Pulmonary Board Review

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Pulmonary Board Review

  1. 1. Pulmonary Board Review Escher Howard-Williams 6/16/08
  2. 2. Topics To Discuss • Oxygen Desaturation During Exercise • Causes of Bronchitis/Exacerbations in COPD • Diagnosis of Wegener’s
  3. 3. COPD • Heterogeneous disorder that includes: – Emphysema – Chronic Bronchitis – Obliterative Bronchiolitis – Asthma w/ bronchitis • GOLD: A disease states characterized by airflow limitation that is not fully reversible. Usually progressive and is associated with abnormal inflammatory response
  4. 4. Diagnosis of COPD • Stage 0: Normal spirometry, chronic cough and sputum production • Stage I: Mild FEV1/FVC <70% predicted and FEV ≥ 80% predicted • Stage II: FEV1/FVC < 70% and FEV1 ≥ 50% and < 80% predicted • Stage III: FEV1/FVC < 70% and FEV1 ≥ 30% and < 50% predicted • Stage IV: FEV1/FVC < 70% and FEV1 < 30% predicted or FEV1 < 50% predicted and chronic respiratory symptoms
  5. 5. COPD Exacerbation • GOLD - a report produced by NHLBI & WHO defines COPD exacerbation as - acute increase in sx beyond normal daily variation • Includes one or more of the following cardinal symptoms (over 2 days): – Cough increases in frequency and severity – Sputum production increases in volume and/or changes character – Dyspnea increases
  6. 6. Etiology • It is estimated that: – 50-60% COPD exacerbations are due to respiratory infections – 10% are due to environmental pollution – 30% are of unknown etiology
  7. 7. Viral Infections • Most infection are thought to be viral, and have been confirmed by viral culture or serology in 18 - 64% of exacerbation • The most common viruses are influenza, parainfluenza, coronavirus, and rhinovirus
  8. 8. Bacterial Infections • Viral infections cause the majority of COPD exacerbations, bacterial infection also trigger exacerbations • Most common bacterial causes: – Haemophilus influenzae – Moraxella catarrhalis – Streptococcus pneumoniae • Less Common include – Kebsiella, Peduomonas – Rarely - Chlamydia and Legionella
  9. 9. Treatment of COPD Exacerbation • Treatment of exacerbations of COPD includes antibiotics directed against H. influenzae, M. catarrhalis, and S. pneumoniae – The use of antibiotics in exacerbations of COPD is based on placebo-controlled trials that found that antibiotics improve clinical outcomes in many patients with an exacerbation of COPD • Brochodilator, sterdoids, O2
  10. 10. Abx Treatment "Standard" Doxycycline 100 mg BID Trimethoprim-sulfamethoxazole DS BID Amoxicillin 500 mg BID "Modernized list" Amoxicillin-clavulanate (Augmentin) 875 mg BID Azithromycin (Zithromax) Z pack (6-250 mg) Cefpodoxime (Vantin) 200 mg BID Cefuroxime (Ceftin) 250-500 mg BID Cefprozil (Cefzil) 500 mg BID Loracarbef (Lorabid) 400 mg BID Levofloxacin (Levaquin) 500 mg QD Ciprofloxacin (Cipro) 500 mg BID
  11. 11. Severe exacerbation • Treatment should consist of broad spectrum antibiotics that cover gram positives, gram negatives and consider double covering pseudomonas
  12. 12. Other Pharmacotherapy • Stable COPD: – Bronchodilaters – Anticholinergics – Steroids – (No mucolytics or leukotrienes)
  13. 13. Note on Surgery • Bullectomy may reduce sx in pt w/ bulla causing compression of adjoining lung tissue -> improve lung function • Lung Volume Reduction surgery - FEV <20% and diffusion capacity <20% and people with upper lobe disease had better outcomes • Lung Transplant - FEV1 <35, PaO2 55-60, PaCO2 >50
  14. 14. Arterial Desaturation w/ Exercise • Exercise testing provides insight into severity of exertional dyspnea and functional stability • Walk is usually done over 6 minutes • Desaturation is considered < 88% or PaO2 <55 (or 89% and PaO2 60 in R heart failure, pulm htn, crit >55%) • Some use - drop in sat by 5% points
  15. 15. Treatment? • Underlying causes – PE – CHF – ILD/IPF – COPD • Pulmonary rehabilitation • Provide Oxygen
  16. 16. Pulmonary Rehabilitation • Includes exercise, counseling / nutrition • Most patients walk 500-600 meters • With rehab can clinically improve walk distance by approximately 50 meters • Goal is improve QOL • No effect on survival or hospitalization rate
  17. 17. Controlled O2 Therapy • Long term administration of O2 to COPD patients >15 hrs/day increases survival, hemodynamics, exercise capacity, lung mechanics and mental status • Goal is sat >90% or PaO2 >60
