• British Thoracic Society Guidelines
• RCGP respiratory e-learning
• Dundee Chest
• Rural Health West Aug 2011 Respiratory
• http://youtu.be/YPz8bVR_Uio
• http://youtu.be/mMQsZimjayI
• http://youtu.be/bklrcFuiH-8
• Pulmonary 1 Seattle Pacific University iTU
• Pulmonary 2 Seattle Pacific University iTU
• Pulmonary part 3 Seattle Pacific University iTU

Patterns of breathing

Patterns of breathing PUK

Spirometry volume flow loop

http://youtu.be/DDzyMYqKd7U

Peak flow meters

http://www.youtube.com/watch?v=LPA-XKU3hD8
http://www.youtube.com/watch?v=dPDHsReZfQ0
www.peakflow.com.

• Peak flow measurement
• Set meter to zero
• Connect disposable mouthpiece
• Stand (or if unable sit) upright
• Make sure fingers do not obstruct the PEFR slide
• Inhale deeply, place lips around meter making a tight seal. Breathe out forecfully whilst holding the meter horizontal.
• Note the reading
• Repeat twice unless patient unable to do so
• Record the highest of the 3 readings.

Asthma

Acute Asthma – see emergencies section

Episodic variable airways obstruction characterised by

• 1 hyper-reactivity and hypertrophy of bronchiolar smooth muscle
• 2 chronic inflammation and oedema of bronchiolar walls and
• 3 excessive secretion of thick mucus which plugs the bronchioles and narrows the airways still further

Symptoms may be triggered by exercise, change in temperature, smoky environments and be worse at night. May be history of atopy.

Diagnosis is suspected clinically based on symptoms but must be confirmed by spirometry, demonstration of pef variability and response to treatment.

• http://www.youtube.com/watch?v=82gn_rDRpHk
• http://www.youtube.com/watch?v=vlZ7R07OrR4
• http://www.asthma.org.uk

Asthma pathophysiology

• http://youtu.be/7EDo9pUYvPE
• http://youtu.be/Zlnsx8zKLvQ
• http://youtu.be/v-qr78Wj4xM
• Asthma pathophysiology @ Emedicine
• slideshare.net Asthma pathophysiology

Diurnal variability

• Worse at night and early morning best in afternoon.
• % variability = (highest- lowest reading)/highest reading x 100
• Asthma likely if
• PEF variabilty > 20%
• > 60 l/min
• Occurs > 3days over 2 week monitoring period

Asthma treatments

3rd/4th line treatments

Single maintenance and reliever therapy SMART

eg Symbicort (budesonide/formoterol) can be used for maintenance therapy and the dose temporarily increased to provide relief of exacerbations – simplifying management and reducing prescription cost to patients. SMART DTB Nov 2011

Poor control

• Use of > two B2 agonist MDIs per month
• Use of a B2 agonist 3x/week or more
• Nocturnal symptoms, daytime symptoms, limitation of normal activity

Inhaler technique

• Shake inhaler
• Remove cap
• Inhale deeply then fully exhale
• Seal mouth lips around mouthpiece
• Breathe in via mouthpiece whilst pressing down on top of inhaler
• Continue breathing in deeply to get drug deep into lungs
• Hold breathe for 10 seconds or as long as is comfortable, then breathe out slowly
• Repeat as necessary after 30 seconds
• Replace cap on mouthpiece
• If steroid inhaler rinse out mouth.

http://youtu.be/51Zjwcx7Zbs

GOLD guide inhalers and spacers

Do healthcare professionals have sufficient knowledge of inhaler techniques in order to educate their patients effectively in their use?

Spacers

• An MDI & spacer is the preferred option in adults and should be used in all < 12s.
• Advantages – greater delivery to the bronchioles, less oral deposition, so reduced frequency of oral thrush and it is as good as a nebuliser during acute exacerbations.
• Should be demonstrated and technique checked.
• Should be washed weekly with detergent and allowed to air dry (NOT wiped dry).
• Should be changed every six months.
• Inspiration should take place as soon as possible after MDI actuation.
• Tidal breathing (x5) is as effective as and more preferable than deep breathing.

http://www.youtube.com/watch?v=CEUm–zy8xY

http://www.youtube.com/watch?v=8BaT2XIrePE

http://www.youtube.com/watch?v=h6eD81NyBAU

http://www.youtube.com/watch?v=esmEVr4qROQ

http://www.youtube.com/watch?v=A7DhGX0p1KY

Inhalers and choice of device

MIMS Chart – asthma & COPD preperationss and devices

MIMS Inhaler Charts – BAIs

MDI

MDI and spacer

Autohaler – Easibreather breath actuated inhaler

DPI / turbohaler

Accuhaler

Asthma (Read Code H33)

Clinical features that increase the probability of asthma

Diagnosis (adults) – base initial diagnosis on a careful assessment of symptoms and spirometry (or PFR if unavailable, see below). Move straight to a trial of treatment if a high probability of asthma.

