PACES Viva Questions Flashcards
List some reasons for performing a pneumonectomy or lobectomy
- Lung malignancy (Common) and Pulmonary Metastasis (Rare)
- Localised bronciectasis with uncontrolled symptoms e.g. recurrent Haemoptysis
- Old TB (Prior to anti-TB meds)
- Fungal infections e.g. aspergilloma
- Traumatic lung injury
- Large emphysematous Bullaea (Bullectomy)
- Congenital lung disease e.g. Cystic fibrosis
- Bronchial obstruction with destroyed lung.
What are the chest radiograph is features in a pneumonectomy /Lobectomy?
On PA CXR the following features will be seen:
- White out on one side (Pneumonectomy)
- In lobectomy there may be volume loss in the ipsilateral hemithorax, increased transradiancy of the ipsilateral lung due to compensatory hyperinflation, the presence of surgical clips and evidence of rib resections.
- Deviated trachea or mediastinum towards the pneumonectomy or lobectomy
- Compensatory hyperinflation of contralateral lung in pneumonectomy.
What is the importance of preoperative evaluation on pneumonectomy?
Preoperative evaluation is vital in both pneumonectomy and lobectomy because of the significant loss of lung function that follows.
Additionally, because such interventions are usually performed in patients with underlying lung disease, it is essential to assess the patients functional reserve and predicted pulmonary function follow surgery.
Pre-operative FEV1 over 2L is associated with low risk, no further testing required in absence of pulmonary hypertension (1.5L is acceptable for patients undergoing lobectomy)
Pre-operative FEV1 less than 2L is high risk, these patients require predicted post operative FEV1 and Gas transfer estimations following quantitative lung ventilation / perfusion scanning.
Preoperative cardiopulmonary tasting can also be performed. A Pre Operative VO2 Max less than 10mL/Kg/Min is associated with a high mortality risk (over 30%) versus those with preoperative VO2 Max over 15mL/Kg/min which are associated with a Mortality Risk less than 15%
Are you aware of any subtypes of pneumonectomy?
There are 2 main types of pneumonectomy:
- simple - removal of affected lung
- Extrapleural - removal of affected lung plus part of the diaphragm, parietal pleura, and pericardium on ipsilateral side. These are then replaced by surgical Gore-Tex
The primary use of extrapleural pneumonectomy is in the treatment of malignant mesothelioma because this particular technique has been shown to have the best survival rates. (Clinical oncology study 2008)
If this patient had a lobectomy secondary to lung malignancy, can you suggest a likely subtype of lung cancer?
Surgery has a greater role in the management of ‘NSCLC’ rather than Small cell Carcinoma the latter of which has a poorer prognosis and is almost always unsuitable for surgical intervention by the time of presentation.
The most common type of NSCLC is squamous, followed by Adenocarcinoma, alveolar cell, large cell, carcinoid.
What proportion of NSCLC are suitable for surgery?
Approximately 25% of NSCLC will be suitable for surgical resection
Comment on the operative mortality or (i) Lobectomy and (ii) Pneumonectomy? Are there any differences between the right and left sides?
Operative mortality for lobectomy is approximately 2-4% and for pneumonectomy this rises to 6%.
There is a marked difference is mortality rates between the right and left sides following pneumonectomy. Right sided pneumonectomy is associated with higher overall mortality (10-12%) as compared to left-sided (1-3.5%). Reasons are uncertain for this difference but are most-likely due to life threatening complications that are encountered at a higher frequency following right-sided procedures such as post-pneumonectomy space empyema, pulmonary oedema, and bronchopleural fistula.
What is the ‘Post-Pneumonectomy syndrome’?
This syndrome results from the extrinsic compression of the distal trachea and main-stem bronchus due to mediastinal shifting and compensatory hyperinflation that occurs in the remaining lung.
Post-pneumonectomy syndrome occurs almost exclusively in patients with right sided pneumonectomy , approximately 6 months post surgery but can occurs years after the procedure.
The syndrome is characterised by progressive dyspnoea, cough, inspiratory stridor, and pneumonia. Treatment includes surgical repositioning of the mediastinum and filling fo the post-pneumonectomy space with non-absorbable material +/- stenting of the bronchi.
This condition can be fatal if not treated.
What are the indications for VATS procedure?
