Exam 2 Flashcards
What is the initial study used for respiratory sxs and which view is preferred?
CXR, PA view preferred
If you note a Hampton hump on CXR, what should you be concerned about?
Pulmonary infarct
What is a c/i to CXR?
Pregnancy
What systematic approach should be used when reading a CXR?
A- airway B- bones C- cardiac silhouette & costophrenic angle D- diaphragms (free air) E- edges F- fields (infiltrates, nodules)
CT is equivalent to how many XRays with respect to radiation?
80
Which form of pulmonary dx imaging is used to clarify abnormal cxr, characterize pulm nodules, eval lung mets/ suspected masses?
CT
CT’s place beds at increased risk of what due to higher sensitivity?
Leukemia/ brain tumors
In utero exposure of radiation with CT’s of pregnant women is linked to what?
Peds CA mortality
Low dose CT’s are used for what?
Screening
What are the indications for iodine contrast w/ CT?
Vessels, malignancy chest trauma
Patients should be pretreated with what due to possibility of iodine allergic rxn w/ CT?
Prednisone and diphenhydramine (Benadryl)
When does CIN occur/ peak?
Occurs @ 24-48 hrs post exposure
Peaks @ 3-5 days
If you note an increased serum creatinine >/= 0.5 mg/dL or >/= 25% from baseline following an iodine contrast CT, what should you be concerned about?
Contrast induced nephropathy (CIN)
When should you check kidney fxn prior to an iodine contrast CT due to concerns of CIN?
> 60 yo, hx of renal disease/ HTN/ DM, taking Metformin
What is the dx imaging of choice for pulmonary vasculature?
CT pulmonary angiography (CTPA)
What is the gold standard for PE eval?
Catheter directed pulmonary angiography (“direct”)
What pulmonary imaging is useful if V/Q scan or CTPA is inconclusive, but there is a high clinical suspicion for PE?
Catheter directed pulmonary angiography
What pulmonary imaging has the following associated risks?
Bleeding @ insertion site, arrhythmia, allergic rxn to contrast, CIN
Catheter directed pulmonary angiography
What pulmonary imaging is best if there is a normal CXR and high suspicion for PE?
V/Q scan
What is the pulmonary imaging test of choice for dx in pregnant women?
V/Q scan
What pulmonary imaging is used to detect cancer?
PET scan
What pulmonary imaging involves detection of radiation from fluorodeoxyglucose (FDG)?
PET scan
A PET scan is better than CT for mediastinal imaging due to the fact that you can ID a tumor in what?
Normal sized lymph nodes
When should an MRI/ MRA be avoided, due to use of Gadolinium contrast dye, and why?
Avoid if GFR < 30 mL/min, possibility of nephrotic systemic fibrosis
What are the specific risks associated with taking a bx with bronchoscopy?
Bleeding, bronchial perforation, pneumothorax
Should airflow spirometry be performed sitting or standing?
Sitting (prevents syncope)
Is FEV-1 most useful for obstruction or restriction?
Obstruction
What value defines the severity of obstruction and assists in differentiating between obstructive and restrictive diseases?
FEV-1: FVC ratio (< 0.7 = obstructive)
What value measures the airflow during the middle 1/2 of forced expiration?
FEF-25-75%
What value is non-specific for airway obstruction but may be an early indicator of disease?
FEF-25-75%
What is considered + on a reversibility testing for bronchodilation?
FEV-1 increases by 12% and 200mL
In which test do you give a dilute bronchoconstrictor at increased concentrations via a nebulizer at 30 and 90 seconds and test FEV1?
Bronchoprovocation (methacholine challenge)
Med = dilute methacholine
What is considered a + on the bronchoprovocation (methacholine challenge) test?
FEV1 decreases by 20%
In obstructive diseases, do you have normal inspiration or expiration?
Inspiration N (but decreased expiration)
In restrictive diseases, do you have normal inspiration or expiration?
Expiration N (but difficulty expanding lungs during inhalation)
What value measures the ability of the lungs to transfer gas and saturate Hgb, and when can it be misleading?
Diffusion capacity of lungs for CO (DLCO)
Misleading if anemic due to false reduction
If lungs are healthy, what will a DLCO show?
Little CO collected during exhalation
If lungs are diseased, what will a DLCO show?
Less CO diffused into lungs = higher levels measured in exhaled gas
What will the following values show for an obstructive lung disease?
TLC, FVC, RV, FEV1, FEV1/ FVC
TLC- inc FVC- N RV- inc FEV1- dec FEV1/ FVC- dec
What will the following values show for an restrictive lung disease?
TLC, FVC, RV, FEV1, FEV1/ FVC
TLC- dec FVC- dec RV- dec FEV1- dec FEV1/ FVC- N/ inc
What are the 5 steps of PFT interpretation?
Examine:
- flow-volume curve
- FEV-1 value
- FEV-1/ FVC ratio
- response to bronchodilator
- DLCO
Will the flow-volume curve be scooped out or peaked with an obstructive lung disease?
Scooped out
What two guidelines classify asthma?
NAEPP and GINA
What are the primary sxs of asthma?
Coughing (nocturnal), > 3 weeks
Wheezing (hallmark)
What disease is characterized by tripod positioning, accessory muscle use, pulsus paradoxus, and tachypnea/cardia?
Asthma
What will the diagnostic values of FEV1, FEV1/FVC and reversibility be for asthma?
