Respirology

Friday, December 9th, 2022

Dr. Waleed S. Ahmed

© Internal Medicine Review 2023

 Royal College Objectives…
• Acute dyspnea • Chronic obstructive lung disease
• Chronic dyspnea • Bronchial asthma
• Cough • Interstitial lung disease
• Wheeze • Pulmonary embolism
• Hemoptysis • Pneumothorax
• Superior vena cava syndrome • Pleural effusion
• Interpretation of Pulmonary • Sarcoidosis
Function Testing • Lung cancer: primary and
• Pneumonia metastatic including paraneoplastic
syndromes

2
 Overview
• Airways Disease
– Asthma
PFT Primer & Practice PFTs:
– COPD
For each topic will – Bronchiectasis
review diagnosis and Check out our Online PFT Self-
• Interstitial Lung Disease
management, and Study Module!
highlight relevant – IPF
guidelines and recent • Pleural Disease
evidence
• Sarcoidosis
• Sleep Disordered Breathing
• Pulmonary Hypertension
• Approach to common respiratory
problems: Hemoptysis, ABG interpretation/hypoxemia
• BONUS SLIDES: CTS choosing wisely, PFT Primer,
Chronic cough, Pulm Nodules, Smoking cessation,
Important COPD/Asthma trials
Bonus: Read
on your OWN
Acronyms Used in this Talk
Acronym Meaning
ATS American Thoracic Society
AECOPD Acute Exacerbation of COPD
CTS Canadian Thoracics Society (respiratoryguidelines.ca)
GINA Global Initiative for Asthma
ICS Inhaled Corticosteroid
LABA Long acting Beta Agonist (ex. Salmeterol)
LAMA Long Acting Muscarinic Antagonist (ex.Glycopyrronium, tiotropium)
LVRS Lung Volume Reduction Surgery
MDD Multidisciplinary Discussion (as happens in diagnostic w/u of IPF)
NAEB Non asthmatic eosinophilic bronchitis
NIV Non Invasive Ventilation (e.g. BiPAP)
NTM NonTuberculous Mycobacteria
PsA Pseudomonas Aeruginosa
PFT Pulmonary Function Test 4
 Asthma
Airways
Disease

Key resources for Royal College Exam:

1. Global Initiative for Asthma (GINA) 2022 guidelines (updated yearly)
2. Canadian Thoracic Society (CTS) Guidelines
• Recognition and management of severe asthma (2017)
• Guideline Update: Diagnosis and management of asthma in preschoolers,
children and adults (2021)
• Guideline Update: A focussed update on the management of mild and very mild
asthma (2021)
– Major points mostly the same between guidelines except when indicated
(if in doubt use CTS)

5
 MCQ 1 2022
A 35 year old man who is a nonsmoker developed Covid infection 6 months ago. He was
vaccinated and his acute infection did not require a hospitalization. He had a persistent
cough which prompted his family doctor to start him on budesonide-formoterol 200/6
mcg inh prn. Spirometry is done which confirms reversible obstruction. Inhaler has
resolved his symptoms somewhat, However he does sometimes have shortness of
breath before going to sleep requiring his bronchodilator, approximately every other
weekend. He has not missed any days at work due to this. Which of the following is an
appropriate next step?

a) Start standing BID budesonide-formoterol

b) Continue prn budesonide-formoterol
c) Change to budesonide-formoterol 400 mcg inh BID + PRN
d) Step down to salbutamol prn only

6
 Asthma
Asthma is a heterogenous disease characterized by chronic airway inflammation.
Symptoms include wheeze, shortness of breath, chest tightness and cough that
vary over time and are related to bronchoconstriction, airway wall thickening,
increased mucus and variable expiratory airflow limitation.

Asthma Diagnosis requires both:

1. History of variable respiratory symptoms (e.g. wheeze, SOB, chest
tightness, cough) that vary over time and intensity
2. Confirmed variable expiratory airflow limitation:
NEED SPIROMETRY TO HAVE DIAGNOSIS OF ASTHMA

7
 Asthma
• Asthma has many clinical phenotypes:
– Allergic: Classic asthma, atopy, eosinophilic inflammation, responds to ICS
– Non-allergic: Neutrophilic, eosinophilic or paucigranulocytic inflammation
with less response to ICS
– Adult-onset: Non-allergic, require higher ICS, rule out occupational asthma
– Associated with obesity: Little eosinophilic inflammation
– Associated with persistent airflow limitation: Longstanding asthma causing
fixed obstruction due to airway remodelling

8
 Asthma – Diagnosis (1)
Expiratory airflow limitation:
• At least once during diagnostic process, confirm reduced FEV1/FVC (below lower limit of normal)
Variability, as demonstrated by any of:
• Positive bronchodilator reversibility (10-15 minutes after 200-400 mcg salbutamol)
– Improvement in FEV1 by > 12% AND 200mL post BD
• Improvement in lung function with anti-inflammatory treatment x 4 weeks:
– Improvement in FEV1 by > 12% AND 200mL post BD
• Excessive FEV1 variation in lung function between visits (>12% and 200 cc variation)
• Peak Flow Variability – Average daily diurnal PEF variability >10%
– Excessive variability in twice daily PEF over 2 weeks
• Positive Bronchial Challenge Test or Exercise challenge test (i.e. methacholine challenge, see next slide)

9
 Asthma – Diagnosis (2)
• Airflow limitation may not be present at the time of initial assessment (ie
can have normal spirometry and still have asthma)
– If normal, may repeat during times of symptoms
– Can perform methacholine or exercise testing

• Methacholine Challenge – look for drop in FEV1 by 20%

– PC20 <4mg/mL = POSITIVE
– PC20 4-16 = borderline
– PC20 >16 = negative

• Exercise Challenge
– Fall in FEV1 of >10% and >200mL from baseline

10
 Assessing Asthma Control –
updated by CTS Nov 2021
• The goal of asthma management is asthma control, (includes both asthma symptoms and
risk of future adverse outcomes), asthma control should be assessed at each visit
• Asthma control implies all of the CTS asthma control criteria are present, see below (NB:
This is from the CTS guideline, GINA uses different cutoffs) KNOW THESE NEW CRITERIA ↓
Characteristic Cutoff
Daytime symptoms ≤ 2 d/week
Nighttime symptoms < 1d/ week and mild
Physical activity Normal
Exacerbations Mild (not requiring systemic steroids or ED visit) and infrequent
Absence from work/school due to exacerbation None
Need for a reliever (SABA or bud/fom) ≤ 2 doses per week Question: “Does need for PRN inhaler
FEV1 or PEF ≥ 90% of personal best prior to exercise count as poor control?”
Answer: (consensus @ IMR) Those who
PEF diurnal variation <10-15% manage symptoms with prophylaxis
Sputum eosinophils <2-3% alone (eg not as a RELIEVER post exercise) have
11
good control.
 CTS 2021 Key Algorithm
CTS 2021 Approach: BOX 1: Risk for severe exacerbation = any 1 of:
#1 Do they have well controlled asthma? • Any history of a previous severe asthma
IF YES à Go to #2 below exacerbation (any of: requiring systemic
IF NO à start daily ICS + PRN SABA steroids, ED visit or hospitalization)
• Poorly controlled asthma per CTS criteria
#2 Do they have risk of severe exacerbation (see Box 1). • Overuse of SABA (=use of more than 2 SABA
IF YES à daily ICS (preferred) or PRN bud/form inhalers per year)
IF NO à prn Bud/form or PRN SABA* • Current smoker
BOTTOM LINE: Pts should be on daily ICS if they
have poorly controlled asthma, or if they have well
Severe Asthma Exacerbation(CTS 2021)=any 1 of
controlled asthma but risk for severe exacerbation. - Requiring systemic steroids
*CTS states to incorporate pt preference – if well controlled, low
- Requiring ED visit
risk exacerbation, may consider continuing prn SABA but putting - Requiring hospital admission
on ICS + PRN SABA may reduce risk of exacerbations Mild exacerbation = 0/3 above criteria
12
Ugly CTS 2021 Management Graphic

13
 Asthma Treatment – GINA 2022, CTS 2021
MAJOR CHANGE
- Prefer Track 1: No more SABA-only treatment as reliever
Never LABA
- ICS-Formoterol new preferred reliever! monotherapy –
- Symbicort – budesonide formoterol (Step 1-2 per guideline) increased risk of
- Zenhale – mometasone/formoterol STEP 5
death! Refer for phenotypic
- Fostair – beclomethasone/formoterol STEP 4
Medium dose assessment, +/-
STEP 3 LAMA add on, Anti
Low dose maintenance ICS-
TRACK 1 formoterol IgE, Anti IL5, Anti IL4,
maintenance ICS-
STEP 1 and 2 Anti-TSLP. Consider
Preferred formoterol
high dose ICS
PRN low-dose ICS formoterol
reliever/controller Formoterol.
PREFERRED RELIEVER: AS NEEDED LOW DOSE ICS FORMOTEROL

STEP 5
STEP 4 Tiotropium +/- refer
Medium/high dose for phenotypic
STEP 3 assessment, Anti IgE
TRACK 2 STEP 2 Low dose maintenance ICS-
LABA Anti IL5, Anti IL4.
Alternative Low dose maintenance maintenance ICS
Consider high dose
STEP 1 ICS LABA
reliever/controller Take ICS with SABA PRN ICS LABA.

ALTERNATIVE (aka not preferred) RELIEVER: AS NEEDED SABA 14

Asthma Treatment – GINA 2022 and CTS 2021
• SABA no longer recommended as sole reliever*
– Endured since >50 years ago, when asthma though of as disease of
bronchoconstriction
– However, asthma is inflammation – constant fire burning in the lungs!
– SABA PRN as sole reliever:
• Increased risk of exacerbation, decreased lung function
• Regular use increases airway inflammation
• Over-use associated with ↑ severe exacerbations and asthma-related death, even if few
interval asthma symptoms!
– Formoterol-containing ICS recommended due to fast onset of action compared to
other LABAs, making it an appropriate reliever
– PRN ICS-formoterol (Cochrane review, 2021):
• ↓Symptoms, Exacerbations, Asthma-Related Hospitalization vs SABA alone
• ↔severe exacerbations(similar rates);↓ ER visits/hospitalizations vs daily ICS+SABA prn

*exception in CTS 2021: Pt with well controlled asthma, no risk for

exacerbation, who prefers to stay on PRN SABA 15
 Asthma Treatment (GINA and CTS 2021)
Pharmacological Pearls:
If patient has symptom control for 2 months and
low risk of exacerbations consider stepping
down therapy
Before STEP UP Therapy: assess and confirm
- Inhaler technique and adherence
- All of the Non-Pharm management
Non-Pharmacological
• Confirm Diagnosis, Educate, Written Asthma
Action Plan
• Weight loss, exercise training
• Allergen / trigger avoidance / allergen
immunotherapy
• Smoking cessation
• Vaccinations
• Avoid NSAIDs (and maybe beta blockers)
• Comorbidities (GERD, PND, Obesity)

