RS Revision - 1 PDF

28 ----- Active space ----- RS REVISION - 1 Weibel’s generation of airways : First 16 : Upto terminal bronchiole Conducting zone. 23 airway generations...

28 ----- Active space ----- RS REVISION - 1 Weibel’s generation of airways : First 16 : Upto terminal bronchiole Conducting zone. 23 airway generations Last 7 : Respiratory bronchiole Alveolar ducts Respiratory zone /acinus Alveoli Approach to Lung Diseases 00:02:47 m o l.c CLASSIFICATION ai gm Diseases 2@ Pathophysiology Chronic obstructive pulmonary Larger & smaller airways t1 ar disease (COPD) : + Parenchymal + Vascular sm sh 1. Chronic bronchitis involvement. yu 2. Emphysema 1. Lung parenchyma involvement at pr 3. Small airway disease Causes : | w (Airways < 2mm diameter). a. Type 2 RF ro ar b. Pulmonary hypertension M c. Cor pulmonale © 2. Alveolar capillary membrane Obstructive lung diseases Type 1 RF Bronchial asthma (BA) : Pure - airway disease. Bronchiectasis - Exception : Traction - bronchiectasis Bronchiolitis - Cystic fibrosis - Medicine Revision v4.0 Marrow 8.0 2024  RS Revision - 1 29 ----- Active space ----- Diseases Pathophysiology Stages : Early : Hypoxia Type 1 RF Interstitial lung disease (ILD) : Diffuse lung parenchymal Pulmonary hypertension Intraparenchymal fibrosis Late : Hypercarbia + hypoxia Oxygen diffusion affected ↑ parenchymal damage Type 3 RF Restrictive Neuromuscular (NM) : lung - Myasthenia gravis diseases m - Amyotrophic lateral o l.c sclerosis (ALS) ai gm - Guillain-Barré Syndrome Extraparenchymal 2@ (GBS) t1 ar Chest wall : sm - Kyphoscoliosis sh yu - Ankylosing spondylitis at pr - Obesity | w Pulmonary hypertension ro ar Vascular lung diseases (PHTN) M Pulmonary thromboembolism © Pneumonia Due to exudate Diffuse alveolar hemorrhage Due to blood (DAH) Filling disorder Filling/ Acute respiratory distress pleura syndrome/ARDS Due to fluid related (Non-cardiogenic) diseases Filling disorder + Lung abscess/necrotizing parenchymal pneumonia destruction Pleural disorder Pleural effusion Note : Lung parenchyma Alveoli + alveolar interstitium + vascular interstitium. Medicine Revision v4.0 Marrow 8.0 2024  30 Medicine ----- Active space ----- Respiratory Failure 00:18:32 Types : Physiology Pa 02 Pa CO2 P(A-a)02 Examples Alveolar filling disorders : - Pneumonia - DAH Diffusion Type 1 ↓ Normal ↑ - ARDS failure ILD Vascular disorders Emphysema Pump : Neuromuscular disorders Ventilatory chest wall issues m Type 2 ↓ ↑ Normal o failure Effector organ : Chronic bronchitis l.c ai Generator : Brainstem disorders gm 2@ Combined t1 diffusion & ILD (Type 1 Type 3) ar Type 3 ↓ ↑ ↑ sm ventilatory Type 2 Type 3 RF is rare sh failure yu at pr Spirometry | 00:21:17 w ro ar Standard Lung Volumes & Capacities : M © Lung volumes Lung capacities Tidal volume : 500 mL Inspiratory capacity = TV + IRV = 3500 ml Inspiratory reserve volume (IRV) : 3000 mL Functional residual capacity (FRC)/Equilibrium/ Expiratory reserve volume (ERV) : 1000 mL Relaxation Volume = RV + ERV = 1/2 FVC = 2200 mL Residual volume (RV) = 1200 mL Forced vital capacity = TV + TRV + ERV = 4.5L Total lung capacity = TV + IRV + ERV + RV (TLC) = 5-6 L Note : Total body plethysmography : Measures RV, FRC, TLC (Spirometer can’t measure them). Medicine Revision v4.0 Marrow 8.0 2024  RS Revision - 1 31 FEV1/Forced expiratory volume in I second : ----- Active space ----- Amount of FVC exhaled in 1st second. FVC = 5L