FEV1: < 80%
FEV1/FVC: N (70-85%)
Reversibility: > 12% w/ FEV1 bronchodilator
What makes up ASA triad/ Samter’s triad?
- sinus disease w/ nasal polyps
- ASA sensitivity
- severe asthma
What is made up of atopic derm, allergic rhinitis, and asthma?
Atopic triad
What is made up of atopic derm, food allergy, allergic rhinitis, and asthma?
Atopic march
What test is used to confirm a dx of asthma?
Spirometry
In regards to asthma classification, which steps are considered intermittent?
Step 1
In regards to asthma classification, which steps are considered persistent?
Steps 2-4
If a patient presents with hx of asthma sxs ≤ 2 days/ week and nighttime awakenings ≤ 2 nights/ month (≥ 5 yo) which step of asthma classification would they be?
Step 1
If a patient presents with hx of asthma sxs > 2 days/ week and nighttime awakenings 1-2x/ month (0-4 yo)/ 3-4x/ month (≥ 5 yo), which step of asthma classification would they be?
Step 2
If a patient presents with hx of asthma sxs daily and nighttime awakenings 3-4x/ month (0-4 yo)/ >1x/ week (≥ 5 yo), which step of asthma classification would they be?
Step 3
If a patient presents with hx of asthma sxs throughout the day and nighttime awakenings >1x/ week (0-4 yo)/ nightly (≥ 5 yo), which step of asthma classification would they be?
Step 4
What will the FEV1 value be for steps 1-4 of asthma?
Step 1: > 80%
Step 2: > 80%
Step 3: 60-80%
Step 4: < 60%
For which steps of asthma classification will the FEV1/ FVC ratio be decreased by 5%?
Steps 3-4
What is the treatment for Step 1 asthma?
SABA prn
What is the treatment for Step 2 (mild) asthma?
Low dose daily ICS
OR
LTRA/ Cromlyn (kids that don’t want steroid)
What is the treatment for Step 3 (moderate) asthma?
- Consider specialist referral
- Medium dose ICS (0-4 to)
OR - Low dose ICS + LABA (≥ 5yo) or LTRA
What is the treatment for Step 4 (severe) asthma?
- Refer to specialist
- Medium dose ICS & LABA (or LTRA 0-4 yo)
OR - Medium dose ICS + LTRA
What is the treatment for Step 5 asthma?
High dose ICS/ LABA (or LTRA if 0-4 yo)
What is the treatment for Step 6 asthma?
High dose ICS/ LABA (or LTRA if 0-4 yo) + oral steroids
When should you consider adding Omalizumab (Xolair) with steps 5-6 asthma?
If ≥ 12 yo with allergies
When would Theophyline with use of ICS be used in the treatment of asthma steps 5-6, and why is this a less attractive alternative?
> 5 yo
Serum levels must be monitored closely
What is the rule of 2’s and what disease does it pertain to?
Asthma
- Sx ≥ 2x/ week
- Awaken w/ asthma sx ≥ 2x/month
- Refill SABA ≥ 2x/ yr
- Peak flow meter measures 20% from baseline ≤2x
If results of a peak flow meter show green, what does this indicate?
> 80%, good control
If results of a peak flow meter show yellow, what does this indicate?
50-80%, caution- SABA + med change
If results of a peak flow meter show red, what does this indicate?
<50%, medical alert/ emergency tx
If a pt shows the following, how well controlled is their asthma?
- Sx frequency/ SABA use: ≤ 2x/ week
- Nighttime awakenings (0-11 yo): ≤ 1x/ month
- Nighttime awakenings (≥ 12 yo): ≤ 2x/ month
- FEV1: > 80%
- FEV1/ FVC: > 80%
Well controlled
If a pt shows the following, how well controlled is their asthma?
- Sx frequency/ SABA use: ≥ 2 days/ week
- Nighttime awakenings (0-4 yo): 1x/ month
- Nighttime awakenings (0-11 yo): ≥ 2x/ month
- Nighttime awakenings (≥ 12 yo): 1-3x/ week
- FEV1: 60-80%
- FEV1/ FVC: 75-80% (5-11 yo)
Not well controlled
If a pt shows the following, how well controlled is their asthma?
- Sx frequency/ SABA use: daily
- Nighttime awakenings (0-4 yo): 1x/ week
- Nighttime awakenings (0-11 yo): ≥ 2x/ week
- Nighttime awakenings (≥ 12 yo): ≥ 4x/ week
- FEV1: < 60%
- FEV1/ FVC: < 75% (5-11 yo)
Very poorly controlled
What is the tx for exacerbation of asthma?
- O2
- SABA/ SVN- Albuterol or Xopenex +/- Ipratropium bromide → repeat PEF, SVN repeated or continuous
- Systemic corticosteroids- prednisolone ~ 1 mg/kg/day w/ max dose based on weight
What role should abx and resp monitoring be considered in the tx of asthma exacerbation?
Abx prn
Resp monitoring if in ED/ inpatient, severe = C-PAP, BiPAP, intubation
How soon should a pt with asthma exacerbation f/u?
Within 1 week
Small airway disease –> ?
Obstructive chronic bronchitis
Blue bloater (hypoxemia, cyanosis, cor polmonale, weight gain) are associated w/ what disease?
Obstructive chronic bronchitis
Infiltration of the submucosal layer by neutrophils is associated w/ what disease?
