Other pulm dx Flashcards
objectives
1
Q
Pulmonary embolism
A
- Pulmonary Thromboembolism: passage of a clot from the venous system that lodges in a pulmonary artery
- Venous thromboembolism (VTE) is the third MC CV illness
- Symptoms: variable
- MC dyspnea followed by pleuritic CP, symptoms of DVT and cough
- Sudden death can occur
- PE: tachypnea and tachycardia
2
Q
PE gold standard Dx
A
- Gold standard: catheter-based pulmonary angiography but this is RARELY used
- For pts where interventional therapy is indicated bc it can combine interventions for clot lysis and diagnosis in one scan
- This will tell you yes or no regardless of how costly/invasive. Not first line a lot!
3
Q
PE dx
A
- Combo of pretest probability, D-dimer, definitive diagnostic imaging, spiral CT pulm angiography (CTPA) and less commonly ventilation perfusion scanning
4
Q
PE pre-test, wells score
A
-
To determine pretest: Wells Score
- 0-2 pts- low risk
- 3-6 pts – moderate risk
- over 6 pts- high risk of PE
- Criteria: suspected dvt 3, alternate dx 3, tachycardia1.5 , post-surgery/disabled in last 4 wks 1.5, previous dvt/pe 1.5, hemoptysis 1 , malignancy past 6 months 1 (causes hypercoag state)
-
For modified wells score: what is used now!
- Over 4, PE is likely
- Under 4, PE is unlikely
5
Q
PE d-dimer
A
- D-Dimer testing: to r/u PE w/unlikely PE pts……………… (TO EXCLUDE PE)
- You will order this first if PE is unlikely
- D-dimers are degradation products of crosslinked fibrin that reflects ongoing activation of hemostatic and thrombolytic system.
- Elevated D-dimer should prompt further testing with diagnostic imaging > 500
- Healthy individuals have a minimal d-dimer
- You CANNOT make a dx of a PE using only d-dimer because you can get false positives (higher w/pregnancy/trauma/surgery/over 50)
6
Q
PE CTPA
A
-
CTPA: First choice diagnostic imaging modality; if PE is likely, get a CTPA- also called CT w/PE protocol
- What is the process? 90% sensitive test
- Images acquired when pt is holding their breath during pulmonary arterial enhancement phase after IV contrast injection.
- The PE will appear as a filling defect in the opacificed pulmonary artery
- You can also use this to disclose causes of hypoxemia
- Use on pts with moderate to high risk of PE! Not for low risk pts
- What is the process? 90% sensitive test
- If the CTPA is inconclusive and cannot confirm or deny PE, then you need more testing.
- V/Q scan, contrast pulmonary angiography, US, MRI pulmonary angiography
7
Q
When to consider using Lung V/Q scan: gamma camera (doesn’t use iodine contrast) for PE
A
- Nuclear Medicine scan with radiopharm (IV and inhalation) that creates an image of air and blood flow patterns in lungs
- Use when CTPA is contraindicated such as with renal insufficiency and hx of severe contrast allergy or if CTPA is inconclusive
- You compare ventilation to perfusion and look for mismatches to indicate PE.
8
Q
CXR for PE
A
- nonspecific as well
- When ordering CXR, you are looking for alternative causes to the pts symptoms.
- Nonspecific abnormalities are common on CXR for PE but many have normal CXR
- Possible signs: not common though
- Hampton’s Hump: shallow, hump-shaped opacity in the periphery of the lung, with its base against the pleural surface and hump towards the hilum
- Pulmonary infarction
- Hampton’s Hump: shallow, hump-shaped opacity in the periphery of the lung, with its base against the pleural surface and hump towards the hilum
- Westermark’s sign: demonstration of a sharp cut-off of pulmonary vessels with distal hypoperfusion in a segmental distribution within the lung
- “less whiteness” aka less vasculature
9
Q
EKG for PE
A
- EKG for PE: nonspecific as well
- Sometimes: S1Q3 pattern
10
Q
USPSTF recommendations regarding screening for lung cancer
A
- Lung cancer is MCC of cancer death in both genders
- 90% due to smoking
- Symptoms:
- Dyspnea, non-productive cough, hemoptysis, pleuritic CP, hoarseness (if presses on laryngeal nerve), pleural effusion, wt loss ~~> advanced disease
- Screening:
- Do not use CXR for SCREENING. They do not reduce mortality.
