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Pulmonary edema facts

Pulmonary edema is typically caused by

Alveoli normally have a thin wall that allows for

this air exchange, and fluids are usually kept out
of the alveoli unless these walls lose their
integrity.

filling of alveoli in the lungs by fluid leaking

out of the blood.

Pulmonary edema may be caused by a

Picture of the alveoli and lung

number of cardiac or non-cardiac

conditions.

Breathing difficulty is the main

Treatment of the underlying cause of

pulmonary edema is an essential step in the
management of pulmonary edema.

What is pulmonary edema?

Edema, in general, means swelling. This typically
occurs when fluid from inside blood vessels
seeps outside the blood vessel into the
surrounding tissues, causing swelling. This can
happen either because of too much pressure in
the blood vessels or not enough proteins in the
bloodstream to hold on to the fluid in the plasma
(the part of the blood that does not contain any
blood cells).
Pulmonary edema is the term used when edema
happens in the lungs. The immediate area
outside of the small blood vessels in the lungs is
occupied by very tiny air sacs called the alveoli.
This is where oxygen from the air is picked up by
the blood passing by, and carbon dioxide in the
blood is passed into the alveoli to be exhaled out.

As mentioned earlier, pulmonary edema can be

broadly divided into cardiogenic and noncardiogenic causes. Some of the common
causes are listed below.

Cardiogenic causes of pulmonary

edema
Cardiogenic causes of pulmonary edema results
from high pressure in the blood vessels of the
lung due to poor heart function. Congestive
heart failure due to poor heart pumping function
(arising from various causes such as
arrhythmias and diseases or weakness of the
heart muscle), heart attacks, or abnormal heart
valves can lead to accumulation of more than
the usual amount of blood in the blood vessels
of the lungs. This can, in turn, cause the fluid
from the blood vessels to be pushed out to the
alveoli as the pressure builds up.

manifestation of pulmonary edema.

What causes pulmonary edema?

Pulmonary edema occurs when the alveoli fill up

with excess fluid seeped out of the blood vessels
in the lung instead of air. This can cause
problems with the exchange of gas (oxygen and
carbon dioxide), resulting in breathing difficulty
and poor oxygenation of blood. Sometimes, this
can be referred to as "water in the lungs" when
describing the condition to patients.
Pulmonary edema can be caused by many
different factors. It can be related to heart failure,
called cardiogenic pulmonary edema, or related
to other causes, referred to as non-cardiogenic
pulmonary edema.

Non-cardiogenic pulmonary edema

Non-cardiogenic pulmonary edema can be
commonly caused by the following:

Acute respiratory distress syndrome

(ARDS), a potentially serious condition
caused by severe infections, trauma, lung
injury, inhalation of toxins, lung infections,
cocaine smoking, or radiation to the lungs.
In ARDS, the integrity of the alveoli become
compromised as a result of underlying
inflammatory response, and this leads to
leaky alveoli that can fill up with fluid from
the blood vessels.

Kidney failure and inability to excrete fluid

from the body can cause fluid build-up in the
blood vessels, resulting in pulmonary
edema. In people with advanced kidney
disease, dialysis may be necessary to
remove the excess body fluid.

High altitude pulmonary edema, which

can happen due to rapid ascent to high
altitudes of more than 10,000 feet.

Brain trauma, bleeding in the brain

(intracranial hemorrhage), severe seizures,
or brain surgery can sometimes result in
fluid accumulation in the lungs, causing
neurogenic pulmonary edema.

A rapidly expanding lung can sometimes

cause re-expansion pulmonary edema. This
may happen in cases when the lung
collapses (pneumothorax) or a large amount
of fluid around the lung (pleural effusion) is
removed, resulting in rapid expansion of the
lung. This can result in pulmonary edema on
the affected side only (unilateral pulmonary
edema).

Rarely, an overdose on heroin or

methadone can lead to pulmonary edema.

Aspirin overdose or chronic high dose

use of aspirin can lead to aspirin
intoxication, especially in the elderly, which
may cause pulmonary edema.

Other more rare causes of noncardiogenic pulmonary edema may

include pulmonary embolism (blood clot

which has traveled to the lungs),

transfusion-related acute lung injury
(TRALI), some viral infections, or eclampsia
in pregnant women.

What are the risk factors for

pulmonary edema?
The risk factors for pulmonary edema are
essentially the underlying causes of the
condition. There isn't any specific risk factor for
pulmonary edema other than risk factors for the
causative conditions.

What are the symptoms of

pulmonary edema?
The most common symptom of pulmonary
edema is shortness of breath or breathlessness.
This may be of gradual onset if the process
slowly develops, or it can have a sudden onset in
the case of acute pulmonary edema.
Other common symptoms may include
easyfatigue, more rapidly developing shortness
of breath than normal with usual activity
(dyspnea on exertion), rapid breathing
(tachypnea), dizziness, or weakness.
Low blood oxygen level (hypoxia) may be
detected in patients with pulmonary edema.
Furthermore, upon examination of the lungs with
a stethoscope, the doctor may listen for
abnormal lung sounds, such as rales or crackles
(discontinuous short bubbling sounds

corresponding to the splashing of the fluid in the

alveoli during breathing).

When should I seek medical care for

pulmonary edema?
Medical attention should be sought for anyone
who is diagnosed with pulmonary edema of any
cause. Many causes of pulmonary edema
require hospitalization, especially if they are
caused acutely. In some cases of chronic (long
term) pulmonary edema, for example, with
congestive heart failure, routine follow-up visits
with the treating doctor may be recommended.
Most cases of pulmonary edema are treated by
internal medicine doctors (internists), heart
specialists (cardiologists), or lung doctors
(pulmonologists).

How is pulmonary edema

diagnosed?
Pulmonary edema is typically diagnosed by
a chest X-ray. A normal chest radiograph (X-ray)
consists of a central white area pertaining to the
heart and its main blood vessels plus the bones
of the vertebral column, with the lung fields
showing as darker fields on either side, enclosed
by the bony structures of the chest wall.
A typical chest X-ray with pulmonary edema may
show a more white appearance over both lung
fields than usual. More severe cases of
pulmonary edema can demonstrate significant
opacification (whitening) over the lungs with

minimal visualization of the normal lung fields.

This whitening represents filling of the alveoli as
a result of pulmonary edema, but it may give
minimal information about the possible
underlying cause.
To identify the cause of pulmonary edema, a
thorough assessment of the patient's clinical
picture is essential. A careful medical history and
physical examination often provide invaluable
information regarding the cause.
Other diagnostics tools used in assessing the
underlying cause of pulmonary edema include
the measurement of plasma B-type natriuretic
peptide (BNP) or N-terminal pro-BNP. This is a
protein marker (a hormone) that will rise in the
blood due to the stretch of the chambers of the
heart. Elevation of the BNP nanogram (one
billionth of a gram) per liter greater than a few
hundred (300 or more) is highly suggestive of
cardiac pulmonary edema. On the other hand,
values less than 100 essentially rule out heart
failure as the cause.
More invasive methods are occasionally
necessary to distinguish between cardiac and
noncardiac pulmonary edema in more
complicated and critical situations. A pulmonary
artery catheter (Swan-Ganz) is a thin, long tube
(catheter) inserted into the large veins of the
chest or the neck and advanced through the
right-sided chambers of the heart and lodged into
the pulmonary capillaries (small branches of the
blood vessels of the lungs). This device has the
capability of directly measuring the pressure in

the pulmonary vessels, called the pulmonary

artery wedge pressure.

A wedge pressure of 18 mmHg or higher

is consistent withcardiogenic pulmonary
edema,
whereas a wedge pressure of less than

18 mmHg usually favors anon-cardiogenic

cause of pulmonary edema.
A Swan-Ganz catheter placement and data
interpretation is done only in the intensive care
unit (ICU) setting.

What is the treatment for pulmonary

edema?
The treatment of pulmonary edema largely
depends on its cause and severity.
Most cases of cardiac pulmonary edema are
treated by using diuretics (water pills) along with
other medications for heart failure. In some
situations, appropriate treatment can be
achieved as an outpatient by taking oral
medications. If the pulmonary edema is more
severe or it is not responsive to oral medications,
then hospitalization and the use of intravenous
diuretic medications may be necessary.
The treatment for noncardiac causes of
pulmonary edema varies depending on the
cause. For example, severe infection (sepsis) is
treated with antibiotics and other supportive
measures, or kidney failure needs to be properly
evaluated and managed.

Oxygen supplementation is necessary if the

measured oxygen level in the blood is too low. In
serious conditions, such as ARDS, placing a
patient on a mechanical breathing machine is
necessary to support their breathing while other
measures are taken to treat pulmonary edema
and its underlying cause.

What are the complications of

pulmonary edema?
Most complications of pulmonary edema may
arise from the complications associated with the
underlying cause. More specifically, pulmonary
edema can cause severely compromised
oxygenation of the blood by the lungs. This poor
oxygenation (hypoxia) can potentially lead to
diminished oxygen delivery to different body
organs, such as the brain.

How can pulmonary edema be

prevented?
In terms of preventive measures, depending on
the cause of pulmonary edema, some steps can
be taken. Long-term prevention of heart disease
and heart attacks, slow elevation to high
altitudes, or avoidance of drug overdose can be
considered preventive.
On the other hand, some causes may not
completely avoidable or preventable, such as
ARDS due to an overwhelming infection or a
trauma.

www.aaaai.org
Asthma Overview
Asthma is a chronic disease involving the airways in the
lungs. These airways, or bronchial tubes, allow air to
come in and out of the lungs.
If you have asthma your airways are always inflamed.
They become even more swollen and the muscles
around the airways can tighten when something triggers
your symptoms. This makes it difficult for air to move in
and out of the lungs, causing symptoms such as
coughing, wheezing, shortness of breath and/or chest
tightness.
For many asthma sufferers, timing of these symptoms is
closely related to physical activity. And, some otherwise
healthy people can develop asthma symptoms only
when exercising. This is called exercise-induced
bronchoconstriction (EIB), or exercise-induced asthma
(EIA). Staying active is an important way to stay
healthy, so asthma shouldn't keep you on the sidelines.
Your physician can develop a management plan to keep
your symptoms under control before, during and after
physicial activity.
People with a family history of allergies or asthma are
more prone to developing asthma. Many people with
asthma also have allergies. This is called allergic
asthma.
Occupational asthma is caused by inhaling fumes,
gases, dust or other potentially harmful substances
while on the job.
Childhood asthma impacts millions of children and their
families. In fact, the majority of children who develop
asthma do so before the age of five.
There is no cure for asthma, but once it is properly
diagnosed and a treatment plan is in place you will be
able to manage your condition, and your quality of life
will improve.
An allergist / immunologist is the best qualified
physician in diagnosing and treating asthma. With the
help of your allergist, you can take control of your
condition and participate in normal activities.

