Case Studies from the Pulmonary Function Laboratory Focus Conference on Respiratory Care and Sleep Medicine, May 2013 Nashville, TN Angela Lorenzo, MS,
Post on 23-Dec-2015
218 Views
Preview:
Transcript
Case Studies from the Case Studies from the Pulmonary Function Pulmonary Function
LaboratoryLaboratory
Focus Conference on Respiratory Care Focus Conference on Respiratory Care and Sleep Medicine, May 2013 Nashville, and Sleep Medicine, May 2013 Nashville,
TNTN
Angela Lorenzo, MS, RRT, RPFT
Respiratory Care DivisionSchool of Health Sciences
Indications for PFTsIndications for PFTs
Establish baseline of pulmonary functionEstablish baseline of pulmonary function Determine presence/severity of diseaseDetermine presence/severity of disease Monitor disease Monitor disease
progression/improvementprogression/improvement Monitor response to therapyMonitor response to therapy Pre-operative assessmentPre-operative assessment Disability evaluationsDisability evaluations Occupational lung diseaseOccupational lung disease
Case 1: Ankylosing Spondylitis Case 1: Ankylosing Spondylitis and MAC c/o DOEand MAC c/o DOE
53 y/o male, Ht 72 “, Wt 90 lbs, Smoker- 53 y/o male, Ht 72 “, Wt 90 lbs, Smoker- 39 pk/yr hx, c/o DOE39 pk/yr hx, c/o DOE
4 Months ago released from hospital for 4 Months ago released from hospital for hemoptysis, Rx’s with antibiotics & Home hemoptysis, Rx’s with antibiotics & Home O2O2
Chest Imaging: LUL cavitating lesion with Chest Imaging: LUL cavitating lesion with an enlarging mycetoma, new densities in an enlarging mycetoma, new densities in RUL & LLL, widespread pulmonary RUL & LLL, widespread pulmonary fibrosisfibrosis
Sputum + for M. xenopi in past (now -)Sputum + for M. xenopi in past (now -)
Case 1: Ankylosing Case 1: Ankylosing Spondylitis and MAC c/o Spondylitis and MAC c/o
DOEDOE Also has Crohn’s Disease and Also has Crohn’s Disease and
treated with 6MP (mercaptopurine) treated with 6MP (mercaptopurine) which in rare cases can cause which in rare cases can cause pulmonary fibrosispulmonary fibrosis
Pt had been treated with Remicade Pt had been treated with Remicade in past (anti-TNF) associated with in past (anti-TNF) associated with TB infectionsTB infections
Case 1: Ankylosing Spondylitis Case 1: Ankylosing Spondylitis and MACand MAC
FVC: 1.47 L (28%)FVC: 1.47 L (28%) FEV1: 1.37 L FEV1: 1.37 L
(33%)(33%) FEV1%: 93%FEV1%: 93% MIP: 52% MIP: 52%
predictedpredicted MEP: 26% MEP: 26%
predictedpredicted
Unable to perform Unable to perform DLCO or N2 DLCO or N2 washout due to washout due to leakleak
Limited ability to Limited ability to open mouth-could open mouth-could not use not use mouthpiecemouthpiece
Case 2: Alpha-1 Antitrypsin Case 2: Alpha-1 Antitrypsin DeficiencyDeficiency
64 y/o male with history of A-1AD64 y/o male with history of A-1AD Has pulmonary and liver involvementHas pulmonary and liver involvement
Up to 15% pts have liver involvementUp to 15% pts have liver involvement Currently taking Aralast 5 g IV weeklyCurrently taking Aralast 5 g IV weekly
