CPC Case 4 Anne, Andy, Jen, Brock, David and Abby

CPC Case 4CPC Case 4

Anne, Andy, Jen, Brock, David and Anne, Andy, Jen, Brock, David and Abby Abby

History of Present IllnessHistory of Present Illness ““I have been coughing and short of breath”I have been coughing and short of breath” 47 yo man with cough, SOB and other respiratory symptoms 47 yo man with cough, SOB and other respiratory symptoms

worsening over the past 3 yearsworsening over the past 3 years Minimal on Sundays and Mondays, worse in the eveningsMinimal on Sundays and Mondays, worse in the evenings He consulted an allergist in 1994, but this evaluation was He consulted an allergist in 1994, but this evaluation was

negative negative In 1994, he consulted a Pulmonologist who found normal In 1994, he consulted a Pulmonologist who found normal

pulmonary function pulmonary function In July 1995 he took a vacation for one week to Florida and In July 1995 he took a vacation for one week to Florida and

noticed his symptoms improved. The symptoms returned to noticed his symptoms improved. The symptoms returned to their usual level after the vacation and even continued to their usual level after the vacation and even continued to worsen. worsen.

HistoryHistory

Smokes ½ ppd from 1967 to 1994Smokes ½ ppd from 1967 to 1994 No family history of respiratory diseaseNo family history of respiratory disease Works at manufacturing company for Works at manufacturing company for

polyurethane foam cushions as a “feedstock polyurethane foam cushions as a “feedstock supply man” States he does not wear the supply man” States he does not wear the respirator because “nobody can stand those respirator because “nobody can stand those things” things”

Physical ExamPhysical Exam

BP 140/80, HR 68, Temp 37BP 140/80, HR 68, Temp 37 Lungs are clear to auscultation and percussion Lungs are clear to auscultation and percussion 2/6 systolic murmur heard best along left 2/6 systolic murmur heard best along left

sternal border, radiating to carotids, and sternal border, radiating to carotids, and diminishing with Valsalva maneuver diminishing with Valsalva maneuver

Class DDxClass DDx

Our DDxOur DDx

COPDCOPD AsthmaAsthma PneumoniaPneumonia CancerCancer Anxiety AttackAnxiety Attack Industrial chemical exposure Industrial chemical exposure

COPDCOPD COPD includes emphysema and chronic bronchitisCOPD includes emphysema and chronic bronchitis Chronic Bronchitis, airflow may be limited by narrowed Chronic Bronchitis, airflow may be limited by narrowed

airways that get tight, swollen, and filled with mucus. airways that get tight, swollen, and filled with mucus. These changes limit airflow into and out of the lungs.These changes limit airflow into and out of the lungs.

Emphysema, the alveoli in your lungs are damaged. They Emphysema, the alveoli in your lungs are damaged. They are overstretched and break down. Air trapping reduces are overstretched and break down. Air trapping reduces amount of air exchange possible. amount of air exchange possible.

Cigarette smoking, breathing in irritants, like pollution, Cigarette smoking, breathing in irritants, like pollution, dust or chemicals, may cause or contribute to COPD. dust or chemicals, may cause or contribute to COPD.

Symptoms include chronic cough, dyspnea and with Symptoms include chronic cough, dyspnea and with progression of disease pursed-lip breathing, barrel chest, progression of disease pursed-lip breathing, barrel chest, productive cough and cyanosis.productive cough and cyanosis.

AsthmaAsthma

Chronic lung disease that inflames and Chronic lung disease that inflames and narrows the airways. narrows the airways.

Combination of genetic factors and certain Combination of genetic factors and certain environmental exposures interact to cause environmental exposures interact to cause asthma to develop.asthma to develop.

Asthma causes recurring periods of wheezing, Asthma causes recurring periods of wheezing, chest tightness, shortness of breath, and chest tightness, shortness of breath, and coughing.coughing.

