DIAGNOSIS & TREATMENT - PART 2 pptx

Bronchiolitis Obliterans With Organizing Pneumonia (BOOP) ■ Essentials of Diagnosis • Bronchiolitis obliterans in adults—also called cryptogenic orga- nizing pneumonia—may follow infections (eg, mycoplasma, viral infection), may be due to toxic fume inhalation or associated with connective tissue disease or organ transplantation, may com- plicate local lung lesions, or may be idiopathic • Usually characterized by abrupt onset of flu-like symptoms, including dry cough, dyspnea, fever, and weight loss • Dry crackles and wheezing by auscultation; clubbing rare • Restrictive abnormalities with pulmonary function studies; hy- poxemia • Chest radiograph typically shows patchy alveolar infiltrates bilaterally • Open or thoracoscopic lung biopsy necessary for precise diagnosis ■ Differential Diagnosis • Idiopathic pulmonary fibrosis • AIDS-related lung infections • Congestive heart failure • Mycobacterial or fungal infection • Severe pneumonia due to bacteria, fungi, or tuberculosis ■ Treatment • Corticosteroids effective in two-thirds of cases • Relapse common after short (< 6 months) steroid courses ■ Pearl One of the “new” diseases; consider this when there is untimely reso- lution of an infiltrate in what you thought was a community-acquired pneumonia. Reference Epler GR: Bronchiolitis obliterans organizing pneumonia. Arch Intern Med 2001;161:158. [PMID: 11176728] 40 Essentials of Diagnosis & Treatment 2 Solitary Pulmonary Nodule ■ Essentials of Diagnosis • A round or oval circumscribed lesion less than 5 cm in diameter surrounded by normal lung tissue • Twenty-five percent of cases of bronchogenic carcinoma present as such; the 5-year survival rate so detected is 50% • Factors favoring benign lesion: age under 35 years, asymptoma- tic status, size under 2 cm, diffuse calcification, smooth margins, and satellite lesions • Factors suggesting malignancy: age over 45 years, symptoms, size greater than 2 cm, lack of calcification, indistinct margins, smoking history • Skin tests, serologies, cytology rarely helpful • Comparison with old chest radiographs essential; follow-up with serial radiographs or CT scans often helpful; CT scan may reveal benign-appearing calcifications • Positron emission tomography (PET) scans are a newly emerg- ing diagnostic modality ■ Differential Diagnosis • Benign causes: granuloma (eg, tuberculosis or fungal infection), arteriovenous malformation, pseudotumor, fat pad, hamartoma • Malignant causes: primary, metastatic malignancy ■ Treatment • Options include fine-needle aspiration (FNA), surgical resection, or radiographic follow-up over 2 years; negative FNA does not exclude malignancy due to high false-negative rate, unless a spe- cific benign diagnosis is made • Thoracic CT scan (with thin cuts through nodule) to look for benign-appearing calcifications and evaluate mediastinum for lymphadenopathy • With high-risk clinical or radiographic features, surgical resection is recommended • In low-risk or intermediate-risk cases, close radiographic follow- up may be justified ■ Pearl In calcified pulmonary nodules, the first digit of the patient’s Social Security number (always present on VA studies) suggests the specific infectious cause. Reference Ost D et al: Evaluation and management of the solitary pulmonary nodule. Am J Respir Crit Care Med 2000;162(3 Part 1):782. [PMID: 10988081] Chapter 2 Pulmonary Diseases 41 2 Asthma ■ Essentials of Diagnosis • Episodic wheezing, colds; chronic dyspnea or tightness in the chest; can present as cough • Some attacks triggered by cold air or exercise • Prolonged expiratory time, wheezing; if severe, pulsus paradoxus and cyanosis • Peripheral eosinophilia common; mucus casts, eosinophils, and Charcot-Leyden crystals in sputum • Obstructive pattern by spirometry supports diagnosis, though may be normal between attacks • With methacholine