PULM neoplasms, Pleural dz, Obstructive and Restrictive Dz Flashcards
3 types of Restrictive Pulmonary Diseases
Intrinsic: diseases of the lung parenchyma, inflammation or scarring of lung tissue.
Extrinsic: Extra-pulmonary diseases involving the chest wall,
Medication induced interstitial lung disease
- Amiodarone
- Methotrexate
- Nitrofurantoin
Idiopathic fibrosing Interstitial Pneumonia (IPF) is causes by?
Risk Factors / occupation?
Unknown – fibroblasts cause thickening of interstitium -> fibrosis
Most common diagnosis among pts w/ intersitial lung dz
- Smoking
- Occupational exposure (stone, metal, wood, organic dust)
- GERD
Diagnostic tests for Idiopathic fibrosing Interstitial Pneumonia (IPF): what would the results of these tests be?
FVC
FEV/FVB
DLCO
6 minute walk test - impaired or not?
CXR
CT
↓ FVC
Normal or elevated FEV1/FVC
↓ DLCO
Impaired 6min walk
CXR –Reticular markings
CT - Diffuse patchy fibrosis with pleural based honeycombing
Tx for Idiopathic fibrosing Interstitial Pneumonia (IPF)
Medications: no steroids!!
- Nitedanib: tyrosine kinase inhibitor
- Pirfenidone (Esbriet): anti-fibrotic drug
Surgery: Lung Transplant
- Age <65
- Free of substance abuse, smoking
- Acceptable BMI (20-29)
Physical Exam findings indicative of Idiopathic fibrosing Interstitial Pneumonia (IPF)
Clubbing
Inspiratory rales (crackle)
Insidious dry cough
Exertional dyspnea
Fatigue
Tachypnea
risk factors for Idiopathic fibrosing Interstitial Pneumonia (IPF)
- Smoking
- Occupational exposure (stone, metal, wood, organic dust)
- GERD
3 types of Pneumoconiosis
coal workers
Silicosis
Asbestosis
Occupations at risk for Silicosis
Mining, masonry, glass manufacturing, foundry work and sandblasting
imaging w/ silicosis
- Acute - bilateral, diffuse ground glass opacities
- Chronic – small, innumerable rounded densities
complications of silicosis
Complications:
Mycobacterial infection (TB) - test for TB*****
Aspergillosis
Lung cancer
Chronic kidney disease
Small rounded nodular opacities w/ preference for upper lobes is a finding consistent with ??
Coal Workers Pneumoconiosis
Tx of Silicosis
No proven specific therapy:
- Avoid further exposure/supportive care
- Steroid therapy – acute phase
- Lung transplantation
CXR and CT findings consistent with asbestosis
CXR – thickened pleura, calcified pleural plaques
CCT – hazy ground glass appearance of peripheral pleural space
•Advanced – coarse honeycombing
complication of asbestosis
•Malignant mesothelioma
Multisystem granulomatous disorder of unknown etiology.
Characterized by non-caseating granuloma
Sarcoidosis
Si/Sx of Sarcoidosis
Cough (dry, hacking)
Progressive dyspnea
Atypical chest discomfort
Fever/night sweats**
Weight loss
CXR and CT findings associated with Sarcoidosis
CXR: Bilateral hilar adenopathy
CT: Right paratracheal lymphadenopathy along with bilateral diffuse reticular infiltrates
•Sarcoid galaxy sign
Tx for sarcoidosis
asymptomatic and symptomatic patientd
Close observation for asymptomatic patients
Symptomatic pts - tapering course of oral corticosteroids over 4-6 weeks. (90% of pts receive benefit)
define DLCO
how is it used to help diagnose restrictive lung diseases
•Measures the overall function of the alveolar capillary membrane.
measures gas diffusion (CO) accross capillar membrane
differentiate the etiology of restrictive lung disease:
- DLCO is low = interstitial lung disease.
