Lung Tumors
Pt has a 37-pack-year history of cigarette smoking and quit smoking at age 55 years. She has COPD but reports no symptoms concerning for lung cancer. Medications are tiotropium inhaler and albuterol inhaler. Which of the following is the most appropriate lung cancer screening test?
Low-dose chest CT
63 y/o f, increasing shortness of breath for the past 2 months. She has ischemic cardiomyopathy and a history of breast cancer treated with surgery and irradiation 9 years ago. When she was between 20 and 30 years of age, she worked installing brakes on automobiles. She is on guideline-directed medical therapy for heart failure. On physical examination, vital signs normal. Cardiac examination reveals an S3, mitral regurgitation, hepatomegaly, possible ascites, and peripheral edema. There is dullness to percussion and absent breath sounds at the left base. CXR shows a moderate left-sided pleural effusion but is otherwise normal. A thoracentesis removes 600 mL of bloody fluid. The pleural fluid LDH level is 208 U/L, and the total protein level is 4.4 g/L. Simultaneous serum LDH level is 279 U/L, and total protein level is 7.6 g/dL (76 g/L). Pleural fluid cytology is pending.
Which of the following is the most likely diagnosis?
Malignant pleural effusion.
The presence of one or more of Light's criteria is very sensitive in the diagnosis of an exudative effusion.
The most common causes of exudative effusions are infection and malignancy.
A 40-year-old man is evaluated 10 days after an emergency department visit for a cough, chest tightness, wheezing, and shortness of breath. He was treated with nebulized albuterol and sent home with a 5-day course of prednisone and an albuterol metered-dose inhaler. Since completing the prednisone, he has felt well, with no further symptoms and no need to use the albuterol. He reports a similar episode requiring an emergency department visit 1 year ago. On physical examination, vital signs are normal. Oxygen saturation is 97% with the patient breathing ambient air. Cardiopulmonary examination is normal. Spirometry is normal.
Which of the following is the most appropriate management?
Methacholine challenge testing
For patients with asthma symptoms and a normal spirometry, a positive bronchial challenge test followed by relief of symptoms with standard asthma therapy confirms the diagnosis of asthma.
A negative bronchial challenge test excludes the diagnosis of asthma in most patients.
A 33-year-old woman is evaluated in the emergency department for respiratory failure. She has a 1-week history of ascending lower-extremity weakness and paresthesia. She has developed progressive dyspnea over the past 48 hours. On physical examination, the patient is alert and cooperative. Blood pressure is 150/90 mm Hg, pulse rate is 100/min, and respiration rate is 26/min. Oxygen saturation is 93% with the patient breathing ambient air. Cardiopulmonary examination is normal. Neurologic examination shows moderate weakness of her feet, legs, hands, and arms. Diffuse areflexia is present but sensation is normal. PH 7.34/PO2 49/ PO2 80 and A-a gradient normal. Chest radiograph is normal. There is a 22% decrement in forced vital capacity while supine compared with the upright position. Maximal inspiratory pressure and maximal expiratory pressure are both less than 50% of predicted.
Which of the following is the most likely cause of this patient's respiratory failure?
Neuromuscular weakness
A greater than 20% decrement in forced vital capacity from the sitting to the supine position and maximal inspiratory and/or expiratory force less than 50% of predicted support the diagnosis of neuromuscular weakness–associated respiratory failure.
A 77-year-old man is evaluated in the hospital for shortness of breath, dry cough, pleuritic chest pain, and unintentional 9-kg (20-lb) weight loss over the past 6 months. On physical examination, the patient appears chronically ill. Vital signs are normal. BMI is 19. There are decreased breath sounds at the right base. Chest radiograph demonstrates an apparent pleural effusion on the right side, but CT scan reveals a nodular pleura-based mass on the right side.
Which of the following is the most likely occupational exposure?
