pulm 4 Flashcards
carcinoid lung tumor
patho:
- Low grade malignant neoplasms
- Grow slowly and rarely _____
- Most occur as _____ or sessile growths in _____ bronchi
- Most patients are under 60 years of age
- Common symptoms are hemoptysis, cough, focal wheezing, and recurrent _____
- Peripherally located carcinoid tumors are rare, present as asymptomatic solitary _____
S/S:
- Carcinoid syndrome is rare
- Symptoms are _____, diarrhea, wheezing, and hypertension
diagnostics:
- Bronchoscopy may reveal a _____ or _____ tumor in a central airway
- _____ can be complicated by bleeding due to a well-vascularized stroma
- _____ scans to monitor growth over time
- Octreotide scans can localize tumors
tx:
- _____ is treatment of choice
- Most are resistant to radiation and chemotherapy
- Prognosis is usually favorable
metastasize
pedunculated
central
pneumonia
pulmonary nodule
flushing
pink
purple
Biopsy
CT
Surgical excision
hypersensitivity pneumonitis
patho:
- Also called extrinsic allergic alveolitis
- Nonatopic, non-asthmatic inflammatory pulmonary disease
- Manifested mainly as an occupational disease
- Exposure to inhaled _____ antigens leads to an acute illness
- Symptoms are usually _____ if the offending antigen is removed from the patient’s environment early in the course of illness
- Continued exposure may lead to progressive disease
- Histopathology is characterized by _____ infiltrates of lymphocytes and plasma cells with _____ granulomas in the interstitium and air spaces
S/S:
- Acute Illness:
- Symptoms have a sudden onset 4-8 hours after exposure to the offending _____
- May occur after the patient has left work
- May occur at night and mimic paroxysmal nocturnal dyspnea
- Malaise, chills, fever, cough, dyspnea, nausea
- ibasilar crackles, tachypnea, tachycardia and cyanosis (occasionally)
- Subacute illness:
- 15% of cases
- Characterized by the insidious onset of chronic _____
- Slowly progressive dyspnea, anorexia and weight loss
- Chronic exposure leads to progressive respiratory insufficiency
- And the appearance of pulmonary _____ on chest imaging
diagnostics:
- Acute Illness:
- Small _____ densities sparing the apices and gases of the lungs are noted on chest radiograph
- Laboratory studies reveal an increase in the _____ with a left shift; hypoxemia; presence of precipitating antibodies to the offending agent in the serum
- PFTs
- _____ dysfunction
- Reduced _____ capacity
- Subacute illness:
- Surgical lung _____ may be necessary for diagnosis
- May be difficult even with biopsy because histopathologic patterns overlap with several idiopathic interstitial pneumonias
tx:
- Identification of the offending agent
- Avoidance of further exposure Severe acute or protracted cases
- Oral corticosteroids
- _____ 0.5 mg/kg daily as a single morning dose for 2 weeks; tapered to nil over 4-6 weeks.