Obstructive chronic bronchitis
Presence of dry cough and sputum production for 3+ months in 2 consecutive years is what?
Obstructive chronic bronchitis
Pink puffer (hypercapnia, weight loss, muscle wasting)
Emphysema
Parenchyma disease –>
Emphysema
Destruction of alveolar walls and reduced alveolar surface area available for gas exchange is associated w/ what disease?
Emphysema
Most common early finding ing COPD?
Dyspnea on exertion
Last COPD presentation?
Dyspnea, chronic cough, sputum production present at rest
Host risk factor for COPD? (3)
- a1-antitrypsin deficiency (AATD)
- asthma
- childhood respiratory infections
Tripod positioning, accessory muscle use, and pursed lip breathing are associated w/ what disease?
COPD
AP diameter increases or decreases w/ COPD?
Increases
Irreversibly after bronchodilator use is consistent w/ what disease?
COPD
FEV1/FVC < 70% indicates restrictive or obstructive disease?
Obstructive
Gold classes for COPD?
I. ≥80%
II. 50-80%
III. 30-50%
IV. <30%
TX goals for COPD? (4)
- Prevent progression (smoking cessation)
- Relieve sx/improve exercise tolerance
- Manage/prevent acute exacerbations
- Reduce mortality
Supplemental O2 sat for long term COPD tx?
88-92%
TX for COPD exacerbation?
SABA +/- SAMA
Prednisone 40 mg QD x 5 days
Mod-severe = + ABX 5-7 days Sever = +/- hospitalization
TX for class A COPD?
SABA PRN
TX for class B COPD?
SABA + LAMA/LABA
TX for class C COPD?
SABA + LAMA
TX for class D COPD?
SABA + LAMA (or LABA/LAMA if severe)
S3 gallop, RVH, hepatomegaly, and peripheral edema are consistent w/ what disease?
Cor Pulmonale
Bleds/bullae are pathognomic for?
Emphysema
Is CT needed for routine COPD dx?
No
Acute changes in baseline dyspnea, cough, sputum that warrant a change is therapy is considered what?
Acute COPD exacerbation
SE of B2 bronchodilators?
Palpitations, tachycardia, insomnia, tremors
Albuterol is falls under what drug classification?
SABA (B2)
Salmeterol and Formoterol are what type of B2 agonists?
LABA
Dry mouth, metallic taste, HA and cough are SEs of what drug class?
Anticholinergics
Atrovent and Combivent are SABA or LABA anticholinergics?
SABA
Spirival and Incruse Ellipta are SABA or LABA anticholinergics?
LABA
Oral candidiasis and bruising are SEs of what meds?
LABA + ICS
Advair and Symbicort are fall under waht drug class?
LABA + ICS
What deficiency requires tx w/ antiprotease therapy?
a-1 antitrypsin (serum level < 11 micromol/L)
ABCD assessment tool combines what tools? (4)
- GOLD
- Modified British Medical Research Council (mMRC)
- COPD assessment tool (CAT)
- Exacerbation hx
Prior hospitalization for COPD exacerbation is predictive of what? (2)
Poor prognosis, ↑ risk of death
Grad A associated w/ (sx, risk)?
↓ sx, ↓ risk
Grad B associated w/ (sx, risk)?
↑ sx, ↓ risk
Grad C associated w/ (sx, risk)?
↓ sx, ↑ risk
Grad D associated w/ (sx, risk)?
↑ sx, ↑ risk
Cough >5 days is consistent w/ what dx?
Acute bronchitis
Acute bronchitis more commonly due to viral or bacterial pathogens?
Viral (90%)
Bacterial agent that causes acute bronchitis?
Bordetella pertussis
Ronchi > w/ expiration is consistent w/ what dx?
Acute bronchitis
First line TX for acute bronchitis?
Reassurance and edu on expected course
When are ABX used to tx acute bronchitis?
Pertussis ONLY
Cough ≥ 3 months for 2 consecutive years is consistent w/ what dx?
Chronic bronchitis
Gold standard diagnostic for pertussis?
Bacterial culture nasopharyngea secretions
Catarrhal, paroxysmal and convalescent are 3 phases of what disease?
Bordetella pertussis
Whooping cough is consistent w/ what disease?
Bordetella pertussis
When is serology used to dx pertussis?
Later stage of disease (2-8 weeks from cough onset)
Abx tx for what disease will ↓ transmission but have little effect on sx?
Bordetella pertussis
Is Bordetella pertussis a reportable disease?
Yes
ABX Tx for Bordetella pertussis in adults?
Macrolide: Azithro, clarithro or erythro
Bactrim if macrolide not tolerated
Fever, HA, myalgia and malaise are consistent with what disease?
Influenza
Viral culture, RIDT or PT-PCR is confirmatory dx for influenza?
Viral culture
Timeline to give antiviral treatment for influenza?
onset-48 hrs
If negative RIDT, but high clinical suspicion can you make dx clinically?
Yes
Acute onset fever and cough w/ crackles is consistent w/ what disease?
CAP
Aspirations from oropharynx is most common form of transmission for CAP, HAP or VAP?
CAP
CXR shoes infiltrate on plane films. This gold standard dx for what?
CAP
CURB-65 is used in the dx of HAP, VAP, or CAP?
CAP
What is CURB-65?
