June 2017 Pulmonary Case of the Month

Robert Horsley, MD

Lewis J. Wesselius, MD 

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 61-year-old woman presented to the emergency department for 3 days of fevers up to 102º F, malaise, and progressive shortness of breath. Her symptoms started immediately after he last naltrexone injection for alcohol use disorder.

Past Medical History, Social History and Family History

• Alcohol use disorder
• Treated with monthly naltrexone injections, received 3 doses total, and gabapentin
• No other previous medical issues
• Nonsmoker

Physical Examination

• Vital signs: Pulse 100, BP 108/90, respiratory rate 34, SpO2 93% 10L non-rebreathing mask
• Cyanotic on room air
• Lungs clear

Radiography

A portable chest x-ray was performed in the emergency department (Figure 1).

Figure 1. AP chest radiograph taken in the emergency department.

A thoracic CT scan was performed (Figure 2).

Figure 2. Representative images from thoracic CT in lung windows.

Laboratory

• CBC showed a white blood cell count of 12,000 cells/mcL.
• The differential showed a left shift.
• Lactate was 5.2 mmol/L

Which of the following is (are) true? (Click on the correct answer to proceed to the second of five pages)

1. A lactate level of 5.2 can be a normal finding in a critically ill patient
2. Her symptoms are likely an allergic reaction to naltrexone
3. The most likely diagnosis is an atypical pneumonia
4. 1 and 3
5. All of the above

Cite as: Horsley R, Wesselius LJ. June 2107 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;14(6):255-61. doi: https://doi.org/10.13175/swjpcc063-17 PDF

May 2017 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Robert W. Viggiano, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 69-year-old man with known heart failure, COPD and prostate cancer with presented with increased shortness of breath. He denied any fever, chills, cough or sputum.

Past Medical History, Social History and Family History

• Diastolic heart failure with a preserved ejection fraction
• Prostate cancer with bone metastasis treated with leuprolide (Lupron^®) 
• COPD treated with salmeterol/fluticasone and tiotropium
• He is married, retired and had quit smoking a number of years ago.
• Family history was unremarkable

Physical Examination

• Oxygen saturation (SpO2) was 93% on room air.
• Physical examination showed jugular venous distention (JVD), bilateral lung rales a laterally displaced pulse of maximal impulse (PMI) and 1+ pretibial edema.

Radiography

A chest x-ray was performed (Figure 1).

Figure 1. Admission chest x-ray.

Based on the history and chest x-ray which of the following is the most likely diagnosis? (Click on the correct answer to proceed to the second of six pages)

1. Community-acquired pneumonia
2. Congestive heart failure
3. COPD exacerbation
4. Metastatic prostate cancer
5. Pulmonary embolism

Cite as: Wesselius LJ, Viggiano RW. May 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;14(5):185-91. doi: https://doi.org/10.13175/swjpcc052-17 PDF

April 2017 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Pulmonary Department

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 63-year-old woman with a prior diagnosis of possible rheumatoid arthritis was referred for dyspnea with more vigorous activities in Prescott where she now lives (elevation 5367 ft.). She is receiving hydroxychloroquine 400 mg/day.

Past Medical History, Social History and Family History

She has a past medical history of hypertension. She smoked about a pack per day from age 20 to 40. There is a history of colon cancer in her mother and  lung cancer in a sister.

Physical Examination

• Vitals: BP 155/102, SpO2 93% on room air
• Chest: slightly decreased breath sounds but clear
• Cardiovascular:  regular rhythm without murmur
• Extremities:  no cyanosis, clubbing or edema
• The remainder of the physical examination is normal

What testing would you perform at this time? (Click on the correct answer to proceed to the second of five pages)

1. Chest X-ray
2. Pulmonary function testing
3. Rheumatoid factor
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. April 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;14(4):129-33. doi: https://doi.org/10.13175/swjpcc040-17 PDF

March 2017 Pulmonary Case of the Month

Maxwell L. Smith, MD 

Department of Laboratory Medicine and Pathology

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

The patient is 52-year-old man who complained of dyspnea on exertion and a dry cough.

Past Medical History, Social History and Family History

He had a history of gastroesophageal reflux disease (GERD) and was taking a proton pump inhibitor.

He never smoked and had no known exposures.

Family history was noncontributory.

Physical Examination

Physical Examination was unremarkable.

Chest X-ray

A chest x-ray was reported as normal.

Which of the following are indicated? (Click on the correct answer to proceed to the second of five pages)

1. Chest CT scan
2. Endoscopy/bronchoscopy
3. Pulmonary function testing
4. 1 and 3
5. All of the above 

Cite as: Smith ML. March 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;14(3):89-93. doi: https://doi.org/10.13175/swjpcc014-17 PDF

February 2017 Pulmonary Case of the Month

Abdalla Fadda, MD

Phoenix VA and Banner University Medical Center Phoenix

Phoenix, AZ USA

History of Present Illness

A 45-year-old man presented with weight loss, copious amounts of light green sputum, low grade fever and chest discomfort on the right. He had moved to Arizona 8 months ago. Two months later he developed hemoptysis and had increased cough with copious phlegm. He denied any fever, chills, malaise or fatigue.

Past Medical History, Social History and Family History

He has a history of tuberculosis in 2010 treated with 4 drug therapy for a year. The tuberculosis was not drug resistant. He had been treated with a 6-month course of voriconazole about 2 years ago.

Physical Examination

He was afebrile and his vital signs were unremarkable. He had decreased breath sounds in his right lower chest.

Laboratory

His CBC, electrolytes and urinalysis were unremarkable.

Chest Radiography

His admission chest x-ray is shown in Figure 1.

Figure 1. Admission PA of chest.

In regards to the chest x-ray which of the following are true? (Click on the correct answer to proceed to the second of six pages)

1. There are cavities in the right lung
2. There is a large right pleural effusion
3. There is volume loss in the right lung
4. 1 and 3
5. All of the above

Cite as: Fadda A. February 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;14(2):45-53. doi: https://doi.org/10.13175/swjpcc005-17 PDF

January 2017 Pulmonary Case of the Month

Jamie Bering, MD

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

The patient is a 53-year-old woman transferred for acute respiratory failure and hemoptysis. She has a prior history of antiphospholipid syndrome and recurrent diffuse alveolar hemorrhage (DAH). She was admitted to another hospital about 2 weeks prior to transfer with hypoxic respiratory failure which ultimately required intubation. Bronchoscopy revealed a bloody aspirate raising concerns for recurrent DAH. She was started on high-dose solumedrol and extubated after 4 days. One week later, her respiratory status decompensated and her chest x-ray showed worsening diffuse bilateral opacities concerning for recurrent DAH. She was transferred to the Mayo Clinic Arizona for further evaluation. Upon arrival, she required 50% FiO2 by face mask to maintain adequate oxygenation and was started on broad-spectrum antibiotics. Her corticosteroids were tapered to 20 mg prednisone daily.

Past Medical History, Social History and Family History

She has a history of a mitral valve replacement with a St. Jude’s mechanical mitral valve and was on chronic anticoagulation with warfarin. In addition, there was a history of moderate aortic stenosis with moderate aortic insufficiency.

She had a history of diffuse alveolar hemorrhage, antiphospholipid antibody syndrome and possible systemic lupus erythematosus.

Medications

• Dapsone 100mg daily
• Ethacrynic acid 75mg daily
• Gabapentin 900mg QHS
• Lisinopril 20mg daily
• Meropenem 1g Q8 hrs
• Metoprolol 50 mg BID
• Prednisone 20mg daily
• Simvastatin 40mg QHS
• Vancomycin 1.5g Q12 hrs
• Warfarin 4mg T,F; 3mg SMWRSa

Physical Examination

• Vitals: T 36.3^◦ C; HR 79 beats/min; BP 100/63 mm Hg; RR 26 breaths/min; SpO2 99% face mask
• Gen: no acute distress
• HEENT: hematoma on chin
• Lungs: clear to auscultation and percussion
• Cardiac: Mechanical valve click

Laboratory

• CBC: WBC 15,900 cells per microliter (mcL); Hemoglobin 9.1 g/dL; hematocrit 29%; platelet count 156,000 cells per microliter.
• Electrolytes: within normal limits.
• BUN and creatinine: within normal limits.
• Blood sugar: 220 mg/dL.

Radiography

Her initial chest x-ray is shown in Figure 1.

Figure 1. Initial chest radiograph.

Which of the following best describes the chest x-ray? (Click on the correct answer to proceed to the second of four pages)

1. Diffuse lung consolidation
2. Previous median sternotomy
3. Previous mitral valve replacement
4. 1 and 3
5. All of the above

Cite as: Bering J, Wesselius LJ. January 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;14(1):1-5. doi: https://doi.org/10.13175/swjpcc146-16 PDF

December 2016 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Lewis J. Wesselius, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

The patient is a 29-year-old man who presented to the emergency room with right-sided pleuritic chest pain, fever, cough, and progressive dyspnea over 2 weeks.

Past Medical History, Social History and Family History

He had no prior significant medical issues and had been well until 2 weeks ago. A native of India, he has been in the US for about 5 months and works at American Express. He is a nonsmoker. Family history is noncontributory.

