Respiratory System Diseases - psc.gov.za · PDF fileRespiratory System Diseases Charles Feldman Professor of Pulmonology . Charlotte Maxeke Johannesburg Academic Hospital . University
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Respiratory System Diseases Charles Feldman Professor of Pulmonology Charlotte Maxeke Johannesburg Academic Hospital University of the Witwatersrand
• Commonest reason for admission of persons to hospital after childbirth
• Together with Influenza is second commonest cause of death in South Africa and is the commonest infection cause of death
• Involves all strata of society • HIV infection is a major risk factor • Should include tuberculosis in the discussion
Risk Factors for Pneumonia
• Age (young and elderly) • Socioeconomic factors • Smoking and alcohol • HIV infection • Chronic medical conditions – cardiac, lung,
liver, kidney • Occupational risk factors
Presenter
Presentation Notes
Pneumococcal pneumonia
Prognosis associated with Pneumonia
• Treatment with antibiotics for ~7 days • Mostly recover complete lung function
except HIV infected persons • Ongoing symptoms may be due to
underlying risk factors • Outpatients less than 1% • In-hospital patients 5-15% • ICU patients up to 50%
Natural History and Prognosis of Pneumonia
• Most studies have examined short-term prognosis – in-hospital or 30-day
• Evaluation of older patients from Medicare database
• 158,960 patients • 794,333 controls
• In-patient mortality 11% versus 5.5% • 1 year mortality 40.9% versus 29.1%
Kaplan et al Arch Intern Med 2003
5
0
Pat
ient
s
10
15 20
25
30 35 40
45
Hospital mortality 1 Year mortality
CAP Control
Kaplan et al Arch Intern Med 2003
1.0
0.6
0.4
0.2
0.0
0.8
Pro
babi
lity
of S
urvi
val
0 50 1000 1500 2000 Time (days)
1.0
0.6
0.4
0.2
0.0
0.8
0 50 1000 1500 2000 Time (days)
Pro
babi
lity
of S
urvi
val
PSI Risk Classification
Class 1 & 2 (n=617)
Class 3 (n=613)
Class 4 (n=1306)
Class 5 (n=748)
Introduction to COPD The deviation of man from the state in which he was originally placed by nature seems to have provided him with a prolific source of diseases
Jenner 18th Century
• This was never more true than when applied to
the effects of cigarette smoke and chronic obstructive pulmonary disease (COPD)
• COPD patients are at increased risk of: • Myocardial infarction, angina • Osteoporosis • Respiratory infection • Depression • Diabetes • COPD and lung cancer
Sutherland ER et al. N Eng J Med 2004; 536: 2689–2697
FEV 1
(%of
pre
dict
ed)
100
50
20
Asymptomatic Lung
function normal
Lung function reduced
Axis of progression
Sym
ptom
s
Severe
Mild
When do Patients Present? • Symptoms generally develop only after a significant
drop in FEV1 (to less than 50%) has occurred
Presenter
Presentation Notes
Notes The course of COPD begins with an asymptomatic phase in which lung function deteriorates without associated symptoms.1 Substantial deterioration has already occurred by the time most patients are symptomatic; symptoms generally develop only after FEV1 has fallen below 50% predicted.1 These patients do not have mild disease when they present to their doctor, but already have moderate or severe COPD according to the GOLD Guidelines (moderate 50-80% predicted FEV1, severe 30-50% predicted FEV1).2 References 1.Sutherland ER et al. N Eng J Med 2004; 536: 2689–2697. 2.National Collaborating Centre for Chronic Conditions (NICE). Thorax 2004; 59(Suppl 1): 1–232.
SYMPTOMS cough
sputum shortness of breath
EXPOSURE TO RISK FACTORS
tobacco occupation
indoor/outdoor pollution
SPIROMETRY
How do you Diagnose COPD?
