1. Pulmonary Diseases by: Eddie K. Lam M.D.

2. RESPIRTORY DISEASES • COUGH • COPD • ASTHMA • CHRONIC BRONCHITIS • EMPHYSEMA • TUBERCULOSIS • PULMONARY NODULES • ALPHA 1 ANTITRYPSIN DEFICIENCY • PLEURISY • PLEURAL EFFUSION • PNEUMOTHORAX • VENOUS THROMBOLISM

3. COUGH • Acute cough ( last < 3 weeks) • Subacute (3 to 8 weeks) • Chronic ( longer than 8 weeks)

4. Acute cough • Most commonly associated with common cold • Differentiate between serious condition such as pulmonary embolism, CHF, pneumonia, asthma, COPD, • Antihistamine or decongestant should be prescribed

5. Subacute cough • Is the cough follow a respiratory infection • Cough began with URI and lingered indicate postinfectious cough • Postnasal drip, upper airway irritation, mucus accumulation, airway spasm

6. Chronic cough • Smoking • Medications • Asthma • GERD • Upper airway cough syndrome • Nonasthmatic eosinophilic bronchitis • Cancer • Atypical infection

7. History and physical Lam’s criteria for cough • Smoking • Throat irritation • Ups or downs • Productive • Itching • Duration • Nasal drip, congestion • Eating • Position • Hemoptysis • E • Weight loss

8. Physical exam • HEENT • Chest, heart • Lymph nodes • Skins/fingers

9. Chest x ray • Reasonable as baseline if cough persists more than 3 weeks • Suspect pneumonia • Weight loss • Hemoptysis • Nightsweats

10. Treatment of cough • URI- 1st generation antihistamine + decongestant • Upper airway- inhaled nasal steroids • Bacterial- appropriate antibiotics + suppressants • Codeine Vs DM • Brochospasm- Anticholinergic agents • Drug induced- Discontinue ACE inhibitors

11. treatment cont. • Inhaled corticosteroids • Oral corticosteroids

12. If all treatment failed • No way • Suspect noncompliance • Suspect other causes: GERD, swallowing disorder • Consider bronchoprovocation test • ? CT • Refer to specialist

13. COPD • CHRONIC OBSTRUCTIVE PULMONARY DISEASE

14. Chronic obstructive pulmonary disease Definition: an inflammatory respiratory disease, mostly by tobacco smoke Exposure to cigarette smoking, airway inflammation, airflow obstruction that is not fully reversible

15. COPD • Chronic bronchitis and emphysema are no longer included in the definition of COPD, though still used clinically • Asthma is the most often confused with COPD

16. Risk factors • Cigarette smoking • Persons who smoke, 12-13 times likely to die from COPD • 2nd hand smoke • Advancing age • Environmental or occupational pollutants • Alpha 1 antitrypsin deficiency • Family history of COPD

17. Occupational exposures • Mineral dust: coal mining, tunnel work, concrete, silica exposure • Organic dust: Cotton, flax, • Noxious gas: Sulfur dioxide, isocyanates, heavy metal, welding fumes

18. pathophysiology • Chronic airway irritation • Mucus production > decreased mucociliary function • Pulmonary scarring/airway scarring • Leads to hallmark of COPD Sx.> coughing and sputum production > • Progressive airway obstruction and dyspnea

19. COPD is more common and fatal in women than men • Lung size • More hyperresponsive to irritants

20. Clinical history • Hallmark Symptoms • Cough, increased sputum production, dyspnea (good predictor of mortality) • Less common : edema, chest tightness, weight loss, nocturnal awakenings

21. Differential diagnosis ??????????

22. Differential diagnosis • Asthma • CHF • Bronchiectasis • Lung cancer • Interstitial lung disease/fibrosis • TB

23. Clinical history • Patient and family history • History of tobacco use • Pack years = number of packs smoked per day multiplied by number of years smoked • Occupational history • Job activities

24. Family history of Alpha 1 antitrypsin deficiency, genetic anomaly of chromosome 14 leads to premature hepatic and pulmonary disease • Increase tissue damage from neutrophil elastase> alveolar damage> loss of elastic recoil> airway obstruction

25. Alpha 1 antitrypsin deficiciency • 59,000 Americans have Sx. COPD caused by alpha 1 antitrypsin deficiency • Screening in symptomatic adults with persistent obstruction on pulmonary function test

