Breathe Easy: Understanding Respiratory Diseases an interview with Respiratory Physician- Dr Thomas Altree

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Every breath we take is something we often take for granted, until it becomes difficult.

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Respiratory conditions affect millions of people worldwide, spanning from common ailments like asthma and COPD to life threatening diseases such as pulmonary fibrosis and lung cancer.

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With environmental pollutants on the rise, the ongoing impact of smoking and the increasing prevalence of a chronic lung disease, the burden of respiratory illness is only growing.

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In fact, chronic respiratory diseases rank among the leading causes of morbidity or mortality globally making them a critical area of focus for medical practitioners, To help us navigate this vast and vital field, we're joined by Dr. Tom Altree, a specialist in respiratory and sleep medicine.

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Dr. Altree is a consultant at the Queen Elizabeth Hospital and sees patients in private practice at Breathe SA, and he serves as a Senior Research Fellow at the Flinders University.

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In addition to his clinical expertise, he leads the Queen Elizabeth Hospital Respiratory Clinicals Trials Unit.

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Where he investigates cutting edge treatments for lung conditions including COPD and pulmonary fibrosis.

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Stay tuned as we explore his expert insights on diagnosing and managing respiratory conditions.

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Good day and welcome to Aussie MedEd.

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The Aussie style Medical podcast are pragmatic and relaxed medical podcast designed for medical students and general practitioners where we explore relevant and practical medical topics with expert specialists.

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Hosted by myself, Gavin Nimon, an orthopaedic surgeon, this podcast provides insightful discussions to enhance your clinical knowledge without unnecessary jargon.

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I'd like to start the podcast by acknowledging the Kaurna people as the traditional custodians of the land on which this podcast is produced.

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I'd like to pay my respects to the elders, both past, present, and emerging, and recognizing their ongoing connection to land, waters, and culture.

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I'd like to say that this podcast is for educational purposes only and does not constitute medical advice.

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Always refer to clinical guidelines and consult a qualified healthcare professional before making medical decisions.

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it's my pleasure now to introduce Dr. Tom Altree Tom's joining us now on Aussie Med Ed to talk to us about respiratory conditions.

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Tom, thank you very much for coming on board.

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It's great to have you here.

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My pleasure.

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Thanks for having me.

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no worries.

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How common are respiratory conditions in society and around the world?

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It's about as big as you can get, Gavin.

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It's an enormous topic.

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Around the world, respiratory conditions contribute to a huge amount of disease burden.

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Just in Australia, just looking at chronic obstructive pulmonary disease in itself Over 600, 000 Australians have COPD.

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That's about two and a half percent of the population.

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And that that disease contributes to a huge amount of disease burden.

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And one of the problems around the world is that, here in Australia, we see a condition like that.

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It's mostly related to smoking.

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But things like smoke from bushfires from pollution from cooking also contribute to lung diseases.

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So, anything that we breathe in can damage our lungs and all the time the lungs are exposed to the environment.

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Which is a unique thing about them.

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Yeah, the thought came to mind was that the actual dryer, where you actually clean out the lint filter, that's what's probably hitting our lungs every day.

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All the time, yep, and our macrophages are going to work trying to break all that stuff up.

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But if it's the wrong thing that's coming into our lungs, that can cause disease.

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Yeah, our lungs are susceptible to all of the different things that are in the air.

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And I was hoping it might be getting a bit better hopefully reducing incidence of smoking.

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But I presume the pollutants in the air are getting greater as well.

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And that's also causing issues as well.

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That's true.

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In Australia, smoking rates are reducing.

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Which has been a fantastic thing to see over the last few years, but rates of chronic obstructive pulmonary disease and rates of respiratory disease around the world are not reducing.

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They're going up.

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And that is related to aging populations, exposure to inhale pathogens.

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And now, of course there's vaping as well.

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So even though in Australia, we see the smoking rates going down, the vaping rates are increasing, especially in young people and that is troubling.

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We don't really know , what the full effect of that is going to be in the long term, but it's a worrying thing to see.

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right, where do we start?

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How do we think about classifying these lung diseases?

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We classify lung diseases really based on what the pattern looks like on spirometry.

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So on lung function testing and we break it down into obstructive or restrictive conditions.

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Now that doesn't cover the whole of respiratory medicine because of course you've got other conditions like vascular conditions, pulmonary emboli pulmonary hypertension, infective disorders and cancers.

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But thinking about lung diseases in terms of obstructive or restrictive is a good way to go about it.

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With obstructive disorders, what we see on the lung function testing on spirometry, and that's where you get, you breathe into the spirometer as hard as you can, and we look at how much air comes out in that first second, compare that to how much air comes out completely.

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If that ratio is less than 0.

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7, then that's what we call an obstructive disorder.

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The main obstructive disorders are asthma, chronic obstructive pulmonary disease, bronchiectasis, and cystic fibrosis.

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On the other end of the scale if there is a disorder which is reducing the lung volume, that is a restrictive disorder.

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And so we'll see in restrictive disorders that the FVC, the forced vital capacity, that's how much air you can breathe out completely, will be reduced.

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And if we want to confirm the restrictive disorder, then the next step is to do full lung volume testing, and that will confirm if there's a restrictive disorder.

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And there's a lot of different diseases that cause restrictive disorders, such as interstitial lung diseases.

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So I like to break them those restrictive disorders down into pulmonary or extra pulmonary disorders.

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So extra pulmonary are things like chest wall, deformities, kyphosis, kyphoscoliosis, neuromuscular diseases these can all cause restriction, or intrathoracic or , true kind of respiratory restrictive disorders that are affecting the lung interstitium and they're the interstitial lung diseases, and there's a lot of those, and we can go into that in more detail if you'd like to, but that's a big topic.

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Okay.

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Would people present the same way, whether it's restrictive or obstructive, or they have different variations in symptomatology?

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No there's a variety in the ways that people present with respiratory diseases.

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I mean, breathlessness is the common presentation.

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And breathlessness can be caused, as you know, by a whole host of different diseases, and they're not all necessarily respiratory.

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But cough.

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Weight loss wheeze, exercise intolerance or pain in the chest as well, are all symptoms that may be due to one of those disorders of the lungs.