Presenter
Presentation Notes
A diagnosis of COPD should be considered in any patient who has cough, sputum production, or dyspnea and/or a history of exposure to risk factors. The diagnosis is confirmed by spirometry. To help identify individuals earlier in the course of disease, spirometry should be performed for patients who have chronic cough and sputum production even if they do not have dyspnea. Spirometry is the best way to diagnose COPD and to monitor its progression and health care workers to care for COPD patients should have assess to spirometry.
Pre Post
Obstructive Very severe obstruction Non reversible COPD
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Ris
k
(GO
LD C
lass
ifica
tion
of A
irflo
w L
imita
tion)
Ris
k
(Exa
cerb
atio
n hi
stor
y) > 2
1
0
(C) (D)
(A) (B)
mMRC 0-1 CAT < 10
4
3
2
1
mMRC > 2 CAT > 10
Symptoms (mMRC or CAT score)
A B
C D
Lower risk
Higher risk
Low symptoms High symptoms
GOLD 2013 combined assessment
More than 1 exacerbation
or 1 admission in previous
year? No
Yes
Breathless during usual daily activity on most days?
No Yes
Simplified to 2 key questions
A B
C D
Lower risk
Higher risk
Low symptoms High symptoms
GOLD 2013 combined assessment
More than 1 exacerbation
or 1 admission in previous
year? No
Yes
Breathless during usual daily activity on most days?
No Yes
Simplified to 2 key questions
4
5
5
3
4
4
5
34
4
Global Strategy for Diagnosis, Management and Prevention of COPD
Modified MRC (mMRC) Questionnaire
Definition of an Exacerbation
“an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnoea, cough, and/or sputum that is beyond normal day-to-day variations, Is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD”
2006 Update
Sym
ptom
s Usual pattern
Time
(a)
Sym
ptom
s
Treatment failure
Time
(b)
Initial treatment
Additional treatment
Sym
ptom
s
Recurrence
Time
(c)
> 4 weeks
> 6 weeks
Soler-Cataluna JJ et al. COPD: J COPD 2010; 7: 276-284
Social withdrawal
Worsening quality of life
More exacerbations
Increased risk of hospitalisation
What Does an Exacerbation Mean to a Patient?
Greater anxiety
Decline in lung function
Garcia-Aymerich J et al. 2001 Donaldson D et al. 2002
Gore JM et al. 2000 Seemungal T et al. 1998
Pauwels Pet al. 2001 Seemungal T et al. 2000
Garcia-Aymerich J et al. 2003 Anto JM et al. 2001
Increased symptoms (I.e. breathlessness)
Increased risk of mortality
Presenter
Presentation Notes
Exacerbations of COPD are a major cause of morbidity, mortality and hospital admission.1,2 Some patients are particularly susceptible to developing frequent exacerbations, an important determinant in health-related quality of life.1–3 The downward spiral of more frequent exacerbations can lead to decline in lung function; greater anxiety; worsening quality of life; social withdrawal; more exacerbations and increased risk of hospitalisation.1-9 As frequent exacerbations are associated with a faster long-term decline in lung function, it has also been suggested that prevention of exacerbations might slow disease progression.9 In addition, a reduction in the frequency or severity of exacerbations offers an obvious means of reducing demand on the healthcare system. Patients who are prone to exacerbations have been found to have higher airway cytokine levels suggesting increased airway inflammation that could increase susceptibility to exacerbation.5 These patients are also prone to larger falls in FEV1 at exacerbations, prolonged and more frequent hospital admissions, more chronic respiratory symptoms and more severe exacerbations.4 Exacerbations that require hospital admission are associated with a high risk of mortality 10. References: 1. Rodriguez-Roisin R. Towards a consensus definition for COPD exacerbations. Chest 2000; 117: 398S–401S. 2. Wedzicha JA. Mechanisms of exacerbations. Novart Found Symp 2001; 234: 84–103. 3. Seemungal TAR, Donaldson GC, Paul EA et al. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998; 157: 1418–22. 4. Garcia-Aymerich J, Monso E, Marrades RM et al. Risk factors for hospitalisation for a chronic obstructive pulmonary disease excerbation - EFRAM study. Am J Respir Crit Care Med 2001; 164: 1002–07. 5. Donaldson GC, Seemungal TA, Bhowmik A, Wedzicha JA. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax 2002; 57(10): 847–52. 6. Gore JM, Brophy CJ, Greenstone MA. How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer. Thorax 2000; 55: 1000–6. 7. Pauwels RA, Buist AS, Calverley PM et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med 2001; 163: 1256–76. 8. Seemungal TA, Donaldson GC, Bhowmik A et al. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000; 161: 1608–13. 9. Garcia-Aymerich J, Farrero E, Felez MA et al. Risk factors of readmission to hospital for a COPD exacerbation: a prospective study. Thorax 2003; 58(2): 100–5. 10. Anto JM et al. Epidemiology of chronic obstructive pulmonary disease. Eur Resp J 2001;17:982-994