Asthma Symptoms & Diagnosis

Asthma Symptoms
According to the leading experts in asthma, the
symptoms of asthma and best treatment for you or your
child may be quite different than for someone else with
asthma.

The most common symptom is wheezing. This is a

scratchy or whistling sound when you breathe. Other
symptoms include:
Shortness of breath
Chest tightness or pain
Chronic coughing
Trouble sleeping due to coughing or wheezing
Asthma symptoms, also called asthma flare-ups or
asthma attacks, are often caused by allergies and
exposure to allergens such as pet dander, dust mites,
pollen or mold. Non-allergic triggers include smoke,
pollution or cold air or changes in weather.
Asthma symptoms may be worse during exercise, when
you have a cold or during times of high stress.
Children with asthma may show the same symptoms as
adults with asthma: coughing, wheezing and shortness
of breath. In some children chronic cough may be the
only symptom.
If your child has one or more of these common
symptoms, make an appointment with an allergist /
immunologist:
Coughing that is constant or that is made worse by
viral infections, happens while your child is asleep, or is
triggered by exercise and cold air
Wheezing or whistling sound when your child
exhales
Shortness of breath or rapid breathing, which may
be associated with exercise
Chest tightness (a young child may say that his
chest hurts or feels funny)
Fatigue (your child may slow down or stop playing)
Problems feeding or grunting during feeding
(infants)
Avoiding sports or social activities
Problems sleeping due to coughing or difficulty
breathing
Patterns in asthma symptoms are important and can
help your doctor make a diagnosis. Pay attention to
when symptoms occur:
At night or early morning
During or after exercise
During certain seasons
After laughing or crying
When exposed to common asthma triggers
Asthma Diagnosis
An allergist diagnoses asthma by taking a thorough
medical history and performing breathing tests to
measure how well your lungs work.
One of these tests is called spirometry. You will take a
deep breath and blow into a sensor to measure the
amount of air your lungs can hold and the speed of the
air you inhale or exhale. This test diagnoses asthma
severity and measures how well treatment is working.
Many people with asthma also have allergies, so your
doctor may perform allergy testing. Treating the
underlying allergic triggers for your asthma will help you
avoid asthma symptoms.

Asthma Treatment & Management

There is no cure for asthma, but symptoms can
be controlled with effective asthma treatment and
management. This involves taking your
medications as directed and learning to avoid
triggers that cause your asthma symptoms. Your
allergist will prescribe the best medications for
your condition and provide you with specific
instructions for using them.
Controller medications are taken daily and include
inhaled corticosteroids (fluticasone (Flovent
Diskus, Flovent HFA), budesonide (Pulmicort
Flexhaler), mometasone (Asmanex), ciclesonide
(Alvesco), flunisolide (Aerobid), beclomethasone
(Qvar) and others).
Combination inhalers contain an inhaled
corticosteroid plus a long-acting beta-agonist
(LABA). LABAs are symptom-controllers that are
helpful in opening your airways. However, in
certain people they may carry some risks.
LABAs should never be prescribed as the sole
therapy for asthma. Current recommendations are
for them to be used only along with inhaled
corticosteroids. Combination medications include
fluticasone and salmeterol (Advair Diskus, Advair
HFA), budesonide and formoterol (Symbicort),
and mometasone and formoterol (Dulera).
Leukotriene modifiers are oral medications that
include montelukast (Singulair), zafirlukast
(Accolate) and zileuton (Zyflo, Zyflo CR).
Quick-relief or rescue medications are used to
quickly relax and open the airways and relieve
symptoms during an asthma flare-up, or are
taken before exercising if prescribed. These
include: short-acting beta-agonists. These inhaled
bronchodilator (brong-koh-DIE-lay-tur)
medications include albuterol (ProAir HFA,
Ventolin HFA, others), levalbuterol (Xopenex HFA)
and pirbuterol (Maxair Autohaler). Quick-relief
medications do not take the place of controller
medications. If you rely on rescue relief more
than twice a week, it is time to see your allergist.
Oral and intravenous corticosteroids may be
required for acute asthma flare-ups or for severe
symptoms. Examples include prednisone and
methylprednisolone. They can cause serious side
effects if used on a long term basis.
Visit the AAAAI Drug Guide for a complete list of
medications commonly used to treat asthma.

If you are pregnant, you may be hesitant about

taking medications, including those for asthma.
This can be a mistake for your health and that of
your baby-to-be. Continue taking your prescribed
asthma medications and make an appointment
with your allergist to discuss treatments that will
help you have a healthy pregnancy. Additionally,
you may want to enroll in a study designed to
monitor medications and pregnancy.
People with asthma are at risk of developing
complications from respiratory infections such as
influenza and pneumonia. That is why it is
important for asthma sufferers, especially adults,
to get vaccinated annually.
With proper treatment and an asthma
management plan, you can minimize your
symptoms and enjoy a better quality of life.

toward developing type 1

hypersensitivity reactions.[8]

4.3 Classification

Treatment of acute symptoms is usually with an

inhaled short-acting beta-2 agonist (such

as salbutamol) and oral corticosteroids.[9]In very

severe cases, intravenous
corticosteroids, magnesium sulfate, and

hospitalization may be required.[10] Symptoms can

be prevented by avoiding triggers, such
as allergens[11] and irritants, and by the use of
inhaled corticosteroids.[12] Long-acting beta
agonists (LABA) or antileukotriene agents may
be used in addition to inhaled corticosteroids if
asthma symptoms remain uncontrolled.[13][14] The
occurrence of asthma has increased significantly
since the 1970s. In 2011, 235300 million people
globally were diagnosed with asthma,[15][16] and it
caused 250,000 deaths.[16]

4.4 Differential diagnosis

Contents

WIKIPEDIA

Asthma

[hide]

1 Signs and symptoms

o

From Wikipedia, the free encyclopedia

1.1 Associated conditions

For other uses, see Asthma (disambiguation).

Asthma (from the Greek , sthma,
"panting") is a
common chronic inflammatory disease of
the airways characterized by variable and
recurring symptoms, reversible airflow
obstruction and bronchospasm.[2] Common
symptoms include wheezing,coughing, chest
tightness, and shortness of breath.[3]

Asthma is thought to be caused by a combination

of genetic and environmental factors.
[4]
Its diagnosis is usually based on the pattern of
symptoms, response to therapy over time
and spirometry.[5] It is clinically classified

according to the frequency of symptoms, forced

expiratory volume in one second (FEV1),
and peak expiratory flow rate.[6] Asthma may also
be classified as atopic(extrinsic) or non-atopic
(intrinsic)[7] where atopy refers to a predisposition

2 Causes
o

2.1 Environmental

2.2 Genetic

2.3 Medical conditions

2.4 Exacerbation
3 Pathophysiology
4 Diagnosis

4.1 Spirometry

4.2 Others

5 Prevention
6 Management
o

6.1 Lifestyle modification

6.2 Medications

6.3 Others

6.4 Alternative medicine

7 Prognosis

8 Epidemiology

9 Economics

10 History

11 References

12 External links

Signs and symptoms

Asthma is characterized by recurrent episodes
of wheezing, shortness of breath, chest
tightness, and coughing.[17] Sputummay be
produced from the lung by coughing but is often
hard to bring up.[18] During recovery from an
attack, it may appearpus-like due to high levels
of white blood cells called eosinophils.
[19]
Symptoms are usually worse at night and in
the early morning or in response to exercise or
cold air.[20] Some people with asthma rarely
experience symptoms, usually in response to
triggers, whereas others may have marked and
persistent symptoms.[21]

Associated conditions
A number of other health conditions occur more
frequently in those with asthma, including gastroesophageal reflux
disease (GERD), rhinosinusitis, and obstructive
sleep apnea.[22] Psychological disorders are also
more common,[23] with anxiety disorders occurring
in between 1652% and mood disorders in 14
41%.[24] However, it is not known if asthma
causes psychological problems or if
psychological problems lead to asthma.[25] Those
with asthma, especially if it is poorly controlled,
are at high risk for radiocontrastreactions.[26]

Causes
Asthma is caused by a combination of complex
and incompletely understood environmental and
genetic interactions.[4][27] These factors influence
both its severity and its responsiveness to
treatment.[28] It is believed that the recent
increased rates of asthma are due to
changing epigenetics (heritable factors other
than those related to the DNA sequence) and a
changing living environment.[29]

Environmental
See also: Asthma-related microbes
Many environmental factors have been
associated with asthma's development and
exacerbation including allergens, air pollution,
and other environmental chemicals.[30] Smoking
during pregnancy and after delivery is associated
with a greater risk of asthma-like symptoms.
[31]
Low air quality from factors such as traffic
pollution or high ozone levels,[32] has been
associated with both asthma development and
increased asthma severity.[33] Exposure to
indoor volatile organic compounds may be a
trigger for asthma; formaldehydeexposure, for
example, has a positive association.
[34]
Also, phthalates in certain types of PVC are
associated with asthma in children and adults.[35]
[36]
There is an association
between acetaminophen (paracetamol) use and

asthma.[37] The majority of the evidence does not,

however, support a causal role.[38] A 2014 review
found that the association disappeared when
respiratory infections were taken into account.
[39]
Use by a mother during pregnancy is also
associated with an increased risk.[40]
Asthma is associated with exposure to indoor
allergens.[41] Common indoor allergens
include dust mites, cockroaches, animal dander,
and mold.[42][43] Efforts to decrease dust mites
have been found to be ineffective.[44] Certain viral
respiratory infections, such as respiratory
syncytial virus and rhinovirus,[45] may increase the
risk of developing asthma when acquired as
young children.[46] Certain other infections,
however, may decrease the risk.[45]
Hygiene hypothesis
The hygiene hypothesis attempts to explain the
increased rates of asthma worldwide as a direct
and unintended result of reduced exposure,
during childhood, to non-pathogenic bacteria and
viruses.[47][48] It has been proposed that the
reduced exposure to bacteria and viruses is due,
in part, to increased cleanliness and decreased
family size in modern societies.[49] Exposure to
bacterial endotoxin in early childhood may
prevent the development of asthma, but
exposure at an older age may provoke
bronchoconstriction.[50]Evidence supporting the
hygiene hypothesis includes lower rates of
asthma on farms and in households with pets.[49]
Use of antibiotics in early life has been linked to
the development of asthma.[51] Also, delivery
via caesarean section is associated with an
increased risk (estimated at 2080%) of asthma
this increased risk is attributed to the lack of
healthy bacterial colonization that the newborn
would have acquired from passage through the
birth canal.[52][53] There is a link between asthma
and the degree of affluence.[54]

Genetic
CD14-endotoxin interaction based on CD14 SNP

C-159T[55]

