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Respiratory - Level 2 Flashcards

1
Q

Definition of asthma?

A
  • Respiratory condition associated with reversible airway inflammation and hyper-responsiveness
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2
Q

Classification of asthma?

A 
o	Extrinsic (Atopy)
	Allergens identified by positive skin prick to common inhaled allergens

o Intrinsic
 No definitive external cause is identified and often develops in middle age

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3
Q

Pathology of asthma?

A

o Usually reversible either spontaneously or treatment
o 1. Airway narrowing
 Smooth muscle contraction, thickening of airway wall by cellular infiltration and inflammation
 Secretions within the airway
o 2. Inflammation
 Mast cells, eosinophils, T cells, dendritic cells cause IgE production and release of histamine, prostaglandin D2, leukotriene C4
o 3. Remodelling
 Hypertrophy and hyperplasia leading to more mucous secreting goblet cells

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4
Q

Epidemiology of asthma?

A
  • 10-15% of people develop asthma in 2nd decade of life
  • More common in developed world
  • 15% of asthma induced at work
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5
Q

Risk factors of asthma?

A
  • FHx of atopic disease
  • Respiratory infections in infancy
  • Tobacco smoke
  • Low birth weight
  • Social deprivation
  • Inhaled particulates
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6
Q

Aetiology of asthma?

A
  • Atopy
    o Defined as people who readily develop IgE antibodies
    o Genetic and environmental predispose to asthma
    o Increased responsiveness of airways to stimuli – provocation tests induce a response (histamine)
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7
Q

Precipitating factors of asthma?

A
  • House dust mite and its faeces
  • Viral infections
  • Cold air
  • Exercise
  • Irritant dust, vapours, fumes (cigarettes, perfume, exhaust)
  • Emotion
  • Drugs (Aspirin, beta-blockers)
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8
Q

Symptoms of asthma?

A
  • Wheezing attacks
  • SOB
  • Chest tightness
  • Cough (nocturnal)
  • Sputum
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9
Q

Features characteristic of asthma?

A
  • Intermittent and worse at night – diurnal variation
  • Quantify exercise tolerance
  • Disturbed sleep
  • Often have atopy – hayfever, eczema
  • Any pets, feathers, job
  • Days per week of school/work
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10
Q

Signs of asthma?

A
  • Tachypnoea
  • Audible wheeze
  • Hyperinflated chest
  • Hyper-resonant percussion
  • Decreased air entry
  • Reduced chest expansion
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11
Q

Investigations of asthma - if suspected asthma?

A
  • If <5 – treat based on symptoms and review child regularly, if still symptoms at 5, carry out objective tests
  • If >5 and unable to perform objective tests – continue to treat and try redoing test every 6-12 months
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12
Q

Investigations of asthma in children 5-17 years - initial investigations to perform?

A

o Offer spirometry to all if diagnosis of asthma considered
 FEV1/FVC <70% if positive tests for obstructive airway disease

o Bronchodilator Reversibility test
 Consider if obstructive spirometry (FEV1/FVC <70%)
 Positive test if >12% increase in FEV1

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13
Q

Investigations of asthma in children 5-17 years - when to diagnose asthma?

A

o Obstructive spirometry and positive BDR

o FeNO >35ppb and positive PEFR variability

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14
Q

Investigations of asthma in children 5-17 years - tests if diagnosis of asthma uncertain and what is a positive result?

A

o FeNO
 If normal spirometry or obstructive spirometry with negative BDR test
 35ppb or more is positive test

o Monitor PEFR variability for 2-4 weeks
 If normal spirometry o robstructive spirometry with negative BDR test and FeNO >35ppb
 >20% variability is positive test
o Refer for specialist assessment if obstructive spirometry, negative BDR and FeNO <35ppb

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15
Q

Investigations of asthma in children 5-17 years - when to refer to specialist?

A

o Refer for specialist assessment if obstructive spirometry, negative BDR and FeNO <35ppb

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16
Q

Investigations of asthma in children 5-17 years - when to suspect asthma?

