Identify the most common cause of lung cancer (CA).List the different types of small-cell and non-small-cell carcinoma.List criteria for staging lung CA.Identify lung CA treatment options based on staging.List signs and symptoms of metastatic lung CA.Identify the most common type of lung CA in non-smokers.Identify the lung CA type associated with the poorest prognosis.List physical changes in the lung seen with the different stages of ARDS.List possible causes of ARDS.List treatment options for ARDS.List treatment goals of low-tidal-volume ventilation.List clinical manifestations of ARDS.Identify the chest x-ray finding most closely associated with ARDS.List goals of permissive hypercapnia.Identify the lowest acceptable pH when using permissive hypercapnia.Select an appropriate mandatory VT for a patient with ARDS, given the IBW.List breath sounds associated with ARDS.Identify physical features of myasthenia gravis.Identify the clinical change to be seen in a myasthenia gravis patient following a rest period.Describe the effect of edrophonium on myasthenia gravis.Identify treatment options in myasthenia gravis.Describe the rationale behind thymectomy in myasthenia gravis.Identify monitoring requirements in myasthenia gravis.Describe the typical chest x-ray appearance in myasthenia gravis.Identify the possible result of the immobilization seen in Guillain-Barré.List treatment options in Guillain-Barré.Differentiate the pathophysiologic changes seen in myasthenia gravis and Guillain-Barré.List signs and symptoms of obstructive sleep apnea (OSA).Describe the physiologic mechanism of CPAP in OSA.List risk factors for OSA.Differentiate the onset of paralysis between myasthenia gravis and Guillain-Barré.Identify a clinical test that may be used to help diagnose myasthenia gravis.Differentiae the pathophysiologic features of OSA and central sleep apnea (CSA).Differentiate OSA, CSA and mixed sleep apnea (MSA) using a sleep study tracing.Identify the primary diagnostic tool used for sleep apnea.List management options in sleep apnea.List clinical features of OSA.differentiate benign and malignant tumors.List clinical features of lung CA.List the method used to identify cancer cell type.List features of the different cancer stages.
Lung Cancer
RCP 3007
Pulmonary Disease
Objectives
? Anatomic Alterations
? Etiology
? Clinical Features
? Management
Anatomic Alterations
? Definition: an abnormal new tissue growth
characterized by progressive, uncontrolled
growth
? Carcinogen: any substance that causes cancer
? Tumor origin: tracheobronchial tree
? Bronchogenic carcinoma: primary lung cancer
Anatomic Alterations
? Growth
? Benign:
? Loculated, encapsulated
? Does not invade other organ systems or form other
tumors
? Malignant:
? travels through the circulation (blood & lymphatics)
? spreads to other organ systems and forms new
tumors
Anatomic Alterations
? Physical manifestations
? Irritated, inflamed & edematous airways
? Excessive mucus production & mucus plugging
? Consolidated or collapsed alveoli
? Intraairway bleeding caused by blood vessel
erosion
Anatomic Alterations
? Physical manifestations
? Airway obstruction by mucus, blood and/or
tumor
? Lung cavitation from rapid cell growth causing
lung destruction
? Pleural effusion
Image and
Microscopic
Presentation
PostMortem
Section
Etiology
? Cigarette smoking: most common cause
? Cigarette smoke contains many carcinogens
? Heredity
? Radon
? Radiation
Etiology
? Asbestos (mesothelioma)
? Nitrogen mustard gas (chemical weapon)
? Vinyl chloride (part of most plastics)
? Air pollution
Types of Cancers
? Small cell (Oat cell) cancer
? Strong correlation with cigarette smoking
? Metastasizes (spreads) quickly
? Worst prognosis
? Staging: level of progression & severity
? Limited disease (20% – 30% of patients)
? Extensive disease (70% – 80% of patients)
Types of Cancers
? Non-small-cell cancer
? Squamous cell carcinoma
? Most common lung cancer in males
? Late metastasis
? Tumor commonly compresses airways causing
obstruction
? Nonproductive cough
? Hemoptysis
? Atelectasis
? Pneumonia
Types of Cancer
? Non-small-cell cancer
? Adenocarcinoma
? Most common type in females and nonsmokers
? Grows from mucus glands
? Abnormal mucus secretion
? Abnormal mucus glands
? Early metastasis
? Cavitation
? Pleural effusion
Types of Cancer
? Non-small-cell cancer
?
