RespiratoryRespiratory diseasesdiseases

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URTIsURTIs

Allergic RhinitisAllergic Rhinitis Hay feverHay fever Onset under age 30Onset under age 30 Peak incidence – childhood & adolescencePeak incidence – childhood & adolescence Most common chronic disease in the USA and significantly Most common chronic disease in the USA and significantly

affects quality of lifeaffects quality of life Pathophysiology : Type I hypersensitivity reaction to Pathophysiology : Type I hypersensitivity reaction to

allergensallergens Common allergens : Common allergens : Seasonal Allergens: Tree pollen (early Seasonal Allergens: Tree pollen (early

spring), Grass pollen (late spring) and Outdoor Molds (summer spring), Grass pollen (late spring) and Outdoor Molds (summer and fall) ) , Perennial : Dust mites and Animal dander Irritant: and fall) ) , Perennial : Dust mites and Animal dander Irritant: Cigarette Smoke Cigarette Smoke

Associated conditions : Associated conditions : Atopy : Eczematous Dermatitis , Atopy : Eczematous Dermatitis , Allergic Rhinitis and AsthmaAllergic Rhinitis and Asthma

Allergic Triad : Aspirin Allergy, Nasal Allergic Triad : Aspirin Allergy, Nasal Polyp and Asthma Polyp and Asthma

Allergic RhinitisAllergic RhinitisSymptoms:Symptoms: SpecificSpecific : Sneezing, Rhinorrhea, Nasal congestion and Pruritus of the : Sneezing, Rhinorrhea, Nasal congestion and Pruritus of the

nose, eyes, and throat , Eye Tearing and Conjunctival discharge nose, eyes, and throat , Eye Tearing and Conjunctival discharge Symptoms due to Chronic Nasal Obstruction: Symptoms due to Chronic Nasal Obstruction: Mouth Breathing, Mouth Breathing,

Snoring, Anosmia, Cough, Headache and Halitosis Snoring, Anosmia, Cough, Headache and Halitosis SignsSigns : * Look for antihistamine induced Hypertension in these guys : * Look for antihistamine induced Hypertension in these guys *Nose exam : *Nose exam : pale blue and boggypale blue and boggy mucosa, clear discharge mucosa, clear discharge*Face exam: “Allergic Shiners” *Face exam: “Allergic Shiners” bluish purple rings arround both bluish purple rings arround both

eyes due to chronic mid face venos congestioneyes due to chronic mid face venos congestion “ “ Dennie’s Lines: Dennie’s Lines: Skin folds under the eyes Skin folds under the eyes “ “ Allergic Salute: Allergic Salute: transverse nasal crease from transverse nasal crease from

chronic rubbingchronic rubbing

*Sinuses: r/o sinusitis *Sinuses: r/o sinusitis purulent discharge, tenderness and purulent discharge, tenderness and impaired transilluminationimpaired transillumination

Allergic RhinitisAllergic Rhinitis Diagnosis : * Skin testing Diagnosis : * Skin testing Gold Standard Gold Standard * RAST * RAST use this if unable to do a skin test or if its use this if unable to do a skin test or if its

contraindicatedcontraindicated * CBC * CBC may show eosinophilia may show eosinophilia * IgE levels are elevated* IgE levels are elevated D/D : 1) Nasal causes of Rhinitis : Nonallergic rhinitis ( eosinophila D/D : 1) Nasal causes of Rhinitis : Nonallergic rhinitis ( eosinophila

synd), Nasal polyps, Vasomotor rhinitis, infectious rhinitis, Rhinitis synd), Nasal polyps, Vasomotor rhinitis, infectious rhinitis, Rhinitis medicamentosamedicamentosa

2) Medications: Aspirin, Clonidine, Hydralazine, Labetalol, 2) Medications: Aspirin, Clonidine, Hydralazine, Labetalol, propranolol, tearazosin, OC pillspropranolol, tearazosin, OC pills

Management Management Do Skin test / RAST and find the responsible Do Skin test / RAST and find the responsible Allergen. Advise the pt to avoid the allergen. “Avoid pets in the bed if Allergen. Advise the pt to avoid the allergen. “Avoid pets in the bed if its found to be animal dander”its found to be animal dander”

Intranasal Steroids ( are the drug of choice for pts Intranasal Steroids ( are the drug of choice for pts with chronic symptoms. Can be used prn but most effective when with chronic symptoms. Can be used prn but most effective when used as maintainance therapy used as maintainance therapy fluticasone, beclomethasone) , fluticasone, beclomethasone) , Antihistamines ( cetrizine, loratidine) , Saline nasal drops , Antihistamines ( cetrizine, loratidine) , Saline nasal drops , decongestants ( pseudoephedrine), nasal cromolyndecongestants ( pseudoephedrine), nasal cromolyn

In severe cases, consider systemic steroidsIn severe cases, consider systemic steroids

Allergic RhinitisAllergic Rhinitis

Antihistamines vs. Nasal Corticosteroids.Antihistamines vs. Nasal Corticosteroids. The majority of The majority of studies favor the use of intranasal corticosteroids over studies favor the use of intranasal corticosteroids over sedating or nonsedating antihistamines for relief of sedating or nonsedating antihistamines for relief of symptoms of nasal allergy. These results are true for symptoms of nasal allergy. These results are true for seasonal and perennial allergic rhinitis.seasonal and perennial allergic rhinitis. ( antihistamines are ( antihistamines are used for immediate symptom relief)used for immediate symptom relief)

Immunotherapy: Immunotherapy: Immunotherapy is indicated in patients who Immunotherapy is indicated in patients who present with any of the following characteristics:present with any of the following characteristics:

Insufficient control by pharmacotherapy; Insufficient control by pharmacotherapy; Insufficient control of symptoms; Insufficient control of symptoms; A desire not to take medication; A desire not to take medication; Medication produces undesirable side effects; and Medication produces undesirable side effects; and A desire to avoid long-term pharmacotherapy (with A desire to avoid long-term pharmacotherapy (with

intranasal steroids)intranasal steroids)

Case StudyCase Study You are treating an 18-year-old white male college You are treating an 18-year-old white male college

freshman for allergic rhinitis. It is September and he freshman for allergic rhinitis. It is September and he tells you that he has severe symptoms every autumn, tells you that he has severe symptoms every autumn, which impair his academic performance. He has a which impair his academic performance. He has a strongly positive family history of atopic dermatitis. strongly positive family history of atopic dermatitis. Which one of the following medication is Which one of the following medication is considered optimal treatment for this condition?considered optimal treatment for this condition?

Intranasal glucocorticoids Intranasal glucocorticoids Intranasal cromolym sodium Intranasal cromolym sodium Intranasal decongestants Intranasal decongestants Intranasal antihistamineIntranasal antihistamine

AnsAns Topical intranasal glucocorticoids are currently believed to be the most efficacious Topical intranasal glucocorticoids are currently believed to be the most efficacious

medications for the treatment of allergic rhinitis. They are far superior to oral medications for the treatment of allergic rhinitis. They are far superior to oral preparations in terms of safety. preparations in terms of safety.

Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it is more effective if started prior to the season of peak symptoms. is more effective if started prior to the season of peak symptoms.

Because of the high risk of rhinitis medicamentosa with chronic use of topical Because of the high risk of rhinitis medicamentosa with chronic use of topical decongestants, these agents have limited usefulness in the treatment of allergic decongestants, these agents have limited usefulness in the treatment of allergic rhinitis.rhinitis.

Some of the newer oral antihistamines have been found to be comparable in Some of the newer oral antihistamines have been found to be comparable in efficacy to intranasal steroids, but their use slightly increases the incidence of efficacy to intranasal steroids, but their use slightly increases the incidence of adverse effects and drug interactions. They are not as useful for congestion as they adverse effects and drug interactions. They are not as useful for congestion as they are for sneezing, pruritis, and rhinorrhea. Newer agents are relatively free of are for sneezing, pruritis, and rhinorrhea. Newer agents are relatively free of sedation. Overall, they are not as effective as topical glucocorticoids. Azelastine , sedation. Overall, they are not as effective as topical glucocorticoids. Azelastine , an intranasal antihistamine, is effective in controlling symptoms but can cause an intranasal antihistamine, is effective in controlling symptoms but can cause somnolence and has a very bitter taste.somnolence and has a very bitter taste.

Vasomotor RhinitisVasomotor Rhinitis Diagnosis of exclusionDiagnosis of exclusion Symptoms similar as Allergic Rhinitis Symptoms similar as Allergic Rhinitis has rhinorrhea, congestion, nasal has rhinorrhea, congestion, nasal

obstruction ( normal nasal exam, normal Ig E and Normal skin test/ obstruction ( normal nasal exam, normal Ig E and Normal skin test/ RAST )RAST )

No specific test is available to diagnose No specific test is available to diagnose vasomotorvasomotor rhinitisrhinitis First First exclude exclude allergic rhinitisallergic rhinitis as the cause of symptoms by using conventional as the cause of symptoms by using conventional skin testing or by evaluation for specific IgE antibodies to known skin testing or by evaluation for specific IgE antibodies to known allergens.allergens.

Rx: Stepwise Approach ( next slide ) Rx: Stepwise Approach ( next slide ) Pregnancy Pregnancy Step 1: Nasal SalineStep 1: Nasal Saline Step 2: Intranasal Atrovent (Pregnancy Category B) Step 2: Intranasal Atrovent (Pregnancy Category B)

Traditional oral antihistamines have no established beneficial effect in patients Traditional oral antihistamines have no established beneficial effect in patients with with vasomotorvasomotor rhinitisrhinitis and may be associated with sedation. and may be associated with sedation.

Newer, less-sedating antihistamines also have no proven effectiveness for Newer, less-sedating antihistamines also have no proven effectiveness for vasomotorvasomotor rhinitisrhinitis, and their administration delays proper treatment while , and their administration delays proper treatment while incurring significant cost and burden to the health care system. Topical incurring significant cost and burden to the health care system. Topical antihistamines are used as first choice if symps are rhinorrhea, sneezing, antihistamines are used as first choice if symps are rhinorrhea, sneezing, post nasal drippost nasal drip

Rhinitis MedicamentosaRhinitis MedicamentosaPathophysiologyPathophysiology Associated with topical agent use >5-7 days Associated with topical agent use >5-7 days Tachyphylaxis associated with medications Tachyphylaxis associated with medications

Nasal Decongestants (Afrin, Neo-Synephrine) Nasal Decongestants (Afrin, Neo-Synephrine) Other associated medications Other associated medications

Reserpine Reserpine Oral Contraceptive pills Oral Contraceptive pills Inderal Inderal Aldomet Aldomet

SymptomsSymptoms Rebound nasal Congestion after nasal DecongestantRebound nasal Congestion after nasal DecongestantSignsSigns Fiery red edema at nasal mucosa Fiery red edema at nasal mucosa ManagementManagement Intranasal Steroid Intranasal Steroid Withdrawal of nasal Decongestant Withdrawal of nasal Decongestant

Acute & Chronic SinusitisAcute & Chronic SinusitisCriteria for diagnosis:Criteria for diagnosis: Maxillary toothache Maxillary toothache Purulent nasal secretion Purulent nasal secretion History of colored Nasal dischargeHistory of colored Nasal discharge Poor response to nasal Decongestants Poor response to nasal Decongestants Abnormal Sinus TransilluminationAbnormal Sinus TransilluminationIf 4 or more criteria + If 4 or more criteria + diagnosis is definite diagnosis is definiteIf 2 or 3 crieria + If 2 or 3 crieria + Diagnosis is intermediate Diagnosis is intermediate recommended initial study Sinus CT recommended initial study Sinus CTIf less than 2 criteria If less than 2 criteria negative for sinusitis negative for sinusitis Most common is maxillary sinusitis. Next common is Frontal. Ethmoids are most Most common is maxillary sinusitis. Next common is Frontal. Ethmoids are most

commonly affected in children. Spenoids has highest risk of intracranial spreadcommonly affected in children. Spenoids has highest risk of intracranial spread Symptoms may last as long as 4 weeks in acute sinusitis, Symptoms b/w 4-8 weeks is Symptoms may last as long as 4 weeks in acute sinusitis, Symptoms b/w 4-8 weeks is

subacute ans symptoms persisting > 8 weeks is chronic sinusitis. subacute ans symptoms persisting > 8 weeks is chronic sinusitis. In recurrent sinusitis, there are 3 or more episodes of acute sinusitis per year, and In recurrent sinusitis, there are 3 or more episodes of acute sinusitis per year, and

different episodes may be caused by different organisms.different episodes may be caused by different organisms. SignsSigns Diagnostic testsDiagnostic tests Step wise TreatmentStep wise Treatment ComplicationsComplications

Acute & Chronic SinusitisAcute & Chronic SinusitisSigns : Signs : Nasal Mucosa erythema and boggy due to edemaNasal Mucosa erythema and boggy due to edema

Contrast with Allergic Rhinitis (Contrast with Allergic Rhinitis (pale,pale, boggy mucosa) boggy mucosa) Nasal exam to view pus discharge from lateral wall Nasal exam to view pus discharge from lateral wall

Instruments Instruments Nasal speculum (minimal visualization) , Flexible Nasal speculum (minimal visualization) , Flexible Nasolaryngoscopy Nasolaryngoscopy

Middle Meatus (hiatus semilunaris) Middle Meatus (hiatus semilunaris) Drains Maxillary, Frontal, and Drains Maxillary, Frontal, and Anterior Ethmoid Anterior Ethmoid Consider local Topical Decongestant application Consider local Topical Decongestant application

Superior Meatus (Rarely discharge is seen) Superior Meatus (Rarely discharge is seen) Drains posterior ethmoid Drains posterior ethmoid sinus sinus

Turbinates enlarged Turbinates enlarged Sinus tenderness to percussion Sinus tenderness to percussion Sinus Transillumination in darkened room Sinus Transillumination in darkened room

Frontal and maxillary sinus Frontal and maxillary sinus

Acute & Chronic SinusitisAcute & Chronic Sinusitis Symptoms suggesting bacterial etiology Symptoms suggesting bacterial etiology Symptoms persist beyond 10 to 14 days, Symptoms persist beyond 10 to 14 days,

Remember that under 10 days, viral sinusitis Remember that under 10 days, viral sinusitis predominates, predominates, By day 10, 40% of sinusitis By day 10, 40% of sinusitis resolves spontaneously resolves spontaneously 0.5% of viral URIs 0.5% of viral URIs develop into bacterial sinusitis develop into bacterial sinusitis

Symptoms worsen after 5-7 days ( “double” Symptoms worsen after 5-7 days ( “double” sickening)sickening)

purulent nasal dischargepurulent nasal discharge “ “Unilateral” maxillary sinus tendernessUnilateral” maxillary sinus tenderness Maxillary tooth or facial pain (esp. if unilateral) Maxillary tooth or facial pain (esp. if unilateral)

Acute & Chronic SinusitisAcute & Chronic Sinusitis Don’t culture nasal swabs Don’t culture nasal swabs not cost effective not cost effective Diagnosis is clinical in Acute SinusitisDiagnosis is clinical in Acute Sinusitis Indications for Imaging Indications for Imaging

Complicated sinusitis , Chronic or recurrent sinusitis , Sinusitis refractory to maximal medical Complicated sinusitis , Chronic or recurrent sinusitis , Sinusitis refractory to maximal medical therapy therapy

Imaging Imaging is not needed in routine casesis not needed in routine cases Empiric therapy for 1-2 courses is appropriate Empiric therapy for 1-2 courses is appropriate

1. Sinus X-Ray (Sinus CT preferred) 1. Sinus X-Ray (Sinus CT preferred) Plain radiographic signs consistent with sinusitis Plain radiographic signs consistent with sinusitis include greater than 6 mm of mucosal thickening in adults and 4 mm in children, include greater than 6 mm of mucosal thickening in adults and 4 mm in children, greater than 33% loss of air space volume in the maxillary sinuses, or opacification–air-greater than 33% loss of air space volume in the maxillary sinuses, or opacification–air-fluid levels.fluid levels.

Single Waters' View X-Ray is sufficient Single Waters' View X-Ray is sufficient Indication (rarely indicated unless CT not available)Indication (rarely indicated unless CT not available)

Complicated Acute Sinusitis & Suspected Chronic Sinusitis Complicated Acute Sinusitis & Suspected Chronic Sinusitis Sinus CT (gold standard) Indications Sinus CT (gold standard) Indications

Osteomeatal complex occlusion Osteomeatal complex occlusion Complicated acute sinusitis Complicated acute sinusitis orbital cellulitis etc orbital cellulitis etc Chronic SinusitisChronic Sinusitis Recurrent Sinusitis Recurrent Sinusitis Allergic Fungal Sinusitis Allergic Fungal Sinusitis

Sinus MRI Sinus MRI No advantage over Sinus CT (and more false positives) No advantage over Sinus CT (and more false positives) Indications : Suspected neoplasm and Fungal Sinusitis Indications : Suspected neoplasm and Fungal Sinusitis

Acute Sinusitis - ComplicationsAcute Sinusitis - Complications Unless severe symptoms of acute sinusitis develop, such as Unless severe symptoms of acute sinusitis develop, such as

fever, facial pain or tenderness, or periorbital swelling, fever, facial pain or tenderness, or periorbital swelling, antibiotics should be withheld for 10 to 14 days. antibiotics should be withheld for 10 to 14 days.

