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Definitions

Outbreak

• incidence of new cases beyond the usual frequency of disease in a population or community in a given

time

Endemic

• consistent existence of infectious agent or disease in a given population or area (i.e. usual rate of

disease)

Epidemic

• an increase, often sudden, in cases of a disease above what is usually expected in a particular

population (e.g. SAKS epidemic)

• can occur due to a recent increase in the virulence or amount of an agent, introduction of a new agent

to an area, enhanced mode of transmission of the agent, altered host response, and/or increased host

susceptibility through more exposure or portals of entry

Pandemic

• epidemic that has spread across international or intercontinental boundaries, alTecting a large number

of people (e.g. COVID-19 pandemic)

Attack Rate

• proportion of an initially disease-free population that develops the disease over a specified time period

• = [(* of new cases of disease) / (initial population size)) ’ 100%

Secondary Attack Rate

• the proportion of individuals who develop disease as a result of exposure to primary contacts during

the incubation period

• = [(total # of cases - initial

- of cases) / (- ofsusceptible individuals - initial # of cases)] * 100%

• measure of infectiousness, which reflects the ease of disease transmission

Active Surveillance

Outreach such as visits or phone calls by

the public health/surveillance authority

to detect unreported cases (e.g. an

infection control nurse goes to the ward

and reviews temperature charts to see il

any patient has a nosocomial infection)

Passive Surveillance

A surveillance system where the public

health/surveillance authority depends

on others to submit standardized forms

or other means of reporting cases(e.g.

ward staff notify infection control when

new cases of nosocomial infections are

discovered)

Virulence

• measure of an infectious agent to cause significant sickness

• = (* of cases that are severely ill or died) / (total # of cases)

Case-Fatality Rate (CFR)

• proportion of individuals with the disease who died as a result of the illness during a specified time

period

• must be dearly differentiated from the mortality rate

Mortality Rate

• proportion of the population that died from any cause during a specified time period

• crude mortality rate (unadjusted for age)

Basic Reproduction Number (RO)

• the average number of secondary infections that arise from one infection

• can only be calculated in a susceptible population

Reducing Inequities During the COVID-19 Pandemic

Public Health Rev 2022:42:1604031

• this review outlines public health recommendations during the COVID-19 Pandemic including

primordial, primary,secondary, and tertiary prevention strategies

Canada's Response to the COVID-19

Pandemic

• In late 2019. the novel coronavirus

(COVID-19) led to a global pandemic

• By May 2020, there were over 70000

cases in Canada and more than 4.3

million cases worldwide

• Symptoms of the virus varied from

dry cough,fever, and fatigue, to mote

severe respiratory symptomssuch as

dyspnea and chest pain

• PHAC developed the following

response:

• Development and implementation

of new diagnostic tests based on

the genetic sequence of COVID-19

• Prompt identification, risk

assessment, management, and

placement of confirmed cases by

healthcare professionals

• Application of routine practices

and additional precautionsfor

healthcare workers: gloves, longsleeved gowns, facial protection,

and masls

• Enforcement of national physical

distancing protocols and 14-day

self-isolation for those returning

from international travel

• Free vaccines against COVID-19

were made available to everyone in

Canada over the course of 2021

• The temporary closure of many

Institutions and reduction in income

for millions of Canadians resulted in

novel social assistance programs,

such astheCanada Emergency

Response Benefit

Source:Gcri«rrxnt ol Canada.Coronavirus(COVI0-19):

Canada'

s llespomo [IntetnctJ. Ottawa (ON}: Govurnmort

ol Canada:2020Moled 2020 Jim 18; ut«d 2020

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Steps to Control an Outbreak

Infection Control Precautions

Contact (e.g. impetigo, chicken pox, warts)

• wash hands

• gloves

• gown

• wipe equipment after use

Droplet (e.g. influenza, mumps, pneumonia) +

• contact precautions PLUS

• goggles/face shield

• surgical mask

PH25 Public Health and Preventive Medicine Toronto Notes 2023

Airborne (e.g. TB)

• contact precautions PLUS

• N95 mask (fit-tested)

• negative pressure room

Figure 16.Epidemic curves

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Table 10. Ten-Step Approach B

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Steps Details

1.Identify the investigation team and resources Local public health units {e.g.Toronto Public Health)

Federal level {e.g.PHAC)

Compaie the number of cases during the suspected outbreak to the

number of cases expected during a non-outbreak time frame

(e.g.receiving a report of a vomiting baseball team after a team dinner

at a restaurant)

Obtain medical records and lab reports

Conduct further clinical testing as needed

3 components:Person. Place.Time {e.g. "Diagnosis A:Person with XVZ

signs and symptoms...Occurred alter visiting X...During months/year'')

A line listing should include clinical information (signs/symptoms,onset

times/dates), demographic Information,exposure information

Create epidemic curves (see figure 16 )

Case -control studies:uselul whennot everyone exposed can be found

and Included in the study

Cohort studies:useful when all persons exposed can be included in

the study

Can occur at any stage inan outbreak (e.g.Isolation)

Involve the media to address public concerns and call for public action

Determine when the outbreak Is over

Document the effectiveness of control measures

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2.Establish existence of an outbreak Day of OnsQt

Figure 16a. Point source epidemic

curve 3.Verify the diagnosis

4.Definea case

»

S.Find cases systemically and create a line listing

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6. Perform descriptive epidemiology anddevelop hypotheses

7.Evaluate hypotheses and conduct additional studies as needed

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Day of Onsot

8. Implement control measures

9.Communicate findings

10.Continue surveillance

Figure 16b.Extended continuous

source epidemic curve

Source: Adopted fiom Mootc 2. Outbreak Investigations: The 10-Step Approach [Internet!. Ninth Carolina: Government of North Carolina;[updated

2019 Dec 16:cited 2020 Jun 20). Available (tom:https:/ /epi.dph.ncdhlis.gov

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Infection Control Targets a '

i:

• interventions should target host, agent, environment, and their interactions z :

nutrition,

sickle coll trait

antimalarials,

proper nutrition

f Day of Onset host

age, immune

response,

susceptibility

-J’

-- Figure 16c. Propagated source

epidemic curve

Q

. educate,

\ avoid exposed

skin at dusk

DISEASE MALARIA

II environment

climate,physical

structures, population

density

plasntodiuin

falciparum

eradicate,

genetically modify

agent tropical.

virulence,toxicity,

ability to survive

outside body

remove stagnant

water sources stagnant water

mosquito netting on homes

Figure 17. Epidemiology triad as framework for infection control interventions:practical example using

malaria

The International Health Regulations (IHR)

• an international agreement involving 196 nations to prevent, protect against, control, and provide a

public health response to pandemics

• a public health emergency of international concern (PHE1C) is “

an extraordinary event which is

determined to constitute a public health risk to other States through the international spread of

disease and to potentially require a coordinated international response"

• the IHR Emergency Committee provides the WHO Director-General with temporary

recommendations on PHE1C events

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PH26 Public Health and Preventive Medicine Toronto Notes 2023

Environmental Health

Environmental Health Jurisdiction

Taking an Environmental Health History

CMAI 2002; 166{8):1049-1055

Definition

• study of the association between environmental factors ( both constructed and natural) and health

• environmental exposures

• four common hazards: chemical, biological, physical, and radiation

four main reservoirs: air, food, water, and soil

• three main routes: inhalation, ingestion, or absorption (skin )

• usually divided into two main settings

• workplace (including schools): may see high level exposure in healthy individuals (see

Occupational Health, PH29)

• non-workplace: lower levels of exposure over a longer period of time; affects vulnerable

populations more severely,such as at extremes of age, and the immunosuppressed; maybe

teratogenic

• health impacts of the environment also include factors (e.g. urban planning) and how individuals

interact with the built environment (e.g.safe pedestrian and bicycle paths can facilitate more active

lifestyles)

CH20PD2

Community

Home

Hobbies

Occupation

Personal habits

Diet

Drugs

BPA, The Toxin Concern of 2009

Bisphenol A (BPA) is a chemical

compound found in some hard,

dear lightweight plastics and resins.

