HCP 8: Edna Ota Emphysema + Lung Cancer

Question 1

DDX Shortness of Breath

Answer 1

CHF (orthopnea, PND)
MI (troponin I)
Cardiac tamponade (muffled heart sounds, hypotension)
ARDS
Pulmonary embolism (DVT)
Pneumothorax (trauma)
Asthma attack (atopy)
Pneumonia (WBC, productive cough)
COPD (smoking)

Question 2

What is the influenza vaccine?
Who should get the influenza vaccine & when?
Is there anyone who should get the vaccine?

Answer 2

Protects against 3 flu viruses, but high rate of mutation so requires annual shot
*Inactivated egg-based (shot) or live-attentuated (nasal spray)
Ab in circulation 2 wks after vaccine
Main season winter
ANYONE >6 months SHOULD get it
ANYONE <6 mo/EGG ALLERGY SHOULD NOT

Question 3

What is the pneumococcal vaccine?
Who should get it?
What are some consequences of pneumococcal disease?

Answer 3

1. PPSV23: Polysaccharide vaccine w/ 23 purified capsular polysaccharide antigens (not recommended in kids); >2 if high risk (immunocompromised, asplenic); 19-64 y.o. smokers; anyone >65
2. Meningitis, pneumonia, sepsis

Question 4

Describe the pathogenesis of emphysema

Answer 4

Smoking -> ROS -> inflammation -> neutrophils -> neutrophil elastase -> protease>anti protease activity (imbalanced) -> proteolysis of elastase & collagen IV-> destroy acini & vasculature -> irreversible enlargement of airways -> emphysema

Question 5

Why do patients with emphysema breathe through pursed lips?

Answer 5

Emphysema patients have decreased alveolar pressure (due to decreased elastic recoil pressure), which shift equal pressure point (Intrapleural p= alveolar p) into small, non cartilage airways (supposed to be near mouth where cartilage can prevent bronchial collapse) & more prone to collapse. Pursed lips increases alveolar p. (Bernoulli’s Principle) & shift equal pressure point back to mouth, preventing expiratory airway collapse.

Question 6

What are the 3 factors that contribute to pulmonary hypertension?

Answer 6

1. Hypoxic vasoconstriction
2. Destruction of pulmonary vasculature forces blood to flow remaining blood vessels
3. Hypoxemia -> erythropoiesis -> blood viscosity

Question 7

What is emphysema?

Answer 7

Not fully reversible destruction & enlargement of air spaces + destruction of alveolar walls (w/o fibrosis)

Question 8

Who is at risk of developing emphysema?

Answer 8

Men, smokers, occupational/environmental exposure, airway hyper responsiveness, a1-antitrypsin deficiency

Question 9

What are the 2 types of emphysema?

Answer 9

Centriacinar (smokers) - don’t affect alveoli, just respiratory bronchiole
Panacinar (a1 AT def) - affect everything

Question 10

What are the EKG findings in Emphysema?

Answer 10

RVH, Right axis deviation, p-pulmonale

Question 11

What would you expect to find in the PFTs of a person with emphysema?

Answer 11

Decreased FEV1/FVC
Increased FRC, RV
Decreased VC

Question 12

What is the MOA of Tiotropium Bromide?

What is used for?

Answer 12

Non-selective muscarinic antagonist
Predominantly inhibits M3 receptors on bronchiole SMC & glands
Decrease ACh binding & stimulation of receptor
Decrease bronchoconstriction & broncho-secretion
*Longer lasting than ipratropium bromide
(M1=exocrine glands in CNS, M3=decrease HR)
-USED in COPD & asthma (2nd line of defense)

Question 13

What is the MOA of Albuterol?
Main side effect?
When is it used?

Answer 13

Short-acting B-agonist
Binds to B2 receptor on bronchiole SMC
Activate adenylate cyclase, cAMP,PKA cascade
Decrease MLC kinase activity & intracellular Ca
Decrease SMC contraction
Decrease bronchoconstriction
SIDE EFFECT: hyponatremia
USED in ACUTE settings (emergency!)

Question 14

What is the MOA of buproprion?

Answer 14

Anti-depressant
BOXED WARNING: suicide, hostility
Begin 1 wk before cessation
Inhibit synaptic reuptake of NE and DA
Increase effects of NE & DA
Decrease withdrawal symptoms

Question 15

What is the MOA of varenicline (Chantix)?

Answer 15

Nicotine partial agonist
More effective than buproprion
Binds to a4/b2 Nicotinic ACh receptors
Prevent nicotine from binding & continue to trigger DA release (smaller doses)
Minimalist withdrawal while decreasing addiction because decrease pleasure gained from smoking

Question 16

What is the goal of NRT?
What are some methods of nicotine replacement therapy?
Who should have NRT?

Answer 16

-Alleviate withdrawal symptoms while quitting so can focus on behavior (not symptoms)
General MOA: Agonist of Nicotinic ACh receptors, but given at lower dose & rate
-Gum, Patch, Lozenge, Nasal spray, Inhaler
-Highly addicted (>20 cigs, morning smoke, early relapse, other addictions)

Question 17

What is the BODE index?

Answer 17

Predicts COPD survival (higher score = increased risk of death)
B=BMI
O=Obstruction of airflow (FEV1)
Dyspnea=MMRC dyspnea scale
E=exercise capacity (6 min walk)

Question 18

What are the 3 types of info we can get from PFT’s?

Answer 18

1. flow rate (spirometry)
2. Lung volumes (helium dilution & body plethysmography)
3. Diffusing capacity (CO test)

Question 19

What are risk factors for SCLC?

