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Respiratory pathology, pulmonary hypertension, pneumoconioses, acute…
Respiratory pathology
pulmonary hypertension
left heart disease
multifactorial
chronic thromboembolic
normal mean artery pressure =10~14 mmHg; HTN≧25 mmHg; result in arteriosclerosis, medial hypertrophy, intimal fibrosis of PA, plexiform lesion; cyanosis, RVH, death from decompensated cor pulmonale
pulmonary arterial hypertension
other causes: drugs, connective tissue disease, HIV infection, portal hypertension, congenital heart disease, schistosomiasis
endthelial dysfunction→↑vasoconstrictors, ↓vasodilators
often idiopathic; heritable PAH mutation in BMPR2 gene
lung disease or hypoxia
pneumoconioses
mesothelioma
hemorrhagic pleural effusion, pleural thickening
psammoma bodies
malignancy of pleura associated with asbestosis
calretinin + in almost all
berylliosis
granulomatous
upper lobe
exposure to beryllium in aerospace and manufacturing industries; ↑risk of cancer and cor pulmonale
coal worker's pneumoconiosis
small, rounded nodular opacities
anthracosis: asymptomatic condition found in many urban dwellers exposed to sooty air
macrophage laden with carbon→inflammation and fibrosis; black lung disease; ↑risk of Caplan disease(rheumatoid arthritis and pneumoconioses); upper lobes
asbestosis(石綿肺)
ivory white calcified, supradiaphragmatic and pleural plaques
golden-brown fusiform(紡錘状) rods resembling dumbbells
shipbuilding, roofing, plumbing; risk of bronchogenic carcinoma>mesothelioma(中皮腫); lower lobe
silicosis(珪肺症)
calcification of hilar lymph nodes
sandblasting, foundries, mines; fibrosis; ↑susceptibility of TB; risk of cancer, cor pulmonale, Caplan syndrome
acute respiratory distress syndrome
diagnosis
bilateral lung opacities; respiratory failure within 1 week of alveolar insult; decreased Pao₂/Fio₂ (<300); symptoms of respiratory failure are not due to HF/fluid overload
treatment
treat underlying cause and mechanical ventilation
pathophysiology
alveolar insult→release of pro-inflammatory cytokines→neutrophil recruitment, activation, release of toxic mediators→capillary endothelial damage and ↑vessel permeability→leakage of protein-rich fluid into alveoli→formation of intra-alveolar hyaline membrane and noncardiogenic pulmonary edema
loss of surfactant also contribute to alveolar collapse
causes
sepsis, aspiration, pneumonia, trauma, pancreatitis
consequence
impaired gas change; ↓lung compliance; pulmonary hypertension
lung physical finding
simple pneumothorax(単純気胸)
breath sounds↓; percussion is hyperresonant; fremitus↓; no tracheal deviation
consolidation (lobar pneumonia, pulmonary edema)
breath sounds(bronchial breath sounds; late inspiratory crackles, egophony(山羊音), whispered pectoriloquy); percussion is dull; fremitus↑; no tracheal deviation
tension pneumothorax
breath sounds↓; percussion is hyperresonantl; fremitus↓; tracheal deviation away from side of lesion
pleural effusion
breath sounds↓; percussion is dull; fremitus↓; no tracheal deviation
atelectasis(無気肺)
breath sounds↓; percussion is dull; fremitus↓; tracheal deviation toward side of lesion
pneumothorax
secondary spontaneous pneumothorax
due to diseased lung, mechanical ventilation with high pressure
tension pneumothorax
air enters pleural space but cannot exit; increased trapped air→tension pneumothorax; trachea deviates away from affected ling
traumatic pneumothorax
blunt, penetrating, iatrogenic trauma
primary spontaneous pneumothorax
due to rupture of apical subpleural bleb or cysts; tall, thin, young male and smokers
accumulation of air in pleural space; fyspnea, uneven chest expansion, pain, ↓tactile fremitus, hyperresonance, diminished breath sound
pneumonia
natural history of lobar pneumonia
red hepatization (day3-4): red-brown consolidated; exudate with fibrin, bacteria, RBC, WBC
gray hepatization (day5-7): gray; exudate full of WBC, lysed RBC and fibrin
congestion (day1-2): red-purple, partial consolidation of parenchyma; exudate with mostly bacteria