According to the NIH, animal studies

suggest that ingested BPA may imitate

estrogen and other hormones.In

Odober 2008, Canada became the first

country in the world to ban the import

and sale of polycarbonate baby bottles

containing BPA. stating that although

exposure levels are below levels that

cause negative effects, current safety

margins need to be higher. The US FDA

does not consider normal exposure to

BPA to be a hazard, however the NIH

has some concern that fetuses, infants,

and children exposed to BPA may be at

increased risk for early-onsct puberty,

prostate, and breast cancer

Table 11. Environmental Health Jurisdiction

Public Health Unit Enforcement of water and food safety regulations (including restaurant food safety)

Assessment of local environmentalrisks

Monitoring and follow-up of reportable diseases

Investigation of environmental contamination,clusters of disease

Waste disposal,recycling,water and sewage Ireatmenl/colleclion/distribution

Water and air quality standards

Industrial emission regulation

Tonic waste disposal

Designating and regulating tonic substances

Regulating food products (e.g. Health Canada (drugs), Canadian food Inspection Agency (CfIA))

Setting policy for pollutants that can travel across provincial boundaries

Multilateral agreements (e.g. Kyoto Protocol,UN Convention on Climate Change. International

Joint Commission)

Municipal Government

Provincial and Territorial Government

Federal Government

International

Source-Path-Receiver Model

• to prevent workplace injuries,strategies can be implemented to improve the safety profile of the

source, modify the path, and/or protect the receiver

Cannabis Legalization and Driving

Under the Influence of Cannabis (DUIC)

Soutce:Put

*

[Health OnUnlo.Evidence BrlvMliivIng

Undei theInliuence ol Cannabis,2017

Since the Government of Canada stated

its commitment to legalize cannabis

via the Cannabis Act (Bill C-45) on April

13, 2017,the Canadian Task Force on

Cannabis Legalization and Regulation

specifically noted driving impairment

as an important consideration. Higher

cannabis use. cannabis-dependence,

lower perceived risk from DUIC, and

normative beliefs about DUIC were

identified as risk factors. As such, an act

to amend the Criminal Code Bill C-46

was simultaneously introduced to enable

the police to request an oral fluid sample

for roadside drug screening and to

implement THC per se whole blood limits

(>2 ng/mL punishable). Public health

was also advised to devise populationbased interventions such as 6 hour

waiting period recommendations before

driving, as well as preventive strategies

through addiction services, massmedia campaigns, and school-based

instructional programs

Environmental Risk Assessment

Hazard Identification and Risk Assessment (HIRA)

Hazard Identification

what is the hazard involved?

• assess potential hazards by taking environmental health history

Risk Characterization

• is the identified agent likely to elicit the patient’

s current symptoms?

• review known health impacts of the hazard and identify specific properties that contribute to or

diminish adverse effects (e.g. evaluate hazard threshold levels)

Exposure Assessment

• is the patient’s exposure to the environmental agent sufficient to have caused the current symptoms?

• quantify exposure through direct measurement or by reviewing frequency and nature of contact with

hazard

Adapted from p.2S0, Sixth Edition ol A Dictionary ol Epidemiology by Miguel Porta

Air

Biological Hazards

• moulds thrive in moist areas; 10-15% of the population is allergic

• bacteria survive as spores and aerosols, can be distributed through ventilation systems (e.g.

Legionella)

• dust mites (yr-round) and pollens (seasonal) can trigger upper- and lower-airway symptoms

Chemical Hazards

• ground-level ozone

• main component ofsmog with levels increasing in major cities

worsens asthma, irritates upper airway

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PH27 Public Health and Preventive Medicine Toronto Notes 2023

•carbon monoxide (fossil fuel-related, common byproduct of combustion)

aggravates cardiac disease at low levels

headache, nausea,dizziness at moderate levels

fatal at high levels

•sulphur dioxide (fossil fuel-related), nitrogen oxides

• contribute to acid rain and exacerbate breathing difficulties

•organic compounds at high levels (e.g. benzene, methylene chloride, tetrachloroethylene)

tend to be fat-soluble, easily absorbed through skin, and difficult to excrete

•heavy metal emissions (e.g. nickel, cadmium, chromium)

variety of health effects: upper airway disease, asthma, decreased lung function

•second-hand tobacco smoke

respiratory problems, increased risk of lung cancer

• particulates associated with decreased lung function, asthma, upper airway irritation

Radiation Hazards

•sound waves

•ionizing radiation

radon is naturally produced by soil containing uranium or radium; can contaminate indoor air

associated with ~20% of lung cancers

•increasing ultraviolet radiation from ozone layer destruction increases risk of skin cancer

•non-ionizing radiation

visible light, infrared, microwave

Particulate Matter Air Pollution and

Cardiovascular Disease; An Update to the

Scientific Statement Irom the American Heart

Association

Circulation 20I0:121(21):2331 23/8

Ascientihc statement by the American Heart

Association in 2004 reported that enposate to

particulate matter air pollution contributesto

cardiovascular morbidity and mortality. An updated

American Heart Association statement in 2010

confirmed a causal relationship between paniculate

matter eiposure and cardiovascular morbidity

and mortality.The statement reported thatsuch

an eiposure over several h to wk may trigger

cardiovascular disease-related mortality and nonfatal events,whereas longer eiposurtsover several

yr may further increase cardiovascular mortality risk

and leducelife eipectanty within higtily-eiposed

populations by several mo to yr

The Walkerton Tragedy

In May 2000, the drinking water system

in the town of Walkerton. ON. became

contaminated with Escherichia coli

0157:H7 and Campylobacter jejuni.

Over 2300 individuals became ill; 27

people developed hemolytic uremic

syndrome and 7 individuals died in the

outbreak

Source:Ministry c4 the Attorney General.Report ot Hie

Walkerton injury.Ontario. 2002

Water

Biological Hazards

• mostly due to human and animal waste

• Indigenous peoples.Black Nova Scotians, and rural Canadians at higher risk

• bacteria: Escherichia coli (e.g. Walkerton, ON),Salmonella, Pseudomonas, Shigella

• protozoa:

(iiardia.Cryptosporidium (e.g. North Battleford, SK )

Chemical/Industrial Hazards

• chlorination by-products (e.g. chlorinated water can cause cancer at high levels)

• volatile organic compounds, heavy metals, pesticides, and other industrial waste products can be

present in groundwater

• mercury from fish (exposure during pregnancy can he neurotoxic for the fetus)

• asbestos (e.g. from old buildings)

• lead (can be found in paint, older buildings, and traditional medicines in dangerous quantities)

Water Fluoridation

Water fluoridation, and the resulting

decrease in dental caries and reduction

in health inequities, is one of the

greatest public health achievements of

the 20th century.At the recommended

concentration of 0.7 mgll, fluoride

reduces cavities by 18-40%.Small but

vocal groups opposed to fluoridation

have claimed that fluoride intake is

not easily controlled, and that children

may be more susceptible to health

problems.These claims have been

widely debunked but still persist,and

have led some communities to opt not

to fluoridate their water, resulting in

increased dental caries (e.g.Calgary).

