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Pulmonary 2
Pulmonary 2
132
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Graduate
11/15/2009

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Term
:chronic multisystem disease of unknown etiology, commonly affecting the lungs, skin, eyes, liver and lymph nodes characterized by the formation of noncaseating granulomas
Definition
Sarcoidosis
Term
What are the two most commonly affected systems with Sarcoidosis?
Definition
Lung and lymph nodes
Term
What bacteria has been found commonly in the lymph nodes of people with Sarcoidosis?
Definition
Propionibacter acnes
Term
Where in the world is Sarcoidosis most common?
What race and sex does it affect most often in the US?
Definition
Most common in Scandinavian counrtries.
Affects blacks and women more often in the US.
Term
What is Lofgren's Syndrome?
Definition
It is a type of Sarcoidosis characterized by Hilar adenopathy, erythema nodosum on the shins, uveitis, fever and arthritis.
Term
Describe the 4 stages of CXR findings seen with Sarcoidosis.
Where are the infiltrates usually seen in the lungs with Sarcoidosis?
Definition
1. hilar adenopathy
2. adenopathy and infiltrates
3. just infiltrates
4. fibrosis
Infiltrates are usually seen in the upper lobes.
Term
What is the most sensitive test for interstitial lung disease? How will Sarcoidosis affect its levels?
Definition
DLCO - carbon monoxide diffusing capability. It will be decreased with Sarcoidosis.
Term
What are the typical CT findings with Sarcoidosis?
Definition
Abnormal lung parenchyma and broncho-vascular bundle thickening or nodules.
Term
What are some typical dermatological symptoms commonly seen with Sarcoidosis?
Definition
Lupus pernio (plaques on nose, cheeks, lips, ears) and Erythema nodosum (red nodules on the legs)
Term
Most common ocular abnormality seen with Sarcoidosis?
Definition
Uveitis (inflammation of the vascular area between the retina and sclera of the eye).
Term
What are the most common bone abnormalities seen with Sarcoidosis?
Definition
osteolytic or cystic lesions and osteopenia.
Term
What are some common neurological abnormalities seen with Sarcoidosis?
Definition
Any cranial nerve can be affected but 7th (facial nerve) and 8th (vestibulocochlear) are most common.
Optic and peripheral neuropathy are also common.
Term
What are some of the cardiac abnormalities seen with Sarcoidosis?
Definition
Heart blocks and arrythmias are most common but it can also lead to restrictive cardiomyopathy heart failure.
Term
Most common oral abnormality seen with Sarcoidosis?
Definition
Asymptomatic parotid gland swelling
Term
How are Angiotensin converting enzyme and ESR affected by Sarcoidosis?
Definition
They are both increased.
Term
What is usually necessary to diagnose sarcoidosis due to its large number of ddx?
How is the diagnosis of Sarcoidosis made?
Definition
A biopsy.
Diagnosis is made based on clinical, radiographic and histologic findings.
Term
How do you treat an active inflammation of Sarcoidosis?
Definition
Corticosteroids (such as Prednisone)
Term
What percent of Sarcoidosis patients die?
Definition
10% fatality rate
Term
:diffuse interstitial fibrosing disease of the lung, directly related to intensity and duration of exposure. Disease takes a minimum of 10 years exposure before it will manifest.
Definition
Asbestosis
Term
What causes the fibrotic lesions seen with asbestosis?
Definition
end result of oxidative injury due to the generation of reactive oxygen species by metals on the surface of the fibers as well as from cells engaged in phagocytosis
Term
What is the causative agent of asbestosis?
Definition
asbestosis fibers in thermal and electric insulation or from mining.
Term
How does asbestosis affect the lungs?
How will asbestosis affect DLCO and SaO2?
Definition
It causes pulmonary fibrosis.
Asbestosis will decrease both of them.
Term
What is the typical clinical presentation of a patient with sarcoidosis?
Definition
Progressive dyspnea, non-productive cough, fatigue, clubbing of the finger/toenails, crackles and rales heard on auscultation.
Term
How is Asbestosis diagnosed?
What are some CXR findings with Asbestosis? CXR findings with severe asbestosis?
Definition
Diagnosed based on a detailed occupational history, physical findings, imaging studies and fibers in the lungs.