A

o FeNO >35 with normal spirometry and negative PEFR variability
o FeNO >35 with obstructive spirometry but negative BR with no variability on PEFR
o Normal spirometry, FeNO <35 and positive PEFR
o Review diagnosis after 6 weeks of treatment by repeating any abnormal tests

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17
Q

Investigations of asthma in adults - objective tests to perform?

A

o FeNO
 >40ppb is positive test

o Spirometry
 FEV1/FVC <70% is positive result of obstructive spirometry

o Bronchodilator Reversibility Test (BDR)
 If obstructive spirometry (FEV1/FVC <70%), positive result is >12% improvement of FEV1 with increase in volume of >200ml

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18
Q

Investigations of asthma in adults - diagnose asthma when?

A

o FeNO >40ppb with either positive BDR or positive PEFR variability or bronchial hyperreactivity
o FeNO between 25-39 and positive bronchial challenge test
o Positive BDR and positive PEFR variability irrespective of FeNO level

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19
Q

Investigations of asthma in adults - tests to perform if diagnosis uncertain?

A

o PEFR variability for 2-4 weeks (>20% variability is positive test)
 If uncertainty and FeNO test and have either:
• Normal spirometry
• Obstructive spirometry with BDR positive but FeNO <39

o Direct bronchial challenge with histamine or methacholine if normal spirometry and either:
 FeNO >40ppb with no PEFR variability
 FeNO <39 with PEFR variability
 PC20 (provoking concentration to induce 20% reduction in FEV1) of 8mg/ml or less is positive result

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20
Q

Investigations of asthma in adults - when to suspect asthma?

A
  • Suspect Asthma if obstructive spirometry and:
    o Negative BDR and either FeNO >40 or FeNO 25-39 and positive PEFR
    o Positive BDR, FeNO 25-39 and negative PEFR
    o Treat patients and review diagnosis after 6-10 weeks by repeating spirometry
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21
Q

Management of asthma - general advice?

A
  • Weight loss
  • Stop smoking
  • Avoid triggers
  • Annual flu vaccine
  • Check inhaler technique and PEFR 2x a day
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22
Q

Management of asthma - medications - under 5s - step 1?

A

o SABA with 8-week trial of paediatric moderate dose ICS

 If symptoms >3x per week, causing waking at night or not controlled on SABA alone

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23
Q

Management of asthma - medications - under 5s - step 2?

A

o After 8 weeks, stop ICS treatment:
 If symptoms resolved then reoccurred within 4 weeks of stopping ICS – restart at paediatric low dose maintenance therapy
 If symptoms resolved but reoccurred beyond 4 weeks after stopping ICS – repeat 8-week trial of paediatric moderate dose of ICS

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24
Q

Management of asthma - medications - under 5s - step 3?

A

o If unresolved on paediatric low dose maintenance therapy:

 Add LTRA

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25
Q

Management of asthma - medications - under 5s - step 4?

A

o If unresolved on ICS and LTRA:

 Stop LTRA and refer to specialist

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26
Q

Management of asthma - medications - child >5 and adults - step 1?

A

o Step 1

 PRN SABA – Salbutamol alone if infrequent

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27
Q

Management of asthma - medications - child >5 and adults - step 2?

A

o Step 2 (if >3 doses PRN SABA, drugs not working, woken)

 Add low dose ICS (beclomethasone) 400mcg starting dose

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28
Q

Management of asthma - medications - child >5 and adults - step 3?

A 
Step 3 (if >3 doses PRN SABA in week, drugs not working, woken)
	Add a LTRA and assess in 4-8 weeks - if not controlled, discuss benefit (stop or continue) (NICE Step 3)

 Add LABA (salmeterol) either fixed dose or MART - if good response - continue (BTS Step 3)
• If benefit of LABA but inadequate, increase beclomethasone dose 800mcg
• If no response to LABA, stop LABA and increase beclomethasone dose 800mcg

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29
Q

Management of asthma - medications - child >5 and adults - step 4 and step 5?

