Lung Diseases😍

Localisation of Pathologies

• Respiratory Epithelium Types

Location	Epithelium Type
Nasal mucosa till Proximal bronchiole	Pseudostratified ciliated columnar epithelium
Terminal bronchiole	Ciliated cuboidal epithelium • No goblet cells • Epithelium change • No hyaline cartilage from here
Respiratory bronchiole	Non-ciliated cuboidal epithelium
Alveolus	Simple squamous epithelium

• Air bronchogram sign:
• Differentiate between parenchymal and extra parenchymal pathologies.
• Seen when:
• The lungs are white.
• The bronchi is patent (containing air - appears black).
• Seen in intraparenchymal pathologies:
• Consolidation.
• Hyaline membrane disease.
• Pulmonary edema
• Absent in
• Mediastinal mass
• Pleural effusion

Consolidation vs Collapse

• DOC: Tiotropium

• MOA: M3 Antagonist

• Treats bronchoconstriction due to:
• Parasympathetic overactivity (reversible component)
• Fibrosis/sclerosis (irreversible component)

• Side Effects
• Dry mouth
• Worsening of BPH

• Olodaterol

• Vilanterol

• Carmoterol

• Karma (Carmeterol) for Old (Olodaterol) Villains (Vilanterol)

New drugs COPD :

• Roflumilast : PDE4 ⛔

• Ensifentrine : Both PDE3 ⛔ and PDE4 ⛔

• Rough (Roflumilast) Siphon (Ensifen)

Genetics:

• Gene for atopy: Chromosome 5q gene Polymorphism

• At birth → TH2 Phenotype
• Normally
• switch to TH1 phenotype
• due to exposure to many outdoor antigens
• TH1 phenotype → Asthma disappears.
• No exposure to allergens
• Persistence of TH2 phenotype.
• Persistence of TH2 phenotype → Asthma persists.

• Associations: 
• IL-13, ADAM33 gene polymorphisms.
• Note: mutation of ADAMTS-13: TTP

• Type 1 hypersensitivity (allergic) reaction.

• IL-5 → Eosinophil mediated Pathology.

Features of Asthma:

• Type I Respiratory Failure:
• No CO2 retention seen.
• No Type II respiratory failure.

• No parenchymal involvement.

• No diffusion defect.
• Normal to ↑ DLCO.

Sputum Microscopy (The Three C's):

• Charcot-Leyden crystals:
• Needle-shaped crystals made of galectin-10
• derived from eosinophils.
• Eda charley, needle vach easy aytt kalakku

• Creola bodies:
• Clusters of epithelial cells.
• Sloughed mucus epithelium.

• Curschmann spirals:
• Whorled Mucus Plugs.

Lung Finding:

• Shows airway remodeling.

Micropathological Changes:

 

• Patchy Epithelial Necrosis

• Sub-Mucosal Glandular Hyperplasia

• Hypertrophy of bronchial smooth muscle

• Reid's Index is normal.

GINA (GLOBAL INITIATIVE FOR ASTHMA) GUIDELINES

Therapy Type	Drug of Choice (DOC)
Acute Attack (Rescue Therapy)	Inhalational formoterol + Low dose inhaled corticosteroids
Maintenance Therapy	Formoterol + Low dose ICS

Brittle Asthma

• Frequent, sudden, and life-threatening attacks

• Occurs despite appropriate therapy

Types of Brittle Asthma

• Airway Hyperresponsiveness assessed by: 
• MCT (Methacholine Challenge Test).

• IgE levels: 
• RAST (Radio AllergoSorbent Test).

• Non Invasive Test to assess airway inflammation: 
• Fractional Exhalation of Nitric Oxide (FeNO).

Pulmonary Function Tests:

• ↓ FEV1/FVC ratio.

