Respiratory Diseases

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Anxiolytics & Sedatives :

Anxiolytics & Sedatives Prepared & Presented by CHALLA BROTHERS Dr. Siva Reddy Challa, M.Pharm,Ph.D Dr. Kishna Reddy Challa, M.B.B.S (Diploma ortho) ----------------------------------------------------- Correspondence: Professor & HOD, Dept. of Pharmacology KVSR Siddhartha College of Pharmaceutical Sciences, Siddhartha Nagar, Vijayawada-520010 Andhra Pradesh, INDIA Email: m


PLEURA Visceral pleura – Invests the lungs Parietal pleura – Lines the pulmoary cavities and inner surface of the thorax Pleural cavity – Lies between the two layers of the pleura Contains a capillary layer of serous fluid Lubrication of the pleural surfaces allow the two layers slide on each other smoothly during lung movements


TRACHEA Divides into two main bronchi at the level of the sternal angle Right main bronchus - Wider, shorter, runs more vertically Left main bronchus Respiratory tract starts at the nose and nasopharynx and then to trachea Branching of the bronchial tree Trachea  Principal bronchus  Lobar bronchi (secondary bronchi)  Segmental bronchi (tertiary bronchi)  Terminal bronchiol e  Respiratory bronchiol e  Alveolar duct  Alveolar sac  Alveolus

Diseases of nose:

Diseases of nose Rhinitis ( common cold ) - an inflammatory condition of the nasal mucosa One in five Americans Symptoms- include nasal obstruction, hyperirritability, and hypersecretion Non- Allergic rhinitis Presents with clear rhinorrhea and nasal obstruction. Epistaxis, pain, and unilateral symptoms may be harbingers of a neoplasm.

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Infectious rhinitis : A gents : viruses ( Adeno, Rhino, Echo) Clinical : Clear discharge, sneezing, congested and inflammed nasal mucosa (thick, edematous, & erythematous), associated with headache, malaise, body aches, and cough. Super infection with bacteria leads to suppurative discharge. Treatment : Spontaneously subsides within week. Vasomotor Rhinitis- associated with changes in temperature, eating, exposure to odors and chemicals, or alcohol use.

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Allergic - rhinitis (Hay fever): IgE mediated type 1 Hypersensitivity reaction to allergens. Clinical Features : Characterized by sneezing, itching, rhinorrhea, and congestion. Mucosal edema, mucus secretions. Can be associated with other chronic conditions, including asthma, otitis media with effusion (OME), rhinosinusitis, and nasal polyposis, viral, bacterial Chronic rhinitis : Recurrent rhinitis. Risk factors: Polyps or DNS

Diseases of Nose:

Diseases of Nose Sinusitis : Inflammation of sinuses, mainly maxillary sinuses. Acute sinusitis of <4 weeks' duration Preceded by rhinitis. Superinfection : Viral URI, Haemophilus influenza, Streptococcus pneumoniae, Moraxella catarrhalis, staphylococcus aureus, fungi Clinical : nasal drainage and congestion, facial pain or tenderness, and headache, thick, purulent or discolored nasal discharge Treatment : Anti histamines, decongestants, Amoxicillin, Antrostomy.

maxillary sinusitis :

maxillary sinusitis

Diseases of Nose:

Diseases of Nose Mucormycosis : opportunistic fungal infection of sinuses. Risk factors : Immunosupression ( Diabetic Ketoacidosis, Steroids, HIV, Immunosupressants). Clinical Features - Invasive disease of sinuses, orbits, lungs In acidotic diabetic patients , black necrotic lesions of nose or sinuses or new cranial nerve abnormalities. Widely disseminated disease more common after aggressive chemotherapy

broad, infrequently septate, thin-walled hyphae of Absidia corymbifera :

broad, infrequently septate, thin-walled hyphae of Absidia corymbifera

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Diagnosis - Biopsy of the tissue. Histology demonstrates organisms in tissues as broad, branching nonseptate hyphae Treatment- High-dose amphotericin B Control of diabetes


Pneumonia Infection of lung parenchyma Predisposing factors: Decreased cough reflex Injury to cilia Decreased function of alveolar macrophages Edema or congestion Retention of secretions Routes of administration: Inhalation of air droplets Aspiration of infected secretions or objects Hematogenous spread respiratory apparatus ( infected ventilatory tubes)


Pneumonia Classification: Community acquired pneumonia : A)Typical : i)Lobar ii)Bronchopneumonia B) Atypical / Interstitial Hospital acquired (nosocomial) pneumonia

