AUGUST 25-27, 2017 UPDATE & BOARD REVIEW. acofp INTENSIVE. Pulmonary Predicaments in Primary Care. Peter F. Bidey, DO

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1 acofp INTENSIVE UPDATE & BOARD REVIEW AUGUST 25-27, 2017 Loews Chicago O'Hare Hotel Rosemont, IL INNOVATIVE COMPREHENSIVE HANDS-ON Pulmonary Predicaments in Primary Care Peter F. Bidey, DO acofp Am eric an College of Osteopathi c Family Physicians The American College of Osteopathic Family Physicians is accredited by the American Osteopathic Association Council to sponsor continuing medical education for osteopathic physicians. The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content.

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3 Pulmonary Predicaments in Primary Care Peter F. Bidey, DO, MSEd Assistant Professor-Family Medicine Philadelphia College of Osteopathic Medicine Program Director PCOM/Suburban Community Hospital Family Medicine Residency ACOFP Intensive Update and Board Review Chicago, IL Objectives Examine and differentiate asthma and COPD diagnosis and treatments Review diagnosis and treatment of Pulmonary Embolism Review diagnosis and treatment of pulmonary tuberculosis in out-patient setting Review diagnosis and treatment of community acquired pneumonia in out-patient setting Case A 45 year old male presents to your office complaining of wheeze and DOE over the past year. Patient states he remembers having some issues with asthma as a child but no issues for many years. He reports a 10 pack year history of tobacco use and quit smoking 15 years ago. He states his mother has COPD and his father has asthma. 1

4 Case Asthma or COPD? How would management change? Thorax 2008;63: doi: /thx Asthma Definition Chronic disorder with recurring symptoms of airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation It is a reversible obstructive lung disease Symptoms Wheeze Cough Shortness of breath (SOB)/Shortness of air (SOA) Chest tightness Asthma Diagnosis History Episodic and trigger-induced wheeze, SOB, DOE, and cough Family History and/or personal history as child Physical Exam Wheeze Atopic dermatitis and allergic rhinitis Viscerosomatic reflexes, diaphragmatic disorders, and rib dysfunctions 2

5 Asthma Diagnosis cont. Studies Spirometry Pre-and Post-bronchodilator Methacholine Challenge Good for patients with normal baseline airflow Peak Expiratory Flow Meter Better for monitoring known disease Labs Chest radiograph Asthma Classification Mild Intermittent Mild Persistent Symptoms 2days/week >2 days/week but not daily Rescue inhaler Use Nighttime awaking Interference with activity Lung function 2days/week >2days/week but not daily Moderate Persistent Daily Daily 2x/month 3-4x/month >1x/week but not nightly Severe Persistent Throughout day Several times /day Often 7x/week None Minor Some Very limited FEV1>80% predicted FEV1/FVC normal FEV1>80% predicted FEV1/FVC normal FEV1>60% but <80% predicted FEV1/FVC reduced 5% FEV1<60% predicted FEV1/FVC reduced >5% Asthma Treatment Goal Daytime symptoms <2x/week and nighttime symptoms <2x month Avoid triggers Vaccines Influenza and Pneumococcal recommendations Stepwise treatment fashion Rescue inhaler use with short-acting β-2 agonists (SABA) Acute exaggerations usually require systemic steroids Asthma action plan 3

6 Asthma Treatment Summary National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. National Institutes of Health, National Heart, Lung, and Blood Institute. August NIH publication Exercise-Induced Asthma Symptoms similar to asthma but usually only associated with exercise Treat with SABA 10 minutes prior to exercise Minimize irritant exposure and can consider leukotriene modifiers Question #1 A 69 year old male presents to your office complaining of cough and wheeze for the past 6 months. He has a 50 pack year smoking history. He also admits to getting winded when he goes up steps. He has a PMHx of HTN which he takes HCTZ 25mg daily. Which test would be LEAST helpful in confirming your diagnosis? a. ECG b. α-1 antitrypsin c. CXR d. CBC e. CMP 4

7 Chronic Obstructive Pulmonary Disease Definition Airflow limitation that is progressive and associated with an enhanced chronic inflammatory response in the airways and lungs to noxious particles and gases Includes sub-types: emphysema, chronic bronchitis, and chronic obstructive asthma 210 million diagnosed worldwide and by 2030 will be 3 rd most common cause of death in the world Symptoms Chronic progressive-cough, sputum production, and dyspnea COPD Diagnosis History Smoking and inhalation exposure Progressive DOE, chronic cough, and increase in sputum production Physical Exam Early disease is usually normal Hyperinflation, decreased breath sounds, wheezes, decreased heart sounds, and crackles at bases Severe disease results in barrel chest, flattening of the diaphragm, and pursed lip breathing COPD Diagnosis cont. Studies Spirometry FEV1/FVC < 0.70 or 5% lower limit of normal(lln) Post-bronchodilator Chest radiograph vs. CT scan Lab tests Can consider: ABG-FEV1 <50% predicted or pulse ox <92% CBC/CMP α-1 antitrypsin 5

