Pulmonary ¡ ABIM ¡Cer1fica1on ¡ Exam ¡Review ¡Course ¡ Leslie Zimmerman, MD Professor of Clinical Medicine, UCSF ICU Director, SFVAMC Conflict ¡of ¡Interest/Disclosures ¡ n None 1
Rela1ve ¡Value? ¡ n Medical Content • CV 14% • Pulmonary 10% • ID 9% • GI 9% n Cross Content • Critical Care 10% • Geriatrics 10% • Prevention 6% • Women’s Health 6% Rela1ve ¡Value? ¡ n Pulmonary: • Obstructive disease: 20% • Pulmonary vascular disease: 12% • Pneumonia: 10% • Pleural Disease: 10% • Restrictive & Interstitial: 10% • 0-2 questions on: ARDS, Sleep, lung cancer, bronchiectasis … 2
Lecture ¡Outline ¡ n Sleep n COPD/Asthma n ILDs n PVD n Solitary Pulmonary Nodule n Etc. Ques1on ¡1 ¡ A 65 year-old man with daytime sleepiness is evaluated for sleep apnea. His Epworth sleepiness scale is 11/24. The polysomnogram reveals an overall apnea-hyponea index (AHI) of 24 (12 events/hour when on his side and 55 events/hour when supine). Lowest oxygen saturation was 86%. He had occasional leg jerks with sleep stage transition; he has no leg symptoms during day. 3
Ques1on ¡1 ¡ 65 yom with overall AHI of 24 (12 on side & 55 when supine). Nadir O2 sat’n = 86%. Occasional leg jerks with sleep stage transition; no leg symptoms during day. He should be offered: A. Screening for iron deficiency B. Modafinil C. Nighttime oxygen D. APAP E. BPAP-ST Sleep ¡Disorders: ¡Office ¡Visits ¡ www.nhlbi.nih.gov/about/factbook-05/chapter4.htm 4
Classic ¡pa1ent ¡with ¡OSA ¡ Obesity = #1 risk factor Genetics Upper airway/facial abnormalities (nasal congestion) Tonsils! en.wikipedia.org Post-menopause Hypothyroidism/ Acromegaly Deeper stages of sleep, neural input to upper airway declines, decreased airway tone, tongue falls back. Not ¡Obese? ¡ http://tonsillectomyrecovery.com/swollen-tonsils/ http://www.sublimis.com 5
OSA ¡ Disruption in sleep causes daytime sleepiness Epworth Scale can estimate “sleepiness” 10 = Sleepy 18 = Very sleepy http//:epworthsleepinessscale.com OSA ¡ (Respiratory Disturbance Index) RDI = AHI + milder hyponeas that don ’ t meet criteria but disrupt sleep 10 seconds 10 seconds Air ir flo low “Hyponea” requires 4% desaturation Apneas + Hyponeas/hour = AHI 6
OSA ¡and ¡Death ¡ Untreated severe OSA (AHI > 30/hour) 3-6 fold increased risk of all-cause mortality compared to individuals without OSA. IN CONTRAST : Patients with untreated mild OSA may not be at increased risk for mortality compared to individuals without OSA. Marin JM et al. Lancet 2005;365(9464):1046. OSA ¡ If AHI of 5-15 and • Asymptomatic • Low Epworth Severity • No HTN/CAD/CVA Mild: AHI 5-15 • Not “ mission critical ” Many would not treat Moderate: AHI 15-30 Severe: > 30 TREAT Medicare reimbursement AHI > 5 if symptoms (sleepiness, fatigue), signs of disturbed sleep (snoring, restless sleep, respiratory pauses), or HTN/CAD/CVA, or job requires Rx AHI > 15 in everyone 7
Mandibular ¡Advance ¡Device ¡ ¡ If ¡AHI ¡< ¡15, ¡sleepy ¡& ¡can ’ t ¡tolerate ¡mask ¡ à à ¡MAD ¡ We use them for symptomatic patients with mild disease who can’t tolerate PAP Repeat sleep study Q. Severe OSA? (AHI > 30) with device to check Wrong answer is MAD for efficacy Our ¡pa1ent ¡ AHI of 24 = moderate sleep apnea Nadir O2 sat’n = 86%. Occasional leg jerks with sleep stage transition; no leg symptoms during day. He should be offered: A. Screening for iron deficiency He just has myoclonic B. Modafinil jerks with C. Nighttime oxygen falling asleep, D. APAP no RLS or PLMD E. BPAP-ST Treatment for narcolepsy 8
Our ¡pa1ent ¡ AHI of 24 = moderate sleep apnea Nadir O2 sat’n = 86%. He should be offered: C. Nighttime oxygen Improves desaturation but D. APAP not AHI, not daytime E. BPAP-ST sleepiness, & not BP in HTN patients* * N Engl J Med 2014; 370:2276-2285 WON’T ASK: CPAP vs. APAP vs. BPAP for the average person with OSA à No study shown superiority Posi1ve ¡Airway ¡Pressure ¡Machines ¡ • Simplest CPAP • Set pressure to bring AHI < 5/hr • Set mid point @ level to bring AHI < 5/ hr +/- 3 or 4 above and below APAP • Can check average pressure needed at next visit (can be used to do “titration”) • Set EPAP to bring Apneas < 5/hr; IPAP until AHI/RDI < 5/hr • USE: BPAP • Comfort if required pressure high • Supports Tidal Volume à essentially “pressure support ventilation” 9
