neoplasms, pulmonary disease/circulation disorders, ARDS

pleuritis/pleurisy

inflammation of parietal pleura worsened with movements

pleuritis alleviating factors

holding breath or lying on affected side

pleuritis aggravating factors

worse with movement like sneezing, coughing, deep breaths, movement

pleuritis cause

viral respiratory infections, PNA, PE, inflammatory disorders, malignancy, ADRs, autoimmune

pleuritis PE

pleural friction rub

pleuritis tx

treat underlying condition, supportive care

pulmonary nodules

solitary pulmonary nodule or “coin lesion”

<3cm isolated rounded opacity seen on imaging

if >3cm is a mass

pulmonary nodules on CXR

usually outlined by normal lung with no infiltrate, atelectasis, adenopathy

pulmonary nodules management

consider age, RF, hx/family hx

volume doubling time risk for cancer

<400

pulmonary nodule size with malignancy risk

21-45mm

pulmonary nodule features on HRCT for malignancy

size, borders, calcification

pulmonary nodules border with malignancy concern

spiculated or ill defined margins, peripheral halo

pulmonary nodule calcification associated with malignancy

sparse, stippled

pulmonary nodules typical tx

serial imaging

PET scan

used to detect glucose metabolism and malignant lesions

VATS

video assisted thoracoscopic surgery

VATS purpose

excise pulmonary nodules

radiologic concern for pulmonary nodules (SPICULE)

size >8mm

previous cancer

irregular margins

calcification absence/eccentricty

upper lobe

lobulated contour

enlarging over time

leading COD d/t cancer

lung cancer

lung cancer RF

exposure to tobacco smoke, radon, asbestos, diesel exhaust, metals, industrial carcinogens

genetics

pulmonary fibrosis, COPD, sarcoidosis

smoking correlation to lung cancer

causes 85-90% of cases

types of lung cancer

non and small cell lung cancer

squamous cell carcinoma lung cancer

from bronchial epithelium, present as intraluminal masses centrally located with hemoptysis

adenocarcinomas

50% of lung cancer, arises from mucus glands or from any epithelial cell within or distal to terminal bronchioles and presents as peripheral nodules or masses

adenocarcinomas in situ

spread along preexisting alveolar structures (lepidic growth) without evidence of invasion

small cell carcinomas

13% of cases, tumors of bronchial origin that begin centrally, infiltrating submucosally to cause narrowing of bronchus without discrete luminal mass, very aggressive, often involve metastasis

large cell carcinoma

1.3%, heterogenous group of undifferentiated cancers that share large cells and do not fit into other categories, aggressive with rapid doubling times, and present as central or peripheral masses

lung cancer CP

varies, weight loss, anorexia, asthenia, cough, hemoptysis, pain, pleural effusion, horner syndrome

asthenia

severe lack of physical and mental energy

superior vena cava syndrome

invasion of tumor into SVC leads to stagnation of flow and thrombosis

superior vena cava syndrome cancer correlation

SCLC MC

superior vena cava syndrome CP

face/neck swelling, dyspnea, head fullness, worsened with laying down/leaning forward, maybe with cerebral edema

paraneoplastic syndromes

patterns of organ dysfunction related to immune mediated or secretory effects of neoplasms

hypercalcemia indication

possible malignancy

common paraneoplastic syndromes

SIADH, digital clubbing, increased ACTH, anemia, hypercoagulability, peripheral neuropathy

lung cancer dx general requirement

examination of tissue/cytology

lung cancer dx options

sputum/CT guided cytology, thoracentesis, fine needle aspiration, fiberoptic bronchoscopy

non-small cell lung cancer staging

TNM international staging system

staging small cell lung cancer

limited and extensive disease

pancoast tumor

lung cancer from superior sulcus, MC from NSCLC

pancoast tumor CP

MC initial sx is shoulder pain, also horner syndrome, bony destruction, atrophy of hand muscles

horner syndrome

ptosis, miosis, anhydrosis

NSCLC tx

onc referral, surgery, chemo

SCLC tx

onc referral, radiation with chemo concurrently

SCLC metastasis

high rate of mets to brain and remission short lived, small survival rate

lung cancer screening

adults with 20 pack year history and smoke/quit in last 15 years should have an annual low dose CT

carcinoid tumor

slow growing cancerous tumor that can produce and release hormones, begins in stomach, appendix, small intestine, colon, rectum, or lungs

lung carcinoid tumor origin

neuroendocrine cells within lungs

neuroendocrine cell purpose

control air/blood flow, control growth of lung cells, detect O2/CO2

carcinoid tumor RF

multiple endocrine neoplasia type 1, neurofibromatosis type 1, females, chronic lung inflammation