LML. BC Medical Journal 2010; 52: April 2010 www.bmcj.org FitzGerald JM. Postgrad Med J October 2011; 87: 655-656
**As a nurse working with a client, what would be some things you could tell him or her about what to expect for each test? A chest x-ray is preformed to search for: pulmonary density, a solidary peripheral nodule (coin lesion) (a mass in the lung or airway) Atelectasis (collapsed lung) Infection fluid in the lung enlarged lymph nodes in the chest “A chest x ray is a painless, noninvasive test that creates pictures of the structures inside your chest, such as your heart, lungs, and blood vessels. "Noninvasive" means that no surgery is done and no instruments are inserted into your body Your ribs and spine are bony and absorb radiation well. They normally appear light on a chest x ray. Your lungs, which are filled with air, normally appear dark. A disease in the chest that changes how radiation is absorbed also will appear on a chest x ray”. (http://www.nhlbi.nih.gov/health/health-topics/topics/cxray/) Chest x rays have few risks. The amount of radiation used in a chest x ray is very small. A lead apron may be used to protect certain parts of your body from the radiation. CT scans shows the size, shape, and position of your lungs and other structures in your chest. Follow up on abnormal findings from standard chest x rays. Find the cause of lung symptoms, such as shortness of breath or chest pain. Find out whether you have a lung problem, such as a tumor, excess fluid around the lungs, or a pulmonary embolism. Most places will provide the patient with a gown. He/she will need to undress, usually down to their underwear, and put the gown on. If the place does not provide a gown the patient should wear loose-fitting clothes. �Any woman who suspects she may be pregnant should tell her doctor beforehand. �Doctors may ask the patient to fast (eat nothing) and even refrain from consuming liquids for a specific period before the scan. �The patient will be asked to lie down on a motorized examination table, which then goes into the giant doughnut-like machine. The couch with the patient goes into the doughnut hole. � MRI is like a CT only it uses magnetism instead of xrays, remove all metallic objects, fill out a screening form, asked to lie down on a comfortably padded table that gently glides you into the scanner. ��earplugs or headphones to protect your hearing because, when certain scanners operate, they may produce loud noises. These loud noises are normal and should not worry you. ��Nurse may inject a contrast agent called "gadolinium" in vein to help obtain a clearer picture of the area being examined. A saline solution will drip through IV to prevent clotting until the contrast material is injected at some point during the exam. �The most important thing for the patient to do is to relax and lie still. Most MRI exams take between 15 to 45 minutes to complete depending on the body part imaged and how many images are needed.�You will be asked to remain perfectly still during the time the imaging takes place, but between sequences some minor movement may be allowed. You will be guided.��may breathe normally, however, for certain examinations it may be necessary for you to hold your breath for a short period of time. ��During your MRI examination, the MR system operator will be able to speak to you, hear you, and observe you at all times. Consult the scanner operator if you have any questions or feel anything unusual.