Module 4.3 - Restrictive (Inflammatory) Lung Diseases Flashcards
Define restrictive lung disease
Restrictive lung diseases are characterized by reduced lung volumes. Unlike obstructive lung diseases which show a normal or increased total lung capacity (TLC), restrictive diseases are associated with a decreased TLC.
What causes restrictive lung disease?
There are many disorders that cause reduction or restriction of lung volumes.
- The first is intrinsic lung diseases or diseases of the lung parenchyma.
- The diseases cause scarring of the lung tissue (interstitial lung disease) or result in filling of air spaces with exudate and debris (pneumonitis)
- The second is extrinsic disorders or extra pulmonary disorders – specifically disorders of the chest wall, pleura and respiratory muscles (neuromuscular disorders).
What is pneumonia?
- Acute febrile inflammatory disorder of the lung(s) associated with cough and exertional dyspnea.
- An infiltrate is seen on CXR, sometimes 24-48 hrs. after symptoms begin.
- Leukocytosis may be present.
Describe the etiology/incidence associated with pneumonia
- Most common of all serious lung conditions, frequent cause of acute care hospitalizations and mortality
- Elderly at risk due to poor immune systems, debilitated state, fragility
- Over treatment with antibiotics of mild URI has contributed to antimicrobial drug resistance, especially S. pneumoniae
- These comorbidities cause a higher mortality in patients with pneumonia: COPD, HF, DM, chronic liver and kidney disease.
- Very young and very old patients are also at high risk for death despite adequate treatment with antibiotics.
What are the typical symptoms associated with pneumonia?
fever, chills, leukocytosis, cough, and sputum production increased fremitus. CXR may show single infiltrate
What are the atypical symptoms associated with pneumonia?
fever may be high, +/- leukocytosis. A left shift may be present, dry cough, HA, sore throat, excessive sweating, chest soreness,
What are the common organisms associated with Community acquired pneumonia (CAP)?
- Most common bacteria – Streptococcus pneumoniae (most common), Haemophilus influenza, Klebsiella pneumoniae, gram negative organisms.
- Atypical pathogens – Chlamydia pneumoniae, Mycoplasma pneumoniae, Mycobacterium tuberculosis.
- Viruses – respiratory syncytial virus, adenovirus, rhinovirus
What is and what are the common organisms associated with Hospital acquired pneumonia (HAP)?
It is a Nosocomial infection that occurs 48 hrs. or more after admission. The most common organisms include:
- Staphylococcus aureus
- Streptococcus pneumoniae
- Haemophilus influenzae
What is and what causes Ventilator acquired pneumonia (VA)?
- Pneumonia that occurs 48-72 hrs. after intubation.
- Most common culprit: Pseudomonas
How would you evaluate a patient with suspected pneumonia?
Conduct a physical exam and look out for – tachycardia, tachypnea, fever, rales or crackles present over the affected lung, mental status changes, or confusion
Obtain a CXR – assess for infiltrates, may repeat if no infiltrate seen initially but pneumonia is still suspected
Check – CBC including white count, blood cultures, gram stain and culture of sputum, ABG and spirometry, procalcitonin levels if available.
How do you treat outpatient pneumonia?
- Treat initially with a macrolide (azithromycin, clarithromycin, Erythromycin) or doxycycline for 5 days
- Therapy should be revised as culture results are reported, if indicated, as initial treatment is empiric.
- Remember to assess patient clinically for ongoing improvement or worsening of symptoms. Use the narrowest spectrum antibiotic. Cover anaerobic organisms incases of known or suspected pneumonia. Not all patients need hospitalization for treatment
What is the criteria for ICU admission for patients with pneumonia?
- Need mechanical ventilation
- Have hypotension (systolic BP ≤ 90 mm Hg) that is unresponsive to volume resuscitation
- Other criteria that mandate consideration of ICU admission include
- Respiratory rate >30/min
- Pao2/fraction of inspired oxygen (Fio2) < 250
- Multilobar pneumonia
- Diastolic BP < 60 mm Hg
- Confusion
- BUN > 19.6 mg/dL
What does the CURB-65 scoring system stand for and what is it used for?
- Confusion
- Uremia (BUN ≥19 mg/dL)
- Respiratory rate > 30 breaths/min
- Systolic BP < 90 mm Hg or diastolic BP ≤ 60 mm Hg
- Age ≥ 65 yr
1 point is given for each risk factor and when added up determines the need for hospitalization.
Describe the point system used in the CURB-65 system.
0 or 1 points: Risk of death is < 3%. Outpatient therapy is usually appropriate.
