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Pulmonary Board Review

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Response to bronchodilator testing: ... His pulmonary function testing demonstrates FEV 86% FVC 102% and FEV1/FVC of 64%. Which severity category does he fall into? – PowerPoint PPT presentation

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Title: Pulmonary Board Review


1
Pulmonary Board Review
  • 2010

2
What were going to speed through
  • Evaluation of symptoms cough and dyspnea
  • PFTs
  • Asthma
  • COPD
  • Interstitial lung diseases
  • Pneumoconioses
  • Pleural disease
  • Sleep

3
Chronic cough
  • Definition cough lasting more than
  • 3 weeks
  • 1 month
  • 3 months
  • 1 year

4
Chronic cough
  • Definition cough lasting more than
  • 3 weeks
  • 1 month
  • 3 months
  • 1 year

5
Chronic Cough- Etiology
  • In non-smoking adults with a normal CXR who are
    not taking ACE inhibitors, chronic cough is
    almost always due to which of the following 3
    conditions?
  • Congestive Heart Failure
  • Post-nasal drip syndrome (PNDS)
  • Asthma
  • Gastroesophageal reflux disease (GERD)
  • Chronic Bronchitis

6
Chronic Cough- Etiology
  • In non-smoking adults with a normal CXR who are
    not taking ACE inhibitors, chronic cough is
    almost always due to which of the following 3
    conditions?
  • Congestive Heart Failure
  • Post-nasal drip syndrome (PNDS)
  • Asthma
  • Gastroesophageal reflux disease (GERD)
  • Chronic Bronchitis

7
Respiratory symptoms cough
  • Chronic Cough
  • First Make sure the patient is not on an ACE
    inhibitor
  • Most common etiologies
  • Postnasal drip syndrome
  • Asthma
  • GERD
  • Others
  • Chronic bronchitis
  • Bronchiectasis
  • ACE inhibitor
  • Post-infectious
  • Eosinophilic bronchitis
  • Endobronchial lesion

8
Respiratory symptoms dyspnea
  • The 4 most common etiologies of chronic dyspnea (
    dyspnea lasting gt 1 month) are
  • Cardiomyopathy
  • Deconditioning
  • Interstitial lung disease
  • COPD
  • Asthma

9
Respiratory symptoms dyspnea
  • The 4 most common etiologies of chronic dyspnea (
    dyspnea lasting gt 1 month) are
  • Cardiomyopathy
  • Deconditioning
  • Interstitial lung disease
  • COPD
  • Asthmma
  • These four etiologies account for 2/3 of all
    cases of chronic dyspnea

10
Dyspnea - Assessment
  • Pratter MR, et al. Cause and evaluation of
    chronic dyspnea in a pulmonary disease clinic.
    Arch of Intern Med. 19891492277-82.
  • Asthma (29)
  • COPD (14)
  • ILD (14)
  • Cardiomyopathy (11)
  • Upper airway (8)
  • Psychogenic (5)
  • Deconditioning (5)
  • GE reflux (4)
  • Extrapulmonary (4)

11
Dyspnea - Assessment
  • PFTs, spirometry with bronchodilator, lung
    volumes, flow-volume loop, DLCO, ABG, muscle
    pressures (inspiratory and expiratory)
  • methacholine
  • CXR, CT scan of the chest, PE protocol CT,
    fluoroscopy of the diaphragm
  • 6 minute walk
  • Cardiac echo, right heart cath
  • Chemistries and CBC, proBNP, Mg, CPK, aldolase,
    serologies, TFT
  • EMGs, MRI of the brain
  • Exercise ergotomy

12
PFTs
13
Inhalation to Total lung capacity
Beginning of Forced Expiratory maneuver
Normal tidal breathing
Volume of air Exhaled 1 sec Into forced expiration
Exhalation to Residual volume
14
PFTs Spirometry
  • Approach
  • Is it a good test?
  • reproducible,
  • adequate exhalation time (at least 6 seconds),
  • technician comments regarding patient effort and
    compliance
  • Is there obstruction? FEV1/FVC lt 70 indicates
    obstructive disease. Severity of obstruction as
    follows
  • I Mild FEV1 gt 80 predicted
  • II Moderate FEV1 lt 50-80 predicted
  • III Severe FEV1 lt 30- 50 predicted
  • IV Very Severe FEV1 lt 30 predicted
  • Is there restriction? FVC lt 80 predicted
    indicates possible restrictive disease
  • Is there airway reactivity? Response to
    bronchodilator testing gt 12 or gt 200mL

15
Lung volumes
16
Lung Volumes
17
  • Which of the following can cause a reduced vital
    capacity?
  • Asthma
  • Kyphoscoliosis
  • Pulmonary fibrosis
  • Obesity
  • Myasthenia gravis

18
  • Which of the following can caused a reduced vital
    capacity?
  • Asthma
  • Kyphoscoliosis
  • Pulmonary fibrosis
  • Obesity
  • Myasthenia gravis

19
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20
DLCOThe blood gas barrier
  • Gas exchange surface
  • 50-100 sq meters
  • 0.3 microns
  • Each alveolus is enveloped by pulmonary
    capillaries
  • There are about 500 to 1000 capillaries per
    alveolus!