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So one of the things that I really like about respiratory medicine is that it covers a huge range of types of diseases.

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There's an enormous amount of variety in what we do.

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You know, we've got genetic diseases, infective, malignant diseases that have been caused by smoking, diseases that have been caused by environmental exposures.

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occupational exposures.

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There's a huge amount of variety there.

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So that kind of keeps it interesting to me.

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And it also means that people can present in a huge variety of ways.

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So generally, how would you work someone up , , I usually would like to think of presentations either as an acute presentation versus a chronic one or something that presents to A& E versus something that presents to your clinic.

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Do you think of it that way as well and does that help guide you yeah, absolutely.

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And of course, respiratory conditions can be life threatening conditions, A and ABC, Dr. ABC is airway.

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And B is breathing.

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So the lungs, you know, when there's an acute problem it's really acute and you've got to act fast.

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And that means that a lot of those diseases are dealt with acutely by paramedics, emergency doctors, intensive care unit doctors.

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And so really in my day to day work, I'm seeing more of the chronic presentation of these diseases, although, We do get the emergencies that occur on the ward as well, like a pneumothorax that needs a chest tube put in straight away.

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Really, if I'm in the clinic and somebody is coming in I start the history very broadly.

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I listen to what their presenting complaint is and try and from that, get an idea about, say, if they're breathless, is this breathlessness an acute problem.

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Is this a chronic problem?

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What makes it worse?

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And what are the comorbidities?

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And if they have got any other history of respiratory disease.

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And then from that, I start to narrow my history taking down.

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Based on what they've told me.

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So if it sounds like this is someone who's had chronic breathlessness for years and they've been smoking for a long time, then that's probably going to be one of those obstructive diseases or, if they're a smoker for a long time, it's probably going to be something like chronic obstructive pulmonary disease.

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Whereas if they happen to be a stone cutter, it's or they've been working in an industry where they've had a lot of asbestos exposure, then I'm going to be thinking about interstitial lung disease.

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So it really depends on a broad history and an occupational history and an environmental exposure history and a respiratory history is very important.

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Then we move on to the physical examination.

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Now once again, it's really guided by their history.

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Because, there are so many different disorders and when I'm talking to medical students about the physical examination I tell them there are a lot of signs that you can see peripherally, like you start off examining the patient just in general, you're looking in the corner.

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Is there an oxygen cylinder?

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Is there a sputum jar?

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Is there all that kind of thing?

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You move on to the next one.

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Their hands and then to their head and their neck, but and there are a lot of signs to see there, especially if there's someone who's got a connective tissue disorder or something like that, causing interstitial lung disease.

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But you want to move through that really quickly because really the money is in the chest.

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So when I'm talking to medical students, I say, really try and get to the chest quickly because the chest examination.

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can take up three or four minutes in, in an OSCE situation.

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And there's a lot to do there.

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So you really want to get there quickly.

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And the other thing I say to medical students is to get out there and practice as much as you can on each other.

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Go and see patients with signs because There are a lot of different presentations that you will see different signs in the respiratory examination, be it consolidation or pleural effusion or a malignancy or a pneumothorax or something like that.

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So I still remember it from my medical school days many years ago has it changed much at all No, the examination hasn't changed much at all.

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What's really changed is the quality of imaging that we can get.

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Once you've moved on from history and examination, and you're thinking about your investigations to do, the quality of imaging has changed a lot.

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But, yeah, in the physical examination, it's You know, it's exactly what it would have said in the textbooks 30, 40, 50 years ago.

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You look at a general inspection, then you go look at the hands, clubbing, connective tissue disorders, is there asterixis, which in reality, you're not going to see that a lot, but but you look for it.

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hypertrophic pulmonary osteoarthropathy, all those things are in the textbook that you might see once or twice in your career.

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You move onto the head, you look for Horner's syndrome, a sign of a apical lung tumor.

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have a look in the back of the throat, try and look at the tonsils.

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Is there any central cyanosis?

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See if the trachea is midline JVP, as you said, and then you move into the chest.

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But I really try and get through all of that stuff really quickly in an exam situation because really the chest is where the findings usually are.

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Now, I've got to put my hand up and be honest and say, I have always been a bit critical of the percussive technique.

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I thought it was more of a way of learning how to do tinnel's sign properly but is percussion really useful?

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, when I was learning as a medical student, I never found it that useful, but I presume it must be.

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You can definitely discern differences.

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So, what are we doing when we're percussing we're trying to transmit a sound back to us.

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So . If you've got a smoker with chronic obstructive pulmonary disease, bad emphysema, and they're very hyper inflated then that percussion is going to be really resident because they're full of air.

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If you've got someone with a pleural effusion or consolidation, then that, that percussion is going to be dull.

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Now, of course, Medicine is much more sophisticated than tapping on somebody's back.

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So we're going to move on.

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We're not going to just rely on percussion but it adds one piece of information to an overall picture of what's going on.

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Excellent.

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And then, when you're doing auscultation, what are the particular things?

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I used to be able to hear bronchial breathing.

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I think you described it to me when we were discussing it before, as being like Darth Vader, the noises coming from the chest.

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If you want to hear Bronchial Breathing, just watch Star Wars.

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Yeah, Darth Vader, he's got Bronchial Breathing all the time.

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If Darth Vader turned up with pneumonia, you wouldn't be able to tell.

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Because he's Bronchial Breathing anyway.

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What what you're listening for in auscultation is are there breath sounds that you can hear throughout all the zones of the chest?

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Because if there aren't, then for some reason, air isn't getting to that part of the lung.

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That may be because of a pneumothorax.

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That might be because of the pleural effusion, the breath sounds.

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really come with training.

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The more lungs you listen to the more your appreciation is of what a normal breath sound is versus what is an abnormal breath sound.

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So something like pneumonia or consolidation, you'll get bronchial breathing.

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In something like a pleural effusion you will have reduced breath sounds in that area, but then you can do vocal resonance.

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And that will be dull as opposed to an area of consolidation where it will be increased.

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So it's a bit like if you jump under the water in a pool and you try and yell out to your mate down the end of the pool, you can't hear that sound or they can't hear that sound very well.

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, but if you get your mate to put their ear down to the.

