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pulmonarydoc - Contemporary Report


									                  Pulmonary                          IDIOPATHIC PULMONARY HEMOSIDEROSIS
                                                     INTERSTITIAL LUNG DISEASE
                                                     LANGERHANS CELL HISTIOCYTOSIS (HISTIOCYTOSIS X)
                     1-7-05                          LARYNGITIS
                                                     LIGHT’S CRITERIA
                                                     LUPUS (SYSTEMIC LUPUS ERYTHEMATOSUS)
                                                     NEOPLASM - ADENOCARCINOMA
                                                     NEOPLASM - ANTERIOR MEDIASTINAL MASSES
                                                     NEOPLASM - BRONCHIOLOALVEOLAR
                                                     NEOPLASM - CARCINOMA
                                                     NEOPLASM - LARGE CELL ANAPLASTIC CARCINOMA
                                                     NEOPLASM - SMALL CELL ANAPLASTIC (OAT CELL)
                                                     NEOPLASM - SOLITARY PULMONARY NODULE/MASS
                                                     NEOPLASM - SQUAMOUS CELL CARCINOMA
                                                     NEUROMUSCULAR DISEASE
                                                     PLEURAL EFFUSION
                                                     PNEUMONIA (ASPIRATION)
                                                     PNEUMONIA (ATYPICAL)
                                                     PNEUMONIA (BACTERIAL)
                                                     PNEUMONIA – EOSINOPHILIC
                                                     PNEUMONIA (GRANULOMATOUS)
                                                     PNEUMONIA (LIPID)
                                                     PNEUMONIA (UNRESOLVING)
                                                     PNEUMONIA (PNEUMOCYSTIS CARINII)
                                                     PNEUMONIA (VIRAL)
                                                     PNEUMOTHORAX (PTX)
                                                     PULMONARY ANGITIS (VASCULITIS)
                                                     PULMONARY CONGESTION
                                                     PULMONARY ALVEOLAR PROTEINOSIS
                                                     PULMONARY EDEMA
                                                     PULMONARY EMBOLISM (PE)
                                                     PULMONARY EMBOLISM – PROBABILITY SCORING
                                                     PULMONARY EMBOLISM – WORKUP – NEW (2001)
                                                     PULMONARY EMBOLISM – WORKUP – OLD (1999)
                                                     PULMONARY HEMORRHAGE
                                                     PULMONARY HYPERTENSION
PULMONARY INFARCTION                                                                                               DVX
                                                                                                                   Cancer, TB, or other cavitary/necrotic process
SEPSIS                                                                                                             Antibiotics - usually PCN or clindamycin (for anaerobe coverage) - total duration of 4-8weeks.
SINUSITIS                                                                                                          Actinomycosis
TUBERCULOSIS - EXTRAPULMONARY                                                                                      OVERVIEW
                                                                                                                   One of the two bacteria which masquerade as fungi (Nocardia is the other).
TUBERCULOSIS - MDR                                                                                                 Infections result in both a suppurative and granulomatous response.
TUBERCULOSIS - PULMONARY                                                                                           Spreads contiguously through anatomic barriers.
UPPER RESPIRATORY INFECTION                                                                                        Most common location of infections are:
                                                                                                                   - cervicofacial
                                                                                                                   – thoracic
                                                                                                                   – abdominal
                                                                                                                   – female genital
A-a Gradient                                                                                                       LABs
                                                                                                                   G+ organism with filamentous branching and “sulfur granules”
0.21*age + 2.5 for adults.                                                                                         RX
                                                                                                                   IV penicillin G injections for 2-6 weeks, followed by oral penicillin for up to 12-18mo. depending on how deep-
ABNORMAL                                                                                                           seated the infection is.
Causes include:
- V/Q mismatch
- Shunt
- Diffusion limitation                                                                                             Alveolar Disease
- Decreased MVO2 (minute ventilation).
                                                                                                                   Anything which fills alveolar lumen
ABPA (Allergic BronchoPulmonary Aspergillosis)                                                                     see various pneumonias
PATHOLOGY                                                                                                          DVX
Hyper Immune response to aspergillus antigens. Like being allergic to cats and having a cat live inside your       “What Can Fill alveoli?”
lungs.                                                                                                             (1) Water – Pulmonary Edema
Only well defined allergic condition where antigen source is resident in lungs.                                    (2) Cells:
Common in CF patients                                                                                              - PMNs – pneumonia, especially bacterial/infectious, pneumonitis
HX                                                                                                                 - Eosinophils – eosinophilic pneumonia
Recurrent productive cough with tan or brown sputum.                                                               - Lymphs/Macrophage – Sarcoidosis, Desquamative Interstitial Pneumonitis (DIP), Lymphocytic Interstitial
                                                                                                                   pneumonitis, hypersensitivity pneumonitis – more commonly present as interstitial infiltrates
LAB                                                                                                                - RBC – diffuse alveolar hemorrhage, trauma (lung contusion)
High levels of IgE to aspergillus (skin test or RAST)
                                                                                                                   - Malignancy - bronchoalveolar cell carcinoma, lymphoma
High total serum IgE (>400IU/ml)
                                                                                                                   (3) Fibrous Tissue – BOOP – Brochiolitis Obliterans Organizing Pneumonia
High levels of IgG (precipitins on ELISA)
                                                                                                                   (4) Foreign Material – Lipoid pneumonia, aspiration pneumonia
High eosinophilia
Oral steroids, bronchodilators
                                                                                                                   ARDS – Acute Respiratory Distress Syndrome
                                                                                                                   ARDS leads to DAD (Diffuse Alveolar Damage), a widespread non-specific pattern of damage to alveolar
Abscess (Lung Abscess)                                                                                             epithelium.
PATHOLOGY                                                                                                          Acute RDS is aka Adult RDS.
Localized accumulation of pus w/destruction of underlying tissue                                                   PATHOLOGY
Can drain to external environment via bronchial tree
                                                                                                                   Acute stage (week 1): Type 1 pneumocytes die, intra-alveolar edema occurs, type II pneumocytes multiply and
Usually polymicrobial – Anaerobic or aerobic
                                                                                                                   line the inside of the alveoli, hyaline membrane forms inside alveoli, hyaline membrane composed of proteinous
Caused by Inhalation of necrotic or caustic material from stomach or nasopharynx or Infection
                                                                                                                   exudate and cell debris. Hyaline membrane is typically an eosinophilic, protein rich, amorphous structure.
Complications – hemoptysis, empyema, disseminated infection
                                                                                                                   Organizing stage: Fibroblast proliferation, fibrosis, honeycomb lung
DIAGNOSTIC CRITERIA                                                                           Compression – Pleural effusion, pneumothorax, neoplasm, high diaphragm (CNS disease), enlarged hilar lymph
Identifiable associated condition (see DDX – cause)                                           nodes
Acute onset                                                                                   Obstruction – LACE – mucus, smooth muscle constriction, neoplasm
Pulmonary artery wedge pressure <18mmHg or absence of LAH                                     Intrinsic ability loss – IPF, loss of elasticity, postoperative pain – V/Q low due to reduced V
Bilateral infiltrates on CXR                                                                  HX
PaO2/FiO2 <200                                                                                can be asymptomatic,
DDX - CAUSE                                                                                   can present with hypoxemia
Aspiration of gastric contents
Multiple Trauma                                                                               Black Lung
Diffuse pneumonia
Inhalation injury                                                                             see CWP (Coal Worker’s Pneumoconiosis)
Reperfusion pulmonary edema
Acute pancreatitis
                                                                                              Blastomycosis dermatitidis
Drug overdose                                                                                 SUMMARY
HX                                                                                            Fungal pneumonia
Dyspnea, cough, acute onset                                                                   North America, Ohio-Mississippi valley, mid-atlantic
                                                                                              Primary infection pulmonary, common for dissemination to skin
PE                                                                                            Solitary or progressive lung disease
Tachypnea                                                                                     Organism is yeast with broad based bud (5-25um)
CXR – bilateral alveolar infiltrates
Hypoxema – PaO2/FIO2 < 200mmHg                                                                BOOP
 if < 300mmHg we say “Acute lung injury”
                                                                                              Bronchiolitis Obliterans with Organizing Pneumonia
Identify and treat cause
                                                                                              Unknown etiology, associated with distinctive pattern of fibrosis that involves distal airways and alveoli.
Minimize complications – nosocomial infections, PE, GI bleeds, etc.
                                                                                              Polypoid plugs of loose fibrous tissue are present in bronchioles, alveolar ducts, and alveoli.
Initiate nutrition
                                                                                              Alveolar spaces contain similar plugs of loose organizing CT.
Use appropriate sedation, but limit paralytics
                                                                                              Corticosteroids, although some recover without them.
Avoid volutrauma – set tidal volume at 6mL/kg
Maintain plateau pressures <30mmHg
Ensure adequate oxygenation – SaO2 >88%
Maintain FiO2<60% (as a goal)                                                                 Bronchiectasis
PEEP – to splint open alveoli and treat severe hypoxemia
Proning – to ventilate different areas of lung.
                                                                                              Chronic dilation of bronchi or bronchioles as a sequel of inflammatory disease or obstruction
                                                                                              Atelectasis, Obstruction or Recurrent pneumonia cause  Bronchial inflammation  Infection, fibrosis 
Aspergillosis                                                                                 Chronic Dilation/destruction of bronchi  bronchiectasis
SUMMARY                                                                                       **Chronic inflammation eats through supporting cartilage of bronchioles/bronchi, causing them to get weak and
Fungal pneumonia                                                                              dilate.
Three types:                                                                                  HX
- Invasive Pulmonary Aspergillosis – angioinvasive, causes thrombi, infarcts, VERY BAD.       Chronic, purulent sputum, hemoptysis
- Aspergilloma – secondary colonization of tumors
- Allergic Bronchopulmonary Aspergillosis – see ABPA                                          PE
                                                                                              Localized chest crackles, clubbing
                                                                                              Dilated, tortuous airways on chest CT scan
collapsed lung due to obstruction, compression, or loss of intrinsic ability to inflate
                                                                                              Bronchitis (Acute)
Usually viral (influenza, rhinovirus)                                                                            RX
Secondary bacterial infection may occur – H. flu, Strep. Pneumo, Staph Aureus                                    see COPD
Purulent sputum indicates secondary infection
We need to sample sputum from LRT, early AM best time to do this.
RX                                                                                                               Clubbing
Five pillars to rhinitis/bronchitis RX:
(1) Rest, drink lots of fluids, eat.                                                                             PE
(2) Decongestants - pseudoephedrine, phenylpropanolamine                                                         (1) Nail normal extends from nailbed at 160 degree angle. If this angle is > 180, we have clubbing.
* Watch hyperglycemia in brittle diabetics, watch tachycardia/HTN in severe CHF/CAD.                             (2) Depth of distal phalanx is greater than middle phalanx.
(3) Antihistamines (first generation) - chlorpheniramine, clemastine (tavist)                                    (3) Schamroth sign – normally we see diamond shape when we hold dorsal surfaces of phalanges together. With
(4) Cough suppressants - only in adults, no suppression for kids!                                                clubbing, we don’t see any light passing between fingers.
Try Albuterol for 1 week, or try anti-tussive w/ DM (dextromethorphan)                                           PATHOLOGY
(5) Analgesia - tylenol, NSAIDs, gargle w/ salt water.                                                           Many conditions cause clubbing:
                                                                                                                 - Neoplastic intrathoracic dx
                                                                                                                 - Suppurative intrathoracic dx
Bronchoscopy                                                                                                     - Diffuse pulmonary dx
                                                                                                                 - Cardiovascular dx
INDICATIONS                                                                                                      - GI dx
(1) Infection – unable to diagnose through sputum, blood, etc.                                                   - Metabolic dx
(2) Cancer – to get cytology through washings
                                                                                                                 NEOPLASTIC INTRATHORACIC DX
(3) Sarcoidosis
                                                                                                                 - Bronchogenic carcinoma
                                                                                                                 - Malignant mesothelioma
                                                                                                                 - Pleural fibroma
Candidiasis                                                                                                      - Metastatic osteogenic sarcoma
SUMMARY                                                                                                          SUPPURATIVE INTRATHORACIC DX
Fungal pneumonia                                                                                                 - Abscess
Ubiquitous – hard to distinguish colonization vs. invasive                                                       - Bronchiectasis
Usually not granulomatous                                                                                        - Cystic fibrosis
                                                                                                                 - Empyema
                                                                                                                 - Mycobacterial or fungal infection – chronic

