1.pulmonary vascular disease 2.pleural disease
DESCRIPTION
1.Pulmonary Vascular Disease 2.Pleural Disease. Prof. Frank Carey. Pulmonary Circulatuion. Dual supply Pulmonary arteries Bronchial arteries Low pressure system Pulmonary artery receives entire cardiac output (a filter). Low pressure system…. Thin walled vessels - PowerPoint PPT PresentationTRANSCRIPT
1.Pulmonary Vascular Disease1.Pulmonary Vascular Disease2.Pleural Disease2.Pleural Disease
Prof. Frank Carey
Pulmonary CirculatuionPulmonary Circulatuion Dual supply
Pulmonary arteries Bronchial arteries
Low pressure system Pulmonary artery receives entire cardiac
output (a filter)
Low pressure system….Low pressure system…. Thin walled vessels Low incidence of atherosclerosis
At normal pressures
Pulmonary OedemaPulmonary Oedema
Accumulation of fluid in the lung Interstitium Alveolar spaces
Causes a restrictive pattern of disease
Pulmonary Oedema (causes)Pulmonary Oedema (causes)
1. Haemodynamic ( hydrostatic pressure)
2. Due to cellular injuryi. Alveolar lining cellsii. Alveolar endotheliumLocalised – pneumoniaGeneralised – adult respiratory distress syndrome
(ARDS)
ARDSARDS Diffuse alveolar damage syndrome
(DADS) Shock lung
Causes include sepsis, diffuse infection (virus, mycoplasma), severe trauma, oxygen
Pathogenesis of ARDSPathogenesis of ARDS
Injury (eg bacterial endotoxin) Infiltration of inflammatory cells Cytokines Oxygen free radicals Injury to cell membranes
Pathology of ARDSPathology of ARDS Fibrinous exudate lining alveolar walls
(hyaline membranes) Cellular regeneration Inflammation
ARDS with hyaline membraneARDS with hyaline membrane
ARDS – cellular reactionARDS – cellular reaction
Outcome of ARDSOutcome of ARDS
Death Resolution Fibrosis (chronic restrictive lung disease
Neonatal RDSNeonatal RDS Premature infants Deficient in surfactant (type 2 alveolar
lining cells Increased effort in expanding lung
physical damage to cells
EmbolusEmbolus A detached intravascular mass carried by
the blood to a site in the body distant from its point of origin
Most emboli are thrombi – others include gas, fat, foreign bodies and tumour clumps
Pulmonary EmbolusPulmonary Embolus
Common Often subclinical An important cause of sudden death and
pulmonary hypertension
95% + of emboli are thromboemboli
Source of most pulmonary Source of most pulmonary emboli…..emboli…..
Deep venous thrombosis (DVT) of lower limbs
Risk factors for PE are those for DVT…. 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
Effects of PEEffects of PE
Sudden death Severe chest pain/dyspnoea/haemoptysis Pulmonary infarction Pulmonary hypertension
Effects of PE depend on…Effects of PE depend on…
Size of embolus Cardiac function Respiratory function
Effect of embolus size…Effect of embolus size…
Large emboli Death Infarction Severe symptoms
Small emboli Clinically silent Recurrent
pulmonary hypertension
Pulmonary Infarct (ischaemic Pulmonary Infarct (ischaemic necrosis)necrosis)
Embolus necessary but not sufficient Bronchial artery supply compromised (eg
in cardiac failure)
Pummonary EmbolusPummonary Embolus
Pulmonary infarct – Pulmonary infarct – tumour tumour embolusembolus
Pulmonary HypertensionPulmonary Hypertension
Primary (rare, young women) Secondary
Pulmonary Hypertension Pulmonary Hypertension (mechanisms)(mechanisms)
Hypoxia (vascular constriction) Increased flow through pulmonary
circulation (congenital heart disease) Blockage (PE) or loss (emphysema) of
pulmonary vascular bed Back pressure from left sided heart failure
Morphology of pulmonary Morphology of pulmonary hypertensionhypertension
Medial hypertrophy of arteries Intimal thickening (fibrosis) Atheroma Right ventricular hypertrophy Extreme cases (congenital heart disease,
primary pulmonary hypertension) – plexogenic change/necrosis
Pulmonary artery – intimal fibrosisPulmonary artery – intimal fibrosis
Plexiform lesion – primary pulmonary Plexiform lesion – primary pulmonary hypertensionhypertension
““Cor Pulmonale”Cor Pulmonale” Pulmonary hypertension complicating lung
disease Right ventricular hypertrophy Right ventricular dilatation Right heart failure (swollen legs, congested
liver etc)
Cardiomegaly due to right ventricular Cardiomegaly due to right ventricular dilatationdilatation
Right ventricular hypertrophy and Right ventricular hypertrophy and dilatationdilatation
The PleuraThe Pleura A mesothelial surface lining the lungs and
mediastinum Mesothelial cells designed for fluid
absorption Hallmark of disease is the effusion
Pleural EffusionPleural Effusion Transudate (low
protein) cardiac failure hypoproteinaemia
Exudate (high protein) pneumonia TB connective tissue
disease malignancy (primary
or metastatic)
Pleural effusionPleural effusion
Purulent EffusionPurulent Effusion
Full of acute inflammatory cells Empyema Can become chronic
PneumothoraxPneumothorax
Air in pleural space Trauma Rupture of bulla
Large bullaeLarge bullae
Pleural NeoplasiaPleural Neoplasia Primary
benign (rare) malignant mesothelioma
Secondary common (adenocarcinomas - lung, GIT, ovary)
MesotheliomaMesothelioma
Asbestosis related Increasing incidence Mixed epithelial/mesenchymal
differentiation Dismal prognosis
MesotheliomaMesothelioma
Pleural biopsy - mesotheliomaPleural biopsy - mesothelioma
Metastases in PleuraMetastases in Pleura
Differential diagnosis of Differential diagnosis of malignant effusions…..malignant effusions…..
Cytology, biopsy Difficult Immunohistochemistry for lineage specific
antigens may help Medicolegal importance