The Lung

Spencer S. Watanabe, MD, DPSP, MHA

Encoded by:
Austin Cabrera – LNU Medicine | Vision 2020
Atelectasis - Collapse or closure of a lung resulting in reduced
or absent gas exchange
- Clinically, it is visible on Chest X-Ray
- Finding is visible as lung opacification or loss of
lung volume
- Important complication of post-op abdominal
surgery because of several mechanisms:
a. Mucus obstruction of a bronchus
b. Diminished respiratory movement because of
post-op pain
- Often asymptomatic, but when severe, it can
result to hypoxemia
 o Results from COMPLETE obstruction of
RESORPTION an airway
o Ex. Mucus plug caused by excessive
secretions, also caused by exudates
within smaller bronchi (asthma, chronic
bronchitis, bronchiectasis), also
aspiration of foreign bodies (pediatric
patients)
o Aspiration – instead of going to the
esophagus, it went down to the trachea
(gag reflex – but in children who have
poor mechanisms of gag reflex = more
prone to aspiration)
o In cases of resorption atelectasis, it is said
that the mediastinum shifts TOWARDS
site of atelectasis
o REVERSIBLE – remove obstruction
 o Results whenever significant
COMPRESSION volume of fluid, tumor or air
accumulate within the pleural cavity
o Fluid (Transudate, exudate, or
blood)
o Mediastinum shifts AWAY from the
affected lung (space occupying
mass in the lung which will push
the contents away from the affected
area)
o REVERSIBLE – remove fluid
CONTRACTION

o Pulmonary/Pleural Fibrosis
o Contraction/Shrunk, lung has
diminished volume in its entirety
o IRREVERSIBLE - Scar tissues
already formed
Bronchiectasis
o Irreversible disorder caused by destruction of
smooth muscle and elastic tissue of the lungs
o CAUSE: Chronic necrotizing infections which is
repetitive, and recurrent
o Feature in gross specimen: Airways are
DILATED (up to 4x the normal size)

o Obstructive: Caused by tumors, foreign bodies,

mucus plugs, and lymphadenopathies (swollen
lymph nodes)
o Non-obstructive: Caused by respiratory
infections
Tram Track Sign

o Dilated airways
o Bronchi are dilated with thickened
walls which contain thick
mucopurulent secretions, and
microscopically, there is severe
inflammation
o X-ray of Patients with Bronchiectasis
o Signs & Symptoms:
o Chronic productive cough with
copus or abundant sputum,
hemoptysis
o Complication: Hypoxia and
Pulmonary hypertension
 Kartagener Syndrome

o Associated with bronchiectasis

o Comprises the TRIAD:
a. Bronchiectasis
b. Sinusitis
c. Dextrocardia
o Picture: Cilia
o There is a defect in ciliary function, whether in the Lungs, Nasal Passage, or
in embryologic development causing dextrocardia
o Abnormal ciliary function: heart will not rotate during development = situs
inversus)
o Dylein arms are the ones affected
o Lack of ciliary activity makes bacterial clearance difficult
o Males: Sperm dismotility  INFERTILITY (d/to a defect in ciliary function)
Bacterial Pneumonia

o Lobar pneumonia – denotes consolidation of an

entire lobe of the lung
o Bronchopneumonia – scattered solid foci in
several lobes
o PICTURE:
LEFT: Bronchopneumonia
RIGHT: Lobar pneumonia
o Most bacteria that causes pneumonia comes
from what location? = normal flora of the
OROPHARYNX that reaches the alveoli by what
mechanism? = ASPIRATION
Bacterial
Pneumonia

• Microscopically, there is exudate = thick

secretion rich in which inflammatory cell? =
NEUTROPHILS, that fills the bronchi,
bronchioles, and alveoli
o Supposed to be airy, white
o but in the picture, it is filled with exudate
containing neutrophils
o Lung is filled with fluid instead of air
(Consolidation)
Community-Acquired Bacterial Pneumonias