Cavitary Lung Mass                                                                                               DIFFUSE PULMONARY DX
                                                                                                                 - IPF
DDX                                                                                                              - Asbestosis
TB                                                                                                               - Pulmonary AV malformation
Abscess – Staph aureus, Anaerobes
                                                                                                                 CARDIOVASCULAR DX
                                                                                                                 - Cyanotic congenital dx
Immune suppressed – Nocardia, Aspergillus, Actinomycetes, Atypical mycobacteria, Fungal – Histo, Coccidio,
                                                                                                                 - Infective endocarditis
Crypto, PCP, Rhodococcus
                                                                                                                 - Arterial graft sepsis
Rhem – Wegeners, Churg-Strauss
                                                                                                                 - Brachial AV fistula
                                                                                                                 - Hemiplegic stroke.
                                                                                                                 GASTROINTESTINAL DX
Chronic Bronchitis                                                                                               - IBD
PATHOLOGY                                                                                                        - Celiac dx
Obstructive lung disease                                                                                         - Hepatobiliary dx
Hypersecretion of mucus, hyperplasia and hypertrophy of mucus glands in trachea and bronchi                      METABOLIC DX
Edema and inflammation (PMNs)                                                                                    - Thyroid acropachy
productive cough for at least 3 months in 2 consecutive years
“Blue bloater” because they cannot get air into lungs through Obstructed opening
wheezes, rhonchi, cyanosis
                                                                                                                 90% of patients with COPD have combination chronic bronchitis and emphysema.
LAB                                                                                                              These patients usually have H. influenza colonizing their lungs.
hypercapnia, hypoxia                                                                                             Most exacerbations are due to LRTI - 30% from H. flu, 12% from Strep. pneumo.

40% of COPDers have pulmonary bacterial colonization when asymptomatic.
85% of COPDers w/ green sputum production have bacterial colonization of RT.
                                                                                                                         COPD – and O2
RX - ACUTE EXACERBATION                                                                                                  PATHOLOGY
                                                                                                                         Giving Oxygen to a COPD patient may cause the CO2 to increase, resulting in an acute respiratory acidosis and
Antibiotics do help, although mean increase in PF only about 11. In general, the more severe the exacerbation,
                                                                                                                         worsening of their condition. Three mechanisms causes this:
the more Abx might help.
                                                                                                                         (1) Change in V/Q mismatch – by increasing the dead space.
PO steroids help, but 2 weeks is as good as 8 weeks, and with many less side fx.
                                                                                                                         (2) Haldane effect – increasing O2 causes binding to Hgb and release of CO2 in serum.
RX - MAINTENANCE                                                                                                         (3) Decreased hypoxic drive to breathe (the least important).
Add these meds in order, push each to max doses listed. If the next change shows no improvement, step back to
last improvement regimen and then proceed to next step.
(1) Salmeterol, 2puffs bid
(2) Ipatropium Bromide, 2-6puffs qid                                                                                     Coal Worker’s Pneumoconiosis (CWP)
(3) Albuterol, 2-4puffs qid                                                                                              OVERVIEW
(4) Consider Nebulizing Albuterol + Ipatropium Bromide tid. Measure PFTs after 2 weeks.                                  Less fibrotic than silicosis, but X-rays still show small, rounded opacities in early stage, and large, glomerular
(5) Corticosteroid trial - Inhaled corticosteroids are controversial, but may help decrease severity and frequency       opacities in late stage.
of exacerbations.                                                                                                        Leads to both a chronic bronchitis and then a restrictive pattern in late stage.
Oral corticosteroids may help some. 10-20% may report subjective improvement w/ steroids.
(6) Theophylline – long acting. Aim for serum levels of 8-12ug/ml.
(7) Other
- Oxygen – can prolong quality of life                                                                                   Coccidiomycosis
- Guaifenesin expectorant may help.                                                                                      SUMMARY
- Consider pulmonary rehab in motivated patients.                                                                        Fungal pneumonia – San Joaquin Valley Fever
EVIDENCE                                                                                                                 Southwestern US, 80% positive - very high in American Indians and Phillipinos.
Salmeterol vs. Ipa Br – Mahler et al, Chest 1999.                                                                        Infection by dust inhalation
Steroids:                                                                                                                60% of people asymptomatic, the rest have flu-like symptoms w/ complete recovery
- Inhaled – Paggiaro et al, Lancet, 1998                                                                                 Thick walled, non-budding spherule 20-60um
- Oral - Callahan et al, Annals of Int Medicine, 1991                                                                    Primarily pulmonary, but can disseminate, cause meningitis
- Oral – Nishimura et al, Chest, 1999.