- Change in occupation is often unavoidable
organic
reversible
interstitial
noncaseating
anigen
cough
fibrosis
nodular
WBC
restrictive
diffusing
biopsy
Prednisone
paraneoplastic syndrome
MC are _____, _____, hypercoagulability, _____, clubbing, Cushing, Lambert-Eton know that it is an _____ (Na, Ca) and fluid imbalance*
SIADH
hypercalcemia
anemia
electrolyte
pneumoconiosis
- Chronic fibrotic lung diseases caused by the inhalation of _____ dusts
- May be asymptomatic with diffuse nodular _____ on chest radiograph
- May be severe, symptomatic, life-shortening disorders
- Treatment is supportive
Coal worker’s pneumoconiosis
- Ingestion of inhaled _____ by alveolar macrophages leads to the formation of coal _____
- Usually 2-5 mm in diameter
- CXR: diffuse small opacities that are especially prominent in the _____ lung
- Simple disease is usually asymptomatic; pulmonary function abnormalities are unimpressive
- Cigarette smoke may have an additive detrimental effect on ventilatory function
- Complicated diseases (“progressive massive fibrosis”)
- Conglomeration and contraction in the _____ lung zones
- Radiographic features resembling complicated _____
- Caplan Syndrome
- Rare condition in coal workers with RA
- Necrobiotic rheumatoid nodules (1-5cm) in the periphery of the lung
Silicosis
- Extensive or prolonged inhalation of free _____ (silicon dioxide) particles in the respirable range (.3-5mcm)
- Causes formation of small _____ opacities (silicotic nodules) throughout the lungs
- Calcification of the periphery of hilar lymph nodes (_____ calcification) …unusual radiographic finding
- Simple silicosis: Usually asymptomatic, No effect on routine pulmonary function tests
- Complicated silicosis: Large conglomerate densities appear in the upper lung. Dyspnea and _____ and _____ pulmonary dysfunction
- Incidence of _____ increases in silicosis
- need TB test and current CXR
- If old healed TB is suspected; multidrug treatment should be instituted
Asbestosis
- Nodular interstitial fibrosis occurring in workers exposed to asbestos fibers (shipyard and construction workers, pipe fitters insulators over many years (typically 10-20 years)
- Usually first seek medical attention at least 15 years after exposure
- S/S
- Progressive dyspnea
- Inspiratory _____
- In some cases: clubbing and cyanosis
- Radiographic features
- _____ at the lung bases
- Opacities of various shapes and sized
- _____ changes in advanced cases
- High resolution CT is best method to detect asbestosis
- Can detect parenchymal _____
- Defines the presence of coexisting pleural plaques
- Cigarette smoking increases prevalence of radiographic pleural and parenchymal changes and markedly increases the incidence of lung carcinoma
- may interfere with clearance of short asbestos fibers from the lung
- PFTs
- _____ dysfunction
- Reduced _____ capacity
- Presence of _____ body in tissue suggests significant exposure
- No specific treatment
inorganic
opacities
coal dust
macules
upper
upper
silicosis
silica
rounded
eggshell
obstructive
restrictive
TB
crackles
linear streaking
honeycomb
fibrosis
Restrictive
diffusing
ferruginous
Acute respiratory failure
patho:
- Definition: respiratory dysfunction causing impairment of ventilation severe enough to threaten _____
- Arterial blood gas (ABG) criteria: PO2 _____ mmHG OR PCO2 _____ mmhg
- Occurs in a variety of pulmonary and nonpulmonary disorders –
- o _____ parenchyma – infectious and non-infectious disorders
- o _____/Chest Wall/Airway – malignant pleural effusion, tension pneumo, rib fractures, hemothorax, airway obstruction
- o _____ – venous, thromboembolism, tumor embolism, pulm veno-occulsive ds
- o _____ – sedative-induced, metabolic encephalopathy, paraneoplastic syndromes
S/S:
- Those of the underlying disease!
- _____ (cyanosis, confusion, tachypnea, lethargy, cardiac arrythmias)
- _____ (dyspnea, headache, hyperemia, papilledema, asterixis)
diagnostics:
Symptoms are both nonspecific and non-sensitive, therefore obtain an _____ if acute respiratory failure is suspected
tx:
- Ensure adequate _____ of vital organs
- General supportive care
vital organs
< 60
>50
Lung
Pleural
Vascular
neuromuscular
Hypoxemia
hypercapnia
abg
oxygenation
acute respiratory distress syndrome
patho:
Causes of ARDS:
- _____ (35%)
- Severe Sepsis (26%)
- Aspiration (15%)
- Trauma (11%)
- Other (13%)
- Drowning, pancreatitis, reperfusion, salicylate and narcotic OD, fat/amniotic embolism, smoke/chemical inhalation
S/S:
- Onset of respiratory distress, progressive respiratory failure within _____ days of known clinical insult
- New, bilateral radiographic pulmonary _____ not explained by pleural effusion, atelectasis, or nodules.
