Pulmonology

Baher Krayem MD
Principles of Spirometry
Flow Volume Loop
Asthma
 Asthma Diagnosis
✓Clinical picture
• Bilateral expiratory wheezing

✓Spirometry Criteria
• FEV 1.0 reduced
• After SABA FEV1.0 increase by 12% or 200 ml

✓Methacholine challenge test → Not done due to

risk of collapse

✓Normal PFTs DO NOT rule out asthma

Asthma severity/control
 Chronic therapy for asthma

▪ Refractory Asthma options-

✓Oral Corticosteroids → not recommended, why?
✓Omalizumab
Side effects of Corticosteroids
 Acute Asthma attack
▪ Severe dyspnea
▪ Wheezing
▪ Blood gases:
➢pH 7.55 HCO3 25 PCO2 25

▪ After treatment with inhaled SABA SAMA and

steroids
➢pH 7.35 HCO3 25 PCO2 45

Any comment?
Management of Acute Asthma
▪ Oxygen if desaturation
▪ Inhaled SABA
▪ Inhaled SAMA
▪ Systemic Steroids

▪ Antibiotics are not routinely used

▪ Early administration of non invasive ventilation
▪ Intubation as last resort
 Asthma of smokers = COPD
– COPD types:
• Emphysema = pink puffers
• Chronic bronchitis = blue bloaters
– COPD in the young’s
• Alpha 1 antitrypsin
– Asthma COPD overlap
syndrome = ACOS
 COPD
– Clinical manifestation:
• Dyspnoea
• Cough
– Volume
– Consistency
– Colour
• Dyspnoea on exertion
– Physical examination:
• Barrel chest
• Wheezes
• Hoovers sign
• If Clubbing then consider ______ ?
 Treatment of Chronic phase
– Treatments that improve prognosis:
• Stop smoking
• Oxygen
– Saturation less than 88%
– Saturation less than 90% with signs of pulmonary hypertension or
right heart failure
• LVRS = lung volume reduction surgery
– ICSs do not improve survival, just reduce
exacerbations
– Inhalers:
• LABA = main therapy
• LAMA = main therapy
• ICS = add in severe cases [recurrent hospitalizations]
Severity classification - GOLD
 COPD Exacerbation
– If a patient arrives to the ER with acute COPD
exacerbation:
• Oxygen
• SABA SAMA [Ventolin and Aerovent]
• Steroids [systemic]
• Antibiotics for all moderate-severe exacerbation
– Why?
– If the patient does not improve?
• CPAP BiPAP
– Contraindications for CPAP BiPAP
– Mechanical ventilation
 Pleural effusion

- Who is the next victim?

• Describe the CXR..
• What you expect to find in
physical exam
• Management
– Criteria for Empyema

– Most common causes of malignant

pleural effusion:
• LBL = lung, breast, lymphoma

– TB pleural effusion diagnosis:

• Adenosine de aminase
• IFN gamma release assay
• Pleural biopsy
– Treatment → Treat TB
 Who is the next victim?

✓LTC
✓Diagnosis?
✓Treatment?
Interstitial Lung Disease
 Idiopathic Pulmonary Fibrosis = IPT

• Most common ILD

• Progressive disease, clubbing
• Only lung transplant treat for cure
• Supportive therapy
 Bronchiectasis
▪ Dilation of bronchial airways
▪ Causes:
✓TB - africa
✓CF – western world
▪ Typical clinical picture:
✓Thick green sputum
✓Mainly obstructive disease
▪ High prevalence of Pseudomonas infections
▪ Treat with antibiotics and inhalations
Bronchiectasis
Venous Thrombo Embolism
 Pulmonary Embolism
– Clinical story
• New onset severe dyspnoea
• Pleuritic chest pain
• Post surgery- especially if DVT present
• High VTE risk patients
– APLA
– Factor V leiden
– Pregnant women
– Diagnosis:
• D-Dimer vs CTA
• ECG findings
– Most common → sinus tachycardia
– Most specific → S1Q3T3
– Treatment:
• Anticoagulants like NOACs and Coumadin and Heparins
• Thrombolysis in severe selected cases
Wells score for PE
 DVT

• Diagnosis:
– Ultrasound doppler
• Treatment:
– Like PE
 Duration of therapy in VTE
• The main problem with VTE is high rate of recurrence.
• First determine if provoked or unprovoked
– Provoked → after surgery or trauma
• If provoked → 3-6 months
• If unprovoked → for life
• If second VTE → for life even if provoked
• If APLA or homozygote FVL → for life
 Who is the next victim?
Clinical Case
60 years old woman comes to the ER due to
melena, on exam you notice that her left leg is
swollen. You perform and USD and reveal that
she suffers from DVT extending to the left iliac
vein.
What is the best management for this patient?