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Pulmonary Diseases by: Eddie K. Lam M.D.

Pulmonary Diseases

Pulmonary Diseases by:

Eddie K. Lam M.D. 1RESPIRTORY DISEASESCOUGHCOPDASTHMACHRONIC BRONCHITISEMPHYSEMATUBERCULOSISPULMONARY NODULESALPHA 1 ANTITRYPSIN DEFICIENCYPLEURISYPLEURAL EFFUSIONPNEUMOTHORAXVENOUS THROMBOLISM2COUGHAcute cough ( last < 3 weeks)Subacute (3 to 8 weeks)Chronic ( longer than 8 weeks)3Acute coughMost commonly associated with common coldDifferentiate between serious condition such as pulmonary embolism, CHF, pneumonia, asthma, COPD, Antihistamine or decongestant should be prescribed4Subacute coughIs the cough follow a respiratory infectionCough began with URI and lingered indicate postinfectious coughPostnasal drip, upper airway irritation, mucus accumulation, airway spasm5Chronic coughSmokingMedicationsAsthmaGERDUpper airway cough syndromeNonasthmatic eosinophilic bronchitisCancerAtypical infection6History and physicalLams criteria for coughSmoking Throat irritationUps or downsProductiveItching DurationNasal drip, congestionEatingPositionHemoptysisEWeight loss7Physical examHEENTChest, heartLymph nodesSkins/fingers

8Chest x rayReasonable as baseline if cough persists more than 3 weeksSuspect pneumoniaWeight lossHemoptysisNightsweats

9Treatment of coughURI- 1st generation antihistamine + decongestantUpper airway- inhaled nasal steroidsBacterial- appropriate antibiotics + suppressantsCodeine Vs DMBrochospasm- Anticholinergic agentsDrug induced- Discontinue ACE inhibitors10treatment cont.Inhaled corticosteroidsOral corticosteroids11If all treatment failedNo waySuspect noncomplianceSuspect other causes: GERD, swallowing disorderConsider bronchoprovocation test? CTRefer to specialist12 COPDCHRONIC OBSTRUCTIVE PULMONARY DISEASE13Chronic obstructive pulmonary diseaseDefinition: an inflammatory respiratory disease, mostly by tobacco smokeExposure to cigarette smoking, airway inflammation, airflow obstruction that is not fully reversible14COPDChronic bronchitis and emphysema are no longer included in the definition of COPD, though still used clinicallyAsthma is the most often confused with COPD15Risk factorsCigarette smokingPersons who smoke, 12-13 times likely to die from COPD2nd hand smokeAdvancing ageEnvironmental or occupational pollutantsAlpha 1 antitrypsin deficiencyFamily history of COPD16Occupational exposuresMineral dust: coal mining, tunnel work, concrete, silica exposureOrganic dust: Cotton, flax, Noxious gas: Sulfur dioxide, isocyanates, heavy metal, welding fumes17pathophysiologyChronic airway irritationMucus production > decreased mucociliary functionPulmonary scarring/airway scarringLeads to hallmark of COPD Sx.> coughing and sputum production >Progressive airway obstruction and dyspnea18COPD is more common and fatal in women than menLung sizeMore hyperresponsive to irritants19Clinical historyHallmark SymptomsCough, increased sputum production, dyspnea (good predictor of mortality)Less common : edema, chest tightness, weight loss, nocturnal awakenings

20Differential diagnosis??????????21Differential diagnosisAsthmaCHFBronchiectasisLung cancerInterstitial lung disease/fibrosisTB22Clinical historyPatient and family historyHistory of tobacco usePack years = number of packs smoked per day multiplied by number of years smokedOccupational historyJob activities23Family history of Alpha 1 antitrypsin deficiency, genetic anomaly of chromosome 14 leads to premature hepatic and pulmonary diseaseIncrease tissue damage from neutrophil elastase> alveolar damage> loss of elastic recoil> airway obstruction24Alpha 1 antitrypsin deficiciency59,000 Americans have Sx. COPD caused by alpha 1 antitrypsin deficiencyScreening in symptomatic adults with persistent obstruction on pulmonary function test25Physical examNot sensitive initiallyLung hyperinflationWidened A-P chest diameterHyperresonance on percussionCor pulmonale- peripheral edema, JVD, hepatomegalyCyanosis, cachexiaClubbing (rare), looking for cancer,fibrosis, brochectasis26Diagnostic testingSPIROMETRYShould perform in all smokers 45years or olderKey features: FEV1 FVC ( forced vital capacity)