Physical Examination

• Vitals signs: Temperature 38.0^◦ C, Blood Pressure 155/85 mm Hg, Heart Rate 140 beats/min, Respirations 24 breaths/min
• General: Appears to be in moderate pain and respiratory distress
• Lungs: Decreased breath sounds on the right
• Heart: regular rhythm with a tachycardia
• Abdomen: unremarkable
• Extremities: unremarkable
• Neurologic: unremarkable

Radiography

His initial chest x-ray is shown in Figure 1.

Figure 1. Initial chest radiograph.

Which of the following best describes the chest x-ray? (Click on the correct answer to proceed to the second of seven pages)

1. Elevated right hemidiaphragm
2. Large right pleural effusion
3. Right lower lobe and middle lobe consolidation
4. Right lung atelectasis
5. None of the above

Cite as: Wesselius LJ. December 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(6):268-75. doi: https://doi.org/10.13175/swjpcc122-16 PDF

Inhaler Device Preferences in Older Adults with Chronic Lung Disease

Laith Ghazala, MD¹

Christian Bime, MD MSc^1,2

Felipe Cortopassi, PT RPFT MBA³

Todd Golden, MS¹

Cristine E. Berry, MD MHS^1,2

¹Department of Medicine and the ²Asthma and Airway Disease Research Center

University of Arizona College of Medicine

Tucson, AZ USA

³ Pulmonary Department

State University of Rio de Janeiro

Rio de Janeiro, RJ, Brazil

Abstract

Introduction: Patient preferences are important for medication adherence and patient satisfaction, but little is known about older adult preferences for inhaler devices.

Methods: We developed a 25-item written self-administered questionnaire assessing experience with inhalers, prior inhaler education, and preferences with respect to inhaler device features and inhaler device teaching. We then conducted a cross-sectional survey of patients at least 65 years of age with chronic lung disease who had experience using inhaler devices for at least six months in the ambulatory setting.

Results: Fifty participants completed the questionnaire. The majority of participants (80%) reported prior experience with a metered dose inhaler (MDI), but only 26% used an MDI with a spacer. Most patients (76%) had received formal instruction regarding proper use of the inhaler, but only 34% had ever been asked to demonstrate their inhaler technique. Physician recommendation for an inhaler, cost of the inhaler device, and inhaler features related to convenience were important with respect to patient preferences. With regard to inhaler education, participants prefer verbal instruction and/or hands-on demonstration at the time a new inhaler is prescribed in the setting of the prescribing provider’s office.

Conclusion:  Patient preferences for inhaler devices and inhaler education among older adults indicate physician recommendation, cost, and convenience are important. The impact of patient preferences on inhaler adherence and clinical outcomes remains unknown.

Introduction

Inhalers represent the mainstay of treatment for most patients with chronic lung disease, especially obstructive lung diseases  (1,2). There are several different inhaler devices, including pressurized metered-dose inhalers, dry powder inhalers, soft mist inhalers, and nebulizers. Evidence suggests that different inhaler devices are equivalent with respect to drug delivery when the technique for appropriate utilization has been mastered (3,4). However, several factors may influence the ability to use an inhaler device properly, such as cognitive function, inspiratory flow rate, or hand strength and dexterity. These issues are particularly relevant to consider when prescribing inhaler devices for older adults (5-7).

The multitude of inhaler devices on the market is growing every day, and while this may allow providers to better tailor therapy to individual patient needs, it also increases the complexity of selecting an inhaler device (3,5). For prescribing providers, it is ever more challenging to consider all the potential factors that may influence both proper use of and adherence to inhaler therapy. Ideally, a provider would assess patient-level factors that impact proper device use and cost of the device to an individual patient, as well as patient preferences. Individual preferences may be shaped by prior experience with inhalers, exposure to advertising, advice from family and friends, lifestyle factors, comorbidities, recommendations from other healthcare providers, and a variety of other factors. Therefore, in selecting an inhaler device for a patient, it is important that providers consider factors beyond those that influence proper inhaler use, as patient preferences may impact adherence to therapy (3,5).

After providers identify an appropriate inhaler device that their patient is capable of using properly (considering physical and/or cognitive limitations) and that is selected based on patient preferences, the next obstacle to achieving maximal inhaler efficacy is ensuring the patient has been properly instructed on the multiple steps required for optimal medication administration from their inhaler device. While the importance of teaching patients about proper inhaler technique has been emphasized in international guidelines for the care of patients with asthma and chronic obstructive pulmonary disease (COPD) (1,2), there is limited information available about patient preferences for device instruction, especially in older adults, including timing, setting, and format of education.

The elderly represent an important population in which inhalers are frequently prescribed but the challenges of inhaler device selection are magnified (6-8). Accordingly, we conducted a single-center cross-sectional study to identify patient preferences for inhaler device features and inhaler device education among older adults in the ambulatory setting. The results of this study have been previously reported in the form of an abstract (9).

Methods

In order to assess patient preferences regarding inhalers, we developed a 25-item written questionnaire survey (see online supplement). In addition to patient preferences about inhaler device features and inhaler device education, the survey also assessed demographic information, medical history, patient experience with inhaler devices and prior device education, and perceived challenges to proper device use.

Participants were recruited from the ambulatory clinics (pulmonary and internal medicine) and pulmonary function laboratory at Banner University Medical Center in Tucson, Arizona between May 2014 and February 2015. Individuals were included if they were at least 65 years of age and had a history of chronic lung disease for which they were prescribed an inhaler device for at least six months. Those who were hospitalized, who did not speak English, or who were unable to read or write were excluded. Surveys were self-administered.

All participants provided written informed consent. This study was approved by the local institutional review board and was conducted according to the ethical principals of the Declaration of Helsinki.

Survey responses were subsequently recorded and tabulated in REDCap (https://projectredcap.org/). Categorical data was described using proportions (N(%)) and continuous data was described using mean with standard deviation (SD) or median with interquartile ratio (IQR).

Results

Fifty participants of mean age 74 (range 65-89) years completed the survey, including 22 men and 28 women (Table 1).

Table 1. Study Participant Demographic and Clinical Characteristics

N=50; continuous variables are described using mean (standard deviation) and categorical variables are described as n (%). *Physician diagnosis of respiratory disease; categories are not mutually exclusive and patients may report multiple diagnoses. COPD=chronic obstructive pulmonary disease.

The vast majority (96%) of participants were living at home, and most participants (78%) reported being independent with respect to activities of daily living. The participants were mostly well-educated, with 26% having completed college and 38% with a graduate degree. Comorbid conditions were common, including factors that may influence inhaler use and education, such as visual impairment (37%), hearing impairment (33%), and hand arthritis (22%). Almost all participants reported a physician diagnosis of chronic obstructive pulmonary disease (COPD) or asthma. In addition five patients also reported a history of interstitial lung disease; two of those had mixed history of asthma and ILD.

The majority of participants (80%) reported prior experience with a metered dose inhaler (MDI), but only 26% used an MDI with a spacer (Table 2).

Table 2. Prior Inhaler Devices Used and Prior Education Regarding Inhalers

N=50; categorical variables are described as n (%). *Categories are not mutually exclusive as patients may have been prescribed multiple inhaler devices by multiple providers and received formal instruction from multiple providers using multiple educational formats. MDI=metered dose inhaler, DPI=dry powder inhaler, Neb=nebulizer.

Most patients (76%) had received formal instruction regarding proper use of the inhaler, but only 34% had ever been asked to demonstrate their inhaler technique (Table 2). The majority of participants (66%) also reported no challenges to using their prescribed inhaler device properly (Table 3).

Table 3. Perceived Challenges Influencing Proper Use of Prescribed Inhaler

N=50; survey respondents could select more than one answer.

When asked to rate how well they understood the purpose of their inhaled medication (1=no understanding, 10=complete understanding), participants reported good understanding with a median rating of 8 (IQR 6-9). When asked to rate their confidence regarding how well they understood the proper use and handling of their inhaler device (1=no confidence, 10=very confident), participants reported a high level of confidence with a median rating of 9 (IQR 8-10).

When asked about the importance of various inhaler features with respect to their own individual preferences, participants provided a rating score ranging from 1 (not important) to 10 (very important) (Table 4).

Table 4. Patient Preferences Regarding Inhaler Features

N= 50; patient ratings are presented as median (IQR) scores and are based on a scale from 1 (not important) to 10 (very important).

Nearly all patients identified physician recommendation of an inhaler device as being very important with a median rating of 10 (IQR 10-10). Other inhaler features that were deemed important by most patients include device portability and short medication administration time. Some factors, such as whether or not an inhaler device required regular cleaning, afforded multiple doses, or was used once daily, received high median scores but demonstrated broader variability in overall response range. Cost of the inhaler was important to many patients as well with a median rating of 10 (IQR 4-10) (Table 4). Although the survey did not ask participants to compare devices, no significant difference was noted in the analysis regarding preferences between those taking nebulizers and those using DPI or MDI.

When asked about their preference for inhaler education format, participants indicated that they preferred hands-on demonstration and/or verbal instructions (Table 5).

Table 5. Patient Preferences Regarding Inhaler Device Education

*Some participants did not respond to all questions and thus denominator reflects total n that responded. Preferences are not mutually exclusive because participants could select multiple options.

