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Resp 03

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Alveolar O2 eqn: PAO2 = (tracheal PO2) - (O2 diffused to capillary)

= (FiO2 x (PB - PH2O)) - (PaCO2 / R)
A-a gradient eqn: PA-aO2 = PAO2 - PaO2
Oxygen content of blood eqn: CaO2 = oxygen bound to HgB + oxygen dissolved in plasma

= (HgB x % sat x 1.34) + (0.003 x PaO2)
Oxygen delivery eqn: TO2 = CaO2 x CO
describe the effusion of empyema: exudative, low glucose, INC WBC, predominance of neutrophils
CHF and cirrhosis - exudate or transudate?: transudate
cancer and TB - effusions contain mostly neutrophils or lymphocytes?: lymphocytes
pulmonary embolism - definition: impaction of a material into the branches of the pulmonary arterial bed; embolic occlusion of the pulmonary artery may be caused by blood clots, fat droplets, air bubbles, amniotic fluid or particulate matter
what is the most common form of pulmonary embolism?: thromboemboli
?: Normal Lung

This low power view shows well-inflated lung parenchyma. Note the alveoli, alveolar ducts, and bronchovascular bundles. The alveolar septa are thin and delicate, and only rare cells (alveolar macrophages) are found in the airspaces.
?: Normal Lung

The terminal bronchioles, the last branches of the bronchial tree completely lined by bronchial epithelium, are distinctive in their histologic appearance. The bronchiolar mucosa has a scalloped or pleated contour, and there is no cartilage in the wall. The diameter of the accompanying muscular pulmonary artery is of roughly equal caliber to that of the bronchiole.
?: Normal Lung

Respiratory bronchioles are lined partly by bronchiolar epithelium and partly by alveoli. These structures open to alveolar ducts, which terminate in alveolar sacs and alveoli.
?: Normal Lung

The alveolar walls are normally thin, and only a few nuclei are evident. These are the nuclei of capillary endothelial cells, interstitial cells, and perhaps a rare mononuclear cell. The alveolar epithelial calls are normal inconspicuous.
what constitutes the "air-blood" barrier in the normal lungs?: The air-blood barrier consists only of the cytoplasm of type I alveolar lining cells, capillary endothelium, and their fused basal laminas.
pores of kohn: pores between adjacent alveoli, allow for some collateral ventilation

important in disease spread
?: Atelectasis

In this section, the alveoli are compressed and alveolar spaces are narrow.
?: Atelectasis

Note that in this case the alveolar walls are of normal thickness and are not inflamed.
what physiologic abnormalities result from atelectasis?: low PaO2
high PaCO2
is atelectasis reversible?: yes
?: Bronchial Asthma

This low-power view shows plugging of bronchioles by mucus (arrow). Some of the mucus is arranged in darkly-staining coils ("Curschmann's spirals"). There is an inflammatory infiltrate in the bronchiolar wall. The alveolar spaces appear irregular in shape, and the septa appear thickened. This actually is due to patchy atelectasis. The septa are collapsed against one another and are not really thickened.
?: Bronchial Asthma

At high power note the mucus admixed with inflammatory cells in the lumen, the focal loss of the bronchiolar epithelium, the thickened basement membrane, the inflammatory cells in the submucosa, and the hypertrophy of the bronchiolar smooth muscle. The arrow indicates bronchiolar epithelium.
Which type of inflammatory cell is characteristic of the infiltrate in bronchial asthma?: principally eosinophils
?: Bronchial Hemartoma

This low power view shows a well-circumscribed border of the tumor with normal lung.
?: Bronchial Hemartoma

The cartilage is slightly disorganized in appearance, but otherwise appears mature. Often there is adipose tissue and fibrous tissue of variable amounts intermixed with the cartilage.
what does the term hemartoma refer to?: a tumor composed of a mix of mature tissue types that are normally present in the organ in which it arises

e.g. pulmonary hemartoma --> cartilage, fibrous tissue, and fat
?: Squamous Cell Carcinoma

Low power view shows an airway replaced by carcinoma in situ and nests of squamous cells infiltrating into adjacent tissue (arrow).
?: Squamous Cell Carcinoma