27FEV1 the volume of air patient can expire in one second following full inspirationFVC -- total maximum volume of air patient can exhale after a full inspiration28Diagnosis of COPDPostbronchodilator FEV1/FVC ratio of less than 0.7 associated with FEV1 less than 80% of predicted value is diagnostic of airflow limitation and confirms COPD

Peak expiratory flow rates are not helpful in diagnosis of COPD29Other diagnostic testSpirometry is the key testCXRCT chestEKGCBCPulse oximetry 30pharmacotherapyBronchodilatorBronchodilatorBronchodilatorBronchodilatorBronchodilatorbronchodilator

31Short acting beta 2 agonistsBeta 2 agonists: stimulate beta 2 receptors, increase cyclic AMP, increase smooth muscle relaxation, lung emptying and air trappingShort acting: Proventil, Ventolin, Proair, XopenexSide effects: Tachycardia, cardiac disturbance, tremors32Long acting beta 2 agonistsMaintenance therapyLonger lasting improvementSalmeterol (Serevent Diskus)Formoterl (Foradil)33Short acting Anticholinergic agentsSmooth muscle relaxation of airwaysAntagonism of acetycholine at M3 receptors on airwaySlower onset of action than beta 2 but longer durationSide effects: Caution w/ glaucoma, BPHIpratropium (Atrovent)34Long acting Anticholinergic agentsSustained action over 24 hoursTiotropium (Spiriva) 24% lower of number exacerbation than Ipratropium35CorticosteroidsAct at multiple points in inflammatory processIncrease FEV1NOT APPROVED FOR SINGLE USE AGENT IN COPDRecommend as addition to maintenance therapySide effects: bruising, candidiasis, voice alteration36Combination therapiesBeta 2 + anticholinergic agent (Combivent)Corticosteroid + long acting Beta 2 (Advair) (Symbicort)37Acute exacerbation of COPDSustained worsening of patients condition from stable state and beyond normal day to day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD38Infectious agents80% gram positive and gram negative bacteriaNosocomial30% viruses5-10% atypical bacteria39Treatment other than bronchodilatorsAntibioticsSmoking cessationPulmonary RehabilitationOxygen therapy: PaO2 < 55mmHg or O2 sat < 88%Long term use increase survival40 COPDASTHMAAGE >4010 pk yrsSputum oftenAllergies infreq.Progressive worseClinical Sx. PersistentAirflow partial reversible 8 mm nodulesWorrisome (18% malignancy)Follow aggressively in 3 months or sent for biopsyRegardless of risk factorsConsider PET or biopsy105Clues to diagnosis malignancyCT appearance- calcification, edge characteristics, growth rate, popcorn appearanceEnhanced CT and positron-emission tomographyBiopsy 106Lung Cancer ScreeningNo guidelines recommend in favor of routine CT screening for lung cancerScreening may not reduce deaths from lung cancerNo decline in number of advanced cases diagnosed or deaths from lung cancerNo relationship between tumor size and survival107Take-home pointsCT screening will uncover many benign nodules likely to receive intensive follow upLung nodules 8 mm in diameter or smaller are likely benignTraditional nodule characteristics predict malignancy are less useful with very small nodules

108Take-home pointsSurveillance with serial chest CT is recommended once they are foundNo guidelines from any professional organization recommend in favor of routine CT screening for lung cancer109 ALPHA 1 ANTITRYPSIN DEFICIENCY110Alpha-1 antitrypsin deficiencyAutosomal codominant conditionPredisposes to emphysema and liver disease100,000 Americans are severely deficient

111Alleles antitrypsin activityM-normalS-intermediateZ-marked decreaseNull-absent (rare)112Phenotypes of antitrypsin deficiencyMM, MS, MZ, no increased riskSZ, mild increased riskZZ, most common severe deficient variant, accounting more than 90% of people with severe alpha-1 antitrypsin deficiency (single amino acid substitution of the protein)113ZZ phenotypeAssociated with emphysema and 10% of chronic liver diseasesLiver disease (neonatal jaundice to cirrhosis to hepatoma)Panniculitis (inflammatory disease of subcutaneous tissue with ulcerating and painful skin lesions)Vasculitis positive for C-ANCA114Clinical presentationsNo different than COPD or cirrhosisOn set of airflow obstruction before 50Family history of liver or lung diseaseEmphysema occurring in nonsmoker or very light smokerPersistent or worsening Sx despite treatmentBasilar hyperlucency >> than apical115Testing for alpha-1 antitrypsin deficiencyVery inexpensiveSerum alpha- antitrypsin levelIf below 100mg/dl, phenotyping116Why is it important?Mean duration between first symptom and initial diagnosis was 8.4 yearsMean number of physicians seen between first Sx and diagnosis was 4 physicians 117Treatment Smoking cessationGenetic counselingAugmentation therapy with recombinant alpha-1 antitrypsin inhibitors118PLEURISY AND PLEURAL EFFUSION PLEURISY119PleurisyInflammation of the parietal pleura that results in characteristic pleuritc pain with variety of causesPleuritic pain is the key feature

