COPD, lung cancer – Flashcards

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neoplasm
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tumor
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Benign tumors
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tumors that do not invade and destroy adjacent normal tissue. They grow slowly and push aside normal tissue but do not invade. They do not travel by bloodstream or lymphatics.
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Malignant tumors
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tumors that invade surrounding tissues, are usually capable of producing metastases, may recur after attempted removal, and are likely to cause death of the host unless adequately treated.
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interchangeable term for lung cancer?
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Bronchogenic carcinoma (lung cancer) - a tumor that originates in the bronchial mucosa
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When a person has lung cancer, what happens to the lung?
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As the tumor enlarges, the surrounding bronchial airways and alveoli become irritated, inflamed & swollen, Surrounding alveoli collapse and consolidate. As the tumor protrudes into the tracheobronchial tree, excessive mucus production and airway obstruction develop, Surrounding blood vessels erode and blood enters the tracheobronchial tree Cavity surrounding the tumor may develop. Pleural effusions, When a tumor invades the parietal pleura & mediastinum
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Major pathologic/ structural changes associated with lung cancer
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Inflammation, swelling, destruction of bronchial airways and alveoli Excessive mucous production• Tracheobronchial mucous accumulation and plugging Airway obstruction (from blood, mucous, or tumor into bronchus) Atelectasis Alveolar consolidation Cavity formation Pleural effusion
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Two groups lung cancer
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Non-small cell lung carcinoma NSCLC Small cell lung carcinoma SCLC
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4 types of lung cancer
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Squamous cell carcinoma Adenocarcinoma Large cell carcinoma Small cell :oat cell: carcinoma
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Squamous cell carcinoma
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Slow growth rate 30% of the bronchogenic carcinomas. Commonly located near a central bronchus and projects into large bronchi. Slow growth rate and a late metastatic tendency (mostly to hilar lymph nodes). Preferred treatment= Surgical resection
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Adenocarcinoma
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moderate growth rate 35-40% of all bronchogenic carcinomas. It arises from mucous glands of tracheobronchial tree. It has the weakest association with smoking. It commonly found in the peripheral regions of the lung parenchyma. Usually smaller than 4 cm. Metastatic tendency is early.
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Large cell carcinoma
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Rapid growth rate 10-15% of all bronchogenic carcinoma. They are a group of cancers with large, abnormal-looking cells that tend to originate along the outer edges of the lungs. Common secondary complications include chest wall pain, pleural effusion, pneumonia, hemoptysis and cavity formation. Metastasis early and widespread.
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Small cell lung carcinoma :SCLC Small cell (oat cell) carcinoma
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15-20% of all lung cancers Most aggressive form usually originates in the large, (primary+secondary) bronchi. grows very rapidly spreads quickly, often before symptoms appear. frequently metastasizes to liver, bone, and brain. Strongest correlation with cigarette smoking Survival time for untreated = 1-3 month. Worst prognosis It responds well to chemotherapy and radiation therapy but nearly all relapse within 24 months.
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Symptoms? lung cancer
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A progressively worsening cough—often includes blood or rust-colored sputum Chest pain—especially with deep breathing, coughing, or laughing Hoarse voice Poor appetite and weight loss Dyspnea Fatigue Frequent bronchial infection or pneumonia episodes Sudden onset of wheezing.
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When lung cancer spreads to others parts of the body, the patient may have other symptoms of
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cancer that include Bone pain (e.g., back or hips) Neurologic problems (e.g., headache) Arm and leg weakness or numbness Dizziness or balance problems Seizures Jaundice Enlarged lymph nodes (e.g., neck or under the arms).
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The system most often used for staging lung cancer is the
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TNM classification (0-4) T represents the size and location of the primary tumor N denotes the lymph node involvement M indicates the extent of metastasis
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Overall stage of the lung cancer
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Stage 0, I, II, III and IV Stages 0, I and II: resectable Stage IIIA : high risk surgery Stages IIIB and IV : not resectable, may be treated with radiation, with or without chemotherapy
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Staging - Small-cell Lung Cancer
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Classified as either Limited or Extensive
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Limited
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The cancer is confined to only 1 lung and its neighboring lymph nodes Common treatment= chemo w/radiation
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Extensive
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The cancer has spread beyond one lung and near-by lymph nodes. It may have invaded both lungs, more remote lymph nodes, or other organs Common treatment= chemo
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Horner's syndrome
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Drooping one eyelid, same side small pupil
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Superior vena cava syndrome
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Headache, dizziness, Swelling face, neck, chest
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Paraneoplastic syndromes
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Tumor produces proteins, hormonelike substances Hypercalcemia, excess growth of certain bones, blood clots.
