Chapter 37: Pulmonary Disorders

Population

• –Adults.

Recommendations

American Academy of Sleep Medicine 2012

• –Primary CSAS

  • Positive airway pressure therapy may be used to treat primary CSAS.

  • Limited evidence to support the use of acetazolamide for CSAS.

  • Zolpidem or triazolam may be used to treat CSAS if patients are not at high risk for respiratory depression.

• –CSAS related to CHF

  • Nocturnal oxygen therapy.

  • CPAP therapy targeted to normalize the apnea-hypopnea index.

• –CSAS related to ESRD

  • Options for therapy include CPAP, nocturnal oxygen, and bicarbonate buffer use during dialysis.

Source

• –http://www.guideline.gov/content.aspx?id=35175

Population

• –Adults.

Recommendations

AASM 2017

• –Recommends that diagnostic testing for OSA be performed in conjunction with a comprehensive sleep evaluation.

• –Recommends that a polysomnogram, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate-to-severe OSA.

• –Recommends that a polysomnogram, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep-related hypoventilation, chronic opioid medication use, and history of stroke or severe insomnia.

• –Recommends that if a single home sleep apnea testing is negative, inconclusive, or technically inadequate, a polysomnogram be performed for the diagnosis or exclusion of OSA.

Sources

• –http://guidelines.gov/summaries/summary/50887/

• –Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(3):479-504.

ACP 2013

• –All overweight adults diagnosed with OSA should lose weight.

• –Recommends nocturnal CPAP (continuous positive airway pressure) therapy as first-line therapy for OSA.

• –Option to use mandibular advancement devices for those patients intolerant of CPAP.

Source

• –http://www.guideline.gov/content.aspx?id=47136

Population

• –Children >5 y and adults.

Recommendations

GINA 2018

• –Assess severity of asthma exacerbation while starting SABA and supplemental oxygen as needed.

• –Consider alternative causes for the patient’s respiratory symptoms. Consider anaphylaxis.

• –Arrange for transfer of patient to acute care facility if there are signs of severe exacerbation, altered mentation, or silent chest. Give inhaled SABA, inhaled ipratropium bromide, oxygen, and systemic corticosteroids as soon as possible while awaiting/arranging for transfer.

• –Start treatment with repeated doses of inhaled SABA, early oral corticosteroids, and supplemental oxygen. Titrate oxygen to maintain oxygen saturation 93%–95% in adults, and 94%–98% in children ages 6–12 y.

• –For severe exacerbations, add ipratropium bromide, consider inhaled nebulized SABA. Consider IV magnesium if patient is not responding to initial treatment.

• –No role for routine antibiotics, chest x-ray, or blood gases in asthma exacerbation. Use antibiotics only for suspected bacterial infections.

• –Follow up and assess response of symptoms frequently.

• –Use the exacerbation as an opportunity to review the patient’s chronic medication regimen, identify misunderstanding, and review the asthma action plan.

• –Arrange for early follow-up of an exacerbation, within 2–7 d. All patients should be followed until their symptoms return to normal.

Comments

1. Corticosteroids dosing:

   1. Prednisolone 1 mg/kg PO daily (up to 50 mg) or equivalent × 7 d for mild-to-moderate exacerbations.

   2. Methylprednisolone 1 mg/kg IV q6h initially for severe exacerbations.

   3. Magnesium dosing: Magnesium sulfate 2 g IV.

   4. Rapid-acting β-agonists (SABA) dosing: 4–10 puffs albuterol pMDI with spacer or 2.5–5 mg nebulized every 20 min for 1 h.

Source

• –Pocket Guide for Asthma Management and Prevention. 2018 Global Initiative for Asthma. http://www.ginasthma.org.

Population

• –Children age >5 y and adults.

Recommendations

GINA 2018

• –Basic Principles:

  • Diagnosis of asthma by history: typical symptoms are a combination of shortness of breath, cough, wheezing, and chest tightness; variability over time and in intensity; frequent triggers; FEV1 and FEV1/FVC ratio are reduced and increase by more than 12% after a bronchodilator challenge.

