PAINE #PANCE Pearl – Pulmonology



Question

A 68yo man, with a history of COPD and 57-pack-year history of smoking, presents to the office with worsening shortness of breath on exertion, dizziness, and leg swelling over the past 6-months. He states that his inhalers don’t seem to be helping as much and he is finding it more and more difficult to walk without getting breathless. He denies orthopnea, paroxysmal nocturnal dyspnea, or increased cough. Vital signs show BP-157/98 mmHg, HR-88 bpm, RR-23 bpm, O2-90% on room air, and temp-98.9o. Physical examination reveals (+) JVD, widened split S2, 1+ pitting edema of the legs to the knee, and hepatomegaly. EKG is below.

  1. What does the EKG show?
  2. What is the diagnosis?
  3. What is the next step in evaluation?
  4. What is the definitive diagnostic study for this condition?


Answer

  1. The EKG shows numerous findings of chronic pulmonary disease including:
    • Right axis deviation
    • Peaked P-waves (>2.5mm) in inferior leads (II, III, aVF)
    • Clockwise rotation of the heart with delayed R/S transition point
    • Absent R-waves in right precordial leads (V1-V3)
    • Low voltage left sided leads
  2. Given the absence of left sided heart failure and the patients extensive pulmonary history, the presentation is highly suggestive of pulmonary hypertension with cor pulmonale.
    • Cor pulmonale is a complication of pulmonary hypertension and is defined as structural alterations or impaired function of the right ventricle
  3. The next step in evaluation of this patient is getting an echocardiogram to evaluate global heart function and degree of pulmonary hypertension present
  4. The definitive diagnostic study of pulmonary hypertension and cor pulmonale is a right heart catheterization.


References

  1. https://litfl.com/ecg-in-chronic-obstructive-pulmonary-disease/

Ep-PAINE-nym



Schamroth Test

Other Known Aliases none

Definition – test used for diagnosing nail clubbing by examining the window seen between the nails of opposite fingers

Clinical Significance there should be a diamond size window in “normal” nails when performing this test. In patients with nail clubbing, this window is obliterated

HistoryNamed after Leo Schamroth (1924-1988), a Belgium-born, South African cardiologist who received his medical doctorate from the University of Witwatersrand in 1948. He completed his residency at Johannesburg General Hospital and joined the staff at Baragwanath Hospital in 1956, where he would stay his entire career culminating in chief physician in 1972. He would publish over 300 papers and eight textbooks in the realm of cardiology, and his Introduction to Electrocardiography is still one of the most stolen medical textbooks in the world. He published his eponymous finding in an article entitled “Personal Experience” in 1972 in the South African Medical Journal.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Schamroth L. Personal experience. S Afr Med J. 1976; 50(9):297-300. [pubmed]

PAINE #PANCE Pearl – Pulmonology



Question

A 68yo man, with a history of COPD and 57-pack-year history of smoking, presents to the office with worsening shortness of breath on exertion, dizziness, and leg swelling over the past 6-months. He states that his inhalers don’t seem to be helping as much and he is finding it more and more difficult to walk without getting breathless. He denies orthopnea, paroxysmal nocturnal dyspnea, or increased cough. Vital signs show BP-157/98 mmHg, HR-88 bpm, RR-23 bpm, O2-90% on room air, and temp-98.9o. Physical examination reveals (+) JVD, widened split S2, 1+ pitting edema of the legs to the knee, and hepatomegaly. EKG is below.

  1. What does the EKG show?
  2. What is the diagnosis?
  3. What is the next step in evaluation?
  4. What is the definitive diagnostic study for this condition?

Ep-PAINE-nym



Hippocratic Fingers

Other Known Aliases clubbing of the fingers

Definition – soft tissue swelling of the terminal phalynx

Clinical Significance this is a nonspecific clinical finding that can be caused by numerous diseases, but is classically associated with any disease that can cause physiologic hypoxia. The exact mechanism for development is unknown, but is theorized to be caused by vasodilation, secretion of growth factors, overproduction of prostaglandin E2, and increased entry of megakaryocytes.

