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Internal medicine lec #4 part 1 19-3-2012

Bronchial Asthma

Dr. who gave this lecture is Basheer Khassawneh, MD, FCCP Bronchial Asthma is a common disease Sometimes in "TIME" magazine they talk about things that are

common health problems that affect the society worldwide and

Bronchial Asthma once made it to the cover page!

Asthma is becoming more and more common

What is Bronchial Asthma? Do you know anybody with Bronchial

Asthma? >> It is usually common!

Definition helps you understand the disease, so it is an airwayinflammation, and it is chronic not transient and goes away

Causing recurrent episodes of symptoms, and this is what yousee of asthma >> recurrent episodes of:

oWheezing

o Breathlessnesso Chest tightnesso Dry cougho Cough particularly at night

Symptoms are worse at night and/or in the early morning

Physiology of the disease:Variable airflow limitation, so they have a narrow airway that the air

flow is limited

And it is variable, so they have good\bad days, and good\bad hours

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Reversibility in this obstruction becomes better spontaneously or with

treatment "medication; bronchodilators for ex"

Another property of asthma is Airway hyper-responsiveness to a variety

of stimuli; which means when those patients are exposed to triggers, forexample the wind outside and this cold air may cause people with

asthma to start coughing and wheezing, dust, or strong smell

The Scope of the ProblemUSA:-Affects 14 -15 million people, and it is a large number of people who

have asthma

-6% of children under the age of 18 years have asthma there, so it isalso common in children, if you take a class or school 6% of the

students would have true asthma and take medication for it

-Inner city children have highest rates, so urbanized areas have more

asthma than ruler areas

-So we expect to see more asthma in more urbanized society,

Amman, middle of Irbid, and Zarqa for example

-Rates higher among females

-In America rates higher among blacks, the Dr. doesn't think that here

in Jordan

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Experience With Asthma: Public SurveyThey ask people around some Qs such as: do you have asthma? Did you

have asthma? Do you have a family member having asthma? Do you

know somebody who has asthma?

As you can see in the chart above most of people either knows someone

with asthma or they have it themselves

How the disease happens?It is a multifactorial disease (such as many internal med diseases) so

there is no single defect that tells why you do have or don't have asthma

Genetics plays a role through atopy "allergy", another effect of genetics

has to do with cytokine dysregulation, and cytokines that are produced

in the airways will have problems, excessive or reduced cytokines will

help to produce asthma

Environmental factors; Allergens, viruses' interactions, diet for example

introducing early allergenic diet to children especially infants can causeasthma so parents should be very careful about what to feed their

children in their early ages, and smoking either passive or active "for

example kids who stay beside their smoking father or mother are more

prone to respiratory tract infections than the others"

What happens at the cellular level?It is complicated and that's why its treatment is tricky, you will find

histamine, leukotrienes, and cytokines who work on the epithelial and

endothelial and cause inflammation

And we have cytokines that works on macrophages and smooth muscles

and cause inflammation

So it is a multi-pathway disease >> for example in kids with asthma if you

give them a drug that works on leukotrienes such as multi leukast they

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usually improve because leukotrienes usually play an important and

predominant role in asthma, BUT in adults it is not as effective as in

children!

-Up until early 90s they used to think of asthma as a mechanical disease

even physicians, asthmatics would have bronchoconstriction all they

need is bronchodilators

-As they started to take biopsies from asthmatic patients they realized

that asthma is more than a bronchoconstriction

-A lot of the lining epithelium in asthmatic airways is destroyed, and

there is mucus plugging, if you take a lung biopsy from people who die

from sever asthmatic attack will find a lot of mucus plugging, and

bronchodilators cannot improve them at all :\

-And we have thickening, and an increase of the smooth muscles of the

airways

-It is not just a simple bronchoconstriction\bronchodilation it is more

than that, there will be lots of inflammation and this reflects our

treatment of asthma patients

Consequence of Inflammation in Asthma:-How do all of these pathways work? People with asthma history if they

had a stimulus (Antigens, virus, pollutants, occupational agent) it will

cause inflammation this inflammation might be acute episode >>

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either goes away by itself or cause hyper-responsiveness and

