Pugging Flashcards
Stage T1
T1a: <2 cm
T1b: >2 cm to 3 cm
Stage T2
T2a: > 3-5 cm
T2b: > 5-7 cm
- Involve main bronchus, >2cm from carina
Stage T3
- Tumor > 7 cm
- Main bronchus <2cm from carina
- Invasion (phrenic n, parietal pericardium, chest wall, diaphragm)
- Additional tumor nodules in same lobe
Stage T4
- Invasion of important structures (trachea, SVC, aorta, recurrent lar. n, esophagus
- Ipsilateral nodules, in different lobe
Stage N1
Ipsilateral hilar
Stage N2
Ipsilteral
- Mediastinal
- Subcarinal
N3
- Contralateral
- Supravlavicular
Stage M1
Metastases M1a: - Contralateral lung - Pleura - Pericardium M1b: - Distant
Surgical resection stage
Up to IIIA
- T4 N0-1 M0
- T3 N1 M0
- T1-3 N2 M0
Surgery options
- Lobectomy
- Bilobectomy
- Pulmonectomy
- Atypical resection (Wedge resection?)
Performance status grading
ECOG
- 0-2 good for treatment (?)
Chemotherapy SCLC first line
Stage I-III:
Cisplatin/carboplatin+etoposide
- 6 cycles
- Thoracic radiation after 3rd (~50Gy)
Stage IV:
- 4-6 cycles
Chemotherapy SCLC second line
- Topotecan OR
- Epirubicine-Cyclophosphamide-Vincristine (4 cycles)
NSCLC adjuvant chemo stage
IB to IIIA
- After surgery
NSCLC neoadjuvant chemotherapy
Before surgery
- Make it resectable
- E.g stage IIIA
NSCLC palliative chemotherapy stage
Stage IIIB-IV
NSCLC chemotherapy
Stage IIIB-IV palliative, or stage IB-IIIA neoadj/adj
Cisplatin or Carboplatin
+
Gemcitabin/Docetaxel/Pemetrexed
NSCLC second/third line chemotherapy
- Chemo: Docetaxel or pemetrexed monotherapy
- Targeted therapy: EGFR blockers
Molecular targeted therapy in IIIB and IV adenocc
1) VEGF antagonist (angiogenesis): Bevacizumab
- With first line chemo
2) EGFR antagonists (tyrosine kinase)
Gefitinib or Erlotinib
- Monotherapy
Radiation therapy
High energy X-rays
- External radiation
- Endoluminal brachytherapy
Light’s criteria (pleural fluid is exudate if)
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)
Protein level and LDH level that suggests effusion is exudate
Protein > 30g/L
LDH > 200 iu/L
Epidemiology of TBC
1) Leading infectious cause of morbidity and mortality
2) 1/3 of population infected
3) 2-3 millions die per year
Treatment TBC
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)
2nd line antiTBC drugs
- Streptomycin
- Ethambutol
- Paraaminosalicylic acid (PAS)
- Fluoroquinolones (levofloxacin)
- Cycloserine
Causative agents community acquired pneumonia
1) Strep pneumo
2-3) M. Pneumo, Chlamydophila pneumoniae
4-5) H. Infl, Klebsiella pn
6) Viruses
Causative agents nosocomial pneumoniae
1) Enterobacteriaceae (E.coli)
2) Pseudomonas
3) Staph aureus
4) Acinetobacter spp
5) H. infl
Fine crackels (rales, crepitations)
- Discontinuous
- Similar to wood burning
- Both phases of resp
- Early insp+exp: chr. Bronchitis
- Late insp: pneumonia, CHF, atelectasis
Wheeze
- Continous
- High or low pitched
- Narrowing of airways
- Insp: stiff stenosis, tumor, foreign body, scarring
- Exp: bronchiolar disease (eg asthma)
Rhonchi
«Low pitched wheeze»
- Continous
- Insp and exp
- Often clear after cough
Pleural rubs
- Discontinous or continous
- Creaking sound (gå på kram snø)
- Insp and exp (whenever chest moves)
Blood gas pneumonia
- Hypoxemia
- Hypocapnia
- Alkalosis
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
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)
Empirical AB treatment PORT I
Amoxicillin-clavulanic acid
OR
Macrolides (Klacid, Sumamed)
Empirical AB treatment PORT II-III
Amoxocillin-clavulanic acid
AND
Macrolides (Klacid, Sumamed) or
Fluoroquinolones (levofloxacin, moxi)
Empirical AB treatment PORT III-IV (hospital, iv)
Amoxicillin-clavulanic acid or cephalosporins (ceftriaxone, cefotaxime)
