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Respiratory path, phys, pharm


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Define pneumonia
Inflammation of the lower respiratory tractm involving the alveolar space.
Definition of asthma
Airway obstruction that is reversible either spontaneously or with treatment (may not be complete)
Airway inflammation
Increased airway responsiveness
Airway remodeling

Identify the disease process and organism.
Histoplasmosis with granulomatous inflammation
Acute phase: Small (2-5 uM) ovoid budding yeast forms seen in macrophages
Local effects of lung tumors
Airway obstruction --> pneumonia, abscess, lobar collapse
Hoarseness due to laryngeal nerve invasion
Pleural effusion
Nerve entrapment syndromes (e.g. Horner's due to Pancoast's tumors in apex)
SVC syndrome
What are the 4 characteristics of asthma?
a) Airway obstruction that is reversible either spontaneously or with treatment
b) Airway inflammation
c) Increased airway responsiveness
d) Airway remodeling

What organism is this?
Candida. Pseudohyphae.

What's going on?
Pleural effusion on R.
Definition of chronic bronchitis
Excessive mucus secretion in bronchial tree
Chronic or recurrent productive cough
Symptoms present most days for minimum of 3 months in year and not less than 2 successive years
clinical presentation
Granulomatous disease, interstitial disease, disseminated infection
Paraneoplastic syndromes
(specifically for small cell, squamous, carcinoid)
Lambert-Eaton syndrome (antibodies to neuronal calcium channels)
Small cell: Hyponatremia due to ADH production, Cushing's due to ACTH
Squamous: hypercalcemia due to PTH production
Carcinoid: serotonin
Adeno: DIC
Pulmonary causes of restriction (alveolar and interstitial)
Alveolar: filling (exudate, CHF), atelectasis/collapse (inadequate surfactant), airway obstruction

Interstitium: increased fluid (CHF), increased cellularity (leukocytes, (myo)fibroblasts), interstitial fibrosis
What are the symptoms of Plummer-Vinson/Patterson-Kelly syndrome?
Anemia, glossitis, esophageal dysphagia

Very rare.
What cytokines are induced by the Th2 response in asthma?

What are the consequences?
IL-4, IL-13, Granulocyte-macrophage colony stimulating factor (GM-CSF)

B cells induced to synthesize IgE
Eosinophils recruited
What is Kartagener's syndrome?
(a.k.a. ciliary dyskinesia)
Cilia do not beat, affecting respiratory epithelium and all other parts of body with cilia.
Predisposition to bacterial colonization and development of serious complications.
Definition of emphysema
Abnormal enlargement of airspaces distal to terminal nonrespiratory bronchiole, accompanied by destructive changes of alveolar wall.
Granuloma or sheets of histiocytes containing fungus

Resembles leishmaniosis (a protozoan)
Squamous cell carcinoma:
common location
Bronchial mucosa
What inflammatory cells are increased in asthma?
Mast cells, eosinophils, neutrophils (which release bronchospastic mediators like histamine and leukotriene, platelet activating factor)
What is the main inflammatory cell involved in bacterial pneumonia?
Neutrophil, filling bronchi, bronchioles, and alveolar space (only alveoli necessary to diagnose as pneumonia)

What is this?
Diffuse Interstitial Lung Disease

What is this?
Irritation fibroma.
nodular mass of fibrous tissue occurring in the buccal mucosa along the bite line.
3 types of anti-inflammatory agents
Cromolyn sodium, nedocromil sodium
Leukotriene modifiers
Usually peripheral, subpleural nodules

Identify disease process and organism
Spherule with large (5-100 uM) endospores inside
When spherule ruptures, you get disseminated infection.

What disease?
Honeycombing, dilated spaces, surrounded by dense fibrosis. Some normal alveoli.
What is the inflammation like in chronic bronchitis? (cell types)
Neutrophils in epithelium, mucous glands, and airways.
Depressed ratio of helper/suppressor T cells
Subepithelial mononuclear cell infiltration of bronchial mucosa (macrophage CD8+ t cells)

What is this?
Irritation fibroma.
Squamous mucosa, fibrosis. Inflammatory cells sprinkled around stroma.

