Exam 4

Pathology

Miliary TB

Tuberculosis that has Spreadthroughout the Body Beyond the Lungs

Tubercle

Lung Tissue that Surrounds the Infected Area and Slowly Produces a Protective Cell Wall

General Appearance for TB

1. Persistent Cough

2. Hemoptysis

3. Loss of Appetite and Weight Loss

4. Night Sweats

Ghon Nodule

Peripheral Pneumonic Infiltrates, Small Calcified Granulomas

Ghon Complex

Combination of Tubercles and Involement of the Lymph Nodes in the Hylar Region

Test Used to Diagnose Latent TB / Dormant TB

Mantoux Tuberculin Skin Test

2 Most Common Meds Used to Treat TB

1. Isoniazid (INH)

2. Rifampin (RIF)

Treatment Time-Frame for TB

Six to Nine Months Protocols of Combined Medications

Primary Cause of TB

Mycobacterium Tuberculosis

Is TB Restrictive or Obstructive?

Restrictive

Bronchiectasis

Chronic Condition Where the Walls of the Bronchi are Thickened from Inflammation and Infection

Pathologic Changes of Bronchiectasis

1. Chronic Dilation and Distortion of Bronchial Airways

2. Excessive Production of Often Foul-Smelling Sputum

3. Bronchospasm

4. Hyperinflation of Alveoli (Air Trapping)

5. Atelectasis

6. Parenchymal Consolidation and Fibrosis

7. Hemoptysis Secondary to Bronchial Arterial Erosion

3 Classifications of Bronchiectasis

1. Cylindrical Bronchiectasis

2. Cystic Bronchiectasis

3. Varicose Bronchiectasis

Cylindrical Bronchiectasis

Dilated and Rigid and have Regular Outlines Similar to a Tube

Cystic Bronchiectasis

Bronchi Progressively Increase in Diameter Until they End in Large, Cystlike Sacs in the Lung Parenchyma

Varicose Bronchiectasis

Dilated and Constricted in an Irregular Fashion Resulting in a Distorted, Bulbous Shape

Most Common Form of Bronchiectasis in the US

Cylindrical Bronchiectasis

Causes of Bronchiectasis

1. COPD

2. Rheumatoid Arthritis

3. Asthma

4. Foreign Body Aspiration

5. Lymphatic Disorders

6. Advanced Age

2 Causes of Abnormal Secretion Clearance Associated with Bronchiectasis

1. Cystic Fibrosis (CF)

2. Primary Ciliary Dyskinesia (PCD)

Sputum Description for Patient with Bronchiectasis

1. Copious Amounts

2. Foul Smelling

3. Dark green

ABG for Stable Advanced Stage of Bronchiectasis

pH - Normal

PCO2 - High

PO2 - Low

HCO3 - High

ABG for Mild/Moderate Exacerbation with Advanced Stage of Bronchiectasis

pH - High

CO2 - Low, High, or Normal

PO2 and SPO2 - Low

HCO3 - High

ABG for Severe Stage Exacerbation with Advanced Stage of Bronchiectasis

pH - Low

CO2 - Significantly High

PO2 and SPO2 - Significantly Low

HCO3 - High

General Management for Bronchiectasis Patients

Aimed at Controlling Pulmonary Infections and Secretions

Airway Clearance Techniques

1. Directed Cough

2. Exercise Breathing Programs

3. Autogenic Drainage

4. Huff Cough

5. Chest Physiotherapy

6. Suctioning

7. Positive Expiratory Pressure (PEP)

8. Oscillatory PEP

9. High-Frequency Chest Wall Compression

Best Tool for Diagnosing Bronchiectasis

1. HR-CT Scan

   1. Based on Internal Diameter of Bronchus

   2. Allows Lung Mapping

Bronchogenic

Lung Cancer

A Tumor that Originates in the Bronchial Mucosa

Malignant

Composed of Embryonic, Primitive, or Poorly Differentiated Cells that Grow in a Disorganized Manner and So Rapidly that Nutrition of the Cells Becomes a Problem

Benign

Tumor that Does Not endanger Life Unless they Interfere with the Normal Functions of Other Organs

Types of NSCLC

1. Squamous Cell

2. Adenocarcinoma

3. Large Cell (Undifferentiated)

Squamous Cell

Type of NSCLC

Located Near a Central Bronchus or Hilus and Projects into the Large Bronchi

Adenocarcinoma

Type of NSCLC

Arises from the Mucous Glands of the Tracheobronchial Tree

Large Cell

Type of NSCLC

Most Agressive Type

Rapid Growth Rate and Early and Widespread Metastasis

2 Types of Lung Cancers

1. NSCLC

2. SCLC

Small Cell (Oat Cell)

In Larger Airway

Correlation with Cigarette Smoking

What is the Most Common Cause of Oat Cell Carcinoma?

Cigarette Smoking

Pathologic Changes that are Associated with Lung Cancer

1. Inflammation,Swelling, and Destruction of Bronchial Airways and Alveoli

2. Excessive Mucus Production

3. Hemoptysis

4. Tracheobronchial Mucus Accumulation and Plugging

5. Airway Obstruction

6. Atelectasis

7. Alveolar Consolidation

8. Cavity Formation

9. Pleural Effusion

What Area of the Lungs Does Pneumonia Affect?

