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Rhinitis
- Inflammation of the nasal mucosa
- Adenovirus is the most common cause
- Presentation: sneezing, congestion, runny nose
- Allergic rhinitis: type I hypersensitivity reaction
- - eosinophils
- - associated with asthma and eczema
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Nasal polyp
- Protrusion of edematous, inflamed nasal mucosa
- Secondary to repeated bouts of rhinitus, CF, aspirin-intolerant asthma
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Angiofibroma
- Benign tumor of nasal mucosa
- -large blood vessels and fibrous tissue
- Presentation: profuse epistaxis
- Males >> females
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Nasopharyngeal carcinoma
- Malignant tumor of nasopharyngeal epithelium
- Associated with EBV, African children, Chinese adults
- Bx: pleomorphic keratin-positive epithelial cells
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Acute epiglottitis
- INflammation of epiglottis
- H. influenzae type b is most common (non-immunized children)
- Presentation: fever, sore throat, drooling with dysphagia, muffled voice, inspiratory stridor
- Risk of airway obstruction
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Laryngotracheobronchitis (Croup)
- Inflammation of the upper airway
- Parainfluenza virus is most common cause
- Presentation: hoarse, "barking" cough, inspiratory stridor
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Vocal cord nodule (Singer's nodule)
- Nodule that arises on the true vocal cord
- Cause: excessive use
- Usually bilateral
- Degenerative (Myxoid) connective tissue
- resolves with rest
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Laryngeal papilloma
- benign papillary tumor of the vocal cord
- HPV 6 and 11
- Usually single in adults, multiple in children
- Presentation: hoarseness
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Laryngeal carcinoma
- Squamous cell carcinoma
- Origin: epithelial lining of the vocal cord
- Risk factors: alcohol, tobacco
- Presentation: hoarseness, cough, stridor
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Primary Pulmonary Hypertension
- Epidemiology:-young adult females
- Presentation:
- -exertional dyspnea
- -R-sided heart failure
- Pathophysiology:
- -PAH ≥ 25 mmHg or > 35 mmHg during exercise
- -results in arteriosclerosis, medial hypertrophy and intimal fibrosis of pulmonary arteries
- -inactivating mutation in BMPR2 gene (normally inhibits vascular SM proliferation)
- Complications:
- -RVH
- -eventual cor pulmonale
- Prognosis:
- -poor prognosis
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Secondary Pulmonary Hypertension
- Pathophysiology:
- -COPD (lung parenchyma destruction)
- -Mitral stenosis (increase resistance leads to increased pressure)
- -Recurrent thromboemboli (decrease cross-sectional area of vascular bed)
- -Autoimmune disease (systemic sclerosis: inflammation → intimal fibrosis → medial hypertrophy)
- -Left to Right Shunt (increase shear stress → endothelial injury)
- -Sleep apnea/living at high altitude (hypoxic vasoconstriction)
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Deep Venous Thrombosis
- Pathophysiology:
- -most common source is femoral, iliac, or popliteal vein
- -predisposed by Virchow's Triad
- -Stasis
- -Hypercoagulability
- -Endothelial damage
- Presentation:
- Complications:
- -can lead to PE
- Treatment:
- -heparin for prevention and acute management
- -warfarin for long-term prevention of recurrence
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Pulmonary Emboli
- Presentation: most often clinically silent
- -sudden-onset dyspnea
- -chest pain
- -tachypnea
- -may present as sudden death
- Pathophysiology:
- -95% arise from DVTs
- Diagnosis:
- -CT pulmonary angiography
- Pathology:
- -Fat (long bone fractures and liposuction)
- -Air
- -Thrombus
- -Bacteria
- -Amniotic fluid
- -Tumor
- "An embolus moves like a FAT BAT"
 - -lines of Zahn (platelets/fibrin and RBCs): only happen premortem
- Fat Emboli:
- -(long bone fractures and liposuction)
- -Triad: hypoxemia, neurologic abnormalities, petechial rash
- Amniotic Fluid Emboli:
- -can lead to DIC, especially post partum
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Obstructive Lung Diseases
-basic principles
-PFTs
-types
- Pathophysiology:
- -obstruction of air flow resulting in air trapping in the lungs
- -airways close prematurely at high lung volumes
- -V/Q mismatch
- PFTs:
- -↑ RV
- -↑ TLC
- -↓ FVC
- -↓↓ FEV1
- -↓ FEV1/FVC ratio
- Types:
- -Chronic Bronchitis
- -Emphysema
- -Asthma
- -Bronchiectasis
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Chronic Bronchitis
" Blue Bloater"
- Pathophysiology:
- -highly associated with smoking
- Pathology:
- -form of COPD
- -hypertrophy of mucus-secreting glands in bronchi
- -Reid index > 50% (thickness of gland layer/total wall thickness)
- Presentation:
- -productive cough for > 3 months per year for > 2 years
- -wheezing
