Goljan Respiratory Notes

7/28/2019 Goljan Respiratory Notes

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CHAPTER8:RESPIRATORY

A-agradient

A-agradient:definedasthegradientbetweenthealveolarO2andarterialO2 Normally,alveolarO2is100andthearterialpO2is95.AnormalA-agradientis

about5mmHg.Theupperlimitofnormalis30mmHg(sethightoachieveahigh

specificity/PPV)

Whyarethetwodifferent?BecauseofphysiologicV/Qmismatcho Whenstandinguptheventilationisbetterthanperfusionintheapex,

whereasperfusionisbetterthanventilationatlowerlobes.

o Thisexplainswhyalmostallpulmonaryinfarctionsareinthelowerlobesperfusionisgreaterthere.

o Also,thisexplainswhyreactivationTBisintheapexTBisastrictaerobeandneedsasmoreO2,andthereismoreventilationintheupperlobes

(higherO2content).

AhighA-agradientmeanshypoxemiaisduetoV/Qdefectinthelungs,andanormalA-agradientmeanshypoxemiaisduetosomethingoutsidethelungs Hypoxemia+highA-agradient(indicativeofprimarylungdisease)

o Ventilationdefects:produceshypoxemia,andthereforeprolongsthegradientdroppingthePO2andsubtracting,andthereforeagreater

differencebetweenthetwo

o Perfusiondefect:e.g.,PEo Diffusiondefect

Hypoxemia+normalA-agradient(indicativeofaproblemoutsidethelungs):o Depressionofthemedullaryrespiratorycenter(aswithbarbiturates)o Nerveproblems:GuillainBarresyndrome,ALSo Obstructionoftheupperairwayfromepiglottitis,

laryngeotracheobronchitis

o Paralysisofdiaphragm Calculation:(0.21x713)pCO2/0.8=100(0.21istheatmosphericO2;760

minusthewatervapor=713;pCO2isnormally40,giveninABG;0.8istheRQ).

MeasuredarterialpO2100=A-adifference


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UpperRespiratoryDisease

NasalPolyps:

Mostcommonisallergicpolyp(developsinadultswithlong-standingallergicrhinitis)

Polypsinnoseofchildren=CF Triadasthma(ASA-intolerantasthma):triadofasthma,aspirininduced

bronchospasm,andnasalpolyps.Classicis35yowomanwithchronicpain

(headachesorfibromyalgia,etc.)withoccasionalasthma(theywonttellyoushe

istakinganNSAID,orthatshehasapolyp!).Mechanism:COXblock=

lipoxygenasepathwaydominanceLTC4,D4,andE4bronchoconstriction.

ThisisNOTatypeIhypersensitivityreaction;ratheritischemicalmediated

Laryngealcarcinoma

Asquamouscellcarcinoma Majorriskfactorsforsquamouscancers

inmouth,esophagusandlarynx:

smoking,alcohol,smokingandalcohol

hassynergisticeffect

Presentswithhoarsenessofthethroat Laryngectomyspecimen

Epiglottitis

InfectioncausedbyH.influenzae Presentswithinsiratorystridor X-rayoflateralneck:thumbprintsignofacute

epiglottitisduetoHemophilusinfluenzae Anothercauseofairwayobstructioniscroup

(PIV)inyoungchildrencausestracheal

inflammation


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RespiratoryDistressSyndromes

NeonatalRespiratoryDistressSyndrome/HyalinemembraneDisease

Collapsingpressureintheairways=surfacetension/radiusofairway.o Onexpiration,normallytheairwaywillbesmallerb/cthereisapostive

intrathoracicpressure.o Surfactantistheretodecrease

surfacetensionandkeep

airwaysopenonexpiration.

o Ifthereisnosurfactant,atelectasiswilloccur

PinkhyalinemembranesareduetodegenerationoftypeIIpneumocytes

andleakageoffibrinogenwhich

congealstoformthemembrane Pathophysiologyofhypoxemia:massiveintrapulmonaryshunt BabieswithRDScommonlyhavePDAbecauseofhypoxemia(normalbreathingis

requiredtoclosePDA)murmur

Tx:PEEPtherapypositiveendexpiratorypressuretopreventairway

collapse,administrationofsurfactant

TypeIIpneumocyte(progenitorcellofthelung)haslamellarbodies(looklike

onion)containingsurfactant;donot

confusewithamacrophage,whichhas

junkinthecytosol

ThreecausesofiRDS

Prematurity:surfactantbeginssynearly,butitpeaksat32-35week,soifyouarebornprematurely,youwillnothaveenoughsurfactant,andbabywill

developincreasedriskofdevelopingRDS.