The majority (70%) would like to receive this teaching at their prescribing doctor’s office, and most (71%) indicated they would like the education to occur at the time a new inhaler is prescribed (Table 5).

Discussion

In our cross-sectional survey of patient preferences in older adults with respiratory disease and prior inhaler experience, we determined that physician recommendation for a given inhaler and the cost of the inhaler were very important to patients. Moreover, patient preferences for inhaler features related to convenience were common, including device portability, once daily dosing, short medication administration time, and multiple-dose devices. The majority of patients also preferred an inhaler device that did not require routine cleaning, such as a nebulizer device. Providers may need to educate patients beyond the purpose of an inhaler by taking time to describe the reasons for selection of a particular inhaler, especially in cases where patient preferences are not aligned with provider objectives in selecting an appropriate inhaler device when there are patient-specific limitations to proper inhaler technique.

This is particularly important for older adults, as we demonstrated in our study that comorbidities that influence proper inhaler use are common among elder patients who have been prescribed inhalers (e.g. hand arthritis, sensory impairment, and stroke). However, in spite of this, we found in our study that spacers remain underutilized, with only a minority of patients who had experience with MDI also reporting prior use with a spacer. Using a spacer in conjunction with a MDI has been recommended for all patients because it minimizes the need for hand-breath coordination and facilitates better drug delivery ², but spacers are thought to be especially important for older adults who may experience additional challenges to proper inhaler technique (7,10). Arthritis that limits flexibility and coordination in the absence of weakness could also impact proper device administration.

Overall, study participants reported being quite confident that they understood how to properly use their inhaler, yet only a minority of patients had ever been asked to demonstrate how they use their inhaler. This is in contrast to international guidelines for obstructive lung disease that recommend checking inhaler technique at each visit. ^{1, 2} Participants also reported very few perceived challenges to proper inhaler use, and several individuals reported no challenges at all, even when they were permitted to provide their own free response in the survey. These findings suggest that patients may underestimate the complexity of inhaler delivery systems and may therefore underappreciate the importance of inhaler education. There are limited data to compare different devices in patients with chronic lung diseases and this was not addressed in our study; however, Komase et al. (11) found that DPI is a preferred device due to its ease of use and association with fewer errors.

Of note, study participants strongly preferred to receive inhaler education at the time a new inhaler is prescribed in the prescribing provider’s office. However, this may be challenging to implement in practice, given the vast number of inhaler devices on the market. Not all clinic staff may be familiar with the features of the different classes of inhaler devices, comparing MDI to DPI to nebulizer, much less feel comfortable teaching about the various features of different DPI devices that are now available. Moreover, placebo devices for patient teaching are not always readily available for each device, which makes it difficult to teach proper use at the time a new device is prescribed. Our study findings indicate participants preferred an educational format of verbal instruction and/or hands-on demonstration, but it may be more feasible for clinic staff to use a web-based video format for initial instruction while patients are still in the office setting and can ask questions as needed and they can then watch the video again at home. This should be followed by another clinic visit to assess proper inhaler technique using the patient’s own device shortly after the prescription is filled. Of course, this is particularly important for older adults because they are more likely to demonstrate errors in inhaler technique than younger patients (12).

To date, there is little evidence that taking into account patient preferences regarding inhaler devices results in improved clinical outcomes. However, preferences may influence multiple factors that are important for disease impact, including inhaler device adherence, health-related quality of life, and patient satisfaction with the selected device (13,14). Further research is needed to establish the relationship between patient preferences with inhaler devices and clinical outcomes in patients with obstructive lung disease. The limited evidence to date regarding patient preferences for inhalers suggests that patients find factors related to convenience very important, similar to our findings. For example, Molimard and colleagues (15) showed that dose recording, multiple-dose carrying, and daily dosing were important to patients with COPD and that delivery device features were more critical to patients than the medication compound that was delivered. Ease of use and ability to use the inhaler device during episodes of dyspnea were also found to be important DPI features in a European study of patients with asthma and COPD (16).

The major strengths of this study include that it is patient-centered with an emphasis on patient preferences for inhaler devices and inhaler education. Moreover, we focused on older adults because this special subpopulation often receives inadequate attention, especially in the study of patient preferences, and the physical and cognitive factors that influence proper inhaler use are particularly relevant among elders. We acknowledge that this study is limited in that we did not directly assess proper inhaler use among the participants but instead queried their understanding of proper inhaler use, and therefore we cannot definitively conclude if participants were overly confident or appropriately confident. It is also important to note that our study participants were predominantly Caucasian and also well educated, and therefore the patient preferences we observed may not be representative of all adults with chronic lung disease. Of note, we did not assess use of soft-mist inhalers (SMI) or preferences related to SMI in our survey because they were not widely available in our region at the start of this study.

Conclusion

In summary, patient preferences for inhaler devices and inhaler education among older adults indicate physician recommendation, cost, and convenience are important. Prescribing providers should explain their rationale for inhaler device selection and the importance of inhaler education because patient preferences may not always align with provider priorities or the individual patient-level physical and cognitive factors a provider may consider when selecting an inhaler device.

References

1. Global Initiative for Obstructive Lung Disease (GOLD). The Global Strategy for Diagnosis, Management and Prevention of COPD (updated 2016). Accessed July 18, 2016 at www.goldcopd.org.
2. Global Initiative for Asthma (GINA). The Global Strategy for Asthma Management and Prevention (updated 2016). Accessed July 19, 2016 at www.ginasthma.org.
3. Yawn BP, Colice GL, Hodder R. Practical aspects of inhaler use in the management of chronic obstructive pulmonary disease in the primary care setting. Int J Chron Obstruct Pulmon Dis. 2012;7:495-502. [CrossRef] [PubMed]
4. Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest. 2005 Jan;127(1):335-71. [CrossRef] [PubMed]
5. Geller DE. Comparing clinical features of the nebulizer, metered-dose inhaler, and dry powder inhaler. Respir Care. 2005 Oct;50(10):1313-21; discussion 1321-2. [PubMed]
6. Taffet GE, Donohue JF, Altman PR. Considerations for managing chronic obstructive pulmonary disease in the elderly. Clin Interv Aging. 2014;9:23-30. [CrossRef] [PubMed]
7. Barrons R, Pegram A, Borries A. Inhaler device selection: special considerations in elderly patients with chronic obstructive pulmonary disease. Am J Health Syst Pharm. 2011 Jul 1;68(13):1221-32. [CrossRef] [PubMed]
8. Jarvis S, Ind PW, Shiner RJ. Inhaled therapy in elderly COPD patients; time for re-evaluation? Age Ageing. 2007 Mar;36(2):213-8. [CrossRef] [PubMed]
9. Ghazala L, Bime C, Cortopassi F, Baalachandran R, Oren E, Berry CE. Inhaler device preferences in older adults with chronic lung disease. Am J Resp Crit Care Med. 2015;191(A5797) [Abstract].
10. Lavorini F, Mannini C, Chellini E, Fontana GA. Optimising Inhaled Pharmacotherapy for Elderly Patients with Chronic Obstructive Pulmonary Disease: The Importance of Delivery Devices. Drugs Aging. 2016 Jul;33(7):461-73. [CrossRef] [PubMed]
11. Komase Y, Asako A, Kobayashi A, Sharma R. Ease-of-use preference for the ELLIPTA® dry powder inhaler over a commonly used single-dose capsule dry powder inhaler by inhalation device-naïve Japanese volunteers aged 40 years or older. Int J Chron Obstruct Pulmon Dis. 2014 Dec 11;9:1365-75. [CrossRef] [PubMed]
12. Chorao P, Pereira AM, Fonseca JA. Inhaler devices in asthma and COPD--an assessment of inhaler technique and patient preferences. Respir Med. 2014 Jul;108(7):968-75. [CrossRef] [PubMed]
13. Anderson P. Patient preference for and satisfaction with inhaler devices. Eur Respir Rev. 2005;14(96):109-116. [CrossRef]
14. Shikiar R, Rentz AM. Satisfaction with medication: an overview of conceptual, methodologic, and regulatory issues. Value Health. 2004 Mar-Apr;7(2):204-15. [CrossRef] [PubMed]
15. Molimard M, Colthorpe P. Inhaler devices for chronic obstructive pulmonary disease: insights from patients and healthcare practitioners. J Aerosol Med Pulm Drug Deliv. 2015 Jun;28(3):219-28. [CrossRef] [PubMed]
16. Hawken NA, Amri I, Elmoctar Neine M, Aballea S, Torvinen S, Plich A. Preferences for Dry Powder Inhaler Attributes Among Patients With Asthma and Chronic Obstructive Pulmonary Disease From Five European Countries. Value Health. 2015 Nov;18(7):A364. [CrossRef] [PubMed]

Quick Look

Current Knowledge:

Inhalers are the mainstay of therapy for obstructive lung disease, but selection of a particular inhaler for an individual can be challenging, particularly in the elderly because of factors related to aging that may influence proper inhaler technique. Providers should also consider patient preferences, but little is known about preferences for inhaler devices among older adults.