AND
Macrolides (Klacid, sumamed) or Levofloxacin
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
Supportive treatment pneumonia
- O2
- Fluid, electrolytes
- Antipyretics
- Insulin
- Antiarrhytmic
- Anticoag (heparin)
- Low dose steroid (antifibrogen)
- Bronchodilator
Normal values FEV1, FVC, ratio
FEV1: 4 L
FVC: 5 L
Ratio: 0.8 (<0.7 indicates obstructive disease)
Assesment of COPD symptoms
- COPD assessment test (CAT)
- mMRC Breathlessness scale/questionaire (modified british medical research council) - grade 0-4
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
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)
Medications COPD
- SABA/LABA
- SAMA/LAMA
- Methylxanthines
- Inhaled/systemic corticosteroids
- Phosphodiesterase-4 inhibitors (roflumilast)
Therapeutic recommendations for COPD medication
- Gr A: Bronchodilator
- Gr B: LABA or LAMA => both
- Gr C: LAMA => both
- Gr D: LABA+LAMA => both+ICS
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
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
Asthma definition
1) Chronic inflammatory
2) Wheeze, cough, dyspnea
3) Airflow limitation
4) Airflow hyperresponsiveness
Asthma classification
1) Severity
- Intermittent, mild-, moderate-, severe persistent
2) Control level
- Controlled, partly controlled, uncontrolled
3) Etiology
- Extrinsic, intrinsic
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
Inhaled corticosteroids (3)
1) Beclomethasone
2) Budesonide
3) Fluticasone
Leukotriene modifiers
- 5-LO inh: Zileuton
- CysLT1 antag: Montelukast, Zafirlukast, Pranlukast
Anti-IgE
Omalizumab
Valve used in pleural suction (ptx)
Heimlich valve
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)
Treatment malignant pleural mesothelioma
Radio+chemo (pemetrexed+cisplatin)
- Poor effect, poor prog
- Survival ~12 months
Pleurodesis
Fusion of visceral and parietal pleura
- For pleural effusion
Other word for pleural tapping of fluid
Thoracocentesis
Sclerosing agents used for pleurodesis (3-4) + SEs (2)
1) Talc
2-3) Doxycycline, Tetracycline
4) Bleomycin
SEs: chest pain, fever
Sleep study
Polysomnography (PSG)
Sleep state scoring
EEG
EMG (electronyography)
EOG (electrooculography)
Sleep apnea «types» (3)
1) Obstructive sleep apnea
2) Central sleep apnea
3) Sleep related hypoventilation syndromes
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)
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
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)
COPD treatment protocol (facebook)
Step
1) SABA, SAMA
2) LABA, LAMA
3) Depends on exacerbation frequency
- High: Corticosteroids
- Low: don’t give
Pleura on US
Highly echogenic
Bone metastases on US
Hypoechoic
Pleural effusion on US
- Transudates: anechoic
- Exudates: can be complex, septated or echogenic
- Malignant: often anechoic
Pneumothorax on US
- Absence of normal lung sliding
- Loss of comet-tail artefacts
- Exaggerated horizontal reverberation artefacts
Lung/pleural tumor on US
Hypoechoic with posterior acoustic enhancement
Atypical mycobacteria examples (5)
1) M. Avium Complex (MAC)
2) M. Kansasii (Kansas)
3) M. Malmoense (Malmö)
4) M. Abscessus
5) M. Xenopi
Examples SABAs (3)
- Fenoterol
- Salbutamol
- Terbutaline
Examples LABAs (3)
- Salmeterol
- Formoterol
- Olodaterol
Examples SAMAs (2) and LAMAs (2)
SAMA: Ipratropium & Oxitropium
LAMA: Tiotropium & Glycopyrronium
Methylxanthine example + disadvantage
Thiophylline
- Narrow TI
Phosphodiesterase 4 inhibitor
Roflumilast
- COPD
Triple therapy COPD
LABA
LAMA
ICS
Comorbidities COPD
1) Lung cancer
2) Cardiovascular
3) Osteoporosis
4) Depressiob/anxiety
5) Sleep apnea
6) GERD