Asbestos
Malignant mesothelioma is associated with occupational asbestos exposure in up to 70% of cases; the radiographic manifestation is usually a unilateral pleural effusion or pleural thickening.
Mesothelioma can have a long latent period, extending into decades after asbestos exposure; therefore, it is essential to obtain a thorough employment history.
62 y/o f with compliants of fatigue, headaches, confusion, and weakness that have progressed over the past 6 weeks. She has an 11.3 kg (25 lb) unintentional weight loss over the past month. She has an 85-pack-year history of smoking and quit smoking 3 months ago. Laboratory evaluation reveals a serum sodium level of 123 mEq/L (123 mmol/L). CT scan of the chest shows a 4-cm mediastinal mass compressing the left upper lobe bronchus with associated bulky mediastinal lymphadenopathy.
Which of the following is the most likely diagnosis?
Small cell lung cancer
Small cell lung cancer typically presents as bulky symptomatic masses with mediastinal involvement, and is associated with paraneoplastic syndromes—most frequently, the syndrome of inappropriate antidiuretic hormone secretion.
An 81-year-old man is evaluated in the hospital for pneumonia. On PE, temperature is 38.0 °C (100.4 °F), blood pressure is 119/65 mm Hg, pulse rate is 110/min, and respiration rate is 24/min. Oxygen saturation is 88% with the patient breathing ambient air. There are coarse rhonchi and decreased breath sounds and dullness to percussion over the left lower half of the chest. CT scan of the chest shows left lower lobe consolidation and loculated left pleural effusion. A thoracentesis is performed.
Which of the following pleural fluid tests is most appropriate in directing therapy?
pH
In the setting of suspected infection, a pleural fluid pH level of less than 7.2 (or glucose <40 mg/dL [2.2 mmol/L] in the absence of pH data) is the best indicator of a complicated pleural effusion that requires drainage.
A 35-year-old woman is evaluated for a cough and wheezing occurring several times during the week, unrelated to exercise. She has a history of asthma that was previously well controlled with a budesonide inhaler. She is also taking albuterol five times weekly with good response. Her symptoms have woken her once in the past month. She reports no additional symptoms and no environmental triggers. She is a nonsmoker. Inhaler technique is good. On physical examination, vital signs are normal. Oxygen saturation is 96% with the patient breathing ambient air. Expiratory wheezing is noted.
Which of the following treatments should be started?
Add formoterol.
The preferred next step for patients with inadequately controlled mild persistent asthma on an inhaled glucocorticoid is combined therapy with a low-dose inhaled glucocorticoid and long-acting β2-agonist in a single inhaler.
Administration of a glucocorticoid and long-acting β2-agonist in a single inhaler is preferred because it improves adherence and may reduce cost compared with administration of each drug in a separate inhaler.
A 44-year-old woman is evaluated 1 day after right mastectomy for breast cancer. Desaturations throughout the night necessitated oxygen initiation. Medications are an oral opioid and subcutaneous enoxaparin. On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is 140/60 mm Hg, pulse rate is 90/min, and respiration rate is 28/min. Oxygen saturation is 93% breathing oxygen, 6 L/min by nasal cannula. The patient has shallow breathing with splinting. Lung examination reveals diminished breath sounds at the right lung base, dullness on percussion, egophony in the right lower lobe, and rhonchi. The remainder of the examination is normal. Chest radiograph shows plate-like opacities in the lung bases consistent with atelectasis.
Which of the following is the most appropriate management?
Pain management.
Postoperative atelectasis is associated with increased morbidity, including hypoxemia, retained secretions, and pneumonia, and may trigger the development of acute lung injury.
In patients with postoperative atelectasis caused by pain, improved pain management should lead to decreased pain and increased chest expansion and may result in resolution of the atelectasis.
A 66-year-old man is evaluated for a 7-month history of gradually progressive shortness of breath and dry cough. Medical history is otherwise unremarkable, and he takes no medications.
