Triennial Pulmonary Workshop 2012

Transcription

1 Triennial Pulmonary Workshop 2012 Rod Richie, M.D., DBIM Medical Director Texas Life Insurance Company, Waco, TX EMSI, Waco, TX Lisa Papazian, M.D., DBIM Assistant Vice President and Medical Director Sun Life Financial, Wellesley Hills, MA 1

2 Triennial Pulmonary Workshop 2012 Rod Richie, M.D., DBIM Lisa Papazian, M.D., DBIM SPIROMETRY FEV1 Forced Expiratory 1 st Second FVC Forced Vital Capacity FEV1/FVC FEF25-75% Forced Expiratory Flow between 25% and 75% of expiratory flow curve also called MMEF or Maximal Mid-Expiratory Flow 2

3 SPIROMETRY 4 3 Liters Time Seconds SPIROMETRY 4 3 Liters 2 FEV Time Seconds 3

4 SPIROMETRY 4 FVC 3 Liters Time Seconds SPIROMETRY 4 3 Liters 2 FEV1/FVC Time Seconds 4

5 SPIROMETRY 4 3 Liters 2 FEF25-75% change per second = Flow Time Seconds Flow- Loops Flow 5

6 Flow- Loops Airway Obstruction Flow Flow- Loops As obstruction worsens, the expiratory limb caves in more and more Flow 6

7 Flow- Loops Restriction a miniaturization of a normal flow-volume loop Flow Flow- Loops Extra-thoracic Airway Obstruction (laryngeal, upper tracheal) Flow Plateauing of inspiratory loop 7

8 Flow- Loops Fixed airway obstruction (tracheal, carinal obstruction) Flow 8

9 PULMONARY CASES Case 1: 52 year old female Chronic symptoms of shortness of breath (SOB), dyspnea on exertion (DOE), cough and sputum production PMH: Asthma since childhood and teenage years o Hospitalized several times in childhood o No hospitalizations in last 30 years Medications: Albuterol MDI daily, Combined inhaled steroid + long-acting beta-adrenergic medication twice a day. o On average per year, requires two brief prednisone courses (50 mg po daily x 5 days) Never smoked Physical exam: Appears well, not in any obvious distress Room air (RA) oxygen saturation (SaO2) at rest 98 % Lung exam shows scattered faint end-expiratory wheezes, made worse with exaggerated breathing which also elicits coughing, moves air well CXR was interpreted as normal Spirometry one year ago: FVC 82% predicted, FEV1 61 % predicted, FEV1/FVC 56%, and FEF % predicted. Post-bronchodilator FEV1 increased to 75% predicted 9

10 Questions: 1) What does the spirometry show? 2 a) Does this client have Asthma? b) What might have happened to her lungs over the years? c) What are the differences between Asthma and COPD? 3) Does it matter when the spirometry was done in the evaluation of the client? 4) What other associated medical problems might she have? 5) What might be the next step in evaluation? Client s PFTs: TLC = 103% predicted FRC = 153% predicted DLCO = 98% predicted 6) What is your interpretation of the PFTs? 10

11 7) How would you assess this case? 8) How does this client s mortality risk compare to a standard insured population? 11

12 CASE 2: 24 year old male Pre-employment CXR showed bilateral hilar lymphadenopathy and fine reticulonodular infiltrate Physician s Evaluation: o Occasional symptoms of wheezing with exertion x 6 months o No fever, night sweats, weight loss or other systemic symptoms Lifelong non-smoker No allergies Physical exam: In no apparent distress RA O2 sat = 95% Lung exam shows occasional faint crackles diffusely 12

13 Questions: 1) What other information would you want in evaluating this client? 2) What would you expect the PFTs to show? Give an example using % predicted values of FEV1, FVC, TLC, RV, FRC and DLCO. 3 a) What do the findings on CXR indicate? b) How does the passage of time influence your decision? 4) What blood tests results would you inquire about? 5) What other lung tests might you inquire about? 6) What prior exposures might you wonder about? 7) What other organs can be affected by this disease? 8) How does this client s mortality risk compare to a standard insured population? 13

