Dry Weight in ESRD patients A Pulmonary Perspective

1. Dry Weight in ESRD patients “ A Pulmonary Perspective” Paul J. Licata, D.O. 125 Shaw St. New London, CT 06320 Phone (860) 443-0305 Fax (860) 444-0823 Goldcoastpsa@yahoo.com

2. Evaluation of Pulmonary Disease in the Renal PatientThe Right Heart – The Lost Frontier Paul J. Licata, D.O. 125 Shaw St. New London, CT 06320 Phone (860) 443-0305 Fax (860) 444-0823 Goldcoastpsa@yahoo.com

3. Identify Etiologies of SOB/DOE Fluid balance achieved via PD/HD. Dry Weight is achieved. Avoiding over dialysis to limit other end organ hypoperfusion. To limit hypotension during HD. PD abd. disten. may cause Pulm. Impairment. Echo usually done – EF% -- > RVP

4. Common Pulmonary Symptoms Cough SOB / DOE Wheezing Hemoptysis Fatigued – Tired feeling Dizziness on exertion

5. Are SOB/DOE Sx. Reliable or Accurate? Subjective complaint of SOB/ DOE does not always Correlate w/ Objective data. Pts. may underestimate deconditioning due to chronic illness of any type. Borg Scale for DOE has helped trend SOB Sxs. Orthopedic or physical limits may lessen pace and thus underestimate Sxs.

6. LVP vs. RVP RVP (preload) is a low pressure system (20mmHg) w/ a RV less forgiving then LV which is a high pressure System (SBP). LVP increase leads to Hypertrophy and increase wall thickness until cavity size decreases and Diastolic Dysfunction occurs. RVP increase leads to a Dilated RV which results from increased PAP response to hypoxia via Hypoxic Vasoconstriction.

7. LVP vs. RVP LVF results in “Wet Lungs” as ventricular function declines from a systolic or diastolic etiology. RVF results in “Wet legs” or edema as Pulmonary pressures increase and RV become more dilated w/ limited compensatory ability. West Zones which change w/ position.

13. Obstructive Disease of the Lung COPD as a General Term includes Tobacco induced disease as well as chronic bronchitis. Asthma should be reserved for non – smokers or Ex-Smokers to avoid underestimation of Tobacco irritation. Hx and PFT’s may help sort out Reversible component to Airway Disease.

14. Restrictive Disease of the Lung(See Ground Glass slides) Usually fibrotic in Nature w/ IPF or Pulmonary fibrosis being usual etiology (UIP). Obesity causes Restrictive physiology as does PD abd. distension. Usually Associated w/ Desats on Ex Ox or decreased DLCo on PFT’s. Hypersensitivity Pneumonitis is only other treatable cause (HP) – remove insulting agent. Sarcoid or Pulmonary Calcinosis are other causes.

15. Acquiring a Hx for SOB/DOE Does pt. smoke. Duration of Sxs. At rest or with Activity. Worse up inclines or Stairs? Assoc. Sx: cough / wheeze Hemoptysis Worse leaning forward or lying flat? Anxiety or “Psyche” component

16. Testing Pulmonary Function Tests (CPET) Exercise Oximetry >> ABG Nocturnal Oximetry PSG or Sleep Study CT Scan w/ Pulm. Emboli Protocol Echo w/ Attention to RVP Rte. Heart Catheterization

17. Treatment Options Stop Tobacco Pulmonary Rehab. as Outpatient Oxygen – day and/or night Maint Rx: ICS – LABA – Anticholenergics SABA or Albuterol as Rescue Avoid Prednisone Coumadin if PE Preload Reduction – Nitrates/Diuretics Afterload Reduction – ACE/Hydralizine/b-blockers OSA treatment via cpap if tolerated

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20. Ground Glass Appearance on CT How to hasten the work up and diagnosis.

21. The Phrase: “Ground Glass” Ground glass is glass whose surface has been ground to produce a flat but rough (matte) finish. A sheet of ground glass is used for the manual focusing of both still and motion picture cameras.