16
 Asthma Treatment – LTRA
• LTRA: may be appropriate as initial controller unwilling/
intolerant of ICS, but less effective than ICS at preventing
exacerbations (GINA)
– Most effective in aspirin-exacerbated asthma, exercise-induced
symptoms, allergic rhinitis
– FDA Black Box Warning: increased suicidality in adolescents and adults
For Adults >12y not achieving asthma control on maintenance
low dose ICS (CTS):
• LABA-ICS is superior to ICS-LTRA
• ↓Exacerbations and Symptoms, ↑QOL and ↑PFT
Question: “For patient with Sampter’s Triad (ASA allergy, asthma, nasal polyps) whose
asthma is not well controlled on low dose ICS – would you add LTRA or increase ICS dose?”
Answer: Offer LTRA given ASA-exacerbated asthma 17
Uncontrolled vs Severe Asthma (CTS Update 2017)
SEVERE ASTHMA
Suggested by patient medications
• Asthma requiring high dose ICS + 2nd
controller for the previous year
• Oral steroids for 50% of the year to
maintain control (or remaining
uncontrolled)
Send additional workup, consider
additional agents on next slide
UNCONTROLLED ASTHMA
Indicated by CTS 2021 asthma control
criteria
• Poor symptom control
• Frequent, severe exacerbations ≥
2/year requiring oral steroids
• One serious exacerbation requiring
hospital/ICU/MV in past year
• Sustained airflow reduction (FEV
<80% personal best)
Usually due to poor adherence, poor
technique, or ongoing trigger
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 Severe Asthma Management (CTS 2017)
(Reaffirmed in CTS 2021; new info re eosinophilia GINA 2022)
WORKUP :
• Total IgE
• Peripheral eosinophil count
– Eosinophils >0.3 – consider strongyloides serology before systemic steroids [GINA 2022]
– Eosinophils >1.5 – consider investigate for conditions such as EGPA [GINA 2022]
• Sputum eosinophils and FeNO where available
• Consider screening for adrenal insufficiency if pt on maintenance oral corticosteroid or high dose ICS-LABA [GINA 2022]
TREATMENT (akin to STEP 5 on GINA algorithm):
• LAMA / tiotropium mist inhaler for uncontrolled asthma despite ICS/LABA
– Increases time to first severe exacerbation (NEJM 2012)
– Pts should be on at least medium dose ICS/LABA before considering add on
• Macrolides for uncontrolled asthma despite ICS/LABA
– “In individuals >18 w severe asthma there is limited evidence that chronic use of macrolides may
decrease frequency of exacerbations” (LANCET AMAZES Trial 2017)
• Biologics (see next slide) just know they exist
• Low dose oral corticosteroids
• Bronchial thermoplasty: role remains unclear, only to be practiced in specialized centers

19
 Biologic Overview For severe asthma:
If high IgE and allergies: think
(don’t memorize) about omalizumab.
If high eosinophil count, think
1. Anti-IgE (Omalizumab) about all the other biologics.
-Indications: allergic asthma IgE 30 – 700, sensitive to at least 1 **Tezepulumab does not
perennial allergen, severe despite high dose ICS and one other require any biomarkers to Rx so
controller (CTS 2017) respirologists are excited about
- ↓ exacerbation, ↓ hospitalization, ↓ in ICS dose, variable effect this.**
on lung function
2. IL-5 (mepolizumab, resilzumab, benralizumab)
-Indication severe eosinophilic asthma (generally >300) and recurrent exacerbation despite high-
dose ICS and one other controller (CTS 2017)
Mepolizumab ↓ exacerbation, ↓ in ICS dose, ↓ symptoms and ↑ FEV1 (NEJM 2017)
3. IL-4/IL-13 (Dupilumab) – add-on option for severe eosinophilic asthma or those with nasal
polyposis or moderate-severe atopic dermatitis.↓ exacerbation, ↓ in ICS dose and ↑ lung
function in patients with severe eosinophilic asthma
4. Anti TSLP (Tezepulumab sc) – new GINA 2022 add on for severe asthma (including non-allergic).
TSLP is a cytokine. ↓ exacerbation,↑ FEV1 and QOL lung function 20
 Special Populations (GINA)
• Seasonal allergic asthma: start ICS immediately when symptoms
commence, and continue for four weeks after relevant pollen season
ends
• Exercise induced: salbutamol pre-exercise, if insufficient then LTRA
pre-exercise, if still insufficient try regular ICS
• Pregnancy: rule of thirds (1/3 better, 1/3 worse, 1/3 same),
exacerbations more common, increased risk of preeclampsia, preterm,
low birth weight, treat as you would anyone else, do not stop ICS, most
evidence for budesonide of all ICS (though likely all safe), do not
withhold oral steroids if exacerbating
• ASA exacerbated respiratory disease (samter’s triad: asthma, nasal
polyps,ASAa/NSAID sensitivity): avoid ASA/NSAIDs, can treat like
normal but usually good response to LTRA, desensitize to ASA if
needed
21
Asthma ‘Plus’ Syndromes/Asthma mimics
• Bronchiectasis including Cystic Fibrosis (see Bronchiectasis Section below)
• Eosinophilic granulomatosis with polyangiitis (EGPA/Churg Strauss)
– Asthma, eosinophilia, granulomatous vasculitis (cardiac, sinusitis, allergic
rhinitis, transient pulmonary infiltrates, purpura, neurologic, GI), 30-60% have
positive p-anca
– Treatment: prednisone, cyclophosphamide if severe disease
• Vocal cord dysfunction
– Abrupt onset inspiratory stridor, may be misdiagnosed as asthma or
complicate asthma
– Dx via laryngoscopy with adduction of the vocal cords upon inspiration
– Rx: education, behavior modification, speech therapy, treat GERD
Asthma ‘Plus’ Syndromes/Asthma mimics
• ABPA
– Complicates asthma (or CF), have recurrent exacerbations, fever, brown
sputum with ‘casts’
– Criteria: asthma, pulmonary infiltrates, skin and serum precipitins to
aspergillus, increased total IgE and aspergillus specific IgE >1000, increased
eosinophils and central bronchiectasis
– Treatment: prednisone +/- itraconazole
• Reactive airways dysfunction syndrome (RADS): Acute form of irritant induced
(often occupational) asthma with symptoms promptly following a single high
dose exposure to vapors, gas or fumes (ie chlorine, bleach), lasts > 3 months,
treat like asthma exacerbation Question: How can we differentiate RADS from Vocal Cord
Dysfunction that might also be triggered by irritants?
Answer: Clinical scenario, + testing – some RADS may have
a normal spirometry but virtually all will have abnormal
methacholine challenge.
 MCQ 1 2022
A 35 year old man who is a nonsmoker developed Covid infection 6 months ago. He was
vaccinated and his acute infection did not require a hospitalization. He had a persistent
cough which prompted his family doctor to start him on budesonide-formoterol 200/6
mcg inh prn. Spirometry is done which confirms reversible obstruction. This has
resolved his symptoms somewhat, However he does sometimes have shortness of
breath before going to sleep requiring his bronchodilator, approximately every other
weekend. He has not missed any days at work due to this. Which of the following is an
appropriate next step?

a) Start standing BID budesonide-formoterol

b) Continue prn budesonide-formoterol
c) Change to budesonide-formoterol 400 mcg inh BID + PRN
d) Step down to salbutamol prn only This is well controlled per CTS 2021 guidelines (<1d/week,
mild nocturnal symptoms). No indication to step up to
standing ICS or high dose ICS. No step down in therapy
warranted as ongoing symptoms.
24
 Airways
Disease
COPD
Go to resources for RC:
1) GOLD 2022 (updated yearly)
2) CTS Guidelines:
i. CTS CPG Update on
Pharmacological Therapy of
COPD 2019
3) ATS CPG Initiating
Pharmacologic Treatment in
Tobacco-Dependent Adults
(2020)
 COPD- Diagnosis CTS 2007, GOLD 2022

Diagnosis: Spirometry is required to make the diagnosis, with a post-bronchodilator FEV1/FVC<0.70

Severity of Airflow Limitation in COPD:

In pts w/ post-bronchodilator FEV1/FVC <0.70:
• Mild: FEV1 > 80% predicted
• Moderate: 50% < FEV1 < 80% predicted
• Severe30% < FEV1 < 50% predicted
• Very Severe: FEV1 < 30% predicted

26
 COPD Assessment and Management
• Determine disease severity: Airflow limitation via FEV1
• Impact on patients health status: mMRC and/or CAT scores
• Risk of future events: Exacerbations, hospitalizations, death

Goals of management (use both pharmacologic and non-pharmacologic interventions)

• Prevent disease progression (smoking cessation only)
• Reduce frequency and severity of exacerbations
• Alleviate breathlessness
• Improve exercise tolerance and daily activity
• Treat exacerbations and complications of the disease
• Improve health status
• Reduce mortality

27
CTS 2019 COPD Management

28
GOLD/CTS : Diagnosis & Non-Pharm Mgmt
• Stress suspicion in those exposed to smoke or biomass fuel
– Women in developing countries
• Diagnosis is key: post-BD FEV1/FVC <0.70 or <LLN, may require repeat measurement if
borderline
• Test those diagnosed with COPD for alpha-1 antitrypsin ONCE (GOLD recommendation)
– This doesn’t always happen in real life but on exam would test every pt w COPD once
• Note – You may have seen OLD MCQs referencing CTS 2012: “Test anyone with COPD <65 y OR if they have
a smoking history of <20 pk yr” – this is now outdated by GOLD 2021/2.
• Non-Pharmacologic treatment:
– smoking cessation* and live in a smoke-free environment
– pulmonary rehabilitation* and remain physically active
– supplemental oxygen*
– vaccination
– self-management and education
– review inhaler technique
– end of life care (palliation, dyspnea management)

*Improve survival in certain subsets of COPD 29

Non-Pharm treatments with SURVIVAL benefit
Note nuances on population w survival benefit for exam MCQs

Non Pharmacologic Therapy

– Smoking Cessation: increased survival for all, decreased rate of decline of FEV1
– Long term Oxygen Therapy: increased survival in severe resting hypoxemia
• Should be offered to patients with severe hypoxemia (PaO2<55 mmHg), or when PaO2<60
mmHg in the presence of bilateral ankle edema, cor pulmonale or Hct >56% (CTS guidelines)
– NOTT Trial 1980: In patients with COPD and hypoxemia, continuous oxygen significantly reduces
mortality compared to nocturnal oxygen only
• No benefit in moderate resting or exercise-induced moderate desaturation
– NEJM LOTT Trial 2016 : In patients with stable COPD and resting (89-93%) or exercise induced
moderate desaturation LTOT did not result in a longer time to death or first hospitalization than no
long-term supplemental oxygen (NEJM LOTT 2016)
– Pulmonary Rehabilitation (CTS 2010 Pulmonary Rehab Guideline)
*Pulmonary rehab ↑ exercise capacity, symptoms, QOL across all grades of COPD (GOLD 2022)
• ↓exacerbations if started following RECENT (<4 week) AECOPD
• Increased survival compared with usual care <4 week post AECOPD (Gr2C recommendation)
based on metanalyses
 CTS COPD Management:
2019 Update
Grade Description – Modified MRC Dyspnea Scale

0 Not troubled by breathlessness except on strenuous exercise

1 Shortness of breath when hurrying on level or walking up slight hill

2 Walks slower than people of the same age on the level b/c of
breathlessness or has to stop for breath when walking at own pace on
the level
3 Stops for breath after walking about 100m or after a few minutes on
the level
4 Too breathless to leave the house or breathless when dressing or
undressing

Treatment is based on subjective level of

dyspnea and rate of exacerbations, NOT
lung function. High risk for AECOPD is
defined as 2 or more exacerbations in the
past year or 1 or more requiring CAT = COPD assessment test
hospitalization. MRC = Med Research Council Dyspnea Grade
31
 CTS 2019 Updates: Inhalers to
↓ symptom burden, ↑activity and ↑health status.
• In stable COPD: LAMA LAMA/LABA LAMA/LABA/ICS
monotherapy Dual therapy Triple therapy

– Start with LAMA monotherapy - If symptoms persist à dual therapy àtriple therapy
• LAMA preferred to LABA (prevents acute exacerbations* compared to LABA)
– LAMA/LABA preferred to LABA/ICS (unless concomitant asthma, then LABA/ICS)
• LAMA/LABA ↑ exercise tolerance over monotherapy, ↓ dyspnea
– Consensus: Can consider stepdown if no improvement in symptoms, though advised
against in those high risk for exacerbation
– Behavioral intervention suggested to increase physical activity

DO NOT GIVE:
– ICS monotherapy : increases risk of pneumonia
– Oral therapies (PDE-4i, PDE-5i, mucolytics, herbal remedies) have no evidence for
symptomatic benefit in stable COPD
32
 COPD Rx to Prevent Acute Exacerbations
Preventing acute exacerbations: à Low Risk of AECOPD:
– LOW RISK: LAMA Monotherapy preferred over LABA or SABA or SAMA no ED visit/hospitalization, ≤1
– HIGH RISK: LAMA/LABA Dual therapy (or LABA/ICS if they were on LABA moderate exacerbation in last
monotherapy)
• LAMA/LABA preferred unless sputum eosinophils >300 year
If at high risk despite use of dual therapy above, recommend LAMA/LABA/ICS Triple
therapy. High Risk of AECOPD:
– Discontinuation or stepdown when stable or if no improvement: ≥2 moderate or ≥1 severe
• If ICS started without indication, can step down, monitor closely exacerbation in past year
• If ICS started according to indication (e.g. poor health status despite LABA/LAMA or history of
frequent/severe exacerbations), don’t step down requiring ED
• Those with Eo > 300 high risk of exacerbating à favour continuing visit/hospitalization.