Fluoride concentrations In municipal

water should be 0.7 ppm

Soil

Biological Hazards

• biological contamination:tetanus, Pseudomonas

Chemical Hazards

• contamination sources: rupture of underground storage tanks, use of pesticides and herbicides,

percolation of contaminated water runoffs, leaching of wastes from landfills, dust from smelting and

coal burning power plants, residue of industrial waste/development (e.g. urban agriculture), lead

deposition, leakage of transformers

• most common chemicals: petroleum hydrocarbons, solvents, lead, pesticides, motor oil, other

industrial waste products

• infants and toddlers at highest risk of exposure due to hand-mouth behaviours

• effects dependent on contaminant:leukemia, kidney damage, liver toxicity, neuromuscular blockade,

developmental damage to the brain and nervoussystem,skin rash, eye irritation, headache, nausea,

fatigue

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PH28 Public Health and Preventive Medicine Toronto Notes 2023

Food

Biological Hazards

Organic Foods

• Foods designated as “organic" in

Canada must conform to the Organic

Products Regulations enforced by the

Canadian Food Inspection Agency

i Organic foods are not free of

synthetic pesticide residues but

typically contain smaller amounts

compared to conventionally grown

foods

• Currently,there has not been

strong evidence to suggest that

eating organic foods is safer or

more nutritious compared to eating

conventionally grown foods

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Table 12. Comparison of Select Biological Contaminants of Food and Effects on Human Health

Source Effects

Salmonella

Campylobacter

Ischetkhiacoli

Raw eggs,poultry,meat

Raw poultry,raw milk

Various including meal, sprouts

Primarily undercooked hamburger meat

Gl symptoms

Joint pain.Gl symptoms

Wateiy or bloody diarrhea

Hemolytic uremic syndrome (especially

children)

Listeriosis:nausea, vomiting,fever,headache,

rarely meningitis or encephalitis

Listeriamonocytogenes Unpasteurized cheeses, prepared salads,

cold cuts

Clostridium botulinum Unpasteurized honey, canned foods Dizziness,weakness,respiratory failure

Gl symptoms:thirst, nausea, constipation

Prion (BSE“ ) Beef and beet products Variant Creutzlcldl-Jakobdisease

‘BSE •(mine spongiform encephalopathy

•other biological food contaminants include:

viruses,mould toxins(e.g. aflatoxin has been associated with liver cancer),parasites(e.g.

Toxoplasma gondii, tapeworm), paralytic shellfish poisoning (rare), genetically modified

organisms (controversial as to health risks/benefits)

Chemical Hazards

•many persistent organic pollutants are fat-soluble and undergo bioamplification

•drugs(e.g. antibiotics, hormones)

•inadequately prepared herbal medications

•food additives and preservatives

nitrites highest in cured meats; can be converted to carcinogenic nitrosamines

« sulphites commonly used as preservatives; associated with sulphite allergy (hives, nausea,shock)

•pesticide residues

• older pesticides (e.g. DDT) have considerable human health effects (e.g. dermatological,

gastrointestinal, neurological, carcinogenic,respiratory, reproductive, and endocrine effects)

•polychlorinated biphenyls (PCBs)

effects (severe acne, numbness, muscle spasm, bronchitis) much more likely to be seen in

occupationally-exposed individuals than in the general population

•dioxins and furans

levels highest in fish and marine mammals, also present in breast milk

• can cause immunosuppression, liver disease, and respiratory disease

Examples of Simple Interventions to Reduce Environmental Exposures and Risk of

Disease

•sunscreen to preventsunburns and U V-related damage

•ear plugs to prevent damage from high intensity sound waves

Environmental Racism

•defined as the deliberate and disproportionate development of environmental hazards and toxic

facilities near communities without a strong voice (Indigenous,immigrant, racialized groups, and

lower SES)

•furthermore, historic and present-day colonialist and racist practices contribute to the

marginalization of these communities, resulting in a diminished organizational capacity and political

power to advocate against the placement and impacts of these environmental hazards

•exposure to these environmental hazards therefore undergird to poorer health outcomes and

marginalization already faced by affected individuals and communities •can also impact livelihood

(e.g.fishing, agriculture, hunting, trapping)

•examples of environmental racism in Canada are ubiquitous against Indigenous communities and

communities of colour. Present-day examples include:the placement of oil and gasindustries(e.g.

the Trans-Mountain pipeline across Indigenous lands); a lack of access to potable water, asseen in

communitiessuch as Attawapiskat, Ontario; and other environmental hazards, with two specific

examples provided below

L J

Grassy Narrows, Ontario

* a reserve in northwest Ontario, which came to public attention in the 1970s when many of its residents

began to develop symptoms of mercury poisoning, including severe neurotoxicity

•the source of contamination was attributed to an upstream paper mill dumping tonnes of untreated

mercury into the water over a period ofseveral years

+

PH29 Public Health and Preventive Medicine Toronto Notes 2023

•a loss of natural resources and environmental stewardship had a devastating pervasive impact on the

community:

• the decimation of two majorsources of employment in the area (fishing and working as guides)

contamination of local food and watersupplies

leaving the community with limited resources to manage the short- and long-term effects of

mercury poisoning

•despite ongoing protest, agreement from the federal government to build a mercury treatment facility

was not reached until 2020, approximately 50 years following the initial contamination of Grassy

Narrows. At time of writing, construction of such a facility had yet to begin

•despite the federal government’

s promise to eliminate drinking water advisories on reserves,61

remain in effect as of February 2020, many in communities that are not even isolated

•oil sands,hydroelectric,diamond mines, and many other projects have negatively impacted

Indigenous territories across Canada. Indigenous peoples have reaped very little of the economic

benefits from these activities

•the remote geographic location of many Indigenous communities, in conjunction with complex

jurisdictional issues, lead to debate over who is responsible for the health of these communities;this

often leaves communities with delayed and inadequate responses to community needs

•Canada'

s adoption of the United Nations Declaration on the Rights of Indigenous Peoples (U NDR1P)

will help rectify some of these detrimental activities on our environment and Indigenous peoples

Africville, Nova Scotia

•Halifax was founded in 1749

•African people, many of whom were descendants ofslavesin Jamaica, dug out roads and built much of

the city

•the early Black community lived a few kilometres north of the city in a community established on the

Bedford Basin in Halifax, an area that became Africville

•the proximity to the waterfront for fishing, prospects for wage labour in the city, and establishment of

structures including a post office,school, and church created a tight-knit Black community which, at

one point, housed over 400 individuals and families

•facilities deemed otherwise unfit forsurrounding areas were established in Africville by city council

and businesses, including an oil plant, tar factory, prison, hospital for infectious diseases, and open

garbage dump, with raw sewage and waste products emptying directly into the water supply

•the community was denied resources available to predominantly White neighbouring areas, despite

being within the municipal jurisdiction, including garbage collection, law enforcement, paved roads,

and appropriate water treatment

•in 1957,the city expropriated the land for industrial use and forced the relocation of residents, many

of whom into public housing

•a settlement was reached between some former Africville residents and the City of Halifax in 2010,

although an application for a class-action lawsuit submitted to the Supreme Court of Halifax was

overturned in 2018

•on 24 February 2010, Halifax Regional Municipality Mayor Peter Kelly apologized for the destruction

of Africville

(

*

;

Taking an Occupational Health Hx:

WHACS

What do you do?

