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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 Acute Acute Acute Acute Acute Acute rhinitis rhinosinusitis nasopharyngitis (the common cold) pharyngitis laryngitis/epiglottitis layngotracheitis 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), pharyngolaryngitis 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 Mortality of HAP 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 It is important to exclude noninfectious causescough, of pulmonary Fever, sputuminfiltrates when Dyspnea, chest evaluatingpleuritic a patient whopain presents with Infiltration in CXR possible HAP !!! Hypoxemia Diagnostic Criteria in HAP New or progressive infiltrate on CXR + Clinical evidence showing infectious origin Fever Leukocytosis Purulent sputum Decline in oxygenation Diagnostic Approach Physical examination Chest radiography Bacteriological identification ; sampling of lower respiratory secretion Sampling 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 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 Symptoms + risk factors + spirometry Spirometric diagnostic criteria for COPD Spirometry: Post-bronchodilator FEV1/FVC < 70% 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 A B-D Essential Smoking cessation (can include pharmacologic treatment) Smoking cessation (can include pharmacologic treatment) Pulmonary rehabilltation Recommended Depending on Local Guidelines Physical activity Flu vaccination Pneumococcal vaccination 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 Thank you for your attention !