BEYOND INHALERS: If ongoing exacerbations & high risk AECOPD despite AECOPD grade : Mild
optimal inhalers, recommended oral therapies: (worsening symptoms),
– Azithromycin (care: QTc, hearing impairment, sputum culture for NTM)
Moderate (needing abx,
– Roflumilast if chronic bronchitis phenotype (caution: diarrhea and weight loss)
steroid), Severe (needing
– NAC 600 mg BID if chronic bronchitis phenotype
– Recommend against theophylline to prevent exacerbations! hospitalization)

33
COPD Rx to Prevent Acute Exacerbations
• Recommended (= Gr1, definitely reduces exacerbations)
– Annual flu vaccine
– Pulm Rehab (if RECENT exacerbation <4 weeks ago)
– Education and Case Management
– Inhaled pharmacotherapy :as per previous slide
• Suggested (“consider these” – no evidence of reduced exacerbations, but
logically they will help COPD patients, Gr2C recommendation CTS 2017)
– Pneumococcal vaccination
– Smoking Cessation [this reduces mortality. This is exam MCQ fodder,
practically ask everyone to stop smoking]
• Do not use the following to prevent AECOPD
– Systemic corticosteroids >30d after initial exacerbation, theophylline

34
 Therapeutic Options: Systemic Drugs
Drug Indicated in maintenance treatment of COPD?
Influenza Vaccine YES, all COPD annually
Pneumococcal Vaccine YES, all COPD >65, significant comorbid conditions, and all those with FEV1<40%
COVID 19 vaccines YES, All COPD, all boosters per NACI guidance (CDC, NACI, GOLD…)
TdAP Pertussis vaccine YES, if not received in adolescence to protect against pertussis (GOLD 2021)
Shingrix vaccine YES, for adults with COPD ≥ 50yrs (new GOLD 2022)
Systemic Corticosteroids NO: Not indicated for maintenance – only use in setting of acute exacerbation
For Patients with MOD-SEVERE COPD: therapies to prevent AECOPD
Roflumilast (DAXAS) – YES – (“Recommend”) for patients with chronic bronchitis and high risk of
PDE4 inhibitor AECOPD despite optimal inhaled therapy (Gr1A)
N-Acetylcystine YES – (“Recommend”) for patients with chronic bronchitis and high risk of
600mg po BID AECOPD despite long-acting inhalers (Gr1B)
Azithromycin/ YES – (“Suggest”) for patients high risk of AECOPD despite optimal inhaled
Macrolides therapy (Gr2A)
Theophylline NO – “Suggest AGAINST” use to prevent AECOPD in those on optimal long-
acting therapies (Gr2B). 35
 Dyspnea in Advanced COPD (CTS 2011)
• Recommended:
– oral (but not nebulized) opioids
(Grade 2C)
– neuromuscular electrical muscle
stimulation (Grade 2B)
– chest wall vibration (Grade 2B)
– walking aids (Grade 2B)
– pursed-lip breathing (Gr 2B)
– continuous oxygen therapy for
hypoxemic COPD patients reduces
mortality, and may reduce dyspnea
(Grade 2B)
• little benefit on QOL
• Not Recommended:
– anxiolytic and antidepressant (Grade
2B)
– supplemental oxygen in nonhypoxemic
patients
• Not enough evidence:
– acupuncture, acupressure, distractive
auditory stimuli (music), relaxation,
handheld fans, counselling and support
programs, or psychotherapy
36
Asthma-COPD overlap ACO (CTS 2017)
• Asthma-COPD overlap characterized by persistent airflow
limitation with several features of both asthma and COPD
– Worse outcomes than COPD or asthma alone
• ↑ exacerbation, ↓ QOL, ↓ lung function
• ↑ mortality
• Suspect a ACO when:
– COPD risk factors and COPD symptoms (cough, sputum, dyspnea,
exercise limitation and exacerbations)
– History of allergy or atopy, asthma (childhood, physician diagnosis,
wheeze, exacerbation or supportive physiology)
– Pre and post bronchodilator spirometry
37
 Asthma-COPD Overlap (ACO)
• Proposed Diagnostic Criteria (CTS 2017)
– REQUIRED:
1. Diagnosis of COPD given risk factors, history, spirometry
2. History of asthma (past history/diagnosis, current symptoms consistent, or
physiology confirmed /w spirometry)
3. Spirometry: post-bronchodilator fixed FEV1/FVC <0.7
– Supportive but not required:
1. Documentation of a bronchodilator improvement of FEV1 by 200ml or 12%
2. Sputum eosinophils >3%
3. Blood eosinophils >300 cells/uL (current or prev documented)
• Special column in CTS 2017 COPD update for treatment:
– LABA-ICS combo first line
– For refractory symptoms, add LAMA to LABA-ICS combo
– Caveat there are no RCTs addressing this population (asthma trials exclude
smokers, COPD trials exclude asthmatics) 38
 Advanced Therapies
• NIV in Stable COPD with Hypercapnia
– CTS 2022: Suggest chronic NIV for patients with severe COPD on home oxygen and chronic hypercapnia
(PaCO2 ≥52) – Consult your Respirologist!
– Several trials showing reduction in hospital re-admission rates; some showing mortality benefit
• Lung Volume Reduction Surgery:
– Surgical procedure in which parts of the lung are resected to reduce hyperinflation improving the
effectiveness of the respiratory muscles
– Increased survival in severe emphysema patients with upper-lobe predominant disease and low
post-rehabilitation exercise capacity (NETT trial 2003)
– Bullectomy may be considered in select patients with large bulla
• Lung transplant:
– Bode score 7-10 and 1 of 1) hospitalized with COPDE with pCO2 >50 2) pulmonary hypertension/cor
pulmonale despite supp oxygen 3) FEV1 <20% with DLCO <20%
– Shown to improve QOL and functional capacity

39
 AECOPD – GOLD 2022 Guidelines
• Acute worsening of respiratory symptoms requiring additional therapy
• Most commonly caused by respiratory tract infection
• 1-year mortality after AECOPD is ~30% vs. 23% with MI!
– Lose additional 8mL/yr of FEV1 with exacerbation
• Treatment:
– Supplemental oxygen
– Short-acting BD with long-acting BD initiated ASAP prior to discharge
– Steroids x 5-7 days – Shorten recovery and hospitalization duration
– Antibiotics x 5-7d (when indicated) – Shorten recovery, reduce relapse/treatment
failure Mild Worsening symptoms without
change in medications
– NIV SEVERITY OF Moderate Antibiotic +/- oral steroid
AECOPD
Severe Hospitalization/ED visit
40
 GOLD 2022 - Antibiotics
Antibiotics should be given in COPD in the presence of three cardinal
symptoms (or two of the following if increased purulence* is one of them):
1. Increase in dyspnea
2. Increase in sputum volume
3. Increase in sputum purulence
Antibiotics should be given if patients require invasive or non-invasive
mechanical ventilation
• Length: 5-7 days
• Choice of antibiotic based on local resistance pattern. Usual choice
includes amox-clav, macrolide, or tetracycline.
Do not use
*Increased purulence has ~95% sensitivity and 52% specificity for high bacterial load! procalcitonin to guide
decision re Antibiotics
41
(GOLD 2022)
 Rx AECOPD: Steroids
• Indications: moderate-severe exacerbations
• Benefit (Source: GOLD 2022)
– Faster recovery time
– Increased FEV1
– Reduced length of stay
• Amount: Prednisone oral equiv 40mg/day
• Duration: 5 days non-inferior to 14 days (REDUCE trial 2013)
– Not to exceed 5-7 days (GOLD 2019)
– Cochrane meta-analysis 2018 showed no difference between steroid duration
of less than or greater than 7 days

42
 Rx AECOPD: NIV
• BiPAP:
– AECOPD: Preferred over invasive ventilation if no contraindication
– Significant mortality benefit and reduction in intubation rate
– Recommended (GOLD 2022) if any of:
• pH ≤7.35 with pC02 ≥ 45
• severe dyspnea (impending respiratory failure)
• persistent hypoxemia despite supp oxygen

43
 Smoking Cessation
Initiating Pharmacologic Treatment in Tobacco-Dependent
Adults (ATS 2020)
• Only 3% of smokers who are untreated will achieve abstinence within a given year
• Initial treatment with varenicline - superior to nicotine patch alone! (strong
recommendation, moderate certainty)
• Recommend varencicline over electronic cigarettes (conditional recommendation)
• Recommend varenicline over buproprion (strong recommendation, moderate certainty)
• Suggest using varenicline + a nicotine patch (conditional recommendation, low certainty)
• Clinicians should begin treatment with varenicline rather than waiting until patients
are ready to stop tobacco use (Strong recommendation, moderate certainty)
• Recommend extended-duration therapy (>12 wk) over standard duration (6–12 wk)
therapy
Bottom line: Treat everyone with varenicline (+/- nicotine patch) even
if they are not ready to quit.
44
 MCQ 2 2023
A 62 year old non-smoking female with a history of recurrent pneumonias is referred to you.
She describes a chronic cough productive of a tablespoon of green sputum twice daily, worse
in the morning. Rarely, it is blood streaked. She has noticed unintentional weight loss of 20
pounds over the last 6 months and feels increasingly tired. There is no family history of lung
disease and she is otherwise healthy with no other features of frequent infections. PFTs reveal
moderate obstruction with no reversibility. Her CT scan is shown. Which of the following is the
most likely pathogen to grow on a sputum culture?
1. Aspergillus fumigatus
2. Pseudomonas aeruginosa
3. Mycobacterium avium complex
4. Mycobacterium tuberculosis

45
 Bronchiectasis
• Good to have very basic approach to diagnosis for the exam Guidelines for reference: ERS 2017, BTS 2019

• “Bronchiectasis is a chronic respiratory disease characterized by a clinical syndrome of cough, sputum

production and bronchial infection, and radiologically by abnormal and permanent dilatation of the
bronchi.
• Most common symptoms:
– Cough with sputum and/or hemoptysis
– Dyspnea and fatigue
– Rhinosinusitis
– Thoracic pain

• Treatment goals (European Resp Society Guideline 2017): STUDY TIP:

– Prevent Exacerbations Workup & Manage Bronchiectasis is a great
– Improve QOL scenario to practice with your study group!
– ↓ disease progression
Check out our 2015 Physical Exam
Video Online for the exam for “causes and
complications of bronchiectasis”
46
Work up should be directed based on history and physical. Everyone should get chest CT and PFTs (expect
Causes of bronchiectasis4–9.
obstruction). Most common causes are post-infectious and idiopathic (accounting for 50% of cases)
Cause Clinical Features Testing
Postinfectious History of previous infection (i.e., pneumonia, pertussis, NTM, TB)
Idiopathic Exclude other causes
Humoral immunodeficiency Recurrent infections Serum immunoglobulins, responses to
pneumococcal, H.flu and tetanus antigens
Cystic Fibrosis Younger age (<45 yrs), history malabsorption, Sweat chloride, CFTR genetic testing
pseudomonas infection, s. aureus, NTM, male infertility.
Autoimmune/CTD Clinical signs of CTD/vasculitis RF, anti-CCP, others dependent on history.
Inflammatory bowel disease Clinical signs of UC or Crohn’s Specialist GI review
ABPA Hx asthma, blood eos >500, positive aspergillus IgG or Total IgE >500 IU/mL, positive A. fumigatus
positive precipitins, sputum culture of A. fumigatus, specific IgE or immediate reaction on skin-
fleeting infiltrates on chest imaging/proximal prick testing
bronchiectasis
Aspiration History of reflux/aspiration VFSS, upper endoscopy,
ambulatory esophageal manometry
Congenital Williams-Campbell syndrome, Mournier-Kuhn, and lung
sequestration
PCD History of chronic respiratory tract problems, otitis media, Measurement of nasal nitric oxide levels and
male infertility. ciliated epithelial biopsy.
Alpha-1-AT Evidence of emphysema/obstruction on spirometry. Serum alpha 1 AT level
Panniculitis.
Adapted from Maeve P. Smith
©2017 by Canadian Medical Association CMAJ 2017;189:E828-E835
 Bronchiectasis Work-up (BTS 2019)
• Allergic BronchoPulmonary Aspergillosis (ABPA):
– Blood count
– Total IgE
– Sensitization to aspergillus (IgE-specific antibodies or skin prick)
• Serum immunoglobulins (IgG, IgA, IgM)
• Test for CF (sweat test) and Primary Ciliary Dyskinesia (nasal nitric oxide)
• Sputum cultures
• Consider:
– RF, anti-CCP, ANA, ANCA
– Alpha1 anti-trypsin
– Videofluoroscopic swallow study
– HIV testing

