• Information
  1. Aspiration Syndromes
  2. Asthma
  3. Bronchiectasis
  4. Broncholithiasis
  5. Chronic Bronchitis
  6. Chronic Obstructive Pulmonary Disease
  7. Emphysema
  8. Hypersensitivity Pneumonitis
  9. Interstitial Lung Disease
  10. Lung Abscess
  11. Pleural Effusion
  12. Pneumothorax
  13. Pneumonia
  14. Pulmonary Edema
  15. Pulmonary Embolism
  16. Pulmonary Infarction
  17. Lung Mass
• Resources

A. Aspiration Syndromes [1]

1. Aspiration pneumonitis (Mendelson's Syndrome) - chemical injury
2. Aspiration pneumonia - infection with oropharyngeal bacteria
3. Airway obstruction - mucus plugging
4. Lung abscess
5. Exogenous lipoid pneumonia
6. Chronic interstitial fibrosis
7. Mycobacterium fortuitum pneumonia

B. Asthma

1. Disease of airways
2. Increased responsiveness to a variety of allergic or other stimuli
3. Result is narrowing of air passages, difficulty breathing, wheezing
4. Chronic inflammation usually consists of eosinophils and lymphocytes
5. Chronic inflammation eventually leads to lung destruction

C. Bronchiectasis [3]

1. Permanent abnormal dilation of one or more (cartilage containing) bronchi
2. Cycle of transmural infection and inflammation with mediator release
3. Illness due to retained inflammatory secretions and microbes
   1. Cause airway obstruction
   2. Damage to airway with chronic dilation
   3. Recurrent infection
4. Associated Diseases
   1. Most commonly associated with cystic fibrosis
   2. Congenital lung dysfunction: ciliary dyskinesia, cartilage deficiency, Marfan Syndrome
   3. alpha1-antitrypsin deficiency
   4. Yellow nail syndrome
   5. Immunodeficiency: primary hypogammaglobulinemia, secondary (cancer, cytotoxics)
   6. Post-bacterial infection: pseudomonas, haemophilus, tuberculosis, aspirgillus
   7. Post-viral: adenovirus, measles, influenza, HIV
   8. Rheumatologic: rheumatoid arthritis, systemic lupus, Sjogren, relapsing polychondritis
5. Symptoms
   1. Cough with sputum production
   2. Hemoptysis is common
   3. Shortness of breath (dyspnea)
   4. Wheezing
   5. Pleuritic chest pain
6. Diagnosis
   1. High-resolution computed tomographic (CT) scan is required
   2. CT shows dilatation of airway lumen, lack of tapering or airway toward periphery, varicose constrictions along airways, ballooned cysts at end of bronchi
   3. Levels of serum immunoglobulin should be obtained
   4. Pulmonary function tests with bronchodilator response should be performed
   5. Consider rheumatoid factor, IgE level, aspergillus serology, alpha1-antitrypsin level
   6. Sputum infectious agent identification should be considered
7. Acute Exacerbation and Treatment
   1. Change in sputum production
   2. Increased dyspnea, cough, and/or wheezing
   3. Fever (>38°C)
   4. Malaise, fatigue, lethargy, decreased exercise tolerance
   5. Reduced pulmonary function / change in chest sounds
   6. Radiographic changes consistent with new pulmonary process
   7. Initial treatment with broad spectrum antibiotics such as levofloxacin, ciprofloxacin
   8. Sputum culture and sensitivity are usually not helpful
   9. With severe wheezing, glucocorticoids should be considered
   10. Intubation to protect airway may be required with severe hemoptysis
   11. Bronchoscopy or CT of chest or aortography may identify bleeding source
8. Prevention of Exacerbation
   1. Inhaled tobramycin or gentamicin
   2. Inhaled glucocorticoids have shown benefits
   3. Recombinant human DNase is not beneficial
9. Surgical removal of damaged or bleeding lung may be beneficial

D. Broncholithiasis

1. Any calcification that impinges on and distorts the wall of a bronchus
2. Calcified tissue fragment within the lumen of a bronchus

E. Chronic Bronchitis

1. Excessive tracheobronchial mucus production sufficient to cause cough
2. Usually in smokers, with intermittant infections
3. Associated Conditions
   1. Mild to moderate dyspnea
   2. Elevated arterial pCO2 (50-60mm)
   3. Low arterial pO2 (45-60mm)
   4. Pulmonary hypertension
4. Pulmonary Function Test Findings
   1. Obstructive Defects
   2. Normal elastic recoil
   3. Near normal DLCO
5. Chest Radiograph (CXR)
   1. Enlarged heart
   2. Increased bronchovasculature

F. Chronic Obstructive Pulmonary Disease

1. Chronic obstruction to airflow due to chronic bronchitis and/or emphysema
2. Definition: chronic cough and sputum production for at least 3 months in a year for at least 2 consecutive years
3. Most often composed of elements of both bronchitis and emphysema
   1. One or the other types usually predominates
   2. Pulmonary Function Tests can help distinguish
   3. Emphysema generally has poorer prognosis (see below)
4. Nearly all patients are or were heavy smokers