  • Recommend classification of asthma by level of symptom control.

  • Recommend a chest radiograph at the initial visit to exclude alternative diagnoses.

  • Recommend assessing for tobacco use and strongly advise smokers to quit.

  • Recommend spirometry with bronchodilators to determine the severity of airflow limitation and its reversibility. Repeat spirometry at least every 1–2 y for asthma monitoring.

  • Consider allergy testing for history of atopy, rhinitis, rhinorrhea, and seasonal variation or specific extrinsic triggers.

  • Recommend an asthma action plan based on peak expiratory flow (PEF) monitoring for all patients.

  • Recommend allergen and environmental or occupational trigger avoidance.

  • Physicians should help educate patients, assist them in self-management, develop goals of treatment, create an asthma action plan, and regularly monitor asthma control.

Population

• –Adults.

Recommendations

ERS/ATS 2017

Source

• –Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017;49(3):1600791.

NICE 2010, GOLD 2018

• –Recommend noninvasive positive pressure ventilation for moderate-to-severe hypercapnic respiratory failure.

• –Prednisolone 30–40 mg orally, or its equivalent IV, should be prescribed for 5–7 d.

• –Recommend antibiotics for 5–7 d for COPD exacerbations associated with more purulent sputum or need for mechanical ventilation.

• –Bronchodilators can be delivered by either nebulizers or meter-dosed inhalers depending on the patient’s ability to use the device during a COPD exacerbation. Bi-level positive airway pressure (Bi-PAP) is indicated for moderate-to-severe COPD exacerbations.

• –Noninvasive mechanical ventilation improves survival, and decreases need for mechanical ventilation, infectious complications, and hospital length of stay.

• –Consider subcutaneous heparin or low-molecular-weight heparin for DVT prophylaxis.

• –Monitor fluid balance.

• –Methylxanthines are not recommended due to side-effect profiles.

Sources

• –Global Initiative for Chronic Obstructive Lung Disease: Pocket Guide to COPD Diagnosis, Management, and Prevention. 2018 Report. https://goldcopd.org/

• –GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD. https://goldcopd.org.

• –http://www.nice.org.uk/nicemedia/live/13029/49397/49397.pdf

Cochrane Database of Systematic Reviews 2018

• –There was no difference in treatment failure or time to next exacerbation between patients treated with 7 or fewer days of systemic corticosteroid compared to treatment longer than 7 d.

Source

• –Walters JAE, Tan DJ, White CJ, Wood-Baker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD006897.

Comment

1. Initial empiric antibiotics should be an aminopenicillin, macrolide, or a tetracycline and should be given for 5–10 d.

Population

• –Adults.

Recommendations

NICE 2010, GOLD 2018

• –Recommend confirming all suspected COPD with postbronchodilator spirometry.

• –Recommend spirometry in all persons age >35 y who are current or ex-smokers and have a chronic cough to evaluate for early-stage COPD.

• –Recommend smoking cessation counseling. Smoking cessation has the greatest capacity to influence the natural history of COPD.

• –Recommend annual influenza vaccination, and pneumococcal vaccination including PPSV23 for adults with COPD and PCV13 for adults age ≥65 y.

• –GOLD initiative assesses severity of COPD by GOLD Grades 1–4 based on spirometry and GOLD Stages A–D based on symptoms and exacerbation history.

• –The main treatment goals are reduction in symptoms and decreasing risk of future exacerbations.

• Stepwise medication approach:^a

  • Short-acting β-agonist (SABA) and short-acting muscarinic agonist (SAMA) as needed (PRN).

  • If persistent symptoms, add:

    • FEV₁ ≥50% of predicted, add either a long-acting β-agonist (LABA) or long-acting muscarinic agonist (LAMA).

    • FEV₁ <50% of predicted, add either LABA + inhaled corticosteroid (ICS), or LAMA.

