1. Two major lung diseases 1. Obstructive – airway disease a) limitations of airflow i) partial or complete obstruction at any level major causes a) asthma – obstructive b) emphysema – loss of elastic recoil c) chronic bronchitis d) Bronchiectasis e) cystic fibrosis f) bronchiolitis www.freelivedoctor.com

3. 2. Restrictive diseases a) FVC is reduced b) ratio of FEV 1 to FVC is increased or near normal 1.- Extrapulmonary disorders a) disorders which affect chest to act as a bellows b ) examples: neuromuscal disorders i) Guillan-Barre Syndrome www.freelivedoctor.com

4. 2. Restrictive diseases (con’t) 2.- acute or chronic interstitial lung disease a) classic – ARDS (ie, shock lung, wet lung) b) chronic disease – idiopathic pulmonary fibrosis, pneumoconiosis, sarcoidosis www.freelivedoctor.com

9. Idiopathic Pulmonary Fibrosis (IPF) (usual interstitial pneumonia - UIP) a) diffuse interstitial fibrosis b) males more affected c) > 2/3 cases, patients older than 60 years d) recurrent cycles of lung injury (alveolitis) i) current concept ii) wound healing  fibroblast foci, a characteristic finding of IPF - Tx might be directed to  fibroblast replication iii) with time, fibrosis causes a “honey- comb” fibrosis www.freelivedoctor.com

10. www.freelivedoctor.com

11. - collapse of alveolar wall - formation of cystic spaces filled with type II pneumocytes and bronchiolar epithelial iv) secondary PH e) begins with some alveolar wall injury f) Hypothesized that immune mechanisms are trigger i) IL-8 and leukotrienes recruit and activate neutrophils! ii) injure alveolar epithelial cells and degrade connective tissue www.freelivedoctor.com

16. www.freelivedoctor.com

25. www.freelivedoctor.com

28. ii) bilateral hilar lymphadenopathy present in > 90% cases !! iii) next in frequency is eye and skin involvement (~ 25% of cases) iv) one of few pulmonary diseases where incidence is higher in non smokers !! v) 10x  in American blacks vs. whites, and in Southeast regions vi) Danish and Swedish  incidence vii)  incidence in women vii)  incidence in young adults < 40 www.freelivedoctor.com

31. d) patients with hilar lymphadenopathy alone  best prognosis; next is… e) lymphadenopathy plus pulmonary infiltrates; poorest outcome is… c) pulmonary disease alone i) most likely to develop pulmonary fibrosis (PPF) www.freelivedoctor.com

32. www.freelivedoctor.com

34. www.freelivedoctor.com

40. b) Congenital PAP i) causes neonatal respiratory distress syndrome ii) fatal disorder w/out lung transplant w/in 3-6 months c) secondary PAP i) immune deficient disorder ii) malignancies iii) lysinuric protein intolerance iv) acute silicosis v) other inhalation syndromes, etc. www.freelivedoctor.com

42. www.freelivedoctor.com

44. www.freelivedoctor.com

45. www.freelivedoctor.com

46. www.freelivedoctor.com

47. c) broadly defined as any infection in the lungs d) classification based on specific etiologic agent or clinical setting e) evolution of lobar pneumococcal pneumonia i) congestion – edema, exudate fluid ii) red hepatization – alveoli packed with neutrophils, RBC, fibrin iii) gray hepatization – dry, firm, color due to lysed RBC, exudate persist iv) resolution – exudate enzymatically digested and resorbed www.freelivedoctor.com

48. www.freelivedoctor.com

49. 1. Community-acquired acute pneumonia a) bacterial in origin i) usually follows viral upper respiratory infection ii) Streptococcus pneumoniae (i.e., pneumococcus)  most common cause of community-acquired pneumonia b) patients present with abrupt: i) high fever ii) shaking chills iii) productive cough (mucopurulent) iv) pleuritic chest pain www.freelivedoctor.com

50. c) These infections occur with increased frequency in patients i) underlying chronic disease (CHF, COPD, diabetes) ii) immunodeficiency (AIDS) iii) decreased splenic function (organ responsible for removing strep pneumoniae from the blood) – seen in sickle cell disease or post splenectomy !! iv) aspiration of S. pneumonia with impaired epiglottic reflex - alcohol intoxication - cold, anesthesia www.freelivedoctor.com

51. d) Other organisms commonly implicated in community-acquired pneumonia i) Hemophilus influenza - most common bacteria cause of acute exacerbation of COPD - is a pediatric emergency with high mortality rate 1. Causes meningitis 2. Pinkeye in children -  ciliary movement - destroys IgA; main class of antibody secreted into airways www.freelivedoctor.com

52. ii) Staph aureus - high incidence of complications (empyema and lung abscess) - important in nosocomial infections - important cause of secondary bacterial pneumonia following viral respiratory illness 1. Measels 2. Influenza - IV drug users at high risk www.freelivedoctor.com

