Respiratory system Flashcards
Define lung cancer
Bronchogenic carcinoma
involves multiple malignancies involving lung or airways
TYPES OF Lung cancer?
non small cell lung cancer (85%)
small cell lung cance(13%)r
___________–most common type of lung camcer
Adenomacarcinoma
Which lung cancer progress faster
SCLC progesses faster ( within 8 to 12 weeks)
NCLS ( over months)
___________ primary risk factors for lung cancer
smoking
_______________other risk factor of lung cancer
second hand smoke, air pollution, radiation, family history of lung cancer, occupational exposure.
Most common symptoms of lung cancer
Cough( 75%)
weight loss ( 68%)
dyspnea (60%)
Other symptoms of lung cancer are
DVT ( unilateral pain in one leg)
fever
Hemoptysis
headache
extremity weakness
chest pain
discomfort
changes im cough texture
larger the lymph node, more chances of malignancy
___________is mostly seen in squamous cell carcinoma and small cell carcinoma as it involves central airway
Cough
Common sites of metastasis are
liver
bone
adrenal gland
brain
Which lung cancer is associated with SIADH?
SCLC
Diagnostic test
Ct of chest
Chest xray
PET ( position emission tomography) to find the spread of lymph node
MRI of the brain if change in neurological status
Cbc
cmp
Biopsy
thoracocentesis
Sputum cytology
Management of Stage 1 and II NSCL cancer
Stage 1 and II : Surgery
Lobectomy ( removal of one lung)
Pneumonectomy ( removal of all lung)
They need to pass PFT ( pulmonary function test)
If they fail, Chemotherapy or conventional radiaiton
Stage III NSCL A
Stage III NSCL B
Stage III NSCL A: surgical resection
Stage III NSCL B: no surgery, chemoradiation
Stage IV nscl
2 years ( survival)
chemothrapy ( carboplatin and paclitaxel)
no surgery
paliative
SCLC lung cancer
no surgery
paliativ care
8 to 13 months survival
How oftend do you do lung cancer screening
Annually with low dose of CT scan for 50 to 80 year old men, whose last smoke was less than 15 years, 20pack a year, currently smoke
When to stop annual lung cancer screening
quit smoking for more than 15 years
health comorbidities
willing to have curative lung surgery
________screeing for those who are heavy smoker
los dose of Ct scan of lungs every three years
Pleural effusion
abnormal amount of fluid in pleural space
What is the length of pleural space?
10 to 20 mm width between visceral and parietal pleurae
Pleural effusion is the manifestation of pulmonary and systemic disease, and most commonly caused by _______
CHF
Other cause of pleural effusion?
Pulmonary TB
PE
Pancreatitis
chest injury trauma
lung breast lymphoma
rheumotoid arthritis
lupus
medication such as nitrofurontoin and amiadarone
RSV
CYTOMEGALO VIRUS
herpex simplex virus
90% of the Pleural effusion is caused by
CHF
Pneumonia
Malignancy
PE
Pathophysiology of pleural effusion
Rate of fluid present is increased than the absorption
Clinical presentation of Pleural effusion
Asymptomatic initially
When symptoms occur; they have dyspnea
non productive cough
pleuretic chest pain and activity intolerance
Most common symptoms of pleural effusion
Dyspnea in recumbent position
how is the pain of pleural effusion
unilateral
localised to affected area
ipsilateral shoulder and abdomen
intermittent/sharp
Dull, steady pain- when malignant is the cause of pleural effusion
Pain is exacerbated in Pleural effusion by
activities
taking deep breathe
cough
what do you find in physical examination for pulmonary effusion
Decreased or absent breath sound
dullness to percussion
reduced or absent tactile fremitus
decreased or absent bronchial breath sound
Egophony (E TO A) at the upper border
Small effusion ( less than 500)
No symptoms
Effusion ( more than 1500 cc)
Uses accessory ms
inspiratory lag
cyanosis
bulging intercoastal margin
jugular vein distension
Diagnostic test for pleural effusion
pleural fluid analysis
chest xray
ultrasound
ct scan
thoracoscopy
thoracocentesis
pleural biopsy
Management of pleural effusion
Thoracocentesis to remove 300 to 500 ml of fluid- symptoms relief
indomethacin for pain management
pleural effusion caused by advanced malignant – comfort measure
viral pleural effusion- no managemnt it will subside itself
Pleurisy
inflammation of pleura
pleural layers rub against each other and pain fiber in parietal pleura is stimulated
not a diagnosis but a symptoms
Pathophysiology of pleurisy?