What's this?
Lobar pneumonia.
Edema, neutrophils
Bronchioalveolar Carcinoma (BAC):
Cellular composition
Peripheral, in terminal bronchiolar cells or alveolar walls
Abundant mucus production
Well differentiated columnar cells containing mucin or cuboidal cells resembing Type II pneumocytes or Clara cells lining preserved septa
Better prognosis than regular adenos when they are solitary and < 2 cm
Southwestern US
Mode of action
Bind to cytoplasmic glucocorticoid receptor, which alloows translocation into nucleus, where it modifies transcription of numerous genes involved in asthma
Down-regulates: cytokines (IL-4, IL-5, GM-CSF), chemokines (Rantes, IL-8)
Up-regulates: β-agonist receptor

Decreases airway edema, increases response to beta-agonists.
What characterizes emphysema?
Abnormal enlargement of airspaces distal to terminal non-respiratory bronchiole, accompanied by destructive changes of the alveolar wall

What disease?
UIP. Fibroblast foci

What disease? What stage?
Lobar pneumonia, red hepatization stage.
Alveolar spaces filled with blood. Neutrohils present, RBCs dominate.

What is this?
Pyogenic granuloma
highly vascular, pedunculated gingival lesion resembling an hemangioma. Occurs in children and pregnant women (“pregnancy tumor”).
Vessels with lobulated appearance. Edema, inflammation, vascular proliferation*.
Midwestern US (Ohio and Mississippi River valleys)
Name corticosteroids:
Inhaled: beclomethasone
Oral: prednisone, prednisolone
IV: methylprednisolone
Pathological findings of UIP/IPF
Patchy, nonuniform, variable interstitial changes, normal lung, active fibrosis and end-stage fibrosis (honeycomb lung).

Fibroblast foci

Mild inflammation
Types of neuroendocrine tumors in the lung
Benign tumorlets, carcinoids, atypical carcinoids, small cell carcinomas (increasing malignant potential)

What disease? What stage?
Lobar pneumonia. Gray hepatization stage.
Accumulation of neutrophils, disintegrating RBCs and fibrin.
What is the inflammation like in emphysema? (cells)
bronchiolitis w/plump, pigmented, activated alveolar macrophages in respiratory bronchioles
What is Wegener's granulomatosis?
Necrotizing vasculitis, with granulomas, areas of necrosis, collections of histiocytes, abundant chronic inflammation
Bronchial carcinoid:
Microscopic appearance
Malignancy and mortality
Main stem bronchi or peripheral
Ribbons of polygonal cells separated by vascular spaces, silver stains show argyrophilic granules
5% have lymph node metastasis, but 5-10 year survival is 50-95%
Clinical presentation
Necrotizing granuloma
Disseminated disease is rare
Side effect
(All depend on dose, delivery, and duration)
Musc: myopathy, osteoporosis
GI: peptic ulcer
CNS: psychiatric
Ophal: post subcapsular cataracts
CV/renal: hypertension
Met: central obesity
Endo: growth failure, suppression of HPA system, exacerbation of hyperglycemia
Inhibition of fibroplasia (wound healing)
Impaired immune response
Clinical characteristics

(age, onset, symptoms, prognosis, therapy)
Most common IIP
Age: 50's, 60's
Onset: insidious
Symptoms: cough, dyspnea
Prognosis: poor
Therapy: none (except transplant)

What inflammatory process is this?
Asthma. the brown cells (bilobed) are eosinophils.
What is the predominant inflammatory cell type in legionella pneumonia?
Macrophage, full of bacilli and nuclear dust.

What neoplasm is this? What are its characteristics?
Nasopharyngeal angiofibroma
Benign, rare. Admixture of mature vascular and fibrous tissue.
Some normal squamous epithelium with bland fibrous stroma witih myxoid areas and prominent vessels.
Occurs almost only in males in teens.
Midwestern US (Mississippi and Ohio River Valleys)
Indications for inhaled corticosteroid
First-line anti-inflammatory in any pt with PERSISTENT asthma (requiring β-ag twice weekly)

Use in COPD is controversial

What disease does this spirogram represent?

What disease?
Desquamative Interstitial Pneumonia (DIP)
Increased macrophages in alveoli. Uniform appearance at low power. Moderate alveolar septal thickening due to collagen deposition.