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor Increased exercise tolerance since Increased exercise tolerance since
beginning A1PI therapy beginning A1PI therapy Progressive weight loss has stabilizedProgressive weight loss has stabilized
Case 2: A1ADCase 2: A1AD FVC: FVC: 4.47 L 4.47 L (98%)(98%) FEV1: FEV1: 2.63 L 2.63 L (74%)(74%) FEV1%: FEV1%: 59%59% FEF FEF 25-75%25-75% 0.99 L/sec0.99 L/sec (29%)(29%) PEFR PEFR 8.09 L/sec8.09 L/sec (93%)(93%) TLC TLC 7.64 L7.64 L (111%)(111%) FRC PL FRC PL 5.00 L5.00 L (141%)(141%) RV RV 3.09 L3.09 L (129%)(129%) DLCO 70%; DLCO/Hb 67%; DLCO 70%; DLCO/Hb 67%;
DLCO/VA 42%DLCO/VA 42%
Case 2: A1ADCase 2: A1AD Alpha-1 antitrypsin is Alpha-1 antitrypsin is
produced in the liverproduced in the liver Protects the lungs Protects the lungs
from the effects of from the effects of elastaseelastase
A-1A inactivates A-1A inactivates elastase carried on elastase carried on WBCs in the lungsWBCs in the lungs
Elastase destroys Elastase destroys alveolialveoli
Prolastin, Zemaira, Prolastin, Zemaira, AralastAralast
Case 2: A1ADCase 2: A1AD
Year 2009 1/2010 12/2010 2012
FVC 3.53 4.47 4.14 92%
4.05 92%
FEV1 2.38 2.63 2.50 70%
2.51 73%
FEV1/FVC 67% 59% 60% 62%
FRC 4.30 121%
4.53 129%
RV 3.31 3.09 3.17 132%
3.62 149%
DLCO 58% 70% 61% 58%
Case 2: A1ADCase 2: A1AD
Diagnosed 6 years ago presenting Diagnosed 6 years ago presenting with DOE, reactive erythrocytosis with DOE, reactive erythrocytosis 2/2 hypoxia2/2 hypoxia
On A1PI 5 yearsOn A1PI 5 years Liver cirrhosis diagnosed 7 years Liver cirrhosis diagnosed 7 years
ago, stable at this timeago, stable at this time Weight loss has stabilizedWeight loss has stabilized No limitations on activityNo limitations on activity
Case 3 CREST/ILDCase 3 CREST/ILD
64 y/o male with CREST is being 64 y/o male with CREST is being evaluated for ILD. evaluated for ILD.
Pt also has goiter. Pt also has goiter. Previous PFTs WNL when pt tested Previous PFTs WNL when pt tested
to see if goiter was obstructing to see if goiter was obstructing tracheatrachea
Case 3: CREST/ILDCase 3: CREST/ILD
FVC 2.60 L 60%FVC 2.60 L 60% FEV1 2.11 L 62%FEV1 2.11 L 62% FEV1% 81%FEV1% 81% FEF25-75% 2.15 FEF25-75% 2.15
67%67% PEF 7.56 89%PEF 7.56 89% No bronchodilatorNo bronchodilator Post-loops assessed Post-loops assessed
effect of goiter on effect of goiter on airwayairway
Case 3: CREST/ILDCase 3: CREST/ILD TLC 4.45L 66%TLC 4.45L 66% VC 2.75 L 63%VC 2.75 L 63% FRC N2 2.63L 74%FRC N2 2.63L 74% ERV 0.94 L 65%ERV 0.94 L 65% RV 1.69 L 69%RV 1.69 L 69% RV/TLC 38% 98%RV/TLC 38% 98% DLCO 58%DLCO 58% DLCO/VA 52%DLCO/VA 52%
Case 4: Asthma, Case 4: Asthma, Allergies, DM2Allergies, DM2
54 y/o asthmatic with hx DM tested54 y/o asthmatic with hx DM tested Pulmonary Medication profile: Pulmonary Medication profile:
advair singulair, albuterol prn (used advair singulair, albuterol prn (used 5 canisters in a 6 month time frame)5 canisters in a 6 month time frame)
At age 49 pt sought treatment for a At age 49 pt sought treatment for a suspected latex allergysuspected latex allergy
Pt had known seasonal allergies. Pt had known seasonal allergies.