On physical examination, vital signs are normal. Oxygen saturation is 93% with the patient breathing ambient air. Auscultation reveals fine end-inspiratory bibasilar crackles. Clubbing is present. There are no rashes or edema. Cardiac examination is unremarkable. Chest radiograph reveals small lung volumes and bibasilar reticular infiltrates without lymphadenopathy. Spirometry reveals an FEV1/FVC ratio of 0.87, an FVC of 62% of predicted, and a DLCO of 48% of predicted.
Which of the following is the most appropriate diagnostic test to perform next?
High-resolution chest CT.
In a patient with a clinical picture suggestive of diffuse parenchymal lung disease, high-resolution CT is the most appropriate diagnostic test.
67 y/o f with a 6-month history of dull right chest pain, persistent cough, and dyspnea on exertion. During this time she lost 9.1 kg (20 lb) and had night sweats. She is a retired ship refitter. She has a 25-pack-year smoking history and quit smoking 20 years ago. There are diminished breath sounds and dullness to percussion over the right lower hemithorax on PE. CXR showed a large pleural effusion on the right side as well as pleural plaques. Chest CT shows basilar fibrosis and moderate to large right-sided pleural effusion with associated pleural thickening and nodularity. Thoracentesis yields 1200 mL of serosanguinous fluid; chemical analysis is compatible with an exudative effusion. Interferon-γ release assay is negative. Cytology findings are negative for malignancy.
Which of the following is the most appropriate diagnostic test to perform next?
Thoracoscopic pleural biopsy
For suspected mesothelioma, tissue biopsy is required to confirm the diagnosis; biopsy can be performed with medical thoracoscopy or video-assisted thoracoscopic surgery.
A 63-year-old man is evaluated for dyspnea. The patient has newly diagnosed stage IV lung adenocarcinoma with a right malignant pleural effusion. A thoracentesis removed 1200 mL of bloody fluid 5 days ago with relief of dyspnea. Follow-up chest radiograph documented incomplete expansion of the right lung, with air replacing the removed pleural fluid. He has returned to the emergency department today with increasing dyspnea. On physical examination, vital signs are normal. Respiration rate is 18/min. Oxygen saturation is 93% with the patient breathing ambient air. Lung examination is consistent with a large right pleural effusion. Repeat chest radiograph shows a large right-sided pleural effusion with loculations.
Which of the following is the most appropriate management?
Indwelling pleural catheter
Initial treatment of a malignant pleural effusion in patients with expandable lung includes either an indwelling pulmonary catheter or chemical pleurodesis with talc.
In patients with a malignant pleural effusion and a nonexpanding lung, an indwelling pulmonary catheter is the treatment of choice.
A 58-year-old man hospitalized 5 days ago for a COPD exacerbation is now evaluated for discharge. He required bilevel positive airway pressure for 1 day because of acute hypercapnic and hypoxic respiratory failure. He was treated with prednisone and levofloxacin. This is his second hospitalization for a COPD exacerbation in the past 6 months and the fourth course of prednisone for his COPD in that time. Before hospitalization, his baseline function was limiting dyspnea after walking a few minutes. Medications are inhaled fluticasone furoate-umeclidinium-vilanterol. On physical examination, oxygen saturation is 96% with the patient breathing ambient air. BMI is 29. He coughs frequently during examination, and faint expiratory wheezing is present in the upper lobes of the lungs. Cardiac examination is normal. PH 7.39, PCO2 43, PO2 75. Prehospitalization spirometry showed a postbronchodilator reduced FEV1/FVC ratio and an FEV1 of 42% of predicted. Inhaler technique is reviewed. He is enrolled in a supervised pulmonary rehabilitation program. Immunizations are up to date.
Which of the following is the most appropriate additional treatment?
Roflumilast
Roflumilast, a selective phosphodiesterase-4 inhibitor, can reduce symptoms and exacerbations in patients with severe COPD who have a chronic bronchitis phenotype or frequent exacerbations.