Peak expiratory flow meters

• Portable, hand-held devices

• Used at home for monitoring PEFR

• Increase diurnal variability of PEFR (peak expiratory flow rate) >13%

Treatment of asthma in children

• As per the latest GINA (Global Initiative for asthma),
• All children with Bronchial Asthma
• daily dose ICS + SABA
• either Symptom driven or daily.
• No role of SABA only Rx in managing acute exacerbations
• It increases r/o exacerbations

Metered dose inhaler

• Used in drug delivery in children with bronchial asthma

• Parts
• Blue colored structure:
• Metered dose inhaler,
• Contains bronchodilator
• White-colored structure:
• Spacer,
• Must since it improves in drug delivery
• Baby mask:
• Required in < 4 years age children.

Management of status asthmaticus in a child

• Medical emergency

• Also known as acute severe asthma

• The pulmonary index score is used for the assessment of the severity

• Primary management
• airway, breathing and circulation
• (Chest x-ray and ABG to look for ventilation therapy)

• Start oxygen therapy and admission

• Continuous nebulization
• levosalbutamol/MDI

• Start systemic steroids
• Inj. hydrocortisone → f/b oral prednisolone
• Ipratropium nebulization can be used

• In case of no improvement:
• Inj. Magnesium sulfate,
• theophylline
• ketamine

• Dilatation of bronchi.

• Normally, bronchus tapers down peripherally.

• In Bronchiectasis
• no tapering → bronchi remain parallel
• Tram track sign
• Signet ring sign:
• Vessel adjacent to the dilated bronchi.

• Bronchiectasis associated with situs inversus
• Kartagener's syndrome

• Military (Miliary) people
• get TB
• Laugh (Loeffler’s)
• Heal by eating chicken (healed varicella)
• make History (Histoplasmosis)

• Presentation:
• Usually a female patient
• dry cough, shortness of breath
• associated with connective tissue disorder.

• M/c type
• Idiopathic pulmonary fibrosis

• IOC - HRCT.
• UIP/IPF pattern
• Honeycombing pattern +
• Basal Lower lobe dominance +
• Traction bronchiectasis
• Ni thanna (Nintendanib) Feni done (Pirfenidone) ayi → lung fibrosis ayi (IPF)



• TGF α → KGF α → Menetriers disease
• TGB β → KGF β → drink Feni
• Ninte Dani → PD Girl Friend (PDGF)

Crazy pavement appearance:

• Interlobular septal thickening is seen with ground glass opacity.

• no air filled cavities are seen.

• Seen in Pulmonary alveolar proteinosis >>> COVID 19

• Mnemonic: Crazy Pappu (PAP) in pavement

Cystic Bronchiectasis

• Some of these dilated bronchi contain mucus.

• Bronchi appears as cysts.

• Bunch of grape appearance.

• Restrictive lung diseases.

• All notifiable except bagassosis.

Range of Dust Particles

• Note: 1-5 micron sizes cause pneumoconiosis

Types

Silicosis vs Asbestosis

Harmful Chemicals

• Egg shell calcification:
• Peripheral Calcification around lymph nodes
• hilar lymphadenopathy
• also in silicosis., Sarcoidosis, Post radiation therapy lymph nodes

• Definition: Inhaled carbon.

• Appearance: Black color lungs.

• Kaplan Syndrome
• CWP + rheumatoid arthritis.

• Note: Felty syndrome

• X ray
• Upper lobes opacities

• We Felt (Felty syndrome) pain fo RA () ENT pg → We gave him a cap (Caplan)

• NOTE:
• Erasmus syndrome: CWP + Systemic sclerosis
• Erase & Cap → CWP syndromes
• EraSS → Systemic sclerosis

• Occupational lung disease - M/c shipyard industry.

• Mnemonic: Asbestos → Holly leaf → comet tail

• M/c radiological finding:
• Calcified pleural plaques - Holly leaf sign.
• Base of lung/Diaphragmatic pleura is affected.

• On CT:
• Comet tail sign:
• Rounded opacity
• vessels pulled towards it
• seen in round atelectasis.
• The white opacity seen along the pleura are the plaques.

• Can give rise to Mesothelioma.

Aspergillus lungs:

• A fungus with septate and acute angle branching hyphae.

• Can cause:
• Allergic Bronchopulmonary aspergillosis (ABPA).
• Aspergilloma.
• Angio invasive aspergillosis.

ABPA:

• Dilated central bronchi filled with mucous - Finger in glove sign.

