Lung Flashcards
How are the lungs divided?
Right lung: 3 lobes, ten segments
Left lung: 2 lobes, 9 segments
Aspiration of gastric contents or foreign bodies is more likely to affect which lung? Why?
RIght lung, especially superior segment or R lower lobe and posterior segment of R upper lobe. It’s bc the R main bronchus doesn’t curve as much as the L one.
What is the arterial supply to the lung?
pulmonary artery bronchial arteries (come from Ao and intercostal vessels)
What are the kinds of benign tumors of the lung?
First: these are very rare. squamous papilloma (HPV 6,11) angioma fibroma leiomyoma chondroma
HPE of benign lung tumors
recurrent pneumonia cough hemoptysis decreased breath sounds on affected side other sx from postobstructive pneumonia (pneumonia that's distal to the bronchial obstruction)
Dx Eval of benign tumor
CXR- shows mass
there is often postobstructive pneumonia if the lesion narrows the bronchial lumen
Rx for angiomas
they frequently regress, so just observe
Rx for benign tumors
Surgical removal- relieves sx and establishes dx.
Partial lung resection or sleeve resection w re-anastomosis of bronchus or trachea.
What kind of benign lung ca has a high recurrence rate?
Squamous papillomatosis
What kind of lung tumors are usu not malignant but have “malignant potential”?
bronchial carcinoids (10% malignant)
adenoid cystic carcinoma
mucoepidermoid tumors
these are all rare
What kind of tumors cause paraneoplastic syndrome?
Carcinoid tumors
What kind of substances do carcinoid tumors release (which can cause paraneoplastic syndrome)?
histamine serotonin VIP gastrin GH insulin glucagon catecholamines
HPE for lung tumors w malignant potential
Cough, dyspnea, hemoptysis, recurrent pneumonia
Carcinoid syndrome (infrequent)
Respi compromise or decreased breath sounds
Carcinoid tumors- valvular heart dz w pulm stenosis, tricuspid regurg
Dx Eval for tumors w malignant potential
CXR- show lesion or post-obstructive pneumonia
Bronchoscopy for tsu dx and to see anatomy
CT is routine for pre-op planning
Rx for tumors w malignant potential
Resect.
What is carcinoid syndrome?
flushing, diarrhea, plus manifestations of specific hormone excess (dep on which hormone it is)
T/F more than 80% of lung cancers are smoking related
True.
Lung cancer is the leading cause of cancer death in the US.
Carcinogens that can cause lung cancer
Smoking Asbestos Formaldehyde Radon gas Arsenic Uranium Chromates Nickel
How is lung ca classified
Small cell (20-25%) Non-small cell (75-80%)
How is non-small cell lung ca classified?
Non-small cell is 75-80% of all lung cancer. It's divided into: squamous cell carcinoma (30%) adenocarcinoma (35%) large cell carcinoma (10%)
Where is small cell cancer located?
Centrally.
T/F small cell lung cancer can be a/w paraneoplastic syndromes
True
5% of pts have SIADH
3-5% have Cushing’s (from too much ACTH)
Where does squamous cell cancer usu occur? What other sx is it a/w?
Occurs centrally
A.w sx of hypercalcemia, secondary to production of PTHrP
Where does adenocarcinoma usu occur?
At the periphery
What signals that the tumor is obstructing the airway?
worsening cough with increased sputum
hemoptysis
Persistent chest, back, shoulder pain in lung ca is related to…
nerve involvement or direct tumor invasion
What are the sx of lung cancer mets?
Bone pain, neurologic sx
fatigue, loss of appetite, weight loss.
HPE of lung cancer
Diminished breath sounds dt pneumonia or malignant pleural effusion
Supraclavicular lymphadenopathy
Hoarsenss- recurrent laryngeal nerve
Why can Horner’s syndrom be present in lung ca?
Superior sulcus tumor causes neural compression –> ptosis, myosis, anhidrosis
What is pancoast syndrome?
shoulder and arm pain on side with lung ca
What is superior vena cava syndrome
obstruction of SVC by malignancy, eg compression of wall dt R upper lobe tumors
Paralysis of the diaphragm indicates tumor involvement of which nerve?
Phrenic
Dx Eval for lung cancer
CXR
CT of chest + liver and adrenals- to see tumor size, lymphadenopathy, pleural effusion, distant mets
Bone scan, brain imaging
PET for distant dz
Invasive testing usu reqd for definitive dx
Flexible bronchoscopy- tsu biopsy, bronchial washings
Transthroacic CT-guided FNbiopsy- tsu sampling
Mediastinoscopy w lymph node biopsy- for staging
What size are T1 lesions?