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end of a table, a wooden table, and then you knock on the table down the other end, they'll hear that really well.

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So that's sound being transmitted through consolidation or pneumonia.

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It sounds gets transmitted through solids really well.

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So all of those different components to the examination add their piece.

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And once you can , put that together at the end of the examination, Depending on what you heard with percussion, auscultation, vocal resonance.

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That helps you to really have a good idea about what's going on in the lungs.

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What about coughs and different types of coughs, different types of shortness of breath, and also whether there's blood in the sputum as well.

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Do those things make a difference to your diagnosis as well, Absolutely.

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Blood in the sputum is a red flag sign.

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And to me, blood in the sputum is lung cancer until proven otherwise.

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Now there's a lot of other reasons why there'll be haemoptysis and most of the time it doesn't end up being caused by a lung cancer, but that is one of those really important signs that has to be investigated very thoroughly.

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Answering the question about cough or different types of breathlessness.

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Yeah, absolutely.

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So cough is an extremely common symptom and a lot of patients that I see have chronic coughs.

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Chronic cough is one of those conditions that can represent a serious underlying abnormality like a lung cancer.

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It may represent true Pulmonary disease people with asthma can get cough but often we work up the patient and it's hard to find the cause of the cough so , that is a cause of symptom burden out there in the community , that is hard to diagnose and can be hard to manage, although there are new types of medications that are coming through the research trials that are directed towards people with chronic cough and they look quite promising.

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So how do you proceed?

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You've got the person presents with their shortness of breath, their coughing.

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You've done a thorough examination and you've assessed them.

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Where do you go to from there?

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Normally imaging will be the next step.

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It depends on what you've found so far, if you think there's connective tissue disorder, for example, and that causes a lot of lung disease then I'd be doing autoimmune blood tests In addition to imaging, but usually imaging is the next step.

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The textbooks will say, do a chest x ray.

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And if you're ordering a chest x ray, you always need to make sure they're doing a lateral as well as a PA. But in reality nowadays for most of the cases where we're ordering chest imaging we'll be doing a CT scan of some sort.

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And there used to be these, HRCTs, high resolution CTs that you would want to do for interstitial lung diseases.

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HRCT really is a higher resolution, but you don't get as many cuts, or you didn't get as many cuts.

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Doing something like an HRCT wouldn't be appropriate if someone's got lung nodules because you might miss the nodules in between the cuts.

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Nowadays, the quality of the scan is so high that you essentially get that high resolution from the old school HRCT with your standard CT scan.

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And then if you need to define vascular structures then you would add contrast into the mix.

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And the timing of the contrast is important.

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CT technicians are good at timing that contrast if you're looking for something like a pulmonary embolus.

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But in, yeah, so in most cases imaging is, the next step.

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And in almost all cases that I see, I'll be ordering a full set of lung function tests as well.

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And we're very lucky at the hospital that I work at, the Queen Elizabeth, we've got an excellent lung function lab.

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Lung function is one of those things that it can be hard to access.

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For all doctors all around the country, there's a lot of variability in the quality of lung function testing that is out there.

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But if you've got access to proper accredited lung function lab getting quality lung function is.

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is really the recommendation because it's very helpful and can tell you a lot about what's going on in the lungs.

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Perhaps just outline what happens to the patient when they come in for those.

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, yeah, so there's three main components So that's spirometry, which we talked about earlier, lung volume testing.

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and diffusing capacity.

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So spirometry, as we mentioned, is that one where you blow into the machine as hard as you can for as long as you can, and you repeat that two or three times.

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And then the lung function technician will get you to inhale a bronchodilator and they'll repeat that again.

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, so that, will show if there's any any reversibility in bronchoconstriction, and that helps us to diagnose, asthma.

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, the next component is the lung volume testing and that's done by sitting in a box in the lung function lab that looks a little bit like like an old telephone booth and that box has got a known volume And then we know the volume of the person by their height and weight so we can tell how much air is displaced when they go into the box and we get them to do some breathing techniques.

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And that tells us a lot about how much air is in the chest.

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But not only is what their total lung capacity is, but different breakdowns of that.

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And I'm sure if you think back to medical school, you remember that graph where there was tidal breathing, a Y line going up and down, and then someone breathed all the way in to the total lung capacity, and then all the way out.

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Down to residual volume, and there were all of these capacities that you were supposed to remember for exams.

00:21:08.434 --> 00:21:13.575
They matter a lot, and I get my medical students to, to memorize all of that when they're on the wards with me.

00:21:13.615 --> 00:21:17.775
Because those different breakdowns of the lung volumes are very important.

00:21:17.815 --> 00:21:32.335
If you've got something like chronic obstructive pulmonary disease, Where the smoke has destroyed the elastic tissue in your lungs and your lungs have lost that elasticity and they've become hyperinflated.

00:21:32.944 --> 00:21:38.295
Then you've got a lot of air stuck in your lungs, but it's really hard to get it in and out.

00:21:38.565 --> 00:21:46.265
So your functional residual capacity, which is the air left in your lungs after the end of a normal breath.

00:21:47.109 --> 00:21:57.660
It becomes a lot higher, and that means that you're breathing with a lot of air in your chest, which is really inefficient, and that makes the work of breathing really hard.

00:21:57.700 --> 00:22:05.009
And if you exert yourself, you can't get all of your air out before you need to take another breath in, so it gets worse and worse.

00:22:05.240 --> 00:22:07.190
That's called dynamic hyperinflation.

00:22:07.200 --> 00:22:10.549
So that's something that we can see on lung volume testing.

00:22:11.315 --> 00:22:17.694
That 3rd component of lung function testing is diffusing capacity or gas transfer.

00:22:18.634 --> 00:22:35.439
And that really is a measure of how well Oxygen is getting from the alveolus across the alveolar membrane, into the blood vessels and how well carbon dioxide is getting from the blood vessels out into the alveoli and then breathing that back out.

00:22:36.203 --> 00:22:43.854
And that, that test will be impaired in many lung diseases, but especially interstitial lung disease.

00:22:44.814 --> 00:22:45.713
And how do you do that test?

00:22:45.713 --> 00:22:47.824
Do you need to do an arterial line to monitor that?

00:22:47.824 --> 00:22:52.203
No, it involves breathing in a small amount of carbon monoxide.

