Common Pulmonary Problems Diana Coffa, MD Family Medicine Board - PowerPoint PPT Presentation

3/16/2015 Obstructive Sleep Apnea Common Pulmonary Problems Diana Coffa, MD Family Medicine Board Review Course, 2015 Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist Asthma COPD ILD Cancer, Nodules Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist 1

3/16/2015 Obstructive Mr. Nap Sleep Apnea 56 year old obese man complaining of daytime somnolence. Difficulty concentrating at work, falls asleep during meetings. Wife notes loud snoring at night and episodes of interrupted breathing. Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist Sequelae Obstructive Sleep Apnea • Repeated episodes of apnea during sleep Neurocognitive • Excessive daytime sleepiness • Defined s >5 episodes per hour • Decreased cognitive • Present in 2-4% of population performance • Increased automobile accidents • Decreased quality of life • Mood disturbance Artist: Basner, R. Continuous Positive Airway Pressure for Obstructive Sleep Apnea Habib M'henni N Engl J Med 2007 2

3/16/2015 Sequelae Physical Exam Cardiac and metabolic • Obesity • Pulmonary hypertension • Crowded pharynx • Coronary artery disease (Friedman Tongue Position) • Cerebrovascular disease • Systemic hypertension • Arrhythmias • Nasal obstruction • Systemic hypertension • Neck circumference > 17” • Insulin resistance • Lower extremity edema Basner, R. Cardiovascular Morbidity and Obstructive Sleep Apnea. N Engl J Med 2014 Diagnostic Testing Diagnostic Testing • Polysomnography: “Sleep Study” • Split night polysomnography – Apnea-hypopnea index – Most common test • Number of apneic or hypopneic events/hour – Diagnostic study for 2-3hr, then titrate – Titrate CPAP pressure and delivery mechanism and monitor effects of CPAP <5 Normal (therapeutic) 5-15 Mild 15-30 Moderate >30 Severe 3

3/16/2015 Treatment Continuous Positive Airway Pressure • Most effective treatment Behavior Modification: – Reduces apneic events • Weight loss – Reduces sleepiness – Also ameliorates cardiovascular risk – Reduces systolic BP • Positioning • Should be offered to anyone with • Tobacco cessation AHI>15 or AHI>5 and sequelae or • Avoid sedative hypnotics cardiovascular risk • Efficacy directly correlates with hours/night used Oral Appliances Surgery • Reduce night-time awakenings, hypoxia • Effective if an obstructing lesion is • Improve neurocognitive function, reduce sleepiness, improve QOL present • No evidence of impact on mortality – Tonsilar hypertrophy • Less effective than CPAP • Uvulopalatopharyngoplasty (UPPP) for other patients – Scant evidence of efficacy – Cure achieved in a minority of patients • Can be offered to patients with mild-moderate OSA who do not want or tolerate CPAP 4

3/16/2015 Upper Airway Stimulation Therapy Mr. Nap • Approved by FDA in 2014 • Polysomnography showed an AHI of 21. • Reduces apneic events by 68% • During the test, CPAP was administered and improved the AHI to normal at a pressure of 5 • Improves quality of life measures mm Hg • Senses inspiration and provides mild • You prescribe CPAP and on follow up, the stimulation to upper airway muscles to patient’s daytime sleepiness has resolved maintain airway patency • Only data so far is in non-randomized cohort trial, so remains second or third line therapy Strollo P et al, Upper-Airway Stimulation for Obstructive Sleep Apnea NEJM Jan 2009 Ms. Wheeze Asthma 34 year old woman complains of episodic COPD shortness of breath and wheezing, particularly severe when she visits her neighbor, who has a dog. Has episodes of dyspnea 3-4 times a week, and wakes at night coughing twice a week. She was hospitalized on multiple occasions for respiratory issues as a child. No smoking history. Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist 5

3/16/2015 Recent guidelines emphasize Asthma Caused by • Assess asthma severity bronchial inflammation • Assess and monitor asthma control Increased secretions • Use inhaled corticosteroids early Bronchial • Use written asthma action plans constriction • Control environmental exposures Assessing Asthma Severity Assess Control Mild Mild Moderate Severe Intermittent Persistent Persistent Persistent > 2 per daily continual Symptoms ≤ 2 per week week symptoms symptoms Nighttime ≤ 2 per > 2 per > 1 per frequent symptoms month month week Lung ≤ 80% ≤ 80% > 60% - function ≤ 60% predicted predicted ≤ 80% FEV1 or PEFR Albuterol PRN Low dose ↑ steroid LABA + inhaled or mod dose steroid Add LABA steroid 6