Aspergilloma:

• Seen when there is a pre existing cavity in the lung.

• Air crescent sign or monod sign.

• Prone CT to confirm aspergilloma:
• fungal ball is mobile
• comes to the dependent position.

Angio Invasive Aspergillosis:

• Central infarct surrounded by GGO - Halo sign.

• i.e. white consolidation surrounded by ground glass opacity.

• Seen in immunocompromised patients.

• Voriconazole

Mucormycosis lungs

• Also called: Black fungus

• Reverse HALO sign (Atoll sign) → centre dark, periphery light

 

• Reverse halo sign on CT

• Neutropenia

• Immunocompromised

• Hyphae: Aseptate, Right angle, Broad, ribbon-like

• Culture:
• Lid-Lifters (SDA)
• May be negative d/t Hyphal fragility (killed by tissue homogenisation)

• Lid lift cheyyumbo mukki povum

• Treatment
• Surgical resection
• Amphotericin B +/- Posaconazole
• Mucus pasha pole - Posaconazole

• Negative Staining Group:
• Blastomyces, Mucorales, Cryptococcus
• Banglore Medical College

Pleural Effusion

(Light, REM and PEM)

• IOC - USG.

• Best X-ray view: Ipsilateral decubitus view.

• Light’s criteria for exudative effusion:
1. Pleural fluid protein/serum protein >0.5
2. Pleural fluid LDH/serum LDH >0.6
3. Pleural fluid LDH >2/3rd upper reference limit of normal for serum.

Pleural effusion vs Hydropneumothorax

• Pleural effusion:
• Ellis's curve.
• Blunting of costophrenic angle.

• Hydropneumothorax:
• Horizontal air fluid level.

• Lateral decubitus X-ray
• Done for pleural effusion.
• Fluid comes to the dependant side.

• Pleural effusion signs:
• Most sensitive
• USG (5 - 10 mL) >
• I/L lateral decubitus > Lateral > CXR PA erect > Supine (500 ml)
• On chest X-ray:
• Ellis's curve.
• Blunting of costophrenic angle.
• due to accumulation of fluid.
• On CT scan (in supine):
• Fluid gravitates posteriorly.
• Appears gray in color.

• Most sensitive investigation:
• USG.

Infected pleural effusion (empyema)

• Empyema causes thickening of surrounding pleura:
• Split pleura sign.

Chylothorax

• L subclavian vein catheterization

• Lymphatic leaks

• Triglyceride > 110 mg/dl

Pseudo chylothorax

• Seen in RA

• Normal TG → Cholesterol crystals +

Pulmonary Embolism Radio

 

• Predisposing factor: DVT — Bedridden patients/immobilized patients.

• Screening investigation: D-dimer (raised).

• IOC - CTPA/CECT.
• Contrast filling defect is seen.

• X-ray Signs
• Palla sign: Enlarged right descending pulmonary artery
• Hampton's hump: Infarct formation.
• Westermark sign: Focal oligemia.

WHO IMNCI PROTOCOL

• Cough/cold:
• No pneumonia.
• Home care advice.

• Fast breathing/chest indrawing:
• Pneumonia.
• Oral amoxicillin/home care advice.
• Reassessed after 48 hours.
• If the child has worsened, refer to a higher center.

• General danger signs:
• Severe pneumonia/very severe disease.
• First dose antibiotic/referral for injectable antibiotic
• 1st dose of Inj. Ampicillin and Gentamycin

SAANS PROTOCOL:

• Social Awareness & Action to Neutralize Pneumonia Successfully.

• Launched in 2019 to reduce deaths due to childhood pneumonia.

• For 2-59 months child with cough +/- difficult breathing.

Management

Severe Pneumonia

• ASHA:
• Pre referral dose of Oral amoxicillin + referral.

• CHO (Community Health Officer):
• Oral amoxicillin + IM Gentamicin + Hospitalization/Referral

Klebsiella Pneumonia:

• Bulging fissure sign:
• Horizontal fissure is curved.

Pneumatocele:

• Cavity filled with air.
• Staphylococci
• PCP (HIV +)
• Pneumatocele + ground glass opacity → perihilar region.