00:22:52.848 --> 00:22:56.898
Not, not anywhere near enough that it would ever cause any problems.

00:22:57.249 --> 00:22:59.229
And this is a really common test that we do.

00:22:59.269 --> 00:23:16.608
We would do it 20 times in a day at the Queen Elizabeth Lung Function Lab but by breathing in that small amount of a known gas that allows us, there's a lot of stuff that goes on in the background, but that allows you to tell how well gas is transferring across that membrane.

00:23:17.769 --> 00:23:25.138
It sounds like someone's there for a few hours having these tests done, yeah, if you're going to do that full set of lung function testing, it'll take about one hour.

00:23:26.038 --> 00:23:32.358
We don't do all three every time, but if we do all three, as we often do, it'll take about an hour.

00:23:32.409 --> 00:23:35.888
And that will tell you whether it's obstructive or restrictive restrictive the spirometry.

00:23:36.459 --> 00:23:43.979
Based on that ratio of the air that goes out in a second versus the air that goes out completely that'll tell us if it's obstructive.

00:23:44.078 --> 00:23:52.439
Those other tests are really adding to the amount of information that we've got and we use those tests to monitor lung disease over time as well.

00:23:52.949 --> 00:24:04.499
So in addition to the bloods and doing either an x ray or preferably a CT scan as well as these lung function tests, what other investigations may you do as a respiratory physician, there's a whole lot of other ones.

00:24:04.548 --> 00:24:09.878
We have an ultrasound machine with us in the clinic which we use to have a look at the lungs.

00:24:09.909 --> 00:24:20.068
And that's especially handy if someone's got a pleural effusion because that can allow us to see what the shape of that effusion is, what the size of that effusion is.

00:24:20.528 --> 00:24:27.048
And if it's amenable to us being able to for example we will often do arterial blood gases.

00:24:27.574 --> 00:24:42.554
On patients and that tells us a huge amount of information about oxygenation, how high the carbon dioxide is the bicarbonate and the pH and really, that's a useful test in those patients who have CO2 retention.

00:24:42.584 --> 00:24:46.413
So it'll tell us if there's respiratory failure chronic or acute.

00:24:46.983 --> 00:24:55.324
And that's something that we would do often on the wards in our patients with respiratory failure from various different causes.

00:24:56.663 --> 00:25:07.574
The oxygen saturations are very helpful, but it doesn't tell us anything about the carbon dioxide, and the carbon dioxide is a marker of ventilation.

00:25:08.144 --> 00:25:18.273
If someone is not ventilating properly, then their CO2 is going to be going up, and then, and that's deadly, as and so if someone's got true acute CO2 retention.

00:25:18.284 --> 00:25:21.453
Something needs to be done about that quickly, depending on the cause.

00:25:21.463 --> 00:25:31.753
And often we'll use non invasive ventilation on the ward, BiPAP machines to, to assist the ventilation to help that lung expand and get the CO2 out.

00:25:31.753 --> 00:25:36.034
But you really need the arterial blood gas to, to know what those blood gases are doing.

00:25:37.003 --> 00:25:44.153
And those people who are retaining CO2 are the blue bloaters is that correct, you can be a CO2 retainer and be a pink puffer as well.

00:25:44.193 --> 00:26:14.513
, that kind of old blue Bloater phenotype is more to do with overweight obese people with COPD who have a more of a chronic bronchitis type phenotype this concept of phenotypes is something that we're appreciating more and more in respiratory disease that although there are overlying umbrella terms like COPD or like asthma, there are a lot of.

00:26:14.634 --> 00:26:21.174
traits within those diseases that are targetable with different treatments and different phenotypes.

00:26:21.184 --> 00:26:42.898
So asthma, for example, I know you've done a topic on asthma in the past, but that's a classic one where there's these different traits where now there are new monoclonal antibody therapies that can be targeted towards the type of oversensitive immune reaction that's going on that's causing asthma in some people, but not all.

00:26:43.923 --> 00:26:50.953
So it's actually been a fantastic thing over the last few years to have some of these new drugs coming on board.

00:26:51.013 --> 00:26:59.574
And that's helped our understanding that all of these diseases really have subcategories and those subcategories are important because they guide treatment.

00:27:00.578 --> 00:27:03.239
It's still an area that has got a long way to go.

00:27:03.419 --> 00:27:11.909
Our understanding of specific genes that might convey more of a susceptibility to smoking.

00:27:12.294 --> 00:27:14.144
Is really in its infancy, I think.

00:27:14.144 --> 00:27:20.134
You get those people who smoke and smoke for their whole life and they don't seem to get any problems from it.

00:27:20.634 --> 00:27:25.673
And then other people are exquisitely susceptible to, to cigarette smoking.

00:27:26.054 --> 00:27:44.586
And There's a genetic basis to that, like an alpha one antitrypsin disease, for example, where those people will will be very prone to developing emphysema in the upper lobes, especially if they smoke that the smoking seems to do something that really drives the damage that's going on.

00:27:44.676 --> 00:27:46.576
Yeah, genetics is.

00:27:47.112 --> 00:27:58.862
Just like in any, in many other kind of subspecialties in medicine genetics plays a huge role and our understanding is not great at the moment, but it's improving and it will guide treatment.

00:27:59.321 --> 00:28:19.622
So if we look at the main classifications, the obstructive lung disease versus restrictive, from my reading and my trying to understand it all, it looked like there was a purely asthma and COPD and maybe bronchiectasis as obstructive lung disease, and the restrictive seemed to be a list as long as your arm of different causes.

00:28:20.061 --> 00:28:22.971
Perhaps you could outline a bit more about that and actually expand upon that.

00:28:23.027 --> 00:28:24.126
Oh, it's complicated.

00:28:24.126 --> 00:28:27.317
And, I scratched my head about the list of interstitial lung disease.

00:28:27.491 --> 00:28:28.882
Diagnoses myself.

00:28:28.922 --> 00:28:31.811
The list is long, but they're also not as common.

00:28:31.951 --> 00:28:39.132
So those obstructive diseases diseases that we see a lot more in practice and that anybody will see a lot more in practice.

