Pulmonology 7

Stratifies patients into high and low risk for pneumonia mortality

Prediction rule focuses on recognizing low risk patients and not overestimating severity of illness

Included primarily patients presenting through emergency departments rather than those evaluated in physicians offices and sent home

Has been extrapolated for use in defining need for hospitalization

Expectorated; Induced (aerosolized NaCl induces cough)

Suctioned from tracheostomy tube

Bronchial washings/aspirates; BAL (Bronchoalveolar lavage); Bronchial brush or biopsy

is normally sterile if directly sampled

Used to evaluate quality of specimen for bacterial culture

Acceptable sputum spec:

Induced specimens, BAL & Bronchial brushings or biopsy

Indicative of oral mucosal contamination

Absence not predictive if pt is immunocompromised (or neutropenic)

numerous WBC’s =

Activated phagocytic cells common in fungal, acid-fast & some atypical bacterial infections

Indicative of allergic reaction or parasitic infection

Mucus secreted to mechanically cleanse respiratory pathway & directly attacks inhaled bacteria via antibodies (primarily IgA) & lysosomes

Distinguish normal flora from pathogens

Lancet shaped gram positive cocci in pairs

Gram negative diplococci…..

can cause pneumonia, especially in patients with alcoholism or chronic obstructive lung disease.

meningococci and Haemophilus influenzae, Moraxella catarrhalis are

Sputum Gram Stain with Mucus strands…

with infection caused by gram negative bacilli or staphylococci is probably the major type of hospital acquired pneumonia, followed by pneumococcal disease.

from a pulmonary abscess….think hospital acquired pneumonia in a ventilator pt or if outpatient, also consider EtOH/substance abuser with aspiration

Anaerobic (aspiration) pneumonia

Inflammation of tracheo-bronchial tree (Acute vs Chronic)

clinical diagnosis - xs bronchial mucus production & daily productive cough for >3 months in 2 consecutive yrs; Predominantly viral (both acute & chronic); Culture never indicated

Inflammation of lower resp. tract usually due to an infection

Standard bacterial culture which isolates most common pathogens (Strep pneumo, H. flu, etc)

treatment takes into consideration lack of anaerobic culture

not always pathognomonic

Requires specific fungal culture order

Important in immunocompromised, immunosuppressed or post antibiotic pts

Candida albicans, Aspergillus, Histoplasmosis, Blastomycosis, Coccidiosis, Zygomycosis

Cultures incubated several weeks before culture results are finalized

Collect serial early AM sputum cultures x 3, (Acid Fast Bacilli)

if positive, presumptively treat for TB in appropriate clinical picture (as low as 20% sensitive)

always reported by micro lab to state health dept for contact evaluation

Causative agent of TB

spread person to person via respiratory droplets in air (cough)

Administer 5 units (0.1 ml) of PPD (purified protein derivative) intracutaneous (volar aspect of forearm) to best detect infection

Requires 2-12 weeks to develop an immune response to TB; delayed type hypersensitivity mediated by T cells

not erythema is measured @ 48 -72 hours

determined by underlying risk

Children < 4yrs old, or infants, children & adolescents exposed to adults @ high risk for active TB:

if pt has no risk factors

if pt has co-morbid risk factors (Diabetes, chronic renal failure, cancer, IVDA, congregate setting (hospital, prison, shelter), foreign born/immigrant <5yrs from endemic area (Asia, Africa, Latin America), Mycobacteriology lab tech, gastrectomy\

if HIV+, contact of TB + person, organ transplant/immunosuppressed, pts with fibrotic CXR (indicates healed TB infection) or pts on >15mg prednisone/day or on TNF alpha inhibitor

is tested to determine if the individual's immune system is functioning well; a normal immune system demonstrates a positive reaction.

the inability to react to skin tests because of a weakened immune system (e.g. advanced HIV infection, malignancy)

develop TB rxn > 10mm within 8 to 12 wks following vaccination (although zone size does not correlate with vaccine protection)

Difficult to distinguish between TB + rxn & BCG rxn therefore: Prior BCG vaccination is not a valid basis for dismissing + rxns so recommend using

usually elicits a positive PPD reaction

may also elicit positive PPD

Pt with + PPD for first time

Pt who previously had documented neg PPD who now tests +

Pt with latent TB may have neg PPD if tested years after infection

Place 1st PPD…if neg, retest in 2 to 3 weeks to access for a delayed “memory” response

indicates Latent TB or prior BCG vaccine & should be classified as reactors, not converters.

If 2nd test neg

more specific test for LTBI & can help exclude BCG or Mycobacterium not TB rxns.

