Lung Month 2023.pptx

LUNG MONTH 2023 LAY FORUM
Dr. Nino JN Doydora
Occupational Physician - Adult Pulmonologist
29 August, 2023, Ormoc City, Leyte, Philippines

DISCLAIMER
I have no conflict of interest with regards to the topic I
am tasked to discuss.
SAMPLE FOOTER TEXT 20XX 2

SPEAKER
3
BS Biology (UP Los Baños)
Medicine (Cebu Institute of Medicine)
Internal Medicine (Visayas Community Medical Center)
Pulmonary Medicine (Univ. of Perpetual Help DALTA Medical Center)
Member, Phil. College of Physicians (PCP)
Member, TB & Sleep Councils: Phil. College of Chest Physicians (PCCP)
Member: European Respirology Society (ERS),
American Thoracic Society (ATS),
American College of Chest Physicians (ACCP)
Visiting Internist/Pulmonologist – OSPA, Ormoc Doctors’ & Gatchalian MC
Member, Local Health Board of Ormoc City representing Ormoc Medical Society

OBJECTIVES
To discuss the common respiratory
illnesses:
Lung Cancer, Asthma/COPD, Pneumonia
and TB
To discuss TB : incidence, classification,
diagnosis, treatment and follow-up.
To discuss the sequelae of TB infection.
 To discuss the DOLE classification of fit to

PULMONARY CLEARANCE AT WORK
• Part of Pre-employment or re-employment
screening.
• Companies can get a detailed analysis of their
prospective employees’ health status.
• This will identify any existing conditions that
might interfere with doing their future job.
• Help ensure that the workers/ prospective
employees are physically capable of performing
the jobs. * https://integrity-asia.com/blog/2020/09/16/pre-employment-screening-the-medical-check-up-of-your-
candidate/

PULMONARY CLEARANCE AT
WORK
• A routine chest radiograph is mandatory in many institutions
as a part of pre-employment screening.
• Some tests related to pulmonary function may be necessary:
• Spirometry (w/ bronchodilator challenge) [asthma / COPD]
• Arterial blood gas analysis [hypoxemia]
• Echocardography [pulmonary hypertension]
* https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5036342/

• When is a
person deemed
fit to work ?

AFTER ROUTINE EXAMINATION, THE PATIENT
WILL BE CLASSIFIED AS FOLLOWS:
DOLE OSH Standards p.180

PULMONARY
CONDITIONS:
• Lung cancer
• Pneumonia
• Chronic respiratory conditions
• Asthma
• COPD
• Tuberculosis
https://news.abs-cbn.com/news/03/17/21/heart-diseases-still-leading-cause-of-death-among-filipinos-

LUNG CANCER:
• the 2nd most common type of cancer in
the world (next to breast cancer)
• Philippines -19,180 new lung cancer
cases in 2020.
• Due to low cancer screening programs,
cancer patients the Philippines are
diagnosed in the late stage of the
illness.
• Chest x ray may be used but less
sensitive.
• Low dose chest CT scan is the
recommended screening test of lung
CA (costly).
• Smoking is the no.1 cause of lung

PNEUMONIA:
• A very common cause of
hospitalization and common diagnosis
in PhilHealth reimbursement.
• Diagnosis: requires (+) CXR finding
• Plus the common signs/symptoms:
• Cough
• Sputum production
• Shortness of breath
• Fever
https://www.psmid.org/wp-content/uploads/2021/12/2020-Community-Acquired-Pneumonia-Clinical-Practice-
• Atypical Pneumonia
-a type of pneumonia usually in
elderly; mainly seen with
minimal cough, body
weakness, poor appetite but
with pneumonia on CXR.

