KMA Annual Meeting 2010 - Allergy - Wheeze, Crackle, POP: When its not Asthma/COPD
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Transcript of KMA Annual Meeting 2010 - Allergy - Wheeze, Crackle, POP: When its not Asthma/COPD
Uof L Division of Pulmonary, Critical Care, and Sleep Disorders MedicineUof L Division of Pulmonary, Critical Care, and Sleep Disorders Medicine
Wheeze, Crackle, Pop: When it’s not Asthma/COPD
Rodney J. Folz, MD, PhDChief, Division of Pulmonary, Critical Care and
Sleep Disorders MedicineUniversity of Louisville School of Medicine
KY Society of Allergy, Asthma & Clinical Immunology2010 KMA Annual Meeting
Sept 22, 2010
Uof L Division of Pulmonary, Critical Care, and Sleep Disorders Medicine
Disclosures
• Funding From:• NIH
• American Heart Association
• Pfizer
• Merck
• Boehringer Ingelheim
• BioMarcks
• GlaxoSmithKline
• Cystic Fibrosis Foundation
Uof L Division of Pulmonary, Critical Care, and Sleep Disorders Medicine
Uof L Division of Pulmonary, Critical Care, and Sleep Disorders Medicine
Uof L Division of Pulmonary, Critical Care, and Sleep Disorders Medicine
Case 1
• 60 yo WF referred for 2nd opinion with chronic cough, asthma, and mild bronchiectasis.
• CC– chronic cough
• Waxed and waned
• Minimally productive
– recurrent pneumonia every couple of years, bronchitis over 34 yrs
– allergic rhinosinusitis and placed on immunotherapy
– bronchoscopy 6 years ago
• Allergic rhinits– Significantly improved with allergy shots
and medications
• Mild asthma dx 15 years ago– Well controlled, improved with allergy
shots and ICS/LABA.
• Mild recurrent sinusitis– Normal sinus CT
• Allergies:– PCN, Sulfa, Ceftin, flagyl
– Lactose intolerant
– Ink, cats, dust, mold allergies
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Case 1
• Meds:– montelukast
– ICS/LABA
– Albuterol
• FH: +recurrent bronchitis (mother)
• SH:– Homemaker
– hobbies: print makeup with some exposure to solvents acetones/solvents
• PE: + bibasilar expiratory crackles
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Adult Combined Skin Tests
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Case 1
Mild obstruction
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Typical Flow‐Volume CurveNormal vs severe obstruction
Normal Severe obstruction
Patient
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Case 1
• Findings:– Coarse lung markings within the base
– Prominent right cardiophrenic fat pad
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Case 1
• Findings:– Scattered parenchymal abnormalities
– Mild left base bronchiectasis
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Case 1
• Immunoglobulin levels– IGG 1180
– IGA 152
– IGM 100
– IGE 246 (High)
• CBC, CMP, TSH, UA normal
• Fungal serologies: neg
• A1AT: 170
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What would you do at this point?
Active Diagnoses:
• Allergic rhinosinusitis
• Asthma / cough
• Prior pneumonia
• Recurrent bronchitis – mild
• Mild bronchiectasis
DDx for Bronchiectasis• Pneumonia, recurrent
• Acquired airway obstruction (foreign body, TB, airway adenoma, amyloid, ABPA, impaction, etc)
• Congenital airway obstruction (bronchial cyst, sequestration,
• Immuno deficiencies
• Chronic granulomatous disease
• Ciliary defects
• Recurrent aspiration
• Inhalation toxic fumes/dusts
• Cystic fibrosis
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Pilocarpine Iontophoresis ‐ “Sweat Chloride”
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CFTR Genotyping
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Overview of Cystic Fibrosis
• Most common “lethal” genetic disease in Caucasian population– 1:3,300 Caucasian– 1:29 Carriers mutant CFTR gene (more in other countries
e.g. N Ireland, Australia)
• Lower incidence in other populations– 1:9,500 Hispanic– 1:15,300 African‐American– 1:32,100 Asian
• ~30,000 patients in U.S.• Close to 50% of those with CF are now adults
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History and Epidemiology
• 1938: “Cystic Fibrosis of the Pancreas” described by Andersen
• 1950’s: Excessive salt loss in sweat recognized in heat wave by di Sant’Agnese
• 1980’s: Specific ion transport abnormalities described (Boucher, Knowles, others)
• 1989: CFTR cloned by Collins, Tsui groups• 1990’s: New treatment strategies, gene therapy• 2000’s: Pathophysiology, gene modifiers, standards of care, quality improvement, novel treaments
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Median Survival
CFF registry data
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Adult with CF are increasing
CFF registry report 2007
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Rodman et al., AJRCCM 171:621-626, 2005
Frequency histogram for age at diagnosis for those >40 years
Median age at diagnosis = 13
years
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CF Genetics
• Monogenetic, autosomal recessive
• Carriers are asymptomatic
• Affected gene– Cystic Fibrosis Transmembrane
conductance Regulator” or CFTR.