Case 4: Asthma, Case 4: Asthma, Allergies, DM2Allergies, DM2
Allergy skin testing + for pollens, grass, Allergy skin testing + for pollens, grass, trees, dust mites, feathers, dogs, cats, trees, dust mites, feathers, dogs, cats, tree nuts, shell fish, some other foodstree nuts, shell fish, some other foods
Blood tests were – for latex x 2, + some Blood tests were – for latex x 2, + some foodsfoods
Pt agreed to Immunotherapy. Pt agreed to Immunotherapy. 11stst PFT 4 years prior to beginning IT PFT 4 years prior to beginning IT 22ndnd PFT 2 years IT PFT 2 years IT FeNO 4 years ITFeNO 4 years IT
Case 4: Asthma, Case 4: Asthma, Allergies, DM2Allergies, DM2
FVC 2.68L FVC 2.68L 85%85%
FEV1 1.98L FEV1 1.98L 75%75%
FEV1% 74%FEV1% 74% FEFFEF25-7525-75 1.44 1.44
27%27% L/SECL/SEC
PEFR 6.32 PEFR 6.32 104%104%
Pre/Post
Case 4: Asthma, Case 4: Asthma, Allergies, DM2 Allergies, DM2
FVCFVC 2.58L 85% 2.58L 85% FEV1 2.52L FEV1 2.52L
79%79% FEV1% 80%FEV1% 80% FEFFEF25-75 25-75 2.82 2.82
57%57% L/SECL/SEC
PEFR 5.96 PEFR 5.96 134%134%
Case 4: Asthma, Case 4: Asthma, Allergies, DM2 Allergies, DM2
20032003 FVC 2.68L FVC 2.68L
85%85% FEV1 1.98L FEV1 1.98L
75%75% FEV1% 74%FEV1% 74% FEFFEF25-7525-75 1.44 1.44 27% 27% L/SECL/SEC
PEFR 6.32 PEFR 6.32 104%104%
L/SECL/SEC
20092009 FVCFVC 2.58L 85% 2.58L 85% FEV1 2.52L FEV1 2.52L
79%79% FEV1% 80%FEV1% 80% FEFFEF25-75 25-75 2.82 2.82
57%57% L/SECL/SEC
PEFR 5.96 PEFR 5.96 134%134%
L/SECL/SEC
Case 4: Asthma, Case 4: Asthma, Allergies, DM2 Allergies, DM2
2012 worsening symptoms after URI2012 worsening symptoms after URI 2 weeks after URI, sinus complaints, 2 weeks after URI, sinus complaints,
productive cough. No fever, chillsproductive cough. No fever, chills Baseline FeNO 17 ppbBaseline FeNO 17 ppb Peak symptoms FeNO 54 ppbPeak symptoms FeNO 54 ppb Advair increased to 250/50: FeNO 34 ppbAdvair increased to 250/50: FeNO 34 ppb Advair increased to 500/50: FeNO 17 ppbAdvair increased to 500/50: FeNO 17 ppb Baseline dose 100/50 resumed: FeNO 17 Baseline dose 100/50 resumed: FeNO 17
ppbppb
Case 4: Asthma, Case 4: Asthma, Allergies, DM2 Allergies, DM2
Advair Dose FeNO Resting Blood Sugar
100/50 15-19 100-110
100/50 54 160’s
250/50 34 140’s
500/50 17 100
100/50 17-19 90-110
Case 5Case 5
72 y/o physician “curious” to see 72 y/o physician “curious” to see what cigarettes have done to her what cigarettes have done to her lungs and what a PFT feels like.lungs and what a PFT feels like.