ComplicationsComplications : Orbital Cellulitis, Meningitis, Extradural : Orbital Cellulitis, Meningitis, Extradural abscess , Subdural abscess , Brain abscess , Osteomyelitis and abscess , Subdural abscess , Brain abscess , Osteomyelitis and Cavernous Sinus Thrombosis Cavernous Sinus Thrombosis

Symptoms: Red Flag (consider immediate ENT referral)Symptoms: Red Flag (consider immediate ENT referral) High Fever over 102.2 F (39 C) or peristent fever High Fever over 102.2 F (39 C) or peristent fever Visual complaints (e.g. Diplopia) Visual complaints (e.g. Diplopia) Periorbital edema or erythema ( check for EOMs Periorbital edema or erythema ( check for EOMs ?pain) ?pain) Mental status changes Mental status changes Severe facial or dental pain Severe facial or dental pain Infraorbital hypesthesia Infraorbital hypesthesia consider referral in immunodeficiency or if persistent symptoms consider referral in immunodeficiency or if persistent symptoms

despite treatmentdespite treatment

Sinusitis - TreatmentSinusitis - Treatment General MeasuresGeneral Measures Symptomatic relief : Warm, moist compresses over sinuses , Symptomatic relief : Warm, moist compresses over sinuses ,

TylenolTylenol Nasal Saline spray (2% buffered saline) Nasal Saline spray (2% buffered saline)

Effective Decongestant Effective Decongestant Also use as pretreatment prior to Intranasal Steroid Also use as pretreatment prior to Intranasal Steroid Effective in recurrent Sinusitis when used daily Effective in recurrent Sinusitis when used daily

Systemic Decongestant: PseudoephedrineSystemic Decongestant: Pseudoephedrine Mucolytic : Guaifenesin (e.g. Mucinex) 600 to 1200 mg PO bid Mucolytic : Guaifenesin (e.g. Mucinex) 600 to 1200 mg PO bid

there is no evidence that mucolytics are useful adjuncts there is no evidence that mucolytics are useful adjuncts Topical Decongestant (Topical Decongestant (Maximum of 3 days of useMaximum of 3 days of use) )

Oxymetazoline or Phenylephrine (Neo-Synephrine) Oxymetazoline or Phenylephrine (Neo-Synephrine) Intranasal Steroid (treat for 3-6 weeks minimum) Intranasal Steroid (treat for 3-6 weeks minimum)

Chronic SinusitisChronic Sinusitis Nasal PolypNasal Polyp

Avoid Antihistamines!!Avoid Antihistamines!! Dries secretions and Impedes osteomeatal complex drainage Dries secretions and Impedes osteomeatal complex drainage

Sinusitis - TreatmentSinusitis - TreatmentANTIBIOTICS:ANTIBIOTICS: Indicated only in acute bacterial Sinusitis Indicated only in acute bacterial Sinusitis Protocol Protocol Antibiotic course Antibiotic course Minimum course: 10-14 days Minimum course: 10-14 days

Longer course for persistent symptoms: 28 days Longer course for persistent symptoms: 28 days Change antibiotic if no improvement in 3 days REMEMBER Change antibiotic if no improvement in 3 days REMEMBER

THAT Beta-lactamase resistance in acute cases: <30% , Beta-THAT Beta-lactamase resistance in acute cases: <30% , Beta-lactamase resistance in chronic cases: 40-50% lactamase resistance in chronic cases: 40-50%

First-Line First-Line Indications to start on first-line agents Indications to start on first-line agents Mild to Mild to moderate symptoms , No daycare exposure & No recent moderate symptoms , No daycare exposure & No recent antibiotic use antibiotic use

Amoxiicillin Amoxiicillin Disadvantages: Misses Beta-lactamase Disadvantages: Misses Beta-lactamase producers : Haemophilus Influenzae , Moraxella catarrhalis & producers : Haemophilus Influenzae , Moraxella catarrhalis & Penicillin Resistant Pneumococcus (increasing) Penicillin Resistant Pneumococcus (increasing)

Trimethoprim Sulfamethoxazole (Bactrim) No longer Trimethoprim Sulfamethoxazole (Bactrim) No longer recommended as first-line agent , Higher resistance rate than recommended as first-line agent , Higher resistance rate than other agents other agents

Disadvantages : Misses Staphylococcus , Risk of Toxic Disadvantages : Misses Staphylococcus , Risk of Toxic Epidermal Necrolysis& Risk of Steven's Johnson Epidermal Necrolysis& Risk of Steven's Johnson Syndrome Syndrome

Sinusitis - TreatmentSinusitis - Treatment Second-Line Second-Line Indications to start on second- Indications to start on second-

line agents : Severe symptoms Daycare line agents : Severe symptoms Daycare exposure , Recent antibiotic use exposure , Recent antibiotic use Amoxicillin-Clavulanate (Augmentin ) or Amoxicillin-Clavulanate (Augmentin ) or

Cefuroxime (Zinacef) , CefpodoximeCefuroxime (Zinacef) , Cefpodoxime Avoid Cefixime ( poor Gram + coverage )Avoid Cefixime ( poor Gram + coverage )

Third Line recommendationThird Line recommendation If no If no improvement with above a) Consider adding improvement with above a) Consider adding Flagyl to second-line agents b) Consider Flagyl to second-line agents b) Consider second-line agent for longer course (4 week) c) second-line agent for longer course (4 week) c) Switch to Fluoroquinolone (avoid under 16 yrs Switch to Fluoroquinolone (avoid under 16 yrs of age ), Moxifloxacin or Gatifloxacin (Tequin)of age ), Moxifloxacin or Gatifloxacin (Tequin)

Sinusitis - TreatmentSinusitis - Treatment

Management : Penicillin or Cephalosporin AllergyManagement : Penicillin or Cephalosporin Allergy

Macrolide antibiotics (High bacterial resistance rate) Macrolide antibiotics (High bacterial resistance rate) Erythromycin , Azithromycin (Zithromax) or Erythromycin , Azithromycin (Zithromax) or Clarithromycin (Biaxin) Clarithromycin (Biaxin)

Trimethoprim-Sulfamethoxazole (Bactrim) Trimethoprim-Sulfamethoxazole (Bactrim) Increasing Increasing bacterial resistance, So other agents are preferred for bacterial resistance, So other agents are preferred for SinusitisSinusitis

Clindamycin Clindamycin Consider in combination with Rifampin Consider in combination with Rifampin if severe , Poor efficacy against Gram Negative Bacteriaif severe , Poor efficacy against Gram Negative Bacteria

Fluoroquinolones ( avoid under age 16 years )Fluoroquinolones ( avoid under age 16 years )

Sinusitis - TreatmentSinusitis - Treatment ““Unless severe symptoms of acute sinusitis develop, such as fever, facial pain or tenderness, or periorbital swelling, antibiotics should be Unless severe symptoms of acute sinusitis develop, such as fever, facial pain or tenderness, or periorbital swelling, antibiotics should be

withheld for withheld for 10 to 14 days10 to 14 days. Although the primary therapy for acute bacterial sinusitis is antibiotics, increasing resistance to penicillin may . Although the primary therapy for acute bacterial sinusitis is antibiotics, increasing resistance to penicillin may necessitate the use of alternative antibiotics. The choice of antibiotics is based on predicted efficacy, cost, and adverse effects. A 10- to 14-necessitate the use of alternative antibiotics. The choice of antibiotics is based on predicted efficacy, cost, and adverse effects. A 10- to 14-day course is generally adequate for acute disease, but shorter courses may be indicated for newer antibiotics. day course is generally adequate for acute disease, but shorter courses may be indicated for newer antibiotics. If there is no improvement If there is no improvement in 3 to 5 days, an alternative antibiotic should be consideredin 3 to 5 days, an alternative antibiotic should be considered” ( guidelines, journal of clinical immunology, 2006)” ( guidelines, journal of clinical immunology, 2006)

Primary therapy for acute bacterial sinusitis is antibiotics with a 10- Primary therapy for acute bacterial sinusitis is antibiotics with a 10- to 14-day course considered adequate. Amoxicillin is a drug of to 14-day course considered adequate. Amoxicillin is a drug of choice with trimethoprim-sulfamethoxazole an alternative. choice with trimethoprim-sulfamethoxazole an alternative.

If no response occurs within 3 to 5 days, a change to high-dose If no response occurs within 3 to 5 days, a change to high-dose amoxicillin-clavulanate, cephalosporins, or macrolides may be amoxicillin-clavulanate, cephalosporins, or macrolides may be indicated. indicated.

In areas of high antibiotic resistance or with failure to improve after In areas of high antibiotic resistance or with failure to improve after 21 to 28 days, broad spectrum single agents should be considered, 21 to 28 days, broad spectrum single agents should be considered, such as amoxicillin-clavulanate, cefuroxime, or cefpodoxime, or use such as amoxicillin-clavulanate, cefuroxime, or cefpodoxime, or use of anaerobic coverage, such as clindamycin or metronidazole. of anaerobic coverage, such as clindamycin or metronidazole.

Nasal corticosteroids are indicated in acute and chronic sinusitis Nasal corticosteroids are indicated in acute and chronic sinusitis and short-term adjunct oral steroids may be used after failure of and short-term adjunct oral steroids may be used after failure of response or when nasal polyps are present.response or when nasal polyps are present.

Saline nasal sprays may help to reduce crusting!!Saline nasal sprays may help to reduce crusting!!

Acute PharyngitisAcute Pharyngitis Symptoms: Symptoms: Sore throat , Dysphagia & Odynophagia (pain with swallowing) Sore throat , Dysphagia & Odynophagia (pain with swallowing) Generalized symptoms : Fever, Chills, Malaise, Headache , Abdominal Pain , Generalized symptoms : Fever, Chills, Malaise, Headache , Abdominal Pain ,

Nausea or VomitingNausea or Vomiting Symptoms suggestive of viral illness: Symptoms suggestive of viral illness: Coryza, Conjunctivitis & HoarsenessCoryza, Conjunctivitis & Hoarseness SignsSigns Viral Viral

Non-exudative pharyngeal erythema Non-exudative pharyngeal erythema Exception: Tonsillar exudate in Mononucleosis (EBV) Exception: Tonsillar exudate in Mononucleosis (EBV)

Vesicular OR ulcerative oral lesions Vesicular OR ulcerative oral lesions Conjunctivits in Adenovirus and Kawasaki Disease Conjunctivits in Adenovirus and Kawasaki Disease

Group A Streptococcus and other bacteria Group A Streptococcus and other bacteria clues are Enlarged tonsils with or clues are Enlarged tonsils with or without exudate , Petechiae on Soft Palate (pathognomonic) , Erythema , Tender without exudate , Petechiae on Soft Palate (pathognomonic) , Erythema , Tender cervical Lymphadenopathy cervical Lymphadenopathy

Strawberry Tongue (in Scarlet Fever) Strawberry Tongue (in Scarlet Fever) Peritonsillar Cellulitis or Peritonsillar Abscess Peritonsillar Cellulitis or Peritonsillar Abscess Suspect Unilateral erythema Suspect Unilateral erythema

of Soft Palate , Uvula deviated , Dysphagia, Odynophagia & Feverof Soft Palate , Uvula deviated , Dysphagia, Odynophagia & Fever Diphtheria Diphtheria Suspect when Gray membranous exudate covers tonsils and Suspect when Gray membranous exudate covers tonsils and

pharynx or Exudate bleeds easily on removal pharynx or Exudate bleeds easily on removal Kawasaki Disease Kawasaki Disease Suspect when Pharyngitis with strawberry Tongue in age Suspect when Pharyngitis with strawberry Tongue in age

<5 years<5 years , Non-purulent Conjunctivitis (also in Adenovirus) & Palmar erythema , Non-purulent Conjunctivitis (also in Adenovirus) & Palmar erythema and cracked red lips after 3 days and cracked red lips after 3 days

STREP THROATSTREP THROAT Acute Pharyngitis caused by Group A beta Acute Pharyngitis caused by Group A beta

hemolytic streptococci.hemolytic streptococci. Most common in children Most common in children 5-12 yr old5-12 yr old Infectivity Infectivity Decreases 1-3 days after Decreases 1-3 days after

antibiotic started antibiotic started

Return to School and day care Return to School and day care recommendations recommendations Child should receive Child should receive Antibiotics for minimum of 24 hours and Antibiotics for minimum of 24 hours and Afebrile Afebrile

Strep ThroatStrep ThroatComplicationsComplications Non-suppurative Non-suppurative

Rheumatic Fever Rheumatic Fever we Rx Strep Throat to prevent this. ABX Rx does we Rx Strep Throat to prevent this. ABX Rx does not prevent PSGNnot prevent PSGN

Acute Post-Streptococcal Glomerulonephritis ( PSGN)Acute Post-Streptococcal Glomerulonephritis ( PSGN) Suppurative Suppurative

Peritonsillar AbscessPeritonsillar Abscess Suppurative Otitis MediaSuppurative Otitis Media Cervical lymphadenitis Cervical lymphadenitis Acute Sinusitis Acute Sinusitis Mastoiditis Mastoiditis Meningitis Meningitis Bacteremia Bacteremia Endocarditis Endocarditis Pneumonia Pneumonia

Strep Throat – Strep ScoreStrep Throat – Strep ScoreOriginal Criteria (interpretation Original Criteria (interpretation

below based on these) below based on these) 1 1 point for eachpoint for each

Tonsillar exudate Tonsillar exudate Tender, anterior cervical Tender, anterior cervical

adenopathy adenopathy Cough absent Cough absent Fever present Fever present Modifiers : Age younger Modifiers : Age younger

than 15 years: +1 point, than 15 years: +1 point, Age 15 to 45 years: 0 points Age 15 to 45 years: 0 points & Age over 45 years: -1 & Age over 45 years: -1 points points

ER and OP probability:ER and OP probability: Score 0: Streptococcus Score 0: Streptococcus

probability 1% (3% in ER) probability 1% (3% in ER) Score 1: Streptococcus Score 1: Streptococcus

probability 4% (8% in ER) probability 4% (8% in ER) Score 2: Streptococcus Score 2: Streptococcus

probability 9% (18% in ER) probability 9% (18% in ER) Score 3: Streptococcus Score 3: Streptococcus

probability 21% (38% in probability 21% (38% in ER) ER)

Score 4: Streptococcus Score 4: Streptococcus probability 43% (63% in probability 43% (63% in ER) ER)

Strep throat (?) - ApproachStrep throat (?) - Approach Strep Score 4 (or Strep Score 2 if patient unreliable) Strep Score 4 (or Strep Score 2 if patient unreliable)

Treat with antibiotics Treat with antibiotics Strep Score 2 to 3: Perform rapid antigen test Strep Score 2 to 3: Perform rapid antigen test

Antigen test positive: Treat with antibiotics Antigen test positive: Treat with antibiotics Antigen test negative: Throat Culture (Requires 24 hour Antigen test negative: Throat Culture (Requires 24 hour

minimum for adequate growth )minimum for adequate growth ) most specific (99%). most specific (99%). Sensitivity 90%. Not recommended as primary test due to Sensitivity 90%. Not recommended as primary test due to 24 hour delay . Remember that –ve Rapid strep does not 24 hour delay . Remember that –ve Rapid strep does not rule out Strep throat rule out Strep throat

Strep Score 0 to 1 Strep Score 0 to 1 Provide Pharyngitis Symptomatic Treatment Provide Pharyngitis Symptomatic Treatment salt water salt water

gargles, sucking candies, ibuprofengargles, sucking candies, ibuprofen

Strep throat - AntibioticsStrep throat - Antibiotics Penicillin is the first choice ( coz its strep) Penicillin is the first choice ( coz its strep)

penicillin VK 500 mg penicillin VK 500 mg If using this standard course If using this standard course duration is 10 days. Alternatively use Amoxicillin duration is 10 days. Alternatively use Amoxicillin 500 bid in adults/ 10 days500 bid in adults/ 10 days

Alternative antibiotics : Five days of alternative Alternative antibiotics : Five days of alternative antibiotics effective antibiotics effective Amoxicillin Clavulanate Amoxicillin Clavulanate (Augmentin) , Ceftibuten, Cefuroxime, (Augmentin) , Ceftibuten, Cefuroxime, Clarithromycin or Erythromycin estolate ( for pen Clarithromycin or Erythromycin estolate ( for pen allergic pts)allergic pts)

Non-Compliant pts Non-Compliant pts single dose benzathine single dose benzathine penicllin IMpenicllin IM

Recurrent Strep Throat Recurrent Strep Throat Cephalosporins are choice Cephalosporins are choice ( Keflex ( Keflex cephalexin 500 bid) or can use cephalexin 500 bid) or can use AugmentinAugmentin

Etiologies for recurrent Streptococcal PharyngitisEtiologies for recurrent Streptococcal Pharyngitis

Poor Compliance with oral medications (most common) Poor Compliance with oral medications (most common) Day 3: 50% stopped antibiotics Day 3: 50% stopped antibiotics Day 6: 70% stopped antibiotics Day 6: 70% stopped antibiotics Day 9: 80% stopped antibiotics Day 9: 80% stopped antibiotics Families reporting taking all the medication: 80% Families reporting taking all the medication: 80%

Repeat exposure in crowded conditions Repeat exposure in crowded conditions School , Daycare & Home or workplace School , Daycare & Home or workplace

Eradicated protective throat flora by prior antibiotic Eradicated protective throat flora by prior antibiotic a-hemolytic Streptococcus is protective normal flora a-hemolytic Streptococcus is protective normal flora Cephalosporins apparently do less harm Cephalosporins apparently do less harm

Selected beta-lactam resistance by prior antibiotic Selected beta-lactam resistance by prior antibiotic Consider Augmentin for 10 day course Consider Augmentin for 10 day course

Suppressed Immune response from prior antibiotics Suppressed Immune response from prior antibiotics Antibiotic ResistanceAntibiotic Resistance

Penicillin resistance is infrequent in strep throat Penicillin resistance is infrequent in strep throat Macrolide (Erythromycin, Biaxin, Zithromax) Macrolide (Erythromycin, Biaxin, Zithromax)

Resistance 2-8% in U.S. Resistance 2-8% in U.S. Chronic Pharyngeal Carriage of Streptococcus pyogenes Chronic Pharyngeal Carriage of Streptococcus pyogenes Consider Pharyngitis due to another cause Consider Pharyngitis due to another cause

School AttendanceSchool Attendance

ADVISE TO PARENTS!!ADVISE TO PARENTS!!

