Respiratory Conference Summary

I. Clinical PEARLS
Always look for both obstructive AND restrictive disease on PFTs: If both, consider obesity for restrictive
For obstructive lung disease, might have concurrent COPD WITH asthma
II. Obstructive Lung Disease
Obstructive Pattern of PFTs Suggests either asthma, chronic bronchitis, emphysema
o Increased residual volume (dead space); Decreased FEV1, dec FVC, dec FEV1/FVC
ASTHMA
COPD
PFTs
FVC OR FEV1 improves > 12% w/ bronchodilator
10% decrease w/ bronchodilator is common for COPD
Decreased DLCO
Treatment
Non-pharm interventions: decrease triggers (dust mites,
FEV1 60-80%: Inhaled bronchodilators; consider
molds, sulfites, cold air)
pulmonary rehab
FEV1 < 60%: Differents recs as monotherapy or combo
Decrease exposure- cover mattresses and pillow; wash
Inhaled bronchodilators
bedding weekly; remove carpets; vacuum clean weekly
with mask; reduce humidity < 45%; clean carpets
Monotherapy: (1) long-acting inhaled anticholinergics
Allergy Testing recommended
- tiotropium; (2) LABA salmeterol/formoterol.
Pharm Interventions
o *Some studies show LABA superior; others
Mild Sx: SABA
anticholinergics (also pts more likely to stop
Moderate Symptoms: SABA + low/medium inhaled
anticholinergics)
corticosteroids
Combination inhaled: (1) long-acting inhaled
Severe: SABA + high dose inhaled corticosteroids; also
anticholinergics; (2) LABA; and/or (3) inhaled
corticosteorids
consider adding LABA (but never use alone; do not use if
o Increase fracture risk corticost.
adequately controlled on lw/medium corticosteroids; step
down once stable; peds use combo)
If all three max dose and fails consider
o Study: tiotropium (anticholindergic) to inhaled
o theophylline;
glucocorticoids superior to doubling inhaled
o oral corticosteroids
glucocorticoids and comparable to adding
o referral to pulmonologist
salmeterol
o roflumilast (phosphodiesterase type 4
Other symptomatic relief: Nasal steroids / antihistamines
inhibitor smooth muscle relaxation) but
dec post nasal drip; Make sure that using inhaler
safety concerns w/ suicide, diarrhea, nausea,
correctly
weight loss
Acute Exacerbations with URI: ALWAYS DO PEAK FLOW
Consider pulmonary rehab
MEASURE
FEV1 < 50%: All pts pulmonary rehab
Mild impairment SABA
Mod / Sev impairment ORAL steroids + SABA
Resting hypoxemia? PaO2 < 55; SPO2 < 88%
Severe Recurrent ORAL steroids at first sign
All pts should be on continuous oxygen
Pathophysiology
o Mechanism of Exercise-Induced Air Trapping: think (1) inability to increase alveolar pressure; (2) area of low V/Q
Exercise need to increase expiratory flow. But decreased elastic recoil not able to increase alveolar pressures
EPP moves toward alveoli premature collapse of airway AND creates area of low V/Q contributing to hypoxemia
o Mechanism of Dyspnea in COPD: Increased ventilatory demand
Sensors: chest wall receptors, pulmonary vagal receptors, chemoreceptors
1) Physiologic dead space (increased dead space to tidal volume):
Because dead space, greater work of breathing necessary to maintain PCO2. Usually subjective feeling of
dyspnea occurs when get to 50-60% of max minute ventilation. But in COPD, resting close to MMV.
2) Hypercarbia: increased minute ventillation but decrease in overal alv ventillation hypercarbia
3) Hypoxemia: Low V/Q areas in extreme (dead space) shunt, contributes to hypoxemia.
Exercise pulmonary blood flow increased increase flow to areas with low V/Q dec pO2.
COPD diffusion capacity decreased even further hindered during exercise because greater flow.
Also decrease in mixed venous O2 due to increased peripheral use of O2 flows through low V/Q builds
o (4) Lower O2 sat premature lactic acidosis
5) If infection more bronchoconstriction AND more CO2 produced
IV. Chronic Cough (> 3 weeks): PANG
Differential diagnosis (most least likely): (1) post nasal drip; (2) asthma; (3) non-asthmastic eosinophilic bronchitis; (4) GERD
Management
o (1) On ACEI / Smoker stop ACE, stop smoking. If continues chest x-ray
o (2) Ask whether hx suggests postinfectious cough?
Yes Do not get x-ray. Treat for post nasal drip. If persists, the evaluate for pertussis and hyperreactive airway