How do you do it?

Ate you concerned about any particular

exposures on or off the job?

Co-workers or others with similar

problems?

Satisfied with your job?

Source:jOcuip tfinoi Med1998:40.680-684

Occupational Health

• a field involved in the prevention of illness or injury and the promotion of health in the work

environment

• services encompass recognizing and controlling exposure to hazards(primary prevention),

occupational health surveillance and screening (secondary prevention), and treatment and

rehabilitation (tertiary prevention)

• occupational disease often looks clinically the same as non-occupational disease and, without a

thorough occupational health history, may go unrecognized as distinct

Occupational Health Statistics

• In 2018,1027 workers died of workrelated causes in Canada

. The average time-lossinjury rate

between 2014-2018 ranged across

Canadian provinces and territories

from 1.02 to 2.89 per 100 workers

• Provincial and territorial

compensation boards do not cover

all workplaces(e.g.most agricultural

workers)

• Compensation board insurance

coverage ranges across provinces

and territoriesfrom 74-99% of the

workforce

Soura:2020Deport OP Stork taljit,end Injury Dates

inCauda

Taking an Occupational Health History

• current and previous duties at place of employment

• exposures

identification:screen for chemical, metal, dust, biological,and physical hazards as well as

psychologicalstressors- workers may bring safety data sheets (formerly MSDSs) that provide

information about hazards of exposure

• assessment:duration, concentration, route, exposure controls (e.g. ventilation and other

environmental controls, personal protective equipment)

• temporal relationship: changes in symptoms in relationship to work environment, latency between

first exposure and currentsymptoms

• presence ofsimilarsymptoms in co-workers

• non-work exposuresto hazardous agents: home, neighbourhood, hobbies

• additional assessment may be required (e.g. chest radiography, ultrasound, PFT)

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Information about worker'

s

compensation at: https://awcbc.org/en/

PH30 Public Health and Preventive Medicine Toronto Notes 2023

Occupational Hazards OuapationalSafcty And Health Enforcement

tool!For Preventing Occupational Diseases

A nd Injuries

Cochrane OBSyst Re*

2013:8.00010183

Purpose: To assessthe effectsof occupational

safety and health regulation enforcement tools for

preventing occupational diseases and injuries.

Outcome: Inspectionsdecrease injuries In the long

term, but notshort term,ruth an unclear magnitude

of effect.

Table 13. Occupational Hazards

Physical Chemical Biological Psychosocial Ergonomic/Safety

Otganic solvents(e.g.

beruene, methyl alcohol:

most toxic is carbon

tetrachloride)

Mineral dusts (e.g.

silica leads to silicosis

and predisposition to

IB. asbestosleadsto

diffuse fibrosis and

mesothelioma, coal leads

Noise|e.g. hearing loss)

Temperature

Heat cramps, beat

exhaustion, heatstroke

Hypothermia,

frostbite

Air pressure (e.g.

barotrauma,

decompression sickness)

Radiation

Exposure to bacteria,

viruses, lungi. protozoa.

Rickettsia

Exposure to biological

proteins, endotoxins,

emymes.animal excreta

Blood should be

considered a potentially

toxic substance due to

blood-borne infectious

diseases(e.g. HIV,

Heavy metals (e.g.nickel, hepatitis B)

Ionizing: UV.x-rays,y rays cadmium, mercury,lead) Consider exposure to

Vibration - related disorders Cases|e.g. halogen gases, disease in endemic

(e.g. secondary Raynaud'

s, sulphur dioxide, caibon countries, travellers Irom

whole body vibration) monoxide, nitrogen oxides) endemic countries, or

Second-hand smoke recent travel history in the

(causal factor for lung setting of acute onset of

cancer, lung disease. symptoms (e.g.malaria,

heart disease, asthma SARS.TB)

exacerbations:may be

linked lo miscarriage)

Skin diseases(major

portion of compensations,

e.g. contact dermatitis,

occupational acne,

pigmentation disorders)

Workload stressors

Responsibility

Fear oljob loss

Geographical isolation Geographical isolation

Shift work Shift work

Bullying

Harassment (sexual/

non-scxual)

Incurs high cost from

absenteeism, poor

productivity,mental illness productivity, mental illness

(e.g. post-traumaticstress (e.g.post-traumatic stress

disorder)

Workplace violence

(involving stall, clients,

the general public)

Workload stressors

Responsibility

Feat of job loss

Bullying

Harassment|sexual/non -

sexual)

Incurs high cost from

absenteeism, poor

Most Effective

Elimination

Physically remove

hazard

Non-ionizing:visible light, to pneumoconiosis)

infrared

disorder)

Workplace violence

(involving staff, clients,

the general public)

e.g. drivurluss car

Substitution

Replace hazard

a.g. replace with train

Engineering

Controls

Isolate Irom hazard

e g. airbags

Administrative

Controls

Change the way

people work

« g. traffic laws

/

Workplace Legislation

• universal across Canada for corporate responsibility in the workplace: reasonable precautions

to ensure a safe workplace, application of Workplace Hazardous Materials Information System

(WHMIS), and existence of joint health and safety committees in the workplace with representatives

from workers and management

• jurisdiction in Canada is provincial (90% of Canadian workers), except for 16 federally-regulated

industries (e.g.airports, banks, highway transport) under the Canada Labour Code

• Ontario’

s Occupational Health and Safety Act

sets out rights of workers and duties of employers, procedures for workplace hazards, and law

enforcement

workers have the right to:

know (e.g. be trained and have information about workplace hazards)

participate (e.g. have representatives on joint health and safety committees)

refuse work (e.g. workers can decline tasks they feel are overly dangerous)

- note: for some occupations, this right is restricted if, for example, danger/risk is

normal part of work or refusal would endanger others (e.g. police, firefighters,some

health care workers)

stop work (e.g. ‘certified’workers can halt work they feel is dangerous to other workers)

enforced by Ministry of Labour via inspectors

• Health Protection and Promotion Act ( HPPA) (Ontario)

• Medical Officer of Health has right to investigate and manage health hazards where workplace

exposures may impact non-workers (e.g. community members living close to the work site)

tt.g. sujtbults

&K/iitenBrown

*

Least Effective 2011

Figure 18. Hierarchy of controls for

reduction of occupational exposures

Source:Modified from CDC.2015. Hiererchy

ot controls, http://www.cdc.gav/niosh/toptcs/

hierarchy/

Ontario's Workplace Safety and

Insurance Act (each province will have

their own corresponding legislation)

• Establishes Workplace Safety

and Insurance Board(WSIB). an

autonomous government agency that

oversees workplace safety training

and administers insurance for

workers and employers

• WSIB decides benefits for workers,

which may include reimbursement

for:

• Loss of earned income

• Non economic loss (e.g.

physical,functional,or

psychological loss extending

beyond the workplace)

• Loss of retirement income

• Health care expenses (e.g.firstaid. medical treatment)

• Survivor benefits (e.g.

dependents and spouses can

receive benefits)

• Employers pay for costs (e.g.no

government funding)

• No-fault insurance (e.g. worker has

no right to sue the employer) in

return for guaranteed compensation

for accepted claims

• Negligence is not considered a factor

• Physicians are required to provide

the WSIB with information about a

worker's health without a medical

waiver once a claim is made

1«rmo litlotmotion:http.1 wwwwill)uruo

'

un1

conmwilly.WSIB

Workplace Health Promotion

• a strategy for addressing the health and well-being of workers in the workplace, not legislated