-
CT screening offered to:
-
Smoker and former smokers 55-74 yo with more than 30 pack-years
- Annual low dose CT scanning
-
Smoker and former smokers 55-74 yo with more than 30 pack-years
- NOT for pts:
- Less than 30 pack-years, outside ages, w/severe comorbidities that could dec ability to cure it or limit life
11
Q
techniques utilized to diagnose and stage lung cancer to include CT scanning, PET scanning, bronchoscopy with endobronchial ultrasound (EBUS)-directed biopsy, and transthoracic needle biopsy.
A
- To diagnosis:
Imaging: use imaging to optimize selection of biopsy site and preferred modality to get sample.
- CXR (PA and lat) is first line imaging choice
- Eventually, every pt should get a CT of chest and upper abdomen to evaluate extent of
Primary tumor and potential spread to liver and adrenal glands
- Pet scan can be used sometimes to evaluate mediastinal LN involvement if sx is option
Tissue biopsy: the cancer diagnosis is based on pathologic evaluation of cytologic of histopathologic specimens
- Cytology: get from thoracentesis or sputum cytology
- More protein and more LDH will be present
- Malignancy will most likely be unilateral
- Bronchoscopy w/biopsy: if malignancy is more centrally located
- Bronchoscopy w/EBUS-directed biopsy is common due to high diagnostic accuracy for getting central primary tumor and most mediastinal LN
- EBUS: used to dx lung cancer, lung infections, enlarged LN/masses in chest
- Uses US with scope to visualize airway wall and structures that guides transbronchial needle aspiration samples (termed TBNA)
- Helpful for biopsy; localizes what’s just outside of bronchi
- Minimally invasive
- For squamous cell carcinomas- you can see this a lot since they lie in the bronchi
- Uses US with scope to visualize airway wall and structures that guides transbronchial needle aspiration samples (termed TBNA)
- EBUS: used to dx lung cancer, lung infections, enlarged LN/masses in chest
- Bronchoscopy w/EBUS-directed biopsy is common due to high diagnostic accuracy for getting central primary tumor and most mediastinal LN
- Transthoracic needle biopsy (TTNB) : peripheral
- Can obtain tissue for accurate diagnosis of peripheral lung nodules/masses
- May use CT and US to guide
- CT is MC
- Complications: pneumothorax is MC and hemoptysis
- May use CT and US to guide
- Can obtain tissue for accurate diagnosis of peripheral lung nodules/masses
12
Q
Two major tests for latent TB
A
-
TST and IGRA
- Evaluates cell- mediated Immunity
13
Q
Latent: LTBI- no symptoms
A
- Clinical diagnosis established by demonstrating prior TB infection and excluding active TB disease
- Latent symptoms: positive TST and positive IGRA, negative sputum smear, stable calcified granulomas
14
Q
Active TB: latent can become active especially when become immunocompromised
A
- Five classic symptoms: cough of 3 weeks, hemoptysis, wt loss, fever, night sweats
- Infectious, positive TST, positive IGRA, abnormal findings
- Culturing sputum for growth of m. tb + staining acid-fast
15
Q
PPD testing: also known as TST
A
- Once you place it, make sure you see a Intradermal bleb.
- Measure longest horizontal diameter in mm of raised/induration reaction 48-72 hours
- Not erythema/redness
- Only record in mm. do not record as positive or negative
- Positive: measurement + pt’s pretest probability
- <5 HIV w/close contact to active contagious case
- >5 immunocompromised, + CXR
- Healthcare workers: > 10 mm
- Health ppl > 15 mm
18
Q
PE dx flow chart
A
