Pulmonary Flashcards
Carcinoid Tumors
Rare neuroendocrine (enterochromaffin cell) tumor with slow growth and low METS
Secrete serotonin, ACTH, ADH, melanocyte stimulating hormone*
Presentation:
- asx +/- wheezing, cough, recurrent pneumonia, hemoptysis
+/- SIADH, Cushing’s, obstruction
Dx:
- bronchoscopy: pink to purple well vascularized central tumor*
- localization via CT and octreotide scan
Mgmt:
- surgical excision: definitive
- often resistant to radiation and chemo
- Octreotide to dec sxs by dec secretion of active hormones
Non Small Cell Lung Cancer
Adenocarcinoma
- MC type, peripherally located
- metastasis, gynecomastia
Squamous cell
- centrally located - hemoptysis, central necrosis
- hypercalcemia
Large cell
- very aggressive
Mgmt:
- surgical resection especially if localized to chest
Small cell lung cancer
Small cell (oat cell) carcinoma
- Early METS, aggressive, surgery usually not an option
- SIADH, hyponatremia, Cushing’s
Lambert Eaton Syndrome
- abs against Ca2+ gated channels at NMJ (like MG)
- weakness improves with continued use
Mgmt: chemo
Lung cancer Dx
CXR
CT
Sputum cytology - central lesions (squamous cell, small cell)
Bronchoscopy - central lesions
Pleural fluid analysis
Transthoracic needle biopsy for peripheral lesions
Pulmonary nodules
Nodule: well circumscribed lesion <3cm
Granulomatous infections: TB (common), histoplasmosis, coccidiomycosis
Tumors
- benign: round, smooth, slow, calcifications, cavitary
- malignant: irregular, speculated, rapid growth (4mo. double time), cavitary with thickened walls
Inflammation: RA, sarcoidosis, Wegener’s granulomatosis
Mediastinal: thymoma (MC)
Dx:
- observation: if low malignant probability (<5%) - if it stays same size, likely benign
- Transthoracic needle aspiration or bronchoscopy
- Resection w/bx: preferred if malignancy >60%
Pleural effusion
Abnormal accumulation of fluid in pleural space
- transudate: MC CHF, nephrotic syndrome, cirrhosis
- exudate: infection, inflammation
Often asx
Sxs:
- pleuritic CP
- cough, dyspnea
Dx:
- PA/lateral CXR
- lateral decub - better for smaller effusions
- thoracentesis**
Mgmt:
- tx underlying condition
- thoracentesis** dx/tx
- chest tube pleural fluid drainage if empyema
- pleurodesis if malignant or chronic effusion
Pleural effusion - lights criteria
Presence of any 3 = exudative
- serum protein > 0.5
- serum LDH > 0.6
- pleural fluid LDH > 2/3 upper limit normal LDH
Pneumothorax
Sxs
- acute dyspnea, pleuritic chest pain
- spontaneous in tall, thin male
- iatrogenic possible w/central line
- consider in chest trauma
Dx
- CXR: dec lung markings, expiratory films will increase size of PTX on CXR
- tension: mediastinum shifts away from PTX
Mgmt:
- <20% = resolves on own
- > 20% = tube thoracostomy
- Tension PTX: immediate needle decompression at 2nd ICS/MCL followed by chest tube
Tension PTX:
- tracheal deviation
- distended neck vein
- AMS, hypotension
PE general
RF: post op, immobilization, pregnancy, OCPs, thrombophlebitis, heart disease, smoking, FHx, prior PE
Sxs:
- abrupt pleuritic chest pain
- MC: dyspnea, tachypnea
- TRIAD: dyspnea, pleuritic CP, hemoptysis
- pulmonary exam usually normal
- normal CXR w/hypoxia is highly suspicious
PE unlikely: get D-dimer
- if neg, PE excluded
- if pos, get CT scan
PE likely: get helical CT
- normal: PE excluded
- indeterminate: pulmonary angio or LE US
Westermarks: avascular markings distal to area of thrombus
Hamptom’s hump: wedge shaped infiltrate (representing infarction)
PE dx/tx
Dx
- PE: tachypnea, tachycardia, hypoxemia, low grade fever, shock
- ABG: pO2 < 80%
- Helical CT scan: best initial test for proximal emboli
- Pulmonary angio** gold standard - order if high suspicion and neg CT or VQ scan
- Doppler US looking for LE DVT
- CXR: atelectasis w/elevated hemi diaphragm
- ECG: S1Q3T, ST changes, sinus tach
- D-dimer, if positive: helical Chest CT w/IV contrast
Mgmt:
- O2 to keep Pox > 94%
- IV crystalloid
Hemodynamic Stable
- anticoagulation: LMWH or UFH, then warfarin for 3mo.
- IVC filter w/anticoag C.I. or unsuccessful
Hemodynamic unstable:
- thrombolysis: streptokinase, alteplase
- thrombectomy/ embolectomy: if unstable/massive PE