• may include education, event planning, information campaigns, and workplace supports to promote

personal worker health and a healthy workforce

Workplace Primary Prevention r “i

i j

• proactive efforts to reduce workplace illness or injury

• achieved through anticipating, recognizing, evaluating, and controlling workplace hazards

• hierarchy of controls (see figure 18) is followed to minimize exposure - elimination/substitution of

hazards is most superior, followed by isolation (engineering controls), training and behavioural efforts

(administrative controls), and lastly, personal protective equipment

+

PH31 Public Health and Preventive Medicine Toronto Notes 2023

Workplace Secondary Prevention

• for workers who are exposed to workplace hazards, goal is to identify earliest signs of overexposure

or disease through medical surveillance ( periodic examinations to identify early changes in a single

worker or multiple workers). Some examples include:

whole blood lead testing to identify effectiveness of controls and to remove workers from

expo

• PET for asthma (e.g. occupational dust exposure)

audiograms for hearing loss (e.g. occupational noise exposure)

sure

Workplace Tertiary Prevention

• treatment of the disease or injury to facilitate safe and timely return to the workforce

• may require rehabilitation, retraining, change in job duties, and/or workers’ compensation (WS1B)

• often also involves accommodating the workplace for a worker who has a non-occupalional injury

or illness, with routine reassessments of the fit between the worker and their duties •work that is

considered safety-sensitive may be restricted for workers with ailments that could impede their ability

to work safely,or a worker may be medically determined to have limitations with what they can

reasonably do at work

• advise relevant authorities if necessary (e.g. report notifiable diseases to public health, conditions

impeding driving to Ministry of Transportation)

Appendix- Mandatory Reporting

Reportable Diseases

As an essential part of the public health system, physicians in Canada are required by provincial law

to report certain diseases to public health. Physician reporting is also outlined by provincial physician

licensing Colleges (e.g. College of Physicians and Surgeons of Ontario (CPSO)). failure to report can

result in suspension of a license to practice.

the reasons that reporting is mandatory include:

1.to identify and control an outbreak

2.to prevent spread if the disease presents a significant threat to individuals or a subset of the

population (e.g. Lassa Fever)

3.if the disease is preventable with immunization (e.g. polio, diphtheria, congenital rubella)

4.if infected individuals require education,treatment, and/or partner notification (e.g.gonorrhea,IB)

5.surveillance (to monitor disease trends overtime)

Diseases of Public Health Significance

Cryptosporidiosis’

Cyclosporiasis'

Diphtheria*

Diseases marked with * (and

Influenza in institutions)should

be reported immediately to the

Medical Officer of Health by either

telephone or fax.Other diseases can

be reported the next working day by

fax, phone, or mail.Each province/

territory has a similar legislation.

Acquired Immunodeficiency

Syndrome (AIDS)

Acute flaccid paralysis <15 yr

Amoebiasis

Anthrax*

2. Hepatitis B

3. HepatitisC

Q Fever*

Rabies*

Respiratory infection outbreaks in

institutions and public hospitals*

Rubella*

Rubella, congenital syndrome

Salmonellosis

Shigellosis*

Smallpox*

Syphilis

Echinococcus midtiloadaris

infection

Encephalitis,including:

1. Primary, viral

2. Post-infectious

3.Vaccine-related

4.Subacute sclerosing

panencephalitis

5. Unspecified

Influenza ( Note: Influenza in

Institutions*)

Lassa Fever*

Legionellosis

Leprosy- Listeriosis

Lyme Disease

Measles*

Meningitis, acute*:

1.Bacterial*

2. Viral

3.Other

Meningococcal disease, invasive*

Mumps

Ophthalmia neonatorum

Tetanus

Trichinosis

Tuberculosis,active and latent

Tularemia

Typhoid Fever

Botulism’

Brucellosis*

Blastomycosis

Food poisoning,all causes

Gastroenteritis, institutional

outbreaks and in public hospitals*

Giardiasis, except asymptomatic

cases*

Gonorrhea

Campylobacter enteritis

Carbapenemase-Producing

Entcrobactcriaceae (GPE)

Chancroid

Chickenpox (Varicella)

Chlamydia trachomatis infections

Cholera*

Clostridium difficile' associated

disease (CDAD) outbreaks in public

hospitals

Coronavirus novel including SARS,

MERS, and COVID-19*

Creutzfeldt-Jakob Disease, all types*

Verotoxin-producing E. coli

infection* indicator conditions,

including Hemolytic Uremic

Syndrome (HUS)*

West Nile Virus illness, including:

1. West Nile fever

2. West Nile neurological

manifestations

j

I laemophilus influenzae b disease,

all types*

Hantavirus pulmonary syndrome*

Hemorrhagic fevers', including:

1.Ebola virus disease*

2.Marburg virus disease*

3.Other viral causes*

Hepatitis, viral*

:

1.Hepatitis A’

Paralytic shellfish poisoning

Paratyphoid fever

Pertussis (whooping cough)

Plague*

Pneumococcal disease, invasive

Poliomyelitis, acute’

Psittacosis/Ornithosis

+

Yersiniosis

PI132 Public Health and Preventive Medicine Toronto Notes 2023

Other Reportable Conditions

• in addition to reporting diseases, physicians have a legal responsibility to report certain conditions.

Ihe list below highlightssome reportable conditionsfor Ontario, but is not exhaustive. See your

jurisdiction’s regulatory body for the full list

Live Births, Stillbirths, and Deaths -to the Registrar General or Coroner’

• all live and stillbirths must be reported within 2 business days

• a physician with sufficient familiarity of a patient’sillness or who was in attendance of a deceased

patient’

slast illness must complete and sign the medical certificate of death

• physicians must contact a coroner or the police if patient issuspected to have deceased from violence,

misadventure, negligence, misconduct or malpractice, or any cause other than disease; by unfair

means;during pregnancy or postpartum from circumstances reasonably attributed to the pregnancy;

suddenly and unexpectedly; front an illness not treated by a legally qualified medical practitioner; or

.. limit’

eaths to the coroner'

under circumstances that may require investig

• physicians must report all medically assisted dr

Child Abuse -to Local Children's Aid Society (CAS)

• all child abuse and neglect where reasonable grounds to suspect exist (including physical harm,

emotional harm,sexual harm, and neglect)

ongoing duty to report; if additional reasonable grounds are suspected, a further report to CAS is

necessary

Gunshots Wounds - to Local Police Service

• all patients with gunshot or stab wounds should be reported as soon as is practical

• self-inflicted knife wounds are not reportable

Abuse of Long-Term Care or Retirement Home Residents -to the Registrar of the

Retirement Homes Regulatory Authority or Long-Term Care Home Director

• any resident suspected of being subject to or at risk of improper or incompetent treatment or care,

abuse or neglect, or unlawful conduct including financial abuse must be reported immediately

Unfit to Drive -to Provincial Ministry of Transportation

• all patients with a medical condition (e.g. dementia, untreated epilepsy, ophthalmological) that may

impede their driving ability

• if a physician does not report and the driver gets into an accident, the physician may be held liable

Unfit to Fly -to Federal Ministry of Transportation

• all patients believed to be flight crew members or air traffic controller with a medical or optometric

condition that islikely to constitute a hazard to aviation safety

Source: CPSO. Mandatory anil Permissive Reporting. 2011.Available Iron: htlps:tfwww.cpso.on.ca/Physieians/Policies-6uidince/Policies/ Mandatory and -

Permissive-Repot ling

Landmark Public Health and Preventive Medicine Trials

Trial Name Reference Clinical Trial Details

Mammography

Swedish Two-County Trial Radiology 2011;260|3):6S8 63 Title: Swedish Iwo County Inal: Impact ol Mammographic Screening On Breast Cancer Mortality

During 3 Decades

Purpose: Evaluate the long-term effect ol mammographic screening on breast cancer mortality.