PNEUMONIA:
https://www.psmid.org/wp-content/uploads/2021/12/2020-Community-Acquired-Pneumonia-Clinical-Practice-

ASTHMA
- Hyper-reactive airways disease; due to chronic airway
inflammation.
- 2 features of asthma:
- • A history of respiratory symptoms of wheezing, shortness
of breath, chest tightness and cough.
- • (+) Expiratory airflow limitation.
- Triggers: exercise, allergen/irritant exposure, change
in weather or respiratory infections.
- Symptoms & airway limitation may resolve
spontaneously or in response to medication.
* https://ginasthma.org/wp-content/uploads/2020/04/GINA-2020-full-report_-final-_wms.pdf

COPD
Chronic Obstructive Pulmonary Disease (COPD)
- a heterogeneous lung condition
- 3 Long-standing respiratory symptoms (shortness of breath,
cough, sputum production and/or exacerbations)
[hangak + Ubo + plema] due to
- abnormalities of the airways (bronchitis, bronchiolitis) and/or
alveoli (emphysema) that cause
- persistent, often progressive airflow obstruction.
- Triggers: exercise, allergen/irritant exposure, change in
weather or respiratory infections.
- Symptoms & airway limitation DOES NOT resolve
spontaneously *

ASTHMA VS COPD
ASTHMA
- Seen in younger individuals.
- Symptoms & airway limitation may resolve spontaneously or in
response to medication.
Chronic Obstructive Pulmonary Disease (COPD)
- Seen in older individuals who are current or previous smokers; or those
exposed to smoke produced by burning firewood or second hand smoke
exposure
- Symptoms & airway limitation DOES NOT resolve spontaneously
BOTH* Triggered by exercise, allergen/irritant exposure, change in
weather or respiratory infections.
* Benefit from inhaled medications (inhaler therapy)
*

ASTHMA VS COPD
SPIROMETRY
- a common pulmonary
function test which measures
air flow through to the lungs
and estimates the amount of
air in the lungs
- differentiate Asthma vs COPD
*
- Asthma : (+) reversibility
- Improvement of
FEV1/FVC of 200ml &
or 12% from baseline
- COPD – no reversibility

ASTHMA VS COPD
*
ASTHMA
- 1 – mild intermittent asthma
- 2 – mild persistent asthma
- 3 – moderate persistent asthma
- 4 – severe persistent asthma

ASTHMA & COPD MGT
*
Goals of management:
1.Recognize the disease (early diagnosis
and intervention)
2.Prevention of disease progression
(COPD)
3.Alleviation of breathlessness &
improvement effort tolerance
4.Pulmonary rehabilitation and education
5.Prevention attacks
6.Prevention and treatment of
complication
7.Reduce incident of death
Inhalers may be:
- Liquid – MDI
- Dry powder inhaler
- Soft mist inhaler
Inhalers are NOT throat sprays

PULMONARY
CONDITIONS:
• Lung cancer
• Pneumonia
• Chronic respiratory
conditions
• Asthma
• COPD
• Tuberculosis

The Philippines ranks 4th worldwide in
Tuberculosis (TB) incidence [India (28%), Indonesia
(9.2%), China (7.4%), the Philippines (7.0%), Pakistan (5.8%),
Nigeria (4.4%), Bangladesh (3.6%) and Congo (2.9%)].
Global TB report 2021 estimated that 1.4 million
deaths are due to Tuberculosis
Nearly 70 Filipinos die DAILY due to TB and its
complications and 1 million Filipinos has TB
today.
https://www.who.int/philippines/news/commentaries/detail/it-s-time-to-end-tb-in-the-Philippines
https://newsinfo.inquirer.net/1744938/doh-still-has-to-catch-up-on-tb-treatments
TUBERCULOSIS

TB
https://ntp.doh.gov.ph/download/ntp-mop-6th-edition/#

PRESUMPTIVE TB
https://ntp.doh.gov.ph/download/ntp-mop-6th-edition/#

TB Infection vs Disease
TB Infection – presence of TB Bacteria
inside the body w/ NO SYMPTOMS
TB Disease - presence of TB Bacteria
inside the body but with SYMPTOMS

TB Diagnostic Tests
 TB Infection: (+)TB Bacteria in the body w/ NO SYMPTOMS
PPD Skin Testing, IGRA, Quantiferon
 TB Disease: (+)TB Bacteria in the body now with
SYMPTOMS
Sputum exams: (1) AFB Microscopy (P500) [54~% Sensitivity]
(2) TB-Lamp – molecular test [95% sensitivity]
(3) Gene Expert MTB Rif (P5-8,000) [~92%]
*blood-stained specimen- least sensitivity (28%)
*salivary specimen has greatest specificity
(96%)
(4) TB Culture (P16,000) [~90%]

