Pugging Flashcards
1
Q
Stage T1
A
T1a: <2 cm
T1b: >2 cm to 3 cm
2
Q
Stage T2
A
T2a: > 3-5 cm
T2b: > 5-7 cm
- Involve main bronchus, >2cm from carina
3
Q
Stage T3
A
- Tumor > 7 cm
- Main bronchus <2cm from carina
- Invasion (phrenic n, parietal pericardium, chest wall, diaphragm)
- Additional tumor nodules in same lobe
4
Q
Stage T4
A
- Invasion of important structures (trachea, SVC, aorta, recurrent lar. n, esophagus
- Ipsilateral nodules, in different lobe
5
Q
Stage N1
A
Ipsilateral hilar
6
Q
Stage N2
A
Ipsilteral
- Mediastinal
- Subcarinal
7
Q
N3
A
- Contralateral
- Supravlavicular
8
Q
Stage M1
A
Metastases M1a: - Contralateral lung - Pleura - Pericardium M1b: - Distant
9
Q
Surgical resection stage
A
Up to IIIA
- T4 N0-1 M0
- T3 N1 M0
- T1-3 N2 M0
10
Q
Surgery options
A
- Lobectomy
- Bilobectomy
- Pulmonectomy
- Atypical resection (Wedge resection?)
11
Q
Performance status grading
A
ECOG
- 0-2 good for treatment (?)
12
Q
Chemotherapy SCLC first line
A
Stage I-III:
Cisplatin/carboplatin+etoposide
- 6 cycles
- Thoracic radiation after 3rd (~50Gy)
Stage IV:
- 4-6 cycles
13
Q
Chemotherapy SCLC second line
A
- Topotecan OR
- Epirubicine-Cyclophosphamide-Vincristine (4 cycles)
14
Q
NSCLC adjuvant chemo stage
A
IB to IIIA
- After surgery
15
Q
NSCLC neoadjuvant chemotherapy
A
Before surgery
- Make it resectable
- E.g stage IIIA
16
Q
NSCLC palliative chemotherapy stage
A
Stage IIIB-IV
17
Q
NSCLC chemotherapy
Stage IIIB-IV palliative, or stage IB-IIIA neoadj/adj
A
Cisplatin or Carboplatin
+
Gemcitabin/Docetaxel/Pemetrexed
18
Q
NSCLC second/third line chemotherapy
A
- Chemo: Docetaxel or pemetrexed monotherapy
- Targeted therapy: EGFR blockers
19
Q
Molecular targeted therapy in IIIB and IV adenocc
A
1) VEGF antagonist (angiogenesis): Bevacizumab
- With first line chemo
2) EGFR antagonists (tyrosine kinase)
Gefitinib or Erlotinib
- Monotherapy
20
Q
Radiation therapy
A
High energy X-rays
- External radiation
- Endoluminal brachytherapy
21
Q
Light’s criteria (pleural fluid is exudate if)
A
1) Pleural fluid protein / serum protein is > 0.5
2) Pleural fluid LDH / serum LDH is >0.6
3) Pleural fluid LDH > 2/3 of the upper limits of normal serum LDH (>266iu/L)
22
Q
Protein level and LDH level that suggests effusion is exudate
A
Protein > 30g/L
LDH > 200 iu/L
23
Q
Epidemiology of TBC
A
1) Leading infectious cause of morbidity and mortality
2) 1/3 of population infected
3) 2-3 millions die per year
24
Q
Treatment TBC
A
Rifampin: 600 mg/day Isoniazide: 300 mg/day Pyrazinamide: 1.5 g/day Ethambutol: 2.0 g/day *all per os (streptomycin is i.v)
25
2nd line antiTBC drugs
- Streptomycin
- Ethambutol
- Paraaminosalicylic acid (PAS)
- Fluoroquinolones (levofloxacin)
- Cycloserine
26
Causative agents community acquired pneumonia
1) Strep pneumo
2-3) M. Pneumo, Chlamydophila pneumoniae
4-5) H. Infl, Klebsiella pn
6) Viruses
27
Causative agents nosocomial pneumoniae
1) Enterobacteriaceae (E.coli)
2) Pseudomonas
3) Staph aureus
4) Acinetobacter spp
5) H. infl
28
Fine crackels (rales, crepitations)
- Discontinuous
- Similar to wood burning
- Both phases of resp
- Early insp+exp: chr. Bronchitis
- Late insp: pneumonia, CHF, atelectasis
29
Wheeze
- Continous