Methods;133065women aged 40-74 yr were randomly assigned to either a group invited lor

mammographic screening ora control group.A negative binomial regression analyzed mortality.

Results; At 29 yr of lollow- up.a large significant reduction in breast cancer mortality wasfound in

the group invited lor mammographic screening compared to the control group (relative risk'0.69;

95% Cl:0.56 to 0.84).

Conclusions: Invitation to mammographic screening leadslo a large significant deciease in bieast

cancer-related mortality.

Vaccination

VAXIC0L J Am Geriatr Soc 2009:57|9):1580 G Title: Effect ol Influenza Vaccination ol Nursing Home Stall on Mortality ol Residents:A Cluster -

Randomized Iria!

Purpose: Evaluate the impact of influenza vaccination among staff on all-cause mortality in nursing

home residents.

Methods:40 nursing homes matched in pairs were randomly assigned to Ihe vaccination arm

or no-vaccination control arm. the vaccination arm involved a vaccine promotion campaign and

adminislration program for staff.

Results:Vaccination rates among stall In Ihe vaccination arm were 69.9% compared to 31.8% in the

no- vaccination arm. A stiong correlation between stall vaccination coverage and all

-cause mortality

ol Ihe residents wasfound (correlation coellidenl- 0.42. P'0.007).

Conclusions:Ihe resultssupport stall of nursing homes being vaccinated against influenza lo reduce

all-cause mortality ol residents.

r i

L J

+

PH33 Public Health and Preventive Medicine Toronto Notes 2023

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Respirology

Brian Bursic, Emma Price, and RajivTanwani, chapter editors

Karolina Gaebc and Alyssa Li, associate editors

Wei Fang Dai and Camilla Giovlno, EBM editors

Dr. Samir Gupta, Dr. Ambrose Lau, and Dr. Christopher Li,staff editors

Acronyms

Approach to the Respiratory Patient

Basic Anatomy Review

Differential Diagnoses of Common Presentations

Pulmonary Function Tests

Chest X-Rays

Airway Disease

Pneumonia

Asthma

Chronic Obstructive Pulmonary Disease

Bronchiectasis

Cystic Fibrosis

Interstitial Lung Disease

Unknown Etiologic Agents

Known Etiologic Agents

Pulmonary Vascular Disease

Pulmonary Hypertension

Pulmonary Embolism

Pulmonary Vasculitis

Pulmonary Edema

Diseases of the Mediastinum and Pleura

Mediastinal Masses

Mediastinitis

Pleural Effusions

Complicated Parapneumonic Effusion

Empyema

Atelectasis

Pneumothorax

Asbestos-Related Pleural Disease

Mesothelioma

Respiratory Failure

Hypoxemic Respiratory Failure

Hpercapnic Respiratory Failure

Acute Respiratory Distress Syndrome

Neoplasms

Lung Cancer

Approach to the Solitary Pulmonary Nodule

Sleep-Related Breathing Disorders

Hypoventilation Syndromes

Sleep Apnea

Introduction to Intensive Care

Intensive Care Unit Basics

Lines and Catheters

Organ Failure

Shock

Sepsis

Common Medications

Landmark Respirology Trials.

References

R2

R2

R7

R13

R18

R19

R23

R26

R28

R29

R30

R34

R35

R39

r i

L J

+

R1 Respirology Toronto Notes 2023

R2 Rcspirology Toronlo Nolcs 2023

Acronyms

CPAP long-acting muscarinic

antagonist

low molecular weight heparin PIT

leukotricne receptor antagonist RA

left atrium

left ventricle

left ventricular end diastolic RF

pressure

maximal expiratory pressure RVEDV

maximal inspiratory pressure

metered dose inhaler

musculoskeletal

non-specific interstitial

pneumonia

nausea/vomiting

obstructive sleep apnea

posteroanterior

arterial partial pressure of

carbon dioxide

arterial partial pressure of

oxygen

alveolar partial pressure of

oxygen

positive airway pressure

atmospheric pressure

pulmonary capillary wedge UC

pressure

pulmonary embolism

positive end expiratory pressure V/Q

peak expiratory flow

pulmonary function tests

inspired oxygen tension

A-a alveolar-arterial

A-aD02 alveolar-arterial oxygen

diffusion gradient

ABG arterial blood gas

ACEI angiotensin converting enzyme CWP

inhibitor

AECOPD acute exacerbation of COPD

continuous positive airway

pressure

central sleep apnea

central venous pressure

coal worker's pneumoconiosis LA

disseminated intravascular

coagulation

carbon monoxide diffusing

capacity of lung

direct oral anticoagulant

distal phalangeal finger depth MDI

dry powdered inhaler

endobronchial ultrasound

early goal-directed therapy

expiratory reserve volume

forced expiratory flow rate

forced expiratory volume in 1 PA

second

fraction of oxygen in inspired air

functional residual capacity Pa02

forced vital capacity

glomerular basement membrane PA02

gastroesophageal reflux disease

headache

hypersensitivity pneumonitis Patm

hypothalamic-pituitary axis

inspiratory capacity

inhaled corticosteroid

interstitial lung disease

interphalangeal depth

idiopathic pulmonary fibrosis PFT

long-acting p-agonist

LAMA PP pulse pressure

proton pump inhibitor

partial thromboplastin time

rheumatoid arthritis

right axis deviation

right atrial pressure

rheumatoid factor

residual volume

right ventricular end diastolic

volume

right ventricular hypertrophy

short-acting (J2-agonists

short-acting muscarinic

antagonist

systemic inflammatory response

syndrome

sepsis-related organ failure

assessment score

quick sepsis-related organ

failure assessment score

stroke volume

superior vena cava

systemic vascular resistance

index

total lung capacity

ulcerative colitis

usual interstitial pneumonia

upper respiratory tract infection

ventilation-to-perfusion

vital capacity

venous thromboembolism

tidal volume

PPI

LMWH

CVI LTRA

RAD

DIC LV RAP

LVEDP

AHI apnea hypopnea index DLCO

acute interstitial pneumonia

RV

A1P MEP

ALI acute lung injury DOAC

ALS amyotrophic lateral sclerosis

ANA antinuclear antibody

ANCA anti-neutrophil cytoplasmic

antibody

MIP

DPD RVH

DPI MSK SABA

EBUS

EGDT

Anti-CCP anti-cyclic citrullinated peptide ERV

antibody

aPTT activated partial thromboplastin FEVt

time

ARDS acute respiratory distress

syndrome

ASA acetylsalicylic acid (Aspirin!