resolution (day8+): enzyme digest component of exudate
bronchopneumonia
S.pneumoniae, S.aureus, H.influenzae, Klebsiella
acute inflammatory infiltrates from bronchioles into adjacent alveoli; patchy distribution involving≧ 1 lobe
cryptogenic organizing pneumonia(特発性器質化肺炎)
noninfectious pneumonia; bronchiolitis obliterans organizing pneumonia
etiology unknown; due to chronic inflammatory disease or medication side effects; - sputum and blood cultures, no response to antibiotics
interstitial pneumonia
diffuse patchy inflammation involving ≧1 lobe
Mycoplasma, Chlamydophila pneumoniae, Clamydophila psittaci, Legionella, virus
lobar pneumonia
S.pneumoniae (most common), Legionella Klebsiella
intra-alveolar exudate→consolidation; involve entire lobe or whole lung
lung cancer
etiology
leading cause of cancer death
cough, hemoptysis, bronchial obstruction, wheezing, pneumonic coin lesion
metastases: to adrenal, brain, bone, liver; from breast, colon, prostate, bladder cancer
complication: cuperior vena cava/thoracic outlet syndrome; pancoast tumor, horner syndrome, endocrine, recurrent laryngeal nerve compression, effusion
risk factors: smoking, secondhand smoke, radon, asbestos, family history
type
squamous cell carcinoma
keratin pearls and intercellular bridge
central; Hilar mass arising from bronchus; cavitation; cigarettes; hypercalcemia (produce PYHrP)
bronchial carcinoid tumor
mass effect and carcinoid syndrome
nests of neuroendocrine cells; chromogranin A+
central or peripheral; excellent prognosis; rare metastasis
adenocarcinoma
glandular pattern on histology, often stain mucin+
bronchioloalveolar subtypes: hazy infiltrates similar to pneumonia; apparent thickning of alveolar walls; tall, columnar cell containing mucus
peripheral; most common; women; non-smokers; mutation in KRAS, EGFR, ALK; associated with hypertrophic osteoarthropathy
large cell carcinoma
pleomorphic giant cells
peripheral; anaplastic undifferentiated tumor; poor prognosis; less responsive to chemotherapy; association with amoking
small cell carcinoma
may produce ACTH, SIADH, antibody against presynaptic Ca²⁺ channels or neurons
amplification of myc oncogenes common
central; very aggressive
Kulchitsky cells→small dark blue cells; chromogranin A+; neuron-specific enolase+; synaptophysin +
lung abscess
caused by aspiration of oropharyngeal contents or bronchial obstruction
treatment: antibiotics
localized collection of pus within parenchyma
air-fluid on CXR; due to anaerobes or S.aureus; often find in right lung
SVC syndrome
juglar venous distention, edema, headache, dizziness, ↑risk of aneurysm/rupture of intracranial artery
by malignancy and thrombosis from indwelling catheters
obstruction of SVC→impaired blood drainage from head, neck and upper extremities
Pancoast tumor
recurrent laryngeal nerve→hoarseness; stellate ganglion→Horner syndrome; superior vene cava→SVC syndrome; branchiocephalic vein→branchiocephalic syndrome; branchial plexus→sensorimotor deficit
apex of lung; Pancoast syndrome by invading cervical sympathetic chain
sarcoidosis
associated with Bell palsy, uveitis, granulomas, lupus pernio(暗紫色の皮膚病変); interstitial fibrosis, erythema nodosum, rheumatoid arthritis-like arthropathy, hypercalcemia
treat with steroids
immune-mediated, widespread noncaseating granulomas, ↑ACE, ↑ CD4+/CD8+
bilateral adenopathy, coarse reticular opacities; extensive hilar and mediastinal adenopathy
sleep apnea(睡眠時無呼吸)
obstructive sleep apnea
associated with obesity, loud snoring, daytime sleepiness; excess parapharyngeal tissue in adults; adenotonsillar hypertrophy in adults
treatment: weight loss, CPAP, surgery
airway obstruction
central sleep apnea
Cheyne-Strokes respiration (oscillations between apne and hyperpnea)
treatment: positive airway pressure
due to CNS injury/toxicity, HF, opioids
obesity hypoventilation syndrome
↓Pao₂ and ↑Paco₂
BMI≧30kg/m²→hypoventilation
repeated cessation of breathing >10 seconds→disrupted sleep and daytime somnolence(傾眠); nocturnal hypoxia→HTN, arrhythmias; hypoxia→↑erythropoiesis