What this paper contributes to our knowledge:

Patient preferences for inhaler devices and inhaler education among older adults indicate physician recommendation, cost, and convenience are important. Providers should consider individual patient factors that influence proper inhaler use along with patient preferences when selecting an inhaler.

Cite as: Ghazala L, Bime C, Cortopassi F, Golden T, Berry CE. Inhaler device preferences in older adults with chronic lung disease. Southwest J Pulm Crit Care. 2016;13(5):225-34. doi: https://doi.org/10.13175/swjpcc097-16 PDF

November 2016 Pulmonary Case of the Month

November 2016 Pulmonary Case of the Month

Anjuli M. Brighton, MB, BCh, BAO

Tania Jain, MBBS

Alan H. Bryce, MD

Ramachandra R. Sista, MD

Robert W. Viggiano, MD

Lewis J. Wesselius, MD

Pulmonary and Hematology/Oncology Departments

Mayo Clinic Arizona

Scottsdale, AZ USA

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Anjuli M. Brighton, MB.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

Our patient is a 76-year-old gentleman  who was referred based on an abnormal CT scan. He has a history of metastatic melanoma and had begun immunotherapy with pembrolizumab 10 months prior to admission. He had low grade fevers and chills and some dyspnea on exertion and dry cough. He also had a 6-8 pound weight loss over 4 weeks.

PMH, SH and FH

He has a history of hairy cell leukemia since 2009; squamous and basal cell cancers; and diabetes on insulin. He is a retired commercial banker and has a 15 pack-year smoking history.

Physical Examination

Physical examination showed and SpO2 of 90% on room air. His lungs were clear. He had numerous depigmented lesions on his skin.

Radiography

A thoracic CT scan was performed (Figure 1) and compared to a scan done 3 months prior which was considered unremarkable.

Figure 1. Video of representative images of contrast-enhanced thoracic CT scan in lung windows.

Which of the following best describe the CT scan? (Click on the correct answer to proceed to the second of four pages)

1. Normal
2. Mosaic pattern of lung attenuation
3. Numerous bronchial-associated ground glass opacities
4. Numerous pulmonary nodules
5. Numerous pulmonary nodules with a halo sign

Cite as: Brighton AM, Jain T, Bryce AH, Sista RR, Viggiano RW, Wesselius LJ. November 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016:13(5):191-5. doi: http://dx.doi.org/10.13175/swjpcc098-16 PDF

Tobacco Company Campaign Contributions and Congressional Support of the Cigar Bill

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Abstract

Although it is widely held that campaign contributions influence support for legislation, the impact of contributions is unclear. Despite lack of a tobacco growing or manufacturing constituency, many members of Congress (MOC) in the Southwest support the pro-tobacco Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2015 (HR 662/S 441), aka the "Cigar Bill". The association between campaign contributions from tobacco companies (2006-16) with cosponsor for the Cigar Bill were examined. There was a highly significant correlation with 92% of Southwest MOC who cosponsored the Cigar Bill having received campaign contributions. In contrast, 31% of those who did not cosponsoring the bill had received tobacco company campaign contributions (p<0.001 by Fisher's Exact Test). These data demonstrates a highly significant correlation between campaign contributions and legislative support for the "Cigar Bill".

Introduction

It is generally accepted that campaign donations buy influence from elected legislators. However, a review by Powell (1) states that "political scientists have had great difficulty determining whether and how much influence contributions have on the legislative process". Studies have been inconsistent with some demonstrating a linkage between campaign contributions and influence while others do not, suggesting that there are other influences in addition to contributions. Powell (1) has pointed out that the influence of donations is likely to occur early in the legislative process such as during cosponsorship for legislation or earmarks.

The Traditional Cigars Manufacturing and Small Business Jobs Preservation Act of 2015 (HR 662/S 441, aka the "Cigar Bill"), would permanently exempt hand-rolled and certain machine-rolled cigars from any sort of FDA regulation. This legislation is opposed by at least 20 medial and public health organizations including the American Thoracic Society (ATS), the parent organization of the state thoracic societies including those in the Southwest US (2). The ATS states that  “HR 662 would undermine the science-based process created by the Tobacco Control Act for determining the appropriate level of oversight of tobacco products. The bill would prohibit FDA from promulgating any public health protections related to 'traditional large and premium cigars'. The bill would specifically exempt from FDA oversight some machine made cigars, including those which can cost as little as $1.00. It also could allow some flavored cigars to qualify for an exemption. Inexpensive and flavored cigars such as strawberry, grape, cherry, and chocolate, are exactly the type of cigars attractive to young people.” Furthermore, the bill would create a giant regulatory loophole for the cigar industry to exploit, including advertising to children, growing the candy-flavored cigar market and returning to false advertising tactics such as "light" or "low tar", and allowing certain machine rolled cigars to be widely distributed.

The Southwest US is not a major center for tobacco growing or manufacturing (3). Furthermore, tobacco consumption tends to be low in Southwest US (4). Therefore, the Southwest is a good area to study the influence of campaign contributions on legislative behavior because of the lack of the confounding influence of a constituency that makes a living by tobacco growing or manufacturing and even has a low prevalence of smokers. In this context, we examined the correlation between prior campaign contributions to MOC and their cosponsorship of the "Cigar Bill".

Methods

Campaign Contributions

Tobacco company political action committee (PAC) contributions to Congressional candidates was obtained from the Campaign for Tobacco-Free Kids website (5). Contributions from the years listed (2006-14) were summed and no effort was made to separate recent from more past contributions. The data was examined for Southwest US Congressmen from Arizona, New Mexico, Colorado, California, Nevada and Hawaii. Appendix A shows contributions to individual Congressmen.

Cosponsorship of the "Cigar Bill"

HR 662 and S 441 were introduced in the 2015 Congress by Rep. Bill Posey (R-FL-8) and Sen. Bill Nelson (D-FL) respectively. Cosponsorship was obtained from Congress.gov (6,7). The bill was cosponsored by 165 members of the US House and 20 members of the US Senate. MOC who did or did not the "Cigar Bill" from Arizona, New Mexico, Colorado, California, Nevada and Hawaii are identified in Appendix B.

Statistics

The relationship between cosponsorship for the "Cigar Bill" and tobacco campaign contributions was done by Fisher's exact test using a 2X2 contingency table. Amounts of campaign contributions were expressed as mean + SD. The Mann-Whitney U test was used to calculate comparisons of the amounts of campaign contributions.

Results

Eighty-four percent of Southwest MOC who cosponsored the "Cigar Bill" had received tobacco campaign contributions. In contrast, only 31% of Southwest MOC not cosponsoring the "Cigar Bill" had received tobacco company campaign contributions (p<0.001 by Fisher's Exact Test). Furthermore, the amount of contributions was larger for those cosponsoring the bill $14024 + $18384 compared to those who did not $4165 + $11240 (p<0.01 by Mann-Whitney U test).

Discussion

This manuscript shows a relationship between tobacco campaign contributions and cosponsorship of the pro-tobacco "Cigar Bill". Furthermore, the campaign amounts tended to be larger to those supporting the legislation compared to those who did no cosponsor the bill. Taken together these data suggest an influence of campaign contributions on legislation.

There is no doubt that cigarette smoking is harmful. Cigarette use among adults and high school students is decreasing compelling US tobacco companies to search for new markets (8). The cigar market, especially the flavored cigar market, represents one strategy to increase tobacco consumption and profits. Flavored cigar and cigarette use is increasing in US middle and high school students (9). Tobacco manufacturers have a history of modifying their products to avoid public health protections or attain lower tax rates (2). Therefore, tobacco companies supporting the "Cigar Bill" is not surprising. By removing regulation the tobacco companies can increase advertising to children and grow the candy-flavored cigar market. Furthermore, it seems likely that cigar manufacturers will modify their products or change their manufacturing processes to qualify for the exemptions provided by the "Cigar Bill" thus increasing the number of cigars on the market.

The title of the HR 662/S 441 is deceiving. The Traditional Cigar Manufacturing and Small Business Jobs Preservation Act is titled to conjure up images of small businesses hand-rolling premium cigars. However, many of the cigars being manufactured would not appear to be the large, thick, and expensive cigars manufactured with fine tobacco but rather small, thin, cheap cigars that are often flavored. There is little tobacco growing or manufacturing in the Southwest US making it difficult for the Congressmen to claim that they are supporting local small business. The lack of a constituency raises the question of why Southwest Congressmen are supporting this bill.  

This manuscript has several limitations. First, it seems likely that more recent campaign contributions might have greater legislative influence. However, we do not have campaign contributions after 2014 and made no effort to separate more recent from past tobacco company campaign contributions. Second, receiving tobacco company campaign contributions and cosponsoring the "Cigar Bill" does not necessarily represent cause and effect. It seems likely that tobacco companies would be more likely to support legislators that they perceive are sympathetic. Third, as pointed out by Powell (1), the issue of buying influence is likely more complex. For example, at least 2 of the legislators in Arizona object to smoking on religious grounds but have taken tobacco company contributions.  

Political support for any candidate is a complex issue. However, during this election year voters might wish to examine the behavior of their elected representatives and factor in support of pro-tobacco legislation when casting their ballot.