00:28:39.652 --> 00:28:50.173
But if we dive into those restrictive disorders, so the interstitial lung disease disorders I think about it in terms of connective tissue disorders.

00:28:50.617 --> 00:29:04.186
environmental or occupational exposures drug induced causes idiopathic, so for many of them and for many severe conditions, just like idiopathic pulmonary fibrosis, , there's no obvious.

00:29:04.491 --> 00:29:07.731
Cause to that, but they get a, quite a severe disease phenotype.

00:29:07.865 --> 00:29:14.134
And then , once you've got those categories then you've got a whole lot of different conditions under each of those categories.

00:29:14.134 --> 00:29:18.500
So for connective tissue related interstitial lung disease, for example.

00:29:19.160 --> 00:29:31.886
SLE, rheumatoid arthritis uh, ankylosing spondylitis, Sjogren's, a whole host of those different connective tissue disorders can all be associated with interstitial lung disease.

00:29:32.239 --> 00:29:42.638
And we work very collaboratively with our rheumatology colleagues because there's so much overlap between rheumatological connective tissue disorders and lung diseases.

00:29:42.638 --> 00:29:52.009
Going back to what I was saying earlier about history taking Those environmental and occupational related interstitial lung diseases are important not to miss.

00:29:52.318 --> 00:29:59.828
There can be avenues for compensation for people who have had occupational exposures who have developed severe lung disease.

00:30:00.348 --> 00:30:06.439
Sometimes there'll be some kind of allergic cause that they're still having an exposure to.

00:30:06.439 --> 00:30:23.118
So you see that in people like bird keepers who can develop a hypersensitivity pneumonitis and that can be a deadly disease and it can also be hard to convince some people to stop the exposure, if that's, that's their, if that's their reason for being keeping their parrots or something that can be tough.

00:30:23.759 --> 00:30:26.028
So yeah there's a whole range of different things.

00:30:26.398 --> 00:30:38.638
different causes there but like any, anything in medicine, if you've got an idea about the classification, then it's a lot easier to recall all of those different diseases.

00:30:38.699 --> 00:30:46.798
I remember being on general medicine ward round once and the the general medicine physician said to me, Tom, give me 10 signs of.

00:30:47.179 --> 00:30:48.419
Thyrotoxicosis.

00:30:48.778 --> 00:31:14.231
And I kind of stood there scratching my head and maybe I came up with one or two but but I really went home and I thought about that and , if you've got a system in your head, if you've got neurological signs, cardiac signs optic signs then, under those headings, then you've got bang, you've got a whole lot of the signs of thyrotoxicosis, for example, and that's just an example that, that applies to, every aspect of medicine.

00:31:14.271 --> 00:31:24.061
That's one of the other things I really drum into students that I have is to try and develop systems of classification, allows you to recall things a lot better.

00:31:24.862 --> 00:31:31.721
It's a perfect segue for those who want to look at my other podcast on the rule of threes as a way of help subdividing things up.

00:31:31.821 --> 00:31:34.142
and using that as a basis for it.

00:31:34.142 --> 00:31:36.612
Remembering that things are two threes, fours and fives.

00:31:36.936 --> 00:31:37.102
yeah.

00:31:37.122 --> 00:31:38.416
Glad we're on the same Wavelength.

00:31:38.876 --> 00:31:43.826
I think it's a good way of remembering things rather than trying to just be ha, haphazard when you're trying to bring things up.

00:31:44.616 --> 00:31:51.297
Once you know the diagnosis, I presume it affects both the treatment options and helps you determine prognosis for the scenarios.

00:31:51.797 --> 00:32:07.781
There are so many different respiratory diseases that the treatments are wide and varied, you think about that breakdown of infectious causes, malignant causes Environmental smoking related causes.

00:32:07.781 --> 00:32:12.852
And that's just a few of the different kind of conditions that can cause respiratory diseases.

00:32:12.892 --> 00:32:14.892
Then the treatments for all of those things.

00:32:15.442 --> 00:32:16.241
Are very different.

00:32:16.622 --> 00:32:25.672
One of the reasons that I got into respiratory medicine was that aside from the variety that you get it's quite a hands on specialty as well.

00:32:25.721 --> 00:32:27.471
We do quite a lot of procedures.

00:32:27.481 --> 00:32:29.531
So we do bronchoscopies.

00:32:29.971 --> 00:32:33.392
And in bronchoscopies, that's getting more and more advanced.

00:32:33.751 --> 00:32:42.801
So in the case of things like lung tumors, if they're affecting the central airways we've got techniques to burn them away and laser them away.

00:32:42.872 --> 00:32:45.001
And sometimes put in stents.

00:32:45.432 --> 00:32:48.571
We do a lot of diagnostic work with bronchoscopy as well.

00:32:48.571 --> 00:33:01.192
We can we can sample the lymph nodes, or if there are peripheral tumors, we can get out to them And use ultrasound on the end of the scope to, to see where we are in the airway and make sure that we're biopsying the right area.

00:33:01.652 --> 00:33:08.701
And if we've got patients with pleural diseases as well putting in things like chest tubes to relieve the pleural effusion.

00:33:08.781 --> 00:33:11.642
And sometimes they're they're long dwelling chest tubes.

00:33:11.872 --> 00:33:13.662
That's a kind of a more complicated.

00:33:13.856 --> 00:33:15.396
Type of chest tube that we put in.

00:33:15.876 --> 00:33:20.217
So there's quite a lot of kind of hands on therapies that we do.

00:33:20.267 --> 00:33:23.656
And that, really drew me towards respiratory medicine.

00:33:24.086 --> 00:33:29.467
But really because there are so many diseases, there are so many different types of treatments.

00:33:29.767 --> 00:33:38.866
The mainstay of treatments in diseases of the airways like chronic obstructive pulmonary disease and asthma, are, inhaled therapies.

00:33:39.557 --> 00:33:40.666
And that's usually it.

00:33:41.332 --> 00:33:49.491
a mixture of anti muscarinic, beta agonists and inhaled corticosteroids depending on the severity of the disease.

00:33:49.951 --> 00:34:05.961
For the interstitial lung disease types of disorders, the mainstay of that is steroids, But the other kind of important way to think about many of those interstitial lung diseases is that they often develop with an inflammatory process.

