Baker/Parks: Smoking and Pleura

Question 1

Congenital anomaly

Caused by anything that impedes normal lung expansion in utero

Answer 1

Agenesis or hypoplasia of the lungs - one lung or single lobes

Question 2

Congenital anomaly

Abnormal detachment of primitive foregut

Answer 2

Foregut cyst

Question 3

Congenital anomaly
Lung tissue without connection to the airway system
Can be internal to lung or external to lung

Answer 3

Pulmonary sequestration

Question 4

Collapse of the lung
Loss of lunge volume caused by inadequate expansion of air spaces
Results in shunting of inadequately oxygenated blood from pulmonary arteries into veins

Answer 4

atelectasis

**three forms: resorption, compression, contraction

Question 5

This form of atelectasis occurs when an obstruction prevents air from reaching the distal airways. The air already present becomes absorbed and alveolar collapse follows.

Answer 5

resorption atelactasis

Question 6

What is the most common cause of resorption collapse of the lung?

Answer 6

obstruction of a bronchus by mucous or mucopurulent plug

**frequently occurs post operatively

Question 7

Pleural effusion can cause this type of atelectasis - build up of fluid, blood or air in the pleural cavity mechanically collapses the adjacent lung

Answer 7

Compression atelactasis

Question 8

Airless pulmonary parencyma
Can occur at birth, from incomplete expansion
Can be acquired

Answer 8

Atelectasis “collapsed lung”

Question 9

3 ways in which you can get “acquired” atelectasis?

Answer 9

1. resorption: airway obstruction leads to resorption of O2 within the alveoli (obstruction can be a mucous plug, a foreign body, or a neoplasm)
2. compression of pleural cavity with fluid, blood, or air
3. contraction from pulmonary fibrosis

Question 10

5 “W’s” that cause post-op fever

Answer 10

wind (pneumonia)
water (UTI)
wound (surgical site infection)
walking (DVT/PE)
wonder drugs (drug or other iatrogenic cause)

Question 11

Pleural space is a potential space with approximately (blank)mL of lubricating serous fluid

Answer 11

15

Question 12

Most pleural disease is secondary to some other condition

Biggest exception to this is (blank)

Answer 12

mesothelioma

Question 13

Any excess accumulation of pleural fluid
Can be symptomatic or asymptomatic
Variety of causes
Transudative vs. Exudative
Non-inflammatory vs. Inflammatory

Answer 13

pleural effusions

Question 14

What usually causes the transudative, non-inflammatory pleural effusions?

What usually causes the exudative, inflammatory pleural effusions?

Answer 14

hydrostatic mechanism: heart failure, renal failure, liver failure

infections, malignancies, immune responses, trauma

Question 15

What are these values/ratios, and what do they tell you about a patient’s pleural effusion?

ProteinF/ProteinS > 0.5
LDHF/LDHS > 0.6
Serum LDH > 2/3 of the upper limit of normal for serum

Answer 15

These values are called Light’s criteria. If you have any of these three criteria, you have an exudative effusion

Protein F = fluid protein
Protein S = serum protein
LDHF = pleural fluid LDH
LDHS = serum LDH

Question 16

Two types of inflammatory effusions

Answer 16

pleuritis: inflammation of the pleura

empyema

Question 17

Purulent pleural exudate
Typically loculated
Etiology
Usually contiguous spread (pneumonia), but can come from a distant source
Purulence can resolve completely, but also can organize and cause permanent respiratory restriction.

Answer 17

empyema

Question 18

If there is a clear/straw-colored effusion, often from cardiac failure or pulmonary edema, we call it a (blank).

If there is frank blood in the pleural space, typically from trauma or vascular rupture, we call it a (blank).

If there is a milky, lymphatic fluid in the pleural space, often from thoracic duct trauma or obstruction, we call it a (blank).

Answer 18

hydrothorax

hemothorax

chylothorax

Question 19

What things and disease processes can cause a pneumothorax?