pleural effusion
transudate
↓protein; due to ↑hydrostatic pressure or ↓oncotic pressure
lymphatic
chylothorax(乳び胸); due to thoracic duct injury from trauma or malignancy; Milky-appearing fluid
exudate
↑protein; due to malignancy, pneumonia, collagen vascular disease, trauma (↑vascular permeability); must be drained
excess accumulation of fluid between pleural layers; treat with thoracentesis(胸腔穿刺)
upper area
rhinosinusitis(副鼻腔炎)
sphenoid or ethmoid sinuses(篩骨)→cavernous sinus
viral(most common); bacteria(S.pneumoniae, H.influenzae, Mcatarrhalis
obstruction of sinus drainage into nasal cavity→inflammation and pain; typically affects maxillary sinuses
epistaxis(鼻血)
life-threatening hemorrhage occur in posterior segment (sphenopalatine artery, branch of maxillary artery)
causes: foreign body, trauma, allergic rhinitis, nasal angiofibromas
nose bleed; commonly in anterior segment of nostril
head and neck cancer
squamous cell carcinoma; HPV-16→oropharyngeal; EBV→nasopharyngeal; other risks are alcohol, tobacco
obstructive/restrictive lung disease
flow-volume
obstructive
RV↑; FRC↑;TLC↑; FEV₁↓↓; FVC↓; FEV₁/FVC↓
restrictive
RV, FRC, TLC, FEV₁, FVC↓; FEV₁/FVC is normal or ↑
obstructive lung disease
obstruction of air flow→air trapping in lung; V/Q mismatch; chronic, hypoxic pulmonary vasoconstriction, cor pulmonale
chronic obstructive pulmonary disease includes chronic bronchitis and emphysema
chronic bronchitis
wheezing, crackles, cyanosis, dyspnea, CO₂ retention, 2° polycythemia
hypertrophy and hyperplasia of mucus-secreting glands in bronchi
emphysema
centriacinar(小葉中心性), associated with smoking, frequently in upper lobes; panacinar(汎細葉性), in lower lobes; enlargement of air space ↓recoil, ↑compliance, ↓Dlco
barrel-shaped chest, exhalation through pursed lips(口すぼめ呼吸)
asthma
cough, wheezing, tachypnea, dyspnea, hypozemia, ↓inspiratory/expiratory ratio, pulsus paradoxus, mucus plugging
from viral URIs, allergens, stress; diagnosed by spirometry, methacholine challenge
reversible bronchoconstriction; smooth muscle hypertrophy and hyperplasia; Curschmann spirals; Charcot-Leyden crystals
type1 hypersensitivity
aspirin-induced asthma is a combination of COX inhibition
bronchiectasis(気管支拡張症)
permanently dilated airways
associated with bronchial obstruction, poor ciliary motility, cystic fibrosis, allergic bronchopulmonary aspergillosis
purulent sputum, recurrent infection, hemoptysis, digital clubbing
restrictive lung diseases
interstitial lung disease
↓diffusing capacity, ↑A-a gradient
pneumoconioses(じん肺), sarcoidosis, idiopathic pulmonary fibrosis, Goodpasture syndrome, granulomatosis with polyangiitis, pulmonary Langerhans cell histiocytosis, hypersensitivity pneumonitis, drug toxicity
types
poor muscular effort
polio, myasthenia gravis, Guillan-Barre syndrome
poor structural apparatus
scoliosis(側弯症), morbid obesity
hypersensitivity pneumonitis
mixed type 3/4 hypersensitivity reaction to environmental antigen (eg. farmers, birds)
↓ lung volume, short, shallow breaths
thrombi
deep venous thrombosis
D-dimer used to rule out DVT
from proximal deep veins of lower extremity
Virchow triad: stasis, hypercoagulability, endothelial damage
unfractionated heparin or low-molecule weight heparin for prophylaxis; oral anticoagulant for treatment
blood clot within a deep vein→swelling redness, warmth, pain
pulmonary emboli
types
fat: associated with long bone fractures and liposuction; hypoxemia, neurologic abnormalities, petechial rash
air: nitrogen bubbles; treat with hyperbaric O₂; can be 2° to invasive procedure
amniotic fluid: can lead to DIC, especially postpartum
thrombus, bacteria, tumor
V/Q mismatch, hypoxemia, respiratory alkalosis; dyspnea, pleuritic(深呼吸時の) chest pain, tachypnea, tachycardia
inhalation injury and sequelae
smoke inhalation from fires or other noxious substances
caused by heat, particulates, or irritants→chemical tracheobronchitis, edema, pneumonia, ARDS