00:34:06.352 --> 00:34:10.811
And then over time that inflammatory process becomes fibrotic.

00:34:11.621 --> 00:34:19.572
And so if you can treat it in that inflammatory window, And that may be years or it may be shorter than that.

00:34:20.001 --> 00:34:30.641
Then often it's a lot more responsive to therapy than down the track when it progresses to a more fibrotic type of disease.

00:34:30.652 --> 00:34:39.581
So even though you've got so many different types of interstitial lung diseases, many of them follow that pattern from inflammatory to fibrotic over time.

00:34:39.911 --> 00:34:46.552
And depending on the disease, we've got different types of medications to try and target that inflammatory period.

00:34:46.552 --> 00:34:54.806
And there's a big overlap with the medications that are used in rheumatology like all of those infusions with monoclonal antibodies.

00:34:55.226 --> 00:35:00.706
But then as we get towards that fibrotic stage, that's when treatment becomes difficult.

00:35:01.367 --> 00:35:09.396
There are antifibrotic drugs, but at the moment, the ones that are available don't tend to turn the disease around.

00:35:09.407 --> 00:35:17.387
They tend to slow the progression of the disease, but there are some promising antifibrotic therapies.

00:35:17.731 --> 00:35:36.516
coming through the clinical trial stage and we're a site for a few of those big international multi center trials at the Queen Elizabeth where these antifibrotic drugs seem to be improving lung function over, over uh, 26 to 52 weeks.

00:35:36.606 --> 00:35:42.197
We're hoping that they are actually breaking down some of that fibrosis, but that's still early stages.

00:35:42.657 --> 00:35:48.246
So you're using lung function test to work out how well someone responds to the treatment.

00:35:48.746 --> 00:35:54.237
Where does the role of classifying obstructive type conditions into the gold classification come into it?

00:35:54.237 --> 00:35:58.364
Is that, that's pretty much just used in chronic obstructive pulmonary disease.

00:35:58.563 --> 00:36:03.704
Yeah, so we've got these kind of gold classes of spirometry impairment.

00:36:04.083 --> 00:36:04.713
And gold is.

00:36:05.923 --> 00:36:09.164
Global obstructive lung disease group.

00:36:09.213 --> 00:36:38.867
So that's a group of international experts who have come together to develop guidelines and those guidelines break down the severity of COPD into their different gold categories and we also use how breathless somebody is and how frequently they're having a COPD exacerbation to help determine the gold stage that will help us to decide which inhaler to start.

00:36:39.023 --> 00:36:43.612
or which inhaler to step up to, or which other types of treatments to change over to.

00:36:44.112 --> 00:36:47.813
And there are classifications for asthma as well.

00:36:47.873 --> 00:36:58.092
There are breakdowns for interstitial lung disease, but yeah, for anybody wanting to learn about COPD management . The gold guidelines are a fantastic resource.

00:36:58.262 --> 00:36:59.123
They're very thorough.

00:36:59.867 --> 00:37:13.768
So there are similar systems used for the other diseases as a way of Deciding what sort of treatment options you're going to use or assessing how well they respond as well So it's not just using the absolute numbers or anything No, it's not the absolute numbers.

00:37:13.818 --> 00:37:14.958
It's disease specific.

00:37:14.998 --> 00:37:23.737
But those absolute numbers we also, we monitor disease and we see if there's disease progression or disease improvement based on their lung function testing over time.

00:37:25.112 --> 00:37:35.523
Right so for the end stage type disease you've tried to take away the pathogen that's caused it, and you're trying to treat the acute flare ups in the inflammatory stages.

00:37:36.003 --> 00:37:41.623
But for the end stages, the fibrotic lung in the restrictive condition or the, end stage obstructive disorders.

00:37:42.032 --> 00:37:44.202
What are the actual fallback options?

00:37:44.213 --> 00:37:52.733
I was looking at the literature, and it looked like the actual final outcome was a lung transplant, which didn't sound that readily available or easily accessible.

00:37:53.322 --> 00:37:56.293
Lung transplant is not to be taken lightly.

00:37:56.333 --> 00:38:05.793
It's a, it's an enormous procedure and there's a very large amount of work up that needs to be done before someone will be deemed eligible to have a lung transplant.

00:38:06.222 --> 00:38:13.072
It is offered in many cases you've got to be robust enough to deal with the surgery because it's a pretty big operation.

00:38:13.407 --> 00:38:28.833
And at the moment that surgery is not done in Adelaide, so you've got to travel interstate, so that brings its own challenges you've got to stay interstate, in that hospital and then near the hospital for at least a few weeks after the procedure, before, before coming back.

00:38:28.833 --> 00:38:34.923
And then like any other transplant, there's immunosuppressive therapies you've gotta be on lifelong afterwards.

00:38:34.963 --> 00:38:40.014
It's a very big step, but can be a fantastic treatment in the right patients.

00:38:41.264 --> 00:38:44.403
That said there are a lot of other treatments, that we use.

00:38:44.414 --> 00:39:02.994
So just getting back to chronic obstructive pulmonary disease in those very hyper inflated patients that I was talking about before there are some new devices called endobronchial valves, and these are very small one way valves that are inserted into the airways.

00:39:03.344 --> 00:39:15.224
of a lobe of the lung that happens to be particularly hyperinflated or particularly affected by emphysema and is essentially not functioning anymore.

00:39:16.344 --> 00:39:22.793
And what those valves do is that they they lead to that part of the lung collapsing.

00:39:23.974 --> 00:39:26.664
So no more air goes to that part of the lung anymore.

00:39:26.664 --> 00:39:31.094
It all goes off to the other parts of the lungs, which are better functioning parts of the lung.

00:39:31.094 --> 00:39:46.929
So this is a a less invasive way to get the same outcome as the cardiothoracic surgeon would do lung volume reduction where they take out the upper lobe or both upper lobes.

00:39:47.458 --> 00:39:53.518
That surgery really isn't done very much anymore, but we can get the same functional outcome bronchoscopically.

00:39:54.539 --> 00:40:02.358
Wow, So that's a pretty cool procedure that, that's come on in the last five, six, seven or so years.

00:40:02.679 --> 00:40:09.228
Would you use that also for someone who has recurrent bullae bursting and causing pneumothoraces and things?