COPD – ABECB                                                                                                             SUMMARY
LAST UPDATED                                                                                                             Fungal pneumonia
Dr. Greg Townsend, 10/03                                                                                                 Worldwide, found in pigeon droppings
                                                                                                                         Chronic granulomatous inflammation, dissemination in immunodeficient host (HIV)
                                                                                                                         Mainly causes meningitis, but can cause meningoencephalitis.
Acute Bacterial Exacerbation of Chronic Bronchitis
- Duration of COPD > 10yrs
- Age > 65                                                                                                               DAD – Diffuse Alveolar Damage (see ARDS)
- Pre-existing cardiopulmonary or cardiovascular dx
- Home Oxygen
ANTIBIOTICS NEEDED FOR                                                                                                   Dead Space
>2 out of 3 of the following:
- Increased dyspnea
                                                                                                                         Lack of perfusion – anything which makes V/Q go to infinity.
- Increased sputum
- Change in Sputum
(1) Strep pneumo (25% have intermediate, 15% have high resistance)                                                       Emphysema
* Note – there is increasing PRP – which are also macrolide resistant                                                    PATHOLOGY
(2) H. flu (40% produce beta-lactamase)                                                                                  Obstructive lung disease , permanent abnormal enlargement and destruction of lung units distal to terminal
(3) Moroxella catarrhalis (80% produce beta-lactamase)                                                                         bronchiole (alveolar epithelium, vascular endothelium)
ANTIOBIOTIC TREATMENT – STRATIFICATION                                                                                   Deficiency in alpha-1 antitrypsin, which is supposed to inactivate serine elastase. Elastase released by PMNs
Mild: - doxycycline, Bactrim, Macrolides                                                                                 during inflammation, and break down elastic fibers in alveolar basement membranes and capillary and small
Complicated/Chronic – FQ (Moxiflox, Gatiflox), Azithromycin                                                              vessels walls and basement membranes.
                                                                                                                         4 types:

       Centrilobular (centriacinar) – associated with smoking                                                       MYXOID FIBROSIS
       Panlobular (panacinar) – associated with alpha-1 antritrypsin deficiency                                     Myxoid - resembling mucus. This must be some sort of fibrotic mucoid plug?
       Paraseptal – distal acinar – may have blebs that rupture leading to pneumothorax
       Irregular – scarring, sometimes asymptomatic
DVX                                                                                                                 Ground-Glass Opacification
LACE for obstructive disease
PFTs                                                                                                                Focal or diffuse veil-like opacification of lung which does not obscure vasculature and does not yield air-
Obstructive tests positive:
                                                                                                                    bronchograms. Indicates parenchymal lung dx below spatial resolution of HRCT.
- Decreased FEV1/FVC (<70%)
                                                                                                                    - Early interstitial lung dx
- Decreased FEV1 (<80%)
                                                                                                                    - Incomplete alveolar filling
- Normal FVC (or slightly decreased)
                                                                                                                    - Increased pulmonary capillary blood volume
Also, w/ emphysema:
                                                                                                                    - Partial collapse of alveoli
- Decreased DLCO (destroyed vessels and alveoli)
- Increased TLC and RV (air trapping)                                                                               DDX - ACUTE
                                                                                                                    Pulmonary edema
PE                                                                                                                  Pulmonary hemorrhage
“Pink puffer” due to air trapping. CO2 may rise but not always.
                                                                                                                    Pneumonia – PCP, viral, AIP (Acute interstitial), AEP (Acute Eosinophilic lung dx)
RX                                                                                                                  Early hypersensitivity pneumonitits
see COPD                                                                                                            DDX – IMMUNOCOMPROMISED
                                                                                                                    Drug reactions
                                                                                                                    Pulmonary hemorrhage
Empyema                                                                                                             Lymphoma
                                                                                                                    In HIV+ patients – ground glass is seen in >90% of PCP cases (95% specific)
Collection of pus in the pleural space.                                                                             DDX – CHRONIC
Four diagnostic criteria for pleural fluid:                                                                         Hypersensitivity pneumonitis
- pH < 7.2                                                                                                          Desquamative Interstitial pneumonitis (DIP)
- Glucose < 50mg/dL.                                                                                                Respiratory bronchiolitis – Associated ILD (RB-ILD)
- LDH > 1000IU/L                                                                                                    Nonspecific Interstitial pneumonitis (NSIP)
- Positive gram stain.                                                                                              Bronchoalveolar cell carcinoma
                                                                                                                    Pulmonary alveolar proteinosis
RX                                                                                                                  Sarcoidosis
Empyema’s require a chest tube and drainage.                                                                        Exudative phase of UIP/IFP, BOOP

Expectorants                                                                                                        Histoplasmosis
GUAIFENESIN                                                                                                         SUMMARY
Mildly effective for loosening mucus due to chronic bronchitis.                                                     Fungal pneumonia.
Mucinex is the only pure long acting Guaifenesin.                                                                   Common in Ohio-mississippi valley region – 80-90% positive - common in rural areas.
Humibid LA is a mixture of guaifenesin + potassium guaiacolsulfonate.                                               Spread by inhaled spores from bird droppings.
                                                                                                                    Similar to MTB in latent, primary, chronic pathologies.
                                                                                                                    Oval or round yeast with narrow based bud (3-5um)
Fungus Ball
Refers to grossly evident masses of fungi, often from cystic necrotic cavities, associated with severe fungal       Hypersensitivity Pneumonitis
infections                                                                                                          PATHOLOGY
                                                                                                                    Interstitial pneumonitis affecting alveolar parenchyma caused by inhalation of various antigenic substances, aka
                                                                                                                    extrinsic allergic alveolitis
Glossary                                                                                                            NOT IgE mediated, instead IgG mediated disease.
                                                                                                                    IgG antibodies easily detectable in preciptin lines (ELISA) - usually type III Immune complex, or type IV cell-
HAMMAN’S SIGN                                                                                                       mediated. Antigen in alveoli is digested by macrophage or bound by antibody, and taken up into interstitial
Retrosternal cruch which is auscultated over mediastinum, due to pneumomediastinum.                                 space. Inflammatory reaction is triggered in interstitium, leading to fibrosis, granulomatosis, and/or pneumonitis
HYALINE MEMBRANE                                                                                                    DVX
Thin, clear basement membrane beneath certain epithelia.                                                            Farmer's Lung - Thermophilic actinomycetes
Pathological when it is created from proteinaceous exudate into alveoli during ARDS.                                Humidifier fever
Pigeon breeder’s lung (Bird fancier's Lung)                                                                               Eosinophilic granuloma (aka LCH, HX)
Maple Bark Stripper's Disease                                                                                             Drug
Mushroom Worker's Disease                                                                                                 IMPORTANT QUESTIONING - Occupational exposure, family exposure, pets, travel, drugs, etc.
HX                                                                                                                              Also check for rashes, arthritis, fever, i.e. systemic effects suggesting connective tissue disease
3 presentations:                                                                                                          HX
      Acute - like bacterial pneumonia - chills, fever, malaise, anorexia, myalgia, symptoms begin 3-8 hours              chronic, progressive dyspnea, usually over months to years. NOT ACUTE
             after exposure, NOTE - cough is usually dry instead of productive                                            Occupational exposures to toxins/carcinogens, drugs, family history, etc. VERY important
      Subacute - less specific symptoms - chronic dry cough, dyspnea, malaise, fatigue, anorexia                          PE
      Chronic - presents like IPF - "nonwheezy dyspnea"                                                                   Fine crackles on inspiration ("Velcro-like"), clubbing
PE                                                                                                                        unlike COPD, patients do not use accessory muscles, nor pursed lip breathing and forward posture until end
Fine crackles on inspiration (velco-like)                                                                                        stage disease
Decreased DLCO on PFT                                                                                                     LAB
Decreased lung volume                                                                                                     CXR – Bilateral diffuse nodular, reticular opacities, w/ distinct borders, as opposed to fluffy borders of alveolar
Hypoxemia                                                                                                                 infiltrates
LAB                                                                                                                       Lymphadenopathy – think sarcoidosis
CXR - Bilateral diffuse nodular, reticular opacities, w/ distinct borders, as opposed to fluffy borders of alveolar       Bronchoscopy w/bronchoalveolar lavage helps diagnosis
infiltrates                                                                                                               Transbronchial biopsy gives strong diagnosis
Normal serum IgE                                                                                                          Open Lung biopsy for definitive diagnosis
No immediate response w/skin tests (disease is IgG, not IgE) – reponse takes 4-6 hours                                    RX
RX                                                                                                                        Immunosuppressive therapy to decrease inflammation:
Removal of all suspected antigens is only effective RX                                                                         High dose corticosteroids
                                                                                                                          Chemotheraputics – cytoxan (cyclophosphamide), Imuran (Azathioprine)

