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1.Pulmonary Vascular Disease 2.Pleural Disease

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

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1.Pulmonary Vascular Disease 2.Pleural Disease

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  1. 1.Pulmonary Vascular Disease2.Pleural Disease Prof. Frank Carey

  2. Pulmonary Circulatuion • Dual supply • Pulmonary arteries • Bronchial arteries • Low pressure system • Pulmonary artery receives entire cardiac output (a filter)

  3. Low pressure system…. • Thin walled vessels • Low incidence of atherosclerosis At normal pressures

  4. Pulmonary Oedema • Accumulation of fluid in the lung • Interstitium • Alveolar spaces • Causes a restrictive pattern of disease

  5. Pulmonary Oedema (causes) • Haemodynamic ( hydrostatic pressure) • Due to cellular injury • Alveolar lining cells • Alveolar endothelium Localised – pneumonia Generalised – adult respiratory distress syndrome (ARDS)

  6. ARDS • Diffuse alveolar damage syndrome (DADS) • Shock lung • Causes include sepsis, diffuse infection (virus, mycoplasma), severe trauma, oxygen

  7. Pathogenesis of ARDS Injury (eg bacterial endotoxin) • Infiltration of inflammatory cells • Cytokines • Oxygen free radicals • Injury to cell membranes

  8. Pathology of ARDS • Fibrinous exudate lining alveolar walls (hyaline membranes) • Cellular regeneration • Inflammation

  9. ARDS with hyaline membrane

  10. ARDS – cellular reaction

  11. Outcome of ARDS • Death • Resolution • Fibrosis (chronic restrictive lung disease

  12. Neonatal RDS • Premature infants • Deficient in surfactant (type 2 alveolar lining cells • Increased effort in expanding lung physical damage to cells

  13. Embolus • 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

  14. Pulmonary Embolus • Common • Often subclinical • An important cause of sudden death and pulmonary hypertension 95% + of emboli are thromboemboli

  15. Source of most pulmonary emboli….. • Deep venous thrombosis (DVT) of lower limbs

  16. Risk factors for PE are those for DVT…. • Factors in vessel wall (eg endothelial hypoxia) • Abnormal blood flow (venous stasis) • Hypercoaguable blood (cancer patients, post-MI etc) - Virchow’s triad

  17. Effects of PE • Sudden death • Severe chest pain/dyspnoea/haemoptysis • Pulmonary infarction • Pulmonary hypertension

  18. Effects of PE depend on… • Size of embolus • Cardiac function • Respiratory function

  19. Large emboli Death Infarction Severe symptoms Small emboli Clinically silent Recurrent pulmonary hypertension Effect of embolus size…

  20. Pulmonary Infarct (ischaemic necrosis) • Embolus necessary but not sufficient • Bronchial artery supply compromised (eg in cardiac failure)

  21. Pummonary Embolus

  22. Pulmonary infarct – tumour embolus

  23. Pulmonary Hypertension • Primary (rare, young women) • Secondary

  24. Pulmonary Hypertension (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

  25. Morphology of pulmonary hypertension • Medial hypertrophy of arteries • Intimal thickening (fibrosis) • Atheroma • Right ventricular hypertrophy • Extreme cases (congenital heart disease, primary pulmonary hypertension) – plexogenic change/necrosis

  26. Pulmonary artery – intimal fibrosis

  27. Plexiform lesion – primary pulmonary hypertension

  28. “Cor Pulmonale” • Pulmonary hypertension complicating lung disease • Right ventricular hypertrophy • Right ventricular dilatation • Right heart failure (swollen legs, congested liver etc)

  29. Cardiomegaly due to right ventricular dilatation

  30. Right ventricular hypertrophy and dilatation

  31. The Pleura • A mesothelial surface lining the lungs and mediastinum • Mesothelial cells designed for fluid absorption • Hallmark of disease is the effusion

  32. Transudate (low protein) cardiac failure hypoproteinaemia Exudate (high protein) pneumonia TB connective tissue disease malignancy (primary or metastatic) Pleural Effusion

  33. Pleural effusion

  34. Purulent Effusion Full of acute inflammatory cells • Empyema • Can become chronic

  35. Pneumothorax Air in pleural space • Trauma • Rupture of bulla

  36. Large bullae

  37. Pleural Neoplasia • Primary • benign (rare) • malignant mesothelioma • Secondary • common (adenocarcinomas - lung, GIT, ovary)

  38. Mesothelioma • Asbestosis related • Increasing incidence • Mixed epithelial/mesenchymal differentiation • Dismal prognosis

  39. Mesothelioma

  40. Pleural biopsy - mesothelioma

  41. Metastases in Pleura

  42. Differential diagnosis of malignant effusions….. • Cytology, biopsy • Difficult • Immunohistochemistry for lineage specific antigens may help • Medicolegal importance

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