Endotoxin levels

CC genotype

TT genotype

High exposure

Low risk

High risk

Low exposure

High risk

Low risk

Family history is a risk factor for asthma, with

many different genes being implicated.[56] If one
identical twin is affected, the probability of the
other having the disease is approximately 25%.
[56]
By the end of 2005, 25 genes had been
associated with asthma in six or more separate
populations, including GSTM1, IL10, CTLA4, SPINK5, LTC4S, IL4R and ADAM33, among
others.[57] Many of these genes are related to the
immune system or modulating inflammation.
Even among this list of genes supported by
highly replicated studies, results have not been
consistent among all populations tested.[57] In
2006 over 100 genes were associated with
asthma in one genetic association study alone;
[57]
more continue to be found.[58]
Some genetic variants may only cause asthma
when they are combined with specific
environmental exposures.[4] An example is a
specific single nucleotide polymorphism in
the CD14 region and exposure to endotoxin (a
bacterial product). Endotoxin exposure can come
from several environmental sources including
tobacco smoke, dogs, and farms. Risk for
asthma, then, is determined by both a person's
genetics and the level of endotoxin exposure.[55]

Medical conditions
A triad of atopic eczema, allergic rhinitis and
asthma is called atopy.[59] The strongest risk
factor for developing asthma is a history of atopic

disease;[46] with asthma occurring at a much

greater rate in those who have
either eczema or hay fever.[60] Asthma has been
associated with ChurgStrauss syndrome, an
autoimmune disease and vasculitis. Individuals
with certain types of urticaria may also
experience symptoms of asthma.[59]
There is a correlation between obesity and the
risk of asthma with both having increased in
recent years.[61][62] Several factors may be at play
including decreased respiratory function due to a
buildup of fat and the fact that adipose tissue
leads to a pro-inflammatory state.[63]
Beta blocker medications such
as propranolol can trigger asthma in those who
are susceptible.[64] Cardioselective beta-blockers,
however, appear safe in those with mild or
moderate disease.[65][66] Other medications that
can cause problems in asthmatics
are angiotensin-converting enzyme
inhibitors, aspirin, and NSAIDs.[67]

There may also be involvement of other

components of the immune
system including: cytokines, chemokines, histami
ne, and leukotrienesamong others.[45]

Diagnosis
Figure A shows the location of the lungs and airways
in the body. Figure B shows a cross-section of a
normal airway. Figure C shows a cross-section of an
airway during asthma symptoms.

Exacerbation
Some individuals will have stable asthma for
weeks or months and then suddenly develop an
episode of acute asthma. Different individuals
react to various factors in different ways.[68] Most
individuals can develop severe exacerbation
from a number of triggering agents.[68]
Home factors that can lead to exacerbation of
asthma include dust, animal dander (especially
cat and dog hair), cockroach allergens and mold.
[68]
Perfumes are a common cause of acute
attacks in women and children. Both viral and
bacterial infections of the upper respiratory tract
can worsen the disease.
[68]
Psychological stress may worsen symptoms
it is thought that stress alters the immune system
and thus increases the airway inflammatory
response to allergens and irritants.[33][69]

Pathophysiology
Main article: Pathophysiology of asthma

Obstruction of the lumen of abronchiole by mucoid

exudate, goblet cell metaplasia, and
epithelialbasement membrane thickening in a person
with asthma.

Asthma is the result of chronic inflammation of

the airways which subsequently results in
increased contractability of the
surroundingsmooth muscles. This among other
factors leads to bouts of narrowing of the airway
and the classic symptoms of wheezing. The
narrowing is typically reversible with or without
treatment. Occasionally the airways themselves
change.[17] Typical changes in the airways include
an increase in eosinophils and thickening of
the lamina reticularis. Chronically the airways'
smooth muscle may increase in size along with
an increase in the numbers of mucous glands.
Other cell types involved include: T
lymphocytes, macrophages, and neutrophils.

While asthma is a well recognized condition,

there is not one universal agreed upon definition.
[45]
It is defined by the Global Initiative for
Asthma as "a chronic inflammatory disorder of
the airways in which many cells and cellular
elements play a role. The chronic inflammation is
associated with airway hyper-responsiveness
that leads to recurrent episodes of wheezing,
breathlessness, chest tightness and coughing
particularly at night or in the early morning.
These episodes are usually associated with
widespread but variable airflow obstruction within
the lung that is often reversible either
spontaneously or with treatment".[17]
There is currently no precise test with the
diagnosis typically based on the pattern of
symptoms and response to therapy over time.[5]
[45]
A diagnosis of asthma should be suspected if
there is a history of: recurrent wheezing,
coughing or difficulty breathing and these
symptoms occur or worsen due to exercise, viral
infections, allergens or air pollution.
[70]
Spirometry is then used to confirm the
diagnosis.[70] In children under the age of six the
diagnosis is more difficult as they are too young
for spirometry.[71]

Spirometry
Spirometry is recommended to aid in diagnosis
and management.[72][73] It is the single best test for
asthma. If the FEV1 measured by this technique
improves more than 12% following administration
of a bronchodilator such as salbutamol, this is
supportive of the diagnosis. It however may be
normal in those with a history of mild asthma, not
currently acting up.[45] As caffeine is a
bronchodilator in people with asthma, the use of
caffeine before a lung function test may interfere

with the results.[74] Single-breath diffusing

capacity can help differentiate asthma
from COPD.[45] It is reasonable to perform
spirometry every one or two years to follow how
well a person's asthma is controlled.[75]

Others
The methacholine challenge involves the
inhalation of increasing concentrations of a
substance that causes airway narrowing in those
predisposed. If negative it means that a person
does not have asthma; if positive, however, it is
not specific for the disease.[45]
Other supportive evidence includes: a 20%
difference in peak expiratory flow rate on at least
three days in a week for at least two weeks, a
20% improvement of peak flow following
treatment with either salbutamol, inhaled
corticosteroids or prednisone, or a 20%
decrease in peak flow following exposure to a
trigger.[76] Testing peak expiratory flow is more
variable than spirometry, however, and thus not
recommended for routine diagnosis. It may be
useful for daily self-monitoring in those with
moderate to severe disease and for checking the
effectiveness of new medications. It may also be
helpful in guiding treatment in those with acute
exacerbations.[77]

Classification
Asthma is clinically classified according to the
frequency of symptoms, forced expiratory volume
in one second (FEV1), and peak expiratory flow
rate.[6] Asthma may also be classified as atopic
(extrinsic) or non-atopic (intrinsic), based on
whether symptoms are precipitated by allergens
(atopic) or not (non-atopic).[7] While asthma is
classified based on severity, at the moment there
is no clear method for classifying different
subgroups of asthma beyond this system.
[78]
Finding ways to identify subgroups that
respond well to different types of treatments is a
current critical goal of asthma research.[78]

Although asthma is a
chronic obstructive condition, it is not considered
as a part of chronic obstructive pulmonary
disease as this term refers specifically to
combinations of disease that are irreversible
such as bronchiectasis, chronic bronchitis,
and emphysema.[79] Unlike these diseases, the
airway obstruction in asthma is usually
reversible; however, if left untreated, the chronic
inflammation from asthma can lead the lungs to
become irreversibly obstructed due to airway
remodeling.[80] In contrast to emphysema, asthma
affects the bronchi, not the alveoli.[81]
Asthma exacerbation
An acute asthma exacerbation is commonly
referred to as an asthma attack. The classic
symptoms are shortness of breath, wheezing,
and chest tightness.[45] The wheezing is most
often when breathing out.[83] While these are the
primary symptoms of asthma,[84] some people
present primarily with coughing, and in severe
cases, air motion may be significantly impaired
such that no wheezing is heard.[82]
Signs which occur during an asthma attack
include the use of accessory muscles of
respiration (sternocleidomastoid and scalene
muscles of the neck), there may be a paradoxical
pulse (a pulse that is weaker during inhalation
and stronger during exhalation), and overinflation of the chest.[85] A blue color of the skin
and nails may occur from lack of oxygen.[86]
In a mild exacerbation the peak expiratory flow
rate (PEFR) is 200 L/min or 50% of the
predicted best.[87] Moderate is defined as between
80 and 200 L/min or 25% and 50% of the
predicted best while severe is defined as 80
L/min or 25% of the predicted best.[87]
Acute severe asthma, previously known as
status asthmaticus, is an acute exacerbation of
asthma that does not respond to standard
treatments of bronchodilators and
corticosteroids.[88]Half of cases are due to
infections with others caused by allergen, air

pollution, or insufficient or inappropriate

medication use.[88]
Brittle asthma is a kind of asthma distinguishable
by recurrent, severe attacks.[82] Type 1 brittle
asthma is a disease with wide peak flow
variability, despite intense medication. Type 2
brittle asthma is background well-controlled
asthma with sudden severe exacerbations.[82]
Exercise-induced
Main article: Exercise-induced
bronchoconstriction
Exercise can trigger bronchoconstriction both in
people with or without asthma.[89] It occurs in most
people with asthma and up to 20% of people
without asthma.[89] Exercise-induced
bronchoconstriction is common in professional
athletes. The highest rates are among cyclists
(up to 45%), swimmers, and cross-country
skiers.[90] While it may occur with any weather
conditions it is more common when it is dry and
cold.[91] Inhaled beta2-agonists do not appear to
improve athletic performance among those
without asthma[92]however oral doses may
improve endurance and strength.[93][94]
Occupational
Main article: Occupational asthma
Asthma as a result of (or worsened by)
workplace exposures, is a commonly
reported occupational disease.[95] Many cases
however are not reported or recognized as such.
[96][97]
It is estimated that 525% of asthma cases
in adults are workrelated. A few hundred
different agents have been implicated with the
most common being:isocyanates, grain and
wood dust, colophony, soldering flux, latex,
animals, and aldehydes. The employment
associated with the highest risk of problems
include: those whospray paint, bakers and those
who process food, nurses, chemical workers,
those who work with animals, welders,
hairdressers and timber workers.[95]
Aspirin-induced asthma
Main article: Aspirin-induced asthma

Aspirin-exacerbated respiratory disease, also

known as aspirin-induced asthma, affects up to
9% of asthmatics.[98] Reactions may also occur to
other NSAIDs.[99] People affected often also have
trouble with nasal polyps.[99] In people who are
affected low doses paracetamol or COX-2
inhibitors are generally safe.[100]
Alcohol-induced asthma
Main article: Alcohol-induced respiratory
reactions
Alcohol may worsen asthmatic symptoms in up
to a third of people.[101] This may be even more
common in some ethnic groups such as
the Japanese and those with aspirin-induced
asthma.[101] Other studies have found
improvement in asthmatic symptoms from
alcohol.[101]

