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Published byGwendolyn Watts Modified over 9 years ago
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1.Pulmonary Vascular Disease 2.Pleural Disease Prof. Frank Carey
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Pulmonary Circulatuion r Dual supply l Pulmonary arteries l Bronchial arteries r Low pressure system r Pulmonary artery receives entire cardiac output (a filter)
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Low pressure system…. r Thin walled vessels r Low incidence of atherosclerosis At normal pressures
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Pulmonary Oedema r Accumulation of fluid in the lung l Interstitium l Alveolar spaces r Causes a restrictive pattern of disease
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Pulmonary Oedema (causes) 1. Haemodynamic ( hydrostatic pressure) 2. Due to cellular injury i. Alveolar lining cells ii. Alveolar endothelium Localised – pneumonia Generalised – adult respiratory distress syndrome (ARDS)
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ARDS r Diffuse alveolar damage syndrome (DADS) r Shock lung l Causes include sepsis, diffuse infection (virus, mycoplasma), severe trauma, oxygen
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Pathogenesis of ARDS Injury (eg bacterial endotoxin) r Infiltration of inflammatory cells r Cytokines r Oxygen free radicals r Injury to cell membranes
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Pathology of ARDS r Fibrinous exudate lining alveolar walls (hyaline membranes) r Cellular regeneration r Inflammation
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ARDS with hyaline membrane
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ARDS – cellular reaction
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Outcome of ARDS r Death r Resolution r Fibrosis (chronic restrictive lung disease
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Neonatal RDS r Premature infants r Deficient in surfactant (type 2 alveolar lining cells r Increased effort in expanding lung physical damage to cells
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Embolus r A detached intravascular mass carried by the blood to a site in the body distant from its point of origin r Most emboli are thrombi – others include gas, fat, foreign bodies and tumour clumps
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Pulmonary Embolus r Common r Often subclinical r An important cause of sudden death and pulmonary hypertension 95% + of emboli are thromboemboli
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Source of most pulmonary emboli….. r Deep venous thrombosis (DVT) of lower limbs
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Risk factors for PE are those for DVT…. 1. Factors in vessel wall (eg endothelial hypoxia) 2. Abnormal blood flow (venous stasis) 3. Hypercoaguable blood (cancer patients, post-MI etc) - Virchow’s triad
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Effects of PE r Sudden death r Severe chest pain/dyspnoea/haemoptysis r Pulmonary infarction r Pulmonary hypertension
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Effects of PE depend on… r Size of embolus r Cardiac function r Respiratory function
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Effect of embolus size… r Large emboli l Death l Infarction l Severe symptoms r Small emboli l Clinically silent l Recurrent pulmonary hypertension
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Pulmonary Infarct (ischaemic necrosis) r Embolus necessary but not sufficient r Bronchial artery supply compromised (eg in cardiac failure)
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Pummonary Embolus
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Pulmonary infarct – tumour embolus
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Pulmonary Hypertension r Primary (rare, young women) r Secondary
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Pulmonary Hypertension (mechanisms) r Hypoxia (vascular constriction) r Increased flow through pulmonary circulation (congenital heart disease) r Blockage (PE) or loss (emphysema) of pulmonary vascular bed r Back pressure from left sided heart failure
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Morphology of pulmonary hypertension r Medial hypertrophy of arteries r Intimal thickening (fibrosis) r Atheroma r Right ventricular hypertrophy r Extreme cases (congenital heart disease, primary pulmonary hypertension) – plexogenic change/necrosis
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Pulmonary artery – intimal fibrosis
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Plexiform lesion – primary pulmonary hypertension
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“Cor Pulmonale” r Pulmonary hypertension complicating lung disease r Right ventricular hypertrophy r Right ventricular dilatation r Right heart failure (swollen legs, congested liver etc)
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Cardiomegaly due to right ventricular dilatation
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Right ventricular hypertrophy and dilatation
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The Pleura r A mesothelial surface lining the lungs and mediastinum r Mesothelial cells designed for fluid absorption r Hallmark of disease is the effusion
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Pleural Effusion r Transudate (low protein) l cardiac failure l hypoproteinaemia r Exudate (high protein) l pneumonia l TB l connective tissue disease l malignancy (primary or metastatic)
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Pleural effusion
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Purulent Effusion Full of acute inflammatory cells r Empyema r Can become chronic
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Pneumothorax Air in pleural space r Trauma r Rupture of bulla
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Large bullae
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Pleural Neoplasia r Primary l benign (rare) l malignant mesothelioma r Secondary l common (adenocarcinomas - lung, GIT, ovary)
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Mesothelioma r Asbestosis related r Increasing incidence r Mixed epithelial/mesenchymal differentiation r Dismal prognosis
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Mesothelioma
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Pleural biopsy - mesothelioma
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Metastases in Pleura
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Differential diagnosis of malignant effusions….. r Cytology, biopsy r Difficult r Immunohistochemistry for lineage specific antigens may help r Medicolegal importance
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