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lung cancer ARDS resp failure Flashcards

1
Q

what are the types of lung cancer?

A

SCC
adenocarcinoma
large-cell
small-cell

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2
Q

what is the epidemiology of small cell lung cancer?

A

20%

smoking

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3
Q

what is the pathology of small cell lung cancer (location + histology)?

A

central location
near bronchi

histology- small, poorly differentiated cells

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4
Q

how does a small cell lung cancer develop?

A

80% present with advanced disease
very chemosensitive but very poor prognosis
ectopic hormone secretion

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5
Q

what is the epidemiology of large cell lung cancer?

A

10%

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6
Q

what is the pathology of large cell lung cancer (location + histology)?

A

peripheral or central

histology- large, poorly differentiated cells

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7
Q

how does a large cell lung cancer develop?

A

poor prognosis

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8
Q

what is the epidemiology of adenocarcinoma?

A

25%
females
non-smokers
far east

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9
Q

what is the pathology of adenocarcinomas (location + histology)?

A

peripherally located

histology: glandular differentiation
gland formation, mucin production

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10
Q

how does an adenocarcinoma behave?

A

extrathoracic mets common + early

80% present with mets

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11
Q

what is the epidemiology of SCC?

A

35%
M>F
smoking
radon gas

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12
Q

what is the pathology of SCC (location + histology)?

A

centrally located

histology- evidence of squamous differentiation- keratinsation

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13
Q

how does an SCC behave

A

locally invasive
metastasise late via LN
PTHrP -> high Ca2+

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14
Q

what are the other types of rare lung cancers?

A

adenoma- 90% carcinoid tumours
hamartoma
mesothelioma

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15
Q

what is the epidemiology of lung cancer?

A

19% of all cancers

27% of cancer deaths- most common

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16
Q

what are the symptoms of lung cancer?

A 
cough + haemoptysis 
dyspnoea
chest pain 
recurrent or slow resolving pneumonia
anorexia + weight loss
hoarseness
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17
Q

what are the general + chest signs of lung cancer?

A

1) general:
cachexia, anaemia
clubbing + HPOA (painful wrist swelling)
supraclavicular +/- axillary LNs

2) chest:
consolidation
collapse
pleural effusion

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18
Q

what are the signs of metastatic lung cancer?

A

bone tenderness
hepatomegaly
confusion, fits, focal neuro
addisons

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19
Q

what are the local complications of lung cancer?

A 
reccurent laryngeal nerve palsy
phrenic nerve palsy
SVC obstruction 
horner's - pancoast tumour
AF
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20
Q

what are the paraneoplastic complications CATEGORIES of lung cancer?

A

endo
rheum
neuro
derm

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21
Q

what are the paraneoplastic complications of lung cancer? endo

A

1) ADH-> SIADH (euvolaemic decrease Na+)
2) ACTH-> cushing’s syndrome
3) serotonin-> carcinoid (flushing, diarrhoea)
4) PTHrP-> 1* HPT (raised Ca2+, bone pain)- SCC

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22
Q

what are the paraneoplastic complications of lung cancer? rheum

A

dermatomyositis/polymyositis

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23
Q

what are the paraneoplastic complications of lung cancer? neuro

A

1) purkinje cells (CDR2) -> cerebellar degeneration

2) peripheral neuropathy

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24
Q

what are the paraneoplastic complications of lung cancer? derm

A

1) acanthosis nigricans (hyperpigmented body folds)