o Comes from the normal environment

o MARKER that will identify patients with bacterial
infection? = C-REACTIVE PROTEIN and
PROCALCITONIN (these are examples of acute-phase
reactants)
o CRP & Procalcitonin: Significantly elevated in bacterial
infections
o Erythrocyte Sedimentation Rate – older test
 o Most common cause of community-acquired
Streptococcus pneumonia
o Who is particularly at risk for this infection? =
pneumoniae Patients with decreased function of which
organ? = SPLEEN
o Is life without spleen possible? = YES
o Decreased/absent splenic function: Post-
splenectomy patients, [Sickle cell disease,
Thalassemia – hematologic conditions]
o IMPORTANT FIRST STEP in Lab Dx of Acute
Pneumonia: Gram-stain of which specimen? =
SPUTUM
o Picture: Sputum Gram-stain of a patient with
Strep pneumonia
o Dots are the bacterial elements
o It is gram-positive, lancet-shaped, diplococci
(shown in pairs)
Pneumococcal Pneumonia
(Congestion Stage)
- Numerous neutrophils with gram (+)
lancet-shaped supports this diagnosis

Congestion
o Lungs: Heavy, boggy (moist,
engorged), and red
Lobar Pneumonia: Red Hepatization

Red Hepatization
o Characterized by massive exudate with
neutrophils, red cells, and fibrin
o Lungs instead of it being airy or
spongy, has been transformed into an
airless, firm organ with a liver-like
consistency
Lobar Pneumonia: Gray Hepatization

Gray Hepatization
o Gray because there is disintegration of red cells
while there is presence of exudate giving a
color change from red to grayish brown
o Exudate remains but there is destruction of red
cells
Lobar Pneumonia: Resolution

o Exudates are now broken down by enzyme

digestion
o Fibroblasts – scar tissue formation

o Stages are not commonly seen anymore d/to

the advent of antibiotics
Klebsiella Pneumonia

- Aside from Strep pneumoniae, this is

another organism which can cause
Lobar pneumonia (K. pneumoniae)
- Just 1% of all cases of community-
acquired pneumonia
- Which patients are at risk? =
ALCOHOLICS, middle-aged men who are
diabetic and alcoholic
Klebsiella pneumoniae

- Sputum is CURRANT-JELLY because of the mucoid

appearance of the lung
- Distinctive characteristic aside from currant-jelly = the
AFFECTED lobe of the lung is increased in size
causing a bulge, there is tissue necrosis and abscess
formation (which then causes bleeding)
- Serious complication of K. pneumonia? =
BRONCHOPLEURAL FISTULA – hole in the lungs
caused by the abscess formation and necrosis
Moraxella catarrhalis

- 2nd most common cause of COPD pneumonia

- Increasingly recognized as a cause of
bacterial pneumonia in the elderly
Staphylococcal Pneumonia

- Caused by staph aureus

- Common case: Seen as a
SUPERINFECTION (initial infection) from
a viral pneumonia and then a secondary
infection caused by staph aureus comes
into play
- Characteristic? = MANY SMALL
ABSCESSES
Pneumatoceles

- Another feature of a staphylococcal pneumonia

- Seen in infants with staphylococcal pneumonia
are more prone
- Thin-walled cystic spaces in the lungs caused by
staph. Pneumonia
- CAUSE: develops when an abscess breaks into
an airway
- Complications: Pleural effusion and Cavitation
Legionella Pneumonia

- “Legionnaire’s disease”
- Caused by: Legionella pneumophila
- Condition/location wherein legionella
organisms thrive or grow? = AQUATIC
ENVIRONMENTS / AIRCONDITIONING UNITS
or cooling towers, condensers
- Transmitted via Aerosols/Droplets from
these locations
- Can this spread from person to person? =
NO
- Transmitted only from the environment
(aerosol) to the person
Gram-negative Pneumonia

- Most common bacteria: E. coli, and

Pseudomonas aeruginosa
- Who are at risk? = AIDS patient, those who are
under immunosuppressants, under cytotoxic
therapies, under broad spectrum antibiotics
Anthrax
Pneumonia - Bioterrorism
- What is the bacteria that causes anthrax? =
Bacillus anthracis (gram positive)
- What form of Anthrax causes the infection? =
INHALATION (anthrax) spores
- Spores are highly resistant to drying and heat
that’s why it can be used for bioterrorism
- When spores are inhaled, where do they go? =
They are transported to the mediastinal lymph
nodes
- From the lymph nodes, the bacilli descending
- PICTURE: Anthrax spores
Anthrax
Pneumonia