48
 Bronchiectasis Treatment (BTS 2019)
Mainstays of treatment:
• Airway clearance: Active cycle of breathing technique
• Mucoactive agents: Hypertonic saline (avoid DNAse unless CF!)
• Antimicrobials
- Inhaled colistin or gentamicin (if Pseudomonas (PsA) colonized)
- Chronic azithromycin if recurrent exacerbations (with or without PsA colonization but rule out NTM)
• Bronchodilator: Unless otherwise indicated, may offer as trial if significant breathlessness
• Pulmonary rehab: If functionally limited by dyspnea (mMRC ≥1)
• Vaccines: Influenza, Pneumococcal, (+ TdAP, COVID, etc per NACI guidelines)
• Supplemental oxygen (same criteria as for COPD)
• Do not routinely offer ICS, oral steroid, PDE4-I

Advanced Therapies:
- Consider surgery / lung resection in localized disease
- Consider transplant if poor lung function and one of: massive hemoptysis, severe PH, ICU admissions or
respiratory failure (require NIV)
- Consider NIV if respiratory failure with hypercapnia, especially if recurrent hospitalization

49
Bronchiectasis Exacerbation (BTS 2019)
• Obtain sputum cultures
• Empiric antimicrobials, covering organisms previously grown, if known*
*no evidence to show antibiotics guided by sensitivity results improves outcomes
• Generally 14 day course recommended, especially if PsA colonized
– Shorter course possible if mild bronchiectasis
• Consider IV antimicrobials if unwell/admitted, resistant organisms or failed
oral therapy
• Major Hemoptysis
– IV antimicrobials Another good
– Tranexamic acid scenario to practice
– Consider embolization as first line managing with
your study group!
50
 MCQ 2 2023
A 62 year old non-smoking female with a history of recurrent pneumonias is referred to you.
She describes a chronic cough productive of a tablespoon of green sputum twice daily, worse
in the morning. Rarely, it is blood streaked. She has noticed unintentional weight loss of 20
pounds over the last 6 months and feels increasingly tired. There is no family history of lung
disease and she is otherwise healthy with no other features of frequent infections. PFTs reveal
moderate obstruction with no reversibility. Her CT scan is shown. Which of the following is the
most likely pathogen to grow on a sputum culture?
1. Aspergillus fumigatus Milder forms of CF can present at later ages.
Bonus note: BAL or serum galactomannan is a
2. Pseudomonas aeruginosa
component of the cell wall of proliferating
3. Mycobacterium avium complex aspergillus. Test for this if there is a suspicion
4. Mycobacterium tuberculosis for invasive aspergillosis!

RML and lingular bronchiectasis in a non-

smoker with constitutional symptoms is
classically suggestive of MAC/NTM infection
and bronchiectasis.
51
 Interstitial Lung Disease
• Heterogenous group of diseases (>200
subtypes)

• Go to resources for RC:

– *Evaluation of patients with fibrotic
interstitial lung disease: A Canadian
Thoracic Society position statement (2017)
– Diagnosis of Idiopathic Pulmonary Fibrosis:
Official ATS/ERS/JRS/ALAT Clinical Practice
Guideline (2018)
OTHERS (if you have lots of spare time):
– ATS/ERS Update of the International Multidisciplinary
Classification of the Idiopathic Interstitial Pneumonias (2013)
– Treatment of IPF: An Official ATS/ERS/JRS/ALAT Guideline
(2015)

52
 ILD: Associated with a known disease or not?

ILD

Other forms of ILD

Known Cause Granulomatous Causes
Lymphangioleiomyomatosis
Connective Tissue Disease Sarcoid Idiopathic Interstitial
Pulmonary Langerhan's Cell
Occupational causes Hypersensitivity pneumonitis Pneumonias (IIP)
Histiocytosis
Drug side effects Drug Side Effects Pulmonary Alveolar Proteinosis

Idiopathic Nonspecific Cryptogenic Lymphocytic Desquamative

Acute Interstitial
Pulmonary Interstitial organizing interstitial interstitial
pneumonia
Fibrosis pneumonia Pneumonia pneumonia pneumonia

Don’t worry about these for the purposes of the exam.

Just highlighting that there are many different IIPs!
53
 Interstitial Lung Disease- Approach
Differential
• Idiopathic (see next page)
• Familial (rare)
• Connective tissue disease
related (SSc, RA, DM, Sjogrens,
MCTD)
• Exposure related
(organic=hypersentivity
pneumonitis,
inorganic=pneumoconiosis)
• Drug related (MTX, Macrobid,
amio, bleomycin, many others)
• Radiation
• Miscellaneous: Sarcoid,
Organizing Pneumonia, others
History/ Physical
Investigations
• Family History
• ALL: ANA, RF, anti- CCP
• Drugs and radiation
• send more serology if
• Inorganic exposures
clinically indicated
o asbestos, mining,
• HRCT Chest
sandblasting, etc
• PFTs +/- 6MWT +/- home ox
• Organic exposures
assessment
o mould/water damage,
• Can send precipitating antibodies
birds, farms, feather
for some known antigens for HP
pillows, hot tubs, etc
• Respirology +/- Rheumatology
• Connective tissue disease
Referral
o joints, rash, mechanics hands,
• Sometimes lung biopsy
Gottrens, Raynaud’s Shawl
sign, heliotrope, scleroderma
findings, proximal muscle
weakness, etc)
54
 IPF (ATS 2018 Guideline)
• Most common IIP
• M > F, 6th or 7th decade (rare <50)
• Many have smoking history
• Chronic, progressive, fibrotic ILD defined by the histologic and/or
radiographic pattern of Usual Interstitial Pneumonia (UIP)
• Diagnosis requires:
1. Exclusion of other known causes of ILD
2. Demonstration of UIP pattern on high-resolution CT (see next page)
3. Specific combinations of HRCT pattern and histopathology patterns in
patients subject to tissue biopsy (most do not require biopsy)

55
 Radiology (ATS 2018)
UIP Pattern (i.e., IPF) Alternative Diagnosis
1. Reticular Changes Features:
2. Subpleural/Basal predominant • Cysts
3. Honeycombing • Mosaic attenuation
4. Absence of inconsistent features à • Predominant GGO
• Profuse micronodules
• Centrilobular nodules
• Nodules
• Consolidation
Predominant Distribution:
• Peribronchovascular
• Perilymphatic
• Upper or mid-lung
 IPF (ATS 2018 Guideline)
Diagnosis of IPF
• Assess for environmental and medication exposures to rule out
other causes of ILD
• Send serologic testing: ANA, RF, anti-CCP +/- myositis panel +/-
Rheum referral
• Referral to Respirology: Patients with new diagnosis of suspected
IPF should undergo Multidisciplinary Discussion (MDD)
• Consideration for further diagnostics (bronchoscopy and BAL,
surgical lung biopsy, etc.) will be the decision of the MDD

57
 IPF Treatment
Treatment:
• Quit smoking, oxygen therapy, PPI, pulmonary rehab, Pneumovax and influenza
vaccination (+ COVID, + update TdaP per NACI…)
• Anti-fibrotic medications (both reduce decline in FVC by about 50%):
Choice based on – Nintendanib (INPULSIS 1/2 trials) – TK inhibitor, resulted in reduced FVC decline, pooled
patient analysis shows trend to reduced mortality. Adverse effects: diarrhea, GI upset, transaminitis
preference, side – Pirfenidone (ASCEND/CAPACITY trials) – reduced FVC decline, 6MWTD decline, pooled analysis
effect profile
showed improved survival.
• No role for corticosteroids or immunosuppression in IPF given increased mortality
(PANTHER-IPF) !
Acute exacerbation:
– Worsening dyspnea, hypoxemia with new diffuse bilateral ground glass on CT
– Rule out infection/PE/HF
– Consider high dose corticosteroids (1g/d x 3 -> 1mg/kg po daily) and empiric antimicrobials
– Dismal prognosis – generally 50% in-hospital mortality
 CTS 2018 ILD Position Statement Summary
• Accurate diagnosis is key
• Treat IPF with anti-fibrotics (pirfenidone, nintedanib) and consider immunosuppression in
non-IPF
*** This is changing as per several recent trials, but not yet routine or guideline based!
• Pulmonary rehab is recommended
– ↓ dyspnea,↑ walking distance and QOL
• There is a role for supplemental oxygen in:
– Resting hypoxemia – Same criteria as COPD
– Exertional hypoxemia (sat <88%) with improved walk distance or dyspnea on supplemental oxygen
• Advanced care planning should be addressed in all patients with fibroitc ILD in course of
their disease
• Dyspnea management: Non-pharmacologic techniques and low-dose opioid (morphine
1.0-2.5mg q4-6h)
• Cough management: Opioids may be considered first-line in refractory cases
• Consider lung transplant referral early for IPF and fibrotic NSIP (for Resp consultant!)
– Criteria for referral: FVC <80%, DLCO<40%, need oxygen, ‘failed’ pharmacotherapy
59
 Non-IPF ILD
Class Cause Imaging / Lab Treatment
Hypersensitivity Organic exposures Upper Lobe predominant Avoid antigen
Pneumonitis (moulds, birds, etc) + precipitating antibodies Steroids
to antigen Sometimes MMF or AZA

Pneumoconioses Inorganic exposures YEARS Variety of imaging Supportive care

ago (asbestos, silica..) patterns Transplant
CTD associated ILD Scleroderma, RA Variety – UIP, NSIP, Glucocorticoids
Dermatomyositis organizing pneumonias DMARDs (MMF or AZA)
Sjogren’s, Mixed Con Tissue and others Rituximab
Disease Cyclophosphamide
Drug induced ILD Methotrexate Drug withdrawal Corticosteroids
Amiodarone
Nitrofurantoin
Bleomycin
Vaping
60
 Anti-Fibrotics in Non-IPF ILD
Can anti-fibrotic therapies be used in non-IPF ILD?
• Two recent trials in 2019 exploring this question:
– Nintedanib for Systemic Sclerosis–Associated Interstitial Lung Disease
(SENSCIS)
– Nintedanib in Progressive Fibrosing Interstitial Lung Diseases (INBUILD)
– Lower rate of FVC decline compared to placebo; GI side effects
(diarrhea) more common with nintendanib
Not yet in guidelines, but may be worthwhile to know concepts for
the purpose of the oral examination.
N Engl J Med 2019;380:2518-28
N Engl J Med 2019;381:1718-27
61
 Pleural Effusion
• Go to guidelines/resources:
– British Thoracic Society Pleural
Disease Guideline 2010
– Medical and Surgical Treatment of
Parapneumonic Effusions: An Evidence-Based
Guideline. Chest 2000.
– Management of Malignant Pleural Effusions.
An Official ATS/STS/STR Clinical Practice
Guideline. (2018)
– Evaluation of the patient with pleural
effusion. CMAJ March 2018.