Wet pleurisy ( excess fluid in between pleural cavity
Dry pleurisy ( no fluid )
Most common cause of pleurisy
TB
Bacterial and viral infection
Less common cause of pleurisy
Trauma
malignancy
Other common cause of pleurisy
connective ts ds
pulmonary infarction
connective ts ds such as lupus erythmatous
Clinical presentation of pleurisy
stabing
shooting pain
localised and radiating to shoulder
complains “stitch in the side”
relief while lying on the affected side due to restrictive movement
Physical examination finding for pleural effusion
deep palpation- tenderness and inflammation
rapid and shallow breathing - due to limited chest expansion
percussion- dull
increased or decreased fremitus
What PE confirm the diagnosis
Loud creek sound
But, when it have fluid, no creak sound is heard
When and where do you hear pleural friction rub?
lateral posterior inferior thorax
when taking deep breathe
not audile- when patient is taking shallow, rapid breathing
Pluerisy- what are other associated symptoms?
TB, pneumonia, pneumothorax: productive cough
Infectious disease: Fever chils
Joint pain and rashes- connective tissue problem
Management of pleurisy
pleura effusion- remove fluid
Associated with connective ts: Corticosteroid, Anti-inflammatory drugs
Associated with infection- treat underlying cause
Pneumonia
infection of lung parenchyma
types of pneumonia
Community acquired
ventilator associated
hospital acquired
health associated
Community acquired
no hospitalization and nursing home for last 14 days before the onset of pneumonia
hospital acquired
Pneumonia after 48 hours of hospitalization/nursing home
VAP
pneumonia 48 hours after ventilator
health care associated
no hospitalization/nursing home
however,needs care for wound, iv medication, hemodialysis clinic, chemotherapy
Types of pneumonia
Typical : Bacterial pneumonia such as streptococcus pneumoniae ( most common bacteria)
Gram neg
gram pos
Atypical : May not be bacteria , if bacteria they donot share the same characterstics
Such as myoplasma pneumonia
virus- para virus, RSV
pneumonia related to smoking
hemophilus influenza ( gram neg)
pneumonia related with cystic fibrosis
pseudomonas aeroginusa
What is the gold standard for CAP?
Chest Xray ; Repeat after 6 months
CBC- wbc increased
sputum c/s and sensitivity
Diagnosis of CAP is based on
presentation
Chest xray
sign and symptoms
CBC is not required for diagnosis; However we can do it, WBC will be elevated
Classic case
T: 100.4
sputum purulent ( rust colored( strep pneumonia)
pleuritic chest pain with coughing and dyspnea
Elderly may have atypical symptoms (afebrile, low grade fever, no cough or mild cough, confuse, weakness)
Physical examination what do you find
Auscultation- rhonchi, crackles, wheezing
Percussion: Dullness over affected lobe
Tactile fremitus and egophony: Increased
Abnormal whispered pectoriloquy (whispered words louder)
Treatment plan for pneumonia
No comorbidity (previously healthy and no risk factors for drug-resistant S. pneumoniae infection): Macrolides are preferred. •Azithromycin (Z-Pack) daily × 5 days •Clarithromycin (Biaxin) BID × 7 days
If patient had an antibiotic in previous 3 months or macrolide-resistance (>25%): •Doxycycline 100 mg BID × 5 to 7 days •Levofloxacin (Levaquin) 750 mg × 5 days •Azithromycin or clarithromycin plus amoxicillin or Augmentin With comorbidity (i.e., alcoholism; congestive heart failure [CHF]; chronic heart, lung, liver or kidney disease; antibiotics in previous 3 months; diabetes; splenectomy/asplenia; others) or high rates (>25%) of macrolide-resistant S. pneumoniae: Respiratory fluoroquinolone as one-drug therapy (duration 5–7 days) •Moxifloxacin (Avelox) 400 mg PO once a day •Levofloxacin (Levaquin) 750 mg daily (minimum dose 750 mg/d) •Gemifloxacin (Factive) 400 mg PO once a day or Beta-lactam plus macrolide (duration 7 days)
•Amoxicillin clavulanate (Augmentin) 1,000/62.5 mg PO BID × 7 days or •Cefdinir (Omnicef) 300 mg PO every 12 hours × 7 days plus azithromycin or clarithromycin
Poor prognosis? How do you know
Curb 65:
If score more than 1. patient needs to be hospitalized
C ( confusion)
u ( Blood urea nitrogen more than 19.6)
R Respiration is more than 30
Blood pressure is less than 90/60
65 years and older.
