9. Miscellaneous Pulmonary Conditions

Obesity hypoventilation syndrome (+ associated condition)

Hypoventilation at alveoli common with OSA

Treatment of OHS

Weight loss, CPAP

Obesity hypoventilation syndrome vs. COPD

Voluntary hyperventilation can return PCO2 and PO2 in OHS (cannot in COPD)

Obstructive sleep apnea

Upper airway obstruction during sleep by decreased pharyngeal muscle tone

MC demographic of OSA

Obese, middle-age man with HTN

Risk factors for obstructive sleep apnea (OSA)

- Alcohol/sedatives

- Nasal obstruction

- Hypothyroid

Significant Ddx to consider with OSA

Drug use, depression, seizure disorder, narcolepsy

S/S of OSA

- Excessive somnolence/fatigue

- AM sluggishness/HA

- Inability to concentrate

- Personality change

S/S with bed partner report of OSA

- Loud cyclical snoring

- Breath cessation

PE findings with OSA

- Systemic HTN

- Excessive oropharynx soft tissue, large tongue

Complications of untreated OSA

- Cardiac arrhythmias

- Severe hypoxemia

- Pulm HTN

- Cor pulmonale

Diagnosis & findings of OSA

Polysomnography — bradyarrhythmia during apnea, tachyarrhythmia with establish airflow

- Erythrocytosis (compensation for hypoxia)

Management of OSA

- Weightless and NO alcohol, sedation med

- Nasal CPAP

Acute respiratory distress syndrome (ARDS)

Life-threatening with diffuse, inflammatory condition with poor oxygenation and non-compliant (stiff) lungs

Pathophys of ARDS

Increased vascular permeability and decreased surfactant

Criteria for diagnosis of ARDS

- Onset of respiratory distress within 7 days of trigger

- New, bilateral opacities NOT via pleural effusion, atelectasis, nodules

- Resp failure NOT via HF or volume overload

- Impaired oxygenation

Risk factors for ARDS

- Sepsis

- Shock/infection

- Any trauma

- Near drowning

S/S of ARDS

Rapid onset severe dyspnea

- Diffuse crackles

- Hypoxemia refractory to supplemental O2

Diagnostic workup & findings of ARDS

CXR: Diffuse patch bilateral infiltrates that consolidate

Management/treatment of ARDS

- ID and treat trigger

- Intubation and positive pressure mechanical ventilation — with low PEEP, low TV, low supplemental O2

- Goal HgB 7

- Volume status → dry

What is the goal hemoglobin with ARDS treatment?

7

Significance of management of ARDS with intubation and positive pressure mechanical ventilation

Use of low PEEP, low TV, low supplemental O2 to avoid excessive alveolar stretch (and further injury)

Prognosis of ARDS

- Mortality with low TV ventilation 30%

- NO improvement within week 1 → poor prognostic sign

- Survivors can have chronic residual lung disease

Bronchiectasis

Disorder of large bronchi with permanent, abnormal dilation and destruction of bronchial walls

Risk factors for bronchiectasis

- CF

- Lung infection/scarring

S/S of bronchiectasis

Chronic cough with copious, purulent, foul-smelling sputum

- Chronic crackles at bases

What type of pulmonary disease is severe bronchiectasis?

Obstruvtive

Diagnostic workup & findings of bronchiectasis

CT: Tram tracks, signet rings (thickened bronchi)

CXR: Dilated, thickened bronchi

Treatment of acute exacerbation of bronchiectasis

- ABX according to sputum culture

- Chest PT for postural drainage

Treatment of suppresion/prevention of bronchiectasis

Prolonged macrolide therapy

Treatment of suppresion/prevention of bronchiectasis in CF patients

Inhaled ahminoglycosides can reduce pseudomonas colonization

MCC of severe chronic lung disease in US

Cystic fibrosis

MC fatal hereditary disorder of caucasians in US

Cystic fibrosis

Risk factors for cystic fibrosis

Autosomal recessive

Pathophys of cystic fibrosis

Abnormal membrane chloride channel across surface of epithelial cells → affects lung mucus glands (+ others) producing THICK mucus

S/S of cystic fibrosis

Pulm: Recurrent lung infections, recurrent hemoptysis, digital clubbing

GI: Steatorrhea, malnourished

Other:

Men - absence of vas deferens/azoospermia

Women - thick cervical mucus

Lung PE with cystic fibrosis

Hyper-resonant with apical crackles

Diagnostic workup & findings of cystic fibrosis

- Newborn screening

- Sweat chloride test - elevated Na/Cl levels in sweat

High res CT:

- Hyperinflation, peribronchial cuffing, mucus plugging

Significance of early detection of cystic fibrosis

Improves survival and symptoms

Treatment/management of cystic fibrosis

- Postural drainage, chest PT

- Inhaled DNAase decrease sputum viscosity

- Yearly screen for mycobacterial colonization

** Lung transplant only definitive treatment

HCM for cystic fibrosis

Important to receive pneumococcal, annual flu, covid

S/S of acute bronchitis

Productive cough, fever

** Worse than cold, better than pneumonia

Lung PE of acute bronchitis

Rhonchi/wheeze

Serious signs indicative of pneumonia NOT acute bronchitis

Decreased breath sounds, ego phony, SOB at rest

MCC of acute bronchitis

Viral

** ABX NOT HELPFUL

Management/treatment of acute bronchitis

- Beta-2 agonist can decrease duration/severity

FYI with acute bronchitis management

Cough lasts 1-2 weeks

E-cigarette or vaping product-associated lung injury (EVALI) prevalence

HIGH hospitalization rate

Risk factor/demographic for EVALI

Male under age 35

Requirements for diagnosis of EVALI

E-cig use within 3 months, no current infection

Presentation of EVALI & FYI

Acute to subacute

** Symptoms mimic respiratory viruses

Diagnostic workup & findings of EVALI

CXR: Bilateral pulmonary opacities

Labs: Leukocytosis, elevated CRP, ESR

** Rule out infection

Indications for hospitalization with EVALI

SpO2 <95% RA, lack of access to f/u

Management/treatment of EVALI (home disposition)

Glucocorticoids

ASAP EMERGENT care with worsening symptoms