Pulm 6/17 Quiz Review Flashcards
Lung CA:
define pulmonary nodule
Lung CA
= small opacities,
less than 3 cm in size
Notes:
usually asymptomatic
usually detected incidentally
or at time of screening
Lung CA:
define lung mass
Lung CA
= any opacity larger than 3 cm in size
Notes:
malignant until proven otherwise
Lung CA:
two primary categories of Lung CA are:
Lung CA
- non small cell lung cancer (NSCLC)
- small cell lung cancer (SCLC)
Lung CA:
growth rate of small cell lung cancer (SCLC) =
Lung CA
grow very very fast
Lung CA:
who predominantly gets SCLC?
Lung CA
```
smokers do
“occur predominantly in smokers”
~~~
Lung CA:
what are the two stages of SCLC? How are they defined?
Lung CA
Limited Stage & Extensive Stage
Limited Stage = all disease w/in single radiation field (i.e. single hemithorax, possibly with some supraclavicular lymph nodes thrown in)
Extensive Stage = disease OUTSIDE a single hemithorax
Lung CA:
what is the most common non-small cell lung cancer (NSCLC)?
Lung CA
adenocarcinoma
Lung CA:
what is the TNM system of staging? What does TNM stand for?
Lung CA
T = tumor N = node M = metastasis
I = solitary tumor, tumor <= 4 cm, no lymph node involvement
II = tumor > 4 cm, regional lymph nodes involved, invasion into local structures
III = medistinal lymph nodes positive
IV = distant metastatic disease (includes pleural effusion)
Lung CA:
how to treat lung cancers at different stages –>
Lung CA
FIRST = biopsy, determine if NSCLC or SCLC!
I - surgical resection
II - surgical resection + chemo
III = chemoradiation
IV = palliative care (incurable)
Lung CA:
name some NSCLC presentations
Lung CA
hyperalcemia
hypertrophic pulm osteoarthropathy (NOT finger clubbing)
inflammatory myopathies
Lung CA:
what is most common subtype of lung cancer?
Lung CA
NON-small cell lung cancer (NSCLC)
Lung CA:
common symptoms for lung cancer = ?
Lung CA
typical: cough, increased sputum, shortness of breath
common: fatigue, wt loss, anorexia, low-grade fever
Lung CA:
name some SCLC presentations
Lung CA
paraneoplastic syndromes: hyponatremia (SIADH) hypertrophic pulm osteoathropathy (NOT finger clubbing, same as NSCLC) inflammatory myopathies (same as NSCLC) Cushing Syndrome Lambert-Eaton syndrome cerebellar degeneration
CF Dx/Trtmt: Epi
What ethnicity carries highest rates of cystic fibrosis?
CF Dx/Trtmt: Epi
Caucasian
CF Dx/Trtmt: Dx approach, newborn screening:
To dx CF, pt must have at least one of these three symptoms:
CF Dx/Trtmt: Dx approach, newborn screening
>1 typical phenotypic features of CF sibling with CF positive newborn screening test
CF Dx/Trtmt: Dx approach, newborn screening:
To dx CF, pt must ALSO have one of these three symptoms (in addition to the three required):
CF Dx/Trtmt: Dx approach, newborn screening
- elevated sweat chloride on 2 occasions - TWO disease-causing CFTR mutations = abnormal nasal potential difference
CF Dx/Trtmt: Dx approach, newborn screening:
Why is newborn screening helpful/important?
CF Dx/Trtmt: Dx approach, newborn screening
“With widespread adoption of newborn screening in recent years, we have seen a….an increasing number of infants diagnosed before a month of age”
CF Dx/Trtmt: Dx approach, newborn screening:
Three most common phenotypical symptoms seen in CF diagnoses
CF Dx/Trtmt: Dx approach, newborn screening
acute/persistent respiratory symptoms (37.3%)
steatorrhea (22.4%)
meconium ileus/intestinal obstruction (17.6%)
CF Dx/Trtmt: Dx approach, newborn screening:
What is the GOLD STANDARD For CF dx?
CF Dx/Trtmt: Dx approach, newborn screening
SWEAT CHLORIDE TESTING (done at an accredited CF Care Center)
CF Dx/Trtmt: Dx approach, newborn screening:
What is required for a positive genetic test for CF?
CF Dx/Trtmt: Dx approach, newborn screening
“TWO defective genes in trans configuration”
CF Dx/Trtmt: Dx approach, newborn screening:
What is the most common mutation for CF?
CF Dx/Trtmt: Dx approach, newborn screening
F508del (70% of mutations)
CF Dx/Trtmt: Dx approach, newborn screening:
How do we test newborns for CF?
