INTERNAL MEDICINE EOR: PULMONOLOGY

Bronchiectasis

Permanent, abnormal dilation & destruction of bronchial walls → impaired mucus clearance → frequent infections

MCC of Bronchiectasis

cystic fibrosis

Bronchiectasis etiology other

recurrent lung infections

Bronchiectasis clinical presentation

chronic cough + copious mucopurulent foul smelling sputum

- Dyspnea

- Hemoptysis

- Recurrent pneumonia

Bronchiectasis physical exam findings

- crackles (MC)

- wheezing

- rhonchi

Bronchiectasis CXR

- "tram track" lung markings: dilated & thickened airways

- "Plate like" atelectasis

Bronchiectasis TOC

CT

Bronchiectasis CT

signet ring sign

Bronchiectasis PFTs

obstructive pattern

- ↓ FEV1, ↓ FEV1/FVC <70%

- hyperinflation: ↑ volumes (RV, TLC, RV/TLC, FRC)

Bronchiectasis acute management

- O2

- Antibiotics

Bronchiectasis chronic management

- Hydration

- Chest physiotherapy

- Inhaled bronchodilators

- Def → Lung Transplant

COPD

Progressive largely irreversible airflow obstruction due to loss of elastic recoil (emphysema) & ↑ airway resistance (bronchitis)

COPD types

Emphysema → gradual decline (pink puffer)

Chronic Bronchitis → episodic (blue bloater)

COPD risk factors

- MC = Smoking

- Alpha-1 antitrypsin deficiency

- Occupational/environmental exposures

- Recurrent airway infections

COPD clinical presentation

- DOE

- Cough

- Wheezing

COPD diagnostic studies

- oxygen saturation

- PFTs

- ABGs

- CXR

COPD gold standard diagnostic test

PFTs

COPD: CXR

- hyperinflation/flat diaphragm

- increased vascular markings

COPD: ABGs

- respiratory alkalosis (emphysema)

- respiratory acidosis (chronic bronchitis)

COPD: PFTs

obstructive

- FEV1 & FVC = low

- FEV1/FVC ratio = < 70%

- Lung Volumes = high

COPD screening

- low dose Chest CT

- 30+ pack year history

PaO2 and saturation to use oxygen in COPD

PaO2 ≤ 55mmHg or saturation ≤ 88%

COPD management

- STOP SMOKING

- O2

- lung reduction surgery

- Lung transplant

- replacement of ⍺1 antitrypsin in some patients

- SABA/LABA/ICS

COPD O2 home treatment indications

- paO2 < 55

- spO2 = < 88%

- Cor pulmonale

COPD management: lung reduction surgery

improves dyspnea by removing damaged lung which allows the remaining lung to expand & function more efficiently

COPD management: Mild s/s + low risk exacerbation

SABA or/+ SAMA PRN

COPD management: Moderate s/s + low risk exacerbation

- SABA/SAMA

- + LAMA (preferred) or LABA

COPD management: Mild s/s on day-to-day basis

- LAMA

- LAMA + LABA

- LABA + ICS

COPD management: Severe symptoms

- LAMA + LABA (preferred)

- LABA + ICS

COPD management: Hypercapnia

Acetazolamide

COPD exacerbation

An acute event characterized by a worsening of the pt's respiratory symptoms that is beyond normal day-to-day variations & leads to a change in medication

COPD exacerbation risk factors

• advanced age, productive cough

• longer duration of COPD, hx of abx therapy

• COPD-related hospitalization within the previous year

• chronic mucous hypersecretion

• peripheral eosinophil count >340cells/microL

• theophylline therapy

• presence of one or more comorbidities (IHD, HF, DM)

COPD exacerbation clinical presentation

Generally includes acute change in 1 or more of the cardinal symptoms:

• cough increases in frequency & severity

• sputum production changes in volume &/or changes character

• dyspnea increases

COPD exacerbation physical exam findings

- wheezing

- tachypnea

- difficulty speaking

- use of accessory muscles

- fever

- myalgias

- diaphoresis

COPD exacerbation management

- SABA + SAMA

- prednisone x 5-14 days

- antibiotics

COPD exacerbation management: antibiotics

- azithromycin 500mg x3d

- cefuroxime 500mg BID x10d

- doxycycline 100mg BID x10d

Chronic Bronchitis: criteria timeline

Productive cough - 3 months/year for 2 consecutive years

- Increases susceptibility to infections

Chronic Bronchitis etiology

- smoking MC

- air pollution

- hazardous dust

Chronic Bronchitis clinical presentation

- cough + sputum + dyspnea

- Cyanotic + obese (Blue Bloater)

Chronic Bronchitis physical exam findings

- crackles (rales)

- rhonchi

- wheezing

- cor pulmonale

signs of cor pulmonale

- hepatomegaly

- JVD

- peripheral edema

Chronic Bronchitis diagnostic studies

- CXR

- PFTs

- EKG

- V/Q

- CBC: increased Hgb & Hct

- hypoxia

Chronic Bronchitis CXR

pulmonary HTN

- enlarged right heart border

- ↑ AP diameter

- ↑ peribronchial/perivascular markings

Chronic Bronchitis PFTs

- gold standard: obstructive pattern that is not fully reversible

- ↓ FEV1 & FEV1/FVC <70% predicted, ↓ FVC

- ↑ volumes (RV, TLC, RV/TLC, FRC), normal DLCO

Chronic Bronchitis EKG

- multifocal atrial tachycardia

- cor pulmonale: RVH, RAE, RAD

Chronic Bronchitis V/Q

severe mismatch

Chronic Bronchitis ABG

respiratory acidosis

Chronic Bronchitis management

Antibiotics

- Macrolides

- Cefuroxime or Cefixime

- Amox/Clav

- FQs

Emphysema

Chronic inflammation (ex: cigs) → degrades elastin in alveoli → airway loses elasticity → alveoli collapse → decreased surface area for gas exchange + difficult exhale

Emphysema etiology

Centrilobular → smoking

Panlobular → A1AT Def

Distal acinar → young adults & spon. pntx

Paraseptal → both or pneumothorax

Emphysema clinical presentation

- DOE (Pink Puffer)

- Chronic cough +/- sputum

- Cachectic + Pursed lip breathing (Pink Puffer)

Emphysema clinical presentation: severe disease

- pursed lip expiration (increased airway & prevents airway collapse)

- semi-tripod positioning (sitting forward) to improve breathing

Emphysema physical exam findings

- Decreased breath sounds

- Decreased TF

- ↑ AP diameter: Barrel Chest

- Hyperresonance to percussion

Emphysema diagnostic studies

- CXR

- PFTs

- ABG

- V/Q scan

Emphysema CXR

- Decreased vas markings

- Enlarged lung fields

- Flattened diaphragms

- Hyperinflation: dark

- Bullae: airspace loss

Emphysema PFTs

OBSTRUCTIVE

- decreased DLCO

Emphysema ABG

respiratory acidosis - IF severe

Emphysema V/Q scan

matched defects

Emphysema management

acute bronchitis

Inflammation of the bronchi

acute bronchitis etiology

MC caused by viruses (adenovirus, parainfluenza, influenza, coronavirus, coxsackie, rhinovirus, respiratory syncytial virus)

acute bronchitis clinical presentation: timeline

Cough > 5 days ~ 2-3 weeks

- +/- sputum

- Constitutional sx

- +/- Fever

- Chest Discomfort

- SOB

- May have hemoptysis (MC cause along w/ bronchogenic carcinoma)

acute bronchitis physical exam findings

- less severe than pneumonia

- normal vital signs

- no rales

- no egophony

acute bronchitis diagnostic studies

clinical diagnosis

acute bronchitis CXR

usually normal or nonspecific

- only indicated if pneumonia is suspected (HR >100, RR >24, T >38C, rales, hypoxemia, mental confusion, systemic illness)