A 36-year-old woman is evaluated for respiratory failure requiring invasive mechanical ventilation following a motor vehicle accident. On physical examination, temperature is 38.0 °C (100.4 °F), blood pressure is 100/65 mm Hg, pulse rate is 100/min, and respiration rate is 26/min. Oxygen saturation is 90% with an FIO2 of 0.50 and positive end-expiratory pressure of 12 cm H2O. There are multiple contusions on her chest. Estimated central venous pressure is normal. Other than tachycardia, cardiac examination is normal. There are diffuse lung crackles. pH 7.3/ PCO2 50/ PO2 66. CXR showed bilateral opacities consistent with pulmonary edema. Hemoglobin has remained stable. Echocardiogram reveals a normal ejection fraction and valvular function. ECG shows only sinus tachycardia.
Which of the following is the most likely diagnosis?
Acute respiratory distress syndrome
The diagnosis of acute respiratory distress syndrome (ARDS) is based on the onset of respiratory failure within 1 week of known ARDS insult; bilateral opacities on chest imaging consistent with pulmonary edema; respiratory failure not related to cardiac failure or volume overload; and arterial Po2/FIO2 ratio less than 300 on at least 5 cm H2O positive end-expiratory pressure.
A 37-year-old woman is evaluated in the emergency department for headache, dyspnea, and cough. Two days ago she traveled from her home at 300 meters (984 feet) above sea level to a mountain ski resort where the slopes are as high as 3914 meters (12,841 feet). She developed the headache yesterday, and today it is worse and she has shortness of breath and a cough. On physical examination, temperature is 38.0 °C (100.4 °F), blood pressure is 124/72 mm Hg, pulse rate is 115/min, and respiration rate is 28/min. Oxygen saturation is 82% with the patient breathing ambient air. Inspiratory crackles are present bilaterally. Chest radiograph demonstrates patchy alveolar infiltrates. High-flow supplemental oxygen by nasal cannula is initiated.
Which of the following is the most appropriate additional treatment?
Descent to a lower altitude.
Treatment of high-altitude pulmonary edema focuses on promptly reducing the pulmonary artery pressure; the patient should be given supplemental oxygen and advised to descend to a lower altitude as soon as possible and to limit physical exertion and cold exposure.
Pt had a incidental finding of a 4-mm solid lung nodule in the right lower lobe on abdominal CT scan. The CT scan showed no other nodules, no lymphadenopathy, and unremarkable lung parenchyma. There are no old scans for comparison. She has no personal or family history of lung cancer. She is asymptomatic, a lifelong nonsmoker, and has no significant exposure history. Which of the following is the most appropriate management?
No further work up
Fleischner Society Recommendations for Single Pulmonary Nodule Follow-Up
A 45-year-old woman is evaluated in the ICU for community-acquired pneumonia and septic shock. Appropriate resuscitation efforts are under way. On physical examination, temperature is 39.2 °C (102.6 °F), blood pressure is 92/50 mm Hg, pulse rate is 120/min, and respiration rate is 25/min. Oxygen saturation is 85% on bilevel positive airway pressure, and FIO2 is 0.60. Auscultation of the lungs reveals decreased breath sounds over the left lung base. Chest radiograph reveals scattered infiltrates in the lower lungs with dense consolidation in the left lower lobe and a small left pleural effusion.
Which of the following is the most appropriate diagnostic test for evaluation of the pleural effusion?
Bedside thoracic ultrasonography.
Thoracic ultrasonography allows for the easy identification of a free-flowing or loculated pleural effusion and can differentiate between solid masses and loculated effusions.
Thoracic point-of-care ultrasonography is a helpful addition particularly in patients who are semirecumbent, such as those who are critically ill, and does not necessitate moving the patient from the ICU.