REMEMBER!
• Some patients will say that they already have TB
infection and were treated previously.
• TB can relapse!
• Some will claim that their sputum test is negative.
• There are 3 (possible) sputum Tests for TB:
• AFB Microscopy
• Gene Expert MTB Rif
• TB Culture

TB Diagnosis
Tuberculosis – bacteriologically diagnosed, based on
Clinical signs and symptoms plus either:
 (+) AFB Microscopy (Sputum, CSF, wound smear, etc)
 (+) Sputum Gene Expert (DNA Detection)
 (+) TB Culture (usually Sputum, CSF, etc)
Tuberculosis – Clinically diagnosed, based on
 Clinical signs and symptoms plus (+) TB in
Chest Xray or CT scan or Biopsy

TB Treatment & FF-up
Type of PTB 1st FF-up 2nd Ff-up 3rd FF-up
New
Bacteriologically
Diagnosed
End of 2nd
month
End of 5th
month
End of
treatment
(6th month)
New Clinically
Diagnosed
End of 2nd
month
End of 5th
month
End of
treatment
(6th month)
Sputum TEST Monitoring is at ZERO, 2nd and 6th MONTHS!

TB Treatment & FF-up
1st Sputum 2nd Ff-up 3rd FF-up
Patient A (+) (-)
(2nd month)
(-)
(6th month)
Patient B (-) (+)
(2nd month)
(+)
(3rd month)
Patient C (-) (-)
(2nd month)
(-)
(6th month)
Sputum TEST Monitoring is at ZERO, 2nd and 6th MONTHS!
Resistant TB?

LATENT TUBERCULOSIS INFECTION (LTBI)
- person is infected with Mycobacterium
tuberculosis, but does not have active/infectious
tuberculosis.
- Active tuberculosis can be contagious while latent
tuberculosis is not.
- It is therefore not possible to get TB from someone
with latent TB.
- There is10% risk of LTBI patients to develop active

LATENT TUBERCULOSIS INFECTION
(LTBI)
- There is10% risk of LTBI patients to
develop active tuberculosis.
- This occurs in situations when the immune
system is weakened or due to advancing
age.
- Asymptomatic but (+) in PPD Skin testing
or TB Quantiferon (antibody detection

2Mos 4Drugs+4Mos 2Drugs
2Mos
4Drugs+10Mos2Drugs
Six
months
12
months

TB Screening & Diagnosis kanamycin (Km),
linezolid (Lzd),
isoniazid (H),
clofazimine (Cfz),
pyrazinamide (Z),
bedaquiline (Bdq),
delamanid (Dlm),
levofloxacin (Lfx),
meropenem-
clavulanate (Mpm-Clv),
amikacin (Am),
imipenem-clavulanate
acid (Ipm-clv), and
cycloserine (Cs)

REMEMBER!
• We are not allowed to treat MDR-TB.
• Patients with MDR-TB who are treated privately
have low survival rates due to high costs &
inappropriate monitoring.
• The WHO recommends the treatment of MDR-TB
should be under PMDT care.

REMEMBER!
• We are not allowed to treat MDR-TB.
• Patients with MDR-TB who are treated privately have low
survival rates due to high costs & inappropriate
monitoring.
• The WHO recommends the treatment of MDR-TB should
be under PMDT care.
• PMDT – Programmatic Management of Drug-resistant TB

?
• When is the
patient deemed
fit to work if
he/she has
Tuberculosis?

CASE
Why refer to the nearest DOTS?
• Studies have shown that TB
patients treated under Directly-
observed Treatment Strategy
(DOTS) have higher success rates
compared to those treated under
private MDs

CASE
Why do we need to screen for co-morbidities?
• TB patients with uncontrolled comorbidity
= LOWER success rates.
Pls screen for :
• Diabetes
• HIV
• Get creatinine (kidney fxn)
• SGPT (liver)
• Uric Acid ( causes arthritis)

CASE
Why do we need to Notify the RHU?
• TB cases should be reported as it is mandated by law.