acute bronchitis admit Indications

O2 =/< 96%

acute bronchitis management

- Symptomatic management

- Antibiotics usually not indicated

acute bronchitis symptomatic management

- Suppressant → Dextromethorphan

- Expectorant, antihistamines, mucolytics

- Airflow obstruction → SABA

- Obstructive pulm disease → CS

- NSAIDs, ASA, APAP

acute bronchitis management: severe cardiopulm disease OR icomp

ribavirin

Influenza MCC

Orthomyxovirus

Influenza vaccination criteria

- > 6 months old x annually

- Avoid → egg allergy, rxn, GBS

- FluMist → avoid with asthma

Influenza diagnostic studies

- Rapid antigen

- Rapid serology: more accurate

- CXR

Influenza CXR

bilateral diffuse infiltrates

whooping cough etiology

- Bordetella pertussis

- gram neg

whooping cough vaccination doses

5 doses - Dtap

1 dose - Tdap

Pregnancy - 1 dose Tdap

whooping cough CC

- Severe paroxysmal hacking cough

- High pitched inspiration = whoop

- > 2 weeks in adults → suspect WC

whooping cough stages

- Catarrhal

- Paroxysmal

- Convalescent

Catarrhal stage

- 1-3 wks

- Cold sx + poor eating/sleeping + conjunctival injection + lacrimation

Paroxysmal stage

- 2-6 wks

- Whoop + inspiratory stridor

Convalescent stage

- 1-2 months

- residual cough

WC diagnostic studies

nasopharyngeal swab + culture

WC management

- Supportive: Steroids, SABA

- Antibiotics

WC management: antibiotics

1st line → Clarithro or Azithro

2nd line → Bactrim

Highly contagious!

Idiopathic pulmonary fibrosis

MC type of ILD

type = Miscellaneous

Idiopathic pulmonary fibrosis patho

Progressive lung scarring → fibrosis

- cause unknown

Idiopathic pulmonary fibrosis patient population

Men 40+ & Smokers

Idiopathic pulmonary fibrosis clinical presentation

Progressive SOB + dry cough

Idiopathic pulmonary fibrosis physical exam findings

- Fine, dry inspiratory crackles

- Clubbing

Idiopathic pulmonary fibrosis CXR or CT

- Diffuse patchy fibrosis: bases

- Reticular honeycombing

- Focal ground glass opacification

- Traction bronchiectasis

Idiopathic pulmonary fibrosis definitive diagnosis

Lung Biopsy → Honeycombing

Idiopathic pulmonary fibrosis management

- no effective medical treatment

- Symptomatic: O2, Corticosteroids

- Only cure → Lung Transplant

Idiopathic pulmonary fibrosis management: slow progression

- Pirfenidone

- Nintedanib

Pulmonary HTN

Elevated mean pulmonary arterial pressure ≥ 20mmHg

Pulmonary HTN patho

increased pulmonary vascular resistance leads to RVH, increased RV pressure, & eventually R-sided HF

Pulmonary HTN etiology

- Primary: idiopathic (MC in middle-aged or young women)

- Secondary: pulmonary disease, sleep apnea, PE

Pulmonary HTN Types

- Class I → idiopathic pulmonary arterial HTN (primary)

- Class II → due to left heart disease

- Class III → due to hypoxemic or chronic lung disease (COPD)

- Class IV → due to chronic thromboembolic disease

Pulmonary HTN clinical presentation

- dyspnea

- fatigue

- chest pain

- weakness

- cyanosis

- edema

Pulmonary HTN physical exam findings

- accentuated S2

- signs of R-sided HF

- pulmonary regurgitation

- right ventricular heave

- systolic ejection click

signs of R-sided HF

- ↑ JVP

- peripheral edema

- ascites