A

o Step 4 (if >3 doses PRN SABA, drugs not working, woken)

SABA + ICS + LABA (continue LRTA if helped)

Step 5
Switch ICS/LABA to MART which includes ICS low dose

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30
Q

Management of asthma - medications - child >5 and adults - step 5?

A

o Step 5 (if >3 doses PRN SABA, drugs not working, woken)
 Referral to specialist
 Oral prednisolone
 Steroid sparing – methotrexate, ciclosporin

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31
Q

Management of asthma - when to refer immediately?

A
  • Immediately if occupational asthma suspected
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32
Q

Management of asthma - follow up?

A
  • Annually
  • 4-8 weeks after medication change or start
  • Long-term/Frequent steroid tablets need BP, HbA1c, cholesterol and vision tested every 3 months
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33
Q

Management of asthma - self-management plan?

A
  • Increased dose of ICS for 7 days when asthma deteriorates (quadruple dose)
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34
Q

Doses of ICS in asthma - adults?

A

o < or equal 400mcg budesonide or equivalent = low dose
o 400mcg – 800mcg budesonide or equivalent = moderate dose
o >800mcg budesonide or equivalent = high
dose

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35
Q

Doses of ICS in asthma - child <16?

A

o < or equal 200mcg budesonide or equivalent = low dose
o >200mcg – 400mcg budesonide or equivalent = medium dose
o >400mcg budesonide or equivalent = high dose

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36
Q

Definition of COPD?

A
  • Characterised by airflow obstruction due to combination of obstructive bronchiolitis and emphysema, resulting from enhanced inflammatory response
  • FEV1 <80% predicted; FEV1/FVC <0.7
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37
Q

Pathology of COPD?

A

 Chronic bronchitis
• Airway narrowing due to hypertrophy and hyperplasia of mucous secreting glands and oedema
• Change to columnar epithelium
• Sputum production for 3 months of 2 successive years

 Emphysema
• Dilatation and destruction of lung distal to terminal bronchioles
• Loss of elastic recoil

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38
Q

Classes of COPD?

A

o Type 1 Respiratory Failure (Pink puffers)
 Normal paO2, PaCO2
 Emphysema predominantly, breathless not cyanosed

o Type 2 Respiratory Failure (blue bloaters)
 Low PaO2, High PaCO2
 Chronic bronchitis – cyanosed develop cor pulmonale and rely on hypoxic drive

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39
Q

Epidemiology of COPD?

A
  • In UK, 3 million people living with COPD
  • Cigarette smoking in 90% of cases
  • 10-20% of the over 40s
  • Age of onset >35 years
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40
Q

Risk factors of COPD?

A
  • Cigarette smoking
  • Exposure to pollutants
    o Mining, building, chemical industries
  • Air pollution
  • Alpha-1-antitrypsin deficiency
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41
Q

Symptoms of COPD?

A
  • Productive, white/clear sputum cough
  • Progressive breathlessness
  • Wheeze
  • Frequent exacerbations
  • Weight loss, fatigue
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42
Q

Signs of COPD?

A
  • Cyanosed
  • Flapping tremor
  • Tachycardia
  • Accessory muscles used
  • Hyperinflated chest
  • Reduced expansion
  • Reduced breath sounds
  • Wheeze
  • Hyper resonant percussion
  • Cor Pulmonale – peripheral oedema, raised JVP, systolic parasternal heave
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43
Q

When to diagnose COPD clinically?

A
  • > 35 years old
  • Risk factor present
  • Typical and other symptoms
    o Exertional SOB, chronic cough, regular sputum production, frequent winter bronchitis, wheeze
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44
Q

Asssessment of COPD?