21
Diffusion Ficks law
  • The amount of gas transferred through a membrane
    is proportional to
  • A area of the membrane
  • D diffusion constant which is determined by
  • Solubiility of the gas
  • Inversely proportional to the square root of the
    moelcular weight
  • Difference in partial pressure
  • Inversely proportional to the thickness of the
    membrane

22
PFTs DLCO
  • Decreased in
  • Diseases that obliterate the alveolar-capillary
    interface
  • Emphysema
  • Fibrotic lung disease
  • Pulmonary vascular diseases pulmonary emboli,
    PAH
  • Diseases that increase the thickness of the
    interface
  • Fibrotic lung diseases
  • Interstitial edema/alveolar edema
  • Anemia

23
PFTs flow volume loops
  • Useful in looking for central airway obstruction

24
Flow volume volumes
25
Obstructive airway diseases
  • 4-8 questions

26
Asthma
  • 22 millions pts per year in U.S.
  • Overall increasing disease prevalence
  • Decreasing number of asthma deaths
  • Significant racial disparities in disease burden
  • Puerto Ricans
  • African Americans

27
Asthma categories of severity 2007 NAEPP report
  • Intermittent
  • Mild persistent
  • Moderate persistent
  • Severe persistent
  • Treatment recommendations based upon severity

28
Classification of severity in treatment naïve
patient
Components of severity Components of severity Intermittent Persistent Persistent Persistent
Components of severity Components of severity Intermittent Mild Moderate Severe
Impairment Symptoms 2 x/week 2 days per week Daily Throughout the day
Impairment Nocturnal awakenings 2x/month 3-4 x/month gt 1/week Near nightly
Impairment SABA use 2x/ week gt 2x/week Daily Several times per day
Impairment Interference with normal activity None Minor Some Significant
Impairment Lung function Normal between exacerbations FEV1 gt80 FEV1 gt 60 FEV1 lt 60
Impairment Lung function Normal between exacerbations FEV1/FVC normal FEV1/FVC reduced 5 FEV1/FVC reducedgt5
Risk Exacerbations requiring systemic steroids 1 per year 2 per year 2 per year 2 per year
Level of severity assigned based upon the single
feature of the highest severity category
29
  • 22 year old man presents because he gets out of
    breath playing basketball after being on the
    court of 30 minutes. He otherwise has no
    symptoms. His pulmonary function testing
    demonstrates FEV 86 FVC 102 and FEV1/FVC of
    64. Which severity category does he fall into?
  • Intermittent
  • Mild persistent
  • Moderate persistent
  • Severe persistent

30
Classification of severity based upon lowest
level treatment required to maintain control
Classification of asthma severity Classification of asthma severity Classification of asthma severity
Intermittent Persistent Persistent Persistent
Intermittent Mild Moderate Severe
PRN short-acting bronchodilator Step 1 Low dose ICS OR Alternative Cromolyn LTRA Step 2 Low dose ICS LABA OR Medium dose ICS OR Medium dose ICS LABA Step 3 or 4 High dose ICS LABA AND Omalizumab, oral corticosteroid Step 5
31
  • Intermittent asthma
  • Symptoms 2 days per week
  • Requirement for rescue albuterol 2 days per
    week
  • Nocturnal awakenings 2 times per month
  • No limitations in ADLs
  • Normal PFTs
  • RX Intermittent albuterol

32
  • Mild persistent asthma
  • Symptoms gt 2 days per week or
  • 3-4 nocturnal awakenings a month or
  • Minor limitation in ADLs
  • AND
  • Normal PFTs
  • RX Step 2 low dose inhaled corticosteroids

33
  • Moderate persistent asthma
  • Daily symptoms or
  • gt 1 nocturnal awakening per week or
  • Moderate limitation in ADLs or
  • Decreased FEV1 but gt 60 and FEV/FVC ratio
    reduced lt 5
  • Rx step 3 in asthma treatment protocol
  • Low dose inhaled corticosteroids LABA
  • Medium dose inhaled corticosteroid

