A 2 year old swallows a coin… where is it most likely to lodge?
Right mainstem bronchus
When sampling amniotic fluid, what indicates fetal lung maturity?
Lecithin-to-sphingomyelin ration > 2
How do you determine physiological dead space?
Vd= tidal volume x (PCO2 in arterial blood - PCO2 in expired air)/ PCO2 in arterial blood
V/Q during airway obstruction
V/Q approaches 0
100% O2 does not improve PaO2
V/Q during blood flow obstruction
V/Q approaches infinity
100% O2 improves PaO2
V/Q at apex of lung
Greater than 1 (wasted ventilation)
V/Q at base of lung
Less than 1 (wasted perfusion)
3 ways CO2 is transported from tissues to the lungs
HCO3
Carbaminohemaglobin
DIssolved in blood
Respiratory response to high altitude
Increased ventilation Increased epo (increased hematocrit) Increased 2,3 BPG (increases O2 release from Hgb) Increased mitochondria Increased renal excretion of HCO3
Drug used for altitude sickness?
Acetazolamide
Tx for carbon monoxide poisoning?
Hyperbaric O2
At what positive G force does visual “black out” occur? why?
4-6 Gs
Force of pooling blood in abdomen and legs, insufficient pumping of blood to brain
S1Q3T3
Deep S in lead 1
Large Q and inverted T in lead 3
Pulmonary Embolism
Stroke after multiple long bone fractures… what caused the infarct?
Fat emboli
FEV1/FVC in normal lung
80%
FEV1/FVC in obstructive disease
FEV1/FVC in restrictive lung disease
> or = 80%
lung volumes are decreased (can’t fill up)
FEV1 and FVC are both decreased, but ratio remains the same
Eosinophilic
hexagnal
Double pointed- needle like crystals
Formed from breakdown of eosinophils in sputum
Charcot-Leyden crystals
Charcot-leyden cyrstals
Curschmann spirals
Asthma
Hyperplasia of mucus-secreting glands in brochi
Reid index > 50%
Chronic Bronchitis
Thickness of gland layer/ thickness of bronchial wall
Reid Index
Daily productive cough > 3 months for at least 2 consecutive years
Chronic Bronchitis
Blue Bloaters
Chronic bronchitis
Centriacinar emphysema
Associated with smoking
Panacinar Emphysema
Associated with alpha1-antitrypsin deficiency
Barrel-shaped chest
Exhalation through pursed lips
Emphysema = pink puffer
Increased ACE enzyme NONcaseating granulomas Hilar Lymphadenopathy Uveitis Hypercalcemia
Sarcoidosis
Honey comb lung
Idiopathic pulmonary fibrosis
*prolonged will increase EPO release from kidney to better perfuse tissues, increasing hematocrit
“Tennis rack” shaped cytoplasmic organelles
Birbeck Granules
Langerhang cell histiocytosis
Iron-containing nodules in the alveolar septum
Ferriginous Bodies = Asbestosis
4 complications of lung cancer
- Superior vena cava syndrome
- Horner syndrome
- Paraneoplastic Syndromes
- Hoarsness
4 common places for lung cancer mets?
Brain
Bone
Liver
Adrenal Glands
Lung cancer associated with SIADH
Small cell carcinoma
Tumor associated with Horner syndrome
Pancoast
Lung Cancer associated with hypercalcemia
Squamous cell carcinoma
Lung cancer associated with Cushing Syndrome
Small cell carcinoma
Lung cancer associated with weakness
Small cell - produces Ab to Ca+ channels (Lambort-Eaton Syndrome)
Substances associated with lung cancer
Smoke
Radon
Silica
Asbestos
Atypical Pneumonia bugs
Mycoplasma Pneumoniae
Legionella
Chlamydophila pneumoniae
Situs Inversus
Chronic sinusitis
Bronchiectasis
Kartagener
Dynein defect
*Bronchiectasis due to a nonfunctional mucociliary elevator
Cancer associated with a shipyard worker?
Asbestos –> mesothelioma
Curshmann Spirals
Charcot-Leyden crystals
Eosinophils in sputum
Bronchial asthma
Pneumonia in immunocompromised
Pneumocystis jirovecii
Most common atypical/walking pneumonia
Mycoplasma Pneumonia
Pneumonia in alcoholics
Klebsiella pneumoniae
Pneumonia in bird handlers
Chlamydophila psittaci
Pneumonia w/ exposure to bats or bat droppings
Histoplasma
Pneumonia w/ recent travel to Cali, New mexico or west texas
Coccidioies
Pneumonia with “currant jelly” sputum
Klebsiella
q fever
Coxiella burnetti
Pneumonia acquired from air conditioners
Legionella pneumophlia
Most common cause of pneumonia in children 1 year or younger
RSV
Pneumonia in a neonate
Group B strep
E. Coli
Most common cause of pneumonia in children and young adults (college students, military, prison)
Mycoplasma
Pneumonia in ventilator patients
Pseudomonas, MRSA
Pneumonia in cystic fibrosis
Pseudomonas
Pontiac Fever
Legionella
What is the relationship of the arteries to the airway in a bronchopulmonary segment?
