An overview of adult respiratory distress syndrome with a focus on the updates in ventilatory management of this important syndrome in the intensive care
This document discusses asthma-COPD overlap (ACO), where patients exhibit features of both asthma and chronic obstructive pulmonary disease (COPD). It defines the conditions and notes that distinguishing them can be difficult, especially in smokers and older adults. Patients with ACO features experience more exacerbations and poorer outcomes than those with asthma or COPD alone. The document provides guidance on diagnosing and initially treating ACO based on GINA and GOLD guidelines, emphasizing inhaled corticosteroids to reduce exacerbation risk in all patients with chronic airflow limitation. Further research is still needed to better classify and treat ACO phenotypes.
1. The document discusses respiratory emergencies like acute exacerbations of asthma and COPD.
2. It provides definitions and levels of severity for acute asthma exacerbations from moderate to life-threatening. Clinical features, investigations and management are described.
3. Acute exacerbation of COPD is also defined and precipitating factors, clinical features, investigations and treatment principles are outlined. Non-invasive ventilation criteria and contraindications are noted.
Asthma or COPD?
More features favor COPD:
- Age >40 years
- Smoking history
- Chronic symptoms not fully relieved by SABA
- Previous LRTI requiring hospitalization
Diagnosis: COPD
Biphasic Cuirass Ventilation for Respiratory Failure and ARDSGary Mefford RRT
There is a great deal of information that points to the potential efficacy of BCV for acute and chronic respiratory failure as well as ARDS. Some is gathered here with a discussion of the open lung concept with BCV.
HFNC therapy provides high flow oxygen through a nasal cannula. It has several benefits over traditional oxygen delivery methods, including more accurate oxygen delivery, washout of dead space, and generation of positive end-expiratory pressure. HFNC is a well-tolerated therapy that can be used for hypoxemic respiratory failure, pre-intubation, and post-extubation. While promising, further research is still needed to establish clear guidelines for its use.
This document discusses controversial issues in non-invasive ventilation. It begins by explaining the normal ventilatory balance and how respiratory failure causes an imbalance. It then discusses how mechanical ventilation can unload the respiratory muscles.
It defines non-invasive positive pressure ventilation (NPPV) and notes that not all ventilators are suitable for each indication. It reviews different interfaces like facial masks, nasal masks, nasal prongs, and others. It also discusses a study comparing the physiologic effects of different interfaces.
The document continues by looking at the rationale for using positive pressure ventilation in cardiogenic pulmonary edema. It reviews several clinical trials that show benefits of NPPV over standard treatment in acute cardiogenic pulmonary edema and respiratory failure
This document discusses asthma and COPD, including key differences and updates. It provides an overview of asthma, describing it as a chronic inflammatory airway disorder characterized by recurrent wheezing, breathlessness, and coughing. It also provides an overview of COPD, describing it as a common lung disease associated with exposure to noxious particles or gases. The document reviews epidemiology, pathophysiology, diagnosis, management, and updates from the GINA and GOLD guidelines for both conditions.
An overview of adult respiratory distress syndrome with a focus on the updates in ventilatory management of this important syndrome in the intensive care
This document discusses asthma-COPD overlap (ACO), where patients exhibit features of both asthma and chronic obstructive pulmonary disease (COPD). It defines the conditions and notes that distinguishing them can be difficult, especially in smokers and older adults. Patients with ACO features experience more exacerbations and poorer outcomes than those with asthma or COPD alone. The document provides guidance on diagnosing and initially treating ACO based on GINA and GOLD guidelines, emphasizing inhaled corticosteroids to reduce exacerbation risk in all patients with chronic airflow limitation. Further research is still needed to better classify and treat ACO phenotypes.
1. The document discusses respiratory emergencies like acute exacerbations of asthma and COPD.
2. It provides definitions and levels of severity for acute asthma exacerbations from moderate to life-threatening. Clinical features, investigations and management are described.
3. Acute exacerbation of COPD is also defined and precipitating factors, clinical features, investigations and treatment principles are outlined. Non-invasive ventilation criteria and contraindications are noted.
Asthma or COPD?
More features favor COPD:
- Age >40 years
- Smoking history
- Chronic symptoms not fully relieved by SABA
- Previous LRTI requiring hospitalization
Diagnosis: COPD
Biphasic Cuirass Ventilation for Respiratory Failure and ARDSGary Mefford RRT
There is a great deal of information that points to the potential efficacy of BCV for acute and chronic respiratory failure as well as ARDS. Some is gathered here with a discussion of the open lung concept with BCV.
HFNC therapy provides high flow oxygen through a nasal cannula. It has several benefits over traditional oxygen delivery methods, including more accurate oxygen delivery, washout of dead space, and generation of positive end-expiratory pressure. HFNC is a well-tolerated therapy that can be used for hypoxemic respiratory failure, pre-intubation, and post-extubation. While promising, further research is still needed to establish clear guidelines for its use.
This document discusses controversial issues in non-invasive ventilation. It begins by explaining the normal ventilatory balance and how respiratory failure causes an imbalance. It then discusses how mechanical ventilation can unload the respiratory muscles.
It defines non-invasive positive pressure ventilation (NPPV) and notes that not all ventilators are suitable for each indication. It reviews different interfaces like facial masks, nasal masks, nasal prongs, and others. It also discusses a study comparing the physiologic effects of different interfaces.
The document continues by looking at the rationale for using positive pressure ventilation in cardiogenic pulmonary edema. It reviews several clinical trials that show benefits of NPPV over standard treatment in acute cardiogenic pulmonary edema and respiratory failure
This document discusses asthma and COPD, including key differences and updates. It provides an overview of asthma, describing it as a chronic inflammatory airway disorder characterized by recurrent wheezing, breathlessness, and coughing. It also provides an overview of COPD, describing it as a common lung disease associated with exposure to noxious particles or gases. The document reviews epidemiology, pathophysiology, diagnosis, management, and updates from the GINA and GOLD guidelines for both conditions.