00:40:09.268 --> 00:40:10.759
Yeah, absolutely spot on.

00:40:10.858 --> 00:40:14.449
Yep, it's a treatment for recurrent pneumothorax.

00:40:14.559 --> 00:40:20.409
You can stop the air going to the part of the lung where the air leak is and and collapse that down.

00:40:20.559 --> 00:40:28.670
And and then often you go in and you take out the valves down the track a few weeks later once once that pleura has had a chance to heal.

00:40:29.110 --> 00:40:33.090
So that's the other good thing about them is that they can be taken out if you need to.

00:40:34.420 --> 00:40:39.360
So that's one kind of additional therapy for chronic obstructive pulmonary disease.

00:40:39.880 --> 00:40:53.934
Pulmonary rehabilitation is a really important part of managing people with lung disease, and that's a kind of a dedicated course of exercise and strength and conditioning run by our physiotherapy colleagues.

00:40:54.275 --> 00:40:59.775
And there's pulmonary rehabilitation programs offered through all of the major hospitals in South Australia.

00:41:00.264 --> 00:41:07.054
And that really helps with people with lung diseases overall condition and their ability to deal with their breathlessness.

00:41:07.525 --> 00:41:08.364
That's key.

00:41:09.204 --> 00:41:12.775
A lot of these diseases are diseases of multi morbidity.

00:41:13.454 --> 00:41:20.735
So it's common that people with respiratory disease will have heart disease, there'll be sarcopenia, there'll be osteoporotic.

00:41:20.744 --> 00:41:24.125
So all of those things have to be managed as well.

00:41:24.675 --> 00:41:31.735
And as disease gets more severe and symptoms get worse, then we really need to focus on those symptoms.

00:41:32.425 --> 00:41:35.914
Hypoxia and breathlessness is key problem.

00:41:36.125 --> 00:41:51.219
And so sometimes oxygen therapy in the home is given, and that might be just when someone needs it for exertion, going down to the shops, it might be just used at night time during sleep, or it might be that someone needs oxygen therapy all day.

00:41:52.570 --> 00:42:14.965
In some people their ventilation is impaired and so they need to use a kind of a type of CPAP device at home called BiPAP, Bi Level Positive Airway Pressure, which helps aid their ventilation which is often worse during sleep when all of the muscles are less effective during sleep.

00:42:16.076 --> 00:42:23.876
So there's a whole range of different adjunctive therapies that we can offer and that, that become more and more relevant as disease severity goes on.

00:42:25.695 --> 00:42:34.445
Thinking about what you've just been saying, the two questions come to mind is, I presume respiratory function even without all these other factors deteriorates with age.

00:42:35.010 --> 00:42:49.210
And also when you look at the young sports person, or particularly the free divers who can hold their breaths for a very long time obviously , even someone who is fit, just training to improve your lung capacity must have some benefits for longevity later on in life.

00:42:49.590 --> 00:42:57.130
Is this something that we all should be doing, going through some sort of respiratory training ourselves, throughout our lives, so we're ready for it as we get older?

00:42:58.041 --> 00:43:00.481
Yes I've got some bad news for you, Gavin.

00:43:01.050 --> 00:43:02.181
We've both peaked.

00:43:03.050 --> 00:43:07.170
We've both, in terms of our lung function we both peaked years ago.

00:43:07.581 --> 00:43:15.530
Lung function or lung, total lung capacity really hits its peak in our early to mid twenties.

00:43:15.916 --> 00:43:17.686
And then it's all downhill from there.

00:43:18.360 --> 00:43:23.451
We slowly lose a little bit of lung function every year from there on.

00:43:23.911 --> 00:43:29.391
And if you're smoking, then that, that rate of loss is a lot higher.

00:43:29.721 --> 00:43:37.561
But if you stop smoking, then your rate of loss goes back to the normal rate that it would have been for anybody else.

00:43:38.061 --> 00:43:42.541
We don't really gain lung function from exercise, unfortunately.

00:43:42.541 --> 00:43:44.320
What we've got is what we've got.

00:43:44.731 --> 00:43:48.621
What we can improve is the efficiency with which we use oxygen.

00:43:48.851 --> 00:43:52.351
So that's really related to muscle adaptations and.

00:43:52.706 --> 00:43:56.335
Cardiovascular adaptations to exercise.

00:43:56.873 --> 00:43:59.733
But, it all just comes down to that old adage, use it or lose it.

00:43:59.972 --> 00:44:14.483
And that's why pulmonary rehabilitation is so important in our patients, because there's this downward spiral that if you become deconditioned Then it's so much harder to get back to that level of fitness that you had beforehand.

00:44:14.913 --> 00:44:23.802
So we really encourage our patients and we've got systems of support in place to maintain exercise and activity in later life.

00:44:24.612 --> 00:44:26.762
In the end it's all about getting oxygen to your blood.

00:44:27.373 --> 00:44:32.362
And erythropoietin can actually improve your red blood cells and improve your blood carrying capacity.

00:44:32.643 --> 00:44:35.485
Has that got a role to play in any of these chronic lung diseases as well?

00:44:36.025 --> 00:44:44.346
We often see in people with chronic lung diseases that they develop polycythemia because of the chronic hypoxia.

00:44:44.585 --> 00:44:51.715
So they've already often in many cases, they've already had that kind of adaptation that you see with altitude.

00:44:52.365 --> 00:45:03.175
We don't have good evidence that adding in something like erythropoietin or giving a blood transfusion, unless they've got anemia, actually helps a lot.

00:45:03.666 --> 00:45:12.099
But yeah it's interesting to see what happens, with the adaptations of the red blood cell to an environment where there's low oxygen.

00:45:12.610 --> 00:45:13.550
Yeah, that makes sense.

00:45:13.570 --> 00:45:17.179
Obviously, if they're reducing oxygen, then they'll actually increase their own EPO to help.

00:45:17.920 --> 00:45:28.219
All right, Tom speaking about these respiratory illnesses and conditions, you mentioned the involvement of other teams, obviously you've talked about physiotherapists and, in rehab for maintaining lung capacity.

00:45:28.699 --> 00:45:31.909
Do you involve a multidisciplinary team in your assessments of these patients at all?

