Respiratory disorders and their management III Flashcards
Lung cancer prevalence?
Main cause of cancer related death
2nd most common cancer
Lung cancer features?
85% NSCLC 15% SCLC 10% operable at diagnosis Risk of spread from primary tumours to nodes and distal organs (bone,liver, lung pleura cavity) T N M1A/1B predicts survival
Lung cancer - NSCLC subtypes?
Squamous Cell
Adenocarcinoma
Adenocarcinoma in situ (aka bronchoalveolar carcinoma)
Lung cancer symptoms?
Depend on stage of disease Sob - lobar collapse, effusion, lymphangitis Chest pain - rib involvement, chest wall invasion Cough Haemoptysis Weight loss Low appetite Low energy levels
Lung cancer - paraneoplastic syndromes causes and effects?
High Ca (PTH release/bone involvement) - nausea, confusion, abdo pain and constipation
SIADH - confusion, fits
Lambert eaton syndrome - neuromuscular weakness
Effects of lung cancer being a metastatic disease?
SVCO due to mediastinal disease
Brain mets - confusion, nausea, headache
Bone mets - path fracture, pain
Liver mets - abdo pain
Signs of lung cancer?
Finger nail clubbing Cachexia Horner's syndrome Neck nodes Chest signs Palpable liver SVCO
How to diagnose lung cancer?
Chest X-ray:
- Cheap
- Won’t detect mediastinal disease or small nodules
- Not a staging tool, but a screening tool
CT:
- Staging tool
- Detailed info
- Requires IV contrast (not allowed in pts with CKD)
- Cannot detect microscopic disease
PET scan for radical treatable disease;
- Infusion of FD glucose
- Detects cancer, infec, vasculitis
- Expensive
- Very sensitive
- False positive rate
Tissue biopsy:
- Image guided
- Bronchoscopy +/- endobronchial US
- Thoracoscopy for pleural disease
- Surgical
WHO performance status for lung cancer?
0 = carry out normal activity 1 = restricted in strenuous activity 2 = capable of self care but unable to do work activities 3 = symptomatic, in chair or bed for 50% of day 4 = disabled, cannot care for self
What does lung cancer treatment depend on?
Stage and WHO performance status
RT or surgery for WHO 1/2
Chemo for extensive disease
Immunotherapy - inhibition of PDL suppression by tumours on T-ells
Oral EGFR mAB for EGFR positive disease WHO PS 0-3
BSC for pts not fit for active treatment
How to treat SCLC?
Systemic Cisplatin based Chemotherapy - disease extensive at presentation
Treat within 7/7 of diagnosis to due speed of deterioration
If localised disease – f/u RT
Classification of interstitial lung disease?
Idiopathic
Drug reaction
Extrinsic allergic alveolitis/hypersensitivity pneumonitis
Associated with rheumatological disease
Symptoms of lung disease?
Types of it?
Dyspnea Cough Constitutional symptoms (fevers, weightloss, headaches) EAA - post exposure IPF - chronic AIP - rapid onset
Signs of lung disease?
Nail clubbing
Sclerodactyly
Signs of steroid use
Chest - audible crackles, distribution may influence diagnosis, squeaks - suggest small airways disease
Idiopathic pulmonary fibrosis features?
Male Older population Median survival 3yrs Associated with clubbing Restrictive spirometry and reduced transfer factor Diagnosis by CT
How to treat Idiopathic pulmonary fibrosis?
Supportive Pulm rehab Pirfenidone when FVC <80% Nintenadib FVC 50-89% Palliative care
EAA triggers?
Occupation - baker, farmer, moulds
Where is EAA mainly located?
Predominant upper zone predominance
EAA treatment?
Antigen avoidance
Trail of corticosteroid therapy
Calcium and vitamin supplementation
Possible bisphosphonate
What is sleep apnea?
Prevalence?
Excessive daytime sleepiness with disordered nocturnal irregular breathing
0.5-4% population prevalence cf Type 1 DM
How is the severity of sleep apnea measured?
Apnea-hypopnea index
Mild - AHI 5-14/hr
Mod - AHI 15-30/hr
Severe - AHI >30/hr
Name the types of sleep apnea
Obstructive sleep apnea
Central sleep apnea
Mixed apnea
Risk factors for OSA?
Obesity >17 inch collar Men x2-3 likely Age Cranio-facial and upper airway abnormalities e.g. short mandible, wide craniofacial base
What does sleep apnoea cause?
Excessive daytime sleeping Impaired conc Snoring Unrefreshing sleep Choking episodes during sleep Restless sleep Nocturia
Obstructive sleep apnoea?
Upper airway collapses = snoring and apnoeas
Epworth Sleepiness Scale
Questionnaire with 0-24 scale 11-14 mild sleepiness 15-18 moderate sleepiness >18 severe sleepiness Screening tool when assessing daytime somnolence
Other tests
Sleep latency test & Maintenance of Wakefulness
Causes of excessive daytime sleepiness in adults?
Fragmented sleep Sleep deprivation Shift work Depression Hypothyroidism Restless leg syndrome Excessive alcohol Neurological conditions - Previous head injury, parkinsons
How to diagnose sleep apnea?
Pulse oximetry:
Cheap
Easy to use
Can be used at home
Can show false negative
Less sensitive in thin patients/issues with tissue perfusion
Measure 4% desaturation rate (ODI) - >10 events per hours suspicious
Polysomnography: Limited vs Full Full considered Gold standard Full PSG requires hospital admission Measurement of EEG, eye & limb movements, nasal flow, thoraco-abdominal movement, ECG & oxygen saturation
Morbidity associated with OSA?