120Pathophysiology of pleurisyVisceral pleura has no nociceptors or pain receptorsParietal pleura innervated by somatic nerves that sense painInflammation extend to pleural space involve parietal pleura, thus resulting pain

121PathophysiologyParietal pleurae of the outer rib cage and lateral aspect of each hemidiaphragm innnervated by intercostal nervesPhrenic nerve innervate central part of each hemidiaphragmWhen fibers are activated, sensation of pain is referred to ipsilateral neck or shoulder122Differential diagnosis of pleurisy (ppppm)Patient presented with pleuritc chest pain, need to rule out:Pulmonary embolismPneumothoraxPericarditisPneumoniaMI

123Once ruled out PPPPMcommon causes of pleurisyViruses (most common): influenza, parainfluenza, coxsakieviruses, RSV viruses mumps, EBVBacterial, TBRenal: CRF, Rheumatologic: Lupus, RA, SjogrenCardiac: post cardiac injury, post MI (dresslers), post pericadiotomyAsbestosisMalignancy, sickle cell124Presentation of pleurisyPleuritic pain localized to area of inflammation or referred pathwayExacerbates with breathing, talking, coughing or sneezingSharp pain worsened with movementLimits motion 125Evaluation of pleurisyHistory and physical examChest X rayIf abnormal >>Pneumonia? Pnemothorx? Cardiomegaly? P.E. ? 126Evaluation of pleurisyIf CXR is normal >> MI, Pulm embolism?EKG abnormal >> MI, PE, PericarditisEKG normal, no suggestion of PE, MI, look for other causes, Viral127Physical exam of pleurisyFriction rub with inspiration or expirationDue to surfaces between parietal and visceral pleurae rub against one another with inflammationDecreased breath sounds, ralesNormal physical with serious conditionHigh index of suspicion128Diagnostic testsChest X ray for pleural effusion, pneumonia, pulmonary embolism, pneumothoraxEKG for MI, pulmonary embolism, pericarditis129Treatment of PleurisyControl pleuritic chest painTreat underlying conditionNSAIDS do not suppress respiratory efforts or cough reflexLimited to IndomethacinSteroids are controversial130PLEURAL EFFUSIONSMost common causes are:Congestive heart failurePneumoniaMalignancyPulmonary embolism131Pathophysiology of Pleural effusionsPleural fluid originates in capillaries of parietal pleura and drained by lymphaticsMore fluid formed > absorbedPleural fluid can originate from interstitial lung spaces, lymphatics and peritoneal cavity132Pathophysiology of pleural effusionsCongestive heart failure

Nephrotic syndrome


Parapneumonic effusion

Hepatic hydrothorax

Increased hydrostatic pressure of vessels

Decreased oncotic pressureObstruction of lymphaticsIncreased capillary permeability

Increased peritoneal fluid

133Subpulmonic effusionsWhen fluid becomes loculated between lower aspect of lung and diaphragm134Parapneumonic effusionsPleural effusions associated with bacterial pneumonia135EmpyemaPleural effusions associated with lung abscessCarry higher mortality than pneumonia and abscess without effusions136Clinical presentationDiffer according to etiologyAsymptomaticDyspnea, pleuritc chest painNonproductive coughFever

137Physical examDullness on percussionDecreased or absent breath soundsDecreased tactile fremitus

138Diagnosis and evaluationChest X ray- PA and lateralBlunting of posterior costophrenic angleElevated hemidiaphragm- suspect subpulmonic effusionUltrasound useful to identify loculated fluidCT scanThoracentesis 139THORACENTESISEXUDATEParapneumonicEmpyemaTBMalignancyRA / lupusChylothoraxTRANSUDATECHFCirrhosisAtelectesisNephrotic syndromePE140EXUDATE TRANSUDATEProtein/ LDHWBC > 1000/ differentialNeutrophils= bacterialLymphocytes = TB,CAGram stainsGlucose < 60ANAAmylaseTriglycerides