Approx 75 pack year historyApprox 75 pack year history No respiratory complaintsNo respiratory complaints
Case 6: BronchiectasisCase 6: Bronchiectasis
49 y/o male with hx severe COPD, pulm TB 49 y/o male with hx severe COPD, pulm TB for which he began tx 1994 for which he began tx 1994
TB relapsed due to noncompliance. TB relapsed due to noncompliance. Completed multi-drug tx > 1 yr 1996Completed multi-drug tx > 1 yr 1996 Now has stable biapical scarring/cavitationNow has stable biapical scarring/cavitation Sputum + MAC 3 of 4 cultures, no MAI txSputum + MAC 3 of 4 cultures, no MAI tx 25 pack year smoking hx, quit 8 years ago25 pack year smoking hx, quit 8 years ago
Case 6: BronchiectasisCase 6: Bronchiectasis
Presents for f/up and sputum inductionPresents for f/up and sputum induction No wt loss, night sweats, fever, chills No wt loss, night sweats, fever, chills Good appetite, good ET >3-4 flights stairsGood appetite, good ET >3-4 flights stairs + phlegm varies clear to brownish, no + phlegm varies clear to brownish, no
blood blood Chest CT: extensive bilat old Chest CT: extensive bilat old
granulomatous disease with bullous and granulomatous disease with bullous and cavitary changes, significant volume loss in cavitary changes, significant volume loss in upper lobes, bronchiectatic changes, upper lobes, bronchiectatic changes, fibrosis/scarring notedfibrosis/scarring noted
Case 6: BronchiectasisCase 6: BronchiectasisYear 2007 2009
FVC 3.12L 63% 3.89L 76%
FEV1 1.27L 32% 1.10L 27%
FEV1/FVC 41% 28%
SVC 92% 3.89L 76%
IC 75% 2.70L
ERV 153% 1.19L 70%
FRCpleth 130% 4.35L 122%
RV 145% 3.17L 144%
DLCO/VA WNL 64%
R/A Pulsox 97% 98%
Pt began Tx with spiriva, foradil, asmanex and albuterol prn in 2007. Asmnex d/c’d 2009
Case 7: Parkinson’s Case 7: Parkinson’s DiseaseDisease
62 y/o male with hx Parkinson’s disease 62 y/o male with hx Parkinson’s disease (1998) eosinophilic PNA 2006-nml eos since (1998) eosinophilic PNA 2006-nml eos since 20082008
Worsening SOB at rest, band-like radiating Worsening SOB at rest, band-like radiating chest tightness that has increased over the chest tightness that has increased over the last several weeks and gets worse as his last several weeks and gets worse as his Parkinson’s meds wear offParkinson’s meds wear off
Parkinson’s meds: carbidopa levodopa Parkinson’s meds: carbidopa levodopa (Sinemet) q 2h (past 8 years), Selegiline (4 (Sinemet) q 2h (past 8 years), Selegiline (4 years); past use comtan d/c’d 2/2 side effectsyears); past use comtan d/c’d 2/2 side effects
Case 7: Parkinson’s Case 7: Parkinson’s DiseaseDiseaseAfter Parkinson’s Meds
2 hours later, feeling SOB
FVC 3.98 L 1.79 L
FEV1 2.98 L 1.77 L
FEV1FVC 75% 99%
Case 7: Parkinson’s Case 7: Parkinson’s DiseaseDisease
Mask facies, tachyneic, speaks in Mask facies, tachyneic, speaks in short sentences, lungs clear with short sentences, lungs clear with shallow respirationsshallow respirations
As dopa wore off, PFT pattern As dopa wore off, PFT pattern changed to restricted- muscle changed to restricted- muscle rigidity affecting respiratory muscles rigidity affecting respiratory muscles which is rarewhich is rare
Dyspnea is a described side effect of Dyspnea is a described side effect of carbidopa levodopacarbidopa levodopa
Case 8: AmiodaroneCase 8: Amiodarone
79 y/o male with h/o cardiomyopathy 79 y/o male with h/o cardiomyopathy and subsequent Afib. and subsequent Afib.
Pt now on amiodaronePt now on amiodarone Pt c/o DOEPt c/o DOE The following tests were ordered: The following tests were ordered:
spirometry and static lung volumesspirometry and static lung volumes DLCO was not orderedDLCO was not ordered Amiodarone known to cause pulmonary Amiodarone known to cause pulmonary
fibrosisfibrosis
Case 8 : AmiodaroneCase 8 : Amiodarone
FVC 2.68L FVC 2.68L 85%85%
FEV1 1.98L FEV1 1.98L 75%75%
FEV1% 74%FEV1% 74% FEFFEF25-7525-75 1.44 1.44
27%27% L/SECL/SEC
PEFR 6.32 PEFR 6.32 104%104%
L/SECL/SEC
Case 8 : AmiodaroneCase 8 : Amiodarone TLC 7.49L TLC 7.49L
94%94% VC 4.68L VC 4.68L
95%95% FRC PL 3.80L FRC PL 3.80L
95%95% ERV 0.99L ERV 0.99L
61%61% RV 2.81L RV 2.81L
95%95% RV/TLC 38% 84%RV/TLC 38% 84%
Case 8 : AmiodaroneCase 8 : Amiodarone
DLCO: 41% predictedDLCO: 41% predicted Discussion followed: was decreased Discussion followed: was decreased
DLCO due to interstitial edema 2DLCO due to interstitial edema 2oo to to cardiac failure or lung disease?cardiac failure or lung disease?