types of lung carcinoid tumors

typical and atypical

types of lung carcinoid tumor classifications

central and peripheral carcinoids

typical lung carcinoid tumors

slow growing, rarely spread, not linked to smoking

atypical lung carcinoid tumors

faster growing, more likely to spread, often found in smokers

central carcinoid tumors

form in walls of bronchi near center of lung, most common by far, usually typical carcinoids

peripheral carcinoids

in bronchioles toward outer edges of lungs, most are typical carcinoids

carcinoid tumor airway CP

pedunculated/sessile growths in central bronchus, pink/purple tumor that bleeds heavily when biopsied, hemoptysis, cough, focal wheezing, recurrent PNA

carcinoid tumor peripheral lesion CP

nodule, usually incidental finding and asymptomatic

carcinoid syndrome

cutaneous flushing, diarrhea, and bronchospasm are classic triad

hypotension, abd pain, wt loss, dry skin

carcinoid heart disease

fibrotic endocardial plaques with right sided heart valve dysfunction (pulm and tricuspid regurg/stenosis)

carcinoid tumor dx

CT, chromogranin (CgA) elevation

localized lung NET carcinoid tumors tx

segmentectomy, lobectomy, or pneumectomy

proximal tumor carcinoid tumor tx

bronchotomy with wedge/sleeve resection

peripheral tumor carcinoid tumor tx

no consensus, maybe segmental surgical resection

pulmonary hypertension

pathologic elevation in pulmonary arterial pressure

normal pulmonary artery pressure

15-30mmHg

pulmonary hypertension criteria

MAP >20, capillary wedge pressure ≤15mmHg, and vascular resistance of ≥3 wood units on resting cardiac catheterization

pulmonary hypertension group 1

idiopathic

pulmonary hypertension group 2

pulmonary venous HTN d/t left heart disease

pulmonary hypertension group 3

pulmonary venous HTN d/t lung disease/hypoxemia

pulmonary hypertension group 4

pulmonary HTN d/t pulmonary obstruction

pulmonary hypertension group 5

pulmonary HTN d/t unclear/multifactorial mechanisms

pulmonary hypertension group 1 features

structural changes, smooth muscle hypertrophy, endothelial dysfunction

pulmonary hypertension group 2 conditions

LV dysfunction, valvular heart disease

pulmonary hypertension group 3 conditions

COPD, ILD, pulmonary fibrosis

pulmonary hypertension group 4 conditions

sarcoma, metastatic malignancy, chronic thromboembolic PH

pulmonary hypertension group 5 conditions

heme/systemic/metabolic disorders

NYHA pulmonary hypertension classifications

1 - no limitation

2 - slight limitation

3 - marked limitation

4 - inability to perform physical activity

MCC of PH in the US

left sided heart failure

pulmonary hypertension CP

none SPECIFIC to PH but DOE, retrosternal CP, nonproductive cough, weakness, fatigue, syncope with exertion

pulmonary hypertension PE

jugular venous distention, narrow splinting, accentuated second heart sound, hepatomegaly, LE edema, maybe systolic ejection click and tricuspid regurg

pulmonary hypertension labs

elevated BNP

pulmonary hypertension EKG

in advanced disease - RV hypertrophy (right axis deviation) and RA enlargement (peaked P wave in inf/R side leads)

pulmonary hypertension gold standard dx

right sided heart cath

other pulmonary hypertension diagnostics

echo, CT chest, PFT, CTPA

PH group 1 dx requirements

RHC with mPAP ≥20 mmHg at rest and PVR ≥3 Wood untis

PH group 2 dx requirements

clinical dx with LHD on echo, PCWP ≥15 mmHg, and normal-reduced CO

PH group 3 dx requirements

PH on RHC or echo with moderate-severe lung dysfunction/hypoxemia

PH group 4 dx requirements

echo or RHC and imaging with thromboembolic/occlusion of vasculature

PH group 5 dx requirements

hemodynamic dx and underlying disorders tested

pulmonary venous hypertension dx

mPAP ≥20mmHg at rest and PCWP >15mmHg

pulmonary arterial hypertension dx

mPAP ≥20mmHg at rest, PCWP ≤15 mmHg, and PVR >3 wood units

pulmonary venous hypertension tx

diuretics, treat underlying disease

pulmonary artery hypertension tx

vasodilators, monitor RV function

general PH tx

refer to specialist

group 1 PAH specific tx

vasodilators, nitric oxide/endothelin/prostacyclin pathways, lung transplant

vasodilator meds

calcium channel blockers - nifedipine, diltiazem

nitric oxide pathway meds

phosphodiesterase inhibitors - sildenafil, tadalafil

soluble guanylate cyclase stimulators - riociguat

endothelin pathway meds

antagonists - ambrisentan