FEV1 = 4L Normal values. Volume (L) FEV1/FVC ≥ 80% Time (Sec) Lung Volumes in Lung Pathologies : Elastic recoil pressure (ERP) : Obstructive lung disease : - ↓ ERP (D/t loss of alveolar Hyperinflation Dynamic compression of m attachments) airways. o l.c Restrictive lung disease : ↑ ERP (D/t fibrosis) ↓ inflation of alveoli. ai gm 2@ Interpretations in lung pathologies : t1 ar sm Obstructive lung diseases Restrictive lung diseases Vascular lung sh Hyperinflation Air trapping Intra yu Extra parenchymal diseases at phase phase Parenchymal pr | FEVI/FVC ↓↓ ↓↓ Normal to ↑ Normal w ro FEVI ↓↓ ↓↓ Normal Normal ar M FVC Normal ↓↓ ↓↓ Normal © Normal DLCO ↓ Normal ↓↓ Exception : Emphysema ↓↓ NM Chest RV disorders wall ↑↑ ↑↑ ↓ Normal Normal Normal TLC ↑↑ Normal ↓↓ ↓↓ Normal Normal RV/TLC - - - ↑↑ Normal - Note : DLCO helps with early diagnosis & prognosis of ILD. Medicine Revision v4.0 Marrow 8.0 2024  32 Medicine ----- Active space ----- Smaller Airway Disease : FEV1/FVC : Normal Forced expiratory flow rate 25-75% (FEF 25-75)/ Volume (L) Maximal mid expiratory flow rate (MMEFR) is used for diagnosis. Time (Sec) DLCO 00:45:30 Measurement of lung’s ability to transfer gas (02) across alvelo-capillary m membrane. o l.c Normal value : 20-30 mL/min/mmHg or 70-140%. ai gm DLCO Measurement : 2@ t1 Gas used : Carbon monoxide (C0). ar sm - ↑↑ hemoglobin affinity. sh - Diffusion limited gas. yu at - Negligible amounts in blood. pr Technique : Single breath technique. | w ro ar Note : M Alveolocapillary membrane (Diffusion occurs) : © Components : - Alveolar epithelium + Basement membrane. - Interstitium - Capillary endothelium + Basement membrane. Surface area : 70 m2. Thickness : 0.2 - 0.5 micrometre. Medicine Revision v4.0 Marrow 8.0 2024  RS Revision - 1 33 Factors Affecting DLCO : ----- Active space ----- Factors : Increased DLCO Decreased DLCO ↑ Blood volume : Valsalva maneuver - Supine position Smoking (↑ carboxyhemoglobin) - ↑ Cardiac output High flow O2 - Congestive cardiac failure Anemia - Polycythemia ↓ PaO2 : High altitude Exercise & obesity Left to right shunts Disorders with altered DLCO : mo l.c Diseases with ↑ DLCO Diseases with ↓ DLCO ai gm DAH : Rheumatological disorders prone to ILD : 2@ - Goodpasture’s disease - Rheumatoid arthritis (RA) t1 - Wegener granulomatosis - Scleroderma ar sm - Microscopic polyangiitis - Mixed connective tissue disease sh yu Bronchial asthma (Normal/↑) - Dermatomyositis at Pulmonary vascular diseases : pr | - P. Hypertension w ro - P. Thromboembolism ar M Bleomycin toxicity © Emphysema Pleural Fluid Analysis 01:00:42 Significance of Pleural Fluid : Pleural fluid Detected by ≥50 mL Ultrasound ≥60-80 mL Chest X-ray lateral view ≥200 mL Chest X-ray PA view ≥300 mL Clinically Note : Normal pleural fliud volume : 10-30 mL. Medicine Revision v4.0 Marrow 8.0 2024  34 Medicine ----- Active space ----- PLEURAL EFFUSION Exudative v/s Transudative Effusion : Light’s criteria : 1. Pleural fluid protein/Serum protein ≥ 0.5. 2. Pleural fluid LDH/Serum LDH ≥ 0.6. 