Respiratory internal medicine


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Respiratory internal medicine

  1. 1. Respiratory Internal MedicineType I respiratory failure Type II Respiratory failureRepresents failure of oxygenation Represents a defect in ventilationand is characterized by a low PaO2 (hypoventilation) and iswith normal or low PaCO2. characterized by decreased PaO2PaO2 : Low (<60 mm Hg) with increased PaCO2.PaCO2 : Normal or Low (≤49 mm PaO2 : Decreased (<60 mm Hg)Hg) PaCO2 : Increased (>49 mm Hg)PA-aO2 : Increased PA-aO2 : NormalCauses: Causes:This type is caused by conditions This type is caused by conditionswhich affect oxygenation, like: causing hypoventilation as in : Parenchymal disease (V-Q  Obstructive lung disease: COPD, mismatch) Foriegn.body Diseases of vasculature/shunts  Decreased central respiratory Examples: drive e.g. CNS disorders like:- - Pneumonia Brain injury, Meningitis - ARDS  Weakness of respiratory muscles - Emphysema e.g - Right to left shunts - Peripheral N.S. disorders like: M.gravis. - Interstitial lung disease. - MS disorders like polymyositis. - Rib cage disorders: Kyphoscoliosis.Type I respiratory failure Type II Respiratory failureHypoxemia with decreased PaCO2 Hypoxemia with increased PaCO2Global institute of medical sciences
  2. 2. Respiratory Internal MedicinePRT Results Obstructive Pattern Restrictive PatternFEV1 Decreased (<80% predicted) Decreased (May be preserved) (Decreased out of proportion to (Decreased in proportion to FVC) FVC)FVC Decreased (may by preserved) Decreased ((<80% predicted)FEV1/FVC Decreased (<0.7) Normal or increased (>0.7)(FEV1%)FEF25-75 <50% predicted Decreased in proportion to loss of lung volumeTLC Normal or elevated DecreasedDLCO Normal Decreased in intrinsic restrictive Decreased in Emphysema lung disease. Normal in neuromuscular or musculoskeletal restrictive disease. Respiratory disease Obstructive Restrictive 1. asthma 2. COPD – Chronic bronchitis Parenchymal Extra parenchymal Emphysema - sarcoidosis 1. Neuromuscular 3. Bronchiectasis - pneumoconiosis disease 4. Cystic fibrosis - idiopathic pulmonary - Diaphragmatic palsy fibrosis - GB syndrome 5. Bronchiolitis - drug/Radiation - Muscular dystrophy induced interstitial - Cervical spine injury lung disease. 2. Cest wall - Kphoscoliosis - Oesity - Akylosing spondylitisGlobal institute of medical sciences
  3. 3. Respiratory Internal Medicine Obstructive lung disease Restrictive lung diseaseTotal lung capacity Normal to increase DecreaseResidual volume Increase DecreaseVital capacity Decrease DecreaseFEV1/FVC Decrease (<0.7) Normal to increase (>0.7)FEF 25-75% Decrease Normal(forced expiratory flowrate)Diffusion capacity Normal (decrease in Decreased emphysema)FVCThe forced vital capacity (FVC) represents the total volume of gas exhaled withmaximum expiration following maximal inspiration. A reduced FVC suggestspulmonary restriction.FEV1% or FEV1/FVCNote that FEV1 expressed as a percentage is actually FEV1/FVC.The volume of gas exhaled during the first second while expiration from FVC is FEC1.FEV1 is often represented as a ration of the FVC (often referred to as FEV1% rather thanFEV1/FVC)Normal to increased FEV1% (FEV1/FVC) suggest restrictive lung diseaseDecreased FEV1% (FEV1/FVC) suggests obstructive lung disease.DLCO : (Diffusion capacity for carbon monoxide)This reflects the ability of lungs to transfer gas across the alveolar – capillary interface.Decreased DLCO is consistent with a diagnosis of: Interstitial lung disease Emphysema Pulmonary hypertensionGlobal institute of medical sciences