challenge, absence of bronchial hyperreactivity makes diagnosis unlikely ■ Differential Diagnosis • Congestive heart failure • Chronic obstructive pulmonary disease • Pulmonary embolism • Foreign body aspiration • Pulmonary infection (eg, strongyloidiasis, aspergillosis) • Churg-Strauss syndrome ■ Treatment • Avoidance of known precipitants, inhaled corticosteroids in per- sistent asthma, inhaled bronchodilators for symptoms • In patients not well controlled on inhaled corticosteroids, long- acting inhaled beta-agonist (eg, salmeterol) • Treatment of exacerbations: oxygen, inhaled bronchodilators (β 2 agonists or anticholinergics), systemic corticosteroids • Leukotriene modifiers (eg, montelukast) may provide an option for long-term therapy in mild to moderate disease • For difficult-to-control asthma, consider exacerbating factors such as gastroesophageal reflux disease and chronic sinusitis ■ Pearl All that wheezes is not asthma, especially over age 45. Reference National Asthma Education and Prevention Program: Expert Panel Report 2: Guidelines for the diagnosis and management of asthma. National Institutes of Health, Publication No. 97-4051, Bethesda, MD, 1997. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm 42 Essentials of Diagnosis & Treatment 2 Chronic Cough ■ Essentials of Diagnosis • One of the most common reasons for seeking medical attention • Defined as a cough persisting for at least 4 weeks • Chest auscultation for wheezing, nasal and oral examination for signs of postnasal drip (eg, cobblestone appearance or erythema of mucosa) • Chest x-ray to exclude specific parenchymal lung diseases • Consider spirometry before and after bronchodilator, metha- choline challenge, sinus CT scan, and 24-hour esophageal pH monitoring • Bronchoscopy in selected cases ■ Differential Diagnosis • Angiotensin-converting enzyme-induced cough • Postnasal drip • Sinusitis • Asthma • Gastroesophageal reflux • Postinfectious cough—can last 4–6 weeks • Bronchiectasis • Chronic obstructive pulmonary disease • Congestive heart failure • Interstitial lung disease • Sarcoidosis • Bronchogenic carcinoma ■ Treatment • Smoking cessation • Treat underlying condition if present • Trial of inhaled beta-agonist (eg, albuterol) • For postnasal drip: antihistamines (H 1 -antagonists or may add nasal ipratropium bromide) • For suspected gastroesophageal reflux disease, proton pump in- hibitors (eg, omeprazole) ■ Pearl In undiagnosed chronic cough, think of ACE inhibitors and asthma; these are far more common than appreciated. Reference Philp EB: Chronic cough. Am Fam Physician 1997;56:1395. [PMID: 9337762] Chapter 2 Pulmonary Diseases 43 2 Chronic Obstructive Pulmonary Disease (COPD) ■ Essentials of Diagnosis • Primarily consisting of emphysema and chronic bronchitis; most patients have components of both • Acute or chronic dyspnea (emphysema) or chronic productive cough nearly always in a heavy smoker • Tachypnea, barrel chest, distant breath sounds, wheezes or rhon- chi, cyanosis; clubbing unusual • Hypoxemia and hypercapnia more pronounced with chronic bron- chitis than with emphysema • Hyperexpansion with decreased markings by chest radiography; variable findings of bullae, thin cardiac shadow • Airflow obstruction by spirometry; normal diffusing capacity (D L CO) in bronchitis, reduced in emphysema • Ventilation and perfusion well-matched in remaining lung in emphysema, not in chronic bronchitis ■ Differential Diagnosis • Asthma • Bronchiectasis • α 1 -Antiprotease deficiency • Congestive heart failure • Recurrent pulmonary emboli ■ Treatment • Cessation of cigarette smoking is most important intervention • Clinical trial of inhaled anticholinergic agent, eg, ipratropium bromide • Pneumococcal vaccination; yearly influenza vaccination • Supplemental oxygen for hypoxic patients (Pa O 2 < 55 mm Hg) reduces mortality • For acute exacerbations, treat