- High or low pitched
- Narrowing of airways
- Insp: stiff stenosis, tumor, foreign body, scarring
- Exp: bronchiolar disease (eg asthma)
30
Rhonchi
«Low pitched wheeze»
- Continous
- Insp and exp
- Often clear after cough
31
Pleural rubs
- Discontinous or continous
- Creaking sound (gå på kram snø)
- Insp and exp (whenever chest moves)
32
Blood gas pneumonia
- Hypoxemia
- Hypocapnia
- Alkalosis
33
Diagnosis pneumonia
- Sputum from lower airw
- Protected brush specimen
- BAL
- Serology: mycopl, chlam, legionella
- Urinary Ag test: Legionella
- M. Tub: Mantoux, direct Koch, culture, PCR, Quantoferon test
34
PORT
```
«Pneumonia outcome research team» points
- Show risk of pneumonia pts
- I-V
- PORT increase w/ age, comorbidities, severity of symptoms
- Lethality
I-III~0.x% (treat at home, AB po)
IV~10% (hospital, AB iv)
V~30% (ICU, AB iv)
```
35
Empirical AB treatment PORT I
Amoxicillin-clavulanic acid
OR
Macrolides (Klacid, Sumamed)
36
Empirical AB treatment PORT II-III
Amoxocillin-clavulanic acid
AND
Macrolides (Klacid, Sumamed) or
Fluoroquinolones (levofloxacin, moxi)
37
Empirical AB treatment PORT III-IV (hospital, iv)
Amoxicillin-clavulanic acid or cephalosporins (ceftriaxone, cefotaxime)
AND
Macrolides (Klacid, sumamed) or Levofloxacin
38
Empirical AB treatment PORT IV-V (hospital, iv)
Cephalosporins (ceftriaxone, cefotaxime) or
Imipenem or Meropenem or
Piperacillin-tasobactam
AND
Macrolides (klacid, sumamed) or
Levofloxacin or
Aminoglycocide
39
Supportive treatment pneumonia
- O2
- Fluid, electrolytes
- Antipyretics
- Insulin
- Antiarrhytmic
- Anticoag (heparin)
- Low dose steroid (antifibrogen)
- Bronchodilator
40
Normal values FEV1, FVC, ratio
FEV1: 4 L
FVC: 5 L
Ratio: 0.8 (<0.7 indicates obstructive disease)
41
Assesment of COPD symptoms
- COPD assessment test (CAT)
| - mMRC Breathlessness scale/questionaire (modified british medical research council) - grade 0-4
42
Classification of severity of airflow limitation in COPD
```
Based on post-SABA FEV1
- GOLD 1: FEV1 = 80 %
- GOLD 2: FEV1 = 50-80%
- GOLD 3: FEV1 = 30-50%
- GOLD 4: FEV1 < 30% predicted
Mild, moderate, severe, very severe
```
43
Assessment of COPD
- Symptoms (CAT, mMRC)
- Airflow limitation (GOLD 1-4)
- Risk of exacerbations (2 or more within last year, or FEV1<50% are high risk)
44
Medications COPD
- SABA/LABA
- SAMA/LAMA
- Methylxanthines
- Inhaled/systemic corticosteroids
- Phosphodiesterase-4 inhibitors (roflumilast)
45
Therapeutic recommendations for COPD medication
- Gr A: Bronchodilator
- Gr B: LABA or LAMA => both
- Gr C: LAMA => both
- Gr D: LABA+LAMA => both+ICS
46
Type I and II respiratory failure
I: Hypoxemic
- PaO2<60mmHg on 60 % oxygen
- Oxygenation failure
II: Hypercapnic
- PaCO2>45mmHg and pH<7.35
- Ventilatory failure
47
Zubrod scale (performance state of patient)
0: Normal activity
1: Can walk, but need support
2: In bed close to 50% of time
3: In bed >50% of daytime
4: Bed-ridden
48
Asthma definition
1) Chronic inflammatory
2) Wheeze, cough, dyspnea
3) Airflow limitation
4) Airflow hyperresponsiveness
49
Asthma classification
1) Severity
- Intermittent, mild-, moderate-, severe persistent
2) Control level
- Controlled, partly controlled, uncontrolled