Idiopathic Pulmonary Fibrosis (IPF)
PATHOLOGY                                                                                                                 Langerhans Cell Histiocytosis (Histiocytosis X)
chronic, progressive dyspnea over months to years. non-productive cough.                                                  PATHOLOGY
Need open lung biopsy to diagnose.                                                                                        Encompasses a spectrum of localized and systemic proliferations of Langerhans cells which have been called
See ILD.                                                                                                                  eosinophilic granuloma, among other things.
                                                                                                                          Characterized by scattered nodular infiltrates with a stellate border, extending into interstitium.
                                                                                                                          Almost never seen in non-smokers.
Idiopathic Pulmonary Hemosiderosis                                                                                        Usually strikes in 30s and/or 40s.
80% of patients are 16yo or less
Hemoptysis                                                                                                                Laryngitis
                                                                                                                          Inflammation of vocal cords.
Interstitial Lung Disease                                                                                                 Viral, bacterial, or overuse
Group of conditions involving alveolar wall and perialveolar tissue, progressive respiratory insufficiency w/
interstitial inflammation and fibrosis                                                                                    Light’s Criteria
PATHOLOGY                                                                                                                 OVERVIEW
inflammation in alveolar walls, derangement of alveolar epithelium and vascular endothelium, leading to fibrosis,         This tells us whether our pleural effusion is an exudate or transudate.
scarring of lung tissue. Pulmonary hypertension results.                                                                  If any of the 3 are met, we have an exudate:
DVX                                                                                                                       - Effusion protein/serum protein > 0.5
SHIT FACED                                                                                                                – Effusion LDH/serum LDH > 0.6
Sarcoidosis                                                                                                               – Effusion LDH > 0.6 max lab LDH
Hypersensitivity pneumonitis
Idiopathic Pulmonary Fibrosis
Tuberculosis                                                                                                              Lupus (Systemic Lupus Erythematosus)
Asbestosis                                                                                                                SUMMARY
Connective Tissue Disease/Carcinoma                                                                                       Intra-alveolar hemorrhage due to acute necrotizing vasculitis involving blood vessels in alveolar septae.
                                                                                                                          see Rheumatology dx file.
                                                                                                                    T - Primary Tumor size, 0-4
Neoplasm - Adenocarcinoma                                                                                            0 - no tumor, or tumor in situ (meaning it has not yet invaded lamina propria)
                                                                                                                     1 - <3cm
SUMMARY                                                                                                              2 - >3cm, other involvement
1/3 of all metastatic lung cancers                                                                                   3 - any size which extends into chest wall, diaphragm, or mediastinum
equal frequency in men/women                                                                                         4 - any size invading mediastinum or involving heart, great vessels, trachea, esophagus, vertebra, carina
5 year survival = 15%                                                                                               N - Nodal Involvement, 0-3
PATHOLOGY                                                                                                            0 - no nodes
Peripheral - most common                                                                                             1 - ipsilateral hilar or peribronchial region
Arises in periphery from bronchiolar or alveolar cells, associated with pleural fibrosis and subpleural scars        2 - ipsilateral mediastinal lymph nodes, subcarinal nodes
                                                                                                                     3 - contralateral metastasis
                                                                                                                    M - Metastasis 0-1
see Neoplasm - Carcinoma
                                                                                                                     0 - no metastasis to other organs
                                                                                                                     1 - metastasis
                                                                                                                    Based on TNM, we stage 0 - IV, and calculate 5 year survival rates.
Neoplasm - Anterior Mediastinal Masses                                                                              0 = TIS, N0, M0
                                                                                                                    1 = T1-2, N0, M0
                                                                                                                    2 = T1-2, N1, M0, or T3N0M0
4 Ts - teratoma, thymoma, thyroid, "terrible" lymphoma
                                                                                                                    3 = Any T, Any N, M0
                                                                                                                    4 = Any T, Any N, M1