<3 cm
What are T2 lesions?
> 3 cm
or involve main bronchus >2cm from carina
or involve visceral pleura
What are T3 lesions?
Invade: chest wall diaphragm mediastinal pleura pericardium main bronchus w/in 2cm of carina
What are T4 lesions
Invade: heart great vessels mediastinum trachea esophagus vertebral bodies carina or have malignant effusions or satellite tumors
What are N1 lesions?
Pos nodes in ipsi peribronchial or hilar region
What are N2 lesions?
pos nodes in ipsi mediastinal or subcarinal region
N3 lesions?
mets either to contralateral nodes or ipsi scalene or supraclavicular regions
Stage IA, Stage IB
1A: T1, N0, M0
1B: T2, N0, M0
T/F M1 automatically means Stage IV
True. Can be any T, any N.
T/F Surgery is rarely indicated for small cell lung cancer
True, bc it’s usu widely disseminated at the time of dx. Only very early stage are considered potentially resectable.
Rx for small cell lung ca
Chemo- usu combo of cisplatin and etoposide
And radiation
What is the Rx if pts respond well to therapy and have complete remission?
Prophylactic whole-brain radiation, to decrease chances of cerebral mets
Rx for non-small cell lung cancer
Early stages- surgery followed by chemo
most commonly lobectomy
T/F all patients who have completely resected lung ca should get chemo
True
Chemo regimen for pts with resected lung ca
a platinum agent (cisplatin or carboplatin)
a nonplatinum agent (etoposide, irinotecan, paclitaxel, gemcitabine)
+Radiation if mediastinal lymph nodes involved
Where is most mesothelioma found?
Visceral pleura
Risk factors for mesothelioma
Asbestos (esp +smoking)
HPE for mesothelioma
chest pain from local extension dyspnea secondary to pleural effusion weight loss unexplained night sweats decrsd breath sounds on side of tumor dt pleural effusion
Dx eval for mesothelioma
CXR- shows pleural effusion
Thoracocentesis- bloody fluid, cytology neg for malignancy
Thoracoscopy and pleural biopsy- do this if there is suggestive hx and recurent pleural effusion and no clear etiology (even if neg fluid cytology)
Rx for mesothelioma
Pgx is poor
Early stg lesions may be resectable but req induction chemo followed by extrapleural pneumonectomy
If non-op: chemo + rad
What is a simple pneumothorax?
Air enters the potential space bt the visceral and parietal pleura, so lung falls away from chest wall
What is an open pneumothorax?
Defect in chest wall allows continuous air entry from outside
What is tension pneumothorax?
Air enters the potential space but can’t escape- one-way valve going inward.
Prs increases, forcibly collapsing the lung, compressing mediastinal structures
What pts get spontaneous pneumothorax?
young thin males
older pts w bullous emphysema
pts on mechanical ventiliation, esp if high prs
pts w infection or tumors
iatrogenic causes (thoracocentesis, needle biopsy, operative trauma)
What infections can cause pneumothorax?
TB or Pneumocystic carinii
HPE for pneumothorax
Can be asx Dyspnea, chest pain Decreased breath sounds Hyper resonance on affected side If tension pneumo- tachycardia, hypotension, hypoxia, tracheal deviation
Dx Eval for pneumothorax
upright CXR- no lung markings in affected area (usu apex). see visible line corresponding to visceral pleural surf of lung. if tracheal dev or mediastinal shift, it’s tension pneumo
Rx for simple pneumothorax
if <20%, just observe as long as there is no size increase on serial CXR
otherwise, chest tube
Rx for open pneumothorax
repair of deficit and tube thoracostomy
Rx for tension pneumothorax
surgical emergency- immed needle thoracostomy in mid-clavicular line, 2nd IC space
Then tube thoracostomy after
What is an empyema?
Infection within the pleural space
What causes empyema?
pneumonia
lung abscess
post-op complication of thoracic surgery
esophageal perf
What organisms cause empyema?
Staph Strep Pseudomonas Klebsiella Ecoli Proteus Bacteroides
HPE for empyema
Hx of prev pneumonia, thoracic surg, esophageal instrumentation
Fatigue, lethargy, shaking chills
Systemic illness
Fever
Decreased breath sounds at affected lung’s base
Dx eval of empyema
WBC elevated
CXR- pleural effusion
Throacocentesis- aspiration of the pleural fluid shows exudate, high WBCs w PMN predominant, low pH, low glucose, high LDH. May see bacteria on gram stain/culture
Rx for empyema
TUbe thoracostomy and abx
rarely, needle aspiration and abx are enough