This document describes the case of 65-year-old Daishi Hayato who was admitted to the hospital with acute respiratory distress, COPD, and peripheral vascular disease. He had a history of smoking 2 packs per day for 50 years. He developed respiratory failure and required intubation and ventilation. Enteral and parenteral nutrition were started but caused excessive calorie intake, as shown by elevated CO2 levels and increased RQ. Nutrition was modified to prevent further complications.
This document discusses non-invasive positive pressure ventilation (NIPPV). It defines NIPPV as ventilation without an invasive airway and notes its increasing use for acute respiratory failure. The document covers the history of NIPPV, indications, goals, advantages, patient selection criteria, initiation procedures, modes (including CPAP, BiPAP, volume vs pressure), and settings. NIPPV can effectively treat various conditions like COPD, heart failure, and respiratory infections while avoiding intubation. Careful patient selection and monitoring are important for successful NIPPV.
Recent Advances in NIV
1) Non-invasive positive pressure ventilation (NIPPV) can effectively treat acute respiratory failure without the need for intubation in conditions like COPD, obesity, and neuromuscular diseases.
2) Different interfaces like facial masks, nasal masks, and helmets can be used for NIPPV, with nasal masks generally better tolerated than other options.
3) NIPPV reduces mortality and need for intubation compared to standard oxygen therapy alone in acute exacerbations of COPD and cardiogenic pulmonary edema.
4) Factors like pH, comorbidities, respiratory rate and effort predict success or failure of NIPPV. Close monitoring is needed in cases with higher
How to manage a case of acute exacerbation of COPD according to GOLD guidelines. Sincere thanks to Dr. Amardeep Toppo who has prepared most of this presentation.
This document provides information on diagnosing and differentially diagnosing COPD, including:
- Key indicators that should prompt consideration of a COPD diagnosis including dyspnea, chronic cough, sputum production, and risk factor exposure. Spirometry is required to confirm COPD.
- Spirometry is the basic investigation needed to diagnose COPD. It assesses airflow limitation through FEV1/FVC ratio and severity through FEV1 levels. Reversibility testing can help differentiate COPD from asthma.
- Additional optional investigations that may be used include imaging like chest X-rays and CT scans to identify emphysema and airway abnormalities, lung volume measurements, diffusing capacity tests, and
Managing Respiratory Symptoms in Advanced MS Rachael MosesMS Trust
This document discusses managing respiratory symptoms in advanced multiple sclerosis (MS). It outlines how MS can affect the respiratory system through weakness of the respiratory muscles and bulbar dysfunction. It describes how to assess the different stages of cough through tests of inspiratory muscles, glottis closure, and expiratory muscles. Various techniques are presented to help clear secretions for patients with weak coughs, such as lung volume recruitment, mechanical insufflation-exsufflation devices, and hyperbaric oxygen therapy. Ethical issues around respiratory management in advanced MS are also addressed.
Managing respiratory symptoms in advanced MSMS Trust
This document discusses managing respiratory symptoms in advanced multiple sclerosis (MS). It summarizes research showing pulmonary dysfunction correlates with disability level in MS. For patients with normal lung function, expiratory muscle strength may still be reduced. Lung volume recruitment (LVR) and mechanical in-exsufflation (MI-E) are presented as techniques that can help preserve lung function and clear secretions by improving peak cough flow. The combination of LVR and manually assisted coughing is shown to be most effective. Case studies demonstrate MI-E and tracheostomy with ventilation can prevent hospital admissions and be life-saving for some advanced MS patients.
This document discusses mechanical ventilation and care of children requiring long-term ventilation. It covers the physiology of ventilation, indications for mechanical ventilation, types of ventilators including transport, ICU, neonatal and PAP ventilators. It describes various ventilation modes like PC, VC, PRVC, SIMV and their applications. Factors in weaning from ventilation are discussed along with complications and troubleshooting. Non-invasive ventilation options like CPAP, BiPAP and protocols for safe weaning are also summarized.
The document discusses the Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD aims to increase awareness of COPD, improve diagnosis and management, and decrease morbidity and mortality. It provides global strategies and guidelines for COPD diagnosis, assessment, treatment and prevention. The document outlines GOLD's structure, board of directors, science committee and evidence levels. It also summarizes chapters in GOLD's 2015 strategy document covering COPD definition, diagnosis, assessment, treatment and management.
The document provides an overview of the ACERS (Acute COPD Early Response Service) team and COPD services in Hackney. The summary is:
- The ACERS team introduces their service model which provides rapid community response for COPD exacerbations and ongoing chronic disease management.
- COPD is projected to be the third leading cause of death by 2020. The ACERS team aims to provide comprehensive, integrated care to meet the needs of COPD patients in Hackney.
- Resources and support available include the NHS London Respiratory Team, British Lung Foundation, NICE guidelines, and the National COPD Project which focuses on reducing readmissions.
This document discusses the use of noninvasive ventilation (NIV) for patients with COVID-19-associated acute hypoxemic respiratory failure (AHRF). It finds that the majority of COVID-19 patients treated with continuous positive airway pressure (CPAP) recovered from moderate-to-severe AHRF. For select patients, NIV may prevent intubation and invasive ventilation. However, patient selection is important and NIV may delay intubation in some cases. Close monitoring is needed to identify patients who require intubation.
The document provides information on chronic obstructive pulmonary disease (COPD) from the Global Initiative for Chronic Obstructive Lung Disease (GOLD). It defines COPD as a common preventable disease characterized by persistent airflow limitation associated with an enhanced inflammatory response in the airways. It discusses mechanisms of airflow limitation, risk factors, assessment of COPD including symptoms, spirometry and exacerbation history, management of stable COPD and exacerbations, and pharmacologic treatment options.
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are associated with high costs, morbidity, and mortality. They result in enormous healthcare expenditures and lost productivity. AECOPD episodes are also linked to accelerated long-term loss of lung function in continuous smokers. While symptoms may recover within a week, full recovery of health-related quality of life can take months. Noninvasive mechanical ventilation should be tried for patients with respiratory acidosis or increased work of breathing from AECOPD as it reduces intubation rates and improves health outcomes. Preventing and properly managing AECOPD is important for reducing its impacts.