  4. 4. Respiratory Internal Medicine Increased PaO2-PaO2 (alveolar arterial difference in oxygen) Correctible with oxygen Not correctible with oxygen V/Q Mismatch shuntV/Q Mismatch: Shunt: - Airway disease (Asthma, - Alveolar collapse COPD) - Intra alveolar filling - Interstitial lung disease 1. pneumonia - Alveolar disease 2. pulm. Edema - Pulmonary vascular disease - intracardiac shunt - vascular shunt within lungDecreased D LCO (diffusion capacity) Increased DLCO (diffusion capacity) 1. interstitial lung disease:- scarring 1. alveolar haemorrhage:- as a Good of alveolar capillary units pasture‟s syndrome: haemoglobin diminishes area of alveolar capillary contained in erythrocytes in bed as well as pulmonary blood alveolar lumen binds Co so exhaled volume carbon monoxide concentration is 2. emphysema:- alveolar walls are diminished & DLCO is increased. destroyed so the surface area of 2. congestive heart failure:- may be alveolar capillary bed is diminished elevated if pulmonary blood 3. recurrent pulmonary embolism volume is increased. Once and primary pulmonary pulmonary edema ensues DLCO hypertension:- disease causes a may decrease as and the net DLCO decrease in cross sectional area and depends on the opposing influences. volume of pulmonary vasculatureGlobal institute of medical sciences
  5. 5. Respiratory Internal Medicine Asthma Extrinsic asthma /allergic asthma Intrinsic asthma/Idiosyncratic asthma - History of atopy is present - Attacks related to environmental - No history of atopy (concomitant exposures nasal polyps are usually present - IgE antibody levels are increased and patients may be aspirin - Early onset of disease (young) sensitive) - Usually is less severe, intermittent - Attacks not related to asthma that may however progress environmental exposures: occur to severe persistent asthma without provocation - IgE antibody levels are normal - Delayed onset of disease (adult onset asthma) - Usually have more severe persistent asthma.The microscopically identifiable features described in sputum are three ‘C’sCharcot Leyden crystals : derived from granules of eosnophils and found only in asthmaCurshmann spirals : curiously twisted casts of airways : Whorls of shed epitheliumCreola bodies : clumps of cells or isolated metaplastic cells.Hypoxia is the universal finding in AsthmaHypocapnia and respiratory alkalosis is seen in most asthmatic patientsHypercarbia and Respiratory acidosis are very late features of asthma and signifysevere obstruction and respiratory failure. These are not universal findings in Asthma.Global institute of medical sciences
  6. 6. Respiratory Internal MedicineManagement of acute bronchial asthma: Sit patient up and give high dose O2 (100%) β2 agonist / Salbutamol (nebulized) Alternate β2 agonist Terbutaline Fenoterol etc. Steroids: hydrocortisone IV or Prednisolone orally Additive treatment if life threatening features are present 1. anticholinergic : iprotropium bromide 2. methylxanthines : aminophyllinesPanacinar emphysema Centriacinar emphysema - acini are uniformly involved - central or proximal parts of from level of respiratory acini formed by respiratory bronchiole to terminal blind bronchioles are affected alveoli. whereas distal alveoli are - Lsions are more common in spared lower zone and bases - lesions are more severe and - Occurs in association with common in Upper lobes α1 antitrypsin deficiency - occurs predominantly in smokers - I the commonest patternGlobal institute of medical sciences