A 62-year-old man is evaluated in follow-up examination for COPD. Despite smoking cessation, adherence to his medical regimen, good inhaler technique, and participation in pulmonary rehabilitation, he continues to experience breathlessness with mild exertion and has diminished quality of life. He has a minimal dry cough, and he has never required treatment for an acute exacerbation of COPD. Medications are fluticasone-umeclidinium-vilanterol and albuterol inhalers as needed. Immunizations are up to date. On physical examination, vital signs are normal. Oxygen saturation is 93% with the patient breathing ambient air. There are diminished breath sounds. A 6-minute walk test shows a minimum oxygen saturation of 90% with the patient breathing ambient air. Spirometry shows an FEV1 of 35% of predicted and a DLCO of 42% of predicted. Chest imaging shows upper-lobe-predominant emphysema.
Which of the following is the most appropriate treatment?
Lung volume reduction surgery.
Lung volume reduction surgery improves quality of life, exercise tolerance, pulmonary function, and survival in selected patients with emphysema.
Ideal patients for lung volume reduction therapy are those with upper-lobe-predominant emphysema, FEV1 and DLCO of 20% of predicted or higher, and low exercise tolerance after completion of pulmonary rehabilitation.
A 29-year-old woman was hospitalized 24 hours ago with hypoxemic respiratory failure due to influenza pneumonia. She was intubated and placed on mechanical ventilation. Treatment includes lactated Ringer solution, intravenous peramivir, propofol, fentanyl, and norepinephrine. On physical examination, temperature is 38.1 °C (100.6 °F), blood pressure is 109/59 mm Hg, pulse rate is 90/min, and respiration rate is 24/min. The arterial PO2 is 60 mm Hg on FIO2 of 0.65, and positive end-expiratory pressure is 10 cm H2O. Tidal volume is 6 mL/kg ideal body weight, and plateau pressure is 27 cm H2O. The patient is sedated but wakes to touch and is calm. Pulmonary rhonchi are present bilaterally. Chest radiograph shows bilateral opacities. Echocardiogram reveals normal cardiac function and chamber size.
Which of the following is the most appropriate intervention to improve oxygenation?
Prone positioning.
Prone positioning for at least 12 hours daily should be considered for patients with acute respiratory syndrome and arterial PO2/FIO2 <150 mm Hg, FIO2 ≥0.60 on positive end-expiratory pressure >5 cm H2O, who have been intubated for less than 48 hours.
A 67-year-old man is evaluated before airline travel. He is planning a trip to Hawaii next month. He has COPD and becomes dyspneic when walking short distances on level ground. Results of his last pulmonary function test indicated an FEV1 of 40% of predicted. He has not yet required oxygen supplementation. Medications are tiotropium, salmeterol, and fluticasone and albuterol inhalers. On physical examination, respiration rate is 16/min. Auscultation of the lungs reveals a prolonged expiratory phase with no wheezes.
Which of the following is the most appropriate next step?
Resting pulse oximetry.
Resting pulse oximetry is helpful in screening patients for in-flight hypoxemia.
Patients not using baseline oxygen and with a resting SpO2 less than 92% should be prescribed supplemental oxygen during air travel without additional testing.
63 y/o f, follow-up visit for a solitary pulmonary nodule. 6 months ago CTA was performed to evaluate a possible pulmonary embolism. The CTA was negative but demonstrated an 8-mm ground-glass (subsolid) nodule in the left upper lobe. The patient has a 15-pack-year history of cigarette smoking but stopped 6 months ago. Medical history is otherwise unremarkable, and she takes no medications. A repeat chest CT scan 6 months after the initial scan shows no change in the size or characteristics of the nodule.
Which of the following is the most appropriate management?
Chest CT every 2 years for 5 years.
A subsolid nodule is a focal rounded opacity that is either pure ground glass in appearance or has a solid component but is still more than 50% ground glass. These nodules often represent premalignant disease, such as adenocarcinoma in situ, and can be very slow growing.
