aspirin Asthma: ( CT production, nasal |Charcot-Leyden crystals), eos, edema, |

| | |histamine,LTC4D4E4, PGD2 |polyps, rhinitis, sinusitis |submucosal gland/ bronchial wall muscle |

| | |reversible bronchoconst |bronchoconstriction |hypertrophy |

|Bronchiectasis |Clinical: purulent, foul-smelling sputum, |Chronic necrotizing infection of bronchi( |Ass’d w/ | |

| |fever, recurrent infections, hemoptysis |permanently dilated airways |-bronchial obstruction |**see Kartagener’s synd below |

| |clubbing, pneumonia |Infection further weakens walls |( atelectasis, sm. muscle relaxation | |

| | | |-CF | |

| | | |-poor ciliary motility** | |

|Restrictive Lung Dz |Restricted lung expansion causes ( lung | |1. Extrapulmonary: |Complic of 2b: cor pulmonale. Can be |

| |volumes ((VC, (TLC) |6. Pulmonary alveolar proteinosis |(poor breathing mech) |seen in diffuse interstitial pulm |

| |(( lung compliance) |7. Idiopathic pulmonary fibrosis |a. poor muscular effort: polio, MG |fibrosis, bleomycin toxicity. Sx’s |

| |1. ARDS |8. Desquamative interstitial pneumonitis |b. poor apparatus: scoliosis |include gradual progressive dyspnea, |

| |2. Pneumoconiosis |9. Pulmonary eosinophilia |2. Pulmonary: |cough |

| |3. Hypersensitivity pneumonitis |10. Sarcoidosis |(poor lung expansion) | |

| |4. Goodpasture’s syndrome |11. Pulmonary Dz w/ collagen vascular d/o’s |a. defective alveolar filling: pneumonia, | |

| |5. Idiopathic pulmonary hemosiderosis | |ARDS, pulm edema | |

| | | |b. interstitial fibrosis: (recoil (CL | |

|Pulmonary flow |Resistance |FVC |FEV1 |(FEV1/FVC) x 100 |

|volume loops | | | | |

|Normal |-- |-- |-- |>80% |

|Restrictive |( |( |( |>80% |

|Obstructive |( |( |(( |50% of cases |Cytokines: m(( IL-1, TNF |

| |alveolar damage (shock, trauma, sepsis, |Coagulation(Hyaline membs (fibrin, cell | |AA metabolites (LT’s, PG’s)( |

| |aspiration) |fragmts) form in alveoli | |chemoattractants (LTB4) |

|Neonatal RDS |Surfactant defic.( ( surface tension( |Surfactant made by type II pneumocytes after |Lecithin: sphingomyelin ratio in amniotic |RF: preterm,C-section,mom w/DM |

|(hyaline memb dz) |alveolar collapse |35th wk gestation |fluid (measure of lung maturity) 1 lobe) |interstitial space, > 1 lobe |3. Gray hepatization fibrin, (pmn, rbc, |

| |may involve entire lung |--PMN infiltrate fr. bronchioles into alveoli |--no alveolar exudate, dry cough, ( cold |wbc |

| |--red followed by grey hepatization | |agglutins |4. Resolution: |

| | | | |resorbed, expectorated |

| | | | |Complic’s if organizes. |

|Pneumonia in immunocompromised|CMV: interstitial |Fungi: P. carinii (see infections) |Other bacteria: |**Pneumonia in diabetics or alcoholics |

| |Large cells, acidophilic inclusions |Cryptococcus, Aspergillus |S. pneumo, S. aureus |( think Klebsiella |

| | | | |“currant jelly sputum” |

|Pancoast’s tumor |Carcinoma that occurs in apex of lung |May affect cervical sympathetic plexus( |Horner’s: ptosis, miosis, anhidrosis |Ulnar nerve pain |

| | |Horner’s syndrome | | |

|Congenital Anomalies |Pulm. Cysts: (1)Bronchogenic: |Pulmonary Atresia( |Pulmonary Sequestrations: |Lobar over-inflation: |

| |--central, near airways |not compatible w/ life |extrapulmonary lung tissue, systemic blood |Bronchial obstruction (d/t cartilage |

| |--may or not connect | |supply |hypoplasia) |

| |2. Pumonary |Pulmonary Hypoplasia( | | |

| |--multiple, peripheral; don’t connect to |Incomplete dev of lobe or entire lung | | |