- DLCO is normal = extrathoracic cause
define Atopy
- A genetic disposition to develop an allergic reaction and produce elevated levels of IgE upon exposure to an environmental antigen and especially one inhaled or ingested
- atopic dermatitis (eczema)
- allergic rhinitis (seasonal allergies, dust mite allergy etc)
- asthma
Differentiate b/e chronic bronchitis and emphysema
Emphysema – pink puffer
- Major complaint dyspnea
- Cough is rare
- Clear mucus
- Pts thin
- Accessory muscle use
- Chest is quiet / soft pitched wheeze
Chronic bronchitis – blue bloater
- Major complaint – chronic cough
- Mucopurulent sputum
- Frequent COPD exacerbations and infections
- Chest is noisy w/ rhonchi and wheezing
PFT that helps distinguish b/w emphysema and chronic bronchitis/asthma
DLCO
emphysema (DEC)
chronic bronchitis/asthma (DLCO normal)
Characteristics of Obstructive Lung Dz:
•FEV1 –
FVC –
- FEV1/FVC -
- DLCO
•FEV1 – decreased
FVC – normal
- FEV1/FVC - <70% or <0.7
- Improvement of FEV1 after bronchodilator (asthma responds better)
- DLCO to distinguish b/w emphysema and COPD or asthma
define emphysema and the 2 types
enlargement of alveolar air spaces that is followed by destruction w/o obvious fibrosis -> loss of elasticity
•Proximal acinar – assoc w/ smokers , abnormal dilation or destruction of thr respiratory bronchiole (coal workers pneumo)
•Panacinar – associated w/ genetic deficiency alpa-1-antitrypsin, enlargement an destruction of all parts of of the acinus
Bronchiectasis is most commonly due to
CF ****
less commonly due to Lung infections - TB, fungal, lung, abscess, pneumonia
si/sx of Bronchiectasis
Chronic daily cough w/ viscid sputum – thick and sticky
Hx of repeated respiratory infections
Hemoptysis
Urinary incontinence
Pulmonary crackles, wheezing
CXR and CT findings in Bronchiectasis
CXR – linear atelectasis
- Dilated thickened airways
- Irregular peripheral opacities
CT - bronchial wall thickening, airway dilation
•Mucopurulent plugs, cysts of bronchial walls
Tx of Bronchiectasis
Abx – cover for pseudomonas***
Tx underlying dz
Loosening secretions
Progressive condition w/ poor quality of life
Stepwise approach for managing asthma in children 0-4 years of age
Intermittent Asthma
•Step 1 – SABA prn (albuterol)
Persistent Asthma
- Step 2 – Low dose ICS
- Step 3 – medium dose ICS
- Step 4 – medium dose ICS + LABA or Montelukast
- Step 5 – high dose ICS + LABA or Montelukast
- Step 6 - high dose ICS + LABA or Montelukast + consider systemic glucocorticoids
Stepwise approach for managing asthma in children 5-11 years of age
Intermittent Asthma
•Step 1 – SABA prn
Persistent Asthma
- Step 2 – Low dose ICS
- Step 3 – either low dose ICS + LABA / theophylline OR medium dose ICS
- Step 4 – medium dose ICS + LABA
- Step 5 – high dose ICS + LABA
- Step 6 - high dose ICS + LABA + short course of oral systemic glucocorticoids
Stepwise approach for managing asthma in patients >12
Intermittent Asthma
•Step 1 – SABA prn
Persistent Asthma
- Step 2 – low dose ICS
- Step 3 – low dose ICS + LABA (or medium dose ICS)
- Step 4 – medium dose ICS + LABA
- Step 5 – high dose ICS + LABA
- Step 6 – high dose ICS + LABA + short course of oral systemic glucocorticoids
Treatment of Acute Asthma Exacerbation:
- Oxygen ( keep SaO2 >90% but <96%)
