Module 3- Pulmonary neoplasms/Sarcoidosis/Environmental &Occupational lung disorders Flashcards
screening for Lung CA
CT scans annually for age 55-74 can help identify disease early. Major concerns are1. Generlizabilty to practice, 2.Duration of screening, 3. overdiagnosis, and 4. cost effectiveness
Solitary pulmonary Nodule
most are asymptomatic and represent an incidental finding on CXR/CT
Imaging evaluation
Rapid progression= infection, ling term stability= benignity, size is correlated with malignancy
Edge Characteristics of nodules
well-defined edge = benign
ill-defined margins/lobular appearance = malignancy
Treatment of Pulmonary nodule
Depends on probability- low, high, intermediate
Low probability
under 30, stable for more than 2 years, pattern of benign calcification- watchful waiting
High Probability
proceed directly to resection following staging, bx rarely yield specific benign diagnosis
Intermediate probability
traditionally- dx bx
PET scan
Sputum cytology
VATS
Right Middle Lobe Syndrome
recurrent/persistent atelectasis of right middle lobe- CT needed to make sure no tumor
Bronchial Carcinoid Tumors
low grad malignant neoplasms
Carcinoid Tumors
hemoptysis, cough, focal wheezing, recurrent PNA,
Most occur in central bronchi- peripheral is rare
Carcinoid Syndrome
Flushing, diarrhea, wheezing, hypotension
Rare, Pink/purple tumor in central airway that are well vascularized stroma, BX likely to complicated by significant bleeding
Bronchial Carcinoid Tumors tx
grow slowly and rarely metastasize
complicaitons- bleeding and airway obstruction
surgical excision due to resistance to chemo and radiation
Mediastinal Masses
S&S is insidious onset of retrosternal chest pain, dysphagia or dyspnea
often is found on routine cxr
Sarcoidosis
systemic disease of unknown etiology characterized in 90% of patient by granulomatous inflammation of the lung
S&S of Sarcoidosis
Malaise, fever, dyspnea of insidious onset, symptoms cause my skin involvement iritis, peripheral neuropathy arthritis or cardiomyopathy may prompt the patient to seek care
Some patients may be asymptomatic
Lab findings for sarcoidosis
leukopenia- elevated erythrocyte sedimentation and hypercalemia or Hypercalciuria
Angiotensin converting enzyme may be elevated
Skin test anergy is present in 70%
ECG may show conduction disturbances and dysrhythmias
Imaging of Sarcoidosis
include b/l hilar adenopathy alone- stage 1
hilar adenopathy and parenchymal involvement- stage 2
Parenchymal involvement alone- stage 3
Stage 4- advance fibrotic changes principally in the upper lobes
Special exams for sarcoidosis
requires histologic demonstration of noncaseating granulomas in biopsies
BX- easy accessible sites
Transbronchial lung biopsy has high yield
Treatment of sarcoidosis
Oral corticosteroids usually over months to years
long term suppressive medications can be used in patients not tolerate to oral steroids
Prognosis for Sarcoidosis
Stage one is the best but stage 4 has worst
most will suffer irreversible lung impairment
Patients require long term follow up with physical exam, pulmonary function test, chemistry panel, eye test, cxr, ecg
Smoke inhalation
Must be assessed for 3 consequences
1. impaired tissue oxygenation
2. thermal injury to upper airway
3. injury to the lower airways and lung parenchyma
e- cigarette/Vaping
S&S- cough, SOB, chest pain, GI symptoms, constitutional symptoms
Imaging- b/l pulmonary opacities and CTs are non specific and show patterns seen in other diseases
Tx- corticosteroids
Acute aspiration of gastric contents
Can be catastrophic
depends on the amount
causes extensive desquamation of the bronchial epithelium, bronchiolitis, hemorrhage, pulmonary edema
S&S- abrupt resp distress, cough, wheezing, fever, tachy, crackles, hypoxemia,
tx- usually measures of acute resp failure
Chronic Aspiration of gastric contents
results from disorders of the larynx or esophagus
linked to asthma, chronic cough, bronchiectasis and pulmonary fibrosis
Cafe Coronary
acute obstruction of upper airway bu food associated with difficulty swallowing, old age, dental problems, impaired chewing,
heimlich procedure- lifesaving
retention of aspirated foreign body
produces both acute and chronic conditions- atelectasis, postobstruction hyperinflation, acute/recurrent PNA, bronchiectasis and lung abscess
Pneumoconioses
chronic fibrotic lung disease caused by inhalation of inert inorganic dust
A. Coal worker
B. Silicosis
C. Asbestosis
Coal Worker Pneumoconiosis
inhalation of coal dust leads to coal macules especially in upper lung, usually asymptomatic and abn are unimpressive,
can resemble silicosis
Caplan syndrome is a rare condition with coal workers with rheumatoid arthritis
Silicosis
extensive or prolonged inhalation of free silia in the respirable range causes the formation of rounded opacities throughout the lung
calcification of periphery of hilar lymph nodes is unusual and suggest this
simple silicosis is asymptomatic
complicated silicosis- dyspnea, obstructive and restrictive pulmonary dysfunction
TB is increased in these patients
Asbestosis
nodule interstitial fibrosis occurring in workers exposed to asbestos fibers,