Note: PFR based diagnosis may be used in a Primary care setting.

>20% diurnal variation in recorded EU PFR (am and pm prior to any beta agonists) on 3 or more days each week for 2 weeks.

Variation % = (maximum PFR-minimum PFR)/ maximum PFR x100.

Diagnosis (children) – assess clinically with symptoms (see below). Move straight to a trial of treatment if high probability of asthma. If less clear, consider lung function tests, if age >5 (spirometry pre and post bronchodilator, PFR).

Do not add children to the asthma register unless you are confident of the diagnosis!

Clinical features that increase the probability of asthma

• More than one of the following symptoms: wheeze, breathlessness,

chest tightness and cough, particularly if:

• Symptoms worse at night and in the early morning
• Symptoms in response to exercise, allergen exposure and cold air
• Symptoms after taking aspirin or beta blockers

• History of atopic disorder

• Family history of asthma and/or atopic disorder

• Widespread wheeze heard on auscultation of the chest

• Otherwise unexplained low FEV1 or PEF (historical or serial readings)

Otherwise unexplained peripheral blood eosinophilia

Spirometry based diagnosis (may be falsely negative in a patient who is well at time of assessment)

Fev1/FVC < 70% = an obstructive picture (Asthma or COPD) but in asthma there is reversibility in the lung function.

>15% or > 200mls improvement in FEV1 after 400mcg (4 puffs via an MDI) of salbutamol via a volumatic.

>15% or > 200mls deterioration in FEV1 after 15mins of exercise.

• Having made the diagnosis please place them on the asthma register and put the H33 Asthma Read code in their Problem page.

• Arrange a New Patient Asthma clinic appointment with the Practice Nurse.

Don’t forget basic health promotion!

1. Smoking status and cessation advice – Read code.

2. Flu vaccination if on inhaled steroids

3. Life style and exercise.

4. Asthma self management plan.

5. Patient information leaflets.

6. Pre-payment certificates for script costs.

Adult asthma guidelines BTS 2011

Step 1 Inhaled short acting B2 agonist as required

Step 2 Add inhaled steroid 200-800mcg BDP equivalent/day bearing in mind that 400mcg is the starting dose for many patients

Step 3 Add inhaled Long Acting B2 agonist (LABA) .

• Continue LABA if there is a good response

• Discontinue LABA if no response and increase inhaled steroid to 800mcg a day

• If some benefit from LABA but control inadequate increase inhaled steroids to 800mcg/day and then consider adding in other therapies e.g. leukotriene receptor antagonists (1 month trial) or SR theophylline.

Step 4 Consider trials of:

• Increased inhaled steroid up to 2000mcg a day.

• 4^th drug. Eg. Leukotriene receptor antagonist, B2 agonist tablets or theophylline.

Step 5 Consider:

• Oral steroid at lowest dose to maintain control

• Maintain high dose inhaled steroid 2000 mcg/day

• Other treatments to minimize oral steroid use.

Refer.

Note: start at the step most appropriate to initial severity. Step up (remember check concordance and diagnosis) or step down depending on control.

Indications to progress to a higher step.

Usage of > one B2 agonist MDI per month = poor control.

Usage of a B2 agonist 3x/week or more = poor control.

Nocturnal symptoms, daytime symptoms, limitation of normal activity = poor control

Please note the preferred CFC free beclomethasone inhaler is Clenil Modulite (should be prescribed as brand) and is dose for dose equivalent to Becotide. Avoid QVAR which is expensive and not bio equivalent to Becotide.

Children 5-12 years asthma guidelines BTS 2011

Step 1 Inhaled short acting B2 agonist as required

Step 2 Add inhaled steroid 200-400mcg BDP equivalent/day bearing in mind that 200mcg is the starting dose for many patients (but dose appropriate to severity of disease)

Step 3 Add inhaled Long Acting B2 agonist (LABA) .

• Continue LABA if there is a good response

• Discontinue LABA if no response and increase inhaled steroid to 400mcg a day

• If some benefit from LABA but control inadequate increase inhaled steroids to 400mcg/day.
• Consider adding in other therapies e.g. leukotriene receptor antgonists or SR theophylline.