HistoryNamed after Hippocrates (460-370 BC), who was a Greek physician and is considered to be the “Father of Medicine”, due to his approach in observation of clinical diseases. Though I cant find an original source for this eponym, it is one of those historical “facts” that nobody really challenges.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com

Ep-PAINE-nym



Ghon Focus and Complex

Other Known Aliasesnone

Definitionradiographic finding in primary tuberculosis where cellular and biochemical reaction to the infection forms a nodular granulomatous structure (focus) which can enlarge and invade adjacent lymphatics and hilar lymph nodes (complex).

Clinical Significance this finding on radiography is pathognomonic for primary active tuberculosis

HistoryNamed after Anton Ghon (1866-1936), who was an Austrian pathologist and recieved his medical doctorate from the University of Graz in 1890. He would spend his entire career in pathology and bacteriology culminating in full professorship at the University of Prague in 1910. He frist published his eponymous findings in his 1912 work entitled “Der primäre Lungenherd bei der Tuberkulose der Kinder”. Unfortunately, we would go on to die from tuberculous pericarditis in 1928


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Der primäre Lungenherd bei der Tuberkulose der Kinder. Berlin & Wien, Urbach & Schwarzenberg, 1912.
  7. Ober WB. Ghon but not forgotten: Anton Ghon and his complex. Pathol Annu. 1983; 18 Pt 2:79-85. [pubmed]

PAINE #PANCE Pearl – Pulmonology



Question

Carcinoid lung tumors are a rare pulmonary malignancy and have classic, characteristics signs and symptoms associated with them.

  1. What are the PULMONARY specific symptoms?
  2. What are the classic SYSTEMIC symptoms of carcinoid syndrome?


Answer

  1. Carcinoid lung tumors typically arise in the proximal airways and patienta can have obstructing symptoms such as dyspnea, cough, wheezing, chest pain, and recurrent pneumonia due to impaired sputum clearance. These tumors are also hypervascular and hemoptysis is also common.
  2. Since carcinoid tumors are neuroendocrine tumors they produce and secrete a host of vasoactive substances that can cause a host of specific signs and symptoms. The classic presentation for carcinoid syndrome include flushing, telangiectasias, diarrhea, and bronchospasm

Ep-PAINE-nym



Cheyne-Stokes Respirations

Other Known Aliasesnone

Definitionoscillating, crescendo-decrescendo pattern of progressive deeper and faster breathing followed a gradual decrease culminating in a period of apnea

Clinical Significance this pattern is theorized to be a delay in changes to ventilation after detection of PaCO2 changes. This lag causes the classic respiratory pattern. Conditions associated with this include cardiac disease, neurologic disease, sedation, acid-base disturbances, prematurity in infancy, and rapid altitude changes.

HistoryNamed after John Cheyne (1777-1836) , who was a British surgeon and received his medical doctorate at the age of 18 from Edinburgh University. He would serve as a military surgeon for several years before joining his father’s medical practice and ultimately, moving to Dublin for the majority of his career. Some have credited him as “The Father of Medicine in Ireland”. He would describe his eponymous findings in his 1818 article entitled ” A case of apoplexy in which the fleshy part of the heart was converted to fat”

William Stokes (1804-1878), was an Irish physician and received his medical doctorate from the University of Edinbugh in 1825. He was a leader and pioneer in the adaptation of the Parisian school of anatomical diagnosis and helped introduce the stethoscope to clinical practice in Ireland. He would note his eponymous findings in his 1854 textbook entitled ” The Diseases of the Heart and Aorta” and cited Dr. Cheyne as observing this first.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Cheyne J. A case of apoplexy in which the fleshy part of the hear was converted into fat. Dubin Hospital Records. 1818;2:216-223. [link]
  7. Stokes W. The Diseases of the Heart and the Aorta. 1954. Dublin. [link]