34
  • Severe persistent symptoms
  • Ongoing daily symptoms with significant exercise
    limitation and frequent nocturnal awakenings
  • FEV1 lt 60 or FEV1/FVC reduced by gt 5
  • Rx
  • Step 4 High dose ICS LABA
  • Step 5 High dose ICS LABA systemic
    corticosteroid therapy
  • AND consider omalizumab

35
Asthma syndromes
  • Cough variant asthma
  • Aspirin-induced asthma or triad asthma
  • Exercise induced asthma
  • Occupational asthma
  • Allergic bronchopulmonary aspergillosis

36
Occupational asthma
  • 5 15 of all asthmatics
  • Over 300 agents have been reported to cause OA
  • Different prevalence for specific populations
  • OA may develop in 2.5 for hospital workers
    exposed to latex
  • 2-40 millers and bakers
  • 20 exposed to acid anhydrides
  • 5 exposed to toluene diisocyanate (TDI)

37
  • OA with a latency period specific antigens
    identified, mostly HMW antigens although some LMW
    antigens as well
  • IgE mediated usually HMV antigen with a median
    latency period of 5 years. Atopy is a risk
    factor
  • Non-IgE mediated usually LMW antigens with a
    median latency period of 2 years. Atopy is not a
    risk factor
  • OA without a latency period
  • 1) nonspecific irritant-induced asthma or
  • 2) reactive airways dysfunction syndrome

38
COPD The Burden
  • Affects up to 30 million Americans (5 of adult
    population)1
  • Annual cost more than 30 billion2
  • 70 with COPD are younger than age 65
  • Direct health care costs of 14.7 billion
  • Indirect costs of 15.7 billion
  • Between 1985 and 1995, the number of physician
    visits for COPD increased from 9.3 to 16 million.
  • The number of hospitalizations for COPD in 2000
    was estimated to be 726,000.
  • 2nd leading cause of disability (behind heart
    disease)

1 Petty TL. J Resp Dis. 199718365369.
2 American Lung Association. COPD Fact Sheet.
August 1999.
39
COPD risk factors
  • Tobacco
  • 15-20 1ppd smokers develop COPD
  • 25 2ppf smokers develop COPD
  • Genetic factors Alpha1-antitrypsin deficiency
  • Gender Males more at risk than females
  • Bronchial hyperresponsiveness
  • Atopy and asthma
  • Childhood illnesses
  • Prematurity

40
Exercise Performance Over Time
100
Healthy
80
COPD
Symptoms
60
Rehabilitation at 45 (mild COPD)
FEV1 () Relative to Age 25
Disability
40
20
Rehabilitation at 65 (severe COPD)
Death
0
50
75
25
0
Age (years)
Adapted from Fletcher et al. BMJ.
197711645-1648.
41
GOLD Classification of Severity of COPD
Stage Characteristics
0 At Risk Normal spirometry Chronic symptoms (cough, sputum production)
I Mild COPD FEV1/FVC lt70 percent FEV1 80 percent predicted
II Moderate COPD FEV1/FVC lt70 percent FEV1 50-80 percent predicted
III Severe COPD FEV1/FVC lt70 percent FEV1 30-50 percent predicted
IV Very Severe COPD FEV1/FVC lt70 percent FEV1 lt30 percent predicted or FEV1 lt50 percent predicted plus respiratory failure
42
COPD
  • Treatment
  • Smoking cessation
  • Oxygen therapy
  • Medical therapy
  • Pulmonary rehabilitation
  • LVRS
  • Transplantation

43
Clinical Algorithm for the Treatment of COPD
Nonpharmacologic Therapy
GOLD Stage(approximate)
Clinicalstage
Inhaled Therapy
0
Smoking cessation Avoidance of exposure
At risk
Intermittentsymptoms
I
Vaccination(influenza, pneumococcal)
Short-acting bronchodilator as needed(for
example, ipratropium, salbutamol, or combination)

Persistentsymptoms
II
Salmeterol or formoterol ipratropium,
salbutamol, or combination
Tiotropium albuterol
Pulmonary rehabilitation(Exercise prescription)
Salmeterol or Formoterol Tiotropium
Tiotropium salmeterol or formoterol
Frequentexacerbations
III
Tiotropium salmeterol or formoterol inhaled
corticosteroid
IV
Supplemental oxygen Lung volume reduction
surgery Lung transplantation
Respiratory failure
Four-step algorithm for the implementation of
inhaled treatment Pathway on left is
recommended pathway on right side is a valid
alternative Defined as need for rescue
medication on more than 2 occasions per week A
short-acting bronchodilator can be used for
rescue. Low-dose methylxanthines can be
prescribed if the response to inhaled
bronchodilator therapy is insufficient
Defined as 2 or more exacerbations per
year. Cooper et al. BMJ. 2005330640-644. (B)
44
Restrictive lung disease/ Interstitial lung
disease/DPLD
  • Up to 5 questions