Ex vivo T cell based assay…T cells of pts previously infected with M. tuberculosis will produce high levels of interferon-gamma. As antigens used in test are not shared by BCG or other Mycobacterium, low cross reactivity

ELISA methodology

x 3 (early AM specs) to evaluate for active dz

honey combing, suggest pulmonary fibrosis

movement of air in and out of the lungs

negative pressure

passive process; Result of natural recoil/elasticity

between the alveoli and pulmonary capillaries

normal Gas exchange

Gas exchange during heavy exercise

Inflammatory/allergic condition, can be childhood or adult onset, may be concurrent with allergies

Cough, wheezing, chest tightness, triggers, exertional, night sxs

Asthma, COPD, Chronic Bronchitis, Emphysema

most often seen in smokers, chronic cough/dyspnea with increased sputum production

chronic dyspnea with destruction of alveoli

Chronic Bronchitis, Emphysema

disorders of the chest wall or pleura; Includes obesity, pleural effusion

Interstitial Lung Disease, Acute pneumonitis

inflammation/scarring of the lung tissue

airspaces filled with exudate or debris (often due to irritant exposure)

Chronic persistent cough, wheezing, dyspnea, exertional cough or chest discomfort, fatigue

Objective assessment of bronchodilator therapy; Evaluation of occupational exposures

Pre-operative risk assessment; Objective assessment of impairment or disability

Chest or abdominal pain of any cause; Oral or facial pain exacerbated by a mouthpiece; Stress incontinence; Dementia or confusional state

measures the amount & rate of air a person breathes in order to diagnose illness or determine progress in treatment

amount of air that can be exhaled with a maximal effort after a maximal inhalation.

Forced expiratory volume in 1 second

proportion of the FVC that can be expelled in the first second of forced exhalation

average flow rate over the middle 50% of expired volume during a maximal forced expiratory maneuver

Spirometry Interpretation: low FEV1 compared to FVC. In late stages can also see low FVC as well.

Spirometry Interpretation: low volume seen on FVC

Decline in lung function more rapid than expected from aging alone.

approximately 30cc/year – less than 1%/yr

Normal variability between results of spirometry sessions

comparison of 5 years or less – 10% to 14% decline or 275 - 400ml/yr decline

comparison of 5 years or less – 15% or more decline or 400 ml or more decline

comparison of over 5 years – between 2-3% per year decline or 55-80 ml/year decline

comparison of over 5 years - 3 % per year or more decline or 80 ml/year or more decline

Uses spectometry to measure oxygen saturation peripherally

Normal > 95%; < 88% at rest required for O2 therapy

Not accurate in using to titrate O2 therapy in advanced COPD

Measures oxygen saturation of hemoglobin in arterial blood - which is a measure of the average amount of oxygen bound to each hemoglobin molecule

DLCO

Most commonly “single breath method”; 3% CO and 10% helium; Uptake of CO measured at exhalation; Two tests, mean value reported; Threshold values have not been standardized – use reference ranges given by facility

Polycythemia; Severe obesity; Asthma

Pulmonary hemorrhage; Left-to-right intracardiac shunting; Mild left heart failure; Exercise just prior to the test

Anemia – mild decrease; Pulmonary vascular disease; Early interstitial lung disease

Emphysema; Cystic fibrosis; Bronchiolitis

Interstitial lung disease & Pneumonitis

Anemia

Carboxyhemoglobin

Altitude

Used to monitor respiratory function in asthma

Based on each patient’s personal best – compare this to standardized reference ranges based on age, height, and sex

Safer to make diagnosis of asthma than using methacholine challenge. Assists patients in therapeutic decisions

Asthma Action Plan -Green zone, Yellow zone, Red zone; Essentially multiple checks of FEV1.

Measures ECG along with pulmonary gas exchange and pulse oximetry.

Evaluation of dyspnea or shortness of breath; Functional status determination in congestive heart failure

occur in cycles 90-120 minutes each – REM vs. Non-REM sleep

active, awake EEG pattern; atonic EMG; presence of rapid eye movements

3 stages

lightest, 2-5% of sleep, transition stage

intermediate, 40-50%, slowing of EEG

deep/slow wave, 20%

wakefulness to Stage 1, then to stages 2, 3, and 4. Stages 3 and 2 reappear, then REM.

stage 2 and REM alternate

Excessive daytime fatigue; Excessive snoring, Witnessed apnea, Obesity/HTN/heart disease, Active/Violent nighttime behaviors, Parasomnias, Insomnia

test records body functions during sleep, including brain activity, eye movement, o2 & co2 blood levels, HR and rhythm, breathing rate and rhythm, the flow of air through your mouth and nose, snoring, body muscle movements, and chest and belly movement.

Sleep time, stages of sleep (NREM and REM), and awake time are normal. No abnormal brain activity (such as a seizure) is noted.

