Respiratory Path from Goljan Rapid Review Flashcards

sputum
Terms Definitions
What is the most common cause of typical community acquired pneumonia?
Streptococcus pneumoniae
What is the most common cause of atypical pnuemonia?
Mycoplasma Pneumoniae
Interstitial pneumonia is...
atypical
bronchopneumonia is...
typical
signs of consolidation, in terms of percussion, egophany, tactile fremitus, whispered pectorliloquy
dullness to percussion
egophany +
increased tactile fremitus
whipsered pectoriliquy +
Consolidation indicates atypical or typical pneumonia?
Typical.
What is the most common source of nosocomial pneumonia infection?
Respirators.
What pathogen is usu responsible for respirator contracted pneumo?
Pseudomonas aeruginosa
What three pathogens are associated with nosocomial pneumo?
Pseudomonas aeruginosa, Escheria coli, Staph aureus.
Most common cause of the common cold.
Rhinovirus
What type of influenzavirus is most often involved?
A
2nd most common cause of atypical pneumonia
Chlamydia pneumoniae
Case: newborn: afebrile, staccato cough, conjunctivitis, wheezing. Pathogen?
Chlamydia trachomatis
Water loving bacteria that causes green sputum
Pseudomonas aeruginosa (respirators!)
Most common cause of pneumonia in alcoholics. Then another cause.
Klebsiella pneumoniae or just S. pneumoniae.
How do you differentiate between the two common causes of pneumo in alcoholics?
Klebsiella pneumoniae causes thick mucoid sputum, where as S pneumo does not.
What bacterial cause of pneumo is associated with water coolers and produce mists?
Legionella pneumophila
Case: Pneumo with hyponatremia. Pathogen and pathophys?
Legionella can cause tubulointerstitial disease with JG destruction learing to hyporeninemic hypoaldosteronism with hyponatremia, hyperk, and met acid.
What is the most common opportunistic fungal infection and where is it found in the community?
Cryptococcus neoformans, found in pigeon poop.
What fungal infection is associated with Ohio/central Mississippi River valley? What 3 animals carry it?
Histoplasma capsulatum. Bats, starlings, chickens. Thus assoc with cave explorers, spelunkers, and chicken farmers.
What systemic fungi is associated with the central and southeast US?
Blastomyces dermatidis.
SW "Valley fever," increases after earth quakes (in dust).
Coccidioides immitis.
Cave explorer in the Arizona desert with nonproductive cough.
Coccidioides, not Histoplasma. SW! dry!
I say pigeons, you say...
Cryptococcus neoformans!
What yeast will be phagocytosed by macrophages?
Histoplasma
A nasal polyp in a kid is most likely caused by...
Cystic fibrosis.
A nasal polyp in an adult is most likely caused by...
Allergies.
A woman with chronic pain has asthma. What else?
A nasal polyp caused by NSAID use. Block cyclooxygenase, leave lipoxygenase path open. Leukotrienes C-D-E are increased, causing bronchoconstriction.
What is a medically significant A-a gradient?
> 30
What causes an increased A-a gradient?
Hypoxemia of pulmonary origin.
Calculate and A-a gradient in a pt breathing .3 O2 who has PCO2 of 80 mmHg and PaO2 of 40 mmHg.
PAO2 = 0.3 (713) - 80/0.8 = 114 mmHg
A-a = 114-40 = 74 mm Hg, which is clinically significant
Name 3 causes of hypoxemia with a normal A-a gradient.
1. Depression of medullary resp centers
- barbituates, brain injury
2. Upper Airway obstruction
-food block, epiglottitis, croup
3. Muscles of respiration dysfunction
-paralyzed diaphragm
Name 3 general causes of hypoxemia with an increased A-a gradient
1. Ventilation defect
2. Perfusion defect
3. Diffusion defect
Example of a ventilation defect
Airway collapse in ARDS - impaired O2 deliver to alveoli
Example of perfusion defect
Pulmonary emobolus blocks blood flow to alveoli
2 Examples of Diffusion defects
Interstitial Fibrosis
Pulmonary Edema
O2 can't diffuse alveoli->capillary
What is the most common cause of fever 24-36 hours after surgery?
Resorption atelectasis.
Ex: mucus plug obstructs airway, alveoli collapse.
On Tension pneumothorax, what side does the trachea deviate to?
Contralateral - pushed by air compressing the lung.
With resorption atelectasis, what side does the trachea deviate to?
Ipsilateral - goes where there is space.
What cell synthesizes surfactant?
Type II pneumocytes.
What increases surfactant synthesis? (2) Decreases? (2)
Increases: cortisol and thyroxine