References

1. Powell LW. The influence of campaign contributions on legislative policy. The Forum: A Journal of Applied Research in Contemporary Politics 2013;11(3):339-55. [CrossRef]
2. American Thoracic Society. ATS opposes cigar bill in Congress. ATS Perspectives. Available at: https://www.thoracic.org/about/ats-perspectives/ats-opposes-cigar-bill-in-congress.php (accessed 8/9/16).
3. Statistica. Statistics and facts about the tobacco industry. Available at: http://www.statista.com/topics/1593/tobacco/ (accessed 8/9/16).
4. Campaign for tobacco-free kids. Key state-specific tobacco-related data & rankings. Available at: https://www.tobaccofreekids.org/research/factsheets/pdf/0176.pdf (accessed 8/9/16).
5. Campaign for Tobacco-Free Kids. Tobacco company political action committee (pac) contributions to Federal candidates. Available at: https://www.tobaccofreekids.org/what_we_do/federal_issues/campaign_contributions/ (accessed 8/9/16).
6. Congress.gov. H.R.662 - Traditional cigar manufacturing and small business jobs preservation act of 2015. Available at: https://www.congress.gov/bill/114th-congress/house-bill/662/cosponsors (accessed 8/9/16).
7. Congress.gov. S.441 - Traditional cigar manufacturing and small business jobs preservation act of 2015. Available at: https://www.congress.gov/bill/114th-congress/senate-bill/441/cosponsors?q=%7B%22search%22%3A%5B%22S441%22%5D%7D&resultIndex=1 (accessed 8/9/16).
8. Centers for Disease Control. Trends in current cigarette smoking among high school students and adults, United States, 1965–2014. Available at: http://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking/ (accessed 8/9/16).
9. King BA, Tynan MA, Dube SR, Arrazola R. Flavored-little-cigar and flavored-cigarette use among U.S. middle and high school students. J Adolesc Health. 2014 Jan;54(1):40-6. [CrossRef] [PubMed]

Cite as: Robbins RA. Tobacco company campaign contributions and congressional support of the cigar bill. Southwest J Pulm Crit Care. 2016;13(4):187-90. doi: http://dx.doi.org/10.13175/swjpcc076-16 PDF

October 2016 Pulmonary Case of the Month

Coya T Lindberg, BS¹

Ryan R Nahapetian, MD²

F Zahra Aly, MD, PhD, FRCPath³

¹University of Arizona College of Medicine Tucson, Tucson, AZ

²Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona, Tucson, AZ

³Brody School of Medicine at East Carolina University, NC

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Coya Lindberg, BS.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

A 49-year-old man presented with chest discomfort to an outside medical facility in Arizona. He was previously healthy and had no chronic medical diseases. Physical examination was unremarkable and he was afebrile. A chest X-ray was performed (Figure  1).

Figure 1. Initial chest x-ray

Which of the following is most likely? (Click on the correct answer to proceed to the second of five panels)

1. There is a large right chest mass
2. There is a loculated pleural effusion in the minor fissure
3. There is a right ventricular aneurysm
4. There is right lower lobe consolidation
5. There is right middle lobe consolidation

Cite as: Lindberg CT, Nahapetian RR, Aly FZ. October 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(4):152-8. doi: http://dx.doi.org/10.13175/swjpcc096-16 PDF

September 2016 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Lewis J. Wesselius, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

The patient is a 52 year-old woman with prior renal transplant in 1998 due to complications of pre-eclampsia. She had a recent decline in renal function leading to re-transplant on June 23 of this year. She was admitted to the hospital on July 8th with ventricular tachycardia. Treatment with amiodarone was begun with no further ventriuclar tachycardia. She is also taking usual anti-rejection medications.

Past Medical History, Social History and Family History

Other than the renal transplantation she has no other significant past medical history and has never smoked. Family history is noncontributory.

Physical Examination

Physical examination was unremarkable other than the surgical wounds associated with her renal transplants.

Radiography

Her chest x-ray is shown in Figure 1.

Figure 1. Admission chest radiograph.

What should be done at this time? (Click on the correct answer to proceed to the second of four panels)

1. Discontinue the amiodarone
2. Empiric antibiotics
3. Plasma brain naturetic peptide (BNP)
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. September 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(3):101-7. doi: http://dx.doi.org/10.13175/swjpcc086-16 PDF

August 2016 Pulmonary Case of the Month

Anjuli M. Brighton, MB, BCh, BAO

Kathryn E. Williams, MB, BCh, BAO

Lewis J. Wesselius, MD

Pulmonary Department

Mayo Clinic Arizona

Scottsdale, AZ USA

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Anjuli M. Brighton, MB.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

The patient is 54-year-old man with type 1 diabetes mellitus admitted for diabetic ketoacidosis (DKA). He complained of somnolence, nausea and vomiting and right foot pain. He had been admitted 2 weeks earlier for right foot gangrene. He had been receiving daptomycin for his right foot gangrene.

PMH, SH and FH

He had a previous history of osteomyelitis, perianal abscess, maxillary abscess, Candida esophagitis, transient ischemic attack, and peripheral vascular disease. He had previous amputations along with thrombectomy/ embolectomy/bypass. He was a former Marine and construction worker with ongoing cigarette use. Family history was noncontributory.

Physical Examination

• Febrile to 38.2ºC
• Crackles bilaterally
• Transmetatarsal stump with dry gangrene

Radiography

An admission chest x-ray was performed (Figure 1).

Figure 1. Admission portable AP of chest.

Which of the following are appropriate at this time? (Click on the correct answer to proceed to the second of four panels)

1. Blood and wound cultures
2. Empiric antibiotics including coverage for Staphylococcus aureus
3. Intravenous insulin and fluids
4. Serially monitor renal function and electrolytes
5. All of the above

Cite as: Brighton AM, Williams KE, Wesselius LJ. August 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(2):40-5. doi: http://dx.doi.org/10.13175/swjpcc070-16  PDF 

July 2016 Pulmonary Case of the Month

Kashif Yaqub, MD

Robert Viggiano, MD

Imran S. Malik, MD

Zayn A. Mian

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Kashif Yaqub, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

A 53 year-old woman presented to the emergency department with dyspnea over 3 weeks. There was no cough, wheezing or other complaints.

Past Medical History, Social History and Family History

She has no significant past medical history. She was a nonsmoker. Family history was unremarkable.

Physical Examination

Decreased breath sounds over the left lower chest but otherwise unremarkable.

Laboratory Evaluation

• Elevated white blood cell count with a left shift
• Na+ 130 mEq/L
• 10-20 RBCs on urinalysis

Radiographic Evaluation

A CT angiogram of the chest was performed for possible pulmonary embolus (Figure 1).

Figure 1. Representative images from the thoracic CT in lung windows (A) and soft tissue windows (B).

Which of the following is appropriate at this time? (Click on the correct answer to proceed to the second of six panels)

1. Biopsy of left pleural mass
2. Bone marrow aspiration
3. Diuretics for congestive heart failure
4. Empiric antibiotics for empyema
5. Thoracentesis

Cite as: Yaqub K, Viggiano R, Malik IS, Mian AZ. July 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(1):1-8. doi: http://dx.doi.org/10.13175/swjpcc051-16 PDF

June 2016 Pulmonary Case of the Month

Katie Murphy, MB BCh BAO¹

Henry D. Tazelaar, MD²

Laszlo T. Vaszar, MD³

¹Departments of Internal Medicine, ²Laboratory Medicine and Pathology and ³Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Katie Murphy, MB.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

A 77-year-old gentleman presented with 6 weeks of:

• Sinus congestion
• Bloody nasal discharge
• Cough with maroon sputum
• Dyspnea
• Hearing loss
• Painful peripheral neuropathy
• Left median neuropathy and left foot drop
• Fevers

Past Medical History, Social History and Family History

• No significant past medical history
• Retired
• Does not smoke
• Family history is noncontributory

Physical Examination

• Temperature of 37.8º C
• Bloody nasal discharge
• Lungs clear to auscultation and percussion
• Heart with a regular rhythm without murmur
• Neurologic findings consistent with his complaints

Laboratory Evaluation

• Elevated white blood cell count with a left shift
• Na+ 130 mEq/L
• 10-20 RBCs on urinalysis

Radiographic Evaluation

Initial chest x-day is shown in Figure 1.

Figure 1. Initial PA radiograph of chest.

Which of the following is (are) the next appropriate steps in the evaluation? (Click on the correct answer to proceed to the second of five panels)

1. Transthoracic echocardiogram
2. Treat with macrolide antibiotics for outpatient pneumonia
3. Thoracic CT scan
4. 1 and 3
5. All of the above

Cite as: Murphy K, Tazelaar HD, Vaszar LT. June 2016 pulmonary case of the month. Soutwest J Pulm Crit Care. 2016 Jun;12(6):205-11. doi: http://dx.doi.org/10.13175/swjpcc041-16 PDF

May 2016 Pulmonary Case of the Month

Jennifer M. Hall, DO

Banner University Medical Center Phoenix

Phoenix, AZ USA

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Jennifer M. Hall, DO.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

A 24-year-old woman was diagnosed with pneumonia while on her honeymoon in Europe. She received an unknown treatment as an outpatient. When she returned a repeat chest x-ray showed persistent lung infiltrates. At that time she was asymptomatic. She was referred to pulmonary for further evaluation.

