Lecture 26 Respiratory Disease I 2023 McGriff.pdf

Respiratory Disease I WIL MCGRIFF, OD, MPH CHRISTOPHER WALKEN, OD, FAAO [email protected] [email protected] 901-722-3334 MOR-COW-BEL Lecture Objectives u Recall epidemiology of common respiratory disorders u Differentiate between physiologic and pathologic changes associated with common resp...

Respiratory Disease I WIL MCGRIFF, OD, MPH CHRISTOPHER WALKEN, OD, FAAO [email protected] [email protected] 901-722-3334 MOR-COW-BEL Lecture Objectives u Recall epidemiology of common respiratory disorders u Differentiate between physiologic and pathologic changes associated with common respiratory disorders u Recognize major ocular effects of sinusitis, sarcoidosis, and tuberculosis NBEO Outline u L. Respiratory System u 1. Epidemiology u 2. Symptoms and signs of respiratory disorders u a. Chronic obstructive pulmonary disease (COPD), emphysema, asthma, etc. u b. Infectious diseases of the lung u c. Neoplastic diseases of the lung u d. Interstitial diseases including pneumoconiosis u 3. Significance of common respiratory symptoms (e.g., cough, hemoptysis, wheezing, shortness of breath) u 4. Symptoms and signs of anaphylaxis u 5. Diagnostic testing and imaging u 6. Pathophysiology and diagnosis Respiratory System u u Upper airway u Lower airway u Nose u Trachea u Mouth u Bronchi u Nasopharynx u Bronchioles u Oropharynx Middle airway u Laryngeal pharynx u Alveoli u ~250 million per lung Respiratory System Functions u Ventilation u u Gas exchange / Diffusion u u Movement of air into and out of the interior of the body Exchange O2 and CO2 between the air and the blood Metabolism u Conversion of angiotensin I to angiotensin II by ACE u Deactivation of bradykinin and prostaglandins u Regulates pH of blood Diffusion Requirements u Intact, non-thickened alveolar walls (~0.2 to 2.5 µm thick) u Minimal interstitial space & without additional fluid Innervation of the Lungs u Respiratory control center u Located in the brainstem (Cranial Nerve 10 – Vagus) u Central and peripheral chemoreceptors u u u Stimulated by pH of CSF, PaCO2, and PaO2 Drives skeletal muscles of respiration Autonomic nervous system u Innervates smooth muscles of the conducting airways u Promotes airway constriction or dilation Leading Causes of Death in US in 2022 u Heart disease u Cancer u COVID – 19 u Accidents/unintentional injuries u Stroke u Chronic lower respiratory diseases u Alzheimer’s disease u Diabetes u Chronic liver disease and cirrhosis u Kidney disease https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm Respiratory Diseases u u All can be categorized as affecting: u Ventilation (Ex: asthma) u Diffusion (Ex: emphysema, COPD) u Perfusion (Ex: pulmonary embolism) Diseases may involve more than one General Manifestations of Respiratory Diseases u u Inflammatory processes u Vasodilation u Increased capillary permeability u Exudate formation Signs and symptoms u Cough u Excess mucus production u Hemoptysis (coughing up blood) u Dyspnea (shortness of breath) u Use of accessory muscles u Chest pain u Barrel chest Ventilation Impairment u Foreign Body u Trauma u u Hemothorax (blood) u Pneumothorax (air) Mucous accumulation u u Smooth muscle spasm u u Cystic fibrosis Asthma Airway edema u Anaphylaxis Upper Respiratory Tract Infections u u Common Cold (Infectious Rhinitis) u Infection, inflammation can spread u Viral (~80% are rhinovirus) u Sinusitis u Spread thru respiratory droplets u Laryngitis u Highly contagious u Bronchitis Signs u Nasal congestion and watery discharge u Mouth breathing u Change in tone of voice u Sore throat, headache, slight fever u Cough Sinusitis u Swollen membranes prevent entry of air into sinus u Acute: 4 weeks or less u Chronic: > 12 weeks u May be recurrent u