as acute asthma and identify under- lying precipitant; if patient has low baseline peak flow rates, antibiotics may be beneficial • Lung reduction surgery in selected patients with emphysema ■ Pearl The blue bloater pushes the pink puffer’s wheelchair (patients with bronchitis have better exercise tolerance than those with emphysema). Reference Barnes PJ: Chronic obstructive pulmonary disease. N Engl J Med 2000;343:269. [PMID: (UI: 10911010] 44 Essentials of Diagnosis & Treatment 2 Cystic Fibrosis ■ Essentials of Diagnosis • A generalized autosomal recessive disorder of the exocrine glands • Cough, dyspnea, recurrent pulmonary infections often due to pseudomonas; symptoms of malabsorption, infertility • Increased thoracic diameter, distant breath sounds, rhonchi, club- bing, nasal polyps • Hypoxemia; obstructive or mixed pattern by spirometry; decreased diffusing capacity • Sweat chloride > 60 meq/L • Genetic testing for gene mutation can confirm diagnosis even if sweat test is negative ■ Differential Diagnosis • Asthma • Bronchiectasis • Congenital emphysema (α 1 -antiprotease deficiency) • Pancreatic insufficiency • Other causes of malabsorption ■ Treatment • Comprehensive multidisciplinary therapy required, including gene- tic and occupational counseling • Inhaled bronchodilators and chest physiotherapy • Antibiotics for recurrent airway infections guided by cultures and sensitivities (high rate of resistant Pseudomonas aeruginosa and Staphylococcus aureus infections seen) • Pneumococcal vaccination; yearly influenza vaccinations • Recombinant human deoxyribonuclease given by aerosol has modest benefit • Chest physiotherapy with a variety of devices may be beneficial • Lung transplantation is the definitive treatment in selected patients ■ Pearl Consider cystic fibrosis in young adults with recurrent pulmonary infections; formes frustes are more common than once thought. Reference Rubin BK: Emerging therapies for cystic fibrosis lung disease. Chest 1999; 115:1120. [PMID: 10208218] Chapter 2 Pulmonary Diseases 45 2 Foreign Body Aspiration ■ Essentials of Diagnosis • Sudden onset of cough, wheeze, and dyspnea • Localized wheezing, hyperresonance, and diminished breath sounds • Localized air trapping or atelectasis on end-expiratory chest radio- graph ■ Differential Diagnosis • Asthma with mucus plugging • Bronchiolitis • Pyogenic upper airway process (eg. Ludwig’s angina, soft tissue abscess, epiglottitis) • Laryngospasm associated with anaphylaxis • Bronchial compression from mass lesion • Substernal goiter • Tracheal cystadenoma ■ Treatment • Bronchoscopic or surgical removal of foreign body, often by rigid bronchoscopy • Emergency attention to airway—may require endotracheal in- tubation ■ Pearl An adult complaining of croup has a substernal goiter until proved otherwise. Reference Reilly JS et al: Prevention and management of aerodigestive foreign body injuries in childhood. Pediatr Clin North Am 1996;43:1403. [PMID: 8973519] 46 Essentials of Diagnosis & Treatment 2 Allergic Bronchopulmonary Aspergillosis ■ Essentials of Diagnosis • Caused by an allergy to antigens of aspergillus species that colo- nize the tracheobronchial tree • Recurrent dyspnea, unmasked by corticosteroid withdrawal, with history of asthma; cough productive of brownish plugs of sputum • Physical examination as in asthma • Peripheral eosinophilia, elevated serum IgE level, precipitating antibody to aspergillus antigen present; positive skin hypersensi- tivity to aspergillus antigen • Infiltrate (often fleeting) and central bronchiectasis by chest radio- graphy ■ Differential Diagnosis • Asthma • Bronchiectasis • Invasive aspergillosis • Churg-Strauss syndrome • Löffler’s syndrome • Chronic obstructive pulmonary disease ■ Treatment • Oral corticosteroids often required for several months • Inhaled bronchodilators as for attacks of asthma • Treatment