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2 Pulm: COPD, Neopl

Step Up to Medicine, Chap 2: COPD, Lung Neoplasms

How is emphysema diagnosed? Pathologically: permanent enlargement of airspaces distal to terminal bronchioles due to destruction of alveolar walls
What is COPD's ranking in top causes of death in US? 4th leading cause
What role does tobacco smoke play in the pathophys of emphysema? Tobacco smoke increases the # of activated PMNs and macrophages which release lung-digesting elastase, inhibits alpha-1-antitrypsin which normally blocks elastase, and increases oxidative stress on the lungs via free radical production. Yuck!
MC type of emphysema? Centrilobular (seen in smokers). Destruction ltd to respiratory bronchioles (proximal acini). Little change in distal acini.
Centrilobular emphysema has a predilection for which lung zones? Upper
Which type of emphysema is more likely to be seen in pts with alpha-1-antitrypsin deficiency? Panlobular (makes sense)
Where does the destruction take place in panlobular emphysema? Which lung zones are most likely to be affected? Destruction involves both proximal and distal acini. Predilection for lung bases.
What must the TLC and FEV1 be in order to diagnose COPD? (general answer) Normal or increased TLC with a decreased FEV1
Do you typically see accessory muscle use in both types of COPD? No. Usually don't see it in bronchitis. More characteristic of emphysema.
Name 3 things that entail clinical monitoring of COPD pts? Serial FEV1 measurements, pulse ox, exercise tolerance
What is the most important intervention in COPD pts? Smoking cessation! (Improves survival rate, but does not decrease it to that of a non-smoker.)
Which medication commonly used in pts with heart disease is contraindicated in acute COPD or asthma exacerbations? Beta blockers
What is the best combo treatment for COPD? Beta agonist albuterol + ipratropium bromide (bronchodilators)
Are corticosteroids a mainstay of treatment in COPD? No. Reserved only for pts whose sx are not controlled by bronchodilators (beta agonist albuterol or ipratropium)
What is the mechanism of theophylline in COPD tx? May improve mucociliary clearance and central respiratory drive. Use is controversial.
What role does oxygen therapy play in the tx of COPD? Shown to improve survival and quality of life in pts with COPD and chronic hypoxemia. (controls pulmonary HTN which can lead to cor pulmonale)
2 major criteria for continuous or intermittent oxygen tx in COPDers? PaO2 <55 OR O2 sat <88% in the context of optimal medical therapy. Also PaO2 55-59 with polycythemia or cor pulmonale.
Vaccination needs for COPD? Influenza annually. Pneumovax (anti-strep pneumo) q5-6y
Define acute COPD exacerbation. Persistent increase in dyspnea not relieved with bronchodilators.
Corticosteroid use in acute COPD exacerbations? IV methylprednisolone-> taper with oral prednisone on clinical improvement. Do NOT use inhaled corticosteroids in an acute exac.
3 MCC of acute COPD exacerbations? INfection, non-compliance with meds, and cardiac disease
MC organisms in COPD pulmonary infections? Strep pneumo, H flu, mycoplasma pneumo, moraxella catarrhalis
Appropriate steps in management for pt presenting with acute COPD exac? 1. CXR 2. Beta 2 agonists and anticholinergic inhalers 3. Systemic coricosteroids (NOT inhaled!) 4. Abx 5. Non-invasive positive pressure ventilation if needed
Asthma triad? Airway inflammation, airway hyperresponsiveness, reversible airflow obstruction
Paradoxic movement of the abdomen and diaphragm on inspiration is sign of _________. Respiratory failure
Diagnostic FEV1/FVC ratio for asthma? <0.75
Definition of reversible airway obstruction? Increase of at least 12% in FEV1 or FVC after use of bronchodilators
Why is a high or normal PaCO2 level a bad sign in COPD/asthma pts? Normally, pt should be hyperventilating and thus have low PaCO2 levels. If they stop hyperventilating, it may be a sign that they are fatigued and decompensating. Intubation may be necessary.
Side effects of oral corticosteroids? Sore throat, oral candidiasis, and hoarseness
Asthma + nasal polyps. Association? Aspirin-sensitive asthma