Past Medical History, Family History, Social History

• Idiopathic thrombocytopenic purpura at age 8
• Recurrent “bronchitis” since childhood
• Lifelong non-smoker, occasional ETOH, no illicit drugs
• No significant family history, other than hypertension in her father

Physical Examination

She had bibasilar fine crackles (fine) otherwise her physical examination was unremarkable.

Radiography

A chest x-ray was performed and interpreted as showing bilateral basilar interstitial infiltrates (Figure 1).

Figure 1. Chest x-ray showing bibasilar interstitial infiltrates.

To better define the abnormalities on chest x-ray a thoracic CT scan was performed (Figure 2).

Figure 2. Representative images from the thoracic CT scan in lung windows.

Based on the CT scan, which of the following diagnosis is least likely? (Click on the correct answer to proceed to the second of five panels)

1. Hematogenous metastasis
2. Hypersensitivity pneumonitis
3. Lymphangitic metastasis
4. Miliary tuberculosis
5. Sarcoidosis

Cite as: Hall JM. May 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016 May;12(5):165-70. doi: http://dx.doi.org/10.13175/swjpcc037-16 PDF 

April 2016 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Rodrigo Cartin-Ceba, MD 

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Lewis J. Wesselius, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

The patient is a 75-year-old woman who presented with a chest mass incidentally found on chest x-ray. She was asymptomatic

Past Medical History, Social History and Family History

She has no significant past medical history and has never smoked. Family history is noncontributory.

Physical Examination

Physical examination was unremarkable.

Radiography

A thoracic CT scan was performed (Figure 1).

Figure 1. Representative thoracic CT scan in soft tissue windows showing  a mass (arrow).

Which of the following are possible causes of the mass? (Click on the correct answer to proceed to the second of four panels)

1. Lymphoma
2. Teratoma
3. Thymoma
4. Thyroid carcinoma
5. All of the above 

Cite as: Wesselius LJ, Cartin-Ceba R. April 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016 Apr;12(4):126-9. doi: http://dx.doi.org/10.13175/swjpcc032-16 PDF 

Pulmonary Embolism and Pulmonary Hypertension in the Setting of Negative Computed Tomography

Peter V. Bui, MD

Sapna Bhatia, MD

Dona J. Upson, MD, MA

Department of Internal Medicine

Division of Pulmonary, Critical Care, and Sleep Medicine

The University of New Mexico and Raymond G. Murphy VA Medical Center

Albuquerque, NM

Abstract

Introduction: Chronic pulmonary hypertension (PH) can display acute elevations in pulmonary arterial pressure (PAP) in the setting of hypoxemia, pulmonary embolism (PE), and possibly sepsis.

Case Description: A 68-year-old man with chronic obstructive pulmonary disease, heart failure, recent tobacco cessation, and recent 2-vessel coronary artery bypass grafting (CABG) presented with one to two weeks of respiratory symptoms and syncope on the day of admission. He was found to have a urinary tract infection and Escherichia coli bacteremia. Transthoracic echocardiography found a systolic PAP of 100-105 mmHg, increased from a mean PAP of 32 mmHg before CABG. PE was not seen on computed tomography angiography (CTA). Ventilation-perfusion scan two days later found evidence of subsegmental PE. PAP prior to discharge was 30-35 mmHg plus right atrial pressure.

Conclusion: PAP can rise substantially in the acute or subacute setting, particularly when multiple disease processes are involved, and decrease to (near) baseline with proper therapy. Chronic PH may even be protective. In a complex clinical setting with multiple possible etiologies for elevated PAP, clinicians should have a high suspicion for PE despite a negative CTA.

Abbreviation List

ADHF acute decompensated heart failure

CABG coronary artery bypass grafting

COPD chronic obstructive pulmonary disease

CTA computed tomography angiography

CXR conventional chest radiograph
EF ejection fraction

HCAP healthcare-associated pneumonia

HFpEF heart failure with preserved ejection fraction

INR international normalized ratio

LV left ventricle

PAP pulmonary arterial pressure

PCWP pulmonary capillary wedge pressure

PE pulmonary embolism

PH pulmonary hypertension

RA right atrium/atrial

RV right ventricle/ventricular

RHC right heart catheterization

SaO2 arterial oxygen saturation

TTE transthoracic echocardiography

UTI urinary tract infection

VTE venous thromboembolism

VQ ventilation-perfusion

Introduction

Pulmonary hypertension (PH) is classified into five groups (1). In the United States, the incidence and prevalence of PH and each of its five groups are largely unclear. Group 2, due to left heart disease, has a prevalence as high as 83% by transthoracic echocardiography (TTE) in patients with heart failure with preserved ejection fraction (HFpEF) (2). For group 3, due to chronic lung disease, in a study measuring pulmonary arterial pressure (PAP) by right heart catheterization (RHC), the prevalence of PH among patients with chronic obstructive pulmonary disease (COPD) was 36% (3). Changes in PAP in the setting of acute or subacute pulmonary embolism (PE) are unknown. We present a patient found to have transient severely elevated PAP in the setting of a negative computed tomography angiography (CTA) and positive ventilation-perfusion (VQ) scan with distractors including HFpEF, COPD, and sepsis.

Case Presentation

A 68-year-old man with severe COPD on four liters per minute of supplemental oxygen, a 50-pack-year smoking history with cessation two months before admission, HFpEF, 3-vessel coronary artery disease, myocardial infarction involving the left circumflex artery, recent 2-vessel coronary artery bypass grafting (CABG), recurrent urinary tract infections (UTIs), chronic prostatitis, and prostatic calculi presented after a syncopal episode. One day prior to admission, he experienced fevers to 40°C and shaking chills. On the day of admission, the patient woke up struggling for breath and experienced syncope while getting out of bed. He had been having altered mental status and one week of productive cough with greenish sputum. He did not have any other respiratory, urinary, and constitutional symptoms. He presented to an outside hospital, where he was treated for presumed sepsis secondary to a UTI and started on an antibiotic. He was transferred to our facility and admitted for a UTI and possible healthcare-associated pneumonia (HCAP).

At presentation at our facility, vital signs included a temperature of 36.8°C, heart rate of 87 beats per minute, blood pressure of 124 mmHg / 69 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 96% on three-to-four liters per minute of supplemental oxygen. The physical examination was notable for expiratory wheezing and trace lower extremity edema. White blood cell was 13.5 K/mm³, neutrophilia of 80.4%, troponin I of 0.048 ng/mL, N-terminal pro-brain natriuretic peptide of 2800 pg/mL, and urinalysis suggestive of UTI. An arterial blood gas was deemed unnecessary for unchanged supplemental oxygen, normal mentation, and lack of respiratory distress. Electrocardiography showed normal sinus rhythm, nonspecific ST and T wave abnormalities, and previously identified signs of inferior-posterior infarction without evidence of acute right heart strain. He did not receive chemoprophylaxis for venous thromboembolism (VTE) because of possible surgical intervention.

Ten days before admission (Table 1), he made a long distance drive to see Cardiothoracic Surgery for post-CABG follow-up.

Table 1. Timeline of events surrounding the patient’s hospitalization. Computed tomography angiography (CTA). Coronary artery bypass grafting (CABG). Conventional chest radiographs (CXR). Ejection fraction (EF). International normalized ratio (INR). Pulmonary arterial pressure (PAP). Pulmonary embolism (PE). Transthoracic echocardiography (TTE). Urinary tract infection (UTI). Ventilation-perfusion (VQ).

He had an increased oxygen requirement from three-to-four to four-to-five liters per minute, bilateral lower extremity edema, and supratherapeutic international normalized ratio (INR) of 4.4 on warfarin for postoperative atrial fibrillation, that had since resolved. TTE showed a normal sized left ventricle (LV), LV ejection fraction of 50-55%, inferolateral wall akinesis, basal inferior wall akinesis, mildly dilated right ventricle (RV), mildly reduced RV systolic function, mildly dilated right atrium (RA), PAP of 70-80 mmHg, and right atrial pressure of 10-15 mmHg. The patient refused hospitalization. Furosemide and metolazone were increased, and warfarin discontinued. His INR was 1.4 four days before admission.

Outpatient medications included amiodarone, simvastatin 10 mg, aspirin 81 mg, metoprolol 25 mg three times a day, and furosemide 80-100 mg daily. Six weeks prior to admission, RHC found RA pressure of 12 mmHg, RV pressure of 45/15 mmHg, PAP of 45/25 mmHg with a mean pressure of 32 mmHg, pulmonary capillary wedge pressure (PCWP) of 15 mmHg, cardiac output of 7.98 L/min, cardiac index of 3.55 L/min/m², SaO2 97%, mixed venous saturation of 71%, pulmonary vascular resistance of 2.1 dynes-sec-cm^-5, and system vascular resistance of 782 dynes-sec-cm^-5.

At presentation, his respiratory symptoms were attributed to pneumonia and not acute decompensated heart failure (ADHF) or COPD. Initial antibiotics for HCAP and UTI coverage were cefepime and vancomycin. Conventional chest radiographs (CXRs) (Figure 1) on hospital day 0 and the CTA a few days later were not suggestive of pneumonia.

