NPLEX Combination ReviewPulmonology

Paul S. Anderson, ND

Medical Board Review Services

Copyright MBRS

Pulmonary Function Tests• Spirometry

– Indications: COPD

• Blood gases– Indications: Respiratory acidosis (Inc PCO2) and alkalosis.– Rule out metabolic and potential hematological disorders.– Pulse oximetry – monitors O2 levels.

NORMAL RESTRICTIVE OBSTRUCTIVE

FVC 5.0 L Lower Norm. or Low

FEV1 3.75L Lower Much Lower

FEV1/FVC 70-75% Higher Lower% PREDICTED FVC

80-100% Lower Normal

Hemoglobin / Oxygen dissociation curve

HYPOXEMIA - CO POISIONING

• Lung– Silhouette sign:

• Border between same density organ is lost, usually caused by pneumonia.

– Air bronchogram sign: • Alveoli become fluid filled, which causes air in the bronchi to be

visible on X-ray. Looks like dark markings on abnormal white lung.

– Enlarged cardiac silhouette: • If the size of the heart is greater than half the width of the chest, it is

positive for cardiac enlargement.• 1/3 – 2/3 Rule

• Miscellaneous Chest Findings– Hiatus hernia: Fundus of the stomach appears as a fluid

density or air fluid level that shows up behind the heart.– Rib fracture: Jagged edges seen at the lateral aspect.

Watch for pneumothorax!

• Causes of lungs to appear too white on X-ray– Pneumonia:

• Consolidation caused by bacteria, • Diffuse interstitial appears as “fluffy” multiple white lines caused mainly by

viral agents or Mycoplasma.

– TB: • Primary infection is seen in the upper lobes, with pleural effusion and hilar

lymph node enlargement. • Secondary infection X-ray is normal or shows small calcifications in lungs

and lymph nodes.

– Atalectasis: • Collapse of the lung. Alveoli do not consist of air, therefore the lung tissue

shows up white on the radiograph.

– Lung Cavity, nodule or mass: • Caused by abscesses, tumor, TB, or other agents (Brucella…).

– Pleural Effusion: • Collection of fluid in the pleural space can consist of blood (hemothorax) or

pus (empyema) or serous fluid (pleural effusion). • Blunt costophrenic angles seen on upright PA.

– Congestive Heart Failure: Plain film shows cardiomegaly.– Chronic interstitial lung disease shows up confined to a particular area or

throughout.

• Causes of lungs to appear too black on

X-ray

– Pneumothorax: • Air between the pleura rising to highest point in chest

(as opposed to fluid, which collects at the lowest point).

• Lung abnormally black with decreased number of vessels.

– Pulmonary embolism: • Artery usually blocked cutting off supply to the lungs

showing up dark on the radiograph.

CT Scan

• CT is often the 3-D image of choice for lung and other chest masses.

• If a suspicious image is seen on Plain Film the typical recommendation is to obtain a spiral chest CT

Respiratory Pharmacology

Respiratory sensitivity and

activity

Respiratory

Antihistamines Non-sedating

MOA Uses Adverse Effects Other

Fexofenadine[Allegra]

H1 Receptor Antagonist

Seasonal allergic rhinitis

Non-sedating Contraindicated with use of erythromycin, ketoconazole or itraconazole due to Fatal arrhythmias.

Desloratadine[Clairinex]Loratadine [Claritin]

H1 Receptor Antagonist

Seasonal allergic rhinitis

Non-sedating

Sedating MOA Uses Adverse Effects Other

Diphenhydramine[Benadryl]Chlorpheniramine[Chlortrimeton]

H1 Receptor Antagonist

Allergic reactions due to type I allergies or for insomnia.

Seizures, sedation, nausea, vomiting, dry mouth, epigastric distress, thrombocytopenia, agranulocytosis

Contraindicated with CNS depressants and MAO inhibitors.