inflammation {the patient will have bronchoconstriction and cough

etc}

-Most of the patients will go into the "Chronic inflammation phase"which will cause injury such as edema and injury to the endothelium

etc; to this injury body does repair what we call remodeling "repair with

recurrent damage" which is important in Asthma

-How do we see this repair in Asthmatic? A patient comes for example at

the age to 20, he doesn't take medication, so he will have recurrent

asthma repair inflammation and so on >> at the age of 30 he comes and

says Dr. I used to have just a simple bronchodilator once in two weeks,then after few years I started to have regular use, but now I go to the

emergency room and they give me steroids needles! NOW in his case it

is a progressive disease, BUT usually it is not a progressive disease it is

stable! A mild patient stays mild moderate stays moderate and so on,

when do you cross these borders? >> When you have remodeling

-So when we have changes on the cellular level only it is important to

enforce management on patients so the Dr. tells his patients that ifyou don't want to take the medication now its fine but this simple

medication won't help you after 3 or 5 years!

-So Chronic inflammation with no medication lots of repair and

inflammation and remodeling >> will lead to permanently altered lung

function

If you take a look at the lung function of a male non-smoker:

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-From the age of 20-80 it slowly decreases but if you look at the

asthmatic it is a rapid decrease because of remodeling and destruction

of the airways! (So they lose their lung function with time)

-Another important issue for public knowledge is that people say Asthmacan go away this is true in children more than in adults, and it depends

on the onset of which if it is at the early age "below 5 yrs" there is higher

chance that the child when he grow up he will grow out of Asthma!

-BUT for adulthood asthma the later Asthma will start the less likely this

will occur (for example someone had asthma at the age of 25-30 it is

unlikely asthma will go away)

-The common Arabic terminology of the Bronchial Asthma is "al- rabo"

and when you tell someone that you have Rabo he will believe that

it will never go away which is true most of the adults will stay at

this chronic phase, some of them will regress and some of them will

progress, but most go into this stable chronic phase!

Risk Factors for Asthma:o Allergy/Atopy which if familial we said people with eczema,

conjunctivitis, or rhinitis makes it more likely to develop asthma!

o Family history of asthma/allergy, so a child with parents havingasthma is more likely to develop asthma than a child with healthy

family!o Perinatal exposure to tobacco smoke, as we said before the Dr.

thinks it is a crime for the parents to smoke inside the house and

cause passive smoking to their children, because carcinogens will

settle on the carpet and things in the house!

o Early viral respiratory tract infectionso Low birth weighto Environmental pollutiono Low socio-economic status

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o Passive smokingAtopy and Asthma:

- Asthmatics are more atopic than non-asthmatics

-Some people come and ask for skin tests but they are usually notrewarding in asthmatics

-They usually have multiple atopic reasons House dust mite for example

and a number of things

-House dust mite is the most common aer-allergen worldwide

Atopy (atopic syndrome) is a syndrome characterized by a

tendency to be hyperallergic. A person with atopy typically

presents with one or more of the following: eczema (atopic

dermatitis), allergic rhinitis (hayfever), allergic conjunctivitis,

or allergic asthma. Patients with atopy also have a tendency to

have food allergies.

Patients with atopy usually develop what is referred to as the

allergic triad of symptoms, i.e., eczema (atopic dermatitis),

hayfever (allergic rhinitis), and allergy-induced asthma (allergic

asthma). They also have a tendency to have food allergies, and

other symptoms characterized by their hyperallergic state. For

example, eosinophilic esophagitis is found associated with atopic

allergies.

Atopic syndrome can be fatal for those that experience seriousallergic reactions, such as anaphylaxis, brought on by reactions to

food or environment.

Wiki

http://en.wikipedia.org/wiki/Eczemahttp://en.wikipedia.org/wiki/Atopic_dermatitishttp://en.wikipedia.org/wiki/Atopic_dermatitishttp://en.wikipedia.org/wiki/Allergic_rhinitishttp://en.wikipedia.org/wiki/Allergic_conjunctivitishttp://en.wikipedia.org/wiki/Allergic_asthmahttp://en.wikipedia.org/wiki/Eosinophilic_esophagitishttp://en.wikipedia.org/wiki/Anaphylaxishttp://en.wikipedia.org/wiki/Anaphylaxishttp://en.wikipedia.org/wiki/Eosinophilic_esophagitishttp://en.wikipedia.org/wiki/Allergic_asthmahttp://en.wikipedia.org/wiki/Allergic_conjunctivitishttp://en.wikipedia.org/wiki/Allergic_rhinitishttp://en.wikipedia.org/wiki/Atopic_dermatitishttp://en.wikipedia.org/wiki/Atopic_dermatitishttp://en.wikipedia.org/wiki/Eczema

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-It lives in dust, it is everywhere, we are allergic to its feces we inhale it!