An obstructive airway diseaseAn obstructive airway disease

Diagnostic TestsDiagnostic Tests

Test Observed Predicted % Predicted Test Observed Predicted % Predicted TLC TLC 4.42 L 4.42 L 5.26 L 5.26 L 84% 84% VC VC 2.92 L 2.92 L 3.55 L 3.55 L 82% 82% FRC FRC 1.96 L 1.96 L 2.94 L 2.94 L 67% 67% RV RV 1.50 L 1.50 L 1.79 L 1.79 L 84% 84% FVC FVC 2.92 L 2.92 L 3.55 L 3.55 L 82% 82% FEFFEF25-7525-75 2.89 L/sec 2.89 L/sec 3.82 L/sec 3.82 L/sec 75% 75% FEV1 FEV1 2.30 L 2.30 L 2.34 L 2.34 L 98% 98% FEV1/FVC FEV1/FVC 82% 82% 100% 100%

PneumoniaPneumonia

Inflammation of the lungs that's usually caused by Inflammation of the lungs that's usually caused by infection with bacteria, viruses, fungi or other infection with bacteria, viruses, fungi or other organisms.organisms.

It often mimics a cold or the flu, beginning with a It often mimics a cold or the flu, beginning with a cough and a fever.cough and a fever.

Chest pain is a common symptom of many types of Chest pain is a common symptom of many types of pneumonia, and symptoms can vary greatly, pneumonia, and symptoms can vary greatly, depending on any underlying conditions and the depending on any underlying conditions and the organism causing the infectionorganism causing the infection


CXR and CBC to check for viral or bacterial CXR and CBC to check for viral or bacterial lung infection.lung infection. CXR was normalCXR was normal CBC showed WBC of 6.2 with no evidence of left CBC showed WBC of 6.2 with no evidence of left

shiftshift RBC and platelet levels were normalRBC and platelet levels were normal Hb of 16.9 and Hct of 46.5%Hb of 16.9 and Hct of 46.5%

CancerCancer

Forms in tissues of the lung, usually in the Forms in tissues of the lung, usually in the cells lining air passages. cells lining air passages.

May be asymptomatic.May be asymptomatic. The growth of the cancer and invasion of lung The growth of the cancer and invasion of lung

tissues and surrounding tissue may interfere tissues and surrounding tissue may interfere with breathing, leading to symptoms such as with breathing, leading to symptoms such as cough, shortness of breath, wheezing, chest cough, shortness of breath, wheezing, chest pain, and hemoptysis.pain, and hemoptysis.


Normal Chest X-rayNormal Chest X-ray

Anxiety AttackAnxiety Attack

The sudden onset of a discrete, brief period of The sudden onset of a discrete, brief period of intense discomfort, anxiety or fear intense discomfort, anxiety or fear accompanied by somatic or cognitive accompanied by somatic or cognitive symptoms.symptoms.

Many symptoms; chest pain, dissiness, feeling Many symptoms; chest pain, dissiness, feeling of choking, sweating, trembling or shaking.of choking, sweating, trembling or shaking.


Arterial Blood Gases Arterial Blood Gases HCOHCO33 (Bicarbonate): 24 mEq/I (Bicarbonate): 24 mEq/I Oxygen saturation: 91.7 % Oxygen saturation: 91.7 % pCOpCO22: 39 mm Hg; : 39 mm Hg; pH: 7.4pH: 7.4 pOpO22: 82 mm Hg: 82 mm Hg

Showing an (A-a) gradient of 18Showing an (A-a) gradient of 18

IsocyanatesIsocyanates

AsthmaAsthma

Coughing, SOB, wheezing, Coughing, SOB, wheezing, and chest tightness. and chest tightness.

Symptoms can occur soon Symptoms can occur soon after exposure or several after exposure or several hours later.hours later.