H1 Blockers(* = Non-Sedating)• Diphenhydramine (Benadryl)

– 12.5, 25 and 50 mg

• Loratadine * (Claritin)– 5 and 10 mg

• Desloratadine * (Clarinex)– 2.5 and 5 mg

• Cetirizine * (Zyrtec)– 5 and 10 mg

• Levocetirizine (Xyzal)– 5 mg

• Promethazine (Phenergan)– 12.5, 25 and 50 mg

• Fexofenadine * (Allegra)– 30, 60 and 180 mg

Methylxanthines MOA Uses Adverse Effects Other

Theophylline Inhibits phosphodiesterase which results in relaxation of smooth muscle of the bronchial airways

Acute bronchospasm

Seizures, restlessness, dizziness, insomnia, nausea, vomiting, respiratory arrest

Do not double dose, intoxication may cause seizures. Treat OD with ipecac, activated charcoal and a cathartic

DirectSympathomimetics

MOA Uses Adverse Effects Other

Epinephrine Vasoconstriction of α1 receptorsVasodilation of β2 receptors

Anaphylactic shockUsed with local anesthetics.

Cerebral hemorrhage, CVA, hypertension, tachycardia, V Fib, shock, N/V, headache, drowsiness

Routes of Administration: IV, IM, SQ and inhalation

General Sympathomimetics

MOA Uses Adverse Effects Other

Amphetamines Release norepinephrine

ADD, Parkinson’s disease, narcolepsy

Hypertension, anxiety, fever, tremor, restlessness.

Ephedrine Simulates α1 receptors causing vasoconstriction

Bronchodilation: for asthma and nasal congestion, and narcolepsy

Similar to amphetamines but less toxic

Phenylephrine hydrochloride

Simulates α1 receptors causing vasoconstriction

Hypotension Arrythmia, anaphylaxis, asthmatic episodes, headache.Do not use with MAO inhibitors!

Do not use with severe hypertension

Pseudoephedrinehydrochloride

Simulates α1 receptors in respiratory tract causing vasoconstriction

Decongestant Anxiety, nervousness, palpitations, headache and insomniaDo not use with MAO inhibitors!

Interacts with antihypertensive medications causing hypotension

Phenylpropanolamine Vasoconstriction Decongestant Anxiety, agitation, hallucinations and hypertension

Bronchodilators MOA Uses Adverse Effects Other

Metoproterenol[Alupent]

B2 adrenergic agonist that causes bronchodilation.

Acute AsthmaInhalation onset of action <5min, duration 3-4 hours

Nervousness, tremor, tachycardia, cardiac arrest, vomiting, nausea,

May cause paradoxical bronchial constriction with excessive use

Albuterol[Proventil, Ventolin]

B2 adrenergic agonist that causes bronchodilation.

Acute AsthmaInhalation onset of action <15min, duration 3-4 hours

Nervousness, tremor, tachycardia, headache, palpitations, vomiting, nausea, bronchospasm

Avoid concomitant use with CNS stimulants

Epinephrine Adrenergic agonist (causes bronchodilation, vasoconstriction, decrease secretions

Severe bronchoconstriction and anaphylaxis

Cerebral hemorrhage, CVA, hypertension, tachycardia, ventricular fibrillation, shock, nausea, vomiting, nervousness, tremor, headache, and drowsiness

Contraindicated in patients with angle-closure glaucoma

Atropine Muscarinic antagonist

Emergency bronchodilation

Dry mouth, tachycardia some CNS effects

OTHER RESPIRATORY DRUGS

Acetylcysteine[Mucomyst]

Reduce viscosity of the respiratory tract fluids

Pneumonia, bronchitis, TB, CF, emphysema, etc.

Rhinorrhea, stomatitis, nausea, vomiting, bronchospasm

Activated charcoal decreases effectiveness

Glucocorticoids End in ‘sone’ ‘onide’ or ‘zone’..

Decrease respiratory irritation and inflammation

Use in conjunction with bronchodilators

Water retention and CV problems; long term osteoporosis, peptic ulcer

Used for short-term adjunct therapy only

Cromolyn Sodium[Intal]

Guiafenasin

ipratropium bromide[Atrovent]

Used as a prophylaxis by preventing the degranulation of mast cells.Mucolytic

anticholinergic bronchodilator chemically related to atropine

Prophylaxis Only

Decreases viscosity of secretions

maintenance treatment of bronchospasm assoc. with COPD

Throat irritation

No major.

Similar to Albuterol

Do not use during acute asthma attacks.