22. Abnormal CXR leads to CT Scan The reading of ground glass is determined by the appearance of a hazy increase in lung opacity (compared with the density of normal lung) not associated with obscuration of underlying vessels. ASAP w/u based on this abnormal CT finding, with the diagnosis of an inflammatory lung process to be established: DDx

23. Multitude of Diagnoses As a result of the long list of DDx, there needs to be a way to narrow the spectrum of diagnoses to accurately treat the patient. Systematic approach to assessing the severity of illness which impacts on the timing and workup of treatment. Case studies that you have reviewed at your table will be examples of the clinical dilemma that ground glass presents due to the variability of the patient’s clinical presentation.

24.  MYTHBUSTERS Ground Glass Does Not = IPF

25. Ground Glass Does Not = IPF There are specific CT findings of classical interstitial lung disease of an idiopathic etiology: hence IPF. The clinical prodrome can vary. Persistent cough – nonproductive, dry Prior antibiotic treatment IPF can be specific by radiographic findings, but highly variable in its clinical presentation.

26. Sx’s and PE Symptoms and PE may be out of proportion to the films. (patients usually underestimate their symptoms) You are looking for systemic symptoms by history or physical exam that is inconsistent with the history the patient may divulge. This will help assess chronic vs. acute.

27. Summary of Testing ordered Pulmonary Function Test Exercise Oximetry Echocardiogram – BNP EKG Bloodwork (see your folder – also found on uptodate.com) Pulmonary Consultation Biopsy

28. History and Physical Once you have your CT Chest with ground glass, you need to go back and look at the history and order tests appropriately. Acute or Chronic Stable vs. Unstable – “too sick to fix” You may need to re-take a history if the finding of ground glass is coincidental

29. Treatable vs. true IPF Etiologies Rule out insulting environmental agents (Hypersensitivity Pneumonitis) Treatment of ID process (Atypical Pneumonias / Viral) Congestive heart failure may appear as such Consider MCTD’s at this time (blood work) RBILD (exclusively in smokers) Drug Reaction with toxicity to the lung Aspiration Pneumonitis (GERD) Other: Lymphangitic Spread – Malignancy etc. Interstitial Lung Disease to be ruled out Normal Variant may be a diagnostic option

30. Hypersensitivity Pneumonitis Hypersensitivity pneumonitis (HP), also called extrinsic allergic alveolitis, is a complex syndrome of varying intensity, clinical presentation, and natural history rather than a single, uniform disease. It represents an immunologic reaction to an inhaled agent, particularly an organic antigen, occurring within the pulmonary parenchyma. HP is an external irritant to the lung that causes an inflammatory process that is readily reversible by ridding the insult (for example: a bird fancier) Acute insults such as cleaning materials (bleach, clorox etc.) By ridding the insult, the process resolves and improves with or without steroids. RADS – an acute documented insult of a single bolus inhalation. RBILD – another insult can be tobacco.

31. CHF These people may or may not have overt manifestations of JVD. Bloodwork - BNP EKG and Echocardiogram to rule out ischemia. Early CHF shows up on PFT with increased DLCO due to increased blood flow. Late CHF shows up on PFT with decreased DLCO due to fluid in the alveolar space. Diuretics such as Lasix. Quick fix clinically.

32. MCTD’s Some mixed connective tissues diseases may present with a pulmonary manifestations prior to the initial rheumatologic manifestations. Battery of tests to be done (see blood work enclosed in your folder) Look for physical exam findings.

33. RBILD Inflammatory process exclusively in smokers which resolves upon stoppage of tobacco with or without steroids. STOP TOBACCO!

34. Drug Reactions Methotrexate Nitrofurantoin Amiodarone Bleomycin (Chemo Agents) Chronic High Percentage (FIO2) Oxygen Singulair – Churg Straus Syndrome Statins TOO MANY MEDS TO LIST – run pt’s med list These people should have regular Chest X-Rays and Pulmonary Function Tests.