Bronchopneumonia & Lobar pneumonia:

Bronchopneumonia & Lobar pneumonia

Bronchopneumonia & Lobar pneumonia:

Bronchopneumonia & Lobar pneumonia

Bronchopneumonia &Lobar pneumonia:

Bronchopneumonia &Lobar pneumonia

Community Acquired Typical Pneumonia:

Community Acquired Typical Pneumonia Lobar pneumonia : Involvement of parenchyma of entire lobe of a lung. Caused by Streptococcus pneumoniae( 95%) and klebsiella in alcoholics Morphology : four classic phases

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Congestion - active hyperemia and edema, with the presence of a proteinaceous exudate and often of bacteria in the alveoli, quickly followed by red hepatization. Red hepatization - presence of erythrocytes in cellular intraalveolar exudate and neutrophils for host defense Gray hepatization - degraded and lysed RBC, fibrin deposition is abundant, and bacteria have disappeared Resolution - healing phase. Macrophage is dominant cell in the alveolar space, debris of neutrophils, bacteria, and fibrin has been cleared, as has the inflammatory response. Micro - intra- alveolar supportive inflammation (neutrophils) and edema

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Bronchopneumonia or Lobular pneumonia Involvement of bronchi along with adjacent parenchyma  scattered patchy consolidation centered around bronchioles Epidemiology -Young, old, or terminally ill are effected more commonly Etiology - Caused by Haemophilus influenza, Moraxella catarrhalis, Staphylococcus aureus, Legionella, klebsiella. Gross - Bilateral, multilobar and basilar Micro - Acute inflammation of bronchioles and surrounding alveoli

Typical pneumonia:

Typical pneumonia Clinical features: cough, fever, plueritic chest pain, sputum production, hemoptysis, high pulse rate. Streptococcus pneumonia —Rusty sputum Klebsiella --- Currant jelly Sputum Inspection:Decreased breath movements. Percussion:Dull note . Increased vocal fremitus Auscultation: Crackles or Rhales. Diagnosis : Chest X ray, Sputum gram staining and culture, blood culture Complications : pleural effusion, lung abscess, empyema septicemia, Bronchiectasis, fibrous scarring and pleural adhesions, pulmonary hemorrhage, pleural space infect.

Community acquired Atypical Pneumonia:

Community acquired Atypical Pneumonia Patchy inflammation of lung parenchyma & alveolar septa. Organisms: Mycoplasma , Chlamydia, legionella , Coxiella , Viruses (RSV, Influenza, Adeno ), Pneumocystis carinii pneumonia. Less clinical features than typical pneumonia. Clinical: dry cough, fever, headache, myopathy , GI symptoms( legionella ), rales and ronchi ( chlamydia ), Diagnosis- chest radiograph shows patchy infiltrate, hilar adenopathy and pleural effusions

Opportunistic pneumonias:

Opportunistic pneumonias Infections that affect immunosuppressed patients Associated disorders: AIDS Iatrogenic Cancer patients Transplant recipients Pneumocystis carinii Aspergillus Cytomegalovirus


Pneumonia Organism Predisposing feature Streptococcus & Haemophilus Splenectomy, Otitis media, Sinusitis. Klebsiella pneumonia Chronic alcoholics & Malnourished Legionella Water coolers, Chronic smokers, Organ transplantation Staphylococcus aureus Measles, Influenza inf, IV drug users, CGD. Pseudomonas Chronic hospitalization, Artificial Ventilation, CF CMV, Phencyclidine (PCP) Immunosuppression (HIV, Steroid) Coxiella Exposure to animals Chlamydia psittasi Exposure to birds Moraxella catarrhalis Otitis media

Lung abscess:

Lung abscess Necrosis of lung parenchyma leads to formation of pus filled cavity. Organisms : Anerobic organisms, Staph aureus, E.coli, Klebsiella. Predisposing factors : Pneumonia (mainly aspiration of gastric secretions), teeth infection, Pulmonary embolism, septic emboli, vasculitis, post obstructive Clinical : fever, foul smelling sputum ( anaerobic ) , chest pain, weight loss , clubbing, poor dentition, cough Diagnosis : X-ray (shows thick walled cavity), aspiration and culture, CT scan. Treatment : Antibiotics (Clindamycin) Complications : bronchiectasis, empyema, septicemia, amyloidosis, pulmonary hemorrhage

Lung abscess:

Lung abscess

Pulmonary tuberculosis:

Pulmonary tuberculosis Caused by Mycobacterium tuberculosis. Transmitted by inhalation of infected droplets. Pathogenesis : Mycobacteria are engulfed by macrophages & mycobacteria replicates in macrophages --> Activation of Th1 Cells--> Th1 cells secretes INF gamma. INF gamma useful for phagocytosis. INF gamma stimulates macropahges to release TNF , causes the granuloma formation .