Not for single use in acute attack

Inhalers:• Know the difference between a patients

type of inhaled medication:– Rescue / Acute inhalers:

• Sympathomimetics only;– Epinephrine, Albuterol, Metoproterenol

– Maintenance inhalers:• Steroids, Advair, Intal, Atrovent…

Guaifenesin • Mucolytic:

– May enhance output of respiratory tract fluid by reducing adhesiveness and surface tension, thus facilitating removal of viscous mucus and making nonproductive coughs more productive and less frequent.

• Immediate-release– Adults and Children (older than 12 yr of age) PO 200 to 400 mg every 4

h (max, 2.4 g/day).– Children (6 to younger than 12 yr of age) PO 100 to 200 mg every 4 h

(max, 1.2 g/day).– Children (2 to younger than 6 yr of age) PO 50 to 100 mg every 4 h

(max, 600 mg/day). Allfen Jr is not recommended for use in children younger than 6 yr of age.

– Children (6 mo to younger than 2 yr of age) PO Individualize dose, 25 to 50 mg every 4 h (max, 300 mg/day).

• Extended-release– Adults and children (older than 12 yr of age) PO 600 mg to 1.2 g every

12 h (max, 2.4 g/day).

• Combination Product: Entex PSE (Guaifenesin / Pseudoephedrine)

Cromolyn Sodium

• Disodium Cromoglycate – Class: Mast cell stabilizer

• Intal- Solution, inhalation 20 mg/amp- Aerosol inhalation 800 mcg/actuation

• Bronchial AsthmaAdults and Children – (2 yr of age and older for solution) Nebulization Initially 20

mg inhaled 4 times daily at regular intervals.

• Adults and Children (older than 5 yr of age) – Aerosol 2 metered sprays (1,600mcg) inhaled 4 times daily

at regular intervals.

Inhaled Steroids

• Budesonide [Pulmicort] 200mcg / inhalation– Dose 1 – 2 inhalations daily

• Fluticasone [Flonase, Flovent]– Nasal 27.5 or 50 mcg / spray

• Dose 1 spray each nostril bid

– Oral 44 – 250 mcg (2 forms)• Dose 1 inhalation bid

Serevent Diskus

• Salemetrol xinafoate Powder– Long acting beta-2 agonist

• Rx 1 or 2 inhalations daily– 1inhl 30 min prior to exercise for exercise

induced asthma– 1inhl q-12 hrs for long acting beta effect

• Increased risk of asthma related death with long acting beta 2 agonists

Advair:• Fluticasone (steroid) and

• Salmeterol (bronchodilator-Long acting Beta-2 agonist)– Diskus (dry) format: 100/50; 250/50; 500/50– HFA (aerosol) format: 45/21; 115/21; 230/21

• Rx: 1 inhl 1 or 2 times daily

– Chronic use (NOT acute / rescue use)– Side effect profile of both steroids and B-2

agonists. • Think infection, cardiac sensitivity…

Diagnostic Aids from Bates’

Lung Diagnosis Section

Trachea deviates AWAY from the lesion

Trachea deviates TOWARD the lesion

Pneumothorax

• Air may enter the pleural space through the chest wall or mediastinum, but usually from rupture of visceral pleura

• If large, may have chest pain of affected side with dyspnea; if small, no sx

breath sounds with hyperresonance to percussion

• ABGs show hypoxemia; CXR shows free air and contralateral shift of mediastinal structures

Atelectasis

• A shrunken and airless state of all or part of the lung often accompanied by infection

• Chest exam reveals absent lung sounds and dullness over affected area (large)

• Eventually both types develop a cough• X-ray shows airless area of lung; size and shape

will depend upon the bronchi involved; trachea, heart and mediastinum will deviate toward affected side in large amount of atelectasis

Consolidation

• Is a loss of air in alveoli without overall loss of volume of lung tissue

• Alveolar air is replaced by blood or inflammatory exudate, so the volume does not change.

• Bronchi in the consolidated area are patent

Pleuritis

• Pain localized, sharp and with cough, sneeze, deep breath or movement

• Old term is “pleurisy”• Frequent causes are viral respiratory inf or

pneumonia• Friction rubs can be heard with

auscultation; may have a “leathery squeak” component

Pleural effusion

• Abnormal accumulation of fluid in pleural space; 5 major types occur:

• Transudate—seen in CHF• Exudate—seen in infections• Empyema—walled off infection• Hemorrhagic (hemothorax)—seen with

pulmonary embolus• Chyliform (chylothorax)—due to lymph fluid

Pleural effusion

• Has same consequence as pneumothorax; as lung decreases in volume, the fluid increases reducing lung capacity, resulting in dyspnea.

