Asthma & Common Respiratory Diseases

Category: Education

Presentation Description

This talk was presented in officers club Dhaka on 29/09/2017. Audiences were officers of different ministry of Peoples Republic of Bangladesh


Presentation Transcript

Asthma & Common Respiratory Diseases:

Asthma & Common Respiratory Diseases Prof. Dr. AKM Mosharraf Hossain FCPS PhD Chairman, Department of Respiratory Medicine Bangabandhu Sheikh Mujib Medical University


RESPIRATORY SYSTEM The human body contains nearly 100 trillion cells Humans have five vital organs brain , heart, kidneys, liver and lungs The Respiratory System allows us to take in vital oxygen and expel carbon dioxide in a process we call breathing. It consists mainly of the trachea, the diaphragm and the lungs. The average adult takes over 20,000 breaths a day

Lung Anatomy:

Lung Anatomy Bronchopulmonary segment →Bronchi→TB( Acini 25000) →RB( Alveoli 300 million)

Innate Defence of Lung:

Innate Defence of Lung EM showing respiratory epithelium with cilia © overlaid by mucus raft (M) EM showing alveolar macrophages patroling over alveolar spaces


Asthma Asthma & Common Respiratory Illness


STORY OF A MOTHER Mrs Momtaz Begum,72 yrs , lives in Dhaka presented with – Fever, SOB, Cough for 5 days. She has been suffering from Asthma for 16 yrs , DM 15 yrs on diet and exercise, and Hypothyroid.

Definition of Asthma:

Definition of Asthma A chronic inflammatory disorder of the airways associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing.

Burden of Asthma:

Burden of Asthma In Bangladesh 70 lac Asthma patient, annual mortality 6.6 per lac, more in elderly In 2016, Worldwide 235 million Asthma patients; 383 thousands died of Asthma in 2015 Prevalence increasing in many countries, especially in children A major cause of school/work absence

Factors that Influence Asthma Development and Expression:

Factors that Influence Asthma Development and Expression Host Factors (Developmental) Genetic - Atopy - AHR Gender Obesity, eg leptin Environmental Factors (Trigger factor) Indoor allergens Outdoor allergens Occupational sensitizers ( both development and trigger factor) Tobacco smoke Air Pollution Respiratory Infections Diet

Factors related to Asthma:

Factors related to Asthma


Source: Peter J. Barnes, MD Mechanisms: Asthma Inflammation


Clinical Features Typical Cough Wheeze SOB Chest tightness Atypical CVA EIB Occupational Asthma Seasonal asthma

Do You Have Asthma?:

Do You Have Asthma? Recurrent episodes of wheezing Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants Colds “go to the chest” or take more than 10 days to clear


Asthma Management and Prevention Program Goals of Long-term Management Achieve and maintain control of symptoms Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal levels as possible Prevent asthma exacerbations Avoid adverse effects from asthma medications Prevent asthma mortality

Classification of severity:

Classification of severity CLASSIFY SEVERITY Clinical features before treatment Symptoms Nocturnal symptoms FEV 1 or PEF STEP 4 Severe persistent STEP 3 Moderate persistent STEP 2 Mild persistent STEP 1 Intermittent Continuous Limited physical activity Daily Attacks affect activity >1 time a week but <1 time a day <1 time a week Asymptomatic and normal PEF between attacks Frequent >1 time week >2 times a month  2 times a month  60% predicted Variability >30% 60–80% predicted Variability >30%  80% predicted Variability 20–30%  80% predicted Variability <20% The presence of one feature of severity is sufficient to place a patient in that category PEF: peak expiratory flow FEV1: Forced Expiratory volume/ second


Component 4: Asthma Management and Prevention Program Reliever Medications Rapid-acting inhaled β 2 -agonists Systemic glucocorticosteroids Anticholinergics Theophylline Short-acting oral β 2 -agonists


Component 4: Asthma Management and Prevention Program Controller Medications Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β 2 -agonists Systemic glucocorticosteroids Theophylline Cromones Long-acting oral β 2 -agonists Anti- IgE


1858: Pressuriesd inhaler- France 1864: Steam driven Nebulizer-German 1930: Electrical Nebulizer 1956: MDI 1964: Ultrasonic Nebulizer 22


MDI MDI 1. Remove cap 2. Shake well 3. Breathe out normally 4. Keep head upright or slightly tilted 5. Seal lips around mouthpiece 6. Inhale slowly, actuating once during first half of inhalation 7. Continue slow and deep inhalation 8. Hold breath for 5 or more seconds 11/11/12 23


MDI with SPACER 1. Remove caps 2. Shake MDI well 3. Insert MDI into spacer 4. Breathe out normally 5. Seal lips around mouthpiece 6. Actuate MDI 7. Inhale slowly and deeply 8. Hold breath for 5 or more seconds

Dry powder inhaler (DPI):

Dry powder inhaler (DPI) 11/11/12 25

Nebulizer :

Nebulizer is a device used to administer medication in the form of a aerosol inhaled into the lungs.