The Alveoli

5 Types of Pneumonia

1. Community Acquired Pneumonia (CAP)

2. Hospital Acquired Pneumonia and Ventilator PNA (HAP + VAP)

3. Aspiration PNA

4. Fungal PNA

5. Necrotizing PNA

Common Bacteria or Viruses for Community Acquired PNA

1. Streptococcus Pnuemoniae

2. Staphylococcal Pneumonia

Common Bacteria or Viruses for Atypical Community Acquired PNA

1. Mycoplasm Pneumonia

2. Viral

Common Bacteria or Viruses for Hospital Acquired PNA

1. Pseudomonas

2. Staphylococcus (MRSA)

What is the Bacteria Causes Most of Community Acquired PNA?

Streptococcus Pnuemoniae

Which Type of PNA is Commonly Called the “Walking Pneumonia'“?

Atypical Community Acquired PNA - Mycoplasm Pneumoniae

What Does Nosocomial Mean?

Hospital Acquired PNA

Common Strategies are Used in Efforts to Prevent VAP?

1. Emphasis on the Importance of Pulmonary Hygiene or ‘Pulmonary Toilet’

   1. Routine Suctioning

   2. Oral Care

   3. Mucus Clearance

      1. CPT

      2. Mucolytics

      3. Bronchodilators

2. Patients Needs to be Minimally at 35 Degree Angle

3. High/Low Evac Type ETT Should be Used if Possible

Causes of Aspiration PNA

1. Endotracheal Intubation

2. GERD

3. TE Fistula - Hole Between Esophagus and Trachea

4. Dysphagia - Trouble Swallowing

   1. Stroke

   2. Traumatic Brain Injury (TBI)

   3. CPMR

   4. Myasthenia Gravis

   5. Drug Overdose

   6. Seizures

What pH Level is Most Associated with Life Threatening Form of Aspiration PNA?

Aspiration of Gastric Fluid with pH < 2.5

Major Cause of VAP

Bacteria via Aspiration

Common Fungal Pneumonias

1. Histoplasmosis (Ohio Valley Fever)

2. Coccidioidomycosis (San Joaquin Fever)

3. Blastomycosis (Chicago Fever)

Most Common Fungal Infection in the US

Histoplasmosis (Ohio Valley Fever)

Most Common Cause of Chronic Pneumonia

Tuberculosis

What Makes Lungs so Ideal for Fungal Infections?

They are Warm, Moist, and Dark Environments

What are the 2 Commonly Coexisting PNA that are Often Seen in Immunocompromised Hosts sush as HIV Patients?

1. Cytomegalovirus (CMV)

2. Pneumocystis Jiroveci

Necrotizing PNA

1. Formation of Cavities Containing Necrotic Debris

2. Is Most Commonly a Complication of Aspiration PNA

X-Ray Findings of PNA

1. Increased Density/Opacity

2. Air Bronchograms

3. Lung Absecesses

4. ALL DEPENDANT ON TYPE OF PATHOGEN

General Management and Respiratory Management of PNA

1. Treatment is Based on Specific Cause and Severity of PNA

2. Bacterial - Antibiotics

3. Fungal - Antifungal

4. Viral - Rest and Fluids

5. Lung Abscess - IV Antimicrobial Therapy, Prompt Drainage, Surgical Debridement, Clindamycin, and Penicillin

What is a Cause of Refractory Hypoxemia?

Consolidation from Pneumonia (Capillary Shunting)

What Labs Would be Helpful in Diagnosing PNA

1. CBC w/ Diff.

2. Sputum Sample

3. Fungal Culture

Clinical Presentation of PNA

1. Increased Temperature

   1. > 101 - Bacterial

   2. < 101 - Viral

2. Cough, Hemoptysis, Sputum

   1. Inital - Dry, Nonproductive Cough

   2. As Disease Progresses, Productive Cough with Small Amounts of Purulent, Blood-Streaked, or Rusty Sputum can be Seen

Respiratory Threapy Treatment and Goals for Lung Cancer

1. Oxygen Therapy

2. Air Clearance Therapy

3. Lung Expansion Therapy

4. Aerosolized Medication

General Management Strategies for NSCLC

1. Chemotherapy

2. Surgery

3. Radiofrequency Ablation (RFA) - Use of High-Energy Waves to Heat the Tumor

4. Radiation Therapy

General Management Strategies for SCLC

1. Chemotherapy

2. Radiation Therapy

3. Surgery

What Test is Used to Definitively Diagnose Cancer?

Biopsy / Cytology

What are the 2 Most Common Imaging Tools Used to Help in Diagnosis of Lung Cancer?

1. X-Ray

2. Pet/CT

Common Physical Findings of Lung Cancer

1. Symptoms are Long Term

2. Progressively Worsening Cough

3. Hemoptysis

4. Hoarse Voice

5. Poor Appetite and Weight Loss

6. Fatigue

Is Lung Cancer a Shunt or Deadspace?

Shunt

Is Lung Cancer Restrictive or Obstructive?

Inside the Lungs - Obstructive

Outside the Lungs - Restrictive

M Scoring for Classification of Lung Cancer

Extent of Distant Metastasis

M = 0-1b

Higher Numbers Represent Increased Severity

N Scoring for Classification of Lung Cancer

Regional Lymph Node Involement

N = 0-3

1. N1 - Hilar Region

2. N2 - Carina

3. N3 - Clavicle or Mediastinal on Opposite

T Scoring for Classification of Lung Cancer

Size and Location of Primary Tumor

T = 1-4

1. T1 = < 3 cm; Does Not Affect Main Bronchi

2. T2 = 3 cm-7 cm; Involves Main Bronchus or Visceral Pleura

3. T3 = > 7 cm; Spread to Chest Wall, Muscles/Pleural Space/ Parietal Pericardium

4. T4 = Any Size Spread to Mediastinum, Large Vessels, etc.