8 Spirometry Results GOLD Criteria Classification of Severity Global Initiative for Chronic Obstructive Lung Disease All have FEV1/FVC<0.7 or <5%LLN of FEV1/FVC GOLD 1-Mild FEV1 80% predicted GOLD 2-Moderate GOLD 3-Severe GOLD 4-Very Severe FEV1 50% predicted and <80% predicted FEV1 30% predicted and <50% predicted FEV1<30% predicted GOLD Disease Category Combines FEV1 level with symptoms and history of exaggerations Individual symptoms Uses modified Medical Research Council (mmrc) or COPD or COPD assessment test (CAT) Number of exaggerations in 12 months 6

9 Combined Assessment of COPD From the Global Strategy for Diagnosis, Management and Prevention of COPD Copyright Global Initiative for Chronic Obstructive Lung Disease (GOLD), all rights reserved. Available from -Accessed June 23, 2016 COPD Treatment-Stable Patients STOP smoking or exposure to other irritants Step-wise treatment fashion Pulmonary Rehabilitation Vaccines Influenza Pneumococcal Oxygen therapy for patient with severe hypoxemia COPD Treatment Patient Group A B C First Choice Second Choice Alternatives Short-acting anticholinergic PRN or SABA PRN Long acting anticholinergic or LABA ICS & LABA or Longacting anticholinergic LAMA or LABA or SABA & SAMA LAMA & LABA LAMA & LABA or LAMA & PDE 4 or LABA & PDE 4 Theophylline SAMA PRN &/0r SABA PRN Theophylline SAMA &/0r SABA Theophylline D ICS & LABA &/or Long-acting anticholinergic ICS & LABA & LAMA or ICS & LABA & PDE4 or LAMA & LABA or LAMA & PDE4 SAMA PRN &/0r SABA PRN Theophylline Carbocysteine 7

10 Acute COPD Exacerbations Systemic Steroids Bronchodilators Antibiotics BiPAP vs. mechanical ventilation Osteopathic Treatments Release the diaphragm Correct rib lesions Lymphatic pumps Rib raising Question #2 A 32 year old pregnant female presents to to your office complaining of shortness breath and some pain with breathing. She recently returned from a trip to England. You suspect a Pulmonary Embolism and this diagnosis is confirmed at the ER. She is hemodynamically stable. Which anticoagulant modality is indicated for this patient? a. Warfarin b. LMW Heparin c. Apixaban d. IVC Filter e. Dabigatran 8

11 Pulmonary Embolism Presentation Acute, Sub-acute, or Chronic Wells Criteria Risks Score Clinical symptoms of DVT 3.0 Other diagnosis less likely than PE 3.0 Heart Rate > Immobilization or surgery in the previous four weeks Previous DVT/PE 1.5 Hemoptysis 1.0 Malignancy Pulmonary Embolism Diagnostic Studies D-Dimer Duplex Ultrasound CXR ECG Arterial Blood Gas V/Q Scan CT Pulmonary Angiography Pulmonary Embolism Treatment Heparin or LMW Heparin Warfarin IVC Filter Thrombolytic Therapy Direct thrombin inhibitors Factor Xa inhibitors Duration 9

12 Question #3 A 27-year-old female medical student presents to have a TST read 48 hours after administration. She was exposed to a patient with confirmed active tuberculosis 8 weeks ago on her Emergency Medicine rotation. The PPD induration measures 14mm. She denies any systemic symptoms and is otherwise without complaints. She has no significant past medical history. A CXR was ordered and shows no abnormalities. She has no history of positive TST or previous BCG vaccination. What is the preferred treatment for this patient? a. INH for 9 months b. Rifapentine for 6 months c. Rifampin for 4 months d. Pyrazinamide for 4 months e. Ethambutol for 6 month Pulmonary Tuberculosis-Latent History Testing should be performed in patients with recent contact and who are at high risk of conversion Diagnosis in HIV-negative patients Tuberculin Skin Test Preferred test for children <5 Interferon Gamma Release Assays Can be used in all settings in place of TST. Preferred test in BCG-vaccinated individuals Possible use for determining false positives Two-Step Testing Performed 1 to 4 weeks after initial testing in absence of exposure Pulmonary Tuberculosis-Latent Treatment Goal To avoid conversion to active tuberculosis Additional Tests Obtain CXR, HIV testing, pregnancy, and baseline LFTs Monitor for any signs of active tuberculosis Medications Isoniazid +/- pyridoxine for 9 months Can consider alternative treatments of INH with rifapentine for 3 months if recent exposure >12 years old Direct observation treatment 10