Slow eye movements are present at the start of sleep and change to rapid eye movements during REM sleep.

No leg jerking or other abnormal muscle movement is present.

Blood O2 level is greater than 90%.

Heart rate and rhythm are normal. No heart rate changes (arrhythmias)-such as an abnormally slow or fast heart rate-are noted.

Reduced air flow (hypopnea) or no air flow (apnea) to the lungs occurs fewer than 5 times in 1 hour.

chest and abdomen move normally throughout the study.

Sleep is restful and not disturbed. Night terrors, sleepwalking, and sleep talking do not occur.

Excessive snoring or abnormal snoring patterns are not present.

Airflow through the mouth and nose is not blocked.

Objective measure of daytime sleepiness

Patient given 4-5 opportunities to nap at 2 hour intervals during the day; Each time, patient is asked to lie down and nap in appropriate environment – measurements taken – EEG, eye movements, muscle tone.

Time from wakefulness to sleep onset is measured to determine

REM sleep presence during > 2 of the naps is consistent with

Taking 10 to 20 minutes to fall asleep in MSLT

5 minutes or less is to fall asleep in MSLT

Patients recline in quiet, darkened room. Try to stay awake as long as possible. Variant of MSLT

Likely to be performed in the primary care/prenatal setting

Increasingly performed in primary care/prenatal setting

Most carrier test are for

Typically carriers of autosomal recessive conditions

Particular genetic carrier tests offered to everyone in the general population

Carrier screening limited to particular groups of people determined to be at higher risk for specific genetic disorders; e.g. ethnicity-based screening

Purpose: To detect couples at risk for prenatally diagnosable genetic disease

Type of testing offered based on clients’ ethnic background

Offered to all individuals of that ethnic background (targeted population screening)

Should be offered to patients: Seeking preconception counseling, OR Seeking infertility care, OR During the first or early second trimester of pregnancy

Depends on gestational age; If early in pregnancy, can do sequential screening; Concurrent testing is an options later in pregnancy

Counseling before screening should include

Patients brochures about CF and other ethnicity- based genetic screening available from multiple sources

informed consent discussion and patient’s decision

Carrier Screening is

Patient education/informed decision-making is

Most tests detect a majority, but

is available and advised for carriers and carrier/carrier couples

Chronic lung disease with GI malabsorption

Incidence in 1 in 2500 – 1 in 3300 in Caucasian and Ashkenazi Jewish Population

Age of onset typically early childhood. Variable symptoms: Life expectancy 20 -35 years. Non-classical forms exist.

Treatment: daily respiratory therapy, digestive enzymes, medication to promote lung function

encodes a protein called the transmembrane conductance regulator; Autosomal recessive; >1000 genes identified

CF Located on q arm of

most common mutation in Caucasian population in CF

As of 2010, all states are required by legislation to include CF screening on the newborn screening panel

as a mild manifestation of CF

The risk of the fetus having CF if both are carriers is

to determine the status of the fetus

The risk of the fetus having CF if one is a carrier and the other has a negative screen is

The risk of the fetus having CF if both have negative screen results is

Major manifestations: Chronic bronchopulmonary infection; Malabsorption; High sweat chloride; Infertility

Autosomal recessive disorder, CF Gene is located on long arm of

is most common mutation in CF

cystic fibrosis transmembrane conductance regulator (CFTR) . CFTR also may regulate activity of other Cl and Na channels, so In airways, hyperabsorption of Na, and decreased Cl secretion

Hydrate epithelial surfaces; Bind and clear bacteria; Detoxify and clear particulates

Protect against oxidants and proteases; Important element of the Innate Immune System in the lungs

Is a Key Component of Normal

Albuterol

Levalbuterol

Formoterol

Salmeterol

Ipratropium

Tiotropium

Albuterol/ipratropium

Cromolyn sodium

Beclomethasone

Budesonide

Flunisolide

Fluticasone

Mometasone

Triamcinolone

Fluticasone - Salmeterol

Budesonide - Formoterol

Theophylline

Montelukast

Zafirlukast

Zileuton

Isoproterenol

Omalizumab

Class: Albuterol

Class: Levalbuterol

Class: Formoterol

Class: Salmeterol

Class: Ipratropium

Class: Tiotropium

Class: Albuterol/ipratropium

Class: Cromolyn sodium

Class: Beclomethasone

Class: Budesonide

Class: Flunisolide

Class: Fluticasone

Class: Mometasone

Class: Triamcinolone

Class: Fluticasone - Salmeterol

Class: Budesonide - Formoterol

Class: Theophylline

Class: Montelukast

Class: Zafirlukast

Class: Zileuton

Class: Isoproterenol

Class: Omalizumab