NTM & Bronchiectasis Presentation Yale Medical Center August - - PDF document

NTM & Bronchiectasis Presentation Yale Medical Center August 15, 2018 “The How, the Who & the When” Current NTM Treatment Protocols Ashley Losier, MD, Senior & Chief Pulmonary & Critical Care Fellow, Yale School of Medicine NTM is increasing about 8% each year. It may be due to climate change, or perhaps more physicians are learning how to diagnose this condition. Studies have shown that patients who are on shorter antibiotic treatment (<10 months) show a greater incidence of reinfection than those on longer treatment durations. Pseudomonas is not a mycobacteria, but a different type of bacteria that causes infection. It is also treated with antibiotics. Cystic fibrosis is genetic. The condition is not developed from exposure to NTM. Exposure to second hand smoke in itself might not pose a risk to developing NTM but it may set up scarring and other things that may lend complication to the condition. Reflux (GERD) has been found to cause inflammation mostly in the lower lobes of the lungs. Other risk factors of developing NTM from bronchiectasis Serious bronchiectasis Environmental exposures Previous infections Underlying health problems To determine a course of treatment, Yale docs track medical toxicities with tests, such as blood work, vision and hearing

• tests. Baselines should be given before treatment, then periodically while taking the antibiotic cocktail.

Yale sends most of its sputum cultures to National Jewish Health in Denver. To prevent recurrence or reinfection, it is important to stay up to date on immunizations. (See attachment from Dr.Dela Cruz

• n Immunizations.) Minimize environmental exposure when possible, such as washing hands thoroughly and avoiding people

who have colds. Avoid water and ice made through the tubing in the fridge, as it cannot be cleaned and can harbor bacteria. Steam showers & indoor swimming pools harbor bacteria. Saunas aren’t thought to be good for us either. Wear a mask when

• gardening. The N-95 mask has the smallest pores, but it is uncomfortable to wear (doesn’t breathe well). It was suggested to

wear a molded mask rather than a soft surgical one. Here is an example. https://www.expressmed.com/show_product/73959- 162525/?msclkid=0af604fb359b1c628e635f8688e428cc&utm_source=bing&utm_medium=cpc&utm_campaign=Shopping%20

• %20Desktop&utm_term=1103400318695&utm_content=Brands

Clean showerheads regularly, as the biofilms accumulated in water transmission can be detrimental to our lungs when

• aerosolized. One of the attendees mentioned she purchases inexpensive showerheads, which she changes regularly and

disposes instead of cleaning. Certainly more cost effective than the shower filters.

https://www.amazon.com/Albustar-Pulse-SPA-Experience-Wall-Mounted- Installation/dp/B07FGFPP1W/ref=sr_1_1?ie=UTF8&qid=1534967563&sr=8- 1&keywords=Albustar+5+Function+Pulse+SPA+Series+Luxury+Showerhead “Brief Update on NTM & Infection Research”

• Dr. Charles DelaCruz, Associate Professor & Director of the Center for Pulmonary Infection & Treatment, Yale School of

Medicine The team was put together in 2016. The focus on the research is on the patient, the environment and the disease and how each is interrelated. https://news.yale.edu/2016/12/01/qa-new-cpirt-director-lung-infections-antibiotics-and-climate-change Phage therapy to treat disease was discussed. Hopefully research will validate the nebulization of phages into the lungs as future treatment, but as of now, we are not there yet. Bacteriophages or "phage" are viruses that invade bacterial cells and, in the case of lytic phages, disrupt bacterial metabolism and cause the bacterium to lyse [destruct]. A question was asked about stem cell treatment. Both Drs. DelaCruz and Ed Chan, lead NTM researcher at National Jewish do not recommend the stem cell centers at this time. There is no research to assess its reliability. Perhaps this may also be a treatment for the future after it is studied. Patient Centered Outcomes Research Institute Yale may be participating. There are other centers in the country involved as well. https://en.wikipedia.org/wiki/Patient-Centered_Outcomes_Research_Institute “Practical Tips on Airway Clearance” Marjorie Cullinan, Pulmonary Function Lab Supervisor Department of Respiratory Care, Yale New Haven Hospital “NTM is not your fault” (great quote). Bacteria love warm, moist and dark places, and they’ve taken up in your lungs. From the Cystic Fibrosis community, there is research data available about airway clearance. It has been found that chest percussion isn’t as effective for adults as it is for children. Marjorie provided us with three handouts. All three are included as attachments on the cover email, and cover each subject in great detail. 1.Huff Cough is an important part of airway clearance. The expulsion of air from the lungs clears mucous. An effective technique is 3 huffs, then one cough to bring up matter deep in the lungs. 2.The Acapella airway clearance device works on positive expiratory pressure (PEP). It uses inhalation & exhalation to remove secretions, providing vibrations you will feel in the airways. 3.The Aerobika airway clearance device uses oscillating positive expiratory pressure (OscPEP), which provides the combination of positive expiratory pressure with high frequency oscillations. It involves breathing with a slightly active expiration against an expiratory resistance through a device. Highlights of Presentation In the airway clearance regiment, Marjorie prefers nebulizing first, then using the Aerobika (or Acapella).

In cleaning the hand held device, warm soapy water is recommended daily, then heavy cleaning once

• weekly. A daily heavy cleaning can compromise the device more quickly over time. Heavy cleaning can be

done in many ways Place in dishwasher on the top shelf when cleaning dishes. Boil in water (NJH recommends 10 minutes in a rolling boil). Place in microwave on top shelf for 5 minutes. (Good for Aerobika, but NOT for Acapella, as Acapella contains metal.) Place in a baby bottle sterilizer, such as the one made by Dr. Brown. Place in sealed steam bag with small amount of water for 3 minutes in microwave. After use, be sure the steam bag remains open. A closed steam bag can harbor bacteria. Dry on paper towel, not on cloth towel. An unwashed cloth towel can also harbor bacteria, as it remains wet. If sick, increase the use of airway clearance (including hand held device, nebulized saline & vest). She suggested using the Aerobika in the car when having a busy day. There are no side effects of airway clearance devices, but be sure to consult your doctor or respiratory therapist as to its use for you. Some patients are able to manage their disease through airway clearance. Your physician will determine if this applies to you based on how you feel, severity of symptoms, and culture, CT scan, blood and lung function test results. Submitted by Debbie Breslawsky 8/24/2018