o Administrationofantenatalglucocorticoidsstimulatessurfactantsynthesis.

o Thyroxineandprolactincantheoreticallyalsodothesameo Complicationsofprematurity:superoxidefreeradicaldamageseenin

retinopathyofprematurityandblindnessandbronchopulmonary

dysplasia GestationalDiabetes:gestationaldiabetesglucosecrossestheplacenta

stimulatesinsulinsynthesisinthebabyinsulinhasanegativeeffecton

surfactantsynthesis

o Marosomia-insulinwillincreasestorageoftriglycerideinadipose,andincreasetheuptakeofaminoacidsintomuscle(likegrowthhormone)

o Thesebabiesarefrequentlyhypoglycemicwhentheyarebornbecausetheglucosesupplyiscutoffbutthebabystillhashyperinsulinemia


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Csection:thestressofvaginaldeliveryleadstoreleaseofACTHandcortisolarenotreleased,andsurfactantisnotmade.

AdultRespiratoryDistressSyndrome(ARDS)

SimilartoiRDS,buttheinjuryisduetoneutrophilicinflammatoryinfiltrate Mostcommoncauseissepticshock(andthemostcommoncauseofseptic

shockisE.colifromanindwellingcatheter)

ForICUpatientso Thefirstdaytheyhavesepticshock,theseconddaytheygetARDS,the

thirddaytheygetDIC.

Pathogenesis:Neutrophilsdestroypneumocytesofthelung,decreasingsurfactantproductionmassiveatelectasis(collapse).

o Hyalinemembranesarisefromholesthatneutrophilspunchinthepulmonarycapillariesastheyextravasate,allowingproteinand

fibrinogentoenterandcausehyalinemembraneformation;leaky

capillarysyndrome

Pathophysiology:intrapulmonaryshunting ReallybadprognosiscomparedtoiRDS


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Pneumothorax

Spontaneouspneumothorax

Majorcauseisarupturedsubpleuralbleb(i.e.anairpocketunderthepleurathatpops,causingaholeinthepleura)

Lungstaysinflatedbecauseofthenegativeintrathoracicpressure,butbreakingthepleuradisruptsthepressuregradientcollapse

o Diaphragmaticelevationonthatsidetofillupthespaceo Deviationofthetracheatothesideofthecollapse

Usuallyseenintallmaleorinascubadiverswhentheycomeuptooquickly

Tensionpneumothorax

Majorcauseduetopunctureinjuriestothelung Cause:atearinthepleurameansthatwitheveryinspiration,airispulledinto

thepleuralcavity,andwithexpirationtheflapclosesastheairbuildsup,it

pushesthelungandmediastinumtotheoppositesideofthethorax,leadingto

compressionatelectasis

Thereisnodeflation,butratherapositiveintrathoracicpressureinthepleuralcavitybearingdownontherestofthethorax

ThiscompressioncanaffecttheSVC,rightventricle,rightatriummedicalemergency.

Withthepositiveintrathroacicpressure,thediaphragmwillgodown


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PulmonaryInfection

Pneumonia

TypicalPNAacuteonsetfever,chillsproductivecougho Productivecoughexudate(pus)o LobarPNAconsolidationinthelung,leading

toincreasedtactile/vocalfremitus,decreased

resonanceofpercussion,egophony,whispered

pectoriloquy

o Ifthereisapleuraleffusionoverlyingthelungtheonlyfindingyouwouldhaveisdecreased

percussion

AtypicalPNAsubacuteonsetofnonproductivecoughwithouthighfever

o Thisisinterstitialinflammationwithoutexudateandsignsof

consolidation

CommunityacquiredPNAo Typicalform:S.pneumoniae

(gram+diplococcus)

Oldtx:PCNG Newtx:azithromycin

o Atypicalform:Mycoplasmapneumoniae,followedby

Chlamydiapneumoniae

NosocomialPNAcouldbeE.coli,P.aeruginosaorS.aureus

Bronchopneumonia

MostcommonlyduetoS.pneumoniae(communityacquired):

LobarPneumonia

MostcommonlyduetoS.pneumoniae Notetheconsolidationintherightupperlobe


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ViralPNA

Rhinoviruso Themostcommoncauseofthecommoncoldo Acidlabiledestroyedbygastricacid(notatummybug!)o Neverwillhaveavaccinebecausethereare>100serotypes