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The primary goal of diagnostic procedures
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1. confirm the presence of a lung carcinoma 2. establish the type of cancer 3. confirm the stage of the cancer.
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Definitive DX made by
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microscopic examination of a tissue sample :biopsy
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lung cancer vital signs
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Increased respiratory rate Increased Heart Rate Increased Blood Pressure
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lung cancer: increased respiratory rate caused by
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Hypoxemia: peripheral chemoreceptors Decreased lung compliance Stimulation of J receptors Pain, anxiety
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J Receptors
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are sensory nerve endings located within the alveolar walls in juxtaposition to the pulmonary capillaries of the lung and are innervated by fibers of the vagus nerve.
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chest x-ray :lung cancer
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most common screening tool used
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lung cancer: CT scan or PET scan
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are frequently used 1) to reveal extremely small lesions and, 2) to determine if the cancer has spread to other areas
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treatment options for NSCLC
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surgery radiation therapy local treatments: radiofrequency ablation photodynamic therapy laser therapy stent placement chemotherapy
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radiation therapy
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EBRT: external beam radiation 3-d CRT: Three-Dimensional conformal IMRT: intensity modulated SBRT: stereotatic body SRS: sterotatic radiosurgery brachytherapy: internal radiation
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EBRT: external beam radiation therapy
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directs a beam of radiation from outside the body at cancerous tissues inside the body. It is a cancer treatment option that uses doses of radiation to destroy cancerous cells and shrink tumors.
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3-D CRT: Three-Dimensional conformal radiation therapy
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maps location of tumor,radiation beams target tumors from several directions, less likely to damage surrounding tissues
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IMRT: intensity modulated radiation therapy
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uses linear accelerators to safely and painlessly deliver precise radiation doses to a tumor while minimizing the dose to surrounding normal tissue. used near important structures like the spinal cord
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SBRT: stereotatic body radiation therapy
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also known as SABR:stereotactic ablative radiotherapy: used to treat very early late stage cancers when surgery is not an option:applies very focused beams of high dose radiation in fewer :1-5 treatments.sucess in smaller tumors is promising with low risk
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SRS: sterotatic radiosurgery
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sterotatioc radiation therapy given in one session, can be repeated if necessary
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brachytherapy: internal radiation
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used to shrink tumors in the airways to reduce symptoms, used more often for head and neck cancer. small amounts of radioactive materials (pellets) via bronchoscop directly into the tumor or in the airway near the tumor, removed after a short time.
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radiation side effects
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sunburnlike skin problems hairloss where radiation enters body fatigue nausea,vomiting loss of appetite, weight loss
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NSCLC surgery
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Sleeve resection Wedge resection Segmentectomy Lobectomy Pneumonectomy
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In what situations
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only in one lung, and up to stage IIIA
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Local or systemic?
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most radiation considered local, chemo is sytemic
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chemotherapy
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general term for chemical agents or drugs selectively destructive to malignant cancer cells. systemic treatment. can damage healthy cells, especially fast growing cells
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chemotherapy side effects
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hair loss mouth sores nausea, vomiting diarrhea, vomiting increased chance of infection: low WBCs easy bruising, bleeding :low platelets fatigue: low RBCs short lived, resolve after treatment is finished
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surgical procedures
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Surgery provides that best chance to cure NSCLC
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Sleeve resection
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removal tumors in large airways then shortened airway is reattached
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Wedge resection
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partial removal of a lung lobe
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Segmentectomy
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removal of a lung segment
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Lobectomy
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removal of one lung lobe
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Pneumonectomy
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removal of whole right or left lung
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Surgery is an option up to what stage
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only in one lung, and up to stage IIIA
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Radiation Therapy: local
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High intensity rays to kill cancer cells. Often given with chemotherapy It may be used with curative intent in patients with non-small cell lung carcinoma who are not eligible for surgery
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External beam radiation therapy EBRT
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Three-dimensional conformal radiation therapy (3D-CRT) Intensity-modulated radiation therapy (IMRT) Stereotactic body radiation therapy (SBRT) Stereotactic radiosurgery (SRS)
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Brachytherapy
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internal radiation therapy
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Chemotherapy common drugs
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Cisplatin and etoposide Carboplatin and etoposide Cisplatin and irinotecan Carboplatin and irinotecan
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the treatment options for SCLC
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Surgery is rarely an option for SCLC. If performed, lobectomy is the preferred choice, then it is followed by chemo and radiation therapy Radiation therapy EBRT, 3D-CRT, IMRT may be used
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palliative care
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Patient receive only comfort or palliative care, which means treating the symptoms of the cancer rather than the cancer itself.