13 Interpretation of Tuberculin Skin Test 5mm HIV infection, close contact of active contagious case, Abnormal CXR consistent with old TB, or immunosuppressed patients 10mm High risk of reactivation-silicosis, ESRD, DM, leukemia, lymphoma, head/neck/lung CA, underweight, jejunoileal bypass, IV-drug user Children <4 years of age Foreign born from countries with incidence >25/ Residents and employees in high risk settings 15mm Healthy persons with low likelihood of true TB infection Pulmonary Tuberculosis-Active History Risks for exposure Fever, night sweats, cough, weight loss, fatigue, and hemoptysis Physical Exam Usually non-specific but include dullness of lung sounds or occasional rales Studies Baseline LFTs, kidney function, CBC, and uric acid HIV and hepatitis testing CXR Sputum culture with AFB testing Baseline visual acuity and red-green discrimination when using ethambutol Pulmonary Tuberculosis-Active Treatment Initial phase consists of 2 months with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) Continuation phase usually then continues with 4 months of isoniazid and rifampin Monitor for side effects 11

14 Pulmonary Tuberculosis-Active Initial Phase Continuation Phase Drugs Interval and doses Drugs Interval and doses INH RIF PZA EMB Seven days per week for 56 doses (8 weeks) or 5 days/week for 40 doses (8 weeks) INH/RIF 7 d/wk for 18 weeks or 5d/wk for 18 weeks INH/RIF Twice weekly for 18 weeks INH/RPT Once weekly for 18 weeks Cavitation on CXR & (+) 2 months require 7 months continuation phase DOT HIV (-), negative no cavitation on CXR Question #4 A 56-year-old diabetic female presents to your outpatient clinic with fever, chills, and cough which has worsened over the past week. She states she had an URI 2 months ago and was treated with Azithromycin and improved. Currently her vitals are- Temp: 101 F, RR-20, HR-101, BP-126/88, and PO- 97%. Her physical exams revealed rhonchi in the left lower lobe. Otherwise exam is unremarkable. Her current medications include Lisinopril 5mg and Metformin 500mg BID. What is your treatment of choice for this patient? a. Azithromycin b. Levofloxacin c. Doxycycline d. Cefuroxime axetil e. Sulfamethoxazole/trimethoprim Community Acquired Pneumonia (CAP) History Fevers, chills, cough, dyspnea, pleuritic chest pain, sputum production Inquire about recent antibiotic use, hospitalizations, or other risks Physical Exam Increased respiratory rate, increased pulse, rales, or rhonchi Studies CXR Optional blood work and sputum/blood cultures (Outpatient) 12

15 Community Acquired Pneumonia (CAP) Treatment Admit or Not to Admit? CURB-65 Confusion (based upon a specific mental test or new disorientation to person, place, or time) Urea (blood urea nitrogen in the United States) >7 mmol/l (20 mg/dl) Respiratory rate >30 breaths/minute Blood pressure (systolic <90 mmhg or diastolic <60 mmhg) Age >65 years Community Acquired Pneumonia (CAP) Treatment Monitor for increased risk of drug resistant strains Age >65 years Recent ABX use in past 3 months Alcoholism Medical comorbidities Immunosuppressive illness or therapy Environmental exposures CAP Pathogens Typical Bacteria S. pneumoniae, H. influenzae, Staphylococcus aureus, group A streptococci, M. catarrhalis, anaerobes, and aerobic gram-negative bacteria Atypical Bacteria Legionella spp, M. pnuemoniae, C. pneumoniae, and Chlamydia psittaci 13

16 Community Acquired Pneumonia (CAP) Treatment No comorbidities or recent ABX use Macrolides or Doxycycline Doxycycline is preferred if concern of QT prolongation Treatment length is at least 5 days and 48 to 72 without fever Comorbidities or recent ABX use or Suspected Resistance Respiratory fluoroquinolone OR beta-lactam effective against S. pneumoniae PLUS a macrolid or doxycycline Follow-up CXR Vaccination Questions 14