3. Pleural fluid LDH ≥ 2/3rd of upper limits of normal serum LDH. Features : Exudative effusion Transudative effusion Light’s criteria : Any 1 of 3 Diagnostic Pleural fluid protein > 2.9 g/dL Light’s criteria : All 3 absent criteria Pleural fluid cholesterol ↑↑ Pneumonia, TB Congestive cardiac failure, SVC m o Drugs obstruction l.c ai Malignancy Cirrhosis, Nephrotic syndrome, gm 2@ Connective tissue disease Hypoalbuminemia, Budd Chiari Causes t1 Esophageal rupture syndrome ar sm Peritoneal dialysis sh Hypothyroidism yu at Urinothorax pr | Drugs causing exudative effusion : w ro Nitrofurantoin. ar M Dantrolene. © Amiodarone. Note : Methysergide. Methotrexate causes : Bromocriptine. Hypersensitivity pneumonitis (M/c). Tyrosine kinase inhibitors. Effusion (very rare). Diseases causing both exudative & transudative effusion : Chronic constrictive pericarditis. Pulmonary embolism. Pulmonary infarction. Acute pancreatitis. Medicine Revision v4.0 Marrow 8.0 2024  RS Revision - 1 35 Components of Pleural Fluid : ----- Active space ----- Normal Empyema Rheumatoid arthritis 1700 cells/μL : Macrophages. 75% macrophages Cells Neutrophils Multinucleate giant cells 25% lymphocytes (Tadpole) Females. - Poor prognosis : Pulmonary hypertension. 2. Non-specific interstitial pneumonia (NSIP). 3. Cryptogenic organising pneumonia (COP). 4. Respiratory bronchiolitis associated ILD (RB-ILD). 5. Desquamative interstitial pneumonia (DIP). 6. Diffuse alveolar damage (Histological counterpart) : - Acute interstitial pneumonia (Covid). - Poor prognosis. 7. Lymphocytic Interstitial pneumonia (LIP). Medicine Revision v4.0 Marrow 8.0 2024  44 Medicine ----- Active space ----- Note : ILD a/w Smoking : RB-ILD. DIP. Langerhans cell histiocytosis (LCH). Rheumatoid arthritis associated ILD (RA-ILD). Patterns of ILD : Pattern Seen in Onset Treatment Idiopathic : Majority Anti PDGF (Platelet UIP RA Chronic derived growth factor) : Males > Females Nintedanib Connective tissue diseases (CTD) Steroid + MMF NSIP Subacute Drugs (Mycophenolate mofetil) m Polymyositis o l.c ai COP Dermatomyositis Subacute Steroid + MMF gm Anti-synthetase syndrome 2@ t1 Sjogren’s Syndrome ar LIP - - HIV sm sh yu CTD a/w ILD : at pr Diffuse systemic sclerosis | Mixed connective tissue disease (MCTD) w ro Sjogren’s syndrome ar M Polymyositis Lower lobe ILD. © Dermatomyositis IgG4 related disease Ankylosing spondylitis (Upper lobe ILD). Inherited causes of ILD : Tuberous sclerosis : A/w lymphangioleiomyomatosis. Neurofibromatosis. Clinical Manifestations : Signs : Symptoms : Clubbing. Exertional dyspnea. Velcro crackles (Bilateral, Fine, End Dry, non-productive cough. inspiratory). Hypoventilation (Type 3 respiratory failure). Medicine Revision v4.0 Marrow 8.0 2024  RS Revision - 2 45 Investigations : ----- Active space ----- PFT : FEV1/FVC : ↑. DLCO : ↓. Chest X-ray (CXR) : B/L, Bibasal, Subpleural reticulonodular infiltrates. HRCT: CXR : ILD IOC. Findings : Reticular & linear shadows. Pattern HRCT findings mo l.c Honey combing ai gm Cystic spaces UIP 2@ UIP : Honey combing Loss of lung architecture t1 Traction bronchiectasis ar sm NSIP Ground glass opacities (GGO) sh yu Consolidation at COP Reverse halo sign : GGO pr | Surrounded by consolidation w ro LIP NSIP + Nodules + Cysts ar M UIP : Honey combing © Note : Halo sign : Consolidation surrounded by GGO Invasive aspergillosis. NSIP Pattern COP : Reverse halo sign COP : Reverse halo sign Medicine Revision v4.0 Marrow 8.0 2024  46 Medicine ----- Active space ----- Conditions Causing Cysts in Lungs : 1. Langerhan cell histiocytosis (LCH) : Young male smoker. Upper lobe ILD : Nodules + Cyst. A/w diabetes insipidus. Birbeck granules : - CD1a cells ≥5%. LCH - Tennis racquet appearance. Pneumothorax. 2. Lymphangioleiomyomatosis (LAM) : Young females with tuberous sclerosis. 