) FVC

AV arteriovenous

BAPE benign asbestos pleural effusion GERD

8G blood glucose

BiPAP bilevel positive airway pressure HP

8SA body surface area

cancer

CCB calcium channel blocker

CF cystic fibrosis

cardiac index

CO cardiac output

COP cryptogenic organizing

pneumonia

NSIP SAMA

N/V SIRS

FEF OSA

SOFA

PaC02

Fi02 qSOFA

FRC

SV

GBM SVC

SVRI

H/A PAP

TLC

HPA PCWP

CA 1C UIP

ICS PE URTI

ILD PEEP

Cl IPD PEF VC

IPF VTE

LABA PiOB VT

Approach to the Respiratory Patient Respiration Patterns

Normal

yww

Basic Anatomy Review

A7V\.

Obstructive (prolonged expiration)

•Asthma. COPO

Bradypnea (slow respiratory rate)

•Drug-induced respiratory depression

•Diabetic coma (nonketotic )

•Increased ICP

Right upper lobe Lelt

upper lobe

Wl/WWWl middle lobe _,

Kussmaul's Breathing (fast and deep)

Metabolic acidosis

•Exercise

•Anxiety '

Inferior lobar < 8,

t. bronchus . « d.

_ •

m

-1 XAA AAA *Lett

Ibwer lobe

:;

Right

lower lobe —1

Biol's/Atnxic

(irregular with long apncic periods)

•Drug-induced respiratory depression

•Increased ICP

•Brain damage (especially mcdullaryl

Lingula 2

—x

8

f

SJ

Figure 1. Lung lobes and bronchi Cheyne-Stokes Breathing ( cyclical

pattern of crcsccndo-dccrcsccndo

breathing between periods ol apnoal

•Drug-induced respiratory depression

•Brain damage (especially cerebral!

•CHF

•Uremia

u ;

-xr

^

rvx/

•

Apneuslic

Pontine lesion

(prolonged inspiratory pause) +

rBonnm Tang 2012 j

Figure 2. Respiration patterns in

normal and disease states

R3 Rcspirology Toronto Notes 2023

Differential Diagnoses of Common Presentations

Table 1. Differential Diagnosis of Dyspnea Table 2, Differential Diagnosis of Chest Pain

Acute Dyspnea (Minutes-Days) Nonpleuritic Pleuritic IPD>DPD DPD>IPu =

Cardiac

Acute Coronary Syndrome

Acute Oecompcnsdtcd Heart Failure

Acute myocardial infarction

CHF exacerbation

Cardiac tamponade

Arrhythmia

Pulmonary

Upper airway obstruction (anaphylaxis,aspiration, croup.EBV)

Airway disease (asthma. COPO exacerbation,bronchitis)

Parenchymal lung disease (ARDS,pneumonia)

Pulmonary vascular disease (PE,vasculitis)

Pleural disease (pneumothorax,tension pneumothorax,pleural

effusion)

Neurologic/Psychogenic

Respiratory control (metabolic acidosis,trauma)

Anxiety

Panic attack (Post Traumatic Stress Disorder)

Pulmonary

Pneumonia

Pulmonary

Pneumonia

PE PE

Neoplasm

Cardiac

Neoplasm

Pneumothorax

Pleurisy

Hemothorax

Ml Schamroths sign

Myocarditisipericarditis

Deconditioning

Esophageal

GERO

Spasm

Esophagitis

Ulceration

Achalasia

Neoplasm

Esophageal rupture

Mediastinal

Lymphoma

Thymoma

Subdiaphragmatic

Peptic ulcer disease

Gastritis

Biliary colic

Pancreatitis

TB Figure 3.Signs of nail clubbing

Empyema

Cardiac

Pericarditis

Drcsster's syndrome

Signs of Respiratory Distress

Tachypnea

Central/peripheral cyanosis

Tachycardia

Inability to speak

Nasal flaring

Tracheal tug

Intercostal indrawing

Tripoding

Paradoxical breathing

Gl

Subphrenic abscess

MSK

Costochondritis

Fractured rib/flail chest

Myositis

Herpestoster

Psychogenic

Anxiety

Panic altackfdisorder

Chronic Dyspnea (+4 Weeks)

Cardiac

Valvular heart disease

Myocardial dyslundion (decreased CO)

Pulmonary

Airway disease (asthma.COPD)

Parenchymal lung disease (interstitial disease)

Pulmonary vascular disease (pulmonary HTN.vasculitis)

Pleural disease (effusion)

Metabolic

Medication

Severe anemia

Hyperthyroidism

Neuromuscular and chest wall disorders

Deconditioning,obesity,pregnancy,neuromuscular disease

Psychogenic

Anxiety

Vascular

Aortic aneurysm

Aortic dissection

Aortic iniury/rupturc Common Causes of Clubbing

• Pulmonary:lung CA.bronchiectasis,

pulmonary fibrosis,abscess,CF.TB.

empyema.A-V fistula/malformation

(NOT COPD)

• Cardiac: cyanotic congenital heart

disease, endocarditis

• Gl:inflammatory bowel disease,

celiac,cirrhosis,neoplasm

• Endocrine:Graves'disease

• Other:other malignancy,primary

hypertrophic osteoarthropathy

MSK

Costochondritis

Skin

Breast

Ribs

Rheumatic disease

Metabolic

Anemia

Hyperthyroidism

Psych

Anxiety

Panic attack/disorder

Miscellaneous

Pregnancy

Weight gain

See Cjrdioloqv and Cardiac Surqciy CS and Emergency MvJ mi- ER21 Clubbing is not seen in COPD -if

present,think malignancy

Table 3. Differential Diagnosis of Hemoptysis Table 4. Differential Diagnosis of Cough

Hemoptysis DDx Cough DDx

Airway Irritants

Inhaled smoke,dusts,lumes

Postnasal drip (upper airway cough syndrome)

Aspiration

Gastric contents (GERD)*

Laryngopharyngeal reflux

Oral secretions

Foreign body

Airway Disease

URTI includingpostnasal drip andsinusitis*

Acute or chronic bronchitis

Bronchiectasis

Neoplasm

Exlcrnal compression by node or mass lesion

Asthma*

COPD

Parenchymal Disease

Pneumonia

Lung abscess

Interstitial lung disease

Hemoptysis

• Most common cause is bronchitis

• 90% of massive hemoptysis is from

the bronchial arteries

• Definitions for hemoptysis vary,often

defined as “massive"if >600 mL/24

h or bleeding rate of >100 mL/h

Airway Disease

Acute orchronic bronchitis’

Bronchiectasis and CF

BronchogenicCA

Bronchial carcinoid tumour

Parenchymal Disease

Pneumonia

IB

lung abscess

Fungal Infection

Primary lung cancer

Pulmonary metastasis

Vascular Disease

Most Common Causes of Chronic

Cough in the Non-smoking Patient

(Cough >3 mo with Normal CXR)

. GERD

• Asthma

• Postnasal drip

. ACEI

PE

Elevated pulmonary venous pressure:

lell ventricular dyslundion,

'

failure

Mitral stenosis

Vascular malformation

Vasculitis:

ANCA related vasculrtides

Goodpasture's syndrome

Idiopathic pulmonary hemosiderosis

Miscellaneous

Iatrogenic (lung biopsy,airway ablation procedures)

Impaired coagulation

Pulmonary endometriosis - catamenial hemoptysis

Trauma

Foreign body

r “i

L J

PE

CHF

Drug-induced (e.g. ACEl)

Smoking + ’"Big Three*

causes of chronic cough

'Most common cause of hemoptysis

Adapted from: Weinberger SE. Principles of pulmonary medicine.Oth ed. 2008. With permission from Elsevier

RIRcspirologv Toronto Notes 2023

Pulmonary Function Tests

• useful in differentiating the pattern of lung disease (obstructive vs. restrictive)