A 25-year-old man is evaluated in the emergency department for worsening shortness of breath and right-side pleuritic chest pain, which developed 1 hour ago. He has an 8-pack-year history of smoking cigarettes. His medical history is otherwise unremarkable, including the absence of lung disease. He is a professional scuba diver. On physical examination, blood pressure is 150/70 mm Hg, pulse rate is 105/min, and respiration rate is 30/min. Oxygen saturation is 92% with the patient breathing ambient air. There are decreased breath sounds, reduced expansion, and hyperresonance to percussion on the right side. Chest radiograph reveals a large right pneumothorax and no signs of tension. Smoking cessation counseling is planned at the time of discharge.
Which of the following is the most appropriate additional pneumothorax management?
Catheter thoracostomy followed by pleurodesis.
Recurrence prevention is recommended after the second episode of pneumothorax on the ipsilateral side in primary spontaneous pneumothorax and after the first occurrence in secondary spontaneous pneumothorax. Recurrence prevention is indicated following a first episode of pneumothorax in spontaneous primary pneumothorax in a patient with a high-risk occupation.
A 54-year-old man is evaluated for a 2-year history of chronic productive cough. He has intermittent wheezing, shortness of breath with exertion, and nasal congestion. On physical examination, vital signs are normal. Bibasilar crackles are present. Cardiac examination is normal. CT scan of the chest shows cylindrical bronchiectasis of bilateral lower lobes.
Which of the following is the most appropriate diagnostic test to perform next?
Immunoglobulin measurement.
Bronchiectasis should be considered in the differential diagnosis of any patient with a chronic cough, especially if the patient has a history of frequent respiratory infections or if the cough is productive.
Initial evaluation of patients with bronchiectasis should include testing for common causes, including abnormal immune function (by measuring immunoglobulin levels) and connective tissue disease.
A 35-year-old man is evaluated in the emergency department 4 hours after being rescued from his burning home by firefighters. He initially refused transportation to the hospital but now desires an evaluation. He reports tracheal irritation with breathing, sore throat, and a change in his voice.
On physical examination, he is alert and in moderate pain. Temperature is 37.5 °C (99.5 °F), blood pressure is 144/90 mm Hg, pulse rate is 100/min, and respiration rate is 26/min. Oxygen saturation is 96% with the patient breathing ambient air. He has dysphonia. There is no soot in the nares or the oral pharynx or burns on his face, neck, or thorax. Nonobstructing edema of the oropharynx is noted. Cardiac examination reveals a regular rhythm. Chest is clear to auscultation; there is no stridor. PH 7.45/PCO2 35/PO2 95. A chest radiograph shows no infiltrates.
Which of the following is the most appropriate management?
Bronchoscopy
Following smoke inhalational injury, immediate protection of the airway is indicated for patients with extensive facial or neck burns, decreased level of consciousness, or airway obstruction.
Following smoke inhalation, one third of patients develop airway edema or mucosal sloughing from epithelial necrosis; airway inspection, bronchoscopy, and chest physiotherapy are frequently necessary to facilitate continued airway clearance.
A 42-year-old man is evaluated for fatigue, dyspnea, and lightheadedness. He was diagnosed with a provoked pulmonary embolism 5 months ago and has been taking apixaban since then. Initially, his dyspnea and tachycardia improved, but over the past 2 months, he has had progressive exertional dyspnea. On physical examination, vital signs are normal. BMI is 28. Cardiopulmonary examination is normal. An echocardiogram reveals right atrial enlargement and right ventricular hypertrophy and an elevated mean pulmonary artery pressure.
Which of the following is the most appropriate diagnostic test?
Ventilation/perfusion scan.
A ventilation/perfusion scan is recommended for all patients with pulmonary hypertension to rule out chronic thromboembolic pulmonary hypertension.
For patients with suspected chronic thromboembolic pulmonary hypertension and an abnormal ventilation/perfusion scan, right heart catheterization and pulmonary angiography will confirm pulmonary hypertension, exclude competing diagnoses, and provide vital information related to potential therapy.