Case 3: Lung function test

68 yr old male came for regular check up.

He had a lung function test last year.

He used to be a heavy smoker, quit last year. His exercise tolerance is limited to around 50m.

What is your diagnosis ?

With a long smoking history and shortness of breath, this lung function indicates Chronic Obstructive Pulmonary Disease (COPD) . COPD is confirmed by the presence of persistent airflow limitation. FEV1/FVC < 0.7.

The problem we are having now is that we over diagnose people with COPD. Around 20-30% of patients who have a diagnosis of COPD has never had spirometry. Remember, COPD is a spirometry diagnosis.

What are your differential diagnoses?

COPD has many causes including asthma, smoking, occupation exposures, and anti tripsin 1 deficiency.

Is this severe disease ?

The current classification from lung foundation Australia classify this patient with severe disease.

How would you manage this patient?

This patient requires multi-disciplinary approach. 

1. GP management plan and TCA
2. Prevention of exacerbation: flu vaccination and pneumococcal vaccination
3. Stop smoking 
4. Optimise medications: use COPD stepwise treatment flowchart (link)
5. COPD action plan 
6. Refer to lung rehabilitation or physiotherapist or exercise physiologist to improve lung function 
7. Regular review and assess inhaler techniques 

According to the latest COPD guideline, severe COPD with more than 2 exacerbations per year should be managed by LABA + Inhale corticosteroid. 

Reference:

1. COPD-X concise guideline

Approach to Dysnoea

Probability diagnosis

• bronchial asthma
• bronchioligitis (children)
• COPD
• Ageing; lack of fitness
• Left heart failure
• Obesity 

Serious disorders not to be missed

• Cardiovascular
• Acute heart failure
• arrhythmia 
• pulmonary embolism
• fat embolism
• pulmonary hypertension 
• dissecting aneurysm 
• cardiomyopathy
• pericardial tamponade
• anaphylaxis
• Neoplasia
• bronchial carncma, other malignancy
• Severe infections
• SARS
• avian influenza
• pneumonia
• acute epiglottitis
• Respiratory disorders
• inhaled foreign body
• upper airways obstruction 
• pneumothorax
• atelectasis
• pleural effusion 
• tuberculosis
• acute respiratory distress syndrome
• Neuromuscular disease
• infective polyneuritis
• poliomyelitis

Pitfalls

• interstitial lung disease 
• idiopathic pulmonary fibrosis 
• extrinsic allergic alveolitis
• sarcoidosis
• chemical pneumonitis
• metabolic acidosis 
• radiotherapy 
• kidney failure (uraemia)
• multiple small pulmonary emboli

Severn masquerades checklist

• Depression 
• Diabetes
• Drugs 
• Anaemia 
• Thyroid disorder 
• Spinal dysfunction 

Is the patient trying to tell me something?

• Consider functional hyperventilation 

Intersitial lung diseases

Condition

• Interstitial lung disease 

Definition

• Interstitial lung diseases comprise a group of disorders that have the common features of inflammation and fibrosis of the inter alveolar septum, representing a non-specific reaction of the lung to injury of various causes

Main features

• Dyspnoea and dry cough
• fine inspiratory crackles at lung base
• finger clubbing 
• PFTs
• restrictive ventilatory deficit
• decrease in gas transfer factor
• Characteristic x-ray changes

Causes

• sarcoidosis
• cryptogenic fibrosing alveolitis
• extrinsic allergic alveolitis
• drug induced
• lymphangitis carcinomatosis
• acute pulmonary oedema
• immunological 

Treatment

• Depends on cause

Sarcoidosis

Condition

• Sarcoidosis

Definitions

• Sarcoidosis is a multisystemic disorder of unknown aetiology which is characterised by non-caseating granulomatous inflammation that involves the lung in about 90% of affected patients. A characteristic feature is bilateral hillier lymphadenopathy, which is often symptomless and detected on routine chest x-ray (CXR). Radiological lung involvement can be associated with or occur independently of hillier lymphadenopathy. 

Main features

• May be asymptomatic (one-third)
• Onset usually third or fourth decade
• Bilateral hilar lymphadenopathy (on CXR)
• Cough
• Fever, malaise, arthralgia
• Erythema nudism
• Ocular lesions (e.g. anterior uveitis)
• Other multiple organ lesions (uncommon)
• Overall mortality 2-5%

Investigation

• diagnosis is usually made by biopsy
• Female with erythema nodosum with an acute swinging fever, malaise and arthralgia in a young adult female is diagnostic of sarcoidosis

Treatment

• Referral

Reference

• John Murtagh's general practice 5th edition 

Approach to Dyspnoea

Murtagh's diagnostic model 

Probability diagnosis 

• Bronchial asthma 
• Bronchiolitis 
• COPD 
• Lack of fitness
• Left heart failure
• Obesity 

Serious disorders not to be missed

• cardiovascular:
• acute heart failure (e.g. AMI)
• Arrhythmia 
• Pulmonary embolism 
• Pulmonary hypertension 
• Dissecting aneurysm 
• Cardiomyopathy
• Pericardial tamponade
• Anaphylaxis
• Neoplasia
• Bronchial carcinoma
• Severe infections
• SARS
• avian influenza
• penumonia 
• acute epiglottis (children)
• Respiratory disorders
• inhaled foreign body 
• upper airways obstruction 
• pneumothorax
• atelectasis 
• pleural effusion 
• tuberculosis 
• Acute respiratory distress syndrome
• infective polyneuritis
• poliomeylitis 

Pitfalls 

• Interstital lung disorder:
• fibrosing alveolitis
• extrinsic allergic alveolitis
• Sarcoidosis
• Chemical pneumonitis
• Metabolic acidosis 
• Radiotherapy 
• Kidney failure 
• Multiple smal pulmonary emboli 