• >1600 individual CFTR mutations identified
• The ΔF508 mutation accounts for 2/3 of CF alleles worldwide
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MSD - Membrane spanning domainNBD - Nucleotide binding domainR - Regulatory domain
CFTR Function
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CF Mutation Frequency
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The Diagnosis of CF
• 71% diagnosed in 1st year of life
• 8% diagnosed after age 10
• 2% have Non Classic CF, which may not be recognized until adulthood
• Diagnosis requires both:– 1 or more typical phenotypic features and
– evidence of CFTR malfunction
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With permission: N Eng J Med 347; 439-442: 2002
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Overview: diagnostic criteria contd..
Laboratory evidence of CFTR dysfunction.
Elevated sweat chloride (>60 mmol/L)
Mutations in CFTR on both alleles
Characteristic bioelectric abnormalitiesnasal PCD – research
Immunoreactive trypsinogen (IRT)newborn screening
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UofL / Kosair Cystic Fibrosis CenterPEDIATRIC PROGRAM
502‐629‐8830
• Nemr Eid, MD– Pediatric Program Director
• Martha Eddy, RN– Peds CF coordinator
• 502‐629‐7455 (office)
• 502‐629‐7540 (fax)
• Dietitian
• Social Worker
• Respiratory Therapists
ADULT PROGRAM
502‐852‐5841
• Rodney Folz, MD, PhD– Adult Program Director
• Kay Burris, RN– Adult CF coordinator
• 502‐852‐1080 (office)
• 502‐852‐1359 (fax)
• Dietitian
• Social Worker
• Respiratory Therapists
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Case #2
• CC:– 35 yo WF c/o referred for wheezing and cough, much worse following
“exposure” to noxious fumes.
• PMH:– Asthma, 15+ years
– Recurrent hoarseness, SOA
– Multiple chemical sensitivities to fumes, odors, fragrances.
– MVR
– Recurrent URIs dating back 15+ years
– Tobacco use, 1‐2 ppd for 15 years. Significant second hand tobacco smoke exposure as a child.
• FHx: CAD, DM, HTN, COPD, asthma
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Case #2
• HPI:– In USOH and claims while at a grocery store parking lot was exposed to strong fumes from an acetic acid container spill nearby.
– Examined in ED. CXR nl. ABG: pH 7.42, pCO2 38, pO2 102
– 10 days later underwent spirometry testing:• 19% (610 ml) improvement in FVC
• 10% (260 ml) improvement in FEV1
– Had several “asthma exacerbations” treated with ICS/LABA, oral corticosteroids.
– 6 months later underwent Challenge testing.
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MCh Case Studies
Post Bronchodilator
Spirometry pre and post albuerol
1. Is this asthma?2. Is this RADs?
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Several Questions
• Is this asthma?
• Is this RADs?
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Exposures known to cause RADS
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Minimally acceptable criteria ‐Spirometry
• Have the patient assume the correct posture.
• Attach the nose clip, place mouthpiece in mouth and instruct patient to close lips around the mouthpiece and breathe quietly.
• Instruct the patient to inhale completely and rapidly with little or no pause (< 1 sec) at TLC.
• Instruct patient to exhale maximally until no more air can be expelled.
• Repeat instructions as necessary, coaching vigorously during the expiratory maneuver.
• Repeat for a minimum of 3 acceptable maneuvers, no more than 8 are usually required.
• Check test repeatability and perform more maneuvers as necessary.
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Between maneuver repeatability criteria for spirometry
• After a minimum of 3 acceptable FVC maneuvers have been obtained:– The 2 largest FVCs are within 0.15 liters of each other.
– The 2 largest FEV1s are within 0.15 liters of each other.