  18. 18. Wegener’s • Systemic vasculitis of small and medium vessel arteries – Rarely in large vessels • Generally affects upper and lower respiratory tracts and kidneys – A limited form is present in 25% of cases that manifests in upper respiratory tract only (or kidneys only)
  19. 19. Presenting signs • The most common URT presenting symptoms include: – persistent rhinorrhea – purulent/bloody nasal discharge – oral/nasal ulcers – polyarthralgias – myalgias – sinus pain • Less common symptoms are hoarseness, stridor, earache, both conductive and sensorineural hearing loss, or otorrhea
  20. 20. Presenting Signs • Most common LRT symptoms: – Cough – Dyspnea – Hemoptysis (due to an alveolar capillaritis, necrotic lesions, or endobronchial disease) – Pleuritic pain
  21. 21. Other Manifestations • Upper and lower airways, including the subglottic region / trachea • Joints (myalgias, arthralgias, arthritis) • Eyes (conjunctivitis, corneal ulceration, episcleritis/scleritis, optic neuropathy, proptosis, diplopia, retinal vasculitis, and uveitis) • Skin (vesicular, palpable purpuric, ulcerative, and hemorrhagic lesions)
  22. 22. Other Manifestations • Nervous system (mononeuritis multiplex, cranial nerve abnormalities, central nervous system mass lesions, external ophthalmoplegia, hearing loss) • Less commonly, the gastrointestinal tract, heart (pericarditis, myocarditis, conduction system abnormalities), lower genitourinary tract (including the prostate), parotid glands, thyroid, liver, or breast
  23. 23. General lab findings • leukocytosis • thrombocytosis • marked elevation of ESR • normochromic, normocytic anemia
  24. 24. Urinary Findings • Proteinuria • Hematuira • Red Cell Cast • Leukocyturia
  25. 25. Radiographic Findings • Nodular Disease • Infiltrates CXR – Diffuse bilateral patchy low denisty or localized lesions and cavities • CT – Bilateral nodueles cavitary and airspace disease with focal consolidation and ground glass
  26. 26. Lung Biopsy • Small and medium vessel vasculitis with necrotizing graulomas and inflammatory infiltrates
  27. 27. Diagnosis • The American College of Rheumatology proposed clinical criteria for patients enrolled in studies of Wegener's and distinguish other forms of vasculitis (pre-ANCA) – Nasal or oral inflammation (painful or painless oral ulcers or purulent or bloody nasal discharge) – Abnormal chest radiograph showing nodules, fixed infiltrates, or cavities – Abnormal urinary sediment (microscopic hematuria with or without red cell casts) – Granulomatous inflammation on biopsy of an artery or perivascular area
  28. 28. ANCA • Approximately 90 percent of patients with active, generalized Wegener's granulomatosis are ANCA- positive • Limited forms of the disease up to 40% of patients may be ANCA-negative • Among Wegener's pts w/ ANCA, 80-90%, PR3- ANCA+, the rest are MPO-ANCA+ • Dual positivity may rarely occur and generally indicates the presence of another condition ie SLE • The majority of patients with renal-limited vasculitis are ANCA-positive, 75-80% MPO-ANCA +
  29. 29. PER MKSAP • C-ANCA in a pt with active disease has a snesitivity of 90-95% and a specificity fo 90% and is considered the most helpful laboratory finding to make the diagnosis of Wegener’s
  30. 30. Tissue Diagnosis • Dx of Wegener's confirmed by tissue biopsy at a site of active disease. • Typical finding on upper respiratory tract biopsies is acute and chronic inflammation, often with granulomatous features. – These findings are consistent with but not diagnostic of Wegener's granulomatosis since the vasculitis is seen in only about one-third of cases.
  31. 31. Other Tissues • Skin reveals a leukocytoclastic vasculitis with little or no complement and immunoglobulin on immunofluorescence. • Kidney biopsy typically reveals a segmental necrotizing glomerulonephritis that is usually pauci- immune on immunofluorescence or electron microscopy
  32. 32. Standard Treatment • Combination therapy of corticosteroids and cyclophosphamide is the standard of care • 3-6 months the disease is generally controlled and tx can be switched to azathioprine – This does not increase the rate of relapse or change kidney function

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