2) trousseau syndrome- thrombophlebitis migrans

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25
what are the complications of metastic lung cancer?
pathological fracture hepatic failure confusion, fits, focal neuro addisons
26
what are the investigations for lung cancer?
1) bloods- FBC UE Ca2+ LFTs 2) cytology- sputum, pleural fluid 3) imaging- CXR, contrast-enhanced volumetric CT, PET-CT, radionucleotide bone scan 4) biopsy 5) lung function tests- assess treatment fitness
27
what can CXR show for lung cancer?
``` coin lesion hilar enlargement consolidation, collapse effusion bony secondaries ```
28
what is contrast ehanced volumetric CT scan used for in lung cancer?
staging- lower neck, chest, upper abdomen | consider CT brain
29
what is PET-CT used for in lung cancer?
to exclude distant mets
30
how are biopsies done in lung cancer?
1) percutaneous FNA- peripheral lesiosn + LNs 2) bronchoscopy- biopsy + assess operability 3) endoscopic bronchial US biopsy- mediastinal LNs 4) mediastinoscopy
31
what are the ddx for CXR coin lesion?
``` FANGS foreign body abscess- staph, TB, klebsiella, mycetoma neoplasia- 1* or 2* granuloma- RA, wegener's, TB, sarcoid structural - AVM ```
32
what staging is used for non-small cell lung cancers?
TNM staging | look at p44 AS notes
33
what is the general management for all lung cancers?
MDT- pulmonologist, oncologist, radiologist, histopathologist, cardiothoracic surgeon, specailist nurses, palliative care, GP assess risk of operative mortality eg thoracoscore (cardioresp fx, co-morbs) smoking cessation advice
34
what treatments can be offered for non-small cell lung cancers?
1) surgical resection for stage I/II (wedge resection, lobectomy or pneumonectomy +/- adjuvant chemo) 2) curative radiothearpy 3) chemo +/- radiothearpy for more advanced disease
35
what is the management of small cell lung cancer?
typically disseminated at presentation | may respond to chemotherapy but invariably relapse
36
what can be done for palliation of lung cancer treatment?
1) radiotherapy - bronchial obstruction, haemoptysis, bone or CNS mets 2) SVC obstruction - stenting + radiotherapy + dexamethasone 3) endobronchial therapy- stenting, brachytherapy 4) pleural drainage/pleurodesis 5) analgesia
37
what is the prognosis of non small cell lung cancers?
50% 5 years without spread | 10% with spread
38
what is the prognosis of small cell lung cancer?
1-1.5 years median survival if treated | 3 months if untreated
39
what is the pathogenesis of ARDS?
may result form direct pulmonary insult or be 2* to severe systemic illness inflammatory mediatores leads to increased capillary permeability + non-cardiogenic pulmonary oedema
40
what are the clinical features of ARDS?
tachypnoea cyanosis bilateral fine creps SIRS/sepsis
41
what investigations would you do for ARDS?
bloods- FBC, UE, LFT, clotting, amylase, CRP, cultures, ABG CXR
42
what does CXR show in ARDS?
bilateral perihilar infiltrates
43
what features leads to diagnosis of ARDS?
acute onset CXR - bilateral infiltrates no evidence of CCF PaO2:FiO2 <200
44
what is the management of ARDS?
admit to ITU for organ support | treat underlying cause
45
what are the indications for ventilation in ARDS?
paO2<8kpa despite 60% FiO2 | paCO2>6kpa
46
what are the side effects of ventilation in ARDS?
VILI VAP weaning difficulty
47
how do you monitor circulation in ARDS (ITU?)
invasive BP monitoring maintain CO + CO2 with inotropes eg norad or dobutamine RF may require haemofiltration
48
what are the management categories for ARDS?
ventilation circulation sepsis- abx nutritional support- enteral is best, TPN
49
what is the prognosis of ARDS?
50-75% mortality
50
what are the pulmonary causes of ARDS?
pneumonia aspiration inhalation injury confusion
51
what are teh systemic causes of ARDS?
``` shock sepsis trauma haemorrhage + multiple transfusions pancreatitis acute liver failure DIC obs- eclampsia, amniotic embolism drugs- aspirin, heroin ```
52
what are the ddx of EXUDATE pulmonary oedema?
ARDS
53
what are the ddx of TRANSUDATE pulmonary oedema if increase in capillary hydrostatic pressure?
CCF iatrogenic fluid overload renal failure relative increase in negative pressure pulmonary oedema
54
what are the ddx of TRANSUDATE pulmonary oedema if decrease in capillary oncotic pressure?
liver failure nephrotic syndrome malnutrition, malabsorption, protein-losing enteropathy
55
what are the ddx of TRANSUDATE pulmonary oedema if increase in interstitial pressure?
decrease lymphatic drainage eg cancer
56
what is type 1 resp failure?
PaO2 <8KPa and PaCO2 <6KPa | V/Q mismatch and diffusion failure
57
what is type 2 resp failure?
PaO2 <8KPa and PaCO2 >6KPa | Alveolar hypoventilation ± V/Q mismatch
58
what are the causes CATEGORES for resp failure?
V/Q mismatch (increase in A-a gradient) alveolar hypoventilation- obstructive + restrictive diffusion failure - fluid + fibrosis (increase in A-a gradient) which both lead to V/Q mismatch + alv hypovent due to decreased compliance
59
what are the causes of V/Q mismatch?
1) vascular- PE, PHT, pulmonary shunt R->L 2) asthma (early) 3) pneumothorax 4) atelectasis
60
what are the causes of OBSTRUCTIVE alveolar hypoventilation?
``` COPD asthma bronchiectasis bronchiolitis intra + extrathoracic - cancer, LN, epiglottitis ```
61
what are the causes of RESTRICTIVE alveolar hypoventilation?
1) decreased drive- CNS sedation, trauma, tumour 2) NM disease- cervical cord lesion, polio, GBS, MG 3) chest- flail, kyphoscoliosis, obesity 4) fluid + fibrosis
62
what are the causes of diffusion failure (fluid)?
pulmonary oedema pneumonia infarction blood
63
what are the clincal features of resp failure?
``` 1) acute hypoxia dyspnoea, agitaiton, confusion, cyanosis 2) chronic hypoxia polycythaemia, PHT, cor pulmonale 3) hypercapnoea headache, flushing + peripheral vasodilatation, bounding pulse, flap, confusion leading to coma ```
64
what is the management of type 1 resp failure
treat underlying cause 02 aim 94-98 assisted ventilation if paO2<8kpa despite 60% O2
65
what is the management of type 2 resp failure
treat underlying cause controlled O2 therapy at 24% O2 aiming for 88-92 and paO2 of >8kpa check ABG after 20 mins - if paCO2 steady or lower can increase FIO2 if needded - if paCO2 higher than >1.5kpa + pt still hypoxic, consider NIV or respiratory stimulant eg doxapram
66
what are the principles of o2 therapy if patient is at risk of hypercapnic resp failure?
start O2 therapy at 24% + do ABG use blue venturi at 2-4L/min clinically- reduced RR with O2 may be useful sign if PCO26kpa- increase target SPO2 to 94-98 if PCO2>6kpa maintain target SPO2
67
what mechanisms of O2 therapy are there?
nasal prongs 1-4L/min= 24-40% O2 simple face mask non-rebreath mask 60-90% at 10-15L ``` venturi mask yellow 5% white 8% blue 24% red 40% green 60% ```

RESP (4 decks)

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