35. Miscellaneous Fracture Fat Emboli Pregnancy Amniotic Emboli Post-op Negative Pressure Pulmonary Edema Possible OSA negative pressure events Malignancy - Lymphangitic spread Aspiration Pneumonitis (GERD) CEP (eosinophilia) LAM – exclusively in young females – estrogen driven LCH – Male smokers Alveolar Proteinosis Allergic Bronchopulmonary Aspergillosis (ABPA)

37. Clinical Decision Point Diseases travel in packs. Early signs of systemic disease in 1 isolated organ? Diseases sputter. Sometimes you’re confused with the diagnosis. Sometimes you’re willing to treat. To Biopsy or Not To Biopsy?

38. Indications for a Biopsy To provide a specific diagnosis (especially in patients with atypical or progressive symptoms) < 50 years old, fever, weight loss, hemoptysis, signs of vasculitis Normal chest x-ray or atypical radiographic features Unexplainable: extra-pulmonary manifestations, pulm. HTN, or cardiomegaly Rapid clinical deterioration or sudden change in radiographic appearance To assess disease activity To Exclude neoplastic and infectious processes that occasionally mimic chronic, progressive interstitial disease. To identify a more treatable process than originally expeected To establish a definitive diagnosis and predict prognosis before preceding with therapies which may have serious side effects.

39. IPF True IPF is subpleural fibrosis that is indolent or slow to progress with the usual presentation being a dry cough for years with lack of response to conventional treatment for infectious or cardiac etiologies.

40. Radiographic Findings Dr. Robbins will show you some examples of GG vs. other related CT findings: Ground Glass - Inflammatory IPF (subpleural) - Fibrotic Consolidated Lung Reticular Nodular Pattern CHF (curly b-line’s)

41. CASE STUDIESwith GROUND GLASS

42. Case Study 1 59 year old female (day care worker) who present with increasing SOB, DOE x weeks. Non-smoker with a CT Scan illustrating diffuse Ground Glass. She was walked (exercise oximetry) in the office with SPO2’s that dropped from the 90’s to 70’s.

43. CT for Case 1

44. Case Study 2 69 year old female inpatient asked to be seen for increasing SOB and DOE x 1 week with prior antibiotic treatment, but no steroids. She has no tobacco history nor evidence of environmental insult. She stated her symptoms began after a viral or bacterial process one month before.

45. CT for Case 2

46. Case Study 3 86 year old female presented with SOB x weeks with peripheral infiltrates or ground glass on CT Scan. Patient recent stopped Amiodarone 2 weeks ago and is clinically stable with no ID prodrome.

47. CT for Case 3

48. Case Study 4 56 year old male with increasing SOB x weeks with prior antibiotic treatment for a viral versus bacterial process. Patient was 87-88% SPO2 at rest, and desat’d to the 70’s on exercise oximetry. Patient symptoms have sputtered with more recent complaint over the last few days. CT shows peripheral fibrotic changes with subpleural involvement and ground glass.

49. CT for Case 4

50. Case Study 5 83 year old male with Bladder Cancer who was treated with BCG therapy with local irrigation to the bladder. He subsequently presents with febrile illness and increasing respiratory complaint. CT scan bilateral worsening reticular nodular pattern.

51. CT for Case 5

52. Case Study 6 50 year old black female with biopsy proven Sarcoid with presumed mixed connective tissue disease overlap. Her CT Scan shows chronic fibrotic disease.

54. CT for Case 6 (2006)

55. Ground Glass on CT Thank you for coming. At this time, we will entertain any questions. Please fill out the survey located in your folders.

56. A Clinically Directed Approach Review objective data available (Ex-Ox, PFT’s, Medication List) Give ABX’s upon visit to treat a presumed ID etiology with atypical coverage using macrolides/Doxy (immunocompetent patient) Lasix if indicated to treat CHF component Oxygen to treat hypoxia until diagnosis is made. Consider Prednisone at this time. VATS vs. Open Lung Biopsy to be entertained.