S&S- progressive dyspnea, inspiratory crackles, clubbing and cyanosis
Imaging- Streaking linear at lung bases, opatices of various shapes and honey comb in advanced cases
There is no specific treatment
Hypersensitivity Pneumonitis
nonatopic, non-asthmatic inflammatory pulmonary disease
Prompt dx is essential since symptoms are reversible if the antigen is removed
Acute illness with Hypersensitivity pneumonitis
sudden onset of Malaise, chills, fever, cough, dyspnea and nausea 4-8 hours after exposures,
bibasilar crackles, tachypnea, tachycardia
Imaging- small nodular densities sparing the apices and baes of the lungs
increase WBC with left shift, hypoxemia and presents of antibodies related to offending agent in serum
Subacute and Chronic illness with hypersensitivity pneumonitis
insidious onset of chronic cough and slowly progressive dyspnea, anorexia and weigh loss, chronic exposure leads to progressive resp insufficiency and appearance of pulmonary fibrosis on imaging
Bx may have to be done for dx
Treatment of hypersensitivity pneumonitis
identification of the offending agent and avoidance of further exposures
severe cases- oral corticosteroids for 2 weeks
Medication induced lung disease
precise dx is difficult b/c results of pulmonary studies are not helpful
acute episodes can disappear 24-48 hours after medication is removed but chronic syndromes can take longer
can treat with steroids
thorough history of medication is critical
Inhalation of Crack cocaine
causes spectrum of acute pulmonary syndromes
corticosteroids can be used with variable successes to treat alveolar hemorrhage
Radiation Lung Injury
two phases of the pulmonary response to radiation are acute phase- radiation pneumonitis and chronic phase radiation fibrosis
Radiation Pneumonitis
happens 2-3 months after therapy
insidious onset of dyspnea, intractable dry cough, chest fullness/pain, weakness, fever
can happen late 6-12 months out
Inspiratory crackles can be heard in involved area
Radiation Pneumonitis lab findings
increase white count, elevated sedimentation rates
Pulmonary function studies, reveal reduced lung volumes, lung compliance, hypoxemia, reduced diffusing capacity and reduced Maximum voluntary ventilation
CXR- sharp borders of an opacity
Radiation Pneumonitis Treatment
No specific therapy is proven effective- Prednisone can help
May improve 2-3 weeks following onset of symptoms
Pulmonary Radiation Fibrosis
with out without antecedent radiation pneumonitis,
CXR- obliteration of normal lung markings- dense interstitial, pleural fibrosis, tenting of the diaphragm, sharp delineation of irradiated area
occurs in most patients receiving radiation who receive the full course of radiation- may be asymptomatic but slowly progressive
Bronchogenic Carcinoma Risk factors
Cigarette smoking causes 85-90%
environmental tobacco smoke, radon, asbestos, diesel exhaust, ionizing radiation, metals,
Familial prediposistions is recognized.
certain lung disease- pulmonary fibrosis, COPD, sarcoidosis
Types of bronchogenic carcinoma
squamous cell carcinomas, Adenocarcinomas, adenocarcinomas in situ, Large cell carcinomas, small cell carcinomas
Clinical findings of bronchogenic carcinoma
lung caner is symptomatic at dx in most patients, clinical presentation depends on type and location of primary tumor, extent of spread, and presence of mets
S&S of Bronchogenic carcinoma
Anorexia, weight loss, asthenia, new cough or change in chronic cough, hemoptysis. complaint of pain, nonspecific chest pain
paraneoplastic syndrome
patterns of organ disfunction related to immune mediated or secretory effects of neoplasms
SIADH, increased ATCH production, anemia, hyper-coagulability, peripheral neuropathy, lambert eaton, myasthenia syndrome
Treatment of primary tumor with improve or resolve symptoms
Lab finding bronchogenic carinoma
sputum cytology, ct-guided bx, thoracentesis, fiberoptic bronchscopy
Screening of Bronchogenic carcinoma
low dose helical CT scans- annually
smokers 50-80 years who have at least a 20 pack year smoking history and who currently smoke or quit within the last 15 years
Pulmonary Metastases
spread of extra-pulmonary malignant tumor through vascular or lymphatic channels by direct extension
CA of breast, kidney, rectum, colon, cervix, melanoma- most common
S&S of Pulmonary metasteases
uncommon but cough, hemoptysis and in advanced cases dyspnea and hypoxia
Imaging of Pulmonary Mets
multiple spherical densities with sharp margins, lesions are usually bilateral, pleural, or sub-pleural
Mesothelioma
Primary tumors arising from surface lining of pleura or peritoneum
related to exposure of asbetos
Risks factors of mesothelioma
asbestos, mining, milling, manufacturing, shipyard work, insulation, brake linings, building construction and demolitions, roofing material and other asbestos products
S&S of msothelioma
2-3 months from onset of symptoms to dx,
insidious onset of SOB, nonpleuritic chest pain and weight loss,
physical findings- dullness, percussion, diminished breath sounds an digital clubbing
Lab findings Mesothelioma
Pleural fluid exudative and often hemorrhagic
