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TRANSCRIPT
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View from the Top How Upper Airways Disease
Can Affect Lung Function:
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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
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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
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Why is the upper airway Important?
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1. Humidifier
2. Air Filter
3. Warmer
Upper Respiratory Tract
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1. Erectile Tissue
2. Mucociliary Clearance
3. Baffles
4. Nerves directly to the Brain - Smell
Upper Respiratory Tract
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› 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
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› Humidifier – Allergic Rhinitis
– Vasomotor Rhinitis
– Vasomotor Rhinitis from CPAP
Illness or Disease related to abnormality function
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› Overload – Clearance
› Occupational
› Amotile Cilia – Kartagener
› Damage from Infection
› Damage from GERD
› Mucous – Cystic Fibrosis
– CTD › – Salivary duct issues –Sjorgrens, RA, etc
Humidifier/ Filter
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› Mucous / Membranes/ Vasculature – Salivary Gland
› Sjorgrens, RA, etc
– Vasculitis › Granulomatosis with Polyangiitis
› Churg Strauss
› Other
– Toxic Irritants › MEK
› Chemicals
› Cocaine
– Trauma
Humidifier/ Filter
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Granulomatosis with
Polyangiitis
a.k.a.
Wegener’s
Granulomatosis
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Tracheal Stenosis
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Upper Airway pathology causing Lower airway issues
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GERD related Inflammation of Arytenoids
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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
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› Looked at Patients diagnosed with erosive esophagitis and esophageal stricture between 1981 and 1994 at discharge from a Veterans Hospital 101,366 people!
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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
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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
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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?
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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
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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
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H Kohrogi, O. Kawano etal Bronchoconstriction due to esophageal Stimulation by HCl is potentiated by Neutral endopeptidase inhibitor in Guinea pigs in Vivo
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› 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
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SM Harding MR Guzzo etal Gastroesophageal reflux induced
bronchosconstriction: Vagolytic doses of Atropine Diminish Airway responses to
esophageal Acid infusion
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– 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
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› No effect on Normal
› Diminished effect on Bronchoconstriction, but not abolished in the Asthmatic with GERD
› People are Guinea Pigs?
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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”
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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.
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› 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:
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› 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:
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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
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Chondyloma
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Viral Pharyngeal Papilloma
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Bronchial Papillomata
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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
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Inadequate Oropharyngeal Care
Hard Palate
Tongue
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Extension of “Crud” on Palate
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Oral Care
› Went into Airway Partially occluding L an R Main Bronchus
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› Definition: Inappropriate adduction of the Vocal Folds on inspiration.
Vocal Cord Dysfunction (VCD)
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› 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
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› Descriptions to the 1800’s
› Can see on inspiration , expiration or both.
› This is a descriptive term – NOT a DIAGNOSIS!
VCD --- Laryngeal Dyskinesia
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DON’T WANT to
CONFUSE it
WITH:
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Tracheal Stenosis
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› 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
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› 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
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› 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
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› 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;
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› 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
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› Identify cause if able
› Speech therapy
› Reassurance
› CPAP (She also has GERD and Borderline OSA)
Treatment
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