In this section, you can see a point of transition in the bronchial mucosa from normal respiratory epithelium to dysplastic squamous epithelium (arrow).
?: Squamous Cell Carcinoma

This section shows carcinoma in situ. The epithelium is entirely replaced by dysplastic squamous cells.
?: Squamous Cell Carcinoma

Invasive squamous cell carcinoma is characterized by keratin formation and/or intercellular bridges. Note the keratinization in this nest of invasive carcinoma.
Where do most squamous carcinomas arise in the lung?: majority occur centrally, i.e. associated with a bronchus
?: Small Cell (Oat Cell) Carcinoma

The cells of small cell or "oat cell" carcinoma are approximately twice the size of normal lymphocytes. They typically have a stippled chromatin pattern, inconspicuous nucleoli, and very little cytoplasm. There are usually numerous mitotic figures
What features characterize the ultrastructure of small cell carcinoma?: "undifferentiated" tumor composed of small cells i.e. high nuclear / cytoplasmic ratio, very little cytoplasm
What is the clinical significance of distinguishing small cell carcinoma from other types of lung cancer?: small cell carcinoma --> especially poor prognosis, be aware of ectopic hormones too
?: Bronchioloalveolar Carcinoma

This subtype of adenocarcinoma is distinguished by the growth pattern of the tumor cells. The tumor cells use the pre-existing alveolar septa as a framework on which to grow. In this view, the septa are lined by tall columnar cells having large nuclei and cytoplasmic mucin. Sometimes the tumor cells form papillary projections.
?: Bronchioloalveolar Carcinoma

Some bronchioloalveolar carcinomas produce abundant mucus. Tumor cells can often be found floating in the mucus in the involved alveolar spaces.
What is the gross appearance of bronchioloalveolar carcinoma?: may present as a solitary mass, multiple nodules, or a diffuse process --> may resemble consolidated pneumonia
Is bronchioloalveolar carcinoma associated with tobacco smoking?: not necessarily --> adenocarcinoma (of which bronchioloalveolar carcinoma is a subtype) is the most common histologic type in non-smokers and women
?: Metastatic Carcinoma

Low power view shows a large mass of tumor with focal necrosis, compressing adjacent lung parenchyma. This is an adenocarcinoma that arose in the colon and metastasized to the lung.
What is the gross appearance of metastatic carcinoma in the lung?: most common pattern of growth is that of multiple tumor nodules involving multiple lobes
What are the most frequent types of carcinoma that spread to the lung?: kidney, colon, thyroid
?: Tracheobronchitis related to prolonged tracheostomy: The tracheobronchial tree has been opened posteriorly. The tracheostomy opening is surrounded by a yellow zone of necrotic ulceration due to prolonged compression of the mucosa. There is marked erythema of the tracheobronchial mucosa, indicating a tracheobronchitis.
?: Hemothorax following trauma: The opened thorax reveals a large collection of blood in the pleural cavity. The large volume of blood in a confined space has caused compression of the lung.
?: Metastatic carcinoma: In many cases of metastatic carcinoma (or sarcoma), multiple rounded nodules of tumor are found diffusely throughout both lungs.
?: Bronchial carcinoid tumor: These tumors usually arise in a bronchus, forming a polypoid mass that may obstruct the lumen. Patients with these tumors may have recurrent pneumonias as a result.
?: Pneumonia

At high power, note that the alveolar septa are congested. In typical cases of bacterial broncho- or lobar pneumonia, the inflammatory exudate is principally confined to the air spaces. Thus, if the pneumonia completely resolves, the pulmonary interstitium may return to normal.
?: Pneumonia

In your slides you may find occasional clumps of bacteria within the alveolar exudate.
What does the term "consolidation" refer to?: areas (of e.g. the lung) which are stiff and full of fluid
what physical findings correspond to lung consolidation?: Feeling the way the chest expands (palpation) and tapping the chest wall (percussion) to identify dull areas which do not resonate can identify areas of the lung which are stiff and full of fluid (consolidated). Examination of the lungs with the aid of a stethoscope can reveal several things. A lack of normal breath sounds or the presence of crackling sounds (rales) when the lungs are listened to (auscultated) can also indicate consolidation. Increased vibration of the chest when speaking (tactile fremitus) and increased volume of whispered speech during auscultation of the chest can also reveal consolidation.
?: Organizing Pneumonia

