Pulmonary Board Review

1. Pulmonary Board Review 2010

2. What we’re 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 > 1 month) are: • Cardiomyopathy • Deconditioning • Interstitial lung disease • COPD • Asthma

9. Respiratory symptoms: dyspnea • The 4 most common etiologies of chronic dyspnea ( dyspnea lasting > 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. 1989;149:2277-82. • 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 < 70% indicates obstructive disease. Severity of obstruction as follows: • I: Mild FEV1 > 80% predicted • II: Moderate FEV1 < 50-80% predicted • III: Severe FEV1 < 30- 50% predicted • IV: Very Severe FEV1 < 30% predicted • Is there restriction? FVC < 80% predicted indicates possible restrictive disease • Is there airway reactivity? Response to bronchodilator testing: > 12% or > 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

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: Fick’s 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 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

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 > 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 • > 1 nocturnal awakening per week or • Moderate limitation in ADLs or • Decreased FEV1 but > 60% and FEV/FVC ratio reduced < 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 < 60% or FEV1/FVC reduced by > 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. 1997;18:365–369. 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 Rehabilitation at 65 (severe COPD) 20 Death 0 0 25 50 75 Age (years) Adapted from Fletcher et al. BMJ. 1977;1:1645-1648.

41. GOLD Classification of Severity of COPD

42. COPD • Treatment: • Smoking cessation • Oxygen therapy • Medical therapy • Pulmonary rehabilitation • LVRS • Transplantation

43. Clinical Algorithm for the Treatment of COPD Nonpharmacologic Therapy Clinicalstage GOLD Stage(approximate) Inhaled Therapy 0 Smoking cessation Avoidance of exposure At risk Intermittentsymptoms I *Short-acting bronchodilator as needed(for example, ipratropium, salbutamol, or combination) Vaccination(influenza, pneumococcal) † Persistentsymptoms‡ II *Tiotropium +albuterol Salmeterol or formoterol +ipratropium, salbutamol, or combination Pulmonary rehabilitation(Exercise prescription) *Tiotropium +salmeterol or formoterol§ Salmeterol or Formoterol +Tiotropium§ 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. 2005;330;640-644. (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. Occupation Travel Drugs Pets Hobbies Systemic symptoms Smoking Family Hx Clubbing Bibasilar rales Signs of cor pulmonale Lymphadenopathy Rash Arthritis Fever Workup of ILD: Hx & PE

49. ATS/ERS International Multidisciplinary Consensus Classification of IIP. AJRCCM 2002

50. 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 Studies