Confusion Urea > 7 mmol/L & BUN ≥ 20 mg/dl RR ≥ 30 b/min BP <90/60 > 65 yrs
2 requirements to dx uncomplicated CAP?
- Previously healthy
2. No ABX use in last 3 months
TX for outpatient CAP? (3)
- ABX ≥ 5 days
- Reassurance (resolution of fever in 3 days and 14 days for cough/fatigue)
- CXR f/u 7-12 wks post tx only in pt >40yrs or smokers
TX for uncomplicated CAP?
Azithromycin 500 mg x 1 day, 250 mg x 4 days
OR
Doxycycline 100 mg BID x 7-10 days
2 requirements to dx complicated CAP?
- Recent ABX use
2. HX of COPD, CA, DM, drug abuse, IMC
Tx for complicated CAP?
Bactrim or Levofloxacin 750 mg QD x 5 days
Most common pathogen of sx based pneumonia?
S. pneumoniae
Rare cause of CAP, especially in IMC pts?
Fungal infection
Is sputum cx definitive dx for CAP?
No, no proof of etiologic agent (not recommend for outpatient)
TX for CURB 65 score of 2
Hospitalization
TX for CURB 65 score of 3-5?
ICU
TX for CURB 65 score of 0-1?
Outpatient
CAP prevention measures (2)?
- Smoking cessation
2. Vaccines
Pneumonia onset 48+ post admission is CAP, HAP, or VAP?
HAP
New or progressive infiltrate and 2+ (fever, purulent sputum, leukocytosis) is dx for what forms of pneumonia?
HAP/VAP
First line tx for HAP & VAP?
Prevention + ABX
Non-resolving pneumonia is concerning for what? (5)
Atypical infection, aspirations, CHF, CA, fibrosis
Pneumonia associated w/ HIV and low CD4?
Pneumocystic Jirovecii Pneumonia (PCP)
CXR w/ reticular, ground glass opacities is concerning for?
Pneumocystic Jirovecii Pneumonia (PCP)
TX for Pneumocystic Jirovecii Pneumonia (PCP)?
Bactrim
When would you tx prophylactically for PCP?
HIV+ or high risk pt
Displacement of gastric contents into the lung is concerning for?
Aspiration pneumonia
RLL infiltrates is most commonly associated with what type of pneumonia?
Apspiration pneumonia
RLL infiltrates is most commonly associated with what type of pneumonia?
Apspiration pneumonia
Interstitial lung disease is also known as?
Diffuse parenchymal lung disease (DPLD)
ILD is generally reversible or irreversible?
Irreversible
Most common cause of IDL?
Idiopathic
Fibrosis and adherent scarring is pathophys. associated with what disease?
ILD
Progressive DOE and persistent non producrtive cough are consistent with what disease?
ILD
ON exam you hear velcro like crackles in the bilateral lung bases and notice digital clubbing what DX are you concerned for?
ILD
Ground glass appearance and reticular net like pattern on CXR is an early finding what disease?
ILD
Honeycombing is indicative of a good or poor prognosis for ILD?
Poor
Why is HRCT used in dx of ILD?
Increased accuracy
If PFTs show low DLCO, what disease are you concerned about?
ILD
Hypoxemia and respiratory alkalosis on ABG are consistent with what lung disease?
ILD
What is the gold standard for dx of ILD?
Lung biopsy
What CXR finding is a C/I for lung biopsy in ILD?
Honeycombing
Inhalation related diseases (except asbestosis) will appear in the upper or low zones on HRCT?
Upper
IPF, connective tissue disease, and asbestosis will appear in the upper or low zones on HRCT?
Lower
All PFTS (TLC, FVC, FEV1, FRC and RV) are decreased with what type of lung disease?
Restrictive
ILD PFTs are most consistent with restrictive or obstructive defect?
Restrictive
Transbronchial bx is used for central or peripheral locations?
Central
Surgical bx is used for larger or smaller sample sizes?
Largers
What bx technique do you use is sarcoid is suspected?
Endobronchial US guided transbronchial needle aspiration (EBUS-TBNA)
What is the most common interstitial lung disease?
Idiopathic pulmonary fibrosis
Peripheral reticular opacities an honeycombing on CXR are dx for what disease?
IPF
HRCT shows bibasilar reticulonodular opacities, traction, and bronchiectasis what disease are you concerned for?
Idiopathic pulmonary fibrosis
When treating IPF what disease must you also treat?
GERD
Pirfenidone is used in the tx of what disease?
IPF
Non-caseating granulomas secrete what enzyme?
ACE
Non-caseating granulomas are associated with what disease?
Sarcoidosis
CXR shows hilar adenopathy and labs show increased ACE what disease are you concerned for?
Sarcoidosis
Lung disease caused by inhalation/deposition of mineral dust
Pneumoconiosis
Black lung is synonymous with?
Coal worker’s pneumoconiosis
The fibronodular disease characterized by the inhalation of silica dust form occupational hazards is what?
Silicosis
What would you expect to see on HRCT for acute silicosis?
Crazy paving pattern
Digital clubbing is common or uncommon with pneumoconiosis?
Uncommon
PFTs for pneumoconiosis will be restrictive or obstructive?
Restrictive
Repeat CXR after the exposure to silica dust has been removed will show the same size or enlarging opacities?
Enlarging
Corticosteroids are used to treat chronic or acute pneumoconiosis?