#62 – Pleural Effusions



***LISTEN TO THE PODCAST HERE***



Pleural Anatomy and Physiology

  • 2 types of pleura in the thorax
    • Parietal pleura
      • Which covers the chest wall and diaphragm
      • 30-40 micrometers thick
      • Contains lymphatic stomata
        • Holes between the mesothelial and subpleural layers that allow for drainage into the lymphatic system
      • Contains intercostal microvessels
        • Produce interpleural fluid
    • Visceral pleura
      • Which covers the lung parenchyma
      • 20-80 micrometers thick
      • Contain bronchial microvessels
        • Arise from pulmonary veins and produce interpleural fluid
  • The interpleural space is between them and produces 0.1-0.2 mL/kg (10-20 mL per hemithorax) of fluid to keep these pleura from adhering to each other and maintain lubrication
    • This fluid is constantly produced (0.01 mL/kg/hr) and absorbed
    • Originates from the systemic pleural microvessels
      • Theorized that parietal is more important
        • Intercostal microvessels are closer to the interpleural space
        • Higher filtration pressure than pulmonary veins
    • Dependent on balance of hydrostatic pressure opposed by the counterbalancing osmotic pressure and membrane permeability
      • Transudative fluid collection
        • Increased hydrostatic pressure
        • Decreased oncotic pressure
      • Exudative fluid collection
        • Decreased pleural membrane permeability
        • Lymphatic blockage

Associated Diseases and Causes


Clinical Presentation

  • Symptoms      
    • Patients can be asymptomatic, have fluid specific symptoms, and have disease specific symptoms
    • Fluid specific
      • Dyspnea
      • Cough
      • Pleuritic chest pain
    • Disease specific
      • Fever, hemoptysis, orthopnea, peripheral edema, weight changes, ascites
  • Physical Examination
    • Fluid specific
      • Decreased or asymmetric chest wall movement
      • Decreased breath sounds
      • Dullness to percussion
      • Decreased tactile fremitus
      • Pleural friction rub
      • (+) egophony
    • Disease specific
      • Crackles, JVD, hepatosplenomegaly, lymphadenopathy, S3 gallop, pitting edema,

Imaging in Suspected Pleural Effusions

  • Chest Radiograph
    • Blunting of the costophrenic angle
      • At least 150mL needed on PA
      • At least 50mL needed on lateral decubitus
    • At least 500mL needed for diaphragm obliteration
  • Computed Tomography
    • Can detect as little as 2mL of fluid
  • Ultrasound
    • Can detect as little as 20mL
    • Phased array probe with patient sitting upright
    • Scan posterior/lateral caudal to cranial to find fluid line
    • (+) spine sign

Thoracentesis

  • Once the diagnosis is made, a thoracentesis needs to be performed for biochemical fluid analysis

Fluid Analysis

  • Routine fluid labs
    • Cell count and differential
    • pH
    • Protein
    • LDH
    • Glucose
    • Cholesterol
  • Non-routine
    • N-terminal BNP
    • Triglycerides
    • Creatinine
    • Amylase
    • Cancer-related biomarkers
  • Lights Criteria
    •  Exudative if one (1) of following present:
      • Pleural/serum protein ratio > 0.5
      • Pleural/serum LDH > 0.6
      • Pleural fluid LDH > 2/3rd ULN of serum LDH
    • Lights Criteria Criticism
      • Needs both pleural fluid and serum
      • Newer studies use only pleural fluid
        • Exudative if one (1) of the following:
          • Pleural fluid cholesterol > 45 mg/dL
          • Pleural fluid protein > 2.6 g/dL
          • Pleural fluid LDH > 0.45x ULN of serum LDH

Treatment

  • Non-malignant effusions
    • Treat underlying condition
    • Repeated drainage for symptomatic patients
    • If persistent:
      • Repeat thoracentesis as needed
      • Revisit primary diagnosis
      • Consider pleurodesis
        • Chemical
          • Talc slurry or doxycycline through chest tube
        • Mechanical
          • VATS
      • Indwelling pleural catheter
        • Reserved for patients who decline, fail, or not candidates for pleurodesis
  • Malignant effusions
    • Can be complicated

Cottage Physician (1898)