RSVo Themostcommoncauseofbronchiolitiso Presentswithwheezing(smallairwayinflammation)andPNAinasmall

child

Influenzao Hemagglutininshelpattachthevirustothemucosao Neuraminidaseboresaholethroughthemucosao Antigenicdrift=minormutationinHAorNA;noneedforanewvaccineo Antigenicshift=majorchangeinHAorNAneedanewvaccine.o TheflushotisagainstAantigen

BacterialPNA

Chlamydiapsittacosisfrombirds(ieparrots,turkeys). Chlamydiatrachomatiswheezingat1weekofage,PNA,increasedAP

diameter,tympanicpercussionsounds,nofever,bilateralconjunctivitis,staccato

cough.

o Mocstcommoncauseofconjunctivitisinthe2ndweekoflifeisChlamydiatrachomatis(althoughoverallmostcommoncauseofconjunctivitisis

inflammationduetoerythromycindrops

Hospital-acquiredgram-negativePNA

Pseudomonaso Waterlovingbacteriao Ventilatorinfectionso Greenproductivecough

Klebsiellao Famousinthealcoholic-highspikingfevers,productivecoughwith

mucoidsputum(Klebsiellahasacapsule)

o AlcoholicscanalsogetS.pneumonia.o Klebsiellalivesintheupperlobesandcancavitate,thereforecancbe

onfusedwithTB.

Legionella

o Atypical,nonproductivecougho Deadlyo Spreadsfromwatercoolersorinmistsingroceriesoratrestaurants.o Legionellacanalsocauseliverdisease,interstialnephritis(juxtaglomerlur

celldiseaselowreninhyponatremia)

o Tx=erythromycin


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FungalInfections

Candidao Indwellingcatheters,usuallythoseinthesubclaviano Candidasepsisisthesystemicform

Histoplasmosiso Midwest(Ohio/Tennesseevalley)o Histoplasmacapsulatumiscarriedby

dungofstarlingsandbats

o Presentsasanon-productivecoughinspelunkers/caveexplorers

o Histoplasmaistheonlysystemicfungusthathasyeastforms

phagocytosedbyalveolar

macrophages

o NotetheyeastformsofHistoplasmainthismacrophageinthebone

marrow

o Infectioncanbesystemic Cryptococcus

o Pigeonsi.e.,NYCexecutivewithpigeonsroostinginhisA/Cunit

developsnon-productivecough

o Lookslikemickeymouseyeastformsarenarrowbasedbuds.

o Tx:AmphotericinBo FieldstainshowsCryptococcus

speciesinlungtissue Blastomycosis

o SoutheastUSAo Skinandlunginfectionso Broadbasedbuddingo Verrucousskinlesion(raised,wart-

like)ontheface:Blastomyces

dermatitidis


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Coccidioidomycosiso SouthwestUSA(NewMexico,

Arizona,SoCal

o SpherulewithendosporesisCoccidioidesimmitis

o LAearthquakefollowedbynonproductivecough:the

arthrospore(theinfectiousform)

isinthedust.

o Or,spelunkerdeveopsnonproductivecoughinthesonarandesert-Coccidiomycosis(notHistob/cthisisnotinthemidwest)

Aspergillosiso Aspergillomaaspergilluslovestoinhabit

abandonedTBfunguscavities

Presentswithmassivehemoptysis Fungusballsinbilateralupperlobe

cavitarylesions

o Invasiveaspergillus:invasionofthevesselsinlung,leadingtothrombosisandinfarction

o Allergiesthemold,leadingtoextrinsicasthmaandtypeIhypersensitivity

o Corona(lookslikeacrown)byPASstain-septatehyphae(unlikemucor)

withnarrow-anglebranching(unlike

mucor)

PneumocystitiscariniiPNAo Fungus(usedtobeaprotozoa)o ThisisthemostcommonAIDS-

defininglesion(CD4


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o Otherorganismsonlyseenwithsilverstain:Bartonellahenselae(bacillaryangiomatosis),Legionella

Tuberculosis

PrimaryTBoccursinthelowerpartoftheupperlobeortheupperpartofthelowerlobeandclosetothepleura

o PrimaryTBhasaGhonfocusandaGhoncomplex.

o Mostpatientsrecover ReactivationTBoccursinICH,andgoe

totheapex,producingacavitarylesion.