Decreases: insulin (maternal diabetes), prematurity, c-section (less cortisol)
How does surfactant work?
Prevents alveolar collapse on expiration by reducing surface tension.
Is Infant RDS a ventilation, perfusion, or diffusion defect?
Ventilation, alveoli collapse.
infant RDS treatment
PEEP
Free radicals from O2 thrx in infant RDS can cause...(2)
blindness
bronchopulmonary dysplasia
What causes hypoglycemia in the newborn?
Excess insulin from response to fetal hyperglycemia in maternal diabetes.
What causes hyaline membranes?
proteins leaking out of damages pulmonary vessels
What causes ARDS? Pathophys.
Pulmonary edema from acute alveolar capillary damage.
What causes capillary damage in ARDS?
Acute damage ->macrophages release cytokines-> chemotactic to netrophils -> neuts transmigrate through pulm capillaries -> leave holes -> protein leakage -> hyaline membranes
Gram + diplocci on sputum stain =
How do you treat?
Strep Pneumo. Treat with Penicillin G.
How do you prevent Pneumocystis in AIDS pts?
Rx TMP/SMX (trimethoprim-sulfamethxazole) when CD4 is <200.
What 3 things can Aspergillus cause?
1. Aspergilloma: fungus ball in old TB site, hemoptysis
2. Allergic reaction
3. Vessel invasion with hemorrhagic infarction and necrotic bronchopnuemo
Where do most PE's come from?
Clot in femoral vein, NOT lower leg DVT.
Where will an aspiration mass go if you are sitting? supine? right sided? Which is most common?
Sitting = R lower lobe, posterobasal
Supine = R lower lobe, superior seg
*most common
Right side= R upper lobe, superior seg
What 2 diagnostic tests are used to diagnose PE? Gold standard?
1. VQ scan - V normal, Q off
2. Gold = pulm angiogram
How do you prevent Pneumocystis in AIDS pts?
Rx TMP/SMX (trimethoprim-sulfamethxazole) when CD4 is <200.
What 3 things can Aspergillus cause?
1. Aspergilloma: fungus ball in old TB site, hemoptysis
2. Allergic reaction
3. Vessel invasion with hemorrhagic infarction and necrotic bronchopnuemo
Where do most PE's come from?
Clot in femoral vein, NOT lower leg DVT.
Where will an aspiration mass go if you are sitting? supine? right sided? Which is most common?
Sitting = R lower lobe, posterobasal
Supine = R lower lobe, superior seg
*most common
Right side= R upper lobe, superior seg
What 2 imaging diagnostic tests are used to diagnose PE? Gold standard?
1. VQ scan - V normal, Q off
2. Gold = pulm angiogram
NOT spiral CT.
D-dimers also useful. Neg rules out PE.
Interstitial Fibrosis
Restrictive or Obstructive?
FEV1
FVC
FEV1/FVC
TLC
Restrictive, all V decreased.
FVC, TLC down
FEV1/FVC increased - FEV1 up bc of increased elasticity
What is Caplan syndrome?
Rheumatoid nodules in lung + restrictive disease like Coal WP or Asbestos disease.
What does Coal WP do to TB risk? Cancer risk?
Does not affect TB or cancer risk.
What does silicosis do to cancer and TB risk?
Increases risk of cancer and TB
What do lung opacities contain in silicosis?
Collagen and quartz. HARD as rocks, as they are made of rocks. Quartz is super fibrogenic
What is the most common lesion related to asbestos exposure? What is the most common disease process?
1. Benign plueral plaques
2. Primary bronchogenic carcinoma
-Mesothelioma takes longer to show up, thus less common than primary cancer
What 2 complications are common in all 3 pneumoconiosis? (silicosis, coalwp, asbetosis)
Cor pulmonale
Caplan syndrome
What do roofing and working in shipyards expose you to?
Asbetos
What do foundries (casting metal), sandblasting, and mines expose you to?
Quartz / Silicosis
What is the most common sxs of Sarcoidosis?
Dyspnea
What does sarcoidosis do to the lung?
causes granulomas in interstitium and nodes, contain multinucleated giant cells
Name 3 other manifestations of sarcoidosis (outside the lung)
1. Nodular skin lesions
2. Eye lesions
3. Granulomatous hepatitis
4. Enlarged lacrimal glands
5. increased ACE
6. Hypercalcemia
What is the likely cause of a pleural effusion in a young woman?
SLE - Lupus
example of serositis
Farmer's Lung is caused by...
Moldy hay = saccharopolyspora rectivirgula / thermophilic actinomyces
Type III hypersensitivity - immune complex mediated
Type IV with Chronic exposure -> granuloma
In Emphysema, compliance___ and elasticity___.
Compliance increases (inhalation)
Elasticity decreases (exhalation)
What's the difference between a transudate and an exudate?
Transudate: ultrafiltrate of plasma. ex: heart failure