Permanent, abnormal dilation and destruction of bronchial walls with damaged cilia. Bronchiectasis
Half of all bronchiectasis cases are caused by? CF
Sx of bronchiectasis? Chronic cough with large amts of mucopurulent, foul-smelling sputum. Dyspnea. Hemoptysis (ruptured BV near bronchial wall surfaces). Recurrent or persistent pneumonia.
Main goal in treating bronchiectasis? Preventing complications of hemoptysis and pneumonia.
Diagnostic study of choice in bronchiectasis? High resolution CT scan
Tx for bronchiectasis? Abx for acute exacerbation (changes in sputum, fever, CP), hydration, chest drainage & percussion, and inhaled bronchodilators
Complications of CF? Average age of death? Chronic pseudomonoas infections, pancreatic insufficiency, and other GI complications. 30yo.
MC type of lung cancer? Non-small cell (includes SCC, adenocarcinoma, large cell CA, and broncheoalveolar cell CA)
Lung cancer with lowest smoking assoc'n? Adenocarcinoma
Staging for small cell lung CA? Limited (confined to chest and supraclavicular nodes) vs Extensive (outside chest and supraclavicular nodes)
Staging for non-small cell lung CA? TNM system
Which lung cancers are usually centrally located? SCC (subset of non-small cell) and small cell lung CA
Which lung cancers are usually peripherally located? Adenocarcinoma and large cell carcinoma
In which type of lung cancer is cavitation seen on CXR? SCC
Which type of lung cancer can be associated with pulmonary fibrosis/scars? Adenocarcinoma
Which type of lung cancer tends to narrow bronchi by extrinsic compression and has characteristic wide-spread metastases? Small cell
Single well-circumscribed nodule seen on CXR with no assoc'd mediastinal or hilar LN involvement. Solitary pulmonary nodule
Management of solitary pulmonary nodule is suspicion of malignancy is high (pt >50yo and/or smoker)? Surgical resection. (Perform transthoracic needle aspiration biopsy or fiberoptic bronchoscopy to rule out malignancy if suspicion is intermediate or surgical risk is high.)
Management for pt with benign solitary pulmonary nodule? CXR or CT scan every few months initially--> every six months
Sign of benign solitary pulmonary nodule? Stable size for 2+ years (malignant ones grow rapidly within months)
SVC syndrome most commonly occurs with which type of lung cancer? Small cell
Findings in SVC syndrome? Facial fullness, facial and arm edema, dilated vv over anterior chest/arms/face, JVD
Pain, upper extremity wekaness due to brachial plexus invasion, Horner's syndrome. What kind of tumor? Pancoast's tumor; usually SCC
MC sites of lung cancer mets? Brain, bone, adrenal glands, liver
Name the lung neoplasm associated with the following paraneoplastic syndrome: SIADH small cell
Name the lung neoplasm associated with the following paraneoplastic syndrome: ectopic ACTH secretion small cell
Name the lung neoplasm associated with the following paraneoplastic syndrome: PTH secretion SCC
Name the lung neoplasm associated with the following paraneoplastic syndrome: hypertrophic pulmonary osteoarthropathy (severe long bone pain) Adenocarcinoma and SCC
Name the lung neoplasm associated with the following paraneoplastic syndrome: Eaton-Lambert (similar to myasthenia gravis presentation) small cell
Sputum cytology is only reliable for which type of lung neoplasm? Central tumors (unable to diagnose peripheral lesions)
What does a stippled or eccentric pattern of calcification indicate in a lung mass? malignancy (benign lesions tend to have a central laminated calcification)
What should you always do for intrathoracic lymphadenopathy? Perform a biopsy
Tx for non-small cell lung CA (SCC, adeno, large cell, bronchoalveolar)? Surgery. (Radiation as adjunct.)
Tx for small cell lung CA? Chemo. (Radiation and surgery not that useful.)
MCC mediastinal mass in older pts? Metastatic cancer, esp lung
Test of choice for mediastinal mass? Chest CT
Management of pt with asymptomatic mediastinal mass and a CT suggestive of benign lesion? Observation
Only reliable radiographic findings for a benign lung lesion? Lack of growth for at least 2 years and a distinctive central laminated calicification pattern
Created by: sarah3148



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