Tuberculosis Morphology : Primary tuberculosis : Ghon focus : subpleural caseous granuloma above or below the interlobar fissure Ghons Complex-Single granuloma at upper part of lower lobe or lower part of upper lobe and also granuloma of hilar lymph nodes. Most of the lesions undergoes fibrosis and calcifications. Secondary tuberculosis : reactivation of primary tuberculosis. More common in apex of the lungs, where the substantially higher mean oxygen tension

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Progressive pulmonary tuberculosis: consolidation large cavitary tuberculosis Miliary pulmonary tuberculosis - multiple small granuloma Tuberculous bronchopnumonia - large granuloma Miliary systemic spread tuberculosis :Small granulomas scattered through out lung parenchyma. Meninges- head caseating granuloma Cervical lymph node (scrofula- painless eventually forms fistulous tract draining caseous material ) neck  laryngeal TB  lung TB ( plueral fluid- purulent and thick contains large numbers of lymphocytes  pericardium. Liver, spleen, kidney, adrenals, ileum are involved. Lumbar vertebrae bone marrow( potts disease ) Fallopian tubes and epididymis

X ray - Tuberculosis:

X ray - Tuberculosis


Tuberculosis Clinical features : Chronic cough with sputum, hemoptysis, night sweats, weight loss- loss of appetite, evening rise of temperature. Depending on the system involved- upper airway -hoarseness, dysphonia, and dysphagia in addition to chronic productive cough Genitourinary tuberculosis- Urinary frequency, dysuria, nocturia, hematuria, and flank or abdominal pain, and in female patients, it affects the fallopian tubes and the endometrium cause infertility, pelvic pain, and menstrual abnormalities

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Tuberculous meningitis – young- hematogeous Gastrointestinal tuberculosis - swallowing of sputum with direct seeding, hematogenous spread, ingestion of milk from cows affected by bovine tuberculosis. Terminal ileum and cecum most common sites Diagnosis :X-ray, caseating granulomas with acid-fast bacilli, Tuberculin skin test (Mantoux test) Lab- pruified protein derivative skin test Complications : Pleural effusion, empyema, pleural fibrosis, Bronchiectasis, Fungal infection

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Classification of positive tuberculin skin test reactions Reaction SizeGroup 5 mm HIV-positive persons, immunosuppresed Recent contacts of individuals with active tuberculosis or prior tuberculosis case Patients with organ transplants 10 mm 1. Recent immigrants (Asia, Africa, Latin America) 2. HIV-negative injection drug users. 3. Mycobacteriology laboratory personnel. 4 people at high risk. 15 mm Persons with no risk factors for tuberculosis.


Atelectasis Area of collapsed or non expanded lung. Types : Resorption/ obstruction type : Obstruction in bronchioles and collapse of the lung beyond that point Ex- foregin body, COPD Compression type : Compression of the lung by Air (pneumothorax), fluid (pleural effusion) or pleural tumor. Contraction/ scar type : Due to fibrosis of lung parenchyma or pleura. Patchy atelectasis - lack of surfactant

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Clinical : Dyspnoea , cough, chest pain fever, shifting of mediastinum. Nonspecific dry crackles, decreased breath sounds, dullness to percussion over the affected lung. Recurrent pneumonia in the same lobe Diagnosis : X-ray, CT. Treatment : Correcting underlying cause. Prevention : Postoperative physiotherapy and continuos positive pressure ventilation.

