2 types of emboli – tiny ones that produce wedge shaped hemorrhagic emboli or can chip off large ones. Where do most Pul emboli embolize from? MC SITE for thrombosis is the deep veins of the lower leg. This is NOT the most common site for embolization; it is the femoral vein (this is the MC site for embolization). Makes sense b/c venous clots propagate toward the heart (deep veins to the femoral vein, and the femoral vein is a larger vessel, therefore it is more likely to chip off). So, the femoral vein is the MC site for embolization to the lung. The deep veins are the MC site where deep venous thrombosis begins. (when it get to the femoral vein, it is dangerous for embolization). So, small ones produces hemorrhagic infarct that is only if you have an underlying lung dz. If I have a small embolus, prob won’t infarct b/c don’t have abnormal lungs. However, if you have preexisting lung dz you will infarct. 85% of the time embolus will not produce infarct. However, in the 15%, most of the pts with infarcts have preexisting lung dz (ie they are smokers). The other type of embolus is a saddle embolus (it is huge) and blocks off the ori5ices of the pulmonary vessels and pulmonary arteries. If you knock off at least 3 out of the 5
ori5ices, you are dead in a millisecond, so there is no infarction b/c you don’t have time to infarct. It produces acute right heart strain and immediate death. Screening test of choice: Ventilation perfusion scan – will have ventilation, no perfusion;
conUirmatory test is pulmonary angiogram.
VII. Restrictive Pulmonary Disease
Restrictive – something is restricting it from 5illing. Example: restricted 5illing of the heart = restrictive cardiomyopathy. Or restriction in 5illing up of the lungs with air. Have 2 terms: compliance (Uilling term, inspiration term) and elasticity (recoil, expiration term);
For restrictive lung dz, picture a hot rubber bottle for restrictive lung dz. The hot rubber bottle is dif5icult to ‘blow up’, therefore compliance is decreased and it is hard to 5ill the lung up with air. So, what’s preventing it from blowing up? Fibrosis (interstial 5ibrosis, MC’ly). If you get the hot water rubber bottle 5illed with air and let the air out, what happens to the elasticity? Increases. So, compliance is decreased and cannot 5ill it up, but once you do 5ill the lung up, it comes out quickly (elasticity increases).
Example: pt with sarcoid – diff to 5ill lungs, but get it out fast (due to 5ibrosis). So, all TLC, RV, TV (all lung capacities have all equally decreased). FEV1/FVC on spirometer – take a deep breath (ie pt with sarcoid) – FEV1 (amount you get out in one sec – normally it is 4 liters) is decreased, FVC (total that got out after deep inspiration) is decreased (b/c increased elasticity) – this is the same as FEV1, so the ratio is often 1. Normally, the FVC is 5 liters, and the FEV1 is normally 4 liters – so, the normal FEV1/FVC ratio is 4/5 =80%. B/c the elasticity is increased, the FVC is the same as FEV1, and therefore the ratio is increased to 1 instead of 0.8.
Examples of restrictive lung dz’s:
1. Pneumoconiosis – airborne/dustborne dz’s – famous in big cities (LA, NY). Cole worker pneumoconiosis – esp. in west Virginia/Penn, have an anthrocotic pigment that causes a 5ibrous rxn in the lung, leading to restrictive lung dz. Have an increased incidence of TB, but not cancer.
2. Silicosis – Sandblasters get graf5iti off things, or work in foundries and deal with rocks (ie quartz), and break them down, and breathe in dust, leading to silicoses).
Have nodules in the lung that are hard has rock (literally) b/c there is quartz in them and it looks like metastatic dz in the lung (silica dioxide – which is sand in the lung) – again, increased of TB, not cancer. If pt happens to have rheumatoid arthritis, and also has one of these pneumoconiosis (ie Cole workers), have a potential for a syndrome, which is called caplan syndrome. Caplan syndrome consists of rheumatoid nodules in the lung (same as extensor surfaces in the arm). Rheumatoid arthritis commonly involves the lung with 5ibrosis. And rheumatoid nodules can form in the lung. The combo of rheumatoid arthritis (rheumatoid nodules) in
the lung, plus pneumoconiosis (silicosis/asbestosis/Cole workers) = caplan syndrome.
