View from the Top How Upper Airways Disease

Can Affect Lung Function:

J Douglass Rolf FRCPC, FCCP

Clinical Associate Professor

Department of Medicine, UBC

Associate Member of Division Respiratory

Medicine

Director of Respiratory Division

and

Associate Director of ICU,

Kelowna General Hospital

Disclosure: October 2015

Talks for: AstraZeneca, Nycomed, GlaxoSmithKline, Bayer, Sanofi-Synthelibo, Pfizer, Intermune, Actelion, Leo, Merck, AMT

Endoscopy, Takeda, Novartis

Clinical Research studies with; Sanofi-Synthelibo, Intermune, GSK, Frazier, Nycomed, Boehringer Ingelheim, Actelion, Gilead,

Forester

Canadian Scientific Medical Officer for Intermune: Capacity and Re-Cap Trials for Pirfenidone

Canadian Regional Advisory Committee Intermune

Why is the upper airway Important?

1. Humidifier

2. Air Filter

3. Warmer

Upper Respiratory Tract

1. Erectile Tissue

2. Mucociliary Clearance

3. Baffles

4. Nerves directly to the Brain - Smell

Upper Respiratory Tract

› Cough seeds Upper Airway

› Upper Airway Seeds the Lower Airway

› If there are issues – all has to be sorted out/ dealt with.

The Infection circle

› Humidifier – Allergic Rhinitis

– Vasomotor Rhinitis

– Vasomotor Rhinitis from CPAP

Illness or Disease related to abnormality function

› Overload – Clearance

› Occupational

› Amotile Cilia – Kartagener

› Damage from Infection

› Damage from GERD

› Mucous – Cystic Fibrosis

– CTD › – Salivary duct issues –Sjorgrens, RA, etc

Humidifier/ Filter

› Mucous / Membranes/ Vasculature – Salivary Gland

› Sjorgrens, RA, etc

– Vasculitis › Granulomatosis with Polyangiitis

› Churg Strauss

› Other

– Toxic Irritants › MEK

› Chemicals

› Cocaine

– Trauma

Humidifier/ Filter

Granulomatosis with

Polyangiitis

a.k.a.

Wegener’s

Granulomatosis

Tracheal Stenosis

Upper Airway pathology causing Lower airway issues

GERD related Inflammation of Arytenoids

Reflux and recurrent aspiration

› “Co-morbid occurrence of laryngeal or pulmonary disease with esophagitis in United States military veterans”. Gastroenterology. 113(3):755-60, 1997 Sep El-Serag HB, Sonnenberg A

› Looked at Patients diagnosed with erosive esophagitis and esophageal stricture between 1981 and 1994 at discharge from a Veterans Hospital 101,366 people!

Results of the Veterans study

› Sinusitis odds ratio 1.60

› Pharyngitis odds ratio 1.48

› Aphonia odds ratio 1.81

› Laryngitis odds ratio 2.01

› Laryngeal stenosis odds ratio 2.02

› Chronic bronchitis odds ratio 1.28

› Asthma odds ratio 1.51

› COPD odds ratio 1.22

› Pulmonary Fibrosis odds ratio 1.36

› Bronchiectasis odds ratio 1.26

GERD

› History

› Physical – Irritative changes on Arytenoids

– Inflammatory changes in airway

› Lab – UGI – water swallow

– Nuclear medicine reflux / aspiration study (2015 they won’t do Aspiration part

– Esophageal pH Manometry

The Effect of the Gut on Reflux?

› Depending on who you talk to, either the Gut is an offshoot of the lung or vice versa

› Life is effected by Hormones, or is it?

Asthmatics, Esophageal pH monitors and PERFs

› About 40 people with Asthma walked around with esophageal pH monitors an PERFS

› Tended to be an association with drop in PERF and pH drop in the distal 1/3 of esophagus

Asthmatics, Esophageal pH monitors and PERFs

› Same Group took Refluxers without Asthma and gave them Methacholine challenges

› Result 25% were “hyper reactive”

› Population only 10-15% at any one time, and only 5% at best ordinarily

H Kohrogi, O. Kawano etal Bronchoconstriction due to esophageal Stimulation by HCl is potentiated by Neutral endopeptidase inhibitor in Guinea pigs in Vivo

› Ligated Esophagus distal 1/3 HCl infusion -Pulmonary resistance increased proportionally -Atropine – no effect (not Vagal)

› Exposed Airway to a neutral endopeptidase (posphoramidon) to destroy Tachykinins -airway response potentiated -Vagotomy had no effect

› Exposed to systemic Capsaicin depleted Tachykinins -Airway response Not potentiated

› STIMULATION with HCL Causes an Axonal release of a tachykinin agent causing constriction

SM Harding MR Guzzo etal Gastroesophageal reflux induced

bronchosconstriction: Vagolytic doses of Atropine Diminish Airway responses to

esophageal Acid infusion

– 3 Groups of individuals › AR 15 (Asthmatic refluxer)

› A 10 (Asthmatic only)

› N 10 (Normals)

– Previous studies showed All had drops in PEFR with esophageal acid infusion

– This time Atropine 0.1 mgm/kg, then 0.1 mgm/min infusion

– Then infusions of NS, 0.1NHCl, NS run with spirometry and Raw, Baseline, 20 min after atropine

› No effect on Normal

› Diminished effect on Bronchoconstriction, but not abolished in the Asthmatic with GERD

› People are Guinea Pigs?