CASE
Why do we
need to Notify
the RHU?
•TB cases
should be
reported as it
is mandated
by law.

TYPES OF TB TREATMENT?
 Curative Treatment: 2HRZE, 4HR
 Preventive Treatment: 6mos INH Tx
 The WHO recommends Preventive TB Treatment for:
 Exposed to sputum gene expert index case
(Household)
 Newly diagnosed HIV (+) with normal CXR
Sputum
monitoring:
0, 2nd & 6th month

HOW TO SCREEN FOR TB?
Adult: Chest Xray
Pedia: PPD Skin Testing
A. PA view B. Apicolordotic View
Chest X-
ray
Sputum gene expert can be done for patients
with co-morbidity or elderly (even without CXR). It
can also be done for children who can produce
adequate specimen.

WHY SCREEN FOR TB?
Philippines is on the road to be #1 when it comes
to TB Incidence worldwide (currently #4 behind
India, Indonesia and China).
Adult: CXR
Pedia: PPD Skin Testing
Sputum gene expert –
For those with symptoms

NOTIFIER’S
REGISTRATION:
SAMPLE FOOTER TEXT 20XX 64

?
• What is the DOLE
Classification of
the patient?
• When is the
patient deemed
fit to work if
he/she has
Tuberculosis?

• When is the patient deemed fit to work if
he/she has Tuberculosis?
Classification When to go back to work?
Bacteriologically
Diagnosed
2 weeks after receiving anti TB
meds (with improvement of
symptoms) with (-) repeat DSSM /
Gene Xpert
Clinically
Diagnosed
5-7 days after receiving anti TB
meds (with improvement of
symptoms)

CASE Patient is DOLE Class
D
Do AFB Smear after 2wks , (-
)
Patient becomes DOLE Class

SEQUELAE OF TB INFECTION
Long-term complications of TB infection:
1. Pulmonary fibrosis
2. Bronchiectasis
3. COPD
4. Pleural Complications

Long-term complications of TB
infection:
1. Pulmonary fibrosis
This refers to the scarring and
thickening of lung tissue that can occur
as a result of the body’s response to TB
infection.
Pulmonary fibrosis can lead to reduced
lung function and breathing difficulties.

Long-term complications of TB
infection:
2. Bronchiectasis:
TB can cause airway damage: airway
widening and thickening.
This result in long-standing cough,
excessive mucus production, and
recurrent respiratory infections.

Long-term complications of TB infection:
3. COPD (Chronic Obstructive Pulmonary Dse)
Long-term lung damage from TB can
lead to the development of COPD.
COPD - airflow limitation,
chronic cough &
shortness of breath.

SUMMARY
Discussed briefly Lung Cancer, pneumonia,
Asthma and COPD.
Discussed TB : incidence, classification,
diagnosis, treatment & follow-up. We need to
SCREEN!
Emphasized on the utilization of the DOLE
classification of fit to work (OSH Standards).
Long-term complications of TB infection exist.

THANK YOU!
Internist, Pulmonologist & Occupational Physician
 REFERENCES:
• *https://www.psmid.org/wp-
content/uploads/2020/03/CPG-TB-2016.pdf
• https://integrity-asia.com/blog/2020/09/16/pre-
employment-screening-the-medical-check-up-
of-your-candidate/
• https://ginasthma.org/wp-
content/uploads/2020/04/GINA-2020-full-
report_-final-_wms.pdf
• https://news.abs-cbn.com/news/03/17/21/heart-
diseases-still-leading-cause-of-death-among-
filipinos-says-psa
• https://www.who.int/philippines/news/commenta
ries/detail/it-s-time-to-end-tb-in-the-philippines
• https://ntp.doh.gov.ph/download/ntp-mop-6th-
edition/#
• Philippine Clinical Practice Guidelines for the
Management of Tuberculosis 2016
• Occupational Safety and Standard . DOLE.
1989
• https://www.who.int/teams/global-tuberculosis-
programme/tb-reports/global-tuberculosis-
report-2022/tb-disease-burden/2-1-tb-incidence
 Dr. Nino JN Doydora
https://www.slideshare.net/kendo_19/lung-month-

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