26. Physical exam • Not sensitive initially • Lung hyperinflation • Widened A-P chest diameter • Hyperresonance on percussion • Cor pulmonale- peripheral edema, JVD, hepatomegaly • Cyanosis, cachexia • Clubbing (rare), looking for cancer,fibrosis, brochectasis

27. Diagnostic testing • SPIROMETRY • Should perform in all smokers 45years or older • Key features: FEV1 • FVC ( forced vital capacity)

28. FEV1 – the volume of air patient can expire in one second following full inspiration • FVC -- total maximum volume of air patient can exhale after a full inspiration

29. Diagnosis of COPD • Postbronchodilator FEV1/FVC ratio of less than 0.7 associated with FEV1 less than 80% of predicted value is diagnostic of airflow limitation and confirms COPD • Peak expiratory flow rates are not helpful in diagnosis of COPD

30. Other diagnostic test • Spirometry is the key test • CXR • CT chest • EKG • CBC • Pulse oximetry

31. pharmacotherapy • Bronchodilator • Bronchodilator • Bronchodilator • Bronchodilator • Bronchodilator • bronchodilator

32. Short acting beta 2 agonists • Beta 2 agonists: stimulate beta 2 receptors, increase cyclic AMP, increase smooth muscle relaxation, lung emptying and air trapping • Short acting: Proventil, Ventolin, Proair, Xopenex • Side effects: Tachycardia, cardiac disturbance, tremors

33. Long acting beta 2 agonists • Maintenance therapy • Longer lasting improvement • Salmeterol (Serevent Diskus) • Formoterl (Foradil)

34. Short acting Anticholinergic agents • Smooth muscle relaxation of airways • Antagonism of acetycholine at M3 receptors on airway • Slower onset of action than beta 2 but longer duration • Side effects: Caution w/ glaucoma, BPH • Ipratropium (Atrovent)

35. Long acting Anticholinergic agents • Sustained action over 24 hours • Tiotropium (Spiriva) • 24% lower of number exacerbation than Ipratropium

36. Corticosteroids • Act at multiple points in inflammatory process • Increase FEV1 • NOT APPROVED FOR SINGLE USE AGENT IN COPD • Recommend as addition to maintenance therapy • Side effects: bruising, candidiasis, voice alteration

37. Combination therapies • Beta 2 + anticholinergic agent (Combivent) • Corticosteroid + long acting Beta 2 (Advair) (Symbicort)

38. Acute exacerbation of COPD • Sustained worsening of patient’s condition from stable state and beyond normal day to day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD

39. Infectious agents • 80% gram positive and gram negative bacteria • Nosocomial • 30% viruses • 5-10% atypical bacteria

40. Treatment other than bronchodilators • Antibiotics • Smoking cessation • Pulmonary Rehabilitation • Oxygen therapy: PaO2 < 55mmHg or O2 sat < 88% • Long term use increase survival

41. AGE >40 10 pk yrs Sputum often Allergies infreq. Progressive worse Clinical Sx. Persistent Airflow partial reversible <40 Usually none/min Infrequent Often Nonprogressive Variable Complete reversible COPD ASTHMA

42. ASTHMA

43. ASTHMA • Underlying cause of 40% young adults being evaluated for dyspnea • Pulmonary testing plays a major role

44. Common risk factors for asthma – host factors • Genetic • Female sex • Low birth weight • Obesity • Atopy/allergies • eczema

45. Environmental factors • Prenatal and childhood exposure to tobacco smoke • Lack of breast feeding • Severe respiratory infections in 1st year of life • Indoor allergens and outdoor pollutants • Occupational exposures

46. Clinical presentation • Waxing and waning symptoms of dyspnea, cough, wheezing and chest tightness • Exacerbation of symptoms usually gradual in onset and cessation

47. Triggers • Exposure to common allergens • Cold weather • Viral infections • Physical exercise

48. Physical exam • Frequently normal • Stigmata of allergic rhinitis • Eczema • Airflow obstruction/wheezing (poor predictor value)

49. Laboratory tests • CXR • Pulse oximetry • CBC

50. Spiromery • NAEPP (National Asthma Education and Preventive Program) recommends using spirometry for initial diagnosis and long term follow up of Asthma • Perform at initial assessment • After treatment initiated • Stabilized and during period of prolonged loss of asthma control and at least every 1 to 2 yrs