- Systemic glucocorticoid (methylprednisolone vs prednisone)
- Short acting bronchodilator (stacked nebs / Duoneb)
- Albuterol
- Add Ipratropium for severe flares in the ER, then resort back to only albuterol once admitted to the hospital
Magnesium (Intravenous) – for severe flares
•**antibiotics have not been shown to improve outcomes unless there is a concomitant infection
Treatment for COPD based on risk Group
A -
PRN
SABA – albuterol
SAMA – Ipratropium
Combo SABA + Ipratropium **
B
LABA – Salumeterol
LAMA – Tiotropium
*persistent symptoms – LABA + LAMA
•Umeclidinium + Vilanterol (Ellipta)
C
LAMA – Tiotropium
*LAMA + LABA combo (Ellipta)
Less preferred LABA + ICS
- Salmeterol/fluticasone (Advair)
- Formoterol/budesonide (Symbicort)
D
LAMA + LABA combo (Ellipta)
LABA + ICS – preferred if sx of asthma
*LABA + LAMA + ICS
Treatment of Acute COPD Exacerbation
- Oxygen (keep SaO2 >90% but <96%)
- Systemic glucocorticoids – MUST TAPER
- Prednisone (oral)
- Methylprednisolone (Solu-medrol) (intravenous)
- Short acting bronchodilator
- Ipratropium & Albuterol nebulizer (Duoneb) à give to hospitalized pts
- Albuterol nebulizer
- Antibiotics (if requires hospitalization or infection) **** give even if no infection
- Cover atypical organisms - Levofloxacin, Azithromycin
Treatment of Acute Bronchiectasis Exacerbation
Oral antibiotics (tailor to microscopy when culture data is available) x 10dys
- Outpatient vs inpatient treatment
- Nebulized hypertonic saline to thin secretions
- Chest Physiotherapy (chest PT)
- Oscillatory positive expiratory pressure (PEP) device to loosen secretions
- Bronchodilators (short acting beta-agonist)
- Pulmonary rehab
cardinal feature of acute bronchitis
Cough – cardinal feature, lasts 1-3 weeks (median duration 18 days)
Dx of acute bronchitis is ?
patient with acute onset but persistent cough (1-3 weeks) without clinical findings suggestive of pneumonia (eg, fever, tachypnea, rales, signs of parenchymal consolidation)
most likely cause of acute bronchitis?
Viral - 60%
Rhinovirus
Parainfluenza
Influenza A and B
Coronavirus 1 to 3
Bacteria: ~6% of cases
Bordetella pertussis
Mycoplasma pneumoniae
Chlamydia pneumonia
Influenza is caused by?
Influenza A and B are RNA viruses à Classified by their surface glycoproteins
- Hemagglutinin (H) – surface glycoprotein that binds to epithelial
- Neuraminidase (N) – allows entrance into cell
Influenza A:
H1, H2, and H3
N1 and N2
Si/Sx of influenza
Abrupt onset fever (100 to 104°F), headache, myalgia and malaise
Testing for the flu
Rapid Antigen Tests –
- Quick results (+ or -)
- Less specific – better sensitivity earlier on in sx)
Molecular Assay – RT-PCR tests
- Nasopharyngeal swabs
- More effective / specific
- Expensive
4 drugs approved to treat flu
- Oseltamivir (Tamiflu) – tx ALL pts including pregnancy and children
- Zanamivir (Relenza) - ag 7 and older
- Peramivir (Rapivab) – 2 yrs and older
- Baloxavir marboxil (Xofluza) 12 yrs and older
flu vaccine is contraindicated in?
- CI: Guillan-Barre w/in 6 wks of prior flu vaccination
- EGG allergy is not CI!!
Acte Bronchitis is defined as
Lower respiratory tract infection involving the large airways (bronchi), without evidence of pneumonia, that occurs in the absence of chronic obstructive pulmonary disease.
