PPT

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PPT

  1. 1. RADIOLOGY - CXRRADIOLOGY - CXR Bronchiectasis - vessel ‘crowding’ - loss of vessel markings - tramline/ring shadows - cystic lesions/ air-fluid levels - evidence of TB Poor:  diagnostic sensitivity  monitoring of progression 3
  2. 2. RADIOLOGY - HRCTRADIOLOGY - HRCT - bronchial dilatation - bronchial wall thickening - classification (pathology)  sensitivity (97%) > CXR 3  chromosomal radiosensitivity - plain CXR (x 3 days background) - HRCT: x 30-40 - conventional CT: x 200 • ? routine baseline • ? (a)symptomatic monitoring
  3. 3. UNSUSPECTED DISEASEUNSUSPECTED DISEASE (Clinical v CXR v HRCT)  Bronchiectasis in Hypogammaglobulinaemia - A Computed Tomography assessment. Curtin et al. Clinical Radiology (1991) 44, 82-84  Radiologic Findings of Adult primary Immunodeficiency Disorders. Obregon et al. Chest (1994)106, 490-495  Chest High Resolution CT in Adults with Primary Humoral Immundeficiency. Feydy et al. British Journal of Radiology (1996) 69, 1108-1116  Clinical Utility of High-Resolution Pulmonary Computed Tomography in Children with Antibody Deficiency. Manson et al. Pediatric Radiology (1997) 27, 794-798  The Value of Computed Tomography in the Diagnosis & Management of Bronchiectasis. Pang et al. Clinical Radiology (1989) 40, 40-44  Review Article: Imaging in Bronchiectasis. Smith et al. British Journal of Radiology (1996) 69, 589-593 3
  4. 4. RADIOLOGYRADIOLOGY Kainulainen et al 1999  CVID x 18, XLA x 4 CXR HRCT Bronchiectasis 3 16  3 year follow-up  Disease progression (5) Serum IgG Case No T=0 T=36 1 9.9 10.0 2 4.6 6.1 8 3.7 5.1 10 3.7 4.9 21 3.1 5.7
  5. 5. RADIOLOGY - HRCTRADIOLOGY - HRCT RCP Specialty Specific Standards ‘Fit’ patients…….CT scanning should be undertaken in a minority of patients but usually not more than once a year or if respiratory function tests or symptoms deteriorate JCIA November 2001 4
  6. 6. MANAGEMENTMANAGEMENT – GENERAL ISSUES– GENERAL ISSUES  Shared Care (Immunologist/Respiratory Physician) optimal 4  Bronchodilators (reversible airflow obstruction)  Mucolytics - insufficient evidence to evaluate routine use (Cochrane Database of Systematic Reviews. 3, 2003)  Physical therapy - insufficient evidence to support or refute usage (Cochrane Database of Systematic Reviews. 3, 2003)  Anti-inflammatory agents
  7. 7. REPLACEMENT THERAPYREPLACEMENT THERAPY  Risk/benefit assessment 4  IV/Sc routes optimal 2   pulmonary infections in XLA/CVID (v untreated) 2  Optimal dosing/frequency/serum IgG level not established  Tailor route/dose/infusion frequency 3 ---------------------------------------------------------------  Maintain IgG >5g/l 2  Paediatric target: mid reference range 4  IgG: >8g/l   infection (v 5g/l, XLA, children) 3 9.4 g/l   infection (v 6.5g/l, XLA/CVID, children/adults) 3  High v standard doses   infections (no. & duration) 2  days hospitalised  serum IgG  Insidious disease progression despite ‘adequate’ replacement 3
  8. 8. REPLACEMENT THERAPYREPLACEMENT THERAPY High dose v low dose: secondary outcome, pulmonary function  Eijkhout et al 2001 (randomised, double-blind, multicentre, crossover, n=43) High dose (mean trough IgG 9.4 g/l): PEFR 37.3 l/min Standard dose (mean trough IgG 6.5 g/l): PEFR 11.4 l/min NS  Roifman & Gelfand 1988 (ramdomised, crossover, n=12) High dose   FVC & FEV1 p<0.01  Roifman et al 1987 (randomised, crossover, n=12) Mean FEV1 & FVC high dose phase v low dose phase p<0.01  Bernatowska et al 1987 (two-dose, crossover, non-randomised, n=13) High dose  Max. expiratory flow & FEV1 NA
  9. 9. ACUTE INFECTIONACUTE INFECTION MICROBIOLOGY  Culture & sensitivity routinely in acute setting 3  Value unclear in chronic situation - confirm original pathogen - ? emerging resistance - additional pathogens ANTIBIOTICS  Effectiveness established in exacerbations (bronchiectasis) 2  Higher doses for longer periods 4  Local treatment protocols 4
  10. 10. ANTIBIOTIC PROPHYLAXISANTIBIOTIC PROPHYLAXIS  Chronic bronchitis - no place in routine treatment (Cochrane Database of Systematic Reviews. 3, 2003)  Cystic fibrosis benefits - principally staphylococci - infancy  3/6 years - ? older children/adults - ? > 3years treatment (The Cochrane Library, Oxford. 2, 2003) (Cochrane Database of Systematic Reviews. 3, 2003) • Bronchiectasis - limited meta-analysis (6 RCTs) - marginal benefit / cautious support (Evans et al. Thorax 2001)
  11. 11. ANTIBIOTIC PROPHYLAXISANTIBIOTIC PROPHYLAXIS  No robust data v placebo  No substantial data v (or additional to) IVIg/SCIg (Silk et al. 1990)  ? Single intervention in mild antibody deficiency - not in more severe phenotypes / tissue damage  Papworth protocol: consider if: > 3 exacerbations / year 4 radiological / PFT deterioration  ? Eradication/clean-up therapy prior to prophylaxis - no clear evidence of benefit in antibody deficiency + structural lung damage  Development of local protocols for management of infections (esp. with Primary Care) and initiating prophylaxis 4
  12. 12. (Heelan et al., ESID 2002) Percentage of sputum samples growing pathogens before and after prophylactic ciprofloxacin 0 10 20 30 40 50 60 70 Prior to ciprofloxacin On ciprofloxacin all pathogens H. Infl (all isolates) H Infl. (resistant to ciprofloxacin) % ANTIBIOTIC PROPHYLAXISANTIBIOTIC PROPHYLAXIS
  13. 13. SURGERYSURGERY  Diagnostic delay > 2 years:  need for surgical procedures Adequate treatment:  lobectomy/pneumonectomy by 95% (UK PAD Audit 1993-96) 3  Important treatment option with favourable outcomes especially in focal bronchiectasis (Cohen et al 1994, Mansharamani & Koziel 2003) 3
  14. 14. QUESTIONS / ISSUESQUESTIONS / ISSUES  HRCT in routine screening & monitoring  Radiological changes a primary therapeutic target - Does HRCT modify our current assumptions about criteria for adequate treatment of antibody deficiency disorders?  Correct level of Ig treatment - arbitrary target serum level (evidence) or individualised (clinical + HRCT factors) - single intervention universally applicable in all patients (probably not) - higher doses: expense, complications, limited commodity  Roles of: antibiotics anti-inflammatory agents bronchodilators aids to airway clearance  Role of co-factors (e.g. α1AT)  Selective IgA deficiency
  15. 15. PIN GUIDELINESPIN GUIDELINES  Identify need for focused clinical research  Encourage debate and discussion  Reflect uncertainties in the field  Proscriptive as necessary, flexible where possible

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