Acute
What specific therapy, if any will alter the disease course for pneumoconiosis?
None
Chronic simple pneumoconiosis is classified by how many years of exposure?
> 10-12 yrs
Chronic simple pneumoconiosis is progressive or non-progressive once exposure is eliminated?
Non-progressive
Chronic complicated pneumoconiosis is defined as what?
> 20 yrs exposure, progressive even after exposure is eliminated
CXR show’s “angle wings” what disease are you concerned for?
Chronic complicated pneumoconiosis
What occupation exposure has a strong associated with mesothelioma?
Asbestosis
What findings should you expect to see on CXR for pt with chronic inhalation of asbestos? (2)
- Opacities in lower lungs
2. Pleural plaques
Open lung bx is the definitive treat for what disease, even though it is not usually indicated?
Asbestosis
PFTS for asbestosis are restrictive or obstructive pattern?
Restrictive
Will immunotherapy and/or steroids alter the disease course for Asbestosis?
No
Inflammatory syndrome due to repetitive inhalation of antigens is what?
Hypersensitivity Pneumonitis (HSP)
First line tx for HSP?
Antigen avoidance & proper prevention techniques
Is HSP reversible?
Yes, remove antigen
Immune mediated systemic vasculitis is what?
Graulomatosis w/ Polyangitis (GPA)
Necrotic blistering purpura, saddle nose deformity, and pulmonary infiltrates are concerning for what disease?
Graulomatosis w/ Polyangitis (GPA)
Stellate shaped peripheral pulmonary arteries on CT chest is concerning for what disease?
Graulomatosis w/ Polyangitis (GPA)
Labs reveal elevates ESR and CCRP with + C-ANCA what disease are you concerned about?
Graulomatosis w/ Polyangitis (GPA)
What is the initial tx for Graulomatosis w/ Polyangitis (GPA)?
Cyclophosphamide (immunosuppressant) + corticosteroid
SX of Cyclophosphamide toxicity
Cardiac, hematologic, renal, GI
What labs might you consider for dx Graulomatosis w/ Polyangitis (GPA)?
ANA, RF
What is the tx for radiation induced ILD?
Steroids
What is the tx for drug induced ILD?
Remove offending drug
Pulmonary langerhans cell histiocytosis is a manifestation to what form of ILD?
Smoking ILD
What is the biggest RF for getting lung cancer?
Smoking
Generally speaking, primary lesions, intrathoracic spread, paraneoplastic syndromes, and metastasis lead to lung cancer being what?
Symptomatic
What are the most common sites of distant mets from lung cancer?
Liver (50%), bone, adrenal glands, brain
What is needed for the dx of lung cancer?
Tissue biopsy
What type of lesions are best evaluated for by sputum culture?
Central lesions
What imaging is used to aid in the dx of lung cancer via short lived radioactive isotopes?
PET
What causes cancer cells to “light up” in a PET scan?
Metabolically active cells accumulate FDG
If a patient w/ lung cancer has no ADL restrictions, what would their performance status be?
0
If a patient w/ lung cancer has restricted ability to perform strenuous physical activity, what would their performance status be?
1
If a patient w/ lung cancer is capable of all self care and ambulatory for > 50% of walking hours but unable to carry out work activities, what would their performance status be?
2
If a patient w/ lung cancer is capable of only limited self care, confirmed to a bed/ chair > 50% of walking hours, what would their performance status be?
3
If a patient w/ lung cancer is completely disabled (cannot carry out any self care, totally bed/ chair confined), what would their performance status be?
4
With regards to performance status, if FEV1 < 60%, what is this a strong indicator of?
Post op complications
N/V, anorexia, weight loss, hematologic toxicity, nephrotoxicity, neurotoxicity, and fatigue are all sxs of what systemic lung cancer therapy?
Cytotoxic chemotherapy
What is the 5 yr survival rate for limited SCLC?
10-13%
Medial survival = 15-20 mos
What is the 5 yr survival rate for extensive SCLC?
1-2%
Median survival = 8-13 mos
What is the 5 yr survival rate for NSCLC?
15% (all stages combined)
In screening for lung cancer, a LDCT (low-dose CT) should be performed in what cases?
High risk =
Current smokers 55-74 yo w/ 30 pack yr hx
Quit smoking w/i 15 yrs
20 pack yr hx w/ 1 additional RF (not second hand smoke)
What is the primary tx for smoking cessation?
Zyban (stop smoking in 5-7 days)
What is the MOA for Zyban? (smoking cessation)
Inhibits neuronal uptake of NE and dopamine
What does Zyban have a black box warning?
Increased risk of SI in children, adolescents, YA
Besides Zyban, what are the possible txs for smoking cessation?
Chantix, (OTC) nicotine replacement
A coin lesion is aka what?
Solitary pulmonary nodule (SPN)
<3cm, well defined, not associated w/ infiltrate/ atelectasis/ adenopathy, and most are benign describes what?
Solitary pulmonary nodule (SPN)
A SPN w/ minimal growth in 2 yrs, calcifications, and smooth, well-defined edges is most likely benign or malignant?
Benign
A SPN w/ doubling in 20-400 days, no calcification, poor defined, irregular, and spiculated is most likely benign or malignant?
Malignant
What is the primary cause of SPN’s in AZ?
Cocci
What is the preferred imaging for nodal eval?
Helical CT of chest w/o contrast, low dose radiation
If a solid nodule is ≤ 6mm, what is the f/u procedure?