High Yield!High Yield!

Contraindications to school attendanceContraindications to school attendance Infectious Infectious FeverFever Vomiting or dehydrationVomiting or dehydrationIndications for school return in viral infectionIndications for school return in viral infection Viral infection examples : Influenza, Rhinovirus (Common Cold) , Fifth Viral infection examples : Influenza, Rhinovirus (Common Cold) , Fifth

Disease, Hand Foot and Mouth DiseaseDisease, Hand Foot and Mouth Disease Indications to return to school Indications to return to school No fever and Child must practice good No fever and Child must practice good

hygiene (i.e. hand washing) hygiene (i.e. hand washing) Indications for school return in bacterial infectionIndications for school return in bacterial infection Bacterial infection examples: Impetigo, Bacterial Conjunctivitis, Bacterial infection examples: Impetigo, Bacterial Conjunctivitis,

Streptococcal Pharyngitis (Strep Throat) Streptococcal Pharyngitis (Strep Throat) Indications to return to school Indications to return to school after Antibiotics for 24 hours after Antibiotics for 24 hours Indications for school return in specific conditionsIndications for school return in specific conditions Chicken Pox Chicken Pox All lesions have crusted over All lesions have crusted over Head Lice Head Lice After anti-lice shampoo and manual nit removal After anti-lice shampoo and manual nit removal Pinworm Pinworm Day after Pyrantel, Mebendazole, or Albendazole Day after Pyrantel, Mebendazole, or Albendazole Vomiting Vomiting 24 hours after last Emesis 24 hours after last Emesis Conditions allowing immediate school returnConditions allowing immediate school return Viral Conjunctivitis (Pink Eye) Viral Conjunctivitis (Pink Eye) Otitis Media (ear infection) Otitis Media (ear infection)

LRTIsLRTIs

Acute BronchitisAcute Bronchitis

Usually viralUsually viral Treat with antibiotics if second sickening or if Treat with antibiotics if second sickening or if

associated with COPD exacerbation associated with COPD exacerbation

PneumoniaPneumonia Community Acquired Pneumonia Community Acquired Pneumonia

Typical etiology : S.pneumoniae. Others: Typical etiology : S.pneumoniae. Others: H.influezae, M.catarrhalisH.influezae, M.catarrhalis

Atypical pneumonia : Legionella, Atypical pneumonia : Legionella, mycoplasma, chlamydiamycoplasma, chlamydia

Health care associated Health care associated

- Nursing home acquired, - Nursing home acquired,

- Hospl acquired , Ventilator associated- Hospl acquired , Ventilator associated

Severe PneumoniaSevere Pneumonia

CURB 65 predicts highly severe pneumoniaCURB 65 predicts highly severe pneumonia RR>30RR>30 DBP<60mmhgDBP<60mmhg BUN>20BUN>20 CONFUSIONCONFUSION Age>65 yrsAge>65 yrs

Whether to admit?Whether to admit?

Most Pneumonias are treated as OutpatientMost Pneumonias are treated as Outpatient

Admission is required if: Admission is required if: Those with underlying immunosuppression Those with underlying immunosuppression

( chemotherapy, HIV)( chemotherapy, HIV) Elderly patients > 65 yrsElderly patients > 65 yrs Pts with altered mental statusPts with altered mental status Those with hemodynamic ( shock) or respiratory Those with hemodynamic ( shock) or respiratory

compromise ( tachypnea, respiratory failure)compromise ( tachypnea, respiratory failure) Pts with poor social support ( homeless) or Pts with poor social support ( homeless) or

without ability to self supervisewithout ability to self supervise

Where to Admit?Where to Admit? Admission to ICU is needed if:Admission to ICU is needed if:LOOK AT VITALS!LOOK AT VITALS! Hypotension (SBP<90)Hypotension (SBP<90) Hemodynamic Instability/ Shock (map<60)Hemodynamic Instability/ Shock (map<60) Hypoxemia<60Hypoxemia<60 Organ failure ( ARF etc)Organ failure ( ARF etc) Impending respiratory failure that may require Impending respiratory failure that may require

mechanical ventilation ( persistent tachypnea, mechanical ventilation ( persistent tachypnea, desaturation etc)desaturation etc)

Deteriorating comorbid illness ( CHF, renal failure Deteriorating comorbid illness ( CHF, renal failure etc)etc)

Heart failure, severe copd exacerbation, Diabetic Heart failure, severe copd exacerbation, Diabetic complications (?DKA)complications (?DKA)

Community acqdCommunity acqd

Outpatient Outpatient Rx with Macrolide Rx with Macrolide ( azithromycin) or newer Quinolones( azithromycin) or newer Quinolones

Inpatient Inpatient Rx with Ceftriaxone + macrolide Rx with Ceftriaxone + macrolide or Fluoroquniolone aloneor Fluoroquniolone alone

Health Care Associated PneumoniaHealth Care Associated Pneumonia Either NH associated or hospital acquiredEither NH associated or hospital acquired NH associated pneumonia may have MRSA and NH associated pneumonia may have MRSA and

Gram –ve bacteria as etiologies ( E.coli, proteus, Gram –ve bacteria as etiologies ( E.coli, proteus, klebsiella) klebsiella) so emperically Rx with Vanco +Zosyn so emperically Rx with Vanco +Zosyn (pip/tazo) before sputum culture results are available. (pip/tazo) before sputum culture results are available. Once Cx and sensitivity are obtained d/c the Once Cx and sensitivity are obtained d/c the antibiotic that’s not neededantibiotic that’s not needed

Hospital acquired pneumonia is the one that develops Hospital acquired pneumonia is the one that develops 48 hrs after hospitalization 48 hrs after hospitalization has a different has a different spectrum of bacteria ( MRSA + resistant gram –ves) spectrum of bacteria ( MRSA + resistant gram –ves) initially can start VANCO + Zosyn before cx initially can start VANCO + Zosyn before cx results are available. If severe, use imipenem instead results are available. If severe, use imipenem instead of Zosyn (pip/tazo)of Zosyn (pip/tazo)

VAPVAP Ventilator Acquired Pneumonia Ventilator Acquired Pneumonia Pneumonia that develops 48 Pneumonia that develops 48

hrs after intubation hrs after intubation diagnosed by diagnosed by c/f like fever, leucocytosis, c/f like fever, leucocytosis, newly developed CXR infiltrates and purulent ET tube newly developed CXR infiltrates and purulent ET tube secretionssecretions the spectrum of bacteria here is more resistant i.e; the spectrum of bacteria here is more resistant i.e; MRSA+ Resistant gram –ves including P.aeruginosa MRSA+ Resistant gram –ves including P.aeruginosa start start emperical VANCO+Imipenem ( do not take chance with emperical VANCO+Imipenem ( do not take chance with resistance here)resistance here)

Culture ET secretions, Get a CXRCulture ET secretions, Get a CXR Bronchoscopy may be required in pts showing no response and Bronchoscopy may be required in pts showing no response and

also to differentiate b/w colonization vs. Infection also to differentiate b/w colonization vs. Infection Recovery of Recovery of bacteria in high concentrations from bronchoalveolar lavage bacteria in high concentrations from bronchoalveolar lavage (BAL) >10,000 col/ml helps in differentiation of non infectious (BAL) >10,000 col/ml helps in differentiation of non infectious from infectious causes of pulmonary infiltrates ( i.e; if the from infectious causes of pulmonary infiltrates ( i.e; if the colonies are this high think of infection other wise think of non colonies are this high think of infection other wise think of non infectious cause like ARDS, CHF etc for explaining these infectious cause like ARDS, CHF etc for explaining these pulmonary infiltrates in vent patients)pulmonary infiltrates in vent patients)

PCP PCP Pneumocystis Carinii pneumonia Pneumocystis Carinii pneumonia Seen in Seen in

immunocompromised ptsimmunocompromised pts Pts who are HIV,{CD4< 200} Pts who are HIV,{CD4< 200} Immunocompromised and pts on high dose steroids Immunocompromised and pts on high dose steroids ( prednisone>20mg/d), ( prednisone>20mg/d),

Symps: dry cough, fever, chills, sob, chestpainSymps: dry cough, fever, chills, sob, chestpain Needs high suspicion for diagnosis Needs high suspicion for diagnosis LDH will help when in LDH will help when in

doubt, Gallium scan will help too doubt, Gallium scan will help too CXR CXR Interstitial infiltrates, LDH high, Ground glass Interstitial infiltrates, LDH high, Ground glass

appearance on CT scan, Sputum for silver staining, appearance on CT scan, Sputum for silver staining, if if sputum –ve, bronchoscopy needed for diagnosis where you do sputum –ve, bronchoscopy needed for diagnosis where you do Bronchoalveolar lavage – silver stainingBronchoalveolar lavage – silver staining

Get an ABGGet an ABG Rx Rx Simple pcp Simple pcp oral bactrim oral bactrim• Severe pcp Severe pcp iv bactrim + steroids ( make sure u give enough iv bactrim + steroids ( make sure u give enough

i.e; prednisone 40mg bid or solumedrol 30mg iv bid i.e; prednisone 40mg bid or solumedrol 30mg iv bid Po2 < Po2 < 70mm hg/ increased A-a > 35are indication for steroid Rx)70mm hg/ increased A-a > 35are indication for steroid Rx)

• Sulfa allergy Sulfa allergy aerosolized pentamidine aerosolized pentamidine

Case StudyCase Study A 36-year-old woman is admitted to the medical

intensive care unit because of respiratory depression resulting from a barbiturate overdose. She is intubated and mechanical ventilation is begun. Physical examination, except for her comatose condition, is unremarkable. Chest radiography and arterial blood gases are within normal limits. Which of the following will minimize her risk of developing a nosocomial infection?

( A ) Ventilator tubing changes every 12 hours ( B ) Elevation of the head of the bed to 45 degrees ( C ) Ceftriaxone, intravenously ( D ) Oropharynx polymyxin B spray every 8 hours ( E ) Enteral feedings by nasogastric tube

Ans.BAns.B

Patients who are mechanically ventilated in the supine position have an approximately six fold increased risk of developing pneumonia compared with patients maintained in a semirecumbent position. Elevation of the patient's head to 45 degrees may reduce aspiration and nosocomial pneumonia.

Nosocomial pneumonia is a major cause of morbidity and mortality in mechanically ventilated patients.

Case StudyCase Study A 21-year-old woman with cystic fibrosis diagnosed at 6 months of age is

evaluated because of increased dyspnea, blood-streaked purulent sputum, decreased energy, and a 1.8-kg (4-lb) weight loss of 4 weeks’ duration. She was last treated with intravenous antibiotics 12 months ago. Her sputum cultures repeatedly grow a mucoid strain of Pseudomonas aeruginosa. Her forced expiratory volume in 1 second (FEV1) has decreased by 400 mL in 6 months and is now 47% of predicted. Chest radiography shows diffuse bronchiectatic changes but no consolidation. She takes replacement pancreatic enzymes, albuterol nebulization three times daily, inhaled recombinant human Dnase once daily,and uses a flutter device to aid expectoration. Which of the following is the best management option at this time?

( A ) Tobramycin, inhaled, twice daily ( B ) Increase Dnase, albuterol nebulizations, and chest physiotherapy ( C ) Piperacillin and tobramycin, intravenously ( D ) Ciprofloxacin, orally, and tobramycin, inhaled, twice daily ( E ) Bronchoscopy

Ans.CAns.C Patients with cystic fibrosis and a bronchitic

exacerbation of chronic bronchiectasis with Pseudomonas aeruginosa require intravenous antibiotics with two antipseudomonal agents for 2 to3 weeks.

The use of aerosolized tobramycin is indicated for patients with chronic Pseudomonas colonization and is associated with long-term improvement in forced expiratory volume in 1 sec (FEV1) of about 10%, as well as decreased need for hospitalization and intravenous antibiotics, but it is not sufficient for an exacerbation.

Pulmonary EmbolismPulmonary Embolism CausesCauses Clinical features Clinical features chestpain, sob, cough, leg chestpain, sob, cough, leg

swellingswelling EKG – Sinus tachy, S1Q3T3EKG – Sinus tachy, S1Q3T3 ABGs – resp alkalosisABGs – resp alkalosis Diagnosis Diagnosis v/q, d-dimer, high resolution CT v/q, d-dimer, high resolution CT

(Spiral CT scan) ( Serum D-dimer < 500ng/ml (Spiral CT scan) ( Serum D-dimer < 500ng/ml Treatment – if shock or if no shock , if Treatment – if shock or if no shock , if

anticoagulation is contraindicatedanticoagulation is contraindicated

PE on EKGPE on EKG Pulmonary embolism (acute cor pulmonale)Pulmonary embolism (acute cor pulmonale)::

Look for new signs of new signs of tachycardia; Look for new signs of new signs of tachycardia; complete or incomplete RBBB; the complete or incomplete RBBB; the S1Q3T3S1Q3T3 patternpattern; and/or right axis shift. There may be ; and/or right axis shift. There may be inferior or RV injury patterns. The most inferior or RV injury patterns. The most common cause of an common cause of an S1Q3T3S1Q3T3 patternpattern is a is a completed inferior MI. completed inferior MI. Get a Right sided Get a Right sided EKG.EKG.

PE on CXRPE on CXR Initial CxR may be Initial CxR may be NORMALNORMAL. .

( PIOPED study showed that ( PIOPED study showed that only 12% of CXRs in pts with only 12% of CXRs in pts with angiographically proven PE angiographically proven PE were interpreted as normal)were interpreted as normal)

May show – Collapse, May show – Collapse, atelectasis, consolidation, small atelectasis, consolidation, small pleural effusion, elevated pleural effusion, elevated diaphragm.diaphragm.

Pleural based opacities with Pleural based opacities with convex medial marginsconvex medial margins are are also known as a Hampton's also known as a Hampton's HumpHump

Hampton's HumpHampton's Hump

Pleural based opacities with convex medial Pleural based opacities with convex medial margins are also known as a Hampton's Hump. margins are also known as a Hampton's Hump. This may be an indication of lung infarction. This may be an indication of lung infarction. However, that rate of resolution of these densities However, that rate of resolution of these densities is the best way to judge if lung tissue has been is the best way to judge if lung tissue has been infarcted. Areas of pulmonary hemorrhage and infarcted. Areas of pulmonary hemorrhage and edema resolve in a few days to one week. The edema resolve in a few days to one week. The density caused by an area of infarcted lung will density caused by an area of infarcted lung will decrease slowly over a few weeks to months and decrease slowly over a few weeks to months and may leave a linear scar may leave a linear scar

PE on CXRPE on CXR

Westermark signWestermark sign – – Dilatation of pulmonary Dilatation of pulmonary vessels proximal to vessels proximal to embolism along with embolism along with collapse of distal collapse of distal vessels, often with a vessels, often with a sharp cut off.sharp cut off.

Pulmonary Embolism with Pulmonary Embolism with Infarction Infarction

Consolidation Consolidation Cavitation Cavitation Pleural effusion (bloody Pleural effusion (bloody

in 65%) in 65%) No air bronchograms No air bronchograms ““Melting” sign of Melting” sign of

healing healing Heals with linear scarHeals with linear scar

Case StudyCase Study A 56-year-old man is evaluated in the emergency department because of

progressive swelling of the right lower extremity during the previous 5 days and right-sided pleuritic chest pain and dyspnea beginning 1 to 2 hours ago.On physical examination, his temperature is 38.2 °C (100.8 °F), pulse rate is 105/min, respiration rate is 28/min, and blood pressure is 160/80 mm Hg. Cardiac and pulmonary examinations are unremarkable. Arterial blood gases with the patient breathing room air are PO2, 78 mm Hg; PCO2, 30 mm Hg; and pH, 7.48.Electrocardiography shows sinus tachycardia and nonspecific ST-T wave changes, and chest radiography is normal.Ventilation-perfusion scanning shows two unmatched segmental defects. The D-dimer value is three times the upper limit of normal.

Which of the following is the most appropriate course of action? ( A ) Heparin ( B ) Helical computed tomography with contrast ( C ) Noninvasive studies of the lower extremities ( D ) Pulmonary angiography

Key PointKey Point

In patients with a high pretest probability of pulmonary embolism

and high-probability ventilation-perfusion scanning, additional

diagnostic testing is not necessary before initiating therapy.