Large-cell Carcinoma
? Uncommon (10% – 15% of all lung cancers)
? Usually grow from peripheral airways
? Early & widespread metastasis
? Clinical Findings
? Chest wall pain
? Pleural effusion
? Pneumonia
? Hemoptysis
? Cavitation
Diagnosis
? Definitive tool: tissue biopsy to identify
cell type
? Chest imaging
? Chest x-ray
? CT scan: for small tumors & metastasis
? Positron emission tomography (PET) scan: for
small tumors & metastasis
? Biomarkers
Staging
? Stage 0: limited to the airway lining
? Stage I: tumor less than 3 cm in
diameter; no lung tissue involvement or
metastasis
? Stage II: invasion of adjacent lymph
nodes or chest wall, no metastasis
Staging
? Stage III A: located in main bronchus with
obstructive atelectasis/pneumonitis of
entire lung, some metastasis present
? Stage III B: local to metastasis of thoracic
structures and lymph nodes, no peripheral
metastasis
? Stage IV: lymph nodes involvement,
metastasis to other organ systems
Management
? Small-cell cancer
? Chemotherapy
? Radiation therapy
? Supportive care: treat symptoms and not the
cancer itself
Management
? Non-small-cell cancer
? Stages I & II
? Lung resection
? Radiation therapy
? Stage III (lymph nodes)
? Chemotherapy
? Radiation therapy
Management
? Non-small-cell cancer
? Stage III (mediastinum)
? Chemotherapy or radiation therapy
? Lung resection (if above is successful)
? Stage IV
? Chemotherapy
? Supportive care
Respiratory Care Management
? Oxygen Therapy
? Be cautious as COPD frequently accompanies
lung cancer (75% of all cancers)
? Airway Clearance Therapy
? Excessive mucus production and retention
Respiratory Care Management
? Lung Expansion Therapy
? Temporary relief of obstructive atelectasis
? Reexpansion following thoracentesis
? Aerosolized Medication Therapy
? Mucolytics
? Bronchodilators
? Antibiotics
ACUTE RESPIRATORY
DISTRESS SYNDROME
(ARDS)
RCP 3007, Pulmonary Disease
ARDS
Definition
• P/F Ratio: PaO2/FiO2
– Normal : ?200
• Severity Criteria
– Acute Lung Injury (ALI) 90%; FiO2 ? 0.50
• PEEP usually needed to meet O2 goals
– Prevents/corrects alveolar collapse
– Increases area for gas exchange
ARDS
Treatment: PEEP
• Optimal PEEP
– ???
• Individualized
• Depends on oxygenation and hemodynamic response
– Most cases: PEEP ~ 15 – 20 cm H2O
ARDS
Optimal PEEP
• Maximize lung compliance
• Lowest PEEP to oxygenate @ FiO2 < 0.50 ARDS Treatment: Lung-Protective Ventilation • VT = 4-6 mL/kg (ARDSNet) • Limit Pplat 7.20 –7.25 – Worsening hypoxemia • Correction: – Recruitment maneuvers – Increasing PEEP ARDS Treatment: Mechanical Ventilation (MV) • Pressure-control ventilation (PC-CMV) – Controlled airway pressures – Controlled inspiratory times – Patient comfort • Treatment Effectiveness – PC-CMV = VC-CMV – PC-CMV results in less ALI & worsening of ARDS ARDS Treatment: Alternate Modes of MV • Inverse-ratio ventilation (TI > TE)
• Airway pressure-release ventilation (APRV)
• Bilevel airway pressure ventilation
• Proportional-assist ventilation (PAV)
• High-frequency ventilation (HFV)
• Extracorporeal membrane oxygenation
(ECMO)
ARDS
Treatment: Prone Positioning
• Multiple proposed mechanisms
– Improved oxygenation
• Can be difficult to implement
• Variable improvement in outcomes (research
ongoing)
• May be useful if implemented early.