Hypersensitivity pneumonitisHypersensitivity pneumonitis

Fever, body aches, SOBFever, body aches, SOB Cough with sputumCough with sputum

Diagnostic Tests Diagnostic Tests

Toluene Diisocyanate Antibody testToluene Diisocyanate Antibody test Detects IgG and IgE specific Ab to TDIDetects IgG and IgE specific Ab to TDI

Research suggests that a positive TDI-specific Research suggests that a positive TDI-specific IgE antibody test result may be useful in the IgE antibody test result may be useful in the diagnosis of TDI-related asthma only if (1) diagnosis of TDI-related asthma only if (1) there is a strong pre-test probability of work-there is a strong pre-test probability of work-related asthma, (2) there is current or recent related asthma, (2) there is current or recent exposure to TDI.exposure to TDI.

Diagnostic Tests Diagnostic Tests

Negative CXR and normal CBC rule out Negative CXR and normal CBC rule out pneumonia/infection.pneumonia/infection.

Positive TDI in light of asthma symptoms Positive TDI in light of asthma symptoms relating to work exposure strengthens relating to work exposure strengthens diagnosis of cyanate toxicity.diagnosis of cyanate toxicity.

ABG shows increased A-a gradient of 18.ABG shows increased A-a gradient of 18. Pulmonary function tests indicate restrictive Pulmonary function tests indicate restrictive

lung disease, which is consistent with the lung disease, which is consistent with the diagnosis.diagnosis.

PolyurethanesPolyurethanes

Reaction polymersReaction polymers Made by reacting isocyanate Made by reacting isocyanate

w/ hydroxylw/ hydroxyl Diisocyanate and a polyol in Diisocyanate and a polyol in

presence of a catylastpresence of a catylast

Major Isocyanate cmpds.Major Isocyanate cmpds. TDITDI toluene diisocyanatetoluene diisocyanate

MDIMDI methylene bis-phenylisocyanatemethylene bis-phenylisocyanate

HDI HDI hexamethylene diisocyanatehexamethylene diisocyanate

NDI NDI naphthalene diisocyanatenaphthalene diisocyanate

HMDI HMDI methylene bis-methylene bis-cyclohexylisocyanatecyclohexylisocyanate

IPDI IPDI isophorone diisocyanateisophorone diisocyanate

IsocyanateIsocyanate

TDI and MDITDI and MDI most-used isocyanates most-used isocyanates mainly to make soft, mainly to make soft,

flexible foams for padding flexible foams for padding or insulationor insulation

rigid foamsrigid foams surface coatings such as surface coatings such as

paints, sealants, and finishespaints, sealants, and finishes

During production or thermal During production or thermal breakdownbreakdown TDI and HDI are especially TDI and HDI are especially

hazardous, because they can hazardous, because they can evaporate quickly to evaporate quickly to produce harmful levels in produce harmful levels in the air.the air.

IsocyanateIsocyanate

Reactivity makes Isocyanates toxic to human Reactivity makes Isocyanates toxic to human tissuetissue

Reactions:Reactions:

SkinSkin

Respiratory TractRespiratory Tract

G.I. TractG.I. Tract

EyesEyes

PathologyPathology

Respiratory Epithelial NecrosisRespiratory Epithelial Necrosis Loss of Epithelial CiliaLoss of Epithelial Cilia Affects Cell Attachments and Attachment to Affects Cell Attachments and Attachment to

Basement MembraneBasement Membrane UlcerationUlceration AtelectasisAtelectasis

Inflammatory ResponseInflammatory Response

a) Exposure may cause sensitizationa) Exposure may cause sensitizationb) Mast cell degranulation and b) Mast cell degranulation and EosinophiliaEosinophiliac) Allergic Asthmac) Allergic Asthmad) Bronchial Constriction (beta blocking d) Bronchial Constriction (beta blocking

theory)theory) e) PMN and Fibrinous Exudatee) PMN and Fibrinous Exudate

Chronic ExposureChronic Exposure

Severe asthma attacks may occur if patient is Severe asthma attacks may occur if patient is sensitized to isocyanatessensitized to isocyanates