Causes: Viral/Bacteria/Fungal/Allergic u Air / pus / mucus trapped within a blocked sinus u Symptoms: u Pain / HA / Tenderness over affected area u “Fullness” / “Pressure” Sinusitis Complications u Inflammatory edema and preseptal cellulitis u Orbital cellulitis u Orbital abscess u Subperiosteal abscess u Cavernous sinus thrombosis u Intracranial complications Restrictive Lung Disease u u u Limited lung expansion u Reduced lung volume u Increased respiratory effort Causes u Pulmonary fibrosis u Neuromuscular diseases u Obesity and kyphosis u Infection Effects u SOB u Cough Interstitial Pulmonary Fibrosis u u u Group of pulmonary connective tissue diseases u Typically present as restrictive lung disease u Fibrosis results in secondary HTN and right heart failure u ~74 cases per 100K population Causes u Idiopathic (IPF)* u Autoimmune diseases (Sarc. & CTD & HP) u Drugs & toxins u Infections u Occupational and environmental inhalants Symptoms u Dyspnea 5% 22% 29% 14% 26% Pneumoconiosis u u u Predisposing factors u Preexisting lung disease u Exposure to dust* (asbestos, silica, coal) u Duration of dust exposure u Amount of dust concentration u Particle size of pollutant Pathogenesis u Macrophages secrete lysozymes u Enzymatic damage causes deposition of collagen Tx: palliative (supplemental O2, smoking cessation, bronchodilators) Pneumoconiosis / Occupational Lung Diseases u u Anthracosis u “Coal workers pneumoconiosis” u “Black lung” Silicosis u u Silica inhalation Asbestosis* u Asbestos inhalation u ~60% of all pneumoconiosis cases Sarcoidosis u u Chronic granulomatous disease (1-40/100K) u Common in 3rd-4th decade of life u 3:1 Blacks > Whites u Women > Men Pathogenesis u Noncaseating epithelioid granulomas u Multiple organs u Lungs* u Lymph nodes u Skin u Eyes Sarcoidosis u u General symptoms u Fever u Cough and SOB u Fatigue u Arthralgias Normal CXR Sarcoid CXR Skin granuloma Classic triad u Pulmonary involvement u Skin granulomas u Eye and joint lesions Iris granuloma ONH granuloma Sarcoidosis u Diagnosis u Treatment u Tissue biopsy u Steroids u Blood tests u Immunosuppressants u Anti-malarials u Tetracycline u Angiotensin converting enzyme (ACE) u Lysozyme u Calcium u Chest x-ray / CT u Pulmonary function tests u Bronchoalveolar lavage Sarcoidosis Ocular Manifestations Ocular manifestations occur first in 30-40% of patients with sarcoid u Conjunctivitis u Intraocular granulomas u Episcleritis u Hypotony or glaucoma u Keratitis u Retinal or choroidal lesions u Scleritis u Retinal vasculitis u Orbital inflammation u Optic disc edema / Papillitis u Lacrimal gland u Optic perineuritis u Anterior, intermediate, or posterior uveitis u Retrobulbar optic neuritis u Cataract (primary or secondary to treatment) Pulmonary Edema: Ventilation and Diffusion impairment u u Pathophysiologic condition u Fluid in and around alveoli u Interferes with gas exchange u Increases work of breathing Two Types u Cardiogenic (heart failure) u Non-Cardiogenic (high permeability) u Acute respiratory distress syndrome (ARDS) u Pulmonary embolism u Viral infection u Toxins (chlorine, ammonia, stomach contents) Acute Respiratory Distress Syndrome u u Widespread pulmonary inflammation u Causes severe hypoxia u 125,000-150,000 cases/year in United States (pre-COVID) u Mortality rate 30%-60% w/ tx Etiology u Noncardiogenic pulmonary edema u Atelectasis u u Alveolar collapse due to disruption of surfactant Fibrosis Acute Respiratory Distress Syndrome u Causes u Sepsis (>40%) u Aspiration of gastric acid (>30%) u Severe trauma u Fat emboli syndrome u Shock Pneumonia u Inflammatory process secondary to infection u Bacteria u Viruses u Fungi u Lung fills with fluid and exudate u Symptoms u Cough with sputum production u Fever u Sharp chest