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Lecture 3

Pulmonary III - "DAD" & Obstructive Lung Disease

Radiographic finding of DAD Diffuse alveolar and interstitial infiltrates in all lung fields. Radiographic characteristics overlaps with images of severe bilateral pneumonia or severe pulmonary edema.
Pathological hallmark of Adult Respiratory Distress Syndrome (ARDS) Diffuse Alveolar Damage (DAD)
Pathophysiology of DAD Process is initiated by an insult to capillary endothelial and alveolar epithelial cells, which results in V/P shunting, atelectasis, pulmonary edema/hemorrhage, and hyaline membrane formation that impairs gas exchange leading to severe hypoxia.
Describe the relationship between pressure, alveolar radius, and surface tension P (pressure) = 2T(Tension)/r (alveolar radius). Surfactant lowers T as r decreases during expiration, so that less P would be required to rexpand the alveoli
What percentages of patients survive ARDS with little or no residual disease? 25%
Favorable Prognostic Factors in ARDS (1) High PaO2 on room air (2) Increase in PaO2 with 10 cm of PEEP
Indications for Mechanical Ventilation (1) PaO2 < 60 mmHg (on O2 mask) (2)A-a gradient >400 on 100% FIO2 (3) RR> 35/min (4) TV < 4 ml/kg
What does an increased A-a gradient indicate? It is a value used to help determine the cause of hypoxemia. Normal value < 5mmHg (ranges 5-20 mmHg). Increased A-a gradient suggests either (1) diffusion defect (2) V/Q(ventilation/perfusion) defect (3) right to left shunt.
Chronic Obstructive Pulmonary Disease (COPD) A syndrome of airflow obstruction consisting of two pathologic processes: Chronic bronchitis and emphysema
A pulmonary disease characterized by persistent cough with sputum production for at least 3 months in at least 2 years. Chronic exposure to irritants leads to hypersecretion of mucus. Inflammatory response is sustained by secondary infections. Chronic Bronchitis
What is the Reid Index in chronic bronchitis? >0.4
Histological characteristics of chronic bronchitis (1) Increase in mucous glands in trachea in bronchi (2) Mucinous secretions and casts fill airways
What are Blue bloaters? Chronic bronchitis patients.
Complication of chronic bronchitis Cor pulmonale
A lung pathology characterzied by abnormal permanent enlargement of the air spaces distal to terminal bronchials, accompanied by destruction of the wall supporting those air spaces. Emphysema
Etiology of chronic bronchitis Inhalation of chronic irritants. Cigarette smoke is the most common irritant followed by air pollution.
Histological findings of emphysema Loss of alveolar parenchyma characterized by free floating fragments or attenuated alveolar septa and alveolar walls
(T or F) Severity of COPD is not dose-dependent False
(T or F) History of recurrent childhood respiratory infection may contribute to COPD True
Type of emphysema that occurs in young non-smoking patient with an early clinical onset of COPD or has a family history of emphysema. Hereditary anti-protease enzyme deficiency
Inheritance pattern of anti-protease enzyme deficiency Autosomal recessive
Anatomical distribution of emphysematous changes seen in the lung in smokers Centrilobular distribution. Predominantly the upper lobes and apices.
What area of the lung are emphysematous changes most apparent in anti-protease enzyme deficient patients? Lower lobe
What are the effect of tobacco smoke on immune cells and alpha1 antitrypsin enzymatic activity? (1)Tobacco smoke particles are phagocytozed alveolar macrophages. (2) Neutrophils are recruited and elastases are released by neutrophils (3) Alpha1 antitrypsin is inactivated by oxidants and free radicals in tobacco smoke.
Function of Alpha1 anti-trypsin Antiprotease enzyme that inhibits actions of elastases released by neutrophils
A pattern of lung injury seen in patients with alpha1-antitrypsin deficiency especially in conjunction with cigarette smokingon of emphysematous changes Panlobular Distribution of emphysematous changes
A pattern of lung injury characterized as emphysematous changes limited to the distal acinus. Usually seen adjacent to scarring and fibrosis. Tends to localize subadjacent to the pleural, which can cause a spontaneous pneumothorax. Paraseptal Distribution of emphysematous changes
What is Irregular Emphysema? Irregular involvement of the acinus with scarring. Usually a complication of various inflammatory processes (TB or histoplasmosis). These findings are usually not clinically evident.
Pulmonary Function Test Abnormalities characteristic of COPD (1) Dec FEV1 (2) Dec Vmax (3) Dec MMEF
(T or F) Peptic ulceration is a complication of COPD True
Lung disease characterized as wide spared narrowing of the bronchi and small airways which change in severity over short periods of time Asthma
A variant of asthma characterized by reactions mediated by type I hypersensitivity involving IgE. Begins in childhood and is associated with hay fever and eczema. Extrinsic type Asthma
A variant of asthma not associated with history of allergy. Begins at any age. Induced by psychogenic factors, cold, infection, or exercise. Intrinsic type Asthma
Pathologic findings in Asthma (1) edema (2) esoinophils (3) Charcot-Leyden crystals (4) hypertrophy of bronchial wall musculature and submucosal mucus-glands (5) Curschmann’s spirals
What are Charcot-Leyden Crystals? Crystalloids of eosinophil-derived proteins
What are Curschmann’s Spirals? Intrabronchial mucus plugs containing whorl-like accumulations of epithelial cells
An extrinsic allergic alveolitis. An immunologically mediated lung disease involving the alveolar parenchyma. Hypersensitivity reaction can be triggered by cell wall or cell coat protein of a variety of bacteria, fungi, and molds. Hypersensitivity Pneumonitis
Most common patient population affected by Hypersensitivity Pneumonitis Farm workers exposed to dusty, moldy hay or stored crops. Ex: thermophilic actinomycetes
Symptoms of Hypersensitivity Pneumonitis (1) dyspnea (2) dry cough (3) fever/chills (4-6 hrs after exposure) (4) fatigue/malaise
Pathological findings of Hypersensitivity Pneumonitis Patchy interstitial pneumonia with lymphoid infiltrate admixed with plasma cells and eosinophils. Scattered interstitial microgranulomas a giant cells.
A lung condition also called cryptogenic organizing pneumonia. Associated with many different pathologic processes. It is a common pattern of reaction to injury characterized by myxoid fibrosis of the distal airways and alveoli. Bronchiolitis obliterans organizing pneumonia
Pathological findings of BOOP Patchy but temporally uniform filling of alveolar spaces and/or terminal bronchioles with loose fibromyxoid connective tissue plugs.
Treatment and prognosis of BOOP Steroids. >75% of patients respond to treatment.
Created by: UVAPATH2