Side effects:Side effects: Interstitial pneumonitis, fibrosisInterstitial pneumonitis, fibrosis Dyspnea, non-productive cough - Dyspnea, non-productive cough -
common presenting symptomscommon presenting symptoms Decreased TLC and DLCODecreased TLC and DLCO
Case 9: DOE, CLL, Case 9: DOE, CLL, LymphomaLymphoma
63 y/o male with Small Cell Lymphoma and 63 y/o male with Small Cell Lymphoma and Chronic Lymphocytic Leukemia c/o DOE and Chronic Lymphocytic Leukemia c/o DOE and persistent unprod cough, 20 pack year hx, persistent unprod cough, 20 pack year hx, quite 11 years agoquite 11 years ago
RituximabRituximab: cardiac= angina, arrhythmia; : cardiac= angina, arrhythmia; pulm = Obliterans bronchiolitis, pneumonitispulm = Obliterans bronchiolitis, pneumonitis
FludarabineFludarabine: pulm- cough, hypersensitivity : pulm- cough, hypersensitivity reactions, pulmonary fibrosis, interstitial reactions, pulmonary fibrosis, interstitial infiltratesinfiltrates
CytoxanCytoxan: cardiac- cardiomyopathy; pulm – : cardiac- cardiomyopathy; pulm – interstitial pneumoniainterstitial pneumonia
Case 9: DOE with CLL, Case 9: DOE with CLL, LymphomaLymphoma
FVCFVC 2.90L 59%2.90L 59% FEV1 2.12L FEV1 2.12L
56%56% FEV1% 73% FEV1% 73% FEFFEF25-7525-75 1.50
43% PEFRPEFR 6.026.02
67%67%
Case 9: DOE with CLL, Case 9: DOE with CLL, LymphomaLymphoma
TLCTLC 4.74L 63% 4.74L 63% VCVC 2.97L 60% 2.97L 60% FRC PL 2.54L 68%FRC PL 2.54L 68% ERV 0.77L 47%ERV 0.77L 47% RV 1.77L 70%RV 1.77L 70% RV/TLC 37% 90%RV/TLC 37% 90% DLCO (Hb 10.8) 44%DLCO (Hb 10.8) 44% DLCO/VA 49%DLCO/VA 49%
Anti-Neoplastic DrugsAnti-Neoplastic Drugs
Hypersensitivity reactionsHypersensitivity reactions: : characterized by cough, SOB, characterized by cough, SOB, bronchospasm, urticaria, allergic bronchospasm, urticaria, allergic alveolitis/pneumonitisalveolitis/pneumonitis Procarbazine, Azathioprine (Imuran), Procarbazine, Azathioprine (Imuran),
AsparginaseAsparginase Pulmonary fibrosisPulmonary fibrosis: :
Busulfan (Myleran), Cyclophosphamide Busulfan (Myleran), Cyclophosphamide (Cytoxan), Bleomycin, Chlorambucil (Cytoxan), Bleomycin, Chlorambucil (Leukeran), Melphalan(Leukeran), Melphalan
Case 10: Lung Case 10: Lung Cancer/ResectionCancer/Resection
68 y/o male referred to PFT Lab for 68 y/o male referred to PFT Lab for pre-op evaluation for LUL lung pre-op evaluation for LUL lung cancercancer
Pt is a 40 pack year ex-smoker who Pt is a 40 pack year ex-smoker who quit 10 years ago. quit 10 years ago.
DOE, Productive cough DOE, Productive cough He presented nearly one year later He presented nearly one year later
for follow up PFTsfor follow up PFTs
Case 10: Lung Case 10: Lung Cancer/ResectionCancer/Resection
Pre-op s/p Left Upper Lobectomy
FVC 2.44L 53% 2.27L 50%
FEV1 1.55L 44% 1.47L 42%
FEV1/FVC 64% 65%
FEF 25-75 0.58L/Sec 18% 0.73L/Sec
TLC 4.18L 59% 3.89L 54%
VC 2.56L 59% 2.34L 51%
FRCpleth 2.29L 62% 2.24L 61%
ERV 0.66L 44% 0.69L 46%
RV 1.63L 63% 1.55L 60%
RV/TLV 39% 40%
DLCO
top related