Answer 19

Cigarette smoke, exposure to asbestos/benzene/coal/tar, low fruit/veg intake, & family history

Question 20

What staging system is used for SCLC?

Answer 20

Anatomy stage: Location of tumor & possible metastatic site
Physiologic stage: asses patient’s ability to withstand anti-tumor treatment
TNM system:
-Tumor size
-Nodal involvement
-Metastasis

Question 21

What are some s/sx of SCLC?

Answer 21

dyspnea, hypoxemia, persistent cough, hemoptysis, Superior vena cava obstruction, hoarseness, dysphagia, hemi-diaphragm paralysis

Question 22

What is the treatment of SCLC?

Answer 22

Chemotherapy + Radiation

Usually don’t ever do surgery because by the time it’s identified, then it has already metastasized

Question 23

What are the other types of lung cancer?

Answer 23

Non-small cell lung cancer
Adenocarcinoma - glands & mucus
Squamous cell carcinoma - keratin pearls, intercellular bridges
Large-cell carcinoma- large anaplastic undifferentiated cells

Question 24

What is the MOA of etoposide?

What is it used for?

Answer 24

Cell-cycle specific (Late S to G2 phase)
Binds to DNA & topoisomerase II
Inhibits resealing of DS DNA breaks
Accumulate DNA strand breaks
DNA repair mech overwhelmed
Apoptosis
CANCER

Question 25

What is the MOA of cisplatin?

Answer 25

Non-cell-specific
BLACK BOX WARNING: Renal toxicity, myelosuppression, ototoxicity
MOA: enter cell & loses Cl-
Binds to DNA (mostly purines)
Inhibit DNA/RNA polymerase & causes cross-linking of abnormal base pairs (-> strand breaks) -> cell cycle arrest in G2 -> apoptosis

Question 26

What is the MOA of demeclocycline?

What is it used for?

Answer 26

SIADH (unlabeled, more common use)& Abx
MOA: Compete with ADH for binding site to receptor at DCT & Collecting duct
Inhibit ADH-induced H2O reabsorption
Diuresis
Reverse hyponatremia
As Abx: binds to 30S->inhibit access of tRNA to acceptor site -> bacteriorstatic

Question 27

What is radiation therapy?

Answer 27

Neoadjuvant: shrink tumor before main treatment
Adjuvant: additional treatment after surgery to lower risk of recurrence
Goals: Generate enough single/ds DNA breaks to overwhelm repair mechanisms
-4 R’s: Tumor cells have ineff. REPAIR mech
Normal cells are efficient, so REPOPULATE
Cancer cells REASSORT into more sensitive states of cell cycle more prone to radiation
REOXYGENATION of cancer cells enhance radiation
MOA: ejected electrons due to ionizing radiation interact directly w/ target or indirectly w/ H2O to produce free radicals which interact w/ target to cause DNA damage & cell death

Question 28

What is Paraneoplastic syndrome?

Answer 28

Disorder associated w/ benign or malignant tumor, but not directly related to effects of mass or invasion
Occurs in 10% of patients w/ cancer
May be first clinical manifestation of cancer
Ex. SIADH, Cushing’s, polycythemia, myasthenia, venous thrombosis, acanthosis nigricans

Question 29

What is a living will?

Answer 29

End of life document for patients terminally ill, permanently unconscious, or end-stage disease
In effect once signed and patient no longer able to make own decisions
Addresses EVERYTHING you want to (or don’t) in terms of medical care (DNR, transfusions, tests, drugs, surgery, respiratory, dialysis, pain meds, IV, tube, hospice)

Question 30

What is an advanced care directive?

Answer 30

Umbrella term that encompasses living will, health care power of attorney, DNR, & donor registration

Question 31

What is a POLST?

Answer 31

Physician orders for life-sustaining treatment
Includes DNR: do not perform CPR
Medical interventions: comfort vs. limited vs. full treatment
Artificial nutrition

Question 32

What is a power of attorney for health care?

Answer 32

Surrogate decision maker, but can’t violate living will

Can complete legal transactions on behalf of patient

Question 33

What is a healthcare proxy?

Answer 33

Designates another health care individual to be able to make health care decisions on your behalf
Has same legal right as a patient would

Question 34

How do you talk about advanced directives etc. with your patients?

Answer 34

BEFORE medical conditions arise & in primary care setting
Discuss various forms
Address myths (unable to change, AD=don't treat, loss of control)
Considerations when selecting a proxy (on the same page, will respect their wishes, lives close

Question 35

What are the different code statuses?

Answer 35

CODE BLUE=patient that req. CPR
Full code: Universal default if no instructions, allowed to perform CPR, defib, intubation, etc.
Limited code: specific methods
No code/DNR
DNI: Do not intubate

Question 36

What is physician assisted suicide?
Where is it legal?
What are some arguments for and against it?

Answer 36

When doctor facilitates patient’s death by providing necessary means &/or info to enable patient to perform life-ending act
LEGAL in OR, WA, VT, MT
Argument for: right to die (autonomy), suffering w/o justification =crime (compassion), living will should be accurate and respected
Argument against: do no harm, potential abuse, protect patients from immoral docs/fam, gateway for other forms (euthanasia), living wills not accurate, errors in diagnosis/prognosis, complications

Question 37

What was Governor Cayetano’s Blue Ribbon Panel?

Answer 37

Established to identify problems associated w/ living/dying
Death with dignity recommended legislation to legalize euthanasia and PAS in 1998-99
Passed House, defeated in Senate (has not come close since)
However 70% of HI residents favor, but Hawaii’s Partnership for Appropriate & Compassionate Care Against