2 points: Risk of death is 9%. Hospitalization should be considered.
≥ 3 points: Risk of death is 15 to 40%. Hospitalization is indicated, and, particularly with 4 or 5 points, ICU admission should be considered.
What 2 vaccinations are available to prevent pneumonia?
- PCV 13: pneumococcal conjugate vaccine for infants, children and adults older than 19 years at high risk for disease
- PPSV23: pneumococcal polysaccharide vaccine for adults older than 65 years of age and those older than 2 years of age at high risk.
What causes tuberculosis?
- Mycobacterium tuberculosis.
- The lungs are the major site for primary infection and disease. Manifestations include primary TB and reactivation TB.
What are the symptoms associated with tuberculosis?
Many patients are asymptomatic.
Typical symptoms include:
- Fever is generally gradual, begins with low grade, can be as high as 390 C and last for 14-21 days
- Cough
- Productive, purulent sputum that may contain blood
- Weight loss
- Night sweats severe enough that may require changing bed linens
- Dyspnea can occur in the setting of extensive parenchymal involvement, if pleural effusions develop or if a pneumothorax occurs.
What does a skin PPD test for, and when and how do you interpret its results?
intradermal purified protein derivative. This test indicates exposure only, not active disease. TB skin test has been used for years as an aid in diagnosing latent tuberculosis infection (LTBI). Its result is a measurement of a hypersensitivity response.
Findings after 48 hours should be interpreted as:
- Less than 5 mm (indurated area only) is negative
- 5 mm or more is positive in HIV infected patient, recent TB exposure, immunocompromised patient or one with chest x-ray typical for TB
- 10 mm or more is positive in health care workers, HIV negative injection drug users, residents in nursing homes, homeless shelters or recent immigrants.
15 mm or more is positive in any situation/person
How is the Quantiferon Gold Test used for TB testing?
- It is a serum test for diagnosis of TB, either latent or active, used instead of PPD.
- The results are less subjective to reader bias and error and is quickly replacing the traditional testing in some practices although the CDC discourages the use for those patients among populations at low risk.
What and when are chest x-ray changes seen for TB?
Infiltrates can be present in any portion of the lungs but are usually seen in the upper lobes or in the superior segments of the lower lobes. Cavitation is seen.
What is Idiopathic pulmonary fibrosis (IPF)?
IPF is a progressive disease that is seen in elderly patients (60-70yrs old), occurs more often in men than women, and usually carries a poor prognosis, especially if the disease proves to be progressing rapidly. The pathogenesis is complex and likely involves cycles of epithelial cell injury and dysregulated repair.
It is strongly linked to cigarette smoking
What conditions should be ruled out prior to treating idiopathic pulmonary fibrosis?
Prior to treatment, the following conditions need to be ruled out:
- Inhalation exposure
- Autoimmune disorders
- Chronic lung infections including TB, fungal infections of Histoplasmosis coccidioidomycosis and spread of prior known cancers
What laboratory tests/diagnostic tests are used to confirm a idiopathic pulmonary fibrosis diagnosis?
- Routine lab is not helpful in diagnosis. PPD should be obtained as well as fungal cultures including Histoplasma capsulatum, Coccidioides immitis and Blastomycosis. Familiarize yourself with your patient’s environment and fungi pertinent to that region.
- CXR and High Resolution Chest CT - show changes in the lung parenchyma especially in the lower lobes. Other findings may include interstitial infiltrates (may resemble HF), nodules and cystic or honeycombing changes. Bronchiectasis may also be seen.
- PFTs - Complete PFTs including spirometry, lung volumes, diffusing capacity and resting and ambulatory pulse oximetry should be obtained. Restrictive defects will be noted along with mild hypoxemia on ABG if obtained, CO2 retention in the later stages. This study will be helpful during the course of the disease to help establish a pattern and assess for additional lung changes: e.g. obstructive
- Fiber optic bronchoscopy with biopsy - is safe and should be done to confirm diagnosis. Broncho alveolar lavage (BAL) obtains specimens for culture. If inadequate tissue is obtained with this procedure, patients will need to undergo open lung biopsy by cardiothoracic surgery, if they are stable enough.
What is Sarcoidosis?
- The disease is characterized pathologically by the presence of non caseating granulomas and interstitial lung disease.
- The systemic manifestations of the disease include lymphadenopathy, cardiac involvement, iritis, cutaneous lesions, arthritis, gastrointestinal involvement and potentially other organs.
- Etiology is unknown and affects individuals worldwide.
What are and describe the stages of sarcoidosis
