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SERF South East Respiratory Forum 13 14th October 200

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SERF South East Respiratory Forum 13 14th October 2006 Ramada Jarvis Crawley W O R K S H O P G Christine Fehrenbach Respiratory Nurse Specialist Bronchiectasis ... – PowerPoint PPT presentation

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Title: SERF South East Respiratory Forum 13 14th October 200


1
SERF
South East Respiratory Forum
13 14th October 2006 Ramada Jarvis Crawley
2
W O R K S H O P G
What am I missing?
  • Christine Fehrenbach
  • Respiratory Nurse Specialist

3
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

4
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

5
Microbial insult
Acute, well controlled inflammation
First line mucociliary clearance
Health
Elimination of microbial insult
6
Microbial insult
Microbes able to inhibit ciliary beating damage
epithelium
Defective mucociliary clearance system
Microbial colonization
Tissue damage
Progressive lung damage
7
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

8
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9
Investigations
  • Clinical history
  • Examination
  • Sputum culture and observation
  • Radiography - CXR CT scan

10
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

11
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

12
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13
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

14
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

15
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.

16
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17
Other Causes
  • Drugs
  • Anti Inflammatory agents
  • Recreational drugs
  • Anti Arrhythmic Amiodarone
  • Antidepressants - Dothiepin

18
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

19
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20
Signs and symptoms
  • Progressive breathlessness
  • Dry cough
  • Clubbing
  • Fine inspiratory crackles
  • Restrictive spirometry
  • Central cyanosis
  • Peripheral oedema
  • Ground glass appearance on CT

21
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22
Treatment
  • Corticosteroids (40-60 mg for 2/12) 40 respond
  • Immunosuppressants
    (Azothioprine, Cyclophosphamide)
  • Oxygen
  • Opiates
  • Palliation
  • Median survival 3.5 years

23
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24
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

25
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26
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

27
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28
Sarcoidosis
  • A multi-system disorder characterised by the
    presence of non-caseating granulomatus lesions.
    More common in Caribbean black, Irish ethnic
    origins.

29
Sarcoid can affect any organ but a Pulmonary
presentation is common
  • Maybe Asymptomatic cough non productive. Sob.
  • Acute presentation
  • lethargy
  • joint aches
  • skin rash erythema nodosum
  • Bilateral hilar lymphadeopathy on CXR
  • most important differential diagnosis lymphoma
  • Blood tests ACE
  • Bronchial biopsy

30
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31
Treatment
  • Aim of treatment - suppress inflammation and
    prevent fibrosis
  • Symptomatic
  • Corticosteroids
  • Other
  • Methotrexate
  • Azothioprine

32
TuberculosisUK
  • 150 Years ago 18 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

33
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34
  • Last 20 years increasing in UK
  • 30
  • 7,000 cases per year
  • 3,000 of those in London
  • 110,000 of the population
  • 350 deaths

35
Symptoms
  • Appetite lost weight
  • Persistent cough
  • Phlegm
  • Tired
  • Fever night sweats
  • Aching pleuritic chest pain

36
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

37
  • 1-5 Develop primary disease
  • Unnoticed resolves without treatment
  • Can reactive later

38
Latent TB Infection
  • No symptoms
  • Cannot spread TB
  • Positive tuberculin skin test
  • Can develop disease later

39
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40
Diagnosis
  • Tuberculin test mantoux
  • CXR
  • Sputum

41
Treatment
  • Isoniazid
  • Rifampicin
  • Pyrazinamide
  • Ethambutal
  • Rifampicin
  • Isoniazid

Two months
Four months
42
Drug Resistance
  • Main cause incomplete treatment

43
  • Medication always supervised
  • by specialist service
  • Non infectious - two weeks

44
  • Screening contacts
  • Rare for children to be infectious

45
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

46
  • Homeless
  • Poor overcrowded
  • Prison
  • Addicted drugs / alcohol
  • Young and old

47
National TB Action PlanOctober 2004
  • Control by
  • Promptly recognising treating
  • Treatment completion
  • BCG high risk
  • Health promotion
  • Concentrating activity on at risk

48
BCG Vaccine
  • Travel 1/12 in high risk countries
  • Babies in high risk areas

49
Lung Cancer
Princess Margaret
  • Edward
  • VII

1 3 Cancer Deaths
50
Causes
  • 90 Cigarette smoking

51
  • 20 Smokers develop disease
  • Genetics
  • Environment
  • Social Deprivation

52
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53
Clinical Presentation
  • 10 - No signs
  • New cough or change in existing
  • Haemoptysis
  • Inspiratory stridor
  • Pain
  • Weight loss
  • Lassitude
  • Finger clubbing

54
Investigations
  • CXR
  • CT scan
  • Bronchoscopy
  • Bloods

55
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56
Treatment
  • Surgery
  • Chemotherapy
  • Radiotherapy
  • Palliative care

57
  • Small cell carcinoma 20
  • Non small cell
  • Adenocarcinoma 40

58
  • Pre laser

Immediately Post Laser
One Month Post Laser
59
Stents
60
Secondaries
  • Brain

Liver
Adrenal deposits
Bone deposits
61
Breathlessness
  • Drain effusions
  • Steriod trial
  • Breathing techniques
  • Non pharmocological
  • Morphine oral nebulised
  • Anxiolytic

62
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63
Haemoptysis
  • Radiotherapy external
  • Brachytherapy
  • Endobronchial cautery

64
Pain
  • Bone pain nsaid opiate
  • Radiotherapy
  • Neural pain - steroids

65
Anorexia
  • Small frequent meals
  • Increase spice / herb use
  • Steroids
  • Anti inflammatory drug

66
Cough
  • Oral opiate
  • Nebulised lignocaine

67
Metastatic Spread to Lungs
  • Renal
  • Melanoma
  • Breast
  • Ovary
  • Gut
  • Colon

68
Chronic Cough
  • Post viral bronchial hyper-reactivity
  • Chronic rhino sinusitis
  • Cardiac failure
  • Reflux
  • Infections

69
  • Full drug history including over the counter and
    herbal remedies
  • Detailed occupational history searching for
    exposures

70
Breathlessness
  • Within minutes PE pneumothorax M.I. cardiac
    rhythm 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 asbestos
    related conditions
  • Years COPD heart value dysfunction obesity

71
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