| |bronchi; infection, hemoptysis, rupture | | | |

|Infections |P. carinii (PCP)--fungal |Pulmonary Abscess |Legionella infection |Diphtheria (C. diphtheria) |

| |AIDS, cancer, fever, malnourished, dyspnea, |-inflamm w/ central liquefaction necrosis |1. Pontiac fever( mild, febrile illness |and Whooping cough |

| |hypoxia, bilateral infiltrate, beefy lung, |Strep, S. aureus, Gm—rods, oral anaerobes |2. Legionnaire’s Dz: severe (broncho) |(B. pertussis) |

| |silver stain |-Cough w/ foul-smelling purulent/bloody sputum|pneumonia, pulse-temp diss’n ((T w/ no |--toxin mediated URI +/_ LRI |

| | |-wt. loss, clubbing, air/fluid level on CXR |change in pulse), mononuclear infiltrate | |

| | | | |Diphtheria toxin( epithelial necrosis( |

| | | | |pseudomembrane |

|Tuberculosis |Primary TB |Secondary TB |Late Pulmonary TB |Miliary |

|Mycobacteria (M.tb) |Caseous LN’s, mid-lung infection, Ghon |Apical reactivation (vs reinfection) |Erosion into airways(multiple cavitary |--widely disseminated via blood. Sites: |

| |complex( calcified lesions |Granulomas w/ caseous infection |lesions |renal cortex, LN, GIT, peritoneum, BM, |

|Isolated TB |Granulomas( caseous necrosis |Fibrocalcific scars |Dissemination via lymph or blood |adrenal…. |

|-M. tb left in 1 organ: | | | |--caseous granulomas |

|scrofula (LN), Pott’s Dz | | | | |

|(vertebrae), tuberculous | | | | |

|meningitis | | | | |

|Pneumoconioses— |1. CWP (coal worker’s) |2. Anthracosis |3. Silicosis: |( CA risk with these 2 |

|restrictive |--blackened sputum |--carbon particles |--mining, glass prod, farming, road |4. Asbestosis (see above) |

| |a. Asx anthracosis |--urban dwellers, smokers, miners |construction |5. Berylliosis: |

| |b. simple: coal macules(calcify |--if isolated(not symptomatic |--( risk TB |--electronic, ceramic, aerospace, |

| |may be Asx |--peribronchiole m( |--m((FGF( fibrotic silicotic nodules( |nuclear industries |

| |c. complicated: progressive massive fibrosis| |“eggshell” lesions on CXR when calcified in |--Type IV hypersensitivity |

| |( cor pulmonale | |LN |noncaseating granulomas |

|Interstitial Restrictive Lung |Goodpasteur’s Synd |Idiopathic Pulm. Hemosiderosis |Pulmonary Alveolar Proteinosis |Idiopathic Pulm Fibrosis = |

|Dz |Glomerulonephritis: crescent, hematuria |Cough, dyspnea, wt loss, pulm infiltrates |PAS + material in alveoli (lamellar bodies, |Usual Interstitial Pneumonitis |

| |Pneumonia: hemoptysis (hemorrhagic |--younger ages, chronic, remittent |refractile crystals), gelatinous, can become|Alveolar wall damage(imm. complx’s, |

| |pneumonitis) |--red-brown consolidation, hemosiderin m(, |fibrotic |edema, fibroblasts, |

| |IF( linear IgG in lung/renal BM |variable fibrosis | |( type II pneumocytes, |

| | | | |end stage: honeycomb lung |

|Interstitial Restrictive Lung |Pulmonary Eosinophilia |Sarcoidosis |Desquamative Interstitial Pneumonitis =DIP |Hypersensitivity Pneumonitis |

|Dz |1. Simple (Loffler’s): dyspnea (PFT evid: |Multisystem: lung, skin, eye, liver, spleen |Lower lobe ground-glass infiltrate |Immune response, alveoli (( airway) |

|(cont) |restrict’n + obstruct’n) |Young, women, blacks |Monos in alveoli (90% m(( PAS+ w/ lamellar |--nodular, diffuse infiltrates |

| |eos infiltrate, Type I hypersens |Non-caseating granulomas |bodies) |--Type III hypersensitivity |

| |2. Chronic: hi fever, night sweats, |( TH (CD4+) in lung |Better steroid response than UIP/IPF |Farmer’s lung: actinomyces |