3 LIP. m Causes of Upper Lobe ILD : o l.c Ankylosing spondylitis. ai gm Sarcoidosis. LAM 2@ Silicosis. t1 Coal worker’s pneumoconiosis. ar sm ABPA : Allergic bronchopulmonary aspergillosis. sh yu Hypersensitivity pneumonitis. at Berylliosis. pr | TB. w ro LCH. ar M LIP © Drug Induced ILD : Amiodarone. Mitomycin. Bleomycin. Bromocriptine. Busulfan. Methotrexate Rare causes. Cyclophosphamide. Anti-TNFα drugs Note : Methotrexate causes hypersensitivity pneumonitis. Occupational Lung Diseases 01:11:26 Silicosis (M/c). Coal worker’s pneumoconiosis (CWP). Complicated. Asbestosis. Berylliosis Uncomplicated. Medicine Revision v4.0 Marrow 8.0 2024  RS Revision - 2 47 Silicosis : ----- Active space ----- Silicon dioxide/SiO2 (Quartz) : Industries : Rock/Slate cutting, blasting & mining. Acute Silicosis Chronic silicosis SiO2 exposure Large exposure within 2 years 10-30 years Symptoms Dyspnea on exertion Dyspnea & cough PAS positive macrophages Affected cell : Pulmonary alveolar macrophage Milky white bronchoalveolar lavage (PAM) Reactivation of TB : CT : Crazy pavement pattern Pleural involvement : Nil (GGO + Nodules + Septation) Parenchymal involvement : - Upper lobe (UL) ILD Findings Note : Radiological findings : Crazy pavement pattern is also seen in : - Angel wing sign Diffuse alveolar hemorrhage - Egg shell calcification (D/t Hilar Pulmonary alveolar proteinosis m lymphadenopathy) o l.c - Cavitation ± ai gm A/w Scleroderma Additional Poor prognosis 2@ Spirometry : Mixed Pattern features Lung Signs in 25% t1 ar sm CWP : sh Affected cell : PAM (No risk of TB reactivation). yu at pr A/w autoimmune conditions : | Caplan’s syndrome : RA + Active synovitis + Nodules + IgA rheumatoid factor +. w ro ar Pleural involvement/Malignancy : Nil. M © Parenchymal involvement : Nodules. Upper lobe fibrosis. Cavitation ±. No hilar lymphadenopathy/Egg shell calcification. Berylliosis : Ceramic industry. D/D : Sarcoidosis. Pleural involvement/Malignancy : Nil Parenchymal involvement : Upper lobe infiltrates Fibrosis Non caseating granulomas Features also seen in Thickening of bronchovascular bundles sarcoidosis. Hilar adenopathy NSIP pattern. Medicine Revision v4.0 Marrow 8.0 2024  48 Medicine ----- Active space ----- Asbestosis : Two types of fibres Amphibole Crocidolite. Serpentine (90%). Amosite (Most dangerous). Duration of exposure : 10 years. Pleural involvement : Unrelated to smoking. Pleural Manifestations : plaques - Thickening Parietal pleura (M/c) : Pleural plaques + calcification. Holly leaf sign/Table mountain sign/Candle drip sign. m o Visceral pleura with lung l.c CXR : Pleural plaques ai retraction : Crow feet’s sign. gm 2@ - Benign asbestos related pleural effusion (Earliest). t1 ar sm sh Exudative. Eosinophilic. Mesothelial cells. yu at pr Parenchymal involvement : | Lower lobe ILD : Diffuse massive fibrosis. w ro Axial CT scan : Pleural plaques Infiltrates dyspnea. ar M No lung signs. © Spirometry : Restrictive pattern. Malignancy : Pleural mesothelioma Ca. lung Smoking Unrelated Related Duration of 30 years 10-30 years exposure Type Epithelioid (M/c) Adenocarcinoma Chest pain CXR : Holly leaf sign Clinical features Cough with hemoptysis Mass detected Pan cytokeratin Markers Calreticulin Medicine Revision v4.0 Marrow 8.0 2024  RS Revision - 3 49 RS REVISION - 3 ----- Active space ----- Airway diseases : No parenchymal involvement. Type 1 respiratory failure (Normal PaCO2). Eosinophilic Lung Disease 00:02:04 Types : BAL (Bronchoalveolar lavage) eosinophilia : > 25%. Lung tissue eosinophilia. Peripheral eosinophilia + lung infiltrates. mo Causes : l.c ai Known : Unknown : gm Parasite : Eosinophilic granulomatous polyangitis (EGPA). 