• ATELECTASIS is also a loss of volume of a segment of lung, caused by internal obstruction (no rupture of visceral pleura), but has same physiological effect as pleural effusion and pneumothorax.

Bronchiolitis

• Can produce severe disease and up to 5% of infants may require hosp during epidemics.

• Annual epidemics occur in winter or spring• Anti-viral Rx is of no benefit• X-ray shows hyperinflation and peri-bronchial

infiltrates

Acute Bronchitis

• Acute inflammation of trachea and bronchi, usually due to infectious agents: influenza, RSV, coxsackie, adenovirus, rhinovirus

• Often follows or is associated with acute sinusitis or pharyngitis

• Bacteria are less common pathogens, but most common ones are Strep pneumoniae, Haemophilus influenza and Moraxella catarrhalis

Pneumonia

• Pathogens Strep pneumo, H. flu, Gram (-) bacteria, Moraxella catarrhalis, Staph aureus

• Remember Klebsiella pneumonia is common in chronic alcoholics

• E. coli is almost always assocaited with diabetes

Hospital Acquired Pneumonia (HAP)

• Acute infection involving distal lung parenchyma that begins 48-72 hrs after hospital admission

• Gram-negative bacilli cause 50-70% of HAP. (Strep pneumoniae cause 30-70% of community-acquired bacterial pneumonias)

Lung Abscess

• Majority are bacterial (65% of these are anaerobes)

• 50% of lung abscesses are due to aspiration of bacteria when pt is recumbent e.g. coma, anesthesia, substance abuse or stroke or those with problems swallowing or coughing

• Symptoms include fever, chills, pain, weakness, wt loss and in 75% of cases foul or musty-smelling sputum mixed with blood

Tuberculosis

• Mycobacteria are intracellular parasitic bacteria that are acid-fast i.e. they do not decolorize by acid alcohol after staining

• The primary infection becomes walled off, lesions shrink and heal, leaving behind caseating granulomas

• Majority of new TB cases are reactivation of untreated tuberculous infection

Tuberculosis

• The screening test for TB is the tuberculin skin test (PPD); bacteriologic culture is diagnostic

• Transmission is almost always airborne; small droplets of bacteria are generated by coughing, sneezing or speech

• TB bacilli lodge in alveoli and replicate; this represents tuberculous infection

• Reactivation TB often presents with upper lobe infiltrates on CXR

Tuberculosis

• Tuberculous infection is usually asymptomatic• Pulmonary tuberculosis (disease) presents as a

chronic pneumonia with fever, wt loss, night sweats and malaise; cough, sputum, hemoptysis and pleurisy

Fungal Infections of the Lung

Aspergillosis (Aspergillus fumigatus)

• Soil pathogens; airborne route (outbreaks have occurred in hospitals related to construction)

• After inhalation, aspergillus can colonize preexisting pulmonary cavities or bronchi leading to fungus balls

• X-ray makes diagnosis; shows solitary lesion, 3-5 cm in diameter, round intracavitary mass

• Sputum culture + in 50% of cases; antibodies seen in > 90%

Cryptococcal Pneumonia

• Cryptococcus neoformans is an encapsulated yeast

• Commonly found in pigeon droppings • Portal of entry is the lung, but more commonly

causes meningitis• Can be asymptomatic; x-ray can show large

solitary nodule, pneumonitis• Dx by biopsy and culture; all pts with crypto

pneumonia should have LP to r/o meningitis• Amphotericin B is Rx

Histoplasmosis (Histoplasma capsulatum)

• Most common mycosis in US, found in Midwest and south central US

• If symptoms do occur, will appear as “atypical pneumonia”; patchy infiltrates on x-ray,with hilar or mediastinal adenopathy, flu-like symptoms

• X-rays show apical lung lesions, cavitation and fibrosis; calcifications are seen in> 75%