Answer 19

most commonly - emphysema, asthma, TB

truama - perforating injury to the chest wall

spontaneous idiopathic pneumothorax in young people due to rupture of small peripheral blebs

Question 20

Progressive worsening of the pneumothorax

Often associated with mechanical ventilation - positive pressure

Answer 20

Tension pneumothorax

Question 21

How do you diagnose a tension pneumothorax?

Answer 21

clinically, NOT via radiograph
look for absence of breath sounds, hyper-resonance to percussion, contralateral deviation of the trachea/mediastinum

**if reduced cardiac output –> medical emergency

Question 22

This is used to decompress the chest when a patient is deteriorating because of a tension pneumothorax. Place in the 2nd intercostal space at the mid clavicular line.

Answer 22

needle thoracostomy

Question 23

Which type of pleural tumors are the most common?

Answer 23

mets!

usu from the lung and breast

**pleural effusion with positive cytology

Question 24

Uncommon
Asbestos-related in 90% of cases
7-10% lifetime risk in heavily exposed people
Risk is not worsened by smoking
Long (25-45 yrs) latent period
Metastatic spread to liver and other distant organs
50% death rate in 12 months, rare survival after 2 years
Not exclusive to pulmonary pleura
Peritoneum, pericardium
Peritoneal mesothelioma is particularly related to heavy exposure
50% have asbestosis coexisting asbestosis

Answer 24

Malignant mesothelioma

Question 25

How will malignant mesothelioma present?

Answer 25

chest pain
dyspnea
recurrent pleural effusions
20% have asbestosis

Question 26

Is the risk of malignant mesothelioma increased by smoking?

Answer 26

no!

Question 27

Disorder of ion transport in epithelial cells that affects fluid secretion in exocrine glands and the epithelial lining of the respiratory, GI and reproductive tracts.
Mutation in the CFTR gene
1 in 2500 live births

Answer 27

cystic fibrosis

Question 28

This is used to test for cystic fibrosis

Answer 28

chloride sweat test

**elevated sweat chloride in CF

Question 29

What are the most serious complications of cystic fibrosis?

Answer 29

viscous mucous leads to chronic infections and bronchiectasis
patients are often colonized by resistant organisms

Question 30

What organisms most commonly cause infection in CF patients?

Answer 30

Pseudomonas

Staph aureus

Question 31

Describe the trends in smoking over time

Answer 31

smoking gradually increased until like the 1970’s and then began to decline

Question 32

What was happening to rates of lung and bronchus cancer from 1930 - 2009?

Answer 32

steadily increasing!

Question 33

T/F: 90% of lung cancer in men is caused by smoking

78% of lung cancer in females is caused by smoking

Answer 33

True

Question 34

What happens over time after the cessation of smoking?

Answer 34

after 2-3 yrs, your risk for cardiac events approaches that of never-smokers

after 5 yrs, your risk for bladder, cervical, oral, and esophageal cancer decreases towards that of never-smokers

after 10 yrs, pancreatic cancer risk drops

after 15 yrs, risk of stroke drops

Question 35

What happens to your chronic cough when you quit smoking?

What happens to your SOB?

Answer 35

cough resolves or markedly improves in 94-100% of patients

SOB improves w/i 1-9 months

Question 36

T/F: Should begin before the doctor even enters the room
When office staff asks about and documents smoking status…
3x more likely that a physician will intervene.
2x more likely that the patient will quit.

Answer 36

True

Question 37

What are the five A’s for encouraging patients to quit smoking?

Answer 37

Ask about tobacco use
Advise to quit
Assess willingness to quit
Assist in quit attempt
Arrange a follow up

Question 38

What are the five R’s when encouraging a patient to quit smoking?

Answer 38

relevance of quitting
risks of smoking
rewards of quitting
roadblocks
repeat at every visit

Question 39

Physicians advice alone increases rates of smoking cessation by (blank)%

Answer 39

30