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Interstitial Lung

Disease(Sarcoidosis)

Jared Scott
RSPT 2233: Respiratory Care
Case Management
McLennan Community College
March 4, 2010
Abstract

This is the case study of Mr. J, a 28-year-old male


diagnosed with Sarcoidosis, a rare disease that is
classified with a group of about 200 diseases known as
Interstitial Lung Disease (ILD). Sarcoidosis and idiopathic
pulmonary fibrosis are the 2 most common diseases,
accounting for 50% of all cases. This presentation follows
the course of Mr. J’s evaluation, diagnosis, and treatment
over the period of one year from his initial doctor’s
appointment.

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Interstitial Lung Disease

 Made up of a large group of diverse diseases that cause lung


damage that results in fibrosis of the lung and reduced lung
volumes and lung area
 Types of interstitial lung disease are classified based on
identifying the etiology of the disease
 Many patients who develop ILD do so as a result of harmful
dusts, such as asbestos, silica, coal and talc
 Often times, ILD occurs with no identifiable etiology

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Interstitial Lung Disease,
cont’d
 In the United States, it is estimated that as many as 81 of
every 100,000 people have some form of ILD
 Only about one third of patients with ILD have an identifiable
agent responsible for inducing lung injury
 Typical inorganic dusts that may induce ILD include
asbestos, silica and talc
 These agents injure the epithelium or endothelium of the lung
directly via or a toxic effect or indirectly by leading to the
production of toxic membranes or activating an immune
response

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Injury

Inflammation

Disordered Repair of Lung Tissue

Pulmonary Fibrosis

End-Stage Lung Disease 5


Medical History

 Mr. J is a 28-year-old African American male employed as


a savings-and-loan computer analyst
 CC: increasing fatigue over the span of several months
 HPI: Progressed the point that he stopped jogging and felt
listless and tired most of the time
 This began as a flu-like illness and left him with a non-
productive cough
 Mr. J denies fever, chills, sore throat, coryza, headaches,
or wheezing
 He notes dyspnea on exertion, but denies awakening with
breathlessness or having dyspnea at rest
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Past Medical History

 Positive for chickenpox, but no measles or mumps


 No surgical history, but broke his leg at age 22
secondary to a skiing accident
 SH: No history of tobacco or illicit drug use; reports
ETOH consumption socially
 FH: Mother with HTN, but father is healthy
 He has two children with no remarkable health
problems

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Physical Exam
 GENERAL: Athletic-appearing man in no
respiratory distress.
 V/S: 97.3°F, pulse 62/min, respiratory rate
14/min, blood pressure 156/96
 HEENT: Unremarkable
 NECK: Swelling of submandibular salivary
glands and serveral 1-2cm lymph nodes in
anterior cervical region; otherwise
unremarkable
 CHEST: Normal chest rise and fall; Fine, difuse
bilateral inspiratory crackles, without wheezing;
Normal resonance to percussion
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Physical Exam, cont’d

 HEART: Regular rate with no murmur or gallop; S1


and S2 have normal intensity and splitting
 ABDOMEN: Soft, nontender; bowel sounds active;
no masses or organomegaly noted; abdominal wall
rises with inspiratory effort
 EXTREMITIES: No edema, clubbing or cyanosis;
extremities warm with good capillary refill
 ROS: Not given

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Hospital Course

 Presentedto physician’s office


 Never admitted

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ABG (on room air)

 pH:7.45
 PaO : 65 mm Hg
2

 PaCO : 32 mm Hg
2

 HCO -: 21 mEq/L
3

 P(A-a)O : 44 mm Hg
2

 Chronic Respiratory Alkalosis with Mild


Hypoxemia

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Labs

CBC Chemistry
Na+ 142
-WBC 9.1 K+ 4.1
-RBC 4.3 Cl- 108
HCO3- 17
-HGB 14.2 BUN 19
-HCT 41 Creat 1.1
Ca 2.5
Phos 2.9
Uric Acid 6.9
Albumin 4.8
Protein 8.2

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LUNG TRANSPLANT: VIABLE TREATMENT

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Chest Radiograph

 Diffuse reticulonodular
opacification
 Bilateral hilar
enlargement
 Consistent with ILD

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VALUE % PREDICTED

Spirometry
FVC (L) 2.79 63
SVC (L) 2.61 59
FEV1 (L) 2.12 67
FEV1/ FVC (%) 76
FEF 25-75 (L/M) 4.11 98
Body Plethsymography
RV (L) 1.20 118
TLC (L) 3.99 74
DLCO (mL/min/mmHg) 11.35 38
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Respiratory Care Plan

 Based on desaturation noted with


moderate exercise, Mr. J begins receiving
supplemental oxygen for home use PRN
 Sarcoidosis is one of the forms of ILD
without a known cause, so therapy is
aimed at suppressing inflammation instead
of preventing further exposure to an
injuring agent

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Medications

 Oxygen

 Prednisone, 20mg daily for 3 months, then 10


mg every other day for inflammation

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PHYSICAL EXAM/HISTORY
DOE, Non-productive cough, increased WOB,
tachypnea, late inspiratory crackles,
swollen lymph nodes, flu-like symptoms?

YES NO
1 -ABG 2 -Consider other diseases
-PFT and rule out
-CXR

3 -Increased
P(A-a)O2
See 4
-Decreased
Lung volumes:
Box
TLC, RV, FEV1=FVC
-Abnormal DLCO 2
-Ground-glass
Appearance on CXR

5 -Reticulonodular Cysts
-Hilar lymphadeonpathy

Bronchoscopy
With
Transbronchial
YES NO
Biopsy

6 7
Findings consistent Adapted from NHBLI Guidelines for the
With ILD? OR Diagnosis of Sarcoidosis
-Scarring of lung tissue, Findings inconsistent with ILD?
Inflammation, cysts. Laboratory See Box 2 19
Identification of sarcoidosis
BEGIN TREATMENT
ATS/ERS Classification of Idiopathic Interstitial Pneumonias
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Conclusion

 One year after the initial diagnosis of Sarcoidosis,


Mr. J feels much better
 After taking Prednisone for 1 year, he shows much
improvement from his initial chest radiograph
 He has less DOE and no longer requires
supplemental oxygen
 Mr. J continues to have a restrictive defect on
spirometry and a reduction in DLCO, but both of
these parameters are improved.

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Works Cited
Valeyre, D., Freynet, O., Bouvry, D., Anesi-Maesano, I., & Nunes,
H. (2009). Epidemiology of interstitial lung diseases.
Presse Med, 39(1), 53-59. Retrieved February 24, 2010,
from the PubMed database.
Wikins, Robert, Dexter, James & Gold, Phillip. (2007). Respiratory
disease: a case study approach to patient care. F A Davis
Co.
Wu, J., & Rashcovsky-Schiff, K. (2004). Sarcoidosis. American
Family Physician, 70(2), 312. Retrieved February 25,
2010, from
http://www.aafp.org/afp/2004/0715/p312.html
Sarcoidosis, lung function, tests, and diagnosis. (2010). National Heart,
Lung and Blood Institute. Retrieved February 25, 2010, from
http://www.nhlbi.nih.gov/health/dci/Diseases/sarc/sar_diagnosis.html
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