• Dx is by sputum culture or biopsy; serology is less useful than with coccidioidomycosis

Blastomycosis (Blastomyces dermatitidis)

• Soil fungus endemic in eastern and mid-western US

• Portal of entry is the lung• Presents as flu-like infection; x-ray findings can

be varied; patients usually recover spontaneously

• Chronic infection presents with hemoptysis, weight loss, pleurisy with lobar or segmental infiltrates

Coccidioidomycosis

• Cocci, or Valley Fever, is a infectious fungal lung disease acquired by inhalation of arthrospores (Coccidioides immitis) that become airborne from fungal mycelia in the soil

• Endemic areas include central San Joaquin Valley, southern California, Arizona, New Mexico, southwestern Texas, Mexico and parts of Central and South America

Coccidioidomycosis

• After an incubation pd of 7-28 days, fever, malaise, dry cough, chest pain, night sweats and anorexia may develop

• Hemoptysis is NOT common and is usually associated with cavitary pneumonia.

• Fine, macular and urticarial rash is seen 20% of cases and precedes development of delayed hypersensitivity (+) skin test

• Erythema nodosum also seen and represents a good prognosis against dissemination

Coccidioidomycosis

• Chest x-ray is abnormal in 70-80% of cases; nonspecific infiltrate acutely; ipsilateral hilar adenopathy is common (25%); pleural effusion less so (10%)

• Serologic tests are diagnostic and are used to monitor disease activity

• IgM precipitins are detectable in 90% of pts serum within 4 wks after onset of symptoms

Asthma

• Asthma is easily recognized by episodic dyspnea, nonproductive cough and/or wheezing in the absence of COPD; an increased responsiveness of the tracheobronchial tree to a variety of stimuli.

• Wheezing is usually reversible with therapy• Lung function is normal between flare-ups, but

some develop chronic and fixed airflow obstruction.

Conditions that can mimic asthma

• CHF

• PE

• GE reflux

• Foreign body aspiration

• Upper airway obstructions that cause stridor e.g. tumors, tracheal stenosis

Asthma

• Airway obstruction due to mucosal edema from inflammation, smooth muscle contraction and mucous plugging.

• Basic pathology is a chronic desquamating eosinophilic bronchitis involving bronchial walls of small and medium caliber airways

• Eosinophilia is seen commonly

Extrinsic Asthma Triggers

• Sinusitis• Viral resp. infections• Poor compliance with

bronchodilators• Exercise• Weather changes• Emotional upheaval

• Environmental allergens:

• Pollens, molds, cockroach antigen, cat dander, occupational chemicals, irritants (cigarette smoke), air pollutants (ozone)

EICOSANOIDS

MEMBRANE PHOSPHOLIPID

ARACHADONATE

LEUKOTRIENESPROSTAGLANDINS /

THROMBOXANES

Lipoxygenase Cyclooxygenase

Phospholipase A2

Stimulated by: Angiotensin - 2 / Bradykinin / Epinephrine / Thrombin

Inhibited by: CORTICOSTEROIDS

Inhibited by:

NSAID’S

Other Etiologies of Asthma

• Exercise induced: occurs 5-10 min after starting exercise.

• Occupational: triggered by substances in workplace

• Cardiac: bronchospasm from CHF• Asthmatic bronchitis: chronic bronchitis with

features of bronchospasm that respond to bronchodilator Rx

• Drug induced: ASA, NSAID’S, beta blockers, histamine,

Common components of Dx

• Hx: • Wheezing• Dyspnea• Cough• Nocturnal sx

• Px:• Bilateral wheezing• Hyperresonance to

percussion• PFT’s normal/abnormal

(diffusing capacity N)

Clinical PearlsPATHOPHYSIOLOGICAL ABNORMALITY

 

Function Asthma Emphysema Fibrosis 

FVC  low  N or low  low 

FEV1  very low  very low  low 

TLC N or high  high  low 

Bronchodilator Response

+ + + +  ±  0

Hemoptysis

• Hemoptysis is:

– TB or– Lung Cancer

– Until proven otherwise!

Cough

Some things to consider:• What is the frequency of cough as a

presentation?

• What causes one to cough?

• What is the importance of it as a symptom and sign?– Can it indicate a life threatening condition?