Types of atelectasis:

Types of atelectasis



Bronchial Asthma:

Bronchial Asthma Chronic inflammatory disorder of the airways resulting in contraction of bronchial muscle Types Extrinsic (atopic, allergic). Allergens: food, pollen, dust Intrinsic (non-atopic) Initiated by infections, drugs, pollutants, chemical irritants, exercise, gastro-esophageal reflux , post nasal drip Release of inflammatory mediators IgE Mast cell Allergen Muscle contraction Mucus secretion Recruitment of leukocytes Epithelial cell injury Muscle contraction Mucus secretion Acute phase Late-phase ATOPIC ASTHMA


Asthma Clinical : Tachypnea, Tachycardia, cough wheezing, retraction of intercostal spaces. Symptoms frequently worse at night or in the early morning Arterial blood gases: In chronic asthma , increased Pa CO2, decreased PH, decreased Pa O2. Diagnosis : Clinical history, Methacholine test. Treatment : Beta2 agonists & Steroids

Chronic bronchitis:

Chronic bronchitis Chronic obstruction and inflammation of bronchi. Persistent Cough and sputum for at least 3 months for in 2 consecutive years. Caused by smoking, atmospheric pollutants. Morphology : pathologic event is an inflammatory process in the airways, with mucosal thickening and mucus hypersecretion , resulting in diffuse obstruction. Goblet cell metaplasia, mucous glands hypertrophy and hyperplasia leads to mucus production , squamous cell metaplasia finally fibrosis of bronchi.

thickness of the mucous glands increases:

thickness of the mucous glands increases

Chronic bronchitis:

Chronic bronchitis Clinical : cough with mucoid sputum, dyspnea, wheezing, cyanosis (so called as blue bloaters), tachycardia Pulmonary function tests : increased total lung capacity and residual volumes. Decreased FEV1/FVC. Chronic respiratory acidosis is present Complications : Cor pulmonale Treatment : Bronchodilators, Corticosteroids & Antibiotics.


Emphysema Abnormal permanent dialation of respiratory bronchiole, alveolar duct and alveoli( airways distal to terminal bronchiole). Causes : Chronic smoking & Alpha1 anti trypsin deficiency. Pathogenesis : Smoking causes recruitment of neutrophils , which secretes elastase . This elastase destroys the elastin in walls of acini . This leads to destruction of acini walls and dialatation and it also causes the destruction of the lung parenchyma .




Emphysema Types : 1)Centriacinar emphysema : Respiratory bronchioles are dialated.common type in smokers. Common in upper lobes of lungs. 2) Panacinar emphysema :Dialation of respiratory bronchiole, alveolar duct and alveolus. Common in alpha1 anti trypsin deficiency. 3) Paraseptal emphysema : Besides septa. Alveolar ducts and alveoli are dialated. Formation of subpleural bullae.


Emphysema Clinical : Dyspnea, progressive nonreversible airway obstruction, and abnormalities of gas exchange, c ough, wheezing, decreased breath sounds, progressive hypoxemia, with exercise. Pulmonary function tests : increased Total lung capacity and Residual volumes. decreased FEV1/FVC Complications : Respiratory acidosis, secondary Infections, c orpulmonale, pneumothorax (due to rupture of bullae or blebs). Treatment : Bronchodialators, antibiotics, oxygen, surgical resection .

Subpleural bullae:

Subpleural bullae


Bronchiectasis Post infectious abnormal permanent dilation of bronchi and bronchioles, due to destruction of walls. Risk factors : cystic fibrosis, necrotizing pneumonia (staph. aureus, haemophilus, Pseudomonas, TB, Aspergillus), bronchial obstruction, Abnormal lung defense mechanisms ( immotile cilia syndrome, deficency of IgA, IgG, IgM immunoglobulins, alpha 1 antiprotease deficiency) Clinical features : Chronic productive cough with dyspnea and wheezing, foul smelling sputum, hemoptysis, weight loss, anemia, clubbing, dyspnea. Gross: dilated bronchi and bronchioles extending out to the pleura

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Diagnosis : CT, x-ray (dilated, thickened airways and scattered, irregular opacities ), Sweat chloride testing, Panhypergammaglobulinemia Complications: Metastatic abscesses, corpulmonale. Treatment: Antibiotics, Postural drainage, Surgical resection.

Pleural effusion:

Pleural effusion Collection of fluid (>15ml) in pleural cavity. Types: 1)Exudate 2)Transudate 3)Haemothorax 4)Chylothorax Exudate Pleural fluid protein/serum protein >0.5 high specific gravity >1.012 LDH pleural fluid/LDH serum >0.6 pH < 7 Protein > 3g/dl (absolute) LDH absolute value >200 IU Decrease glucose

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Underlying inflammatory conditions in lung -- Empyema – collection of pus Rheumatoid pleuritis, SLE TB Pneumonias Pulmonary infarction Malignancy

Pleural effusion:

Pleural effusion Transudate protein <3g/dl low specific gravity <1.012 Glucose level = serum level Normal pH WBC < 1000/ml Causes: Congestive heart failure, Nephrotic syndrome, cirrhosis.