If it were in respiratory bronchioles, it would be RB-Interstitial Lung Disease (RB-ILD)
What is atypical about atypical carcinoid tumors in the lung?
More cytologic atypia, focal necrosis, mitoses
What is the antibiotic of choice for Legionellosis?

What neoplasm is this?
Sinonasal papilloma, fungiform/transitional cell type
Note the transitional epithelium
Clinical presentation
Similar to tuberculosis: pulmonary nodules and/or cavity
Indications for oral corticosteroids
Rescue therapy for acute exacerbation in out-patient asthma
Small cell carcinoma:
Gross appearance
Microscopic appearance
bulky, white masses with necrotic areas

sheets and nests of small, hyperchromatic, round, oval, polygonal, or spindle cells with nuclear molding, crush artifact, DNA encrustation of BVs
What are the effects of cigarette smoke?
Increased mucus secretion, alveolar wall thickening, smooth muscle contraction
Damages nerve endings --> substance P --> mucus
Recruits inflammatory cells
Destroys cilia to move mucus out

What disease?
Desquamative Interstitial Pneumonia

Macrophages in alveolar space. Moderately thickened alveolar septae.

What is this?
Sinonasal papilloma, inverted type.
See epithelial layer "growing in"
High rates of recurrence

What pneumonia?

Looks like necrosis.
Mononuclear cells look dirty (nuclear dust).
If stained with warthrin-starry, you'd see bacilli.
Clinical characteristics
(Age, onset, symptoms, associations, prognosis, treatment)
Cough/dyspnea, clubbing in 50%
30% mortality (RB-ILD not fatal)
60% respond to steroids, some improve spontaneously
Epithelial lung cancer types
Nonsmall cell types: Squamous cell carcinoma 25-40%, adenocarcinoma (including BAC) 25-40%, large cell carcinoma 10-15%
Prognosis better (resection possible)

Small cell carcinoma (20-25%)
Worse prognosis (chemo and radiation only)

Identify disease process and organism
Broad area of contact between dividing yeast
Large yeast form
Indications for IV corticosteroids in asthma
Acute exacerbation in hospital
What are PFT findings of chronic bronchitis?
Decreased expiratory flow
Decreased FEV1
Normal FVC (lung volumes are normal)
What differentiates pseudomonas aeruginosa pneumonia?
Vascular haze, vasculitis with hemorrhage and pumonary infarcts. (bacteria need lots of O2, so it localizes near BVs --> hemorrhage and infarct)

What is this, if it also is immunopositive for S-100, neutron specific enolase, and chromogranin?
Olfactory neuroblastoma.
Cromolyn sodium, nedocromil sodium:
Mechanism of action
Stabilizes mast cell membranes, interferes with signal transduction in mast cells
How does asthma differ from CB?
Type of inflammatory cell: TH2 and eos in asthma, macrophages, neutrophils, and CD8 T cells in CB
Location of inflammatory cells
How those cells lead to obstruction
Pneumocystis carinii pneumonia (PCP):
Clinical presentation
-Insidious, slow progressive atypical pneumonia.
-Fast progressive pneumonia.
-Typically presents as bilateral shadowing on a chest x-ray.
-Respiratory failure is the most common cause of death. PCP can cause diffuse alveolar damage.

What disease?
Acute Interstitial Pneumonia (AIP) or Hamman-Rich Disease

Diffuse alveolar damage, epithelial cell death, hyaline membranes, thombi, diffuse, active fibrosis with proliferating fibroblasts and myofibroblasts.
Temporarily uniform appearance, but rapid evolvement of honeycomb lung.
Looks like ARDS.

What is this?
Squamous cell carcinoma - making pearls

What neoplasm is this?
Squamous cell carcinoma (could be nasopharyngeal carcinoma)

What pneumonia is this?
Pseudomonas aeruginosa. Vascular haze and hemorrhage.
Indications for neocromolyn sodium
Can be offered as first-line anti-inflammatory therapy, often in peds
Not as effective as CS, not effective in some pts at all.

No side effects.
PCP pneumonia:
Pathologic changes
Intraalveolar, pink, foamy, honeycomb exudate that contains the cysts and trophozoites of P. carinii.