WBC 2/3 of serum LDH141TreatmentTreat underlying conditionsTherapeutic thoracentesisChest tube drainageThoractomy with decorticationPleurodesis (fusion of visceral and parietal pleural to prevent recurrence of effusion)142PNEUMOTHORAXIntroduction of air into pleural spaceSpontaneous or trauma or iatrogenic

143Spontaneous pneumothoraxNo clinically apparent diseasesMen > womenTall, thin male under 40 smokes or notRadiographically inapparent subpleural bullaeMay be associated physical activities144Secondary spontaneous pneumothoraxAsthma, COPDInterstitial lung diseasesPneumocystis carinii pneumoniaMarfans syndrome145Clinical presentation of spontaneous pneumothoraxIpsilateral pleuritc chest painDyspneaTachycardiaShift of trachea by examHyperresonance to percussionDecrease breath soundsHypotension 146Diagnosis PeumothoraxChest X rayChest CT for bullae147Treatment of pneumothoraxCatheterChest tubeSurgerypleurodesis148 VENOUS THROMBOEMBOLIC DISEASES 149VENOUS THROMBOEMBOLIC DISEASEDeep Vein ThrombosisPulmonary Embolism150Deep venous thrombosis (DVT)Venous stasis from immobilityVirchows triadVenous stasisVessel wall damageIncreased blood coagulability151Clinical risk factorsRecent surgeryMajor traumaPrevious DVTIncreasing agePregnancy, postpartumOral contraception/smokeImmobilityConnective tissue disease

152Familial thrombophilic diseaseActivated protein C resistance (factor V leiden),defect in factor VProthrombin 20210A, gene defect with increased prothrombin and thrombinProtein C and S deficiencyAntithrombin III deficiency

153Clinical presentationLeg pain and swellingHomans sign, less than 40%Calf to thigh swelling and tendernessMost are asymptomaticBE ALERT

154Complication of DVTPulmonary EmbolismThigh/Proximal DVT associated with PE70-90% of patients with symptomatic PE have silent thigh DVT155Diagnosis Clinical prediction rulesWELLS PREDICTION RULESEstablish the pretest probability of VTEEstimate the probability of DVT and PE before performing and interpreting other diagnostic testsBest applied to younger patient without other comorbidities156D-Dimer AssayMost often ordered by ER physiciansEnzyme linked immunosorbent assay (ELISA)Negative D-Dimer in younger patients whose pretest probability is low excludes VTEIn older patients with comorbidities and long duration of Sx, D-Dimer not enough157UltrasonographyHigh Specificity and sensitivity for diagnosing proximal DVT of LE for those who are symptomaticRecommended for patients who are at intermediate and high risk for DVTShould be repeated if suspected case where initial test is negativeContrast venography is the definite test158Helical computed tomography (CT)Higher specificity and sensitivity compared with pulm arteriography for PEVQ scan for those with high pretest probability159Wells prediction rule for DVTAlternative diagnosis as likely as DVT -2Active cancer 1Calf swelling 3cm > asymptomatic side 1Collateral superficial vein 1 Paralysis, paresis or recent plaster cast 1Pitting edema on symptomatic leg 1 Recent bedridden >3days/major surgery within 12 weeks 1 Swollen leg 1

160Wells prediction rule for DVTClinical probability of DVT is Low if score 0 or lessIntermediate 1 or 2High if 3 or more161Wells prediction rule for PECancer1Hemoptysis1HR > 100bpm 1.5Previous PE or DVT1.5Recent surgery/immobil1.5Alternative Dx less likely3Clinical signs of DVT3162Wells prediction of PEProbability of PE if score 0-1 low

2-6 intermediate

7> high 163Management of VTELow-molecular-weight Heparin (LMWH)Superior than unfractionated heparin for DVTFor PE, either LMWH or heparinLess risk of major bleeding Recommended for initial inpatient and outpatient management of VTE164Oral anticoagulationCoumadin (Warfarin)Maintained for three to six months for patients with VTE due to transient risk factorsFor recurrent DVT, 12 months therapyLMWH for those with difficult to control INR (international normalized ratio)165Complication of DVTPost thrombotic syndromeChronic postural dependent pain and edema or localized discomfort, in the context of a history of DVT166Complication of DVTPOST-THROMBOTIC SYNDROMEWear over the counter or custom-fit compression stockingsInitiated within one month of DVTUse at least one year167 THE END168