Respiratory - Level 2 Flashcards
1
Q
Definition of asthma?
A
- Respiratory condition associated with reversible airway inflammation and hyper-responsiveness
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
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
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
5
Q
Risk factors of asthma?
A
- FHx of atopic disease
- Respiratory infections in infancy
- Tobacco smoke
- Low birth weight
- Social deprivation
- Inhaled particulates
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)
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)
8
Q
Symptoms of asthma?
A
- Wheezing attacks
- SOB
- Chest tightness
- Cough (nocturnal)
- Sputum
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
10
Q
Signs of asthma?
A
- Tachypnoea
- Audible wheeze
- Hyperinflated chest
- Hyper-resonant percussion
- Decreased air entry
- Reduced chest expansion
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
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
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
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
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
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
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
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
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
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
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
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
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
24
Q
Management of asthma - medications - under 5s - step 3?
A
o If unresolved on paediatric low dose maintenance therapy:
Add LTRA
25
Management of asthma - medications - under 5s - step 4?
o If unresolved on ICS and LTRA:
| Stop LTRA and refer to specialist
26
Management of asthma - medications - child >5 and adults - step 1?
o Step 1
| PRN SABA – Salbutamol alone if infrequent
27
Management of asthma - medications - child >5 and adults - step 2?
o Step 2 (if >3 doses PRN SABA, drugs not working, woken)
| Add low dose ICS (beclomethasone) 400mcg starting dose
28
Management of asthma - medications - child >5 and adults - step 3?
```
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
29
Management of asthma - medications - child >5 and adults - step 4 and step 5?
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
30
Management of asthma - medications - child >5 and adults - step 5?
o Step 5 (if >3 doses PRN SABA, drugs not working, woken)
Referral to specialist
Oral prednisolone
Steroid sparing – methotrexate, ciclosporin
31
Management of asthma - when to refer immediately?
- Immediately if occupational asthma suspected
32
Management of asthma - follow up?
- Annually
- 4-8 weeks after medication change or start
- Long-term/Frequent steroid tablets need BP, HbA1c, cholesterol and vision tested every 3 months
33
Management of asthma - self-management plan?
- Increased dose of ICS for 7 days when asthma deteriorates (quadruple dose)
34
Doses of ICS in asthma - adults?
o < or equal 400mcg budesonide or equivalent = low dose
o 400mcg – 800mcg budesonide or equivalent = moderate dose
o >800mcg budesonide or equivalent = high
dose
35
Doses of ICS in asthma - child <16?
o < or equal 200mcg budesonide or equivalent = low dose
o >200mcg – 400mcg budesonide or equivalent = medium dose
o >400mcg budesonide or equivalent = high dose
36
Definition of COPD?
- Characterised by airflow obstruction due to combination of obstructive bronchiolitis and emphysema, resulting from enhanced inflammatory response
- FEV1 <80% predicted; FEV1/FVC <0.7
37
Pathology of COPD?
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
38
Classes of COPD?
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
39
Epidemiology of COPD?
- 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
40
Risk factors of COPD?
- Cigarette smoking
- Exposure to pollutants
o Mining, building, chemical industries
- Air pollution
- Alpha-1-antitrypsin deficiency
41
Symptoms of COPD?
- Productive, white/clear sputum cough
- Progressive breathlessness
- Wheeze
- Frequent exacerbations
- Weight loss, fatigue
42
Signs of COPD?
- 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
43
When to diagnose COPD clinically?
- >35 years old
- Risk factor present
- Typical and other symptoms
o Exertional SOB, chronic cough, regular sputum production, frequent winter bronchitis, wheeze
44
Asssessment of COPD?
- 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
45
Investigations to perform in COPD?
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
46
Classification criteria in COPD?
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
47
When and what additional tests can be used in COPD?
- 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
Management of COPD - general advice?
- 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
Management of COPD -self management plan?
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
Management of COPD -pulmonary rehab?
- 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
Management of COPD - when to step up from SABA to Step 2?