A
  • MRC Dyspnoea scale
    o 1 – not troubled by breathlessness except strenuous
    o 2 – SOB when hurrying or walking up slight hill
    o 3 – Walks slower than contemporaries due to breathlessness, must stop when at own pace
    o 4 – stops for breath about 100m or few minutes
    o 5 – Too breathless to leave house, breathless when dressing
  • Symptoms of anxiety or depression
  • Calculate BMI
  • Arrange spirometry, CXR, FBC
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45
Q

Investigations to perform in COPD?

A

Post-bronchodilator spirometry

  • Reduced FEV1, FEV1/FVC <0.7, PEFR
  • Reversibility <20% post-bronchoscopy

CXR
o Hyperinflation (>6 anterior ribs seen above diaphragm MCL)
o Flat hemidiaphragm

FBC

BMI

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46
Q

Classification criteria in COPD?

A

Diagnosis – GOLD Criteria

  • Mild – FEV1 ≥80% of predicted
  • Moderate – FEV1 50-79% of predicted
  • Severe – FEV1 30-49% of predicted
  • Very Severe – FEV1 <30% of predicted
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47
Q

When and what additional tests can be used in COPD?

A
  • Sputum culture – if sputum persistently present or purulent
  • Serial home PEFR – exclude asthma
  • ECG & Echo – any cardiac disease or pulmonary hypertension suspected
  • CT – investigate signs that other lung diagnosis present, abnormal CXR, suitability for lung volume reduction procedures
  • Alpha-1-antitrypsin – if early onset, minimal smoking or FHx
48
Q

Management of COPD - general advice?

A
  • Stop smoking – offer smoking cessation
  • Yearly influenza and pneumococcal vaccine
  • Encourage exercise
  • Flying – need to assess whether fit to fly or refer to respiratory specialist, carry inhalers in hand luggage, inform airport/transport, avoid smoking and alcohol
49
Q

Management of COPD -self management plan?

A

o Lifestyle – diet, exercise (at own level, to become a little out of breath), smoking cessation
o Recognise early sign of exacerbation
o Supply of rescue Abx and corticosteroids if worsens
 If had exacerbation within last year and competent to take them

50
Q

Management of COPD -pulmonary rehab?

A
  • Pulmonary rehabilitation if MRC dyspnoea scale grade 3 or more
    o Do not offer if unable to walk or have unstable angina or recent MI
  • Chest physio if lots of sputum
51
Q

Management of COPD - when to step up from SABA to Step 2?

A

Remain breathless or exacerbations depite:
 Offered smoking cessation advice
 Optimal non-pharmacological management and relevant vaccines
 Using SABA

52
Q

Management of COPD - when to step up from Step 2 to triple therapy?

A

 Acute episodes of worse symptoms caused by COPD exacerbations (hospitalisation or 2 moderate exacerbations per year)
 Adversely impacting on QoL

53
Q

Management of COPD -step 1?

A

o PRN SABA (salbutamol) or SAMA (ipratropium bromide)

54
Q

Management of COPD - step 2 if no asthmatic features or not steroid responsive?

A

o Add LABA + LAMA

o Discontinue SAMA if having LAMA

55
Q

Management of COPD - step 2 if asthmatic features (previous asthma diagnosis, high blood eosinophils, FEV1 variation over time >400mls, >20% PEFR variability)?

A

o Add LABA plus ICS combination (never just ICS, Seretide (salmeterol & fluticasone)/Symbicort(formoterol & budesonide)

56
Q

Management of COPD - step 3?

A

o Add LABA + LAMA + ICS

 If no asthmatic features – trial 3 month and if no improvement, move back to LABA + LAMA

57
Q

Management of COPD - oral therapy?

A
  • Oral theophylline or aminophylline if still symptomatic or cannot use inhalers
  • Mucolytic if chronic cough with sputum
  • If cor pulmonale – furosemide diuretic
  • Prophylactic antibiotics (azithromycin)
  • Long-term oral corticosteroids
58
Q

Management of COPD - follow up?

A
  • In very severe (FEV1 <30%), twice a year
  • In mild, moderate or severe, once a year
  • Consists of: spirometry, BMI, MRC scale, O2 sats, symptom control, drug treatment, inhaler technique, referral
59
Q

Management of COPD - when to refer to respiratory?