- -crackles
- -cyanosis (early onset hypoxemia due to shunting)
- -late-onset dyspnea
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Emphysema
-Centriacinar
-Panacinar
" Pink Puffer"
- Pathophysiology:
- -↑ elastase activity
- -↑ lung compliance due to loss of elastic fibers
- -destruction of alveolar air sacs
- Centriacinar:
- -associated with smoking
- -inflammation leads to protease mediated damage
- -mostly in upper lobes
- Panacinar:
- -α1-antitrypsin deficiency
- -lack of antiprotease
- -mostly in lower lobes
- -also get liver cirrhosis
- Presentation:
- -dyspnea and cough (minimal sputum)
- -pursed lip expiration
- -weight loss
- -barrel-chest
- -late-onset hypoxemia
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Asthma
-Pathophysiology
-Diagnosis
-Presentation
-Pathology
- Pathophysiology:
- -bronchial hyperresponsiveness
- -reversible bronchoconstriction
- -can be triggered by viral URIs, allergens and stress
- -most often due to type I hypersensitivity
- Diagnosis:
- -methacholine challenge
- Presentation:
- -cough
- -wheezing
- -tachypnea
- -dypsnea
- -hypoxemia
- -↓ I/E ratio
- -pulsus paradoxus
- -mucus plugging
- Pathology:
- -smooth muscle hypertrophy
- -Curschmann's spirals (shed epithelium forms mucus plugs)
- -Charcot-Leyden crystals (formed from breakdown of eosinophils in sputum)
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Bronchiectasis
-Pathophysiology
-Causes
-Presentations
-Complications
- Pathophysiology:
- -chronic necrotizing infection of bronchi
- -causes permanently dilated airways
- Causes:
- -Cystic Fibrosis
- -Smoking (poor ciliary motility)
- -Kartagener's Syndrome
- -Allergic bronchopulmonary aspergillosis
- -Bronchial obstruction
- Presentation:
- -purulent sputum (foul smelling)
- -recurrent infections
- -hempotysis
- Complications:
- -hypoxemia with cor pulmonale
- -secondary AA amyloidosis
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Restrictive Lung Disease
-Pathophysiology-PFTs
-Types
- Pathophysiology:
- -restricted lung expansion causes decreased lung volumes
- PFTs:
- -↓ FVC
- -↓ TLC
- -FEV1/FVC > 80%
- 1. Poor Breathing Mechanics
- -Pathophysiology: extrapulmonary, periperal hypoventilation, normal A-a gradient
- -poor muscular effort: polio, myasthenia gravis
- -poor structural apparatus: scoliosis, morbid obesity
- 2. Interstitial Lung Diseases
- -Pathophysiology: pulmonary, lowered diffusing capacity, ↑ A-a gradient)
- -ARDS
- -Neonatal respiratory distress syndrome
- -Pneumoconioses (anthracosis, silicosis, asbestosis)
- -Sarcoidosis (bilateral hilar adenopathy, noncaseating granulomas, elevated ACE and Ca2+)
- -Idiopathic pulmonary fibrosis
- -Goodpasture's Syndrome
- -Wegener's
- -Langerhans cell histiocytosis (eosinophilic granuloma)
- -Hypersensitivity pneumonitis
- -Drug toxicity (bleomycin, busulfan, amiodarone, methotrexate)
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Pneumoconioses
types, risk, lung region
↑ risk of cor pulmonale and Caplan's syndrome
- Anthracosis: coal miner's lungs, "black lung" (upper lobes)
- -mild exposure results in anthracosis; not clinically significant
- Silicosis: sand blasting, foundries, mines (upper lobes)
- -"Eggshell" calcification of hilar lymph nodes
- -Macrophages respond to silica and release fibrogenic factors
- -↑ susceptibility to TB
- -↑ risk of bronchogenic carcinoma
- Berylloisis: beryllium miners, workers in aerospace
- -Noncaseating granulomas in the lung, hilar lymph nodes, systemic organs
- -↑ risk for lung cancer
- Asbestosis: ship building, roofing, plumbing (lower lobes)
- -"Ivory white" calcified pleural plaques are pathognomonic of exposure, not precancerous
- -↑ incidence of bronchogenic carcinoma and mesothelioma
 - -long, golden-brown fibers with associated iron (asbestos bodies)
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Neonatal respiratory distress syndrome
cause, risk factors, tx
- Cause/features:-Surfactant deficiency → ↑ surface tension, resulting in alveolar collapse
- -Lecithin:sphingomyelin ratio <1.5 in amniotic fluid is predicitive
- -Persistently low O2 tension → risk of PDA
- -Diffuse granularity of lungs ("ground glass" appearance on CXR)
- Risk factors:
- -Prematurity
- -Maternal diabetes (elevated fetal insulin)
- -Cesarean delivery (↓ release of fetal glucocorticoids)
- Tx:
- -maternal steroids before birth
- -artificial surfactant for infants
- -*Supplemental O2 can result in retinopathy of prematurity and bronchopulmonary dysplasia
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Acute respiratory distress syndrome (ARDS)
aka Adult respiratory distress syndrome
Diffuse alveolar damage → ↑ alveolar capillary permeability → protein-rich fluid leakage into alveoli
- Features:
- -hyoxemia
- -cyanosis
- -respiratory distress
- -"White-out" on chest X-ray
- Cause: initial damage due to release of neutrophilic substances toxic to alveolar wall, activation of coag cascade, oxygen derived free radicals...
