back to basics review: respirology in under two hours
DESCRIPTION
Back to Basics Review: Respirology in Under Two Hours. Nha Voduc MD FRCPC Original Presentation by Jen Block MD FRCPC. April 8, 2011. The Plan. Pulmonary Function Testing Asthma COPD Sleep Apnea Pleural Effusion Lung Cancer. Spirometry: Measurement of Airflow. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/1.jpg)
Back to Basics Review:Respirology in Under Two Hours
Nha Voduc MD FRCPCOriginal Presentation by Jen Block MD FRCPC
April 8, 2011
![Page 2: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/2.jpg)
The Plan...
• Pulmonary Function Testing
• Asthma
• COPD
• Sleep Apnea
• Pleural Effusion
• Lung Cancer
![Page 3: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/3.jpg)
Spirometry: Measurement of Airflow
![Page 4: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/4.jpg)
1. Take as deep a breath as possible2. Blast out the air into spirometer3. Continue exhaling for several more seconds
UpToDate
![Page 5: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/5.jpg)
RVTLC
Flow Volume Loop
![Page 6: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/6.jpg)
Interpretation
• Upper Airway Abnormalities
• Obstructive Lung Disease
• Restrictive Lung Disease
![Page 7: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/7.jpg)
Upper Airway Abnormalities
• Variable extrathoracic obstruction impairs inspiratory flow more than expiratory flow -- negative pressure during inspiratory “sucks in” (narrows) airway
• Variable intrathoracic obstruction impairs expiratory flow more than inspiratory flow -- positive intrathoracic pressure compresses in airway
ERJ 2005; 26: 948-968
![Page 8: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/8.jpg)
Obstructive Lung Disease
• FEV1/FVC is <70%and
• FEV1 < 80%(or < 2 standard deviations)
• “scooped out”
• lung volumes may show Hyperinflation or “gas trapping”(increased residual volume)
ERJ 2005; 26: 948-968
![Page 9: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/9.jpg)
Restrictive Lung Disease
• TLC < 80% (or < 2 standard deviations)
• normal FEV1/FVC ratio
• Neuromuscular, Chest wall,
Interstitial Lung disease
ERJ 2005; 26: 948-968
![Page 10: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/10.jpg)
Asthma
• Pathophysiology
• Diagnosis
• Chronic Management
• Acute Management
![Page 11: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/11.jpg)
Asthma: Definition
• paroxysmal or persistent symptoms (dyspnea, chest tightness, wheeze, cough)
• variable airflow limitation and airway hyper-responsiveness
• due to inflammation
![Page 12: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/12.jpg)
Comprehensive Asthma Management
• Suspect asthma and confirm diagnosis
• Education
• Assess severity
• Avoid / control triggers and environmental modification
• Medications for chronic disease
• Assess control
• Management plan for exacerbation
• Regular follow-up
![Page 13: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/13.jpg)
• If FEV1 is low, try to increase it using a short-acting bronchodilator
(reversibility)
• ≥12% and ≥180 ml improvement in FEV1 from baseline 15 minutes after the
use of an inhaled short-acting bronchodilator
Asthma Diagnosis: Requirements PFTs
![Page 14: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/14.jpg)
• If FEV1 is normal, try to see if airways are hyperresponsive by giving an
irritant (methacholine challenge)
Asthma Diagnosis
![Page 15: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/15.jpg)
Comprehensive Asthma Management
• Suspect asthma and confirm diagnosis
• Education
• Assess severity
• Avoid / control triggers and environmental modification
• Medications for chronic disease
• Assess control
• Management plan for exacerbation
• Regular follow-up
![Page 16: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/16.jpg)
Asthma Management
![Page 17: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/17.jpg)
Relievers – Short Acting Beta-Agonists
• SABAs for acute relief• ‘rescue’ medication used as needed• MDI salbutamol (Ventolin) • dry powder terbutaline (Bricanyl)
• Frequent use of SABA indicates poor control• Regular use associated with tachyphylaxis
![Page 18: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/18.jpg)
Asthma Management
![Page 19: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/19.jpg)
Inhaled Corticosteroids (ICS)
• Anti-inflammatory ICS mainstay of therapy
– Prevent symptoms, improve PFTs, decrease hyper-responsiveness, reduce morbidity
![Page 20: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/20.jpg)
Inhaled Corticosteroids – How do they work?