Lobectomy and pneumonectomy
Correction of spontaneous primary pneumothorax
Wedge resection
Lung parenchymal biopsy
Bullectomy and lung volume reductions surgery
What are the main differences in approach in VATS vs Open Thoracotomy?
VATS is associated with better cosmetic outcomes utilising smaller incisions, reduced in hospital recovery and total recovery. Less discomfort.
However it is associated with an increased risk of recurrent pneumothorax 5% vs 1% in Open thoracotomy.
Describe the Risk factors for developing Lung Cancer
Smoking - estimated 90% of all lung cancers caused by smoking. Adenocarcinoma is the only subtype not associated with smoking. Current smoker of 40 Pack years has a 20-fold increase risk.
Radiation therapy
Environmental exposure to passive smoke, asbestos, radon, metals (Arsenic, Chromium, Nickel)
Pulmonary fibrosis
COPD
Alpha 1 Antitrpsin deficiency,
Genetic factors i.e increased risk in those with family history.
Describe the histological classification of lung cancer.
Non-Small Cell Lung Cancer (NSCLC)
- 75%-80% of lung cancer
- Squamous, adenocarcinoma, alveolar, large cell
Small Cell Lung Cancer
- 20-25% of lung cancer
- rapidly proliferating tumour with early dissemination.
Name the common sites of Lung metastases.
Liver
Adrenal Glands
Bone - Osteolytic appearance, most commonly in vertebral bodies
Brain
What are the most common paraneoplastic syndromes that affect lung cancer patients?
Hypercalcaemia
SIADH
Describe the staging classification of NSCLC
Classified using TNM classification:
T1 tumour less than 3cm
T2 tumour greater than 3cm or involves main bronchus, or more than 2cm distal to the carina, or invading visceral pleura.
T3 tumour of any size that invades the chest wall, diaphragm, mediastinal pleura, parietal pericardium or tumour in main bronchus less than 2cm distal to the carina.
T4 tumour of any size that invades the mediastinum, heart, great vessels. Trachea, oesophagus. Or a tumour with malignant pleural/pericardial effusion or a tumour with satellite lung nodules within the same lobe as the primary.
N0 - No regional lymph nodes
N1 metastasis to ipsilateral peribronchial or hilar lymph nodes
N2 metastasis to ipsilateral mediastinal or subcarinal nodes
N3 metastasis to contralateral nodes or ipsilateral scalene or supracalvicular nodes.
M0 No distant Metastasis
M1 Distant metastases
Describe the classification of SCLC
Limited disease:
- Disease confined to ipsilateral hemithorax
- Median range survival 15-20 months
Extensive Disease:
- Metastatic Disease outside ipsilateral hemithorax
- Median range of survival 8-13 months
What other prognostic factors help guide treatment in lung cancer?
WHO Performance Score:
- 0 Asymptomatic
- 1 symptomatic but ambulatory and able to carry out light work
- 2 in bed less than 50% of the day
- 3 in bed over 50% of the day and unable to self care
- 4 bed bound
Weight Los
Describe the management of patients with NSCLC
Patients should be discussed at a lung cancer MDT meeting and given information regarding their diagnosis and treatment. Lung cancer nurse specialists are essential to provide continuing support or the patient and coordinate their care.
Surgery:
- Surgical resection in the form of lobectomy or pneumonectomy offers the best long-term survival for patients with lung cancer
- Considered in patients with stage I and II disease and considered on an individual basis in patients with Stage IIIa disease.
- Patients need to be careful selected based on adequate lung function and co-morbidities.
- Classically patient with an FEV1 greater than 2L (or 80% predicted) can tolerate pneumonectomy and FEV1 greater than 1.5L patient can tolerate Lobectomy. Patients with a DLCO over 80% have low postoperative risk.
- Patients who do not clearly fit a low-risk category can have further testing to assess their predictive postoperative lung function, taking into account preoperative lung function, amount of tissue to be resected and preoperative contribution of tissue to be resected to overall lung function. A Predicted postoperative FEV1 of over 40% normal predicted is required for surgery.
- Cardiopulmonary exercise testing is performed to assess the level of work a patient can achieve, measured by maximal oxygen consumption VO2 Max. VO2 Max less than 10mL/Kg/Min is associated with increased risk (30% mortality) whereas VO2 max over 15mL/Kg/Min is deemed acceptable (Less than 15% mortality)
- Postoperative adjuvant chemotherapy has been shown to improve survival with patients with Stage II disease.