Note the presence of a plug of fibrous tissue within an airspace (arrow).
?: Organizing Pneumonia

When a pneumonia fails to resolve, fibroblasts may grow into the alveolar exudate and lay down collagen, producing intra-alveolar fibrosis. This constitutes an organized pneumonia. Note that there is also some interstitial fibrosis, adjacent to a blood vessel at the edge of the section.
?: Pulmonary Aspergillosis

Aspergillus species may infect abnormal airways (e.g. old tuberculous or bronchiectatic cavities) and remain non-invasive. In immunocompromised patients, however, this fungus may invade the lung parenchyma, causing a severe, often necrotizing, pneumonia. In this section taken from the lung of an organ transplant patient, the bronchial lumen is virtually filled by a mass of fungal hyphae.
?: Pulmonary Aspergillosis

At higher power, note the hyphae invading the bronchial wall.
?: Pulmonary Aspergillosis

There is a severe pneumonia involving the adjacent alveolar parenchyma.
?: Pulmonary Aspergillosis

Note the red cells and fibrin filling the alveolar spaces, and the hyaline membranes. Aspergillus invades blood vessels, leading to ischemic changes.
?: Pneumocystis carinii Pneumonia

Low Power: The alveolar spaces are filled by pink proteinaceous exudate and there is an interstitial infiltrate.
?: Pneumocystis carinii Pneumonia

High Power: Vacuoles or spaces in the intra-alveolar exudate give it a "foamy" appearance. Note the inflammatory cells in the alveolar septa and the focal metaplastic epithelium.
?: Pneumocystis carinii Pneumonia

At high power, note that the cysts tend to cluster in groups. The cysts generally appear round or helmet-shaped. Their location within the alveolar spaces and the absence of budding help to distinguish Pneumocystis from fungal yeast.
How is pneumocystis pneumonia diagnosed clinically?: diagnosis by Giemsa stain of sputum, tissue, alveolar lavage fluid
?: Bronchiectasis

Low power view shows marked dilatation and inflammation of a bronchus. The arrow indicates intact respiratory epithelium.
?: Bronchiectasis

The dilated bronchi and bronchioles are commonly inflamed. There is often chronic inflammation in the wall, and frequently there is acute inflammation and erosion of the bronchial mucosa. In this section, a portion of the epithelial lining of the bronchiole is replaced by an inflammatory exudate. This erosion of the mucosa sometimes results in hemoptysis.
?: Emphysema

Note the disruption of the normal alveolar architecture, with widening of the air spaces.
?: Emphysema

At higher power, note the disruption of the alveoli. The alveolar walls are of normal thickness.
?: Pulmonary Sarcoidosis

Sarcoid granulomas are typically compact aggregates of epithelioid histiocytes, with variable numbers of lymphocytes and giant cells. There is usually no central necrosis.
?: Pulmonary Sarcoidosis

The giant cells of granulomas may contain a variety of inclusions, such as calcium oxalate crystals. This section shows a giant cell with an "asteroid body," which ultrastructurally consists of microfilaments and microtubules. It is thought that these peculiar structures result from reorganization of the cytoplasmic framework of the histiocytes when they fuse into giant cells.
What other change may occur in the lung in some cases of sarcoidosis?: alveolitis
?: Normal lung, whole mount: Note the regular distribution of bronchi and airspaces. Use this picture as a reference when looking at the whole mounts of abnormal lungs.
?: Emphysema, whole mount: In this case, enlarged airspaces are pronounced. The centrilobular distribution may be difficult to discern.
?: Emphysema, whole mount: In this example, there are several large bulla in the subpleural parenchyma.
?: Pulmonary fibrosis, whole mount with elastic tissue stain: There is diffuse irregularity and some dilatation of the airspaces, and their walls are thickened by fibrous tissue.
?: Diffuse pulmonary fibrosis: These lungs are stiff and firm in consistency. Note the "cobblestoned" appearance of the pleural surface, caused by retraction of the pleura by the interstitial fibrosis.
?: Bronchiectasis: There is marked dilatation of these peripheral bronchial structures, extending almost to the pleural surface. Note the ridging of the mucosa caused by accentuation of the circumferential smooth muscle of the bronchiolar walls. Abnormal pooling of secretions in these dilated airways usually results in acute and chronic infection.
?: Hyaline Membrane Disease