• Like steroids produced endogenously by adrenal cortex
• Anti-inflammatory – inhibit production of cytokines, which:
– reduces eosinophil infiltration– inhibits macrophage function– reduces production of leukotrienes
![Page 21: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/21.jpg)
Dosing Guide
Drug Low Daily Dose (μg) Medium Dose (μg) High Daily Dose (μg)
Fluticasone(Flovent)
≤250 251-500 >500
Budesonide(Pulmicort)
≤400 401-800 >800
Beclomethasone(Qvar)
≤250 251-500 >500
Ciclesonide(Alvesco)
≤200 201-400 >400
![Page 22: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/22.jpg)
ICS Adverse Effects
• thrush• dysphonia
• osteoporosis• decreasedgrowth velocity (?)• glaucoma • cataracts• adrenal insufficiency
![Page 23: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/23.jpg)
Asthma Management
![Page 24: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/24.jpg)
Long Acting β2-Agonists (LABAs)
• add if not controlled by moderate dose ICS
• better than doubling ICS
• “not recommended as maintenance monotherapy”
– Increased mortality!
• doesn’t replace SABAs
• salmeterol (Serevent), formoterol (Oxeze)
![Page 25: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/25.jpg)
Combination LABA / ICS Products
– Salmeterol/fluticasone (Advair) MDI and diskus
– Budesonide/formoterol (Symbicort) turbuhaler
![Page 26: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/26.jpg)
Leukotriene Receptor Antagonists (LTRAs)
• Second or third choice medication or in patients who can’t take ICS
• Montelukast (Singulair)
• Oral medication
• Use in patients with:
– symptoms despite LABA/ICS
– ASA sensitivity, nasal polyps
– exercise-induced asthma
![Page 27: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/27.jpg)
IgE Antagonists: Omalizumab (Xolair)
• Monoclonal antibodies block action of IgE on mast cell
• Effective if IgE levels are only slightly elevated (500-1200)
• Monthly injection
• Extremely expensive
• Use if frequent need for oral steroids despite optimum conventional Rx and patient has drug plan or $$$
![Page 28: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/28.jpg)
Comprehensive Asthma Management
• Suspect asthma and confirm diagnosis
• Education
• Assess severity
• Avoid / control triggers and environmental modification
• Medications for chronic disease
• Assess control
• Management plan for exacerbation
• Regular follow-up
![Page 29: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/29.jpg)
Assess Control
• Both physicians and patients over-estimate their degree of control (many patients are much worse than they think they are)
![Page 30: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/30.jpg)
Comprehensive Asthma Management
• Suspect asthma and confirm diagnosis
• Education
• Assess severity
• Avoid / control triggers and environmental modification
• Medications for chronic disease
• Assess control
• Management plan for exacerbation
• Regular follow-up
![Page 31: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/31.jpg)
Asthma Exacerbation
• ABC’s– include RR, O2 sats, assess work of breathing, wheezing
• history: – Diagnosis– Environmental triggers– Previous exacerbations/admissions/intubations– Treatment history
• Compliance• Inhaler technique
– Other medical illnesses or medications
![Page 32: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/32.jpg)
• short-acting beta-agonists ie. salbutamol (Ventolin)
• short-acting anti-cholinergics ie. ipratropium (Atrovent)
• systemic anti-inflammatory therapy– oral = prednisone– intravenous = solumedrol
• very severe: MgSO4, intubation, anesthetic
Asthma Exacerbation
![Page 33: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/33.jpg)
COPD
• Definition
• Constrast from asthma
• Pathophysiology
• Diagnosis
• Chronic Management
• Acute Management
![Page 34: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/34.jpg)
COPD Definition
• respiratory disorder largely caused by smoking characterized by:
- progressive, partially reversible airway obstruction
- hyperinflation
- systemic manifestations
- increasing frequency and severity of exacerbations
![Page 35: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/35.jpg)
![Page 36: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/36.jpg)
COPD Risk Factors
• Host Factors:
- genetics (alpha-1-antitrypsin deficiency)
- bronchial hyper-responsiveness
• Environmental Factors:
- smoking
- childhood viral infections
- occupational & environmental exposures
![Page 37: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/37.jpg)
Pathophysiology - Airflow Obstruction
• alveoli and support structures are destroyed– decreased elastic recoil– lack of tethering gives airway collapse
• airway compression by adjacent overdistended lung units
• mucosal inflammation and secretions
![Page 38: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/38.jpg)
Pathophysiology - Hyperinflation
• expiratory flow limitation in COPD results in air trapping
• end-expiratory lung volumes are increased
• further hyperinflation with exercise (increased respiratory rate results in decreased expiratory time)
• decreased inspiratory capacity a major cause of dyspnea– Increased load on inspiratory
muscles
![Page 39: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/39.jpg)
COPD Diagnosis
• do not screen asymptomatic individuals
• assess symptomatic patients with spirometry
• post-bronchodilator FEV1/FVC ratio less than 0.7
COPD Stage Post-bronchodilator FEV1
(% predicted)
mild ≥ 80
moderate 50 - 79
severe 30 - 49
very severe < 30
![Page 40: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/40.jpg)
COPD Management
![Page 41: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/41.jpg)
![Page 42: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/42.jpg)
![Page 43: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/43.jpg)
![Page 44: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/44.jpg)
BMJ 2008; 336: 598-600.
Education - Effects of Smoking on FEV1
Mortality Benefit
![Page 45: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/45.jpg)
Education
“Tobacco is the only legal consumer product that kills
one third to one half of those who use it as intended
by its manufacturers, with its victims dying on
average 15 years prematurely”
- World Health Organization
![Page 46: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/46.jpg)
What Can You Do?
• 2007: 19% of adult Canadians are active smokers
• smoking cessation advice– even brief advice increases chances of patients quitting
• Personalized, direct but non-judgmental message
– www.gosmokefree.ca– www.smokershelpline.ca
• nicotine replacement therapy– many different types– any form of NRT increases chances of quitting vs. control
• buproprion, varenicline
![Page 47: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/47.jpg)
Other Prevention
• vaccination:– flu vaccine yearly– pneumococcal vaccine q5years
![Page 48: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/48.jpg)
COPD Management
![Page 49: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/49.jpg)
Short-Acting Bronchodilators
• Even patients with “fixed” airflow obstruction can have good clinical response to bronchodilators even if FEV1 changes very little
• Reduces hyperinflation, reduces dyspnea and increases exercise capacity
![Page 50: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/50.jpg)
Short-Acting Bronchodilators
• anti-cholingergics: ipatropium (Atrovent)– dry mouth– glaucoma if sprayed into eye– urinary retention
• β2-agonists: salbutamol (Ventolin)– tachycardia, palpitations– sleeplessness, tremor
• improves PFTS, dyspnea and exercise performance
![Page 51: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/51.jpg)
COPD Management
![Page 52: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/52.jpg)
Long-acting anti-cholinergic
• tiotropium (Spiriva)
• once a day
• blocks M3 muscarinic receptors in bronchial
smooth muscle
• improves:– PFTs, dyspnea, exercise capacity, quality of life– decreases exacerbations– maybe more improvement than LABA
![Page 53: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/53.jpg)
Long-acting β2-agonist (LABA)
• salmeterol (Serevent) and formoterol (Oxeze)
• twice daily
• more sustained improvement in PFTs, dyspnea and QOL than short-
acting bronchodilators
![Page 54: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/54.jpg)
COPD Management
![Page 55: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/55.jpg)
Dyspnea – Downward Spiral of Deconditioning
Respiratoryimpairment
Dyspnea during moderate exertion
Abstentionfrom exercise
Physical deconditioning
Dyspnea during mild exertion
Furtherabstention
Furtherdeconditioning
Dyspneaduring ADL
*
* = stay at home. Depression, oxygen
therapy etc.