45
Restrictive lung disease
  • Definition
  • Any disease process that results in a decrease in
    total lung capacity
  • Interstitial lung disease
  • CHF
  • Obesity
  • Neuromuscular disease
  • Thoracic cage disease
  • Pleural disease

46
Classification
ATS/ERS International Multidisciplinary Consensus
Classification of IIP. AJRCCM 2002
47
Normal CXR
Patient 1 CXR
48
Workup of ILD Hx PE
  • Occupation
  • Travel
  • Drugs
  • Pets
  • Hobbies
  • Systemic symptoms
  • Smoking
  • Family Hx
  • Clubbing
  • Bibasilar rales
  • Signs of cor pulmonale
  • Lymphadenopathy
  • Rash
  • Arthritis
  • Fever

49
ATS/ERS International Multidisciplinary Consensus
Classification of IIP. AJRCCM 2002
50
Studies
  • CBC with diff
  • ESR
  • Renal liver function
  • Urinalysis
  • ANA/ ANCA/RF
  • EKG
  • Chest Xray
  • ABG
  • 6 min. walk
  • PFTs
  • DLCO
  • HRCT
  • Bronchoscopy with BAL TBBX if you are thinking
    of specific disease entities

51
  • Which is the earliest PFT abnormality seen in
    interstitial lung disease?
  • Decreased vital capacity
  • Decreased total lung capacity
  • Decreased residual volume
  • Increase in mid flows (FEF 25-75)
  • Decrease in DLCO

52
  • Which is the earliest PFT abnormality seen in
    interstitial lung disease?
  • Decreased vital capacity
  • Decreased total lung capacity
  • Decreased residual volume
  • Increase in mid flows (FEF 25-75)
  • Decrease in DLCO

53
PFTs in ILD
  • Earliest sign is a widened A-a gradient or
    desaturation with exercise
  • Decreased DLCO precedes restrictive FVC, FEV1,
    TLC and RV
  • Flows as seen by FEV1/FVC ratio are supernormal
    due to increased elastic recoil in pure
    restrictive disease
  • However, in specific diseases or mixed disease,
    you can see a mixed obstructive/restrictive
    picture
  • Hypercarbia is a late, preterminal finding

54
DPLD radiologgy
  • Chest Xray can be normal in
  • 10-15 patients with diffuse lung disease
  • 30 patients with bronchiectasis
  • 60 patients with emphysema
  • High resolution chest CT
  • Sensitivity of 90 and specificity approaching
    100
  • Can provide a confident diagnosis in 50 cases
    93 of these cases are ultimately proven correct
  • Findings usually seen in DPLD
  • Ground glass opacity
  • Findings consistent with fibrosis
  • Interlobular and intralobular septal thickening
  • Honeycombing

55
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56
HRCT findings linear and reticular opacities
  • Intralobular interstitial thickening
  • fine reticular pattern with lines of opacity
    separated by a few mmm
  • Fine lacy or netlike appearance
  • When seen in fibrosis, often seen in conjunction
    with dilated bronchioles (bronchiolectasis)
  • DDX
  • IPF
  • Chronic hypersensitivity pneumonitis
  • Pneumoconioses
  • ILD NSIP, DIP
  • Lymphangitis carcinomatosis
  • Pulmonary edema
  • Pulmonary hemorrhage
  • Pneumonia
  • Alveolar proteinosis

57
Figure 3-24
58
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59
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60
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61
IIPs and HRCT rules of thumb
Diagnosis Typical distribution Typical radiographic features
IPF (UIP) Peripheral subpleural Basilar Reticular, honeycombing Traction bronchiectasis and bronchiolectasis Architectural distortion, modest ground glass
NSIP Peripheral subpleural Basilar Ground glass opacities predominent Reticular opacities present
COP Subpleural and peribronchial Patchy bilateral consolidation
AIP Diffuse Consolidation and ground Traction bronchiectasis occurs later
DIP Lower lung zone Peripheral predominance (mostly) Ground glass Reticular lines
RBILD Diffuse and can be upper Bronchial wall thickening Centrilobular nodules Patchy ground glass
LIP Diffuse Centrilobular nodules, ground glass, septal and bronchovascular thickening. Thin-walled cysts
62
Diagnosis
  • Bronchoscopy
  • BAL limited utility
  • Look for eosinophilia (gt 10)
  • Lymphocytosis
  • Mast cells
  • Biopsy limited utility
  • Helps if high pre-test probability of
    sarcoidosis, HP, LIP, lymphangitic carcinomatosis
  • Dismal if you are thinking UIP or NSIP