PneumothoraxPneumothorax Causes – Trauma, bulla rupture, necrotizing Causes – Trauma, bulla rupture, necrotizing

pneumoniapneumonia Clinical features Clinical features chest pain, dyspnea, shock chest pain, dyspnea, shock Ventilator associated Pneumothorax Ventilator associated Pneumothorax ? sudden ? sudden

hypotension while on vent hypotension while on vent look at peak and look at peak and plateau pressuresplateau pressures

Treatment Treatment needle thoracentesis, needle needle thoracentesis, needle thoracostomy, tube thoracostomythoracostomy, tube thoracostomy

ARDSARDS Diffuse pulmonary capillary damage leading to increased Diffuse pulmonary capillary damage leading to increased

permeability of alveolar capillaries permeability of alveolar capillaries pulm edema pulm edema Criteria Criteria 1) There should be a cause 2) PO2/Fio2 ( in 1) There should be a cause 2) PO2/Fio2 ( in

liter) Ratio, Po2/Fio2 < 300 liter) Ratio, Po2/Fio2 < 300 ALI, <200 ALI, <200 ARDS 3) ARDS 3) B/L CXR infiltrates 4) Should not be due to CHF; Clues: B/L CXR infiltrates 4) Should not be due to CHF; Clues: 2D ECHO EF Good/ no diastolic dysfunction. If in doubt 2D ECHO EF Good/ no diastolic dysfunction. If in doubt whether CXR infiltrates are due to CHF or ARDS whether CXR infiltrates are due to CHF or ARDS measure PCWP ( Swan Ganz insertion )measure PCWP ( Swan Ganz insertion )

Ventilation strategies Ventilation strategies Low Vt ( 6cc/kg) ( Low Vt ( 6cc/kg) ( prevent prevent overdistension injury) and High PEEP strategy ( reduce overdistension injury) and High PEEP strategy ( reduce derecruitment injury)derecruitment injury)

Causes Causes TTP, Sepsis, Shock, Aspiration pneumonia, TTP, Sepsis, Shock, Aspiration pneumonia, chemical pneumonitis, Drugs like Heroin, Pancreatitis, chemical pneumonitis, Drugs like Heroin, Pancreatitis, Burns, DrowningBurns, Drowning

Case StudyCase Study A 58-year-old man is admitted to the intensive care unit with increasing dyspnea after

developing influenza symptoms 3 days previously. On physical examination, his temperature is 39.1 °C (102.3 °F), pulse rate is 110/min, and bloodpressure is 135/83 mm Hg. He weighs 73 kg (161 lb). He is using accessory muscles of respiration, and he has finecrackles throughout all lung fields. Cardiac examination is unremarkable, and no edema is noted. Chest radiographyshows diffuse infiltrates throughout both lungs with patchy areas of consolidation. The patient has a history of moderate obstructive lung disease secondary to smoking. Several months before hospitalization his forced expiratory volume in 1sec (FEV1) was 53% of predicted, and he had normal oxygen saturation and no hypercapnia.Shortly after hospitalization, he is intubated because of increasing hypoxemia and hypercapnia. Subsequent arterial blood gases with the patient breathing 100% oxygen and 10 cm H2O of positive end-expiratory pressure are PO2, 68mm Hg; PCO2, 65 mm Hg; pH, 7.23; and bicarbonate, 26 meq/L. Tidal volume is 450 mL, respiration rate is 25/min,inspiratory flow rate is 100 L/min, and inspiratory/expiratory ratio is 1:5. Peak airway and plateau ventilatory pressures are 48 cm H2O and 32 cm H2O.

Which of the following is the best option? ( A ) Increase the tidal volume ( B ) Increase the respiration rate ( C ) Increase the positive end-expiratory pressure ( D ) Decrease the positive end-expiratory pressure ( E ) Administer sodium bicarbonate, intravenously

Key PointsKey Points Ans. EAns. E In patients with acute respiratory distress syndrome, mortality was significantly

improved by ventilating patients with tidalvolumes of 6 mL/kg of ideal body weight and keeping plateau ventilatory pressure at =30 cm H2O.

If changes in respirator settings required to prevent hypercapnia have associated untoward effects, it is reasonable to allow arterial PCO2 to rise and, if necessary, prevent acidemia by administration of buffer as in this case!! ( don’t increase tidal volume here low Vt is good for this remember Permissive Hypercapnia)

Increasing PEEP is not good here. Increasing PEEP is not good here. Raising PEEP is undesirable because this will narrow the pressure difference between the plateau ventilatory pressure and the PEEP, decreasing the pressure available to deliver the tidal volume. This will reduce the tidal volume and exacerbate hypercapnia. PEEP should remain unchanged because the patient has acceptable oxygenation with the present setting. The level of PEEP cannot be reduced since reduction likely will lead to unacceptable hypoxemia. The patient is barely at an acceptable level without any reduction.

Increasing the respiration rate likely will increase auto-positive end-expiratory pressure (PEEP) in this patient with chronic obstructive pulmonary disease ( they have proloned expiration!) by “breath stacking,” that is, delivering the next breath before the previous breath is completely expired.This will also raise the plateau ventilatory pressure above a desirable range.

Case StudyCase Study A 57-year-old man with severe chronic obstructive pulmonary

disease is hospitalized with respiratory distress of 12 hours’ duration. Arterial blood gases with the patient breathing 35% oxygen through a face mask are PaO2, 50 mm Hg; PaCO2, 70 mm Hg; and pH, 7.24. When seen as an outpatient 1 month previously, his arterial blood gases while breathing room air were PaO2, 58 mm Hg; PaCO2, 50 mm Hg; and pH, 7.37. Despite maximal therapy, mechanical ventilation is required. During controlled breaths, his peak airway pressure is 25 cm H2O, and plateau ventilatory pressure is 12 cm H2O. The arterial blood gases are checked after 1 hour. Which of the following is the most desirable set of arterial blood gas values?

( A ) Pa O2, 50 mm Hg; PaCO2, 45 mm Hg; pH, 7.44; FIO2, 0.3 ( B ) Pa O2, 65 mm Hg; PaCO2, 52 mm Hg; pH, 7.38; FIO2, 0.4 ( C ) Pa O2, 65 mm Hg; PaCO2, 40 mm Hg; pH, 7.48; FIO2, 0.4 ( D ) Pa O2, 90 mm Hg; PaCO2, 60 mm Hg; pH, 7.32; FIO2, 0.5 ( E ) Pa O2, 133 mm Hg; PaCO2, 55 mm Hg; pH, 7.41; FIO2,

0.6

Ans.BAns.B When instituting mechanical ventilation in a patient with

chronic hypercapnia, it is critical to avoid the development of respiratory alkalemia secondary to overventilation, and ventilator settings should have pH as a target, rather than PaCO2.

When seen 1 month before hospitalization, the patient had chronic carbon dioxide retention. When instituting mechanical ventilation in a patient with hypercapnia, it is critical to avoid the development of respiratory alkalemia secondary to overventilation. Severe alkalosis in this setting may result in cardiovascular instability, arrhythmias, andseizures. Ventilator settings should have pH as a target, rather than PaCO2.

Acute Pulmonary EdemaAcute Pulmonary Edema

Treatment Treatment morphine, loop diuretics in LVF, morphine, loop diuretics in LVF, Ventilation strategies in ARDS and Ventilation strategies in ARDS and Hemodialysis when indicatedHemodialysis when indicated

Causes Causes ARDS, Acute LVF, Fluid Overload, ARDS, Acute LVF, Fluid Overload, Missing HemodialysisMissing Hemodialysis

A 58-year-old man is admitted to the intensive care unit with increasing dyspnea after developing influenza symptoms 3 days previously. On physical examination, his temperature is 39.1 °C (102.3 °F), pulse rate is 110/min, and blood pressure is 135/83 mm Hg. He weighs 73 kg (161 lb). He is using accessory muscles of respiration, and he has fine crackles throughout all lung fields. Cardiac examination is unremarkable, and no edema is noted. Chest radiography shows diffuse infiltrates throughout both lungs with patchy areas of consolidation. The patient has a history of moderate obstructive lung disease secondary to smoking. Several months before hospitalization his forced expiratory volume in 1 sec (FEV1) was 53% of predicted, and he had normal oxygen saturation and no hypercapnia. Shortly after hospitalization, he is intubated because of increasing hypoxemia and hypercapnia. Subsequent arterial blood gases with the patient breathing 100% oxygen and 10 cm H2O of positive end-expiratory pressure are PO2, 68 mm Hg; PCO2, 65 mm Hg; pH, 7.23; and bicarbonate, 26 meq/L. Tidal volume is 450 mL, respiration rate is 25/min, inspiratory flow rate is 100 L/min, and inspiratory/expiratory ratio is 1:5. Peak airway and plateau ventilatory pressures are

48 cm H2O and 32 cm H2O. Which of the following is the best option for improving this patient’s acid–base disorder? ( A ) Increase the tidal volume ( B ) Increase the respiration rate ( C ) Increase the positive end-expiratory pressure ( D ) Decrease the positive end-expiratory pressure ( E ) Administer sodium bicarbonate, intravenously

Ans.Ans.

In patients with acute respiratory distress syndrome, mortality was significantly improved by ventilating patients with tidalvolumes of 6 mL/kg of ideal body weight and keeping plateau ventilatory pressure at =30 cm H2O.

If changes in respirator settings required to prevent hypercapnia have associated untoward effects, it is reasonable to allowarterial PCO2 to rise and, if necessary, prevent acidemia byadministration of buffer.

COPDCOPD

COPD – Screening with SpirometryCOPD – Screening with Spirometry Consider screening smokers or former smokers with Consider screening smokers or former smokers with

certain clinical characteristics for COPD with pulmonary certain clinical characteristics for COPD with pulmonary function testing. function testing.

In patients who smoke or have smoked, consider obtaining In patients who smoke or have smoked, consider obtaining screening spirometry readings to document obstruction if they screening spirometry readings to document obstruction if they give a history of cough or sputum production or have findings give a history of cough or sputum production or have findings compatible with emphysema on chest x-ray. compatible with emphysema on chest x-ray.

Obtain spirometry readings if the patient has limiting Obtain spirometry readings if the patient has limiting symptoms such as dyspnea inappropriate to the level of symptoms such as dyspnea inappropriate to the level of activity, frequent episodes of acute bronchitis related to upper activity, frequent episodes of acute bronchitis related to upper respiratory tract infections (i.e., a possible acute exacerbation), respiratory tract infections (i.e., a possible acute exacerbation), difficulty sleeping due to cough and dyspnea, and general difficulty sleeping due to cough and dyspnea, and general diminished activity levels and energy from difficulty in diminished activity levels and energy from difficulty in breathing. breathing.

If the patient has no other clinical characteristics for COPD, If the patient has no other clinical characteristics for COPD, but has a but has a significant history of smokingsignificant history of smoking, consider obtaining , consider obtaining spirometry readings because significant pulmonary function spirometry readings because significant pulmonary function impairment may still be present. impairment may still be present.

COPD ExacerbationsCOPD Exacerbations COPD – Chr.bronchitis, Emphysema – blue bloaters, Pink puffersCOPD – Chr.bronchitis, Emphysema – blue bloaters, Pink puffers COPD exacerbations COPD exacerbations History, Clinical exam, get pulse ox, History, Clinical exam, get pulse ox, Mild, Moderate, Severe Mild, Moderate, Severe classify depending on 3 criteria (Increase in classify depending on 3 criteria (Increase in

amount of sputum, Increased sputum purulence, worsening dyspnea)amount of sputum, Increased sputum purulence, worsening dyspnea)

Mild exacerbationMild exacerbation ( 1 of above criteria) ( 1 of above criteria) use simple antibiotics like Bactrim use simple antibiotics like Bactrim or Doxycyclineor Doxycycline

Moderate exacerbationModerate exacerbation ( 2 of above criteria) ( 2 of above criteria) use 2 use 2nd line nd line Antibiotics like Antibiotics like quinolones, b-lactam/clavulanate ( Augmentin)quinolones, b-lactam/clavulanate ( Augmentin)

Severe ExacerbationSevere Exacerbation ( 3 of above criteria) ( 3 of above criteria) Look at the ABGs, o2 Look at the ABGs, o2 inhalation, nebulizer with ipratropium + albuterol inhalation, nebulizer with ipratropium + albuterol caution with o2, o2 caution with o2, o2 inhalation only as much as to maintain sao2>90%. inhalation only as much as to maintain sao2>90%. If no response , non If no response , non invasive ventilation ( positive pressure ventilation, BIPAP) invasive ventilation ( positive pressure ventilation, BIPAP) Pt must be Pt must be cooperative for this cooperative for this if altered mental status, no response with non invasive if altered mental status, no response with non invasive ventilation ventilation Intubate and ventilate. Intubate and ventilate.

Remember to get ABGs after u place a COPD guy on oxygenRemember to get ABGs after u place a COPD guy on oxygen Beware of posthypercapnic alkalosis Beware of posthypercapnic alkalosis if develops, acetazolomide if develops, acetazolomide COPD exacerbation COPD exacerbation ? Ask urself secondary to what ? Ask urself secondary to what Acute bronchitis, Acute bronchitis,

pneumonia pneumonia use of antibiotics in COPD exacerbations use of antibiotics in COPD exacerbations Steroids is a MUST Steroids is a MUST methylprednisolone high doses 125mg q6hrsmethylprednisolone high doses 125mg q6hrs, then , then

tapering steroidstapering steroids

When To Admit?When To Admit?Indications for hospitalization of patients with COPD: Indications for hospitalization of patients with COPD: Patient has acute exacerbation plus one or more of the following: Patient has acute exacerbation plus one or more of the following:

Inadequate response of symptoms to outpatient management Inadequate response of symptoms to outpatient management Inability to walk between rooms (patient previously mobile) Inability to walk between rooms (patient previously mobile) Inability to eat or sleep due to dyspnea Inability to eat or sleep due to dyspnea Conclusion by family, physician, or both that patient cannot manage at home and Conclusion by family, physician, or both that patient cannot manage at home and

supplementary home care resources are not immediately available supplementary home care resources are not immediately available Presence of a high-risk comorbid condition, pulmonary (e.g., pneumonia) or Presence of a high-risk comorbid condition, pulmonary (e.g., pneumonia) or

nonpulmonary nonpulmonary Prolonged, progressive symptoms before emergency department visit Prolonged, progressive symptoms before emergency department visit Altered mentation Altered mentation Worsening hypoxemia Worsening hypoxemia New or worsening hypercarbia New or worsening hypercarbia

Patient has new or worsening cor pulmonale unresponsive to outpatient Patient has new or worsening cor pulmonale unresponsive to outpatient management management

A planned invasive surgical or diagnostic procedure requires analgesics or A planned invasive surgical or diagnostic procedure requires analgesics or sedatives that may worsen pulmonary function sedatives that may worsen pulmonary function

Comorbid conditions (e.g., steroid myopathy or vertebral compression Comorbid conditions (e.g., steroid myopathy or vertebral compression fractures) have worsened pulmonary function fractures) have worsened pulmonary function

Where To Admit?Where To Admit? Admit patients with COPD to an intensive care Admit patients with COPD to an intensive care

unit if they meet specific criteria. unit if they meet specific criteria. Confusion, lethargy, or respiratory muscle fatigue Confusion, lethargy, or respiratory muscle fatigue Persistent or worsening hypoxemia despite supplemental Persistent or worsening hypoxemia despite supplemental

O2 or severe or worsening of respiratory acidosis (pH O2 or severe or worsening of respiratory acidosis (pH 7.30); use of supplemental oxygen 7.30); use of supplemental oxygen should be at the lowest should be at the lowest flow rateflow rate to raise PaO 2 >60 or SaO 2 >90% to avoid to raise PaO 2 >60 or SaO 2 >90% to avoid hyperoxic hypercapnia hyperoxic hypercapnia

Need for assisted mechanical ventilation, whether through Need for assisted mechanical ventilation, whether through means of tracheal intubation or noninvasive techniques means of tracheal intubation or noninvasive techniques

Severe dyspnea that responds inadequately to initial Severe dyspnea that responds inadequately to initial emergency room therapy emergency room therapy

COPD – Home Oxygen TherapyCOPD – Home Oxygen Therapy

At discharge, evaluate pt for home 02 therapy. At discharge, evaluate pt for home 02 therapy. Especially at nights when pts may desaturate Especially at nights when pts may desaturate ( acidosis at nights shifts curve to right). Goal ( acidosis at nights shifts curve to right). Goal maintain sao2 90 or po2 60maintain sao2 90 or po2 60

Indications :Indications : Po2<55 or sao2 <85%Po2<55 or sao2 <85% Po2 b/w 56 to 59 if corpulmonale or Po2 b/w 56 to 59 if corpulmonale or

polycythemia ( erythrocytosis) ( polycythemia ( erythrocytosis) ( these these suggest evidence of hypoxia)suggest evidence of hypoxia)

Lung Volume Reduction SurgeryLung Volume Reduction Surgery Consider LVRS for patients whose initial clinical criteria Consider LVRS for patients whose initial clinical criteria

include: include: CT scan evidence of bilateral emphysema CT scan evidence of bilateral emphysema Prerehabilitation postbronchodilator TLC and residual volume >/= to Prerehabilitation postbronchodilator TLC and residual volume >/= to

100% and 150% predicted, respectively 100% and 150% predicted, respectively Maximum FEV1 </= 45% predicted Maximum FEV1 </= 45% predicted PaCO2 </= 60 mm Hg PaCO2 </= 60 mm Hg PaO2 >/= 45 mm Hg PaO2 >/= 45 mm Hg Completion of a pulmonary rehabilitation program Completion of a pulmonary rehabilitation program

Do not consider LVRS for patients whose clinical criteria Do not consider LVRS for patients whose clinical criteria include: include: FEV1 less than or equal to FEV1 less than or equal to 20% predicted ( very low for surgery)20% predicted ( very low for surgery) and and

either homogenous emphysema or carbon monoxide diffusing capacity either homogenous emphysema or carbon monoxide diffusing capacity less than or equal to 20% predicted (DLCO) less than or equal to 20% predicted (DLCO)

Non-upper-lobe emphysema and high baseline exercise capacity Non-upper-lobe emphysema and high baseline exercise capacity