In this low power view, the airspaces appear irregular in shape, with thickened walls. This apparent thickening is caused by alveolar septa collapsed against one another; the residual airspaces are mostly alveolar ducts and some proximal alveoli, while most of the peripheral alveoli are unexpanded.
?: Hyaline Membrane Disease

This view shows a respiratory bronchiole opening into an alveolar duct that is lined by a hyaline membrane. The apparent cellularity of the adjacent alveolar parenchyma is caused by the marked atelectasis and immaturity of the lung tissue.
?: Hyaline Membrane Disease

Hyaline membranes are composed of fibrin and necrotic cellular debris that results from hypoxic damage to the lining epithelium.
?: Anthracosilicosis

A low power view of an anthracosilicotic nodule shows dense collagen with interspersed black carbon pigment.
?: Anthracosilicosis

Note the broad, dense collagen bands. There is focal fibroblastic proliferation with scattered lymphocytes. Coal dust is present between collagen fibers and sometimes is seen in histiocytes.
?: Asbestosis

In this low power view, the airspaces appear irregular and the alveolar walls appear thickened. This thickening is due both to collapse of alveoli and to fibrous thickening of their walls.
?: Asbestosis

At high power, look for asbestos bodies (also known as ferruginous bodies). These are fibers of asbestos that are coated with iron pigment.
How does the pattern of fibrosis in asbestosis differ from silicosis?: asbestosis -- bibasilar linear opacities

silicosis -- small, rounded nodular opacities in upper lobes
What other malignant tumor is associated with asbestos, besides carcinoma of the lung?: bronchogenic cancer
?: Pulmonary Hemorrhage and Early Infarction

At low power, there is sharp demarcation between relatively normal lung and an area of intra-alveolar hemorrhage.
?: Pulmonary Hemorrhage and Early Infarction

Within the area of hemorrhage, there is loss of many of the nuclei that would ordinarily be present within the alveolar septa. (Compare this area with the relatively normal lung on your slides) This is evidence of infarction. The thromboembolus that caused these changes is not present on your slides. Hemorrhage occurs following embolization to the lung when blood flows into the affected parenchyma by way of bronchopulmonary collaterals. If blood flow to the affected area is insufficient to maintain the viability of the alveoli (as occurs when the venous outflow is sluggish), infarction results.
?: Pulmonary Infarction

This section shows a more advanced area of infarction. Notice the rim of congested and hemorrhagic parenchyma at the edge of the infarct.
?: Pulmonary Infarction

At high power, within the infarct, one can make out the "ghost" outlines of alveolar septa.
?: Pulmonary Infarction

The vessel lumen is markedly reduced by fibrous tissue within which smaller blood-filled spaces are present. When a thromboembolus is not completely lysed, it may undergo organization, by ingrowth of fibroblasts into the thrombus. Endothelial cells also grow into the organizing thrombus, forming smaller vascular channels within the vessel ("re-canalization"). The arrows indicate the walls of the blood vessel.
Which patients are at greatest risk of infarction following pulmonary thromboembolism?: older patients with chronic cardiac or lung disease
What other tissues or substances can embolize to the lungs?: other than blood clots: fat droplets, air bubbles, aminotic fluid or particulate matter
?: Pulmonary Thromboembolism

Pulmonary embolism: This large thromboembolus is lodged at the bifurcation of the pulmonary artery ("saddle embolus"). Its size and shape suggests its origin in a leg vein.
?: Pulmonary Thromboembolism

Pulmonary embolus and infarct: A thromboembolus is lodged in a peripheral branch of a pulmonary artery (arrow). Note the hemorrhagic area of lung distal to this, representing flooding of alveoli by blood derived from the bronchial circulation via collateral flow.

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