with itraconazole (for 16 weeks) improves disease control • Complications include hemoptysis, severe bronchiectasis, and pulmonary fibrosis ■ Pearl One of the three ways aspergillus causes disease—all different patho- physiologically. Reference Stevens DA et al: A randomized trial of itraconazole in allergic broncho- pulmonary aspergillosis. N Engl J Med 2000;342:756. [PMID: 10717010] Chapter 2 Pulmonary Diseases 47 2 Bronchiectasis ■ Essentials of Diagnosis • A congenital or acquired disorder affecting the large bronchi causing permanent abnormal dilation and destruction of bron- chial walls; may be a consequence of untreated pneumonia • Chronic cough with copious purulent three-layered sputum, hemop- tysis; weight loss, recurrent pneumonias • Coarse, moist crackles; clubbing • Hypoxemia; obstructive pattern by spirometry • Chest x-rays variable, may show multiple cystic lesions at bases in advanced cases • High-resolution CT scan is essential for diagnosis in many cases • Often associated with underlying systemic disorder (eg, cystic fibrosis, hypogammaglobulinemia, IgA deficiency, common variable immunodeficiency, primary ciliary dyskinesia), chro- nic pulmonary infection (eg, tuberculosis, lung abscess), and HIV infection ■ Differential Diagnosis • Chronic obstructive pulmonary disease • Tuberculosis • Chronic lung abscess • Pneumonia due to any cause ■ Treatment • Smoking cessation • Antibiotics selected by sputum culture and sensitivities • Chest physiotherapy • Inhaled bronchodilators • Surgical resection in selected patients with unresponsive local- ized disease or massive hemoptysis • Complications include cor pulmonale, amyloidosis, and secondary visceral abscesses (eg, brain abscess) ■ Pearl Paragonimiasis is the most common cause worldwide, as bronchiecta- sis is the world’s most common cause of hemoptysis. Reference Cohen M et al: Bronchiectasis in systemic diseases. Chest 1999;116:1063. [PMID: 10531174] 48 Essentials of Diagnosis & Treatment 2 Acute Tracheobronchitis ■ Essentials of Diagnosis • Poorly defined but common condition characterized by inflam- mation of the trachea and bronchi • Due to infectious agents (bacteria or viruses) or irritants (eg, dust and smoke) • Cough is most common symptom; purulent sputum production and malaise common • Variable rhonchi and wheezing; fever is often absent but may be prominent in cases caused by Haemophilus influenzae • Chest x-ray normal • Increased incidence in smokers ■ Differential Diagnosis • Asthma • Pneumonia • Inhaled foreign body • Inhalation pneumonitis • Viral croup ■ Treatment • Symptomatic therapy with inhaled bronchodilators, cough sup- pressants • Antibiotics are not recommended in all patients because they shorten the disease course by less than 1 day • Patients encouraged to stop smoking ■ Pearl Sputum culture does not help in this disorder. Reference Gonzales R et al: Uncomplicated acute bronchitis. Ann Intern Med 2000;133: 981. [PMID: 119400] Chapter 2 Pulmonary Diseases 49 2 [...]... Reference Allen JN et al: Eosinophilic lung diseases Am J Respir Crit Care Med 1994;150(5 Part 1):1 423 [PMID: 79 525 71] 2 62 Essentials of Diagnosis & Treatment Hypersensitivity Pneumonitis 2 I Essentials of Diagnosis • Work and environmental history suggesting link between activities and symptoms • Acute form: 4– 12 hours after exposure, onset of cough, dyspnea, fever, chills, myalgias; tachypnea, tachycardia,... Community-acquired pneumonia in adults: guidelines for management The Infectious Diseases Society of America Clin Infect Dis 1998 ;26 :811 [PMID: 9564457] 2 52 Essentials of Diagnosis & Treatment Anaerobic Pneumonia & Lung Abscess 2 I Essentials of Diagnosis • Cough producing foul-smelling sputum; hemoptysis; fever, weight loss, malaise • Patients with periodontal disease, history of impaired deglutition... evaluation Pearl All murmurs of mitral stenosis may be