00:45:31.909 --> 00:45:34.829
And does that have a role to play in respiratory conditions?

00:45:36.135 --> 00:45:36.585
Yeah.

00:45:36.625 --> 00:45:41.614
The multidisciplinary team is used mostly in the context of lung cancer.

00:45:41.744 --> 00:45:48.284
That, that would be the, that would be the respiratory condition where the MDT really plays a pivotal role.

00:45:48.887 --> 00:45:54.907
And we hold a lung cancer MDT weekly across both the Royal Adelaide and the Queen Elizabeth Hospital.

00:45:55.027 --> 00:45:55.456
And.

00:45:55.773 --> 00:46:00.963
It really improves the quality of care, bringing all of those specialists into the one room.

00:46:01.373 --> 00:46:12.844
And there are so many different examples that I can think of where the decisions that have been made about treatment or about further investigations have changed based on having everybody there.

00:46:13.434 --> 00:46:13.983
together.

00:46:14.384 --> 00:46:27.983
So for respiratory lung cancer, MDTs we'll often have a mixture of respiratory physicians cardiothoracic surgeons, medical oncologists radiation oncologists, and radiologists.

00:46:28.023 --> 00:46:34.173
And then in our particular MDT, we're very lucky that we've also got nuclear medicine and pathologists in the room.

00:46:34.594 --> 00:46:39.284
And the pathologists are able to show us the cells from the biopsies.

00:46:39.869 --> 00:46:45.208
So it's it's a very comprehensive MDT and it's a very effective MDT.

00:46:46.438 --> 00:47:01.278
Because the respiratory diseases are diseases of multi morbidity and they affect so many aspects of life it's really important to involve different different clinicians in the care of our patients.

00:47:01.289 --> 00:47:11.088
So we've got a fantastic nurse led outreach team who follow up on many of our clinic patients, especially the ones on oxygen.

00:47:11.679 --> 00:47:14.548
Our physiotherapy team are fantastic.

00:47:14.938 --> 00:47:18.614
And you know, it just, it really improves the quality of care.

00:47:19.025 --> 00:47:22.684
That our patients receive by having all of those different people involved.

00:47:23.144 --> 00:47:23.190
Absolutely.

00:47:23.190 --> 00:47:23.235
Absolutely.

00:47:24.614 --> 00:47:28.351
Is there anything else you think we should cover when we're looking at respiratory conditions?

00:47:28.362 --> 00:47:34.094
Is there anything we've perhaps missed out for the medical students they might want to remember when assessing person with a respiratory condition?

00:47:34.684 --> 00:47:53.144
Yeah, I guess one of the things is that, these respiratory conditions, because they're often associated with other conditions, or they can be caused by other conditions It's important to try and keep in mind the varying impacts that those conditions may have on the person overall and on the lung.

00:47:53.188 --> 00:48:09.059
So, For example, in ankylosing spondylitis or other rheumatological conditions, you might see that someone's developed an interstitial type process from their connective tissue disorder, but they can also have extrathoracic changes that can affect the.

00:48:09.298 --> 00:48:17.059
respiratory function like chest wall deformities or, , the stiff vertebrae that you can get in ankylosing spondylitis, for example.

00:48:17.148 --> 00:48:21.539
Just keep in mind that more than one thing might be affecting respiratory function.

00:48:22.603 --> 00:48:30.097
it's a great sort of thought to have for an OSCE where it's more than just one area you need to look at as well also for the GP who's assessing the patient too.

00:48:30.606 --> 00:48:33.186
Where do you think things are heading for the future in this scenario?

00:48:33.197 --> 00:48:35.456
Yeah, it sounds like it's progressed a lot over the years.

00:48:35.876 --> 00:48:54.277
I think a lot of the improvements in the near future are related to our improving understanding of the immune function in lung diseases so immune function affects inflammatory processes in all of the different lung diseases that are out there.

00:48:54.286 --> 00:49:01.086
And so a lot of the clinical trials now are looking at monoclonal antibodies targeted to particular.

00:49:01.791 --> 00:49:08.581
types of inflammatory cells or particular interleukins in a whole range of different respiratory diseases.

00:49:08.581 --> 00:49:19.061
So we've got trials of anti interleukin monoclonal antibodies in chronic obstructive pulmonary disease, in asthma, in interstitial lung diseases at the moment.

00:49:19.556 --> 00:49:23.746
And it's meant that we've had to really get our heads around immunology.

00:49:24.077 --> 00:49:28.637
I thought that after my physician's exams, I wouldn't really need to worry about all that kind of stuff anymore.

00:49:28.766 --> 00:49:33.367
But the way things are going it's becoming more and more relevant again for us.

00:49:33.376 --> 00:49:40.157
So I think looking to the future, the next 5 or 10 years, that's the big thing that's going to change in respiratory medicine.

00:49:41.157 --> 00:49:44.717
It's pretty impressive stuff, so look, I really thank you very much for your time today, Tom.

00:49:44.717 --> 00:49:46.597
It's great having you on board on Aussie Med Ed.

00:49:47.047 --> 00:49:48.257
Really appreciate your help.

00:49:49.001 --> 00:49:52.692
Oh, thanks for asking me to come and talk about respiratory conditions.

00:49:52.711 --> 00:49:54.021
I'm very happy to do so.

00:49:54.251 --> 00:49:54.692
it's brilliant.

00:49:54.692 --> 00:49:55.742
Thank you very much.

00:49:56.492 --> 00:50:02.291
I'd like to remind you that all the information presented today is just one opinion, and that there are numerous ways of treating all medical conditions.

00:50:02.641 --> 00:50:06.652
It's just general advice, and may vary depending upon the region in which you are practising or being treated.

00:50:07.592 --> 00:50:14.632
The information may not be appropriate for your situation or health condition, and you should always seek the advice from your health professionals in the area in which you live.

00:50:15.871 --> 00:50:23.371
Also, if you have any concerns about the information raised today, Please speak to your GP or seek assistance from health organisations such as Lifeline in Australia.

00:50:24.291 --> 00:50:28.411
Thanks again for listening to the podcast and please subscribe to the podcast for the next episode.

00:50:28.802 --> 00:50:30.722
Until then, please stay safe.