Pulmonary effusion

Condition

• Pulmonary effusion 

Main features

• Normal pleural space has 10-20 ml fluid
• Can be detected on x-ray if > 300 ml fluid in pleural space
• Can be detected clinically if > 500 ml fluid 
• Can be sub pulmonary - simulates a raised diaphragm 
• May be asymptomatic 
• Dyspnoea common with large effusion 
• Chest pain in setting of pleuritis, infection or trauma 
• Signs: mid line trachea, reduce in chest wall movement, stony dull percussion note, reduce in breath sounds, absent or decreased vocal fremitus and no adventitious sounds 
• The fluid may be transudate or exudate (diagnosed by aspirate)
• If blood stained - malignancy, pulmonary infarction , TB

The effusion fluid can be classified into transudate and exudate 

• Transudate (protein content < 30g/L, lactic dehydrogenase < 200 IU/L)
• Causes 
• Heart failure (90% of cases)
• Hypoproteinaemia e.g. nephrotic syndrome
• Liver failure with ascites
• Constrictive pericarditis
• Hypothyroidism 
• Ovarian tumour - right sided effusion (Meigs syndrome)
• Exudate
• Protein content > 30 g/L; lactic dehydrogenase > 200 IU/L
• Causes
• Infection - bacterial pneumonia, pleurisy, empyema, TB, viral 
• Malignancy - bronchial carcinoma, mesothelioma, metastatic 
• Pulmonary infarction 
• Connective tissue diseases (e.g. SLE, RA)
• Acute pancreatitis 
• Lymphoma 
• Sarcoidosis 
• HIV with parasitic pneumonia

Management

• Depends on the extend of the effusion 
• Aspiratin may be required to ascertain diagnosis 

Reference:

John Murtagh's General Practice 5th edition 

Community acquired Pneumonia

Condition: Pneumonia


What bacteria commonly cause pneumonia in Australia?
- Most common cause is streptococcus pneumonia
- atypical pathogens mycoplasma pneumoniae, chlamydophila pneumoniae and legionella species
- Haemophilus influenzae < 5 % CAP, predominately in people with COPD
- In tropical regions of Australia, gram negative organisms Burkholderia pseudomallei and Acinetobacter baumanni

How do patients present?
- fever
- rigors
- malaise
- anorexia
- dysnoea
- cough
- purulent sputum
- haemoptysis
- pleuritic chest pain

What are the examination findings?
- fever, cyanosis, confusions, tachypnoea, tachycardia, hypotension, signs of consolidation (diminished expansion, dull percussion note, increase tactile vocal fremitus/vocal resonance, bronchial breathing) and a pleural rub.

How do you treat pneumonia ?

Risk stratification. Assess severity and cater treatment according to severity.


If the following features are present, it is likely that the patient suffers from severe pneumonia and will require in-patient management.

Red flags for community acquired pneumonia in adults
- RR> 30
- Systolic bp < 90
- SaO2 < 92 %
- Acute onset confusion
- HR > 100 bpm
- Multilobar involvement on chest x-ray

CAP treatment flowchart from therapeutic guideline

Mild pneumonia: amoxycillin 1g orally 8 hourly 5 to 7 days or doxycycline 100 mg orally 12 hourly for 5-7 days. (Use this regime if patient can return for review in 48 hrs, if not, give both)

If hypersensitve to amoxycillin, use doxycycline. If can't tolerate doxycycline, use clarithromycin

Other options if hypersensitiv to penicillin, cefuroxime 500 mg 12 hourly (given it is not immediate hypersensitive), consider switching to moxifloxacin 400 mg orally for patients with immediate hypersensitivity to penicillins

Moderate pneumonia: Try to obtain culture before starting treatment.

Benzylpenicillin 1.2 g IV 6 hourly until significant improvement then amoxycillin 1g orally 8 holy for a total of 7 days + doxycycline 100 mg orally 12 hourly for 7 days. (If doxycycline is in appropriate e.g. in pregnant women, switch to clarithromycin)

If hypersensitive to penicillin, use ceftriaxone 1 g IV daily until significant improvement, then cefuroxime 500 mg orally, 12 hourly for a total of 7 days

References:
- Therapeutic guideline

Respiratory examination

My study for the day.......Respiratory examination from Clinical examination by Talley and O'Connor

• General inspection 
• Sputum mug contents (blood, pus etc)
• Type of cough
• Rate and depth of respiration, and breathing pattern at rest
• Accessory muscles of respiration 
• Hands
• Clubbing 
• cyanosis 
• Nicotine staining
• Wasting, weakness - finger abduction and adduction (lung cancer involving the brachial plexus)
• Wrist tenderness (hypertrophic pulmonary osteoarthropathy)
• Pulse (tachycardia; pulsus paradoxus)
• Flapping tremor (co2 narcosis)
• Face
• Eyes - Horner's syndrome (apical lung cancer)
• Mouth - central cyanosis 
• Voice - hoarseness (recurrent laryngeal nerve palsy)
• Chest posteriorly
• inspect 
• shape of chest and spine
• Scars
• Palpate
• Cervical lymph nodes 
• Expansion 
• Tactile femitus
• Percuss
• Supraclavicular region 
• Back
• Axillae
• Auscultate 
• Breath sounds
• Adventitious sounds
• Vocal resonance
• Chest anteriorly
• Inspect
• radiotherapy marks
• Other signs as noted above
• Palpate
• supraclavicular nodes
• Expansion 
• Tactile fremitus
• Percuss
• Auscultate
• Assessment of right heart failure