• assess lung volumes, flow rates,and diffusion capacity

• note: normal values for FEVt are approximately ±20% of the predicted values (for age,sex, and

height); “Race” differences in predicted values are recognized but are not fully understood and likely

represent genetic ancestry and the effects of the social determinants of health

Table 5. Comparison of Lung Flow and Volume Parameters in Lung Disease

Figure 4A. Lung volumes and

capacities

Obstructive Restrictive

Decreased flow rales (most markedduring expiration)

Air trapping (increased RV/HC)

Hyperinflation (increased IlC)

Asthma,CORD,bronchiolitis.bronchiectasis/Cf•

Decreased lung compliance

Decreased lung volumes

m

I-

/•

DDx IlD.pleuraldisease, neuromuscular disease, chest wall

disease

Elevated or normal

Reduced

Reduced,normal or elevated

Normal or elevated (neuromuscular disease may have elevated

RV/TU ratio)

Reduced or normal depending on whether parenchymal or

extraparenchymal restrictionis present

i

v

t H f

'

- , ;

"

-

Ob&tfuctve - s’. , T

FEWFVC Reduced

Elevated or normal .1second

time framer

ILC

Elevated or normal

Elevated or normal

RV

6 C 20

RV , NQ VOll Ml /HC in

Figure 4B. Expiratory flow volume

curves

Adapted with permission from Elsevier.

Weinberger SE.Principles of pulmonary medicine.

5th ed.2008

DLCO Normal or reduced depending on disease state

'Bronchiectasis can be obstructive or mixed

Table 6. Common Respirology Procedures

Technique Purpose Description

Measure ERC After a normal expiration,the patient inhales against a closed mouthpiece

Resultant changes in the volume and pressure of the plethysmograph are used to

calculate the volume of gas in the thorax

Useful lor patients with air trapping

A patient breathes from a closed circuit containing a known concentration and

volume olhelium

Since the amount olhelium remains constant. ERC is determined based on the

final concentration olthe helium in the closed system

Only includes airspaces that communicate with thebronchial tree and is

dependent on airflow - may underestimate volumes inpatients with gas trapping

A flexible or rigid bronchoscope is used for visualization of a patient's airways

allows lor:

Bronchial and broncho- alveolar lavage (washings)loi culture, cell count

analysis,and cytology

Endobronchial ortransbronchial tissue biopsies

Removal of secretions/foreign bodies/blood

Laser resections

Airway stenting

Mediastinal lymph nodes can also be sampled using a special bronchoscope

equipped with an U/S probe (EBUS)

Plethysmography ("body

box")

Lung Volumes

ERV Expiratory Reserve Volume

Forced Expiratory Flow Rate

Forced Expiratory Volume

(in one second)

Functional Residual Capacity

Inspiratory Capacity

Residual Volume

FEF He Dilution Measure ERC FEVr

FRC

1C

RV

TLC - Total Lung Capacity

FVC - Forced Vital Capacity

VT - Tidal Volume

Bronchoscopy Diagnosis and therapy

PvImMMv Fanctlon Tests IPFTs)

i i

FEV,;FVC >LLN FEV yEVC <LLN

Airflow obstf ucton

» I J

^

Lunq voluTtinormal j Lung volurr•» low.

especta .y TIC.RV [

Give branched

*

tor

t

s

0L»

I

*

T

^

Normal j

0

Rise KV J."

- , SIKI

jJOO CC » cl 01 positive

methachobie tail

[ ]

No significant

I changa in FEV.

fNorma PFT^

V, J I t

ANEMIA

PULMONARY VASCULAR

DISEASE. NTERSTIHAL

DISEASE (EARLYI,

EMPHYSEMA(EARLY)

t Flow volume loop,lung

volumes.Dtn INTERSTITIAL

LUNG DISEASE ASTHMA ri

L J

T

I I

J f n

-un TCC,uwOC (

J Decreased Normal TLC andDL^

TLC and FRC.

normalRV

Decreased TLC and FRC •

mc/fjiedRV (and low

MlPandMEPl t

CHRONIC BRONCHITIS.

BRONCHIOLITIS.

BROCHIECTASIS I

EMPHYSEMA +

CHEs

"

?WALL

DISEASE

NEUROMUSCULAR

•LLN DISEASE -lower lirriof normal

Figure 5.Interpreting PFTs

R5 Respirology Toronto Xotcs 2023

Chest X-Rays

• see Medical Imaging. M14

Table 7. CXR Patterns and Differential Diagnosis

Pattern Signs Common DDx

Consolidation ("Airspace disease") Acute: water (CHF ). pus ( pneumonia), blood

(hemorrhage)

Chronic: neoplasm (lymphoma, bronchioloalveolar

carcinoma),inflammatory (eosinophilic pneumonia ,

organicing pneumonia), infection (T8.fungal)

110|IPF, collagen vascular disease,asbestos, drugs.

Airbronchogram

Silhouette sign

less visible blood vessels

Reticular ( “Interstitial disease") Increased linear markings

Fine or ground glass opacities

Honeycombing (clustered cystic changesseen

in IPF usually, but also in rheumatoid arthritis,

asbestosis etc.)

Cavitary vs.non cavitary

HP)

Cavitary: neoplasm ( primary -squamous cell

carcinoma vs.metastatic cancer), infectious

(anaerobic or Cram negative, IB.fungal),

inflammatory (RA.sarcoidosis, granulomatosis with

polyangiitis (G PA))

Non- cavitary:above *sarcoidosis. Kaposi'ssarcoma

(in HIV),silicosis,and coal worker's pneumoconiosis

Hodular

10D

Arterial Blood Gases

• provides information on acid-base and oxygenation status

• see Nephrology. NPI7

BO

5 CD e

Approach to Acid-Base Status 3

1 . Is the pH acidemic ( pH <7.35), alkalemic (pH >7.45), or normal (pH 735-745)?

2. What is the primary disturbance?

metabolic: change in HCOJ and pH in same directions

respiratory:change in HCOi- and pH in opposite directions

3.is there appropriate compensation? (see Table S )

metabolic compensation occurs over 2-3 d reflecting altered renal HC03- production and excretion

respiratory compensation through ventilatory control of FaCOj occurs immediately

inadequate compensation may indicate a second acid-base disorder

u

2 ti &

pH 7.40. T=3S"C

20

^ 0 2D -CD GO 30 ICO

pOilmmHgl

Figure 6. Oxygen-Hb dissociation

curve

Table 8. Expected Compensation for Specific Acid-Base Disorders

Disturbance PaC02 (mmHg) (normal~40) HCOrTmmHg) (normal

'-24)

Factors that Shift the Oxygen-Hb

Dissociation Curve to the Right Respiratory Acidosis

Acute

Chronic

110 1 1

"CADET, face right!"

tIO t 3 COl

Add

2,3-DPG

Exercise

Temperature (increased)

Respiratory Alkalosis

Acute

Chronic

Metabolic Acidosis

*

4 10 2

* 1 0 * 5

Note: 2,3-DPG (2,3-diphosphoglycerate)

is now called 2.3-BPG

(2,3-biphosphoglycerate)

*

1 « t

Metabolic Alkalosis tS-7 »10

4. If the patient has metabolic acidosis, what is the anion gap and osmolar gap?

• anion gap =|Na + ]-(|Cl"

)+|HCOj'

]); normal 5-14 mmol/L

• osmolar gap = measured osmolarity - calculated osmolarity = measured -(2[ Na

'