Component 4: Asthma Management and Prevention Program Allergen-specific Immunotherapy Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis The role of specific immunotherapy in asthma is limited Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma Perform only by trained physician

Asthma Management and Prevention Program Special Considerations:

Asthma Management and Prevention Program Special Considerations Special considerations are required to manage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma

Asthma Prevention:

Asthma Prevention Primary Prevention- primary prevention to reduce the level of exposure to common risk factors, particularly tobacco smoke, frequent lower respiratory infections during childhood, and air pollution (indoor, outdoor, and occupational exposure ); Secondary prevention- Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.


PNEUMONIA Asthma & Common Respiratory Diseases

Pneumonia? :

Pneumonia? Pneumonia is a syndrome caused by acute infection, usually bacterial, characterized by clinical & /or radiological signs of consolidation of a part or parts of one or both lung .


CAP-Incidence The annual incidence in the community is 5–11 per 1000 adult population . The incidence varies markedly with age, being much higher in the extremes of age- in the very young and elderly, Between 1.2% and 10% of adults admitted to hospital with CAP are managed on an ICU . The mortality rate of patients with severe CAP requiring admission to an ICU is high at over 30%


Pathogenesis and Pathology:

Pathogenesis and Pathology CAP is usually spread by droplet infection Most cases occur in previously healthy individuals predisposed by several factors- 1.Cigarette smoking 2.Upper respiratory tract infections 3.Alcohol 4.Corticosteroid therapy 5.Old age 6.Recent influenza infection 7.Pre-existing lung disease Once the organism settles in the alveoli, an inflammatory response ensues. The classical pathological response evolves through the phases of congestion, red and then grey hepatisation , and finally resolution with little or no scarring.

Pneumonia-clinical features:

Pneumonia-clinical features Typical presentation- sudden onset of fever, cough productive of purulent sputum, pleuritic chest pain, signs of consolidation Atypical presentation- gradual onset dry cough prominent extrapulmonary sympto (headache, myalgia, GIT upset, fatigue) minimal sign in the lung except rhonchi abnormalities in the CXR

Severity of Pneumonia:

Severity of Pneumonia Low Severity Moderate Severity High Severity

CAP-How to investigate?:

CAP-How to investigate? Full blood count Chest radiograph Examination of sputum should be considered for patients who do not respond to empirical antibiotic treatment . Urea, electrolytes and liver function tests . ABG- when SaO2 <92% or with features of severe pneumonia

Pneumonia-General measures:

Pneumonia-General measures Stop smoke, rest,drink plenty of fluids . Pleuritic pain : paracetamol, opiates Nutritional supplements Pulse oximetry Review after 48 hours or earlier if clinically indicated. if no improvement after 48 hours, consider hospital admission or chest radiography


Complications Para-pneumonic effusion-common Empyema Retention of sputum causing lobar collapse Development of thromboembolic disease Pneumothorax-particularly with Staph. aureus Suppurative pneumonia/lung abscess ARDS, renal failure, multi-organ failure Ectopic abscess formation (Staph. aureus) Hepatitis, pericarditis, myocarditis, meningoencephalitis Pyrexia due to drug hypersensitivity


CAP-mortality The reported mortality rate of adults with CAP managed in the community is very low at less than 1% . The reported mortality rate of adults admitted to hospital with CAP has varied between 5.7% and 12% The mortality rate of patients with severe CAP requiring admission to an ICU is high at over 30% . The long-term mortality of CAP is between 35.8% and 39.1% at 5 years.




VACCINATION H influenzae vaccine: In the UK recommended for all ages with: chronic respiratory disease including asthma; chronic heart disease; chronic renal disease; immunosuppression due to disease or treatment; diabetes mellitus; all those aged 65 years or older; those in long stay residential care. Pneumococcal vaccine: In UK recommended for 2 yrs and older with- asplenia ; severe splenis dysfunction in sickle cell disease and coeliac disease; chronic renal disease or nephrotic syndrome; chronic heart disease; chronic lung disease; chronic liver disease diabetes mellitus; immunodeficiency or immunosuppression


TUBERCULOSIS Asthma & Common Respiratory Diseases


When, in 1820, the poet John Keats (1795-1821) coughed a spot of bright red blood , he told a friend, "It is arterial blood. I cannot be deceived. That drop of blood is my death warrant. I must die". He died within a year, at just 25 years of age. Poet John Keats 28 September 2017 46


TB was documented in Egypt, India, and China as early as 5,000, 3,300, and 2,300 years ago. Typical skeletal abnormalities, including Pott’s deformities, were found in Egyptian and Andean mummies and were also depicted in early Egyptian and pre-colombian art . Clinical features of Pulmonary tuberculosis were well described by Hipocrates in about 400 BC. HISTORY OF TUBERCULOSIS 28 September 2017 47




Hermann Brehmer (1826-1889) a Silesian botany student suffering from TB, was instructed by his doctor to seek out a healthier climate. He traveled to the Himalayas where he studied the mountain’s flora. He returned home cured and began to study medicine. In 1854, he presented his medical dissertation “Tuberculosis is a Curable Disease”. Brehmer then opened an in-patient hospital in Gorbersdorf, where patients received good nutrition and fresh air SANATORIUM AND INITIAL TB Tx 28 September 2017 49

