Term
| risk factors of pulmonary thrombiemboli 7 |
|
Definition
prolonged bed rest
surgery (esp orthopedic of knee and hip)
severe trauma (esp burn, multiple fractures)
congestive heart failure
oral contraceptives (esp high estrogen)
disseminated cancer
primary hypercoaguability |
|
|
Term
| what is the main determinant of which artery a thromboemboli will occlude in lung |
|
Definition
cardiopulmonary stats of patient
size of emvoli |
|
|
Term
| where do most pulmonary thrombi come from |
|
Definition
| 95% come from DVT in lower popliteal or larger veins above knee |
|
|
Term
| complications of a blocked pulmonary artery 7 |
|
Definition
increased pressure
neurogenic induced vasospacm
ischemia downsteam parenchyma
decreased CO, right side heart failure, sudden death
hypoxemia |
|
|
Term
| explain how pulmonary thrombi causes hypoxemia |
|
Definition
perfusion of lung zones becomes atlectatic (alveoli collapse due to ischemia reducing surfactant production and causing pain so chest wall dosent move as much)
hypoxic areas clamp off and shunt blood to areas of the lung normally hypoventilated
this decreases CO and widens difference in arterial venous O2 saturation (can induce R to L shunt in PDA) |
|
|
Term
| why isnt ischemic necrosis a complication of a blocked pulmonary artery |
|
Definition
| bronchial artery provides blood flow back up |
|
|
Term
| what are the 4 different types of pulmonary emboli and where do they land |
|
Definition
saddle: main pulmonary artery or bifurcation
small emboli: medium and small pulmonary arteries
medium emboli: causes pulmonary infarct of medium arteries
recurrent multiple: around lung causing HTN |
|
|
Term
| what are the consequences of a pulmonary infarct that is saddle 3, small 2, medium 1, recurrent multiple 4 |
|
Definition
saddle: death from hypoxemia, acute cor pulmonale
small: alveolar hemorrhage due to ischemic endothelial damage, fibrinolutic activity breaks down (clinically silent), parenchyma spared due to bronchial artery
medium: pulmonary infarct
recurrent multiple: pulmonary HTN, cor pulomonale, sclerosis, dyspneia |
|
|
Term
| describe the lesion in a pulmonary infarct: shape, early and late appearance, why |
|
Definition
wedge shape with base at pleural surface pointing to hilum and occlusion at apex
hemorrhagic: red/blue early, adjacent with pleura fibrous exudate
RBC lyse in 48h making it pale then red brown as hemosiderin builds up
over time fibrous replacement makes it gray-white then scars |
|
|
Term
| causes of nonthrombotic pulmonary emboli 5 |
|
Definition
| air, fat, amniotic fluid, foreign body, marrow, talc |
|
|
Term
| how can you identify a talc pulmonary emboli 3 |
|
Definition
| granulomatous response in interstitium of pulmonary arteries that causes fibrosis and HTN |
|
|
Term
| why do marrow pulmonary emboli occur 2 |
|
Definition
| hematopoetic and fat cells after massive trauma or bone infarct secondary to sickle cell |
|
|
Term
| clinical signs of pulmonary infarct: multiple recirrent 4, medium 1, small 1, complications 5 |
|
Definition
small: usually clinical silent and removed by fibrinolysis
medium: circiulatory insufficiey
CV collapse, shock, right heart failure: chest pain, dyspnea (occurs when >60% pulmonary vasculature occluded)
recurrent multiple emboli: pulmonary HTN, chronic right heart strain, pulmonary vascularsclerosis, worsening dyspnea |
|
|
Term
| prophylaxis of pulmonary ischemia 5 |
|
Definition
anticoagulation
early ambulation for postop and postpartum patients
elastic stickings
intermittent calf compression
isometric leg exercises if bed ridden |
|
|
Term
|
Definition
small emboli recieve anticoagulation
large emboli recieve thrombotics |
|
|
Term
| prognosis of pulmonary iscemia |
|
Definition
1/3 not diagnosed before death
normally resolve after initial acute event
predisposition factors make small emboli present as large
HISTORY OF PULMONARY EMBOLI INCREASES CHANGES OF ANOTHER BY 30% |
|
|
Term
| how is pulmonary HTN defined |
|
Definition
| increased pressure in the normally low resistance pulmonary circulation when pulmonary pressure reaches 1/4 or more the systemic levels (MAP>25 when normal is 10) |
|
|
Term
| what are the 3 categories of causes of secondary pulmonary HTN and some examples of diseases in each |
|
Definition
hypoxemia: COPD, interstitial lung disease, athlerosclerosis of pulmonary trunk, fibrosis
recurrent pulmonary embolism
increased lung volume in pulmonary circut: mitral stenosis, congenital heart disease, eismengers |
|
|
Term
| how does hypoxemia lead to secondary pulmonary HTN |
|
Definition
plexiform lesion: tufts of capillaries seen in long standing disease
destruction of parenchyma and reduction of alveolar capillaries increases pulmonary artery resistance and increases pressure |
|
|
Term
| how does recurrent pulmonary embolism cause secondary pulmonary HTN |
|
Definition
reductionin cross sectional area of vessels increases resistance
long standing emboli thicken vascular wall causing HTN |
|
|
Term
| how does increaed volume in the pulmonary circut cause secondary pulmonary HTN |
|
Definition
| causes smooth muscle hypertrophy |