pain on inspiration Pneumonia u u u Common causes u Treatment u Rhinovirus, RSV, Influenza virus u Antibiotics u M. pneumonia, B. pertussis, S. pneumoniae u Antivirals* u Rest u Fluids Uncommon causes u Legionella pneumophila u Pneumocystis jirovenci Healthy CXR Diagnosis u Chest x-ray u Lung auscultation u Sputum culture Pneumonia CXR Types of Pneumonia Bronchial Lobar Interstitial COVID-19 (Coronavirus disease) u SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) u Enveloped (+)RNA virus u Same family as SARS-CoV and MERS-CoV u u u Middle East respiratory syndrome coronavirus u Airborne transmission (masking works!) u 103.4M cases in U.S. as of 12/4/23 (772M globally) u 1.14M deaths ins U.S. as of 12/4/23 (6.99M globally) Major risk factors for severe disease u Age (81% of deaths >65yoa) u Race (minority groups at higher risk) u Sex (M>F) u Comorbidities and disability Vaccines prevented infection or reduce severity of disease COVID-19 deaths by risk factor The Lancet Public Health 2021 6e817-e825DOI: (10.1016/S2468-2667(21)00206-1) Copyright © 2021 Elsevier Ltd Terms and Conditions Medical conditions that increase risk of severe COVID-19 u Cancer* u Mental health conditions u Chronic liver disease u Organ transplant u Chronic lung disease* u Overweight and obesity* u Dementia u Pregnancy u Diabetes (1 & 2)* u Sickle cell u Down syndrome u Smoking u Heart conditions & HTN* u Substance use disorders u HIV u Tuberculosis u Immunocompromised states u u Targets ACE2 receptors u Nasal epithelium u Lung u Vascular endothelium u GI u Heart u Corneal epithelium u Brain u Prostate & testes u Pancreas u Liver u Kidneys u Bladder Interrupts RAAS pathway u Excess ANGII (pro-inflam) Potential severe COVID-19 manifestations and outcomes u Bilateral interstitial pneumonia u Acute respiratory distress syndrome (ARDS) u Precipitated and/or worsened by cytokine storm u Sepsis u 2ndary infection u Long-term reduced organ fxn u u Lungs u Kidneys u Heart u Brain COVID positive CXR Long-COVID symptoms Healthy CXR Reported Ocular Manifestations of COVID-19 u u Symptoms u Dry eye u FBS u Redness u Tearing Ocular diseases u Conjunctivitis* u BRVO/CRVO u CRAO u Vasculitis Tuberculosis u u Mycobacterium tuberculosis u Spread person to person during close contact u 1/3 of the world pop is positive u 5-8% of US pop tests positive / 9,272 cases in 2016 Risk factors u Close-contact with infected individuals u Occupational u Domestic u Alcohol and IV drug abuse u Diabetes u Cancer u HIV Tuberculosis u Inhaled droplet nuclei bypass upper airway defenses u Alveolar macrophages ingest bacterium but are unable to destroy them u u u Caseating granuloma formation Results: u Asymptomatic primary TB (90%) u Progressive primary TB (5%) u Secondary TB (5%) Famous consumptives: Voltaire, Henry David Thoreau, Doc Holliday, Frederic Chopin, Igor Stravinsky, Eleanor Roosevelt, Desmond Tutu, Tom Jones Tuberculosis u Common symptoms u Diagnosis u Fatigue u Skin tests u Fever u Chest x-rays u Weight loss* (Consumption) u Sputum analysis u Coughing u Polymerase Chain Reaction (PCR) u Night sweats u Normal Treatment u Inactive TB: isoniazid u Active TB: isoniazid in combination u Vaccine available TB Tuberculosis and the Eye u Occurs in 1.4% of cases u Can occur anywhere in orbit or adnexa u Most common manifestations: u Choroiditis > Anterior Uveitis > Sclerokeratitis Lecture Objectives u Recall epidemiology of common respiratory disorders u Differentiate between physiologic and pathologic changes associated with common respiratory disorders u Recognize major ocular effects of sinusitis, sarcoidosis, and tuberculosis Respiratory Disease I WIL MCGRIFF, OD, MPH CHRISTOPHER WALKEN, OD, FAAO [email protected] [email protected] 901-722-3334 MOR-COW-BEL