A
  • Haemoptysis
  • Worsening/Severe COPD – FEV1<30% or decline
  • Cor pulmonale
  • Person <40
  • MDT for physiotherapy, social care, OT, dietetic
60
Q

Management of COPD - when is pulmonary rehab and chest physio?

A

o Pulmonary rehab if MRC 3 or above, or acute hospitalisation – can improve QoL, usually 2-3 sessions/week for 6-12 weeks – physical training, education, nutrition

o Chest physio for excessive sputum

61
Q

Management of COPD - specialist treatments - oxygen?

A 
When to refer
	O2 <92% on air
	FEV1 <30%
	Cyanosis
	Secondary polycythaemia
	Peripheral oedema and raised JVP

Cannot smoke when on oxygen

Measure ABG on 2 occasions at least 3 weeks apart:
 LTOT if PaO2 <7.3 or 7.3-8.0 and secondary PCV, peripheral oedema or pulmonary hypertension

Ambulatory Oxygen
 If exercise desaturations

62
Q

Management of COPD - specialist treatments - lung volume reduction?

A

o Bulllectomy if breathless and CT scan shows bulla occupying >1/3 of hemithorax
o Refer to repiratory for surgery if:
 Severe COPD (FEV1 <50) and breathless despite optimal medical treatment
 Do not smoke
 Can complete 6-minute walk distance of at least 140m
o Can have lung transplant

63
Q

Management of COPD - end stage COPD?

A

End-Stage FEV1<30%

  • Unresponsive to treatment
  • Discuss with palliative care team to relive symptoms and improve quality of life
64
Q

Prognosis of COPD?

A
  • Progressive and accounts for 5% of deaths each year

- Mortality rate 3-4% in hospital

65
Q

Complications of COPD?

A
  • Poor QoL
  • Depression/Anxiety
  • Cor pulmonale (caused by pulmonary hypertension)
  • Frequent chest infections
  • Polycythaemia
  • Lung cancer
66
Q

Definition of primary and secondary spontaneous pneumothorax?

A
  • Primary spontaneous pneumothorax occur in previously healthy individuals
  • Secondary spontaneous pneumothorax occur in >50 years and significant smoking history or evidence of underlying lung disease on exam or CXR
67
Q

Causes of spontaneous pneumothorax?

A

o Spontaneous – ruptured subpleural bullae (young thin man)
o Chronic lung disease – asthma, COPD, CF, lung fibrosis, sarcoidosis
o Infection – TB, pneumonia, lung abscess
o Traumatic – iatrogenic
o Carcinoma
o Marfan’s, Ehlers-Danlos syndrome

68
Q

Symptoms of spontaneous pneumothorax?

A

o Can be asymptomatic
o Unilateral sudden-onset pleuritic chest pain
o SOB

69
Q

Signs of spontaneous pneumothorax?

A

o Tachycardia, tachypnoea
o Reduced expansion
o Hyper-resonance to percussion
o Diminished breath sounds

70
Q

Severe signs of spontaneous pneumothorax?

A

o Unable to speak, low SpO2
o Think tension pneumothorax
o If not tension, emergency CXR and senior doctor review

71
Q

Initial management of spontaneous pneumothorax?

A 
Monitor pulse, SpO2, BP
IV access
High flow O2
ABG (if no sign of tension pneumothorax)
Erect CXR
	Loss of lung markings
	Measure rim of air by chest wall to lung edge at level of hilum
CT Scan
	In subacute setting for assessing bullous disease in stable patient
72
Q

Interventions performed in primary spontaneous pneumothorax?

A

 If not SOB and rim of air on CXR <2cm – discharge and OPD F/U in 2/4 weeks

 If SOB and/or rim of air on CXR >2cm – Aspiration 16-18G cannula (<2.5L)
• If successful – discharge and OPD F/U in 2-4 weeks
• If not successful – Seldinger Chest Drain 8-14Fr

73
Q

Interventions performed in secondary spontaneous pneumothorax?