|
|
Term
| how does mitral stenosis cause pulmonary HTN |
|
Definition
| increases LA pressure and thus venous pressure |
|
|
Term
| signs of secondary pulmonary HTN |
|
Definition
symptoms reflect underlying disease
seen at any age
respiratory insufficiency
right sided heart strain |
|
|
Term
| what ae the two causes of primary / idiopathic pulmonary HTN and their prevalence |
|
Definition
|
|
Term
| how does familial primary pulmonary HTN cause HTN |
|
Definition
AD germline mutation morphogenic protein receptor type 2 (BMPR-2) binds to TGF-b causing abnormal vessel endothelial and lung smooth muscle proliferation
not all who have mutation have disease, modifier genes affect penetrance |
|
|
Term
| how does sporatic primary pulmonary HTN cause HTN |
|
Definition
| serotonin transporter gene (5HTT) on pulmonary smooth muscle cells have increased proliferation on serotinin exposure |
|
|
Term
| sigs of primary/idiopathic pulmonary HTN 9 |
|
Definition
young adult, usually women
fatigue, syncope (esp with exercise)
dyspnea on exertion, CP
2-5y later respiratory insufficiency, cyanosis, cor pulmonale |
|
|
Term
| explain the cellular changes that occur in pulmonary HTN 5 |
|
Definition
endothelial cell and smooth muscle dysfunction due to mechanical or biochemical injury
reduces vasodilators (NO, prostacyclin), increases vasoconstrictors (endothelial
produces GF and cytokines to induce margination and replication of vascular smooth muscle and ECM |
|
|
Term
| what changes occur in main elastic arteries in pulmonary HTN |
|
Definition
| atheromas similar to systemic athleroscleriosis |
|
|
Term
| what changes occur in the medium arteries in pulmonary HTN |
|
Definition
| proliferation of myointimal and smooth muscle cells thickens intima and media and narrows lumen |
|
|
Term
| what chages occur int he small arteries and arterioles in pulmonary HTN |
|
Definition
thickening, medial hypertrophy, replication of elastic membranes
thickness may exceede diameter and obliderate lumen |
|
|
Term
| how can you distinguish primary vs secondary pulmonary HTN by morphology |
|
Definition
| idiopathic pulmonary HTN has plexiform lesions with proliferation in multiple lumina in small arteries where they branch into medium arteries |
|
|
Term
|
Definition
vasodilators
antithrombolytics
prostacyclin infusion |
|
|
Term
| prognosis of pulmonary HTN |
|
Definition
| poor, will need lung transplant if due to chronic condition |
|
|
Term
| what is a diffuse alveolar hemmorhage syndrome |
|
Definition
| primary immune mediated disease with triad of hemoptysis, anemia, and diffuse pulmonary infiltrates |
|
|
Term
| what are 4 diffuse alveolar hemorrhage syndromes |
|
Definition
goodpasture
idiopathic pulmonary hemosiderosis
pulmonary angiitis and granulomatosis (wegner granulomatosis)
limited wegner granulomatosis |
|
|
Term
| goodpastures: cause and effect |
|
Definition
| proliferative rapid progressive glomerulonephritis and hemorrhagic interstitial pneumonitis due to autoantibodies to noncollagenous domain a3 on collagen IV on BM |
|
|
Term
| what changes occur in lungs in goodpasture 7 |
|
Definition
| diffuse alveolar hemorrhages: heavy, red brown consolidations, focal necrosis of alveolar walls, fibrous thickening of septa, hypertrophic type II pneumocytes, hemosiderin in macriphages and extracellular |
|
|
Term
| what changes occur in kidney in goodpasture |
|
Definition
| linear pattern of IgG deposition on renal biopsy (this can sometimes be seen in alveolar septa) |
|
|
Term
| how is goodpastures diagnosed |
|
Definition
| antibodies in serum of 90% of patients |
|
|
Term
|
Definition
plasmapharesis
immune supression
evuntal renal transplant |
|
|
Term
| idiopathic pulmonary hemosiderosis; epidemology |
|
Definition
| usually kids, but adults ahve better prognosis |
|
|
Term
| idiopathic pulmonary hemosiderosis; cause |
|
Definition
| probablly immune mediated (periodic inactivity and remission) |
|
|
Term
| morphology of idiopathic pulmonary hemosiderosis; |
|
Definition
pulmonary histologically like goodpastures but no renal disease or anti BM antibody
diffuse alveolar hemorrhages |
|
|
Term
| tx of idiopathic pulmonary hemosiderosis 2, and prognosis |
|
Definition
steroids
immune supression
improves survival by 2.5 y |
|
|
Term
| what is another name for wegner granulomatosis |
|
Definition
| pulmonary antgiitis and granulomatosis |
|
|
Term
| cause of wegener's granulomatosis |
|
Definition
|
|
Term
| wegener's granulomatosis: morphology, location |
|
Definition
| necrotizing vasculitis (angiitis) and perenchymal necrotizing granulomatosis inflammation |
|
|
Term
| signs of wegener's granulomatosis 6 |
|
Definition
| 80% develop pulmonary upper respiratory signs: chronic sinusitis, epistaxis, nasal perforation, cough, hemoptysis, CP |
|
|
Term
| CXR in wegener's granulomatosis |
|
Definition
| multiple nodular densities (confluence of granulomas, some cavitated |
|
|
Term
| how is limited wegener's granulomatosis different than wegener's granulomatosis |
|
Definition
| same disease be restricted to the lung |
|
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