CF Dx/Trtmt: Dx approach, newborn screening
We check for immunoreactive trypsinogen
(this is an exocrine pancreatic protein, which is elevated in newborns with CF (3-5 x higher))
CF Dx/Trtmt: CF pathophys:
Describe CFTR
CF Dx/Trtmt: CF pathophys
what is it? gene
location: long arm of chromosome 7
function: codes for protein in cell membrane of many organs
action: acts as chloride channel
(also controls other channels)
CF Dx/Trtmt: CF pathophys:
name three basic symptoms of CFTR mutation
CF Dx/Trtmt: CF pathophys
GI
Upper Respiratory System
Lower Respiratory System
CF Dx/Trtmt: CF pathophys:
Name three common GI symptoms of CF
CF Dx/Trtmt: CF pathophys
pancreatic insufficiency (85%) hepatobiliary disease (70%) GERD (25-100%)
CF Dx/Trtmt: CF pathophys:
Name two common upper respiratory symptoms of CF
CF Dx/Trtmt: CF pathophys
recurrent or chronic sinus disease (100% of CF pts) nasal polyps (up to 25% of CF pts)
CF Dx/Trtmt: CF pathophys
four manifestations of lower respiratory symptoms of CF
CF Dx/Trtmt: CF pathophys
inflammation (occurs early after birth)
CF-specific pathogens
bronchiectasis
pulmonary exacerbations (lead to loss of lung fxn)
CF Dx/Trtmt: Epi:
Why do we see increased numbers of adult patients?
two reasons
CF Dx/Trtmt: Epi
mild phenotype diagnosis discovered in adulthood
increased life expectancy
CF Dx/Trtmt: Dx approach, newborn screening:
What are three requirements for sweat chloride testing?
CF Dx/Trtmt: Dx approach, newborn screening
newborn > 36 weeks (gestational age)
two weeks old (post-partum)
minimum body wt = 2 kg
CF Dx/Treatment:
quality care is dependent upon these two factors
CF Dx/Trtmt
CF Foundation’s evidence-based or consensus standards
Healthcare Team of PCP and CF Care Center personnel
they have to coordinate & communicate
CF Dx/Treatment
Functional Mutation Classes
Should we know this slide???
Class I – altered biosynthesis
No CFTR produced
Class II – altered maturation
Minimal and dysfunctional CFTR at cell surface
Class III – altered regulation
Adequate CFTR at cell surface, reduced or no function
Class IV – altered conductance
Adequate CFTR at cell surface, reduced function
Class V – reduced synthesis
Decreased but functional CFTR
Class VI – increased turnover
CF Dx/Treatment: CF clinical practice guidelines:
What three pharmacological interventions are used as anti-inflammatory treatments for CF?
CF Dx/Treatment: CF clinical practice guidelines
corticosteroids, oral
ibuprofen (high dose)
azithromycin (macrolide anitbiotics)
CF Dx/Treatment: CF clinical practice guidelines:
When pts are diagnosed at a younger age, the community acquired bacteria that most commonly colonize the airways are _________ (name three).
CF Dx/Treatment: CF clinical practice guidelines
H. influenza
Strep pneumo
MSSA (methicillin-susceptible Staphylococcus aureus)
CF Dx/Treatment: CF clinical practice guidelines:
As CF pts get older, two bacteria are the most common infection threat. They are _________ .
CF Dx/Treatment: CF clinical practice guidelines
Pseudomonas aeruginosa
MRSA (Methicillin-resistant Staphylococcus aureus)
Note: these two cause decreased life expectancy and worsening outcomes!
CF Dx/Treatment: CF clinical practice guidelines:
What is done to monitor for bacterial infection in CF patients?
CF Dx/Treatment: CF clinical practice guidelines
throat cultures, 4x/year (have pt return to clinic 4x/year to culture and monitor for Pseudomonas and MRSA).
CF Dx/Treatment: CF clinical practice guidelines:
What are the four basic components of lower respiratory tract therapy pulmonary toilette?
CF Dx/Treatment: CF clinical practice guidelines
Bronchodilators
Mucolytics
Hypertonic Saline
Airway Clearance
Pulm HTN: definition
Define pulmonary hypertension
Pulm HTN: definition
condition of the lungs in which blood vessels of lungs become narrow
rare
pathological
narrowing progresses over time
results in increase of bp in these vessels
Pulm HTN: WHO definition
What is Group 1 Pulmonary Hypertension?
Pulm HTN: WHO definition
Group 1 = pulmonary arterial hypertension (PAH)
Idiopathic, familial
(only group 1 is called pulmonary “arterial” hypertension, but all 5 grooups may be referred to as PH)
Pulm HTN: WHO definition
What is Group 2 Pulmonary Hypertension?
Pulm HTN: WHO definition
Group 2 = PH due to L heart disease (most common)
Pulm HTN: WHO definition
What is Group 3 Pulmonary Hypertension?
Pulm HTN: WHO definition
Group 3 = PH due to lung disease and/or hypoxemia
Pulm HTN: WHO definition
What is Group 4 Pulmonary Hypertension?