Atypical presentations: granuloma, bullous pneumotorax, DAD, interstitial fibrosis.
What are the physical exam findings of emphysema?
Thin, pursed lips, decreased breath sounds, hyper-resonance, distant, faint heart sounds

What disease?
Acute interstitial pneumonia (Hamman-Rich)

Diffuse fibrosis
What is the prognosis of nasopharyngeal carcinoma?
Poor. Grows slowly and unnoticed until unresectable size. Often spreads to lymph nodes and distally.

What is this?
Adenocarcinoma - glandular
What organism is most associated with bacterial pulmonary abscess?
Staph aureus.
Actions of LTB4
Actions of LTC4, LTD4, LTE4
LTB4: chemoattractant
the rest: smooth muscle contraction, mucus secretion
Acute Interstitial Pneumonia (Hamman-Rich Disease):
Clinical presentation
(Common? onset, symptoms, associations, mortality, therapy)
Acute onset
Dyspnea, resp failure (like ARDS)
Viral prodome in most
60% mortality
Supportive therapy
How does emphysema lead to airway collapse?
Destruction of alveolar septae --> loss of elastic recoil --> collapse during expiration

Identify process and organism
Foamy exudate. Cyst does not stain with normal staining methods.

What benign neoplasm is this?
Laryngeal polyp. Myxoid/gray appearance with fibrous stroma covered by squamous epithelium, some vascular proliferation in between.
What is a potential complication of eosinophilic pneumonia?
Churg-Strauss syndrome (eosinophilic vasculitis), which creates large areas of necrosis in any area of body.

What is this?
Small cell carcinoma
Small, dark, like lymphocytes, scant cytoplasm

Identify organism
PCP cysts (w/silver stain)
Note cup shape of cysts

What disease?
Nonspecific Interstitial Pneumonia
varying amounts of inflammation (lymphocytes and plasma cells) and fibrosis in alveolar walls, but no specific findings of other ILDs.
Temporary uniform appearance
No fibroblast foci

What is this?
Large cell carcinoma - big, pleomorphic, undifferentiated

What is this? Imagine that it's growing in exophytic fronds.
What is it related to in children?
Laryngeal squamous papilloma.
Exophytic fronds of squamous epithelium with fibrovascular cores.

HPV 6 and 11

What type of pneumonia is this?
Zafirlukast, Montelukast:
Mechanism of action
Leukotriene receptor antagonist

Identify organisms at blue and black arrows
Blue: PCP (foamy, extracellular)
Black: CMV (owl's eye)

What disease?
Nonspecific Interstitial Pneumonia
What is treatment for eosinophilic pneumonia?
Steroids (not an infection)

What the hell is this?
Branchial cyst
Squamous or columnar lining with mural lymphoid infiltrate.
Florid lymphocytic proliferation in underlying stroma.
Which tumor is most associated with smoking?
Squamous cell carcinoma
Mechanism of action
Blocks action of 5-lipoxygenase (which generates leukotrienes from arachidonic acid
(Pathological findings)
Interstitial pneumonia -- parenchymal granulomas, including cavitary lesions
Immunocompromised: interstitial or alveolar involvement w/o inflammation
Mucin capsule protects from immune system

Can cause meningitis in immunocompromised host
Leukotriene modifiers:
Side effects
Churg-Strauss-like syndrome
Nonspecific Interstitial Pneumonia:
Clinical presentation
(age, onset, symptoms, mortality, associations)
mean age 50
Insidious onset
dyspnea, cough
10-20% mortality
Some have CVD (Collagen Vascular Disease), lung-toxic drugs or recent lung injury (e.g. pneumonia)

What is this?
Squamous cell carcinoma (pink cytoplasm with distinct cell borders and intercellular bridges)

What neoplasm is this?
nests of bluish cells with vesicular looking nuclei. bland, growing in nested pattern with fibrous stroma between them. Called Zell-Ballen pattern

Don't often see mitotic figures or necrosis

What type of pneumonia is this?
Interstitial (an atypical pneumonia, caused mostly by Mycoplasma pneumoniae)
Bronchiolitis Obliterans Organizing Pneumonia (BOOP):
granulation tissue plugs within the lumens of small airways. extends into alveolar ducts and alveoli.
(1) proliferation of connective tissue that forms intramural polyps (proliferative bronchiolitis obliterans);
(2) fibrinous exudates;
(3) alveolar accumulation of foamy macrophages; (4) inflamed alveolar walls;
(5) evenly spaced, rounded balls of myxomatous connective tissue.

