Respirology

     

     

    Imaging

    Chest Xray

    • CXR Conditions with upper lobe prominence:
      • Sarcoidosis
      • Silicosis
      • Langerhan Cell Histiocytosis
      • Cystic Fibrosis
      • Reactivation of TB
      • (Chronic hypersensitivity pneumonitis)
    • CXR with lower lung zones
      • IPF, NSIP
      • Cryptogenic Organizing Pneumonia
      • Asbestosis
      • Heart Failure
    • Response to treatment:
      • Pneumonia
      • Heart Failure
      • Pneumothorax

     

    Chest CT

    • Indicated for:
      • ILD
      • Bronchiectasis
      • Pulmonary Nodules (small)
      • Cancer, signs of spread
      • Pulmonary Embolus
      • Lymphadenopathy
      • Characterizing pulmonary nodules (calcifications etc..)
    • Contrast CT for:
      • Helps see large blood vessels.
      • Identify metastasis to liver/adrenals. 
      • Vascular concerns (dissection, PE)
    • Differential for "Ground Glass"
      • Atypical Infections
        • Viruses (HSV, CMV)
        • Fungi (PCP, Aspergilosis [halo sign w/ surrounding groundglass])
      • Chronic Interstitial Diseases
        • Eosinophilic Pneumonia
        • Idiopathic Interstitial Pneumonia (UIP/NSIP/COP etc..)
        • Sarcoidosis
      • Alveolar Diseases
        • Pulmonary Edema (ARDs, Heart failure)
        • Pulmonary Hemorrhage
        • Hypersensitivity Pneumonitis

     

    PET CT

    • PET combined with CT
      • Higher Sn and Sp when done together.
      • Expensive, but saves pts from unnecessary surgery.
    • Using for staging lung cancers.
    • FDG (Flurodeoxy glucose) - see if mass is metabolically active.
      • If does not light up does not exclude Ca, but makes it less likely.

    PET Scan

    • Sp 90%, Sp 85% for mediastinal spread.. (30 and 40% for standard CT).
    • Not useful for <1cm diameter
    • False Positive PET:
      • Infection (TB, fungal, other atypical)
      • Sarcoidosis.
    • False Negative PET:
      • Low grade variants of adenocarcinoma
      • Carcinoid (both metabolically slow).

     

    Bronchoscopy

    • Insert the scope and collect 
    • Good way to visualize and biopsy central pulmonary lesions.
    • Peripheral nodules are possible to biopsy if >2cm in diameters.  (<2cm likelihood is low <50% success) May need CT-guided percutaneous biopsy.
      • Radial US and electromagnetic navigation tools. (tells bronchoscopist which way to go)
    • Endobronchial ultrasound... easier to get tissue that was formerly only done via mediastinoscopy.
    • Sarcoidosis, silicosis, hypersensitivity pneumonitis
    • Reasons to do Bonchoscopy:
      • Tissue Samples
        • Under electromagnetic guidance or endobronchial ultrasound (EBUS)
      • Broncho-Alveolar Lavage
        • Helps with diagnosis, to obtain cultures
        • Normally see alveolar macrophages (95%)
          • If other cells can help diagnosis. (i.e. lymphocytosis, eosinophilia, neutrophilia).
      • Therapeutic
        • Clearance of secretions.
        • Foreign bodies.
        • Palliative (if airway tumor blocking airway), can debulk tumors and rarely put stents.
    • Safety:
      • Risk is low.
      • Discuss bleeding, sedation medications, cardiac arrest if limited lung reserve, biopsies can cause pneumothorax.
      • Very rare to die from bronchoscopy 1 in 1000.

     

    Hemoptysis

    • No standard definition between minor/major hemoptysis - generally 200cc of blood used as a cutoff.
    • Causes:
      • Bronchial Bleeding:
        • Bronchitis, bronchiolitis
        • Foreign bodies
        • Trauma
        • Broncho-vascular fistula (tracheostomy erodes into innominate artery-> trachea erodes into anterior wall)
        • Vascular abnormalities (duelafoy lesions)
      • Pulmonary Parenchymal
        • Infection (pneumonia, TB av-fistulas etc, aspergillomas)
        • Lung abscesses
        • Inflammatory (Wegener's, Goodpastures)
        • Pulmonary Embolism
      • Other
        • Ehlers-Danlos Syndrome
        • Coagulopathies
        • Bevacizumab
      • Vascular
        • PE
        • Osler-Weber-Rendu (hereditary hemorrhagic telangictatia) - Pulmonary AV malformations
        • High PCWP - LV failure, Mitral Stenosis
        • Iatrogenic
        • Swan-Ganz Catheter
      • Massive Hemoptysis:
        • Most common cause is Lung Cancer.
        • Bronchiectasis
        • TB
    • History
      • Sputum with streaks? clots? small clots? Large volume?
      • Smoking?
      • Quantify.
      • Trach?
      • Rule out PE, Aortic Dissection, etc..
      • TB risk factors
    • Management:
      • >40yo -> need to work up
      • <40y --> may not need to
      • Recurrent hemoptysis
      • Try to localize a side
      • Workup:
        • Chest Xray
          • If abnormal - investigate further.
          • If normal - decide to investigate or not
            • based on age, malignancy risk factors. 
            • Can do CT scan.
              • Bronchoscopy after CT has very little value.
      • Massive Hemoptysis
        • Identify bleeding side
        • Position: Roll on bad lung (take a guess).
        • Airway: if intubating, put in largest bore ET tube (8.0 or greater)
          • Can push into the good lung to intubate mainstem bronchus
        • Recommended no to use double-lumen, can dislodge + other problems.
      • Stop bleeding:
        • Iced Saline
        • Topical agents (epinephrine) or inject.
        • Balloon tamponade
          • Fogarty catheters (will pull out clots with tube).
        • Embolization
        • Surgery (need to know which side)
        • Other:
          • Tranexamic acid - can use it, few down sides. (use if in community hospital).