Untreated x2-3 risk of RTA (DVLA)
Associated with CHD, CCF, PAH & Hypertension & CVD
Insulin resistance (Metabolic syndrome) & T2 DM
Concurrent obesity is a confounding factor in studies
Increased risk of post-operative complications
Treatment of OSA?
Weight loss/lifestyle change
Continuous Positive Airway Pressure (CPAP)
Mandibular Advancement Device (MAD)
Continuous positive airway pressure - how does this treat OSA?
Delivery of constant pressure by face/nasal mask
Abolition of apneas/hypopneas with improvement in oxygen saturation
Very effective
Adherence variable
Essential to maintain licence validity
When to use a mandibular advancement device for treating OSA?
Role when CPAP not tolerated
Mild-Moderate OSA
Adherence is key to success
How does the mandibular advancement device work?
When is MADD, CPAP and UPPP better to use?
Anterior displacement of mandible
MAD better than no-MAD
- CPAP better than MAD for reduction of AHI/ODI
MAD better than CPAP for pt preference
MAD better than UPPP for AHI/ODI but snorindg same for both
Give examples of short acting bronchodilators?
Salbutamol, terbutaline
How to short acting bronchodilators work?
Relief of symptoms For PRN use Use in COPD & Asthma Immediate bronchodilation 4-6hour duration Increase in cAMP with reduction in cell Ca2+ leading to relaxation of smooth muscle
Side effects of short acting bronchodilators?
Increased HR & palpitations Tremor Hypokalaemia Headache Nervousness
Give examples of long acting bronchodilators?
Salmerterol, formoterol
How do long acting bronchodilators work?
Alternative to increasing dose of steroids
Given by inhaled route
Not to be used in monotherapy in Asthma
High selectivity for B2 adenoceptor in pulmonary tissue
Can increase glucocorticord receptor availability
Concern of sudden cardiac death when used in monotherapy
Examples of anticholinergic agents?
Ipratropium, tiotropium, glycoporronium, aclindinium
How to anticholinergic agents work?
Relief of symptoms
Primarily for COPD
Reduction in exacerbation frequency in COPD
Improvement in FEV1
Mode of action Blockade of muscarinic receptors M1-3
Systemic absorption low
Side effects of anticholinergic agents?
Possible effect on urinary retention
Dry mouth
Possible adverse cardiovascular effects (seen in severe cardiac disease)
Given examples of inhaled steroids
Beclomethasone, Budesonide, Fluticasone, Ciclesonide
How do inhaled steroids work?
Mainstay of asthma medication
Prevent symptoms
Reduces risk of exacerbations and death
Usually twice daily medication
Not useful in acute attack
Binds to cytosolic GR with reduction in cytokines
Reduces bronchoconstriction and airway inflammation
Side effects of inhaled steroids?
Oral candida
Voice change
Risk of skin bruising, bone mineral density change and cataracts with high dose
Examples of oral steroids
Prednisolone, deflazacort
How do oral steroids work?
Given in acute asthma or chronically in severe asthma
Avoid if possible as long term therapy but essential if asthma worsens
Clearer role in eosinophilic asthma
Time to efficacy 4hours for IV & PO routes
Side effects of oral steroids?
Weight gain Hyperglycaemia Skin change Hypertension Eye change Mood change Reduce bone mineral density
Examples of theophyllines?
Nuelin SA, Slophyllin
How do theophyllines work?
Tablets and intravenous Useful in acute and chronic asthma Method of action unclear Possibly acting upon cAMP via PDE inhibition Possibly acting upon HDAC pathway Requires serum level monitoring Drug interactions
Side effects of theophyllines?
Nausea Vomiting Palpitations Headaches Dyspepsia Arrhythmias Confusion
Examples of Antileukotrienes? (treatment taken at night)
Montelukast, Zafilukast
How do antiluekotrines work?
Oral
Useful in chronic asthma
Not useful in acute asthma
Role in exercise induced asthma & patients with aspirin hypersensitivity
Leukotrienes within phospholipid cell membranes and derived from inflammatory cells
Can promote smooth muscle contraction and inflammatory changes in airway wall
Side effects of antileukotrines?
Headache N&V Sleep disturbance Sore throat GI disturbance
What is the 1st line treatment for asthma and COPD?
Short acting B2 agonists PRN
When are long acting B2 agonists used in asthma and COPD?
Asthma = always with ICS COPD = symptomatic relief
When are anticholinergics used?
Asthma = adjunct with ICS COPD = symptomatic relief
When are inhaled steroids used?
Asthma = 2nd line
COPD = not licensed in monotherapy
Used to reduce exacerbation frequency and symp relief
When is LAMA/LABA (long acting beta agonists) used?
Asthma = not licensed COPD = reduce exacerbation freq and symp relief
When to use theophylline?
Asthma = 3rd line defence COPD = symp relief
When to use Oral Leukotriene Antagonist?
Asthma = symp relief COPD = no obvs role
When to use oral steroids?
Asthma = long term low dose for difficult asthma and short term high dose for exacerbations COPD = Short term for exacerbations
How does oxygen therapy work?
Delivered by mask, nasal cannulae or ET tube
Controlled i.e. concentration known
Venturi systems, e.g. 24,28,35,60…%
Uncontrolled i.e. concentration guessed
Full face masks
Cannulae – highly dependent on respiratory rate
How to do O2 therapy in acutely unwell pts?
SpO294-98% unless concern of hypercapnea
How to do O2 therapy in COPD?
SpO2>88-92% until ABG taken