A

 If rim of air >2cm or SOB on CXR – Seldinger Chest drain 8-14Fr

 If not SOB & rim of air 1-2cm on CXR – Aspiration 16-18G cannula
• If unsuccessful – Seldinger Chest Drain 8-14Fr
• If successful – Admit with high-flow oxygen and observe for 24 hours

 If not SOB and rim of air <1cm on CXR - admit, high-flow O2 and observe for 24 hours

74
Q

Whent to get surgical advice in spontaneous pneumothorax?

A

o If bilateral pneumothoraces, lung fails to expand after drain insertion, 2 or more previous pneumothoraces on same side
o Options – open thoracotomy and pleurectomy or video-assisted thoracoscopy (VATs) or talc pleurodesis

75
Q

Discharge information in spontaneous pneumothorax?

A

o Patients without SOB and PSP consider discharge
o Give verbal and written instruction to return if symptoms worsen
o Do not fly and diving not allowed
o Appointment with respiratory physician in 2-4 weeks

76
Q

When to remove chest drain in spontaneous pneumothorax?

A

o Refer to respiratory physician within 24h of admission

o Remove 24 hours after cessation of air leak without clamping

77
Q

Definition of pleural effusion?

A
  • Lungs covered with visceral pleura and chest wall and pericardium covered with parietal pleura
  • Excessive accumulation of fluid in pleural space
  • Detected on x-ray when >300ml present, clinically if >500ml
78
Q

Risk factors of pleural effusion?

A

o CHF
o Pneumonia
o Malignancy
o Recent CABG/MI

79
Q

Aetiology of pleural effusion - transudate? ( protein <30g/L)

A 
	Cardiac Failure
	Liver Failure – cirrhosis
	Constrictive Pericarditis
	Fluid Overload
	Nephrotic Syndrome
	Hypothyroidism
	Meig’s syndrome
80
Q

Aetiology of pleural effusion - exudate? ( protein >30g/L)

A 
	Pneumonia
	TB
	Pulmonary infarction
	RA
	SLE
	Malignancy – lung/breast cancer
	Lymphoma
	Pancreatitis
81
Q

Symptoms of pleural effusion?

A

o Often asymptomatic
o SOB (extertional)
o Cough
o Pleuritic chest pain

82
Q

Signs of pleural effusion?

A 
o	Decreased expansion
o	Stony dull percussion
o	Diminished breath sounds
o	Tactile vocal fremitus and decreased vocal resonance
o	Tracheal deviation away from side
83
Q

Investigations of pleural effusion?

A
  • Bloods as appropriate
    o FBC, BNP, ESR, CRP, albumin, amylase, TFTs, blood cultures
  • ABG
  • CXR
    o Blunt costophrenic angles
     Dense haemogenous shadows
    o Mediastinal Shift
  • Ultrasound
    o Aids diagnosis and guiding of chest drain/aspiration
84
Q

How to aspirate pleural effusion? What to send for?

A

 Percuss upper border of effusion and go 1-2 ICS below it

 Send for cultures (AAFB, M, C &S), biochemistry (protein, glucose, LDH), cytology, pH

85
Q

When to aspirate pleural effusion?

A

 Clinical picture suggests exudate

 NOT FOR TRANSUDATE OR BILATERAL PLEURAL EFFUSIONS

86
Q

Pleural aspiration- appearance features?

A

 Clear, straw – transudate, exudate
 Turbid – empyema, pneumonia
 Red – trauma, malignancy, infarction

87
Q

Pleural aspiration- cytology features?

A

 Neutrophils – PE, pneumonia
 Lymphocytes – TB, malignancy, RA, SLE, Sarcoidosis
 Mesothelial – mesothelioma, infarction
 Multinucleated – RA

88
Q

Pleural aspiration- chemistry features?