CXR findings include reticular (net-like) nodular, linear opacities that start in the lower lung and obscure the heart border and a "ground glass" appearance may be present and "honeycombing" is seen with more advanced Asbestosis.
Term
What are pleural plaques on CXR and what are they indicative of?
Definition
They are the irregular thickening or calcification of parietal pleura and are indicative of a previous exposure to Asbestos.
Term
What is the most common location for cancer associated with asbestos?
What is the only pleural malignancy and is caused by asbestosis in almost all cases?
What is the lifetime risk for developing asbestosis in patients who deal with asbestos?
Definition
Most common cancer location is lung cancer

Pleural mesothelioma
10% lifetime risk
Term
What are the most common specific kinds of cancer seen with asbestos?
Definition
Squamous cell and Adenocarcinoma
Term
How much more likely is an asbestos exposed individual that smokes to develop a neoplasm?
Is mesothelioma associated with smoking?
Definition
60-100x more likely.

Mesothelioma is not associated with smoking.
Term
How do you treat Asbestosis?
Definition
No treatment, just supportive. Smoking cessation is important.
Term
What is Mesothelioma and how does it relate to Asbestos?
What percentage of Mesothelioma patients have extrathoracic spread?
Definition
Mesothelioma is primary tumors from mesothelial cells that line the pleural cavities. It has an average latency w/ asbestos workers of 30 years.
90% of Mesothelioma patients have extrathoracic spread.
Term
What does Mesothelioma look like on CXR?
What is often needed to diagnose?
Treatment of Mesothelioma?
Mesothelioma prognosis?
Definition
Diffuse unilateral or bilateral pleural thickening with blunted CP angles due to pleural effusion.
A biopsy is often needed to diagnose.
The only treatment is supportive.
Prognosis is up to a year or less.
Term
:progressive pulmonary fibrosis that may be rapidly fatal in less than 2 years due to inhalation of silicon dioxide. Common in mining, stone cutting, cement, foundry, glass making, making abrasive soapes, stone quarrying (granite) and sandblasting (silica, quartz) industries.
Definition
Silicosis
Term
What does Silicosis increase your risk for?
Definition
Increases risk of TB and Mycobacterial disease.
Term
What is characteristic in the diagnosis of acute silicosis? Chronic silicosis?
Where does silicosis like to go in the lungs?
Definition
Acute = “crazy paving” (intralobular lines superimposed on ground-glass)
Chronic = “eggshell” calcifications (thin layer of calcification around a lymph node)
Predominance for upper lobes
Term
Treatment of Silicosis?
Definition
Removal from exposure, whole lung lavage (flush), and lung transplant in selected patients.
Term
What causes Coal Worker's Pneumoconiosis?
How does it appear on CXR?
What is recommended annually?
Definition
Coal dust.
Appears on CXR as diffuse, small, rounded opacities or nodules.
Recommended annual TB skin test.
Term
:severe dyspnea, rapid onset, diffuse infiltrates, hypoxemia, and respiratory failure.
Definition
ARDS
Term
Most common disorders associated with ARDS?
Describe the exudative, proliferative and fibrotic phases of ARDS.
Definition
Pneumonia, FB Aspiration, Pulmonary contusion, sepsis, severe trauma and drug overdose.
Exudative is days 1-7 (alveolar edema).
Proliferative is days 7-21 (early fibrosis).
Fibrotic is over 21 days (extensive fibrosis).
Term
How do you treat ARDS?
Mortality rates for ARDS?
Definition
Recognize and treat underlying cause, mechanical ventilation and intubation, keep lungs dry, and corticosteroids after 7 days.
Mortality rate is 41-65%
Term
:autosomal recessive disorder characterized by thick, sticky mucous and impaired lung defense against infection.
Definition
Cystic Fibrosis
Term
What are the most common organisms seen in chronic lung infections in patients with Cystic Fibrosis?
Definition
S. aureus and P. aeruginosa
Term
How is Cystic Fibrosis diagnosed?
Cystic Fibrosis treatment?
Definition
Clinical criteria plus sweat test (analyzes Na and Cl).
Treatment includes chest physiotherapy, high dose antibiotics, bronchodilators, pancreatic enzyme replacement and lung transplatation.
