ANZSRS

2010 marks the 30th Annual Scientific Meeting of the ANZSRS (Australian & New Zealand Society of Respiratory Science). Regional Respiratory Medicine is generously sponsoring Heather and me to attend the Annual Scientific Meeting March 19th -24th in sunny Brisbane. The program looks interesting in that it looks back at the history of respiratory science and celebrates past achievements of the Society, but also looks to the future and ponders what challenges await us. The program will look at the past, present and future and cover such varied topics as the development in the recording of lung function measurements; the use of exhaled breath biomarkers; and a “clinical controversies” session on the pre-operative assessment using cardio-pulmonary exercise test, or the clinical utility of expired Nitric Oxide. The organizing committee has recruited some outstanding international speakers to provide input, educate and challenge us. We not only look forward to this opportunity to attend the meeting but also the opportunity to share the knowledge we gain with our team at Regional respiratory Medicine upon our return.

Vanessa

Nasal Irrigations

Even the sound of it may make one cringe a little but there is strong evidence that a saline nasal rinse can relieve, or decrease incidence of, allergy and sinus symptoms,

Allergies and infections can cause excessive mucous production from the nasal and sinus lining. This leads to symptoms such as a runny or stuffy nose or post nasal drip. An effective nasal rinse will wash away excess mucous and allergens such as pollen, dust particles, pollutants and bacteria, so reducing inflammation of the mucous membrane. Normal mucosa will fight infections and allergies better which will reduce or maybe even cure symptoms.

There are various nasal irrigation products on the market which fulfill this purpose. There are also some home recipes utilizing distilled, filtered or cooled boiled water, non iodized salt and bicarbonate of soda, which if mixed in the correct proportions performs adequately.

The main aim is to deliver enough volume of solution into a nostril so that it washes all in its path out of the nose through the other nostril. This is achieved by leaning over a basin with the head forward and to the side and gently instilling the recommended amount of saline solution into the upper nostril and allowing it to drain out the lower nostril. After gently blowing each nostril this procedure is repeated on the other side.

Sometimes the solution may continue to drain for some time after, so it is not recommended that you do this just before bed (or other important engagements) and prescription nasal sprays should not be administered until at least 30 minutes post irrigation for this same reason. The nasal rinse is usually prescribed once or twice a day.

It is best that nasal irrigations are recommended by a physician or ENT surgeon as they are not suitable for everyone. They are contraindicated for individuals who have an ear infection or completely blocked ears. For those who have had ear surgery medical guidance is necessary. The procedure is also not advised for young children, adults who have reduced comprehension, or debilitated or bed bound patients.
The procedure is often recommended to patients following sinus surgery.


In short saline irrigations are a quick, simple, well tolerated and cost effective option in the management of sinus disease, and may reduce the need for prescription drugs.

So if your physician recommends this treatment for you, don’t screw up your nose, it is for a good reason.

Irene

Measurement of Lung Volumes

More detailed assessment of lung function usually involves the measurement of the static lung volumes. These can be very helpful in sorting out restrictive and obstructive disorders. The most important measurements are total lung capacity (TLC), residual volume (RV) and functional residual capacity (FRC) which is the gas volume remaining in the lungs after the vital capacity (VC) has been exhaled. We are able to measure absolute lung volumes beyond the inspired and expired volumes measured by spirometry.

Several methods can accomplish this. Each method has its own advantages and disadvantages. The two dilutional lung volume methods, helium (He) dilution and nitrogen (N2) washout involve having the patient breathe gases or gas concentrations not normally present in the lungs whilst the third method uses the body plethysmograph to measure the volume of thoracic gas (VTG).

We are fortunate in our lab to have the “Gold-standard” measurement VMAX body plethysmograph which delivers precision engineering of the highest quality.

The body plethysmograph is a pulmonary function system consisting of a panorama glazed cabinet in which the patient sits during the test and a computer that controls testing and data output.