G. Emphysema

1. Distension of air spaces distal to the term bronchiole with destruction of alveolar septa
2. Loss of elastic recoil, normal lung resistance (ie. have increased compliance)
3. Low diffusing capacity (reduced DLCO) is required
4. Arterial pCO2 usually normal, low pO2 (65-75mm) typically
5. Hyperinflated lungs with reduced vasculature on chest radiograph

H. Hypersensitivity Pneumonitis

1. Extrinsic allergic alveolitis
2. Immunologically induced inflammation of the lung parenchyma
3. Usually from repeated inhalation of variety of dusts
4. Various fungal and animal products often implicated [3]
   1. Aspirgillus fumigatus
   2. Micropolyspora faeni
   3. Thermoactinomyces candidus
   4. T. sacchari
   5. T. vulgaris
   6. Pigeon serum
   7. Mycobacterium avium-intracellulare (MAI) - "hot-tub" lung [4]
5. Presence of pulmonary fibrosis with pneumonitis is associated with reduced survival [5]

I. Interstitial Lung Disease [3]

1. Infectious Disease
2. Idiopathic and Autoimmune Diseases
3. Rheumatologic Diseases
4. Environmental or Occupational Exposure
   1. Hypersensitivity Pneumonitis
   2. Asbestosis, Silicosis
   3. Berylliosis, Talcosis
   4. Granulomatous interstitial pneumonitis
5. Drug Related Diseases
   1. Nitrofurantoin
   2. Methotrexate
   3. Other chemotherapeutic agents (especially bleomycin)
6. Lymphangitic carcinomatosis

J. Lung Abscess

1. Necrotic area of lung parenchyma containing purulent material
2. Empyema is a region of the pleura with an infected (purulent) abscess or cavity present

K. Pleural Effusion

1. Accumulation of fluid between visceral and parietal pleura
2. Can be caused by infection, tumor, collagen vascular disease, others

L. Pneumothorax

1. Spontaneous, traumic, iatrogenic types
2. Spontaneous is either primary or secondary (to other primary pulmonary diseases)
3. Air introduced into pleural space
4. Increasing air in pleural space prevents lung from fully expanding
5. If pressures in pleural space increase above end expiratory pressure, lung remains deflated
   1. Tension pneumothorax occurs when air cannot escape from pleural space
   2. Air tension builds up leading to lung collapse
   3. Pulmonary pressures increase leading to acute right heart failure
   4. Tension pneumothorax can cause cardiac arrest and/or electromechanical dissociation

M. Pneumonia

1. Inflammation in the lung parenchyma of the portion distal to the terminal bronchioles
2. Usually refers to acute infections
3. Airspace (alveolar) pneumonia
   1. Nonsegmental, dense homogeneous consolidation
   2. Visible air bronchogram
   3. Usually caused by "typical" organisms
4. Interstitial pneumonia
   1. Linear or reticular pattern
   2. Usually caused by "atypical" organisms
5. Bronchopneumonia: segmental infiltrate, without visible air bronchogram
6. Aspiration pneumonia: infection after inhalation of oropharyngeal bacteria [1]

N. Pulmonary Edema

1. Transudate into alveoli
2. Major types distinguised by elevated capillary pressure or normal capillary pressures
   1. Adult respiratory distress syndrome (ARDS) - due to capillary leak, normal pressures
   2. Congestive Heart Failure (CHF) - due to elevated Left Ventricular pressures
3. Either type present with shortness of breat (SOB), tachypnea
4. Often associated with pleural effusions
5. Less common but reported with very low serum albumin levels (nephrotic syndrome)

O. Pulmonary Embolism

1. Usually follows deep vein thrombosis (DVT)
   1. Dislodging from above calf position in leg
   2. Causing lobular, or segmental perfusion block
   3. Pulmonary thrombi release vasoconstrictors causing pulmonary hypertension
2. Chest Radiography
   1. Pulmonary infiltrates, often bilaterally
   2. Increased heart size
3. May progress to pulmonary infarction

P. Pulmonary Infarction

1. Due to prolonged pulmonary ischemia
2. Usually due to pulmonary embolism
3. Chest Radiograph
   1. Often shows a wedge-shaped density in the lateral region of lung
   2. Called "Hampton's Hump."
   3. This density is infarcted lung parenchyma
4. Pulmonary infarction is relatively infrequent
5. This is due to the dual pulmonary blood supply: bronchial and pulmonary arteries

Q. Lung Mass

1. Small Cell Lung CA (SCLC, Oat Cell Ca)
2. Non-Small Cell Lung cancer (NSCLC)
   1. Squamous Cell CA
   2. Adenocarcinoma
   3. Large Cell CA
   4. Bronchogenic CA
3. Carcinoid
4. Mesothelioma
5. Bronchogenic Cyst
6. Abscess
7. Metastatic Cancer
8. Hemangioma

Resources

Aa Gradient

References

1. Marik PE. 2001. NEJM. 344(9):665
2. Barker AF. 2002. NEJM. 346(18):1383
3. Schwartzstein RM and Mark EJ. 2000. NEJM. 343(9):642 (Case Record)
4. Systrom DM and Wittram C. 2005. NEJM. 352(12):1238 (Case Record)
5. Vourlekis JS, Schwartz MI, Cherniack RM, et al. 2004. Am J Med. 116(10):662