Radical Radiotherapy:
-CHART (Continuous hyperfractionated accelerated radiotherapy) is considered in patients with Stage I, II, III disease who are inoperable but have good performance status
Chemotherapy:
- Offered to patients with III or IV cancer with good performance status. (WHO 0-1)
- Usually a platinum-based drug (Carboplatin, Cisplatin) combined with a 3rd generation drug (Docetaxel, gemcitabine, paclitaxel, or vinorelbine)
- COmbination of chemotherapy and radiotherapy provides a survival advantage in patients with stage III disease.
Palliative Treatment:
- Stage IV Disease
- Radiotherapy to control symptoms
- Chemotherapy in patients with good performance status can prolong survival without significant impairment of quality of life.
- symptoms control wit analgesics, anti-emetics, steroids (may improve appetite and performance status)
- planning end of life care wit the support of the palliative care team.
Describe the management of small cell lung cancer
Combination treatment with radiotherapy and platinum-based chemotherapy
Prophylactic cranial irradiation considered in patients who respond to treatment - shown to reduce the incidence of brain metastases (Common after treatment for SCLC due to inadequate penetration of chemotherapy agents through the blood-brain barrier) and prolong survival
What treatment are available to help patients stop smoking?
Smoking cessation improves symptoms, improves lung function (there is a significantly reduced rate of decline in FEV1 with a return to near normal age-related decline over time) and is the only treatment sown to alter disease course.
Behavioural Treatment:
- 5 A approach endorsed by the BTS, Ask about smoking status, Assess readiness to quit, Advise to quit, Assist in efforts to quit, Arrange follow-up.
- Patients should be encourage to identify a quit day.
- Informing patients of abnormal lung function increases their likelihood of quitting
- Group-counselling includes lectures, habit recognition, copying skills and suggestions for relapse prevention.
Nicotine Replacement Therapy:
- Insufficent evidence to conclude one form of NRT is more effective than another.
- Nicotine patches, gum, inhalers (Can cause bronchospasm), nasal sprays (REsults in more rapid rise in plasma nicotine levels mimicking smoking, can cause nasal irritation)
Buproprion:
-Antidepressant which enhances CNS noradrenergic and dopaminergic function.
Varenicline:
-Partial agonist of nicotinic acetylcholine receptors, Side-effects include abnormal dreams, nausea and neuropsychiatric symptoms.
Some evidence of increased efficacy with combination treatment. No evidence for the effectiveness of acupuncture or hypnosis.
Describe the treatment options available for COPD
Non-Pharmacological Treatment:
- Pulmonary rehabilitation, multidisciplinary programme of care incorporating disease education, physical training, nutritional, psychological and behaviour interventions. Leads to a statistically significant improvement in exercise capacity and quality of life and reduces dyspnoea with conflicting evidence regarding effect in reducing hospital admissions. Consider in patients with MRC Dyspnoea Grade 3+
- Optimize nutrition, poor nutritional states associated with increased mortality, impaired respiratory muscle function and reduced immune function
- Vaccinations, infleunza should be offered to all patients and pneumococcal in patients over 65 of with an FEV1 less than 40% predicted.
Pharmcological Treatment:
- Treatment aims to reduce symptoms, decrease frequency and severity of exacerbation, improve quality of life and increase exercise capacity. Medication can be relieved by pressurised metered dose inhaler, dry powder inhaler with or without spacer or nebulisers. Inhalers can achieve response equivalent to nebulisers if used correctly an inhaler technique should be checked regularly.
- Short acting bronchodilators, short acting beta 2 agonists act directly on bronchial smooth muscle to cause bronchodilation e.g. salbutamol terbutaline.
- Short acting anticholinergics inhibit resting bronchomotor tone and affect muscular secretion e.g. Ipratropium bromide.
- combination treatment has additive effect. Does not alter the frequency of exacerbations.
- Long-acting bronchodilators: recommended in patients who remain symptomatic on above treatment of experience more then 2 exacerbations a year.
- Long acting beta 2 again it’s : TORCH STUDY (TOwards a Revolution in COPD Health) - salmeterol reduced exacerbation rates, improved lung function and health-related unlit you of life compared to placebo.
- Long-acting anticholinergics: UPLIFT study (Understanding the Potential Long-term Impact on Function with Tiotropium) treatment with tiotropium therapy (Versus placebo in patients permitted to use other respiratory medications except anticholingergics) shown to improve lung fun UTI mood reduce exacerbation and improve health-elated quality life over a 4 year period.
