1.Pulmonary Vascular Disease 2.Pleural Disease

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1.Pulmonary Vascular Disease2.Pleural Disease

• Prof. Frank Carey

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Pulmonary Circulatuion

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

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Low pressure system.

• Thin walled vessels
• Low incidence of atherosclerosis
• At normal pressures

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Pulmonary Oedema

• Accumulation of fluid in the lung
• Interstitium
• Alveolar spaces
• Causes a restrictive pattern of disease

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Pulmonary Oedema (causes)

• Haemodynamic ( hydrostatic pressure)
• Due to cellular injury
• Alveolar lining cells
• Alveolar endothelium
• Localised pneumonia
• Generalised adult respiratory distress syndrome
  (ARDS)

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ARDS

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

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Pathogenesis of ARDS

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

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Pathology of ARDS

• Fibrinous exudate lining alveolar walls (hyaline
  membranes)
• Cellular regeneration
• Inflammation

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ARDS with hyaline membrane
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ARDS cellular reaction
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Outcome of ARDS

• Death
• Resolution
• Fibrosis (chronic restrictive lung disease

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Neonatal RDS

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

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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

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Pulmonary Embolus

• Common
• Often subclinical
• An important cause of sudden death and pulmonary
  hypertension
• 95 of emboli are thromboemboli

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Source of most pulmonary emboli..

• Deep venous thrombosis (DVT) of lower limbs

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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)
• - Virchows triad

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Effects of PE

• Sudden death
• Severe chest pain/dyspnoea/haemoptysis
• Pulmonary infarction
• Pulmonary hypertension

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Effects of PE depend on

• Size of embolus
• Cardiac function
• Respiratory function

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Effect of embolus size

• Large emboli
• Death
• Infarction
• Severe symptoms

• Small emboli
• Clinically silent
• Recurrent pulmonary hypertension

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Pulmonary Infarct (ischaemic necrosis)

• Embolus necessary but not sufficient
• Bronchial artery supply compromised (eg in
  cardiac failure)

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Pummonary Embolus
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Pulmonary infarct tumour embolus
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Pulmonary Hypertension

• Primary (rare, young women)
• Secondary

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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

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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

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Pulmonary artery intimal fibrosis
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Plexiform lesion primary pulmonary hypertension
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Cor Pulmonale

• Pulmonary hypertension complicating lung disease
• Right ventricular hypertrophy
• Right ventricular dilatation
• Right heart failure (swollen legs, congested
  liver etc)

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Cardiomegaly due to right ventricular dilatation
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Right ventricular hypertrophy and dilatation
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The Pleura

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

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Pleural Effusion

• Transudate (low protein)
• cardiac failure
• hypoproteinaemia

• Exudate (high protein)
• pneumonia
• TB
• connective tissue disease
• malignancy (primary or metastatic)

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Pleural effusion
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Purulent Effusion

• Full of acute inflammatory cells
• Empyema
• Can become chronic

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Pneumothorax

• Air in pleural space
• Trauma
• Rupture of bulla

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Large bullae
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Pleural Neoplasia

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

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Mesothelioma

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

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Mesothelioma
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Pleural biopsy - mesothelioma
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Metastases in Pleura
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Differential diagnosis of malignant effusions..

• Cytology, biopsy
• Difficult
• Immunohistochemistry for lineage specific
  antigens may help
• Medicolegal importance

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