Commonest cause of pulmonary edema?
Heart failure
cardiogenic pulmonary edema
What are the most common causes of left heart disease/dysfunction leading to cardiogenic pulmonary edema
coronary disease (myocardial ischemia or infarction), chronic hypertension, cardiomyopathy, aortic valve disease, new-onset arrhythmias, and mitral stenosis (now uncommon). - minority of cases: volume overload (blood or fluid)
What do you see on physical exam with cardiogenic pulmonary edema?
Tachypnea, tachycardia, cool extremities, rales, rhonchi and wheezes, cardiac murmurs, JVD
Commonest cause of non-cardiogenic pulmonary edema?
How does it present?
Acute respiratory distress syndrome ARDS
Dyspnea, Hypoxemia, and diffuse bilateral pulmonary inflitrates
Pathology of ARDS?
diffuse alveolar damage with alveolar hyaline membranes - can resolve normally or lead to pulmonary fibrosis and death
You are overseas in a war zone. A young man comes in with a traumatic leg injury from a mortar shell. He has developed symptoms of pulmonary edema and has diffuse inflitrates on CXR. You discover he does not have pneumonia. What is the diagnosis?
Trauma-induced ARDS
How is acute lung injury similar and different from ARDS?
Acute interstitial pneumonia leading to respiratory failure without a clear precipitating etiology (can follow URI)
High mortality rates
Describe Interstitial Parenchymal Lung Diseases: (ILD)
Restrictive, noninfectious lung disease - risk of pulmonary fibrosis
decreased TLC and FVC
Describe how a physician would go about diagnosing chronic pulmonary infiltrates of unknown type?
Pulmonary Medicine consultation will attempt to classify as either:
1) Fungal, mycobacterial, or other bug.
2) Neoplasm simulating pneumonia or ILD.
3) ILD with known causation
4) Idiopathic ILD: what subtype?
Idiopathic ILD in a young Black person, think:
Sarcoidosis
What is the most lethal, common ILD?
70-80% mortality
Idiopathic pulmonary fibrosis
often seen in male smokers older than 40
Histology of idiopathic pulmonary fibrosis:
Usual interstitial pneumonia -patchy interstitial fibrosis alternating with normal/near-normal lung parenchyma: both old (fibrotic) and young (fibroblastic) areas of scarring
(with honeycomb change!)
Commonest worldwide cause of environmental ILD?
Silicosis
(silica inhalation, like sandblaster workers)
Fibrotic nodules lead to massive fibrosis
Feared risk of asbestos exposure:
mesothelioma (even with small exposure)
also increased lung cancer risk
best tx for hypersensitivity pneumoonitis?
Avoid the offending agent!
Key features of eosinophilic pneumonia:
Allergic/hypersensitive rxns
- ) Acute = febrile illness with cough, dyspnea, diffuse pulmonary infiltrates: life-threatening hypoxemia - esp. new smokers.
- ) Chronic – subacute/chronic respiratory symptoms with peripheral pulmonary infiltrates: 30-50% of patients have underlying asthma.
- ) Simple pulmonary eosinophilia – migratory pulmonary opacities: minimal symptoms. - drug rxns
Tx with corticosteroid
African American Former smoker presents with painful bumps on shins, cough, dyspnea, chest pain, fever, weight loss, and fatigue. Lung shows bilateral hilar adenopathy with pulmonary opacities. What is the diagnosis?
Sarcoidosis!
Know this one!
Look for the non-caseating granulomas along lympathatics too!
Dx of exclusion!
After srugery a patient has a drop in systolic BP, increased central venous pressure, right heart failure and then death.
Possible diagnosis?
Massive PE!
A 40 year old patient suffers a DVT and then PE following a long plane ride. Any important things to consider?
Patients under 50 that are otherwise healthy and have a DVT/PE should be evaluated for an underlying hyper-coagulable state
Name some of those PE symptoms you know and love:
hypotension, dyspnea, tachycardia, pleuritic chest pain, hemoptysis, cough, calf/thigh pain and swelling, RV failure
Pulmonary hypertension is defined as:
Pulmonary artery pressure greater than 25 mmHg at rest
How do you treat pulmonary hypertension?
Treat underlying disease if you can
Supplementary Oxygen, cardiac meds, diuretics, pulmonary vasoactive drugs
Commonest causes of hemoptysis
Bronchogenic pneumonia
Bronchiectasis
Tuberculosis (outside of U.S.)
Common causes of ARDS (acute respiratory distress syndrome):
Sepsis** Pulm. Infection Gastric aspiration general trauma/head injury (shock lung)** Inhaled irritants Drug overdose/drowning transfusion
Tx for idiopathic pulmonary fibrosis?
Pretty much just lung transplant
Death comes with hypoxemia, cyanosis, and digital clubbing
Requirement for pneumonia dx?
Imaging!
Name for chronic infection/inflammation of larger airways unrelated to smoking leading to irreversible bronchial dilation:
Bronchiectasis
Commonest cancer death in males and females:
Lung cancer for both males and females
Compare your differential in acute vs chronic shortness of breath presentations:
Acute: anaphylaxis, bronchospasm, MI, PE, penumothorax, aspiration, toxic inhalation, massive hemorrhage
Chronic: COPD, CHF, Progressive anemia, obesity/deconditioning
Imagine Witrak saying this:
“Fever and chills with respiratory symptoms is ______ until proven otherwise.”
Pneumonia!!!!!!!
Patient presents with pneumonitis with diffuse infiltrates. Hx reveals she is has taken a medication for a heart arrythmia. What’s going on?