Differential diagnosis
Many other conditions can cause symptoms
similar to those of asthma. In children, other
upper airway diseases such as allergic
rhinitis and sinusitis should be considered as well
as other causes of airway obstruction
including: foreign body aspiration, tracheal
stenosis or laryngotracheomalacia, vascular
rings, enlarged lymph nodes or neck masses.
[102]
Bronchiolitis and other viral infections may also
produce wheezing.[103] In
adults, COPD, congestive heart failure, airway
masses, as well as drug-induced coughing due
to ACE inhibitors should be considered. In both
populations vocal cord dysfunction may present
similarly.[102]
Chronic obstructive pulmonary disease can
coexist with asthma and can occur as a
complication of chronic asthma. After the age of
65 most people with obstructive airway disease
will have asthma and COPD. In this setting,
COPD can be differentiated by increased airway
neutrophils, abnormally increased wall thickness,
and increased smooth muscle in the bronchi.
However, this level of investigation is not
performed due to COPD and asthma sharing

similar principles of management:

corticosteroids, long acting beta agonists, and
smoking cessation.[104] It closely resembles
asthma in symptoms, is correlated with more
exposure to cigarette smoke, an older age, less
symptom reversibility after bronchodilator
administration, and decreased likelihood of family
history of atopy.[105][106]

Prevention
The evidence for the effectiveness of measures
to prevent the development of asthma is weak.
[107]
Some show promise including: limiting smoke
exposure both in utero and after
delivery, breastfeeding, and increased exposure
to daycare or large families but none are well
supported enough to be recommended for this
indication.[107] Early pet exposure may be useful.
[108]
Results from exposure to pets at other times
are inconclusive[109] and it is only recommended
that pets be removed from the home if a person
has allergic symptoms to said pet.[110] Dietary
restrictions during pregnancy or when breast
feeding have not been found to be effective and
thus are not recommended.[110] Reducing or
eliminating compounds known to sensitive
people from the work place may be effective.[95] It
is not clear if annual influenza
vaccinations effects the risk of exacerbations.
[111]
Immunization; however, is recommended by
the World Health Organization.[112] Smoking bans
are effective in decreasing exacerbations of
asthma.[113]

Management
While there is no cure for asthma, symptoms can
typically be improved.[114] A specific, customized
plan for proactively monitoring and managing
symptoms should be created. This plan should
include the reduction of exposure to allergens,
testing to assess the severity of symptoms, and
the usage of medications. The treatment plan
should be written down and advise adjustments

to treatment according to changes in symptoms.

[115]

The most effective treatment for asthma is

identifying triggers, such as cigarette smoke,
pets, or aspirin, and eliminating exposure to
them. If trigger avoidance is insufficient, the use
of medication is recommended. Pharmaceutical
drugs are selected based on, among other
things, the severity of illness and the frequency
of symptoms. Specific medications for asthma
are broadly classified into fast-acting and longacting categories.[116][117]
Bronchodilators are recommended for short-term
relief of symptoms. In those with occasional
attacks, no other medication is needed. If mild
persistent disease is present (more than two
attacks a week), low-dose inhaled corticosteroids
or alternatively, an oral leukotriene antagonist or
a mast cell stabilizer is recommended. For those
who have daily attacks, a higher dose of inhaled
corticosteroids is used. In a moderate or severe
exacerbation, oral corticosteroids are added to
these treatments.[9]

Lifestyle modification
Avoidance of triggers is a key component of
improving control and preventing attacks. The
most common triggers include allergens, smoke
(tobacco and other), air pollution, non selective
beta-blockers, and sulfite-containing foods.[118]
[119]
Cigarette smoking and second-hand
smoke (passive smoke) may reduce the
effectiveness of medications such as
corticosteroids.[120] Laws that limit smoking
decrease the number of people hospitalized for
asthma.[121] Dust mite control measures, including
air filtration, chemicals to kill mites, vacuuming,
mattress covers and others methods had no
effect on asthma symptoms.[44] Overall, exercise
is beneficial in people with stable asthma.[122]

Medications
Medications used to treat asthma are divided into
two general classes: quick-relief medications

used to treat acute symptoms; and long-term

control medications used to prevent further
exacerbation.[116]
Fastacting

Salbutamol metered dose inhaler commonly used to

treat asthma attacks.

Short-acting beta2-adrenoceptor
agonists (SABA), such
as salbutamol (albuterol USAN) are the first
line treatment for asthma symptoms.[9] They
are recommended before exercise in those
with exercise induced symptoms.[123]

Anticholinergic medications, such

as ipratropium bromide, provide additional
benefit when used in combination with SABA
in those with moderate or severe symptoms.
[9]
Anticholinergic bronchodilators can also be
used if a person cannot tolerate a SABA.[79] If
a child requires admission to hospital
additional ipratropium does not appear to
help over a SABA.[124]

Older, less selective adrenergic agonists,

such as inhaled epinephrine, have similar
efficacy to SABAs.[125] They are however not
recommended due to concerns regarding
excessive cardiac stimulation.[126]
Longterm control
Fluticasone propionate metered dose inhaler
commonly used for long-term control.

Corticosteroids are generally considered

the most effective treatment available for
long-term control.[116] Inhaled forms such
asbeclomethasone are usually used except
in the case of severe persistent disease, in
which oral corticosteroids may be needed.
[116]
It is usually recommended that inhaled

formulations be used once or twice daily,

depending on the severity of symptoms.[127]

symptoms. However, insufficient evidence is

available to determine whether a difference
exists in those with severe disease.[138]

Long-acting beta-adrenoceptor
agonists (LABA) such
as salmeterol and formoterol can improve
asthma control, at least in adults, when given
in combination with inhaled corticosteroids.
[128]
In children this benefit is uncertain.[128]
[129]
When used without steroids they increase
the risk of severe side-effects[130] and even
with corticosteroids they may slightly
increase the risk.[131][132]

Adverse effects

Leukotriene receptor antagonists (such

as montelukast and zafirlukast) may be used
in addition to inhaled corticosteroids, typically
also in conjunction with a LABA.[14]
[116]
Evidence is insufficient to support use in
acute exacerbations.[133][134] In children they
appear to be of little benefit when added to
inhaled steroids.[135] In those under five years
of age, they were the preferred add-on
therapy after inhaled corticosteroids by the
British Thoracic Society in 2009.[136] A similar
class of drugs, 5-LOX inhibitors, may be
used as an alternative in the chronic
treatment of mild to moderate asthma among
older children and adults.[14][137] As of 2013
there is one medication in this family known
as zileuton.[14]

Long-term use of inhaled corticosteroids at

conventional doses carries a minor risk of
adverse effects.[139] Risks include the
development of cataracts and a mild regression
in stature.[139][140]

Others
When asthma is unresponsive to usual
medications, other options are available for both
emergency management and prevention of
flareups. For emergency management other
options include:

Oxygen to
alleviate hypoxia if saturations fall below
92%.[141]

Oral corticosteroid are recommended

with five days of prednisone being the same
2 days of dexamethasone.[142]

Magnesium sulfate intravenous treatment

has been shown to provide a bronchodilating
effect when used in addition to other
treatment in severe acute asthma attacks.[10]
[143]
In adults it results in a reduction of hospital
admissions.[144]

Heliox, a mixture of helium and oxygen,

may also be considered in severe
unresponsive cases.[10]

Intravenous salbutamol is not supported

by available evidence and is thus used only
in extreme cases.[141]

Methylxanthines (such as theophylline)

were once widely used, but do not add
significantly to the effects of inhaled beta-

Mast cell stabilizers (such as cromolyn

sodium) are another non-preferred
alternative to corticosteroids.[116]
Delivery methods
Medications are typically provided as metereddose inhalers (MDIs) in combination with
an asthma spacer or as a dry powder inhaler.
The spacer is a plastic cylinder that mixes the
medication with air, making it easier to receive a
full dose of the drug. A nebulizer may also be
used. Nebulizers and spacers are equally
effective in those with mild to moderate

agonists.[141] Their use in acute exacerbations

is controversial.[145]

The dissociative anesthetic ketamine is

theoretically useful
if intubation and mechanical ventilation is
needed in people who are approaching
respiratory arrest; however, there is no
evidence from clinical trials to support this.[146]

For those with severe persistent asthma not

controlled by inhaled corticosteroids and
LABAs, bronchial thermoplasty may be an
option.[147] It involves the delivery of controlled
thermal energy to the airway wall during a series
of bronchoscopies.[147][148] While it may increase
exacerbation frequency in the first few months it
appears to decrease the subsequent rate. Effects
beyond one year are unknown.[149] Evidence
suggests that sublingual immunotherapy in those
with both allergic rhinitis and asthma improve
outcomes.[150]

Alternative medicine
Many people with asthma, like those with other
chronic disorders, use alternative treatments;
surveys show that roughly 50% use some form of
unconventional therapy.[151][152]There is little data to
support the effectiveness of most of these
therapies. Evidence is insufficient to support the
usage of Vitamin C.[153] There is tentative support
for its use in exercise induced brochospasm.[154]
Acupuncture is not recommended for the
treatment as there is insufficient evidence to
support its use.[155][156] Air ionisers show no
evidence that they improve asthma symptoms or
benefit lung function; this applied equally to
positive and negative ion generators.[157]
Manual therapies,
including osteopathic, chiropractic, physiotherape
utic and respiratory therapeutic maneuvers, have
insufficient evidence to support their use in
treating asthma.[158] The Buteyko breathing
technique for controlling hyperventilation may
result in a reduction in medication use; however,

the technique does not have any effect on lung

function.[117] Thus an expert panel felt that
evidence was insufficient to support its use.[155]

Prognosis
Disability-adjusted life year for asthma per
100,000 inhabitants in 2004.[159]

The prognosis for asthma is generally good,

especially for children with mild disease.
[160]
Mortality has decreased over the last few
decades due to better recognition and
improvement in care.[161] Globally it causes
moderate or severe disability in 19.4 million
people as of 2004 (16 million of which are in low
and middle income countries).[162] Of asthma
diagnosed during childhood, half of cases will no
longer carry the diagnosis after a decade.
[56]
Airway remodeling is observed, but it is
unknown whether these represent harmful or
beneficial changes.[163] Early treatment with
corticosteroids seems to prevent or ameliorates a
decline in lung function.[164]

Epidemiology
Main article: Epidemiology of asthma
As of 2011, 235330 million people worldwide
are affected by asthma,[15][16][165] and approximately
250,000345,000 people die per year from the
disease.[17][166] Rates vary between countries with
prevalences between 1 and 18%.[17] It is more
common in developed thandeveloping countries.
[17]
One thus sees lower rates in Asia, Eastern
Europe and Africa.[45] Within developed countries
it is more common in those who are economically
disadvantaged while in contrast in developing
countries it is more common in the affluent.[17] The
reason for these differences is not well known.
[17]
Low and middle income countries make up
more than 80% of the mortality.[167]
While asthma is twice as common in boys as
girls,[17] severe asthma occurs at equal rates.[168] In

contrast adult women have a higher rate of

asthma than men[17] and it is more common in the
young than the old.[45] In children, asthma was the
most common reason for admission to the
hospital following an emergency department visit
in the US in 2011.[169]
Global rates of asthma have increased
significantly between the 1960s and 2008[170]
[171]
with it being recognized as a major public
health problem since the 1970s.[45] Rates of
asthma have plateaued in the developed world
since the mid-1990s with recent increases
primarily in the developing world.[172] Asthma
affects approximately 7% of the population of the
United States[130] and 5% of people in the United
Kingdom.[173] Canada, Australia and New Zealand
have rates of about 1415%.[174]