- Impaired _____ with ratio of pao2/fio2 < 300 mmhg with a peep 5 cm of h20 or more
- Respiratory failure not explained by heart failure or volume overload
- Clinica findings
- Profound dyspnea
- Marked hypoxemia that is refractory to _____
- Labored breathing, tachypnea, _____, crackles
- Depending on the underlying cause, patients may have evidence of multiple organ failure
diagnostics:
Chest x-ray
- New, _____ radiographic opacities
- Diffuse or patchy bilateral infiltrates rapidly become confluent
- _____ common
- Pleural effusions small to non-existant
tx:
- Evidence based management of ARDS:
- Treat the underlying cause
- Low tidal volume _____
- Use _____ (EVERY ARDS PATIENT NEEDS IT)
- Goal is to maximize alveolar recruitment and prevent cycles of recruitment/decruitment
- Prone position
- Monitor Airway pressures
- Conservative fluid management
- Reduce potential complications
- Fluid Mangement:
- Increased lung _____ is the underlying cause of many of the clinical abnormalities in ARDS (decreased compliance, poor gas exchange, atelectasis)
- After resolution of shock, effort should be made to attempt _____
- CVP used as guide, goal <4
- Shortens time on vent and ICU length of stay (13 days vs 11 days)
- Supportive Therapies:
- Treat underlying infection
- DVT prophylaxis / stress ulcer prevention
- HOB 30°
- Hand washing
- Use full barriers with chlorhexadine
- Sedation / analgesia
- Feeding protocol
- Avoid contrast nephropathy
- Pressure ulcer prevention, turning Q2h
- Avoid steroid use
Pneumonia
7
opacities
oxygenation
supplemental oxygen
intercostal retractions
bilateral
air bronchograms
ventilation
PEEP
water
diuresis
risk factors for radiation lung injury
- A _____ caused by the therapeutic use of ionizing radiation to treat malignancies
- Occurs in about 10% of patients undergoing XRT for breast cancer, 5-15 % lung cancer, 5-35% lymphomas
- Degree of lung injury is determined by the lung volume _____, dose and rate of _____, potentiating factors (previous XRT, chemotherapy, withdrawal of steroids)
- Occurs in two phases:
Acute phase: radiation pneumonitis
- Generally occurs 2-3 months after completion of XRT
- Insidious onset of dyspnea, dry cough, chest fullness
- PFTs show _____ lung compliance, hypoxemia, reduced diffusing capacity
- Chest x-ray doesn’t always correlate with degree of sxs
- No specific treatment, but anecdotally treated with steroids, _____ 1 mg/kg/day orally x 1 week, followed by slow taper
Chronic phase: radiation fibrosis
- Can occur after radiation pneumonitis, or as a solo presentation
- Most common in patients receiving a _____ course of XRT
- Patients have milder sxs, some may be asymptomatic
- Dense interstitial fibrosis
pneumonitis
irradiated
exposure
reduced
Prednisone
longer
Common meds causing medication lung injury
- Pulmonary complications occur as a result of allergic reactions, idiosyncratic reactions, overdose, or side effects.