• How do you investigate a cough?– History– Physical Examination– Related Diagnostic Investigations

•How do I chart all this?

Some causes of cough:

Collins’ Differential Diagnosis - 2001

Related Diagnostic Investigations

• Spirometry• pO2• CBC + Differential• Chest X-Ray• C.T.

– Sinus study– Chest CT in cases of suspicious CXR findings

• Cultures– Nasal– Pharyngeal

Cough Duration:

• Acute: 0-3 Weeks

• Sub-acute: 3-8 Weeks

• Chronic: > 8 Weeks

Irwin, R. S. et al. Chest 2006;129:1S-23S

Acute cough algorithm for the management of patients >= 15 years of age with cough lasting 0 - 3 weeks

Irwin, R. S. et al. Chest 2006;129:1S-23S

Subacute cough algorithm for the management of patients >= 15 years of age with cough lasting 3 to 8 weeks

Irwin, R. S. et al. Chest 2006;129:1S-23S

Chronic cough algorithm for the management of patients >= 15 years of age with cough lasting > 8 weeks

Chronic cough algorithm for the management of patients >= 15 years of age with cough lasting > 8 weeks (Continued)

OBSTRUCTIVE vs RESTRICTIVE LUNG DISEASE• Chronic obstructive lung disease

– State characterized by airflow limitation from obstruction that is not fully reversible.

– The lungs gradually fill with air behind the obstruction and much lung tissue is destroyed by chronic infection.

– The lungs are over inflated (increased residual volume). The lungs are large, missing a lot of tissue, and have increased compliance.

– It is difficult to have efficient comfortable breathing if the lungs are fully expanded when trying to overcome resistance in the airways.

• Interstitial (Restrictive) lung disease– Denotes a broad collection of pulmonary processes, some of unknown

cause, whose common feature is the infiltration of inflammation and scarring of lung parenchyma.

– The common consequence of these diverse pathologic processes is wide spread lung fibrosis, producing increased lung elastic recoil and decreased lung compliance (restrictive lung disease).

– The lung becomes smaller in volume and the patient has to work harder to breath against the decreased compliance. (the lungs get more like rubber)

LOWER RESPIRATORY DISEASE

• Emphysema: “pink puffers” – Normal pCO2– Permanent dilation of part or all of the acinus with eventual

destruction of alveolar walls; – Cigarette smoking or def. of serum alpha 1 protease inhibitor

in non-smokers;– Barrel chest, pursed lips, slow forced expiration

• Chronic Bronchitis: “blue bloaters” – Increased pCO2– Persistent cough with sputum for at least 3 mos in at least

two consecutive yrs;– Obese, cor pulmonale, cyanotic– Do not retain hypercapnic drive to breathe

Chronic Obstructive Pulmonary Disease (COPD)

• COPD is a pulmonary disease characterized by chronic obstruction to airflow

• This term means a combination of emphysema and chronic bronchitis

• Some patients with COPD also have a component of asthma

Chronic Bronchitis

• A clinical diagnosis made by history: productive cough for at least 3 months out of the year for at least 2 years in a row

• Physical exam may be normal, except for prolonged forced expiratory vital capacity time, e.g. > 4 seconds when listening with the diaphragm of the stethoscope over the upper sternum

PA diameter of chest and flat diaphragms• Accessory inspiratory muscles are used

Emphysema

• Is a pathological diagnosis: represents a condition of the lung characterized by an increase in the size of the air spaces distal to the terminal bronchioles accompanied by destruction of their walls

• Px of the lungs may be normal except for a prolonged FVC time

breath sounds plus hyperresonance with percussion because of air trapping

Causes of COPD

• SMOKING is most common cause of emphysema and chronic bronchitis

• Occupational exposure may lead to emphysema• Air pollution: minor factor in emphysema• Alpha-1 ante-trypsin deficiency is hereditary

cause of emphysema• Familial tendency in emphysema and asthma

Pulmonary Embolism

Cystic Fibrosis

• Autosomal recessive disorder of exocrine glands

• In the respiratory tract, inadequate hydration of the tracheobronchial epithelium impairs mucociliary function