Step 4 Increase inhaled steroid up to 800mcg a day.

Step 5 Consider:

• Use daily steroid tablet in lowest dose possible to maintain control.

• Continue high dose inhaled steroid 800mcg a day

Refer.

Children under 5 years BTS asthma guidelines 2011

Step 1 Inhaled short acting B2 agonist as required

Step 2 Add inhaled steroid 200-400mcg BDP equivalent/day bearing in mind that 200mcg is the starting dose for many patients (but dose appopropriate to severity of disease) or leukotriene receptor antagonist if inhaled steroid can’t be used.

Step 3 Children < 2 years consider going to step 4.

Children > 2 years:

• In those taking inhaled steroids 200-400mcg/day consider adding leukotriene receptor antagonists.

• In those taking leukotriene receptor antagonists alone reconsider the addition of inhaled steroid 200-400mcg/day.

Step 4 Refer

Note: monitor growth in children.

Factors to assess on asthma/medication review – 10 points!

1. Patient understanding of ‘preventers’ and ‘relievers’ and their appropriate usage, also ask about any side effects.

2. Check inhaler & spacer technique.
3. Compliance as per computer and patient history – number of salbutamol MDIs used in last 12 months

4. Have they had a new spacer within the last 12 months?

5. Smoking status and cessation advice.

6. Any exacerbations, hospital admissions or oral steroid use since last review?
7. The RCP 3 Questions

1. Has your asthma interfered with your usual activities (e.g. housework, work, school, hobbies etc)?

2. Have you had difficulties sleeping because of your asthma symptoms (including cough)?

3. Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness?)

8. Having to use a reliever more than 3 x per week?

9. The need to step up or step down treatment – ? change self management plan.*

10. Are they aware of the month of their next annual review (schedule of care)?

*Review should incorporate a written action plan (BTS 2011). Download the ‘Be in Control’ asthma action plan ( or ‘My Asthma for age 6-11) from www.asthma.org.uk/control .

Osteoporosis risk

Treatment strategy for preventing steroid induced osteoporosis
Consider every patient for active osteoporosis prevention who has had:

• Oral or iv steroid treatment for greater than 3 months.
• A cumulative lifetime dose of 1g oral prednisolone (e.g. > 4 x seven day courses in a lifetime).
• Inhaled steroid > 1000mcg day beclomethasone.

If unable to have a DEXA then treat, 1^st line = a bisphosphonate.

If steroid course likely to > 3 months then treat, 1^st line = a bisphosphonate.

If able to have a DEXA and the T score above -1.5 treat with lifestyle measures +/- calcium supplementation.

NB DEXA needs repeating every 3 years

If the T score is = -1.5 or lower then treat, 1^st line = a bisphosphonate.

NB DEXA needs repeating every 3 years

Indication for consultant referral

1. Diagnosis unclear.

2. Failure to control symptoms beyond Step 4.

3. Consideration for home nebs or home oxygen.

4. Acute severe exacerbations.

5. Troublesome drug side effects or complications of Rx/asthma.

6. Suspected occupational asthma

Structure of the asthma service

All patients with proven asthma will be tagged with the H33 Read code, as this is required for Read code QOF based recall which identifies patients who have not had a formal asthma review in the last 15 months.

At repeat medication re-authorisation doctors must look at:

1. Beta 2 agonist over usage – arrange GP review?

2. Spacer on repeat script? Check when last issued.

3. Oral steroid/high dose inhaled steroid usage and need for osteoporosis prophylaxis.

4. Correct Read H33 Read coding & is it in the Problem page?
5. Annual review in date?
6. If seeing the patient for their annual review ask and document the ten point review ( use S1 template along with prompts from the auto-consultation).

QOF 2011/12

Asthma 3 – Annual recording of smoking status in asthmatic patients ages 14-19.

Target 80%.

Asthma 6 – Annual asthma review to be recorded.

Target 70%.

Asthma 8 – Post 1/4/06 need to record ‘measures of variability or reversibility’ at

diagnosis of patients aged 8 and over.

Target 80%.

References: British Guideline on the Management of Asthma – BTS.

May 2011.

www.asthma.org.uk

QOF.