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BLOOD- pleural fluid hematocrit/peripheral hematocrit ratio > 0.5 Hemothorax – blood collection in pleural cavity Causes: cancer, chest trauma, ruptured aorta. Lymph - chylothorax >100 mg/dl Chylomicrons Triglycerides Cause: Thoracic duct trauma

Pleural effusion:

Pleural effusion Clinical features : Severe, dyspnoea, cough chest pain on respiration Decreased breath movements, crackles on auscultation, percussion – dull note. Diagnosis: X ray Treatment: Drainage of fluid, Antibiotics.

Pleural effusion:

Pleural effusion


Pneumothorax Air in the pleural cavity. Causes : 1)Spontaneous pneumothorax : Idiopathic, Marfans syndrome, Scuba diving, COPD Primary spontaneous pneumothorax is due to rupture of subpleural bullae . 2)Tension pneumothorax : occurs when intrapleural pressure exceeds atmospheric pressure throughout expiration, Penetrating injuries into chest. Traumatic pneumothorax - iatrogenic, penetrating injuries Clinical : Sudden dyspnea & pleuritic chest pain. Deviation of mediastinum to opposite side.Loss of breath Sounds.

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Clinical : Sudden dyspnea & pleuritic chest pain. Deviation of mediastinum to opposite side. Loss of breath sounds. Cardiopulmonary collapse and hemodynamic instability, marked tachycardia, tachypnea with labored breathing, hypotension, and cyanosis is common in Tension PT Percussion: Resonance note Diagnosis - chest radiograph Treatment : Decompression by piercing bored needle into intercostal space. Chest tube into under water seal. Large tube thoracostomy Complications - bronchopleural fistula and reexpansion pulmonary edema



Pulmonary embolism:

Pulmonary embolism Occlusion of pulmonary arteries by embolus. Causes : Hypercoaguble states (Polycythemia vera , Factor V Leiden, Hyperhomocystinemia , Antiphospholipid syndrome), Sedentary life style, Bed ridden pts, obesity, hip fractures, pregnancy, DVT. Most common source : deep veins of legs. Clinical features : Sudden death, Severe chest pain, sudden dyspnea, cough, Hemoptysis , tachypnea Diagnosis : CT scan Pulmonary angiography—Wedge shaped lesion , Ventilation-perfusion scan- widened alveolar–arterial Po2 difference EKG- classic S1Q3T3 Treatment: Anticoagulants, Fibrinolytics , Thrombolectomy .

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Diagnosis : CT scan Pulmonary angiography—Wedge shaped lesion , Ventilation-perfusion scan- widened alveolar– arterial Po2 difference EKG- classic S1Q3T3 Treatment: Anticoagulants, Fibrinolytics, Thrombolectomy.

Pulmonary Hypertension:

Pulmonary Hypertension Increase in blood pressure in pulmonary vessels and capillaries. Causes: 1.Primary (Idiopathic) 2.Secondary:Left heart failure, COPD, High altitudes, Sleep apnea, Interstitial lung diseases, Scleroderma, Left to right shunts, Pulmonary emboli Clinical: Progressive dyspnea, Chest pain on exertion, fatigue, hemoptysis (frothy), cyanosis. Complications : Right heart failure (cor pulmonale) Treatment : Vasodialators (Ca channel blockers, Nitrates).

Pulmonary hypertension (enlargement of both pulmonary arteries):

Pulmonary hypertension (enlargement of both pulmonary arteries)

Restrictive lung diseases:

Restrictive lung diseases Decreased lung compliance due to interstitial lung diseases. Diseases : Idiopathic pulmonary fibrosis, Pneumoconioses, sarcoidosis Clinical : Dyspnea on exertion, dry cough, Lab : All lung volumes and capacities decreases. FEV1/FVC. Increased A-a gradient Chest X ray : Diffuse bilateral reticular infiltrates (ground glass appearance)

Idiopathic pulmonary fibrosis (ground glass appearance):

Idiopathic pulmonary fibrosis ( ground glass appearance )


Pneumoconiosis Disorders caused by inhalation of inorganic elements, primarily metals ( Carbon, Silicon ,Asbestos, Bretylium ). Injury is determined by: Length of exposure Physicochemical characteristics Host factors 1. Coal worker’s pneumoconiosis : Disease due to inhalation of carbon dust. i ) Simple anthracosis ii)Simple coal worker’s pneumoconiosis iii)Progressive massive fibrosis Complications: Pulmonary hypertension,Chronic bronchitis,Emphysema ( centrilobular ) Caplan syndrome: Pneumoconiosis + Rheumatoid arthritis.