Who have poor prognosis and needs to be transferred to hospital?
Elderly 60 y
multiple lobe invol
AMS
Alcoholic ( risk for aspiration pneumonia)
How to prevent pneumonia
influenza
pneumococcal polysaccaride vaccine ( pneumovax) if older than 65
PCV23 when to give?
65 yrs
start giving after 19 years of age if high risk
Dosing of PCV13 * pneumococcal conjugate vaccine Prevnar 13
and PPSV23 * Pnuemococcal polysaccaride vaccine 23)
13 is given first and after 1 year 23 IS GIVEN
If, 23 was taken early, after 1 year, 13 can be taken
if PCV13 is given only one time, no double dose
PCV23 if given early, next dose within 5 years
PCV23 at 65 if healthy, that is enough for lifetime
What is high risk?
impaired immunity- splenectomy, spleen problem, alcoholics, cirhosis of liver, HIV, CKD, ASTHMA, CHF, emphysema, sickle cell, multiple myeloma
Which demographic mostly get atypical pneumonia?
Children
young adult
what is the other name of atypical pneumonia
walking pneumonia
Breakout at summer and fall
classic case of atypical pneumonia
Fatigue several week
cough nonproductive
cold like symptoms such as sorethroat, clear rhinitis, low grade fever
Continue to go school despite symptoms, coworker have the same symptom
Physical examination of atypical pnuemonia
Ausculation : Wheezing, crackles and rhales
Nose: Clear mucus
thorat: Erythematous without pus, exudates
Chest xray: Diffuse interstitial infiltrate ( pleural effusion in 20%)
CBC: looks normal
Treatment for Atypical pnuemonia
Doxicycline
Azithomycin
levofloxacin
Antitusive * dextromethorphan
increased fluid and rest
tuberculosis
Infection caused by Mycobacterium tuberculosis
Most common place where you get mycobacterium tuberculi
lungs (85%
Kidney
brain
lymph nodes
adrenals
bones
Tranferred from one organ to other by blood or lymphnode
How TB is spread?
aerosol droplets, airborne precuation
What do you see in chest xray of Tb?
Cavitation, adenopathy, granulomas on the hila of the lungs
Who are at risk of getting Tb?
Immigrants from high prevalence country
illegal drug user
nursing hom e
adult home resident
HIV
immunocompromised
Prolonged corticosteroid use
silicosis ( inhalling silica drug)
Chest xray ( showing previous tb infection
chronic malabsorption syndrome
low body wt
ESRD
Cancer of head and neck
Clinical manifestation of TB?
Symptoms are gradual
low-grade fever, cough night sweats, fatigue, anorexia, and weight loss, chest pain, irregular menses
Both type of cough may be present- productive and non productive
uHemoptysis
asymptomatic on initial presentation
Clinical case for Tb
night sweats
immigration
weight loss
productive( later sign)
non productive ( early sign)
Physical examination of TB patient
Diminished bronchial sound
crackles
fremitus
Diagnosis of TB?
Acid fast bacili/sputum C/s X 3 to find out mycobacterium
Chest xray- lesion in the upper lobes
tuberculin test
management of TB?
Screening is the first thing
What is the preferred and standard method to screen TB?
Mantoux tuberculin skin test (
How to do Mantoux test
0.1 ml of purified protein derivative is injected intradermally in dorsal or volar forearm, create skin elevattion
well demarcated wheel of 6 to 10 mm
positive is when you see induration and redness after 48 to 72 hours
interpretation of Monteux test?