Chronic Obstructive Pulmonary Disease (COPD) is a common lung disease characterized by persistent respiratory symptoms and airflow limitation. It includes chronic bronchitis and emphysema. The main risk factor is cigarette smoking. Symptoms include dyspnea, cough, and sputum production. Diagnosis is confirmed by spirometry showing airflow limitation. Management involves smoking cessation, bronchodilators, pulmonary rehabilitation, oxygen therapy, and treating exacerbations with corticosteroids and antibiotics.
This document discusses asthma-COPD overlap syndrome (ACOS). It defines asthma and COPD, noting their differences and similarities. Both are chronic inflammatory airway diseases but COPD is characterized by persistent airflow limitation and progressive lung function decline while asthma is often reversible. The document then discusses clinical features that can help distinguish asthma from COPD. It notes that some patients have features of both diseases, termed ACOS. Spirometry, biomarkers, imaging and response to treatment are discussed to help identify ACOS. The inflammatory patterns in asthma and COPD are compared, showing that eosinophilic inflammation is more prominent in asthma while neutrophilic inflammation dominates in COPD.
Pediatric Acute Respiratory Distress Syndrome Owais Mohd
The document discusses pediatric acute respiratory distress syndrome (ARDS). It provides definitions and criteria for ARDS according to the 1994 and 2012 Berlin definitions. It describes the pathogenesis, phases, diagnosis, and management of ARDS. Management involves controlling the underlying cause, oxygen administration, ventilation strategies including low tidal volumes and permissive hypercapnia, and considering therapies like prone positioning, high frequency ventilation, inhaled nitric oxide, and extracorporeal membrane oxygenation. The goal of management is to minimize ventilator-induced lung injury while maintaining oxygenation and ventilation. Outcomes depend on disease severity with higher mortality seen in more severe cases.
This study analyzed 114 cases of neonatal Candida bloodstream infection from a tertiary care hospital in central India over 5 years. Non-albicans Candida (NAC) infections like C. tropicalis and C. parapsilosis were associated with higher mortality and longer hospital stays. Resistance to fluconazole and amphotericin B was also higher in NAC infections. Prolonged use of central lines, nil oral intake, mechanical ventilation and longer hospital stays were identified as risk factors. The study highlights the need for timely identification of Candida species and antifungal susceptibility testing to help improve outcomes.
This document summarizes recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD). It discusses definitions, pathophysiology, epidemiology, clinical presentation, diagnostic tests including 24-hour pH monitoring and endoscopy, and treatment options including lifestyle modifications, medications like PPIs, and surgical procedures. Key recent advances mentioned include new diagnostic markers, multichannel intraluminal impedance pH monitoring, narrow-band imaging, and endoscopic assessment of mucosal impedance. Surgical treatments discussed are laparoscopic anti-reflux surgery and the Linx device, and recent studies comparing partial versus complete fundoplication and surgical versus medical therapy.
GERD is caused by the reflux of stomach contents into the esophagus, causing troublesome symptoms. The main determinants of GERD are abnormalities in the lower esophageal sphincter (LES) and the nature of refluxate. While PPIs help symptoms, they do not stop the progression of GERD due to permanent changes in the LES and ongoing exposure of the esophagus to bile acids at a pH of 3-7. Multichannel intraluminal impedance (MII)-pH monitoring is the best test to detect both acid and non-acid reflux that may contribute to progression. Management aims to modify refluxate composition and prevent reflux to stop disease progression
This document describes the case of 65-year-old Daishi Hayato who was admitted to the hospital with acute respiratory distress, COPD, and peripheral vascular disease. He had a history of smoking 2 packs per day for 50 years. He developed respiratory failure and required intubation and ventilation. Enteral and parenteral nutrition were started but caused excessive calorie intake, as shown by elevated CO2 levels and increased RQ. Nutrition was modified to prevent further complications.
This document discusses non-invasive positive pressure ventilation (NIPPV). It defines NIPPV as ventilation without an invasive airway and notes its increasing use for acute respiratory failure. The document covers the history of NIPPV, indications, goals, advantages, patient selection criteria, initiation procedures, modes (including CPAP, BiPAP, volume vs pressure), and settings. NIPPV can effectively treat various conditions like COPD, heart failure, and respiratory infections while avoiding intubation. Careful patient selection and monitoring are important for successful NIPPV.
Recent Advances in NIV
1) Non-invasive positive pressure ventilation (NIPPV) can effectively treat acute respiratory failure without the need for intubation in conditions like COPD, obesity, and neuromuscular diseases.
2) Different interfaces like facial masks, nasal masks, and helmets can be used for NIPPV, with nasal masks generally better tolerated than other options.
3) NIPPV reduces mortality and need for intubation compared to standard oxygen therapy alone in acute exacerbations of COPD and cardiogenic pulmonary edema.
4) Factors like pH, comorbidities, respiratory rate and effort predict success or failure of NIPPV. Close monitoring is needed in cases with higher
How to manage a case of acute exacerbation of COPD according to GOLD guidelines. Sincere thanks to Dr. Amardeep Toppo who has prepared most of this presentation.
This document provides information on diagnosing and differentially diagnosing COPD, including:
- Key indicators that should prompt consideration of a COPD diagnosis including dyspnea, chronic cough, sputum production, and risk factor exposure. Spirometry is required to confirm COPD.
- Spirometry is the basic investigation needed to diagnose COPD. It assesses airflow limitation through FEV1/FVC ratio and severity through FEV1 levels. Reversibility testing can help differentiate COPD from asthma.
- Additional optional investigations that may be used include imaging like chest X-rays and CT scans to identify emphysema and airway abnormalities, lung volume measurements, diffusing capacity tests, and
Managing Respiratory Symptoms in Advanced MS Rachael MosesMS Trust
This document discusses managing respiratory symptoms in advanced multiple sclerosis (MS). It outlines how MS can affect the respiratory system through weakness of the respiratory muscles and bulbar dysfunction. It describes how to assess the different stages of cough through tests of inspiratory muscles, glottis closure, and expiratory muscles. Various techniques are presented to help clear secretions for patients with weak coughs, such as lung volume recruitment, mechanical insufflation-exsufflation devices, and hyperbaric oxygen therapy. Ethical issues around respiratory management in advanced MS are also addressed.