  • If persistent symptoms, add:

    • LAMA to LABA + ICS.

    • Roflumilast, a phosphodiesterase-4 inhibitor, improves lung function and reduces moderate-to-severe exacerbations for patients with severe COPD.

    • In refractory cases, consider extended course (up to 1 y) azithromycin 250 mg/d for severe COPD to prevent exacerbations.

• Recommend pulmonary rehabilitation for symptomatic patients with moderate-to-severe COPD (FEV₁ <50% of predicted).

• Continuous oxygen therapy should be prescribed for COPD patients with room air hypoxemia (PaO2 ≤55 mm Hg or SpO2 ≤88%).

• Recommend screening COPD patients for osteoporosis and depression.

• Recommend against regular mucolytic therapy.

• Nutritional support indicated for patients with severe COPD with malnutrition.

• Recommend calculating the BODE index (BMI, airflow obstruction, dyspnea, and exercise capacity on a 6-min walk test) to calculate the risk of death in severe COPD.^b

Sources

• –Global Initiative for Chronic Obstructive Lung Disease: Pocket Guide to COPD Diagnosis, Management, and Prevention. 2018 Report. https://goldcopd.org/

• –GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD. http://goldcopd.org

• –http://www.nice.org.uk/nicemedia/live/13029/49397/49397.pdf

Comments

1. FEV₁/FVC <0.7 confirms the presence of airflow obstruction and COPD.

2. Classification of COPD by spirometry:

   1. Mild COPD = FEV₁ ≥80% of predicted.

   2. Moderate COPD = FEV₁ 50%–79% of predicted.

   3. Severe COPD = FEV₁ 30%–49% of predicted.

   4. Very severe COPD = FEV₁ <30% of predicted.

3. Can consider lung volume reduction surgery in patients with severe upper lobe emphysema and low post-pulmonary rehab exercise capacity.

4. Consider roflumilast, a phosphodiesterase-4 inhibitor, to reduce exacerbations for patients with severe chronic bronchitis and frequent exacerbations.

Population

• –Adults with cough >8 wk duration.

Recommendations

ACCP 2006, 2018

• –In order to identify the cause of the cough, it is most helpful to determine the duration of the cough as acute (<3 wk), subacute (3–8 wk), or chronic (>8 wk), as this can limit the differential diagnosis.

• –Evaluation to include—Review of red flag symptoms, occupational/environmental exposures, travel exposures, physical exam, and chest x-ray.

• –The most common causes of chronic cough with a normal chest x-ray include smoking, ACE inhibitor use, upper airway cough syndrome (formerly known as postnasal drip syndrome), asthma, GERD, and nonasthmatic eosinophilic bronchitis.

• –Recommend evaluation of chronic cough using a guideline/protocol-based approach that includes objective testing for bronchial hyperresponsiveness and eosinophilic bronchitis, or a therapeutic corticosteroid trial.

• –If history and physical suggest no cause and there is no exposure to cigarette smoke or ace inhibitor, the Chest guideline offers a protocol suggesting the following steps:

  • Empiric treatment of upper airway cough syndrome

  • Empiric therapy for GERD

  • Evaluation or empiric therapy for asthma

  • Evaluation for sputum eosinophilia

• –Unexplained chronic cough is defined as chronic cough lasting >8 wk without an identifiable cause after investigation and supervised therapeutic trials.

• –For unexplained chronic cough, consider treatment with speech therapy or gabapentin.

Comments

1. Red flag symptoms for cough:

   1. Hemoptysis

   2. Smoker age >45 with new cough, change in cough or coexisting voice disturbance

   3. Adults age 55–80 with a 30-pack year history or who have quit in the last 15 y

   4. Dyspnea, especially at rest or at night

   5. Hoarseness

   6. Systemic symptoms: fever, weight loss, peripheral edema with weight gain

   7. Dysphagia

   8. Vomiting

   9. Recurrent pneumonia

   10. Abnormal physical exam or chest x-ray

Sources

• –CHEST Guideline and Expert Panel Report. CHEST 2018;153(1):196-209.