14 CASE 3: 45 year old male former smoker Symptoms cough and SOB Previous evaluation 6 months ago o CXR showed CHF o Normal B-type natiuretic peptide o Normal Echocardiogram o Normal Stress Nuclear Test o Normal Cardiac Catheterization o Reassured nothing serious Physical Exam: In no apparent distress RA O2 sat = 91% Lung exam bilateral dry crackles diffusely 14

15 Questions: 1) What other information would you want in evaluating this applicant for life Insurance? Client s PFTs: FEV1 = 66% predicted FVC = 60% predicted FEV1/FVC = 91% TLC = 56% predicted FRC = 45% predicted DLCO = 46% predicted 2) What is your interpretation of the PFTs? 3) What would you expect to see on a chest CT, a high resolution chest CT, and an echocardiogram? 5) What would you expect to see on oximetry if the client walked 40 feet? 6) What other physical findings would you expect? 7) How does this client s mortality risk compare to a standard insured population? 15

16 CASE 4: 30 year old morbidly obese male (BMI 57 kg/m2) Symptoms: SOB / DOE, fatigue, daytime sleepiness PMH: Hypertension and Obstructive Sleep Apnea Non-smoker Physical Exam: Appears somewhat sleepy, but answers questions appropriately Resting O2 sat on RA = 93% Physical Exam: Retrognathic chin, long soft palate, prominent tonsils and long uvula, deviated nasal septum Lung exam was clear Extremities 2+ to 3+ pitting lower extremity edema. Overnight Sleep Study (split night study): Total Sleep Time = 210 minutes (3.5 hours) Sleep Latency = 3 minutes REM Latency = minutes Total REM Sleep = 32.5 minutes % REM Sleep = 15% Total Obstructive Apneas = 140 Total Obstructive Hypopneas = 18 Lowest O2 sat = 71% 16

17 21% of sleep occurred with O2 sat < 89% Apnea Hypopnea Index = 45 events / hour Titration with CPAP was initiated, and optimal final pressure of CPAP was determined to be 16 cm H2O pressure. CXR: normal Client s PFTs: FEV1 = 74% predicted FVC = 75% predicted FEV1/FVC = 99%, TLC = 77% predicted FRC = 62% predicted DLCO = 47% predicted Echocardiogram: Right ventricular enlargement, right ventricular systolic pressure (RVSP) = 45 mm Hg, normal LV size, EF 55 to 60% 17

18 Questions: 1) What are the significant findings on the sleep study? 2a) Define apnea and hypopnea b) Define obstructive and central events c) Explain what an Epworth Sleepiness Scale Score is 4) Calculate the AHI before treatment with CPAP 5 a) How would you assess compliance with CPAP treatment? b) How does blood pressure factor into your assessment? 6) What are the appropriate treatments for OSA? 7) What are the expected outcomes for OSA treated with CPAP and for OSA not treated with CPAP? 8) Comment on the O2 desaturation seen on the sleep study. What might you see on an arterial blood gas? 18

19 9 a) What do his PFTs show? b) Name several types of restrictive lung diseases which are not interstitial lung diseases. 10) What does the echocardiogram show? 11) How does our client s mortality risk compare to a standard insured population? References: RC Richie. Assessing Mortality Risk in COPD. JIM 2008; 40; Paul Quartararo. A Breath of Fresh Air for COPD. JIM 2008; 40; RC Richie. Sarcoidosis: A Review. JIM 2005; 37: Joanne Mambretti. Chest X-ray Stages of Sarcoidosis. JIM 2004; 36: RC Richie. Sleep Apnea: A Review for Life Insurance Medical Directors and Underwriters. JIM 2003; 35: Keith Clark. Association of Sleep-Disordered Breathing, Sleep Apnea, and Hypertension in a Large Community-Based Study. JIM 2000; 32: Mason RJ, Broaddus VC, Murray JF et al (eds). Murray and Nadel s Textbook of Respiratory Medicine, 4 th edition. Philadelphia: Elsevier Saunders, Kryger MH, Roth T, Dement WC (eds). Principles and Practice of Sleep Medicine, 4th edition. Philadelphia: Elsevier Saunders,