Pulmonary Diseases Sang-Min Lee Division of Pulmonary and Critical Care Medicine Department of Internal Medicine Seoul National University College of Medicine

Pulmonary Diseases  Infectious disease  Airway disease  Interstitial lung disease  Pulmonary vascular disease  Pleural disease  Malignancy

Pulmonary Diseases  Infectious disease  Airway disease  Interstitial lung disease  Pulmonary vascular disease  Pleural disease  Malignancy

Infectious Disease  Upper respiratory tract infection ; Common cold  Lower respiratory tract infection ; Pneumonia

Upper Respiratory Tract Infection (URI)  Acute rhinitis  Acute rhinosinusitis  Acute nasopharyngitis (the common cold)  Acute pharyngitis  Acute laryngitis/epiglottitis  Acute layngotracheitis  Acute tracheitis

Common Cold Syndrome  General term of acute inflammatory disease of the upper respiratory tracts such as nasal cavity, tonsils, pharynx and larynx  Includes rhinitis, tonsilitis, pharyngitis, laryngitis (including croup), pharyngo-laryngitis

Symptom of Common Cold  Nasal obstruction  Sneezing  Sore throat  Cough  Sputum  Headache  Fever  General malaise

Viruses associated with Common Cold

Seasonal Variation of Pathogens in URI

Treatment of Common Cold  To keep room warm and humid  Taking rest  Enough rehydration  Taking nourishing food

Symptomatic Treatment of Common Cold  Antihistamine and/or decongestant  Antitussive with expectorant  NSAIDs or Topical anesthetic for sore throat

Role of Antibiotics in Common Cold  No role in uncomplicated nonspecific URI Single course of macrolide can lead to macrolide resistance among oral streptococci  Even purulence from the nares and throat does not confirm bacterial infection

Pneumonia  Community acquired pneumonia  Hospital acquired pneumonia

Community Acquired Pneumonia  an acute infection of the pulmonary parenchyma in a patient who has acquired the infection in the community

Diagnosis of CAP  Symptom : cough, fever, pleuritic chest pain, dyspnea and sputum production  Radiographic abnormality

Pathogens of CAP

Empirical Antibiotic Therapy in CAP  Outpatient ℬ -lactam ± macrolide –amoxicillin, amoxicillin-clavulanate, cefpodoxime, cefditoren ± azithromycin, clarithromycin,erythromycin, roxithromycin Respiratory fluoroquinolone –Gemifloxacin, levofloxacin, moxifloxacin

Empirical Antibiotic Therapy in CAP  Inpatient (general ward) ℬ -lactam + macrolide –ceftriaxone, cefotaxime –ampicillin/sulbactam or amoxicillin/clavulanate + azithromycin, clarithromycin,erythromycin or roxithromycin Respiratory fluroquinolone –Gemifloxacin, levofloxacin, moxifloxacin

Empirical Antibiotic Therapy in CAP  Inpatient (ICU, suspected Pseudomonas) Antipneumococcal, antipseudomonal ℬ -lactam (cefepime, piperacillin/tazobactam, imipenem,meropenem) + ciprofloxacin or levofloxacin Antipneumococcal, antipseudomonas ℬ -lactam + aminoglycoside + azithromycin Antipneumococcal, antipseudomonas ℬ -lactam + aminoglycoside + antipneumococcal fluoroquinolone (gemifloxacin, levofloxacin, moxifloxacin)

Hospital-Acquired Pneumonia  Pneumonia not incubating at the time of hospital admission and occurring 48 hrs or more after admission

Ventilator-Associated Pneumonia  Pneumonia occurring >48 hours after endotracheal intubation

Incidence of HAP  22% of hospital acquired infection  10% of intubated patients  Up to 70% of ARDS patients  6~20 times higher among mechanically ventilated patients  22% of hospital acquired infection  10% of intubated patients  Up to 70% of ARDS patients  6~20 times higher among mechanically ventilated patients

Mortality of HAP  Crude mortality ; 20 ~ 50%  Highest in Bacteremic patients Infected with high risk pathogens ICU patients  Crude mortality ; 20 ~ 50%  Highest in Bacteremic patients Infected with high risk pathogens ICU patients

Route of Infection in HAP  Aspiration of oropharyngeal secretion  Aspiration of esophageal/gastric contents  Inhalation of aerosol containing bacteria  Hematogenous spread

Clinical Manifestations in HAP  Not so different from community-acquired pneumonia  Fever, cough, sputum  Dyspnea, pleuritic chest pain  Infiltration in CXR  Hypoxemia  Not so different from community-acquired pneumonia  Fever, cough, sputum  Dyspnea, pleuritic chest pain  Infiltration in CXR  Hypoxemia  It is important to exclude noninfectious causes of pulmonary infiltrates when evaluating a patient who presents with possible HAP !!!