Indication for consultant referral

• Diagnosis unclear.
• Failure to control symptoms beyond Step 4.
• Consideration for home nebs or home oxygen.
• Acute severe exacerbations.
• Troublesome drug side effects or complications of Rx/asthma.
• Suspected occupational asthma

Asthma management plans

Asthma in adults: Creating an asthma action plan Mayo Clinic

Asthma control test adults and children

Asthma allergies and rhinitis

There is an overlap between asthma and atopic conditions such as eczema and allergic rhinitis.

Patients may have raised IgE and eosinophils and may test positive on RAST or patch testing.

Treatment of allergic rhinitis will improve asthma control.

Asthma and rhinitis are type 1 (immediate) hypersensitivity reactions – inhaled antigens bind to IgE on surface o mast cells causing degranulation and release of inflammatory mediators. Symptoms can come on over 5-10 min.

Asthma and Allergic Rhinitis Questionnaire allergy uk.org

http://youtu.be/aF-JIMGsDrs

Allergy Testing

http://youtu.be/oED7kAIjFFY

http://youtu.be/Nqp6S7RJ38A

http://youtu.be/oF6n0l5ErOA

Allergy Testing NHS Choices

Allergen avoidance

Grass and fungal pollens

Housedust mites

Pets

Occupational

Asthma prevention

Breastfeeding may have protective effect on child, and so should be encouraged due to other beneficial effects.

Breathing exercises

breathing exercises.com

abc of yoga.com pranayama

http://youtu.be/LDgvhZjz0g8

Buteyko

http://youtu.be/LTXabQfAgQs

COPD

Chronic slowly progressive lung disease of smokers.

Obstructive pattern on spirometry.

Degree of impairement is relatively stable over period of months (without diurnal or day to day variability).

Airflow obstruction is partially/minimally reversible by bronchodilator or other therapy.

• COPD
• Characteristic signs and symptoms plus an obstructive spirometry with post-bronchodilator FEV1/FVC ratio of 0.7.
• FEV1 < 80% predicted
• FEV1/FEV ratio < 70 % (ie obstructive picture)
• no diurnal variation and little <15% or 200mls reversibility.

COPD diagnosis

Hx > 10 pack years smoking hx and > 35 years – if not reconsider the diagnosis.

FEV1/FEV ratio <70%, with no significant reversibility

Grade and record mild, moderate or severe on the basis of Fev1/predicted.

CXR to exclude bullae, tumour, pulmonary oedema, bronchiectasis etc.

FBC if suspicion of anaemia or polycyctheamia.

COPD NICE CG101

COPD prodigy.clarity.co.uk

http://youtu.be/qo8azwv_RLU

http://youtu.be/KqoHYJ3pOoY

http://youtu.be/HttxNPQ6SzM

http://youtu.be/aktIMBQSXM

http://youtu.be/oMPcku-B0So

http://youtu.be/f_OreoetpLc

COPD management

Nonpharmacological

• Smoking cessation is the most important intervention and will slow further decline to the rate of a non-smoker (see Pareto graph)
• Pulmonary rehabilitation should be offered to all patients who are functionally limited by COPD, (MRC Grade 3 and above) including those who have had a recent hospitalisation or exacerbation. Pulmonary rehabilitation is not suitable for patients who are unable to walk or who have had a recent MI. Polmonary rehab invimvolves a 6-12 w program of exrercise, education psychological and social interventions delivered by MDTs of respiratory physiotherapists and nurse.
• Explanation and information about COPD for patient and carers.
• Flu & Pneumovax vaccination.
• Increasing exercise +/ weight loss increase lung function and decrease symptom scoring.
• Screen for and treat depression, which is often missed by doctors.
• Met. Office Health Forecasting – early warning and telephone support for patients
• Winter fuel programmes
• Work with the patient to develop a self management plan:
• When to seek an antibiotic.
• When to seek oral steroids.
• When to seek medical advice.
• When to seek emergency medical advice.

When to refer

• Uncertain diagnosis e.g. Hx or Ex = age <35, < 10 pack years, wt loss, haemoptysis etc, unilateral signs.
• Atypical spirometry – restrictive rather than an obstructive picture.
• Failure to respond to Rx. Check compliance and technique first
• Consideration for oral steroids long term, home nebs or LTOT
• Complications, such as Cor Pulmonale
• Severe COPD.
• surgery bullectomy, lung transplant, lung volume reduction surgery

Refer for LTOT if

• FEV< 30%
• Cyanosis
• Polycythemia
• Cor pulmonale
• Peripheral oedema
• O2 sats <92% in room air.