Managing respiratory symptoms in advanced MSMS Trust
This document discusses managing respiratory symptoms in advanced multiple sclerosis (MS). It summarizes research showing pulmonary dysfunction correlates with disability level in MS. For patients with normal lung function, expiratory muscle strength may still be reduced. Lung volume recruitment (LVR) and mechanical in-exsufflation (MI-E) are presented as techniques that can help preserve lung function and clear secretions by improving peak cough flow. The combination of LVR and manually assisted coughing is shown to be most effective. Case studies demonstrate MI-E and tracheostomy with ventilation can prevent hospital admissions and be life-saving for some advanced MS patients.
This document discusses mechanical ventilation and care of children requiring long-term ventilation. It covers the physiology of ventilation, indications for mechanical ventilation, types of ventilators including transport, ICU, neonatal and PAP ventilators. It describes various ventilation modes like PC, VC, PRVC, SIMV and their applications. Factors in weaning from ventilation are discussed along with complications and troubleshooting. Non-invasive ventilation options like CPAP, BiPAP and protocols for safe weaning are also summarized.
The document discusses the Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD aims to increase awareness of COPD, improve diagnosis and management, and decrease morbidity and mortality. It provides global strategies and guidelines for COPD diagnosis, assessment, treatment and prevention. The document outlines GOLD's structure, board of directors, science committee and evidence levels. It also summarizes chapters in GOLD's 2015 strategy document covering COPD definition, diagnosis, assessment, treatment and management.
The document provides an overview of the ACERS (Acute COPD Early Response Service) team and COPD services in Hackney. The summary is:
- The ACERS team introduces their service model which provides rapid community response for COPD exacerbations and ongoing chronic disease management.
- COPD is projected to be the third leading cause of death by 2020. The ACERS team aims to provide comprehensive, integrated care to meet the needs of COPD patients in Hackney.
- Resources and support available include the NHS London Respiratory Team, British Lung Foundation, NICE guidelines, and the National COPD Project which focuses on reducing readmissions.
This document discusses the use of noninvasive ventilation (NIV) for patients with COVID-19-associated acute hypoxemic respiratory failure (AHRF). It finds that the majority of COVID-19 patients treated with continuous positive airway pressure (CPAP) recovered from moderate-to-severe AHRF. For select patients, NIV may prevent intubation and invasive ventilation. However, patient selection is important and NIV may delay intubation in some cases. Close monitoring is needed to identify patients who require intubation.
The document provides information on chronic obstructive pulmonary disease (COPD) from the Global Initiative for Chronic Obstructive Lung Disease (GOLD). It defines COPD as a common preventable disease characterized by persistent airflow limitation associated with an enhanced inflammatory response in the airways. It discusses mechanisms of airflow limitation, risk factors, assessment of COPD including symptoms, spirometry and exacerbation history, management of stable COPD and exacerbations, and pharmacologic treatment options.
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are associated with high costs, morbidity, and mortality. They result in enormous healthcare expenditures and lost productivity. AECOPD episodes are also linked to accelerated long-term loss of lung function in continuous smokers. While symptoms may recover within a week, full recovery of health-related quality of life can take months. Noninvasive mechanical ventilation should be tried for patients with respiratory acidosis or increased work of breathing from AECOPD as it reduces intubation rates and improves health outcomes. Preventing and properly managing AECOPD is important for reducing its impacts.
Chronic Obstructive Pulmonary Disease (COPD) is a common lung disease characterized by persistent respiratory symptoms and airflow limitation. It includes chronic bronchitis and emphysema. The main risk factor is cigarette smoking. Symptoms include dyspnea, cough, and sputum production. Diagnosis is confirmed by spirometry showing airflow limitation. Management involves smoking cessation, bronchodilators, pulmonary rehabilitation, oxygen therapy, and treating exacerbations with corticosteroids and antibiotics.
This document discusses asthma-COPD overlap syndrome (ACOS). It defines asthma and COPD, noting their differences and similarities. Both are chronic inflammatory airway diseases but COPD is characterized by persistent airflow limitation and progressive lung function decline while asthma is often reversible. The document then discusses clinical features that can help distinguish asthma from COPD. It notes that some patients have features of both diseases, termed ACOS. Spirometry, biomarkers, imaging and response to treatment are discussed to help identify ACOS. The inflammatory patterns in asthma and COPD are compared, showing that eosinophilic inflammation is more prominent in asthma while neutrophilic inflammation dominates in COPD.
Pediatric Acute Respiratory Distress Syndrome Owais Mohd
The document discusses pediatric acute respiratory distress syndrome (ARDS). It provides definitions and criteria for ARDS according to the 1994 and 2012 Berlin definitions. It describes the pathogenesis, phases, diagnosis, and management of ARDS. Management involves controlling the underlying cause, oxygen administration, ventilation strategies including low tidal volumes and permissive hypercapnia, and considering therapies like prone positioning, high frequency ventilation, inhaled nitric oxide, and extracorporeal membrane oxygenation. The goal of management is to minimize ventilator-induced lung injury while maintaining oxygenation and ventilation. Outcomes depend on disease severity with higher mortality seen in more severe cases.
This study analyzed 114 cases of neonatal Candida bloodstream infection from a tertiary care hospital in central India over 5 years. Non-albicans Candida (NAC) infections like C. tropicalis and C. parapsilosis were associated with higher mortality and longer hospital stays. Resistance to fluconazole and amphotericin B was also higher in NAC infections. Prolonged use of central lines, nil oral intake, mechanical ventilation and longer hospital stays were identified as risk factors. The study highlights the need for timely identification of Candida species and antifungal susceptibility testing to help improve outcomes.
This document summarizes recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD). It discusses definitions, pathophysiology, epidemiology, clinical presentation, diagnostic tests including 24-hour pH monitoring and endoscopy, and treatment options including lifestyle modifications, medications like PPIs, and surgical procedures. Key recent advances mentioned include new diagnostic markers, multichannel intraluminal impedance pH monitoring, narrow-band imaging, and endoscopic assessment of mucosal impedance. Surgical treatments discussed are laparoscopic anti-reflux surgery and the Linx device, and recent studies comparing partial versus complete fundoplication and surgical versus medical therapy.