Identify organism
Cryptococcus neoformans
4-7 uM oval budding yeast
Capsule contains mucin
Unencapsulated forms are more often found in HIV (less pathogenic)
Leukotriene modifiers:
May be used as 1st line for mild asthma, but usually an add-on with CS. May not be active in all pts

What is this?
Squamous cell carcinoma
at the upper left is a squamous eddy with a keratin pearl. At the right, the tumor is less differentiated and several dark mitotic figures are seen.

What neoplasm is this?
BOOM! it's not a neoplasm.
This is normal salivary gland, with serous glands, ducts, and adipose tissue.
What type of pneumonia is especially associated with bone marrow transplants?
Adenovirus pneumonia.

Name organism
Cryptococcus neoformans
(long neck budding)
Use this if it's unencapsulated
Short β-agonists:
2 examples
Albuterol sulfate

What disease?
Bronchioltis Obliterans Organizing Pneumonia
(intraluminal buds of granulation tissue (bronchiolitis obliterans), involving distal airways more than alveoli)
What is the pathology of adenovirus pneumonia?
ulceration of bronchi and bronchioli with shedding of the cilia from respiratory epithelium (ciliocytophthoria). May lead to interstitial pneumonia.

What is this?
Inflammatory cells have taken over gland, destroyed many ducts.

What's this?
Bronchioalveolar carcinoma.
Composed of columnar cells that proliferate along the framework of alveolar septae. The cells are well-differentiated.
Clinical features
(Onset, symptoms, associations, PFTs, treatment)
Subacute (faster onset - weeks)
Dyspnea, cough, weight loss
Heralded by flu-like illness, looks like community-acquired pneumonia
PFTs show restriction

Name the organism (mucin stain)
Cryptococcus neoformans
Short-acting β agonists:
Mechanism of action
Relaxation of smooth muscles with β2 receptors through activation of adenylate cyclase and increased cAMP levels

what is this?
Small cell carcinoma
Arising centrally in this lung and spreading extensively is a small cell anaplastic (oat cell) carcinoma. The cut surface of this tumor has a soft, lobulated, white to tan appearance. The tumor seen here has caused obstruction of the main bronchus to left lung so that the distal lung is collapsed.

What is this? (it's in a salivary gland)
Benign Lymphoepithelial Lesion - non-neoplastic enlargement of glands. Abnormal proliferation of lymphocytes in stroma and epithelium.

May be associated with Sjogren's syndrome

What type of pneumonia is this?
Look at the smudge cell (arrow) in alveolar space. Also, hyaline membrane and DAD.
(Clinical presentation)
Debilitated pts with neutropenia (not relevant in AIDS because mostly controlled by neutrophils)\

1) Allergic bronchopulmonary aspergillosis (ABPA)
2) Aspergilloma (fungus ball)
3) Invasive aspergillosis
Name the benign salivary gland neoplasms.
i. Pleomorphic adenoma/benign mixed tumors (50%)
ii. Warthrin's tumor (5-10%)
iii. Oncocytoma (1%)
iv. Ductal papilloma (rare)
v. Monomorphic adenoma (5-10%)
a. Basal cell adenoma
b. Canalicular adenoma
What are the clinical characteristics of DAD/ARDS?
Rapid onset of severe resp insufficiency
Arterial hypoxemia
Refractory response to O2 (gets worse)

What disease?
(granuloma of CD4+ T cells, epithelioid cells, macrophages, giant cells, fibroblasts, mast cells, may get fibrotic deposition if granuloma does not resolve)

What's this?
Small cell carcinoma
small dark blue cells with minimal cytoplasm are packed together in sheets.
β-agonist side effects
Tremor, palpitations, hyperglycemia, hypokalemia.