- In the lungs, the disease manifests as

hemorrhagic bronchitis
- Aside from Anthrax, what is the other
bacteria that can be used for bioterrorism? =
YERSINIA PESTIS which is the cause of the
disease? = PLAGUE
- How is Yersinia pestis transmitted? = Vector
(rodents)
Haemophilus - Gram negative bacteria that can occur in
encapsulated or non-encapsulated form
influenzae - How many types of encapsulated forms are
there? = 6 serotypes (A-F)
- Which is the most virulent? = Serotype B
(HiB)
- Who is at risk? = young children (3-5 y/o)

- Aside from pneumonia, another

complication is Meningitis
- Is it still common? = declined incidence d/to
vaccination/immunization
- Most common bacterial cause of acute
exacerbation of COPD (2nd = Moraxella
catarrhalis)
Pseudomonas aeruginosa

- Most common cause of HOSPITAL-ACQUIRED

PNEUMONIA
- Who is at risk? = burn patients (because of their
immunocompromised state), Neutropenic
patients (under chemotherapy), Organ transplants
(suppressed immune system to prevent rejection)

- MOST VIRULENT, why? = Very aggressive,

satanic infection, rapid and invasive (has the
propensity to invade blood vessels causing wide
spread)
Pneumonic Plague

- Yersinia pestis
- Characteristic lesion in the skin: BUBOES
- Used to be a medieval infectious disease
Atypical Pneumonia

- Cause: Mycoplasma pneumoniae

- Why atypical? – “WALKING pneumonia
patient”, absent/slight leukocytosis, respiratory
symptoms are minimal to moderate, can give a
simple antibiotic (erythromycin)

- TYPICAL pneumonia – high fever, cough,

elevated levels of neutrophils, leukocytosis,
severe respiratory symptoms
Complications of Pneumonia:
Lung Abscess
- Lung abscess – localized accumulation of pus caused
by destruction of lung tissue
- CAUSE: aspiration of anaerobic bacteria from the
oropharynx (conditions: someone with impaired gag
reflex)
- Patients with altered mental status, severe alcoholic
intoxication, those who are intubated = prone to
aspiration
- Bacteria that causes lung abscess: POLYMICROBIAL
(bacteroides is usually isolated among the anaerobes)
Lung Abscess

- What is the most common condition that

predisposes to lung abscess? =
ALCOHOLISM

- Neurologic disorder that causes

impairment of the gag reflex = Epileptic
patients, those who have suffered drug
overdose
Pleural Effusion

- “tubig sa baga”
- Build up of excess fluid within the layers of the
pleura outside of the lungs
- X-ray: BLUNTING of the costo-phrenic angle
- What type of atelectasis is shown? =
COMPRESSION (Mediastinum shifts AWAY from
the affected lung)
- Other complications of pneumonia: Pleuritis
(infection spread from lungs to pleura)
- Pyothorax – infection of pleural effusion
Empyema

- Prolonged / Persistent pyothorax

- Collection of pus/abscess within the pleural
walls
- Another complication: Sepsis
- Sepsis complications: Metastatic abscesses
Bacteremic Dissemination

- Sepsis complication: Infection of

heart valves (infective endocarditis)
- It can also spread to the brain,
kidneys, joints (suppurative arthritis)
Community-Acquired Viral Pneumonia

Examples of viruses:
- Influenza (Types A and B)
- RSV (Respiratory syncytial virus)
- Human metapneumovirus
Interstitial vs Alveolar Inflammation
Nosocomial Pneumonia

- “health care associated pneumonia”

- Hospitalization of AT LEAST 2 DAYS
- Predisposing conditions:
- Recent antibiotic therapy, hemodialysis,
nursing homes or long-term care facility
- Most common organism isolated in
nosocomial pneumonia (Pseudomonas)
- Methycillin-Resistant SA as well
- Mortality is HIGHER as compared to
community-acquired pneumonia
- Condition that is particularly HIGH-RISK:
Under Mechanical ventilation
Aspiration Pneumonia

- Those who are unconscious, patients after a

stroke, repeated vomiting, abnormal gag and
swallowing reflex
- Most common cause: POLYMICROBIALS
(bacteria from oropharynx)
- Most common complication: LUNG ABSCESS
Chronic Obstructive Pulmonary
Disease (COPD)

- Applies to which conditions of the lungs:

a. Emphysema
b. Chronic bronchitis
- Diagnosed via PFTs (Pulmonary function tests)
- Which parameter is DECREASED in
spirometry/PFTs? = FEV (Forced expiratory
volume)
- Narrowing of the airways producing increased
resistance and also with decreased elastic recoil
(elastic recoil: ability of lungs to regain volume
during inhalation)
Chronic Bronchitis