- -Trauma
- -Sepsis
- -Shock
- -Gastric aspiration
- -Uremia
- -Acute pancreatitis
- -Amniotic fluid embolism
- Histology:
- -Formation of intra-alveolar hyalin membrane
- Tx:
- -Treat underlying cause
- -Ventilation with PEEP
- -**Most have normal lungs 1yr following
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- Obstructive lung volumes > normal
- ↑ TLC, ↑ FRC, ↑ RV
- FEV1 is more dramatically reduced compared to FVC
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- Restrictive lung disease
- Volumes < normal
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Sleep apneaa
- -Repeated cessation of breathing > 10 seconds during sleep → disrupted sleep → daytime somnolence
- -Hypoxia → ↑ EPO release → ↑ erythropoiesis
- Central sleep apnea
: no respiratory effort- Obstructive sleep apnea
: respiratory effort against airway obstruction- -Associated with obesity, loud snoring, systemic/pulmonary hypertension, arrhythmias, and possibly sudden death
Tx: weight loss, CPAP, surgery
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Pleural effusion
- ↓ breath sounds
- Dull to percussion
- ↓ fremitus
- no tracheal deviation
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Atelectasis (bronchial obstruction)
- ↓ breath sounds
- Dull to percussion
- ↓ fremitus
- Tracheal deviation toward side of lesion
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Spontaneous pneumothorax
- ↓ breath sounds
- Hyperresonant to percussion
- ↓ fremitus
- Tracheal deviation toward side of lesion
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Tension pneumothorax
- ↓ breath sounds
- Hyperresonant to percussion
- ↓ fremitus
- Tracheal deviation away from side of lesion
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Consolidation
(lobar pneumonia, pulmonary edema)
- Bronchial breath sounds; late inspiratory crackles
- Dull to percussion
- ↑ fremitus
- No tracheal deviation
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Lung cancer
presentation, complications, smoking
- -Leading cause of cancer death
- -Metastatic cancer is most common cause
- (breast, colon, prostate, bladder cancer)
- -Sites of metastases: adrenals, brain, bone (pathologic fracture), liver (jaundice, hepatomegaly)
- Presentation
:- -Cough
- -hemoptysis
- -bronchial obstruction
- -wheezing
- -weight loss
- -pneumonic "coin" lesion on CXR
- -noncalcified nodule on CT
- Complications: SPHERE
- -Superior vena cava syndrome
- -Pancoast tumor
- -Horner's syndrome
- -Endocrine (paraneoplastic)
- -Recurrent laryngeal symptoms (hoarseness)
- -Effusions (pleural or pericardial)
- Smoking:
- -All are associated with smoking except brronchioalveolar and bronchial carcinoid
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Lung cancer
Small cell vs non-small cell
- Small cell carcinoma: 15%
- -no surgical resection
- -treat with chemotherapy
- Non-small cell carcinoma: 85%
- -Adenocarcinioma (40%)
- -Squamous cell carcinoma (30%)
- -Large cell carcinoma (10%)
- -Carcinoid tumor (5%)
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Lung cancer
Adenocarcinoma
- Location: peripheral
- -Most common lung cancer in nonsmokers and females
- -Activating mutations in k-ras common
- -Associated with hypertrophic osteoarthropathy (clubbing)
- Bronchioloalvolar subtype: CXR often shows hazy infiltrates similar to pneumonia; excellent prognosis
- -Histology: grows along alveolar septa → apparent "thickening" of alveolar walls
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Squamous cell carcinoma
- Location: Central
- Hilar mass arising from bronchus
- Cavitation
- Cigarrettes (linked to smoking)
- hyperCalcemia (produces PTHrP)
- Most common tumor in male smokers
- Histology: keratin pearls and intercellular bridges
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Small cell (oat cell) carcinoma
- Central
- Undifferentiated → very aggressive
- May produce ACTH, ADH, or Antibodies against presynaptic calcium channels (Lambert-Eaton syndrome)
- Amplification of myc oncogenes common
- Male smokers
- Tx
: Inoperable; treated with chemotherapy - Histology: neoplasm of neuroendocrine Kulchitsky cells → small dark blue cells
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Large cell carcinoma
- Location: peripheral (or central)
- Highly anaplastic undifferentiated tumor (no keratin pearls, intracellular bridges, glands or mucin)
- poor prognosis
- less responsive to chemotherapy
- surgical resection
- Smoking
- Histology: Pleomorphic giant cells
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Bronchial carcinoid tumor
- Location: -
- Excellent prognosis; metastasis is rare
- Not smoking related
- Sx usually due to mass effect
- Occasionally carcinoid syndrome (serotonin secretion → flushing, diarrhea, wheezing)
- Histology: Nets of neuroendocrine cells; chromogranin positive
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Mesothelioma
- Location: Pleural
- Malignancy of the pleura associated with asbestosis
- Results in hemorrhagic pleural effusions and pleural thickening
- Histology: Psammoma bodies
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Pancoast tumor
- Carcinoma that occurs in apex of lung may affect cervical sympathetic plexus
- Horner's syndrome: ipsilateral ptosis, miosis, anhidrosis
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Superior vena cava syndrome
- Obstruction of the SVC that impairs blood drainage from:
- -head ("facial plethora")
- -neck (jugular venous distention)
- -upper extremities (edema)
- -Commonly caused by malignancy and thrombosis from indwelling catheters
- -Medical emergency!
