Interstitial Lung Disease(Sarcoidosis)

Interstitial Lung Disease(Sarcoidosis)

Jared Scott

RSPT 2233: Respiratory Care Case Management

McLennan Community College

March 4, 2010

March 4, 2010 RSPT 2233 Sarcoidosis - Mr. J - Jared Scott 2

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.


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


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


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


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


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

Physical Exam


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


Hospital Course

Presented to physician’s office Never admitted


ABG (on room air)

pH: 7.45 PaO2: 65 mm Hg

PaCO2: 32 mm Hg

HCO3-: 21 mEq/L

P(A-a)O2: 44 mm Hg Chronic Respiratory Alkalosis with Mild

Hypoxemia



Labs

CBC

-WBC 9.1

-RBC 4.3

-HGB 14.2

-HCT 41

ChemistryNa+ 142K+ 4.1Cl- 108HCO3- 17BUN 19Creat 1.1Ca 2.5Phos 2.9Uric Acid 6.9Albumin 4.8Protein 8.2


LUNG TRANSPLANT: VIABLE TREATMENT


Chest Radiograph

Diffuse reticulonodular opacification

Bilateral hilar enlargement

Consistent with ILD


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


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


Medications

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

mg every other day for inflammation

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PHYSICAL EXAM/HISTORYDOE, Non-productive cough, increased WOB,

tachypnea, late inspiratory crackles, swollen lymph nodes, flu-like symptoms?

YES

NO

-ABG-PFT-CXR

-Consider other diseases and rule out

-Increased P(A-a)O2

-Decreased Lung volumes:

TLC, RV, FEV1=FVC-Abnormal DLCO

-Ground-glassAppearance on CXR

-Reticulonodular Cysts-Hilar lymphadeonpathy

1 2

3 4SeeBox

2

YESBronchoscopy

WithTransbronchial

Biopsy

Findings consistent With ILD?

-Scarring of lung tissue, Inflammation, cysts. Laboratory

Identification of sarcoidosisBEGIN TREATMENT

Findings inconsistent with ILD?See Box 2

OR

NO

5

6 7Adapted from NHBLI Guidelines for the Diagnosis of Sarcoidosis

March 4, 2010 RSPT 2233 Sarcoidosis - Mr. J - Jared Scott

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ATS/ERS Classification of Idiopathic Interstitial Pneumonias

http://thoracic.org/statements/resources/respiratory-disease-adults/idio2.pdf






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.


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

Interstitial Lung Disease(Sarcoidosis)

Documents

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