• Sweat chloride [ ] >80 meq/L in adults (> 60meq/L under age 20) on 2 occasions

• Pancreatic insufficiency, especially in children• Chronic Pseudomonas aeruginosa or Staph

aureus bronchitis and bronchiectasis with recurrent exacerbation

Bronchiectasis

• Characterized by irreversible dilatation of the bronchial tree

• The obstruction can arise from tumor, foreign bodies, impacted mucus, external compression

• Congenital form is rare; cystic fibrosis is the most common form

• Infections include pertussis, rubella, RSV and TB

Bronchiectasis

• Usually present with purulent sputum, but can only have a dry cough

• Rales and clubbing are common• Recurrent pulmonary infections are common;

hemoptysis seen in 50% of cases and may be the only sign initially

• Usually nonspecific with loss of definition and in # and size of bronchovascular markings

• Loss of lung volume and honeycombing and cystic spaces may be seen

Bronchiolitis Obliterans

• Bronchiolitis Obliterans, to Pulmonologists, implies a chronic scarring process affecting the small airways of the lungs, which results in progressive obliteration of the small airways resulting in obstructive lung disease

• It can be an acute process as in children following a viral illness or more chronic as in RA or organ transplant

Collagen Vascular Disease

• Two-thirds of pts with CVD will have clinical pulmonary disease and almost all pts at autopsy are affected

• Common in SLE; 50% of pts with scleroderma develop pulmonary fibrosis

• Pleural disease occurs in all CVD except polymyositis/dermatomyositis

• Pulmonary nodules occur in RA, may be single or multiple and can cavitate

Cryptogenic Organizing Pneumonia (COP)

• Also called (idiopathic bronchiolitis obliterans with organizing pneumonia) is a rapidly developing pneumonia-like illness characterized by lung inflammation and scarring that obstruct the small airways and air sacs of the lungs (alveoli).

• Patients complain of several weeks of dry cough and exertional dyspnea and fever; usually endure 2-10 weeks before seeking help

• chest x-ray is distinctive with features that appear similar to an extensive pneumonia, with both lungs showing widespread white patches.

Sarcoidosis

• Systemic disease of unknown etiology involving the lung 90% of cases; characterized by noncaseating granulomas on histopathology

• 15-20% have permanent loss of lung function• Occurs from 20-40 yrs of age; 75% under 40• Chest x-ray early shows bilateral hilar adenopathy;

reticulonodular infiltrate common• PFTs show restrictive pattern ( lung volumes)• The disease usually regresses spontaneously within two

years of initial presentation

Goodpasture’s syndrome

• Autoimmune disorder of basement membrane in lung and kidney

• Occurs mainly in men in 30’s and 40’s• Hemoptysis, dyspnea, cough, hypoxemia,

diffuse bilateral alveolar infiltrates seen• Iron def anemia and hematuria• Dx based on IgG deposits in glomeruli and

presence of anti-glomerular basement membrane antibody in serum

Wegener’s granulomatosis

• A rare disorder which causes inflammation of blood vessels (vasculitis) in the upper respiratory tract (nose, sinuses, ears), lungs, and kidneys.

• Many other areas of the body may also be affected, with arthritis (joint inflammation) occurring in almost half of all cases. The eyes and skin may also be affected.

• Serum anti-neutrophil cytoplasmic antibodies (ANCA) elevated in 90% of cases

Wegener’s granulomatosis

• Early symptoms are often systemic and may include fatigue, malaise (an ill feeling), fever, and a sense of discomfort around the nose and sinuses. Upper respiratory infections such as sinusitis or ear infections frequently precede the diagnosis of Wegener's Granulomatosis.

• Labs and Biopsy

Silicosis

• Etiologic agent is crystalline silicon dioxide• Mechanism of lung injury is inhalation of particles of

silica• Industries at risk include: sandblasting, mining,

quarrying, tunneling, stonecutting, polishing; foundry work, glass, brick and pottery manufacturing; and finely ground silica used in abrasive soaps, polishes and filters

• Pathologically, the alveoli are filled with eosinophilic debris

Asbestosis

• Asbestos was used in thousands of commercial products for strength, flexibility and resistance to acid and heat

• Pathologic hallmarks include pulmonary fibrosis associated with presence of asbestos bodies

• Exposure also associated with pleural plaques (dense plaques of collagen on parietal pleura) and pleural effusion

risk of bronchogenic carcinoma and mesothelioma is well established

Berylliosis

• Affects 2% of people exposed to beryllium (aerospace workers, nuclear industry)

• Pathologically, it is characterized by presence of non-caseating granulomas of lungs and hilar nodes; very similar to sarcoidosis.