Term
What is idiopathic pulmonary fibrosis?
AKA?
Definition
Lung tissue becomes thick, stiff or scarred and the cause is not known. AKA (Interstitial pneumonitis)
Term
Signs and symptoms of pulmonary HTN?
Most common cause of pulmonary HTN?
Definition
S&S = SOB, dizziness, fainting, fatigue, non-productive cough, peripheral edema and hemoptysis.
MCC is left sided heart failure
Term
What is Cor Pulmonale?
Causes?
Definition
Right heart failure caused by a massive PE, COPD or end stage pneumoconiosis.
Term
2 most common causes of hemoptysis?
Definition
Bronchitis and bronchogenic carcinoma.
Term
2 most common causes of massive hemoptysis?
Definition
TB and bronchiectasis
Term
What treatments can be used to stop massive hemopytsis?
Definition
Balloon catheter
Laser
Electrocautery
Resection of the area of lung
Embolotherapy
Term
What is the leading location of cancer leading to death in men and women?
What are the 4 most common types of lung cancer? Most common of the 4?
Definition
Lung cancer
4 most common types include: Squamous cell carcinoma, Small (Oat) cell carcinoma, Large cell carcinoma and Adenocarcinoma.
Adenocarcinoma is the most common.
Term
Where are Squamous/Small cell cancers typically found? Adenocarcinoma/Large cell?
Definition
squamous/small cell cancers = central masses
Adenocarcinoma and large cell = peripheral nodules or masses
Term
What is Bupropion (Wellbutrin) used for?
Definition
Used for smoking cessation.
Term
What is the typical clinical presentation of lung cancers?
Definition
cough, hemoptysis, wheeze, stridor, dyspnea, chest pain, dyspnea, trachea obstruction, esophageal compression, recurrent laryngeal nerve paralysis (hoarseness) and Horner's syndrome (enopthalmos, ptosis, miosis and ipsilateral anhydrosis)
Term
:tumor in the apex of the lung with involvement of the 8th cervical and 1st or 2nd thoracic nerves, with shoulder pain, characteristically radiates in the ulnar distribution of the arm, often with radiologic destruction of the 1st or 2nd ribs and often exhibits Horner's syndrome (enopthalmos, ptosis, miosis and ipsilateral anhydrosis).
Definition
Pancoast Tumor
Term
What kind of carcinoma is a Pancoast tumor?
Pancoast tumor treatment?
Survival rate for those who underwent complete resection?
Definition
It is a non-small cell carcinoma.
Treatment involves radiation, chemo and resection.
70% survival rate for complete resection.
Term
What extrapulmonary problems can arise with a Pancoast Tumor?
Definition
superior vena cava syndrome from vascular obstruction and cardiac tamponade, arrythmia or cardiac failure.
Term
What percentage of squamous cell carcinoma, adenocarcinoma, large cell carcinoma and small cell carcinoma where seen to have extrathoracic metastatic disease at autopsy?
Definition
>50% of patients with squamous carcinoma
80% of patients with adenocarcinoma and large cell carcinoma
>95% of patients with small cell carcinoma
Term
What are the 2 major components of the staging for lung cancer treatment?
Definition
Anatomic staging (location) and Physiologic staging (can the patient handle the treatment).
Term
For Non-small cell cancer, what is the stage that prognosis for treatment becomes very bad? What is the treatment for the stages below that?
Definition
Stage IIIa
If below IIIa then do surgery.
Term
Name and describe the 2 stage system for small cell lung cancer.
Definition
Limited stage - 30% of patients, One hemithorax and regional lymph nodes.

Extensive stage - 70% of patients, disease beyond the limited stage (tamponade, pleural effusion, etc).
Term
What are the main uses for PET scans in lung cancer?
Definition
Good for evaluating solitary pulmonary nodules and it is used as a guide for mediastinal biopsies.
Term
What percentage of Solitary Pulmonary Nodules are malignant? How does this affect your treatment?
Definition
35%, so you should resect them.
Term
What is brachytherapy?
Definition
(local radiotherapy delivered by placing radioactive “seeds” in a catheter in the tumor bed) provides a way to give a high local dose while sparing surrounding normal tissue.
Term
What are two common chemotherapy drugs?