Figure 1. Conventional radiography of the chest showing no acute cardiopulmonary findings but enlarged pulmonary arteries.

An influenza viral panel was negative. Outside blood cultures grew Escherichia coli, while blood, urine, and sputum cultures from our facility were negative. CXRs over the following week were unchanged.

Because of the elevated PAP found prior to admission, Pulmonology was consulted for pulmonary hypertension. TTE on hospital day 3 found a normal RV size, mildly reduced RV systolic function, mildly dilated RA, systolic PAP of 100-105 mmHg, and RA pressure of <5 mmHg. His Wells score for PE was 3.0 to 4.5, suggesting moderate risk (4). The CTA did not identify a PE. In view of a high suspicion for PE, Pulmonology reviewed the CTA with a chest radiologist, who noted that the images were of suboptimal thickness. A VQ scan (Figure 2) was ordered on hospital day 5 and showed multiple bilateral VQ defects consistent with a high probability for PE.

Figure 2. Ventilation-perfusion scan on hospital day 5 showing multiple bilateral ventilation-perfusion defects. The study was consistent with a high probability for pulmonary embolism.

Ultrasound Doppler studies of the lower extremities on hospital day 6 were normal. Repeat TTE on hospital day 5 found a normal sized LV, LV EF of 45-50%, basal inferior wall akinesis, inferolateral wall akinesis, mildly dilated RV, mildly reduced RV systolic function, normal RA size, and PAP of 30-35 mmHg plus RA pressure. The patient was discharged on anticoagulation and antibiotics.

Discussion

We describe a patient who developed transiently elevated PAP in the setting of sepsis secondary to UTI and E. coli bacteremia, acute or subacute PE, HFpEF, and COPD. At baseline, he likely had PH from COPD and HFpEF out of proportion to PCWP. The increased PAP to 70-80 mmHg 1.5 weeks prior to admission was thought to be due to the hypervolemia observed by outpatient Cardiothoracic Surgery. Recent CABG, long-distance travel, and infection predisposed him to VTE. PE may have caused the dyspnea and syncope experienced on the day of admission. The negative CTA and systolic PAP of 100-105 mmHg on TTE on hospital day 3 may have reflected movement of PE downstream to the subsegmental or smaller arteries and thus inability to be seen on CTA, especially given the suboptimal thickness of the images. Volume status and vascular changes in the setting of recent hypervolemia, possibly due to HF or PH, and concurrent infection may have contributed to this elevated PAP. In light of the presentation of unexplained dyspnea and syncope, Wells score of 3.0 to 4.5, and elevated PAP, suspicion for PE was high. The high pretest probability of PE precipitated obtaining a VQ scan on hospital day 5. The scan supported the presence of bilateral PE, likely in the subsegmental or smaller arteries. PAP of 30-35 mmHg on subsequent TTE suggested resolution of PE.

CTA is the most common study to diagnose acute PE. A number of early studies found CTA to be at least as equivalent in sensitivity and specificity to VQ scan (5-10). Studies using data from the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II found the sensitivity and specificity of CTA to be 83% and 96%, respectively, and of VQ scan to be 77.4%. and 97.7%, respectively (11, 12). However, CTA miss up to 20% to 36% of PE in subsegmental and smaller arteries (13-15). A meta-analysis of Wells criteria found sensitivity and specificity of 0.84 and 0.58, respectively, for a cutoff score of less than 2 and 0.60 and 0.80, respectively, for a cutoff score of 4 or less (16).

The degree to which HFpEF, COPD exacerbation, acute or subacute PE, and sepsis affect PAP has had limited investigation. In patients with ADHF, Aronson et al. (17) found PH in 42.6% and pulmonary arterial systolic pressures as high as 70 to 80 mmHg. Sibbald et al. (18) found that 57% of septic patients developed PH and had increases in mean PAP (27 ± 7 mmHg in septic patients found to have PH versus 15 ± 3 mmHg in septic patients found not to have PH, p < 0.01). In patients with chronic bronchitis who went into acute respiratory failure, Abraham et al. (19) found transient increases in mean PAP of approximately 15-20 mmHg (mean PAP 52.2 mmHg at admission and 36.5 mmHg prior to discharge).

The mechanism of PH can be mechanistically complex or intuitively simple. PH involves changes in nitric oxide, endothelin, thromboxane, and prostacyclin pathways, among other possible cellular and biological pathways of pulmonary endothelial dysfunction (20-25). Proinflammatory signals such as during infection affect these pathways (26). Other mechanisms include vascular congestion in HF, physical obstruction from PE, and vasoconstriction in hypoxemia leading to elevated PAP and subsequent PH (27-31). In our patient, there was likely a combination of several mechanisms contributing to his elevated PAP and PH.

Our patient may have been able to tolerate such an acute rise in pulmonary hypertension because of the effects of chronic pulmonary hypertension, although the pathophysiologic mechanisms have not been fully elucidated. Vonk-Noordegraaf et al. (32) described adaptive and maladaptive remodeling in pulmonary hypertension. In adaptive remodeling, the RV size is normal to moderately dilated; the RV mass/volume ratio is higher than normal, as seen in concentric remodeling; and the RVEF is normal to mildly decreased. For our patient, multiple TTE suggested adaptive remodeling, although our cardiologists did not comment on concentric remodeling.

We present the case of a patient with multiple comorbidities including HFpEF and COPD that likely caused the baseline PH seen on previous RHC and the subsequent development of severely increased PAP in the setting of sepsis and acute or subacute PE. His underlying chronic PH may have been protective given that he did not develop acute right HF from the sudden increase in PAP, and survived. The transient elevation in PAP in our patient reiterates that many disease processes can affect PAP, whether directly or indirectly, through simple or complex mechanisms. A CTA to evaluate possible PE should be verified to have the proper technique. A high suspicion for PE in the setting of acute PH despite a negative CTA warrants further investigation.

Acknowledgements

Dr. Loren Ketai of the Department of Radiology of The University of New Mexico reviewed the images of the computed tomography angiography and ventilation-perfusion scans.

Cecilia Kieu assisted in the preparation of the figures for this manuscript.