3/16/2015 Ms. Wheeze Mr. Hack • You diagnose mild persistent asthma and 72 year old man complaining of 2 years of prescribe progressively worsening dyspnea and cough productive of white sputum. – Albuterol PRN 50 pack year smoking history. – Low dose inhaled steroid On exam, diffuse expiratory wheeze is – Avoidance of dogs and other triggers heard. • On follow up, the patient reports dyspneic episodes once or twice a month, no nightime awakening 7

3/16/2015 Chronic Obstructive Pulmonary Risk Factors Disease • 4 th leading cause of • Smoked tobacco death in United • Particulate air pollutants States • Indoor wood burning stoves or open fires • Progressive • Occupational chemicals development of • α1–antitrypsin deficiency (<1%) airflow limitation that is not fully reversible Diagnosis and Severity Treatment FEV1/FVC FEV1 Mild <70% ≥ 80% Moderate <70% 50% ≤ FEV1<80% • Vaccine: flu, Severe <70% 30% pneumonia ≤ FEV1<50% Long acting • Smoking bronchidilator: cessation Very Severe <70% <30% anticholinergic • PRN short Inhaled or acting steroid Oxygen beta agonist bronchidilator With emphysema, will see a greater ↓ in DLCO Consider Surgery 8

3/16/2015 Mr. Hack • PFTs: FEV1/FVC = 64%, FEV1 = 53%. • Diagnosis: Moderate COPD You discuss smoking cessation with the patient, who enrolls in a smoking cessation group. You initiate albuterol PRN and tiotropium daily. You provide a pneumococcal and flu vaccine. ILD On his return visit, the patient notes much Cancer, Nodules improved dyspnea and the ability to walk to the grocery store without difficulty. Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist Ms. Pant Interstitial Lung Disease • Progressive dyspnea on exertion 58 year old woman presents with 3 years of slowly progressive dyspnea on • Non-productive cough exhertion and 1 year of nonproductive • Fatigue, malaise cough. She tires easily, and is able to walk • History of occupational exposure only 1.5 blocks before resting. Exam reveals dry rales throughout bilateral • Time course is variable, depending lung fields and clubbing of the digits. on diagnosis 9

3/16/2015 Exam Categories of interstitial lung disease • Environmental/Occupational exposure • Dry crackle or “velcro rales” • Autoimmune disorders • May be best heard in the posterior – polymyositis/dermatomyositis axillary line or bases – rheumatoid arthritis, • Signs of cor pulmonale may be present in – systemic lupus erythematosus advanced cases – scleroderma – Accentuated S2 – mixed connective tissue disease – Right sided heave • Drug induced, particularly antineoplastic • Clubbing may be present • Idiopathic Diagnostic testing • Plain chest radiograph variable, but Reticulonodular opacities in most cases – reduced lung volumes – bilateral reticular or reticulonodular opacities 10

3/16/2015 Diagnostic Testing Treatment • Spirometry: Restrictive Pattern • Avoid exposures – Reduced TLC and FVC • Tobacco cessation – Normal FEV1/FVC • Corticosteroids for some • HRCT sensitive and specific • Immunosuppressive and cytotoxic – can be diagnostic or guide biopsy therapy for some • Biopsy diagnostic • O 2 and Bronchodilators – not always recommended for mild, non-progressive disease Ms. Pant Mr. Spot Spirometry shows FVC of 46% predicted and 49 yo man requires chest x-ray for a physical FEV1/FVC of 86%, which is normal. exam for work. No cough, dyspnea, or chest pain. You obtain a HRCT, which shows reticular abnormalities with traction bronchiectasis and Chest radiograph shows 1 cm nodule in right honeycombing in a peripheral and basilar upper lobe with central calcification predominant pattern consistent with Usual Interstitial Pneumonia, a type of idiopathic ppd negative ILD. No prior films for comparison 11