2@ t1 - Loeffler’s syndrome : Hypersensitivity to Acute eosinophilic pneumonia (AEP) : ar sm ascaris. - ARDS like presentation. sh - Lung fluke invasion. - Quick recovery. yu at Drugs : Nitrofurantoin. Chronic eosinophilic pneumonia (CEP) : pr Tropical pulmonary eosinophilia (D/t - Reverse batwing appearance. | w microfilaria). Idiopathic hyper eosinophilic syndrome. ro ar Allergic bronchopulmonary aspergillosis M © (ABPA). Note : Conditions not under eosinophilic lung diseases : - HSP (Hypersensitivity pneumonitis) in lung. - Bronchial asthma (A/w eosinophilia). - Pulmonary eosinophilic granuloma diseases. BAL eosinophilia with > 40% : CEP & Tropical pulmonary eosinophilia. Aspergillus in Lung  00:06:56 Organism : Note : Aspergillus fumigatus. Aspergillus niger in ear infections. Saprophyte. Septate hyphae : Forms mucus plug. Medicine Revision v4.0 Marrow 8.0 2024  50 Medicine ----- Active space ----- Manifestations of aspergillus infection : 1. ABPA. 2. Aspergilloma : Old tuberculosis cavity. 3. Chronic Cavitary Pulmonary Aspergillosis (CCPA) : COPD patients : Thick walled cavities + bronchial wall invasion. 4. Invasive aspergillosis : - Immunocompromised (Neutropenic patients)/steroid use. - CT : Halo sign Consolidation surrounded by ground glass opacities. ABPA Pathophysiology : A.fumigatus Bronchial asthma/ colonization Type 1 > Type 3 hypersensitivity. Cystic Fibrosis (CF) patients m o l.c Clinical Manifestations : ai gm Fever. 2@ Cough with brownish thick mucus plugs : t1 Bronchiectasis : Proximal B/L symmetrical ar sm central type. sh Fleeting infiltrates (Eosinophilic). yu at Crackles/clubbing (15% patients). pr | Lung findings (20% patients). w CXR : Tram track lines ro Rare : Converted to ILD (Upper lobe). ar M Investigations : © IgE > 1000 (Obligatory criteria & follow up). Precipitin +. Eosinophilia > 500 (Supportive criteria). Imaging : CXR : Transient, irregular, parenchymal infiltrates. Finger in glove appearance Tram track appearance (Dilated airways). Finger in glove appearance : D/t mucoid impaction in dilated airways. CT : T  ree in bud appearance (Also seen in Sarcoidosis & TB). Endobronchial involvement. HRCT : Tree in bud appearance (Central bronchiectasis) Medicine Revision v4.0 Marrow 8.0 2024  RS Revision - 3 51 Treatment : ----- Active space ----- Steroids : Itraconazole : Omalizumab : DOC In steroid non responders Monoclonal antibody For 12 weeks For 16 weeks against IgE HYPERSENSITIVITY PNEUMONITIS (HSP) AKA Extrinsic allergic alveolitis. Pathophysiology : Repeated exposure to organic dust Type 4 > Type 3 hypersensitivity. Involvement : Airways > Parenchyma Features : IgE/eosinophils absent. m Precipitin +. o l.c Non caseating granuloma. ai gm Non - fleeting interstitial infiltrates (Parenchyma). 