![Page 56: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/56.jpg)
Pulmonary Rehabilitation
– Exercise + psychosocial support
– Aerobic exercise + strength training
– improves dyspnea, endurance, QOL
– trend to decreasing mortality
– need a maintenance program
www.lungchicago.org www.altru.org
![Page 57: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/57.jpg)
COPD Management
![Page 58: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/58.jpg)
Combination LABA / ICS Products
– Salmeterol/fluticasone (Advair) MDI and diskus
– Budesonide/formoterol (Symbicort) turbuhaler
– add to therapy if patient has persistent dyspnea or recurrent exacerbations
– improve PFTs, QOL, decrease exacerbations
– Benefits much more modest than in asthma
![Page 59: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/59.jpg)
COPD Management
![Page 60: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/60.jpg)
Indications for long term oxygen therapy
• pO2 on room air of≤ 55 mmHg< 60 mm Hg if evidence of
– Polycythemia– Cor pulmonale– Right heart failure
• Mortality benefit
![Page 61: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/61.jpg)
COPD Management
![Page 62: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/62.jpg)
Surgery
• Lung Volume Reduction Surgery- benefits patients with upper lobe (heterogenous) emphysema and
poor exercise capacity
• Lung Transplantation- single or double lung- non-smoker (must have quit smoking)- generally age< 65 without significant cardiac, renal, hepatic disease- post-transplant survival is 5-6 years on average- death from infection (early) and chronic rejection (later)
![Page 63: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/63.jpg)
COPD Management
![Page 64: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/64.jpg)
End of Life Issues
• Empathetic, realistic conversations about illness• Opportunity to express wishes re: intubation
• Dyspnea- morphine po, sc, iv- benzodiazepines
• Cough- opioids (codeine, morphine)
• Secretions- scopolamine
![Page 65: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/65.jpg)
What Decreases Mortality?
Non-Pharmacologic• Smoking cessation Yes• Flu shot No• Pneumonia vaccine No• Pulmonary Rehab ?
Pharmacologic• Oxygen Yes• Systemic Steroids No• Antibiotics No• SABA (Ventolin) No• Anti-cholinergics No• Theophylline No• Inhaled Steroids No• LABAs No• Combo ICS/LABA No
![Page 66: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/66.jpg)
COPD
• Contrast from asthma
• Definition
• Pathophysiology
• Diagnosis
• Chronic Management
• Acute Management
![Page 67: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/67.jpg)
Acute exacerbations of COPD
• Over 50% are associated with a bacterial infection• Decision to use antibiotics based on Anthonisen (Winnipeg)
criteria• Antibiotics are helpful if there are at least two of:
– Increased dyspnea– Increased volume of sputum– Increased purulence of sputum
![Page 68: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/68.jpg)
Acute exacerbations of COPD
• Treatment:
– ABCs
– O2 sat monitoring and oxygen prn
– history and p/e to rule out other causes of dyspnea
– CXR, ABG, sputum C&S
– Bronchodilators
– systemic steroids: prednisone 50 mg/d x 10-14 days (?)
– antibiotics if purulent sputum
– NIPPV
![Page 69: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/69.jpg)
Antibiotics for Community Acquired Pneumonia
![Page 70: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/70.jpg)
Obstructive Sleep Apnea Syndrome
• Elevated Apnea-Hypopnea Index on Sleep study (Polysomnography)
AND
• Nighttime Symptoms: Snoring, witnessed apneas
OR
• Daytime Symptoms: Morning headache, daytime sleepiness
![Page 71: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/71.jpg)
Obstructive Sleep Apnea Syndrome
• Apnea Hypopnea Index (AHI):– normal <5/hour– mild 5-15/hour– moderate 16-30/hour– severe >30/hour
• Treatment:– weight loss, avoid sedatives– positional therapy (off supine)– Non-invasive positive pressure therapy: CPAP / BiPAP– oral appliance, UPPP, tracheostomy less common / less effective
![Page 72: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/72.jpg)
Pleural Effusion
![Page 73: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/73.jpg)
Pleural Fluid Accumulation
• In normal pleural space, the rate of fluid formation is balanced by the rate of removal
• Rate of fluid formation is determined by the Starling equation
– hydrostatic forces push water out of vessel
– osmotic forces pull water back into vessel
• Pleural effusion is due to abnormalities in one of these processes
![Page 74: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/74.jpg)
• Cell count and differential• Gram stain• Culture• AFB• Cytology
• LDH• Total protein• Glucose • pH
Pleural Effusion Evaluation
![Page 75: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/75.jpg)
Light’s Criteria• pleural fluid protein/serum protein > 0.5• pleural fluid LDH / serum LDH > 0.6• pleural fluid LDH > 2/3 upper limit normal LDH
Any of these three criteria means fluid is EXUDATE
Pleural Effusion Evaluation
![Page 76: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/76.jpg)
Many!
