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Lecture 3
Pulmonary III - "DAD" & Obstructive Lung Disease
| Question | Answer |
|---|---|
| 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. |
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