Neoplasm - Bronchioloalveolar
Summary                                                                                                             Neoplasm - Large Cell Anaplastic Carcinoma
subtype of adenocarcinoma that grows along preexisting alveolar walls
                                                                                                                    Diagnosis of exclusion - poorly differentiated non-small cell carcinoma w/ no features of squamous or glandular
Neoplasm - Carcinoma                                                                                                Peripheral carcinoma
                                                                                                                    10% of invasive carcinomas
cancer of the lung parenchyma. CRUCIAL distinction between small cell (oat cell) and all other types.
Small cell:
                                                                                                                    Neoplasm - Small Cell Anaplastic (Oat Cell) Carcinoma
- SCC - Small cell carcinoma                                                                                        SUMMARY
Non-small cell                                                                                                      10-20% of invasive lung cancers
- Squamous cell carcinoma                                                                                           Strongly associated with smoking
- Adenocarcinoma                                                                                                    Equal frequency in men and women
- Large cell undifferentiated                                                                                       5 year survival = 1%
- Location - central vs. peripheral
                                                                                                                    Central carcinoma
- Nodule/mass characteristics
                                                                                                                    Malignant epithelial tumor with neuroendocrine features - tumor can secrete serotonin, ACTH, ADH, MSH,
- Metastasis
                                                                                                                    Calcitonin (Small Cell Always Always Morbid).
- Paraneoplastic syndromes
                                                                                                                    Thus, we could see:
LAB                                                                                                                 - SIADH - low Na due to excess ADH retaining water and diluting plasma
Cytology - from sputum, bronchial lavage, FNA (Fine Needle Aspiration)                                              - Cushings - SEC - Excess cortisol due to excess ACTH production
HX                                                                                                                  - Hyperpigmentation due to excess MSH
Dyspnea, cough, hemoptysis, weight loss, anorexia, fatigue
Other symptoms based on metastatic sites
RX - NON_SMALL CELL                                                                                                 Neoplasm - Solitary Pulmonary Nodule/Mass
Surgical resection (best option), if PFTs permit it - we need post-surgical FEV1 > 0.8-1.0L.                        SUMMARY
Adjunctive Radiation                                                                                                nodule = single lesion less than 3 cm in diameter
Chemotherapy - least effective                                                                                      mass = single lesion > 3cm in diameter
RX - SMALL CELL                                                                                                     PATHOLOGY
Surgery not an option, chemo/radiation
5 year survival for small cell is 1%
95% are one of the following:                                                                                  We can classify respiratory diseases by location - into URT and Pulmonary disease.
- primary, or metastatic carcinoma                                                                             We will also include a general "Allergy" classification, although this contains much overlap.
- granuloma (TB, fungus, sarcoid)                                                                              URT DISEASES
- benign neoplasm - usually hamartoma                                                                          (1) Infections
DVX                                                                                                            - Rhinitis
smoking history - 85% of all lung cancers                                                                      - Sinusitis
Age - cancer uncommon under 35y                                                                                - Epiglottitis
Size - <1cm likely benign, >2.5cm likely cancer                                                                - Laryngotracheobronchitis (Croup)
Shape - smooth, well-defined = benign or metastatic lesion, irregular, radiating edge = cancer                 (2) Tumors
Occupational/exposure history - may indicate fungus such as histoplasmosis instead of neoplasm                 - Nose/sinuses
Stability - no change in 2 years = benign                                                                      - Larynx
Calcification - certain patterns indicate benign                                                               PULMONARY DISEASES
LAB                                                                                                            Obstructive diseases - LACE
If no change in 2 years or calcification pattern indicates benign, no further evaluation needed                Restrictive diseases - PAINT
If further eval needed:                                                                                        Chest masses and nodules
1. Chest CT scan - to look for other nodules/metastasis, etc.                                                  Sleep Apnea
2. PFTs - to see if patient can tolerate resection
3. Follow up CXR q3-4 mo if low likelihood of cancer or poor surgical candidate
Diagnostic options:
- Bronchoscopy
                                                                                                               Pleural Effusion
- Transthoracic fine needle biopsy (FNA - fine needle aspiration)                                              SUMMARY
RX                                                                                                             Excess fluid between visceral and parietal pleura
No further eval if no change in 2 years or calcification indicates benign pattern                              Often caused by something making parietal pleural vessels leaky, or by edema process in lungs pressing through
Surgical resection without biopsy (due to false negative rate for both bronchoscopy and FNA) if PFTs are       visceral pleura
sufficient                                                                                                     PATHOLOGY
                                                                                                               Normal person – fluid secreted from parietal pleura, absorbed by visceral pleura
                                                                                                               Hydrothorax – effusion resembles water (edema).
                                                                                                               - Heart failure (CHF)
Neoplasm - Squamous Cell Carcinoma                                                                             - Low osmotic pressure due to nephrotic syndrome, cirrhosis, starvation
SUMMARY                                                                                                        - Collagen vascular diseases – Systemic lupus erythematosus, Rheumatoid arthritis, Asbestosis
1/3 of all metastatic lung cancers                                                                             Pyothorax – fluid w/many PMNs due to infection of pleura
80% male                                                                                                       - Trauma w/ secondary infection
Strongly linked to smoking                                                                                     - Complication of bacterial pneumonia extending to pleural surface
5 year survival = 30%                                                                                          - Empyma – pus (liquefaction necrosis - PMNs, macrophages, fluid, acid hydrolases, necrotic tissue)
PATHOLOGY                                                                                                      Hemothorax – blood in pleural cavity
Central, beginning with bronchial respiratory epithelial metaplasia to squamous cells.                         - pulmonary artery infarction
Usually triggered by irritant, such as cigarette smoking.                                                      - dissecting aortic aneurysm
Necrosis and cavitation common                                                                                 - TB
Hypercalcemia from PTH production by neoplasm                                                                  - Neoplasm
                                                                                                               Chylothorax – Chyle (milky, lipid rich fluid) in thorax, from lymphatic obstruction
RX                                                                                                             - Lymphoma in mediastinum – usually involving lymph nodes in posterior mediastinum
see Neoplasm - Carcinoma                                                                                       - Nematode (Roundworm) infestation
Neuromuscular Disease                                                                                          PE
Restrictive disease, due to proximal muscle weakness (myopathy).
Often presents with difficulty rising from a chair, or reaching up onto a shelf.
                                                                                                               High PMN in WBC means acute inflammation (pneumonia, PE)
LAB                                                                                                            WBC >= 50% small lymphocytes means malignancy or TB
PImax, PEmax less than 30%, or less than 50% with accompanying obstructive disease.                            If cytology and stains are negative (from thoracocentesis), do pleural biopsy
                                                                                                               Pleural fluid hematocrit > 2% serum hematocrit means cancer, trauma, PE, MTB
Overview                                                                                                       dyspnea, cough, chest pain – pleuritic (sharp, increased with inspiration)
                                                                                                               may be asymptomatic
PE                                                                                                                       DVX
dullness to percussion                                                                                                   (1) All hospitalized patients get: CBC w/differential, blood chemistries, liver function tests, 2 sets of blood
decreased breath sounds and tactile fremitus over affected area                                                          cultures, sputum gram stain and cultures, ABG or O2 sat.
Egophony, rales, bronchial breath sounds above effusion, possible atelectic lung above effusion                          (2) Also can do Ziehl-Nielson stain (mycobacterium), KOH prep (fungi), silver stain (pneumocystis), cytology
LAB                                                                                                                      (malignancy)
CXR – lateral decubitus Xray best                                                                                        (3) Anyone with pleural effusion gets thoracenteses
Ultrasound – better than CXR, aids in thoracocentesis                                                                    HX
Thoracocentesis – do unless:                                                                                             Febrile (> 38.5), tachycardia, rigor (shaking chill), dyspnea, productive cough, pleuritic chest pain – sharp, worse
       small pleural effusion with pneumoccal pneumonia                                                                  w/ inspiration, night sweats, fatigue, lethargy, anorexia, weight loss
       small typical pleural effusion with CHF                                                                           PE
       small effusion in first few days following abdominal surgery                                                      Consolidation alone, or w/pleural effusion: Dullness to percussion, bronchial breath sounds (high pitch, loud),
       small effusion in patient with ARDS                                                                               increased tactile fremitus egophony (E  A) - suggests bacteria
If exudate instead of transudate (effusion protein/serum protein > 0.5, or effusion LDH/serum LDH > 0.6, or              Other: Rales (crackles), Wheezing, tachypnea, tachycardia
effusion LDH > 0.6 max lab LDH), then test:
       PHAGS W/CC - pH, hematocrit (if bloody), amylase, glucose, WBC w/ differential, stains and cultures for           RX
MTB,                                                                                                                     Complete lab data should be acquired. WBC count can help differentiate infectious, atypical, and non-infectious.
       fungus, bacteria, cytology,                                                                                       Thorough workup of a good quality sputum specimen (less than 10 squamous epithelial cells, > 25 leukocytes per
Pleural biopsy most useful for diagnosing malignancy or MTB                                                                   high power field), is best means for identifying infectious organism and selecting antibiotics.
1. Treat underlying disease (MTB, pneumonia, PE, trauma, neoplasm)
2. Chest tube – for significant pneumothorax, hemothorax, empyema, complicated parapneumonic effusion                    Pneumonia (Aspiration)
3. Pleurodesis for untreatable malignancy
                                                                                                                         Inhalation/aspiration of gastric material and/or oropharyngeal flora (anaerobes).
                                                                                                                         Note – clinically very rare, what we typically see is aspiration pneumonitis, and the anaerobes have never been
Pneumoconiosis                                                                                                           proven to be responsible.
environmental disease caused by chronic inhalation of inorganic dust particles:
Asbestosis – occupational exposure, presence of ferruginous bodies, increased risk of bronchogenic carcinoma             Pneumonia (Atypical)
and malignant mesothelioma. Ferruginous bodies are yellow/brown rod shaped with clubbed ends.
Silicosis – miners, stone cutters, causes silicotic nodules (silicotuberculosis)
                                                                                                                         Onset is insidious, leukocytosis is absent or slight, prolonged course
Anthracosis - carbon dust, urban areas, marked by carbon carrying macrophages
                                                                                                                         Mycoplasma pneumonia
                                                                                                                         Chlamydia pneumonia
Generalized term for infiltration/inflammation of alveoli and/or interstitium with edema, leukocytes, and fibrin,        Pneumonia (Bacterial)
leading to lung consolidation. Technically pneumonia means that infectious agents are the cause.
                                                                                                                         Acute inflammation and PMN infiltrate in alveolar tissue (Bacterial hallmark is PMN, viral hallmark is
Lobar vs. Diffuse:
- Strep pneumo is lobar (classic teaching, but no 100%).
                                                                                                                         General cause is phagocytic impairment or enhanced bacterial growth
- Other bacterial are distributed - Staph, Klebsiella, Strep pyogenes, H. flu
- Atypical bacteria and viral are interstitial - Chlamydia, Mycoplasma, Legionella, viral                                PATHOLOGY
CXR:                                                                                                                     Aerogenous seeding, hematogenous seeding, or direct traumatic introduction
- Fluffy = alveolar                                                                                                      4 stages:
- Distinct borders (Reticulonodular) = Interstitial                                                                      (1) Congestion and edema – day 0-2
                                                                                                                         (2) Red hepatization – day 2-4 – massive PMN influx, fibrin and RBC influx
                                                                                                                         (3) Gray hepatization – day 4-8 – RBC disintegrate, more fibrin, Macrophages replace PMN
Acute – usually infectious (bacterial, fungal, viral, etc.)
                                                                                                                         (4) Resolution – day 8-21 – clearing of exudate, reestablishment of normal structure/function
Chronic – usually immunologic
                                                                                                                         Complications – pleural effusion, sepsis, bronchiectasis, empyema, fibrosis, lung abscess
Can be community acquired vs. nosocomial vs. opportunistic
Route of infection:                                                                                                      DVX
- Most common – aspiration of oropharyngeal secretions                                                                   Most bacterial pneumonias are normal inhabitants of oropharynx and nasopharynx and reach alveoli by aspiration
- Hematogenous spread of chronic infection                                                                               of secretions
- Inhalation of aerosolized particles (viruses)                                                                          Those predisposed to pneumonia – smokers, chronic bronchitis, alcoholism, malnutrition, impaired immunity,
                                                                                                                         poorly controlled diabetes
ETIOLOGY - BY RISK FACTOR                                                                                              RX
(1) Hospital acquired pneumonias (occur after in-patient for >48 hours) – most likely gram negative bacilli,           Corticosteroids
Staphylococcus aureus, Pseudomonas aeruginosa
(2) Community acquired pneumonias – Streptococcus pneumonia, Haemophilus influenza, viruses, mycoplasma,
(3) Smokers - think Haemophilus influenzae
                                                                                                                       Pneumonia (Granulomatous)
(4) Drinkers (ETOH) - think Klebsiella                                                                                 PATHOLOGY
(5) Aspirators - think anaerobes                                                                                       Mycobacterial and fungal
(6) Young healthy people - think Mycoplasma pneumoniae                                                                 Usually diffuse interstitial infiltration
ETIOLOGY - SPECIFIC ORGANISMS                                                                                          Chronic irritation by poorly digestible pathogens, which take up residence in macrophages.
(1) Streptococcus pneumonia (70%) – young/middle age people, after viral URT infection, Pneumococcus are               Granuloma forms, with microphages, converted to epithelioid cells, fusing to form giant cells on inside,
normal flora for nasopharynx                                                                                           surrounded by helper T lymphocytes, surrounded by fibrous tissue.
(2) Staphylococcus aureus (10%) – superinfection after other viral URT, CF, intubated patients Gram Negative           DVX
Opportunistic Pneumonia: (5-30%)                                                                                       If no necrosis, think sarcoidosis, fungal infection, biological dust disease
(3) Klebsiella pneumonia – middle aged male alcoholics, diabetes, COPD                                                 If necrosis, thinking Mycobacterium TB, atypical Mycobacterium infection, or Wegener’s Granulomatosis
(4) Hemophilus influenza - smokers, COPD
(5) Escherichia coli – complication of bacteremia after abdominal and UG surgery, chronic lung or heart disease
(6) Pseudomonas Aeruginosa – immunocompromised, burns, CF, nosocomial
(7) Other:                                                                                                             Pneumonia (Lipid)
- Streptococcus pyogenes – after viral pneumonia                                                                       SUMMARY
- Legionella pneumophilia – organism thrives in aquatic environments                                                   Exogenous – inhaled lipids such as mineral oil (some people inhale to moisten nasal mucosa)
- Anaerobic Organism Pneumonia - Peptostreptococci, fusobacteria, Bacteroides                                          Endogenous – from cell membrane breakdown
HX, PE                                                                                                                 Diagnosis based on lipids in pathologic slide.
see Pneumonia
CXR – patchy peribronchial or diffuse alveolar lobar infiltrates (depending on anatomical distribution of              Pneumonia (Unresolving)
pneumonia)                                                                                                             IMAGING
Sputum - good culture means >25 WBC and <10 squamous epithelial cells / High power field
                                                                                                                       90% of patients <50 show X-ray resolution in 4 weeks, while 30% of patients>50 show resolution in 4 weeks
RX - OUTPATIENT                                                                                                        ETIOLOGY
Doxycycline - 100mg bid x10d
                                                                                                                       (1) 20% of presumed CAP which does not respond to Abx is likely non-infectious – think of neoplastic,
Erythromycin - 500mg tid x10d
                                                                                                                       inflammatory, drug-induced, and vascular diseases
Azithromycin - 5d
                                                                                                                       (2) Mycobacteria (either TB or Atypical mycobacteria)
Cefuroxime - 500mg bid x10d
                                                                                                                       (3) Nocardia (localized alveolar infiltrate) or Actinomyces (alveolar infiltrate which extends across fissures and
Augmentin - 875mg bid x10d
                                                                                                                       invades chest wall)
Gatifloxacin - 400mg qd x10d
                                                                                                                       (4) Fungi – Histoplasmosis, Coccidiomycosis, Blastomycosis, Cryptococcus – especially in endemic areas
RX - INPATIENT                                                                                                         (5) Aspergillosis – in immunocompromised or elderly on chronic steroids for COPD
- ER gives 1g Ceftriaxone IVPB                                                                                         (6) Resistant bacteria
- Inpatient team chooses one of the following 4 regimens:                                                              (7) Undiagnosed host immunodeficiency
(1) Ceftriaxone 1g IV q24hrs w/ or w/out Azithromycin 500mgIV q24hr for 2 days, then                                   (8) Sequestered foci of infection (empyema, abscesses)
PO Cefuroxime or PO Augmentin                                                                                          (9) BOOP
(2) Cefuroxime 1.5g IV q8hr w/ or w/out Azithromycin 500mg IV q24hr for 2 days, then                                   (10) Pulmonary Alveolar Proteinosis
PO Cefuroxime                                                                                                          (11) PE
(3) Unasyn 3g IV q8hr w/ or w/out Azithromycin 500mg IV q24 for 2 days, then                                           NEOPLASTIC CAUSES
PO Augmentin
                                                                                                                       Bronchogenic carcinoma and carcinoid tumors – leads to post-obstructive pneumonia
(4) Gatifloxacin 400mg IV q24hr for 2 days, then
                                                                                                                       Bronchoalveolar cell carcinoma, lymphoma – cause alveolar infiltrates which resemble pneumonia
PO Gatifloxacin
- Note - if ICU patient, continue IV antibiotics, and consider Vancomycin if MRSA is suspected.                        INFLAMMATORY CAUSES
                                                                                                                       Wegener’s granulomatosis
                                                                                                                       Alveolar hemorrhage syndromes