Brhemers Sanatorium Gorbersdorf in late 1870:

Brhemers Sanatorium Gorbersdorf in late 1870 28 September 2017 50


Robert Koch discovered M.tuberculosis ansd astouned on 24 th March 1882 (World TB day) at Berlin . 28 September 2017 51


Defintion Tuberculosis (TB) is caused by infection with Mycobacterium tuberculosis (MTB) complex. MTB complex includes M. tuberculosis, M. bovis (reservoir cattle), M. africanum (reservoir human),M. canettii,M. microti, M caprae and M pinnipeddi. 28 September 2017 52


28 September 2017 53 Incidence : 8.7 million in 2011 (13% co-infected with HIV). 2.9 million women. (Children: 0.5 million) Deaths from TB: 1.4 million 990 000 among HIV-negative individuals and 430 000 among people who were HIV-positive . These deaths included 0.5 million among women, (300,000 HIVneg+ 200,000 HIV+ve) MDR : Globally 3.7% of new cases and 20% of previously treated cases are estimated to have MDR-TB GLOBAL TB Scenario : 2011

Bangladesh Scenario:2011:

Bangladesh Scenario:2011 Population: >150 million Incidence rate (all TB cases): 225 /100,000 / yr Prevalence rate ( all TB cases): 411/ 100,000 Mortality rate 45 / 100,000 / yr TB patients co-infected with HIV : <0.1% Proportion of MDR-TB new cases: : 1.4% previously treated cases : 29% 28 September 2017 54 ( Ref. WHO Global TB Report 2012) ☻ Ranks Seventh among 22 HBC


28 September 2017 55


28 September 2017 56

CF-Post primary (reactivation) TB:

CF-Post primary (reactivation) TB Insidous, undiagnosed weeks or months Cough, wt loss,fatigue-50-70% Fever & nt sweats or nt sweats alone-50% Chest & dyspnoea-33% Hemoptysis-25% Incidental pul TB-33% Empyema and painful ulcers of the mouth, tongue, larynx, or GI tract due to chronic expectoration and swallowing of highly infectious secretions rarely Anorexia, wasting and malaise in advanced disease 28 September 2017 57

CF-rare presentattion:

CF-rare presentattion Laryngeal TB Lower lung field TB Endobronchial TB Tuberculoma 28 September 2017 58


Site of involvement Percentage Pulmonary tuberculosis 86 Extra pulmonary tuberculosis 14 Lymphatic 27 Pleural 21 Genitourinary 16 Milliary 9 Bone and Joint 8 Meningial 4 Peritoneal 4 Others 1 Distribution sites of Tuberculosis 28 September 2017 59

Phlyctenular conjunctivitis:

Phlyctenular conjunctivitis 28 September 2017 65

Erythema nodosum (a) and erythema induratum of Bazin (b). :

Erythema nodosum ( a ) and erythema induratum of Bazin ( b ). 28 September 2017 66

Diagnostic Methods:

Diagnostic Methods AFB smear staining:  Easiest and most rapid diagnosis  It is less sensitive than culture (50‑80%)  To be positive need 5000 - 10000 bacilli/ml(10-100 bacilli/ml for culture)  A tubercle bacilli is not found as commensal or carrier. Presence of AFB is virtually diagnostic Sputum: Rinse mouth with water before collection. Collect only exudative material brought up from lung after a deep productive cough. On an average 3 consecutive sputum sample should be collected Pulmonary specimen : Sputum*, Tracheal aspirate, Gastric levage, BAL . Extra pulmonary specimen : CSF, Aspirated fluid in case of Bone and Joint infection, Body fluids, Urine, Aspirated or draining pus, Surgically excised tissue, Endometrial tissue etc. 28 September 2017 68

Complications of TB:

Complications of TB PULMONARY Hemoptysis Pneumothorax Bronchiectasis Extensive pulmonary destruction Chronic pulmonary aspergillosis Septic shock Malignancy NON-PULMONARY Empyema necessitans Laryngitis Enteritis Anorectal disease Amyloidosis Poncets polyarthritis 28 September 2017 69


TUBERCULIN SKIN TEST 28 September 2017 70

Drug History:

Drug History 1944 - streptomycin (SM) and paraaminosalicylic (PAS) were discovered 1950 - the first trial was performed by SM & PAS as Mono/combined therapy. 1952- isoniazid (INH), was added to the previous combination for 18-24 months. 1960- ethambutol (EMB) substituted PAS, and the treatment course was reduced to 18 months. 1970-the introduction of rifampicin (RIF) into the combination treatment was shortened to 9 months. 1980- pyrazinamide (PZA) was introduced into the antituberculosis treatment, reduced to 6 months. 28 September 2017 71

WHO Anti-TB Regimen:

WHO Anti-TB Regimen Category of TB Initial phase Continuation phase New smear+ PTB Severe smear- PTB Severe extrapulmonary TB Severe concomitant HIV 2m HRZE 4m HR Previously Treated smear+ PTB Relapse, Failure Treatment after default 2m HRZES 1m HREZ 5m HRE 28 September 2017 72