3. Asbestos – asbestos 5ibers look like dumbbells (therefore ez to recognize).
These are called ferruginous bodies. Asbestos 5ibers coated with iron, therefore can call them either asbestos bodies or ferruginous bodies. MC pulmonary lesion assoc with asbestos is not cancer – it is a 5ibrous plaque with a pleura, which is b9 (not a precursor for mesothelioma). MC cancer assoc with asbestos = primary lung cancer, 2nd MCC = mesothelioma, which is a malignancy of the serosal lining of the lungs. If you are a smoker and have asbestos exposure, you have an increased chance of getting primary lung cancer. This is a good example of synergism (other causes of lung cancer (SCC) include smoking, alcohol). Asbestos + smoker = will get cancer. There is no increased incidence of mesothelioma with smoking (not synergistic). Example: Roofer for 25 years, nonsmoker (do tell you, but you had to know that 25 years ago, all the roo5ing material had asbestos in it; in other parts of NY, many buildings were torn down, and there was asbestos in the roo5ing of those buildings, which was inhaled by many people, and 10-‐30 years later they developed primary lung cancer or another complication of asbestosis). What would he most likely get? Primary lung cancer (primary pleural plaque was not there). If he was a smoker? Primary lung cancer. Mesothelioma takes 25-‐30 years to develop. Lung cancers take about 10 years to develop. Lung cancers are more common, and you die earlier. What is the main cause of asbestos exposure? Roofers or people working in a naval shipyard (b/c all the pipes in the ship are insulated with asbestos), also in brake lining of cars and headgear.
4. Sarcoidosis =2nd MCC restrictive lung dz.
Example: classic x-‐ray – lymph nodes (hilar lymph nodes are big), haziness seen, too, which is interstial 5ibrosis. Sarcoid is a granulomatous dz that has NO relationship to infection (cause = unknown). Causes a noncaseating granuloma (not caseating b/c no relationship to TB and systemic fungal infections). The lungs are ALWAYS involved (lungs are the primary target organ), and more common in blacks. Example: black person, 35 y/o, with dyspnea, see hilar nodes on x-‐ray, uviitis (blurry vision – this is in5lammation of the uveal tract – this dz always affects something in the face, and the face the 2nd MC site a lesion will occur with this dz, can also involve salivary glands or lacrimal glands – something in the head/neck/face area (behind the lungs). This dz is a dx of exclusion, therefore must rule out anything that causes granuloma (TB, Histo), along with the correct physical presentation = Sarcoidosis. Rx = steroids. ACE enzymes are very high in these pts b/c granulomas in kidney; hypercalcemia – macrophages (epitheloid cells) make 1-‐alpha-‐
hydroxylase. If they are making 1-‐alpha-‐hydroxylase, what is the mech of hypercalcemia? Hypervitaminosis D. you are second hydroxylation more vit D and therefore have excess vit D, and vit D promotes reabsorption of calcium and
phosphorus, leading to hypercalcemia. This is the MC noninfectious cause of granulomatous hepatitis (TB is the MCC of infectious hepatitis, 2nd MC = pneumoconiosis).
5. Hypersensitivity pneumonitis (farmer’s lung, siloUillers dz, bysinosis) These are restrictive lung dz’s. Don’t confuse farmer’s lung and silo5illers dz – they are BOTH seen in farmers. So, remember one, the other is the other!
SiloUillers dz – put things in silos, which is a closed space, and fermentation of gas occurs, the gas is nitrogen dioxide – Example: farmer went into a room in his barn and suddenly developed wheezing and dyspnea, why? B/c he took in nitrogen dioxide, which is a fermenting problem. (silo can explode b/c gas from fermentation).
Farmer’s lung – thermophilic actinomyces (a mold).
Example: on tractor, dust being blown up in the air and thermophilic actinomyces (which is a mold) is inhaled; leading to hypersensitivity and HPY pneumonitis and they end up with a restrictive lung dz.
Bysinosis – worker in textile industry, and they get dyspnea. These are the HPY and restrictive lung dz’s.
Goodpasture syndrome
Begins in the lungs with a restrictive lung dz (with coughing up blood – hemoptysis), and ends up very shortly with renal dz (therefore, it starts in the lung and ends in the kidneys). This is a restrictive lung dz.
VIII. Obstructive lung Dz