Pneumonia – Eosinophilic                                                                                               DRUG-INDUCED CAUSES
                                                                                                                       Amiodarone toxicity
HX                                                                                                                     Nitrofurantoin
Rapid onset of fever, non-productive cough, dyspnea, and pleuritic chest pain.                                         Methotrexate
XRAY                                                                                                                   Bleomycin
Subtle reticular or ground-glass infiltrates which can progress to diffuse bilateral alveolar disease.                 WORKUP
(1) High Resolution Chest CT                                                                                            CXR – usually see pleural line
(2) Bronchoscopy – very good for excluding fungi and mycobacteria                                                       RX
                                                                                                                        Immediate 14guage needle decompression at MCL on affected side (BEFORE waiting for CXR confirmation).
                                                                                                                        Chest tube for all but smallest 15%
Pneumonia (Pneumocystis Carinii)
Ubiquitous protozoan (fungus by RNA analysis) which responds to antibacterial therapy                                   Pulmonary Angitis (Vasculitis)
Causes interstitial pneumonia, diffuse alveolar damage, frothy eosinophilic exudate                                     SUMMARY
Original opportunistic AIDS defining illness                                                                            inflammation of pulmonary blood vessels.
                                                                                                                        Wegener’s Granulomatosis, Necrotizing Sarcoidosis, Churg-Strauss, etc.

Pneumonia (Viral)
PATHOLOGY                                                                                                               Pulmonary Congestion
Inflammation and infiltrate of lymphocytes as opposed to PMNs (bacterial)                                               SUMMARY
Infecting virus must show tropism towards certain cells – tracheobronchial lining cells, bronchiolar epithelial         elevated hydrostatic pressure in pulmonary capillaries, can lead to pulmonary edema
cells, alveolar pneumoncytes, capillary endothelial cells, etc.
Inflammation is usually more interstitial and less exudative, due to intracellular nature of virus.
- Most common viruses are Influenza, Parainfluenza, Herpes simplex, Herpes Group, Measles, Cytomegalovirus,
Adenovirus, Varicella-Zoster Virus                                                                                      Pulmonary Alveolar Proteinosis
- Bacterial intracellular pathogens which mimic viral pneumonia are Mycoplasma, Rickettsia, Chlamydia
- CMV is most common cause of pneumonia in immunocompromised Xplant patients
                                                                                                                        Rare diffuse lung dx, characterized by massive accumulation of a phospholipid and protein rich substance in the
- VZV causes pneumonia in adults
DVX                                                                                                                     HX
Bacterial pneumonia - has more productive cough and more acute, severe symptoms
                                                                                                                        Insidious onset of dyspnea, fatigue, non-productive cough, rales, cyanosis, low grade fever, and weight loss.
HX, PE                                                                                                                  IMAGING
see Pneumonia
                                                                                                                        Nonspecific central alveolar opacities in lower and middle lung zones w/ sparing of areas adjacent to diaphragm
                                                                                                                        and heart.
Pneumonitis                                                                                                             Lung biopsy shows PAS+ material in alveoli.
SUMMARY                                                                                                                 RX
noninfectious inflammatory reaction in lung alveoli or interstitium                                                     Total bronchoalveolar lavage
Causes include: pulmonary hemorrhage, eosinophilic granuloma, sarcoidosis, drug induced lung injury,
hypersensitivity pneumonia

                                                                                                                        Pulmonary Edema
Pneumothorax (PTX)                                                                                                      SUMMARY
                                                                                                                        plasma like fluid flowing out of pulmonary capillaries into alveoli, transudate – mostly water, or exudate – plasma
SUMMARY                                                                                                                 like composition
Air in pleural space
PATHOLOGY                                                                                                               Increased hydrostatic pressure – due to LV failure from MI, CHF, cardiac valvular disease, arrythmia, CAD
One way valve process in which air can enter pleural sac during inspiration, but cannot leave during exhalation         Decreased oncotic pressure – nephrotic syndrome (loss of proteins), liver failure (to make proteins)
Tension pneumonthorax – if thorax cannot bleed off pressure (to outside, etc.) and intrapleural pressure exceeds        Endothelial injury - Shock – type I pneumoncytes die (ischemia), hyaline membrane forms, see ARDS
intraalveolar pressure, forcing atelectasis                                                                             High altitude – decreased atmospheric pressure
Mortality w/ tension PTX is caused by increased intrathoracic pressures, which kink the SVC and IVC, thus               Increased intracranial pressure/cerebral infarction
decreasing venous return to the heart.
HX                                                                                                                      Restrictive Lung Disease, PAINT – A=alveolar filling processes
Dyspnea, cough, pleuritic chest pain, acute onset
PE                                                                                                                      Dyspnea
Tachycardia, tachypnea, hypotension – all vessels will dilate to get more oxygen, wider intercostal spaces,
hyperresonant to percussion, JVD, decreased breath sounds on affected side, decreased tactile fremitus on
                                                                                                                        Crackles (rales) on auscultation
affected side.
LAB                                                                                                                     PFT