3) Etiology
- Extrinsic, intrinsic
50
PEF (abbreviation+unit+normal+asthma)
```
Peak expiratory flow
(L/min)
- Normal range: 400-600 L/min
- Asthmatics: 200-400 L/min
- Daily PEF variability >20% suggest asthma
```
51
Inhaled corticosteroids (3)
1) Beclomethasone
2) Budesonide
3) Fluticasone
52
Leukotriene modifiers
- 5-LO inh: Zileuton
| - CysLT1 antag: Montelukast, Zafirlukast, Pranlukast
53
Anti-IgE
Omalizumab
54
Valve used in pleural suction (ptx)
Heimlich valve
55
Methods for pleural biopsy (4)
1) Closed needle biopsy (Cope-Ramel needle)
2) CT guided core biopsy
3) Medical thoracoscopy
4) Surgical biopsy (VATS, open surgical biopsy)
56
Treatment malignant pleural mesothelioma
Radio+chemo (pemetrexed+cisplatin)
- Poor effect, poor prog
- Survival ~12 months
57
Pleurodesis
Fusion of visceral and parietal pleura
| - For pleural effusion
58
Other word for pleural tapping of fluid
Thoracocentesis
59
Sclerosing agents used for pleurodesis (3-4) + SEs (2)
1) Talc
2-3) Doxycycline, Tetracycline
4) Bleomycin
SEs: chest pain, fever
60
Sleep study
Polysomnography (PSG)
61
Sleep state scoring
EEG
EMG (electronyography)
EOG (electrooculography)
62
Sleep apnea «types» (3)
1) Obstructive sleep apnea
2) Central sleep apnea
3) Sleep related hypoventilation syndromes
63
Diagnostic criterias sleep apnea (OSAS) («3»)
1) Excessive daytime sleepiness (EDS)
2) 2 or more:
a. Airflow cessations (apneas) during sleep
b. Repetitive awakenings during night
c. Bad sleep quality
d. Impaired memory and learning skills
3) At least 5 apnea/hypopnea per hour during polysomnography (AHI>5)
64
AHI + scale
Apnea-Hyponea index
= «average no. of apneic and hyponeic episodes per 1 hour of sleep»
AHI 5-15: Mild disorder
AHI 15-30: Moderate
AHI >30: Severe
65
Asthma treatment protocol (step 1-5)
1) SABA as needed
2) Add Low-dose ICS
3) Add LABA
4) Medium/high-dose ICS + LABA (and/or LT modifier, theophylline)
5) Add Oral glucocorticoids and/or Anti-IgE (Omalizumab)
66
COPD treatment protocol (facebook)
Step
1) SABA, SAMA
2) LABA, LAMA
3) Depends on exacerbation frequency
- High: Corticosteroids
- Low: don’t give
67
Pleura on US
Highly echogenic
68
Bone metastases on US
Hypoechoic
69
Pleural effusion on US
- Transudates: anechoic
- Exudates: can be complex, septated or echogenic
- Malignant: often anechoic
70
Pneumothorax on US
- Absence of normal lung sliding
- Loss of comet-tail artefacts
- Exaggerated horizontal reverberation artefacts
71
Lung/pleural tumor on US
Hypoechoic with posterior acoustic enhancement
72
Atypical mycobacteria examples (5)
1) M. Avium Complex (MAC)
2) M. Kansasii (Kansas)
3) M. Malmoense (Malmö)
4) M. Abscessus
5) M. Xenopi
73
Examples SABAs (3)
- Fenoterol
- Salbutamol
- Terbutaline
74
Examples LABAs (3)
- Salmeterol
- Formoterol
- Olodaterol
75
Examples SAMAs (2) and LAMAs (2)
SAMA: Ipratropium & Oxitropium
LAMA: Tiotropium & Glycopyrronium
76
Methylxanthine example + disadvantage
Thiophylline
| - Narrow TI
77
Phosphodiesterase 4 inhibitor
Roflumilast
| - COPD
78
Triple therapy COPD
LABA
LAMA
ICS
79
Comorbidities COPD
1) Lung cancer
2) Cardiovascular
3) Osteoporosis
4) Depressiob/anxiety
5) Sleep apnea
6) GERD