Do not usually require f/u
+/- CT at 12 mos
Individualized care
If a solid nodule is 6-8mm, what is the f/u procedure?
F/u w/ CT at 6-12 mos
Repeat as indicated
What is the eval procedure for a solid nodule > 8mm with a low probability (< 5%) of malignancy?
No growth?
Growth?
Get CT @ 3 mos
No growth = serial CT @ 9-12 and 18-24 mos
Growth = pathologic eval
What is the eval procedure for a solid nodule > 8mm with an intermediate probability (5-65%) of malignancy?
FDG PET/ CT and/ or bx
What is the eval procedure for a solid nodule > 8mm with an intermediate probability (5-65%) of malignancy and FDG avid?
Biopsy/ excision
What is the eval procedure for a solid nodule > 8mm with an intermediate probability (5-65%) of malignancy and PET/CT unavailable, negative, or indeterminate?
Individualized management based on clinical suspicion
For a solid nodule > 8mm with an intermediate probability (5-65%) of malignancy, what is an acceptable alternative to bx?
CT surveillance at 3, 9-12, and 18-24 mos?
What is the eval procedure for a solid nodule > 8mm with an intermediate probability (>65%) of malignancy?
Biopsy/ excision
+/- staging w/ PET/CT
If evaluation of a SPN shows:
- New/ enlarging/ indeterminate lesion
- Lesion > 3cm, unstable, non-calcified, irregular/ spiculated, what should you do?
Refer
A solid pulmonary mass (SPM) is what size?
> 3cm
Small cell lung cancers are aka what?
Oat cell carcinoma
What type of lung cancer is more commonly seen in central airways and is highly aggressive, rapid double times, and early mets?
SCLC
Sxs of cough, dyspnea, weight loss, and debility are most commonly associated with what type of lung cancer?
SCLC
If upon imaging you see a large hilar mass w/ bulky mediastinal adenopathy, what should you be concerned about?
SCLC
What type of lung cancer is associated w/ SVC, SIADH, Cushing’s, and Eaton-Lambert syndromes?
SCLC
If a SCLC tumor affects ipsilateral hemithorax, what is it staged at?
Limited disease (less common)
If a SCLC tumor extends beyond hemithorax and includes pleural effusions, what is it staged at?
Extensive disease (more common)
What are the 3 types of NSCLC?
Which is the most common?
Adenocarcinoma (most common)
Squamous cell
Large cell
Which type of lung cancer affects the mucous glands/ epithelial cells in or distal to the terminal bronchioles?
NSCLC - Adenocarcinoma
If a pt presents with peripheral nodules/ masses, thrombophlebitis, clubbing, and a hx of smoking, what should you be concerned for?
NSCLC - Adenocarcinoma
If a pt presents with evidence of cancer centrally/ in the main bronchus that extends into the main hilum and mediastinum, what should you be concerned for?
NSCLC - squamous cell
If a pt presents with slower growing/ late mets, sxs of cough, hemoptysis (& PTH/ hypercalcemia), what should you be concerned for?
NSCLC - squamous cell
What will be seen on CXR of a pt with NSCLC - squamous cell?
Cavitations
Which type of cancer is associated w/ central or peripheral masses, aggressive/ rapid doubling time, and is primarily a dx of exclusion?
NSCLC - large cell
What is the TNM staging?
T- primary tumor
N- nodal involvement
M- distant metastases
What is the treatment of choice for localized lung cancers?
Surgical resection
What is the tx for lung cancer stage I-IIIa with adequate pulmonary fxn?
Surgery
What is the tx for lung cancer stage IIIb-IV?
Palliative radiation or combo chemo
What is the 5 yr survival rate for stage 1 lung cancer?
75%
What is the 5 yr survival rate for stage 2 lung cancer? (advanced primary tumors/ mets to ipsilateral nodes)
40%
What is the 5 yr survival rate for stage 3 lung cancer?
17%
What is the 5 yr survival rate for stage 4 lung cancer?
<1%
What is the tx for stage 4 lung cancer?
Palliative
Targeted therapy- EGFR inhibitors
Pleural effusion, pericardial effusion, and hoarseness are concerning for what with regards to lung cancer?
Intrathoracic spread
What are the 3 types of intrathoracic spread?
SVC syndrome
Pancoast syndrome
Paraneoplastic syndrome
What type of intrathoracic spread is due to compression or direct invasion and shows a pathologic process from the right lung > lymph nodes > other mediastinal structures?
SVC syndrome
What is the most common cause of SVC syndrome?
Intrathoracic malignancy/ NSCLC
If a pt presents w/ the following sxs, what should you be concerned about?
- Dyspnea
- Facial swelling/ head fullness
- Dilated neck veins
- Prominent venous pattern on chest
- Arm swelling, cough, chest pain, dysphagia
SVC syndrome
What is the gold standard for dx of SVC syndrome?
Superior vena cavogram (id obstruction, extent of thrombus formation)
What is the initial study for sx of SVC syndrome with indwelling devices/ arm swelling?
Duplex US
What is the tx for SVC syndrome if there is stridor from central airway obstruction, laryngeal edema, or coma from cerebral edema?
Emergency radiation therapy
What type of intrathoracic spread is caused by a tumor involving the superior sulcus causing compression of the brachial plexus and cervical sympathetic nerves?