Chronic respiratory symptoms may be seenChronic respiratory symptoms may be seen The maximum allowable concentration in the The maximum allowable concentration in the

working environment, at present proposed in working environment, at present proposed in the U.S.A. is 0.005 ppmthe U.S.A. is 0.005 ppm

TreatmentTreatment Most importantly, removal from enviroment or source Most importantly, removal from enviroment or source Personal dust respirators, airstream helmets, and ventilated helmets with a Personal dust respirators, airstream helmets, and ventilated helmets with a

supply of fresh air are increasingly efficient means of purifying inhaled air. supply of fresh air are increasingly efficient means of purifying inhaled air. If symptoms recur or physiologic abnormalities progress in spite of these If symptoms recur or physiologic abnormalities progress in spite of these

measures, then measures, then more effective measures to avoid antigen exposure must be pursued.more effective measures to avoid antigen exposure must be pursued.

The chronic form of Hypersensitivity Pneumonitis (or pulmonary The chronic form of Hypersensitivity Pneumonitis (or pulmonary isocyanate poisoning) typically results from low-grade or recurrent isocyanate poisoning) typically results from low-grade or recurrent exposure over many months to years, and the lung disease may already be exposure over many months to years, and the lung disease may already be partially or completely irreversible. These patients are partially or completely irreversible. These patients are usually advised to avoid all possible contact with the offending agent. usually advised to avoid all possible contact with the offending agent.

Patients with the acute, recurrent form of HP usually recover without need Patients with the acute, recurrent form of HP usually recover without need for for glucocorticoids. glucocorticoids.

Treatment (cont)Treatment (cont) Subacute HP may be associated with severe symptoms and marked Subacute HP may be associated with severe symptoms and marked

physiologic impairment and may continue to progress for several days physiologic impairment and may continue to progress for several days despite hospitalization. Urgent establishment of the diagnosis and prompt despite hospitalization. Urgent establishment of the diagnosis and prompt institution of glucocorticoid treatment are indicated in such patients.institution of glucocorticoid treatment are indicated in such patients.

Prednisone at a dosage of 1 mg/kg per day or its equivalent is continued Prednisone at a dosage of 1 mg/kg per day or its equivalent is continued for 7 to 14 for 7 to 14 days and then tapered over the ensuing 2 to 6 weeks at a rate that depends days and then tapered over the ensuing 2 to 6 weeks at a rate that depends on the on the patient's clinical status.patient's clinical status.

Patients with chronic HP may gradually recover without therapy following Patients with chronic HP may gradually recover without therapy following environmental control. In many patients, however, a trial of prednisone environmental control. In many patients, however, a trial of prednisone may be useful to obtain maximal reversibility of the lung disease. may be useful to obtain maximal reversibility of the lung disease. Following initial prednisone therapy (1 mg/kg per day for 2 to 4 weeks), Following initial prednisone therapy (1 mg/kg per day for 2 to 4 weeks), the drug is tapered to the lowest dosage that will maintain the functional the drug is tapered to the lowest dosage that will maintain the functional status of the patient. Many patients will not require or benefit from long-status of the patient. Many patients will not require or benefit from long-term therapy if there is no further exposure to antigen.term therapy if there is no further exposure to antigen.

Question 1Question 1

Hypersensitivity pneumonitis is a(n)Hypersensitivity pneumonitis is a(n)1.1. Obstructive airway diseaseObstructive airway disease

2.2. Restrictive airway diseaseRestrictive airway disease


The most important part of treatment is:The most important part of treatment is:1.1. glucocorticoid glucocorticoid

2.2. BB22 agonist agonist

3.3. Removal from environment Removal from environment

4.4. RestRest


The current maximum amount allowed in The current maximum amount allowed in working environment is:working environment is:

1.1. .001 ppm.001 ppm

2.2. .005 ppm.005 ppm

3.3. .001 ppb.001 ppb

4.4. .005 ppb.005 ppb

Documents

CPC Case 4 Anne, Andy, Jen, Brock, David and Abby