2@ Systemic Symptoms : Nil. t1 ar Forms : sm Subacute (M/C) : A/w response to steroids. sh yu Acute & chronic : Rare. at pr Imaging : Mosaic/head cheese pattern | w HRCT : Mosaic/head cheese pattern (Various densities seen). ro ar Organic Dust Exposure : M © Disease Exposure Antigen Farmer's lung (M/C) Moldy hay Thermophilic actinomycete (M/C) : Bagassosis Moldy Sugarcane Thermoactinomyces vulgaris Mushroom worker's lung Moldy compost/mushroom Malt worker's lung Barley Tobacco worker's lung Mold on tobacco Aspergillus clavatus (2nd M/C) Compost lung Compost Wood worker's lung Wood pulp - Other causes of organic dust exposure : Note : Bird fancier’s lung : Droppings of pigeon/parrots/chicken. HSP & ABA : Unrelated to smoking. (Obstructive/emphysematous pattern) Chemical worker’s lung : Polyurethane foams (Isocyanates). Hot tube/humidifier/air conditioner lung : Cladosporium, MAC. Wood trimmer’s lung : Rhizopus. Familial HP/wood workers : Bacillus subtilis. Medicine Revision v4.0 Marrow 8.0 2024  52 Medicine ----- Active space ----- Comparison with Differentials : Asthma ABPA Extrinsic allergic alveolitis/HSP Colonization of airways Interstitial lymphocytic Pathology Hypertrophied mucus glands Viscid mucoid impaction infiltration Tissue eosinophilia Non caseating granuloma Radiographic features : Migratory peripheral infiltrates Diffuse alveolar interstitial Early Normal hyperinflation Atelectasis infiltrates Bronchiectasis Reticulonodular interstitial Late Normal hyperinflation Fibrosis opacities Skin test reactions to aspergillus antigens : Immediate + + + m Delayed - + + o l.c Other findings : ai gm Peripheral - + 2@ - eosinophilia t1 ar IgG aspergillus + + + sm precipitins sh Serum IgE levels Normal/mildly elevated Marked elevation Normal yu at Note : BAL lymphocytosis. pr | Sarcoidosis : CD4/CD8. w >2:1 ro HSP : CD8/CD4. ar M Bronchiectasis © 00:23:50 Obstructive type. - Exception : Traction bronchiectasis Restrictive type. Features : Demographics : Females > males, 50-70 years. Areas affected : Left lower lobe (M/c). Middle lobe : Mycobacterium avium complex (MAC). Right middle lobe : Brock’s syndrome (D/t lymph node in TB). Pathological Changes : 1. Abnormal irreversible dilatation of bronchi : D/t loss of smooth muscles & elastic tissue. - Causes : Idiopathic (30%). Tuberculosis (40-50%), Measles & pertussis. Medicine Revision v4.0 Marrow 8.0 2024  RS Revision - 3 53 Genetic Alpha-1 antitrypsin deficiency. ----- Active space ----- Yellow nail syndrome, William Campbell syndrome. - Types of dilatation : Cylindrical (M/c) Cystic : Tubular Varicose Children A/w clubbing 2. Obliterative fibrosis of bronchioles : Outer wall Loss of cilia Cilia Increased mucus Mucus mo l.c ai Mucous gland Destruction of walls gm 2@ Normal bronchus Bronchiectasis t1 Clinical Features : ar sm Chronic cough with mucopurulent (Foul smelling) sputum. sh Hemoptysis. yu at Early & mid inspiratory coarse crackles, diffuse rhonchi. pr | Note : Dry bronchiectasis (Sicca) TB w ro Imaging : ar M IOC : Volumetric multidetector helical CT scan/HRCT. © Findings : Airway dilatation : 1 - 1.5 times adjacent vessel diameter Signet ring sign. Tram track sign. Tree in bud pattern. Treatment : CT : Signet ring Airway clearance : - Physiotherapy & postural drainage (Best). - Nebulized 7% hypertonic saline/steam inhalation. Recombinant DNAse : For CF a/w bronchiectasis. Resection : Localized bronchiectasis + recurrent + unresponsive to drugs. Prophylaxis : Macrolides (Azithromycin) x 6 - 9 months. Note : M/c organism causing infection in bronchiectasis : Pseudomonas. Medicine Revision v4.0 Marrow 8.0 2024  54 Medicine ----- Active space ----- Chronic Obstructive Pulmonary Disease (COPD) 00:36:00 Types : Chronic bronchitis (Clinical) : Cough with sputum x 