Diagnostic Criteria in HAP New or progressive infiltrate on CXR Clinical evidence showing infectious origin  Fever  Leukocytosis  Purulent sputum  Decline in oxygenation  Fever  Leukocytosis  Purulent sputum  Decline in oxygenation +

Diagnostic Approach  Physical examination  Chest radiography  Bacteriological identification ; sampling of lower respiratory secretion  Physical examination  Chest radiography  Bacteriological identification ; sampling of lower respiratory secretion

Sampling Methods  Endotracheal aspiration  Bronchoscopic sampling  Blinded invasive methods  Endotracheal aspiration  Bronchoscopic sampling  Blinded invasive methods

Initial Therapy for HAP  Most initial Tx for HAP is empirical !!!  Selection of drugs Local bacteriologic patterns Local patterns of antimicrobial resistance Cost Availability  Most initial Tx for HAP is empirical !!!  Selection of drugs Local bacteriologic patterns Local patterns of antimicrobial resistance Cost Availability

Risk for MDR pathogens IDSA Guidelines. Clin Infect Dis 2016

Airway Disease  Bronchial asthma  Chronic Obstructive Pulmonary Disease (COPD)

Bronchial asthma  Clinical manifestation Symptoms – breathlessness, cough, wheezing Episodic  Physical Examination Wheezing, hyperinflation

Tests for Diagnosis of Asthma  Lung function test – variable airflow limitation, reversibility Spirometry: FEV1 Microspirometry PEFR  Airway hyperresponsiveness Airway challenge tests  Allergic status Skin prick tests Serum specific IgE

Treatment Strategy for Asthma

Assessment of control level in Asthma

COPD  Chronic airflow limitation Small airway disease –Obstructive bronchiolitis –Obstruction of conducting airway Parenchymal destruction –Emphysema –Loss of elastic recoil

Symptoms of COPD  Chronic airflow limitation Chronic and persistent dyspnea Cough Sputum  Slowly progress, persistent  Chronic bronchitis Chronic productive cough for three months in each of two successive years in a patient in whom other causes of chronic cough have been excluded

Diagnosis of COPD Spirometry: Post-bronchodilator FEV1/FVC < 70%  Symptoms + risk factors + spirometry  Spirometric diagnostic criteria for COPD

Phenotypes of COPD

Spectrum of COPD phenotype

Pharmacotherapy in COPD

Inhalers

Non-Pharmacologic Management of COPD Table 4.3. Non-Pharmacologic Management of COPD Patient Group Essential Recommended Depending on Local Guidelines A Smoking cessation (can include pharmacologic treatment) Physical activity Flu vaccination Pneumococcal vaccination B-D Smoking cessation (can include pharmacologic treatment) Pulmonary rehabilltation Physical activity Flu vaccination Pneumococcal vaccination

Classification of Pulmonary Embolism  Thrombotic Pulmonary Embolism Pulmonary (Thrombo)Embolism  Non-thrombotic Pulmonary Embolism Fat embolism Air embolism Amniotic fluid embolism Tumor embolism Septic embolism

Pulmonary (Thrombo)Embolism  Definition Migration of (a) clot(s) from systemic veins to the lungs  Sources of Emboli Most pulmonary emboli from deep veins in the legs Uncommon but important sources, esp. in women – pelvic veins Rare source – emboli from right heart Recently, upper extremities d/t invasive procedures

Pathogenesis of PTE

Risk Factors - Acquired

Clinical Presentation of PTE

CT Pulmonary Angiography Primary diagnostic test for pulmonary embolism Positive predictive value varies –97% with main or lobar –68% with segmental –only 25% with isolated subsegmental pulmonary artery CT pulmonary angiography can lead to contrast induced nephropathy and is associated with substantial radiation exposure

CT Pulmonary Angiography

Lung Perfusion Scan Crit Care Clin 2011;27:841

Treatment of PTE Anticoagulation Thrombolytic therapy IVC Filter Thromboembolectomy

Anticoagulation of Acute PTE N Engl J Med 2010;363:266

Thrombolysis Significantly accelerated resolution of pulmonary emboli In pulmonary embolism with hypotension & shock Complications –significantly higher hemorrhage rates

IVC filter Should be reserved for patients with contraindications to anticoagulant treatment Complications –death –filter migration –filter erosion –IVC obstruction Retrievable vena cava filters may be an option for patients with presumed time-limited contraindications to anticoagulant therapy

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