Consider Palliative care if 2 or more of following consistently

• FEV1 <30% of predicted
• SOB on any exertion
• Significant wt loss
• Recurrent admissions for exacerbations
• Social isolation/depression
• Severe heart failure

COPD inhalers

LABAs in COPD and asthma

Controversies Regarding Long-acting ?2-agonists Medscape

http://www.pamf.org/asthma/medications/inhaled/longacting.html

fda.gov LABAs

LABAs in Asthma Cochrane

Mucolytics in COPD

Oxygen in COPD

http://hacking-medschool.com/oxygen-prescription-domicilliary-oxygen

JEMS connect

http://youtu.be/XFieSB3TzK4

http://youtu.be/FT7t9hroLLg

http://youtu.be/iRniUCT0zWw

Exacerbations COPD

1 Increased sputum volume or discoloured sputum use antibiotics for 1 week (amoxycllin or erythromycin 1st line).

30% are viral, 30-50% bacterial in origin with the remainder undetermined.

Prescribe antibiotics if increased sputum purulence.

If no increase in sputum purulence then antibiotics are not needed unless consolidation on chest x-ray or other signs of pneumonia.

Organism H.influenzae, S.pneumoniae, M.catarrhalis.

Rx Amoxicillin 500mg three times daily for five days, or doxycycline 200mg Day 1 then 100mg daily for 4 days.

Co-amoxiclav or ciprofloxacin 2nd line for 1 week if no improvement

2 SOB/wheeze – increase salbutamol use to at least QDS via a spacer.

3 Consider oral steroids (prednisolone 40mg a day for 7 to 10 days) if

a) are known to be steroid responsive

b) a new presentation where steroid responsiveness in unknown or

c) are already on steroids.

Remember they need a DEXA scan and consideration for osteoporosis prophylaxis if they have more than 3 months of oral steroids or 3 courses on oral steroids in a 12month period.

Indications for admission

Admit to hospital if unwell (e.g. confused, cyanosed, very short of breath), no improvement on treatment, unable to cope at home

• Signs of a severe acute exacerbation = cyanosis, RR > 25, Pulse > 110, unable to speak in sentences or confused.
• Patient already on maximum treatment
• Patient on LTOT
• Patient unable to cope at home
• Failure to respond to Rx
• Complications e.g. Cor pulmonal

COPD patient letter

We are writing with some important information for you about your COPD (also known as chronic bronchitis and emphysema)

Many people with COPD get flare ups of their condition (sometimes called chest infections or exacerbations). Flare ups happen much more frequently in the winter months, particularly if the weather is very cold. This increase in flare ups leads to increased pressure on emergency services, hospitals and A&E departments. However we know that if you can recognise a flare up early and take the correct action you can avoid A&E and reduce your risk of a hospital admission.

Reducing your risk of flare ups and hospital admissions

Make sure you have at least a week’s supply of your regular medicines throughout the winter.

Keep your house warm. The living area should be around 21 degrees and the bedroom 18 degrees. If you would like help with keeping your house warm contact AWARM on 245 7422.

Recognise the early signs of a flare up:

• More breathless than usual
• More phlegm than usual
• Your phlegm changes colour

If you think you are experiencing a flare up contact your GP or practice nurse as soon as possible for advice.

If you already have a self management action plan use your rescue medications as soon as you notice a flare up starting.

You can also contact NHS Direct on 0845 4647 for advice if you are unsure about your symptoms or your medications.

If you are known to the CAST team, you can ring them directly on their number that you will have been supplied with previously. If they are not available to take your call leave a short clear message on the answer phone with your name and contact details. They will get back to you within 24 hours.

Please only attend the A&E Department at the Hospital if you are unwell and your condition can’t wait or if you have accessed all of the above without improvement. Remember that A&E services are for major injuries and life threatening illness only.

Remember to keep warm, keep well and choose well this winter.

(Salford NHS)

COPD self management plan

KNOW YOUR MEDICATION

INHALERS

Bronchodilators (Relievers): These relax the muscles in your airways & make it easier for you to breathe. Shorting acting inhalers start to work within about 10 minutes & the effect should last about 4 hours. Your short acting ‘reliever’ medication is ______________________

Long acting inhalers (Preventers) take longer to take effect but last 12 –24 hours.

Your long acting medications are__________________

Steroid inhalers (Preventers): usually used with a spacer device. They are often combined in a single inhaler with one of the long acting bronchodilators.

Your steroid inhaler is _____________

Please contact your surgery in plenty of time to ensure you don’t run out of any of your medication

EXACERBATIONS (when you get worse)

You should increase your treatment early when you are unwell. You should have a ready supply at home of additional tablet medications needed if you are feeling worse (eg antibiotics, steroids). If you are unwell, follow the instructions on page 3 of this leaflet.