3 months for 2 consecutive years. Emphysema (Pathological) : Airspace dilatation (Distal to terminal bronchiole) Followed by Destruction of walls of airspaces. Types of Emphysema : Respiratory bronchioles Alveolus Terminal bronchioles Alveolar duct Normal acinus m Respiratory bronchiole Alveolar ducts and alveoli o l.c ai Terminal bronchioles Alveolar duct Terminal bronchioles gm Septum 2@ Septum t1 Chronic inflammation ar Respiratory bronchiole sm and fibrosis Alveoli sh Centriacinar emphysema Paraseptal emphysema yu at pr Alveolar ducts and alveoli | Alveolar duct Alveolus w ro Terminal Terminal bronchioles ar bronchioles Septum Septum M © Respiratory Respiratory bronchiole bronchiole Panacinar emphysema Irregular emphysema Centriacinar (M/C) Panacinar Paraseptal Demographics Males Younger population Younger males Smokers + - + Areas of lung Respiratory bronchiole Complete involvement - involved Upper lobe predominant Lower lobe predominant α-1 antitrypsin deficiency Spontaneous Associations - Liver disease pneumothorax Note : α-1 antitrypsin phenotypes PiMM : Normal. Pi : Severe deficiency. Medicine Revision v4.0 Marrow 8.0 2024  RS Revision - 3 55 Features of Chronic Bronchitis & Emphysema : ----- Active space ----- Chronic Bronchitis Emphysema Parenchyma (more) Structure involved Airway Vascular changes ↓PaO2 ↓ PaO2 Gaseous changes ↑PaCO2 Normal PaCO2 Type of respiratory failure Type 2 Type 1 Hypoxia More Less severe Pulmonary hypertension/ Right ventricle failure/ More common Less common Infections Prognosis More mortality Better outcomes Note : Pulmonary hypertension : D/t ventilation perfusion mismatch Leads to Cor pulmonale. m Treatment : o l.c ai Guidelines : gm 2@ mMRC 0-1, CAT< 10 mMRC ≥ 2, CAT ≥ 10 t1 0 to 1 moderate exacerbations (Not ar Group A : Bronchodilators (Short acting) Group B : LABA + LAMA sm leading to hospital admission) sh Group E : yu ≥ 2 moderate exacerbations or ≥ 1 LABA + LAMA at leading to hospitalization pr LAMA + LABA ± ICS (If blood eos ≥ 300µL) | w Key : ro ar LABA : Long acting beta agonist. M © LAMA : Long acting muscarinic antagonists. ICS : Inhaled Corticosteroids. mMRC : Modified medical research council dyspnea questionnaire. CAT : COPD assessment test. eos : Blood eosinophil count in cells per microliter. Exacerbation : SABA + Short oral steroid therapy x 5-10 days. Long Term Oxygen Therapy (LTOT) : Given for 14-18 hours/day after exacerbation. Indications : - PaO2 < 55 mmHg. - PaO2 55-60 mmHg (Pulmonary hypertension/RV failure). Lobe resection : Localized emphysema (Limited cardiac problem, FEV > 20%). Lung transplant : Severe cases. Medicine Revision v4.0 Marrow 8.0 2024  56 Medicine ----- Active space ----- Pneumonia Management 00:53:36 CURB 65 Score : C : Confusion. Interpretation : U : Urea > 42 mg/dL. Score 0, 1 : Outpatient management. R : Respiratory rate > 30/min. Score 2 : Inpatient management. B : < 90/60 mm Hg. Score 3 : ICU management. 65 : ≥ 65 years. Management : Inpatient : Severe (ICU) : - Beta lactam + Macrolide. OR m - Beta lactam + Levofloxacin. o l.c Non Severe : ai gm Beta lactam antibiotics 2@ (Ampicillin-Sulbactam 1.5 - 3 g Q6h) Levofloxacin t1 OR ar + (75o mg OD) sm sh Macrolide (Azithral 500mg OD) yu at Outpatient : pr | Amoxicillin 1g TDS / Amoxyclav 625mg BD (If risk factors like diabetes + ) w ro ar + M © Azithromycin 500mg OD / Doxycycline 100mg BD. Medicine Revision v4.0 Marrow 8.0 2024