Murine Spooner Respiratory Lecture

Common Long Cases:

COPD
CF
Asthma
Bronchiectasis
Pulmonary Fibrosis
Dyspnea unknown cause
PE
Pleural Effusion
Intestinal Lung Disease

Common Symptoms
Dyspnea
o Make sure you specify how dyspenic distance to dyspnea always get
baseline and how compares to know
Chests pain
o (pleuric pain) does the pain get worse on breathing in, coughing,
sneezing, laughing ? (usually can isolate site with one finger)
PND orthopnea (rule out cardiac cause)
Cough any clots in it frothy white sputum
Hemoptysis
Wheeze ( relieved by bronchodilators )
Fever Night Sweats
Hoarseness (smoking,
Weight loss
o important in CF less than 17 contraindicated for transplant ,
pneumonia, tb, GOLD stage 4, end stage pulmonary fibrosis
Weight Gain
o Patients with cor pulmonole
Stridor
Prior to hospital : Confusion , respiratory rearrest confusion

Ask about that you can increase medications: did you have to use your salbutamol
more than often how many times do you use it, did it provide relief (same for home
o2 and cpap)

Why Patients come in with chronic illness:

Inpatients COPD, CF, work up for CF, post CF (nutrition optimalization) blood
glucose, intense physiotherapy , failure IV
Fibrosis: come in to make diagnosis, decompensated ( acute exacerbation)
Pneumonia : why smoker, underlying immunology disease, chem/radiation
Pneumothorax
Pleural effusion: cancer and CHF, thyroid disease, renal failure, liver failure, ovarian
pathology

Risk Factors
COPD : Smoking History
Do they smoke? When did they quit? How long did they smoke for? What is
the most they smoked and for how long? What is the least they smoked for
and how long? Active smoker ask previous attempts at smoking any aids
they used (nicotine, bupropion)
Is anyone sick at home? Any one smoking at home?
Previous history of asbestosis, TB
Alpha 1 trypsin deficiency (gene SZ abnormality) [1/1000 autosomal co-
dominant]
o Homozygote ZZ, SS, SZ will have early onset emphysema/COPD
o MZ only develop Emphysema/ COPD if they smoke
o SZ usually develop Emphysema/COPD but severity depends on if they
smoke worse asthmatic symptoms
CF: Inheritance : autosomal recessive
Anyone in the family have it (sister, cousins etc)
Pneumothorax
Obstructive airway disease (asthma, COPD)
CF (mixed obstructive/restrictive)
Pulmonary Fibrosis
LAMB (chronic bullous disease)
Collagen vascular disorders
Tall thin young man
Smoking
Trauma
Ventolatory associated pneumothorac
ENT/ thoracic surgery placemen
o Primary no obvious cause
o Secondary-Underlying disease causes
Pleural Effusion
Transudate: CHF, CRF, cirrhosis , thyroid disease
Exudate: malignancy, PE, pulmonary infection. autoimmune disease,
pancreatitis
Bilateral= peritoneal dialysis
Fibrosis
Smoking
Medications : MTX,nitrofutoin, amiodarone, started in last few years
Autoimmune disease
TB, asbestosis, aspergillus, silicosis
PE
Obesity, smoking, OCP
 Underlying cancer (1/6-1/10 of ppl presenting with PE will have cancer)
Surgery, immobility, long hall flights (8+)
Inherited thrombophilia ( clot in the leg or lung, unexplained sudden death
or miscarriages)
Any history of previous clots in past?

Past Medical History

COPD/Bronchiectasis long standing history :
When where they diagnosed?
When was there last PFT and what was their FEV1
How many hospitalizations in last two years?
o Have they been on CPAP or BIPAP ?
o Have they ever been intubated or in ICU?
How many times did they have to see their GP?
How many courses of abxx/ steroids?
Did you get flu or pneumo vaccine?
Do you know what is growing in your sputum?
Are you on home 02?
Portal oxygen: PRN symptomatic relief
Long term: Po2<7.3 Pc02 >6 acidosis or features of CCF (core
pulmonary therapy) prescribed for a minimum of 16 hours a day
[decreases number of admissions and prolongs life]

CF same as above plus

Ever have a pneumothorax, pleural effusion, hemoptysis
Ever had a chest drain put in (more complications with transplant later)
Ever been told you have Aspergillous, TB
Are you on a transplant list? Have you ever been called (they call 5 people
and see who has best HLA matching)
o Get on list when FEV1 <25 usual criteria
Are they on any trials ?
Do they have DM ?
o How long have you had it for?
o What is your last HBA1c
Do they see an opthomologist?
Do see a nephrologist?
Do you have osteoporis or osteopenia? When was last DEXA scan?
Do you have liver disease? When was last liver ultrasound?
Have you ever had a bowel obstruction?
Abdominal Surgeries due to CF?
Do you have a PEG?
Do you have malabsoption(Ask: Are you taking creon/taking vitamins
ADEK)?
Past Surgical History
PEG, Port, pic line (if you want to include)
Nasal Polyps
Transplant : lung, kidney?
Bowel resections
Pleurectomy- VATS (endoscopic), mediastinotomy
mediastinotomy: (nodule must be central) diagnosis of Sarcoidosis,
mediastinotomy
** scar similar to thyroidectomy scar slightly lower and shorter
If they had a transplant ask :
how many days out
where you put on bypass
Do you know how much blood lost
Where you transfused
How long did it take for them to wake you up?
Wound Healing well ?

Allergies
*if CF patient has load of allergies to do with antibiotics go into detail of what the
reactions was since they need to be on antibiotics due to recurrent respiratory
infections
- did they have a IgE checked?

Medications
Bronchodilators : betagonist or anticholinergic (ipratropium bromide)
Combination
**If you don't recognize the drug ask if its your preventer or reliever and if
you have any combination ones?
Leukotriene antagonist
Oral steroids (vitamin D and calcium +/- PPI)
Tobramycin / colomycin if colonized with pseudomonas
Pulmozyme
Hypertonic Saline
Antifungal: Fluconazole
Antibiotics: beta lactam, tazosin,
Antipseudomonal agent- fluoroquinolones (based on sputum culture
sensitivities)
Pulmonary Hypertension Patients
o Nitrates, Sildenafil
Fibrosis Patients
 o Started on a 6 week trial of steroids if they do well they will stay if
they don't they will switch them off
Kaleidico
o Used for G551D mutation has been used in D508 mutation
o In cystic fibrosis the problem is with the CFTR receptor and in
G551D they have the receptor but wrong location so kaledico
brings receptor to right site to allow for normal chloride change
o Massively improved FEV1, number of hospital admission
o Tablet you take once a day lots of research done at Beaumont on
medication (article in NEJM 2012)
Insulin
Liver Drugs
o Cholestyramine
o Vitamin ADEK
Folic acid
Laxative
LMWH and warfarin = for PE
o Enxoparin
Prophylactic 40mg BID SC or 40mg OD and 20mg OD SC if
renal failure or over 65
Theraputic 1mg-1.5mgkg
o Tinzaparin
Prophylactic 3500 units (massively obese 5000mg)
Therapeutic 1.75 units/kg

Social
Who they are living with?
Is there stairs in the house?
Any pets or people smoking in the house? ~ approxi amount of time
Are they missing school or work due to illness?
Smoking/ Alcohol/ Street drugs?
Ask about daily living if they are old

Family History
Any family history of breathing problems?
o Asthma, Alpha antitrypsin 1, CF