Inhaled Corticosteroids:
- Reduce airway and systemic inflammation. Indicated for patients with an FEV1 Less than 50% predicted who are having more than 2 exacerbation a year. 12 RCTs demonstrated reduction in risk of exacerbation versus placebo with no significant effect on mortality. TORCH study fluticasone propionate reduced rate of moderate severe exacerbation and improved quality of life and improved lung function vs placebo.
- Frequency of pneumonia increase in patients use ICS and increased risk of oral candies is but this did not have a significant effect on mortality.
Oral Corticosteroids:
-Associated with increased morbidity and mortality and therefore use of oral cortical steroids is not recommend. Trial of oral corticosteroids does not predict response to inhaled treatment.
Combination treatment LABA + ICS:
-TORCH Study showed salmteraol and fluticasone combined improved lung unction, health status and frequency exacerbation compared to individual therapies and placebo. Mortality reduced compared to placebo but had borderline significance. Further analysis has showed therapy to slow rate of lung function decline.
Theophylline:
- Unclear mechanism of action, relaxes airway smooth muscles. May improve diaphragm strength and affect mucociliary clearance.
- Given potential toxicity and drug interaction and need to monitor plasma levels it is no recommended for initial treatment.
Oxygen:
- LTOT is indicated in patients with PaO2 less than 7.3kPa, or less than 8kPa in the presence of secondary polycythaemia, nocturnal hypoxaemia, cor pulmonale or pulmonary hyfunction hypertension. Needs to use more than 15hours a day and improves survival and quality of life.
- AMbulatory oxygen is considered in patients who desaturate on exercise of show improvement in exercise capacity with oxygen.
- Short-burst oxygen is on spider in patients with epsiodes of severe breathlessness not relieved by alternative treatments
Non-Invasive Ventilation:
- Considered in patients with CHronic II respiratory failure despite adequate treatment.
- May rest fatigued respiratory muscles, improve sleep quality and by reducing nocturnal hypoventilation, may reset respiratory centre leading to improvements in daytime hypercapnia
Describe the role of surgery in patients with COPD
Lung Volume reduction surgery:
- Removing areas of poorly functioning lung (and thus allowing expansion of more physiologically useful lung) can improve exercise capacity, quality of life and mortality in a select group of patients
- Patients who remain symptomatic despite maximal medical therapy and pulmonary rehabilitations and have FEV1 over 20% predicted, PaCO2 less than 7.3kPa, TLCO over 20% predicted and predominantly upper lobe emphysema should be referred for consideration
Bullectomy:
- Bullectomy improves symptoms and lung function by reducing airway resistance and functional residual capacity, improving elastic recoil, restoring the mechanical linkage between the chest wall and normal lung and moving the diaphragm into more efficient position.
- Should be considered in patients with progressive dyspnoea despite maximal medical treatement, FEV1 less than 50% predicted and bullae over 1/3 hemithorax with preserved function in surrounding lung.
Lung Transplant:
- can improve functional capacity
- The international Society for Heart and Lung Transplant registry report an overall 1 year survival of 78% and 5 year survival of 51%. However the true increase in survival over the natural history of COPD is less clear
- Guidelines for referral include: BODE index > 5, post bronchodilator FEV1 less than 25%, resting hypoxaemia and hypercapnia, secondary pulmonary hypertension and accelerated decline in FEV1.
What causes an acute exacerbation of COPD?
Infection (60%):
- Viruses: Rhinovirus, influenza, parainfluenza, cornavirus, adenovirus
- Bacteria: haemophilus influenza, Moraxella catarrhalis, streptococcus pneumonia, pseudomonas, enterobacteria, Incidence of atypical is low
Environmental pollution (10%)
Unknown Aetiology (30%)
How are infective exacerbations of COPD treated?
- Controlled oxygen therapy to achieve arterial oxygen saturation’s of 88-92%
- nebulised beta-2-agonists
- nebulised anticholinergics
- oral corticosteroids: improve lung function and reduce hospital length of stay
- antibiotics: initial empirical treatment with amino penicillin, macrolides or tetracycline.
- Aminopylline: not recommend as first line treatment, RCT have failed to show benefit compared to effect of bronchodilators and steroids. Significant side-effects including nausea, tremor and tachyarrhythmia
- Discharge planning should involve a community COPD treatment team.