Control and Prevention:

Control and Prevention BCG (the Calmette-Guérin bacillus) is a live attenuated vaccine derived from M. bovis , used to stimulate protective immunity and prevent the dissemination of MTB in an infected host. Reports on the efficacy of BCG are variable (20-60%) but it appears to be most effective in preventing disseminated disease, including tuberculous meningitis, in children. 28 September 2017 73

Control and Prevention:

Control and Prevention Patient should wear a mask or at least cover mouth and nose when coughing or sneezing. Expectorated sputum should be handled carefully and properly disposed. Adequate negative pressure isolation room and use of UV lighting are very effective in reducing the number of infectious particles in the air. Extra care needed when cleaning RT equipment Health care workers should wear personal respiratory protective devices. The most effective measure to control of infectivity of the patient with active TB is early proper chemotherapy 28 September 2017 74


Prognosis Following successful completion of chemotherapy, cure should be anticipated in the majority of patients. There is a small (< 5%) and unavoidable risk of relapse. Most recurrences occur within 5 months and usually have the same drug susceptibility. In the absence of treatment a patient with smear-positive TB will remain infectious for an average of 2 years; in 1 year, 25% of untreated cases will die. A few patients die unexpectedly soon after commencing therapy and it is possible that some of these individuals have subclinical hypoadrenalism that is unmasked by a rifampicin-induced increase in steroid metabolism. HIV-positive patients have higher mortality rates and a modestly increased risk of relapse. 28 September 2017 75


COPD Asthma & Common Respiratory Diseases


What Is COPD?

Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998:

Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998 0 0.5 1.0 1.5 2.0 2.5 3.0 Proportion of 1965 Rate 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 –59% –64% –35% +163% –7% Coronary Heart Disease Stroke Other CVD COPD All Other Causes Source : NHLBI/NIH/DHHS


Epidemiology Globally 80 millions people suffer from mod-severe COPD. Among white males, airflow limitation was present in 14.2% of current smokers, 6.9% of ex-smokers, and 3.3% of never smokers. Among white females, the prevalence of airflow limitation was 13.6% in smokers, 6.8% in exsmokers , and 3.1% in never smokers. Airflow limitation was more common among white smokers than among black smokers.


81 Risk Factors for COPD Nutrition Infections Socio-economic status Aging Populations




STORY OF A FREEDOM FIGHTER Md Hossain , 84 yrs , presented with fever, cough, SOB, leg oedema for 20 days. He is suffering from COPD for 15 yrs. 30 pack- yrs smoking history, still smoker. A freedom fighter.


LUNG INFLAMMATION COPD PATHOLOGY Oxidative stress Proteinases Repair mechanisms Anti-proteinases Anti-oxidants Host factors Amplifying mechanisms Cigarette smoke Biomass particles Particulates Source : Peter J. Barnes, MD Pathogenesis of COPD


Alveolar wall destruction Loss of elasticity Destruction of pulmonary capillary bed ↑ Inflammatory cells macrophages, CD8 + lymphocytes Source : Peter J. Barnes, MD Changes in Lung Parenchyma in COPD


Chronic hypoxia Pulmonary vasoconstriction Muscularization Intimal hyperplasia Fibrosis Obliteration Pulmonary hypertension Cor pulmonale Death Pulmonary Hypertension in COPD Source : Peter J. Barnes, MD

Diagnose COPD:

Diagnose COPD Consider a diagnosis of COPD for people who are: over 35, and smokers or ex-smokers, and have any of these symptoms: - exertional breathlessness - chronic cough - regular sputum production, frequent winter ‘bronchitis’ wheeze [2004]

Physical signs:

Physical signs

How to Investigate ?:

How to Investigate ? Spirometry and bronchodilator reversibility test CXR- bulla, hyperinflation Echocardiography CT scan ABG Alpha-1-antitrypsin


Spirometry Symptoms Exercise Impairment Dyspnea, Wheezing Cough  Sputum Exposure Tobacco Occupational Pollution

COPD Radiology:

COPD Radiology



Model of Annual Decline of FEV1:

Model of Annual Decline of FEV1 If smoking is stopped, subsequent loss is similar to that in healthy non-smokers




Brief Strategies to Help the Patient Willing to Quit Smoking ASSIST For the patient willing to make a quit ttempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts. ARRANGE For the patient willing to make a quit attempt, arrange for followup contacts, beginning within the first week after the quit date. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.

Vicious cycle of Disability:

Vicious cycle of Disability 06/11/2010 Mosharraf Hossain

Pulmonary rehabilitation:

ERS-ATS COPD Guidelines Pulmonary rehabilitation Pulmonary rehabilitation is a multidisciplinary programme of care that is individually tailored and designed to optimise physical and social performance and autonomy. Pulmonary rehabilitation should be considered for patients with COPD who have dyspnoea or other respiratory symptoms, reduced exercise tolerance, a restriction in activities because of their disease, or impaired health status. Pulmonary rehabilitation programmes include: exercise training, education, psychosocial/behavioural intervention, nutritional therapy, outcome assessment, promotion of long-term adherence to the rehabilitation recommendations.