missing in that condition, leading to an inaccurate diagnosis of primary pulmonary hypertension Reference Gaine SP et al: Primary pulmonary hypertension Lancet 1998;3 52: 719 [PMID: 9 729 004] 2 58 Essentials of Diagnosis & Treatment Silicosis 2 I Essentials of Diagnosis • A typical pneumoconiosis: a chronic fibrotic lung disease caused by the inhalation of various... [PMID: 91 420 77] 2 60 Essentials of Diagnosis & Treatment Pulmonary Alveolar Proteinosis 2 I Essentials of Diagnosis • May be idiopathic or secondary (ie, post lung infection, immunocompromised host) • Progressive dyspnea and low-grade fever • Physical examination often normal • Hypoxemia; bilateral alveolar infiltrates suggestive of pulmonary edema on chest radiography • Characteristic intra-alveolar... smoking Reference American Thoracic Society Idiopathic pulmonary fibrosis: diagnosis and treatment International consensus statement American Thoracic Society (ATS), and the European Respiratory Society (ERS) Am J Respir Crit Care Med 20 00;161 (2 Part 1):646 [PMID: 1067 321 2] Chapter 2 Pulmonary Diseases 55 Sarcoidosis I Essentials of Diagnosis • A disease of unknown cause with an increased incidence in North... receiving oral feedings, H2 inhibitors, or sucralfate • Prevention in high-risk patients (eg, intensive care setting) using these same agents I Pearl Ninety-five percent of gastroenterologists and a high proportion of other health care workers carry H pylori Reference Tytgat GN: Ulcers and gastritis Endoscopy 20 00; 32: 108 74 Essentials of Diagnosis & Treatment Duodenal Ulcer I Essentials of Diagnosis • Epigastric... statement was endorsed by the Council of the Infectious Disease Society of America, September 1999 Am J Respir Crit Care Med 20 00;161(4 Part 1):1376 [PMID: 10764337] 2 54 Essentials of Diagnosis & Treatment Idiopathic Pulmonary Fibrosis (Usual Interstitial Pneumonia) 2 I Essentials of Diagnosis • Insidious onset of dyspnea and dry cough in patients usually in their sixth or seventh decades • Inspiratory... esophagoscopy with biopsy at 1- or 2- year intervals I Pearl When brisk upper gastrointestinal bleeding occurs in a patient with Barrett’s esophagus, suspect cardioesophageal fistula Reference Bremner CG et al: Barrett’s esophagus Surg Clin North Am 1997;77:1115 70 Essentials of Diagnosis & Treatment Mallory-Weiss Syndrome (Mucosal Laceration of the Gastroesophageal Junction) I 3 Essentials of Diagnosis • Because... Rathbun SW et al: Sensitivity and specificity of helical computed tomography in the diagnosis of pulmonary embolism: a systematic review Ann Intern Med 20 00;1 32: 227 [PMID: 10651604] Chapter 2 Pulmonary Diseases 57 Primary Pulmonary Hypertension I Essentials of Diagnosis • A rare disorder seen primarily in young and middle-aged women • Defined as pulmonary hypertension and elevated peripheral vascular resistance... esophageal motility disorders West J Med 1997;166 :26 3 66 Essentials of Diagnosis & Treatment Achalasia I Essentials of Diagnosis • Progressive dysphagia, odynophagia, and regurgitation of undigested food • Barium swallow demonstrates a dilated upper esophagus with a narrowed cardioesophageal junction (“bird’s beak” esophagus); chest x-ray may reveal a retrocardiac air-fluid level • Lack of primary peristalsis . Society (ERS). Am J Respir Crit Care Med 20 00;161 (2 Part 1):646. [PMID: 1067 321 2] 54 Essentials of Diagnosis & Treatment 2 Sarcoidosis ■ Essentials of Diagnosis • A disease of unknown cause. computed tomography in the diagnosis of pulmonary embolism: a systematic review. Ann Intern Med 20 00;1 32: 227 . [PMID: 10651604] 56 Essentials of Diagnosis & Treatment 2 Primary Pulmonary Hypertension ■ Essentials. obstructive pulmonary disease. N Engl J Med 20 00;343 :26 9. [PMID: (UI: 10911010] 44 Essentials of Diagnosis & Treatment 2 Cystic Fibrosis ■ Essentials of Diagnosis • A generalized autosomal recessive