Interpretation of PFT’SInterpretation of PFT’S Restrictive vs. ObstructiveRestrictive vs. Obstructive FEV1 to FVC Ratio (Normally over 75%) FEV1 to FVC Ratio (Normally over 75%) Not useful if both FEV1 and FVC are normal Not useful if both FEV1 and FVC are normal Obstructive lung: Moderately to severely decreased Obstructive lung: Moderately to severely decreased Restrictive lung: Normal or increased Restrictive lung: Normal or increased Reversibility:Reversibility: Bronchodilator response (Significant values) Bronchodilator response (Significant values) Response suggests reversible component ifResponse suggests reversible component if FVC or FEV1 improves by 12 to 15% over baseline FVC or FEV1 improves by 12 to 15% over baseline FVC or FEV1 increases by at least 200 ml FVC or FEV1 increases by at least 200 ml FEF25-75 improves by 15 to 25% over baseline FEF25-75 improves by 15 to 25% over baseline

COPD Outpatient RxCOPD Outpatient Rx By MDIs By MDIs Ipratropium all the time ( q6hrs) Ipratropium all the time ( q6hrs)

+ albuterol as needed. Can use tiotropium + albuterol as needed. Can use tiotropium because its long actingbecause its long acting

Evaluate for home o2 therapyEvaluate for home o2 therapy Steroids/ antibiotics in acute exacerbations Steroids/ antibiotics in acute exacerbations

only. only. ( unlike in Asthma, steroids are not a ( unlike in Asthma, steroids are not a part of chronic therapy in COPD)part of chronic therapy in COPD)

MDIs deliver only fixed dose of drug. MDIs deliver only fixed dose of drug. Nebulizers deliver larger dose of drugNebulizers deliver larger dose of drug so in so in exacerbation u start with nebulizer if MDIs exacerbation u start with nebulizer if MDIs don’t workdon’t work

COPD with AsthmaCOPD with Asthma

Asthma may be present in about 10% of cases Asthma may be present in about 10% of cases of COPD; however, reversibility of FEV1 of COPD; however, reversibility of FEV1 alone should never be used to make a alone should never be used to make a diagnosis of asthma in the diagnosis of asthma in the absenceabsence of other of other supporting evidence such as a supporting evidence such as a childhood childhood history of asthma, atopic symptomshistory of asthma, atopic symptoms, , blood or blood or sputum eosinophiliasputum eosinophilia, or , or onset of symptoms onset of symptoms before substantial history of cigarette smokingbefore substantial history of cigarette smoking

COPD in the YoungCOPD in the Young

A 38-year-old man is evaluated because of a morning cough productive of clear sputum, chest tightness, and shortness of breath when walking. He has smoked two packs of cigarettes per day since his teenage years and says that previous chest radiography showed "early emphysema." He is a baker but notes no improvement in symptoms when on vacation. His wife has three indoor cats, and he has an outdoor dog. The patient has normal vital signs. The chest is hyperresonant to percussion, breath sounds are decreased in intensity, and expiration is prolonged. Pulmonary function tests show forced expiratory volume in 1 sec (FEV1) is 45% of predicted, forced vital capacity (FVC) is 65% of predicted, total lung capacity (TLC) is slightly increased (120% of predicted), and diffusing lung capacity for carbon monoxide (DLCO) is moderately reduced (60% of predicted). Chest radiography shows hyperinflation with a suggestion of several small bullae in the lower lung fields.

Which of the following tests is indicated? ( A ) Sputum Gram stain and culture ( B ) Methacholine inhalation challenge test ( C ) Skin tests for allergens and serum precipitins to wheat extract ( D ) Measurement of serum a 1-antitrypsin level ( E ) Esophageal pH monitoring for 24 hours

Severe chronic obstructive pulmonary disease in young persons is suggestive of a1-antitrypsin deficiency, and an a1-antitrypsin level should be measured.

Smoking is an important precipitating factor and also increases progression

Case StudyCase Study A 67-year-old man with longstanding chronic obstructive pulmonary disease

(COPD) is hospitalized with a 1-week history of increasing cough productive of large amounts of purulent sputum, low-grade fever, lethargy, and shortness ofbreath.On physical examination, his vital signs are normal except for a temperature of 38.2 °C (100.7 °F) and a pulse rate of 108/min. The neck veins are not distended. The anterior–posterior chest dimension is increased and is hyperresonant to percussion, breath sounds are reduced, and expiration is prolonged.Arterial blood gases are normal except for a PO2 of 62 mm Hg with the patient breathing 28% oxygen through a venturi mask. Chest radiography shows changes compatible with COPD but no acute process.In the emergency department, treatment with inhaled bronchodilators and antibiotics was begun.

Which of the following options is the best choice? ( A ) Add inhaled fluticasone, every 12 hours ( B ) Add methylprednisolone, 500 mg intravenously once ( C ) Add methylprednisolone, 125 mg intravenously every 6 hours for 3 days,

then taper over 2 weeks (D) No need to add steroids in this patient E) Intubate the patient

Key PointKey Point

Patients with exacerbations of chronic obstructive pulmonary

disease (COPD) who receive intravenous corticosteroids and a

tapering dose of prednisone over 2 weeks experience shorter

hospitalization and less treatment failures.Two weeks of tapering prednisone is just as effective as 8

weeksin treating exacerbations of COPD.

A 57-year-old man with severe chronic obstructive pulmonary disease is hospitalized with respiratory distress of 12 hours’ duration. Arterial blood gases with the patient breathing 35% oxygen through a face mask are PaO2, 50 mm Hg;

PaCO2, 70 mm Hg; and pH, 7.24. When seen as an outpatient 1 month previously, his arterial blood gases while

breathing room air were PaO2, 58 mm Hg; PaCO2, 50 mm Hg; and pH, 7.37. Despite maximal therapy, mechanical

ventilation is required. During controlled breaths, his peak airway pressure is 25 cm H2O, and plateau ventilatory

pressure is 12 cm H2O. The arterial blood gases are checked after 1 hour. Which of the following is the most desirable set of arterial blood gas values? ( A ) Pa O2, 50 mm Hg; PaCO2, 45 mm Hg; pH, 7.44; FIO2, 0.3 ( B ) Pa O2, 65 mm Hg; PaCO2, 52 mm Hg; pH, 7.38; FIO2, 0.4 ( C ) Pa O2, 65 mm Hg; PaCO2, 40 mm Hg; pH, 7.48; FIO2, 0.4 ( D ) Pa O2, 90 mm Hg; PaCO2, 60 mm Hg; pH, 7.32; FIO2, 0.5 ( E ) Pa O2, 133 mm Hg; PaCO2, 55 mm Hg; pH, 7.41; FIO2, 0.6

QQ 65 Y/O comes with cough and exertional sob of several month duration. He has smoked for 35

years. On physical examination, he is sweating, ruddy, and cyanotic. His pulse rate is120/min and regular, respiration rate is 30/min and labored, and blood pressure is 150/90 mm Hg. The neck veins are distended to the angle of the jaw when sitting upright. The chest shows hyperinflation, prolonged expiration, wheezing, and crackles at each posterior base. The pulmonic sound is increased, and there is a summation gallop. An enlargedand tender liver edge is felt 2 cm below the costal margin. He has marked dependent edema up to the knees.The hematocrit is 55%, and leukocyte count is 8000/μL. Arterial blood gases with the patient breathing room air arePaO2, 47 mm Hg; PaCO2, 50 mm Hg; and pH, 7.30. Spirometry performed 2 years earlier showed a forced expiratoryvolume in 1 sec (FEV1) of 0.65 L and a forced vital capacity (FVC) of 3.05 L. Chest radiography shows hyperinflation, clear lung fields, and biventricular enlargement. Ventilation-perfusion lung scanning shows multiple matched fillingdefects that are not segmental. Doppler studies of the legs are negative.After treatment of the patient’s acute condition, which of the following is the best long-term therapy for

this patient? ( A ) Nifedipine ( B ) Warfarin ( C ) Bosentan ( D ) Oxygen ( E ) Phlebotomy

Case StudyCase Study A 65-year old male hospital in-patient has smoked cigarettes since he was 18 years A 65-year old male hospital in-patient has smoked cigarettes since he was 18 years

old. He has a chronic cough and marked sputum production. When his doctor starts old. He has a chronic cough and marked sputum production. When his doctor starts to give him the usual talk about losing weight, he explains that since he has about to give him the usual talk about losing weight, he explains that since he has about fifty pounds to lose, he has tried to exercise, but is unable to because of shortness fifty pounds to lose, he has tried to exercise, but is unable to because of shortness of breath with any activity. Upon further questioning, he comments that his of breath with any activity. Upon further questioning, he comments that his symptoms have been present for a very long time, but he was hospitalized due to a symptoms have been present for a very long time, but he was hospitalized due to a marked exacerbation of his complaints. On auscultation, rhonchi and wheezes are marked exacerbation of his complaints. On auscultation, rhonchi and wheezes are heard.His laboratory results are as follows:heard.His laboratory results are as follows:

pCO2 60 mm Hg(35-45 mm Hg) pCO2 60 mm Hg(35-45 mm Hg) pH 7.34( 7.35-7.45) pH 7.34( 7.35-7.45) bicarbonate 31 mEq/L( 24 mEq/L) bicarbonate 31 mEq/L( 24 mEq/L) Na+ 140 mEq/L( 135-145 mEq/L) Na+ 140 mEq/L( 135-145 mEq/L) K+ 4.0 mEq/L( 3.5-5.5 mEq/L) K+ 4.0 mEq/L( 3.5-5.5 mEq/L) Cl-100 mEq/L(98-109 mEq/L)Cl-100 mEq/L(98-109 mEq/L) What is the primary disorder?What is the primary disorder?

a) metabolic acidosis with a normal anion gapa) metabolic acidosis with a normal anion gapb) metabolic acidosis with an elevated anion gapb) metabolic acidosis with an elevated anion gapc) metabolic alkalosisc) metabolic alkalosisd) respiratory acidosisd) respiratory acidosise) respiratory alkalosise) respiratory alkalosis

Ans.DAns.D This patient has symptoms and signs of chronic obstructive pulmonary This patient has symptoms and signs of chronic obstructive pulmonary

disease, specifically chronic bronchitis.disease, specifically chronic bronchitis.Symptoms and signs include cough, sputum production and dyspnea with Symptoms and signs include cough, sputum production and dyspnea with exertions. Patients tend to be stocky or overweight, as the case here.exertions. Patients tend to be stocky or overweight, as the case here.Auscultation will reveal wheezes and rhonchi. This patient is retaining Auscultation will reveal wheezes and rhonchi. This patient is retaining CO2, since his pCO2 is elevated. CO2 is in equilibrium with carbonic acid. CO2, since his pCO2 is elevated. CO2 is in equilibrium with carbonic acid. An increase in CO2 will shift the Henderson Hasselbalch equation to the An increase in CO2 will shift the Henderson Hasselbalch equation to the left, resulting in acidosis. Since the cause of the primary problem is left, resulting in acidosis. Since the cause of the primary problem is respiratory, e.g. retention of CO2, this is arespiratory, e.g. retention of CO2, this is arespiratory acidosis.respiratory acidosis.

This is reflected in the pH being reduced as well.Metabolic acidosis This is reflected in the pH being reduced as well.Metabolic acidosis (choice a, choice b) is incorrect because the primary problem is not due to (choice a, choice b) is incorrect because the primary problem is not due to a administration of acid, excess metabolic acid formation, or loss of base. a administration of acid, excess metabolic acid formation, or loss of base. Although the bicarbonate level is abnormal in this patient, that is due to Although the bicarbonate level is abnormal in this patient, that is due to metabolic compensation for the respiratory acidosis.metabolic compensation for the respiratory acidosis.

Alkalosis (choice c, choice e) are incorrect because his pH is acidotic. Alkalosis (choice c, choice e) are incorrect because his pH is acidotic. Although compensatory mechanisms can bring the pH towards the normal Although compensatory mechanisms can bring the pH towards the normal range, compensatory mechanisms will never overshoot.range, compensatory mechanisms will never overshoot.

A 54-year-old man is hospitalized because of severe shortness of breath, ankle swelling, and confusion of 5 days’ duration. He has smoked for 35 years. On physical examination, he is sweating, ruddy, and cyanotic. His pulse rate is 120/min and regular, respiration rate is 30/min and labored, and blood pressure is 150/90 mm Hg. The neck veins are distended to the angle of the jaw when sitting upright. The chest shows hyperinflation, prolonged expiration, wheezing, and crackles at each posterior base. The pulmonic sound is increased, and there is a summation gallop. An enlarged and tender liver edge is felt 2 cm below the costal margin. He has marked dependent edema up to the knees. The hematocrit is 55%, and leukocyte count is 8000/μL. Arterial blood gases with the patient breathing room air are PaO2, 47 mm Hg; PaCO2, 50 mm Hg; and pH, 7.30. Spirometry performed 2 years earlier showed a forced expiratory volume in 1 sec (FEV1) of 0.65 L and a forced vital capacity (FVC) of 3.05 L. Chest radiography shows hyperinflation, clear lung fields, and biventricular enlargement. Ventilation-perfusion lung scanning shows multiple matched filling defects that are not segmental. Doppler studies of the legs are negative. After treatment of the patient’s acute condition, which of the following is the best long-term therapy for this patient?

( A ) Nifedipine ( B ) Warfarin ( C ) Bosentan ( D ) Oxygen ( E ) Phlebotomy

Ans. DAns. D

In patients with cor pulmonale caused by chronic hypoxemia, oxygen therapy is the treatment of choice; it may decrease the heart failure and polycythemia seen in this condition.

AsthmaAsthma Classification: Classification: Management Grouping Management Grouping Mild Intermittent Asthma Mild Intermittent Asthma

Occasional exacerbations (Less than twice per week) Occasional exacerbations (Less than twice per week) Mild Persistent Asthma Mild Persistent Asthma

Frequent exacerbations (>twice weekly, but not daily) Frequent exacerbations (>twice weekly, but not daily) Moderate Persistent Asthma Moderate Persistent Asthma

Daily symptoms with daily Beta Agonist use Daily symptoms with daily Beta Agonist use Severe Persistent Asthma Severe Persistent Asthma

Continuous Symptoms and frequent exacerbations Continuous Symptoms and frequent exacerbations

Treatment Treatment short acting MDIs as needed, long acting bronchodilators short acting MDIs as needed, long acting bronchodilators ( once asthma becomes moderate to severe add these as adjuncts to inhaled ( once asthma becomes moderate to severe add these as adjuncts to inhaled steroids), inhaled steroids ( first line agent in all persistent asthmas) , steroids), inhaled steroids ( first line agent in all persistent asthmas) , systemic steroids, monteleukast ( add this as adjunct in moderate to severe systemic steroids, monteleukast ( add this as adjunct in moderate to severe asthma)asthma)

Status asthmaticusStatus asthmaticus

AsthmaAsthmaExamples of different therapeutic approaches:Examples of different therapeutic approaches: Mild Intermittent: use only prn albuterol; if related to exercise, Mild Intermittent: use only prn albuterol; if related to exercise,

use albuterol one-half  hour prior to exercise; also used: use albuterol one-half  hour prior to exercise; also used: cromolyn one half-hour prior to exercise. cromolyn one half-hour prior to exercise.

Mild Persistent: daily: low dose inhaled steroids; and use Mild Persistent: daily: low dose inhaled steroids; and use albuterol intermittently as needed.  May use inhaled cromolyn. albuterol intermittently as needed.  May use inhaled cromolyn.

Moderate Persistent: use peak flow meter daily; use med dose Moderate Persistent: use peak flow meter daily; use med dose inhaled steroid or low dose steroids plus serevent or singulair.  inhaled steroid or low dose steroids plus serevent or singulair.  Others switch to Advair. PO steroids prn. Others switch to Advair. PO steroids prn.

Severe Persistent: use peak flow meter daily; po steroids as Severe Persistent: use peak flow meter daily; po steroids as needed.  Daily meds to include high dose inhaled steroids, needed.  Daily meds to include high dose inhaled steroids, singulair, serevent or possibly Advair. singulair, serevent or possibly Advair.

Classification:

 

Mild Intermittent

Mild Persistent

Mod Persistent

Severe Persistent

Symptoms

< 2 / week

> 2 / week

Daily Continual

Night sx

< 2 / month

> 2 / month

> 1 / week

Frequent

FEV1

> 80% predicted

> 80%predicted

60-80% < 60%

Peak flow Variability

< 20% 20-30% > 30 % > 30%

Management  of different categories of Asthma:

 

Mild Intermittent

Mild Persistent

Mod Persistent

Severe Persistent

Peak Flow Meter                 X       X

Preventive Meds (daily):

--Inhaled Cromolyn   X (X)  

--Inhaled Steroids  X (low dose)

X (med dose)

X (high dose)

--Po Singulair   X X X

--Advair Diskus ( Salmetrol/ Fluticasone)

    X X

--Serevent ( Salmetrol)

    X X

Rescue Medications

--Albuterol X X X X

--Po Prednisone prn Prn Prn prn

 Skin Testing: Allergy Evaluation

   Consider  Consider  Consider

Trigger Identification

X X X X

Case StudyCase Study A 68-year-old man with asthma is evaluated because he needs

to use his albuterol inhaler at night once or twice a week after waking up with chest tightness. His forced expiratory volume (FEV) is 2.18 L (65% of predicted) before and 2.62 L(82% of predicted) after inhaled albuterol. Current medications include inhaled fluticasone, 440 μg twice daily, and an albuterol metered-dose inhaler as needed. Which of the following should be done next to better control his symptoms?