• –CHEST Guideline and Expert Panel Report. CHEST 2016;149(1):27-44.

Population

• –Non-small cell lung cancer patients treated with curative intent.

Recommendation

American College of Chest Physicians (ACCP) 2013

• –Follow-up Program

  • Chest CT scan should be performed every 6 mo for first 2 y after resection then once a year thereafter out to 10 y (second primary in 10% who survive first lung cancer).

  • Routine imaging with PET scanning is not recommended.

  • Patients should be seen every 3–4 mo for 2 y then less frequently. Health-related quality of life should be assessed with each visit.

  • Surveillance biomarker testing should not be done outside of clinical trials.

  • Smoking cessation interventions recommended. Annual influenza vaccine and every 5 y pneumococcal vaccinations encouraged.

Source

• –JAMA. 2010;303:1070.

Comments

• Lung Cancer Facts

  1. Only 30%–35% of patients diagnosed with NSCLC are candidates for surgery with curative intent. Lung CA is responsible for 165,000 deaths/y.

  2. Cure rates are reflective of stage:

     1. Stage I— 65%–70%

     2. Stage II—40%

     3. Stage IIIA—25%

     4. Stage IIIB—18%

  3. Platinum-based chemotherapy is standard of care for NSCLC resected for cure. This adjuvant therapy reduces recurrence risk by 5%–10%.

  4. Symptoms of local recurrence include increase or change in cough, dyspnea, and chest pain.

  5. Lung cancer is the most common malignancy to metastasize to brain—headache or neurologic symptoms should be an indication for brain MRI with gadolinium.

  6. In older, compromised patients with a Stage I lung cancer, less than 3 cm in size, treatment with radiosteriotactic body radiation has a 70%–75% chance of prolonged disease-free survival.

Population

• –Adults with undiagnosed unilateral pleural effusion.

Recommendations

BTS 2010

• A posteroanterior chest x-ray (CXR) should be used to detect the presence of a pleural effusion. A lateral decubitus CXR may be used to differentiate pleural liquid from pleural thickening.

• CT scans can detect very small effusions (less than 10 mL of fluid). CT scan should be performed in the investigation of undiagnosed exudative pleural effusions prior to complete pleural fluid drainage. CT scan should be performed in the setting of pleural infection which has not responded to initial chest tube drainage.

• Thoracic ultrasound is more sensitive than CT scan to distinguish loculations. During thoracentesis, bedside ultrasound guidance improves the likelihood of successful pleural fluid aspiration and reduces risk of organ puncture.

• Undiagnosed effusions of more than 1 cm from the chest wall on lateral decubitus CXR should be diagnostically evaluated by ultrasound-assisted thoracentesis. Thoracentesis should not be performed on bilateral pleural effusions in a setting which is strongly suggestive of a transudative process, unless there are atypical features or a failure to respond to therapy. In patients with advanced cancer, thoracentesis for small effusions is unnecessary. All patients with a pleural effusion in the setting of sepsis or pneumonic illness should have diagnostic thoracentesis.

• Pleural fluid should be sent for cell count and differential, gram stain and culture, protein, lactate dehydrogenase (LDH), and cytology. A minimum of 50–60 mL of pleural fluid should be withdrawn for analysis. Pleural fluid pH should be assessed in nonpurulent effusions when pleural infection is suspected. Check pleural fluid glucose when pleural fluid pH is not available and pleural infection is suspected.

• A chest physician or thoracic surgeon should be involved in the care of all patients who require chest tube drainage for pleural infection.

Sources

• –BTS Pleural Disease Guideline. 2010

• –Thorax. 2010; 65(suppl 2):ii1-76.

Population

• –Adult men and women with lung cancer or metastatic malignancy to the lung with a malignant pleural effusion.