62
 MCQ 3 (2022)
A 70 year old man who is a nonsmoker born in China was referred
to you for management of a pleural effusion. He has been having
fatigue, unintentional weight loss, and a dry cough for 4 months
and a chest X-ray demonstrates a moderate to large left sided
pleural effusion. Initial drainage of the effusion revealed an
exudate. Cell count shows 80% lymphocytes, 10% macrophages,
5% eosinophils. What is the next best step in management?
1. Send pleural fluid for AFB
2. Bronchoscopy to rule out TB
3. Induced sputums x 3 for AFB
4. VATS/Pleuroscopy for pleural biopsy

63
 Pleural Effusion
• When to do a thoracentesis
– Aspiration should NOT be performed for bilateral effusions in a clinical setting strongly suggestive of a transudate /
heart failure
– Thoracentesis should be considered if:
• Suspect exudate
• Cause unclear
• Parapneumonic effusion (as per CHEST guidelines, if less than 1 cm of fluid on lateral decubitus in context of
pneumonia can forgo sampling and instead follow radiographically)

Exudate NYD:
• Can repeat thoracentesis once for increased sensitivity;
sensitivity of pleural fluid cytology for malignancy Light’s Criteria
increases to approx 80% with two thoras Pleural fluid is an exudate if ≥ 1 of the following
• Get CT chest criteria are met:
• Refer for pleural biopsy: Can do CT guided if area of • Protein in fluid : serum > 0.5
obvious abnormality • LDH in fluid : serum >0.6
• Thorascopy with pleural biopsy is preferred test • Pleural fluid LDH >2/3 the upper limit of normal
• Mesothelioma usually cannot be diagnosed from value for serum LDH.
pleural fluid and requires pleural biopsy
 Pleural Effusion Examples
• Chylothorax – (TGs >1.24mmol, +CM)
– Malignancy #1 (most commonly lymphoma)
– Trauma/surgery, TB, LAM (young woman with cystic lung disease/PTX)
• Pleural fluid eosinophilia - (>10%)
– Etiology depends on history
• Asbestos related (BAPE), drugs (ex. nitrofurantoin), malignancy (lung), infection
(parasites), PE, eGPA
• Low glucose - (glc<3, eff/serum<0.5)
– Severity:
• <1 mmol – RA, empyema
• 1-3mmol – malignancy, TB, SLE
• Lymphocytosis
– >80% TB vs lymphoma, TB often AFB negative and would suggest sputum AFB
– Carcinoma, yellow nail, sarcoidosis, RA
65
 Management of Parapneumonic Effusion
(CHEST/BTS)
• In case of suspicion of pleural infection, sample fluid if >1 cm on lateral decubitus
• Chest drain needed if (does not need to be surgical chest tube): * MUST KNOW
– drainage of frank pus/cloudy
– positive gram stain or culture
– pH <7.2 (if unavailable use glucose <3.4 mmol/L)
– >50% of hemithorax or loculations on imaging
ENSURE THAT YOU PAY ATTENTION TO THE SIDE OF THE EFFUSION – IPSILATERAL TO PNEUMONIA
• Abx should cover what is isolated
– Beta lactams preferred
– if no culture then treat for CAP plus anaerobes (empiric – add anaerobic!)
• Usually prolonged antibiotic course (often at least 3 weeks, based on clinical and
radiographic response)
• Further treatments like intrapleural lytics and VATS require consultation with Resp or
Thoracic Surgeon

66
 MCQ 3 (2022)
A 70 year old man who is a nonsmoker born in China was referred
to you for management of a pleural effusion. He has been having
fatigue, unintentional weight loss, and a dry cough for 4 months
and a chest X-ray demonstrates a moderate to large left sided
pleural effusion. Initial drainage of the effusion revealed an
exudate. Cell count shows 80% lymphocytes, 10% macrophages,
5% eosinophils. What is the next best step in management?
1. Send pleural fluid for AFB
2. Bronchoscopy to rule out TB Pleural AFB is rarely positive, the
3. Induced sputums x 3 for AFB yield of 3 induced sputums is
comparable to bronchoscopy (Cdn
4. VATS/Pleuroscopy for pleural biopsy TB Standards 2022), VATS/pleural
biopsy would be the last step.

67
Take a minute to Catch your breath…

68
 MCQ 4 (2023)
A 20-year-old woman presents to the ED with sudden onset chest pain and dyspnea. A
chest x-ray shows a 1.5 cm pneumothorax. Her vital signs are T 36.9, HR 90, BP 95/65,
RR 20, and oxygen saturation of 96%. She received supplemental oxygen. She is
previously healthy and on no medications. You examine her and she is saturating 100%
on 4LNP. Her chest exam reveals decreased breath sounds to the right apex. She has a
BMI of 18 and is tall. Initial bloodwork reveals a Na 134, K 4.9, Cl 100, HCO3 24,
creatinine 43. ABG on room air is 7.48/30/95/22. What is the next best treatment?
Which of the following would you suggest for managing her pneumothorax?
a) Insertion of a pigtail catheter
b) Insertion of a large bore chest tube
c) Surgical pleurodesis
d) If stable for 8h in the ED, discharge home with follow up

69
 Pneumothorax
• Primary spontaneous pneumothorax (PSP): Absence of lung disease
– RF = smoking*, family history, Marfan syndrome, thoracic endometriosis
• Reoccur 25-50%, most in first year
– Small <2cm with minimal signs and symptoms = monitor
– If >2cm or signs and symptoms = needle aspiration +/- chest tube insertion
– Surgery if persistent leak
• Secondary spontaneous pneumothorax (SSP): Presence of lung disease
– COPD>>> Others (CF, TB, PCP)
– Even small SSP can lead to significant symptoms; often requires admission
– More likely to require chest drain given underlying lung abnormalities and risk of
air leak, consult Resp/Thoracic Surgery
SOURCE: BTS Guidelines
70
Conservative versus Interventional Treatment for
Spontaneous Pneumothorax
In practice, there is significant variability in management of pneumothorax.
• RCT of conservative management as compared with interventional
management of moderate-to-large primary spontaneous pneumothorax
• Conservative management (monitoring for 4 hrs in ED, then discharge
home with close follow up) was noninferior to interventional management
for radiographic resolution within 8 weeks (issues with statistical analysis
plan)
• Conservative management: ↓ hospitalization days, ↓ likelihood of
prolonged chest-tube drainage, ↓ recurrence of pneumothorax, ↓ need
for surgery, and ↓ adverse events
• Bottom line: conservative observational approach may be reasonable in
young, healthy patients with a spontaneous pneumothorax that would
have otherwise warranted intervention
N Engl J Med 2020;382:405-15.
71
 MCQ 3 (2023)
A 20-year-old woman presents to the ED with sudden onset chest pain and dyspnea. A
chest x-ray shows a 1.5 cm pneumothorax. Her vital signs are T 36.9, HR 90, BP 95/65,
RR 20, and oxygen saturation of 96%. She received supplemental oxygen. She is
previously healthy and on no medications. You examine her and she is saturating 100%
on 4LNP. Her chest exam reveals decreased breath sounds to the right apex. She has a
BMI of 18 and is tall. Initial bloodwork reveals a Na 134, K 4.9, Cl 100, HCO3 24,
creatinine 43. ABG on room air is 7.48/30/95/22. What is the next best treatment?
Which of the following would you suggest for managing her pneumothorax?
Primary spontaneous pneumothorax
a) Insertion of a pigtail catheter can be safely managed conservatively
b) Insertion of a large bore chest tube if follow up is arranged.
c) Surgical pleurodesis
d) If stable for 8h in the ED, discharge home with follow up

72
 Sarcoid
• Multisystem granulomatous disease of
unknown etiology
– Pathology reveals noncaseating
granulomas in involved organs
– Usually involves the lungs (>90%) but up to
30% of patients present with
extrapulmonary sarcoid including:
• Heart, CNS, eyes* need urgent
treatment!
• Other: liver, spleen, musculoskeletal
system, kidney
Guideline • Most are asymptomatic
ATS 2020 Guidelines on the Diagnosis and Detection of – Two thirds of patients will have remission at
Sarcoidosis a decade
ERS 2021 Clinical Practice Guidelines on Treatment of
Sarcoidosis (NEW)
– After one year of spontaneous remission
relapse is very uncommon
 Sarcoid Syndromes
• Lofgren’s Syndrome
– Bilateral hilar adenopathy ATS Recommends:
– Erythema nodosum 1. Lofgren’s syndrome, Heerfordt’s syndrome, lupus
– Migratory polyarthralgias pernio: No biopsy required for diagnosis.
– Fever (Conditional recommendation, very low quality
– Seen primarily in women of evidence)
2. Asymptomatic bilateral hilar adenopathy: no
– High likelihood of spontaneous remission
recommendations for/against. Close clinical
• Heerfordt’s Syndrome follow up required if no biopsy.
– Anterior uveitis 3. EBUS guided lymph node sampling, rather than
– Parotid enlargement mediastinoscopy, is recommended as the
– Facial palsy sampling method of choice (Conditional
– Fever (uveoparotid fever) recommendation, low quality of evidence)
 Sarcoid: Pulmonary Involvement
• 90% have pulmonary involvement; often asymptomatic hilar
lymphadenopathy
• Stage reflects chance of spontaneous remission
• Symptoms can vary: dyspnea, cough, chest pain, wheeze
• PFTs can show anything: normal, restriction, obstruction, or both
(+/- reduced DLCO) Stage Rate of Chest X Ray Findings
• Co-existent asthma is common spontaneous
remission
• Pulmonary hypertension is rare 1 55-90% [75%] Bilateral adenopathy

but described 2 40-70% [50%] Adenopathy + parenchymal

lesions
3 10-30% [25%] Parenchymal lesions with no
adenopathy
4 0-5% [0%] Fibrosis 75
Sarcoidosis: Extrapulmonary Involvement
• Cutaneous: Common (about 1/3 of patients), lupus pernio, erythema
nodosum, others
• Liver and Spleen: ~10% of patients, elevated liver enzymes, cholestasis,
rarely liver failure, can see liver and spleen lesions on imaging
• Neurologic: Cranial nerve palsy, headache, ataxia, weakness, LP
nonspecific lymphocytic inflammation, MRI imaging chest of choice
• Ocular: Anterior uveitis most common
• Cardiac: ~5% of patients clinically (more at autopsy), cardiomyopathy,
arrhythmia, heart block, screen with ECG +/- echo, then cardiac MRI and
PET scan if concern
• Hypercalcemia: Common, rule out other causes of hypercalcemia, due
to increased conversion of 25 to 1,25-D3.

76
 Investigations
• CXR +/- CT, PFTs
• Tissue biopsy: LN or transbronchial biopsy
• CBC: anemia of chronic disease, lymphopenia, thrombocytopenia
• Calcium, Alb, LFTs, Cr
• ECG
– If cardiac disease suspected – Cardiac MRI is preferred, or cardiac PET if unavailable
– If PH suspected – do TTE
• 1,25- OH Vitamin D
• Ophtho referral to r/o sarcoid ocular
Rule out: HIV serology, Rule out TB
• Bronchoscopy/BAL: low CD8, elevated CD4/CD8 ratio
• 24 hour urine (hypercalciuria)
• Serum ACE level is not necessary
– increased ACE is ~70% sensitive and 90% specific with active disease;
– Reflects granulomatous load and can be false positive in other granulomatous disease
 Sarcoidosis Treatment
• Most patients will not require treatment
– Most patients with stage 1 or 2 disease will have spontaneous remission, with low recurrence (4-5%)
– Steroids accelerate remission at the cost of higher risk of recurrence (60-70%) – indicated if end-organ
failure from granulomatous inflammation. Dose is 20-40 mg (higher if life threatening inflammation).
• Indications for treatment *fatigue alone is not indication for treatment*
– Pulmonary: Bothersome symptoms (cough and dyspnea), deteriorating lung function as measured with
PFTs, or development of pulmonary hypertension. ICS can be used for mild symptoms and stable PFTs.
– Extrapulmonary: Eye disease, CNS disease, cardiomyopathy/active cardiac involvement *, severe skin
disease, hypercalcemia, symptomatic liver disease are usually treated (for skin disease refractory to
steroids, consider INFLIXIMAB)
• Duration of treatment
– Usually 1-3 months at initial dose, SLOW taper to ~10 mg/d (total treatment for 1 year)
– If relapse can consider other agents like MTX (less commonly HCQ, LEF, TNF alpha inhibitors)