Exudate: protein-rich, cell-rich fluid
ex: pneumonia, infarction, metastasis
Pleural fluid protein / serum protein = 0.6

Transudate or exudate?
over 0.5 = exudate

(more protein in fluid than plasma)
Pleural fluid LDH/serum LDH = 0.7

Transudate or exudate?
over 0.6 = Exudate
What lung cancer can cause Horner's syndrome and why?
Pancoast tumor of superior sulcus - usu primary sq cell cancer in extreme apex. Can destroy superior cervical ganglion and cause horners (eye lid lag, miosis - pinpoint pupil, anhydrosis - no sweating)
What is the most common type of lung cancer?
Metastatic more common than primary.

Primary, most common is Adenocarcinoma.
Are cancers caused by smoking usually peripheral or central?
Central
However, after filters were installed in cigarettes, the big carcinogens got filtered out. Now, peripheral cancers caused by the small carcinogens are increasing.
Which two cancers have the strongest association to smoking?
1. Squamous cell
2. Small cell
Is adenocarcinoma related to smoking? Where in the lungs is it usually found.
Adenocarcinoma is not usually associated with smoking, usually found peripherally.
What is the most important first step in evaluating a "coin lesion" on a chest x-rays.
Compare size from previous x-rays.
What three cancers are most often associated with lung mets?
1. Primary Breast
2. Colon, Renal Cell
What is the most common symptom of primary lung cancer? What about metastatic?
Cough for primary, dyspnea for metestatic. (Still have dyspnea in primary.)
Where does primary lung cancer metastisize to?
1. Hilar lymph nodes
2. Adrenal gland
3. Liver (50%), brain (20%), bone
Name 5 issues associated with CF that are not pulmonary.
1. Malabsorption - pancreatic exocrine def
2. Type 1 diabetes - chronic pancreatitis
3. Male infertility
4. Meconium ileus in bebes
5. 2ary Biliary cirrhosis - bile duct obstruction by thick secretions
What is the most common respiratory pathogen in CF?
pseudamonas aeruginosa
What is the most common cause of death in CF?
Respiratory infection.
Most common cause of bronchiectasis in US? INternational?
US - CF
Int - TB
What condition is associated with cupfuls of sputum production?
Bronchiectasis, due to dilation of bronchi and bronchioles that get filled with pus. Ew.
Extrinsic asthma is associated with what type of hypersensitivity rxn?
Type 1 - IgE dependent activation of Mast cells.
All these things are involved in asthma pathology. Tell me the story of how: Eotaxin, IL4, T cells, eosinophils, mast cells, major basic protein, IL5, histamine, cationic protein, LTC-D-E, Acetylcholine
1. Inhaled allergen sensitizes by stimulating helper T cells (CD4Th2) that release IL 4 and IL 5.
IL 4 - IgE production
IL 5 - production and activation of eosinophils
2. Antigens crosslink IgE on mast cells, release histamine + mediators -> bronchoconstriction, mucus, leukocytes
3. Late phase (4-8 hrs later)
Eotaxin - chemotactic for eosinophils
Eosinophils release major basic protein and cationic protein, which damage epithelial cells and produce airway constriction
LTC-D-E cause prolonged bronchoconstriction
Acetylcholine causes airway muscle contraction.
How are IL4 and IL5 involved in extrinsic asthma?
Released by Tcells
IL4 stimulates isotope switching to IgE production.
IL5 stimulated production and activation of eosinophils.
Name two causes of emphysema
1. Smoking
2. alpha-1-antitrypin def (AAT)
What causes airway collapse in emphysema?
Loss of elastic tissue - loss of radial traction.
What causes panacinar emphysema? Centriacinar?
Panacinar = AAT def
Centriacinar = smoking
Curschmann spirals and Charcot-Leyden crystals are histologic evidence of what disease?
Asthma.
What lung cancer is associated with hypercalcemia?
Squamous Cell
What lung cancer is associated with Cushings?
Small Cell
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