- Must take a detailed history to aid with diagnosis
- Most labs not clinically helpful
- Need to stop the medication ASAP
- _____*****
- _____ and _____ – more likely to cause indirectly
Amiodarone
B-Blockers
NSAIDs
sarcoidosis
patho:
- Systemic disease of unknown etiology characterized in about 90% of patients by _____ inflammation of the lung
S/S:
- Malaise, fever, dyspnea of insidious onset
- Skin involvement (extra-pulmonary manifestations)
- _____, _____ (is a chronic raised indurated (hardened) lesion of the skin, often purplish in color. It is seen on the nose, ears, lips, cheeks and forehead. It is pathognomonic of sarcoidosis) iritis, peripheral neuropathy, arthritis or cardiomyopathy
- Physical findings
- Atypical of interstitial lung disease; crackles are uncommon on chest exam
- Other symptoms
- Parotid gland enlargement, hepatosplenomegaly and lymphadenopathy
diagnostics:
- Some individuals are asymptomatic and come to medical attention after abnormal findings on CXR
- Typically bilateral _____ and right paratracheal lymphadenopathy
- Lab findings:
- Leukopenia, elevated _____ and hypercalcemia (about 5%) and hypercalciuria (20%)
- _____ levels are elevated in 40-80% of patients with active disease
- Physiologic testing may reveal evidence of airflow _____ but _____ changes with decreased lung volumes and diffusing capacity are more common
- Skin test anergy is present in 70%
- ECG may show conduction disturbances and dysrhythmias
- Imaging
- Variable and include:
- Bilateral hilar adenopathy alone (radiographic stage I)
- Hilar adenopathy and parenchymal involvement (radiographic stage II)
- Parenchymal involvement only (radiographic stage III)
- Usually manifested by diffuse reticular infiltrates
- Focal infiltrates, acinar shadows, nodules and rarely cavitation may be seen
- Stage IV disease refers to advanced fibrotic changes principally in the upper lobe
- Pleural effusion is noted in less than 10% of patients
- Special examinations
- All patients require complete _____ evaluation
- Diagnosis generally requires histologic demonstration of _____ granulomas in biopsies from patient with other typical manifestations
- Easily accessible sites such as palpable lymph nodes, skin lesions or salivary glands are likely to be positive
- Biopsy necessary when alternative diagnosis such as lymphoma must be ruled out
- Bronchoalveolar lavage fluid is usually characterized by an increase in lymphocytes and a high CD4/CD8 cell ration
- Does not establish diagnosis but may be useful in following the activity in selected patients
tx:
- Oral _____; long term therapy over months to years; indicated in patients
- Disabling constitutional symptoms
- Hypercalcemia
- Iritis
- Uveitis
- Arthritis
- CNS involvement
- Cardiac involvement
- Granulomatous hepatitis
- Cutaneous lesions other than erythema nodosum
- Progressive pulmonary lesions
- Immunosuppressive medications for patients intolerant of corticosteroids or who have corticosteroid refractory disease.
- Methotrexate
- Azathioprine
- Infliximab
granulomatous
Erythema nodosum
lupus pernio
hilar
ESR
ACE
obstruction
restrictive
ophthalmologic
noncaseating
corticosteroids
pneumocystitis jirovecci
Pathophysiology –
PPP: pneumocystitis jirovecii is a yeast like _____ that doesn’t respond to antifungals
Transmission: _____
· HIV pts – “pt who has risky _____ behavior or injection drug user comes into clinic”
· Rare in general populations and affects two groups à epidemics of primary infections among premature/debilitated/marasmi infants in hospital wards in underdeveloped parts of world + sporadic cases among older children and adults who have abnormal/altered cell immunity) – MC in AIDS and _____
S/S – asymptomatic or wildly symptomatic
· AIDS Pt: other evidence of HIV-associated ds – fever, fatigue, weight loss for weeks-months preceding illness
· Sporadic Form of Ds: abrupt fever, tachypnea, SOB, nonproductive cough
o PE – slight and disproportionate to degree of illness and radiograph finding. Bibasilar _____
· Adult Pts: spontaneous pneumothorax if previous episode or using aerosolized pentamidine prophylaxis
Testing –
· CXR – _____ – diffuse or formal consolidation, cystic changes, nodules, or cavitations w/n nodules
· High Resolution _____ – help distinguish from other pneumonias
· (-) PCR from Bronchovascular Lavage – rules out ds
· Open lung bx and needle bx – sometimes
TX –
· _____ (Bactrim) – 1st line
· Others, but she said focus on Bactrim
fungus
inhalation
sexual
immunocompromised
crackles
interstitial infiltrates
CT
TMP-SMX
Granulomatosis with Polyangiitis (Wegner granulomatosis)
patho:
- Idiopathic. _____, vasculitis of upper and lower respiratory tracts, small-vessel vasculitis
S/S:
- Chronic _____, arthralgias, fever, rash, weight loss. Pulmonary c/o less common.
diagnostics:
- CXR – _____ pulmonary infiltrates, serologic testing.