GERD is caused by the reflux of stomach contents into the esophagus, causing troublesome symptoms. The main determinants of GERD are abnormalities in the lower esophageal sphincter (LES) and the nature of refluxate. While PPIs help symptoms, they do not stop the progression of GERD due to permanent changes in the LES and ongoing exposure of the esophagus to bile acids at a pH of 3-7. Multichannel intraluminal impedance (MII)-pH monitoring is the best test to detect both acid and non-acid reflux that may contribute to progression. Management aims to modify refluxate composition and prevent reflux to stop disease progression
This document discusses fluid resuscitation in acute kidney injury (AKI). It notes that AKI is common in critically ill patients, especially those with septic shock. While early goal-directed therapy was previously recommended, large trials found no benefit over usual care. The document discusses assessing volume status and differentiating fluid responders from non-responders using techniques like passive leg raising. It recommends crystalloids over colloids for initial fluid resuscitation in AKI. Normal saline may remain a reasonable first-line crystalloid but balanced solutions have not been shown to cause harm. Fluid overload can worsen outcomes and should be avoided.
Gastroesophageal reflux disease in children.Indian Society of Pediatric Gast...Vijitha A S
Gastroesophageal reflux disease in children.Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition (ISPGHAN) 2022 update
DR VIJITHA A S
Acute respiratory distress syndrome (ARDS) occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. The fluid keeps your lungs from filling with enough air, which means less oxygen reaches your bloodstream. This deprives your organs of the oxygen they need to function.
This patient presents with an acute exacerbation of asthma/COPD. The document reviews guidelines on asthma and COPD, including epidemiology, pathophysiology, diagnosis and treatment approaches. It also presents two case studies, one involving a 19-year old female student with asthma symptoms and another involving a 72-year old female with multiple inhalers for COPD. Treatment strategies and inhaler techniques are discussed.
Catheterisation study and operability assessmentIndia CTVS
This document discusses catheterization and assessment of operability in patients with left-to-right shunts. Catheterization is needed to calculate pulmonary and systemic blood flows, vascular resistances, and reversibility. Reversibility testing uses pulmonary vasodilators like oxygen and nitric oxide to see if pulmonary vascular resistance decreases significantly. A positive response predicts operability. Balloon occlusion, lung biopsy, and other tests can also provide information but have limitations. The goal is to determine if pulmonary hypertension is fixed or responsive to treatment to guide surgical or medical management.
Diagnosis and management of asthma in older adultsDoha Rasheedy
This document discusses the diagnosis and management of asthma in older adults. Some key points include:
- Asthma is often misdiagnosed in the elderly due to similar symptoms with other common conditions. Spirometry and demonstrating reversibility are important for diagnosis.
- Asthma in the elderly can be classified as long-standing or late-onset. Long-standing asthma is associated with worse outcomes.
- Fixed obstructive patterns on pulmonary function tests may indicate airway remodeling from long-term inflammation.
- Alternative lung function measures like impulse oscillometry may be better for elderly patients who cannot perform standard spirometry.
- Treatment focuses on inhaled corticosteroids and bronchodilators, but
This document defines chronic obstructive pulmonary disease (COPD) and describes its pathophysiology, classification, clinical manifestations, diagnostic assessment, management, and nursing care. COPD is characterized by airflow limitation caused by chronic bronchitis or emphysema. It involves inflammation in the central and peripheral airways leading to mucus hypersecretion, cilia dysfunction, and structural remodeling. Management includes pharmacological therapy, pulmonary rehabilitation, oxygen therapy, and nursing interventions focused on breathing exercises and airway clearance.
This document describes a study evaluating the effectiveness of different airway clearance therapies for patients with ALS. The study aims to compare the combination of mechanical insufflation/exsufflation (MIE) and high frequency chest wall oscillation (HFCWO) devices to using each device alone. 28 participants were randomized into three groups testing MIE alone, MIE+HFCWO, or HFCWO alone. The primary outcome is to evaluate respiratory complications severity using scales. Participants commit to daily device use and clinic visits at 3 months. Descriptive results found attrition with 10 completing the study. Discussion notes the difficulties conducting research in ALS and that patients may present at later disease stages.
This document summarizes new developments in pediatric acute respiratory distress syndrome (ARDS). It discusses the definition and pathophysiology of ARDS, as well as associated clinical disorders and outcomes. Therapies covered include mechanical ventilation strategies like low tidal volumes, permissive hypercapnia, high frequency oscillation, and prone positioning. Pharmacological approaches discussed are surfactant, steroids, inhaled nitric oxide, and partial liquid ventilation. The use of extracorporeal membrane oxygenation for severe respiratory failure is also mentioned.
1. ARDS is a respiratory condition characterized by diffuse pulmonary edema and hypoxemia that develops rapidly within one week of a known clinical insult.
2. The Berlin Definition from 2011 revised the diagnostic criteria for ARDS, requiring an onset within 1 week of a known clinical insult, bilateral opacities on chest imaging not fully explained by cardiac failure or fluid overload, and a ratio of arterial oxygen partial pressure to fractional inspired oxygen of ≤300 mm Hg for mild ARDS or ≤200 mm Hg for moderate/severe ARDS.
3. Management of ARDS involves mechanical ventilation with low tidal volumes, conservative fluid management to avoid pulmonary edema, and treating the underlying cause of lung injury while minimizing additional lung injury from
Interstitial lung diseases (ILDs) are a group of more than 200 different disorders that cause scarring in the lungs. Scar tissue in the lungs can make it harder for you to breathe normally. In ILDs, scarring damages tissues in or around the lungs’ air sacs and airways.
The document discusses ventilatory management of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). It defines ALI and ARDS based on ratios of arterial oxygen partial pressure to fractional inspired oxygen. It describes that mechanical ventilation can lead to ventilator-associated lung injury if not performed carefully. Lung protective ventilation strategies aim to reduce lung injury by limiting tidal volume and airway pressures. The use of positive end-expiratory pressure, recruitment maneuvers, permissive hypercapnia, and alternative ventilation modes are also discussed. Ongoing research is still needed to refine best practice for ventilation of patients with ALI/ARDS.