Definition
Cisplatin and Carboplatin
Term
What is the mean survival length for small cell lung cancer that is untreated?
Treated with chemo?
Definition
Untreated = 12 weeks
Chemo = 18 months
Term
What are the most common benign lung neoplasms?
Definition
bronchial adenomas and hamartomas
Term
Where are bronchial adenomas most commonly located? What kind of tumors are most bronchial adenomas? What are some characteristics of bronchial adenomas that you would want to consider before surgery?
Definition
They are mostly centrally located in the lungs. Most of them are carcinoids. They are hypervascular and bleed profusely.
Term
What are some general characteristics of carcinoids?
5 year survival rate for carcinoids?
Definition
They are generally resistant to chemo and they secrete hormones that cause paraneoplastic syndromes.
5 year survival rate is 90%
Term
Where are Hamartoma's usually found in the lungs? Are they usually benign? What are their characteristic calcifications?
Definition
They are usually peripheral and benign and have characteristic "popcorn" calcifications.
Term
What are 2 renal manifestations of lung cancer?
Definition
Nephrotic syndrome and glomerulonephritis
Term
What are 2 dermatological manifestations of lung cancer?
Definition
Dermatomyositis and Acanthosis nigricans
Term
Are screening tests recommended for lung cancer?
Definition
No, because of false positive results that lead to unnecessary invasive diagnostic procedures.
Term
What additional tests do you want to order for a small cell carcinoma?
Definition
Brain CT/MRI and a bone marrow biopsy because of its inclination to METS there.
Term
Treatment for small cell carcinoma for limited stage? Extensive stage?
Definition
Limited stage = chemo and radiation
Extensive stage = just chemo
Term
Solitary Pulmonary Nodules are more likely to be benign if they appear how on a CXR?
Definition
As a dense central calcification or multiple punctate calcifications (small circular calcifications).
Term
What is a pulmonary infarction?
Most common etiology?
Characteristic sign on CXR of a pulmonary infarction?
Definition
The lung infarcts as does the heart, when vessels are occluded with emboli and the surrounding tissue is damaged. Most commonly due to a PE.
Will see "Hampton's Hump"(wedge-shaped consolidation in the lung periphery) on CXR.
Term
What percentage of patients with a PE die within the first 30 days of diagnosis, even with treatment?
Definition
10%
Term
How will PE's look initially on CXR? What will they progress to?
Definition
Over days, CxR = consolidation over the infarcted segment, then pleural effusion
Term
Most common complaint of non-infarcting PE's?
What are the 8 components of the "PERC" (Pulmonary Embolism Rule out Criteria)?
Definition
dyspnea
PERC = low pretest probability plus: age less than 50, pulse less than 100, O2 saturation greater than 94%, no hormone use, no hemoptysis, no unilateral leg swelling, no recent major surgery/trauma and no prior PE or DVT.
Term
What is the most common EKG result from obstructive PE's?
Definition
PEA (pulseless electrical activity)
Term
What is the typical clinical presentation of a patient with a PE?
Definition
pleuritic chest pain, dyspnea, hemoptysis, tachycardia, tachypnea and a pulse Ox less than 95%.
Term
Why do you order a CMP or BMP with a suspected PE? Why do you order a urine BHCG for a suspected PE?
Definition
Must check renal function for the CT angiogram dye.
It will show if a female patient is pregnant.
Term
What is "Westermark's sign" for PE's?
Definition
Seen on CXR and is a rare sign of very large PE's and is the absence of blood vessel markings beyond the location of a pulmonary embolism.
Term
Why do you only check D-dimer levels for low to moderate risk PE populations?
Definition
Because you have enough other findings that you do not need it for high risk populations.
Term
What is the sensitivity and specificity for D-Dimers in respect to PE's?
Definition
92-95% sensitive and 50% specific
Term
What is the gold standard for diagnosing a PE?
Definition
CT pulmonary angiogram
Term
When is V/Q scan preferred over CT for PE diagnosis?
Definition
In pregnant women.
Term
If you cannot get a scan on someone right away that has a suspected PE, what should you give them in the meantime?
Definition
Lovenox (anticoagulant)
Term
Most common diagnosis found with a negative CT angiogram for PE?