• Pulmonary granulomas become progressively fibrotic and may lead to cor pulmonale and resp failure.

Bronchogenic Carcinoma

• Bronchogenic carcinoma refers to a group of aggressive malignant tumors of the lung

• Most common cause of death due to cancer in the U.S. for both men and women (30% and 23%)

• Tobacco smoking most important cause; “Second-hand” tobacco smoke increases risk by 40-70%

Bronchogenic Carcinoma

• Bronchogenic carcinoma begins as an area of in situ• Common symptoms and signs (cough, dyspnea,

wheezing and hemoptysis)• Hemoptysis, any change in the pattern of cough,

unexplained chest pain, recurrent pain, unintentional weight loss with anorexia or hoarseness in a 2 pack/day smoker over 40 yrs of age

• Chest pain is a late symptom

Clinical Features of Bronchogenic Carcinoma

Tumor Incidence RadiologicFindings

5-YearSurvival

Adeno-carcinoma

35% Peripheral mass,solitary nodule

Squamous cell

30% Hilar mass,atelectasis orpost-obstructive pn.

Large cell 15% Largeperipheral mass

Small cell 20% Hilar mass,adenopathy

27%

<1%

37%

27%

Sleep Apnea Syndrome

• Sleep apnea profiles can be diagnosed by a sleep study

• Central apnea is the cessation of air flow and no movement of rib cage or abdomen

• Obstructive apnea has paradoxical motion of the rib cage and abdomen without air flow

• Mixed apnea has both components• There is a fall in oxygen saturation (SaO2) in all

3

Sleep Apnea Syndrome

• Obstructive sleep apnea syndrome (OSAS) is fairly common—24% of middle-aged men and 12% of middle-aged women—resulting in daytime somnolence, fitful sleep and impaired concentration

• 85% of pts are male and most are obese• There is fat deposition around the upper airway

causing a critical narrowing during sleep in these pts

Adult Respiratory Distress Syndrome (ARDS)

• ARDS is a life-threatening condition in which inflammation of the lungs and accumulation of fluid in the air sacs (alveoli) leads to low blood oxygen levels.

Adult Respiratory Distress Syndrome (ARDS)

• ARDS is a medical emergency. It can be caused by any major lung inflammation or injury. Some common causes include pneumonia, septic shock, trauma, aspiration of vomit, or chemical inhalation.– shortness of breath – labored, rapid breathing– low blood pressure or shock (low blood pressure

accompanied by organ failure) – often, persons affected by ARDS are so sick,

they are unable to complain of symptoms

Acute Pulmonary Edema

• Usually associated with CHF• May appear suddenly with chronic heart failure

or be the first manifestation of cardiac disease• Severe dyspnea, worse with lying supine;

production of pink frothy sputum, diaphoresis, tachycardia, cyanosis, wheezing, rales.

• CXR shows blurred vascular outline, heart size and interstitial markings

Costochondritis

• Inflammatory process of the costochondral or costosternal joints causing localized pain and tenderness.

• More than one site is involved in 90% of cases.

• Etiology is usually obscure

Hyperventilation Syndrome (HVS)

• General: weakness, fatigue, sleep disturbances, blurred vision

• Psychiatric: anxiety, depression, phobias, feeling far away, sensations of unreality

• Neurologic: paresthesias in extremities or periorally, lightheadedness, disorientation, syncope, headaches

• Cardiologic: palpations, chest pain• Respiratory: dyspnea, sighing respirations, yawning,

breathlessness• GI: dry mouth, bloating, belching, flatulence• Muscular: cramping, spasm, chest wall pain

Cheyne-Stokes Respiration

• Abnormal breathing pattern, occurring in pts with CHF and neurologic diseases

• Alternating periods of tachypnea and apnea

• In the majority of pts, these ventilatory patterns are not recognized

• C-S respiration may cause oxygen desaturation, cardiac arrhythmias and mental status changes

ADRENERGIC (Epi. / NE) RECEPTORS