cystic fibrosis - chhatrapati shahu ji maharaj...
TRANSCRIPT
Know the clinical features of cystic
fibrosis.
Know how CF is inherited.
Be familiar with criteria to diagnose
CF.
Become aware of the myriad of
treatments used in CF.
A multisystem disease
Autosomal recessive inheritance
Cause: mutations in the cystic fibrosis
transmembrane conductance
regulator (CFTR) gene
➢ chromosome 7
➢ codes for a c-AMP regulated chloride
channel
Very salty-tasting skin
Appetite, but poor
growth & weight gain Coughing, wheezing ,at times
with phelgum &
shortness of breath
Lung infections, e.g.
pneumonia/bronchitis
➢ greasy, bulky stools or
difficulty in bowel movements
6
C Chronic respiratory disease
F Failure to thrive
P Polyps
A Alkalosis, metabolic
N Neonatal intestinal obstruction
C Clubbing of fingers
R Rectal Prolapse
E Electrolyte in sweat
A Aspermia / absent vas deferens
S Sputum – S.aureus/P.aeruginosa
CFTR controls
chloride ion
movement in
and out of the
cell.
The CFTR gene is located on
the long arm of chromosome 7.
There are 1604 mutations in
CFTR listed on the CFTR
mutation database
The most common mutation is
Δ F508---70% CF alleles in
caucasians.
➢ Defects in (CFTR), - encodes for a protein that functions as chloride channel & regulated by (cAMP).
➢ Abnormalities of cAMP-regulates chloride transport
➢ Defective CFTR - decreased secretion of chloride and increased re-absorption of sodium and water
➢ Reduced height of epithelial lining fluid
➢ Decreased hydration of mucus - that is stickier to bacteria
➢ Result in viscid secretions
CF:
Clinical Signs
Cystic fibrosis affects entire body15
• Lungs and sinuses
• GI, liver and pancreas
• Reproductive system
• Nutritional
Endobronchial disease
➢ Cough / sputum production
➢ Air obstruction---wheezing; evidence
of obstruction on PFTs
➢ Chest x-ray anomalies
➢ Digital Clubbing
Sinus disease
➢ Nasal Polyps / sinusitis/ hemoptysis
Hyperinflation
Peribronchial
cuffing
Bronchiectasis
Diffuse fibrosis
Atelectasis
Mucous in the airways cannot be easily cleared from
the lungs.
Presentation of Disease inlung
Benign lesions in nasal
airway(5-20 yrs)
If large - associated with
nasal
obstruction, drainage, heada
ches, snoring
associated with chronic
inflammation
need surgical intervention
High recurrence rate
Intestinal abnormality➢ Meconium ileus (15-20% of newborn with CF)
➢ Distal intestinal obstruction syndrome (DIOS)
➢ Intussusception / Rectal prolapse
➢ Volvulus / atresia / meconium peritonitis
Hepatobiliary disease➢ steatorrhea
➢ Focal biliary cirrhosis
➢ Multilobular cirrhosis
Pancreatic endocrine dysfunction➢ Cystic fibrosis related diabetesCy
stic
Fib
ro
sis
Focal inspissation ofbile
➢ Obstructs biliary ductules
Second leading cause of death inCF
Prevalence 9-37%
Spectrum of disease➢ increased liver enzymes
➢ biliary cirrhosis
➢ portal hypertension
➢ GB stones
Cy
stic
Fib
ro
sis
Pancreatic insufficiency➢ ―cystic fibrosis of the pancreas‖---mucus
plugging of glandular ducts
➢ Chloride impermeability affects HCO3-
secretion and fluid secretion in pancreatic
ducts
Pancreatic enzymes stay in ducts and are activated
intraductally
➢ Autolysis of pancreas
➢ Inflammation, calcification, plugging of ducts, fibrosis
➢ Malabsorption
Failure to thrive
Fat soluble vitamin deficiency(ADEK)
Cy
stic
Fib
ro
sis
Men➢ Abnormal embryologic development of the
epididymal duct and vas deferens-- incomplete
or absent
➢ Congential bilateral absence of vas deferens—
97-98% of men with CF
Women
➢ Lower fertility rate than non-CF women
➢ Viscid mucoid cervical secretions of low
volume in women with CF
Pregnancy and CF:
➢ Goss et al, 2003---no significant difference
in survival in women who became
pregnant with CF compared to women
who did not become pregnant (after
adjusting for disease severity)➢ Fertility is mildly impaired
CF:
Diagnostic Methods
One or more clinical features of CF
OR
A history of CF in a sibling
OR
A positive newborn screening test
Plus
➢ Laboratory evidence for CFTR dysfunction: Two elevated sweat chloride concentrations obtained on separated days
OR
Identification of two CF mutations
OR
An abnormal nasal potential difference measurement
First described by Gibson and Cooke,1950
➢ Chemical that stimulates sweating placed under electrode pad; saline under other electrode pad on arm
➢ Mild electric current is passed between electrodes
➢ Sweat collected(75-100gm)