complications of the flu
Pneumonia – primary or secondary bacterial pneumonia
Myositis – mostly legs – unknown mechanism – mostly Influenza B
Stages of TB infection (clearance -> non clearance)
- Immediate clearance of the organism – no infection
- majority of inhaled bacilli are trapped in the upper airways and expelled by ciliated mucosal cells (<10% reach the alveoli) - MOST COMMON
Those who do not clear the organism
- Primary Tuberculosis (~10%) Symptomatic - SICK
- Latent infection (~90%) Asymptomatic – unlikely to spread dz
- Reactivation disease after a period of latency
systemic disease that is a risk factor for TB
CKD
Close contact (household members) – most important risk factor for TB
si/sx of latent TB vs Active TB
Latent TB - ASYMPTOMATIC
- Unlikely to spread dz
- TB skin or blood test
- Normal CXR
- Normal sputum smear
Active TB - SICK – (less 10%)
- Cough – persistent for 3 wks
- Diurnal fevers (nighttime)
- Hematopysis
- Night sweats
- Weight loss, Anorexia
- Malaise
Findings:
- Lung apices involved
- Erythema nodosum
Diagnostic tests used for Latent TB
T_uberculin Skin Test (TST) or Mantoux test, PPD_
- Delayed type hypersensitivity test – can be positive if vaccinated for TB (BCG vaccination)
- Looking for INDURATION not erythema
- Positive >15mm
IGRA serum test – can detect latent TB vs vaccination rxn - used to confirm positive TST skin test
- QuantiFERON TB GOLD
- T-SPOT.TB
IF POSITIVE? -> EXCLUDE ACTIVE TB
Tx of Latent TB
Rifampin and Isoniazid
Diagnostic Tests for active TB
Sputum Nucleic acid amplification - Xpert MTB/RIF (Ultra)** -> IF positive then tx for TB
Sputum AFB Microscopy
Mycobacterial culture – MGIT system
Tx of active TB
Intensive phase (2 mo) – RIPE
- Isoniazid, Rifampin, pyrazinamide and ethambutol
- pyrazinamide can be excluded due to hepatoxicity, gout or pregnancy
C_ontinuation Phase (4-7 mo)_
- Isoniazid and rifampin
- 7 mo if pyrazinamide excluded from RIPE
When treating active TB it is important to monitor?
LFTs
Avoid Tylenol and ETOH while being treated
Peripheral neuropathy, maculopapular rashes
Extrapulmonary TB spreads to what sites most commonly?
- Lymph node (most common) à Scrofula - painless swollen LN
- Pleural TB à pleural effusion
- GU
- Skeletal
Define Miliary TB with si/sx
Hematogenous dissemination of mycobacterium tuberculosis
Failure to thrive
Night sweats
Fever
Dysfunction of organ systems
Complications of TB
- Pneumothorax
- Bronchiectasis
- Bronchiolithiasis
- Extensive Pulmonary Destruction
- Sepsis
- Lung Cancer
- VTE
- TB Spread – extra pulmonary involvement
CXR findings noted in TB
Ghon Focus - localized lymphadenopathy, usually peripheral and associated with hilar adenopathy
Cavitary reactivation of latent tuberculosis in posterior apical segment of right upper lobe
CXR findings of Miliary TB
COVID 19 Diagnostics
Nucleic Acid Amplification Tests (NAAT) - PCR assay from the upper respiratory tract is the preferred initial diagnostic test (highly sensitive)
Antigen Test - less sensitive then NAAT but results in <1 hour (nasopharyngeal swab)
Antibody Test - CDC does not reccommend antibody testing to diagnost acute infection
CXR of COVID 19
consolidation
ground glass opacities with bilateral peripheral and lower lung zone distributions with peak severity 10-12 days after onset
may be normal in early or mild disease
Chest CT
bilateral wih peripheral distribution and involve lower lobes
ground glass opacities -83%
ground glass opacifications with mixed consolidation - 58%
adjacent pleural thickening - 52%
interlobal septal thickening - 48%
air bronchograms - 46%
COVID 19 lab features associated with worse outcomes
Lymphopenia*
D-Dimer
Define “pulmonary nodule”
A lesion that is both within and surrounded by pulmonary parenchyma. (also called ‘coin’ lesion)
Less than 3 cm in size and not associated with atelectasis or lymphadenopathy.
•A lesion > 3 cm in diameter is called a mass.
Benign Causes of pulmonary nodule
Infectious granulomas comprise about 80% of all benign nodules. (Histoplasmosis, coccidiomycosis, mycobacterium.)
Inflammatory nodules comprise 10 % of benign nodules
(Rheumatoid, Wegener granulomatosis, Sarcoidosis.)
Hamartoma – 10% of benign tumors. Benign tumors of the lung that are comprised of cartilage, fat, muscle.
(‘Popcorn’ calcification)
Larger lesions are more likely to be (benign / malignant)
malignant
compare and contrast benign vs malignant pulmonary lesions
Border:
- Malignant lesions will have a more irregular or spiculated border.
- Benign lesions will have a smooth and discrete border.
