ILD + sleep apnea

interstitial lung disease aka

pulmonary fibrosis

what is ILD?

acute or chronic inflammatory infiltration of alveolar walls by cells, fluid, and connective tissue

can ILD be reversible and when can it not be reversible

Yes, only if it is treated appropriately when diagnosed. If it is untreated then it becomes irreversible

ILD alterations

• Extensive inflammation (edema + infiltrate of WBC’s)

• Pulmonary fibrosis (severe)

• Granulomas (severe)

• Honeycombing (severe)

• Cavity formation 

  • Excessive bronchial secretions and bronchial inflammation

chronic ILD structural changes

• Destruction of the alveoli and adjacent pulmonary capillaries 

• Fibrotic thickening of the respiratory bronchioles, alveolar ducts, and alveoli 

• Granulomas 

• Honeycombing 

• Fibrotic pleural plaques (asbestosis)

• Bronchospasm

  • Excessive bronchial secretions/inflamed airways

ILD etiology and epidemiology: occupation + environment

• Asbestosis - most common

• Coal dust - black lung/coal worker pneumoconiosis

• “Farmer lung”- moldy hay + sugar cane 

• Hypersensitive pneumonitis 

ILD: diseases associated

scleroderma

sarcoidosis

rheumatoid arthritis

systemic lupus

Scleroderma

• Chronic thickening of the skin from new collagen “stiff lungs” 

• Pulmonary involvement is the most severe 

• Most likely to cause significant scarring to lung parenchyma

• Common in women 30-50 years old 

• Pulmonary complications:

  • Diffuse interstitial fibrosis 

  • Severe pulmonary hypertension 

  • Pleural disease 

    • Aspiration pneumonia 

Sarcoidosis

• Common disorder

• Enlargement of the lymph glands

Pulmonary alveolar proteinosis

• Alveoli is filled with protein and lipids 

• It looks like pulmonary edema 

• Diagnosis confirmed by BAL 

• Most commonly seen in adults 20-50 years old 

• Men are affected 2x as much as women 

Good pasture syndrome 

• Pulmonary hemorrhage and hemoptysis

• Increased DLCO

• Usually seen in young adults 

ILD vital signs

• Tachypnea

• Tachycardia 

• Hypertension

ILD physical exam

• Cyanosis 

• Peripheral edema and venous distension 

  • Distended neck veins 

  • Pitting edema 

  • Enlarged and tender liver “flank pain” 

• non-productive  cough 

  • Digital clubbing 

ILD chest assessment

• Increased tactile and vocal fremitus

• Dull percussion note ( bc of fluid)

• Bronchial breath sounds

• Fine crackles (fluid in alveoli)

• Pleural friction rub 

ild pft

restrictive disease

ILD DLCO

all decreased expect for good pasture syndrome

ABG mild + moderate

• acute respiratory alkalosis 

  • pH ⬆ PaCO2⬇ HCO3⬇ PaO2⬇ SaO2⬇

    • Breathing fast + no oxygenation

ILD chronic

• chronic respiratory acidosis

pH Normal  PaCO2⬆ HCO3⬆ PaO2⬇ SaO2⬇

ILD hemodynamics

• CVP⬆ PA⬆(shunting)  PCWP normal (not related to the heart)

  • Hematology: polycythemia (increased hemoglobin)

ILD CXR/CT

• Bilateral reticulondular pattern 

• Irregular shaped opacities 

• Granulomas

• Cavity formation 

• Honeycombing 

• Pleural effusion 

  • Pleural thickening

general management

• inflammation-> corticosteroids

• Auto-immune -> immunosuppressive agents, used to reduce the reaction of the immune system 

• Good pasture syndrome -> plasmapheresis

• Pulmonary alveolar proteinosis -> bronchial lavage 

obstructive sleep apnea/CSA

recurring collapse of the upper airway durning sleep 

OSA signs and symptoms

• Loud snoring 

• Observed breathing cessation durning sleep 

• Abrupt awakening by shortness breath

• Insomnia

• moodiness/irritability 

• Lack of concentration 

• Memory impairment

• Dry mouth /sore throat

• Morning headache

• Nausea

• Hypersomnia (daytime sleepiness)

• Personality changes

• Depression 

• Nocturnal enuresis (peeing on yourself while sleep)

• Sexual impotence

• Night sweats 

OSA risk factors

• Excess weight - 50% of pts

• Neck size - larger than 17 inch

• Hypertension 

• Diabetes (3x likely)

• Smoking (3x likely)

  • alcohol/sedatives - relax the upperairway

Pickwickian syndrome

obesity hypoventilation

hyperventilation CSA

most common

cheyne stokes

hypocapnia → central apnea → hypercapnia -. hyperpnea

hypoventilation csa

• secondary problem due to underlying medical conditions (CNS disease, CNS suppressing drugs or substances)

  • Durning sleep pt no longer has to stimulus to breah (alveolar hypoventilation)

apnea diagnosis

• History from pt/pt bed partner 

• Snoring 

• Sleep fragmentation 

• Periods of apnea durning sleep 

• Persistent daytime sleepiness

  • polysomnography (psg)

polysomnography

• specialized sleep test that monitors and records a number of physiological parameters that occur durning sleep **** diagnostic of choice*****

Mild OSA

5-15 events/hr

mod osa

15-30 events/hr

severe OSA

over 30

• General MGMT: OSA

• Pt education is key 

• Behavior modification (weight loss, exercise, etc.)

• PAP therapy

• surgery implantable upper airway stimulator

PAP therapy

1st line therapy for OSA

CSA

NIPPV

O2 therapy sleep apnea

saturation > 92

pharm sleep apnea

doxapram