➢ Positive Sweat chloride: 60-165 meq/L
➢ Borderine sweat chloride: 40-60 meq/L
➢ Normal sweat chloride:
0-40
False positives:➢ Hypothyroidism
➢ Addison disease
➢ Ectodermal dysplasia
➢ Glycogen storage disease
➢ Edema
➢ Malnutrition
➢ Lab error (evaporation or contamination of sample)
False negatives:➢ Edema
➢ Malnutrition
➢ Some CF mutations
➢ Sample diluted
DNA testing- 30–80 of CFTR mutations.This identifies ≥90% who carry 2 CF
mutations
increased potential differences across
nasal epithelium with reference to
forearm
loss of potential
difference with topical amiloride
application is more in CF
Pancreatic function
➢ Fat estimation in stool
➢ OGTT
Pulmonary radiologic finding
Pulmonary function
Microbiologic studies
➢ More than 1604 mutation identified
➢ 2 CFTR mutations in association with
symptom is diagnostic
Goal: early diagnosis may be
associated with better nutritional
outcome
➢ Immunoreactive trypsinogen usually first followed by
either sweat or DNA testing
CF:
Treatment
Pulmonary Therapy
Inhalation Therapy
Airway Clearance Therapy
Infection-Antibiotic Therapy—
➢ Oral
➢ Aerosolized
➢ IV
Bronchodilator
Antiinflammatory
Endoscopy & lavage
Nutrition➢ Diet
➢ Pancreatic enz replacement
➢ Vitamins
Gastrointestinal & Rx of complication
Infertility
Others-
➢ Nasal polyp
➢ Rhinosinusitis
➢ Salt depletion
➢ Growth & maturation
Social Issues
Atelactasis
Hemomptysis
Pneumothorax
Allergic aspergilosis
Nontuberculous mycobactria infection
Bone & joint complication
Sleep-Disordered Breathing
Acute Respiratory Failure
Chronic Respiratory Failure
Heart Failure
Nutritional therapy.
➢ Follow nutrition parameters closely
➢ Pancreatic enzymes
➢ Vitamin supplementation
➢ Other nutritional supplementation
➢ Tube feedings
➢ High calorie supplemental shakes,
formulas
Meconium Ileus.
Distal Intestinal Obstruction Syndrome
Gastroesophageal Reflux
Rectal Prolapse
Heptobiliary Disease
Pancreatitis
Hyperglycemia.
Nasal Polyps
Rhinosinusitis.
Salt Depletion
Growth and Maturation Surgery.
Follow nutrition parameters closely
Pancreatic enzymes
➢ Porcine extract, 2000U/kg/meal
➢ TheraCLEC-Total, micro derived under
Vitamin supplementation-➢ ADEK
Other nutritional supplementation➢ Tube feedings
➢ High calorie supplemental shakes, form
Microsurgical epididymal sperm aspiration coupled plus in vitro
technology
Percutaneous epididymal sperm
aspiration
Testicular sperm extraction
Maternal genetic testing
Quality of life
➢ Frequent hospitalizations
➢ Time spent on therapies
➢ Morbidity from disease
➢ Restrictions secondary to disease
Adherence to therapies
Family planning
End of lifeissues
Mucolytic-
➢ Pulmozyme -to thin mucus
➢ Dornase alfa- enzyme hydrolyse DNA-
improve airway clearance
Antibiotics- Inhaled TOBI
➢ Cayston- Aztreonam, monobactem AB
inhaled for p. aeruginosa
Antioxidant
ACTs loosen thick, sticky lung mucus➢ move mucus from small to large airways to be coughed or huffed
out.
Coughing is the most basic ACT.
Huffing is a type of cough. involves taking a
breath in and actively exhaling. It is more like
―huffing‖ onto a mirror or window to steam it up
Chest Physio Therapy
Oscillating Positive Expiratory Pressure (Oscillating
PEP) an ACT where the person blows all the way out
many times through a device named
FlutterTM, AcapellaTM, CornetTM and Intrapulmonary
Percussive Ventilation (IPV). Breathing with devices
vibrate & dislodge.
High-frequency Chest Wall Oscillation
Positive Expiratory Pressure (PEP)
Active Cycle of Breathing Technique
(ACBT) It gets air behind
mucus, lowers airway spasm and clears
mucus.
Thoracic expansion exercises – deep breaths in.
➢ done with chest clapping or vibrating,
followed by breathing control.
Forced expiration technique – huffs of varied
lengths with breathing control.
Autogenic Drainage (AD) means ―self-
drainage.‖
➢ uses varied airflows to move mucus.
➢ aims to reach very high airflows in different
lung parts. This moves mucus from small to
large airways.
Lung Transplant
➢ 900 LT /year in USA
➢ 1600 received LT from 1991
➢ 2003– 17 pts received from living donor & 126 from cadaveric lung transplant
Gene therapy is the use of normal DNA to "correct" for the damaged genes that cause disease.
In the case of CF, gene therapy involves inhaling a spray that delivers normal DNA to the lungs.
The goal is to replace the defective CF gene in the lungs to cure CF or slow the progression of the disease.
ThankYou!