Recommendations

BTS 2010, ACCP 2014

• –Diagnosis and baseline investigations:

  • All effusions should be sent for cytology if a patient does not have a diagnosis of an MPE. Diagnosis can be made of MPE with pleural fluid cytology in about 60% of cases. A minimum of 50–60 mL of fluid should be sent. Increased amounts of fluid (100–200 cc) can be sent for a cell block and molecular testing (eg, epidermal growth factor receptor mutation, Alk gene rearrangement, and ROS 1 rearrangement).

  • All patients with a diagnosis of significant MPE should be referred to pulmonologist and/or thoracic surgery for treatment options.

  • Chest ultrasound is recommended at point of care for any thoracentesis or percutaneous chest drain placement (including indwelling pleural catheter [IPC]).

  • Treatment is not required in asymptomatic patients but follow-up should be frequent especially if large MPE present.

• –Symptomatic patients:

  • Patients with symptoms should have initial therapeutic thoracentesis to relieve symptoms. The recommended amount of fluid removed per session is 1000–1500 mL. The rate of reaccumulation of the pleural effusion, and the patient’s clinical and symptomatic response and prognosis will help to guide the subsequent choice of therapy.

  • Outpatient therapeutic thoracentesis alone may be indicated for patients with survival expected to be less than 1 mo and/or poor performance status (PS) and/or slow reaccumulation of the pleural effusion (ie, more than 1 mo).

  • Patients should be considered for more definitive intervention after the first or second thoracentesis.

  • All treatment decisions should be guided by patient preferences.

  • Selection of a treatment approach is largely dependent on projected duration of survival and availability of adequate resources. The management of a malignant pleural effusion (MPE) should be individualized and these patients should be commonly presented to a multidisciplinary Tumor Board for advice. (JAMA. 2012;307:2432).

  • Management of MPE is palliative, and treatment decisions should focus on type of malignancy, patient’s symptoms, life expectancy, functional status, quality of life, and goals of therapy. Palliative therapy goals should improve patient’s quality of life through (1) relief of dyspnea and (2) less need for reintervention and reduced hospitalizations and length of stay.

• –Treatment options:

  • Indwelling (tunneled) pleural catheter (considered for patients with trapped lung who obtain some relief following thoracentesis) or patients who want to avoid hospitalization or discomfort of pleurodesis. (Chest. 2012; 142:394)

  • Talc pleurodesis (Talc poudrage) via thoracoscopy consider for patients with longer projected survival and those who don’t want an indwelling catheter. This approach is contraindicated for patients with trapped lung.

  • Talc pleurodesis (slurry) via chest tube—Indicated for patients with longer anticipated survival or contraindication to thoracoscopy. Contraindicated for patients with trapped lung.

  • Chemotherapy may be considered as an adjunct treatment option. In particular, patients undergoing first-line systemic therapy for tumors with high response rates (small cell lung cancer and lymphoma) may avoid the previously discussed definitive treatments.

Comment

1. Indwelling pleural catheter (IPC-pleurex catheter) requires a regular outpatient drainage schedule that may be a burden for the patient or caregiver. This issue needs to be addressed. Complications from IPCs are uncommon. The infection rate is 5% with more than half the patients responding to antibiotics without removing the catheter. (Chest. 2013; 144:1597) Other problems with IPCs include pneumothorax (5.9%), cellulitis (3.4%), obstruction/clogging (3.7%), and unspecified catheter malfunction (9.1%). The most common adverse events with talc pleurodesis include fever, pain, and GI symptoms. Less common are cardiac arrhythmia, dyspnea, systemic inflammatory response, empyema, and talc dissemination.

Sources

• –https://www.guideline.gov/summaries/summary/49355/management-of-malignant-pleural-effusion.

• –Chest. 2013;143(5):e4555-e4975.

• –J Natl Compr Canc Netw. 2012;10:975.

• –Thoracic Society Pleural Disease Guideline. 2010.