Gastroesophageal reflux disease (GERD) is defined as the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus. It is a condition which develops when the reflux of stomach contents causes troublesome symptoms and complications.
A 41-year-old female presented with right upper quadrant abdominal pain and was diagnosed with symptomatic gallstones and acute cholecystitis. She underwent a laparoscopic cholecystectomy under general anesthesia. General anesthesia was induced and tracheal intubation was performed. Pneumoperitoneum was created and maintained at 12 mmHg during the laparoscopic procedure. The surgery was completed without complications and the patient was extubated and transferred to the recovery unit in a stable condition.
Gastro esophageal Reflux Disease (GERD) and its managementDr. Ankit Gaur
In this presentation I have tried to explain in brief about gastro esophageal Reflux Disease (GERD), its etiology, risk factors, diagnosis, and its management via pharmacotherapy.
Acute kidney injury is important topic for students.
the presentation covers all aspects including guidelines from KDIGO, harrison 20th edition and relevant articles.
COURTSEY - DEPARTMENT OF CRITICAL CARE
ABVIMS & DR RML HOSPITAL NEW DELHI.
COPDTeam Members Adewale OkanlawonFatimoh OlatejuUchennAlleneMcclendon878
COPD
Team Members:
Adewale Okanlawon
Fatimoh Olateju
Uchenna Orji
Tracie Pemberton
Marlene Rosales
COPD
“Chronic obstructive pulmonary disease, or COPD, refers to a group of diseases that cause airflow blockage and breathing related problems. It includes emphysema and chronic bronchitis.” (CDC, 2018)
As you can see on the left lung presented here, the bronchioles are filled with mucous. This causes the ‘crackles’ that are heard upon auscultation of the lungs.
Biographics
Name: Ana Jones
Gender: Female
Ethnicity: Hispanic/Latino
Age: 56 years old
Ht/Wgt: 5’2, 152 lbs (69.09 Kg)
Admitting Doctor: Dr. Snow, MD direct admission
Medical Diagnosis: COPD Exacerbation with possible Lung Infection
Code: Full
Diet: Low Sugar
Activity as tolerated
Our patient has a history of Diabetes, admits to poor diet and lack of physical activity. Patient states has a history of elevated cholesterol levels and hypertension. Patient experienced an MI 3 years previous. Patient does not smoke or drink alcohol and does not use illegal substances.
Chief Complaint
Patient presents with:
Chief complaint: “I can’t catch my breath and I am burning up”
fever
shortness of breath
uncontrolled chills
extreme fatigue
low/no appetite
cough with greenish mucous
chest pain when coughing 6/10 on scale
As always, ABC is top priority, so have patient on supplemental oxygen and will now proceed with examination
Biographics Continued
Past Health History:
Diabetes
Hypertension
COPD
MI (3 years previous)
Social:
Patient brought in by her husband. Married 30 years, 2 adult aged children, housewife.
Husband states “he is very worried about his wife as she doesnt seem to be able to breath at all”. Husband informed us their daughter and sick grandbaby had been visiting last week.
Biographics Continued
Current Medication:
Metformin
Hydralazine
Nebivolol
Albuterol
Fluticasone
Metoprolol
Patient is currently on Metformin for blood glucose control, Hydralazine and Nebivolol for control of hypertension, Albuterol and Fluticasone for COPD and Metoprolol for MI
Physician Orders
Administer oxygen via nose cannula and titrate to 98% O2 saturation, 2L/m
Start IV, with 0.9 Saline
Respiratory - breathing evaluation and treatment
Sputum Test (stat)
Ct Scan
Labs:
Full CBC
ABG
Cholesterol Panel
V/S q 4 hours
Administer: Levofloxacin 750 mg IV , Tylenol 650 Mg PO, fever greater than 101.,
Call with Lab report
Nurses Notes: Keep patient elevated at 45% to facilitate breathing, advise client to call for assistance when needs to use use the restroom. Sputum test MUST be done before administering Levofloxacin. CT Scan is to check for any inflammation or fluid in the lobes of the lungs. We will be expecting to see an elevated WBC. Physician is suspecting streptococcus pneumococcus This would be supported by the S/S of dyspnea, cough with sputum and activity intolerance.
Vital Signs
Temperature: 103.6 F
R ...
Similar to Can the gut affect the lungs in scleroderma? (20)
Andrea Murray is developing light-based imaging techniques like nailfold capillaroscopy, laser Doppler imaging, and multispectral imaging to better measure and monitor scleroderma disease severity, progression, and treatment response. These non-invasive techniques could provide improved disease management. Specifically, her research has advanced nailfold capillaroscopy by automating capillary measurement, shown laser Doppler imaging can measure blood flow changes in digital ulcers, and a pilot study found multispectral imaging can differentiate oxygenation changes between scleroderma patients and healthy controls. The overall aim is to validate these techniques to better target and monitor scleroderma treatments.
This document discusses personalised care planning for patients with scleroderma. It begins by introducing shared decision making and the role of personalised care plans. It then discusses the Portsmouth Hospitals NHS Trust experience developing a scleroderma personalised care plan through patient focus groups and piloting. Feedback from patients who used the care plan was positive, finding it increased their feeling of control and was informative. The document concludes personalised care plans can promote patient choice and support self-management of long-term conditions.
This document summarizes information about scleroderma in children and young people. It discusses the different subtypes of juvenile scleroderma, including localized scleroderma (morphea) and systemic sclerosis. Localized scleroderma is more common than systemic sclerosis. The document reviews epidemiological data on incidence rates and clinical manifestations. It also discusses disease assessment, treatments such as methotrexate for localized scleroderma, and outcomes. Prognosis is generally better for juvenile scleroderma compared to adult-onset disease, but internal organ involvement can still lead to mortality in severe cases. The document advocates for more collaborative research to improve understanding and treatment of scleroderma in children
This document provides information about Raynaud's phenomenon and scleroderma. It begins by defining Raynaud's as episodes of color change in the extremities induced by cold or stress. It notes there are primary and secondary forms, with the secondary type associated with underlying conditions like scleroderma. Scleroderma is then defined as hardening of the skin, with types including limited and diffuse cutaneous forms. The document provides details on diagnostic tests and classifications for these conditions and discusses their symptoms, treatments, and epidemiology.