  7. 7. Respiratory Internal Medicine Asbestos related lung disease Pulmonary Pleural Non malignant Malignant Non malignant Malignant Diffuse Bronchogenic interstitial - Pleural plaques - Mesothelioma carcinoma - Diffuse pleural Both plerural fibrosis All histological thickening and peritoneal (asbestosis) subtypes of - Acute benign mesotheliomas Asbestosis is lung cancer pleural effusion develop in defined as a occur with - Rounded persons diffuse interstial increased atelectasis exposed to fibrosing disease frequency but asbestos of lung caused by adenocarcino exposure to ma has the asbestos fibres. highest incidenceSilicosis has predilection for upper lobesRadiographs typically show fine nodularity in the upper zones of the lungRounded opacities appear in the upper lobes on chest radiographSilicosis is associated with calcific Hilar adenopathyCalcification of hilar lymph nodes may occur in as many as 20% oc cases and produce acharachteristic “egg shell” pattern.Silicosis is associated with tuberculosisBecause silica is cytotoxic to alveolar macrophages, patients with silicosis are at greaterrisk of acquiring lung infections that involve these cells as a primary defense includingmyocobacterium tuberculosis, atypical mycobacteria and fungiGlobal institute of medical sciences
  8. 8. Respiratory Internal Medicine Clinical spectrum of pulmonary aspergillosis saprophytic infection invasive aspergillosis Allergic aspergillosis aspergilloma (fungal - Invasive bronchial ball) - Allergic bronchial aspergillosis (IBA) asthma - Chronic pulmonary - Allergic aspergillosis (CPA) bronchopulmonary - Invasive pulmonary aspergillosis(ABPA) aspergillosis (IPA) - Extrinsic allergic alveolitis (type to hypersensitivity pneumonitis)kleibsella pneumoniakleibsella pneumonia presents as a typical ‘air space’ pneumonia withcough productive of purulent sputum. ‘purulent sputum production and„air space‟ diseases X ray are typical‟causes of atypical pneumonias: 1. mycoplasma pneumonias 2. viral pneumonias - influenza - RSV - Adenovirus - Rhinovirus - Rubeola - Varicilla - Corona virus 3. Chlamydia pneumonia 4. coxiella burnetti 5. pneumocystis cariniiGlobal institute of medical sciences
  9. 9. Respiratory Internal Medicine Crona virus is an infrequent cause of pneumonia. Pneumocytic carinni pneumonia is characterized by a prominent eosinophilic exudates and mild interstitial pneumonitis. These is damage to type I pneumocytes and associated compensatory hypertrophy of type II pneumocytes. Classic histopathology in pneumocystis pneumonia Intra alveolar changes interstitial changes Mild interstitial pneumonitisProminent eosinophilic foamy, vacuolated - Mononuclear interstitial cell intra alveolar exudeate (HE staining) infiltrate (mild)- Intra alveolar exudates contains the - Damaged type I pneumocytes organisms, which can be identified in - Hypertrophy / proliferation of type various stages of development II pneumocytis (reparative (throphozoite and cystic stage) by the response) use of special stains such as pneumocystis attaches to and 1. methamine silver / Toluidine stain damages type 1 pneumocytes. 2. wright giemsa stain There is associated 3. papanicolaou’s stain compensatory hypertrophy of type II pneumocytes. Global institute of medical sciences
  10. 10. Respiratory Internal Medicine Montoux test Montoux test is carried out by injecting one tuberculin unit (1TU) of PPD in 0.1 ml on the flexor surgace of forearm (PPD RT 23 with Tween 80) Test is read after 72 hrs (not 48 hrs) look for erythema and induration <6 mm 6-9 mm >10 mm negative doubtful Positive - a positive test indicates that patient is infected with M. tuberculosis. It does not however prove that the person is ‘suffering’ from the disease - studies indicate that 92% of new cases occur in persons who already are tuberculin reactors - 6-9 mm induration does not indicate high chances of developin tuberculosis. Infact patients with 25 mm induration have more chances of developing tuberculosis than those with 6-9 mm induration.Global institute of medical sciences
