Working in partnership Quality Care Innovation lead clinician for integrated respiratory service georges ng* man kwong chest physician pronounced ning qualified 1990 chief clinical information officer formerly clinical director 2004-2015 respiratory, speciality medicine & long term conditions at Pennine Acute for over ten years based in Oldham since may 2012 Pennine Lung Service@Oldham 0161 627 8522 an integrated respiratory service
the respiratory response in primary care a clinical education event
breathlessness pain palpitations heart valve disease COPD heart failure pulmonary embolism obesity anaemia lack of physical fitness asthma pneumonia panic attack anxiety pulmonary fibrosis bronchiectasis pneumothorax
5 breathlessness scenarios What s the most likely diagnosis and why? What would you do? What key handover information might you offer? What investigations might you suggest? What treatments would you recommend?
Case 1 35 year old female smoker shaky, wheezy and breathless RR 28/min PR 120 SpO 2 94% Peak flow 180 (usual 380)
Acute asthma Acute severe PEF 33-50%, inability to speak sentences, RR > 25 HR > 110 Life threatening PEF <33%, SpO2 < 92% silent chest, cyanosis, poor resp effort, exhaustion, reduced conscious level High dose inhaled salbutamol Give steroids in all cases and admit
National Review of Asthma Deaths 5.4 million people in UK currently receiving treatment for asthma. 1 every 10 seconds, someone is having a potentially life threatening asthma attack 1 Asthma attacks kill 3 people each day, most tragically many of these deaths could be prevented. 1 Asthma UK
National Review of Asthma Deaths key elements of routine care missing prescribing errors widespread asthma attacks poorly managed people with severe asthma were not always referred to a specialist when they should have been.
NRAD recommendations Urgent review if > 12 SABA inhalers in previous 12 months Inhaler technique, checked by pharmacist non-adherence & use of combination inhalers refer to specialist asthma service if >2 systemic corticosteroids in previous 12m or BTS step 4 or 5
Case 2 74 year old lady from Huddersfield visiting sister in Rochdale A bit breathless after walking from bus stop, vomited on arriving at sisters, collapsed twice Hypertension on atenolol BP 100/64 PR 102 SpO 2 93%
999 to A&E ECG = RBBB CXR normal D-dimer 3449 (0-250) Case 2
Bilateral pulmonary embolism with respiratory failure and circulatory collapse Treated with therapeutic enoxaparin Discharged after three days Out-patient anticoagulation Advice to patient and GP Follow up Case 2
Pulmonary embolism Risk factors and pre-test probability Low risk D-dimer 97% sensitivity Anticoagulation options Provoked vs unprovoked embolism Chronic venous thrombo-embolic pulmonary hypertension < 3%
Case 3 29 year old man, smoker Left sided chest pain and breathlessness Sudden onset on bending forwards RR 24 PR 98 SpO 2 96%
Case 3 What s the most likely diagnosis and why? What might you find on examination? What else would you do?
Left sided spontaneous (primary) pneumothorax, previous episode 2010 Chest tube insertion, required suction Analgesia, oxygen therapy Smoking cessation Case 3 Advice to patient and GP Attended clinic and referred for surgical pleurodesis
Pneumothorax Primary vs secondary Clinical and radiological severity Conservative mgt. vs aspiration vs chest tube Risk of recurrence 20-60% Smoking cessation Advice for air travel
Secondary pneumothorax
Case 4 72 year old female recently back from holiday vomiting and diarrhoea fever, confused, cough with green sputum RR 26/min BP 100/54 PR 120 SpO 2 92% Crackles at left base
Chest radiograph on admission QuickTime and a decompressor are needed to see this picture.
CURB-65 Severity assessment 1 Confusion (AMT 8), Urea >7, Respiratory rate >30, Blood pressure [systolic <90, diastolic 60, Age 65 years 2 Clinical judgment is essential Must consider co-morbid illness and social circumstances 1 BTS guidelines, Thorax 2009;64, S3 2 Thorax 2003;58:377
Severity assessment 1 CURB-65 risk of death at 30 days 0=0.6% 1=3.2% 2=13% 3=17% 4=41.5% 5=57% CRB-65 can be used to assess severity and guide management in primary care Consider hospital assessment for CRB-65 of 2+ 1 BTS guidelines, Thorax 2009;64, S3 2 Thorax 2003;58:377
Case 5 75 year old man COPD FEV1 48%, on long term oxygen Housebound, agitated and breathless RR 20/min SpO2 88% Cyanosed, leg swelling BMI estimated 17kg/m 2
Scenario 1 Case 5 999 paramedics administer high flow oxygen to maintain high SpO 2 and transfer to A&E Scenario 2 COPD self-management and rescue pack Reassurance and handover Next day home visit from respiratory team
Case 5 Hospital care Exacerbation of end stage severe COPD Oral steroids, antibiotics and nebulised bronchodilators Controlled oxygen therapy (target 88-92%) Non-invasive ventilation as ceiling of care Community respiratory team and care plan Advice to patient and GP
Case 5 Home care Exacerbation of end stage severe COPD Oral steroids, antibiotics and nebulised bronchodilators Controlled oxygen therapy (target 88-92%) Community respiratory team and care plan Advice to patient and GP
COPD exacerbation 55% are acute and rapid onset < 24 hours Mean duration 11-13 days 1 in 4 relapse within 30 days Oral steroids reduce failure rate Role of antibiotics Psycho-social issues and anxiety
and finally 45 year old woman Smoker, trying to quit Acute cough episode after using e-cigarette What s going on? What would you recommend?
left lower lobe At bronchoscopy
an unusual finding aspiration of foreign body e-cigarettes not regulated patient says she will quit smoking!
breathlessness pain palpitations heart valve disease COPD heart failure pulmonary embolism obesity anaemia lack of physical fitness asthma pneumonia panic attack anxiety pulmonary fibrosis bronchiectasis pneumothorax
28-61% of older patients refractory breathlessness invisibility definition population incidence 9-61% impact on emergency admissions 36% chronic lung conditions 20% attend because of breathlessness breathlessness gets worse prior to death regardless of cause associated with hospital admissions & predicts significant events dyspnoea crisis theoretical model ATS 2009
5 breathlessness scenarios Asthma Pulmonary embolism Pneumothorax Pneumonia COPD exacerbation
the respiratory response in primary care a clinical education event