A

 Transudate - <25g/L
 Exudate - >35g/L
• 25-35g/L – use lights criteria
 Glucose <3.3, pH<7.2, LDH (pleural:serum >0.6) – empyema, malignancy, TB, RA, SLE

89
Q

Pleural aspiration- immunology features?

A

 RF – RA
 ANA – SLE
 Complement levels low – RA, SLE, malignancy, infection

90
Q

What is Light’s criteria in pleural effusion?

A
  • Light’s Criteria when protein between 25-35g/L, exudate if….
    o Pleural fluid to serum protein ratio >0.5 or
    o Pleural fluid to serum LDH ratio >0.6 or
    o Pleural fluid LDH concentration >2/3 upper limit of normal for serum LDH
91
Q

Further testing to perform in pleural aspiration?

A 
-	If aspiration does not give diagnosis, refer to chest physician and consider:
o	CT
o	Pleural Biopsy
o	Bronchoscopy
o	Thoracoscopy
92
Q

Management of pleural effusions - cause?

A

o CHF – IV/oral furosemide, physiotherapy, chest drain and oxygen
o Infective – Abx, chest drain, physio, oxygen
o Empyema – Tube thoracostomy

93
Q

Management of pleural effusions -drainage?

A
  • Pleural aspiration
  • Chest Drain
    o No more than 1.5 litres drained – fluid shift risk
    o If malignant effusion and recurrent – insert PleureX drain
94
Q

Management of pleural effusions - when to pleurodesis?

A

o If recurrent malignant effusions

o Tetracycline/bleomycin/talc

95
Q

Management of pleural effusions -when to perform surgery?

A

o Pleurodectomy/pleuroperitoneal shunts

o If persistent collections of fluid, usually malignancy

96
Q

Definition of lung cancer?

A
  • Tumours usually arise from epithelium of large and medium sized bronchi (rarely lung parenchyma)
97
Q

What is Small Cell Lung Cancer (15%)? Associated syndrome?

A

 Highly aggressive, rapidly growing tumours
 Usually metastasised prior to diagnosis
 Can be very responsive to chemotherapy but relapse rapidly
 Prognosis poor
 Associated with paraneoplastic syndromes
• SIADH (hyponatraemia)
• Cushing’s syndrome (ACTH production)
• PTH – hypercalcemia
• HCG - gynecomastia
• Lambert Eaton Myaesthenia syndrome (LEMS)

98
Q

What are the types of non-small cell lung cancer (85%)? Locations?

A

 Squamous cell carcinoma (42% of NSCLC)
• Often central, close to bronchi and can present with bronchial obstruction
• Closely linked to cigarette smoking
• SCC can secrete PTHrp leading to hypercalcaemia

 Adenocarcinoma (39% of NSCLC)
• Often peripheral
• More frequent in women, non-smokers and previous asbestos exposure
• Associated with mutation in EGFR and ALK

 Large Cell carcinoma (8% of NSCLC)
• Less differentiated and metastasise early

 Others
• Carcinoid, mesothelioma, sarcoma, lymphoma

99
Q

Spread of lung cancer?

A
  • Spread to brain, bone, liver and adrenal
100
Q

Epidemiology of lung cancer?

A
  • 3rd most common cancer in UK
  • Men > Women
  • 1 in 13/15
  • Accounts for 22% of cancer related deaths in UK
101
Q

Risk factors of lung cancer?

A 
o	Genetics
o	Cigarette smoking
o	Increased age
o	COPD
o	Industrial exposure to asbestos, chromium, arsenic and iron oxide
o	Exposure to radiation
102
Q

Symptoms of lung cancer?

A 
o	Cough
o	Haemoptysis
o	Dyspnoea
o	Chest Pain
o	Recurrent pneumonia
o	Lethargy, anorexia, weight loss
103
Q

Signs of lung cancer?

A 
o	Cachexia
o	Anaemia
o	Clubbing
o	Lymph nodes (axilla, supraclavicular)
o	Consolidation, collapse, effusion (often unilateral)
104
Q

Metastases of lung cancer?