Definition
pneumonia
Term
What is the standard initial treatment for a suspected PE?
Definition
Unfractionated Heparin or other anticoagulants (Lovenox)
Term
What drug reverses a Heparin OD?
Definition
Protamine sulfate
Term
When would you consider using thrombolytics for a PE?
Definition
Only if you think the patient has a very high risk of dying from the PE, otherwise the risk of hemorrhage is too great.
Term
What is the standard for diagnosing a DVT?
Definition
D-dimer and duplex ultrasound
Term
What are some signs and symptoms of a DVT?
Definition
unilateral calf cramp, soreness, fullness, swelling, edema, erythema and warmth.
Term
Most common cause of pleural effusion in the western world?
Definition
CHF (left sided heart failure)
Term
What conditions cause transudative pleural effesions?
Definition
(NONINFECTIOUS/NONCANCER)
Congestive heart failure   
Cirrhosis with ascites   
Nephrotic syndrome   
Hypoalbuminemia   
Myxedema   
Peritoneal dialysis   
Glomerulonephritis   
Superior vena cava obstruction    Pulmonary embolism
Term
What conditions cause exudative pleural effusions?
Definition
(INFECTIOUS PLUS CANCER)
Bacterial pneumonia   
Bronchiectasis   
Lung abscess   
Tuberculosis   
Viral illness   
Neoplasms   
Primary lung cancer   
Mesothelioma   
Pulmonary/pleural metastases   
Lymphoma
Term
Describe the protein content of transudates vs. exudates.
Definition
Transudates have little protein and Exudates have high protein content.
Term
What type of effusion is seen with increased pulmonary vascular pressure? Ischemia and destruction of the pleural membrane?
Definition
Increased pulm vascular pressure = transudative
Ischemia and destruction of the pleural membrane = exudative
Term
What volume of pleural effusion is DOE seen with?
Definition
500cc
Term
What is the most common diagnostic study to confirm pleural effusion?
Definition
CXR (blunted costophrenic angle)
Term
What modality is used to guide thoracentesis in the draining of a pleural effusion?
Definition
ultrasound
Term
What is a chylothorax? What should you check?
Definition
white, milky colored pleural fluid due to chylomicrons in the fluid due to lymphatic fluid accumulating in the pleural space. Check Trigs, Cholesterol and Total Lipid Content.
Term
What should you think if you have:
Black
Brown
Yellow-green
Highly Viscous
Putrid odor
or Ammonia odor fluids in the pleural space?
Definition
Black = think aspergillus
Brown(chocolate) = think rupture of amebic liver abscess
Yellow-green = think rheumatoid pleurisy
“highly viscous” = think cancer, malignant mesothelioma
Putrid odor = think anaerobes
Ammonia odor = think urinothorax
Term
What are some clinical features of a pneumothorax?
What will you see on CXR with a tension pneumothorax?
Definition
Sharp pleuritic chest pain that worsens with deep inspiration, acute onset, dyspnea, mild tachycardia, decreased breath sounds over affected area and hyperresonance to percussion.

With tension you will see tracheal and mediastinal shift to contralateral side on CXR.
Term
Most common condition associated with secondary pneumothorax?
Definition
COPD
Term
What happens in a pneumothorax to cause the extra air?
Definition
There is an alveolar-pleural defect that acts as a one way valve that during inspiration the air gets stuck and you cannot exhale it.
Term
Most common physical exam finding with a spontaneous pneumothorax?
Definition
Mild sinus tachycardia is the most common physical exam finding.
Term
What occurs as a result of a tension pneumothorax?
Definition
Decreased cardiac output develops which leads to tachycardia and hypoxia. Trachial deviation may or may not be present.
Term
How are pneumothoracis diagnosed? How will a tension classically look on CXR?
Definition
CXR and the average width of the band is used to estimate the size of it (where you see the collapsed lung).
A tension will show complete lung field collapse with gross distension of the thoracic cavity on the affected side and shift of the mediastinal structures across the midline.
Term
What is the gold standard for diagnosing pneumothoraces?
Definition
CT scan
Term
Is spontaneous pneumomediastinum an emergency? How is it diagnosed?
Definition
It is an emergency and is diagnosed by the presence of subcutaneous emphysema (presence of air under the skin, usually the chest, neck or face) and the finding of mediastinal air on CXR.