• –Thorax. 2010;65(suppl 2):132.

Population

• –Adults with diagnosis of community-acquired pneumonia.

Recommendations

IDSA/ATS 2007

• –Initial antimicrobial treatment:

  • For previously healthy patients with no risk factors for drug resistant pathogens, choose a macrolide or doxycycline.

  • For patients with comorbidities (including CHF, COPD, CKD, liver disease, DM, asplenia, or immunosuppression), antibiotic treatment within the last 3 mo, or other risk factors for drug-resistant pathogens, choose a respiratory fluoroquinolone or beta-lactam plus a macrolide. For penicillin-allergic patients, choose a respiratory fluoroquinolone.

Source

• –The IDSA/ATS consensus guidelines on the management of CAP in adults. Breathe. 2007;4(2):110-115.

Population

• –Adults with diagnosis of spontaneous pneumothorax.

Recommendations

BTS 2010

• –Standard standing chest x-ray is recommended for the initial diagnosis; expiratory films are not necessary. CT scan is recommended for uncertain or complex cases.

• –Symptoms including dyspnea are more important in determining the management strategy rather than size of the pneumothorax alone.

• –Tension pneumothorax is a medical emergency, which should be suspected in the setting of respiratory distress or hypotension. Treatment includes oxygen supplementation and needle decompression.

• –If the patient has pneumothorax size <2 cm and minimal symptoms, consider discharge with outpatient follow-up and return precautions.

• –If the patient has significant dyspnea or pneumothorax size >2 cm, recommend needle aspiration with 16-18G needle. If pneumothorax is then <2 cm and symptoms improved, consider discharge with outpatient follow-up. For pneumothorax >2 cm with minimal symptoms, consider conservative management/observation. If after needle aspiration, the patient is still symptomatic, or size still >2 cm, recommend chest drain size 8-14 French and admission.

• –Needle aspiration and small bore chest drains (<20 Fr) are preferred over large bore chest drains, and may be associated with reduced hospitalization and length of stay.

• –If there is a persistent air leak at 48 h, recommend consultation with Chest Physician.

• –Smoking cessation counseling is recommended to prevent recurrence.

Notes:

• These recommendations do not apply for secondary pneumothorax, or pneumothorax in the setting of underlying lung disease. For these patients, admission is recommended at a minimum for observation and oxygen, even if not actively managed.

Sources

• –Thoracic Society Pleural Disease Guideline. 2010.

• –Thorax. 2010;65(suppl 2):ii18-31.

Population

• –Adults with incidental pulmonary nodules. These guidelines do not apply to immunocompromised patients, patients with cancer, or for lung cancer screening.

Recommendations

BTS 2015

• –Do not recommend nodule follow-up or further work-up for nodules with:

  • Size <5 mm.

  • Diffuse, central, or laminated pattern of calcification or fat.

  • Perifissural or subpleural nodules that are <1 cm and homogenous, smooth, or solid with a lentiform or triangular shape.

• –Recommend thin-slice CT surveillance for nodules 5–8 mm after 3 mo and 1 y.

  • No further surveillance needed for stable nodules after 1 y.

• –Recommend using the Brock model for initial risk assessment of pulmonary nodules 8 mm or larger in patients who have ever smoked.

• –Consider a PET-CT scan for patients with a pulmonary nodule and an initial risk of malignancy >10%.

• –Suggestions for pulmonary nodules management:

  • Serial CT scans when the malignancy risk is <10%.

  • CT-guided biopsy when the risk of malignancy is 10%–70%.

  • Video-assisted thoracoscopic surgery when the chance of malignancy exceeds 70%.

  • Consider bronchoscopy when a bronchus sign is present on CT scan.

Sources

• –https://guidelines.gov/summaries/summary/49569

• –Fleischner Society 2017.

Source

• –Guidelines for Management of Incidental Pulmonary Nodules Detected from CT Images: From the Fleischner Society 2017. Radiology. 2017;284(1):228-243.