This document summarizes an expert talk on emerging therapies for systemic sclerosis. It discusses how scleroderma is now treatable with licensed therapies for pulmonary arterial hypertension and digital ulcers. Guidelines and access to treatments need improvement. Immunosuppression can benefit patients if risks are balanced. Targeted therapies are possible. Three recent clinical trials were encouraging by informing disease mechanisms and supporting therapy advances.
Raynaud's phenomenon and scleroderma are linked vascular conditions. Raynaud's involves reduced blood flow to the extremities while scleroderma causes fibrosis of skin and organs. Damage to blood vessels from Raynaud's attacks may trigger antibodies, inflammation, and attempts to repair tissue through fibrosis. Understanding these pathways could help guide new treatments to prevent complications like lung scarring and kidney or lung failure.
This document discusses stem cell transplantation for the treatment of scleroderma. It summarizes that stem cell transplantation is a complex, multi-step treatment involving high-dose chemotherapy, antibodies, and reinfusion of stem cells. It can potentially improve skin thickening, functional ability, and quality of life for scleroderma patients, but it also carries risks like infertility, infections, and malignancy. The document concludes that stem cell transplantation is an effective treatment for early, severe scleroderma, especially in non-smoking patients, though most scleroderma patients do not require it and it remains a specialized treatment.
This document discusses Raynaud's phenomenon and its link to systemic sclerosis. It begins with an overview of Raynaud's phenomenon, including its causes stemming from problems with blood vessel function. It then discusses systemic sclerosis and how Raynaud's phenomenon is more complex and can lead to worse issues when associated with sclerosis, like skin thickening and lung/organ problems. The document covers treatments aimed at improving blood vessel function and managing symptoms. It emphasizes the need for early, aggressive treatment of Raynaud's in sclerosis patients to potentially slow disease progression and prevent complications.
The document summarizes the role of a specialist nurse in rheumatology. It discusses how specialist nurses (1) provide education and support to help patients manage their symptoms, (2) follow national and local guidelines in their care, and (3) add value through activities like reducing waiting times and hospital admissions. It also provides examples of how one specialist nurse supports patients with conditions like Raynaud's and scleroderma through clinic consultations, education on managing symptoms, and promoting self-management.
This document discusses current and future treatment options for systemic sclerosis (SSc). It covers treatments for Raynaud's phenomenon like nifedipine, iloprost, and bosentan which aim to dilate blood vessels and improve blood flow. It also discusses immunosuppressants like cyclophosphamide and methotrexate used to treat lung disease and skin thickening. Symptoms of gastrointestinal problems, arthritis, lung fibrosis, pulmonary hypertension, and kidney disease are reviewed along with their treatment options. The document concludes by mentioning research into new treatments like rituximab and autologous stem cell transplant and the work of research groups to advance treatment of SSc.
This document provides information to help patients manage Raynaud's phenomenon and scleroderma. It discusses caring for skin, preventing and treating digital ulcers, managing fatigue, and looking after dry eyes/mouth, the gut, and heart/lungs. Specific recommendations include applying moisturizers daily, protecting skin from the sun, taking medications to improve blood flow, setting activity goals, using artificial tears and saliva, managing reflux through diet, and promptly reporting any new or worsening symptoms. The overall message is for patients to listen to their body and seek medical advice if symptoms change significantly.
This document discusses Raynaud's phenomenon, scleroderma, and the link between the two conditions. Raynaud's phenomenon is characterized by episodic discoloration of the fingers, toes, or other areas in response to cold or stress. It is often an early symptom of scleroderma, a condition characterized by fibrosis of the skin and internal organs. In scleroderma, damage to blood vessels from factors like antibodies, viruses or toxins leads to intermittent episodes of Raynaud's phenomenon. Over time, this causes scarring and thickening of the skin and organs as the body attempts to repair the damage through fibrosis instead of normal wound healing. Understanding the pathogenesis could help guide new treatments to prevent
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
1. Can the gut affect the lungs in
scleroderma?
Elizabeth Renzoni
ILD Unit
Royal Brompton Hospital
2. Structure of the gullet (esophagus)
Upper esophageal sphincter: bundle of
muscles that keeps food/liquids from going
down the windpipe
Lower esophageal sphincter: bundle of
muscles that keeps the stomach contents
from flowing back up into the gullet
3.
4. The upper gut in scleroderma
•The gullet often affected in scleroderma
•Difficulty swallowing because the muscles in
the wall of the gullet work less well
•The muscle bundles of the lower gullet valve
(LES) don’t close the entrance to the stomach as
tightly, and may cause reflux from the stomach
5. •What is the relationship between reflux and
interstitial lung disease (ILD) in scleroderma ?
13. SSc-ILD
HR 95% CI
p value
Survival
Time to decline in FVC
Time to decline in DLco
Time to progression free
survival
1.35 1.06, 1.65 0.02
1.45 1.22, 1.68 <0.0005
1.30 1.08, 1.52 <0.01
1.36 1.13, 1.58 <0.005
Serum KL6 versus outcome
Unpublished data, Goh et al
14. Is microaspiration of gastric
contents associated with lung
fibrosis in scleroderma?
15. Manometry: measures strength and muscle
coordination of the gullet (oesophagus)
LES pressure may not correlate with reflux - reflux may be due to delayed clearance rather than low LES pressure
16. Failed peristalsis with preserved
amplitudes in upper gullet LOS
diaphragm
Patient with SclerodermaHealthy individual
17. 24 hour impedance: allows measurement of
duration and frequency of both acid and non
acid reflux
18. Gastro-esophageal reflux (GER) in
SSc-ILD
Manometric abnormalities in SSc associated with ILD
and lung function decline at 2 yrs (Marie et al 2001)
Number of acid and non-acid reflux episodes higher in
SSc-ILD than no ILD (Savarino et al 2009)
Baseline manometry did not predict worsening lung
function; however most patients had mild ILD (Gilson
et al 2010)
19. Investigation into the role of GER in
Pulmonary Fibrosis in Scleroderma
(clinicaltrials.gov N: NCT02136394)
Collaboration between RBH ILD Unit and RFH
Rheumatology and Gastroenterology Depts;
funded by the RSA
20. Aims
•What is the impact of reflux on symptoms and quality
of life of patients with scleroderma?