BRONCHIETASIS Asthma & Common Respiratory Diseases


BRONCHIECTASIS Definition: Abnormal and permanent dilation of bronchi. Focal or diffuse distribution Clinical consequences – chronic and recurrent infection and Pooling of secretions in dilated airways.

Types Of Bronchiectasis:

Types Of Bronchiectasis Classification : Cylindrical (fusiform) Saccular Varicose

Aetiology: A. Infections-Micro-organisms:

Aetiology: A. Infections-Micro-organisms Measles and Pertussis Adeno & Influenza virus Bacterial infection with virulent organisms: S.aureus, Klebsiella Anaerobes Atypical mycobacteria Mycoplasma HIV Tuberculosis Fungi


AETIOLOGY : NON-INFECTIOUS Toxins or toxic substances NH 3 ; gastric contents Immune responses, ABPA Inflammatory diseases: ulcerative colitis, rheumatoid arthritis, Sjögren syndrome. -1-Antitrypsin deficiency Yellow nail syndrome


CLINICAL MANIFESTATIONS Persistent or recurrent cough with purulent sputum. Haemoptysis Initiating episode: Severe pneumonia, or insidious onset of symptoms or asymptomatic or non-productive cough – dry bronchiectasis in upper lobe, Dyspnoea, wheezing – widespread bronchiectasis or underlying COPD. Exacerbation of infection: Sputum volume increase, purulence or blood.


PHYSICAL EXAMINATION Any combination of rhonchi, creps or wheezes. Clubbing of digits. Chronic hypoxaemia  cor pulmonale  R heart failure Amiloidosis (rare)


Md Mozibur Rahman , 35 yrs , Moulavibazar , Sylhet suffering from cough 5 yrs , recuurent hemoptysis. He is never smoker.


PHYSICAL EXAMINATION Weight loss Any combination of rhonchi, creps or wheezes. Clubbing of digits. Chronic hypoxaemia  cor pulmonale  R heart failure


DIAGNOSIS - 1 Clinical Radiology: Chest XR: May be non-specific mild disease – normal XRC advanced disease – cysts + fluid levels peribronchial thickening, “tram tracks”, “ring shadows” CT Scan: Peribronchial thickening, dilated bronchioles. Sputum culture: Pseudomonas aeuruginosa, H.influenzae.




DIAGNOSIS - 2 Lung function: Airflow obstruction – FEV1 decreased. Air trapping - RV increased Sweat test – increased sodium and chloride in cystic fibrosis Bronchoscopy: Obstruction – foreign body, tumor. Immunoglobulin Cilia function and structure – Kartagener syndrome.


TREATMENT - 1 4 Goals: 1. Eliminate cause 2. Improve tracheo bronchial clearance 3. Control infection 4. Reverse airflow obstruction


TREATMENT - 2 1 . Immunoglobulin 2. Antituberculous drugs 3. Corticosteroids (ABPA) 4. Remove aspirated material Chest physio therapy Mucolytics Bronchodilators


TREATMENT - 3 Antibiotics – short course, prolonged course, intermittent regular courses, inhalation. Initial empiric Rx: Ampi, Amox, Cefaclor, Septran Ps.aeruginosa – Quinolone, aminoglycoside, 3 rd generation cephalosporin, pipracillin. Surgery: Oxygen and diuretics Lung transplant


DPLD/ILD Asthma & Common Respiratory Diseases




ILD? Medicine Int 2008 ILDs are a group of over 200 disorders that affect pulmonary interstitium including perivascular and perilymphatic tissues, often present with breathlessness, chronic cough, inspiratory crackles and abnormal spirometry .


Copyright ©2010 BMJ Publishing Group Ltd. Dempsey, O. J. et al. BMJ 2010;340:c2843 Fig 2 Arrows indicate pulmonary interstitium in (left) healthy lung and (right) pulmonary fibrosis. The grossly thickened interstitium in pulmonary fibrosis impairs gas exchange.


Burden About 50 million people suffer from ILD globally, In respiratory clinic 15% case load is due to ILD, IPF and sarcoidosis are common having annual incidence of 5-10/100,000 people per year. Medicine Int 2008


Pathogenesis The lung is naturally exposed to repetitive injury from a variety of exogenous and endogenous stimuli. Several local and systemic factors (e.g., fibroblasts, circulating fibrocytes, chemokines, growth factors, and clotting factors) contribute to tissue healing and functional recovery. Dysregulation of this intricate network through genetic predisposition, autoimmune conditions, or superimposed diseases can lead to aberrant wound healing with the result of pulmonary fibrosis. Alternatively, excessive injury to the lung may overwhelm even intact reparative mechanisms and lead to pulmonary fibrosis . Harrison 17th Ed

IPF ?:

IPF ? IPF is defined as a specific form of chronic fibrosing interstitial pneumonia limited to the lung and associated with the histologic appearance of usual interstitial pneumonia (UIP) on lung biopsy. ATS 2006

IPF Burden:

IPF Burden Commonest ILD type Annual incidence 5-10/100,000 person-yr, Median survival 2.9-5 yrs at diagnosis

IPF-Risk Factors:

IPF-Risk Factors Unknown aetiology Cigerete smoking Drugs-antidepressant Chronic aspiration due to GERD Environmental exposure- wood dust and metal dust esp steel, brass, lead, pine wood. Infectious agents-EBV, CMV, HIV Genetic predisposition: 2-5% cases of IPF occurs in families, usually occur in younger age, may be in children


Mrs Selina , 55 yrs , from Laxmipur , Noakhali presented with dry cough for 1 yr , progressive breathlessness for 1 yr. Diabetic and hypertensive for 10 yrs. Hospitalized for worsened SOB for last 2 months

Clinical Feature-IPF:

Clinical Feature-IPF Symtoms : Onset gradual, with dyspnea the most prominent and disabling symptom, nonproductive cough is usual and may be paroxysmal and often refractory to antitussive agents. Age 40-70 y, M>F=3:2. Constitutional symptoms are unusual. Signs : digital clubbing 25-50%, late ins creps in 90%, cyanosis, PH, Right heart failure late ATS 2006


Investigations Lab test: ↑ESR, + ANA, + RF in low titre 10-20%. PFT: restrictive pattern with ↓ DLCO and ↓ resting PaO2, which falls on exercise. 1. A TLCO level of less than 40% is indicative of advanced disease in fibrotic IIP. 2. In IPF a fall from baseline of >10% in forced vital capacity (FVC) or >15% in TLCO in the first 6–12 months identifies patients with a much higher mortality. 3. Desaturation during the 6 minute walk test at presentation is a stronger prognostic determinant in IPF than resting lung function.


Investigations CXR: 80% sensitivity for ILD. The commonest abnormality is peripheral, asymmetric, basal reticular opacity, often associated with honeycombing and lower lobe volume loss. HRCT: 94% sensitivity for ILD. Commonly shows patchy, predominantly peripheral, subpleural , bibasal reticular abnormalities. There may also be a variable amount of ground glass opacity (<30%) that is usually limited in extent. In areas of more severe involvement there is often traction bronchiectasis and bronchiolectasis and/or subpleural honeycombing. Most patients with clinically significant diffuse lung disease have an abnormal HRCT scan but a normal HRCT scan does not exclude ILD in all cases.




Investigations BAL: Limited role in the diagnosis of IPF. A finding of raised neutrophils (.4%) and raised eosinophils (.2%) is characteristic of IPF, TBLB: not an initial inv of choice, Biopsy: Usual interstitial pneumonia (UIP) is the pathological abnormality essential to the diagnosis of IPF. The histologic hallmark and chief diagnostic criterion is a heterogeneous appearance at low magnification with alternating areas of normal lung, interstitial inflammation, fibrosis, and honeycomb change.


Copyright ©2010 BMJ Publishing Group Ltd. Dempsey, O. J. et al. BMJ 2010;340:c2843 Fig 4 Idiopathic pulmonary fibrosis. (A) Digital clubbing is commonly, but not always, seen. (B) Chest radiograph noting small lungs with bilateral subpleural shadowing with a lower zone predominance (arrows). (C) Computed tomography noting gross abnormalities of both lungs including intralobular and interlobular septal thickening with honeycombing


Treatment- ipf BSC: Best supportive care should be considered a specific and important treatment strategy in all patients with IPF, to date there is no therapy proven to improve survival or otherwise significantly modify the clinical course of IPF, Combination therapy: Prednisolone (tapering from 0.5 mg/day to 10–20 mg/day) with azathioprine (2 mg/kg, maximum150 mg/day) and Nacetylcysteine (NAC, 600 mg three times a day) has been shown to have a significantly better treatment, Treatment, if started, could be equally reasonably initiated at presentation or following objective evidence of disease progression or in moderate/severe disease, Lung transplantation: should be made if the disease is advanced (TLCO ,40% predicted) or progressive (>10% decline in FVC or >15% decline in FVC during 6 months of follow-up) excluding those over the age 65 and/or those with significant co-morbidity BTS guideline 2008


Drug dose : Days 1 to 7: 267 mg (1 capsule) 3 times daily (total daily dose: 801 mg) Days 8 to 14: 534 mg (2 capsules) 3 times daily (total daily dose: 1602 mg) Day 15 and thereafter: 801 mg (3 capsules) 3 times daily (total daily dose: 2403 mg daily); maximum dose in any patient: 2403 mg daily Reinitiation of therapy following interruption: If interruption <14 consecutive days, may reinitiate therapy at previous daily dose without retitration ; if interruption ≥14 consecutive days, reinitiate therapy with the initial 2-week titration period up to recommended daily dose. Missed dose : If a dose is missed, the next dose should be taken at the next scheduled time. Do not take two doses at the same time to make up for a missed dose. Pirfenidone

Treatment-ipf contd.:

Treatment- ipf contd. Cough: Oral opiates, Supplemental O 2 : LTOT, if persistent resting hypoxaemia PaO 2 at or below 7.3 kPa (55 mm Hg) or below 8 kPa with clinical evidence of PH and who are breathless should be considered for palliative oxygen at home delivered by oxygen concentrator. If SpO 2 <90% during activity inetermittent O 2 therapy for 10-20 mins should be considered, PH: Sildenafil improve exercise tolerence and reduce symptoms.