53. iii) Klebsiella pneumonia - most frequent cause of gram (-) bacterial pneumonia - commonly associated with alcoholism 1. debilitated 2. malnourished - only other organism which causes lobar pneumonia - accounts for only ~ 1 % of all CAP www.freelivedoctor.com

54. iv) Legionella pneumophila - flourishes in artificial aquatic environments such as AC, water towers, water tubing for drinking, water, etc. - common in people with predisposing condition (heart, renal, immunologic, blood) - organ transplant patients  risk v) Moraxella catarrhalis (in elderly) - 1 of the 3 (i.e., S. pneumoniae, H. influenza) most common causes of otitis media in children www.freelivedoctor.com

55. e) S. pneumoniae normal inhabitant of nasopharynx - - false positive cultures i) blood cultures more reliable - resistant strains to penicillin - sensitivity test OTHER a) Chlamydia psittaci i) causes Psittacosis ii) inhaled in dust contaminated with excreta from birds, usually parrots ! iii) other pets as well b) Pontiac fever (mainly febrile illness; Legionella sp.; www.freelivedoctor.com

57. 2. Community-acquired atypical pneumonias (mycoplasma + viruses) a) most common organisms is mycoplasma pneumoniae (others include viruses, chlamydiae and rickettsiae) b) sputum production, WBC modest increase, bacteria and influenza A viruses not found c) Chlamydia pneumonia increasing prevalence and important cause of this type pneumonia www.freelivedoctor.com

58. d) Can produce some alveolar fluid accumulation, thus minimizing bacterial pneumoniae e) secondary bacterial infections f) mycoplasma infections common in children and young adults i ) sporadic outbreaks in close communities (schools, military camps, prisons) g) viral infections of lower respiratory tract – influenza A and B i) most common in adults h ) adenovirus pneumoniae i) common in young army recruits www.freelivedoctor.com

60. 3. Nosocomial pneumonia a) pseudomonas sp. Most common gram (-) rods (also Enterobacteriaceia) i) gram(+) cocci – staph aureus b) Pulmonary infections acquired in the course of a hospital stay c) Common in patients with severe underlying disease, immunosupression, antibiotic therapy, invasive devices such as catheters i) mechanical ventilator increase incidence (“ventilator-associated pneumonia”) d) strep. Pneumoniae NOT major pathogen www.freelivedoctor.com

61. 4. Aspiration pneumonia a) occur in severely debilitated patients (unconscious e.g., following stroke), or during repeated vomiting i) have abnormal gag and swallowing reflexes b) pneumonia partly chemical (gastric or chemical irritant) plus bacterial i) anerobes and aerobes c) necrotising frequent cause of death d) patients who survive usually develop abscess www.freelivedoctor.com

63. b) Anaerobic bacteria are present in almost all lung abscesses i) primarily those found on oral cavity ii) most common aerobes are: - S. aureus - Nocardia - β – hemolytic strep. www.freelivedoctor.com

64. 5. Opportunistic pneumoniae a) more common since advent of immunosuppressive and cytotoxic therapy b) AIDS epidemic i) Pneomocyctic carinii (fungus) ii) most common bacteria are E. coli and Pseudomonas aeruginosa - E.coli  complication of bacteremia, cancer patients given chemotherapy, chronic heart and lung disease. RESPONDS POORLY TO TREATMENT !! www.freelivedoctor.com

65. P. Aeruginosa (Con’t) - P. aeruginosa  often seen in burn patients, cystic fibrosis and immunocompromised pts. - prior history of antibiotic treatment for another infection is common - infectious vasculitis often result in pulmonary infarction - ANTIBIOTIC TREATMENT IS USUALLY UNSSATISFACTORY !! www.freelivedoctor.com

70. c) Eskimos more prone to develop progressive primary TB d) Lymphohematogenous dissemination severe complication i) tuberculosis meningitis ii) miliary TB (organisms drain through lymphatics and into central veins then to lungs – almost all organs are “seeded”) (liver, spleen, bone marrow, meningitis) e) hallmark of TB is caseating granulomas and cavitation (secondary) www.freelivedoctor.com

71. i) implant in distal airways - lower part of upper lobe or - upper part of lower lobe ii) as sensitization develops - gray-white consolidation emerges  “GHON FOCUS” (parenchymal lesion and nodal involvement  GHON COMPLEX ) iii) center of GHON focus undergoes caseous necrosis iv) GHON COMPLEX undergoes progressive calcification  RANKE COMPLEX (detectable by x-ray) www.freelivedoctor.com

72. www.freelivedoctor.com

74. - erodes along airway and becomes source of infection  pt. Raises sputum containing bacilli ! d) HIV patients i) less severe immunosupression – “usual” secondary TB (apical disease with cavitation) ii) more severe immunosuppression – clinical picture resembling “progressive primary TB” (lower and middle lobes, hilar lymphadenopathy, non cavitating) www.freelivedoctor.com

75. www.freelivedoctor.com

76. www.freelivedoctor.com