��When the MRI procedure is over, you may be asked to wait until the images are examined to determine if more images are needed. After the scan, you have no restrictions and can go about your normal activities. � Sputum cytology is rarely used to make a dx of lung Ca; medical test in which a sample of sputum (mucus) is examined under a microscope to determine whether abnormal cells are present. A sample may be obtained either by the person coughing up mucus at home or in the doctor’s office or during a bronchoscopy. Remove dentures if you wear them. • Rinse your mouth with water. • Take about four deep breaths followed by a few short coughs, then inhale deeply and cough forcefully into the container. Make sure to get a sample from deep in your airway. (http://www.lung-cancer.com/sputum.html) however fibreoptic bronchoscopy is more commonly used and provides a detailed study of the tracheobronchial tree and allows for brushings, washings, and biopsies of suspicious areas. Test to see inside the airways of your lungs, or to get samples of mucus or tissue from the lungs. Bronchoscopy involves placing a thin tube-like instrument called a bronchoscope through the nose or mouth and down into the airways of the lungs. The tube has a mini-camera at its tip, and is able to carry pictures back to a video screen or camera. not to eat after midnight the night before (or about 8 hours before) the procedure. You will also receive instructions about taking your regular medicines, smoking and removing any dentures before the procedure. Before beginning the procedure, you will inhale an aerosol spray of a medicine like Novocain, which numbs the nose and throat area and helps to prevent coughing and gagging during the procedure. After that you will be given a sedative by vein. The sedative will help you to relax, and may make you feel sleepy. The sedative may also help you to forget any unpleasant sensations felt during the test. After the procedure, do not drink for 1⁄2 to 1 hour or until the numbness completely wears off. Do not drive home by yourself after the procedure; arrange for a family member or friend to take you home. Contact your doctor immediately if you have shortness of breath or chest pain, or you cough up more than a few tablespoons of blood at home. (http://patients.thoracic.org/information-series/en/resources/fiberoptic-bronchoscopy.pdf) A transthoracic fine needle aspiration A fine needle aspiration biopsy is a test done to see if a tumor is benign (non-cancerous) or malignant (cancerous.) Fine needle aspiration (FNA) is done by inserting a thin needle into a tumor and removing cells that can be evaluated under the microscope. A pathologist looks at the cells to see if the suspicious tumor is cancer, and if it is cancer, what type of cancer. With lung cancer, the needle is inserted into the chest through the skin. Doctors can make sure the needle goes to the right part of the lung by watching it through ultrasound or a CT scanner. Given cough suppressant, CT scan or help find target of biopsy, skin cleaned just above ribs, sedative and local anesthetic for area, <30mins, small incising in skin, hold breathe stay still, insert needle thru skin and chest wall, feel pressure and pain when reach surface of lung, pain when reach area for tissue extraction. CXR done to see no collapse, short recovery time and home the same day unless a complication. (http://www.youtube.com/watch?v=abvYaB2VcmI) http://lungcancer.about.com/od/glossary/g/FNA.htm
Lung Biopsy
Presenter
Presentation Notes
A lung biopsy removes a small piece of lung tissue which can be analyzed at under a microscope to determine if the tumor is cancer or not to determine the type of cancer to determine the grade of cancer (slow or fast)
Lung Cancer Staging
Clinical Staging Pathological
• based on findings gathered by the doctor
• used to plan the initial therapy • may be modified by additional
information found during pathological examination
• Based on the examination of the tissue samples obtained from the primary tumor, nodes or metastasis
• Helpful in planning additional treatment and follow-up
Presenter
Presentation Notes
Clinical staging is used to plan the preliminary therapy to treat the cancer. And it may be changed by additional data found during pathological examination. It is based on findings gathered by the doctor used to plan the initial therapy may be modified by additional information found during pathological examination.
Presenter
Presentation Notes
Apical segment LLL pneumonia
Presenter
Presentation Notes
Lung mass =- carcinoma
• Under discussion today • Pneumonia • Bronchitis • COPD • Lung Cancer
• Also need to be considered? • Asthma • Tuberculosis • HIV infection