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cancer: Oxygen Therapy Protocol
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To treat hypoxemia, decrease WOB. Hypoxemia caused by capillary shunting alveolar compression and consolidation often is refractory to O2 therapy
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cancer: Bronchopulmonary Hygiene Therapy Protocol
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IS, IPPB, CPT, Percussion and vibration, postural drainage, etc
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cancer :Lung Expansion Therapy Protocol
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Cough and deep breathing, IS, IPPB, CPAP, etc
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cancer: Aerosolized Medication
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- Bronchodilators and mucolytics - 75% of lung cancer coexists COPD
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COPD
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Chronic Bronchitis and Emphysema
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Two organizations
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The American Thoracic Society (ATS) The Global Initiative for Chronic Obstructive Lung Disease (GOLD)
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Chronic bronchitis definition by ATS -; duration
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Is defined clinically as chronic productive cough for 3 months in each of 2 successive years in a patient in whom other causes of productive chronic cough have been excluded.
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Anatomic alterations of the lungs associated with chronic bronchitis
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Chronic inflammation and swelling of the peripheral airways Excessive mucus production and accumulation Partial or total mucus plugging of the airways Smooth muscle constriction of bronchial airways (bronchospasm) Air trapping and hyperinflation of alveoli—occasionally in the late stages
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Anatomic alterations of the lungs associated with emphysema
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Weakening and permanent enlargement of the air spaces distal to the terminal bronchioles and by destruction of the alveolar walls. As these structures enlarge -; the alveoli coalesce-; gas exchange surface area decreased. Permanent enlargement and deterioration of the air spaces distal to the terminal bronchioles Destruction of pulmonary capillaries Weakening of the distal airways, primarily the respiratory bronchioles Air trapping and hyperinflation of alveoli
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Two kinds of emphysema.
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Panacinar emphysema : Panlobular emphysema and Centriacinar emphysema: Centrilobular emphysema
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Panacinar emphysema : Panlobular emphysema
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Abnormal weakening and enlargement of all alveoli distal to the terminal bronchioles. Panlobular emphysema commonly is found in the lower parts of the lungs. Most severe type.
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Centriacinar emphysema: Centrilobular emphysema
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Involves the respiratory bronchioles in the proximal portion of the acinus. Most common form of emphysema. Strongly associated with cigarette smoking.
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What are the risk factors?
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Exposure to particles, Genetic predisposition, Lung growth and development
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Exposure to particles
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Tobacco smoke: most commonly encountered risk factor for COPD Occupational dusts and chemicals: vapors, irritants, fumes Indoor air pollution: biomass fuel used for cooking and heating: more women Outdoor air pollution; silicates, sulfur dioxide, ozone
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Genetic predisposition
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Alpha 1-antitrypsin deficiency ?100,000 in US
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Lung growth and development
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Conditions that affect normal lung growth: Low birth weight, Respiratory infections
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What is Alpha1-antitrypsin deficiency
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Alpha1-antitrypsin = being produced by liver, it protects lungs by blocking effects of powerful enzyme, "elastase". Elastase is carried by white cells to 1) help kill bacteria , and to 2) neutralize small particles inhaled into lungs. In normal circumstances, when old white cells are destroyed, elastase is released. ?1-antitrypsin works to inactivate the released elastase. But when ?1-antitrypsin level is low, elastase is free to attack and destroy elastic tissue of the lungs.
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Alpha1-antitrypsin deficiency found more in
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Severe A1AT deficiency causes panacinar emphysema or COPD in adult life in many people with the condition ,especially if they are exposed to cigarette smoke.
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What are the phenotype for A1AT defeciency?
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MM phenotype = normal: 150-350 mg/dL ZZ phenotype = severely low serum concentration MZ phenotype (1 from each parent)
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MMphenotype has
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normal serum level, 150-350 mg/dL
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key indicators for considering a COPD diagnosis?
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Dysypnea: progressive over tome, worse with exercise, persistent Chronic cough: can be intermittent or nonproductive Chronic sputum production History of exposure to risk factors: tobacco smoke, smoke from home cooking, and/or heating fuels, work related dusts ,chemicals Family history of COPD: alpha1 antitrypsin deficiency
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Three main spirometry tests used to identify COPD?
