presenter of reproduction property for not 2020/lo¢  rheumatoid factor/ccp, ssa, ssb ige...

Download Presenter of Reproduction Property for Not 2020/Lo¢  Rheumatoid factor/CCP, SSA, SSB IgE (initial per

If you can't read please download the document

Post on 20-Aug-2020

0 views

Category:

Documents

0 download

Embed Size (px)

TRANSCRIPT

  • Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Diagnosis, Management &

    Beyond

    Steven E. Lommatzsch, MD

    Associate Professor of Medicine

    Director of Non-Cystic Fibrosis Bronchiectasis

    National Jewish Health, Denver http://chestatlas.com/gallery/main.php?g 2_itemId=841

    Bronchiectasis:

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • • I have no conflicts of interest with this topic or presentation on Non-CF bronchiectasis management.

    Disclosures

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Objectives

    • Summarize the etiology and evaluation of non-CF bronchiectasis

    • Discuss the management of bronchiectasis and infections including Pseudomonas and Nontuberculous Mycobacterium (NTM)

    • Review current and emerging therapies for the treatment of bronchiectasis

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Etiology &

    Evaluation

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Bronchiectasis Basics

    • Definition of bronchiectasis: bronchial widening leading to a dilated airway larger than its associated blood vessel, which causes tortuosity of the bronchi and a propensity for infection

    • Estimated that 350,000 to 500,000 adults in the US have the condition

    • The condition is twice as common in women than men, and the disease increases in prevalence with increasing age

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Bronchiectasis Symptoms

    • Cough (98%)

    • Chronic sputum production (78%)

    • Chronic sinusitis (73%)

    • Dyspnea (62%)

    • Fatigue (43%)

    • Hemoptysis (27%)

    • Wheezing (20%) Pr

    op ert

    y o f P

    res en

    ter

    No t fo

    r R ep

    rod uc

    tio n

  • Bronchiectasis Etiologies

    • Congenital: PCD

    A1AT

    Cystic Fibrosis

    Tracheobronchomegaly

    Cartilage deficiency

    Pulmonary sequestration

    Marfan’s syndrome

    Yellow Nail Syndrome

    Young’s Syndrome

    • Immunodeficiencies:

     Hypogammaglobulinemia

     CLL

     Chemo

     Immunosuppression

    • Postinfectious:

     Bacteria

     Mycobacterium

     Aspergillus

     Viruses

    • Rheumatologic:

     RA

     SLE

     Sjögren’s syndrome

     Relapsing polychondritis

     IBD

    • Aspiration/Inhalation:

     Chlorine

     Overdoses

     Foreign bodies

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • • CXR abnormal in most patients Focal pneumonitis

    Irregular opacities

    Atelectasis

    Ring-like shadows

    Tram lines

    https://medpix.nlm.nih.gov/case?id=47d4298e- 51bf-4f68-9396-197debc5d5a3

    Radiographic CXR Patterns

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • • Common findings: Airway lumen dilation

    Lack of tapering

    Varicose constrictions

    Ballooned cysts

    • Nonspecific findings: Consolidation

    Thickened bronchial walls

    Mucous plugs

    Enlarged LNs

    Reduction in vascular markings https://err.ersjournals.com/content/27/149/180016

    Radiographic CT Patterns

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • • 2 different presentations:

    Local/Focal

    Diffuse

    • 3 different types:

    Cylindrical/Tubular

    Varicose

    Saccular/Cystic

    https://www.researchgate.net/figure/Tram-track-sign-seen-in- cylindrical-bronchiectasis-on-the-chest-CT-scan-in-a- patient_fig13_313820333

    https://slideplayer.com/slide/4636158/

    https://pt.slideshare.net/hytham_nafady/bronchiecta sis-14219103/9

    Radiographic Patterns

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Radiographic Patterns

    • Upper Lobe Predominant • Cystic Fibrosis

    • Sarcoidosis

    • Pneumoconiosis related

    • Central or RML/Lingular Location • ABPA

    • NTM

    • Lower Lobe Predominant • PCD

    • CVID

    • A1AT

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • History and Physical

    HRCT

    PFTs

    CBC and diff, IgG, IgA, and IgM

    Rheumatoid factor/CCP, SSA, SSB

    IgE (initial per BTS)

    Aspergillus precipitins (initial per BTS)

    IgG subclasses

    A1AT level/genotype

    Sinus CT

     Antibody titers to pneumococcal vaccination (initial work-up per BTS)

     Sputum bacterial, mycobacterial, and fungal cultures

     Bronchoscopy with mucosal biopsy or cultures

     Testing for PCD or CF (CF is first line per BTS if under40yo)

     Aspiration and GERD evaluation

    Diagnostic Evaluation

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • So what do I actually need to order?

    • Everyone: HRCT

    Spirometry - PFTs

    Sputum cultures

    CBC with diff

    IgG/IgM/IgA/IgE

    A1AT level/genotype

    Often:

    Esophagram

    Tailored swallow

    • In selected patients: CF/PCD testing Sinus CT  IgG subclasses and titers to

    vaccines ABPA panel or ST RF, CCP, ANA, ANCA, SSA/B Methacholine and eNO O2 assessment pH probe Bronchoscopy

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Targeted Management &

    Treatment Strategies

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Treatment Section

    • Discuss methods of airway clearance

    • Review indications for chronic macrolide therapy

    • Examine the utility of inhaled antibiotics

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Bronchiectasis Treatment

    • Start with detailed history and evaluation to try and identify cause • Treat underlying disease

    • Infection: TB, NTM, etc.

    • Immunodeficiency states: CVID

    • Aspiration: oropharyngeal, GERD

    • Allergic Bronchopulmonary Aspergillosis (ABPA)

    • Rheumatologic/Inflammatory disease: RA, Sjogren’s, Sarcoidosis, IBD

    • Alpha-1 Antitrypsin deficiency

    • Tracheobronchomegaly Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Bronchiectasis Treatment

    • Goals of Chronic Maintenance Regimen

    • Reduce symptoms and improve quality of patient life

    • Prevent exacerbations

    • Slow or stop disease progression and lung function decline

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Cornerstones of Management

    1. Airway clearance

    2. Airway clearance

    3. Airway clearance

    Amazingly this cornerstone is often forgotten and overlooked!Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Maintenance Therapy

    • Improving bronchial hygiene • Airway clearance

    • Reducing airway inflammation • Anti-inflammatory treatment

    • Treat conditions like asthma or COPD

    • Smoking cessation

    • Controlling airway microbiota • Identify organisms present by surveillance sputum cultures

    • Vaccination

    • Suppressive antibiotic therapy

    Treat comorbidities such as GERD, aspiration, chronic rhinosinusitis, etc. as they can worsen airway disease control

    Pr op

    ert y o

    f P res

    en ter

    No t fo

    r R ep

    rod uc

    tio n

  • Improving Bronchial Hygiene

    • Recommended • Use one to two times per day

    • Short acting Beta-agonist prior to treatments

    • Mechanical Airway Clearance

    • Hypertonic Saline Nebulization

    • Aerobic Exercise is a great form of airway clearance

    • Not Recommended • Dornase alpha nebulization (1, 2)

    • Routine use of anticholinergics – unless there is another indication

    (1) O’Donnell AE, et al. Treatment of Idiopathic Bronchiectasis with Aerosolized Recombinant Human DNase. CHEST. 1

View more >