63
IPF or Usual Interstitial Pneumonitis
  • gt 60 of all cases of IPF
  • age gt 50 with 2/3 gt 60 MgtF
  • prevalence 10-20 cases per 100,000 pop.
  • Risk factors smoking, chronic aspiration, metal
    wood dust, viruses, genetic - autosomal
    dominant with variable penetrance
  • Median survival after Dx 2.8 years.

64
ATS/ERS International Multidisciplinary Consensus
Classification of IIP. AJRCCM 2002
65
ATS/ERS International Multidisciplinary Consensus
Classification of IIP. AJRCCM 2002
66
Example of disease progression over time
ATS/ERS International Multidisciplinary Consensus
Classification of IIP. AJRCCM 2002
67
UIP Continued
  • Histopathology
  • Temporally heterogeneous
  • Fibroblastic foci
  • Interstitial inflammation is only mild to
    moderate with infiltration by
  • Lymphocyte
  • Plasma cells
  • Histiocytes
  • Full spectrum of fibrosis

68
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69
Nonspecific Interstitial Pneumonitis
  • Second most common IIP
  • Clinical presentation
  • DOE cough for months to years
  • Flu-like symptoms may precede or co-exist
  • Median age of onset 40 to 50
  • W gt M
  • No association with smoking
  • Examination
  • 10-35 patients have clubbing
  • Most have crackles
  • Chest Xray - lower zone reticular opacities

70
NSIP CT scan
ATS/ERS International Multidisciplinary Consensus
Classification of IIP. AJRCCM 2002
71
NSIP
  • Path temporally uniform with interstital
    inflammation
  • Rad ground glass with areas of fibrosis
  • Often also seen with CTD such as scleroderma

72
Cryptogenic organizing pneumonia
  • First described 1983
  • Clinical presentation
  • M F
  • Mean age 55 years
  • Mean symptom duration 3months cough, dyspnea,
    weight, seats, chills, fevers and myalgias
  • Labs Elevated ESR, CRP, and ANC
  • BAL
  • Lymphocytosis (can be gt 40)
  • CD4CD8 decreased

73
COP radiographic findings
  • gt90 with areas of consolidation on CT
  • Tends to be patchy
  • Subpleural or peribronchial distribution in up to
    50 cases
  • 60 with ground glass attenuation usually seen
    associated with the areas of consolidation
  • 10-50 cases with small nodular opacities
  • 15 cases with large nodular opacities (gt 1cm)
  • Tend to have an irregular margin with air
    bronchograms /- pleural tags, spicules, pleural
    thickening, and parenchymal bands
  • Minority with a reticulonodular pattern

74
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75
Histopath Organizing pneumonia
  • Histopathologic correlate Organizing pneumonia
    within the alveolar ducts and alveoli /-
    organization within the bronchioles
  • Intraluminal organizing fibrosis
  • Patchy distribution with preservation of the lung
    architecture and associated mild interstitial
    chronic inflammation
  • You do NOT see interstitial fibrosis,
    granulomas, neurophils, necrosis, airspace fibrin
  • Non-specific and seen with a multitude of
    clinical conditions!
  • COP
  • Organizing DAD
  • Organizing infection
  • Organizing aspiration pneumonia
  • Organizing drug reactions, inhalational injuries
  • Collagen vascular disease
  • HP
  • Eosinophilic lung disease
  • IBD
  • Reparative reaction around abscesses, neoplasms,
    Wegenerss, etc..