Economics
From 20002010, the average cost per asthmarelated hospital stay in the United States for
children remained relatively stable at about
$3,600, whereas the average cost per asthmarelated hospital stay for adults increased from
$5,200 to $6,600.[175] In 2010, Medicaid was the
most frequent primary payer among children and
adults aged 1844 years in the United States;
private insurance was the second most frequent
payer.[175] Among both children and adults in the
lowest income communities in the United States
there is a higher rates of hospital stays for
asthma in 2010 than those in the highest income
communities.[175]

History
1907 advertisement for Grimault's Indian Cigarettes,
emphasising their alleged efficacy for the relief of
asthma and other respiratory conditions

Asthma was recognized in Ancient Egypt and

was treated by drinking an incense mixture

known as kyphi.[176] It was officially named as a

specific respiratory problem by Hippocrates circa
450 BC, with the Greek word for "panting"
forming the basis of our modern name.[45] In 200
BC it was believed to be at least partly related to
the emotions.[24]

Lung cancer is the number one cause of

cancer deaths in both men and women in

the U.S. and worldwide.
Cigarette smoking is the principal risk

In 1873, one of the first papers in modern

medicine on the subject tried to explain
the pathophysiology of the disease while one in
1872, concluded that asthma can be cured by
rubbing the chest with chloroform liniment.[177]
[178]
Medical treatment in 1880, included the use
ofintravenous doses of a drug called pilocarpin.
[179]
In 1886, F.H. Bosworth theorized a connection
between asthma and hay fever.
[180]
Epinephrinewas first referred to in the
treatment of asthma in 1905.[181] Oral
corticosteroids began to be used for this
condition in the 1950s while inhaled
corticosteroids and selective short acting beta
agonist came into wide use in the 1960s.[182][183]

factor for development of lung cancer.

Passive exposure to tobacco smoke also

can cause lung cancer.

The two types of lung cancer, which grow

and spread differently, are the small cell

lung cancers (SCLC) and non-small cell
lung cancers (NSCLC).
The stage of lung cancer refers to the

extent to which the cancer has spread in

the body.
Treatment of lung cancer can involve a

combination of surgery, chemotherapy,

and radiation therapy as well as newer
experimental methods.
The general prognosis of lung cancer is

poor because doctors tend not to find the

disease until it is at an advanced stage.
Five-year survival is 40%-50% for early
stage lung cancer, but only 1%-5% in
advanced, inoperable lung cancer.
Smoking cessation is the most important

A notable and well-documented case in the 19th

century was that of young Theodore
Roosevelt (18571919). At that time there was
no effective treatment. Roosevelt's youth was in
large part shaped by his poor health partly
related to his asthma. He experienced recurring
nighttime asthma attacks that caused the
experience of being smothered to death,
terrifying the boy and his parents.[184]
During the 1930s1950s, asthma was known as
one of the "holy seven" psychosomatic illnesses.
Its cause was considered to be psychological,
with treatment often based on psychoanalysis
and other talking cures.[185] As these
psychoanalysts interpreted the asthmatic wheeze
as the suppressed cry of the child for its mother,
they considered the treatment of depression to
be especially important for individuals with
asthma.[185]

measure that can prevent the

development of lung cancer.

Medicine.net
Lung Cancer

Lung cancer facts

Cancer of the lung, like all cancers, results from

an abnormality in the body's basic unit of life, the
cell. Normally, the body maintains a system of
checks and balances on cell growth so that cells
divide to produce new cells only when new cells
are needed. Disruption of this system of checks
and balances on cell growth results in an
uncontrolled division and proliferation of cells that
eventually forms a mass known as a tumor.

Tumors can be benign or malignant; when we

speak of "cancer," we are referring to those
tumors that are malignant. Benign tumors usually
can be removed and do not spread to other parts
of the body. Malignant tumors, on the other hand,
grow aggressively and invade other tissues of
the body, allowing entry of tumor cells into the
bloodstream or lymphatic system and then to
other sites in the body. This process of spread is
termed metastasis; the areas of tumor growth at
these distant sites are called metastases. Since
lung cancer tends to spread or metastasize very
early after it forms, it is a very life-threatening
cancer and one of the most difficult cancers to
treat. While lung cancer can spread to any organ
in the body, certain locations -- particularly the
adrenal glands, liver, brain, and bones -- are the
most common sites for lung cancer metastasis.
The lung also is a very common site for
metastasis from tumors in other parts of the
body. Tumor metastases are made up of the
same type of cells as the original (primary) tumor.
For example, if prostate cancer spreads via the
bloodstream to the lungs, it is metastatic prostate
cancer in the lung and is not lung cancer.
The principal function of the lungs is to exchange
gases between the air we breathe and the blood.
Through the lung, carbon dioxide is removed
from the bloodstream and oxygen from inspired
air enters the bloodstream. The right lung has
three lobes, while the left lung is divided into two
lobes and a small structure called the lingula that
is the equivalent of the middle lobe on the right.
The major airways entering the lungs are the
bronchi, which arise from the trachea. The
bronchi branch into progressively smaller airways

called bronchioles that end in tiny sacs known as

alveoli where gas exchange occurs. The lungs
and chest wall are covered with a thin layer of
tissue called the pleura.
Lung cancers can arise in any part of the lung,
but 90%-95% of cancers of the lung are thought
to arise from the epithelial cells, the cells lining
the larger and smaller airways (bronchi and
bronchioles); for this reason, lung cancers are
sometimes called bronchogenic cancers or
bronchogenic carcinomas. (Carcinoma is another
term for cancer.) Cancers also can arise from the
pleura (called mesotheliomas) or rarely from
supporting tissues within the lungs, for example,
the blood vessels.

What causes lung cancer?

Smoking
The incidence of lung cancer is strongly
correlated with cigarette smoking, with about
90% of lung cancers arising as a result of
tobacco use. The risk of lung cancer increases
with the number of cigarettes smoked and the
time over which smoking has occurred; doctors
refer to this risk in terms of pack-years of
smoking history (the number of packs of
cigarettes smoked per day multiplied by the
number of years smoked). For example, a
person who has smoked two packs of cigarettes
per day for 10 years has a 20 pack-year smoking
history. While the risk of lung cancer is increased
with even a 10-pack-year smoking history, those
with 30-pack-year histories or more are
considered to have the greatest risk for the
development of lung cancer. Among those who

smoke two or more packs of cigarettes per day,

one in seven will die of lung cancer.
Pipe and cigar smoking also can cause lung
cancer, although the risk is not as high as with
cigarette smoking. Thus, while someone who
smokes one pack of cigarettes per day has a risk
for the development of lung cancer that is 25
times higher than a nonsmoker, pipe and cigar
smokers have a risk of lung cancer that is about
five times that of a nonsmoker.
Tobacco smoke contains over 4,000 chemical
compounds, many of which have been shown to
be cancer-causing or carcinogenic. The two
primary carcinogens in tobacco smoke are
chemicals known as nitrosamines and polycyclic
aromatic hydrocarbons. The risk of developing
lung cancer decreases each year following
smoking cessation as normal cells grow and
replace damaged cells in the lung. In former
smokers, the risk of developing lung cancer
begins to approach that of a nonsmoker about 15
years after cessation of smoking.
Passive smoking
Passive smoking or the inhalation of tobacco
smoke by nonsmokers who share living or
working quarters with smokers, also is an
established risk factor for the development of
lung cancer. Research has shown that
nonsmokers who reside with a smoker have a
24% increase in risk for developing lung cancer
when compared with nonsmokers who do not
reside with a smoker. The risk appears to
increase with the degree of exposure (number of
years exposed and number of cigarettes smoked
by the household partner). An estimated 3,000
lung cancer deaths that occur each year in the
U.S. are attributable to passive smoking.

Asbestos fibers
Asbestos fibers are silicate fibers that can persist
for a lifetime in lung tissue following exposure to
asbestos. The workplace was a common source
of exposure to asbestos fibers, as asbestos was
widely used in the past as both thermal and
acoustic insulation. Today, asbestos use is
limited or banned in many countries, including
the U.S. Both lung cancer
and mesothelioma (cancer of the pleura of the
lung as well as of the lining of the abdominal
cavity called the peritoneum) are associated with
exposure to asbestos. Cigarette smoking
drastically increases the chance of developing an
asbestos-related lung cancer in workers exposed
to asbestos. Asbestos workers who do not
smoke have a fivefold greater risk of developing
lung cancer than nonsmokers, but asbestos
workers who smoke have a risk that is fifty- to
ninety-fold greater than nonsmokers.
Radon gas
Radon gas is a natural radioactive gas that is a
natural decay product of uranium. Uranium
decays to form products, including radon, that
emit a type of ionizing radiation. Radon gas is a
known cause of lung cancer, with an estimated
12% of lung-cancer deaths attributable to radon
gas, or about 20,000 lung-cancer-related deaths
annually in the U.S., making radon the second
leading cause of lung cancer in the U.S. As with
asbestos exposure, concomitant smoking greatly
increases the risk of lung cancer with radon
exposure. Radon gas can travel up through soil
and enter homes through gaps in the foundation,
pipes, drains, or other openings. The U.S.

Environmental Protection Agency estimates that

one out of every 15 homes in the U.S. contains
dangerous levels of radon gas. Radon gas is
invisible and odorless, but it can be detected with
simple test kits.
Familial predisposition
While the majority of lung cancers are associated
with tobacco smoking, the fact that not all
smokers eventually develop lung cancer
suggests that other factors, such as individual
genetic susceptibility, may play a role in the
causation of lung cancer. Numerous studies have
shown that lung cancer is more likely to occur in
both smoking and nonsmoking relatives of those
who have had lung cancer than in the general
population. One study in never-smokers showed
that a genetic change at a single region on
chromosome 13 was associated with an increase
in risk for developing non-small cell lung cancer.
A large genetic study of lung cancer that involved
over 10,000 people from 18 countries and led by
the International Agency for Research on Cancer
(IARC), identified a small region in the genome
(DNA) that contains genes that appear to confer
an increased susceptibility to lung cancer in
smokers. The specific genes, located on the q
arm of chromosome 15, code for proteins that
interact with nicotine and other tobacco toxins
(nicotinic acetylcholine receptor genes).
Lung diseases
The presence of certain diseases of the lung,
notably chronic obstructive pulmonary disease
(COPD), is associated with an increased risk
(four- to six-fold the risk of a nonsmoker) for the
development of lung cancer even after the
effects of concomitant cigarette smoking are

excluded. Pulmonary fibrosis (scarring of the

lung) appears to increase the risk about sevenfold, and this risk does not appear to be related
to smoking.
Prior history of lung cancer
Survivors of lung cancer have a greater risk of
developing a second lung cancer than the
general population has of developing a first lung
cancer. Survivors of non-small cell lung cancers
(NSCLCs, see below) have an additive risk of
1%-2% per year for developing a second lung
cancer. In survivors of small cell lung cancers
(SCLCs, see below), the risk for development of
second lung cancers approaches 6% per year.
Air pollution
Air pollution from vehicles, industry, and power
plants can raise the likelihood of developing lung
cancer in exposed individuals. Up to 1% of lung
cancer deaths are attributable to breathing
polluted air, and experts believe that prolonged
exposure to highly polluted air can carry a risk for
the development of lung cancer similar to that of
passive smoking.

