Step 1 - Pulm 2

denniskwinn's version from 2015-04-25 16:16


Question Answer
Chronic bronchitis pathologyHypertrophy of mucus- secreting glands in the bronchioles → Reid Index
Reid index [definition and value in COPD]Mucus secreting gland depth /total thickness of bronchial wall; in COPD, is > 50%
Chronic bronchitis clinical definitionProductive cough For> 3 consecutive months in > 2 years. Disease of small airways
Chronic bronchitis findingswheezing, crackles, cyanosis (early onset hyypoxemia due to shunting), late onset dyspnea
Emphysema pathologyEnlargement of air spaces and ↓ recoil resulting From destruction of alveolar wall . ↑ in elastase activity→ ↑ lung compliance (loss of elasticity)
Emphysema findingsdyspnea, ↓ breath sounds, tachycardia, exhalation through pursed lips to ↑ airway resistance and prevent airway collapse - late onset hypoxemia due to eventual loss of capillary beds (occurs with loss of alveolar walls) - early onset dyspnea


Question Answer
Centriacinar emphysema assoc w/smoking [a/w which type of emphysema]
Panacinar emphysema assoc w/A1-AT deficiency (also liver cirrhosis) [causes what type of what]
Paraseptal emphysema assoc w/bullae which can rupture leading to spontaneous pneumothorax - often in young otherwise healthy males.
Asthma pathologyBronchial hyperresponsiveness causes reversible bronchoconstriction. . Smooth muscle hypertrophy and Curschmann's spirals (shed epithelium from mucous plugs).
Asthma triggersviral URIs, allergens, stress
Asthma findingscough, wheezing, dyspnea, tachypnea, hypoxemia, ↓ I/E ratio, pulsus paradoxus, mucus plugging
BronchiectasisChronic necrotizing infection of bronchi → permanently dilated a airways, purulent sputum, rccurrent infections, hemoptysis,
Brochiectasis associationbronchial obstruction, CF, poor ciliary motility, Kartagener’s syndrome, can develop aspergillosis


Question Answer
Restrictive lung diseaserestricted lung expansion causes ↓ lung volumes (↓ FVC and TLC). PFTs- FEV1/FVC ratio > 80%
Poor breathing mechanics restrictive lung diseases1. Poor muscular effort (polio, myasthenia gravis) 2. Poor structural apparatus (scoliosis, morbid obesity)
Interstitial lung diseases (restrictive)all lower diffusing capacity - Acute respiratory distress syndrome (ARDS, Neonatal respiratory distress syndrome (hyaline membrane disease), Pneumoconioses (coalminer's,.silicosis, asbestosis) , Sarcoidosis, Idiopathic pulmonary fibrosis (repeated cycles of lung Injury and wound healing with ↑ collagen), Goodpasture's syndrome, Wegener's granulomatosis, Eosinophilic granuloma (histiocytosis X), Drug toxicity (bleomycin, busulfan, amiodarone)
Coal miners pneumoconiosisAssociated with coal mines. Can result in cor pulmonale, - Caplan's syndrome - Affects upper lobes
SilicosisAffects upper lobes, eggshell calcifications of hilar lymph nodes - Associated with foundries, sandblasting, and mines. 2. Macrophages respond to silica and release fibrogenic factors, leading to fibrosis. It is thought that silica may disrupt phagolysosomcs and impair macrophages, increasing susceptibility to TB.
AbestosisAssociated with shipbuilding, roofing, and plumbing. Results in "ivory white," calcified pleural plaques. Associated with an ↑ Incidence of bronchogenic carcinoma and mesothelioma 2. Affects lower lobes 3. Abestos bodies are golden-brown fusiform rods resembling dumbbells located inside macrophages
Neonatal respiratory distress syndromeSurfactant deficiency leading to ↑ surface tension. resulting in alveolar collapse. Surfactant made most abundantly after 35th week of gestation. lecithin-to-sphingomyelin ratio in the amniotic fluid, a measure of lung maturity, is usually < 1.5 in neonatal respiratory distress syndromc. Persistently low O2 tension→ risk of PDA. Therapeutic supplemental O2 can result in retinopathy of prematurity.
NRDS risk factorsprematurity, maternal diabetes (due to elevated insulin which decreases surfactant production), cesarean deliver (↓ release of fetal glucocorticoids)
NRDS treatmentmaternal steroids before birth; artificial surfactant for infant, thyroxine
Acute Respiratory distress syndromediffuse alveolar damage → ↑ alveolar capillary permeability→ protein rich leakage into alveoli. Results in formation of intra-alveolar hyaline membrane. Initial damage due to neutrophilic substances toxic to alveolar wall. Activation of coagulation cascade or oxygen-derived free radicals
ARDS causestrauma, sepsis, shock, gastric aspiration, uremia, acute pancreatitis or amniotic fluid embolism