Pancoast syndrome
What is the most common cause of Pancoast syndrome?
NSCLC - squamous cell
If a pt presents with rib destruction, atrophy of hand muscles, and pain in the C8, T1, and T2 nerve roots on the same side of the tumor, what should you be concerned about?
Pancoast syndrome
If a pt presents with pain greatest closer to the tumor site that radiates down the R shoulder + finger pain, what should you be concerned about?
Pancoast syndrome
Injury of the sympathetic nerves of the face, causing mitosis, anhidrosis/ lack of sweating, and ptosis describes what?
What is it associated with?
Horner’s syndrome
Associated w/ Pancoast syndrome
What type of intrathoracic spread is triggered by altered immune response to a neoplasm?
Paraneoplastic syndromes
A lung cancer pt presents w/ anorexia, weight loss, cachexia, and suppressed immunity… what should you be concerned about?
Paraneoplastic syndromes
Can paraneoplastic syndromes be treated?
Can reduce effects but may be temporary
What 3 organ systems are likely to be affected with paraneoplastic syndromes?
Hematologic, endocrine, neurologic
What neurologic effect of paraneoplastic syndromes is immune mediated, AB at NMJ leading to decreased DTRs, and what type of cancer is it greatest with?
Eaton-Lambert
> small cell
What endocrine effect of paraneoplastic syndromes is associated w/ hypercalcemia and is greatest in SC NCLC?
PTH like substance
What endocrine effect of paraneoplastic syndromes is associated w/ gynecomastia and milky nipple discharge and is greatest in LC NCLC?
Excess HCG
What endocrine effect of paraneoplastic syndromes is associated w/ personality changes, confusion, coma, and respiratory arrest and is greatest in SCLC?
SIADH
What endocrine effect of paraneoplastic syndromes is associated w/ ectopic ACTH, muscle weakness, weight loss, and hirsutism and is greatest in SCLC?
Cushing’s syndrome
Where in the body does TB present itself?
Lung –> lymph node, kidney’s, spine and brain
How is TB transmitted?
Airborne droplet nuclei –> into alveoli
Is prolonged exposure required for transmission of TB?
Yes
What form of TB must a pt have to spread disease?
Active
Is a pt has latent TB, will they present with sx?
no
Are latent TB pt’s able to transmit TB infection?
No
Is active or latent TB more common?
Latent
When would latent TB become active?
If becomes IMC (unable to fight infection, granulomas breakdown)
What pt population is at the highest risk for for active BT infection/
HIV
If pt is TB positive, could this be the first indication that they are also HIV positive?
Yes
Within what time frame do you need to report TB dx?
24 hrs
What are the 3 primary sx of TB?
- Cough >3+ wks
- Fever
- Pleuritic/retrosternal chest pain
Primary finding on PE for TB?
Posttussive crackles
Also dullness/decreased fremitus & clubbing if severe
Imaging study for sx TB or if positive infection testing?
CXR (will r/o TB disease if negative)
If you notice cavitary lesions and infiltrate, +/- milliary pattern on CXR is this initial presentation of TB, latent TB, or reactivation of latent TB?
Reactivation
Initial = hilar lymphadenopathy Latent = dense nodules
Due to fact that TB is obligate aerobe where would you expect to find abnormalities on CXR?
Apical/posterior upper lobes
Is you notice Gohn lesions and ipsilateral calcified hilar lymph nodes on CXR, what is this concerning for?
Ranke complex.
Do you measure induration or erythema on TB skin test (TST)?
Induration
Within what time frame should you measure TST?
48-72 hours
True or false: TST might be negative 2-8 wks following exposure?
True
If pt w/ hx of BCG vaccine, what DX test might produce false positive?
TST
TST induration is ≥ 5mm. Who is this a positive test for?
Anyone even w/o TB RF’s
TST induration is ≥ 5mm. What populations is this a positive test for? (5)
- HIV +
- Recent contacts w/ active TB pt
- Evidence of TB on CXR
- IMC (chronic steroids)
- Organ transplant
TST induration is ≥ 10mm. What populations is this a positive test for? (8)
- ≥ 10mm
- Recent immigrants from countries w/ high TB infection rates
- HIV - injection drug users
- Mycobacteriology lab personnel
- Residents/ employees of high risk congregate settings
- High risk medical conditions
- Children < 4 yo
- Children/ adolescents exposed to adults @ high risk
IGRA: QuantiFeron TB Gold and T-Spot TB measures what in the blood?
The immune responce to TB (IFN-g concentration)
What test is used to test for latent TB disease if you received BCG vaccine?
IGRA: QuantiFeron TB Gold and T-Spot TB
Does QuantiFeron TB Gold and T-Spot TB distinguish b/w active and latent disease?
No
How many sputum specimens needs to be collected for TB dx? And in what time frame?
3 collected 8-24 hrs apart w/ at least 1 in the AM
Will AFB smear confirm TB dx?
No
Will Nucleic acid amplification (NNA) smear confirm TB dx?
No
If pt w/ suspected TB has positive AFB and NNA, do you wait for culture to start tx?
No, start tx ASAP
What is gold standard for dx of TB?
Culture, but takes weeks
Xpert MTB/RIF assay will identify what? (2)
- M. tb DNA
2. Rifampin resistance
Can you used Xpert MTB/RIF in pt that has been on Tb tx < 3 days?
