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What are the restrictive and obstructive occupational lung diseases mentioned?
Restrictive - asbestos related and silica related
Obstructive - cotton related and occupational asthma
What is the dangerous form of asbestosis?
Crocidolite
Where can someone get asbestos exposure?
1) mining and handling
2) insulation spraying
3) textiles
4) cement product
5) paper products
6) automotive products (breaks)
7) insulation
8) shipbuilding
What are 5 clinical syndromes associated with asbestos exposure?
Pleural plaques
Pleural effusion
Pulmonary Fibrosis
Bronchogenic Carcinoma
Malignant Mesothelioma
Where do pleural plaques occur?
On parietal pleura, but not located in costophrenic angle or apices
T/F - you never see asbestosis in pleural plaques.
False. Uncoated fibers are often present
What is a benign pleural effusion related to asbestosis look like?
Bloody exudative effusion, associated with fever, chest pain, increased WBC.
T/F - pleural effusions occur within days of asbestos exposure.
False... asbestos expsorue may be current or minimal in the remote past
What histological features do you see in asbestosis?
Peribronchiolar Fibrosis
Alveolitis
Perivascultiis
T/F - there is a strong correlation in pleural plaques and lung cancer by asbestos.
False.
How does asbestos cause carinogenesis?
Induces synthesis of polyamines in cells and "frustrated phagocytosis"
What are the types of malignant mesothelioma?
Epithelial
Mesenchymal
Undifferentiated
Mixed
What things can be associated with Silica exposure?
Abrasive sand blasting
Cleaning fossil fuel furnaces, flues
Metal preparation and Steel production
Mining
Glassblowing
Brick production
Sculpturing stone
Tool grinding
What type of silica has the most lung scarring potential?
Tridamite
2 forms of natural silica
Sandstone
Granite
Different syndromes in acute and chronic silicosis?
Acute - Silicoproteinosis
Chronic - pulmonary fibrosis and progressie massive fibrosis
What is Byssinosis associated with?
Cotton workers
What is believed to be the causitive agent in byssinosis?
Endotoxin
What types of asthma occur with occupational asthma?
1) asthma with latency (IgE dependent and independent)
2) asthma without latency (reactive airways dysfunction syndrome RADS)
What are common high and low molecular weight substances that cause occupational astham?
High - snow crab, flours, latex, animals
Low - platinum salts, acid anhydrate,
What is the requirement to diagnos reactive airways dysfunciton syndrome, a form of occupation asthma?
1) documented absence of preceding respiratory symptoms
2) onset of symptoms after single exposure
3) exposure at high concentration
4) within 24 hours after exposure, lasting for 3 months
5) symptoms of asthma, cough, wheeze, dyspnea
What disease did rescuers in 9/11 get?
RADS (reactive airways dysfunction syndrome)
What are the differences in EEG and EMG during stages of wakefulness/sleep?
Wake - EEG desynchronized, EMG variable
NREM - EEG synchronized, EMG attenuated but present
REM - EEG desynchronized, EMG absent (active paralysis)
what EEG rhythm do you see in quet alertness with closed eyes?
Alpha rhythm
What is the mos common sleep frequency?
Theta rhythm
What rhythm do you see in N1 sleep?
Alpha waves but increasing number of delta waves
What rhythm do you see in N2?
Theta
Along with sleep spindles and K complexes
What rhythm do you see in N3?
Delta
When is stage N3 (delta sleep) most prominent during the night?
In first 1/3
When is REM more prominent during the night?
Later in the night
What stage of sleep do we spend most of our time?
N2 - 50-55%
(note REM is 1/4 of our night)
What stage of sleep decreases and disappears with age?
N3
What happens to body temp in sleep stages?
NREM - decreases 1-2 degree
REM - thremoregulation lost, become cold blooded animals (decreased sweating, shivering)
When do growth hormone secretions peak in sleep?
N3 (delta sleep)
What do prolactin secretions start during sleep?
At first 2 hours of sleep onset
What happens to testosterone levels during sleep?
Rise and continue to rise during night
What happens to PTH hormone during sleep?
Peaks at N3 stage
That happens to thyroid stimulating hormone during sleep?
Inhibited by sleep
WHat happens to respiration during sleep?
NREM - more regular breathing, increased airway resistance b/c of decreased muscle tone, decreased ventilation due to mild decrease in hypoxic ventilatory drive
REM - paralysis, except diaphragm, so FURTHER decrease in ventilaiton and upper airway tone and greater decreaes in hypoic ventilatory drive
What happens to the autonomic nervous system during sleep?
NREM - PS tone increased, SY tone decrease
REM - PS tone decreased a little (compared to NREM), SY tone greater compared to NREM
What happens to CV system during sleep?
NREM - decrease blood pressure, HR, and cerebral blood flow
REM - Increase cerebral blood flow and brain metabolism
What stage of sleep do you see genital erection (or i hope you don't see it)
REM
What happens to blood gasses on sleep onset?