76
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77
AIP
  • Rapidly progressive form of ILD
    histopathologically indistinguishable from ARDS
  • Clinical presentation
  • Wide age range although mean age 50
  • No gender predominance and no association with
    tob
  • Typically prior illness consistent with viral URI
  • Median time from first symptoms to presentation lt
    3 weeks
  • No proven treatment
  • Mortality rate 50 with most deaths occurring
    within 1 to 2 months of illness onset
  • Most survivors experience recurrence and chronic
    progressive ILD

78
DIP/RBILD smoking related ILD
  • RBILD
  • Clinical presentation
  • Current smokers usually 40 to 50 years old
  • Average gt 30 pack years when it occurs in
    younger smokers, typically seen with heavier
    tobacco use
  • M gt W
  • PFTS Usually primarily obstructive physiology
    with a decrease in transfer factor
  • Radiology
  • Centrilobular nodules
  • Patchy ground glass
  • Thicekning of bronchial walls
  • Mosaic pattern due to air trapping
  • BAL fluid contains pigmented macrophages /-
    modest increase in neutrophils
  • Histopath Pigmented intraluminal macrophages
    within the first and second order respiratory
    bronchioles
  • DIP
  • Considered to represent the end of a spectrum of
    RBILD
  • Rare lt 3 of all ILDs
  • Clinical manifestations
  • 90 are smokers, MgtF
  • age - 40s,
  • Clubbing in 50
  • Subacute illness with dyspnea cough, fatigue,
    weight loss, weakness, chest pain
  • Chest Xray is normal in 20
  • Survival 70 10 yrs., steroids help 60

79
DIP/RBILD
  • Path
  • Pigmented macrophages
  • Peribronchiolar inflammation
  • Rad
  • Patchy ground glass
  • Intralobular septal thickening
  • Mosaic pattern

80
DPLD Hypersensitivity pneumonitis
  • Disease of varying intensity and manifestation
    caused by the immunologic response to inhaled
    antigen, usually organic
  • Hundreds of antigens have been described.
    Occupations with highest frequency of HP
  • Farmers Farmers lung
  • Poultry workers Poultry workers lung, Bird
    breeders lung, Bird fanciers lung
  • Animal workers
  • Grain processing Grain handlers lung
  • Textiles
  • Lumber
  • Also described with inhalation of contaminated
    water
  • Humidifier lung, Air conditioner lung, Hot
    tub lung

81
Subacute HP
Mostly mid to upper lung zones
82
Chronic HP
83
HP Treatment and prognosis
  • Treatment
  • Remove the inciting antigen from the environment
    or remove the patient from the environment
  • Corticosteroids for severe cases
  • Prognosis
  • Acute and subacute disease have excellent
    outlooks
  • Chronic can progress to end stage fibrosis

84
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85
Sarcoidosis Four stages
86
Sarcoidosis in the lungs Stage I
  • Only the lymph nodes are enlarged
  • Pulmonary function is intact
  • 55-90 pts with Stage I sarcoidosis resolve
    spontaneously

87
Sarcoidosis Stage II
  • Lymph nodes enlarged
  • Inflammation in the lung
  • Lung function is impaired
  • 40-70 pts resolve spontaneously

88
Sarcoidosis Stage III
  • Lymph nodes are not enlarged
  • Only 10-20 resolve spontaneously

89
Sarcoidosis
  • 90 with lung involvement
  • 75 liver
  • 20 skin
  • 20 eyes
  • 25 spleen
  • 10 MSK
  • 5 heart
  • 5

90
Occupational lung diseases
  • Up to 4 questions

91
Occupational and environmental lung diseases
  • Occupational asthma
  • Hypersensitivity pneumonitis
  • Pneumoconioses

92
Pneumoconioses
  • Silicosis
  • CWP
  • Asbestosis
  • Talcosis
  • Berylliosis

93
Silicosis Exposure
  • Mining
  • Quarrying
  • Tunneling
  • Stone cutters
  • Sandblasting
  • Glass manufacturing
  • Foundry work
  • Enameling
  • Quartz crystal manufacturing
  • Rubber industry

94
Silicosis clinical presentations
  • Chronic silicosis
  • Accelerated silicosis
  • Progressive massive fibrosis
  • Acute silicosis

95
Chronic silicosis
  • Usually 10-30 years after initial exposure.
  • Can become radiographically apparent even after
    removal of exposure
  • Ranges from asymptomatic with normal PFTs to very
    very symptomatic with restrictive spirometry and
    low DLCO

96
Chronic silicosis CXR findings
  • Simple silicosis is the earliest finding of
    chronic silicosis
  • Nodules usually 1-3 mm

97
Chronic silicosis CXR findings
  • As disease progresses, nodules increase in number
    and coalesce to form larger lesions

98
Chronic silicosis CXR findings
  • Eggshell calcification

99
Progressive massive fibrosis (PMF)
  • Occurs in a minority of pts with chronic
    silicosis
  • More likely to occur in pts with accelerated
    silicosis
  • PFTs abnormalities mixed obstructive/restriction,
    air trapping