- Diagnosis confirmed via _____ of lung, sinus, kidney showing necrotizing granulomatosis _____
tx:
_____ +/- oral _____
Treat until remission has been achieved, can use methotrexate or azathioprine for maintenance if needed
Bactrim used for adjuvant therapy
Glomerulonephritis
sinusitis
nodular
biopsy
vasculitis
Cyclophosphamide
prednisone
goodpastures syndrome
patho:
- Immune diffuse alveolar _____, rapidly progressing glomerulonephritis. Mainly in men 30s-40s.
S/S:
_____, dyspnea
diagnostics:
- CBC – _____
- CXR – pulmonary infiltrates that rapidly _____
- Serum – detectable anti-glomerular basement antibodies
- Biopsy – _____ depositis
tx:
_____, _____, _____
Prognosis is good with adequate treatment
hemorrhage
hemoptysis
anemia
clear
IgG
Prednisone, cyclophosphamide, plasmapheresis
idiopathic pulmonary hemosiderosis
patho:
- Occurs in children or young adults, associated with _____ disease
S/S:
- Similar to Goodpasture’s syndrome, without the _____ involvement. Signs of _____ (fatigue, pallor)
tx:
- Acute phase treated with _____
Recurrent hemorrhages can lead to pulmonary fibrosis
Celiac
iron deficiency anenia
renal
corticosteroids
occupational asthma
- Offending agents: Grain dust; wood dust; tobacco; pollens; enzymes; gum Arabic; synthetic dyes; isocyanates; rosin; inorganic chemicals; trimellitic anhydride; formaldehyde……
- Diagnosis depends on high suspicion, appropriate history, _____ studies before and after exposure to the offending substance and _____ measurements in the work place
- Bronchial _____ testing may be helpful in some cases
- Treatment consists of avoidance of further exposure to the offending agents and ______
- Symptoms may persist for years after workplace exposure has been terminated
spirometric
peak flow
provocation
bronchodilators
solitary pulmonary nodule
S/S:
- Less than _____ cm
- If >3 than cm it would be considered a mass
- Isolated, _____ opacity on chest imaging, outlined by normal lung
- No inflitrate, atelectasis, or adenopathy
- Carries a significant risk of malignancy
- Benign findings include _____ and _____ granulomas
diagnostics:
- Pulmonary nodule evaluation
- Goal is to identify and resect malignant tumors while avoiding invasive procedures in benign disease
- Identify nodules with a high probability of malignancy to warrant biopsy or resection OR a low probability of malignancy to warrant observation
- Use age and risk factors to evaluate overall risk of malignancy
- Most important information can come from prior imaging studies
- Chest _____ is indicated in any suspicious solitary pulmonary nodule found on CXR
- Doubling time is an important marker for malignancy
- Rapid progression suggests _____ while long doubling time suggests _____ nodule
- Size is correlated with malignancy
- 65-80% malignancy rate in nodules 21-45 mm
- Appearance can be helpful
- Smooth and _____ lesion is usually benign
- Ill-defined or _____ or spiculated margins suggest malignancy
- Calcification pattern
- Dense calcifications tend to be benign
- _____ calcifications in malignant lesions
- Cavitary lesions with irregular, thick walls are likely malignant
tx:
Low probability (less than 5%)
- Usually age under 30, lesion stable for more than 2 years, characteristic pattern of benign calcification
- Watchful waiting with serial _____ studies
High probability (greater than 60%)
- Directly to _____ following staging, provided surgical risk is acceptable
Intermediate probability
- Remains controversial
- Traditional approach is diagnostic biopsy
- Can obtain diagnosis through sputum cytology or thoracentesis
- _____ scan to guide decision making
- Video assisted thoracoscopic surgery (VATS)
PET Scan
- Detects increased _____ metabolism in malignant cells
- Usually only available as outpatient
_____ (video assisted thoracoscopic surgery)
- Surgeon takes sample or remove nodule and evaluate in or with frozen section
- If malignant will proceed w lymph node sampling and possibly larger resection
3
rounded
hamartomas
infectious
CT
infection
benign
well-defined
lobulated
Sparse
imaging
resection
PET
glucose
VATS