{YUCK}

-It is very hard to get rid of it, and very hard to avoid it

Indoor Air Triggers:o Environmental tobacco smokeo Cockroacheso House dust mites - commono Animal dander - catso MoldOutdoor Air Triggers:

Here in Jordan OliveAdditional Triggers:

-1st

problem as additional triggers for us as doctors are medications

-Some patients with asthma they exacerbate by the use of aspirin

o Viral upper respiratory infectionso Exercise and hyperventilationo GERD

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o Sinusitis and rhinitiso Dieto Cold airo Drugso Aspirin, NSAID which are the most commonly used in Jordanian

market and you as dentist want to give a patient a medication and

you prescribe a NSAID for him and the exacerbate so you have to

pay attention!, beta blockers

Asthma Diagnosis:-It is usually diagnosed clinically by taking history and symptoms of the

patient, as we said before they would have the Syndrome of Asthma

(go back and review them)

Symptoms and Signs:o Variety of symptomso wheezeo shortness of breatho chest tightnesso cough

Asthma symptoms tend to be:

o Variable and intermittento Worse at night, and early morningso Provoked by triggers, strong smells, cold air etc

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Additional Elements in History:

Personal or family history of:

o Asthmao Atopic condition:eczema, allergic rhinitis >> makes

the case stronger to be asthmatic as well

Physical Signs of Asthma:-They can be normal, especially if he came to you as a dentist

During exacerbations: Wheezes!

Differential Diagnoses:-COPD, Chronic obstructive pulmonary disease, which occurs in elderly,

in smokers usually, so it can be very similar to asthma

-Acid reflux, they would have recurrent cough

-Post nasal drip, usually with cough early in the morning

-And other things that can mimic asthma:

o Cystic fibrosiso Tumor: Laryngeal, tracheal, lungo Bronchiectasiso Foreign bodyo Vocal cord dysfunctiono Hyperventilation

Diagnostic Tools:>> Peak flow monitoring, a small piece of plastic that measures the peak

flow

>>Pulmonary function testing (spirometry), asthmaticpatient who has an obstructive defect "pattern" they would

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have: FEV1/FVC < 70% and the Forced Vital Capacity will

decrease, and less FVC in 1 sec "decreased FVC1"

-And they have reversibility >> which means when we give

them a bronchodilator in the clinic and I test them again theywould be better and with better airflow

-FEV1 increases by 15% after inhalation of a rapid-acting

beta-2-agonist

Asthma Management:Goals of management nowadays are better:

No (or minimal) daytime symptoms No limitations of activity No nocturnal symptoms No (or minimal) need for rescue medication Normal lung function No exacerbations

>> This is almost a normal person and this is achievable by medications

Levels of Asthma Control:Not that much important :\

BUT take a look next page

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-Doctors should believe that there is no current cure for asthma, but

most important to know that if you give them medications "symptoms

wide" they can live a normal life ^^:

-While the doctor was preparing for the lecture he opened google pix

and searched Bronchial asthma and the most common thing that he

found is ??? Someone holding an inhaler!

>>> So inhalers are stigma for Asthma! 2 / week

Lung function

(PEF or FEV1)

Normal < 80% predicted or

personal best (if

known) on any day

Exacerbation None 1 / year 1 in any week

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-So we said Asthma is an inflammation so you should give anti-

inflammatory drugs and the best one is Inhaled glucocorticosteroids;

because it is locally delivered to the site of the disease with minimal

systemic effect

-Leukotriene modifiers, as we said a subset of patients benefit from that

especially children

-We have a new treatment which is: Anti-IgE , for people with atopic or

allergic Asthma, very expensive

-An old medication:Theophylline, less used these days-We use Systematic glucocorticosteroids, during exacerbations andpatients who doesn't respond

>>So the main treatment of Asthma is: inhaled corticosteroids

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Those are the various types of inhalers that we have!