| |consolidation (eos/lymphs) |80% hilar/mediastinal LAD | |Byssinosis: cotton, linen, hemp |

| | |Schaumann bodies (Ca2+, prot) | | |

| | |Asteroid bodies (stars w/ giant cells) | | |

|Restrictive Pulm. Dz w/ |Scleroderma |4. Wegener’s Granulomatosis |5. Lymphomatoid Granulomatosis | |

|Collagen Vascular D/O’s |SLE |acute, necrotizing vasculitis in lung, kidney,|pleomorphic cell infiltrate( | |

| |RA |URT (sinuses) **C-ANCA |destroy tissue (B cell lymphoma) | |

|Vascular D/O’s | Pulmonary Edema | 1o pulmonary HTN |2o pulm. HTN |Pulmonary Embolus |

| |Usu (Pc interstium(alveoli |Etiology unclear: multiple small emboli, |Etiology: know dz( (pulm b.f. (ASD,VSD, PDA,|Common, venous stasis (bed rest, CHF, 1o|

| |Cardiogenic: LVF, MS |neurohormonal vasc. hyperrxn, imm cmplx dz, |Eisenmenger’s), hypoxic vasoconstriction, ( |venous dz), m/c = DVT |

| |Noncardiogenic: septic shock, pancreatitis, |diet/meds |L heart pressure, pulmonary vessel |RF: obesity, CA, pregnancy, OC’s, |

| |burns, toxin inhalat’n, O2 tox, narcotic OD,|Medium art’s: medial hypertrophy, intimal |destruction |hypercoagulabilty, mutiple fx’s, prior |

| |pneumonia, organic solvents |thickens, ( elastic memb |Artery changes similar to 1o; also organized|DVT |

| | |Small a’s: medial thickening |thrombi, atherosclerosis |Bed-ridden pt dev’s SOB( think PE, do |

| | |Plexiform lesions | |V/Q scan. |

| | | | |Wedge-shaped, red infarct, scar fibinous|

| | | | |exudate on apposed pleura |

|Lung Tumors |Hamartomas: m/c benign |Bronchial Adenoma: mucous gland |Hemangioma: peripheral, subpleural |Chondroma: bronchial cartilage |

|(most mets, m/c 10 = |--Mesenchymal neoplasm |Leiomyoma: smooth muscle, endobronchial |Lipoma: endobronchial |Endometriosis: mets or pleuripotential |

|bronchogenic) |--calcification( popcorn cells | |Teratoma |pulm tissue |

|Mediastinal Masses |Anterior mediastinum |Middle Mediastinum |Posterior Mediastinum | |

| |--thymoma |--cysts: pericardial, bronchogenic, enteric |Neurogenic tumors: | |

| |--teratoma |--lymphoma |Schwannoma, neurofibroma, ganglioneuroma, | |

| |--lymphoma: nodular sclerosis HD |--carcinoma |ganglioneuroblastoma, neuroblastoma | |

| |--cysts |--granuloma | | |

| |--intrathoracic goiter | | | |

|Dz’s of Pleura |Pleural Effusions | |PTX |Pleural Tumors |

| |1. Transudates (non-inflamm) |2. Exudates (inflamm) |Air or gas in pleural cavity( collapse of |1. mets (usu breast/lung) |

| |a. Hydrothorax: transudate in pleural cavity|a. Serofibrious pleuritis |underlying lung (atelectasis) |2. malignant mesothelioma |

| |--Meig’s synd: ovarian CA, ascites, pleural |b. Suppurative pleuritis = empyema |--traumatic |--rare tumor arising from parietal or |

| |effusion |bact/fungal (purulent exudate) |--tension (tracheal deviation) |visceral pleura, ass’d w/ asbestos |

| |b. Hemothorax: blood in pl. space |c. hemorrhagic pleuritis | |exposure (long latency) smoking ( ( risk|

|Laryngeal Dz |Benign Laryngeal Neoplasm |Malignant Neoplasms |Congenital anomalies | |

| |1. polyps: loose CT w/ squamous epithelium |Squamous cell carcinoma |Laryngeal stenosis, atrresia | |

| |(smoking/ overuse) |Dyshagia, hoarseness, pain, hemoptysis |Require tracheostomy | |

| |2. papilloma: friable, on true cords, |RF: smoking, EtOH, frequent irritation |Cardiac/ renal defects, too | |

| |ulcerate + bleed | | | |

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