Erythema with out induration ( soft)- nothing
a reaction of 0 to 4 mm : nothing
In montauk test, 5 mm or greater induration for this type of patient to be pos for TB
immunocompromised
Child who had close contact with Tb or person who have TB for more than 5 years
Person who had old TB Or fibrosis on chest xray
In montauk test, 10 mm or greater induration for this type of patient to be pos for TB
health care worker
resident of nursing home/jail
jail worker , health care worker, immigrant from high prevalent country
children younger than 4 years of age
who have received BCG
Alcoholic
IV drug user
diabetic patint
steroid therapy
In montauk test, 15 mm or greater induration for this type of patient to be pos for TB
no risk factor
Cause of false negative tuberculin test ?
new born
age more than 45 years
immunosuppresive
vira. fungal and bacteria infection
live vaccines ( mmr, polio)
malnutrition, cachexia, zinc def
CKD
Hematological disorder ( hodgkins ds)
Sarcoidosis
stress
improper storage
alcoholism
bypass surgery
Old or young people, who gets life threatening form of TB?
Young
How quantiferon work?
Enzyme linked immunoobserbent essay (ELISA) that detect the release of interferon gamma by white blood cells when the blood of a patient with TB is incubated with peptide similar to those of M. Tuberculosis.
Does quantiferon resulr are affected by bcg?
No
Clinical classification of Tb
0: No exposure
1: exposure; no evidence of infection
2: latent infection; no active infection ( PPD_ POS, NO clinical evidence of active TB
3. D
What if quantiferon is pos?
Has previous infection with TB
does not say anything about active progression of the ds
How does the chest xray look like in TB?
Nodules/cavitation in upper lobes with or with out fibrotic changes ( Scar)
Chest xray on RT Middle lobe pneumonia?
Consolidation ( white colored area) on the right middle lobe,
TB management
Anti- tb for 6 to 12 months
consider- drug resistance, therefore, needs four or more medication to ensure completion of therapy
needs development of new anti-Tb medication
First four first line medication for Tb?
isoniazid ( INH),
rifampin ( Rifadin)
INH pyrazanamide ( PZA)
Rifampin ( Rifater)
Above 4 medicaiton is given every day for 8 weeks and, then we can give
INH and Rifampin or INFand Rirfapentine for 4 to 7 months.
Rifapentine ( Priftin) are given twice a week to improve adherence
4 months only for most people
7 months only for those who have sputum C/S positive after 2 months, for thos initial treatment did not include PZA, after initial phase, sputum C/s is positive.
Second line medication for TB?
Capreomycin ( Capastat)
ethionamide ( Trecator)
para aminosalicyclate sodium,
cycloserine ( seromycin)
Potential effective medication for TB?
Aminoglycoside
quinoles
rifabutin
clofazimine ( lamprene)
Which medication is taken to prevent peripheral neuropathy caused by INH?
Vitamin B ( pyridox
Which medication can be used as prophalyctic?
INH ( Preventive) for 6 to 12 months
for high risk people
hiv/iv drug user.
active tb household
high risk comorbid condition and PPD with 10 mm of induration or more
35 years
fibrotic lesion due to old tb
PPD with 5 mm or more
PPD shows change from previous
35 years and older who are high risk such as foreign born, homeless, jail, with PPD result is 10 mm,
When is the Tb patient non infectious
after 2 to 3 weeks of continues medication therapy
How do you check pt adherence
liver enzyme
BUN
Cr
AFB
Who needs referal for TB?
Clinically active
MDR TB - infectious ds or pulmologist
immunocompromised patient with active TB
disseminated ds and active TB
Side effect of INH
Hepatotoxicity- Jaunice, LFT, peripheral neuritis, ( numbness and tingling), anemia, agranulocytosis
hypersensitivity.
Side effect of Rifampin
low toxicity as compared with INH
orange color discoloration fo body fluids
monitor LFT and RFT
Pyrazanamide SE?
hepatotoxicity
elevate uric acid level/ gout/joint pain
same monitoring
Ethambutal SE?
Optic neuritis - loss of vision, red/green color discrimination.
obtain baseline vision screening
Streptocmycin SE
Ototoxicity and nephrotoxicity
monitor 2.5 to 3 l of fluids per day , LFT/RFT/hearing test.