Question Answer
Obstructive lung volumes> normal (↑ TLC, ↑ FRC, ↑ RV) [volumes in which type of lung disease]
Restrictive lung volumes< normal [volume in which type of lung disease]
Central sleep apneano respiratory effort
Obstructive sleep apnearespiratory effort against airway obstruction
Sleep apnea associationsobesity, loud snoring, systemic/pulmonary hypertension, arrhythmias, and possibly sudden death
Sleep apnea treatmentweigh loss, CPAP, surgery


Question Answer
Physical findings for bronchial obstructionAbsent/↓breath sounds over affected area, ↓ resonance, ↓ fremitus, tracheal deviation towards lesion
Physical findings for pleural effusionbreath sounds ↓'d over the site; dullness; ↓ fremitus
Physical findings for pneumonia (lobar)may have bronchial breath sounds over lesion, dullness, ↑ fremitus
Physical findings for tension pneumothorax↓ breath sounds, hyperresonance, absent fremitus, tracheal deviation away from side of lesion
Lung cancer complicationsSPHERE - Superior vena cava syndrome, Pancoast’s tumor, Horner’s syndrome, Endocrine (paraneoplastic), Recurrent laryngeal symptoms (hoarseness), Effusions (pleural or pericardial)
Presentation of lung cancercough, hemoptysis, bronchial obstruction, wheezing, pneumonic "coin" lesion on x-ray film .
Metastases to lung-most common presentation =dyspnea [most common presentation of what?]
Primary tumor in lung-presents withcough. [presenting sx for]


Question Answer
Pancoast’s tumorCarcinoma that occurs in apex of lung and may affect cervical sympathetic plexus, causing Horner's syndrome
Lobar pneumoniaIntraalveolar exudate→consolidation, may involve entire lung - Pneumococcus most frequently, Klebsiella
BronchopneumoniaAcute inflammatory infiltrates from bronchioles into adjacent alveoli; patchy distribution involving lobes - S.aureus, H. Flu, Klebsiella, S.pyogenes
Interstitial pneumoniaDiffuse patchy inflammation localized to interstitial areas at alveolar walls; distribution involving 1+ lobes - generally follows a more indolent course than bronchopneumonia - Viruses(RSV, adeno), mycoplasma, legionella, Chlamydia
Lung abscessLocalized collection of pus within parenchyma, usually resulting from bronchial obstruction (e.g., cancer) or aspiration of oropharyngeal contents (especially in patients predisposed to loss of consciousness, e .g., alcoholics or epileptics). Often due to S. aureus or anaerobes
Pleural transudate↓ protein content. Due to CHF, nephrotic syndromc, or hepatic cirrhosis
Pleural exudate↑ protein content, cloudy. Due to mallgnancy , pneumonia. collagen vascular disease, trauma (occurs in states of ↑ vascular pemeability) must be drained in light of risk of Infection.
Pleural lymphatic effusionMilky fluid, ↑ triglycerides