BPAP ¡ BPAP-S* (Regular) BPAP-ST** • Central Sleep Apnea • OSA needing • Obesity Hypoventilation high pressures (comfort) • NM disease • Chronic respiratory failure *S= Spontaneous **ST = Spontaneous • No effort, no breath + Timed delivery if no effort Basically a Non-invasive Ventilator Our ¡pa1ent ¡ AHI of 24 = moderate sleep apnea Nadir O2 sat’n = 86%. He should be offered: D. APAP Given his big difference between E. BPAP-ST side and supine, compliance may be better with APAP (but CPAP would be correct answer as well) No report of: • Obesity Hypoventilation • Central Sleep Apnea • NM disease • Chronic respiratory failure 10
What ¡were ¡those ¡OSA ¡numbers? ¡ n AHI 5-15 & symptoms or HTN/CAD/CVA à PAP (MAD if can ’ t comply with f/u sleep study to prove efficacy). If “ mission critical ” job à PAP because only way to monitor compliance! n AHI 15-30 à PAP n AHI > 30 and esp. if < 70 years old, clearly at increased CV mortality if not treated (so we really encourage use!) Ques1on ¡2 ¡ A 59 year old man comes to the ED with a COPD exacerbation triggered by nearby forest fires. There is no increase in cough or purulence. He is on home tiotropium, formoterol, ICS and as needed albuterol. He is wheezy but responds to albuterol/ipatropium neb and you anticipate that he will be able to go home. O2 saturation is 91%. You add: A. Home O2 by NC at 2 LPM B. Azithromycin 250 mg daily C. Roflumilast daily D. Theophylline daily E. Prednisone 40 mg x 5 days F. Doxycycline x 7 days 11
2004: ¡Worldwide ¡Leading ¡Causes ¡of ¡Death ¡ Affects 9% of World Population By 2020, will Millions move to 3 rd leading cause of death http://www.who.int/mediacentre/factsheets/fs310_2008.pdf In US, only common disease with RISING mortality Percent Change in Age-Adjusted Death In US, h in COPD Rates, US, 1965-1998 (proportion of 1965) deaths is driven by very large 3.0 CAD CVA Other COPD All h in CVD Other 2.5 women. In 2000, 2.0 for 1 st time, more 1.5 women died of 1.0 COPD than men 0.5 in US. - 59% - 64% - 35% +163% - 7% 0 http://www.goldcopd.org 12
COPD ¡Pathogenesis: ¡Aging ¡+ ¡Genes ¡ ¡ ¡+ ¡Noxious ¡S1muli ¡ Lung function (FEV1; alveoli) Lung Aging Healthy COPD Lung Mature Total dysfunction 18-25 years 130-140 years Chest 2009;135:173. In US, 15-20% of COPD caused in part by occupational exposures (esp. dusts) In ¡non-‑smokers, ¡environmental ¡ exposure ¡is ¡primary ¡risk ¡factor ¡ World Health Organization http://www.who.int/heli/risks/indoorair/en/webiapmap.jpg Indoor smoke from biomass solid fuels à Contribute up to 35% of COPD in above countries 13
Diagnosis: ¡PFTs ¡ n Low FEV1/FVC = diagnosis of obstructive disease (Asthma, chronic bronchitis, emphysema) n FEV1 = severity of obstruction n TLC ↑ TLC supports obstructive ↓ TLC diagnoses restrictive disease disease Especially emphysema Also long-standing poorly controlled asthma n DLCO: low in “airsac” disease and PVD, not asthma CT: ¡ ¡Map ¡of ¡the ¡lungs? ¡ Can diagnose emphysema (not asthma or chronic bronchitis). Not (yet) able to predict FEV1, but More emphysema on CT à higher mortality Ann Intern Med 2014;161:863 14
Ques1on ¡2 ¡ A 59 year old man comes to the ED with a COPD exacerbation triggered by nearby forest fires. There is no increase in cough or purulence. He is on home tiotropium, formoterol, ICS and as needed albuterol. He is wheezy but responds to albuterol/ipatropium neb and you anticipate that he will be able to go home. O2 saturation is 91%. You add: < 88% or PaO2 < 55 A. Home O2 by NC at 2 LPM or < 59 if ↑ Hct or RHF B. Azithromycin 250 mg daily C. Roflumilast daily D. Theophylline daily E. Prednisone 40 mg x 5 days F. Doxycycline x 7 days Ques1on ¡2 ¡ A 59 yom with a COPD exacerbation triggered by nearby forest fires. No increase in cough or purulence. On home tiotropium, formoterol, ICS prn albuterol. Wheezy but responds to albuterol and you anticipate that he will be able to go home. O2 saturation is 91%. You add: E. Prednisone 40 mg x 5 days JAMA. 2013;309:2223-2231. 40 mg x 14 days 40 mg x 5 days Just as good for average COPDer 15
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