And they have combination of medication within those inhalers, steroids

and bronchodilators

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The figure above illustrates the step therapy for asthma

It is a traditional slide for asthma patients everywhere you go you will

find it

Although we don't follow these rules, but as you can see the general

concepts are important

For example all patients should be well educated about their disease,

and environmental control

As you can see all patients take inhaled corticosteroids but with variable

doses!

Asthma ExacerbationsAsthma during exacerbations is similar to regular asthma; let's look to

asthma as camping fire you just put water on it to stop it what if you

have a big fire in the whole wood! The same concept you bring water to

stop it but in a larger scale!

Asthma during exacerbation is similar to regular asthma, for example

instead of inhaled CS we give systemic CS

Instead of2-agonists every 6 hours I give it every 4 hours and so

They may be treated in the hospital!

For example if you had a patient in your clinic and he had asthmatic

attack you give him O2 (the amount doesn't really matter) followed by

CS >> if they had good response that is good if not you give them

systemic CS and then they go to the hospital!

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There is an article in the magazine dentistry and medicine the Dr. advice

us to look at it! it is about increased risk of caries in asthma patients and

-Reduced salivary flow-Oral mucosal changes

-Gingivitis

-Orofacial abnormalities

Increased upper anterior and total anterior facial height Higher palatal vaults Greater overjets Higher prevalence of posterior crossbites

So there is an association between asthma and dental diseases!

You should be aware if the patient has allergy to any component and if

the local anesthetic is not good for him!

As we said the attacks comes early in the morning so we tell them to goto the dentists in the afternoon!

Take your medication before you go! Simple things make a big

difference in management

Qs? Dr. answered some Qs but they where general and he answered in

general as well

Dr. said Qs comes from the slides

) (..

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Internal medicine lec #4 part 2 19-3-2012

Community Acquired Pneumonia

-Dr. who gave this lec is Shaher M. Samrah, MBBS, FCCP

Types of pneumonia:-

Community Acquired Pneumonia (CAP) Hospital Acquired Pneumonia Pneumonia in Immune-compromised Host

Pneumonia in Patients with HIV >> which is considered a special type

of pneumonia

-What we are concerned about is CAP

Epidemiology-The sixth leading cause of death

-The most common infectious cause of death

Mortality< 1% in the outpatient setting will die

-But the mortality increases according to the severity; 5-12% for

patients requiring hospital admission and 22-50% for patients

requiring ICU admission

MicrobiologyWe think of a variety of bacterial and viral pathogens, but CAP most

commonly caused by bacteria

Streptococcus pneumoniaeis the most common organism

In sever dental caries patients with bad oral hygiene and lots of

cavities they would have anaerobic infections other than

Streptococcus pneumoniae

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Take a look at this list of pneumonias:

Alcoholism Streptococcus pneumoniae, oral anaerobes, Klebsiella

pneumoniae, Acinetobacterspecies, Mycobacterium

tuberculosis

COPD and/or smoking Haemophilus influenzae, Pseudomonas aeruginosa,

Legionella species, S. pneumoniae, Moraxella

catarrhalis, Chlamydophila pneumoniae

Aspiration Gram-negative enteric pathogens, oral anaerobes

Lung abscess CA-MRSA, oral anaerobes, endemic fungal pneumonia,

M. tuberculosis, atypical mycobacteria

Exposure to bat or bird

droppings

Histoplasma capsulatum

Exposure to birds Chlamydophila psittaci(if poultry: avian influenza)

Exposure to rabbits Francisella tularensis

Exposure to farm animals or

parturient cats

Coxiella burnetti(Q fever)

Influenza active in community Influenza, S. pneumoniae, Staphylococcus aureus, H.

influenzae

Cough >2 weeks with whoop or

posttussive vomiting

Bordetella pertussis

Structural lung disease (eg,

bronchiectasis)

Pseudomonas aeruginosa, Burkholderia cepacia, S.

aureus

Injection drug use S. aureus, anaerobes, M. tuberculosis, S. pneumoniae

Endobronchial obstruction Anaerobes, S. pneumoniae, H. influenzae, S. aureus

In context of bioterrorism Bacillus anthracis (anthrax), Yersinia pestis (plague),

Francisella tularensis (tularemia)

Alcoholism, Aspiration, Lung abscess all of which you can see anaerobic

organisms in the list!