o Cavitarylesionlinedbycaseousmaterial

o NoGhonfocusorcomplex AcidfaststaininTB-mycolicacidinthecellwallisresponsibleforacid-fastness

CXRwithmiliaryTB:

Otherthingsthatcavitateinupperlobes:

o WhichsystemicfungusistheTBofthelungs?Histoplasmosiso Whichcancercancavitateinthelung?Squamouscelllungcarcinomao Whichbacteriacanproducecavitationsintheupperlobe?K.pneumoniae


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ForeignBodies

Ifyouarestandingorsittingup,foreignbodywillgotoposterobasalsegmentoftherightlowerlobe(i.e.,themostposteriorsegmentoftherightlowerlobe)

Ifyouarelyingdown(mostcommonwaytoaspiratethings),foreignbodywillgotosuperiorsegmentoftherightlowerlobe.

Ifyouarelyingontherightside,foreignbodywillgotoeithero Middlelobeofrightlungo Posteriorsegmentofrightupperlobe(thisistheonlyonethatisinthe

upperlobe.

Ifyouarelyingdownontheleftside,foreignbodywillgotothelingula.

Abscess

Mostcommoncauseofabscessisaspirationoforopharyngealmaterialo Riskfactors:poordentition,alcoholismo Aspirateconsistsofaerobesandanaerobes,fusobacterium,bacteroides

(putridsmell)

AsecondarycauseoflungabscessisPNA:S.aureus,Klebsiella

CXRwillshowfluid-filledcavitiesinthelung

Lungabscessinsuperiorsegmentoftherightlowerlobe(patientmust

havebeenlyingdown)


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PulmonaryVascularDisease

PulmonaryEmbolus

Smallemboliproducewedgeshapedhemorrhagicinfarcts,onlyifyouhave

underlyinglungidseaseo 85%ofthetimeemboluswillnot

produceinfarct

Largeemboli(saddleembolus)lodginginthepulmonaryartery

o Ifthisembolusblocksatleast3outofthe5orifices,youaredeadinamillisecondacuterightheart

strainsuddendeath

Mostcommonsiteforthrombosisisthedeepveinsofthelowerleg.

Themostcommonsiteforembolizationtothelungisthefemoralvein

Screeningtestofchoice:ventilationperfusionscanshowingventilation,butno

perfusion

o ObservePEtotherightlowerlobe(RLL)

Confirmatorytestispulmonaryangiogram.


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o Smoking+asbestos=greatlyincreasedriskofprimarylungcancero Noincreasedincidenceofmesotheliomawithsmoking(notsynergistic)

Notethato Mesotheliomatakes25-30yearstodevelop

mostpeoplediebeforetheygetto

mesothelioma!o Lungcancerstakeabout10yearstodevelopo Lungcancersaremorecommon,andyoudie

earlier

Maincausesofasbestosexposure:roofers,peopleworkinginanavalshipyard(allthepipesintheship

areinsulatedwithasbestos),alsoinbrakeliningof

carsandheadgear

Mesothelioma-entirelungisencasedbythickenedpleura,ahighlymalignanttumor

Sacroidosis

Agranulomatousdiseaseofunknownetiology The2ndmostcommonrestrictivelungdisease Morecommoninblackpeople ClassicCXR:enlargedhilarLNs(potatonodes),

hazinessofinterstitialfibrosis(alongbothlung

basesthereisaveryfinereticulonodular

pattern)

Non-caseatinggranulomainahilarlymphnodeinapatientwithsarcoidosis-notethe

multinucleatedgiantcellsandthepinkstainingepithelioidcellsrepresentingactivatedmacrophages:

Presentswithdyspnea,uveitis(blurryvision)duetoinflammationintheuveal

tract),involvementofsalivaryglandsorlacrimalglands,nodularskinlesionswith

noncaseatinggranulomas

o Also,hypercalcemia:macrophages(epitheloidcells)make1-alpha-hydroxylasehypervitaminosisDabsorptionofCa++fromgut,

reabsorptionofCa++inkidneys

Diagnosisofexclusionruleoutothercausesofgranuloma(TB,histo)


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DiagnoseviahighACE(goodmarkerofdiseaseactivityandresponsetotx)o ACEiselevatedbecauseofgranulomasinthekidney

Tx:steroids Sarcoidisthemostcommonnoninfectiouscauseofgranulomatoushepatitis(TB

isthethemostcommoncauseofinfectioushepatitis)