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FVC FEV1 FEV1/FVC ratio :FEV1%
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The presence of COPD is confirmed when both the
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FEV1 and FEV1/FVC ratio are decreased
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COPD volumes
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IC low, VC low increased TLC,FRC,RV
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Four stages of COPD
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mild,moderate, severe, very severe
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Stage I: Mild COPD
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FEV1/FVC ; 70%, FEV1 ? 80% predicted Pt may not recognize abnormal lung function
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Stage II: Moderate COPD
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FEV1/FVC ; 70%, FEV1 50-79% predicted Pt often complains of SOB
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Stage III: Severe COPD
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FEV1/FVC ; 70%, FEV1 30-49% predicted Symptoms have an impact on pt's quality of life
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Stage IV: Very severe COPD
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FEV1/FVC ; 70%, FEV1 ;30% predicted or QOL is impaired + exacerbations may be life threatening.
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Diagnosis of COPD is made when the patient demonstrates 3 things.
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The presence of symptoms compatible with COPD Spirometry demonstrating airflow limitation Absence of an alternative explanation for the symptoms and airflow limitation
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What is Modified Medical Research Council ; mMRC; questionnaire?
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Description of Breathlessness 0 I only get breathless with strenuous exercise. 1 I get short of breath when hurrying on level ground or walking up a slight hill. 2 On level ground, I walk slower than people of the same age because of breathlessness or have to stop for breath when walking at my own pace. 3 I stop for breath after walking about 100 yards or after a few minutes on level ground. 4 I am too breathless to leave the house, or I am breathless when dressing.
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GOLD "Combined Assessment of COPD" is a scoring rubric using which 3 assessments
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the symptoms assessment :mMRC questionnaire airflow limitations assessment gold 1-4 and risk of exacerbations assessment
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Additional Diagnostic Studies of COPD
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• Bronchodilator reversibility testing To rule out asthma • Chest x-ray To exclude TB, PNA, CHF, etc. • Arterial blood gas measurement (examples) Stable COPD: 7.36/79/61/43 impending ventilatory failure: 7.52/52/46/40 acute ventilatory failure: 7.28/99/34/45 • Alpha1 antitrypsin deficiency screening
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Pink Puffer
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Type A COPD: Emphysema
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Pink Puffer (Type A COPD: Emphysema)
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Reddish complexion, rapid respiratory rate, thin, barrel chest, use accessory muscles for inspiration, and exhales through pursed lips.
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Pink Puffer more COPD: Emphysema
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Progressive elimination of pulmonary capilaries leads to reduced pulmonary blood flow increased ventilation-perfusion ratio. to compensate, pt hyperventilates. maintain relatively normal PaO2, and ruddy skin complexion. PaCO2 drops But end stage, PaO2 decreases and PaCO2 increases
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Blue Bloater
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Type B COPD: Chronic Bronchitis
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Blue Bloater (Type B COPD: Chronic Bronchitis)
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Cyanosis, stocky and over-weight, chronic productive cough, swollen ankles, distended neck veins, cor pulmonale. Pulmonary capillaries are not damaged.
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Blue Bloater more COPD: Chronic Bronchitis
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Pt responds to ?airway obstruction by decreasing ventilation and increasing Cardiac Output decreased ventilation-perfusion ratio. chronically low PaO2, high PaCO2, Normal PH : compensated respiratory acidosis respiratory drive depressed. polycythemia
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PFT findings Moderate to Severe Chronic Bronchitis ; Emphysema Obstructive Lung Pathophysiology
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PFTS all reduced
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Lung Volume ; Capacity Findings Moderate to Severe Chronic Bronchitis ; Emphysema
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VT normal or up IRV normal or down ERV normal or down RV up VC down IC normal or down FRC up TLC normal or up RV/TLC ratio normal or up
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Acute/mild-moderate stages copd
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Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) p.H up P.a.C.02 down H.C.O3 slightly down P.a.O2 down
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Severe/compensated copd
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Chronic Ventilatory Failure with Hypoxemia (Compensated Respiratory Acidosis) p.H normal P.a.C.O2 UP H.C.O3 significantly up P.a.O2 down
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CXR/CT findings Chronic Bronchitis
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Lungs may be clear if only large bronchi are affected Occasionally: Translucent, Depressed or flattened diaphragms Common: Cor pulmonale Bronchogram: Small spikelike protrusions
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CXR/CT findings Emphysema
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Common: Translucent Depressed or flattened diaphragms Long ; narrow heart Increased retrosternal air space (= hyperinflation) Occasionally: cor pulmonale
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COPD Therapeutic options
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Smoking Cessation Nicotine Replacement products Occupational exposure Indoor and outdoor air pollution Physical activity Pharmacologic therapy for stable COPD Bronchodilators Inhaled corticosteroids Oral corticosteroids
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COPD Other pharmacologic treatment options
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- Vaccines - Alpha-1 antitrypsin augmentation - Antibiotic - Mucolytic agents
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