ADDITIONAL TABLET MEDICATIONS.

These tablet medications may be prescribed to help your breathing.

Steroid Tablets (Prednisolone 5mg): A course of these may need to be taken during an exacerbation and are taken in one morning dose.

Steroid tablet instructions: _________________________

Antibiotics: These should be taken if you have symptoms of infection ie coloured phlegm, increased phlegm being coughed up.

Antibiotic instructions: ______________________________

COPD Review

http://hacking-medschool.com/qof-copd

Hospital at home

HAH RVH

Pulmonary Rehabilitation @ medscape

BTS Pulmonary Rehab Guidelines

http://youtu.be/3goKl9Vr8iw

Alpha 1 antitrypsin deficiency

A1 antitrypsin breaks down neutrophil elastase in the lung. Congenital deficiency (Autosomal Codominant) allows the latter to run amok breaking down lung parenchymal tissue causing COPD and emphysema at an earlier age in smokers and nonsmokers.

Alpha 1 antitrypsin defficiency Medscape

http://youtu.be/CEYNJxDR_QM

http://youtu.be/SqGoZRBrlvs

http://youtu.be/wYsaosI26oQ

Pink Puffers and Blue Bloaters

Respiratory failure PUK

Respiratory failure Medscape

Respiratory failure scottishintensivecare.org.uk

http://youtu.be/I7u9GvwkMxw

http://youtu.be/yet-VyVEPKw

http://youtu.be/M5WKos0pLeg

Prescribe on HOOF form and fax directy to supplier (dependant on local arrangements/contracts) who then deliver directly to patients home.

MIMS Oxygen Concentrators: Procedure for Prescribing Tables

NHS Home Oxygen

Oxygen prescription PUK

Oxygen is a drug and should therefore be prescribed. Inappropriate concentrations may have serious or even lethal effects.

Patients should be advised of the fire risks with oxygen and they or their contacts must not smoke in the same environment.

Oxygen can be delivered either nasally or by mask. Prescribers should specify the oxygen delivery percentage, and flow rate for the mask, and the flow rate for nasal delivery.

The administration of high oxygen concentrations in acute COPD and other conditions vulnerable to hypercapnic respiratory failure leads to worsening of hypercapnic respiratory failure and respiratory acidosis. Patients with COPD (and other at-risk conditions) who have had an episode of hypercapnic respiratory failure should be issued with an oxygen alert card and a 24% or 28% Venturi mask. They should be instructed to show the card to the ambulance crew and emergency department staff in the event of an exacerbation. Alert cards are issued by the respiratory liaison nurse during a hospital admission.

http://youtu.be/h6jp68qsyGk

Acute Respiratory Failure

Acute respiratory failure

Acute respiratory failure Nursing Times.net

ARDS

Adult Respiratory Distress Syndrome

http://youtu.be/aXjaxvL6y7I

http://youtu.be/gEPJeHCKNAk

http://youtu.be/kQ9eCywj_Hs

Obstructive sleep apnoea

Sign 73 OSAHS – obstructive sleep apnoea/hypopnoea syndrome

Due to repeated intermittent upper airway colapse during sleep causing total obstruction (apnoea – patient stops breathing) or partial obstruction with (hypoventilation / hypoapnoea and snoring)

Patient goes through cycle of deep sleep with airways collase then stimulation /arousal with increased inspiratory effort and restoration of muscle tone then deeper sleep again.

Causes daytime sleepiness and increased CVS risk (via increased BP and as indipendant risk factor)

britishsnoring.co.uk epworth scale

Diagnosis is confirmed by sleep studies involving measurement of pulse oximetry, nasal airflow, snoring and respiratory effort.

Treatment

Behavioural

Wt loss, smoking, alcohol, eelevation of bed, avoid sleeping on back.

CPAP

Positive pressure from nasal or face mask splints open the upper airways preventing collapse and apnoea during deep sleep. Used for moderate (30-50) and severe (>50 apnoea/hypoapnoeas per hr) sleep apnoea.

