Respiratory 2 Flashcards
What are the 2 main types of lung cancer?
small cell lung cancer (SCLC) - 20%
non-small cell lung cancer (NSCLC) - 80%
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%)
Which type of lung cancer can lead to development of paraneoplastic syndromes?
small cell lung cancer - contain neurosecretory granules - release neuroendocrine hormones
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
How does lung cancer typically present?
SoB
cough
haemoptysis
finger clubbing
supraclavicular lymphadenopathy
weight loss
recurrent chest infections
hoarseness - Pancoast tumours
SVC syndrome
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
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
When should patients be referred for suspected (lung) cancer pathway?
CXR findings consistent with lung cancer
40+ y.o. with unexplained haemoptysis
What examination findings can be found in lung cancer?
fixed, monophonic wheeze
supraclavicular lymphadenopathy / persistent cervical lymphadenopathy
finger clubbing
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)
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
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
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
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
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
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
What paraneoplastic features are associated with lung adenocarcinoma?
gynecomastia
HPOA (hypertrophic pulmonary osteoarthropathy)
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
What investigations are used to diagnose lung cancer?
bloods - thrombocytosis
CXR
staging CT scan
bronchoscopy with endobronchial ultrasound - with biopsy
PET CT -
What findings can be found on CXR in lung cancer?
hilar enlargement
peripheral opacity - visible lesion
pleural effusion (usually unilateral)
lung collapse
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
What are the treatment options for SCLC?
usually palliative chemo+radiotherapy
tends to present later and already metastatic
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)?
- CXR - to rule out other pathologies
- 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