  11. 11. Respiratory Internal MedicineSarcoidosisSarcoidosis is a chronic multisystem disorder of unknown causes characterized byaccumulation of T lymphocytes and mononuclear phagocytes in various tissues of body Non caseating SARcoid granulomas in affected organs Lung (90%) lymphnodes skin Others (75-90%) -Eye :- uveitis - interstitial - Erythema - B/L hilar - Kidney (rare):- lung disease. nodosum Lymphadenopathy renal . fibrosis of lung - Lupus hypercalcemia is the hallmark of perenium parenchyma sarcoidosis with or without - Pleura is (purple blue hypercalcuria - Parotid shiny involved in 5% of enlargement B/e - Skeletal :- cases u/e swollen arthritis involvement is the lesions on pleural effusion vuli - Nervous - Cavitation is nose, system:- rare cheeks, lips, peripheral ears). neuropathy - Heart :- cor pulmonleInclusions seen in giant cells in sarcoidosis (remember as SARcoidosis) - Schaumann bodies - Asteroid bodies - Residual bodiesGlobal institute of medical sciences
  12. 12. Respiratory Internal Medicine Pneumothorax traumatic Spontaneous pneumothorax pneumothorax (non spontaneous pneumothorax) -These Primary spontaneous Secondary spontaneous penumothoraces occur pneumothorax pneumothorax as a result of : 1. blunt trauma or - Occur in persons with No • occurs in persons 2. penetrating trauma clinical evidence of lung with an underlying - Iatrogenic disease and without lung disease as a pneumothorax is precipitating event. complicationof the subcategory of - Most of these patients have underlying disease traumatic occult lung disease (sub process pneumothorax clinical) with subpleural blebs Causes of iatrogenic on CT scan Etiology of pneumothorax characterstics of affected secondary - Thoracocentesis people are :- - tall, thin, males pneumothorax - Insertion of central - smokers venous catheter - Mechanical - subpleural blebs on lungs ventilation (IPPV, assisted ventilation etc) - Surgery Obstructive lung disease Malignancy Interstitial lung disease Connective tissue Infection diseaseGlobal institute of medical sciences
  13. 13. Respiratory Internal MedicineFacts to rememberMost frequent histological type AdenocarcinomaMost frequent histological type in India Squamous cell carcinomaMost common histological varieny in life time non-smokers AdenocarcinomaMost common histological variety in young patients AdenocarcinomaMost common histological variety in females AdenocarcinomaMost common site for metastasis from Ca lung LiverMost common endocrine organ to be involved by metastasis Adrenalsfrom Ca lungCa lung which metastizes to opposite lung AdenocarcinomaCommonest tumor to metastise to heart Ca lung (Bronchognic Ca)Histological varieties that cavitate Squamous cell and large cellHistological varieties that are central in distribution Squamous cell and small cellHistological varieties that are peripheral in distribution AdenocarcinomaPancoost tumor is histologically Squamous cellMost common variety associated with paraneoplatic syndrome Small cell varietyMost common variety associated with hypokalemia Small cell (presumably d/t ACTH)Most common variety associated with hypercalcemia Squamous cell (presumably d/t PTH)Histological variety most responsive to chemotherapy Small cellHistological variety response to radiotherapy Small cellGlobal institute of medical sciences
  14. 14. Respiratory Internal MedicineHistological variety associated with hest prognosis Squamous cellThe most common malignancy of lung is adenocarcinoma (overall/world wide):-Most common lung cancer worldwide is AdenocarcinomaMost common lung cancer in India is swquammous cell carcinomaMost common lung cancer in women is adenocarcinomaMost common lung cancer in smokers is squammous cell carcinomaMost common lung cancer in nonsmokers is adenocarcinomaMost common lung cancer in young patients is adenocarcinomaMost common lung cancer to metastasize is small cell carcinoma.Ectopic hormones produced by small cell Paraneoplastic syndromecarcinomas - ACTH Cushings syndrome - SIADH/ANP Hyponatremia - Calcitonin Hypocalcemia - Gonadotropins gynaecomastiaGlobal institute of medical sciences