ARDS
Treatment: Vasodilators
• Nitric oxide (NO) has 83% response rate
• Problems:
– Special equipment
– Rebound phenomenon
– No improvements in outcomes
• Prostacyclin may be a better agent
ARDS
Treatment: Other Modalities
• Iloprost
• Antiinflammatory agents
– Steroids may have a role
• Antioxidants
• Surfactant replacement
ARDS
Prognosis
• Mortality
– 35% – 40%
– Death from respiratory failure = 15% – 18%
• Most common cause of death – sepsis/infection
• Outcomes
– Majority of survivors have near-normal lung
function
• Small % develop pulmonary fibrosis
– Neuropsychiatric issues – ICU psychosis
Next Week . . .
• Midterm Exam
Neuromuscular Disease and
Sleep Apnea
RCP 3007
Pulmonary Diseases
Objectives
? Anatomic Abnormalities
? Etiology
? Diagnosis
? General Management
? Respiratory Care Management
Anatomic Abnormalities
? Guillain-Barré
? Myasthenia Gravis
? Myelin sheath of
? Chronic lack of
nerves is lost
? Inflammation &
edema of nerves
also occurs
? Also called:
postinfectious
polyneuropathy
acetylcholine at the
myoneural junction
? Impulse
transmission is
impaired
Etiology
? Guillain-Barré
? Myasthenia Gravis
? Unknown
? Antibodies (from
? May be caused by
thymus gland)
disrupt
acetylcholine
function and
destroy receptor
sites
? Descending
paralysis
inflammation that
accompanies
infection
? Nerves loose
protective myelin
sheath
? Ascending paralysis
Diagnosis
? Guillain-Barré
? Recent history of an
infection
? Myasthenia Gravis
? Positive Tensilon
test
? Tensilon temporarily
increases
acetylcholine levels
causing temporary
improvement in
symptoms
Physical Findings
? Muscle weakness
? Shallow breathing (hypopnea)
? Hypoxemia
? Hypercapnia
? Quiet, nasal speech
General Management
? Guillain-Barré
? Myasthenia Gravis
? Frequent monitoring
? Frequent monitoring
of VC (should be
?15mL/kg IBW),
ABGs & SpO2
? Plasmapheresis in
severe cases
of VC (should be
?15mL/kg IBW),
ABGs & SpO2
? Drug therapy
? Tensilon
? Removal of plasma
? Neostigmine
from blood
? Plasma replacement
is given
? Pyridostigmine
? Corticosteroids
? Thymectomy
Respiratory Care Management
? Guillain-Barré
? Myasthenia Gravis
? Oxygen as
? Oxygen as
necessary
? Bronchial hygiene
for secretion
removal
? Hyperinflation for
atelectasis
? Mechanical
ventilation for
ventilatory failure
necessary
? Bronchial hygiene
for secretion
removal
? Hyperinflation for
atelectasis
? Mechanical
ventilation for
ventilatory failure
Sleep Apnea
? Types:
? Obstructive
? Central
? Mixed
Sleep Apnea Types
Diagnosis
? History
? Obstructive
? Hypersomnolence (daytime sleepiness)
? Obesity (not always)
? Central
? History of neurologic pathology (e.g. organic
brain disease, head trauma, cerebral anoxia)
? Sleep study (primary diagnostic test)
Diagnosis
? Apnea-Hypopnea Index (AHI)
? Number of apneas & hypopneas divided by
hours of sleep
? Apnea: cessation of breathing or decrease
in inspiratory airflow of 5 – 1 – 15 – 5 – 30
>10
Sleep Study
Sleep Study
Pediatric Sleep Study
Polysomnograph
Management
? Weight loss
? Sleep position (side or prone)
? O2 therapy (for frequent desaturations)
? Drug therapy (for central sleep apnea)
? Surgery
? Tracheostomy
? Mandibular advancement
Management
? Mechanical ventilation
? Continuous Positive Airway Pressure
(CPAP)
? Continuous Mechanical Ventilation (CMV)
? Negative Pressure Ventilation (NPV)
? Phrenic pacemaker
? Oral appliances (e.g. SnoreGuard,
PureSleep)
Assessment of Effectiveness
? Improved sleep study: effectiveness
assessed during initial sleep study
? Improved symptoms over time
Next Week . . .
? Lung Cancer