HypersensitivityPneumonitides

Farmerslungo Thermophilicactinomyces(amold)isblownupintheairo Hypersensitivityanddyspnea

SilofillersDiseaseo Fermentationinthesilonitrogendioxidewheezinganddyspnea.o Silosexplodebecauseofgasproductionfromfermentation

Byssinosiso Workersintextileindustry(linen,cotton,hemp)o Dyspneaduringtheweek,andMondaymorningblueswhentheyhaveto

gobacktoworkonMonday

Goodpasturesyndrome

Beginsinthelungswitharestrictivelungdiseasehemoptysis Proceedstorenaldisease


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ObstructiveLungDisease

OverviewofObstructiveDisease

Obstructiondifficultyexpiringo Compliance(filling/inspirationterm)highcomplianceinobstructive

disease,becauseelastictissuesupportisdestroyed(floppylungmakesiteasytogetairin)

o Elasticity(recoil/expirationterm)decreaseelasticityinobstructivediseasebecausethelungcollapsesonexpiration

Hyperinflationo IncreasedresidualvolumeandTLCo DiaphragmaticdepressionandAPdiameterincreaseo Asairtrappinggetsworseandworse,othervolumesarecompressed

down:tidalvolume,vitalcapacity,andothervolumesdecrease

o So,TLCandRVincreases,everythingelsedecreases FEV1/FVCwaydecreased,clearlydistinguishingrestrictivefromobstructive

lungdisease

o FEV1isverylow;cantakeagestoexpirealltheairo FVCisalsodecreased

ChronicBronchitis

Definedclinicallyasproductivecoughfor3monthsoutoftheyearfor2consecutiveyears.

Adiseaseoftheterminalbronchioleso Anatomy:mainstembronchus,segmentalbronchi,terminalbronchioles,

respbronchioles,alveolarducts,alveoli.Airflowchangesformturbulent

tolaminarattheterminalbronchioleso Smallairwaydisease;presentswithwheezing

Adiseaseofthemucusglandso Mucusglandhyperplasiainproximalairwayo Gobletcellmetaplasiao Mucousplugs

Result:V/Qmismatcho Bluebloaterscyanosisbecauseofinabilitytoventilatecloggedairways

Pinkpuffer(left)vsbluebloater(right)

oPinkpufferspredominantlyhave

emphysema,which

involvesthe

respiratoryunit,while

bluebloatershave

chronicbronchitis


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Emphysema

Adiseaseoftherespiratoryunit(i.e.,non-respiratorybronchiole)distaltowherechronicbronchitishits

o Evendestructionofrespiratoryunitandvasculaturesurroundingito EvenlossofVandQnoCO2retentionpinkpufferphenotype

respiratoryalkalosis Presentswithexpiratorywheeze COPDCXR:hardtoseetheheart,depresseddiaphragmsincreasedAPdiameter OtherCXRslikethisoccurinotherobstructivediseaseswithair-trapping:3

montholdwithRSV,newbornwithC.trachomatisPNA

Typesofemphysema:centrilobularandpanacinar CentrilobularEmphysema

o Associatedwithsmokingo Involvesupperlobeso Primarilydestructionofrespiratory

bronchiolebyneutrophils(PMNs

chemotaxinresponsetocigarette

smoke)

o Smokershavedenaturedalpha-1antitrypsin

o Triggerhappyneutrophilsdestroytheelastictissuesupportofthe

respiratorybronchiolesnoelasticrecoilcysticspaceswithair-

trapping

PanacinarEmphysemao Destructionoftheentire

respiratoryunit(panacinar)o Geneticabsenceofalpha-1

antitrypsin

o Presentsatayoungagewithdestructionofthelowerlobes

o SmokerswithacquireA1ATdeficiencycanalsohavean

elementofpanacinaremphysema

Bronchiectasis

Abnormaldilationsofbronchifurtherthanthehilum,abuttingthepleura

Mechanism:infection,destructionofelastictissuesupport,dilatationoftheairways.