Amiodarone has pulmonary toxic effects. Probably caused the pneumonitis.
Explain what lung auscultation finding can tell us in regards to specifying respiratory disease: Expiratory wheeze: Rhonchi: Inspiratory Stridor: Crackles/rales: Decreased Breath Sounds:
Expiratory wheeze: COPD, asthma
Rhonchi: bronchitis, bronchiectasis, COPD
Inspiratory Stridor: Upper airway obstruction (larynx or trachea)
Crackles/rales: Pneumonia, pulmonary edema, interstitial/fibrosing disease
Decreased Breath Sounds: emphysema, pneumothorax, pleural effusion, pulmonary consolidation
What is Resorptive atelectasis vs Compression atelectasis?
What are some common causes?
Resorptive:
Alveolar collapse due to pneumonia or poor lung ventilation. Poor ventilation can occur from neuromuscular weakness/poor cough reflex and post-general anesthesia
Compression:
collapse due to mass effect.
Pleural effusion, pneumothorax, tumor, cysts, congenital anomalies, blebs
What does asthma usually look like on CXR?
Usually no CXR findings unless its real complicated.
Explain to me please, the etiological differences between Centriacinar and Panacinar emphysema:
Centriacinar = vast majority of cases. Predominately affects upper lobes of lung.
(affects more proximal respiratory bronchioles)
Panacinar = Very advanced common emphysema of ALPHA-1-Antitrypsin deficinecy. Upper and lower lung lobes are involved. (affects more distal alveolar ducts)
Emphysema Clinical Pearl: Under 50 and NOT a smoker –> you should think about panacinar w/ alpha1 antitrypsin deficinency
Mechanism of emphysema pathology:
Neutrophil elastase causes alveolar tissue damage, destroying alveolar walls and merging alveolar sacs.
Neutrophil elastase is increased by either congenital alpha-1-antitrypsin deficiency or tobacco smoke that causes free radicals to inactivate antiproteases. Without these anti-trypsins and antiproteases, they are free to wreak havoc on alveolar tissue.
Young child with over 1 month of unexplained respiratory symptoms. Think ________.
Foreign body aspiration
Kartagner’s syndrome. How does it relate to pulmonary disease?
It is a classic disease association with bronchiectasis.
Ciliary dyskinesia prevents the individual from coughing up enough mucus
Commonest lethal adult infection?
Pneumonia yo!
If you are ID’ing a viral cause of pneumonia using PCR it’s impossible to tell if the organism is causative or a colonizer. What is the one exception to this rule?
Influenza - always causative.
Likewise in bacterial pneumonia with: legionella, Tb, and bioterror stuff like anthrax
What is the commonest cause of bacterial pneumonia?
Hint: Tends to cause lobar pneumonia
Strep Pneumonia
What is the commonest cause of bacterial pneumonia in COPD patients?
Strep Pneumo
Hemophilus Influenza
M. Catarrhalis
Cause of pneumonia that likes water reservoirs and patients with predisposing chronic diseases - elderly.
Also associated with hyponatremia
Legionella Pneumophilia
ARDS presentation in patient in the southwestern U.S. Mice infestation discovered in the patient’s motor home. What are you thinking?
Hanta virus
Patient in clinic with pneumonia after a splunking trip to the ohio/mississippi river valley. Empiric treatment with antibacterials for gram +/- bacteria was ineffective. What do you think?
Histoplasmosis!
What kind of fungal pneumonia would be common in Minnesota?
Blastomycosis!
Systemically shows up often as non-healing lumps and bumps on skin
If you were going to get fungal pneumonia in the Southwest USA, what would the organism be?
Coccidiomycosis
Often has systemic signs in skin, joints, just like blastomycosis
With what disease will you find serum anti-GBM antibody?
Goodpasture’s Syndrome
How do you treat Wegener’s?
Steroids and cytoxan (cytotoxic immunosuppression)
cytoxan AKA cyclophosphamide
What are the three non-small cell carcinomas?
Adenocarcinoma - female dominant, can have lack of smoking hx
Squamous Carcinoma
Large cell
Name for a well-differentiated neuroendocrine carcinoma:
carcinoid tumors (1-5%)
If you get a lung cancer, get this one, its not too bad
Typical clinical presentation of common lung cancer:
- Over 40yo smoker
- cough, hemoptysis, chest pain, dysnea, hoarseness
- mass
- atelectasis or pneumonitis
- hilar/mediastinal adenopathy
- pleural/pericardial effusion
If a smoker has hoarseness, what are a couple serious things on your differential?
Recurrent nerve paralysis from mediastinal metastases BUT ALSO laryngeal carcinoma
What is superior vena cava syndrome?
SVC can be compressed by upper mediastinal adenopathy
Pts present with puffy upper body and face
What kind of paraneoplastic syndromes are produced by small cell carcinoma?
- Syndrome of inappropriate ADH with HYPONATREMIA (SIADH)
- Cushing’s Syndrome (from ACTH)
- Neuro syndromes from autoantibodies (lambert-eaton, cerebellae ataxia)
what are survival rates like for non-small cell and small cell carcinoma?
non-small cell = 15%
small cell = 5%
Survival rate for carcinoid lung cancer?
87%
usually resectable
commonest site of metastatic neoplasm
lungs
commonest congenital lung lesion?
CPAM
Congenital Pulmonary Airway Malformation
Has cystic nature
Spectrum of presentaion ranges from lack of lung development to milder incidental discovery later in life