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Christine_Fehrenbach_Workshop - SERF South East Respiratory...

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Unformatted text preview: SERF South East Respiratory Forum 13 –14th October 2006 Ramada Jarvis Crawley WORKSHOP G What am I missing? Christine Fehrenbach Respiratory Nurse Specialist FUTURE Bronchiectasis Chronic dilatation of one or more bronchi The bronchial wall becomes damaged as a consequence of earlier inflammation and infection of the bronchi or neighbouring lung tissue FUTURE Causes • Severe infection especially in childhood – TB, Whooping cough, measles, pneumonia • • • • • Rheumatoid arthritis recurrent infections Male infertility – ciliary dysfunction Ciliary dyskinesia co existing sinusitis Hypogammaglobulinaemia Obstruction – Tumour, foreign body, external compression FUTURE Microbial Microbial insult insult Acute, well Acute, well controlled controlled inflammation inflammation First line First line mucociliary mucociliary clearance clearance Health Health Elimination of Elimination of microbial microbial insult insult FUTURE Microbes remain longer in sinobronchial tree Microbia Microbia ll insult insult Defective mucociliary clearance system Microbes able to inhibit ciliary beating & damage epithelium Microbial colonization Tissue damage Chronic inflammation Progressive lung Progressive lung damage damage Signs and symptoms • • • • ‘Rattly cough Sputum on change of position Occasional small haemoptysis Exacerbations, fevers, breathlessness, pleurisy, wheeze • Chest examination localised inspiratory crackles • Finger clubbing FUTURE FUTURE Investigations • Clinical history • Examination • Sputum culture and observation • Radiography - CXR CT scan FUTURE Management • • • • • • • • Physiotherapy daily Antibiotics – sputum culture prolonged courses intravenous Airway inflammation – inhaled steroids Airflow limitation - bronchodilator Surgery Disease progression leads to respiratory failure Immunoglobulin deficiency – IV products Localised areas may be resected FUTURE Interstitial Lung Disease • Hypersensitivity to an organic antigen, resulting in an inflammatory response in the alveoli • The antigens that cause this type of reaction are usually between 1 and 5 microns in diameter • Less common in smokers • The risks are real, eg about 10-20% of people who are in regular contact with pigeon will develop bird fanciers lung FUTURE FUTURE Presentation Symptoms occur about 4 - 8 hour following exposure to the antigen and include: cough, breathlessness, headache, fever, muscle ache and feel generally unwell. Medical examination may reveal crackles and wheezes when the patient inhales and the x-ray may show diffuse interstitial shadowing, but may be normal. Blood tests for lgG antibodies e.g. ‘avian precipitins’ are positive. Lung function tests show a reduction in lung volume, and a decrease in the movement and gases across the alveolar membrane FUTURE Tests and investigations • X-ray show fibrosis - with shadowing more marked in the upper areas of the lung • Chest auscultation may reveal inspiratory crackles and may be late inspiratory “squawk” (Ogilvie, 1982) • Spirometry – restrictive pattern • Blood for “precipitins” is positive FUTURE Treatment: • Avoidance of exposure to allergen, e.g removal of pigeons or budgies from the home • Avoidance measures e.g. wearing protective clothing • Where there is intermittent exposure to birds, the use of face masks has been shown to significantly reduce the symptoms experienced by the patient • The use of oral steroids has been shown to be helpful in the short term. The long term use of steroids for this type of illness is less clear. FUTURE FUTURE Other Causes Drugs Anti Inflammatory agents Recreational drugs Anti – Arrhythmic – Amiodarone Antidepressants - Dothiepin FUTURE Cryptogenic fibrosing alveolitis • Uncommon – becoming more prevalent • Occurs in late middle age – male predominance • Cause unknown – but related to metal/wood dusts viral infections • Widespread fibrosis of the lung parechyma FUTURE FUTURE Signs and symptoms Progressive breathlessness Dry cough Clubbing Fine inspiratory crackles Restrictive spirometry Central cyanosis Peripheral oedema Ground glass appearance on CT FUTURE Treatment • Corticosteroids (40-60 mg for 2/12) 40% respond • Immunosuppressants (Azothioprine, Cyclophosphamide) • Oxygen • Opiates • Palliation • Median survival – 3.5 years FUTURE Asbestos Inhaled asbestos fibres passing via lymphatics or penetrating across pleural space. • Pleural plaques – clinically silent • Diffuse pleural thickening – sob due to restricting thoracic movement • Asbestos – chronic airway inflammation • Mesothelioma – tumour of mesothelial cells of the