What is dyspnea and what can be done about it? Dan Culver DO
Outline • What is dyspnea? • What tests do we use for it? • Questions
What is dyspnea?
What is dyspnea? Central Airways narrowing Acid build-up “Difficulty in breathing or Lung blood vessels in catching the breath” Low oxygen Muscle weakness delivery Restriction of lung motion
The main role of the lungs is gas exchange
Subpleura Interlobular septa Bronchovascular area
Sarcoidosis likes to involve the airways too “Pebbly mural” appearance
Bronchoscopy results LUL LLL Upper division RUL lingula
Pulmonary hypertension in sarcoidosis 80 70 Percent with Pulmonary 60 Hypertension 50 40 30 20 10 0 Kyoto Detroit Milan New York Cincinnati Transplant All patients Only Dyspneic Patients
Muscle weakness in sarcoidosis
Muscle weakness relates to other variables affecting QOL 6MWD Hand grip Extensor Quadrice HPT Pi max ps PT Men -0.25 -0.25 -0.29 -0.17 -0.36 0.24 Women -0.12 -0.21 -0.30 -0.04 -0.043 0.051 Marcellis RG. ERJ 2011
Outline • What is dyspnea? • What tests do we use for it? • Questions
Spirometry Flow-volume loop showing obstruction
Data at the time of evaluation
The main role of the lungs is gas exchange
Scadding X-ray stages Stage I: 85-90% Stage II: 50-65% Stage III: 20-30% Stage IV: 0%
Which patient has worse pulmonary function tests? 69 year-old male 46 year-old male
Some potential causes of shortness of breath in sarcoidosis • Involvement of the lung tissue • Airways involvement (usually asthma-like) • Deconditioning (out of shape) • Anemia (low blood counts) • Airways involvement with stenosis • Poor heart function • Muscle inflammation RARE • High blood pressures in the lungs (pulmonary hypertension)
Chest x-ray is not a very good marker of disease activity 51% 25 23 20 n=36 ĸ=0.54 15 15 9 10 7 6 4 5 3 3 1 1 0 0 0 0 0 0 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 Judson MA. Respirology 2008
What about chest CT scan?
Does ACE help? Correlation with respiratory functional impairment in 144 non-smoking patients Rothkrantz-Kos S. Clin Chem 2003
Correlation of biomarkers with outcome Acute sarcoidosis Chronic sarcoidosis AUC 0.89 (0.79-1) sIL2R AUC 0.72 (0.52-0.92) for ACE Rothkrantz-Kos S. Clin Chem 2003
Sarcoidosis penumbra Lazar CA. SRCCM 2010
Pulmonary sarcoid with bulky adenopathy
Overdosing steroids? • 36 acute exacerbations • Mean steroid dose 19 mg • FVC improved from 68% to 82% • Median assessment at 21 days Goldstein DS. Thorax 1986 McKinzie BP. AM J Med Sci 2010
Predictors of requirement for therapy at 2 years in ACCESS 120 n=205 Independent predictors 100 Initial treatment No. of subjects 80 O.R. 3.6 (1.8-7.2) 60 Dyspnea O.R. 2-4 40 20 0 No early treatment Early treatment Baughman RP. QJM 2006
Data at the time of evaluation
Making the diagnosis: Bronchoscopy Overall diagnostic yield 70-97% Yield in non-chest diseases Sensitivity TBBx: 43-96% EBBx: 40-75% TBNA: 46-66% Combination: 91% “Pebbly mural” appearance
Treatment • Treat the disease – Immunosuppressives – TNF antagonists variably successful • Cognitive behavioral therapy • Aerobic and strength training • Stimulants Hoving JL. Scand J Rheumatol 2009 Chauffier K. Rheumatology 2011 White PD Lancet 2011 Lower EE. Chest 2008
Endobronchial stenosis requiring lung transplant
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