- -Can raise intracranial pressure (if obstruction severe) → headaches, dizziness, and ↑ risk of aneurysm/rupture of cranial arteries
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Lobular Pneumonia
organism, characteristics
- Lobar: S. pneumoniae most frequently, Klebsiella-Intra-alveolar exudates → consolidation
- -May involve entire lung
- -Phases: congestion → red hepatization → gray hepatization → resolution
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Bronchopneumonia
organism, characteristics
- S. pneumoniae, S. aureus, H. influenzae, Klebsiella
- Acute inflammatory infiltrates from bronchioles into adjacent alveoli
- Patchy distribution involving ≥ 1 lobe
 
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Interstitial (atypical) pneumonia
organisms, characteristics
- Viruses (influenza, RSV, adenovirus), Mycoplasma, Legionella, Chlamydia
- Diffuse patchy inflammation localized to interstitial areas at alveolar walls
- Distribution involving ≥ 1 lobe
- Generally follows a more indolent course
- -Atypical presentation: mild upper respiratory symtoms
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Aspiration pneumonia
- Seen in pts at risk for aspiration (alcoholics and comatose patients)
- Bacteria of the oropharynx (e.g., Bacteroides, Fusobacterium, Peptococcus)
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Lung abscess
- Localized collection of pus within parenchyma
- Causes
:- -bronchial obstruction (e.g., cancer)
- -aspiration of oropharyngeal contents (pts predisoposed to loss of consciousness - alcoholics, epileptics)
- -Air-fluid levels seen on CXR
- -S. aureus or anaerobes (Bacteroides, Fusobacterium, Peptostreptococcus)
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Tuberculosis
Mycobacterium tuberculosis
- Primary: focal, caseating necrosis in the lower lobes and hilar LNs
- -Generally asymptomatic
- Secondary: reactivation in the apex of lung (high O2 tension)
- -Cavitary foci of caseous necrosis
- -may progress to miliary TB or TB bronchopneumonia
- Features: nigh sweats, fevers, cough with hemoptysis, weight loss
- -Bx: caseating granulomas
- -AFB stain +
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Hypersensitivity pneumonitis
- Mixed type III/IV hypersensitivity reaction to environmental antigen
- Granulomatous reaction to inhaled organic antigens
- Presentation: dyspnea, cough, chest tightness, headache
- Who: farmers, those exposed to birds
- Chronic exposure leads to interstitial fibrosis
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Pleural effusion
transudative vs exudative
Transudate: ↓ protein content
-Due to CHF, nephrotic syndrome, hepatic cirrhosis
Exudate: ↑ protein content, cloudy
- -Due to malignancy, pneumonia, collagen vascular disease, trauma (occurs in states of ↑ vascular permeability)
- -Must be drained in light of risk of infection
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Pleural effusions
Lymphatic
- aka chylothorax
- Due to thoracic duct injury from trauma, malignancy
- Milky-appearing fluid
- ↑ triglycerides
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Pneumothorax
presentation
- Unilateral chest pain and dyspnea
- unilateral chest expansion
- ↓ tactile fremitus
- hyperresonance
- diminished breath sounds
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Spontaneous pneumonthorax
- Accumulation of air in the pleural space
- Most frequently in tall, thin, young males (caused by rupture of apical blebs)
- Trachea deviates toward affected lung
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Tension pneumothorax
- Usually occurs in setting of trauma or lung infection
- Air is capable of entering pleural space, but not exiting
- Trachea deviates away from affected lung
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