May develop tolerance
Allergic bronchopulmonary aspergillosis
(clinical presentation)
In certain asthmatic pts - unusual immunologic rxn to Asp.
Transient pulmonary infiltrates on CXR
Elevated IgE
Thickened bronchial walls w/mucus plugs on CXR
Proximal bronchiectasis w/plugs
Increased goblet cells, thickening of basment membrane
No invasion of bronchial wall

TREATMENT: steroids to get rid of inflammation
Is bronchial carcinoid associated with smoking?
Name the malignant neoplasms of salivary glands.
i. Mucoepidermoid cancer (15%)
ii. Adenocarcinoma/NOS (10%)
iii. Acinic cell cancer
iv. Adenoid cystic cancer
v. Malignant mixed tumor
vi. Squamous cell
vii. Other
Clinical features
(age, associations, treatment)
Earlier (10-40)
Multisystem disease, may be associated with Lofgren's syndrome: erythema nodosum, often on legs, caused by panniculitis, an inflammation of subcutaneous adipose tissue), hilar adenopathy, migratory polyarthralgias, fever
May spontaneously resolve, esp if symptoms were acute (Lorfgren's). Corticosteroids may give short term improvement, but long term effects are unknown.
Short-acting β-agonists:
All patients with bronchospasm, on PRN basis for fast relief. If needed more than twice weekly --> add anti-inflammatory agent
What is the pathogenesis of DAD/ARDS?
Initial injury to alveolar capillary endothelium and epithelium --> leaky capillaries and intraalveolar edema, fibrosis and reorganization of parenchyma

Bronchial carcinoid
note nests and chords of cells
(fungus ball)
May grow in preexisting cavities
No tissue invasion
Usually asymptomatic, but may result in massive hemoptysis --> emergency
Long-acting β-agonists:
Maintenance (preventative) therapy
NOT for acute exacerbation
NOT as anti-inflammatory
not to be used w/o anti-inflammatory agent

Name the two diseases
Chronic eosinophilic pneumonia (left)
CHF (right)

negatives of each other

What disease process is this?
Diffuse Alveolar Damage (DAD).
Lots of edema, disorganized. Cells where alveoli should be. Thick walls, cells are separated.

What neoplasm is this?
BOOYAH. Not a neoplasm.

Normal salivary gland tissue.

Hypersensitivity pneumonia
Granulomas and/or mononuclear cells
Interstitial infiltrates, fibrosis in chronic

Name organism
Aspergillus spp
Mechanism of action
Unknown, but may increase cAMP by decreasing action of phosphodiesterase and/or inhibit adenosine actions.

What disease process?
DAD, later stage.
Hyaline membrane
What is the most common benign lesion in the lungs?
Hamartoma (mature cartilage)
Looks like a "coin lesion" on X-ray

What neoplasm of the salivary glands is this?
Pleomorphic adenoma/benign mixed tumor

You can see all types of differentiation here

Hamartoma. Mature cartilage, well-circumscribed.

Contains admixture of fibrous tissue, fat, blood vessels.
Occasionally contains cysts lined w/respiratory epithelium

Hypersensitivity pneumonitis
granuloma, monocytes, fibrosis (looks like UIP)
Invasive aspergillosis
(Pathologic features)
Multiple patchy densities with target lesions (necrotic center w/ hemorrhagic periphery)
Tissue destruction w/vascular invasion with thrombosis
Only aspergillosis that invades -- wedge shaped lesion caused by fungus invading vessel walls
Main pathologic finding in BOOP.
Intraluminal organization characterized by airspace of bronchiolar plugs of fibroblasts and chronic inflammation. Organizing pneumonia --> fibrosis in alveolar space.
Oral: slow-release, metabolized in liver that are rapidly excreted.
Lots of variation in response. May be altered by CHF, cigarettes, other meds (cimetidine, erythromycin, CCBs).
Monitor levels.
Also available IV

What neoplasm is this?
Warthrin's tumor
Oncotic epithelium (very eosinophilic with abundant cytoplasm) lining cystic spaces. Abundant lymphocyte proliferation surrounding.