Transudate = fluid overload or reduced oncotic pressure (low albumin)heart, liver, kidney
Exudate = infectious inflammatory malignant iatrogenic
Pleural Effusion Etiology
![Page 77: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/77.jpg)
• If exudate with no determined cause, you want to rule-out malignancyCT chest with contrast
pleuroscopy or VATSbronchoscopy
follow / repeat thoracentesis
Pleural Effusion Etiology
![Page 78: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/78.jpg)
Treatment is palliative (reduce symptoms associated with effusion)Cure generally not possibleIn most cases, effusion will persist despite chemotherapy
Most places, patients admitted for symptomatic thoracentesis +/- tube drainage and pleurodesis (talc)
In Ottawa, patients mostly receiving PleurX (indwelling) catheters to allow home drainage
Malignant Pleural Effusions
![Page 79: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/79.jpg)
Many causes - both benign and malignant
Solitary Pulmonary Nodule
Infectious granulomas fungal tuberculous
Benign neoplasm hamartoma lipoma
Vascular AVM
Developmental Bronchogenic Cyst
Inflammatory Wegener’s
Bronchogenic Cancer SCLC NSCLC - adenocarcinoma squamous large cell carcinoid
Metastatic Cancer breast colon others...
![Page 80: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/80.jpg)
Many causes - both benign and malignant
Clinical (age, smoking history) and radiographic features help
Solitary Pulmonary Nodule
Benign Malignant
Size smaller (<1 cm) larger (>3 cm)
Margins round, smooth irregularspiculated
Over time stable growth
Calcification popcorn, centralconcentric, diffuse None or asymmetric
![Page 81: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/81.jpg)
Management depends on risk of maligancy
Options:IgnoreFollow (repeat imaging within 3-6 months)BiopsyResect (almost never done without first attempting biopsy)
Solitary Pulmonary Nodule
![Page 82: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/82.jpg)
Small Cell Lung Cancer
• Approximately 20% of lung cancers• more rapid doubling time, earlier metastases• responsive to chemotherapy and radiation but quickly relapses
• smokers• central airways• present with metastases• paraneoplastic syndromes
PEIR Digital Library http://peir2.path.uab.edu
![Page 83: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/83.jpg)
• Limited (30-40%): involves only one hemithorax (maximum allowable for radiation portal)
- concurrent chemo + radiation- median survival 15-20 months
- (very small chance of cure)
• Extensive (60-70%): extends beyond hemithorax- Chemotherapy only- median 8-13 months
- (cure not possible)
Small Cell Lung Cancer
PEIR Digital Library http://peir2.path.uab.edu
![Page 84: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/84.jpg)
Non Small Cell Lung Cancer
• 80% of all lung cancers• 10-15% survival at 5 years
• staging by TNM systemT = tumourN = nodeM = metastases
Up To Date www.utdol.com
![Page 85: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/85.jpg)
Non Small Cell Lung Cancer
• Subtypes:- Adenocarcinoma (now most common)- Squamous cell carcinoma - Large cell carcinoma
PEIR Digital Library http://peir2.path.uab.edu
Bronchoalveolar Carinoma (BAC)
![Page 86: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/86.jpg)
Non Small Cell Lung Cancer
• Treatment and prognosis depend on stage
• Early Stage (1 or 2)–Surgical resection if tolerated–Adjuvant chemotherapy to reduce risk of recurrence
• Later Stage (3B or 4)–Chemotherapy if performance status is reasonable–Palliative Radiotherapy for symptoms
• Majority of NSCLC will not be resectable and/or operable
u
![Page 87: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/87.jpg)
The Plan...
• Spirometry
• Asthma
• COPD
• Sleep Apnea
• Pleural Effusion
• Lung Cancer
![Page 88: Back to Basics Review: Respirology in Under Two Hours](https://reader036.vdocuments.net/reader036/viewer/2022062410/56815a30550346895dc77152/html5/thumbnails/88.jpg)
Good Luck
• Questions?