References

  1. Lai-Fook SJ. Pleural mechanics and fluid exchange. Physiol Rev. 2004; 84(2):385-410. [pubmed]
  2. Jantz MA, Antony VB. Pathophysiology of the pleura. Respiration. 2008; 75(2):121-33. [pubmed]
  3. Feller-Kopman D, Light R. Pleural Disease. N Engl J Med. 2018; 378(8):740-751. [pubmed]
  4. http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/apd/plep.htm
  5. Saguil A, Wyrick K, Hallgren J. Diagnostic approach to pleural effusion. Am Fam Physician. 2014; 90(2):99-104. [pubmed]
  6. Wong CL, Holroyd-Leduc J, Straus SE. Does this patient have a pleural effusion? JAMA. 2009; 301(3):309-17. [pubmed]
  7. Chesnutt AN, Chesnutt MS, Prendergast NT, Prendergast TJ. Pleural Effusion. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis and Treatment 2020. McGraw-Hill; Accessed July 05, 2020. https://accessmedicine-mhmedical-com.ezproxy.uthsc.edu/content.aspx?bookid=2683&sectionid=225058693
  8. Light RW. Disorders of the Pleura. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e. McGraw-Hill; Accessed July 05, 2020. https://accessmedicine-mhmedical-com.ezproxy.uthsc.edu/content.aspx?bookid=2129&sectionid=192031615
  9. Moskowitz H, Platt RT, Schachar R, Mellins H. Roentgen visualization of minute pleural effusion. An experimental study to determine the minimum amount of pleural fluid visible on a radiograph. Radiology. 1973; 109(1):33-5. [pubmed]
  10. Radiopaedia. Pleural Effusions. https://radiopaedia.org/articles/pleural-effusion?lang=us
  11. Gonlugur U, Gonlugur TE. The distinction between transudates and exudates. J Biomed Sci. 2005; 12(6):985-90. [pubmed]
  12. Heffner JE, Brown LK, Barbieri CA. Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators. Chest. 1997; 111(4):970-80. [pubmed]
  13. Steger V, Mika U, Toomes H, et al. Who gains most? A 10-year experience with 611 thoracoscopic talc pleurodeses. Ann Thorac Surg. 2007; 83(6):1940-5. [pubmed]
  14. Patil M, Dhillon SS, Attwood K, Saoud M, Alraiyes AH, Harris K. Management of Benign Pleural Effusions Using Indwelling Pleural Catheters: A Systematic Review and Meta-analysis. Chest. 2017; 151(3):626-635. [pubmed]
  15. Feller-Kopman DJ, Reddy CB, DeCamp MM, et al. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med. 2018; 198(7):839-849. [pubmed]
  16. Bibby AC, Dorn P, Psallidas I, et al. ERS/EACTS statement on the management of malignant pleural effusions. Eur Respir J. 2018; 52(1):. [pubmed]

Ep-PAINE-nym



Light’s Criteria

Other Known Aliasesnone

Definitionset of laboratory findings in pleural effusions that helps differentiate the fluid as transudative or exudative

Clinical Significance after performing a diagnostic thoracentesis, the fluid can be sent to the lab for biochemical analysis. The results of this analysis can tell the medical team the whether the fluid is transudative or exudative, which can narrow down the causes and provide a diagnostic schema for management.

HistoryNamed after Richard W. Light, a practicing pulmonologist from Vanderbilt University in Nashville, TN. He received his medical doctorate from Johns Hopkins University in 1968 and completed his residency and fellowship there in 1972. He would spend the next 20 years at UC-Irvine building his international reputation as an expert on pleural diseases. He is the author and editor for 16 current textbooks, including the gold standard textbooks Pleural Diseases and The Textbook of Pleural Diseases, as well as authored more than 450 peer reviewed articles. His eponymous criteria were first introduced in 1972 in an article he published as a fellow in the Annals of Internal Medicine….his very first paper as a physician.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med. 1972; 77(4):507-13. [pubmed]
  7. Biography of Richard Light. https://respiratory.annualcongress.com/ocm/2019/richard-w-light-vanderbilt-university-nashville
  8. Newman JH. Giants in chest medicine: Richard W. Light, MD. Chest. 2014; 146(5):1152-1154. [pubmed]