Restrictive tests positive:                                                                                       (3) Discontinue heparin 5d after INR reaches desired range w/ warfarin administration.
- FEV1/FVC > 70%                                                                                                  (4) Discharge and continue oral coumadin for 6 months – only if positive of DVT diagnosis
- FVC < 80%                                                                                                       RX – ACUTE/OTHER
- TLC < 80%                                                                                                       Oxygen for hypoxemia
PImax, PEmax = normal                                                                                             AVP (vasopressin – ADH) for hypotension
FRC, RV decreased                                                                                                 Fluid to increase venous return to RV
A-a gradient > 15 (DLCO decreased)                                                                                IVC filter (Greenfield filter) in patients w/contraindication to anticoagulants
LAB                                                                                                               Best RX is prevention w/ SCDs, TED hose, early ambulation.
PaCO2 normal or decreased (hyperventilation?)                                                                     RX – THROMBOLYTICS
SHUNT – PaO2 is low (< 45mmHg) and refractory to oxygen                                                           Only indicated for systemic hypotension, and no trials have ever shown mortality benefit.
CXR shows opaqueness                                                                                              Can give tPA 100mg over 2 hours.
RX                                                                                                                Contraindications – CPR > 10min, Hx of hemorrhagic CVA, Active intracranial neoplasm, recent intracranial
diuretic                                                                                                          surgery, active internal bleeding in last 6 months, thrombocytopenia < 100K, SBP > 200, DBP> 110
Mechanical ventilation w/ supplemental O2

                                                                                                                  Pulmonary Embolism – Probability Scoring
Pulmonary Embolism (PE)                                                                                           SOURCE
SUMMARY                                                                                                           Wicki, Archives of Internal Medicine, 2001.
Any embolus which lodges in a pulmonary artery, causing ischemia distal to point of embolus.                      SCALE
Second most common acute nosocomial pulmonary lesion (pneumonia is first).                                        Age 60-79, +1
PATHOLOGY                                                                                                         Age >=80, +2
Most commonly – thrombus from venous circulation, usually distal ileofemoral vein, due to DVT                     Prior DVT/PE, +2
Fractures – bone marrow, fat, air can become emboli                                                               Recent surgery, +3
Infection – inflammatory tissues/cells can become emboli                                                          HR > 100, +1
Tumor – piece of neoplasm can become emboli                                                                       PaCO2 <36, +2
Blockage causes rise in pulmonic pressure, leading to RV failure – (cor pumonale)                                 PaCO2 36-38.9, +1
Hypotension – due to lack of preload for left ventricle                                                           PaCO2 on RA <48.8 (SaO2 <84%), +4
3 main causes of DVT: stasis, hypercoagulation, injury to venous intima (Virchow's triad).                        PaCO2 on RA 48.9-59.8 (SaO2 84-90%), +3
DVX                                                                                                               PaCO2 on RA 59.9-71.1 (SaO2 91-93%), +2
Primary pulmonary vascular disease                                                                                PaCO2 on RA 71.2-82.4 (SaO2 94-95%), +1
                                                                                                                  CXR shows plate-like atelectasis, +1
HX                                                                                                                CXR shows elevated hemidiaphragm, +1
Acute alteration in consciousness, shock, or chest pain, dyspnea
Precordial, retrosternal chest pain, cough, hemoptysis
                                                                                                                  0-4 = 10% incidence
PE                                                                                                                5-8 = 38% incidence
cyanosis, tachypnea, diaphoresis, atelectasis, Homan’s sign (dorsiflex foot), hypotension                         9-12 = 81% incidence
Increased A-a gradient and hypocapnia – maybe
D-Dimer – measures byproducts of fibrinogen (clot) breakdown, which are present whenever a clot exists.
                                                                                                                  Pulmonary Embolism – Workup – New (2001)
V/Q scan - inject radiolabelled albumin for the Q aspect.                                                         COMPUTE CLINICAL PROBABILITY SCORE
Doppler ultrasound scan of lower extremities – less risky than pulmonary arteriogram                              Four or less? goto Vidas d-Dimer.
Pulmonary arteriogram (angiogram) – gold standard test, but most invasive                                         Five or more?
Spiral CT – also a good test. aka CT-PA (CT Pulmonary angiogram). This test is basically a CT w/ contrast.        - Anticoagulate if PE suspected and not contraindicated.
                                                                                                                  - Goto CXR
(1) Anticoagulation w/ heparin – can start before diagnosis complete!                                             VIDAS D-DIMER
If using IV HMW heparin, adjust dose according to aPTT results with goal to prolong aPTT to 1.5x nl               <500? Stop. No PE.
If using SC LMW heparin, give 1mg/kg q12hours and do not worry measuring aPTT.                                    >500?
Most likely, LMW heparin will replace HMW heparin when the cost is reduced.                                       - Anticoagulate if PE suspected and not contraindicated.
LMW heparin works as well as unfractionated – NEJM 2003 (Fondaparinux)                                            - Goto CXR.
(2) Start on warfarin during 1st hospital day.                                                                    CXR
Check PT, INR daily.                                                                                              nl or Serum Cr > 1.5? Goto VQ scan
Adjust warfarin dose to prolong INR to 2-3.                                                                       Abnl – Pleural effusion, COPD, or Infiltrate? Goto CT-PA.
                                                                                                                  VQ SCAN
nl? Stop. No PE.                                                                                          (3) Blood problem:
Low or intermediate prob? Goto LE Doppler U/S                                                             - increased viscosity (polycythemia vera)
High prob? Anticoagulate. We have PE                                                                      - increased blood flow (Left to right shunts - PDA, VSD)
LE DOPPLER U/S                                                                                            DDX
Positive for DVT? Anticoagulate. We have DVT and reason to treat suspected PE.                            Mean pressures < 35-40 can be explained by sleep apnea or COPD, higher pressures need other explanation
Negative? Goto Clin Prob decision.                                                                        (think PE).
CLIN PROB DECISION (AKA WICKI SCORE)                                                                      RX
Four or less? Stop. Do not treat unless clinical suspicion is very high.                                  Treat the cause before we need a heart-lung transplant.
Five or more? Goto Pulmonary Arteriogram.                                                                 PATHOLOGY
CT-PA                                                                                                     Histological grading:
Positive? Anticoagulate. We have PE.                                                                      I – III – muscle hypertrophy, fibrosis, reversible
Negative? Stop. Unless clinical suspicion is very high, then goto Pulmonary Arteriogram.                  IV-VI – plexiform lesions, arterial dilation, necrosis, irreversible
Positive? Anticoagulate. We have PE.
Negative. Stop. No PE.                                                                                    Pulmonary Infarction
                                                                                                          Ischemic necrosis of a portion of the lung, often due to combination of CHF and PE.
Pulmonary Embolism – Workup – Old (1999)                                                                  PATHOLOGY
WORKUP                                                                                                    Ischemic coagulation necrosis of portion of the lung. If the necrosed portion cavitates, the area of infarction may
(1) Assess pre-test probability - low (<20%), indeterminate, or high (>80%). If not low, continue.        be converted to an abscess cavity, and infection is probably present. Infarct will be hemorrhagic due to dual
(2) V/Q scan.                                                                                             blood supply. Pleural effusion occurs in 30-40%
- if normal, stop.                                                                                        HX
- if high probability, treat.                                                                             Dyspnea, hemoptysis, pleuritic chest pain (sharp, stabbing, exacerbated by deep breathing, coughing, generally
- if low prob, or indeterminate, look for DVTs.                                                           over lower portion of chest), fever
(3) Doppler U/S
- if positive - RX
- if negative, then either repeat serial Doppler U/S exams, or goto pulmonary arteriogram.
(4) Pulmonary Arteriogram                                                                                 Rhinitis - Acute
- if positive, treat.
- if negative, stop.
                                                                                                          Most likely viral - see Bronchitis (Acute) for discussion of pathogens and Rx.
This is gold standard.