• Erythema nodosum usually good response to NSAIDs alone

• Pulmonary rehab is 1st line treatment for fatigue.
European Respiratory Society Clinical Practice Guidelines, Nov 2021
 Pulmonary Hypertension (PH)
Relevant guidelines: CCS/CTS 2020 Position Statement on Pulmonary Hypertension
2022 ESC/ERS Guidelines for the diagnosis and treatment of Pulmonary Hypertension
• Defined as: mean pulmonary artery pressure >20mmHg on right heart
catheterization and PVR >2WU (previously PVR > 3WU), is consistent with pre-
capillary PH
• Typically presents with slowly progressive dyspnea on exertion and eventually right
ventricular failure
• Suspect in dyspnea on exertion, isolated reduced DLCO
– Most important screening is echocardiogram – Assess how RV is doing!
• Initial work up directed at identifying PH etiology
– Classify into a WHO group (determines management)
• Everyone should get:
– CBC -lytes -LFTs -TSH -BNP -echo -PFTs -6MWT
– CT pulmonary angiogram, -VQ scan -screening serology for connective tissue disease,
viral hepatitis - HIV - sleep study if suspicious clinical features
– right heart catheterization
79
 Pulmonary Hypertension
Group 1: (mPAP>20 with PVR > 2WU) Group 2:
– Idiopathic (IPAH) – Pulmonary hypertension due to left heart disease
– Heritable • Systolic dysfunction, diastolic dysfunction, valvular
– Drug/toxin induced disease
– Associated with: CTD, HIV, portal HTN, • Treat underlying cause
schistosomiasis Group 3:
– (Group 1’: PVOD) – Due to lung disease/hypoxemia (COPD, ILD, etc)
TREATMENT: Should be referred to a PH centre – Treat underlying cause
– Vasoreactivity testing to determine if candidate for CCB Group 4
– PDE5 inhibitor or riociguat (soluble guanylate cyclase – Chronic thromboembolic pulmonary hypertension
inhibitor) *APLAS testing for all. If + à warfarin* (ERS 2022)
– Endothelin receptor antagonist Refer for pulmonary thromboendarterectomy,
– Prostanoid anticoagulation
– Influenza/pneumococcal/COVID etc vaccines Group 5:
– Supervised Exercise – PH with unclear mechanisms – Treat underlying disease
– Women – pregnancy counselling (avoid pregnancy) • Heme disorders (myeloproliforative disease,
splenectomy)
• Systemic disorders (sarcoid, LCH, LAM) 80
 Pulmonary Hypertension –
ERS 2022
• Patients with a diagnosis of PH should be
evaluated/treated at a specialized PH centre!
• Notes from this guideline applicable to GIM:
– Screen patients with scleroderma annually for PH
with echo and DLCO
– Echo to screen for PH in patients with portal
hypertension undergoing transplant w/u
– If dyspnea or exercise intolerance after at least 3
months of uninterrupted anticoagulation post acute
PE assess for CTEPH with echo and V/Q lung scan
– Patients with CTEPH – test for APLAS

For your Reference only! Clues for PH on ECHO:

RVSP (not a hard cutoff/not sensitive) but ≥40 mmHg
”RV enlargement” “RV overload” “IVS flattening”, or TR jet
velocity ≥ 2.8, TAPSE < 1.7 cm, FAC < 35% – GIM do not
need to know ECHO criteria, just when to suspect/refer. 81
 ERS 2022 Recommendations Class Level

PH guidelines Echocardiography recommended first-line non-

invasive diagnostic investigation in suspicion of PH
I C

VQ Scan recommended in unexplained PH to I C

• Treatment goals
– Achieving low-risk profile based
on 2015 ERS Risk Assessment
Table (combination of factors
including WHO functional class,
6MWD, BNP, and hemodynamics
on F/U RHC)
• General therapies
– Diuretics for volume overload
– Physical activity/rehab
– contraception
– Oxygen if hypoxemic
exclude CTEPH
Routine biochem, CBC, immunology, HIV testing I C
and TSH recommended in all patients with PAH to
identify an associated condition
Abdo U/S recommended to screen for portal htn I C
PFT + DLCO recommended in the initial evaluation I C
of patients with PH
Patients with Scleroderma should be evaluated I C
annually for the risk of PH.
In patients with SSc and unexplained dyspnea I C
following non-invasive assessment, RHC is
recommended to exclude PAH
Consider HRCT in all patients with PH IIa C

Pulmonary angiography should be considered in IIa C

workup of CTEPH
Open/thorascopic lung biopsy not recommended III C
in PAH 82
 Hypoxemia
Assessing Hypoxemia:
A-a Gradient: PAO2 – PaO2
estimated from alveolar gas equation measured from ABG

A-a =[FiO2 * (Patm – PH2O) – (PaCO2/R)] – PaO2

On room air at sea level the first term simplifies to approximately 150
Respiratory Quotient (R) Depends on carbohydrate metabolism but
usually 0.8 is used
A-a = [150- (PaCO2/0.8)]– PaO2
Approximate Normal A-a Gradient for reference: (Age (yrs)/4)+4
 Hypoxemia
Normal A-a gradient (normal gas exchange)
– Hypoventilation
• CNS depression (drugs, stroke, tumour, bleed, meningitis), spinal cord injury, chest wall
abnormality, diaphragm dysfunction (ie phrenic nerve injury or myopathy), neuromuscular
disorder, obesity hypoventilation
• Check PaCO2 – if elevated think of hypoventilation
– Low inspired FiO2 (e.g. altitude)
Widened A-a gradient
– V/Q mismatch (improves with 100% FiO2)
• E.g. COPD, PE
– Shunt (does not improve completely with administration of 100% FiO2)
• CAUSE: intracardiac with R->L shunt (eg PFO, ASD, VSD), intrapulmonary (ie pulmonary AVM),
physiologic (ie severe pneumonia with perfused alveoli that are not ventilated)
– Diffusion Abnormality
• E.g. ILD
 Hypoxemia

• Home O2 Requirements (Ontario)

– PaO2 <= 55
– (SaO2 <= 88%)
– PaO2 = 55-59 with:
• Cor pulmonale
• Pulmonary hypertension
• Persistent erythrocytosis
• Based on the NOTT trial showing mortality benefit
in COPD, extrapolated to all lung disease
 Respiratory Blood Gases
RESPIRATORY ACIDOSIS RESPIRATORY ALKALOSIS
Reflects a decrease in alveolar ventilation. Reflects an increase in alveolar ventilation
If marked limitation in pulmonary reserve (i.e., pain, fever, anxiety, liver disease, pregnancy)
(increased deadspace), or hypoventilation In the presence of mechanical ventilation,
will lead to consequent acidosis. decreased carbon dioxide production (i.e.,
sedation, skeletal muscle paralysis,
hypothermia) can cause respiratory
alkalosis

ACIDOSIS ALKALOSIS
For every 10 pt rise in For every 10 pt drop in
CO2, HCO3 rises by: CO2, HCO3 falls by:
ACUTE ↑1 ↓2
CHRONIC ↑3 ↓5
86
 Hemoptysis Differential
Bronchitis, TB,
Infection bronchiectasis

Young non-smoker with lung collapse

(endobronchial tumors, can fill lumen)
Carcinoid Preop Workup: if suspect carcinoid
syndrome, TTE to rule out carcinoid heart
Tumour disease (TR)

Hemoptysis
(GI and upper Malignant NSCLC or SCLC
airway ruled out)
Goodpasture's
CTD (antiGBM), GPA (or
other vasculitis), SLE
Approach depends on
Cocaine, whether massive or non-
Drugs/Toxin anticoagulation massive hemoptysis

Pulmonary AVM, bronchial

Vascular art. aneurysm, PE, florid CHF
87
 Hemoptysis
• Massive (variable definitions; ~200-600 cc/24 hours)
– Acute management à Airway, Breathing, Circulation
– If able to localize bleeding side
• position patient in decubitus position to protect unaffected lung
– Hold anti-coagulation/ correct coagulopathy
– CBC, coagulation profile, ABG
– Cross-type, IV fluids, oxygen
• Investigations
– Need imaging if patient is stable enough (CXR/CT)
– Flexible bronchoscopy can be used for localization prior to IR guided embolization
• Management dependent on local center
– Interventional Radiology – Arterial embolization #1 if available
– Thoracic Surgery – Ability for rigid bronchoscopy/Resection
– Patients die of asphyxiation NOT exsanguination

ATS Guidelines. 2003

 COVID-19 and Respiratory Diseases
• Asthma: Patients at no increased risk of acquiring COVID, but may be at risk of triggering an
exacerbation/more severe illness. No evidence that inhaled/oral steroids or biologics adversely affect
patients. Avoid/use caution with nebulizers (GINA 2022).
• COPD: Emphasis on advanced care planning. No increased risk of acquiring COVID, but 5-fold increased
risk of severe disease. Treat COPD exacerbations with prednisone—no evidence of harm, expectation
of low risk of harm (CHEST 2020).
• ILD: Patients without prior lung disease develop imaging features of ILD after COVID-19 disease, but no
data on long-term prognosis (CJRCCSM 2020, Lancet 2021).
“COVID19 organizing pneumonia” – described as late complication (>4 wks post infxn),
requiring high dose steroids
• Sleep Disordered Breathing: If suspected/confirmed COVID and using PAP device, must use a separate
room/bathroom and sterilize mask daily. Caregivers at risk. If admitted to hospital with mild-moderate
OSA, may be reasonable to withhold CPAP for infection control (CRJCCM 2020). If
suspected/confirmed COVID case need to follow local infection control protocols and consider
risk/benefit of withholding PAP device.
• Pulmonary rehabilitation: Virtual programs developed, in 2022 many programs back to in person with
appropriate precautions.

89
“Long COVID” – CTS 2021 Position statement on rehab for COVID-19
and Ontario Science Table statement
“We suggest that all pts with COVID-19 be assessed for persistent or new symptoms
and functional limitations 6-8 wks after their acute infection.”

• Long COVID / post-COVID condition / Post-Acute-Sequelae of SARS COV2 (PASC)

– No firm definition, variable prevalence
– >50 different long-term effects reported, fatigue, dyspnea, and neurocog sx most common
– No specific therapies

• For referral to Pulmonary Rehab they suggest the following criteria be used:
New / ongoing respiratory symptoms (dyspnea and/or cough and/or exercise intolerance) and
functional limitations after resolution of acute COVID-19
AND
New or ongoing requirement for supplemental O2
OR At least 1 of:
i) Persistent radiographic pulm. Abnormality (eg new or persistent reticular changes or fibrosis)
ii) PFTs showing new/persistent reduction in lung volumes, airflow limitation and/or decrease in
DLCO
90
 QUESTIONS?
• Be Sure to Check out BONUS Slides in Your Course Pack!
– Choosing Wisely CTS
– Chronic Cough Approach (ACCP)
– OSA
– Lung Nodules (Fleischer 2017 guidelines)
– Smoking Cessation Counselling ** HIGH YIELD for Oral Scenarios** (VAPING has
made it newsworthy)
– A Couple more slides on less high yield ILD subtypes
– Relevant Asthma and COPD trials
– Clubbing
– **PFT Approach, Some PFT “CLANG ASSOCIATIONS” to know **
• Our ONLINE MODULE also covers this, but some like a paper copy of notes
– CXR Approach

91
 Choosing Wisely Resp 2021 Update
1. Don’t initiate long term maintenance inhalers in stable patients with suspected COPD if
they have not had confirmation of post bronchodilator airflow obstruction with spirometry.
2. Don’t perform CT screening for lung cancer among patients at low risk for lung cancer.
3. Don’t perform CTA or VQ scan to evaluate for PE in patients with low clinical probability and
negative D-dimer.
4. Don’t treat adult cough with antibiotics even if it lasts more than 1 week, unless bacterial
pneumonia suspected (mean viral cough duration 18d).
5. Don’t initiate asthma treatment in patients who have not had reversible airflow limitation
with spirometry or positive methacholine, or sufficient expiratory flow variability.
6. Don’t use antibiotics for asthma exacerbations without clear signs of bacterial infection.
7. Don’t delay conversations about wishes and goals with patients who have serious or
progressive chronic respiratory illness, such as COPD, IPF, PH, or CF. Unnecessary and
potentially harmful treatments can be avoided by having discussions and documenting
these conversations. (NEW 2021)

92
 Cough (ACCP)
Acute (<3 • Life threatening: Pneumonia, COPDE,
asthma,PE,heart failure, other serious disease

weeks) • Non-life threatening: Infectious (URTI or LRTI),

Environmental / occupational (RADS)