What are the types of lung cancer?

Lung cancers, also known as bronchogenic
carcinomas, are broadly classified into two types:
small cell lung cancers (SCLC) and non-small
cell lung cancers (NSCLC). This classification is
based upon the microscopic appearance of the
tumor cells themselves. These two types of
cancers grow and spread in different ways and
may have different treatment options, so a
distinction between these two types is important.
SCLC comprise about 20% of lung cancers and
are the most aggressive and rapidly growing of
all lung cancers. SCLC are strongly related to

cigarette smoking, with only 1% of these tumors

occurring in nonsmokers. SCLC metastasize
rapidly to many sites within the body and are
most often discovered after they have spread
extensively. Referring to a specific cell
appearance often seen when examining samples
of SCLC under the microscope, these cancers
are sometimes called oat cell carcinomas.
NSCLC are the most common lung cancers,
accounting for about 80% of all lung cancers.
NSCLC can be divided into three main types that
are named based upon the type of cells found in
the tumor:
Adenocarcinomas are the most

commonly seen type of NSCLC in the

U.S. and comprise up to 50% of NSCLC.
While adenocarcinomas are associated
with smoking, like other lung cancers,
this type is observed as well in
nonsmokers who develop lung cancer.
Most adenocarcinomas arise in the outer,
or peripheral, areas of the lungs.
Bronchioloalveolar carcinoma is a

subtype of adenocarcinoma that

frequently develops at multiple sites in
the lungs and spreads along the
preexisting alveolar walls.
Squamous cell carcinomas were

formerly more common than

adenocarcinomas; at present, they
account for about 30% of NSCLC. Also
known as epidermoid carcinomas,
squamous cell cancers arise most
frequently in the central chest area in the
bronchi.
Large cell carcinomas, sometimes
referred to as undifferentiated

carcinomas, are the least common type

of NSCLC.
Mixtures of different types of NSCLC are

also seen.
Other types of cancers can arise in the lung;
these types are much less common than NSCLC
and SCLC and together comprise only 5%-10%
of lung cancers:
Bronchial carcinoids account for up to

5% of lung cancers. These tumors are

generally small (3 cm-4 cm or less) when
diagnosed and occur most commonly in
people under 40 years of age. Unrelated
to cigarette smoking, carcinoid tumors
can metastasize, and a small proportion
of these tumors secrete hormone-like
substances that may cause specific
symptoms related to the hormone being
produced. Carcinoids generally grow and
spread more slowly than bronchogenic
cancers, and many are detected early
enough to be amenable to surgical
resection.
Cancers of supporting lung tissue such

as smooth muscle, blood vessels, or cells

involved in the immune response can
rarely occur in the lung.
As discussed previously, metastatic cancers from
other primary tumors in the body are often found
in the lung. Tumors from anywhere in the body
may spread to the lungs either through the
bloodstream, through the lymphatic system, or
directly from nearby organs. Metastatic tumors
are most often multiple, scattered throughout the
lung, and concentrated in the peripheral rather
than central areas of the lung.

What are lung cancer symptoms and

signs?
Symptoms of lung cancer are varied depending
upon where and how widespread the tumor is.
Warning signs of lung cancer are not always
present or easy to identify. Lung cancer may not
cause pain or even any symptoms at all in some
cases. A person with lung cancer may have the
following kinds of symptoms:
No symptoms: In up to 25% of people

who get lung cancer, the cancer is first

discovered on a routine chest Xray or CT scan as a solitary small mass
sometimes called a coin lesion, since on
a two-dimensional X-ray or CT scan, the
round tumor looks like a coin. These
patients with small, single masses often
report no symptoms at the time the
cancer is discovered.
Symptoms related to the cancer: The
growth of the cancer and invasion of lung
tissues and surrounding tissue may
interfere with breathing, leading to
symptoms such as cough, shortness of
breath, wheezing, chest pain, and
coughing up blood (hemoptysis). If the
cancer has invaded nerves, for example,
it may cause shoulder pain that travels
down the outside of the arm (called
Pancoast syndrome) or paralysis of the
vocal cords leading to hoarseness.
Invasion of the esophagus may lead to
difficulty swallowing (dysphagia). If a
large airway is obstructed, collapse of a
portion of the lung may occur and cause

infections (abscesses, pneumonia) in the

obstructed area.
Symptoms related to metastasis: Lung

cancer that has spread to the bones may

produce excruciating pain at the sites of
bone involvement. Cancer that has
spread to the brain may cause a number
of neurologic symptoms that may
include blurred vision, headaches,
seizures, or symptoms of stroke such
as weakness or loss of sensation in parts
of the body.
Paraneoplastic symptoms: Lung

cancers frequently are accompanied by

symptoms that result from production of
hormone-like substances by the tumor
cells. These paraneoplastic syndromes
occur most commonly with SCLC but
may be seen with any tumor type. A
common paraneoplastic syndrome
associated with SCLC is the production
of a hormone called adrenocorticotrophic
hormone (ACTH) by the cancer cells,
leading to oversecretion of the hormone
cortisol by the adrenal glands (Cushing's
syndrome). The most frequent
paraneoplastic syndrome seen with
NSCLC is the production of a substance
similar to parathyroid hormone, resulting
in elevated levels of calcium in the
bloodstream.
Nonspecific symptoms: Nonspecific
symptoms seen with many cancers,
including lung cancers, include weight
loss, weakness, andfatigue.
Psychological symptoms such

as depression and mood changes are

also common.
When should one consult a doctor?
One should consult a health-care professional if
he or she develops the symptoms associated
with lung cancer, in particular, if they have
a new persistent cough or worsening of

an existing chronic cough,

blood in the sputum,
persistent bronchitis or repeated

respiratory infections,
chest pain,
unexplained weight loss and/or fatigue,
breathing difficulties such as shortness of

as clubbing, also may indicate chronic

lung disease.
The chest X-ray is the most common

first diagnostic step when any new

symptoms of lung cancer are present.
The chest X-ray procedure often involves
a view from the back to the front of the
chest as well as a view from the side.
Like any X-ray procedure, chest X-rays
expose the patient briefly to a small
amount of radiation. Chest X-rays may
reveal suspicious areas in the lungs but
are unable to determine if these areas
are cancerous. In particular, calcified
nodules in the lungs or benign tumors
called hamartomas may be identified on
a chest X-ray and mimic lung cancer.
CT (computerized tomography,

breath or wheezing.

How is lung cancer diagnosed?

Doctors use a wide range of diagnostic

procedures and tests to diagnose lung cancer.
These include the following:
The history and physical
examination may reveal the presence of
symptoms or signs that are suspicious for
lung cancer. In addition to asking about
symptoms and risk factors for cancer
development such as smoking, doctors
may detect signs of breathing difficulties,
airway obstruction, or infections in the
lungs. Cyanosis, a bluish color of the skin
and the mucous membranes due to
insufficient oxygen in the blood, suggests
compromised function due to chronic
disease of the lung. Likewise, changes in
the tissue of the nail beds, known

computerized axial tomography, or

CAT) scans may be performed on the
chest, abdomen, and/or brain to examine
for both metastatic and lung tumors. A CT
scan of the chest may be ordered when
X-rays do not show an abnormality or do
not yield sufficient information about the
extent or location of a tumor. CT scans
are X-ray procedures that combine
multiple images with the aid of a
computer to generate cross-sectional
views of the body. The images are taken
by a large donut-shaped X-ray machine
at different angles around the body. One
advantage of CT scans is that they are
more sensitive than standard chest Xrays in the detection of lung nodules, that
is, they will demonstrate more nodules.
Sometimes intravenous contrast material

is given prior to the scan to help

delineate the organs and their positions.
A CT scan exposes the patient to a
minimal amount of radiation. The most
common side effect is an adverse
reaction to intravenous contrast material
that may have been given prior to the
procedure. This may result in itching,
a rash, or hives that generally disappear
rather quickly. Severe anaphylactic
reactions (life-threatening allergic
reactions with breathing difficulties) to
contrast material are rare. CT scans of
the abdomen may identify metastatic
cancer in the liver or adrenal glands, and
CT scans of the head may be ordered to
reveal the presence and extent of
metastatic cancer in the brain.
A technique called a low-dose helical
CT scan (or spiral CT scan) is
recommended for use annually in current
and former smokers between ages 55
and 80 with at least a 30 pack-year
history of cigarette smoking who have
smoked cigarettes within the past 15
years per the USPSTF
recommendations. The technique
appears to increase the likelihood of
detection of smaller, earlier, and more
curable lung cancers. Three years of lowdose CT scanning in this group reduced
the risk of lung cancer death by 20%.
Use of models and rules for analyzing the
results of these tests are decreasing the
need for testing to evaluate detected
nodules when the likelihood is high the
nodule is not cancerous.

Magnetic resonance imaging (MRI)

scans may be appropriate when precise

detail about a tumor's location is
required. The MRI technique uses
magnetism, radio waves, and a computer
to produce images of body structures. As
with CT scanning, the patient is placed
on a moveable bed which is inserted into
the MRI scanner. There are no known
side effects of MRI scanning, and there is
no exposure to radiation. The image and
resolution produced by MRI is quite
detailed and can detect tiny changes of
structures within the body. People with
heart pacemakers, metal implants,
artificial heart valves, and other surgically
implanted structures cannot be scanned
with an MRI because of the risk that the
magnet may move the metal parts of
these structures.
Positron emission tomography (PET)
scanning is a specialized imaging
technique that uses short-lived
radioactive drugs to produce threedimensional colored images of those
substances in the tissues within the body.
While CT scans and MRI scans look at
anatomical structures, PET scans
measure metabolic activity and the
function of tissues. PET scans can
determine whether a tumor tissue is
actively growing and can aid in
determining the type of cells within a
particular tumor. In PET scanning, the
patient receives a short half-lived
radioactive drug, receiving approximately
the amount of radiation exposure as two

chest X-rays. The drug accumulates in

certain tissues more than others,
depending on the drug that is injected.
The drug discharges particles known as
positrons from whatever tissues take
them up. As the positrons encounter
electrons within the body, a reaction
producing gamma rays occurs. A scanner
records these gamma rays and maps the
area where the radioactive drug has
accumulated. For example,
combining glucose (a common energy
source in the body) with a radioactive
substance will show where glucose is
rapidly being used, for example, in a
growing tumor. PET scanning may also
be integrated with CT scanning in a
technique known as PET-CT scanning.
Integrated PET-CT has been shown to
improve the accuracy of staging (see
below) over PET scanning alone.