No chest x-ray.
If abnormal evaluate
If normal empircal treatment for postnasal drip (upper airway cough syndrome)
(3) If normal chest x-rays and cough persists after empiral tx for postnasal drip tx asthma
(4) If persists tx for non-asthmatic eosinophilic bronchitis
(5) If persists consider GERD

o
o
o

V. Upper Respiratory Complaints

Prevention: Get pneumovax if > 65 or have chronic cardio disease, asthma, COPD, diabetes, smoke cigarettes, alcoholism, chronic
liver disease, sickle cell disease, splenectomy, chronic kidney disease, HIV

Acute bronchitis: Cough productive of purulent sputum and increased dyspnea, low / absent fever
o An acute respiratory infection with cough as the predominant symptom, with or without sputum production, usually lasting
no more than 3 to 4 weeks. Patients will not have clinical or radiographic evidence of pneumonia, and will not have the
common cold, acute asthma, or an exacerbation of chronic obstructive pulmonary disease (COPD).
o Healthy patient w/ uncomplicated acute bronchitis
Etiology
Suspect virus (95%); rarely mycoplasma, pertussis, chlamydia pneumonia
o Viral causes: influenza A/B, parainfluenza, RSV, coronavirus, adenovirus, rhinovirus
o Suspect pertussis if cough after 2 weeks culture/PCR. Give antibiotic but for public health
purpose, not to treat symptoms, as will decrease shedding, but does not hasten resolution of
cough
Bronchial edema and mucus formation sputum production, cough, sx airway obstruction
Hx
HPI:
o Classic Sx: initial sx of URI; then cough (productive/nonproductive) > 5 days; purulent sputum
(50%); dyspnea w/ exertion; obstruction
Cough lasts up to 3 weeks in 50% of patients; greater than 1 month in 25% patients
o Associated sx: fever, sore throat, nasal congestion, runny nose
PMH: asthma associated condition (34% found to have asthma or chronic bronchitis on formal testing)
SH: Exposure to other toxic substances (cigarette smoke, sulfur dioxide, ammonia)
PE:
HEENT: may have rhinitis/pharyngitis; may have conjunctivitis or otitis media w/ adenovirus
Neck: may have LAD
Pulm: Useful but NOT diagnostic (wheezing, rhonchi, prolonged expiratory phase)
o Obtain forced expiration in prone patient to detect wheezing
o PFTs will only be reversibly lowered in 17% patients
DDx
Pneumonia: cough in absence of fever, tachycardia, tachypnea suggests bronchitis (except elderly)
o Other respiratory infections: bronchiolitis, sinusitis, common cold
Pertussis: suspect if close contacts, cough > 2 wks w/o other cause, paroxysmal cough w/ posttussive
emesis or characteristic whoop; order PCR if suspect
Reactive airway disease: asthma, allergic aspergillosis, chronic bronchitis
Bronchiectasis
Heart Failure: bibasilar rales, orthopnea
Causes of chronic cough: ACE inhibitor use; GERD, smoke exposure, bronchogenic tumor)
Dx:
Clinical diagnosis
Perform chest x-ray only if HR > 100 BPM, RR > 24 BPM, Body temp > 38C, chest exam shows focal
consolidation, egophony, fremitus
Tx:
< 75 years old
o Consider albuterol if significant dyspnea w/ evidence of airflow obstruction
Can also consider dextromethorphan / codeine

Antibiotics: Do NOT treat with antibiotics; if suspect need, can use procalcitonin levels (> .25
mcg/L encouraged)
o Sx Management: Consider pelargonium sidoides extract shown to reduce sx greater than
placebo and allow quicker return to work (2 days faster)
> 75 years old: if fever, COPD,HF, insulin-dependent diabetes, immunocompromised antibiotic
o