Remain breathless or exacerbations depite:
Offered smoking cessation advice
Optimal non-pharmacological management and relevant vaccines
Using SABA
52
Management of COPD - when to step up from Step 2 to triple therapy?
Acute episodes of worse symptoms caused by COPD exacerbations (hospitalisation or 2 moderate exacerbations per year)
Adversely impacting on QoL
53
Management of COPD -step 1?
o PRN SABA (salbutamol) or SAMA (ipratropium bromide)
54
Management of COPD - step 2 if no asthmatic features or not steroid responsive?
o Add LABA + LAMA
| o Discontinue SAMA if having LAMA
55
Management of COPD - step 2 if asthmatic features (previous asthma diagnosis, high blood eosinophils, FEV1 variation over time >400mls, >20% PEFR variability)?
o Add LABA plus ICS combination (never just ICS, Seretide (salmeterol & fluticasone)/Symbicort(formoterol & budesonide)
56
Management of COPD - step 3?
o Add LABA + LAMA + ICS
| If no asthmatic features – trial 3 month and if no improvement, move back to LABA + LAMA
57
Management of COPD - oral therapy?
- 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
Management of COPD - follow up?
- 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
Management of COPD - when to refer to respiratory?
- Haemoptysis
- Worsening/Severe COPD – FEV1<30% or decline
- Cor pulmonale
- Person <40
- MDT for physiotherapy, social care, OT, dietetic
60
Management of COPD - when is pulmonary rehab and chest physio?
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
Management of COPD - specialist treatments - oxygen?
```
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
Management of COPD - specialist treatments - lung volume reduction?
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
Management of COPD - end stage COPD?
End-Stage FEV1<30%
- Unresponsive to treatment
- Discuss with palliative care team to relive symptoms and improve quality of life
64
Prognosis of COPD?
- Progressive and accounts for 5% of deaths each year
| - Mortality rate 3-4% in hospital
65
Complications of COPD?
- Poor QoL
- Depression/Anxiety
- Cor pulmonale (caused by pulmonary hypertension)
- Frequent chest infections
- Polycythaemia
- Lung cancer
66
Definition of primary and secondary spontaneous pneumothorax?
- 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
Causes of spontaneous pneumothorax?
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
Symptoms of spontaneous pneumothorax?
o Can be asymptomatic
o Unilateral sudden-onset pleuritic chest pain
o SOB
69
Signs of spontaneous pneumothorax?
o Tachycardia, tachypnoea
o Reduced expansion
o Hyper-resonance to percussion
o Diminished breath sounds
70
Severe signs of spontaneous pneumothorax?
o Unable to speak, low SpO2
o Think tension pneumothorax
o If not tension, emergency CXR and senior doctor review
71
Initial management of spontaneous pneumothorax?
```
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
Interventions performed in primary spontaneous pneumothorax?
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
Interventions performed in secondary spontaneous pneumothorax?
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
Whent to get surgical advice in spontaneous pneumothorax?
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
Discharge information in spontaneous pneumothorax?
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
When to remove chest drain in spontaneous pneumothorax?
o Refer to respiratory physician within 24h of admission
| o Remove 24 hours after cessation of air leak without clamping
77
Definition of pleural effusion?
- 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
Risk factors of pleural effusion?
o CHF
o Pneumonia
o Malignancy
o Recent CABG/MI
79
Aetiology of pleural effusion - transudate? ( protein <30g/L)
```
Cardiac Failure
Liver Failure – cirrhosis
Constrictive Pericarditis
Fluid Overload
Nephrotic Syndrome
Hypothyroidism
Meig’s syndrome
```
80
Aetiology of pleural effusion - exudate? ( protein >30g/L)
```
Pneumonia
TB
Pulmonary infarction
RA
SLE
Malignancy – lung/breast cancer
Lymphoma
Pancreatitis
```
81
Symptoms of pleural effusion?
o Often asymptomatic
o SOB (extertional)
o Cough
o Pleuritic chest pain
82
Signs of pleural effusion?