Bone scans are used to create images

of bones on a computer screen or on

film. Doctors may order a bone scan to
determine whether a lung cancer has
metastasized to the bones. In a bone
scan, a small amount of radioactive
material is injected into the bloodstream
and collects in the bones, especially in
abnormal areas such as those involved
by metastatic tumors. The radioactive
material is detected by a scanner, and
the image of the bones is recorded on a
special film for permanent viewing.
Sputum cytology: The diagnosis of lung
cancer always requires confirmation of

malignant cells by a pathologist, even

when symptoms and X-ray studies are
suspicious for lung cancer. The simplest
method to establish the diagnosis is the
examination of sputum under a
microscope. If a tumor is centrally located
and has invaded the airways, this
procedure, known as a sputum cytology
examination, may allow visualization of
tumor cells for diagnosis. This is the most
risk-free and inexpensive tissue
diagnostic procedure, but its value is
limited since tumor cells will not always
be present in sputum even if a cancer is
present. Also, noncancerous cells may
occasionally undergo changes in reaction
to inflammation or injury that makes them
look like cancer cells.
Bronchoscopy: Examination of the
airways by bronchoscopy (visualizing the
airways through a thin, fiberoptic probe
inserted through the nose or mouth) may
reveal areas of tumor that can be
sampled (biopsied) for diagnosis by a
pathologist. A tumor in the central areas
of the lung or arising from the larger
airways is accessible to sampling using
this technique. Bronchoscopy may be
performed using a rigid or a flexible
fiberoptic bronchoscope and can be
performed in a same-day outpatient
bronchoscopy suite, an operating room,
or on a hospital ward. The procedure can
be uncomfortable, and it requires
sedation or anesthesia. While
bronchoscopy is relatively safe, it must
be carried out by a lung specialist

(pulmonologist or surgeon) experienced

in the procedure. When a tumor is
visualized and adequately sampled, an
accurate cancer diagnosis usually is
possible. Some patients may cough up
dark-brown blood for one to two days
after the procedure. More serious but
rare complications include a greater
amount of bleeding, decreased levels of
oxygen in the blood, and heart
arrhythmias as well as complications
from sedative medications and
anesthesia.
Needle biopsy: Fine-needle aspiration
(FNA) through the skin, most commonly
performed with radiological imaging for
guidance, may be useful in retrieving
cells for diagnosis from tumor nodules in
the lungs. Needle biopsies are
particularly useful when the lung tumor is
peripherally located in the lung and not
accessible to sampling by bronchoscopy.
A small amount of local anesthetic is
given prior to insertion of a thin needle
through the chest wall into the abnormal
area in the lung. Cells are suctioned into
the syringe and are examined under the
microscope for tumor cells. This
procedure is generally accurate when the
tissue from the affected area is
adequately sampled, but in some cases,
adjacent or uninvolved areas of the lung
may be mistakenly sampled. A small risk
(3%-5%) of an air leak from the lungs
(called a pneumothorax, which can easily
be treated) accompanies the procedure.

Thoracentesis: Sometimes lung cancers

involve the lining tissue of the lungs

(pleura) and lead to an accumulation of
fluid in the space between the lungs and
chest wall (called a pleural effusion).
Aspiration of a sample of this fluid with a
thin needle (thoracentesis) may reveal
the cancer cells and establish the
diagnosis. As with the needle biopsy, a
small risk of a pneumothorax is
associated with this procedure.
Major surgical procedures: If none of

the aforementioned methods yields a

diagnosis, surgical methods must be
employed to obtain tumor tissue for
diagnosis. These can include
mediastinoscopy (examining the chest
cavity between the lungs through a
surgically inserted probe with biopsy of
tumor masses or lymph nodes that may
contain metastases) or thoracotomy
(surgical opening of the chest wall for
removal or biopsy of a tumor). With a
thoracotomy, it is rare to be able to
completely remove a lung cancer, and
both mediastinoscopy and thoracotomy
carry the risks of major surgical
procedures (complications such as
bleeding, infection, and risks from
anesthesia and medications). These
procedures are performed in an
operating room, and the patient must be
hospitalized.
Blood tests: While routine blood tests
alone cannot diagnose lung cancer, they
may reveal biochemical or metabolic
abnormalities in the body that

accompany cancer. For example,

elevated levels of calcium or of the
enzyme alkaline phosphatase may
accompany cancer that is metastatic to
the bones. Likewise, elevated levels of
certain enzymes normally present within
liver cells, including aspartate
aminotransferase (AST or SGOT) and
alanine aminotransferase (ALT or SGPT),
signal liver damage, possibly through the
presence of tumor metastatic to the liver.
One current focus of research in the area
of lung cancer is the development of a
blood test to aid in the diagnosis of lung
cancer. Researchers have preliminary
data that has identified specific proteins,
or biomarkers, that are in the blood and
may signal that lung cancer is present in
someone with a suspicious area seen on
a chest X-ray or other imaging study.
Molecular testing: For advanced
NSCLCs, molecular genetic testing is
carried out to look for genetic mutations
in the tumor. For example, testing may be
done to look for mutations or
abnormalities in the epithelial growth
factor receptor (EGFR) and the
anaplastic lymphoma kinase (ALK)
genes. Other genes that may be mutated
include MAPK and PIK3. Targeted
therapies are available that may be
administered to patients whose tumors
have alterations in these genes.

What is staging of lung cancer?

The stage of a cancer is a measure of the extent

to which a cancer has spread in the body.
Staging involves evaluation of a cancer's size
and its penetration into surrounding tissue as
well as the presence or absence of metastases
in the lymph nodes or other organs. Staging is
important for determining how a particular cancer
should be treated, since lung-cancer therapies
are geared toward specific stages. Staging of a
cancer also is critical in estimating the prognosis
of a given patient, with higher-stage cancers
generally having a worse prognosis than lowerstage cancers.
Doctors may use several tests to accurately
stage a lung cancer, including laboratory (blood
chemistry) tests, X-rays, CT scans, bone scans,
MRI scans, and PET scans. Abnormal blood
chemistry tests may signal the presence of
metastases in bone or liver, and radiological
procedures can document the size of a cancer as
well as its spread.
NSCLC are assigned a stage from I to IV in order
of severity:
In stage I, the cancer is confined to the

lung.
In stages II and III, the cancer is confined

to the chest (with larger and more

invasive tumors classified as stage III).
Stage IV cancer has spread from the

chest to other parts of the body.

SCLC are staged using a two-tiered system:
Limited-stage (LS) SCLC refers to cancer

that is confined to its area of origin in the

chest.
In extensive-stage (ES) SCLC, the
cancer has spread beyond the chest to
other parts of the body.

What is the treatment for lung cancer?

Treatment for lung cancer can involve surgical
removal of the cancer, chemotherapy, or
radiation therapy, as well as combinations of
these treatments. The decision about which
treatments will be appropriate for a given
individual must take into account the location and
extent of the tumor as well as the overall health
status of the patient.
As with other cancers, therapy may be
prescribed that is intended to be curative
(removal or eradication of a cancer) or palliative
(measures that are unable to cure a cancer but
can reduce pain and suffering). More than one
type of therapy may be prescribed. In such
cases, the therapy that is added to enhance the
effects of the primary therapy is referred to as
adjuvant therapy. An example of adjuvant
therapy is chemotherapy or radiotherapy
administered after surgical removal of a tumor in
an attempt to kill any tumor cells that remain
following surgery.
Surgery: Surgical removal of the tumor is
generally performed for limited-stage (stage I or
sometimes stage II) NSCLC and is the treatment
of choice for cancer that has not spread beyond
the lung. About 10%-35% of lung cancers can be
removed surgically, but removal does not always
result in a cure, since the tumors may already
have spread and can recur at a later time.
Among people who have an isolated, slowgrowing lung cancer removed, 25%-40% are still
alive five years after diagnosis. It is important to
note that although a tumor may be anatomically

suitable for resection, surgery may not be

possible if the person has other serious
conditions (such as severe heart or lung disease)
that would limit their ability to survive an
operation. Surgery is less often performed with
SCLC than with NSCLC because these tumors
are less likely to be localized to one area that can
be removed.
The surgical procedure chosen depends upon
the size and location of the tumor. Surgeons
must open the chest wall and may perform a
wedge resection of the lung (removal of a portion
of one lobe), a lobectomy (removal of one lobe),
or a pneumonectomy (removal of an entire lung).
Sometimes lymph nodes in the region of the
lungs also are removed (lymphadenectomy).
Surgery for lung cancer is a major surgical
procedure that requires general anesthesia,
hospitalization, and follow-up care for weeks to
months. Following the surgical procedure,
patients may experience difficulty breathing,
shortness of breath, pain, and weakness. The
risks of surgery include complications due to
bleeding, infection, and complications of general
anesthesia.
Radiation: Radiation therapy may be employed
as a treatment for both NSCLC and SCLC.
Radiation therapy uses high-energy X-rays or
other types of radiation to kill dividing cancer
cells. Radiation therapy may be given as curative
therapy, palliative therapy (using lower doses of
radiation than with curative therapy), or as
adjuvant therapy in combination with surgery or
chemotherapy. The radiation is either delivered
externally, by using a machine that directs
radiation toward the cancer, or internally through

placement of radioactive substances in sealed

containers within the area of the body where the
tumor is localized. Brachytherapy is a term used
to describe the use of a small pellet of
radioactive material placed directly into the
cancer or into the airway next to the cancer. This
is usually done through a bronchoscope.
Radiation therapy can be given if a person
refuses surgery, if a tumor has spread to areas
such as the lymph nodes or trachea making
surgical removal impossible, or if a person has
other conditions that make them too ill to
undergo major surgery. Radiation therapy
generally only shrinks a tumor or limits its growth
when given as a sole therapy, yet in 10%-15% of
people it leads to long-term remission and
palliation of the cancer. Combining radiation
therapy with chemotherapy can further prolong
survival when chemotherapy is administered.
External radiation therapy can generally be
carried out on an outpatient basis, while internal
radiation therapy requires a brief hospitalization.
A person who has severe lung disease in
addition to a lung cancer may not be able to
receive radiotherapy to the lung since the
radiation can further decrease function of the
lungs. A type of external radiation therapy called
the "gamma knife" is sometimes used to treat
single brain metastases. In this procedure,
multiple beams of radiation coming from different
directions are focused on the tumor over a few
minutes to hours while the head is held in place
by a rigid frame. This reduces the dose of
radiation that is received by noncancerous
tissues.
For external radiation therapy, a process called
simulation is necessary prior to treatment. Using