pleura • Lung cancer – asbestos exposure increases risk FUTURE FUTURE Mesothelioma Males aged 50 – 70 • Progressive breathlessness • Visceral chest pain • Chest examination – pleural fluid • Outlook poor – median survival 12-18 months • Palliation • Industrial injury benefit FUTURE FUTURE Sarcoidosis A multi-system disorder characterised by the presence of non-caseating granulomatus lesions. More common in Caribbean black, Irish ethnic origins. FUTURE Sarcoid can affect any organ but a Pulmonary presentation is common • Maybe Asymptomatic cough – non productive. Sob. • Acute presentation – – – • • • • lethargy joint aches aches skin rash – erythema nodosum Bilateral hilar lymphadeopathy on CXR most important differential diagnosis lymphoma Blood tests – ACE Bronchial biopsy FUTURE FUTURE Treatment Aim of treatment - suppress inflammation and prevent fibrosis • • • Symptomatic Corticosteroids Other – Methotrexate – Azothioprine FUTURE Tuberculosis UK 150 Years ago 1:8 deaths • 1980 Uncommon in UK • due to better housing, early detection & • better treatments World Now • Last year more deaths from • TB than anytime - 8,000 per day FUTURE FUTURE • Last 20 years increasing in UK • 30% • 7,000 cases per year • 3,000 of those in London • 1:10,000 of the population • 350 deaths FUTURE Symptoms • Appetite lost – weight • Persistent cough • Phlegm • Tired • Fever – night sweats • Aching pleuritic chest pain FUTURE TB Spread • TB lungs or larynx • Droplet infection • Prolonged repeated contact • Only 10% develop clinical disease • But not at that time • Active later when weakened FUTURE • 1-5% Develop primary disease • Unnoticed resolves without treatment • Can reactive later FUTURE Latent TB Infection • No symptoms • Cannot spread TB • Positive tuberculin skin test • Can develop disease later FUTURE FUTURE Diagnosis • Tuberculin test – mantoux • CXR • Sputum FUTURE Treatment Isoniazid Rifampicin Pyrazinamide Ethambutal Two months Rifampicin Isoniazid Four months FUTURE Drug Resistance Main cause incomplete treatment FUTURE Medication always supervised by specialist service Non infectious - two weeks FUTURE Screening contacts Rare for children to be infectious FUTURE High Risk • Close contacts • Visited, lived or worked in high rates TB • Children of parents whose country origin has high TB rate • Weakened immune system FUTURE • Homeless • Poor overcrowded • Prison • Addicted drugs / alcohol • Young and old FUTURE National TB Action Plan October 2004 Control by • Promptly recognising & treating • Treatment completion • BCG – high risk • Health promotion • Concentrating activity on at risk FUTURE BCG Vaccine • Travel 1/12 in high risk countries • Babies in high risk areas FUTURE Lung Cancer Princess Margaret Edward VII 1:3 Cancer Deaths Causes 90% Cigarette smoking FUTURE 20% Smokers develop disease • Genetics • Environment • Social Deprivation FUTURE Clinical Presentation • • • • • • • • 10% - No signs New cough or change in existing Haemoptysis Inspiratory stridor Pain Weight loss Lassitude Finger clubbing FUTURE Investigations • CXR • CT scan • Bronchoscopy • Bloods FUTURE FUTURE Treatment • Surgery • Chemotherapy • Radiotherapy • Palliative care FUTURE Small cell carcinoma 20% Non small cell Adenocarcinoma 40% FUTURE Pre laser FUTURE Immediately Post Laser One Month Post Laser Stents FUTURE Secondaries Brain Liver Adrenal deposits Bone deposits FUTURE Breathlessness • Drain effusions • Steriod trial • Breathing techniques • Non pharmocological • Morphine – oral & nebulised • Anxiolytic FUTURE FUTURE Haemoptysis • Radiotherapy – external • Brachytherapy • Endobronchial cautery FUTURE Pain • Bone pain – nsaid opiate • Radiotherapy • Neural pain - steroids FUTURE Anorexia • Small frequent meals • Increase spice / herb use • Steroids • Anti inflammatory drug FUTURE Cough • Oral opiate • Nebulised lignocaine FUTURE Metastatic Spread to Lungs • Renal • Melanoma • Breast • Ovary • Gut • Colon FUTURE Chronic Cough • Post viral bronchial hyper-reactivity • Chronic rhino – sinusitis • Cardiac failure • Reflux • Infections FUTURE Full drug history including over the counter and herbal remedies Detailed occupational history searching for exposures FUTURE Breathlessness • Within minutes – Within minutes – PE pneumothorax M.I. cardiac rhythm PE pneumothorax disturbance dissecting aneurysm acute asthma • Hours or days – pneumonia pleural effusion LVF, asthma, blood loss, lobar collapse, muscle weakness • Weeks – Infiltration – sarcoid, alveolitis malignancy. Pneumonia, MND, main airway OB. Anaemia, valvular dysfunction • Months – same as weeks + obesity obesity asbestos – related conditions • Years – COPD heart value dysfunction obesity FUTURE FUTURE ...
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