Pulm HTN: WHO definition
Group 4 = PH due to chronic thromboembolism
Pulm HTN: WHO definition
What is Group 5 Pulmonary Hypertension?
Pulm HTN: WHO definition
Group 5 = PH with unclear multifactorial mechanisms
Pulm HTN:
where would you expect back flow in the heart in a case of Pulmonary Hypertension?
Pulm HTN
backflow of blood from pulmonary artery into R ventricle and even further back into R tricuspid and R atrium
Pulm HTN:
Name some signs of PH
Pulm HTN
Cyanosis (bluish lips and skin) Chest pain Fluttering chest Shortness of breath Fatigue, weakness Dizziness, lightheadedness Dry cough Abdominal bloating Rapid weight gain Swollen ankles, legs
Pulm HTN:
What does a split in the S2 heart sounds indicate?
Pulm HTN
(this split is b/w aortic (A2) and pulmonic (P2) valve closures…Aortic valve may close earlier due to higher resistance from systemic circulation)
This means there is less resistance in the pulmonary arterial bed causing a later P2
Pulm HTN:
How do we assess PH?
Pulm HTN
cardiac catheterization (“cath”) Gold Standard (just not always possible, esp for little kids)
echocardiogram –> R ventricle pressure estimated via flow through tricuspid valve
EKG
Chest Xray
Pulm HTN:
What is the basic pathogenesis of PH?
Pulm HTN
increased vasoconstrictors
decreased vasodilators
Pulm HTN:
What three therapy pathways do we use to treat Pulmonary Hypertension via Vascular Biology?
Pulm HTN
NO-cyclic guanosine monophosphate (cGMP)
(and phosphodiesterase inhibitors like Viagra)
ET-1 (Bosentan, Ambrisentan)
PGI2 (Epoprostenol, Flolan, as continuous IV….not the best option) Treprostinil is preferred now.
Foxworth Pharm:
Pneumonia Trtmt, adults, first line:
Foxworth Pharm
Amoxicillin
Doxycycline
Foxworth Pharm:
Pneumonia Trtmt, adults, if comorbidity exits
Foxworth Pharm
amox/CA + AZ
Foxworth Pharm:
Pneumonia Trtmt, adults, if pneumonia is respiratory
Foxworth Pharm
quinolone or amox/CA
Foxworth Pharm:
If pneumonia treatment resistance to macrolides is <25%, what treatment should be chosen?
Foxworth Pharm
AZ
Foxworth Pharm:
How long do we usually treat pneumonia?
Foxworth Pharm
5-7 days
(pt should be afebrile >48 hrs, clinically stable, not vomiting, able to eat (these are all po treatments!))
Foxworth Pharm:
How do we treat pneumonia with alcoholism, COPD, or post-influenza comorbidity?
Foxworth Pharm
respiratory flouroquinolones (FQ) or AZ + high dose amox or high dose amox/CA
Foxworth Pharm:
List some side effects for flouroquinolones (FQ)
Foxworth Pharm
- Wt bearing cartilage damage in children
- Tendon rupture in adults
- MS changes (agitation, delirium, nervousness, < memory)
- Food and drug interactions
- QTc
- hypoglycemia & hyperglycemia (DM, > age, renal disease)
- C diff
Foxworth Pharm:
Explain admission criteria
CURB-65
and
CRB-65
Foxworth Pharm
give a point for each of the following ~ CURB-65 = Confusion Uremia Resp rate Blood pressure >65 y/o
CRB-65 = Confusion Resp rate Blood pressure >65 y/o
Foxworth Pharm:
When would you admit w/ a CURB-65 of 0?
Foxworth Pharm
o Immunocompromised o DM o Someone with pulse ox that’s low o Someone w/ complications o Someone who will not follow treatment plan after discharge
Foxworth Pharm:
After culture confirms bacterial agent, how would one treat CAP with a hospitalized (not ICU) pt?
Foxworth Pharm
ceftriaxone (CFTX) IV
+
AZ
Foxworth Pharm:
After culture confirms bacterial agent, how would one treat CAP with AN ICU pt?
Foxworth Pharm
ceftriaxone (CFTX) IV \+ levofloxacin \+ AZ IV \+ van or linezolid
Foxworth Pharm:
After culture confirms bacterial agent, how would one treat nosocomial pneumonia?
Foxworth Pharm
cefepime
or
“pip/tazo”
Note: add vanc if hospital acquired MRSA is >20% prevelant, or if antibiotics were used w/in 90 days, or in case of septic shock
Foxworth Pharm: resistance
Which antibiotic has shown some Strep pneumo resistance?
Foxworth Pharm
AZ
Note: use FQ as an alternative
Foxworth Pharm:
What is recommended treatment for bronchitis?
Foxworth Pharm
NO ANTIBIOTICS
Note: treatment is controversial! maaayyybeeee consider AZ for persistent cough bronchitis.
