Pulmonary Board Review

1. Pulmonary Board Review Dave Brush M.D. 3/15/10

2. Pulmonary Function Testing • Lung Volumes • Normal 80-120 • TLC • FRC • RV • Airflow = Spriometry • Exp/Insp Loop • DLCO • Alveolar/Hg surface area of the lung • Confounders

5. Assess Severity

8. Asthma Syndromes • Occupational Asthma • Worst at work • Peak flow at work may help diagnose • Reactive Airways Dysfunction Syndrome • Acute exposure to chemicals/irritants • Cough Variant Asthma • Allergic Bronchopulmonary Aspergillosis • Bronchiectasis, IgE >1000, IgE vs Aspergillus or skin test • Exercise Induced Bronchospasm • How best to test? • Aspirin Sensitive Asthma • 20% of asthmatics • Do you have to stop the ASA?

10. Asthma Mimics • COPD • Vocal Cord Dysfunction • CHF • Bronchiectasis • Cystic Fibrosis • Eosinophillic Pulmonary Syndromes • Mechanical Obstruction

11. Vocal Cord Dysfunction

13. Fixed Airflow Obstruction

15. Inpatient Asthma Does this person need intubation? 7.39/40/95/98% Depends….make sure to read the whole question!!!

17. Therapy at Each Stage of COPD New (2003) 0: At Risk I: Mild II: Moderate III: Severe IV: Very Severe Characteristics Chronic Symptoms Exposure to risk factors Normal spiro FEV1/FVC < 70% FEV1  80% With or without symptoms FEV1/FVC < 70% 50% < FEV1 < 80% With or without symptoms FEV1/FVC < 70% 30% < FEV1 < 50% With or without symptoms FEV1/FVC < 70% FEV1 < 30% or FEV1 < 50% predicted plus chronic respiratory failure Avoidance of risk factor(s); influenza vaccination Add short-acting bronchodilator when needed Addregular treatment with one or more long-acting bronchodilators Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Addlong-term oxygen if chronic respiratory failure Consider surgical treatments

19. Oxygen Therapy 100 90 80 PaO2<55 mm Hg SaO2<88% (rest) COT 70 60 50 Cumulative Survival (%) NOT MRC O2 40 MRC controls 30 20 10 0 0 10 20 30 40 50 60 70 Months COT = continuous oxygen therapy; NOT = nocturnal oxygen therapy; MRC controls = no oxygen therapy; MRC = domiciliary oxygen therapyFlenley DC. Chest. 1985;87:99-103. Reproduced with permission of American College of Chest Physicians.

21. Do not pass GO…do not refer for LVRS if • FEV1 < 20% • DLCO < 20% • Homogenous emphysema on CT • Gets better after pulmonary rehab

24. Idiopathic Pulmonary Fibrosis • Older adults • UIP on path • Characteristic CT • Honeycombing on CT • Basilar Predominate • Edge fibrosis • Rare/no ground glass • NO THERAPY except Lung Transplantation

26. Sarcoidosis • Numerous CT appearances • Apical predominate • Restrictive/obstructive • Dx by TBBx and TBNA • Non-caseating granulomas • Loffler’s syndrome • E nodosum • Systemic involvement • Prednisone/MTX

27. Lymphangiomyomatosis • Woman • Non-smoker • Tuberous sclerosis • Chronic onset • Obstructed PFTs

28. Acute Eosinophillic Pneumonia • Rapid onset dyspnea • 4 quadrant airspace filling • Looks like ARDS • BAL with >30% eosinophils

29. Diffuse Parenchymal Lung Diseases • Idiopathic pulmonary fibrosis • No tx, refer for lung tx if possible, familial types occur • Nonspecific interstitial pneumonia • Find the underlying cause ! • Collagen vascular related ILD • Hints at other organs or systems involved • Vasculitic Pulmonary Syndromes • Wegner’s, Goodpasture’s, etc. • Cryptogenic organizing pneumonia • Subacute, non-specific, tx with prednisone • Acute interstitial pneumonia • Subacute ARDS-like • Eosinophillic syndromes • Churg-Struass, AEP, CEP • Respiratory bronchiolitis ILD • Smoker, ground glass, reticular-nodular pattern • Lymphangiomyomatosis • Woman, “thin walled cysts”, Tuberous Sclerosis