Growth:
- Lesions that are malignant tend to have an interval increase in size between 4-6 months.
- Therefore, nodules that grow very rapidly are more likely benign.
- Air Bronchogram
risk factors for development of lung cancer
- Smoking: 85-90% *Packs/yr (20-25 cigarettes in a pack)
- Occupational/Environmental
- Radon, Asbestos, Wood smoke, Diesel exhaust, Air pollution
- Genetic Factors/Family History
- Benign lung disease (Fibrosis, COPD, Alpha-1 antitrypsin deficiency, TB)
- Ionizing Radiation
- *Second-Hand Smoke/Third hand smoke
Most common type of lung cancer – especially in nonsmokers
Adenocarcinoma
- Adenocarcinoma in situ
- Minimally invasive adenocarcinoma
- Invasive adenocarcinoma
commonly found in the lung periphery,
persistent subsolid nodules have a much slower growth rate
carry a high risk of malignancy
what type of pulmonary lesion??
Adenocarcinoma
define the TNM stage
TNM Stage -> guide therapy
- Local (T= Tumer)
- Regional (N = nodes)
- Distant (M = Metastasis) à stage IV
lung cancer that occur Centrally and are classically associated w/ a Hx of smoking!!!
Squamous cell Carcinoma
imaging of squamous cell carcinoma shows
extensive central necrosis and cavitation
Type of lung cancer almost exclusively found in smokers and most common in heavy smokers.
Oat Cell (Small Cell)
small cell lung cancer is described as
Poorly differentiated neuroendocrine tumor that commonly occurs as a large hilar mass with bulky mediastinal adenopathy.
Has a rapid doubling time, high growth fraction, and early development of widespread metastases.
Dx of Small Cell lung cancer
Two stage system:
•Limited Disease: Disease confined to the ipsilateral hemithorax and within a single radiotherapy field
•Extensive Disease: Metastatic disease outside the ipsilateral hemithorax
•At presentation: 60-70% of patient will have extensive stage; 30-40% will have limited stage.
prognosis of small cell lung cancer
Much more fatal
Limited Disease: 15-20 months - 5 yr survival: 10-13%
Extensive Disease: 8-13 months - 5 yr survival 1-2 %
Malignant epithelial neoplasm lacking glandular or squamous differentiation that usually presents as large peripheral mass with prominent necrosis
Large Cell
how large cell lung cancer is diagnosed
Usually a diagnosis of exclusion, to include all poorly differentiated NSCLCa that are not further classifiable.
Diagnosis of large cell lung cancer includes what type of tests
- CT guided needle biopsy
- Bronchoscopy +/- Lavage
- Endobronchial Ultrasound biopsy (EBUS)
- Video-assisted Thoracoscopic Surgery (VATs) biopsy
- Thoracentesis
neuroendocrine differentiation
- made up of peptide and amine producing cells.
- They appear throughout the body: GI tract, Thymus, lung, and ovaries.
Carcinoid tumors
most common primary lung neoplasm in children.
carcinoid
si/sx of carcinoid lung cancer
indolent clinical behavior.
Cough
Wheeze
Hemoptysis
Recurrent Pneumonias ***
Asymptomatic
Carcinoid syndrome- rare with bronchial carcinoid.
Acromegaly
Bronchial obstruction à lung deflates
2 cell types in carcinoid tumors
They are comprised of two main cell types:
- Typical carcinoid have an excellent prognosis and are about 4 x more common than atypical.
- Atypical carcinoid have a greater tendency to metastasize
how carcinoid tumors appear on imaging
Tumors appear as round, ovoid opacities and may be hilar or perihilar.
Commonly arise in the proximal airways causing bronchial obstruction
Tx of carcinoid tumors
En bloc surgical resection is the treatment of choice.
non surgical candidates, intraluminal, bronchoscopic resection
prognosis of carcinoid tumors
Typical – more common and better prognosis
Atypical – greater tendency to metastasize
metastatic carcinoid, the role of chemotherapy and radiation therapy is limited.
List the most common malignancies that metastasize to the lung
Malignant melanoma
Sarcomas
Carcinomas of the:
- Breast
- Kidney
- Bladder
- Colon
- Prostate