( A ) Increase fluticasone to 880 μg twice daily ( B ) Add salmeterol ( C ) Add prednisone ( D ) Add allergen immunotherapy ( E ) Add a long-acting theophylline at bedtime

Key PointKey Point

In patients with moderate-to-severe asthma not responding to

adequate doses of a short-acting ß-agonist and inhaledcorticosteroids, the next step is addition of a long-acting

ß-agonist.

Case StudyCase Study A 25-year-old woman is evaluated because of a 3-year history of a

nonproductive cough. The cough is aggravated by bicycle riding and occasionally awakens her from sleep. During the past year, she experienced two episodes of bronchitis followed by a dry cough persisting for 2 months. The cough worsened when she visited her sister in Alaska. She has seasonal symptoms of watery, runny nose and sneezing. There is no postnasal discharge, nasal congestion, heartburn, weight loss, or night sweats. She does not smoke. Her physical examination and chest radiography are normal. Spirometry shows forced expiratory volume in 1 sec (FEV1) 3.29 L; forced vital capacity (FVC), 4.13 L; and FEV1/FVC ratio of 79%. Which of the following is the best next management step?

( A ) Chest computed tomography ( B ) Bronchoscopy ( C ) Methacholine inhalation challenge testing ( D ) Observation and reassurance ( E ) Therapeutic trial of a proton pump inhibitor

Cough Variant AsthmaCough Variant AsthmaCough-variant asthma is nonproductive, provoked by

exerciseand cold air, disturbs sleep, and worsens after a lower

respiratory tract infection.The inhalation of methacholine produces airway obstruction

inmost patients with asthma; less than 10% of normal persons

have positive responses ( false +ves) .

Case StudyCase Study A 45-year-old woman is evaluated because of dyspnea during exercise that

began when she started an aerobics class. She has dyspnea, chest tightness, and a nonproductive cough after 15 minutes of vigorous step exercises. The symptoms worsen slightly when she stops, then gradually abate. She has a 5-pack-year smoking history but quit 10 years ago. The physical examination, chest radiography, and electrocardiography are all normal. Spirometry shows forced expiratory volume in 1 sec (FEV1), 2.72 L (83% of predicted); forced vital capacity (FVC), 3.2 L(86% of predicted); and FEV1/FVC ratio of 85%. Postexercise spirometry shows FEV1, 2.04 L (25% drop from baseline),and FVC, 3.00 L (2% drop from baseline). Which of the following management options should be done next?

( A ) Reassure the patient ( B ) Prescribe an albuterol inhaler 15 minutes before exercise ( C ) Perform an exercise stress test ( D ) Measure lung volumes and diffusing capacity ( E ) Perform high-resolution computed tomography of the chest

Ans.bAns.b

For patients with exercise-induced asthma, an inhaled ß-agonist should be prescribed before exercise.

Case StudyCase Study

WHEN CONSIDERING THE DRUG TREATMENT WHEN CONSIDERING THE DRUG TREATMENT OF ASTHMA WITH INHALER DEVICESOF ASTHMA WITH INHALER DEVICES

A. The incidence of oral candidiasis is increased by A. The incidence of oral candidiasis is increased by the use of spacer devices.the use of spacer devices.B. Salmeterol is indicated for p.r.n. usage.B. Salmeterol is indicated for p.r.n. usage.C. Intermittent terbutalin has been shown to lead to C. Intermittent terbutalin has been shown to lead to long term worsening of asthma.long term worsening of asthma.D. Steroid dosage of 600mg daily has been shown to D. Steroid dosage of 600mg daily has been shown to be associated with adrenal suppression in adults.be associated with adrenal suppression in adults.E. Sodium cromoglycate is of no proven value in E. Sodium cromoglycate is of no proven value in treating acute asthmatic attacks treating acute asthmatic attacks

Ans.EAns.E Spacer devices decrease the incidence of oral Spacer devices decrease the incidence of oral

candidiasis by preventing the deposition in the candidiasis by preventing the deposition in the mouth. Salmeterol is a long acting beta antagonist, its mouth. Salmeterol is a long acting beta antagonist, its action is slow in onset and therefore it should be action is slow in onset and therefore it should be given regularly rather than p.r.n. The Committee on given regularly rather than p.r.n. The Committee on Safety of Medicines has reported that salbutamol and Safety of Medicines has reported that salbutamol and terbutaline have not been shown to lead to a terbutaline have not been shown to lead to a worsening of mild asthma. In adults an inhaled worsening of mild asthma. In adults an inhaled dosage of steroid of 1,500 micrograms daily is dosage of steroid of 1,500 micrograms daily is associated with adrenal suppression . Sodium associated with adrenal suppression . Sodium cromoglycate is of no value in and acute attack and is cromoglycate is of no value in and acute attack and is only indicated for prophylaxsis.only indicated for prophylaxsis.

OSAOSA

Check for symptoms of excessive daytime sleepinessCheck for symptoms of excessive daytime sleepiness Diagnose by sleep study.Diagnose by sleep study. Obesity – neck circumference > 17cm important Obesity – neck circumference > 17cm important

predictor.predictor. Check local anatomy, Throat crowding, secondary Check local anatomy, Throat crowding, secondary

factors (thyroid, cushings) causing obesity. factors (thyroid, cushings) causing obesity. Obesity Hypoventilation syndromeObesity Hypoventilation syndrome Rx – c-pap at nightsRx – c-pap at nights

QQ A 43-year-old man is evaluated because of uncontrolled hypertension,

documented in and outside of the office, despite moderate doses of hydrochlorothiazide and enalapril. For the past 6 months he has noted increased fatigue and irritability that he attributes to personal problems at work. He admits to difficulty concentrating at work. He has two beers before bed to fall asleep. He is a salesman, smokes one pack of cigarettes per day, and lives alone. His neck circumference is 17.5 in. On physical examination, he has a ruddy complexion, body mass index is 32, and blood pressure is 158/88 mm Hg. Jugular venous distention cannot be evaluated because of obesity. An S4 is present. The remainder of the examination is normal. A complete blood count, serum electrolytes, serum creatinine, blood urea nitrogen, electrocardiography, and chest radiography are normal.

Which of the following is most likely to establish a diagnosis? ( A ) Ambulatory blood pressure monitoring ( B ) Pulmonary function studies ( C ) Polysomnography ( D ) Arterial blood gases and blood volume determination

Q2Q2 A 58-year-old man is evaluated because of daytime sleepiness. He is

requesting an evaluation at this time because last week he fell asleep while driving and had a minor accident. He is a lifetime nonsmoker and is otherwise healthy. On physical examination, his body mass index is 26. There are no obvious abnormalities of his oropharynx. Chest and cardiac examinations are normal. There is no peripheral edema. Chest radiography and electrocardiography are normal. Overnight polysomnography for 6 hours of sleep shows 60 episodes of apnea (cessation of airflow for more than 10 seconds) per hour accompanied by frequent oxygen desaturation below 85%. There is evidence of rib cage and abdominal motion during the apneic periods. Which of the following is the most appropriate form of therapy for this patient?

( A ) Nasal continuous positive-airway pressure ( B ) Uvulopalatopharyngoplasty ( C ) Progesterone ( D ) Mandibular repositioning device ( E ) Nocturnal supplemental oxygen by nasal cannula

Ans. AAns. A Nasal continuous positive-airway pressure (CPAP) is the

standard initial treatment for patients with symptomatic moderate-to-severe obstructive sleep apnea syndrome. It works by splinting the upper airway in an open position.

Surgical procedures such as uvulopalatopharyngoplasty (UPPP) and tracheostomy are best considered in severely ill patients for whom more conservative measures such as nasal CPAP are ineffective.

Although tracheostomy cures obstructive sleep apnea, it carries associated complications and is poorly accepted by patients. UPPP, whether performed with conventional or laser surgery, has variable long-term results and also has associated complications.

Restrictive Diseases - SarcoidosisRestrictive Diseases - SarcoidosisPathophysiologyPathophysiology Noncaseating granuloma formation Noncaseating granuloma formation Idiopathic Idiopathic underlying genetic predisposition underlying genetic predisposition

Precipitated by trigger Precipitated by trigger Infection (e.g. Mycobacteria, Borrelia Burgdorferi), Infection (e.g. Mycobacteria, Borrelia Burgdorferi), Environmental exposure (e.g. Beryllium, Aluminum) Environmental exposure (e.g. Beryllium, Aluminum)

Common involvement sites (affects all organ systems) Common involvement sites (affects all organ systems) Lungs (>90%): Interstitial Lung Disease Lungs (>90%): Interstitial Lung Disease Lymphadenopathy: Hilar adnenopathy (>95%) Lymphadenopathy: Hilar adnenopathy (>95%) Liver (50-80%) : Hepatic Granulomas (86%), Increased Alkaline Phosphatase Liver (50-80%) : Hepatic Granulomas (86%), Increased Alkaline Phosphatase SpleenSpleen Skin lesions (25%) Skin lesions (25%) Eyes : Anterior Uveitis ( also in Spondyloarthropathy) , Posterior Uveitis, Eyes : Anterior Uveitis ( also in Spondyloarthropathy) , Posterior Uveitis, Heart (5%) Heart (5%)

Tachyarrhythmias Tachyarrhythmias Cardiomyopathy Cardiomyopathy

ERYTHEMA NODOSUM SUGGESTS BETTER PROGNOSISERYTHEMA NODOSUM SUGGESTS BETTER PROGNOSIS Associated with acute arthritis (Lofgren's Syndrome) Associated with acute arthritis (Lofgren's Syndrome) -- Not associated with chronic arthritis Not associated with chronic arthritis Most common associated nonspecific skin sign Most common associated nonspecific skin sign

SarcoidosisSarcoidosisDiagnosisDiagnosis Pulmonary Function Testing Pulmonary Function Testing

Findings consistent with Interstitial Lung Disease Findings consistent with Interstitial Lung Disease Serum Angiotensin-converting enzyme (Serum ACE) Serum Angiotensin-converting enzyme (Serum ACE)

Increased in 50-80% of Sarcoidosis patients Increased in 50-80% of Sarcoidosis patients Biopsy or Cytology (Gold standard) Biopsy or Cytology (Gold standard)

Finding Finding Discrete noncaseating epithelioid granuloma Discrete noncaseating epithelioid granuloma

Biopsy sites Biopsy sites Transbronchial lung biopsy (preferred site) Transbronchial lung biopsy (preferred site) Bronchoalveolar lavage (CD4-CD8 ratio >3.5) Bronchoalveolar lavage (CD4-CD8 ratio >3.5) Skin biopsy of lesion Skin biopsy of lesion Palpable peripheral lymph node biopsy Palpable peripheral lymph node biopsy Salivary Gland biopsy Salivary Gland biopsy

Sarcoid - lungSarcoid - lung

Radiology: Chest XRay (abnormal in 90% of cases)Radiology: Chest XRay (abnormal in 90% of cases) Type 0: No abnormality (<10% of cases) Type 0: No abnormality (<10% of cases) Type I: Lymphadenopathy alone (43% of cases) Type I: Lymphadenopathy alone (43% of cases)

Bilateral hilar Lymphadenopathy Bilateral hilar Lymphadenopathy Mediastinal LymphadenopathyMediastinal Lymphadenopathy Right paratracheal LymphadenopathyRight paratracheal Lymphadenopathy

Type II: Adenopathy and Infiltrates (24% of cases) Type II: Adenopathy and Infiltrates (24% of cases) Lymphadenopathy as in Type I Chest XRay findings Lymphadenopathy as in Type I Chest XRay findings Parenchymal infiltrates Parenchymal infiltrates Symptomatic respiratory disease presentation Symptomatic respiratory disease presentation

Type III: Infiltrates alone (13% of cases) Type III: Infiltrates alone (13% of cases) Parenchymal infiltratesParenchymal infiltrates

Sarcoidosis - TreatmentSarcoidosis - Treatment Cutaneous Cutaneous for Erythema nodosum use for Erythema nodosum use

NSAIDS, For sarcoid lesions use intralesional NSAIDS, For sarcoid lesions use intralesional CorticosteroidsCorticosteroids

For uveitis For uveitis topical CS, Systemic CS if topical CS, Systemic CS if refractoryrefractory

For pulmonary sarcoidosis stage 2 or 3 For pulmonary sarcoidosis stage 2 or 3 Indications : Dyspnea , Persistent cough and Indications : Dyspnea , Persistent cough and Widespread debilitating disease Widespread debilitating disease systemic CS/ systemic CS/ AZAAZA

Sarcoidosis - PrognosisSarcoidosis - Prognosis

PrognosisPrognosis Overall mortality (from respiratory failure): 1-5% Overall mortality (from respiratory failure): 1-5% Factors suggestive of Factors suggestive of worseworse prognosis prognosis

Onset after age 40 years Onset after age 40 years Black race Black race Chronic Hypercalcemia Chronic Hypercalcemia Specific higher risk organ involvement Specific higher risk organ involvement

Neurologic involvement Neurologic involvement Cardiac involvement Cardiac involvement Eye involvement (Chronic Uveitis) Eye involvement (Chronic Uveitis) Renal involvement (Nephrocalcinosis) Renal involvement (Nephrocalcinosis) Cystic bone lesions Cystic bone lesions Progressive pulmonary fibrosis Progressive pulmonary fibrosis

Idiopathic Pulmonary FibrosisIdiopathic Pulmonary Fibrosis CXR – PictureCXR – Picture Physical – chest bibasal crepsPhysical – chest bibasal creps HRCT confirmatoryHRCT confirmatory Not responsive to steroidsNot responsive to steroids

TB - ScreeningTB - Screening Screen for LTBI in persons at increased risk of recent infection, including Screen for LTBI in persons at increased risk of recent infection, including

immigrants within the last 5 years from high prevalence countries; pre- and immigrants within the last 5 years from high prevalence countries; pre- and postexposure in travelers visiting countries with a high prevalence of TB; postexposure in travelers visiting countries with a high prevalence of TB; those in recent contact with a case of infectious TB; health care workers those in recent contact with a case of infectious TB; health care workers with potential exposure to mycobacteria; and residents and employees of with potential exposure to mycobacteria; and residents and employees of high-risk congregate settings where local epidemiology indicates a high high-risk congregate settings where local epidemiology indicates a high rate of TB. rate of TB.

Screen for LTBI in persons with conditions associated with an increased Screen for LTBI in persons with conditions associated with an increased risk of developing active TB, including HIV infection, diabetes, silicosis or risk of developing active TB, including HIV infection, diabetes, silicosis or exposure to silica dust, low body weight, chronic renal failure or exposure to silica dust, low body weight, chronic renal failure or hemodialysis, gastrectomy, jejunoileal bypass, cirrhosis of the liver, organ hemodialysis, gastrectomy, jejunoileal bypass, cirrhosis of the liver, organ transplantation, anticancer chemotherapy and other immunosuppression transplantation, anticancer chemotherapy and other immunosuppression (e.g., TNF-α antagonists), malignant head or neck carcinoma, or fibrotic (e.g., TNF-α antagonists), malignant head or neck carcinoma, or fibrotic changes on CXR film compatible with previous TB. changes on CXR film compatible with previous TB.

Screen children and adolescents for LTBI who have risk factors for Screen children and adolescents for LTBI who have risk factors for development of active disease (e.g., HIV), have been exposed to adults at development of active disease (e.g., HIV), have been exposed to adults at high risk for TB, or have been adopted from abroad, especially if they were high risk for TB, or have been adopted from abroad, especially if they were born in countries with endemic TB. born in countries with endemic TB.

TB - ScreeningTB - Screening PPD test is used for screening and its sensitivity PPD test is used for screening and its sensitivity

approaches 100% in pts with normal immunity.approaches 100% in pts with normal immunity. As an alternative to the PPD, consider using a whole-As an alternative to the PPD, consider using a whole-

blood IFN-γ assay such as QuantiFERON-TB Gold, blood IFN-γ assay such as QuantiFERON-TB Gold, recognizing its limitations in children and recognizing its limitations in children and immunocompromised patients and that all currently immunocompromised patients and that all currently available studies on the sensitivity and specificity of available studies on the sensitivity and specificity of this test are limited by the lack of an eternal “gold this test are limited by the lack of an eternal “gold standard” for the diagnosis of tuberculous infection, standard” for the diagnosis of tuberculous infection, but that there is good reason to believe that the but that there is good reason to believe that the QuantiFERON-TB Gold test QuantiFERON-TB Gold test is superior to the TST in is superior to the TST in BCG-vaccinated individuals because it employs the BCG-vaccinated individuals because it employs the ESAT-6 antigen that is lacking in BCGESAT-6 antigen that is lacking in BCG

TB and PPDTB and PPD

Interpretation: PPD under 5 mmInterpretation: PPD under 5 mm Negative Negative Observe Patient Observe Patient Interpretation: PPD 5 mm or greaterInterpretation: PPD 5 mm or greater Positive if Positive if

HIV Infection HIV Infection Tuberculosis contactTuberculosis contact Immunosuppressed (e.g. HIV, Prednisone >15 mg qd) Immunosuppressed (e.g. HIV, Prednisone >15 mg qd) Abnormal finding on Chest XRay Abnormal finding on Chest XRay

Management Management Chest XRay and exam for disseminated disease Chest XRay and exam for disseminated disease If cxr –ve INH for 9 mosIf cxr –ve INH for 9 mos

TB and PPDTB and PPD

Interpretation: PPD 10 mm or greaterInterpretation: PPD 10 mm or greater Positive if Positive if

Health care workers Health care workers New immigrant within last 5 years New immigrant within last 5 years Intravenous Drug Abuse Intravenous Drug Abuse Homeless Homeless Under 4 years old Under 4 years old Malnutrition Malnutrition Diabetes Mellitus Diabetes Mellitus Silicosis Silicosis Tuberculosis endemic to region Tuberculosis endemic to region

Management Management Chest XRay and exam for disseminated disease Chest XRay and exam for disseminated disease

TB and PPDTB and PPDInterpretation: PPD 15 mm or greaterInterpretation: PPD 15 mm or greater Positive in all persons Positive in all persons Management Management

Chest XRay and exam for disseminated diseaseChest XRay and exam for disseminated disease INH 9 mos if no active disease ( i.e; you are treating INH 9 mos if no active disease ( i.e; you are treating

Latent TB)Latent TB) If active disease If active disease First step Sputum for AFB smear x First step Sputum for AFB smear x

3, Sputum for AFB cx and Sensitivity; isolate the 3, Sputum for AFB cx and Sensitivity; isolate the patient, isolate organism for susceptibility testing patient, isolate organism for susceptibility testing start emperic multi drug regimens HRZE start emperic multi drug regimens HRZE

For failure/ resistant TB For failure/ resistant TB SHRZE SHRZE Sputum –ve pts can be taken off Isolation.Sputum –ve pts can be taken off Isolation.