•How frequent is microaspiration into the lungs?
•Is microaspiration into the lungs correlated with
markers of epithelial injury (KL-6)?
•Is microaspiration more frequent in patients with
progressive lung fibrosis?
21. Prospective assessment of patients with
scleroderma associated ILD:
Symptoms of reflux/indigestion/bloating
Symptoms of cough/breathlessness
Gullet involvement: manometry and 24 hr impedance
Lungs: full lung function tests (and CT) and on follow
up
22. Look for markers of microaspiration of stomach
contents (pepsin) into the lungs in:
–Exhaled breath condensate (pepsin, pH)
–Saliva (pepsin)
–In a subset of patients, in bronchoalveolar lavage
23. •Correlate markers of microaspiration with
serum KL6, a marker measured in the blood that
reflects epithelial damage in the lungs
24. Inclusion criteria
-SSc with lung fibrosis (CT extent > 5 %)
-age > 18
Exclusion criteria:
-current smoker
-Barrett’s esophagus
GER in SSc-ILD
25. GER and pulmonary fibrosis in
scleroderma
Screen
Consent
history
Baseline
physical exam
Full lung function
HRCT chest
Blood for serum
Respiratory and gut
symptoms
Manometry
24 hour impedance
Exhaled breath
condensate/Saliva
BAL
6 months
Exam and history
Full lung function
Respiratory symptoms
Gut/reflux symptoms
(Blood for serum)
Exhaled breath
condensate
Saliva
12 months
Exam and history
Full lung function
Respiratory symptoms
Gut/reflux symptoms
Blood for serum
Exhaled breath
condensate
Saliva
18 months
Exam and history
Full lung function
Respiratory symptoms
Gut/reflux symptoms
Exhaled breath
condensate
Saliva
Ongoing 6-12
monthly
reviews with
lung function
tests
26. Patients (Number) 27
Age (years) 57.3 (SD 10)
Female 70.3%
Ever smoker 33.3%
Diffuse SSc 26.1%
Scl-70 antibody 78%
Forced vital capacity 74% (SD 21.8)
Gas transfer (DLCO) 42% (SD 13.4)
On immunosuppression 89%
Characteristics of patients: so far recruited 42, interim analysis
of 27 patients
28. Medications for GER
•6% on no GER treatment
•47% on proton pump inhibitor (PPI) alone
•29% on PPI + ranitidine
•18% on PPI + ranitidine + domperidone
29. Symptoms (gut)
•Heartburn
•Reported by 52% of patients on Proton pump inhibitors
(PPI), and 78% off PPI. Even on PPIs, 40% of patients have at
least 3-4 episodes per week
•Vomiting
•Appx 20% have at least 1-2 episodes per week,
whether on/off PPI
•Swallowing problems
•50% of the patients report at least 1-2 episodes per week,
whether on/off PPI
•Bloating
•Reported by 58% of patients on PPI and 78% off PPIs.
Approximately ¼ have at least 5-7 episodes per day.
30. NS
P=0.06
Even on proton pump inhibitors, roughly half of
patients felt stomach pain and/or bloating could
interfere with social activities
32. PEPSIN MEASUREMENTS
•Pepsin undetected in
exhaled breath
condensate (EBC)
•Pepsin detected in
saliva samples 14/27
patients
•Pepsin detected in all
BAL samples
performed so far
33. Saliva
pepsin
BAL
pepsin
Residual LES pressure 0.4 ns
% upright reflux 0.38 0.8
% recumbent reflux ns 0.7
Total reflux episodes 0.5 0.8
Acid reflux episodes 0.5 ns
Cough index 0.6 ns
Forced vital capacity% ns -0.8
Gas transfer (DLCO)% ns -0.8
Correlation between reflux measurements
and pepsin in saliva and BAL
34. Correlation between oesophageal
measurement and cough
Cough
Questionnaire
Mean UOS pressure 0.52
Mean LOS pressure 0.44
% upright reflux 0.4
% recumbent reflux ns
%total time reflux 0.43
Acid reflux 0.44
Non acid reflux 0.6
Proximal reflux
episodes
0.58
35. R=0.44; p=0.02 R=0.43; p=0.03
Lung function parameters correlate with lower
oesophageal sphincter pressures
36. Preliminary conclusions
•Symptoms related to gullet abnormalities have a
significant impact in patients with scleroderma
•Anti acid reflux drugs (proton pump inhibitors) benefit
only some of the gut symptoms, and reduce frequency
of troublesome cough
•Significant correlation between cough and acid/non
acid reflux measured by 24 hr impedance
•Upright but not recumbent reflux episodes correlate
with cough and with saliva pepsin
37. •Pepsin is measurable in saliva and BAL samples
but not in exhaled breath condensate
•There appears to be a correlation between BAL
pepsin and lung function severity, although still
too few patients
•Further recruitment and ongoing analyses
needed to assess relationship between reflux
and ILD
•Prospective assessment will be crucial to assess
whether microaspiration contributes to lung
disease progression
39. Manometry in keeping
with SSc-related gullet
involvement
57.7%
DeMeester score (overall
acidity exposure, normal <
14.7)
Mean 27.8
(SD 38.32)
% non acid reflux Mean 53% (SD 30.6%)
% time with reflux (acid/nonacid) Mean 4% (SD 10%)
40. Correlation between oesophageal
measurement and cough
Cough
Questionnaire
(off PPI)
Cough
Questionnaire
(on PPIs)
Mean UOS pressure 0.52
Mean LOS pressure 0.44
% upright reflux 0.4 0.7
% recumbent reflux
%total time reflux 0.43 0.7
Acid reflux 0.44
Non acid reflux 0.6
Proximal reflux
episodes
0.58
41. Common events in fibrosis progression across
different tissues
Friedman et al 2013