Respiratory 2 Flashcards by Rebeka Jirsak

What are the 2 main types of lung cancer?

small cell lung cancer (SCLC) - 20%
non-small cell lung cancer (NSCLC) - 80%

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What are the different types of non-small cell lung cancer?

adenocarcinoma (40%) - peripheral lesions
squamous cell carcinoma (20%) - cavitating lesions
large cell carcinoma (10%) - peripheral lesions
other types (10%)

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Which type of lung cancer can lead to development of paraneoplastic syndromes?

small cell lung cancer - contain neurosecretory granules - release neuroendocrine hormones

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What is mesothelioma?

lung malignancy affecting mesothelial cells of pleura
linked to inhalation of asbestos
latent period between asbestos exposure and development of mesothelioma ~ 45 years
poor prognosis

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How does lung cancer typically present?

SoB
cough
haemoptysis
finger clubbing
supraclavicular lymphadenopathy
weight loss
recurrent chest infections
hoarseness - Pancoast tumours
SVC syndrome

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What are the CXR referral criteria for suspected lung cancer?

CXR within 2 weeks for patients 40+ y.o. with:
- clubbing
- supraclavicular lymphadenopathy
- thrombocytosis
- recurrent / persistent chest infections
- chest signs of lung cancer

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When should you offer CXR when suspecting lung cancer?

patient over 40 with 1+ (if smoked/asbestos exposure) or 2+ (if non-smoker) of the following: (non-specific symptoms)
- cough
- SoB
- chest pain
- fatigue
- weight loss
- loss of appetite

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When should patients be referred for suspected (lung) cancer pathway?

CXR findings consistent with lung cancer
40+ y.o. with unexplained haemoptysis

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What examination findings can be found in lung cancer?

fixed, monophonic wheeze
supraclavicular lymphadenopathy / persistent cervical lymphadenopathy
finger clubbing

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What paraneoplastic features are associated with small cell lung cancer?

SIADH - syndrome of inappropriate ADH -> ectopic ADH produced -> hyponatraemia
Cushing’s syndrome - ectopic ACTH secretion
Lambert Eaton syndrome - caused by antibodies to SCLC cells
Limbic encephalitis - antibodies to brain tissue (esp. limbic system)

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What is SIADH? What type of lung cancer is it associated with?

syndrome of inappropriate ADH
associated with SCLC
production of ectopic ADH
presents with hyponatraemia

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How does Cushing’s syndrome present in lung cancer? What type of lung cancer is it associated with?

associated with SCLC
ectopic secretion of ACTH
atypical presentation
HTN, hyperglycaemia
hypokalaemia
alkalosis
muscle weakness

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What is Lambert Eaton syndrome? Which type of lung cancer is it associated with?

antibodies against SCLC cells
antibodies also damage voltage gated Ca channels on presynaptic terminals in motor neurons
causes weakness of proximal muscles
can also affect:
- intraocular muscles - diplopia
- levator muscles - ptosis
- pharyngeal muscles - slurred speech, dysphagia
can also lead to autonomic dysfunction:
- dry mouth
- blurred vision
- dizziness
- impotence

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What is limbic encephalitis? What type of lung cancer is it associated with?

SCLC
production of antibodies to the limbic system -> inflammation
presents with
- short-term memory loss
- hallucinations
- confusion
- seizures

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What paraneoplastic features are associated with squamous cell lung cancer?

parathyroid hormone-related protein secretion -> causes hypercalcaemia
finger clubbing
HPOA - hypertrophic pulmonary osteoarthropathy
ectopic TSH -> hyperthyroidism

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What is HPOA? What types of lung cancer is it associated with?

squamous cell and adenocarcinoma
hypertrophic pulmonary osteoarthropathy
clubbing
proliferative periostisis involving that typically involves the long bones
causes pain

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What paraneoplastic features are associated with lung adenocarcinoma?

gynecomastia
HPOA (hypertrophic pulmonary osteoarthropathy)

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What complications can result from lung cancer?

recurrent laryngeal nerve palsy - hoarseness, caused by tumour compression of the nerve
phrenic nerve palsy - diaphragm weakness - SoB
SVC obstruction - facial swelling, SoB, distended neck and upper chest veins; Pemberton’s sign (facial congestion and cyanosis when arms raised)
Horner’s syndrome - associated with Pancoast tumour pressing on sympathetic ganglion; ptosis, anhydrosis, miosis

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What investigations are used to diagnose lung cancer?

bloods - thrombocytosis
CXR
staging CT scan
bronchoscopy with endobronchial ultrasound - with biopsy
PET CT -

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What findings can be found on CXR in lung cancer?

hilar enlargement
peripheral opacity - visible lesion
pleural effusion (usually unilateral)
lung collapse

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What are the management options for lung cancer?