IPF-natural course:

IPF-natural course


Prognosis Respiratory failure is the most frequent cause of death in 40% of patients with IPF. Other causes of death in patients with IPF include heart failure, ischemic heart disease, infection, and pulmonary emboli . Bronchogenic carcinoma 10-fold increased chance in IPF. Indicators of longer survival among patients with IPF include the following : • Younger age (<50 yr) • Female sex, • Shorter symptomatic period (< 1 yr) with less dyspnea , relatively preserved lung function • Presence of ground glass and reticular opacities on HRCT • Increased proportion of lymphocytes (20 to 25%) in BAL fluid • A beneficial response or stable disease 3 to 6 mo after initial corticosteroid therapy IPF have mean survival among ranging from 2 to 4 yr (5-yr survival range, 30 to 50%)


OBSTRUCTIVE SLEEP APNEA SYNDROME Asthma and Common Respiratory Diseases




OSA & OSAS OSA is characterized by recurrent episodes of complete or partial upper airway obstruction during sleep, OSA along with daytime sleepiness is OSAS 10/07/2017 143

Pickwickian Syndrome :

Pickwickian Syndrome OSA was called the Pickwickian syndrome by Charles Dickens in the Pickwick papers where Joe the fat boy had typical features with snoring, obesity, sleepiness and “dropsy”. 10/07/2017 144

Prevalence of OSAS:

Prevalence of OSAS In USA, prevalence of OSAS among middle-aged men and women were 4% and 2% (Young et al) In Bangladesh, the prevalence of OSAS were 4.49% & 2.14% in men and women respectively . 10/07/2017 145

Anatomy of OSA:

10/07/2017 146 Anatomy of OSA NORMAL SNORING SLEEP APNEA

Symptoms of OSA:

Symptoms of OSA Night time Snoring Witnessed apnoea Frequent nocturnal awakenings Waking up choking or gasping for air Unrefreshed sleep Restless sleep N octuria Dry mouth Decreased libido 10/07/2017 147

Symptoms of OSA:

Symptoms of OSA Daytime Early morning headaches Fatigue Daytime sleepiness Poor memory, concentration or motivation Unproductive at work Falling asleep during driving Depression 10/07/2017 148

Laboratory Polysomnography :

Laboratory Polysomnography EOG - Electrooculogram EEG - Electroencephalogram EMG - Electromyogram EKG - Electrocardiogram Tracheal noise Nasal and oral airflow Thoracic and abdominal respiratory effort Pulse oximetry 10/07/2017 149

How to Diagnose OSA?:

How to Diagnose OSA?


10/07/2017 151 C3 O1 Electroencephalography in the Overnight Sleep Study G1 G2 Paper or computer screen A2 Differential Amplifier C3-A2 O1-A2 G1 G2


10/07/2017 152 Left and Right Electrooculogram LOC ROC Eye Blinks Electrooculography picks up the inherent voltage of the eye. The cornea has a positive voltage output, while the retina has a negative polarity. 152


Treatment NON - SURGICAL Positional Tx Wt loss CPAP/BPAP Oral appliances Avoid sedative SURGICAL Tracheostomy UPPP Glossectomy Hyoid advancement Mandibular advancement 10/07/2017 153

Body Position:

Body Position Raise HOB Avoid supine position-Tennis ball in pajamas/Backpack/Side pillow 10/07/2017 154

CPAP Therapy:

CPAP Therapy Works as a pneumatic Splint 1 st choice of treatment in moderate to severe OSAHS Success rate 95-100% Long term compliance 60-70% 10/07/2017 155


LUNG CANCER Asthma and Common Respiratory Diseases


Mrs Selina , 45 yrs , from Munshigonj hospitalized for left sided chest pain and fever for 2 months. She has left sided pleural effusion and was on treatment of Tuberculosis. But she was not improving. FNAC from right cervical LN showed adenocarcinoma.

Lung Cancer:

Lung Cancer Mr Hashem Khan, 60 yrs , from faridpur presented with right sided chest pain, low grade fever, dry cough for 1 mon. smoking history 30 p-yrs. FNAC Ctguided revealed adenocarcinoma.