So not everyone with CAP has streptococcal infection, but you have to

think about it because it is the most common microorganism

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And you should think of the risk factor that is most likely to cause the

disease!

Previously they used to say that there is what we call typical and atypical

pneumonia but they don't use it anymore because and the might goinside each other's classes and in the end the treatment is the same,

because as well at least 10-40% Co-infection with one pathogen of the

list

Diagnostic Approach to CAPClinical Evaluation >> we start with History we ask about symptoms,

fever, chills, and so on Physical exam Simple laboratory tests

Radiological Evaluation Chest X-Ray CT chest

Microbiological studies

Clinical Evaluation: (Symptoms)90% patients will have cough regardless productive or dry

Purulent sputum 66%

Dyspnea 66%Pleuritic chest pain 50%Fever and chills 30-40%

Physical Signs: Vital signs:

Tachycardia, tachypnea, fever, hypotension Signs of consolidation: This means when the lung has an

infection!Dullness, egophony, bronchial breath sounds,

crepetations

Signs of pleural effusion: this means fluid around the lung

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Stony dullness "Dr.s have a test by the finger they

knock on the cavity or any place in the body you

should hear resonance when you don't hear it they

cavity is filled with something else fluid or so",

diminished breath sound

Investigation:Depends whether it is an outpatient or inpatient

We start with Routine tests performed on admission: Chest radiograph Complete blood count Urea, electrolytes and liver function tests, because there

are microorganisms that produce liver dysfunction

Oxygenation assessment: ABGYou detect if the patient has hypoxia

SaO2

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-Pleural effusion: Parapneumonic or empyema

And they may have: -Lung abscess

-So when a patient comes to you and you start detecting the dysfunction

and see what the symptoms that he has are, cough, fever, and shortness

of breath I ask for an X-ray and you will find lobar infiltrate

-What other things that I can do to help me diagnose? Some people

might ask for culture from this lung to see what is this microorganism?

This is pneumonia in the right upper lobe of the lung

Here we have the right lower lobe having more infection, but you feel

bilateral infiltrate exist! >> Right lower + middle Lobes

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Here we can see the infection in the right lower lobe but there iseffusion as well! >> Pleural Effusion

Here we have infiltrate on the left lower lobe, but there is some sort offluid level! So cavity with fluid >> Lung abscess

Microbiologic Diagnosis:Some people ask for sputum for culture which is good but should not

guide you through diagnosis!

Because you have to start treatment before, according to the risk factor

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So you don't have to wait for culture to start treatment unless you

have moderate and severe cases and you want to make sure of the

microorganism that is causing the infection!

Microbial cause is not found in 2560% of cases You diagnosis Should be guided by:

The severity of pneumonia Epidemiological risk factors The response to treatment

So Sputum culture is not really needed!

~ 30% has unable to produce sputum Helps to broaden the empiric antibiotic therapy

o Blood Culturesometimes it is recommended preferably beforeantibiotic treatment, so when you have a patient you take a blood

culture from him before you start antibiotics to make sure that

you are not treating a resistant microorganism

o Pleural fluid if the patient had plural infusion! Gram stain and culture

o And in some cases we make what we call Bronchoscopy (BAL, PB) , .. In rare infection and rare presentations, and risk cases

for example when a patient comes and you suspect he has TB and you

tell him to give you sputum which has a totally different treatment!

Pneumonia is a systemic infection it is not local it reaches the blood!

So you have to start antibiotics as soon as possible

And at least order blood culture and it helps you later on

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For example when an outpatient comes we treat him without blood nor

sputum culture so it depends on the severity and sometimes we

don't use chest X-ray

Serology:Sometimes you take a urine sample and you find antigens in it!