Term
What could cause a secondary Pneumomediastinum?
Definition
Boerhaave's syndrome (rupture of the esophageal wall due to vomiting) or other forms of esophageal perforation.
Term
What is the temporary and definitive treatment for pneumomediastinum?
Definition
Temporary is needle decompression and definitive is tube thoracostomy.
Term
What is the follow up for a pneumomediastinum patient that has been discharged?
Definition
24 hours
Term
What is Hyaline Membrane Disease?
Cause?
Treatment?
Definition
Also called Respiratory Distress Syndrome (RDS) and it is a common problem in premature infants caused by the lack of surfactant production.
Treatment includes ET tube, mechanical ventilation, supplemental oxygen, continuous positive air pressure, artificial surfactant and meds for sedation/pain.
Term
What are atypical carcinoids notorious for?
What is the 5 year survival rate for atypical carcinoids?
Definition
METS in 70% of their cases.
5 year survival rate is 65%
Term
What is chemical pneumonitis?
Treatment?
Definition
Chemical pneumonitis is inflammation of the lungs or breathing difficulty due to inhaling chemical fumes, or aspirating (breathing in and choking on) gastric acid from the stomach, mineral oil, gasoline, or other damaging chemicals.

Treatment is focused on reducing symptoms. Oxygen therapy may be helpful. Corticosteroids may be given to reduce inflammation. Antibiotics are usually not helpful or needed.
Term
What are some concerns with supraclavicular lymphadenopathy?
Definition
Lung carcinoma, TB and esophageal cancer. Supraclavicular lymphadenopathy are the most worrisome for malignancies.
Term
What is a lobectomy?
Definition
Surgical removal of a lobe of the lung.
Term
What is a pneumonectomy?
Definition
Surgical removal of an entire lung.
Term
What is thoracentesis?
Definition
Procedure to remove air or fluid from the pleural space.
Term
What is a tube thoracostomy?
Definition
AKA chest tube, it is a flexible plastic tube that is inserted through the side of the chest into the pleural space to drain air, fluid or pus.
Term
What is needle decompression and what does it treat?
Definition
The insertion of a large bore needle into the pleural space, releasing the pressure from a tension pneumothorax and converting to back to a non-tension where tube thoracostomy can treat that.
Term
Explain how ABG's can be used to evaluate Respiratory Acidosis/Alkalosis vs. Metabolic Acidosis/Alkalosis.
Definition
Respiratory Acidosis will have a decreased pH but increased HCO3 and PCO2.

Respiratory Alkalosis will have an increased pH and a decreased HCO3 and PCO2.

Metabolic acidosis will have a decreased pH, HCO3 and PCO2.

Metabolic alkalosis will have an increased pH, HCO3 and PCO2.
Term
Major renal abnormality seen with Sarcoidosis?
Definition
Hypercalciuria
Term
What did the PIOPED study show?
Definition
Showed that CTPA is better than VQ scan for PE diagnosis.
Term
If CTPA is negative for PE what is the next step?
Definition
Do a Doppler of the legs
Term
What circumstances would an individual need surgery for a PE?
Definition
If the patient has a very large embolus that cannot undergo fibrinolysis, they have a floating embolus in the right side of their heart or they have severe hypotension.
Term
What stages of lung cancer would you use brachytherapy?
Definition
Stage 1a through 2b
Term
What is a parapneumonic effusion?
Definition
pleural effusion from a pneumonia
Term
What is a loculated pleural effusion?
Definition
pleural effusion that is not free flowing
Term
Describe stages To, Tx, T4, No, Nx, N3, Mo, Mx and M1 for the TNM staging system.
Definition
To = No evidence of primary tumor.
Tx = positive cytology but no lesion on CXR or bronchoscopy.
T4 = Tumor invades mediastinum, heart, great vessels, carina, spine, or malignant pleural/pericardial effusion or satellite tumor in same lobe.
No = No regional nodal involvement.
Nx = Regional nodes cannot be assessed.
N3 = Contralateral mediastinal or hilar nodes or scalene or supraclavicular node involvement.
Mo = No distant METS.
Mx = Distant METS cannot be measured.
M1 = Distant METS present.
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