Subacute (3- • Post infectious: Pneumonia, bronchitis,

pertussis, worsening asthma, GERD, UACS,
COPD, NAEB
8 weeks) • Non-infectious (same as chronic ddx)

Chronic (>8 • UACS – upper airway cough syndrome, asthma,

NAEB, GERD, smoking, ACEi use

weeks)
93
 Cough Approach
• CXR and exclude ACE-inhibitors
• In this order, test and treat for:
– UACS
• Confirmed by response to Tx with 1st generation antihistamine/ decongestant (bronpheniramine/SR
pseudoephedrine)
• Sinus imaging if does not improve
– Asthma
• Methacholine challenge and/or empiric ICS (may treat NAEB as well)
– NAEB
• Sputum eosinophils, if available, or an empiric trial of corticosteroids
– GERD
• If “clinical profile” fits (not necessarily GI symptoms), treat empirically
– Lifestyle: coffee, chocolate, citrus, smoking ,etc.
– H2RA/PPI
– Prokinetic
• 24h pH monitoring on therapy if cough persists
• Antireflux surgery if refractory 94
 Obstructive Sleep Apnea
• Go to resource: 2011 CTS Guideline on Sleep Disordered Breathing,
JAMA RCE for OSA, 2019 AASM Guideline on OSA and PAP
• Defined by presence of both:
– Symptoms (sleepiness, choking, awakenings etc) and
– Objective testing (> 5 apnea/hypopnea events during sleep monitoring)
• Mild 5-15 (events/h) / Moderate 15-30 / Severe >30
• Physical Exam: (JAMA 2013 – Does this patient have OSA)
– Most helpful finding was nocturnal choking/gasping (LR 3.3)
– Snoring is non-specific
– No findings on history or physical are good enough to rule in or
out OSA, hence patients require sleep study
95
 Obstructive Sleep Apnea
• Treatment Indications
– Patients with symptoms of excessive sleepiness or impaired sleep-related QOL
– Comorbid HTN
– Asymptomatic patients with severe OSA
• Treatments
– Weight loss (diet/exercise)
– CPAP
• All patients should be offered therapy, asymptomatic patients should be treated if
have comorbidities (ie. HTN), AHI >30, critical occupation
– Oral appliances – for mild-moderate disease
– Surgery (rare) – Tonsillectomy if appropriate, uvulopalatopharyngoplasty in select
patients
• Recent Evidence: CPAP for Prevention of Cardiovascular Events in Obstructive Sleep Apnea,
NEJM 2016 (RCT). Use of CPAP DID NOT reduce cardiovascular events for asymptomatic
patients with moderate-severe OSA. Significance of this result still heavily debated.

96
CTS OSA 2014 / CMA 2019 Driving Guidelines
– Updated guidelines for driving in OSA
– Severity of OSA alone is not a reliable predictor of collision risk and
should not be used in isolation to assess fitness to drive
• Consider co-morbidities, meds, sleep schedule and history of collisions in
addition to severity
• Patients need to be compliant with therapy (CPAP/appliance), defined as
>= 4hrs >70% of nights in past 30 days
• Efficacy of therapy should be documented (reversal of symptoms/AHI)
– CMA Driver’s Guide 2019 (9.1 edition) now reflects these changes
Know:

CTS 2014 97
 Solid Lung Nodules – Fleischner 2017
Guidelines Simplified for IMR
SOLID NODULE Risk? <6mm 6-8mm >8mm
Single Solid Nodule Low Risk No routine f/u CT at 6-12 mos then Consider CT at 3
consider 18-24mos mos, PET – CT or
High Risk Optional CT at 12 CT at 6-12 mos, AND biopsy
mos CT at 18-24 mos.
Multiple Solid Low Risk patient No routine f/u CT at 3-6 mos, then consider CT at 18-24
Nodules mos*
High Risk Patient Optional CT @ CT at 3-6 mos, and CT at 18-24 mos*
12mos
This guideline applies to Adults >35 years and Pertains to incidental nodules, NOT in lung cancer
screening population, patients with history of primary cancer, or immunosuppression

*With multiple nodules, use most suspicious nodule to guide interval for followup.

High risk = estimated risk of cancer >5%. (use clinical and radiographic risk – older age, heavy smoking,
irregular nodule, spiculated, upper lobe location … there is ambiguity in guideline about this) 98
 Subsolid Lung Nodules – Fleischner 2017
Guidelines Simplified for IMR
SUBSOLID NODULE Description of <6mm >= 6mm Notes
nodule
Single nodule Ground Glass No routine f/u CT at 6-12 mos then if every 2h Increase
til 5yr in nodule
by
Partsolid No routine F/U CT at 6-12 mos, then if
>=2mm
persistent annual CT to 5 yrs significant
Multiple subsolid Low risk CT at 6-12 mos
Nodules CT at 3-6 mos then depends on most
suspicious nodule
High risk CT at 6-12 mos then
at 2y , 4y if high risk

This guideline applies to Adults >35 years and Pertains to incidental nodules, NOT in lung cancer
screening population, patients with history of primary cancer, or immunosuppression

*With multiple nodules, use most suspicious nodule to guide interval for followup.
99
 Smoking Cessation Counseling
5 A’s: Ask, Advise, Assist, Assess, Arrange
• Ask: Have you thought about quitting?
– If you’re not ready:
• What do you enjoy about smoking?
– Relaxation, break, socialization, familiarity
• What don’t they like about smoking?
– ”Some people tell me they worry about not being there for family in the future...or setting an example for their kids…Or
the cost….or the smell….do those bother you?”
• Does what you enjoy about it outweigh what worries you about it?
• Does your spouse/child think differently?
– What worries you about quitting?
• Withdrawal symptoms – first 48h toughest
• Failure – most try once per year and require 7 attempts
• Mood/stress - have to pick a good time
• Weight gain – this is real (average 7kg); managed by diet; NRT and zyban can delay it
• Advise: This is why I think quitting is important.
– Young patients: Save money, better breath, clean teeth and fingernails, fewer wrinkles, reduced risk of impotence
• Quitting age 25-34 = 10 years of life gained (British Doctor’s study)
– Older patients: reduced risk of lung cancer (50% at 10yr LC death vs. smoker), heart disease (50% at 1 yr CAD vs. smoker), stroke
100
 Smoking Cessation Counseling
• Assess: do they seem ready to quit?
– If no, tell them to continue to think about it and you’re happy to discuss it again. Emphasize no judgment and personal decision.
– If yes, assess the logistics:
• Dependence: > 1 pack/d or cigarette < 6min after awakening predict HIGH dependence level
• Support: internet sites, support person, smoker’s help line, CAMH
• Stress: pick a good time
• Stop date: mark a calendar, tell friends & family
• Stop other substances (EtOH)
• Assist: with pharmacotherapy
– NRT (HR 1.5-2)
• Combination NRT superior to monotherapy
• Base: Patch 21mg/d x 6 weeks, then 14mg/d x 2 weeks, then 7mg/d x 2 weeks (for > 10cig/d)
– Apply in AM to non-hairy site and remove at night (vivid dreams otherwise, but likely to need early AM breakthrough)
• Breakthrough: Spray/ Inhaler/Gum
– Gum 2mg if smoke < 25cig/d, 4mg if >25cig/d
– Chew and park (otherwise swallow nicotine which is ineffective and causes s/e)
• Generally used up to 2-3 months (up to 1y in some studies); can be used while still smoking
• Arrange frequent follow up
– Short, directed counseling by physician at every visit increases quit rates substantially
101
 ATS Lung Transplantation Guidelines
1. COPD
– FEV1<=25% +/- PaCO2 >= 55mmHg
– Severe disease, resting hypoxemia <55mmHg
2. Cystic Fibrosis/Bronchiectasis
– FEV1<=30% +/- PaCO2 >50mmH
3. IPF/ILD
– Symptomatic
– FVC <60-65%
4. pHTN
– NYHA Class III or IV or severe
Bottom line:
Obstructive Lung Disease à FEV1<30%
Restrictive Lung Disease/pHTN à Severe or symptomatic disease
102
 Clubbing
• Clubbing is enlargement of the terminal • Diffuse Pulmonary Disease
segments of the fingers due to – Pulmonary Fibrosis
proliferation of the connective tissue
between the nail matrix and the distal • Cardiac Disease
phalynx – Cyanotic CHD
– Infective Endocarditis
• Neoplastic Intrathoracic Disease • Gastrointestinal Disease
– Bronchogenic Carcinoma – IBD
– Mesothelioma • Metabolic Disease
• Suppartive Intrathoracic Disease – Graves
– Lung Abscess
– Empyema
– Bronchiectasis
– CF
 Clubbing
1. Phalangeal depth ratio (DPD/PPD) > 1.0
2. Profile angle (defined by the angle made by nail
as it exists from the proximal nail fold) > 176
3. Hyponychial angle (constructed by drawing a
line from distal digital crease to the cuticle and
another line from the cuticle to hyponychium
which is the thickened stratum corneum of
epidermis lying under the free edge of the nail)
> 192 degrees is abnormal
• Schamroth & palpation not validated
PFTs

Tidal

105
 Spirometry Glossary of Terms
• FEV1: Forced Expired Volume in 1 second (in litres)
• FVC: Forced Vital Capacity: maximum volume of gas that can be expired when a subject exhales
as forcefully and rapidly as possible after maximal inspiration. (in litres).
• VC: Vital Capacity (or Slow Vital Capacity): the volume of gas measured from a slow, complete
exhalation.
• Look at patient demographics!
• Look at the Curve! Obstructive vs. restrictive
 PFT Approach

A. Fixed upper-airway obstruction (intrathoracic or extrathoracic)

• Glotic stenosis (prolonged intubation), subglotic stenosis
(Wegner’s, sarcoid, polychondritis)
B. Variable extrathoracic obstruction
• Flattening of inspiratory curve
• Vocal cord dysfunction/paralysis
C. Variable intrathoracic obstruction
• Flattening of expiratory curve
• E.g. tracheomalacia of intrathoracic airway
 PFT Approach
Spirometry:
1. Is there Obstruction? (FEV1/FVC<LLN)
• If yes, is it reversible or fixed (FEV1 >12% + 200cc)?
2. Is there reduction in FVC suggesting restriction or gas trapping
• Does it vary with patient position (e.g. worse supine?)
– Make sure the bronchodilator trial is indeed a bronchodilator trial not sitting/supine

108
 PFT Approach
Volumes:
1. Is there restriction?
• TLC < LLN
– If yes, is it parenchymal (reduced DLCO) or extra parenchymal (normal DLCO)
2. Is there gas trapping?
• RV/TLC >ULN
3. Is there hyperinflation?
• TLC>ULN

109
 PFT Approach
3. DLCO: Is there a gas exchange anomaly?
– Isolated decreased DLCO?
• Parenchymal vs. vascular vs. hemoglobin
– Increased DLCO?
– Is there concomitant obstructive or restrictive
physiology?
 PFT Clang Associations and Pitfalls
• Restrictive pattern varying with position
– Vital Capacity decreases when lying down by >10%
• Gravity eliminated therefore unmasks diaphragm dysfunction, confirm with MIPs/MEPs
• May be presented as a post-op scenario (e.g. CABG) or NMD (e.g. ALS)

• Isolated decrease in DLCO?

– Classically pulmonary hypertension, also early ILD/emphysema, anemia
• Increased DLCO
– Pulmonary hemorrhage/polycythemia, LV failure, asthma, obesity

• More than one process can occur in the same patient!