CO2 increases, pH decreases, and PaO2 decreases
T/F - at N1, minute ventilation is from 1-10 L/min?
true
When are respiratory changes in REM most prominent?
During phasic REM (eye movement)
What happens to breathing pattern during REM?
Respiratory rate my increase, and tidal volume decreases
The hypoxic ventilatory response decreases most in NREM in who?
Men
T/F - the hypercapnic ventilatory response increases with sleep.
False, it decreases
What produces a better arrousal response, hypoxia or hypercarbia?
Hypercarbia (but techincally if you have BOTH, the hypoxia makes you more sensitive to hypercarbia)
What receptors cause arrousal in sleep apnea?
Mechanoreceptors
Which stage of sleep has faster arrousal?
REM sleep
What drugs suppress upper airway muscle activity, and impari arousal, increasing risk of sleep apnea?
Alcohol
Narcotics
Benzodiazpeines
Barbiturates
What classifies as sleep apnea?
1) repetitive episodes of complete (apnea) or parital (hypopnea) uper airway obsturction during sleep
2) last minimum of 10 sec
3) ASSOCIATED WITH O2 DESATURATION
4) terminated by brief arrousal
5) Apnea-Hypopnea Index (AHI): number of events per HOUR
Risk factors for developing OSA?
Age
Obestiy
Male Gender
Monapause and females
Family History
Craniofacial features
Alcohol consumption
Hypothyroidism and acromegaly
Nasal congestion
What are the symptoms of sleep apnea?
Daytime sleepiness
Cognitive impariment/depression
Risk of MVA
Decreased quality of life
Headache
Weight gain/insulin resistance
CV events
OSA treatment has been shown to improve what CV disease?
HTN
What muscles of upper airway lose tone and cause sleep apean?
Levator palatini (elevates palate)
Tensor palatini (stiffen palate
Genioglossus (protrudes tongeu)
Pharygneal constrictors (form lateral pharygeal walls)
women dont' typically present with normal sleep apneic symptoms. What do they present with?
More excessive daytime sleepiness
More likely to be treated for depression
What craniofacial feature might indicate OSA?
Retrognatia (little or no jaw angle)
T/F - nasal CPAP has good compliance rate?
false
What is the medicare criteria for CPAP?
AHI>15
AHI 5-14 with comorbidies or symptoms
Compliance
When do you use oral appliances to treat OSA?
1) for just snoring
2) for mild to moderate OSA in pts who don't use CPAP
3) in severe OSA w/ failed CPAP and failed surgery
What surgery removes some soft palate to open the airways up?
Uvulopalatopahrygoplasy
What is normal pulmonary artery pressure?
Systolic: 15-30
Diastolic: 4-12
Mean: 9-18
CWP: 6-12
What is the pathogenesis of venous thrombi?
stasis of blood
abnormalities of the vessel wall
alteration in coagulation system
What effects does a PTE have on pulmonary function?
1) circulation - obstruction and vasoconstriction
2) ventilation - bronchoconstriction and loss of surfactant
3) gas exhcange - v/q mismatch
What are predisposing factors to a PTE?
1) surgery/ansethesia
2) shock
3) immbolization
4) CHF
5) Trauma/Burns
6) Prior VTE
7) malignancy
8) preganncy
9) high estrogen intake
10) hypercoagulable state
What might indicate poor prognosis for a PTE?
Pre-existing cardiopulmonary disease
What can you use to diagnose PTE?
A V/Q lung scan
Pulmonary arteriogram (gold standard)
CT Angiography
Echocardiography
D-Dimer levels - can exclude PE
How do you treat PTE's?
Anitcoagulation (heparin/warfarin)
IVC Filter
Fluids, O2
Rarely - thrombolytics and embolectomy
What is the definitiion of pulmonary HTN?
Mean PAP > 25
What pressures in P-HTN do you see RV dysfunction?
PA pressures > 40 mmHg acutely
PA pressures > 60 chronically
T/F - sarcoidosis can cause HTN.
True.
What happens to pulmonary arterial pressure as pulmonary HTN progresses?
It increases up unitl a point, then as CO decreases, it drops as well
What CT scan might indictate pulmonary HTN?
Severe ILD - honeycombing
What is chronic thromboembolic pulmonary HTN?
Where you get vascular obstruction resulting from remote or recurrent pulmonary emboli, with symtoms of cor pulmonale (R heart failure)
What is cor pulmonale?
secondary right heart disease due to any primary disease of lung
- COPD
- Fibrosis
What are pulmonary AV malformations?
Mostly congenital problem that presents with cyanosis, clubbing, erythrocytosis, and can lead to paradoxical embolus, brain abscesses, and hemoptysis
What is one type of pulmonary AV malformation?
Osler-Weber-Rendu
What can cause pulmonary artery aneurysms?
-congenital
-infectious (Staph, TB, syphillis)
-Iatrogenic
-Vasculitis - Behcet's syndrome, Takayasu's
- Hughe's-Stovin Syndrome