Latent TB – Imp PointsLatent TB – Imp Points

In case of patients who are TB contacts:In case of patients who are TB contacts:

Do PPD test and if –ve repeat another after 8-12 wksDo PPD test and if –ve repeat another after 8-12 wks

Begin latent TB therapy in contacts such as children Begin latent TB therapy in contacts such as children and patients with HIV and patients with HIV even if the initial skin test is even if the initial skin test is negative.negative.

If the second test is also negative, stop medication in If the second test is also negative, stop medication in immunocompetent immunocompetent individuals. If a known individuals. If a known high-risk high-risk TB exposureTB exposure has occurred in a patient with has occurred in a patient with HIV HIV infectioninfection, continue LTBI treatment for the full period, , continue LTBI treatment for the full period, regardless of TST results. regardless of TST results.

Tuberculosis & PPD – Imp PointsTuberculosis & PPD – Imp Points

PPD skin testPPD skin test Next step if ppd +ve ( Latent TB)Next step if ppd +ve ( Latent TB) INH rxINH rx When screening for LTBI in TB contacts, if the initial When screening for LTBI in TB contacts, if the initial

PPD result is negative a second PPD should be done PPD result is negative a second PPD should be done 8 to 12 weeks8 to 12 weeks after the last known exposure ( In a after the last known exposure ( In a review of literature, several studies support a review of literature, several studies support a maximum interval of 8 weeks from initial infection to maximum interval of 8 weeks from initial infection to development of a delayed-type hypersensitivity development of a delayed-type hypersensitivity reaction. A Tuberculin Skin Test > 8 weeks from last reaction. A Tuberculin Skin Test > 8 weeks from last exposure is recommended. )exposure is recommended. )

Tuberculosis & PPD – Imp PointsTuberculosis & PPD – Imp Points

Do not do a Tuberculin Skin Test on any patient Do not do a Tuberculin Skin Test on any patient with a history of severe blistering reactions with a history of severe blistering reactions with previously documented active TB, With a with previously documented active TB, With a

history of treatment for TB, With a documented history of treatment for TB, With a documented previous positive TST result previous positive TST result because the TST because the TST remains positive in most of these patients remains positive in most of these patients

Do not use TST to see if it turns –ve to monitor Do not use TST to see if it turns –ve to monitor the success of your treatment the success of your treatment that wont that wont happen happen TST remains +ve even after therapy. TST remains +ve even after therapy.

Tuberculosis & PPD – Imp PointsTuberculosis & PPD – Imp Points Delay the PPD Test for Delay the PPD Test for 4 to 64 to 6 weeks after a weeks after a

major viral illness such as measles, mumps, major viral illness such as measles, mumps, rubella, or influenza, because cutaneous anergy rubella, or influenza, because cutaneous anergy can develop, leading to a false-negative TST can develop, leading to a false-negative TST result. result.

Do periodic serial PPD screening in persons Do periodic serial PPD screening in persons with ongoing exposure to TB ( Health Care with ongoing exposure to TB ( Health Care Workers, Residents) Workers, Residents) q1year is good enough! q1year is good enough!

Chronic CoughChronic Cough

Common Causes of Chronic CoughCommon Causes of Chronic Cough

Smoker’s coughSmoker’s cough Chronic bronchitis due to smokingChronic bronchitis due to smoking Post-nasal dripPost-nasal drip Post-infectious Viral  Bacterial—Bordetella Post-infectious Viral  Bacterial—Bordetella

pertussis, Mycoplasma, Chlamydia pertussis, Mycoplasma, Chlamydia ( tracheobronchitis)( tracheobronchitis)

Gastroesophageal reflux diseaseGastroesophageal reflux disease AsthmaAsthma Angiotensin converting enzyme inhibitors Angiotensin converting enzyme inhibitors

Less Common Causes of Chronic Less Common Causes of Chronic CoughCough

Infectious causes Infectious causes  Tuberculosis—typical or atypical, Tuberculosis—typical or atypical, FungalFungal Endobronchial lesions  Endobronchial lesions   Benign — bronchial adenoma, carcinoid tumor  Benign — bronchial adenoma, carcinoid tumor   Malignant — bronchogenic carcinoma, metastatic cancer  Malignant — bronchogenic carcinoma, metastatic cancer   Foreign bodyForeign body Interstitial lung diseases  Interstitial lung diseases   Hypersensitivity pneumonitis  Hypersensitivity pneumonitis   Bronchiolitis obliterans with organizing pneumonia, ( BOOP)  Bronchiolitis obliterans with organizing pneumonia, ( BOOP)   Sarcoidosis  Sarcoidosis   Chronic interstitial pneumoniaChronic interstitial pneumonia Chronic aspiration Chronic aspiration Masses in the neck/thyroid disorders Masses in the neck/thyroid disorders Hair impinging on the tympanic membrane Hair impinging on the tympanic membrane Bronchiectasis Bronchiectasis Occult congestive heart failure Occult congestive heart failure Disorders of the pleura, pericardium, diaphragm Disorders of the pleura, pericardium, diaphragm Psychogenic/habitual cough Psychogenic/habitual cough Occupational bronchitis Occupational bronchitis Enlarged tonsils or uvulaEnlarged tonsils or uvula

HistoryHistory The cause(s) of chronic cough may become apparent after The cause(s) of chronic cough may become apparent after

taking a careful history. taking a careful history. Is the symptom a cough or “hawking” or clearing the throat? Is the symptom a cough or “hawking” or clearing the throat?

It helps to have the patient act out the cough to distinguish It helps to have the patient act out the cough to distinguish true cough from throat clearing. true cough from throat clearing.

Is the cough dry or productive? If so, what is produced? Is the cough dry or productive? If so, what is produced? Are systemic symptoms such as fever, night sweats or weight Are systemic symptoms such as fever, night sweats or weight

loss present? loss present? A detailed history of the work and home environment should A detailed history of the work and home environment should

be taken with emphasis on possible exposure to noxious be taken with emphasis on possible exposure to noxious inhalants or allergens. The history should include the time and inhalants or allergens. The history should include the time and circumstances of onset, frequency, and aggravating and circumstances of onset, frequency, and aggravating and relieving factors. relieving factors.

Patients with asthma may note worsening of cough on Patients with asthma may note worsening of cough on exposure to cold air, irritants or allergens. Is there an allergic exposure to cold air, irritants or allergens. Is there an allergic history? Does the patient wheeze with cough? history? Does the patient wheeze with cough?

HISTORYHISTORY Is the cough accompanied by dyspnea? If so, congestive heart Is the cough accompanied by dyspnea? If so, congestive heart

failure or interstitial lung disease may be suspected. failure or interstitial lung disease may be suspected. Is the cough related to time of day, eating or position? Is the cough related to time of day, eating or position? A A

nocturnal cough may be associated with asthma, post-nasal nocturnal cough may be associated with asthma, post-nasal drip, congestive heart failure or gastroesophageal reflux drip, congestive heart failure or gastroesophageal reflux disease (GERD). Half of the patients with GERD have none of disease (GERD). Half of the patients with GERD have none of the classic symptoms. the classic symptoms.

Does the patient cough while eating? Chronic aspiration is Does the patient cough while eating? Chronic aspiration is common in the elderly patient, especially following stroke. common in the elderly patient, especially following stroke.

Is the patient on angiotensin converting enzyme inhibitors or Is the patient on angiotensin converting enzyme inhibitors or other drugs that may predispose to cough or asthma? other drugs that may predispose to cough or asthma?

Do not overlook ophthalmic preparations. Beta blocker eye Do not overlook ophthalmic preparations. Beta blocker eye drops may precipitate asthma. drops may precipitate asthma.

PhysicalPhysical The physical examination may provide clues to the The physical examination may provide clues to the

causes of cough. causes of cough. Examination of the upper airways may show nasal Examination of the upper airways may show nasal

mucous membrane swelling, post-nasal drip or nasal mucous membrane swelling, post-nasal drip or nasal polyps. polyps.

The finding of wheezes, rhonchi or crackles may The finding of wheezes, rhonchi or crackles may indicate asthma, bronchitis, COPD, interstitial lung indicate asthma, bronchitis, COPD, interstitial lung disease or congestive heart failure. disease or congestive heart failure.

The finding of unilateral wheezing may be due to an The finding of unilateral wheezing may be due to an endobronchial lesion or foreign body.endobronchial lesion or foreign body.

Masses in the neck, including thyroid enlargement, Masses in the neck, including thyroid enlargement, can compress the trachea and cause cough.can compress the trachea and cause cough.

Diagnostic TestsDiagnostic Tests The work-up for chronic cough should begin with standard posterior- anterior and The work-up for chronic cough should begin with standard posterior- anterior and

lateral chest x-rays lateral chest x-rays these often reveal the presence of underlying infectious or these often reveal the presence of underlying infectious or neoplastic causes of chronic cough. neoplastic causes of chronic cough.

Spirometric studies before and after bronchodilator administration may reveal Spirometric studies before and after bronchodilator administration may reveal reversible airways obstruction (asthma). reversible airways obstruction (asthma).

In patients with normal base-line spirometry In patients with normal base-line spirometry methacholine inhalation challenge methacholine inhalation challenge (MIC) is indicated to rule out asthma that presents primarily with cough. ( COUGH (MIC) is indicated to rule out asthma that presents primarily with cough. ( COUGH VARIANT ASTHMA)VARIANT ASTHMA)

Computerized tomograms (CT) of the sinuses are superior to plain x-rays in Computerized tomograms (CT) of the sinuses are superior to plain x-rays in identifying sinusitis. identifying sinusitis.

High-resolution or spiral CT scans of the thorax may reveal subtle changes High-resolution or spiral CT scans of the thorax may reveal subtle changes consistent with cough due to chronic interstitial pneumonia or bronchiectasis. consistent with cough due to chronic interstitial pneumonia or bronchiectasis.

The finding of a reduced single breath diffusing capacity (DLCO) may suggest The finding of a reduced single breath diffusing capacity (DLCO) may suggest interstitial lung disease. interstitial lung disease.

Barium esophagograms and upper gastrointestinal endoscopy have a low sensitivity Barium esophagograms and upper gastrointestinal endoscopy have a low sensitivity (48%) and specificity (76% ) for identifying GERD as the culprit in chronic cough (48%) and specificity (76% ) for identifying GERD as the culprit in chronic cough monitoring the esophageal pH for 24 hours is the gold standard. ( If cough is monitoring the esophageal pH for 24 hours is the gold standard. ( If cough is the only symptom of GERD it gets difficult to diagnose the only symptom of GERD it gets difficult to diagnose so, 24hr Ph monitoring) so, 24hr Ph monitoring)

In patients suspected of having chronic aspiration, a video swallowing study with a In patients suspected of having chronic aspiration, a video swallowing study with a speech therapist in attendance should be performed. ( SWALLOW speech therapist in attendance should be performed. ( SWALLOW EVALUATION)EVALUATION)

A systematic approach to the work-up of a patient with A systematic approach to the work-up of a patient with nondrug-relatednondrug-related chronic chronic cough is presented in THE NEXT SLIDE. If you suspect Drug related cough cough is presented in THE NEXT SLIDE. If you suspect Drug related cough stop the drug and observestop the drug and observe

Chronic CoughChronic CoughPost-nasal Drip SyndromePost-nasal Drip Syndrome Post-nasal drip syndrome is said to be one of the most Post-nasal drip syndrome is said to be one of the most

common causes of chronic cough and is caused by a variety of common causes of chronic cough and is caused by a variety of conditions including vasomotor rhinitis, allergic rhinitis, nasal conditions including vasomotor rhinitis, allergic rhinitis, nasal polyps and chronic sinusitis. polyps and chronic sinusitis.

The diagnosis is made on clinical grounds. The diagnosis is made on clinical grounds. Patients may complain of a tickle or drainage of liquid in the Patients may complain of a tickle or drainage of liquid in the

back of the throat. back of the throat. On examination, cobblestoning of the nasal or oropharygeal On examination, cobblestoning of the nasal or oropharygeal

mucosa may be observed. In many patients cough may be the mucosa may be observed. In many patients cough may be the only symptom of post-nasal drip syndrome. only symptom of post-nasal drip syndrome.

Confirmation of the diagnosis may depend on the resolution of Confirmation of the diagnosis may depend on the resolution of symptoms after treatment with antihistamines and intranasal or symptoms after treatment with antihistamines and intranasal or systemic corticosteroids. systemic corticosteroids.

Chronic CoughChronic CoughAsthma & Cough-variant AsthmaAsthma & Cough-variant Asthma Typically, asthma patients complain of episodic wheezing, cough, Typically, asthma patients complain of episodic wheezing, cough,

chest tightness and dyspnea and demonstrate reversible obstructive chest tightness and dyspnea and demonstrate reversible obstructive air flow. air flow.

In so called cough-variant asthma In so called cough-variant asthma a dry cough, particularly at a dry cough, particularly at night, is the only symptom and routine spirometry is normal. night, is the only symptom and routine spirometry is normal.

Diagnosis : Spirometry is normal in cough variant type Diagnosis : Spirometry is normal in cough variant type The The diagnosis is often made on the basis of a favorable clinical diagnosis is often made on the basis of a favorable clinical response to empirically administered beta2-agonist bronchodilators response to empirically administered beta2-agonist bronchodilators and inhaled corticosteroids, and a positive bronchoprovocation test and inhaled corticosteroids, and a positive bronchoprovocation test using methacholine inhalation challenge (MIC) using methacholine inhalation challenge (MIC) A positive MIC A positive MIC test, defined as a 20% or greater decrease in the FEV1 after MIC, test, defined as a 20% or greater decrease in the FEV1 after MIC, indicates bronchial hyperreactivity but not necessarily asthma. For indicates bronchial hyperreactivity but not necessarily asthma. For example, bronchial hyperreactivity may follow viral respiratory example, bronchial hyperreactivity may follow viral respiratory tract infections and persist for as long as 6 weeks. Because MIC tract infections and persist for as long as 6 weeks. Because MIC has a positive predictive value of from only has a positive predictive value of from only 60% to 80%,60% to 80%, Irwin and Irwin and colleagues advise that a positive test colleagues advise that a positive test must be correlatedmust be correlated with with favorable response to therapy favorable response to therapy before concluding that a patient has before concluding that a patient has cough-variant asthma.cough-variant asthma.

Chronic CoughChronic CoughGastroesophageal Reflux-related Chronic Cough Gastroesophageal Reflux-related Chronic Cough GERD is a very common problem. Surveys of the general population have GERD is a very common problem. Surveys of the general population have

led to estimates that 10% of the adult population of the United States have led to estimates that 10% of the adult population of the United States have daily heartburn and a third have intermittent symptoms; moreover, GERD daily heartburn and a third have intermittent symptoms; moreover, GERD has been shown to cause 10% to 40% of cases of chronic cough has been shown to cause 10% to 40% of cases of chronic cough Cough Cough in GERD is triggered by reflux of acid into the distal esophagus and in GERD is triggered by reflux of acid into the distal esophagus and stimulation of an esophageal-tracheobronchial reflex. Cough is not stimulation of an esophageal-tracheobronchial reflex. Cough is not dependent on aspiration into the larynx or tracheobronchial tree. dependent on aspiration into the larynx or tracheobronchial tree.

Proving the relationship of chronic cough to GERD can be difficult. The Proving the relationship of chronic cough to GERD can be difficult. The lack of typical symptoms of reflux and negative endoscopic and lack of typical symptoms of reflux and negative endoscopic and radiographic studies do not rule it out. radiographic studies do not rule it out.

The 24-hour esophageal pH monitoring test has become the gold standard The 24-hour esophageal pH monitoring test has become the gold standard for diagnosis and has both a sensitivity and specificity approaching 90%. for diagnosis and has both a sensitivity and specificity approaching 90%.

Correlation of the results of pH monitoring with response to therapy adds Correlation of the results of pH monitoring with response to therapy adds to the reliability of the test.to the reliability of the test.

If GERD is the sole cause of chronic cough, aggressive anti-reflux therapy If GERD is the sole cause of chronic cough, aggressive anti-reflux therapy should eliminate the cough in nearly all cases. One study reported 100% should eliminate the cough in nearly all cases. One study reported 100% success. Treatment involves the use of dietary, mechanical and drug success. Treatment involves the use of dietary, mechanical and drug therapy. Drug therapy should be initiated with proton pump inhibitors for therapy. Drug therapy should be initiated with proton pump inhibitors for GERD. GERD.