Identify organism
Aspergillus (invasive)
(Branched hyphae shown w/silver stain)
Invading blood vessel and pulmonary parenchyma
Is a solitary fibrous (aka localized submesothelial fibroma or pleural fibroma) accompanied by pleural effusion?
Side effects
GI, insomnia, headache, seizures, cardiac arrhythmias
What is the origin of Warthrin's tumor?
lymphoid cells in salivary gland.
What process is ground-glass opacity indicative of?
Acute inflammation rather than fibrosis

What's this?
Fibrous plug within bronchus and alveolar spaces.

Mesothelioma from asbestosis. Also see plaques on left side.

Identify organism
Aspergillus (invasive)
Septate, branched hyphae
Maybe in pts who still have symptoms despite other treatments. Some use in COPD.
What is the treatment for BOOP?

What neoplasm is this?
Mucoepidermoid carcinoma
Mixture of squamous cells, mucin (goblet) cells, and transitional cell forms
Anticholinergic agents:
Mechanism of action
Muscarinic (M3) receptors in lung respond to ACh and lead to contraction of SMCs.
Engagement of M2 --> inhibits release of ACh
Release is increased in asthma
Anti-ch agents block action of M receptors nonselectively
Blocking M3 --> block SMC contraction
Blocking M2 --> increase ACh release and counter relaxation
(Clincal presentation)
Multisystem granulomatous disease
Interstitial pneumonia, enlarged hilar lymphadenopathy.
Mild dyspnea and cough, but may be asymptomatic
CXR: bilateral interstitial opacities with or without hilar LN enlargement
What are the diagnostic criteria for ARDS?
acute illness leading to hypoxemic respiratory failure, with diffuse pulmonary infiltrates that are not due to CHF.
Ipratropium bromide
(course and treatment)
2/3 resolve spontaneously
Others may get pulmonary insufficiency, CNS, or CV involvement

Tx: corticosteroids
What is the physiology of ARDS?
Initial damage and consequence?
What happens to membranes?
Ultimate consequence
Diffuse alveolar damage --> leaky capillaries--> Fibrosis
fibrin deposition--> hyaline membranes and surfactant dysfunction
Thrombi form --> flooding and collapse of alveoli
Hypoxemia and increased dead space
Respiratory failure, need for mechanical ventilation
Relaxant effect on bronchial smooth muscle via stimulation of beta2-receptors. Beta2-stimulation also prevents mast cell secretion of histamine and other autocoids, thus antagonizing its effect on end organs and reversing bronchoconstriction and edema. Furthermore, alpha-stimulation may decrease secretions from the bronchial mucosa, attenuating the development of edema. There is some evidence that epinephrine's alpha properties make it more effective than pure beta-agonists for the treatment of some pulmonary conditions such as bronchiolitis in children.

Identify process
(Well-formed, non-necrotizing granuloma along lymphatic route)

name processes and disease
L: acute exudative phase (hyaline membranes lining alveolar space)
R: proliferative phase (later) - fibroblast proliferation and collagen deposition
Bronchodilator with slow onset of action (45 min).
Not a first line drug in asthma - more effective in COPD (first line)
Acute exacerbation of asthma
Wegener's Granulomatosis
(Pathological findings)
Systemic granulomatous inflammatory process with accompanying vasculitis, which predominantly affects the upper and lower respiratory tract and kidney.
1) Vasculitis
2) Necrotic granuloma
3) Inflammation (around BVs)

What type of disease is this?
Restrictive. Stiff lung. Smaller flow rates than normal, bowed out at top (increased recoil). Flow:volume ratio shows that it is very efficient.
Name 5 corticosteroids:
Low potency: Beclomethasone, triamcinolone, flunisolide

High potency: Budesonide, fluticasone
Wegener's granulomatosis

Identify what's going on
Wegener's granulomatosis

Necrotizing granulomatous inflammation centered around blood vessels (veins and arteries) with an inflammatory background.
Long acting beta-agonist: names
Extrinsic allergic alveolitis
(What is it?)
Hypersensitivity pneumonitis caused by variety of agents (birds, etc)

What's going on here?
Extrinsic allergic alveolitis
Ill-definied interstitial granulomas with lots of giant cells
Granuloma is in alveolar septae
Extrinsic allergic alveolitis
Cough, fever, dyspnea, pulmonary infilitrates

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