A 
o	Bone tenderness
o	Hepatomegaly
o	Confusion
o	Fits
o	Focal CNS signs
o	Proximal myopathy
105
Q

Complications of lung cancer?

A 
o	Recurrent laryngeal/phrenic nerve palsy
o	SVC obstruction
o	Horner’s syndrome (Pancoast tumour)
	Partial ptosis, miosis, anhidrosis
o	Pericarditis, AF
o	DIC
o	Dermatomyositis 
o	Acanthosis Nigricans
106
Q

Initial investigations of lung cancer?

A

CXR
o Round shadow, edge fluffy or spiked
o Cavitation, lobar, collapse, pleural effusion (unilateral)

CT chest and upper abdomen
o Assess extent of local and distant disease, TMN staging

PET scan
o Used in operable disease to check for distant metastases

Bronchoscopy
o Fibre-optic or rigid bronchoscopy allows visualisation, biopsy and bronchial washing
o Endo-bronchial ultrasound used to biopsy lymph nodes

Trans-thoracic biopsy

107
Q

Further investigations of lung cancer?

A
  • Pulmonary Function Tests
    o Assess underlying lung function
  • Cardiopulmonary Exercise Testing
    o Important for patients considered for surgical resection to ensure fitness
108
Q

When to refer on lung cancer pathway in primary care?

A

o >40 and unexplained haemoptysis

o >40, cough, fatigue, SOB, chest pain, weight loss (≥1 if smoker, ≥2 if non-smoker)

109
Q

Management of SCLC - if limited stage?

A

radical radiotherapy

110
Q

Management of SCLC - if palliative?

A

o Chemotherapy
 Mainstay of treatment, very chemo-sensitive, responds within days
 SVCO and MSCC treated with chemotherapy
 Most patients will relapse and die from chemo-resistant progression

o	Radiotherapy
	Highly radio-sensitive
	Three indications:
•	Treatment of primary tumour
o	Thoracic radiotherapy as consolidation or concurrent treatment
•	Prophylactic cranial irradiation
•	Palliative

o Surgery
 Early dissemination so surgery inappropriate mostly
 Patients usually require adjuvant chemo/radiotherapy

111
Q

Management of NSCLC - surgery for Stage 1/2?

A

o Stage 1/2 managed with surgical excision (30%)
o Lobectomy preferred over pneumonectomy due to mortality risk
o Adjuvant chemotherapy and radiotherapy used if able to/positive margins

112
Q

Management of NSCLC - radiotherapy?

A

o Patients with early stage not suitable for surgery
o Radical radiotherapy for stage 1/2
 Continuous, hyper-fractionated accelerated radiotherapy (CHART) given TDS for 12 days
o Concurrent chemo-radiotherapy given in Stage 2/3

113
Q

Management of NSCLC - chemotherapy?

A

o Mainstay for metastatic/locally advanced disease used in combinations (Carboplatin/Gemcitabine)

o Dependent on histological subtype:
 Biologic Therapy:
• Patients positive for EGFR, ROS-1 and ALK – TKI (Afatinib and Crizotinib)
 Immunotherapy:
• Pembrolizumab for advanced NSCLS with high PDL1 expression

114
Q

Management of NSCLC - SABR?

A

o Early NSCLC located peripherally given stereotactic ablative body radiotherapy (SABR)
 Delivers <5 very large doses of radiotherapy to small volume around tumour

115
Q

Follow up in lung cancer?

A
  • Primary care follow-up according to MDT review
  • Specialist appointment 6 weeks after treatment completion
  • CT scan at 1 year and 2 year then discharged
116
Q

Prognosis of SCLC?

A

o Extremely poor prognosis with median survival 2-4 months – improved to 6-12 months with chemotherapy
o Prognostic Factors – extent at presentation, number of mets, performance status, degree of weight loss

117
Q

Prognosis of NSCLC?

A

o Without treatment, prognosis short 3-6 months

o If suitable for treatment and targeted therapies, survival can be improved by 1-2 years

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