Segmentalbronchifillwithpus

Presentation:cupfullsofsputum Causes

o MostcommonlyintheUS:cysticfibrosis


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o Mostcommonlyin3rdworld:TBo Kartagenerssyndrome

Immotilecilia Ciliahavea9+2configurationarrangementwithciliaand

microtubules

Absentdyneinarmabsenceofarmskeepingthe9microtubulesontheoutsidetogether

Presentswithsinusitis,bronchiectasis,infertility(spermandfallopiantubecilia)anddextrocardiawithouttranspositionof

greatvessels,orsitusinversus

Main-stembronchuscancerassociatedwithbronchiectasis.Atthetopoftheslidethereisawhitecoloredmassthathascompletelyobstructedthemain-

stembronchus:

Asthma

Canbeextrinsic(type1HPY)orintrinsic(chemicals)twoseparateentities!

Intrinsicasthma:o TriadasthmainpatientstakingNSAIDso Exercise-inducedasthmatxwithcromolyn

sodium

o Coldtemperaturecancauseasthma. Thewheezingisduetoinflammationoftheterminal

bronchiolesbecauseLTC4,D4,E4andPGscausing

inflammationandnarrowingoftheairways

IncreasedAPdiameterinchronialasthma SputumwithCharcot-Leydencrystalsinapatientwithbronchialasthma


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LungCancer

Location

CXRs:leftx-raywithaprimaryperipheraladenocarcinoma,rightx-raywithprimarycentrallylocatedcancer

Centrallylocated

o Havethehighestassociationwithsmoking.o Includesquamouscellcarcinoma(morecommon)andsmallcell

carcinoma(lesscommon)

o Generallylocatedaroundthemainstembronchuso Primarymain-stembronchuscancernotethattoothpicksarenecessary

tokeepthelumenopen.Notethewhitematerialencirclingandinvading

intothelumenofthemain-stembronchi.Thiscouldbeeithera

squamousorsmallcellcancer

o Welldifferentiatedsquamouscellcarcinomaoflungs-notethe

concentricareasofeosinophilicstainingcellsonthelowermarginofthe

side.Thesearemalignantsquamouscellswithkeratinformation(called

squamouspearls)


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Peripherallylocatedo Adenocarcinomas:themostcommonprimarylungcancer,more

commonthansquamous-moreperipheralthancentral.

o Shiftedtotheperipheryb/cofthefiltersonthecigarettes-thefilterspreventedthelargecarcinogensfrompassingin,butthesmall

carcinogensstillpassedthrough,andtheyarenottrappedinthemainstem,buttrappedintheperiphery.Thus,filtersincigarettesare

responsiblefortheincreaseinperipherallylocatedadenocarcinoma

o Thereareatleast3or4typesofadenocarcinoma. Oneobviouslydoeshaveasmokingrelationship Theonesthatdonothaveasmokingrelationshipinclude

bronchiolaralveolarcarcinoma,andlargecelladenocarcinomaof

thelung,scarcancers

Cytology:

Papsmearstainskeratinbrightred Squamouscellcarcinomainsputumspecimen:

Papsmearwithamalignantsquamouspearl-notetheconcentricappearanceof

thismalignantcellcontainingkeratin

Smallcellcarcinoma-smallcellsthatlook

likelymphocytes;thisisthemostmalignant

cancerofthelung.TxviaCtx/RT(forSCLC

surgeryisineffective).Thesetumorshave

neurosecretorygranules(canmakeADHand

ACTH)andareS-100Agpositive

Biopsyandpapsmearshowntotheright


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AslightlylessmalignanttumorwithAPUDoriginisbronchiocarcinoid.o Lowgrademalignancyofthesametypesofcellsthatproducesmallcell

carcinoma.

o Theycaninvade,metastasize,andevenproducecarcinoidsyndrome(make5-HT)

o Veryuncommon

MetastaticDisease

Themostcommoncancerofthelungbreastisthemostcommon Notethemultifocalnatureofmetastasis(left);canspreadtothevisceralpleura

(whitenodularmasses,middle),andlymphatics(whitetumorencirclingsmall

airwaysthroughoutthelungs,right)

Hornerssyndrome

Pancoasttumor/superiorsulcustumortumorsthatareintheupperlobeposteriorly(inpostmediastinum)

o Mostofthetimeiscausedbysquamouscarcinomainthatarea Tumorinvadeslocallyintothelower

trunkofthebrachialplexus,socan

getlowertrunkbrachialplexusfindings

Tumorinvadeslocallyintothesuperiorcervicalganglionknock

outsympatheticactivity

o Ptosis(eyeliddroop)o Anhydrosis(lackofsweating)o Miosis(pinpointpupil)

PleuralEffusion

Exudatevs.transudate

o Exudate:protein>3grams,andhascellsinit(PNA,pulmonaryinfarction)o Transudate:

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