```
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
Investigations of pleural effusion?
- 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
How to aspirate pleural effusion? What to send for?
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
When to aspirate pleural effusion?
Clinical picture suggests exudate
| NOT FOR TRANSUDATE OR BILATERAL PLEURAL EFFUSIONS
86
Pleural aspiration- appearance features?
Clear, straw – transudate, exudate
Turbid – empyema, pneumonia
Red – trauma, malignancy, infarction
87
Pleural aspiration- cytology features?
Neutrophils – PE, pneumonia
Lymphocytes – TB, malignancy, RA, SLE, Sarcoidosis
Mesothelial – mesothelioma, infarction
Multinucleated – RA
88
Pleural aspiration- chemistry features?
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
Pleural aspiration- immunology features?
RF – RA
ANA – SLE
Complement levels low – RA, SLE, malignancy, infection
90
What is Light's criteria in pleural effusion?
- 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
Further testing to perform in pleural aspiration?
```
- If aspiration does not give diagnosis, refer to chest physician and consider:
o CT
o Pleural Biopsy
o Bronchoscopy
o Thoracoscopy
```
92
Management of pleural effusions - cause?
o CHF – IV/oral furosemide, physiotherapy, chest drain and oxygen
o Infective – Abx, chest drain, physio, oxygen
o Empyema – Tube thoracostomy
93
Management of pleural effusions -drainage?
- 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
Management of pleural effusions - when to pleurodesis?
o If recurrent malignant effusions
| o Tetracycline/bleomycin/talc
95
Management of pleural effusions -when to perform surgery?
o Pleurodectomy/pleuroperitoneal shunts
| o If persistent collections of fluid, usually malignancy
96
Definition of lung cancer?
- Tumours usually arise from epithelium of large and medium sized bronchi (rarely lung parenchyma)
97
What is Small Cell Lung Cancer (15%)? Associated syndrome?
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
What are the types of non-small cell lung cancer (85%)? Locations?
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
Spread of lung cancer?
- Spread to brain, bone, liver and adrenal
100
Epidemiology of lung cancer?
- 3rd most common cancer in UK
- Men > Women
- 1 in 13/15
- Accounts for 22% of cancer related deaths in UK
101
Risk factors of lung cancer?
```
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
Symptoms of lung cancer?
```
o Cough
o Haemoptysis
o Dyspnoea
o Chest Pain
o Recurrent pneumonia
o Lethargy, anorexia, weight loss
```
103
Signs of lung cancer?
```
o Cachexia
o Anaemia
o Clubbing
o Lymph nodes (axilla, supraclavicular)
o Consolidation, collapse, effusion (often unilateral)
```
104
Metastases of lung cancer?
```
o Bone tenderness
o Hepatomegaly
o Confusion
o Fits
o Focal CNS signs
o Proximal myopathy
```
105
Complications of lung cancer?
```
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
Initial investigations of lung cancer?
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
Further investigations of lung cancer?
- Pulmonary Function Tests
o Assess underlying lung function
- Cardiopulmonary Exercise Testing
o Important for patients considered for surgical resection to ensure fitness
108
When to refer on lung cancer pathway in primary care?
o >40 and unexplained haemoptysis
| o >40, cough, fatigue, SOB, chest pain, weight loss (≥1 if smoker, ≥2 if non-smoker)
109
Management of SCLC - if limited stage?
radical radiotherapy
110
Management of SCLC - if palliative?
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
Management of NSCLC - surgery for Stage 1/2?
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
Management of NSCLC - radiotherapy?
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
Management of NSCLC - chemotherapy?
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
Management of NSCLC - SABR?
o Early NSCLC located peripherally given stereotactic ablative body radiotherapy (SABR)
Delivers <5 very large doses of radiotherapy to small volume around tumour
115
Follow up in lung cancer?
- 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
Prognosis of SCLC?
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
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Prognosis of NSCLC?
o Without treatment, prognosis short 3-6 months
| o If suitable for treatment and targeted therapies, survival can be improved by 1-2 years
