Pulmonary lymphatic drainage

There are two types of lymphatic vessels in the lungs. The superficial vessels run along the margins of fissures and end in the bronchopulmonary nodes. The deep efferents pass to the hilum of the lungs to reach the same bronchopulmonary nodes. The vessels which drain the bronchial tree follow a pattern. Lymphatic vessels of the upper lobe end up in the superior tracheobronchial nodes, while those in the lower lobe enter the inferior tracheobronchial nodes. The tracheobronchial and bronchopulmonary nodes all end in the bronchomediastinal lymph trunk. This trunk reaches the thoracic duct on the left and the right lymph duct on the right or the right jugulosubclavian junction.

Intrapulmonary lymph nodes –> left and right bronchopulmonary (hilar) lymph nodes –> carinal lymph (inferior tracheobronchial) nodes –> tracheobronchial lymph nodes –> paratracheal lymph nodes –> jugular trunk –> thoracic duct

An unusual feature of this anatomy is that carinal nodes, collect lymph from the left lower lobe but drain that fluid into the right tracheobronchial lymph nodes. This is significant because a suspicious-appearing lymph node in the right hilar region should prompt evaluation of the left lower lobe and the right lung.

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FVC/DLCO ratio

PAH and ILD
FVC/DLCO ratio

1)Isolated PAH have a long history of Raynaud’s phenomenon, limied scleroderma, anticentromere antibody positivity, an extremely low diffusing capacity for carbon monoxide (DLco), near-normal forced vital capacity (FVC), minimal pulmonary fibrosis, and an FVC:DLco ratio of > 1.8 at the time of the diagnosis.

2)Patients with diffuse systemic sclerosis and pulmonary interstitial fibrosis have antitopoisomerase antibody (SCL-70 antibody) and a very low FVC and a DLco that is decreased to a similar degree, so the FVC:DLco ratio remains close to 1.

3)Patients with mixed ILD-PAH have antinucleolar antibody, moderate interstitial fibrosis and then later develop severe PAH outo f proportion to the degree of fibrosis. The patients have vasculopathy in addition to the fibrosis. The FVC:DLco ratio is > 1.8. Recently a multicenter study is being conducted by members of the Scleroderma Clinical Trials Consortium (Pulmonary Hypertension Assessment Registry of Scleroderma – PHAROS). The consortium’s website is http://www.sctc-online.org. PHAROS participation will give best way to contribute to really making a difference in scleroderma.

Radiation pneumonitis

Radiation pneumonitis (Murray)
beginning 3 to 8 weeks after initiation of radiation therapy and may rapidly progress to a fatal outcome in spite of institution of corticosteroids.
The chronic effects of radiation begin 3 to 6 months or later after radiation therapy.
Recently, a form of radiation pneumonitis has been observed outside the treatment fields, usually in patients with breast cancer.
Tissue examination has revealed bronchiolitis obliterans with organizing pneumonitis in these cases.

Organizing pneumonia

organizing pneumonia

1. Secondary Organizing Pneumonia: this is when an identified cause resulted in the pneumonia.
Pneumococcal PNA, atypical bacteria, viral infxns, fungi, parasites
Typically thought that the OP occurs after etiological agent gone and inflammation continues

2. Cryptogenic Organizing Pneumonia: Idiopathic

3. Bronchiolitis Obliterans Organizing Pneumonia: Granulation tissue is present in the bronchiolar lumen

Fissure

blue dotted lines–right and left major fissures (oblique fissures),
red line–minor fissure (horizontal fissure)

บุหรี่ม้วนเอง

Diffuse tiny nodule / Miliary

diffuse tiny nodules (less than 5 mm) other than TB

1. Miliary fungal disease (histoplasmosis, coccidioidomycosis, blastomycosis, cryptococcosis),
2. varicella pneumonia,
3. hematogenous metastatic malignancy (especially tumors of the thyroid, kidney, breast, and pancreas, and choriocarcinoma and melanoma),
4. bronchioloalveolar carcinoma,
5. lymphangitic tumor and lymphoma,
6. silicosis and other pneumoconioses, sarcoidosis, and eosinophilic granuloma [1].

Very rare causes include hemosiderosis, alveolar microlithiasis, amyloidosis, hypersensitivity pneumonia, nocardia, and bronchiolitis.

• Multiple, fine, pinpoint (< 2 mm.)
– จากการทํา lymphogram
– สูดสารบางชนิดเข้าปอด เช่น hair spray, talc, barium

• Small nodular (3-5 mm.)
– TB, Histoisplasmosis, coccidioidomycosis
– bone formation จาก mitral value disease
– chicken pox
– microlithiases
– Talc, iron, barium

• Soft tissue density (2-5 mm.)
– Miliary fungi
– Hemosiderosis
– miliary metastasis
– pneumoconiosis
– sarcoidosis
– acute extrinsic allergic alveolitis

Schistosomiasis

S. japonicum
found in Indonesia and parts of China and Southeast Asia
S. mekongi
found in Cambodia and Laos

Schistosomiasis is an important cause of disease in many parts of the world, most commonly in places with poor sanitation. School-age children who live in these areas are often most at risk because they tend to spend time swimming or bathing in water containing infectious cercariae.

Predictor pleurodesis failure

Prognostic factors of failed pleurodesis in malignant pleural effusion

PF pH<7.2
PF glucose<60mg/dl
Pleural elastance>19cm.H2O

The most important factor influencing the life expectancy in patients with malignant pleural effusion is the source of the tumor.
the median survival for gastrointestinal primaries = 2.3 Mo
for lung cancer = 3 Mo
for breast and unknown primary = 5 Mo
for mesothelioma = 6 Mo

Pleural fluid pH level < 7.20, a pleural fluid glucose < 60 mg/dL, or a pleural fluid LDH >2x UNL of serum are associated with poor prognosis but none of them really accurate at predicting survival.