- Disease of cigarette smokers

- Productive cough that lasts for 3months or
more per year for at least 2 years
- Main microscopic finding:
- Increase in size of the mucus secreting
structures in the lungs  hyperplasia and
hypertrophy of mucus cells
“Blue Bloater”

- A patient with Chronic bronchitis

- Cyanotic and bloated/edematous which is
secondary to pulmonary hypertension
leading to COR PULMONALE
Emphysema

- Irreversible enlargement of air spaces DISTAL to the

TERMINAL BRONCHIOLE accompanied by tissue
destruction WITHOUT fibrosis
- Picture: Dilated airspaces (similar to
bronchiectasis)
- BOTH IRREVERSIBLE
- In emphysema, enlargement distal to terminal
bronchiole (SMALLER airways)
- In bronchiectasis, LARGER airspaces are involved
- Major cause: Cigarette smoking
α-1-antitrypsin (1-AT)

- Emphysema is r/to a-1-antitrypsin

- Normal persons WITHOUT emphysema has
an adequate amount of a-1-antitrypsin
- Smokers has DECREASED amount
- A-1-antitrypsin is good because it
counteracts elastase which are found in
neutrophils or in inflammation
- Cigarette smoking = increased elastase
protease
- Unopposed/Increased elastase 
destruction of elastic tissue of the lungs
Emphysema BASED ON
Categories LOCATION
Centrilobular (Centriacinar) Emphysema

- Seen in UPPER lobes of the lungs

- Pattern is most typically seen in smokers
- MORE COMMON
Panlobular (Panacinar) Emphysema

- Typical of a-1-antitrypsin deficiency =

EARLY ONSET EMPHYSEMA
(panlobular/panacinar)
Bullous Emphysema

- Blebs or Bullae that occur in emphysema

- Complication: if bullae ruptures because walls are
weak
 Pneumothorax (AIR in the lungs)
 Compression atelectasis
- Spontaneous pneumothorax: NOT RELATED TO
EMPHYSEMA Typical patient: lanky (tall and thin)
who suddenly suffered DOB

- MANAGEMENT: Stab the upper level of the chest

within the ribs with a SYRINGE. Why? = For air to
evacuate
Asthma

- Patients who suffer from asthma

typically have dyspnea, wheezing, and
cough
- Pathophysiologic mechanism: bronchial
hyperresponsiveness or hypersensitivity
- Lungs react easily to inflammatory
stimuli: Dust, pollen, exercise causing
bronchoconstriction mucus
hypersecretion, and smooth muscle
hypertrophy
- Most common: Allergic type (fur, dust)
Allergic Asthma

- Infectious
- RSV – in children
- Rhinovirus and Influenza – older children
and adults
Drug-induced Asthma

- BEST KNOWN CAUSE: Aspirin (bronchospasm)

- Air pollution – environmental pollutants: Sulfur
dioxide ozone, Nitrogen oxide
- Emotional factors – psychological stress
Hyperinflated Lung in Status Asthmaticus
Charcot-Leyden
Crystals

- Eosinophils are implicated in asthma

- Crystals composed of eosinophil
protein
Curschmann Spirals

- Mucus plugs which may cause DOB

which can follow airway shape
- This mucus plug can cause
RESORPTION Atelectasis
Airway Remodeling
Eosinophils in Asthmatic Lung
 Asbestosis

- Pneumoconiosis is a term that describes a

lung reaction to inhaled mineral dust
encountered usually in the workplace
- Asbestos – causative agent
- Asbestos – type of silicate associated with
pulmonary fibrosis with pulmonary
carcinoma associated with mesothelioma
- Mesothelioma – cancer of pleura
- Asbestos – long and thin crystal
- Fiber becomes coated with calcium and iron
= ferruginous body
Ferruginous Bodies

- Serpentine form – accounts for 90% of

asbestos used in the industry
- Amphibole – less prevalent; MORE
PATHOGENIC
Pleural Plaques

- Typical manifestation of asbestosis

- Well-circumscribed plaques
Silicosis

- MOST COMMON pneumoconiosis

- Silica occurs in various forms:
Crystalline/Amorphous
- MORE Pathogenic: Crystalline form
- Which among the crystalline forms is most
commonly implicated in causing lung
disease? = QUARTZ
Eggshell Calcification