Yes
If pt w/ negative TB culture, but high clinical suspicion how do you proceed?
Treat, but monitor response to tx
If pt w/ + TB culture, what is your next step?
Drug susceptibility testing
Tissue biopsy in TB is taken only if needed, what is the hallmark finding?
Necrotizing granulomas
First line drugs to active TB? (4)
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
Direct observed therapy (DOT) is required for treatment of what TB disease?
ALL pt’s w/ TB disease
Initial (intensive) phase for active TB tx?
RIPE meds daily x 8 weeks (56 doses)
After completing intensive tx phase for TB what is next? (3)
Repeat CXR, AFB smear, culture
RIF and INH daily x 18 weeks (126 doses) is what phase of tx for active TB?
Continuation phase
Why would you extend continuation phase for tx of active TB? (2)
Sputum culture, med tolerance
Red-orange secretions are SE’s for what TB medication?
Rifampin
Hepatotoxicty is a SE for what 2 TB drugs?
Isoniazid and Pyrazinamide
Ethambutol can cause optic neuritis. In what population is it contraindicated?
Infants/children
When is a pt being treated for TB not considered infectious? (3)
- 2 wks tx regimen
- 3 neg sputum smears
- Sxs improve
An infectious TB pt is able to go home under what circumstances? (3)
- Strict f/u arrange w/ DOT
- No children < 5 yo or IMC living in home
- No travel (except to health care visits)
6-9 month regimen of Isoniazid using DOT is tx for what form of TB? And preferred for what populations?
Latent. Preferred in pregnant women and children 2-11 yo
12 doses of INH and Rifampin under DOT/SAT is preferred latent tx for what populations?
Adults & children ≥ 12 yo, otherwise healthy HIV+ pts
NOT during pregnancy
If pt’s w/ latent TB can’t tolerate INH what do you tx with?
Rifampin 120 doses (daily x 4 months)
In what populations do you preform targets TB testing? (3)
- High risk of TB exposure & high risk for developing disease once infected
- Health care workers
- Prophylaxis offered to pt’s w/ latent TB
Resistance to INH and RIF is MDR or XDR?
MDR
BCG vaccine is contraindicated in what populations because it is live?
Pregnant and IMC
BCG vaccine does not prevent primary infection or activation of LTBI, what is its goal?
Decrease risk of severe consequences to TB disease (meningitis and disseminated TB, especially in children)
Exposure to soil contaminated w/ bird/bat dropping is concerning for?
Histoplasmosis
Fungal spores are turned into what once inhaled? This leads to Histoplasmosis
yeast
HIV+ presents with dysphagia w/ esophageal narrowing, what should you be concerned for?
Histoplasmosis
Pt present for physical exam for upcoming spelunking adventure? What disease should you warn them about?
Histoplasmosis
Acute symptomatic pulmonary histoplasmosis is self limited or requires tx? If tx, what is it?
Self limited
Form of histoplasmosis that is most common in IMC pts, involves multiple organ systems and is fatal w/in 6 weeks?
Progressive disseminated histoplasmosis
Chronic pulmonary histoplasmosis results in progressive lung changes in what population?
Older COPD pts
Immunodiffusion (ID) serology measures for the presence of what Ab in histoplasmosis and cocci?
IgM - Will tell you if pt has acute or chronic infection
Complement fixation (CF) serology measures for the presence of what Ab in histoplasmosis and cocci?
IgG
Antigen serology, Enzymes immunoassay (EIA) test is used first in dx the diagnosis of what two diseases?
Histoplasmosis, Cocci
CXR for histoplasmosis will show what?
Patchy or nodular infiltrates in the lower lobes
What is the tx for asymptomatic histoplasmosis?
None
What is the most common form of histoplasmosis in otherwise healthy individuals?
ASX primary histoplasmosis
TX for mild-mod acute pulmonary histoplasmosis?
< 4 wk, none
> 4w itraconazole
Tx for acute-severe and progressive disseminated pulmonary histoplasmosis?
AmphoB then itraconazole
TX for chronic histoplasmosis?
Itraconazole
TX for HIV/Aids pts w/ histoplasmosis?
AmphoB + itraconazole
Inhalation of spores from desert soil is concerning for what?
Cocci
If pt presents with pulmonary complaints and 1+ of erythema nodosum, erythema multiforme, eosinophilia what should you be concerned for?
Cocci
Is sub-acute valley fever infection protective from future disease?
yes
Is CAP + fever, cough, pleuritic CP, HA, fatigue, desert rheumatism and erythema nodosum concerning for primary cocci infection or disseminated disease?
Primary infection
More pronounced lung findings, bone lesions, lymphadenitis, and meningitis are concerning for what?
Disseminated cocci disease (increased risk in IMC pts)
Slight leukocytosis with eosinophilia is concerning for what disease?
Cocci
Is coccidiodin or spherulin skin test dx for cocci?
No
Thin walled cavities on CXR should disappear in what time frame if Cocci?
2 years
If pt with cocci is stable is treatment required?
No
If IMC pt with severe cocci infection what is first line med?
“Azole” (no ketoconazole) OR amphoB if pregnant or v severe
If no med therapy for cocci when does pt follow up?
Every 2-4 weeks for 1 year
True or False all pts dx with cocci will follow up every 2-4 weeks regardless of treatment provided?
True
When would a Cocci pt continue annual follow up for 2+ years?
If started on med therapy