CT scans, computers, and precise

measurements, simulation maps out the exact
location where the radiation will be delivered,
called the treatment field or port. This process
usually takes 30 minutes to two hours. The
external radiation treatment itself generally is
done four or five days a week for several weeks.
Radiation therapy does not carry the risks of
major surgery, but it can have unpleasant side
effects, including fatigue and lack of energy. A
reduced white blood cell count (rendering a
person more susceptible to infection) and low
blood platelet levels (making blood clotting more
difficult and resulting in excessive bleeding) also
can occur with radiation therapy. If the digestive
organs are in the field exposed to radiation,
patients may experience nausea, vomiting,
or diarrhea. Radiation therapy can irritate the
skin in the area that is treated, but this irritation
generally improves with time after treatment has
ended.
Chemotherapy: Both NSCLC and SCLC may be
treated with chemotherapy. Chemotherapy refers
to the administration of drugs that stop the
growth of cancer cells by killing them or
preventing them from dividing. Chemotherapy
may be given alone, as an adjuvant to surgical
therapy, or in combination with radiotherapy.
While a number of chemotherapeutic drugs have
been developed, the class of drugs known as the
platinum-based drugs have been the most
effective in treatment of lung cancers.
Chemotherapy is the treatment of choice for
most SCLC, since these tumors are generally
widespread in the body when they are
diagnosed. Only half of people who have SCLC

survive for four months without chemotherapy.

With chemotherapy, their survival time is
increased up to four- to fivefold. Chemotherapy
alone is not particularly effective in treating
NSCLC, but when NSCLC has metastasized, it
can prolong survival in many cases.
Chemotherapy may be given as pills, as an
intravenous infusion, or as a combination of the
two. Chemotherapy treatments usually are given
in an outpatient setting. A combination of drugs is
given in a series of treatments, called cycles,
over a period of weeks to months, with breaks in
between cycles. Unfortunately, the drugs used in
chemotherapy also kill normally dividing cells in
the body, resulting in unpleasant side effects.
Damage to blood cells can result in increased
susceptibility to infections and difficulties with
blood clotting (bleeding or bruising easily). Other
side effects include fatigue, weight loss, hair loss,
nausea, vomiting, diarrhea, and mouth sores.
The side effects of chemotherapy vary according
to the dosage and combination of drugs used
and may also vary from individual to individual.
Medications have been developed that can treat
or prevent many of the side effects of
chemotherapy. The side effects generally
disappear during the recovery phase of the
treatment or after its completion.
Prophylactic brain radiation: SCLC often
spreads to the brain. Sometimes people with
SCLC that is responding well to treatment are
treated with radiation therapy to the head to treat
very early spread to the brain (called
micrometastasis) that is not yet detectable with
CT or MRI scans and has not yet produced
symptoms. Brain radiation therapy can cause

short-term memory problems, fatigue, nausea,

and other side effects.
Treatment of recurrence: Lung cancer that has
returned following treatment with surgery,
chemotherapy, and/or radiation therapy is
referred to as recurrent or relapsed. If a recurrent
cancer is confined to one site in the lung, it may
be treated with surgery. Recurrent tumors
generally do not respond to the
chemotherapeutic drugs that were previously
administered. Since platinum-based drugs are
generally used in initial chemotherapy of lung
cancers, these agents are not useful in most
cases of recurrence. A type of chemotherapy
referred to as second-line chemotherapy is used
to treat recurrent cancers that have previously
been treated with chemotherapy, and a number
of second-line chemotherapeutic regimens have
been proven effective at prolonging survival.
People with recurrent lung cancer who are well
enough to tolerate therapy also are good
candidates for experimental therapies (see
below), including clinical trials.
Targeted therapy: Molecularly targeted therapy
involves the administration of drugs that have
been identified to work in subsets of patients
whose tumors have specific genetic changes.
For example, the drugs erlotinib (Tarceva)
and gefitinib (Iressa) are so-called targeted
drugs, which may be used in certain patients with
NSCLC who are no longer responding to
chemotherapy. Targeted therapy drugs more
specifically target cancer cells, resulting in less
damage to normal cells than general
chemotherapeutic agents. Erlotinib and gefitinib
target a protein called the epidermal growth
factor receptor (EGFR) that is important in

promoting the division of cells. This protein is

found at abnormally high levels on the surface of
some types of cancer cells, including many
cases of non-small cell lung cancer.
Other attempts at targeted therapy include drugs
known as antiangiogenesis drugs, which block
the development of new blood vessels within a
cancer. Without adequate blood vessels to
supply oxygen-carrying blood, the cancer cells
will die. The antiangiogenic drug bevacizumab
(Avastin) has also been found to prolong survival
in advanced lung cancer when it is added to the
standard chemotherapy regimen. Bevacizumab
is given intravenously every two to three weeks.
However, since this drug may cause bleeding, it
is not appropriate for use in patients who are
coughing up blood, if the lung cancer has spread
to the brain, or in people who are receiving
anticoagulation therapy ("blood thinner"
medications). Bevacizumab also is not used in
cases of squamous cell cancer because it leads
to bleeding from this type of lung cancer.
Ramucirumab (Cyramza) is another
angiogenesis inhibitor that can be used to treat
advanced non-small cell lung cancer.
Cetuximab is an antibody that binds to the
epidermal growth factor receptor (EGFR). In
patients with NSCLC whose tumors have been
shown to express the EGFR by
immunohistochemical analysis, the addition of
cetuximab may be considered for some patients.
Other targeted therapies include ALK tyrosine
kinase inhibitor drugs (for example, crizotinib,
ceritinib) that are used in patients whose tumors
have an abnormality of the ALK gene.
Photodynamic therapy (PDT): One newer
therapy used for different types and stages of

lung cancer (as well as some other cancers) is

photodynamic therapy. In photodynamic
treatment, a photosynthesizing agent (such as a
porphyrin, a naturally occurring substance in the
body) is injected into the bloodstream a few
hours prior to surgery. During this time, the agent
is taken up in rapidly growing cells such as
cancer cells. A procedure then follows in which
the physician applies a certain wavelength of
light through a handheld wand directly to the site
of the cancer and surrounding tissues. The
energy from the light activates the
photosensitizing agent, causing the production of
a toxin that destroys the tumor cells. PDT has the
advantages that it can precisely target the
location of the cancer, is less invasive than
surgery, and can be repeated at the same site if
necessary. The drawbacks of PDT are that it is
only useful in treating cancers that can be
reached with a light source and is not suitable for
treatment of extensive cancers. The U.S. Food
and Drug Administration (FDA) has approved the
photosensitizing agent called porfimer sodium
(Photofrin) for use in PDT to treat or relieve the
symptoms of esophageal cancer and non-small
cell lung cancer. Further research is ongoing to
determine the effectiveness of PDT in other
types of lung cancer.
Radiofrequency ablation (RFA):
Radiofrequency ablation is being studied as an
alternative to surgery, particularly in cases of
early stage lung cancer. In this type of treatment,
a needle is inserted through the skin into the
cancer, usually under guidance by CT scanning.
Radiofrequency (electrical) energy is then
transmitted to the tip of the needle where it
produces heat in the tissues, killing the

cancerous tissue and closing small blood vessels

that supply the cancer. RFA usually is not painful
and has been approved by the U.S. Food and
Drug Administration for the treatment of certain
cancers, including lung cancers. Studies have
shown that this treatment can prolong survival
similarly to surgery when used to treat early
stages of lung cancer but without the risks of
major surgery and the prolonged recovery time
associated with major surgical procedures.
Experimental therapies: Since no therapy is
currently available that is absolutely effective in
treating lung cancer, patients may be offered a
number of new therapies that are still in the
experimental stage, meaning that doctors do not
yet have enough information to decide whether
these therapies should become accepted forms
of treatment for lung cancer. New drugs or new
combinations of drugs are tested in so-called
clinical trials, which are studies that evaluate the
effectiveness of new medications in comparison
with those treatments already in widespread use.
Experimental treatments known as
immunotherapies are being studied that involve
the use of vaccine-related therapies or other
therapies that attempt to utilize the body's
immune system to fight cancer cells. Vaccine
therapies against lung cancer are another area in
which research is ongoing, and lung cancer
treatment vaccines are also being studied in
clinical trials.

What is the prognosis (outcome) of

lung cancer?

The prognosis of lung cancer refers to the

chance for cure or prolongation of life (survival)
and is dependent upon where the cancer is
located, the size of the cancer, the presence of
symptoms, the type of lung cancer, and the
overall health status of the patient.
SCLC has the most aggressive growth of all lung
cancers, with a median survival time of only two
to four months after diagnosis when untreated.
(That is, by two to four months, half of all patients
have died.) However, SCLC is also the type of
lung cancer most responsive to radiation therapy
and chemotherapy. Because SCLC spreads
rapidly and is usually disseminated at the time of
diagnosis, methods such as surgical removal or
localized radiation therapy are less effective in
treating this type of lung cancer. When
chemotherapy is used alone or in combination
with other methods, survival time can be
prolonged four- to fivefold; however, of all
patients with SCLC, only 5%-10% are still alive
five years after diagnosis. Most of those who
survive have limited-stage SCLC.
In non-small cell lung cancer (NSCLC), the most
important prognostic factor is the stage (extent of
spread) of the tumor at the time of diagnosis.
Results of standard treatment are generally poor
in all but the smallest of cancers that can be
surgically removed. However, in stage I cancers
that can be completely removed surgically, fiveyear survival approaches 75%. Radiation therapy
can produce a cure in a small minority of patients
with NSCLC and leads to relief of symptoms in
most patients. In advanced-stage disease,
chemotherapy offers modest improvements in
survival although rates of overall survival are
poor.

The overall prognosis for lung cancer is poor

when compared with some other cancers.
Survival rates for lung cancer are generally lower
than those for most cancers, with an overall fiveyear survival rate for lung cancer of about 17%
compared to 67% for colon cancer, 90% for
breast cancer, 81% for bladder cancer, and over
99% for prostate cancer.
How can lung cancer be prevented?
Cessation of smoking and eliminating exposure
to tobacco smoke is the most important measure
that can prevent lung cancer. Many products,
such as nicotine gum, nicotine sprays, or nicotine
inhalers, may be helpful to people trying to quit
smoking. Minimizing exposure to passive
smoking also is an effective preventive measure.
Using a home radon test kit can identify and
allow correction of increased radon levels in the
home. Methods that allow early detection of
cancers, such as the helical low-dose CT scan,

also may be of value in the identification of small

cancers that can be cured by surgical resection
and prevented from becoming widespread,
incurable, metastatic cancer.