Burden of Lung Cancer:

Lung cancer is the most common cancer world-wide, accounting for 1.2 million new cases annually in 2000, and causing 18% of all cancer deaths, Tobacco use is the major preventable cause, Just as tobacco use and cancer rates are beginning to fall in some developed countries, both smoking and lung cancer are rising in Eastern Europe and in many developing countries, The prognosis of primary lung carcinoma remains poor, with an average of 20% surviving at 1 year and 5% at 5 years, Carcinomas of other organs, in particular the breast, kidney, uterus, ovary, testes and thyroid, may give rise to metastatic pulmonary deposits, as may an osteogenic or other sarcoma. Burden of Lung Cancer


Smoking : Lung cancer is increased about 13 fold by active smoking and about 1.5-fold by long-term passive exposure to cigarette smoke. The lung cancer death rate is related to the total amount (often expressed in "cigarette pack-years") of cigarettes smoked, such that the risk is increased 60- to 70-fold for a man smoking two packs a day for 20 years as compared with a nonsmoker. Conversely, the chance of developing lung cancer decreases with cessation of smoking but may never return to the nonsmoker level. Women have a higher relative risk per given exposure than men (~1.5-fold higher). This sex difference may be due to a greater susceptibility to tobacco carcinogens in women, although the data are controversial. the most common form of lung cancer arising in lifetime nonsmokers, in women, and in young patients (<45 years) is adenocarcinoma . About 15% of lung cancers occur in individuals who have never smoked. The majority of these are found in women. The reason for this sex difference is not known but may be related to hormonal factors. Aetiology

Aetiology contd.:

Age : <50yrs, 5-10% Sex: F > M Race : Black > White Air pollution : Fossil fuel combustion and correlated with lung cancer mortality rates. Carcinogenic agents present in ambient urban air may include inorganic particles or fibers (e.g., arsenic, asbestos, chromium, nickel, uranium); radionuclides and organic gaseous and particulate combustion products (e.g., dimethylnitrosamine, benzene, benzo(a)pyrene, 1,2-benzanthracene). Radiation: Inhalation to naturally occurring radon or thoracic radiation exposure. Nutrition: An increased risk of lung cancer has been reported in association with high dietary intake of foods rich in fat and cholesterol, or with elevated indices of abdominal adiposity. Non-neoplastic lung diseases : Lung cancer risk has been reported to be increased among persons with a history of tuberculosis, pulmonary fibrosis as in silicosis, or chronic bronchitis and emphysema. Genetic: lung cancer in a first-degree relative was associated with a 2.6-fold increase in risk of lung cancer in cases diagnosed under 50 years of age Aetiology contd.

Clinical Presentations:

Symptoms due to primary tumour-cough, dyspnoea, cavity Symptoms due to local spread-pleura,chest wall, mediastinum-trachea, oesophagus, hoarseness, Horner’s syndrome, Pancoast syndrome,SVC syndrome Extra-thoracic matestasis-brain, bone, bone marrow,liver, adrenals Paraneoplastic syndrome Skeletal–connective tissue syndromes: clubbing, HPOA Neurologic-myopathic syndromes Trousseau's syndrome-migratory venous thrombophelibitis Asymptomatic 5-10% Clinical Presentations



Acanthosis nigricans:

Acanthosis nigricans

Erythema gyretum repens:

Erythema gyretum repens

Bronchial Obstruction:

Bronchial Obstruction

Malignant Cavity:

Malignant Cavity Large cavitated bronchial carcinoma in left lower lobe


CXR, HRCT chest Sputum cytology Bronchoscope: Bronchial biopsies and brush samples, and a direct assessment can be made of operability.If tumour is not visible at bronchoscopy, bronchial washings and brushings can be taken from the radiologically affected lung segment, but the diagnostic yield is much lower. Percutaneous needle biopsy under CT or ultrasound guidance Pleural biopsy is indicated in all patients with pleural effusions. TBNA- needle aspiration through the bronchial wall at bronchoscopy, Endoscopic ultrasound guidance, Mediastinoscopy under general anaesthetic. Thoracoscopy or thoracotomy Needle aspiration or biopsy of affected lymph nodes, skin lesions, liver or bone marrow Investigations


PET SCAN FDG, a glucose analogue is used Malignant tumors have increased uptake of FDG Sensitivity 85-91% / > CT Specificity86-88% / >CT PET has higher sensitivity than CT for evaluation of mediastinum A (-) PET may obviate need for mediastinoscopy PPV 87-100% A (+) PET should not be taken as unresectability, because of false positives, PPV 74-80%


Radical radiotherapy can offer long-term survival in selected patients with localised disease in whom comorbidity precludes surgery. Palliative radiotherapy: superior vena caval obstruction, recurrent haemoptysis, and pain caused by chest wall invasion or by skeletal metastatic deposits, obstruction of the trachea and main bronchi Radiotherapy can be used in conjunction with surgery Concurrent radiotherapy in the treatment of small-cell carcinoma and is particularly efficient at preventing the development of brain metastases in patients who have had a complete response to chemotherapy. Continuous hyperfractionated accelerated radiotherapy (CHART) in which a similar total dose is given in smaller but more frequent fractions, may offer better survival prospects than conventional schedules. Radiotherapy


Ttreatment of small-cell carcinoma : combination chemotherapy including combinations of i.v. cyclophosphamide, doxorubicin and vincristine or i.v. cisplatin and etoposide. Neoadjuvant and adjuvant chemotherapy: In non-small-cell carcinoma, there is early evidence that chemotherapy given before surgery may increase survival and can effectively 'down-stage' disease with limited nodal spread. Post-operative chemotherapy is also useful when operative samples show nodal involvement by tumour. Palliative : in stage IV non-small cell Cancer Chemotherapy

Have a Good Night:

Have a Good Night

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