• If both of these criteria are not met, continue testing until – Both of criteria are met with additional acceptable maneuvers, OR
– A total of 8 maneuvers have been performed, OR
– The patient cannot or should not continue.
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MCh Case Studies
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PostPre
Spirometry did not meet ATS standards
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Should we order MCh Challenge Testing?
baseline diluent MCh 1 mg/dl Albuterol #1 Albuterol #2
80%
Questions:1. Is this a positive Mch challenge test?2. Does this patient have bronchial hyperreactivity?3. Does this patient have asthma or RADS?
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Asthma: Four Domains
1. Symptoms
2. Variable airway obstruction
3. Airway hyperresponsiveness
4. Airway inflammation
• No one domain is essential for the diagnosis.
• Primary care mostly uses symptoms to diagnose asthma can lead to incorrect diagnoses
• Increasing awareness of different asthma phenotypes and associated response to treatments.
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Measurements ofBronchial Hyperresponsiveness (BHR)
1. Methacholine Challenge Testing (MCT)
2. Exercise Induced Bronchoconstriction (EIB)
3. Challenge testing can also be performed at specialized centers using:• Allergens
• Histamine
• Drugs
• cold air
• occupational sensitizers
• Eucapneic hyperventilation
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MCT indications
• When asthma is a serious possibility and traditional methods unable to establish the diagnosis.– Wheezing, chest tightness,
dyspnea, cough following:• Cold air exposure
• Exercise
• URI
• Work place exposure
• Allergen exposure
• Determine relative risk of developing asthma
• Response to therapy
• Clinical research trials
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Contraindications for MCT
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Technician Training Qualifications
• Be familiar with this guideline and knowledgeable about specific test procedures
• Be capable of managing the equipment including set‐up, verification of proper function, maintenance, and cleaning
• Be proficient at spirometry
• Know the contraindications to MCT
• Be familiar with safety and emergency procedures
• Know when to stop further testing
• Be proficient in the administration of inhaled bronchodilators and evaluation of the response to them
• 4 days of hands on training
• Minimum of 20 supervised tests
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Safety Considerations ‐ Patients
• Patient– Acute bronchospasm
– Hypoxia
– V/Q mismatch
• 1000 COPD patients ‐MCT• 25% cough
• 21% dyspnea
• 10% wheezing
• 6% dizziness
• 2% headache
• 2/3 no symptoms
• 700 histamine challenge• 20% cough, chest tightness, or
flushing
• Delayed effects are rare
• No deaths
• However, there have been fatalities reported with
– antigen challenge
– distilled water challenge.
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Safety Considerations ‐ Technician
• Technician– Minimize exposure to aerosol
– 2 exchanges per hour
– Extra precautions or avoidance in technicians with asthma.
– Use of HEPA cleaner.
English Wright Nebulizer
DeVilbiss model 646 nebulizer
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Safety Considerations
• Technician– Survey of 600 allergy specialists:
• 20% report symptoms
• 2 cases of asthma in nurses who use MCh
English Wright Nebulizer
DeVilbiss model 646 nebulizer
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Factors that influence MCT results
• Excellent sensitivity
• Mediocre positive predictive value
• BHR is also seen in:• COPD – tobacco induced
• CHF
• CF
• Bronchitis
• Allergic rhinitis
• Sarcoidosis
• Bronchiectasis
• Siblings of asthmatics
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Environmental factors that enhance bronchial hyper‐responsiveness and their duration of effect
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Agents that decrease bronchial hyper‐responsiveness and their duration of effect
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MCh Dosing Protocols2 Methods
• 2 min tidal breathing– Recommended by the Canadian Thoracic Society.