- Caused by calcification that occurs

in lymph nodes
Collagenous Scars
Lung Cancer
- Most frequently diagnosed major cancer in the world
- 2 large grps of lung cancer:

a. Small cell carcinoma

o Respond to chemotherapy
b. Non-small cell carcinoma
o Squamous cell
o Adenocarcinoma
o Large cell carcinoma
o Treated surgically and DO NOT usually respond
well to chemotherapy
- There is a difference in therapy and prognosis
- CX-ray: Large lung mass, most probably malignant
Tobacco Smoke

- 80% of lung cancers happen in active

smokers
- Only 11% of smokers can develop cancer
- But lung cancer is known to have a poor
prognosis (<45% 5yr survival rate) even in
Stage 1
- Women have higher susceptibility to
carcinogens than men
- How do you consider someone as a heavy
smoker? = two cigarette packs a day for 20
yrs
Squamous Cell Carcinoma

- Found in men, strongly associated with smoking

- PRECURSOR lesions (before lung cancer): squamous
metaplasia which will transform into a dysplasia
which will transform into carcinoma in situ which will
transform into carcinoma
- Lasts for several years
- Usual location: CENTRAL PORTION
- Which mutation is associated? = P53 (highest
frequency)
Squamous Cell Carcinoma
Keratin Pearls

- Microscopic feature of squamous cell carcinoma

- Keratinization/squamous pearls
Intercellular Bridges

- Another characteristic of Squamous cell

carcinoma
- In between the spaces between the cells,
there are ridges (lines)
- Both keratin pearls and bridges are seen in
WELL-DIFFERENTIATED carcinomas
Small Cell Carcinoma

- “Oat-cell carcinoma”
- Highly malignant tumor of the lung that
exhibits neuro-endocrine features
- Carcinoma with strongest association
with smoking
- Most common mutation: TP53, and RB
Salt and Pepper Pattern

- Salt and Pepper pattern –

responsive to chemotherapy;
highly malignant
- Most aggressive of the lung
tumors
- Spreads widely, almost always
fatal
- Small nuclei, salt and pepper
pattern of chromatin
Adenocarcinoma

- Most common form of lung cancer

(cigarette filter tips is finer = causing
deeper inhalation of smoke thereby
exposing more airways to carcinogens)
- Adeno = glandular malignancy
- Malignant epithelial tumor with glandular
differentiation or mucin production
- Location: More peripheral
- Smaller in size
Glandular Elements

- What is a common mutation? =

EGFR
- There is targeted therapy for
EGFR using EGFR tyrosine
kinase inhibitor = ONLY FOR
ADENOCARCINOMA
Adenocarcinoma is also the most
common cancer in non-smokers
- 25% of lung cancers occur in
patient who do not smoke
- Non-smokers = EGFR mutation
Large Cell Carcinoma

- Poorly differentiated tumor that is

neither squamous or adeno (but not
small cell)
- Why large cell? = cells in the
microscope, HAVE LARGE NUCLEI
Pancoast Tumor

- Lung cancer located in the

superior pulmonary sulcus in the
lung apex
- Has a tendency to invade the
neural structures around the
trachea including the cervical
sympathetic plexus – what is the
effect? = HORNER’S SYNDROME
Horner’s Syndrome

- Ptosis, myosis (pupil constriction),

and anhidrosis (loss of sweat) on the
SAME SIDE of lesion
Carcinoid Tumor

- Low-grade material neoplasm

(low-grade better than high grade)
- Can produce carcinoid syndrome
which is characterized by
diarrhea, flushing, and cyanosis
- They do not usually metastasize
- Surgical resection
Coin Lesion of Lung

- Solitary lung module in the size of a

large coin
- Most common Benign tumor found
in the lung
= HAMARTOMA
Hamartoma

- Well circumscribed
- Less than 3-4cm in diameter
- Benign tumor of the lung
- Most common tissue:
cartilage (fibrous tissue and
fat is also present)
Hamartoma
Metastatic Cancer

- Most common cancer found in the lung:

Metastatic cancer
- PRIMARY cancer found in the lungs:
Adenocarcinoma
- Secondary cancer found in the lung:
Metastatic cancer
- Appearance of a metastatic cancer =
cannon-ball like appearance of the
nodules scattered on the lungs