100
PMF CXR findings
  • The nodules coalesce into conglomerate masses
  • Calcified lymph nodes eggshell calcification

101
Coal workers pneumoconiosis
  • AKA, black lung disease or anthrasilicosis
  • Rate and quantity of dust accumulation most
    important factor in pathogenesis of CWP
  • Clinical presentations similar to silicosis
  • Simple
  • Chronic
  • PMF

102
Asbestos-related lung diseases
  • Pleural plaques
  • Pleural fibrosis
  • Benign asbestos related pleural effusion
  • Asbestosis
  • Mesothelioma

103
Asbestos Pleural plaques
  • Usually first identified gt 20 years after initial
    exposure
  • Occur in 50 persons exposed to asbestos
  • Parietal pleura adjacent to ribs, particularly
    along 6th-9th ribs and along diaphragm
  • Calcifications on CXR in 20 and on chest CT in
    50

104
Asbestos Pleural plaques
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106
Pleural fibrosis
  • Very rare, progressive process characterized by
    diffuse pleural fibrosis
  • Can be exacerbated with concurrent administration
    of medications such as bromocriptine

107
Benign asbestos pleural effusion
  • Most common pulmonary manifestation within the
    first 20 years of exposure but can present lt1
    post-exposure to gt50 years after first exposure
  • Typical presentation acute pleuritic CP, fever,
    other systemic sx but can be insidious
  • Can resolve spontaneously
  • Pleural fluid analysis exudative,
    serosanguinous, predominance of eosinophils,
    cytology with atypical macs, occasionally
    positive for RF
  • Rounded atelectasis and/or diffuse pleural
    thickening may be sequelae

108
Rounded atelectasis
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Asbestos Mesothelioma
  • Annual incidence 11,000,000/year
  • Incidence peaking now b/c of inadequate control
    measures in 60s and 70s
  • Any level of exposure may be a risk factor
  • Usually presents 20-40 years after exposure

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Asbestosis
  • Presents gt 30 years after initial exposure
  • Requires long term, heavy exposure
  • Criteria for diagnosis
  • History of asbestos exposure
  • Dyspnea
  • Basilar crackles in two or more locations
  • Reduced lung volumes
  • Radiographic abnormalities

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Talc related diseases
  • Talcosilicosis caused talc mined with a high
    silica content
  • Talcoasbestosis crystalline talc contaminated by
    asbestos fibers
  • Talcosis inhalated of pure talc leading to
    bronchitis
  • IV talc injection from cutting heroin with talc
    ? formation of granulomas within the pulmonary
    vasculature ? pulmonary hypertension

112
Berylliosis
  • Think aerospace, automotive, computer, ceramics,
    and nuclear industries
  • Clinical manifestations
  • Acute disease due to direct irritant effects
    rhinitis, pharyngitis, tracheobronchitis,
    chemical pneumonitis
  • Chronic disease Think sarcoidosis except we have
    an etiology. Dx finding beryllium somewhere or
    lymphocyte transformation test.

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Pleural disease
  • Up to 4 questions

114
Diagnostic evaluation of pleural effusion
  • Thoracentesis
  • Helpful in 75 cases
  • Can be therapeutic as well
  • Routine labs
  • LDH, total protein, glucose, pH, gram stain and
    culture, cytology, cell count and differential
  • Additional labs that may also be helpful
  • Albumin, cholesterol, triglycerides, amylase,
    adenosine deaminase, AFB

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Pleural fluid analysis Lights criteria
  • Pleural fluid protein/serum protein gt 0.5
  • Pleural fluid LDH / serum LDH gt 0.6
  • Pleural fluid LDH gt 2/3 upper limits of normal
    for serum LDH
  • Very accurate at identifying exudates (98) but
    less accurate with transudates

116
Pleural fluid analysis Other pleural chemistries
to help differentiate exudate from transudate
  • Cholesterol
  • Absolute pleural fluid cholesterol gt 45- 60mg/dL
  • Pleural fluid albumin gradient lt 1.2 g/dL
  • Bilirubin pleural fluid bilirubin/serum
    bilirubin gt 0.6

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Pleural fluid analysis cell count
  • Red blood cells
  • Blood-tinged fluid typically 5000 to 10000
    RBC/mm3
  • Grossly bloody 100000 RBC mm3
  • Trauma
  • Malignancy
  • Pulmonary embolism
  • Infection
  • Hemothorax pleural fluid hct to blood hct gt 50