Mandibular Advancement devices

Dental appliances which pull the jaw forward increasing airway diameter. Used in mild sleep apnoea or in patients intolerant of CPAP

http://youtu.be/CCi3l-T6PiQ

http://youtu.be/wk8c4rNrQ-A

http://youtu.be/Bxw_Bzsilf0

CAP

http://hacking-medschool.com/cap-emergencies

http://hacking-medschool.com/cap

http://www.cks.nhs.uk/chest_infections_adult#-294272

Inpatient Management CAP – Tayside

http://youtu.be/3CEhafxHcHI

http://youtu.be/Blwvh3nfQS0

• CAP Organisms
• Strep pneumoniae
• Haemophilus influenzae
• Moraxellia catarrhalis
• Atypicals
• Influenza A
• Unidentified

• Atypical pneumonias
• Legionella
• Chlamydia pneumoniae
• Chlamydia psittaci
• Mycoplasma
• Coxiella burnetti (q fever)

Treatment

Home Rx: Amoxicillin 1g tds or doxycycline 200mg Day 1 then 100mg od for total 7 days.

If referring urgently – amoxicillin 1g oral or benzylpenicillin 1.2g IV before transfer (IV chloramphenicol 1 g if allergy).

severe or non-responding – add clarythromycinn…… edit this

HAP

Pneumocystis pneumonia

Influenza (respiratory)

250textbooks/influenza-virus

250textbooks/influenza-vaccine

Flu vaccination (respiratory)

250textbooks/influenza-vaccination

Pandemic flu

http://youtu.be/OrS3VGer4Ew

http://youtu.be/utQExEhel9k

http://youtu.be/L_8MNofjd60

http://youtu.be/DcbH_x3nChA

Severe acute respiratory syndrome SARS (respiratory)

http://youtu.be/qXql5eFLZA0

http://hacking-medschool.com/sars

SARS factsheet cdc.gov 2004

Tuberculosis TB

Due to droplet transmission of Mycobacterium tuberculosis from person with active pulmonary TB.

Primary TB

Post primary TB

Diagnosis

Tuberculin test (Mantoux and Heaf)

BCG vaccination

http://youtu.be/h6z7Af-ssxw

http://youtu.be/v-6rXsJaW_o

http://youtu.be/JtyX694ubio

http://youtu.be/TQizZTX6ytw

http://youtu.be/hhdgqiAj0M0

http://youtu.be/lDrG7g96Wcw

WHO TB Factsheet

NICE CG117 Mar 11 TB

North West Medicines Information Centre Nice Bites Jul 11 Tuberculosis

Tuberculosis in the UK—time to regain control BMJ Jul 2011

Stopping routine vaccination for tuberculosis in schools BMJ 2005

Routine BCG vaccination of schoolchildren against tuberculosis stopped in 2005.

BCG vaccination will now be offered to infants in communities with an average incidence of tuberculosis of at least 40 per 100000 and to unvaccinated families from countries of similar incidence. Most people born in the UK now will not receive BCG. As most will not be exposed to mycobacteria, tuberculin testing will become more efficient in detecting infection.

NICE CG33 Clinical diagnosis and management of TB and measures for its prevention and control

Consolidation

Localised area of pneumonia (??) due to infection, infarction, malignancy.

Shows on X-ray as homogenous opacity with ill defined margins.

• Clinically
• Reduced chest movement on affected side
• No shift of trachea or apex beat.
• Increased vocal fremitus.
• Reduced percussion note
• Bronchial breathing
• Fine or coarse crepitations
• Increased vocal resonance
• Whispering pectoriloquy.

Lobar collapse

• Decreased movement and flattening of chest wall on side of collapse
• Trachea shift (upper lobe collapse) and apex shifted (lower lobe collapse) towards side of collapse
• Decreased PN
• Reduced breath sounds +/- bronchial breathing and creps if assosciated consolidation
• CXR shows homogenouus dense opacity. Lateral view may help locaise affected lobes.

Causes

• Obstruction of major bronchus by Ca, FB, lymph nodes or pus
• Lung compression by pleural effusion or pneumothorax.

Pleural effusion

Clinically

Decreased chest movements on side of effusion

Trachea and apex not shofted unless effusion is massive

Vocal fremitus reduced or absent

Absent or reduced BS

Absent Vocal Resonance

Bronchial breathing over upper level of effusion

Pleural Effusion medscape

http://youtu.be/fF6dbnKdpf0

http://youtu.be/bwzrnedOWF0

Atelectasis

Atelectasis Medscape

http://youtu.be/VQRggeFb_J0

http://youtu.be/soNg3oVW6F8

http://youtu.be/MUT0_r6xtXs

Fibrosing alveolitis

Idiopathic diffuse interstitial fibrosis characterized by dyspnoea, dry cough, clubbing, fine velcro crepitations in lower lungs.