So this helps to guide diagnosis but it doesn't guide treatment

So you always have to treat Legionella for example

And it helps in screening and epidemiological studies, BUT we don't wait

for those to come back to decide treatment ^^:

The antibiotics that we use in CAP cover those other organisms, such as

Legionella, Pneumococcal antigens so usually the antibiotic covers the

microorganisms included in the disease

And sometimes you have other signs such as Legionella causes liver

dysfunction for example and they have hyponatremia so in this case to

make sure that Legionella is the cause and to rule out other dysfunctions

we order a urine test or serum test

It takes 4-6 weeks to get the resultsWhich is not recommended to wait that much!

As we said you have to decide where to treat out\in patient, and if the

patient need to be in ICU

We have some things that help us decide but we don't use them all

For example:

Pneumonia Severity Index (PSI) CURB-65

Pneumonia Severity Index (PSI)

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We have classes from 1-5, depends on the scores

1\2 >> outpatient

4\5 >> inpatients

More than 5 >> they usually go to ICU

Those are the scoring points:

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It is COMPLICATED and we don't use it often

So we go to the other thing which is CURB 65

It is a summary of the risk factors and when we see them we say

this patient has severe pneumonia and this doesn't

CConfusion

UUrea > 7 mmol/lRRespiratory rate > 30/minBBP: Systolic < 90 mm Hg

Diastolic < 60 mm Hg

Hypotension, renal failure, and confused patient!

65Age > 65 Years

The older the patient the more severe his case will be!

So if the patient had the things above he has severe pneumonia

And if the patient had end organs involvement we say he has sepsis,

it became systemic so there is risk factors in severe pneumonia

that are really scary and we should take of them

Studies play a role here because of the need of knowing the effect of

the risk factors on the severity of the disease

Criteria for Severe CAPThe slides say minor and major not necessary, you know what the things

you should think about to decide admission to ICU or not

Major Criteria >> Invasive mechanical ventilation

Patient that needs invasive ventilation

Where to put him?

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If the patient had Septic shock requiring vasopressors whatever the

cause is

It is very difficult to treat him in the floor

Minor Criteria >> Respiratory rate > 30/min

PaO2 / FIO2 < 250

Multi-lobar infiltrates

Confusion Uremia (BUN > 20 mg/dl) Neutropenia

Thrombocytopenia Hypothermia"the same as fever it is a bad thing that means the

patient is no longer having defense no white cells defense to produce

fever"

Patients with very low oxygenation or having bilateral lung abscess they

are at high risk of getting worse you're always concerned whether

they'll need more oxygen

CAPTreatment:Microbiological DX unknown in up to 50%

Initiate therapy within 8 hours

((patient with pneumonia >> antibiotics))

Always think about co-infection and X-rays

How to decide what kind of treatment you want to use??

>> If the patient was previously healthy, and did not use antibiotics

"Previously healthy + No antimicrobials within the previous 3 months"

Simple Macrolideis enough for example: eryhthromycin,

Clarithromycin, Azithromycin

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>> "Comorbidities or antimicrobials within the previous 3 months"

-Respiratory fluoroquinolone: levofloxacin

--lactam + macrolideThe later we have to use two antibiotics because the microorganism

pneumonia has 30% increased resistant

Macrolide are not enough for severe pneumonia we have to use other

antibiotics

Inpatient Treatment-Non ICUSame as we said:

Respiratory fluoroquinolone

Levofloxacin, Moxifloxacin, Gemifloxacin

-lactam + Macrolide

Ceftriaxone, Cefotaxime

Dental pneumonia!In cases of aspiration and lung abscess pneumoniae where anaerobic

infection

Which are found in the mouth dental caries, decays

A patient that is alcoholic and is always sleeping, with bad oral hygiene

which is a risk factor for two things: dental pneumonia, and infective

endocarditic

What are the antibiotics used in this case?

Clindamycin (first-line therapy) covers anaerobic only Amoxicillin-clavulanate Metronidazole + Amoxicillin/Penicillin G

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We have vaccinations:

There is another thing which is Influenza virus Vaccine

In October or November to decrease mortality from such as infections

And they are given to the staff as well

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It takes time to heal ... 4 weeks to resolve depends on the severity it

is a reversible disease

Most common pneumonia caused by bacteria

It is infectious

At the end the Dr. showed a pic of a casino in Las Vegas why I don't kn!

Sorry for any mistake

..

~ " "

:- - ...( ):

Life is short try not to waste it unhappy