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Pleural fluid analysis Cell count and
differential
  • Neutrophils
  • Typical of acute inflammatory process
  • Eosinophils gt 10
  • air, blood most common etiologies.
  • Other
  • Parapneumonic 1,
  • malignancy, tuberculosis, BAPE, drugs
    (dantrolene, bromocriptine, nitrofurantoin),
    parasites, Churg-Strauss
  • Lymphocytes gt 50
  • malignancy, tuberculosis (sarcoidosis, s/p CABG)
  • Mesothelial cells
  • Uncommon in tuberculous effusions. Major
    exception AIDS

119
Pleural fluid analysis Glucose
  • Glucose lt 60mg/dL suggestive of the following
    disorders
  • Parapneumonic effusion
  • the lower the glucose, the more complicated the
    effusion
  • Malignant effusion
  • 15-25 pts with malignant effusion have low
    pleural glucose levels. The lower the glucose,
    the higher the tumor burden
  • Rheumatoid disease
  • majority of pts with rheumatoid effusion (78)
    have pleural glucose lt 30mg/dL
  • Tuberculous effusion
  • Rare Paragonimiasis, hemothorax, Churg-Strauss,
    lupus

120
Pleural fluid analysis amylase
  • Elevated levels suggestive of 1 of 3 dx
  • Pancreatitis often higher than serum levels
  • Pseudocyst communication amylase gt 1000U/L
  • Esophageal rupture
  • Malignant effusions amylase level elevated in 10

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Pleural fluid analysis pH
  • pH lt 7.2
  • Parapneuymonic effusion
  • Esophageal rupture
  • Rheumatoid pleuritis
  • Tuberculous pleuritis
  • Malignant pleural disease
  • Hemothorax
  • Systemic acidosis
  • Paragonimiasis
  • Lupus pleuritis
  • Urinothorax
  • Reasons for caution
  • Often not measured correctly must be measured
    using a blood gas machine
  • Must be collected in a heparinized syringe
  • Lidocaine may falsely lower the pH

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Pleural fluid analysis some pathognomic findings
  • ADA level gt 50 U/L in pts without empyema or
    rheumatoid arthritis is virtually diagnostic of a
    tuberculous effsuion
  • Interferon-gamma level gt 3.7 U/mL also quite good
    at distinguishing tuberculous effusions
  • RF Pleural fluid titer gt 1320 strongly
    suggestive of rheumatoid effusion
  • ANA tends to correlate with serum ANA
  • Triglycerides gt 110 mg/dL ? diagnostic of
    chylothorax
  • Pus or positive culture ? empyema

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Parapneumonic effusionsACCP recommedations
  • Class I Small lt 10mm on decubitus film
  • No thoracentesis needed
  • Class II Typical parapneumonic effusion
  • More than 10mm on decubitus film ? needs sampling
  • Pleural fluid characteristics
  • Glucose gt 40
  • pH gt 7.2
  • LDH lt 3x ULN
  • Treatment antibiotics alone
  • Class III Borderline complicated
  • pH 7.0 -7.2 or LDH gt 3x ULN
  • Normal glucose
  • Negative pleural micro
  • Treatment Antibiotics plus serial thoracenteses
  • Class IV through VII Complicated
  • pH lt 7.0 or glucose lt 40 or pleural fluid micro
    positive ? tube thoracostomy

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Sleep disordered breathing
  • Obstructive sleep apnea
  • RFs
  • Obesity
  • Facial soft tissue abnormalities
  • Smoking!
  • Nasal congestion
  • DM
  • Mild
  • AHI 5-15
  • Sedentary daytime sleepiness
  • Sats gt 90 more than 95 of time during sleep
  • Moderate
  • AHI 15-30
  • Daytime sleepiness requiring behavioral changes
  • Severe
  • gt 30
  • disabling daytime sleepiness and signs of
    cardiopulmonary failure
  • Nocturnal sats lt 90 more than 20 of the time

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Sleep disordered breathing
  • Outcomes
  • 3-6x risk of all cause mortality
  • Associated with HTN, PH, MI, CVA, arrythrmias
  • Treatment is associated with decreased mortality
  • Treatment
  • Weight
  • Alcohol and drug avoidance
  • NIPPV for
  • AHI gt 5 and clinical sequelae (sleepiness, mood
    disorder, cardiovascular disease)
  • AHI gt 15 without symptoms
  • Oral appliances
  • Surgery (UPPP)

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Obesity hypoventilation syndrome
  • Definition
  • Awake alveolar hypoventilation (pCO2 gt 45)
  • Obesity (BMI gt 35)
  • No other cause of hypoventilation
  • Usually seen with
  • OSA
  • Cor pulmonale
  • Outcomes
  • High mortality

127
Whew!
  • Thanks for your attention
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