CB – 69 Female living over a “Shop on a farm”

› Prior to meeting current spouse – no Cardiorespiratory symptoms

› She presented – coughing up “Worms” all of the time.

› Investigations / History:

› Asthma – Nonspecific irritants, P, HS etc

› Chronic Bronchitis

› Bronchiectasis.

› She has required steroids, Bronchodilator's, Mucolytics (Guaifenesin, N-Acetyl Cystiene), inhaled steroids, Physio with postural drainage and antibiotics

› “Not able to get off steroids”

CB continued

› Sinusitis/ Atopic State -- Nasal irrigations, avoidance

› GERD – aggravated her airways with recurrent aspiration and Laryngospasm. Mentioned on occasion burning in nose

› M.A.I.C. - colonization

› One point Allergic Bronchopulmonary Aspergillosis Requiring Itraconazole

› OSA – developed. Was aggravating the GERD, Sinuses and Asthma. Awakening with Laryngospasm at times.

› Atopic – with Development of Chronic Rhinosinusitis. – ENT – regular Nasal and sinus irrigation

– Allergist – avoidance of dusts, triggers

› Gastroesophageal reflx: – Strict anti-reflux measures,

– Medications

› Sleep apnea – started upon CPAP

› Environment evaluation – Community RT / Dust/ other avoidance measures/ Moving?

Treatment:

› Treatment of the GERD - helped

› CPAP +++ helped. – Helped decrease GERD

– No Laryngospasm

– Sinuses improved

› Still needing steroids. › IgG’s were checked – low

› No further Nocturnal attacks › Improved, Not normal but ……

Currently:

CPAP – Decreases GERD

› It increased the LES 8-10 cm

› Shepherd KL etal. Am J Physiol Gastrointest Liver Physiol. 2007 May;292(5):G1200-5. The Impact of continuous positive airway pressure on the lower esophageal sphincter.

› Shoenut JP etal. Chest. 1994 Sep;106(3):738-41. The effect of nasal CPAP on nocturnal reflux in patients with aperistaltic esophagus.

› Kerr P, Shoenut JP etal. Chest. 1992 Jun;101(6):1539-44. Nasal CPAP reduces gastroesophageal reflux in obstructive sleep apnea syndrome.

› Others

Chondyloma

Viral Pharyngeal Papilloma

Bronchial Papillomata

Papillomatosis

› Cough – incessant

› Tx – Prevent – Gardasil?

– Resect

– Cryo

– One bite – suddenly cough gone

– Burn = potential Aerosolization › Worse for patient

› Potentially Bad for you – infection wise

Inadequate Oropharyngeal Care

Hard Palate

Tongue

Extension of “Crud” on Palate

Oral Care

› Went into Airway Partially occluding L an R Main Bronchus

› Definition: Inappropriate adduction of the Vocal Folds on inspiration.

Vocal Cord Dysfunction (VCD)

› Synonyms: – Paroxysmal Vocal Fold Dysfunction (PVCF)

– Laryngeal Dyskinesia

– Paradoxical Vocal Cord Motion (PVCM)

– Periodic Occurrence of Laryngeal Obstruction (POLO)

– Munchhausen’s Stridor

– Episodic paroxysmal Laryngospasm

– Psychogenic Stridor

– Functional Stridor

– Irritable Larynx Syndrome

– Factitious Asthma

VCD

› Descriptions to the 1800’s

› Can see on inspiration , expiration or both.

› This is a descriptive term – NOT a DIAGNOSIS!

VCD --- Laryngeal Dyskinesia

DON’T WANT to

CONFUSE it

WITH:

Tracheal Stenosis

› Asthma – misdiagnosis but also in Association

› Exercise – 14% Young female Athletes (of 831, 43 elite and 70% Female – These less likely to have other etiologies

› Post Extubation

› Irritants – eg NH4+, Soldering fumes, chemicals, aerosolized machine fluids, dust, some onset within 24 hours of exposure

› Reflux

› Neuro injury

› Psychosocial Stress

VCD Etiologies -Usually multifactorial

› History of: – Latex - Skin Rash

– Sulfite sensitivity - swelling, Angioedema, asthma

› Eczema age 14 – seasonal, but petroleum/ latex /dust

› Vacuuming - short of breath, Hx of hanging up a Latex shower curtain Tight chest, short of breath

› Settled with avoidance

› Asthma Confirmed/ documented 2005 on PFT/ Spirometry

LS 50 Year old Female/ RN

› Exposed to Peanut butter the night before. She felt restless then itchy and SOB. Felt like she was choking.

› Daughter went with her to ER.

› Epipen Used in ER while in waiting Room

› Then saw ERP and ENT – told she had “POLO”

› Second episode with peanut butter exposure

› Third episode in lunch room of work and work room

New Job – Transfusion

› Latex – RAST/ patch – normal

› Peanut RAST was –VE

› Still work issues Symptoms – something there

› Immune work Up – NORMAL RF, ANA, ENA, Anti-CCP, C1Q esterase inhibitor, IgG, IgM,

IgA, IgE, Lymphocyte count

› RAST - +ve for Dust mites

› WorkSafe – WORK PLACE CHALLENGE

Investigations;

› Examined

› Blind folded – and Nose Plug – Exposed to Peanut fumes, latex fumes, then some of the chemicals in

the cleaning agents and plastics bags at work

› Reacted with tightening of airway and voice – Chemicals from work

– Peanut.

Occupational Health

› Identify cause if able

› Speech therapy

› Reassurance

› CPAP (She also has GERD and Borderline OSA)

Treatment