Arteries run with the airways in the center of the segments
Mucoid exudate forming a cast of the airways
Curschmann spirals found in viscous mucus of asthma patients
Collections of crystalloid made up eosinophil membrane protein
Charcot-Leyden crystals found in viscous mucus of asthma patients
Neutropenic Patient
“Air-crescent sign”
Asperigillus fumigatus
**45 degree branching septae hyphae
Absent breath sounds and positive peristaltic bowel sounds in chest
Congenital diaphragmatic hernia = failure of pleuroperitoneal canal to close completely
Most common cause of death in congenital diaphragmatic hernia
Pulmonary hypoplasia, secondary to lack of space for the lung to grow
What molecules are diffusion limited?
O2 in emphysema or fibrosis
CO
*gas does not equilibrate by the time blood reaches the end of the capillary
Bronchiolitis
RSV
ssRNA non-segmented genome
Initial phase: malaise, dry cough, chest pressure
Second phase: ARDS, hemorrhagic mediastinitis, bloody pleural effusion, mediastinal widening
Bacillus anthracis
“Wool-sorter’s disease”
Death in 24 hours if not treated due to septic shock from exotoxin.
**protein capsule
Detection of mycoplasma pneumoniae
Cold agglutinin testing
Symptomatic difference between cystic fibrosis and kartagners syndrome?
Kartagner’s will NOT have steatohrea
Clinical difference between granulomatosis with polyangiitis and goodpastures?
Granulomatosis w/ polyangitis will have mucosal ulcers and a + c-ANCA
Two lung cancers commonly associated with pancoast tumors?
Adenocarcinomas
Squamous Cell carcinomas
Infectious complication arising from pulmonary silicosis?
Silica may disrupt phagolysosomes & impair macrophages
**increased susceptibility to TB
Substances causing methemoglobinemia
Nitrates/Nitrites
Anti-malarial drugs
Methemoglobinemia
Oxidized form of Hb (ferric, Fe3+) that does not bind O2 as readily, but has increased affinity for cyanide
Carboxyhemoglobin
Form of Hb bound to CO in place of O2
Causes decreased oxygen binding capacity with left shift in hbg curve
Less oxygen unloading to tissues
Tx: 100 O2
Decreased breath sounds
Decreased percussion
Decreased tactile fremitus
Pleural effusion
**pneuomnia has INCREASED tactile fremitus
Child with nasal polyp
CYSTIC FIBROSIS!
Adults with nasal polyp
Allergic polyp (allergic rhinitis)
Adults with:
Asthma
Aspirin induced bronchospams
Nasal Poly
Aspirin Intolerant Asthma
Nasopharyngeal carcinoma is associated with what infection?
Ebstein Barr Virus
Life threatening nose bleed
Posterior segment Sphenopalantine artery (branch of maxillary)
Atypical pneumonia in infant
RSV
Most common bug in atypical pneumonia
Mycoplasma Pneumoniae
Complication of mycoplasma Pneumoniae
Hemolytic anemia (IgM = cold)
Atypical pneumonia with post transplant immunosuppressive therapy
CMV
Post viral secondary infection
Staph Aureus
Atypical Pneumonia
High Fever
Farmer or Vet
Coxiella Burnetii = Q fever
Found in tick poo or cow placenta
Chronic necrotizing infection of bronchi
Permanently dilated airways
Purulent, foul selling sputum
Recurrent Infections
Hemoptysis
Bronchiectasis
Smoking
Kartagener
Cystic Fibrosis
Allergic bronchopulmonary aspergillosis
What induces fibrosis in intestial pulmonary fibrosis?
TGF-B from injured pneumocytes induces fibrosis
anthrocosis
Carbon-laden macrophages - found in urban dwellers exposed to sooty air
Caplan Syndrome
Coal worker’s pneumoconiosis associated with Rheumatoid arthritis
Sanblaster
Silicosis
How does silica affect macrophages
Silica impairs phagolysosome formation by macrophages
Increased risk for TB
Only pneumoconoiosis with increased risk for TB?
Silicosis
Also increased risk for lung cancer
Miners and aerospace industry
Berylliosis
Noncaseating granulomas in lung and hilar lymph nodes and systemic organs in aerospace worker
Berylliosis!
Sounds like sarcoid, don’t get confused!
Construction workers
Plumbers
Shipyard Workers
Asbestosis
Furrigonous body
Asbestos body, Iron deposits
Dumbbell shaped
Dyspnea/ Cough
Elevated serum ACE
Hypercalcemia
Sarcoid
Why is there hypercalcemia in Sarcoid?
Non caseating granulomas have an increased 1 alpha hydroxylase activity that activates Vit. D
Inactivating mutation of BMPR2
Leads to proliferation of vascular smooth muscle and primary pulmonary HTN
> 25 mmHg
Treatment for ARDS
Ventilation with positive end-expiratory pressure
**recovery may be complicated by interstial fibrosis (Type 2 pneumocytes are injured and can’t regenerate so get fibrosis)
Main component of surfactant
Lecithin = phosphatidylcholine
How does Maternal diabetes increase risk for NRDS?
Increased blood sugar
Baby produces more insulin
Insulin INHIBITS surfactant production
How does C-section increase your risk fro NRDS?
Going through birth canal is stressful, release cortisol, increase surfactant production
Don’t have that during c-section
Complications of NRDS
Hypoxemia =Patent ductus arteriosus and necrotizing enterocoliits
Supplemental Oxygen can cause free radical injury
Keratin pearls or intercellular bridges
Squamous cell carcinoma
*PTHrP
Chromogranin positive
Neuroendocrine Tumor
Small cell and Carcinoid tumor
Where does lung cancer like to metastasize to?
adrenal gland