COPD:
1) Make sure that on all classes of inhaled therapy; anticholinergic; LABA, SABA
2) Give PO corticosteroids (40 mg / 5 days)
3) Consider whether antibiotics indicated
Need 2/3: (1) inc dyspnea; (2) change color sputum; (3) inc production
Suspected agents (distinct from non-COPD pt): MORe vaccines Moraxella; H. Flu; pneumococcus
Treatment depends on risk: FEV1<50%, over 65, 3 or more exacerbations per year, cardiac disease
o HIGH RISK QUIt it with AMOXICILLIN (quinolone; amoxicillin w/ clevulonic acid)
o LOW RISK: Aze CDO_P = Azithromycin; Cefuroxime; DOxycycline; tmP-sulfa
If had antibiotic in last 3 months choose different class*
Pneumonia
o Ddx:
Legionnaires Pneumonia:
Hx: Cough, expectoration, dyspnea, thoracic pain, hemoptysis
o Associated Sx: High fever w/ relative bradycardia; headache (20-35%); confusion (30-35%);
nausea/vomiting/diarrhea (22-35%)
o SH: Consider w/ males (2-3x risk of females) who travel abroad (26x RF), smoker, cancer,
driver by profession, diabetes
Dx: urine antigent assay; obtain sputum culture for confirmation; CXR show single / unlilateral inflitrates
in 70-80%; in immunocompromised, see cavitation
Tx:
o Antibiotics: Fluoroquinolones (levofloxacin) are DOC; macrolides are an alternative
o Hospitalize if CRB65 score > 1
Diastolic BP < 60 or systolic BP < 90
Presence of confusion (disorientation in person, place or time
RR >=30/min
BUN > 19 mg/dl
Age >=65
o Pneumonia with patchy infiltrate in healthy patient do NOT give antibiotics
Most likely cause (agent): atypicals (mycoplama, chlamydia, legionnaires), viral, pneumococcus
Sore throat
o Sore throat w/ lymphadenopathy, mild LUQ tenderness
Differential: strep throat, virus/mycoplama, EBV (mono)
Centor criteria for Group A Strep: (1) absence of cough; (2) subjective fever; (3) tender lymphadenopathy; (4)
exudate
Rhinitis: is either (1) allergic; (2) non-allergic; or (3) mixed
o Mixed: Combination of allergic and nonallergic symptoms; 50% allergic become non-allergic
Allergic (3x more common than non-allergic)
Non-Allergic
Seasonal or perennial at any age
Usually perennial begins after 20
Triggers: allergic
Triggers: vasomotor - environmental
conditions (temp; odor; smoke; alcohol;
sexual arousal; emotional)
Sx: sneezing, rhinorrhea, nasal congestion, nasal itching, eye itchiness, conjunctivitis (75% Sx: sneezing and rhinorrea less common;
have eye sx)
nasal obstruction and post nasal drip
FH: asthma or allergic rhinitis
FH: none needed
Tx:
Tx:
Severity
Severity:
Mild: nasal steroid vs. antihistamine
Mild: Intranasal corticosteroids or nasal
Moderate-Severe: Nasal steroids w/ antihistamine and antileukotrienes
antihistamines (azelastine)
o

Symptoms
-Sneezing, nasal pruritis: antihistamines (azelastine)
-Rhinorrhea: Antihistamine; chromolyn (but 4x daily dosing); antileukotrienes
-Congestion: Nasal steroids; alpha agonists (but intranasal rebound congestion- rhinitis
medicametosa); chromolyn (mast cell stabilizers), but 4x daily dosing; antileukotrienes
-Conjunctivitis: either nasal steroids or antihistamines

Symptoms:
Persistent: nasal antihistamine
Pure rhinorrhea w/o congestion: nasal
ipratropium

