Pulmonary Hot Topics

 

  • Pulmonary Function Testing
  • Lung Cancer Screening
  • Interventional Radiology
PULMONARY FUNCTION TESTING
  • Spirometry:  Indications – symptomatic patient, abnl physical exam, abnormal imaging or SaO2, known pulm or neuromusc disorders.
  • Two important measurements:
    • FVC – max amount of air exhaled
    • FEV1 – first second exhalation
  • Spirometry alone can tell you alot – FEV1/FVC 70% or less – they’ve got obstruction; severity based on %FEV predicted.
  • If FEV1/FVC > 80% – FVC % predicted suggests restriction or not (normal).
REVERSIBILITY WITH BRONCHODILATORS DOES NOT PROVE THE PRESENCE OF ASTHMA – Reversibility only tells us that there is reversibility.  The only way to diagnose asthma is a methylcholine challenge.
  • TLC < 80% – restriction; TLC > 120% – hyperinflation; TLC 80-100% normal.
  • RV > 130% hyperinflation
  • DLCO – measures CO from alve
  • Measures diffusion of CO from alveoli to capillary hemoglobin; CO used because of its high affinity for hgb.
    • Pitfalls:  fingersticks is often wrong; if low hgb, may be wrong.
    • DLCO < 80% – abnormally low
  • DO NOT ORDER PFTs in HOSPITALIZED SICK PATIENTS!
LUNG CANCER SCREENING
  • 55-74 yo
  • At least a 30-pack-year history, current or former smoker (quit in the last 15 years)
  • No symptoms concerning for lung CA (hemoptysis, weight loss).
    • NLST Study:  20% RRR in lung cancer mortality with annual screening; performs better than mammography, better than PSA screening.
    • The radiation dose with LDCT is about 1/5 that of a normal CT.
  • If we order it (PCPs) – we have to document informed consent including chance of finding benign nodules that need follow-up; smoking cessation counseling; must be tracked.
  • Referral to Lung and Sleep Center – meets with NP, patient reviewed to ensure criteria met, education done, tracked.
  • SMH is the only ACR-accredited medical center doing LDCT screening.
MULTIDISCIPLINARY THORACIC ONCOLOGY CONFERENCE
Meets every Tuesday at noon at the Pavilion
  • Pulm, thoracic surg, med onc, rad onc, radiology, pathology, support staff
  • Consensus agreement for diagnostic and treatment plans
INTERVENTIONAL PULMONOLOGY
  • Endobronchial ultrasound:  can see structures next to the airway walls or distally.
    • Outpatient procedure, 60-90 min, conscious sedation and local anesthesia, real-time imaging with sampling.
    • Can get to more nodal stations than old mediastinoscopy
    • Navigational bronch – CT-based 3D mapping of the thoracic organs; CT mapping done immediately prior to the bronchoscopy
    • Therapeutic bronchoscopy:  FB removal, resolving obstruction (malignant and non-malignant), post-intubation tracheal stenosis (usu 3-4 mos after intubation), etc.
      • Done with rigid bronchoscopy – pt is ventilated
    • Lung volume reduction therapy
    • Rad onc procedures – brachytherapy, placing markers, etc.
    • Lung volume reduction procedures with coils or one-way valves
    • Fistula therapies – resolving fistulae with stents and sealants
    • Thoracentesis, tunneled pleural catheters (recurrent pleural effusion, end-stage HF, liver failure) – has taken the place of standard talc pleurodesis.  If you’ve had to tap a patient 3x, think of a tunneled catheter.
    • Chest tube placement (PTX, pleural effusions, empyema)
Dr Ellen Volker – pager 3320; cell 801-503-7022
Sees clinic pts in the AM, procedures in the PM; Thurs in the OR.
  • from UpToDate, 2016, via Dr Volker lecture
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