References

1. Simonneau G, Gatzoulis MA, Adatia I, Celermajer D, Denton C, Ghofrani A, Gomez Sanchez MA, Krishna Kumar R, Landzberg M, Machado RF, Olschewski H, Robbins IM, Souza R. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2013 Dec 24;62(25 Suppl):D34-41. [CrossRef] [PubMed]
2. Lam CS, Roger VL, Rodeheffer RJ, Borlaug BA, Enders FT, Redfield MM. Pulmonary hypertension in heart failure with preserved ejection fraction: a community-based study. J Am Coll Cardiol. 2009 Mar 31;53(13):1119-26. [CrossRef] [PubMed]
3. Andersen KH, Iversen M, Kjaergaard J, Mortensen J, Nielsen-Kudsk JE, Bendstrup E, Videbaek R, Carlsen J. Prevalence, predictors, and survival in pulmonary hypertension related to end-stage chronic obstructive pulmonary disease. J Heart Lung Transplant. 2012 Apr;31(4):373-80. [CrossRef] [PubMed]
4. Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000 Mar;83(3):416-20. [PubMed]
5. Blachere H, Latrabe V, Montaudon M, Valli N, Couffinhal T, Raherisson C, Leccia F, Laurent F. Pulmonary embolism revealed on helical CT angiography: comparison with ventilation-perfusion radionuclide lung scanning. AJR Am J Roentgenol. 2000 Apr;174(4):1041-7. [CrossRef] [PubMed]
6. Chen SW, Mouratidis B. Comparison of lung scintigraphy and CT angiography in the diagnosis of pulmonary embolism. Australas Radiol. 2002 Mar;46(1):47-51. [CrossRef] [PubMed]
7. Macdonald WB, Patrikeos AP, Thompson RI, Adler BD, van der Schaaf AA. Diagnosis of pulmonary embolism: ventilation perfusion scintigraphy versus helical computed tomography pulmonary angiography. Australas Radiol. 2005 Feb;49(1):32-8. [CrossRef] [PubMed]
8. Mayo JR, Remy-Jardin M, Müller NL, Remy J, Worsley DF, Hossein-Foucher C, Kwong JS, Brown MJ. Pulmonary embolism: prospective comparison of spiral CT with ventilation-perfusion scintigraphy. Radiology. 1997 Nov;205(2):447-52. [CrossRef] [PubMed]
9. McEwan L, Gandhi M, Andersen J, Manthey K. Can CT pulmonary angiography replace ventilation-perfusion scans as a first line investigation for pulmonary emboli? Australas Radiol. 1999 Aug;43(3):311-4. [CrossRef] [PubMed]
10. Teigen CL, Maus TP, Sheedy PF 2nd, Stanson AW, Johnson CM, Breen JF, McKusick MA. Pulmonary embolism: diagnosis with contrast-enhanced electron-beam CT and comparison with pulmonary angiography. Radiology. 1995 Feb;194(2):313-9. [CrossRef] [PubMed]
11. Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, Leeper KV Jr, Popovich J Jr, Quinn DA, Sos TA, Sostman HD, Tapson VF, Wakefield TW, Weg JG, Woodard PK; PIOPED II Investigators. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006 Jun 1;354(22):2317-27. [CrossRef] [PubMed]
12. Sostman HD, Stein PD, Gottschalk A, Matta F, Hull R, Goodman L. Acute pulmonary embolism: sensitivity and specificity of ventilation-perfusion scintigraphy in PIOPED II study. Radiology. 2008 Mar;246(3):941-6. [CrossRef] [PubMed]
13. Goodman LR, Curtin JJ, Mewissen MW, Foley WD, Lipchik RJ, Crain MR, Sagar KB, Collier BD. Detection of pulmonary embolism in patients with unresolved clinical and scintigraphic diagnosis: helical CT versus angiography. AJR Am J Roentgenol. 1995 Jun;164(6):1369-74. [CrossRef] [PubMed]
14. Oser RF, Zuckerman DA, Gutierrez FR, Brink JA. Anatomic distribution of pulmonary emboli at pulmonary angiography: implications for cross-sectional imaging. Radiology. 1996 Apr;199(1):31-5. [CrossRef] [PubMed]
15. van Rossum AB, Pattynama PM, Ton ER, Treurniet FE, Arndt JW, van Eck B, Kieft GJ. Pulmonary embolism: validation of spiral CT angiography in 149 patients. Radiology. 1996 Nov;201(2):467-70. [CrossRef] [PubMed]
16. Lucassen W, Geersing GJ, Erkens PM, Reitsma JB, Moons KG, Büller H, van Weert HC. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med. 2011 Oct 4;155(7):448-60. [CrossRef] [PubMed]
17. Aronson D, Darawsha W, Atamna A, Kaplan M, Makhoul BF, Mutlak D, Lessick J, Carasso S, Reisner S, Agmon Y, Dragu R, Azzam ZS. Pulmonary hypertension, right ventricular function, and clinical outcome in acute decompensated heart failure. J Card Fail. 2013 Oct;19(10):665-71. [CrossRef] [PubMed]
18. Sibbald WJ, Paterson NA, Holliday RL, Anderson RA, Lobb TR, Duff JH. Pulmonary hypertension in sepsis: measurement by the pulmonary arterial diastolic-pulmonary wedge pressure gradient and the influence of passive and active factors. Chest. 1978 May;73(5):583-91. [CrossRef] [PubMed]
19. Abraham AS, Cole RB, Green ID, Hedworth-Whitty RB, Clarke SW, Bishop JM. Factors contributing to the reversible pulmonary hypertension of patients with acute respiratory failure studies by serial observations during recovery. Circ Res. 1969 Jan;24(1):51-60. [CrossRef] [PubMed]
20. Christman BW, McPherson CD, Newman JH, King GA, Bernard GR, Groves BM, Loyd JE. An imbalance between the excretion of thromboxane and prostacyclin metabolites in pulmonary hypertension. N Engl J Med. 1992 Jul 9;327(2):70-5. [CrossRef] [PubMed]
21. Cooper CJ, Jevnikar FW, Walsh T, Dickinson J, Mouhaffel A, Selwyn AP. The influence of basal nitric oxide activity on pulmonary vascular resistance in patients with congestive heart failure. Am J Cardiol. 1998 Sep 1;82(5):609-14. [CrossRef] [PubMed]
22. Cooper CJ, Landzberg MJ, Anderson TJ, Charbonneau F, Creager MA, Ganz P, Selwyn AP. Role of nitric oxide in the local regulation of pulmonary vascular resistance in humans. Circulation. 1996 Jan 15;93(2):266-71. [CrossRef] [PubMed]
23. Giaid A, Saleh D. Reduced expression of endothelial nitric oxide synthase in the lungs of patients with pulmonary hypertension. N Engl J Med. 1995 Jul 27;333(4):214-21. [CrossRef] [PubMed]
24. Giaid A, Yanagisawa M, Langleben D, Michel RP, Levy R, Shennib H, Kimura S, Masaki T, Duguid WP, Stewart DJ. Expression of endothelin-1 in the lungs of patients with pulmonary hypertension. N Engl J Med. 1993 Jun 17;328(24):1732-9. [CrossRef] [PubMed]
25. Moraes DL, Colucci WS, Givertz MM. Secondary pulmonary hypertension in chronic heart failure: the role of the endothelium in pathophysiology and management. Circulation. 2000 Oct 3;102(14):1718-23. [CrossRef] [PubMed]
26. Toney BM, Fisher AJ, Albrecht M, Lockett AD, Presson RG, Petrache I, Lahm T. Selective endothelin-A receptor blockade attenuates endotoxin-induced pulmonary hypertension and pulmonary vascular dysfunction. Pulm Circ. 2014 Jun;4(2):300-10. [CrossRef] [PubMed]
27. Barman SA. Potassium channels modulate hypoxic pulmonary vasoconstriction. Am J Physiol. 1998 Jul;275(1 Pt 1):L64-70. [PubMed]
28. Setaro JF, Cleman MW, Remetz MS.The right ventricle in disorders causing pulmonary venous hypertension. Cardiol Clin. 1992 Feb;10(1):165-83. [PubMed]
29. Gelband CH, Gelband H. Ca2+ release from intracellular stores is an initial step in hypoxic pulmonary vasoconstriction of rat pulmonary artery resistance vessels. Circulation. 1997 Nov 18;96(10):3647-54. [CrossRef] [PubMed]
30. Post JM, Hume JR, Archer SL, Weir EK. Direct role for potassium channel inhibition in hypoxic pulmonary vasoconstriction. Am J Physiol. 1992 Apr;262(4 Pt 1):C882-90. [PubMed]
31. Wang J, Juhaszova M, Rubin LJ, Yuan XJ. Hypoxia inhibits gene expression of voltage-gated K+ channel alpha subunits in pulmonary artery smooth muscle cells. J Clin Invest. 1997 Nov 1;100(9):2347-53. [CrossRef] [PubMed]
32. Vonk-Noordegraaf A, Haddad F, Chin KM, Forfia PR, Kawut SM, Lumens J, Naeije R, Newman J, Oudiz RJ, Provencher S, Torbicki A, Voelkel NF, Hassoun PM. Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology. J Am Coll Cardiol. 2013 Dec 24;62(25 Suppl):D22-33. [CrossRef] [PubMed]

Cite as: Bui PV, Bhatia S, Upson DJ. Pulmonary embolism and pulmonary hypertension in the setting of negative computed tomography. Southwest J Pulm Crit Care. 2016 Mar;12(3):116-25. doi: http://dx.doi.org/10.13175/swjpcc016-16 PDF 

March 2016 Pulmonary Case of the Month

Ramachandra R. Sista, MD

Maxwell L. Smith, MD

 Lewis J. Wesselius, MD

Departments of Pulmonary Medicine and Pathology

Mayo Clinic Arizona

Scottsdale, AZ

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Ramachandra R. Sista, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

A 74-year-old man was referred for a recently identified right pleural effusion and dyspnea on exertion.  

Past Medical History, Family History and Social History

He has a history of anemia, hypertension, and prostate cancer with a prostatectomy in 2015. He is a life-long nonsmoker and has no occupational exposures. Family history is noncontributory.

Physical Examination

He had diminished breath sounds at the right lung base and a palpable spleen. Otherwise the physical examination was unremarkable.

Laboratory

CBC: hemoglobin  8.5 g/dL, white blood count  7.7 X 109 cells/L,  platelets 357 X 109 cells/L.

Radiography

A chest X-ray showed a right pleural effusion. Representative images from the CT scan are shown in Figure 1.

Figure 1. Representative images from the CT scan.

Which of the following is the most likely diagnosis? (Click on the correct answer to proceed to the second of five panels)

1. Empyema
2. Lung cancer
3. Tuberculosis
4. Usual interstitial pneumonia
5. Valley fever (coccidioidomycosis)

Cite as: Sista RR, Smith ML, Wesselius LJ. March 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;12(3):74-80. doi: http://dx.doi.org/10.13175/swjpcc020-16 PDF

February 2016 Pulmonary Case of the Month

Ashley Garrett, MD

Karen Swanson, DO

Pulmonary Department

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 77-year-old woman presented with dyspnea on exertion which was progressive for several years.  She remains active but is "winded" with vigorous exercise or altitude. She denied cough, orthopnea , paroxysmal nocturnal dyspnea, chest pain or a prior history of pulmonary infections.  

Past Medical, Social and Family History

She has a history of a seizure disorder and fibromyalgia. She has never smoked or drank and has no history of occupational exposures. There was no family history of respiratory disease.

Physical Examination

Her physical exam was unremarkable.

Current Medications

Topamax and alprazolam.

Radiography

A chest radiograph was performed (Figure 1).

Figure 1. Initial chest radiography.

Which of the following describe the initial chest x-ray? (Click on the correct answer to proceed to the second of five panels)

1. The chest x-ray is normal
2. There is a left lower mass
3. There is bronchial dilatation and edema
4. There is hyperinflation
5. Three is a retrocardiac left lower pneumonia

Cite as: Garrett A, Swanson K. February 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;12(2):34-40. doi: http://dx.doi.org/10.13175/swjpcc012-16 PDF