Coal workers pneumoconioses:

Coal workers pneumoconioses

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2.Silicosis: Lung disease due to inhalation of Silicon dioxide (Silica). Common in sand blasters,foundry workers. Crystalline forms (quartz,crystobalite, tridymite) are more pathogenic than amorphous form.

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Pulmonary Neoplasia Bronchogenic carcinoma Epidemiology leading cause of cancer death, among both men and women Increasing in women (increased smoking) most commonly from 50-80 years of age Major risk factors Cigarette smoking Occupational exposure - asbestosis, uranium mining, radiation Air pollution

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Common genetic mutations Oncogenes L-myc: small cell carcinomas K-ras: adenocarcinomas Tumor suppressor genes p53 and retinoblastoma gene Clinical features Cough, sputum production, weight loss, anorexia, fatigue, dyspnea, hemoptysis, and chest pain Obstruction may produce focal emphysema, atelectasis, bronchiectasis, or pneumonia

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Adenocarcinoma (35%) Males = females; less closely associated with smoking than squamous cell Gross: peripheral gray-white mass with pleural puckering May develop in areas of parenchymal scarring ( scar carcinoma ) Micro: tumor forms glands and may produce mucin

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Bronchioloalveolar carcinoma (5%) Subset of adenocarcinoma Arises from terminal bronchioles or alveolar walls Gross: peripheral mucinous gray-white nodules Micro: columnar tumor cells grow along the walls of pre-existing alveoli

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S quamous cell (30%) Males > females; strongly related to s moking Gross: centrally located, gray-white bronchial mass Arises from bronchial epithelium after a progression: metaplasia —> dysplasia —> carcinoma in situ —> invasive carcinoma Micro Invasive nests of squamous cells Intercellular bridges (desmosomes) Keratin production - squamous pearls

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Small cell (oat cell) carcinoma (20%) Males > females; strong association with smoking Very aggressive: rapid growth and disseminate early Gross: central, gray-white masses Micro: small round or polygonal cells in clusters EM: cytoplasmic dense-core neurosecretory granules Commonly associated with paraneoplastic syndromes

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Large cell carcinoma (10%) Micro: large anaplastic cells without evidence of differentiation Intrathoracic spread Lymph nodes (50%): hilar, bronchial, tracheal, and mediastinal Pleural involvement (adenocarcinoma) Pancoast tumor (apical tumor) causing Horner syndrome Superior vena cava syndrome Obstruction of SVC by tumor Distended head and neck veins Plethora Facial and upper arm edema Esophageal obstruction: dysphagia Recurrent laryngeal nerve involvement: hoarseness Phrenic nerve damage: diaphragmatic paralysis

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Extrathoracic sites of metastasis: adrenal (>50%), liver, brain, and bone Paraneoplastic syndromes Endocrine/metabolic syndromes ACTH —» Cushing syndrome ADH->SIADH PTH —> hypercalcemia (squamous cell carcinomas) Eaton-Lambert syndrome Acanthosis nigricans Hypertrophic pulmonary osteoarthropathy Periosteal new bone formation Clubbing Arthritis Treatment - Nonsmall-cell lung cancer: surgery Small cell lung cancer: chemotherapy and radiation Prognosis: poor; overall 5-year survival: 10%

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Bronchial Carcinoids Younger age group; age <40 Gross: polypoid intra bronchial mass Micro: small, round, uniform cells growing in nests (organoid pattern) EM: cytoplasmic dense core neurosecretory granules

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Metastatic carcinoma to the lung Most common malignant neoplasm in the lung Gross: multiple, bilateral, scattered nodules Common primary sites: breast, stomach, pancreas, colon

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Laryngeal squamous cell carcinoma Uncommon Risk factors: smoking, alcohol, and frequent cord irritation Hoarseness, difficulty swallowing, pain, hemoptysis, and eventual respiratory compromise Complications: direct extension, metastases, and infection

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Mesothelioma Rare, highly malignant neoplasm Occupation exposure to asbestos in almost 90% Recurrent pleural effusions, dyspnea, chest pain Gross: encases and compresses the lung Micro: carcinomatous and sarcomatous elements (biphasic pattern) EM: long, thin microvilli Poor prognosis

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