     

    Cystic Fibrosis in Adults

    • Mutation in CFTR gene that causes epithelial mucous dehydration and viscous secretions
      • +++ Infections and can occlude respiratory airways
    • Life expectancy: 41.1y in 2012 (prev was 30y)
    • Symptoms
      • Increase suspicion for CF:
        • Recurrent Pancreatitis
        • Male infertility
        • Chronic sinusitis
        • Severe nasal polyps
        • Non-tubercuous mycobacterial infection
        • Allergic bronchopulmonary aspergillosis
        • Bronchiectasis
        • Positive sputum for Burkholderia cepacia
    • Diagnosis:
      • Clinical findings
        +
      • Either biochemical (sweat chloride) OR Genetic (CFTR gene)
      • Burkholderia cepacia 
    • Associations:
      • Diabetes Mellitus (30%)
      • Azoospermia (95%)
      • Liver disease (10%) - fatty infiltration and intrahepatic cholestasis.
        • 5-15% multilobular cirrhosis and portal HTN
    • Treatment:
      •  
      • 4 Pillars:
        • Airway Clearance
        • Antibiotics
        • Nutrition support
        • Psychosocial support
      • Note: Majority die from lung infection
      • Cystic Fibrosis Foundation (CFF) practice guidelines.  Following: improve lung function, decrease exacerbations:
        • Mucolytics
        • Hydrating agents
        • Inhaled antibiotics
        • Oral macrolides
        • CFTR potentiators
      • End-Stage Lung Disease --> Transplantation

     

    Exacerbations

    • CF exacerbation is defined as acute deterioration of lung function with acutely worsening respiratory symptoms.
      • Cough, increased sputum, SOB, CP, loss of appetite, weight loss, lung function decline.
    • Often caused by infection.  Most commonly:
      • Staph aureus, Pseudomonas
    • Treatment:
      • Select one antibiotic for each bacterial isolate from resp secretions and two for Pseudomonas (if possible)
        • antipseudomonal therapies: pip-tazo, ceftazidime, imipenem, meropenem + one of: tobramycin, amikacin, ciprofloxacin.
        • Generally use high-dose of agents to penetrate sputum.
        • minimum 10 days but 14-21 days usually necessary.  (even longer for some)
      • If pseudomonas first detected: use inhaled tobramycin (300mg in 5mL BID) x28days.  Repeat if coninue to grow pseudomonas.
      • Non-Tuberculous Mycobacteria also commonly identified
        • Can be just bystanders, or can cause deterioration of lung function.
        • Annual screening recommended.
        • Often chronic azithromycin is haulted if NTM is detected or suspected to prevent resistance
      • Intensified chest physiotherapy
    • Avoid Transmission of pathogens:  (AT ALL TIMES)
      • Gown + surgical masks (contact/droplet precautions)
      • Patients wear surgical masks in healthcare setting.
      • Inpatients get single-patient rooms
      • DO NOT congregate CF patients (keep 6ft clearance).
    • Improve airway clearance:
      • Hypertonic saline via nebulizer for chronic cough and reduction of FEV1
        • Order: 4mL of 7% saline following bronchodilator BID
      • Chest Physio --> if produce mucous
      • Chronic Azithromycin if airway inflammation (chronic cough, reduction of FEV1) regardless of pseudomonas status.  To avoid resistance, do not give azithro if colonized with NTM.  [azithro slows lung function decline]
      • DNase (dornase alfa) [children]
      • DO NOT use inhaled corticosteroids
      • DO NOT use systemic glucocorticoids cronically.
      • Consider lung transplant for severe CF disease.
    Tag page (Edit tags)
    • No tags
    Page statistics
    15751 view(s), 12 edit(s) and 10665 character(s)

    Comments

    You must login to post a comment.

    Attach file

    Attachments