Chronic CoughChronic CoughPost-infectious CoughPost-infectious Cough Patients who have had recent viral respiratory tract Patients who have had recent viral respiratory tract

infections may have prolonged cough that is infections may have prolonged cough that is refractory to treatment. Airway hyperresponsiveness refractory to treatment. Airway hyperresponsiveness can be demonstrated by can be demonstrated by MICMIC testing in testing in somesome cases. cases. Treatment with bronchodilators and inhaled or Treatment with bronchodilators and inhaled or systemic corticosteroids in moderate to high doses systemic corticosteroids in moderate to high doses may help relieve symptoms. The cough can be self-may help relieve symptoms. The cough can be self-perpetuating and cause continuing trauma to the perpetuating and cause continuing trauma to the airways, and in these cases, prolonged suppression airways, and in these cases, prolonged suppression with narcotics may eventually allow resolution. with narcotics may eventually allow resolution.

Bordetella pertussis (the cause of whooping cough) Bordetella pertussis (the cause of whooping cough) infection in adults should be included in the infection in adults should be included in the differential diagnosis of chronic cough. In one series differential diagnosis of chronic cough. In one series of 75 patients with chronic cough lasting longer than of 75 patients with chronic cough lasting longer than 2 weeks, 21% had pertussis. 2 weeks, 21% had pertussis.

Chronic CoughChronic CoughAngiotensin Converting Enzyme Inhibitor Cough Angiotensin Converting Enzyme Inhibitor Cough Angiotensin converting enzyme inhibitor (ACEI) drugs are frequently used Angiotensin converting enzyme inhibitor (ACEI) drugs are frequently used

in the treatment of hypertension, congestive heart failure and myocardial in the treatment of hypertension, congestive heart failure and myocardial infarction. Ten to 20% of patents taking ACEI drugs develop cough. There infarction. Ten to 20% of patents taking ACEI drugs develop cough. There is no evidence at this time that any one ACEI drug is less likely to cause is no evidence at this time that any one ACEI drug is less likely to cause cough than another. In spite of this well-documented side effect, referrals cough than another. In spite of this well-documented side effect, referrals to a specialist for evaluation of chronic cough still occur frequently. Many to a specialist for evaluation of chronic cough still occur frequently. Many of these patients have had extensive and costly work-ups and treatment of these patients have had extensive and costly work-ups and treatment with a variety of medications, including antihistamines, antibiotics, cough with a variety of medications, including antihistamines, antibiotics, cough suppressants and corticosteroids, without relief. suppressants and corticosteroids, without relief.

Clinically, the cough may begin from as early as 3 weeks to as long as a Clinically, the cough may begin from as early as 3 weeks to as long as a year after starting treatment. The severity of the cough can vary from a year after starting treatment. The severity of the cough can vary from a mild tickle in the throat to a severe hacking, debilitating cough that mild tickle in the throat to a severe hacking, debilitating cough that interferes with sleep, work and social function. It is frequently worse at interferes with sleep, work and social function. It is frequently worse at night and in the supine position. night and in the supine position.

When the ACEI drug is discontinued, the cough usually abates in 2 weeks When the ACEI drug is discontinued, the cough usually abates in 2 weeks but may persist for months. but may persist for months.

Angiotensin ll receptor antagonists have not been associated with an Angiotensin ll receptor antagonists have not been associated with an increased incidence of cough. increased incidence of cough.

Chronic CoughChronic Cough

Less Common Causes of Cough Less Common Causes of Cough Chronic cough may be the presenting Chronic cough may be the presenting

complaint in patients who ultimately prove to complaint in patients who ultimately prove to have tumors, both benign and malignant, have tumors, both benign and malignant, sarcoidosis or other infiltrating lung diseases; sarcoidosis or other infiltrating lung diseases; all these conditions require special all these conditions require special investigations to make the diagnosis.investigations to make the diagnosis.

Psychogenic or habitual cough does exist but Psychogenic or habitual cough does exist but patients should not be put in this category patients should not be put in this category without an exhaustive work-up, failure of without an exhaustive work-up, failure of empirical therapy and prolonged follow up.empirical therapy and prolonged follow up.

Chronic CoughChronic CoughSymptomatic TreatmentSymptomatic Treatment The treatment of cough is effective only if directed at the cause, but patients should The treatment of cough is effective only if directed at the cause, but patients should

be offered symptomatic relief while awaiting the results of specific therapy. be offered symptomatic relief while awaiting the results of specific therapy. Expectorants such as iodides and guaifenesin, hydration, inhaled steam, cough Expectorants such as iodides and guaifenesin, hydration, inhaled steam, cough lozenges and hard candies are helpful. Dextromethorphan and codeine are effective lozenges and hard candies are helpful. Dextromethorphan and codeine are effective cough suppressants. cough suppressants.

When to ReferWhen to Refer When the patient with chronic cough remains symptomatic despite evaluation and When the patient with chronic cough remains symptomatic despite evaluation and

treatment for 6 to 8 weeks, the primary care physician should consider referral to a treatment for 6 to 8 weeks, the primary care physician should consider referral to a specialist. In difficult cases referral to a pulmonologist for evaluation, therapy and specialist. In difficult cases referral to a pulmonologist for evaluation, therapy and for specific testing such as fiberoptic bronchoscopy and MIC is recommended. for specific testing such as fiberoptic bronchoscopy and MIC is recommended. Referral for upper gastrointestinal endoscopy and 24-hour pH monitoring may be Referral for upper gastrointestinal endoscopy and 24-hour pH monitoring may be indicated to rule out cough due to GERD. Referral to an allergist may be indicated indicated to rule out cough due to GERD. Referral to an allergist may be indicated for allergy testing and subsequently for for allergy testing and subsequently for immunotherapy if the patient is sensitive to immunotherapy if the patient is sensitive to an unavoidable antigen. an unavoidable antigen.

Medicolegal IssuesMedicolegal Issues One of the most common reasons patients file suit is for failure to diagnose cancer. One of the most common reasons patients file suit is for failure to diagnose cancer.

Even though bronchogenic carcinoma is an uncommon cause of chronic cough Even though bronchogenic carcinoma is an uncommon cause of chronic cough in the context of a normal chest x-ray, it must not be overlooked .in the context of a normal chest x-ray, it must not be overlooked .

Failure to diagnose tuberculosis is another cause of litigation but again would be an Failure to diagnose tuberculosis is another cause of litigation but again would be an unlikely cause of chronic cough with normal chest roentgenograms .unlikely cause of chronic cough with normal chest roentgenograms .

Solitary Pulmonary Solitary Pulmonary NoduleNodule

Characteristics of Solitary Pulmonary Nodules

Variable Benign Malignant

Age < 30 years > 50 years

Calcification

Popcorn, dense, concentric

None or minimal

Nodule edge

Smooth, round Irregular, spiculated

Smoking history

Never smoked > 20 pack-years

Size of diameter

< 1.5 cm > 1.5 cm

 

X-ray Characteristics of SPNX-ray Characteristics of SPN Benign nodule charecterestics : the presence of calcification, which can be Benign nodule charecterestics : the presence of calcification, which can be

a diffuse speckled, or “popcorn,” pattern, typical of a hamartoma, or a a diffuse speckled, or “popcorn,” pattern, typical of a hamartoma, or a large central nidus or concentric calcification typical of a granuloma. large central nidus or concentric calcification typical of a granuloma.

The second important factor distinguishing a malignant from a benign The second important factor distinguishing a malignant from a benign nodule is the growth rate. Since the “doubling time” of a lung cancer nodule is the growth rate. Since the “doubling time” of a lung cancer ranges from 15 to 450 days, the nodule that does not increase in diameter ranges from 15 to 450 days, the nodule that does not increase in diameter over a two year period can be considered benign. Any lesion that increases over a two year period can be considered benign. Any lesion that increases in size over a two year period of observation, or less, must be considered in size over a two year period of observation, or less, must be considered malignant until proven otherwise. One exception is a nodule doubling in malignant until proven otherwise. One exception is a nodule doubling in less than 20 days, which usually suggests an acute inflammatory process.less than 20 days, which usually suggests an acute inflammatory process.

The third important characteristic is the appearance of the nodule’s edge. The third important characteristic is the appearance of the nodule’s edge. Benign lesions have smooth rounded edges, whereas the incidence of Benign lesions have smooth rounded edges, whereas the incidence of neoplasm increases dramatically in lesions with irregular, spiculated neoplasm increases dramatically in lesions with irregular, spiculated borders. An increasing incidence of malignancy occurs, ranging from 20-borders. An increasing incidence of malignancy occurs, ranging from 20-93%, depending on the degree of border irregularity 93%, depending on the degree of border irregularity

DiagnosisDiagnosis The first step in evaluating a SPN is to try to obtain old chest x-rays for The first step in evaluating a SPN is to try to obtain old chest x-rays for

comparison comparison If this is not possible, and the nodule does not have a classic, If this is not possible, and the nodule does not have a classic, calcified appearance typical of a granuloma or hamartoma, then further testing or calcified appearance typical of a granuloma or hamartoma, then further testing or a period of careful observation must be undertaken. a period of careful observation must be undertaken.

A CT scan can help distinguish the pattern of calcification, and classify lesions as A CT scan can help distinguish the pattern of calcification, and classify lesions as “indeterminate” based on the presence of stippled or eccentric calcification and “indeterminate” based on the presence of stippled or eccentric calcification and medium density, or “benign” based on the presence of fat density typical of a medium density, or “benign” based on the presence of fat density typical of a hamartoma.hamartoma.

The most common CT finding in early stage adenocarcinoma and squamous cell The most common CT finding in early stage adenocarcinoma and squamous cell carcinoma of the lung is that of a solitary pulmonary nodule which enhances after carcinoma of the lung is that of a solitary pulmonary nodule which enhances after administration of IV contrast. In small cell carcinoma, however, hilar and administration of IV contrast. In small cell carcinoma, however, hilar and mediastinal adenopathy secondary to metastases is the most common CT mediastinal adenopathy secondary to metastases is the most common CT presentation. The presence of irregular margins, associated air bronchogram, presentation. The presence of irregular margins, associated air bronchogram, convergence of the surrounding structure, or the involvement of three or more convergence of the surrounding structure, or the involvement of three or more blood vessels is more likely in malignant lesions. blood vessels is more likely in malignant lesions.

If a period of observation is chosen, chest x-rays, and possibly serial CT scans, If a period of observation is chosen, chest x-rays, and possibly serial CT scans, should be done at should be done at 3-month intervals over at least a two year period to 3-month intervals over at least a two year period to determine if any change in the size of the nodule has occurred. An increase in determine if any change in the size of the nodule has occurred. An increase in the diameter of the nodule by 25% indicates a doubling of the mass the diameter of the nodule by 25% indicates a doubling of the mass volumevolume a sign of malignancy. a sign of malignancy.

Diagnosis - PETDiagnosis - PET Because of the difficulty with Because of the difficulty with noninvasivenoninvasive diagnosis of the diagnosis of the

SPN, new radiologic techniques are being studied, including SPN, new radiologic techniques are being studied, including positron emission tomography imaging (PET), which is able to positron emission tomography imaging (PET), which is able to distinguish benign from malignant pulmonary nodules by distinguish benign from malignant pulmonary nodules by measuring measuring 18-fluorodeoxyglucose (FDG),18-fluorodeoxyglucose (FDG), and by showing and by showing increased FDG uptake and retention in malignant cells. PET increased FDG uptake and retention in malignant cells. PET scanning is a valuable, noninvasive tool with a scanning is a valuable, noninvasive tool with a 95% sensitivity95% sensitivity for identifying malignancy and a for identifying malignancy and a specificity of 85%specificity of 85% or greater. or greater. However, false positive results may be obtained in lesions However, false positive results may be obtained in lesions containing containing an active inflammatory process (for example a an active inflammatory process (for example a reactive lymphadenopathy)reactive lymphadenopathy), and this diagnostic modality is not , and this diagnostic modality is not generally available. generally available.

SPNSPNWhen to ReferWhen to Refer Once the decision has been made that the patient’s SPN may represent a Once the decision has been made that the patient’s SPN may represent a

malignancy, a histologic diagnosis is needed. If the patient’s SPN has malignancy, a histologic diagnosis is needed. If the patient’s SPN has characteristics strongly suggesting malignancy, and there are no characteristics strongly suggesting malignancy, and there are no contraindications to surgery, refer to a thoracic surgeon.contraindications to surgery, refer to a thoracic surgeon.

In most other circumstances refer to a pulmonologist for further workup. In most other circumstances refer to a pulmonologist for further workup. Diagnostic procedures may include: fiberoptic bronchoscopy aided by Diagnostic procedures may include: fiberoptic bronchoscopy aided by fluoroscopy, or CT-guided transthoracic fine needle aspiration. The yield fluoroscopy, or CT-guided transthoracic fine needle aspiration. The yield of these procedures in the diagnosis of the small solitary pulmonary nodule of these procedures in the diagnosis of the small solitary pulmonary nodule (< 1.5 cm in diameter) is about 40% for fiberoptic bronchoscopy, and 50% (< 1.5 cm in diameter) is about 40% for fiberoptic bronchoscopy, and 50% for fine needle aspiration. The incidence of pneumothorax requiring chest for fine needle aspiration. The incidence of pneumothorax requiring chest tube insertion from bronchoscopic transbronchial biopsy is about 5% and tube insertion from bronchoscopic transbronchial biopsy is about 5% and from needle aspiration about 25%, depending on patient characteristics and from needle aspiration about 25%, depending on patient characteristics and variation of local physician technique.variation of local physician technique.

Thoracoscopic resection or thoracotomy is needed for diagnosis in about Thoracoscopic resection or thoracotomy is needed for diagnosis in about 20% of patients, in whom the less invasive techniques were not successful. 20% of patients, in whom the less invasive techniques were not successful.

A 43-year-old woman is evaluated because of an abnormal chest radiograph taken before an elective hysterectomy for fibroids. She has no previous history of pulmonary disease. Her cardiac and pulmonary review of systems is unremarkable. The patient smoked one pack of cigarettes per day from age 16 to 33 years, but has not smoked since then. On physical examination, her blood pressure is 120/60 mm Hg and the lung fields are clear. The remainder of the examination is unremarkable. Her laboratory evaluation, including a complete blood count and chemistry profile, is normal. Spirometry shows forced expiratory volume in 1 sec (FEV1), 2.72 L (84% of predicted); forced vital capacity (FVC), 3.68 L (98% of predicted); and FEV1/FVC ratio of 74%. Chest radiography shows an approximately 1-cm nodule in the left lower lobe periphery. There are no previous radiographs. High-resolution helical computed tomography (CT) of the 1.2-cm lesion in the left lower lobe is shown. The full chest CT shows no evidence of mediastinal adenopathy. Which of the following is the best management option?

( A ) Bronchoscopy with transbronchial biopsies ( B ) No further studies are needed ( C ) Repeat high-resolution CT in 3 months ( D ) Resection of the lesion with video-assisted thoracoscopic surgery ( E ) Percutaneous fine needle aspiration of the lesion

The likelihood of a solitary pulmonary nodule being malignant substantially decreases if the lesion is small (approximately 1cm), has smooth borders, is located in a lower lobe, and, most importantly, has central calcification.

Observation at 3 month intervals for 2 years to ensure stability of the finding is sufficient!!

Pleural EffusionsPleural Effusions

EFFUSIONSEFFUSIONS

EXUDATES: pleural fluid [protein] / plasma EXUDATES: pleural fluid [protein] / plasma [protein] > 0.5 and/or pleural fluid [protein] > 0.5 and/or pleural fluid [LDH] / plasma [LDH] > 0.6 and/or pleural fluid [LDH] / plasma [LDH] > 0.6 and/or pleural fluid LDH >200 or >2/3 of serum LDHLDH >200 or >2/3 of serum LDH

TRANSUDATES – Nephrotic syndrome, CHF, TRANSUDATES – Nephrotic syndrome, CHF, Atelectasis, Cirrhosis (Hydrothorax)Atelectasis, Cirrhosis (Hydrothorax)

EMPYEMAEMPYEMA Diagnosis Diagnosis By thoracentesis. Except in known By thoracentesis. Except in known

CHF, must be done in all pleural effusions. CHF, must be done in all pleural effusions.

A 56-year-old man with chronic alcoholism is evaluated because of fatigue, decreased appetite, and episodes of sweating. He has a cough productive of purulent, foul-smelling grayish-green sputum and describes heaviness in the right lower chest. The patient has reduced his activity, but only missed 2 days of work as a painter because of his illness. On physical examination, his temperature is 37.4 °C (99.3 °F), pulse rate is 84/min, respiration rate is 14/min, and blood pressure is 132/85 mm Hg. There is dullness to percussion at the right lateral and posterior lung base associated with decreased breath sounds. Chest radiography shows a large right-sided pleural effusion and a small parenchymal infiltrate. The effusion did not layer along the chest wall in a lateral decubitus film. A thoracentesis is performed, and the leukocyte count is 32,500/μL with83% neutrophils, the pH is 7.12, and glucose is 25 mg/dL. The fluid is sent for culture, and antibiotics are begun.\

Which of the following should be done next to manage the pleural fluid? ( A ) Insertion of a pigtail catheter into the pleural space ( B ) Insertion of a large-bore chest tube ( C ) Repeat thoracentesis if the pleural effusion does not improve in 48 hours ( D ) Open surgical decortication ( E ) Reevaluation of the pleural effusion in 7 days

Ans.Ans.

Frankly purulent pleural fluid, pleural fluid pH <7.20, and,possibly, loculated collections of fluid are indications for chest tube drainage