– Uses doubling doses of MCh
• 0.03, 0.06, 0.125, 0.25, 0.5, 1, 2, 4, 8, 16 mg/dl
– Perform 2 minutes of tidal breathing from FRC
• 5 breath dosimeter– Standardized by NIAID
– Uses quadrupling doses of MCh
• 0.0625, 0.25, 1, 4, 16 mg/dl
– Perform 5 inhalations from FRC
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Advantages / Disadvantages
• 2 min tidal breathing– Allows more precise steps– More commonly used by
clinical research protocols.– May shorten overall time by
starting at 1 mg/ml if no history of asthma
– May omit next dose if < 5% drop in FEV1
• 5 breath dosimeter– Quicker method– Reduced MCh exposure to
technician
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Interpretation strategies
• Factors to consider when interpreting PC20– Pretest probability of asthma
– Presence or degree of baseline airway obstruction
– Quality of patient’s spirometry maneuvers
– Symptoms reported by patient at end‐of‐test
– Degree of recovery after bronchodilator
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Interpretation StrategiesCategorical Method Decision analysis
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MCh Case Studies
• EH
• 65 yo WF
• 20 py
• Referred for– chronic cough
• Normal PFTs
• BMI 29
• BH
• 60 yo WF
• Never smoke
• Referred for– chronic cough and dyspnea
• Normal spirometry
• BMI 32
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MCh Case Studies
• EC
• 63 WF
• Never smoke
• Referred for:– SOB, DOE
• BMI 33
• PH
• 43 WF
• Never smoke
• Referred for:– Sarcoidosis, cough
• BMI 33
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Methacholine challenge
baseline diluent MCh 1 mg/dl Albuterol #1 Albuterol #2
80%
Poor QualityStudy:1. Started at 1 mg/dl MCh.2. Constricted with first dose albuterol.3. Second dose albuterol had opposite effect.
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Case Presentation
14 yo WF presents with:Intermittent cough a/w exerciseIntermittent chest tightness a/w exerciseSeasonal allergiesOtherwise completely healthyAntihistamines and Singulair not helpful
14 minutes treadmillHeart rate 200 bpm
Does this patient have Exercise-Induced Bronchoconstriction (EIB)?
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EIB ‐ Indications
1. Evaluation of breathlessness during or after exertion
2. When EIB would impair a person (with a history suggestive of asthma) to perform demanding work
1. Lifeguard
2. Firefighter
3. military or police
3. Determine effectiveness and optimal dosages of medications used to treat EIB
4. Evaluate effects of antiinflammatory therapy
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EIB ‐Mechanism
• The major factors that determine the severity of EIB are:• the pulmonary ventilation reached and sustained
• water content and temperature of inspired air
• The stimulus for airway narrowing is• Rapid loss of water
• The mechanisms involved are:• Thermal and /or osmotic effects of dehydration and cooling
• Stimulates release of inflammatory mediators » Histamine
» cysteinyl leukotrienes)
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EIB ‐ Contraindications
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EIB – patient prep
• Wear comfortable clothes and gym shoes
• Light meal
• Avoid vigorous exercise for > 4 hours– Prior exercise exerts protective effect.
– 50% of EIB are refractory to second challenge with 60 minutes.
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Treadmill versus Cycle Ergometers
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Exercise Challenge Testing Protocol
• Patient breathes dry air in air conditioned room.
• Target 4‐6 minutes of near‐maximum exercise, total duration 6‐8 minutes.
• Advance exercise to reach 80‐90 Max HR in 2‐3 minutes. (220 – age).
• Alternatively target work rate in watts» (53.8 X FEV1) – 11.07
• Valid test requires:• Exercise intensity sustained for 4‐6 min
• Reach target HR within 4 minutes
• Monitor HR, O2 Sats, EKG
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Assessing Response
• FEV1 is primary outcome variable.
• Assess at 5 min, 10 min, 20 or 30 min.
• Decrease from baseline FEV1 of 10% is a generally accepted as an abnormal response.
• A fall of 15% appears more diagnostic of EIB.
• Healthy subjects generally increase FEV1.
• Nadir FEV1 occurs most often within 5‐10 minutes.
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Case Presentation
14 yo WF presents with:Intermittent cough a/w exerciseIntermittent chest tightness a/w exerciseSeasonal allergiesOtherwise completely healthyAntihistamines and Singulair not helpful
14 minutes treadmillHeart rate 200 bpm
Does this patient have Exercise-Induced Bronchoconstriction (EIB)?
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Case Presentation
• 14 yo WF presents with:
• Intermittent cough
• Intermittent chest tightness
• Seasonal allergies
• O/W completely healthy
• Antihistamines and Singulair not helpful
14 minutes treadmillHeart rate 200 bpm
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EIB therapeutic options
• Improve control of underlying concomitant asthma.
• Patient education.
• Improve cardiovascular fitness.
• Breath through scarf or mask to warm/humidify air.
• Prophylactic SABA
• Prophylactic mast cell stabilizers.
• Antileukotriene agents
• Diet enriched with omega‐3 fatty acids
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Thank you for your attention