Pulmonary Hemorrhage                                                                                      Sepsis
                                                                                                          2 or more of any of the following indicators of systemic inflammation:
Cells (erythrocytes) leaking out into alveoli through pulmonary capillaries
                                                                                                                Temperature >38 or <36
Common in: Lupus, Goodpasture’s, Wegener’s Granulomatosus, any pulmonary angitis (vasculitis)
                                                                                                                Pulse >90
                                                                                                                Respirations >20
                                                                                                                PaCO2 <32
Pulmonary Hypertension                                                                                          WBC >12,000 or <4,000
see Heart_Vascular file for complete discussion.                                                                >10% immature PMNs
Increase in pulmonary BP from nominal 19/6 to something higher.
PHYSIOLOGY                                                                                                Shunt
Three mechanisms:                                                                                         PATHOLOGY
(1) Pulmonary artery problem (reduced cross-sectional area):                                              Pneumonia, edema, atelectasis – anything which makes V/Q go to zero.
- emphysema - loss of pulmonary vascular bed
- vasoconstriction - from chronic hypoxemia, chronic respiratory acidosis (Pickwickian syndrome)
- obstruction of vessels - multiple pulmonary emboli
(2) Pulmonary venous problem:                                                                             Silicosis
- left heart disease (mitral stenosis)                                                                    SUMMARY
- pulmonary venous disease

Pneumoconiosis caused by chronic inhalation of free silica dust - seen in miners, glass manufacturers, stone                   see “Neuropath” file.
cutters. Interstitial fibrotic nodules w/ silica (macrophages cannot digest silica). Silica visible in polarized light.

                                                                                                                               Tuberculosis - MDR
Sinusitis                                                                                                                      PATHOLOGY
PATHOLOGY                                                                                                                      Multi-drug resistant TB.
Inflammation in paranasal sinuses (Frontal, maxillary, ethmoid, sphenoid?), extension of infection/inflammation                Causes:
from nasopharynx.                                                                                                              - Most common cause is prior TB treatment and non-compliance.
Usually viral, but if bacterial the 3 most common organisms are:                                                               - HIV
- Streptococcus pneumonia                                                                                                      - IV drug use.
- Haemophilus influenza
- Moraxella catarrhalis
HX                                                                                                                             Tuberculosis - Pulmonary
Best five predictive factors of bacterial sinusitis are:
- Failure to transilluminate on PE                                                                                             SUMMARY
- Double sickening (acute worsening of symptoms after 5-7 days)                                                                Pulmonary infection characterized by cavitary granulomas surrounding caseous necrosis, caused by
- Failure to respond to decongestants and antihistamines                                                                       Mycobacterium tuberculosis bacteria.
- Hx or PE of purulent nasal discharge                                                                                         PATHOLOGY
- Maxillary tooth pain, especially unilateral                                                                                  1-3 cm Cavitary lesions of caseous necrosis within 1-2 cm of pleural surfaces.
RX                                                                                                                             Diffuse granulomatous inflammation with giant cells, epithelioid cells, lymphocytes, and fibrosis.
Amoxicillin is DOC according to Wispelway.                                                                                     Primary infection consists of primary Ghon complex formation. Caseous necrosis spreads to regional lymph
Bactrim is also good choice.                                                                                                   nodes. Usually asymptomatic. Individuals are now PPD positive and have latent TB.
3 days is as good as 10days                                                                                                    Secondary infection arises in latent TB individuals. Usually begins in apical or posterior superior lobe (M TB
Azithromycin for 3 days = Augmentin for 10 days. Source – Antimicrob Agents Chemo 2003: 47; 2770                               likes high [O2]).
                                                                                                                               GHON COMPLEX
                                                                                                                               Peripheral lung nodule (TB granuloma) with infection of mediastinal lymph node.
Tuberculosis - Extrapulmonary                                                                                                  DVX
                                                                                                                               PAINT - Interstitial disease
OVERVIEW                                                                                                                       Sarcoidosis
15% of patients with active MTB have infections outside the lung.                                                              Nocardiosis - a genus of aerobic, nonmotile, actinomycetes
PPD test is very helpful.                                                                                                      Anaerobic aspiration pneumonia, PCP pneumonia
LYMPHATIC TUBERCULOSIS                                                                                                         Fungal infections
Typically causes cervical lymphadenopathy (scrofula).                                                                          Neoplasm
RX - same as pulmonary MTB.                                                                                                    PE - pulmonary infarction
TUBERCULOUS PLEURISY                                                                                                           Classic sign is chronic productive cough > 3 weeks
Develops when a pulmonary TB granuloma ruptures through the adjacent visceral pleura into the pleural space.                   Risk factors include alcoholism, immunosuppression, diabetes, poor nutrition, previous residence in Asia, Africa,
Symptoms include fever and unilateral pleuritic pain.                                                                          or Latin America
Pleural fluidis exudative with mononuclear inflammatory cells.                                                                 HX
RX - same as pulmonary MTB.                                                                                                    Febrile (mid-afternoon), night sweats, weakness, fatigue, loss of appetite, weight loss.
GU TUBERCULOSIS                                                                                                                Chronic productive cough lasting > 3 weeks, Hemoptysis, dyspnea
Can involve urinary tract at any level.                                                                                        Pleuritic chest pain
Dysuria, gross hematuria, flank pain.                                                                                          PE
Abnormal urine sediment, which includes red cells, white cells, or both.                                                       Consolidation or pleural effusion: Dullness to percussion, bronchial breath sounds (high pitch, loud), egophony
RX - same as pulmonary MTB.                                                                                                    (E  A) - suggests bacteria.
SKELETAL TUBERCULOSIS                                                                                                          Rales (crackles)
Commonly involves vertebral bodies and/or epiphysis of long bones.                                                             LAB
RX - same as pulmonary MTB.                                                                                                    (1) Pleural effusion WBC >= 50% small lymphocytes means malignancy or TB.
MILIARY (DISSEMINATED) TUBERCULOSIS                                                                                            (2) AFB (Acid-Fast Bacillus) stain of sputum smears, detects mycolic acid in Mycobacterium's cell walls.
Rapidly progressive, lethal dissemination of either primary or reactivation MTB.                                               (3) Sputum Mycobacterium culture - more sensitive than a smear.
Fever, weight loss, fatigue, weakness.                                                                                         (4) CXR - shows cavitary infiltrate in posterior-apical segment of upper lobe, or superior segment of lower lobe.
Eventually, CXR may show small white nodules throughout lungs and other organs.                                                CONVERSION FROM LATENT TO ACTIVE TB
RX - same as pulmonary MTB.                                                                                                    HIV positive - 50% in 1st year, 10%/year afterwards
TUBERCULOUS MENINGITIS                                                                                                         HIV negative - 5-15% in year 1, 0.3%/year afterwards.

PPD = Purified Protein Derivative
Mantoux test is the standard. 5u of PPD tuberculin are injected intradermally. Usually will be positive within 4-
6 weeks after primary exposure.
Test is positive if:
(1) >5mm induration, and
- recent close contact with person w/ active MTB.
- patient is HIV positive.
- Fibrotic pattern or scar on chest X-rays consistent with old, healed MTB.
(2) >10mm induration, and
- history of IV drug abuse
- medical risk factors (DM, chronic renal failure, immunosuppression)
- Health care workers
- Children under 4
- Foreigners from high MTB prevelance country within 5 yrs of arrival.
(3) >15mm of induration for anyone.
A live, attenuated form of Mycobacterium bovis is given (Attenuated by Calmette and Guerin).
PPD response from vaccine wanes around 10 years.
Long term antibiotics - multi-drug regimen:
(1) Isoniazid, Rifampin, Pyrazinamide, streptomycin (or ethambutol) for 6 months. Also monitor with monthly
sputum culture.
(2) Once organism is proven sensitive to isoniazid and rifampin, stop ethambutol/streptomycin immediately, and
stop pyrazinamide after 2 mo of therapy. Continue isoniazid/rifampin for 6 mo.
**Remember - INH carries risk of hepatitis, check LFTs monthly, stop when 5x normal. Also, give Vitamin B6
to patients w/neuropathy.
(1) Regardless of Age:
- HIV infected or risky
- Recent MTB converters
- Abnormal chest films w/ old, healed MTB.
- High risk medical conditions.
HIV positive - INH (Isoniazid) for 9mo, rifampin and pyrazinamide for 1st 2mo.
HIV negative - INH for 9mo.
*Note – we only need to check LFTs for patients who have:
- Pre-existing liver disease
- Pregnant or postpartum women
- ETOH abusers
Guidelines state that we should stop prophylaxis if LFTs are >5x normal, or >3x normal and patient has
symptoms of hepatitis.
We do NOT routinely follow LFTs in everybody, because lots of people get elevations in LFTs from isoniazid,
but this leads us to unnecessarily stop prophylaxis and have more harm from TB than from hepatitis.

Upper Respiratory Infection
Acute Rhinitis
Croup (Acute Laryngotracheobronchitis)


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