***Evaluate for asthma- 1/3 pts will develop asthma; so treat aggressively b/c can prevent
development of asthma (allergy shots)
Sinusitis
o Overview: Often classified as rhinosinusitis because of concurrent symptoms
o Hx:
HPI:
Classic sx: (1) purulent nasal discharge, (2) facial pain, pressure, fullness (above/below w/ leaning); (3)
nasal obstruction (congestion, blockage, stuffiness)
Associated sx: fever, cough, fatigue, hyposmia, anosmia, ear fullness/pressure, maxillary toothache
Distinguishing characteristics: hx colored nasal discharge, mucopurulence on exam, poor response to
antihistamines, double worsening (viral before bacterial)
Irrelevant: fever
PMH: Asthma (17-30% have sinusitis), viral URIs, allergy (allergic rhinitis), immunodeficiency; CF
SH: smoking (RF) / second hand smoke
o Px: HEENT
Look for anatomic abnormalities (deviated septum, polyps, tortuous nasal passages) = RFs
Purulent nasal discharge / nasal obstruction; swelling / edema over cheekbone or periorbital area, pain with
percussion
Signs of extrasinus involvement: orbital or facial cellulitis, eye movement abnormalities, neck stiff
o Pathogenesis: URI mucosal edema and ostia obstruction stagnation secretions, dec pH, lower O2 growth
Viral infection
Bacterial infection: Strep pneumo, H. flu, Moraxella catarrhalis
Fungal etiology: consider for immunocompromised patients and patients w/ diabetes (Aspergillus)
o Ddx:
Viral URI
Allergic rhinitis
Migraine
o Dx: Dx: acute (< 4 weeks); recurrent acute (4 or more episodes / yr); subacute (4-12 weeks); chronic (>12)
o Tx:
Supportive Therapy: analgesics and antipyretics PRN, intranasal corticosteroids (e.g. beclomethasone), intranasal
saline, mucolytics (guaifenesin); antihistamines (only if allergic component, can worsen congestion by drying
mucosa), decongestants (lack evidence for effectiveness, nasal decongestants can cause rhinitis medicamentosa)
Antibiotics: Usually tx for 5-7 days
Only if under following scenarios:
o 1) 10 days of persistent symptoms w/o improvement
o 2) Severe symptoms / signs of high fever (102) + purulent nasal discharge/facial pain > 3-4 days
o 3) Double sickening: new fever, headache, increase in nasal discharge following URI of 5-6 days
Benefit: increase cure rate at 7-14 days by 25%; amoxicillin showed no improvement at day 3
No antibiotic is superior: Augmentin (5 days = 10 days); levofloxacin / moxifloxacin (if severe or
resistance); TMP/SMX (160/800 mg BID, 3 days may = 10 days)
o Complications / Prognosis:
Acute: Orbital cellulitis (75% cases of orbital celluitis from sinusitis); osteomyelitis
Chronic: bacterial meningitis, cavernous sinus thrombosis, osteitis

Rhinosinusitis
o Acute:
Cause: virus + MORe vaccines + staph aureus (*Strep pneumonia about 1/3; h. influenza 1/3; mix rest)
Natural history: Most last 1-33 days; most well in 7-10 days; most viral and resolve without antibiotics
When prescribe antibiotics?
1) Last > 10 days w/o evidence of clinical improvement
2) High fever (102) and purulent discharge/pain for MINIMUM 3-4 days
3) Double sickening- follows URI of 5-6 days duration w/ fever, headache, inc nasal discharge
Antibiotics: (Similar to tx for acute bronchitis)
1st line: amoxicillin-clavulonic acid 5-7 days adult; 10 days children
2nd line: doxycycline
3rd line (heavy hitters): levofloxacin, moxifloxacin (resp quinolone)
o *Start here if over 65, prior antibiotics in last month; prior hospitalization; comorbid; HIV
o *Also use if dont respond in 3-5 days or worsen after 72 hours;
alt = clindamycin + cefixime
Always do sinus aspiration (direct) at time of prescription
Other treatment: intranasal steroids and nasal irrigation (little evidence for antihistamines / decongestants)
o Recurrent: defined as 4 or more episodes per year w/ no sx between episodes
think (1) allergies; (2) anatomical (scarring, polyps); (3) immune deficiency; (4) CF / immotile cilia
o Chronic (> 12 weeks) and persistent: think staph aureus (plus acute bugs) but not all bacterial
Sx: anterior/posterior mucopurulent drainage; (2) nasal obstruction; (3) facial pain/pressure; (4) dec sense smell
3 classes: (1) CRS w/ nasal polyps; (2) CRS w/o nasal polyps (most common); (3) allergic fungal rhinitis
Tx: Treat when there is nasal purulence cover anaerobes as well- BUT MUCH LONGER (21 days)
ABS: QUIt it w/ amoxicillin + clindamycin
Nasal steroids; if polyps prednisone course
Workup: after initial therapy; sinus CT.
If fungal in origin, need drainage but no antifungals.

Sleep apnea complications: hypertension, accidents, sexual dysfunction, hypersomnolence, cor pulmonale