Question Answer
H1 blockersReversible inhibitors of H1 histamine receptor
1st gen H1 blockersDiphenhydramine, dimenhydrinate, chlorpheniramine
1st gen H1 blocker clinical useallergy, motion sickness, sleep aid
1st gen H1 blocker toxicitysedation, antimuscarinic, anti alpha adrenergic
2nd generation H1 blockersLoratadine, fexofenadine, desloratadine, cetirizine
2nd generation H1 blocker clinical useallergy [indication for which drug]
2nd generation H1 blocker toxicityfar less sedating than 1st generation because of ↓ entry into CNS


Question Answer
lsoproterenolrelaxes bronchial smooth muscle (β2). But is nonspecific so causes tachycardia (β1)
Albuterolβ2 agonist - relaxes bronchial smooth muscle - used for acute exacerbation
Salmeterolβ2 agonist - relaxes bronchial smooth muscle - long acting agent for prophylaxis - adverse effects are tremor and arrhythmia
Theophyllinea methylxanthine - likely causes bronchodilation by inhibiting phosphodiesterase, thereby ↓ cAMP hydrolysis. Usage is limited because of narrow therapeutic index (cardiotoxicity, neurotoxicity); metabolized by P-450. Blocks actions of adenosine.
Ipratropium competitive block of muscarinic receptors, preventing bronchoconstriction. - Also used for COPD.
CromoylnPrevents release of mediators from mast cells. Effective only for the prophylaxis of asthma. Not effective during an acute asthmatic attack. Toxicity is rare
Beclomethasone, prednisonecorticosteroids that inhibit synthesis of virtually all cytokines. Inactivate NF-kβ, the transcription Factor that induces the production of TNF-α, among other inflammatory agents. 1st-line therapy for chronic asthma
ZileutonAntileukotrienes - A 5-lipoxygenase pathway inhibitor. Blocks conversion of arachidonic acid to leukotrienes.
Zafirlukast, montelukastblock leukotriene receptors. Especially good For aspirin-induced asthma.
Guaifenesin (robutussin)expectorant - Removes excess sputum but large doses necessary; does not suppress cough reflex.
N-acetylcysteineexpectorant - mucolytic - can loosen mucous plug in CF patients - also used as antidote for acetominphen overdose
BosentanUsed to treat pulmonary hypertension. Competitively antagonizes endothelin-1receptors, decreasing pulmonary vascular resistance


Cancer typeLocationCharacteristicsHistology
Squamous cell carcinomaCentralHilar mass arising from bronchus; Cavitation, Clearly linked to Smoking; parathyroid-like activity →PTHrPKeratin pearls and intercellular bridges
Bronchial adenocarcinomaperipheralDevelops in site of prior pulmonary inflammation or injury (most common lung cancer in nonsmokers and females)Clara cells→type II pneumocytes; multiple densities on CXR
Bronchioalveolar adenocarcinomaperipheralNot linked to smoking, grows along airways; can present like pneumonia - can result in hypertrophic osteoarthropathyClara cells→type II pneumocytes - multiple densities on CXR
Small cell carcinomaCentralUndifferentiated → very aggressive, often associated with ectopic production of ACTH or ADH , may lead to Lambert-Eaton syndrome (autoantibodies against calcium channels). Responsive to chemotherapy. Inoperable.Neoplasm of neuroendocrine Kulchitsky cell → small dark blue cells
Large cell carcinomaperipheralHighly anaplastic undifferentiated tumor; poor prognosis; less responsive to chemotherapy. Removed surgicallyPleomorphic giant cells with leukocyte fragments in cytoplasm
Carcinoid tumorSecretes serotonin, can cause carcinoid syndrome (flushing, diarrhea, wheezing, salivation, R sided Heart failure
Mesothelioma Malignancy of pleura associated with abestosis - results in hemorrhagic pleural effusions and pleural thickeningPsammoma bodies
Metastases Very common, adrenals, brain (epilepsy), bone (path fracture), and liver (jaundice, hepatomegaly)