Idiopathic Pulmonary Fibrosis PUK

Fibrosing Alveolitis Pulmonary fibrosis British Lung Foundation

http://youtu.be/lUAcjuolIaQ

http://youtu.be/J6zM-KhvQuQ

http://youtu.be/YDPCm4MZYx8

Extrinsic allergic alveolitis

Inflammation of the alveoli and small airways (pneumonitis) due to a type III (delayed) hypersensitivity reaction to inhaled organic antigens – bird proteins, fungi and protozoa. The antigen must be small enough to be depositied in the distal lung. It becomes bound to circulating IgG forming immune complexes which then cause mast cell degranulation and inflammatory cell infiltration. Symptoms develop 4-12 hours after exposure.

Symptoms may also be subacute / insidious due to ongoing exposure, or chronic due to fibrosis.

Bird fanciers lung

Farmers lung

Humidifier fever

Maltworkers Lung

The alveolar and small airway inflammation impairs gas transfer and causes breathlessness and cough. Spirometry shows a restrictive pattern (reduction in lung volumes)

Extrinsic Allergic Alveolitis PUK

Extrinsic Allergic Alveolitis British Lung Foundation

Farmers Health Rural Health West

http://youtu.be/gl1BVcxCzj8

http://youtu.be/pcdLEu3PN78

Pulmonary eosinophilia

http://youtu.be/fmXqRomZSzk

Pulmonary eosinophilia umm.edu

Pulmonary eosinophilia medscape

Pulmonary eosinophilia Respiratory Reviews.com

Sarcoidosis

Chronic multisystem disorder characterised by development of non-caseating (cf TB) granulomas (small foci of chronic inflammation) particularly in the lungs skin and eyes.

May be asymptomatic or may present with respiratory symptoms, erythema nodosum, joint or opthalmic symptoms, hypercalcaemia.

• Staging of pulmonary sarcoidosis
• Stage 1 – bilateral hilar lymphadenopathywithout parenchymal disease
• Stage 2 – BHL with non-fibrotic parenchymal disease
• Stage 3 – Non -fibrotic parenchymal disease alone ( hilar glands have shrunk)
• Stage 4- fibrosis and distortion of lung

http://youtu.be/1NeQmJz9DL4

http://youtu.be/fuD022heiYw

http://youtu.be/9_S95Y7J9ZY

http://youtu.be/dG_42jXthCE

Sarcoidosis BMJ 2009

sarcoid.co.uk

sila.org.uk

Other granulomatous disorders include TB Crohns aspergillosis and autoimmune disorders.

Drugs causing lung damage

Drugs causing lung damage Medscape

Immunological lung disease

slideshare.net immune mediated lung diseases

Occupational lung disease

http://youtu.be/yUaJ0ZzOsVI

http://youtu.be/2lButiuzeBI

asthma hse.gov.uk

Industrial Dust Diseases PUK

Pneumoconiosis

http://youtu.be/CUb9WvR2Hvs

http://youtu.be/ELPcXVv9tlg

hse.gov.uk pneumoconiosis

Asbestos related disease

Pleural plaques

Asbestosis

Lung Cancer

Mesthelioma

http://youtu.be/uHLeockYQJQ

http://youtu.be/W2ll4N0xnBw

http://youtu.be/ZAiudmamIYo

Mesothelioma Medscape

Mesothelioma PUK

mesothelioma.uk.com

asbestos.com mesothelioma

mesothelioma.com

Lung cancer

Lung Cancer Types

Non Small Cell

Respond poorly to chemo Rx – localised peripheral lesions may be cured by surgery.

Squamous Cell 35-45%

Adenocarcinoma 15%

Large cell carcinoma 10%

Carcinoid 1%

Bronchoalveolar cell carcinoma

Small cell (20%)

endocrine (APUD) derived fast growing highly malignant metastasises early

http://youtu.be/LRLk0AVZ2PM

http://youtu.be/TJmpE-Yf6hk

Lung cancer staging

http://youtu.be/fxqn7Lr7ed0

http://youtu.be/IWOzzqA3l7c

http://youtu.be/o_E3NvE7wDo

Lung Cancer Treatment

http://youtu.be/Kvmoj_xEeUs

Lung Cancer MacMillan.org

Early CDT-Lung

NICE CG24 Lung cancer Feb 2005 QRG

Therapeutic advances in non-small cell lung cancer Thorax Nov 2011

Pancoast tumour

Pancoast Tumour Medscape

http://youtu.be/5ItfmghpW5Q