– Mixed obstructive and restrictive process: Obese smoker, bronchiectasis, sarcoidosis, HP
• Ask for full PFTs including lung volumes and DLCO if possible:
– If “what you see is what you get”, interpret based on the best of your ability:
• “Mild obstructive lung disease. I would ask for further testing to evaluate for a bronchodilator
response and measure lung volumes and DLCO to help with my differential diagnosis.”
 PFT Contraindications
• Contraindications to PFTs: (BMJ)
• 1. Hemoptysis
• 2. Pneumothorax
• 3. Unstable cardiovascular status including recent MI
• 4. Aneurysms – thoracic, abdominal or cerebral
• 5. Recent eye surgery – eg. Cataracts
• 6. Recent thoracic or abdominal surgery
• 7. Presence of acute illness that may interfere with test performance
• Contraindications to Methacholine Challenge: (ATS)
– Absolute:
• 1. Severe airflow limitation FEV1<50% or <1L
• 2. Recent MI or Stroke in last 3m
• 3. Uncontrolled HTN, SBP >200/100
• 4. Known Aortic Aneurysm
– Relative:
• 1. Moderate airflow limitation FEV1<60% or <1.5L
• 2. Pregnancy or nursing mothers (methacholine is category C)
• 3. Use of cholinesterase inhibitor (myesthenia gravis)
112
 PFTs Perioperatively
• Patients with lung cancer being considered for surgery should have
FEV1 and DLCO measured and predicted post-op FEV1 and DLCO
should be calculated (ACCP 2013)
– If both PPO FEV1 and DLCO are >60% predicted no further testing is needed
• Low risk for perioperative death and cardiopulmonary complications following
resection including pneumonectomy
– If either is <60%, further testing is required (and those are deemed high risk)

• Predictors of adverse perioperative pulmonary events:

1. Surgical site (aortic> intrathoracic> upper abdominal> abdominal)
2. Age, prexisting lung disease

Preventing post op complications

– Epidural analgesia decreases atelectasis and pneumonia (Ann Surg 2014)
 Diaphragmatic Weakness
• Often idiopathic, often unilateral (and may be entirely asymptomatic)
• Causes include:
– Trauma or surgery (C3-5 injury during trauma, phrenic nerve injury during cardiac surgery)
– Mechanical ventilation
– Myopathy/neuropathy
• ALS, MG, critical illness myopathy/neuropathy
• WE often get asked: What is the most specific and most sensitive test for diagnosis
of diaphragm weakness/paralysis?
– Most SENSITIVE = MIP.
– Most SPECIFIC: There isn't really a good specific test on PFTs for diaphragmatic weakness.
Proceed to ultrasound if you want specificity. If forced to choose we “guess” FVC… because it's
associated with poor prognosis in diaphragmatic dysfunction as per the ALS CTS guidelines.

114
 Diaphragmatic Weakness
55F with ALS presents with SOBOE and orthopnea. CXR
shows small lung fields with no focal airspace disease or
increased interstitial markings. Diaphragmatic elevation
is noted. What is the most sensitive test for
diaphragmatic weakness?
a) MEP
b) FEV1
c) MIP
d) CO2

• A normal MIP excludes respiratory muscle weakness

(good negative predictive value) but a low MIP does not
confirm the presence of resp muscle weakness
– Poor effort/technique are common
115
 PFT MCQ
45 year old male post CABG with respiratory distress post
extubation. CXR shows bibasilar atelectasis. PAWP 8, VC 1.8 L
decreasing to 0.9 L supine. The likely cause for this clinical picture is:
1) T-spine injury
2) Bilateral phrenic nerve injury
3) Thromboembolus
4) Veno-occlusive disease
5) Prolonged neuromuscular blockade

116
 Approach to CXR
Think ABCDEFGH…
• Assess quality: • Effusions
– Position: Supine? AP? Lateral? – Costophrenic angle and remember lateral film for small
– Inspiration: count ribs posterior effusions
– Exposure: do you see interverbral discs • Fields, fissure, foreign body
– Rotation: position of spinous process to the medial – Lungs – interstitial vs. alveolar, mass, consolidation, air
aspect of clavicle bronchograms, PTX and vascular markings (showed taper
• Bones and soft tissue out to periphery)
– Symmetry, fractures, osteoporosis, lesions – Fissures: thick, fluid filled and position
– Soft tissue, foreign body, swelling, subcutaneous air – Foreign body: ETT, NGT, leads, CVP, clips
• Cardiac – Upper vs Lower Lobe distribution (see next slide)
• Great vessel/gastric bubble
– Heart <50% of chest diameter on PA films, shape,
calcification, prosthetic valves – Aortic size and shape, pulmonary vessel size and aortic
knuckle
• Diaphragm
– Position (right 1-1.5 rib space higher) and shape (flat • Hila and mediastinum
in Copd) – Lymphadenopathy, calcification, mass.
– Widening of tracheal strip = aortic dissection
– Tracheal deviation – mass, goiter, tension PTX 117
 BONUS MCQ 1 – 2023 NEW
A 27F with severe depression and headaches is referred for asthma in
the context of seasonal allergies and nasal polyps. Today in clinic she
describes worsening symptoms due to a change in weather. She took
ASA for a headache this morning. She is taking Salbutamol 100 mcg
puffs as needed and takes it roughly 4 times a year. She has never
presented to the ER and this does not affect her work. Which of the
following is an appropriate next step?
1. Start budesonide/formoterol prn
2. Start montelukast
3. Send for total IgE, CBC with diff and sputum eosinophils
4. CT Chest

118
 BONUS MCQ 1 – 2023 NEW
A 27F with severe depression and headaches is referred for asthma in
the context of seasonal allergies and nasal polyps. Today in clinic she
describes worsening symptoms due to a change in weather. She took
ASA for a headache this morning. She is taking Salbutamol 100 mcg
puffs as needed and takes it roughly 4 times a year. She has never
presented to the ER and this does not affect her work. Which of the
following is an appropriate next step? This is mild to moderate asthma with
1. Start budesonide/formoterol prn features of ASA-exacerbated respiratory
disease. Treatment for asthma is
2. Start montelukast appropriate, however given severe
3. Send for total IgE, CBC with diff and sputum eosinophils
depression, montelukast should be
avoided (black box warning for
4. CT Chest suicidality).

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 BONUS MCQ 2 – 2023 NEW
A 30 year old pregnant woman at 36 weeks gestation presents to the ED with
worsening dyspnea and wheezing 7 days after COVID 19 infection. She has had a prior
diagnosis of asthma but stopped taking her inhalers during pregnancy. She has not
received any vaccines since childhood.
Vital signs reveal T 36.2, HR 110, BP 110/65, RR 24, SpO2 98% on room air. ABG reveals
pH 7.49, pCO2 30, pO2 98, HCO3 26. She was given nebulized salbutamol and
ipratropium as well as supplemental oxygen by the ER. What is the next best step for
definitive management?
1) Magnesium sulfate 4g IV
2) Inhaled steroids
3) Dexamethasone 6 mg po daily x 10d
3) PO prednisone
4) Montelukast

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 BONUS MCQ 2 – 2023 NEW
A 30 year old pregnant woman at 36 weeks gestation presents to the ED with
worsening dyspnea and wheezing 7 days after COVID 19 infection. She has had a prior
diagnosis of asthma but stopped taking her inhalers during pregnancy. She has not
received any vaccines since childhood.
Vital signs reveal T 36.2, HR 110, BP 110/65, RR 24, SpO2 98% on room air. ABG reveals
pH 7.49, pCO2 30, pO2 98, HCO3 26. She was given nebulized salbutamol and
ipratropium as well as supplemental oxygen by the ER. What is the next best step for
definitive management? Steroids are recommended to be used in
1) Magnesium sulfate 4g IV asthma exacerbations in pregnancy as an
2) Inhaled steroids untreated asthma exacerbation in
3) Dexamethasone 6 mg po daily x 10d pregnancy poses significant risks to
mother and baby.
3) PO prednisone
4) Montelukast Dexamethasone crosses placenta.
Therefore, RECOVERY trial preferred pred
or methylpred for pregnant women.

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 BONUS MCQ 3 – 2023 NEW
A 25 year old woman is referred to you for dyspnea of unclear etiology. She has a past
medical history significant for Raynaud’s phenomenon and dysphagia that is being
worked up. She describes progressively worsening exertional dyspnea associated with
presyncope when she plays soccer. She also describes vague abdominal pain and
occasional nausea not associated with vomiting, diarrhea, or fever. On physical exam,
you notice that she has skin tightening limited to her hands, digital ulcers, as well as
facial telangiectasias. Serology is positive for anti-centromere antibody and you make a
diagnosis of scleroderma. Her chest x-ray is normal and a TTE shows normal LV function
with an incomplete Doppler spectral profile. What is the most appropriate next step?
1) Repeat TTE in one year
2) Bronchoscopy
3) CT Chest
4) Right heart catheterization

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 BONUS MCQ 3 – 2023 NEW
A 25 year old woman is referred to you for dyspnea. She has a past medical history
significant for Raynaud’s phenomenon and dysphagia that is being worked up. She
describes progressively worsening exertional dyspnea associated with presyncope when
she plays soccer. She also describes vague abdominal pain and occasional nausea not
associated with vomiting, diarrhea, or fever. On physical exam, you notice that she has
skin tightening limited to her hands, digital ulcers, as well as facial telangiectasias.
Serology is positive for anti-centromere antibody and you make a diagnosis of
scleroderma. Her chest x-ray is normal and a TTE shows normal LV function with an
incomplete Doppler spectral profile. What is the most appropriate next step?
1) Repeat TTE in one year Patients with unexplained dyspnea
2) Bronchoscopy despite non-invasive testing in
3) CT Chest scleroderma should be referred for RHC
to assess for PH.
4) Right heart catheterization

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 BONUS MCQ 4 - 2023
A 70 year old male who is an ex-smoker is referred to you for management of severe
COPD. He is maintained currently on Indacaterol/Glycopyrrolate (LABA/LAMA). He was
discharged from hospital 2 weeks ago after being admitted for an acute exacerbation of
COPD. His stay was brief and he was managed with steroids, antibiotics after initially
requiring BiPAP. He has quit smoking but since his discharge he continues to feel tired
and weak. Most recent CBC shows Hgb 140, WBC 8 (Eos 0.3) and platelets 221. His PFTs
show very severe obstruction with FEV1 1.3 (28%). He walks 320 m on 6MWT with an
oxygen nadir of 89% at the end of the test and maximum HR of 110 bpm. His CT scan
shows diffuse centrilobular emphysema. Which of the following interventions would be
associated with increased survival in this individual?
1. Initiation of home oxygen
2. Roflumilast
3. Pulmonary rehabilitation
4. Addition of ICS to his regimen

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 BONUS MCQ 4 - 2023
A 70 year old male who is an ex-smoker is referred to you for management of severe
COPD. He is maintained currently on Indacaterol/Glycopyrrolate (LABA/LAMA). He was
discharged from hospital 2 weeks ago after being admitted for an acute exacerbation of
COPD. His stay was brief and he was managed with steroids, antibiotics after initially
requiring BiPAP. He has quit smoking but since his discharge he continues to feel tired
and weak. Most recent CBC shows Hgb 140, WBC 8 (Eos 0.3) and platelets 221. His PFTs
show very severe obstruction with FEV1 1.3 (28%). He walks 320 m on 6MWT with an
oxygen nadir of 89% at the end of the test and maximum HR of 110 bpm. His CT scan
shows diffuse centrilobular emphysema. Which of the following interventions would be
associated with increased survival in this individual?
1. Initiation of home oxygen Pulmonary rehabilitation within 4 weeks of
an AE-COPD is associated with increased
2. Roflumilast
survival. Home oxygen only beneficial in
3. Pulmonary rehabilitation patients with resting hypoxemia. Roflumilast
4. Addition of ICS to his regimen and addition of ICS not associated with
reduced mortality.

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 BONUS MCQ 5
A 65 year old male with COPD visits your office for follow up after discharge from hospital 2
weeks ago for COPD exacerbation. He has had 4 exacerbations in the past 2 years. Current
medications include tiotropium, salmeterol, fluticasone, and roflumilast. Pulmonary function
testing shows obstruction with an FEV1 of 38% of predicted, a venous blood gas shows a pH of
7.38 and pC02 of 46, and a CT scan of the chest shows severe homogenous emphysema. He
performed a 6 minute walk test which showed a resting oxygen saturation of 90%, and a nadir
saturation during walking of 83%. He just quit smoking one month ago. Which of the following
may result in improved survival?
1. Referral to thoracic surgery for lung volume reduction surgery
2. Referral to pulmonary rehab
3. Initiation of home oxygen
4. Initiation of nocturnal non-invasive ventilation (ie BiPAP)
5. Start chronic macrolide therapy (ie azithromycin)

Answer: 2 – Refer to Pulm Rehab

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