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https://www.youtube.com/watch?v=j_oRQS2dnck

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male, 73y/o, progressive dynpnea on excretion, dry cough, no weezes. non-smoker

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-Patient details (ID)
-Current complaint/help request
-Medical history
-Family history
-Social/occupational history

-     Complaints

o   Worsening dyspnea, dry cough, no sputum production/fevers/hemoptysis,

-       Anamnesis & Physical examination

o   Low FVC (<70%)  indicates restriction or obstruction

o   Normal range FEV1/FVC (>80%)  indicates not obstructive

o   Very low TLC (<80%)  indicates restrictive, not obstructive

o   Very low DLCO (<80%)  indicates abnormal alveolar surface/ parenchymal lung disease

-       Problem

o   A restrictive lung disease

-       Differential diagnosis

o   Infection; interstitial pulmonary edema...

-       Additional investigation

o   CT scan  for looking at tissue density; X-ray  show small volume lungs with shadowing

-       Diagnosis

o   Pulmonary fibrosis? Idiopathic

-       Therapy & Prognosis

o   2-5 years life span post diagnosis; variable

o   Perfenidone & Nintedanib

o   Transplant assessment

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Spirometry

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Because it has a higher affinity for hemoglobine than O2. Since the body normally does not use O2.  The diffusion rate of CO and O2 are the same.

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to see where the airflow imitation is. If reduced from predicted = restricted. If it is concave = obstructie.

first 25%: bigger airways  limitation

last 25%: smaller airways are affected

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Spirometry is good, but if the patient is not cooperating, the test results wont be accurate.

The plethysmography is a good meausre, but if the patient is clastrophobic, it is not an option Body plethysmography is a pulmonary (lung-related) function test that determines how much air is in your lungs after you take in a deep breath. It also measures the amount of air left in your lungs after you exhale as much as you can.

What does it measure?

§  ITGV, RV, TLC

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look at equilibrium. used to measure RV.

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bad quality, because there is fluid in the lungs. You use US when you think there is leakage in the lungs

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they can provoke airway with histamine. They want to see if your hyper-reactive. They measure the FEV1 before and after histamine. if it falls more than 20% then the patient is hyper-reactive. They can asses the severity of the condition.

What does histamine do? It is part of our immune system. histamine is related to allergic reaction. With histamine you induce an allergic reaction. People with allergies have a hyper-reaction to "normal" substances.

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opens up the bronchi. When you have asthma: in pre test, you see decreased functioning. in post test, you see improvement after brochodialator. Bronchodialator works on the smooth muscle of the lungs and thus the lungs open up more.

Athsma is reversible! Until its not any more, then you have COPD

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Bronchoprovocation = looks at how responsive your bronchi are to allergants and stimuli.
1. Histamine challenge. Everytime the dose of histamine doubles. In what range do you see a drop in FEV1? The range tells you about severity (everyone will respond at some point).
2. Methacholine = More or less same test, but different ranges . Are there different pathways that can be triggered? Methacholine is a non-selective muscarinic receptor agonist that acts directly on airway smooth muscle receptors to induce bronchoconstriction.
3. Mannitol = More or less same test, but different ranges. Bronchial provocation testing uses a variety of direct and indirect inhalational challenges to evaluate airway hyperreactivity. Mannitol, a simple, easy-to-administer hypertonic stimulus available in many countries, is currently under review by the FDA in the US. Healthy subjects show no airway response to inhaled mannitol; asthmatic patients respond with airway narrowing similar to challenges with hypertonic saline and exercise. Mannitol challenge also has a tussive effect that is independent of bronchoconstriction, suggesting different physiologic pathways. Patients with chronic cough show increased sensitivity to mannitol, and mannitol testing may be useful for evaluating heterogeneity in the cough response.
4. Exercise testing = See if your asthma becomes worse/active when exercising.
5. Eucapnic Hyperventilation test = Person sits and hyperventilates cold dry air (similar effect as exercise). Spirometry after hyperventilation.