MDT meeting
surgery - first line for NSCLC (SCLC usually already metastatic)
radiotherapy - can be curative in NSCLC
chemotherapy - adjuvant to other treatments, palliative
endobronchial treatment - stents, debulking - to improve QoL

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What are the treatment options for SCLC?

usually palliative chemo+radiotherapy
tends to present later and already metastatic

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What are the surgical options for lung cancer?

segmentectomy / wedge resection - removing a section of a lobe
lobectomy - removing the entire lobe
pneumonectomy - removing the entire lung

What are the surgical methods available for lung cancer?

thoracotomy - open surgery
VATS (video-assisted thoracoscopic surgery) - keyhole surgery
robotic

What are the main thoracotomy incisions used in lung cancer surgery?

anterolateral axillary posterolateral - most common

What are some potential features of pulmonary embolism?

pleuritic chest pain SoB haemoptysis tachycardia tachypnoea

What are the PERC (PE Rule-out Criteria)?

Age >50 HR >100 O2 sats <94 Previous DVT / PE Recent trauma / surgery (past 4 weeks) Haemoptysis Unilateral leg swelling Oestrogen use

When is PERC negative?

when all criteria are absent chance of PE is then < 2%

What are some risk factors for DVT / PE?

immobility recent surgery (past 4 weeks) long haul travel pregnancy malignancy oestrogen use polycythaemia SLE thrombophilia

What is the Wells score? When is it used?

Wells score predicts the probability of a patient having a PE performed when PE is suspected PE likely - more than 4 points

What investigations are performed when PE is likely (Wells score > 4)?

1. CXR - to rule out other pathologies 2. CTPA (CT pulmonary angiogram) - if delayed - give anticoagulation before CTPA can be performed - if positive = PE - if negative = proximal leg vein USD if DVT suspected

What investigations are performed when PE is unlikely (Wells score < 4)?

D-dimer 1. if positive -> CTPA (anticoagulation if delay) 2. if negative -> PE unlikely, consider other Dx

What are some possible ECG findings in PE?

S1Q3T3 - large S in lead 1 - large Q in lead 3 - inverted T in in lead 3 RBBB R axis deviation sinus tachycardia

What conditions (other than PE) can create a high D dimer?

pregnancy pneumonia malignancy HF surgery

What is the first line management of PE?

anticoagulation 1. apixaban / rivaroxaban - first line 2. LMWH if DOACs not suitable

How long should patients with PE be anticoagulated for?

at least 3 months if DVT provoked (obvious precipitating event) - 3 months if DVT unprovoked - 6 months

How are haemodynamically unstable patients with PE managed?

thrombolysis - e.g. alteplase

How are patients with PE assessed regarding outpatient/inpatient treatment?

PESI (PE severity index)

When is pleural effusion transudate?

when < 30g/L protein

What are some causes of transudative pleural effusion?

secodary causes of lung pathologies / systemic: HF hypoalbuminaemia hypothyroidism Meig's syndrome

When is pleural effusion exudative?

when > 30g/L protein EXudative - EXtra protein

What are some causes of exudative pleural effusion?

primary lung pathologies: infection - pneumonia, TB connective tissue disease neoplasia pancreatitis PE yellow nail syndrome Dressler's syndrome

What are some features of pleural effusion?

SoB non-productive cough chest pain

What are some examination findings in pleural effusion?

dullness to percussion reduced breath sounds reduced chest expansion

What imaging is used in pleural effusion?

PA CXR USD contrast CT

What is the typical management of bronchitis?

analgesia high fluid intake ATB only if: - systematically unwell - pre-existing co-morbidities - elevated CRP (above 20)

What is the first line ATB in bronchitis?

doxycycline

What is lung abscess?

well-circumscribed infection within the lung parenchyma

What are the potential causes of lung abscess?

most commonly secondary to aspiration pneumonia poor dental hygiene previous stroke haematogenous spread bronchial obstruction secondary to lung tumour

What are the most common causative organisms of monomicrobial lung abscess?

Staph aureus Klebsiella pneumonia Pseudomonas aeruginosa

What are the features of lung abscess?

similar to pneumonia but subacute - symptoms develop over weeks - systemic features - night sweats, weight loss fever productive cough with foul smelling sputum chest pain SoB

What are some examination signs of lung abscess?

dullness to percussion bronchial breathing clubbin

What investigations can be used in lung abscess>

CXR - fluid-filled space within area of consolidation - air-fluid level can be seen sputum cultures blood cultures

What is the management of lung abscess?

IV ATB percutaneous drainage - if not resolving

When is pleural effusion exudative, according to Light's criteria?

any 1 of: pleural fluid protein / serum protein > 0.5 pleural fluid LDL / serum LDL > 0.6 pleural fluid LDL more than 2/3 the upper limits of normal serum LDH