Our body box’s ease of operation, patient comfort and reliability will meet pulmonary function testing needs for years to come. The streamlined testing allows the scientist to focus on the patient.

FRC measured with the body plethysmograph (FRCpleth) refers to the volume of intrathorax gas measured when airflow occlusion occurs at FRC. The technique is based on Boyle’s law relating pressure to volume. Boyle’s law states that volume varies inversely with pressure if temperature is held constant. Measurement of FRCpleth is a complex procedure achieved by carefully instructing each patient in the required manoeuvres.

Plethysmography offers several advantages over other methods of measuring lung volumes.

1. VTG is not affected by the distribution of ventilation
2. Multiple measurements can be made quickly and averaged
3. and it provides a more accurate estimate of lung volumes in patients who have airway obstruction.

In general, the body box is regarded as the more acceptable technique, but is more demanding for the patient and more technically complex.

It is often useful to compare FRC values obtained by plethysmography with values obtained by gas dilution methods, particularly in patients with obstructive disease. The ratio of FRCpleth/FRCN2 or FRCpleth/FRCHE can be used as an index of gas trapping. This ratio is usually near 1.0 in patients with normal lungs, or even those with a restrictive lung disorder. Values greater than 1.0 indicate gas volumes detectable by the plethysmograph but hidden to the gas dilution techniques. This ratio has been used to evaluate candidates for lung volume reduction surgery.

Some evidence suggests that in severe airway obstruction, FRC may actually be overestimated when the plethysmographic technique is used. This occurs primarily because PMOUTH (measured when the shutter is closed) may not equal alveolar pressure if the airways are severely obstructed. Rapid panting rates aggravates this inaccuracy. Care should be taken that patients with spirometric evidence of obstruction pant at a rate of 0.5 – 1 HZ.

In the above photo of our plethysmograph in our Hamilton Lab you will also see four gas cylinders two are required for our gas transfer testing and the remaining two are gases used to calibrate the analyser and cross reference for calibration.

Also note the dual computer screen which is used with the cycle ergometer which you can just see the tip of at the right of the photo. I will showcase our cardio pulmonary exercise test next month.

Vanessa

Pneumothorax

Two weekends ago I was able to talk to a conference of local GPs gathered in Warrnambool. The brief was to discuss respiratory emergencies around a scenario that involved a hypothetical bus crash. Amongst other conditions we discussed management of pneumothorax.

Management of a traumatic pneumothorax is something which I am generally very happy to leave in the hands of the surgeons. Spontaneous pneumothorax is much more in my ball-park.

Spontaneous pnemothoraces – where the surface of the lung develops a ‘blow-out’ type of air leak, and the lung – as a consequence – collapses are considered as either:
- primary (no underlying lung disease) or
- secondary (underlying lung disease)

Management is different for the two different sorts of patients. The British Thoracic Society guidelines published in 2003 are excellent. They simplify evaluation of spontaneous pneumothorax, so that we differentiate in addition to the above discriminators (primary or secondary) predominantly only on whether the pneumothorax is small (less than 2cm rim between the lung edge and the ribs) or large (more than a two centimeter rim). Once that discrimination has been made, the acute management will follow along the lines indicated in the following flow charts:

Note that conservative management is very seldom pursued if the pneumothorax is secondary.

Once the emergency management plan has been implemented, the question is whether to refer for surgical treatment – either resection of blebs on the lung surface or pleurodesis (usually done videoscopically). There is around about a 40% risk of pneumothorax after the first spontaneous pneumothorax. The following is a fair list of indicators for referral for surgical intervention / referral
- second ipsilateral (same side) pneumothorax
- first contralateral (other side) pneumothorax
- bilateral spontaneous pneumothorax
- persistent air leak once a chest tube has been inserted (>5-7 days of tube drainage, air leak persist or lung has failed to fully re-expand)
- spontaneous haemothorax
- professions at risk – eg pilots, divers – where a recurrence would be disastrous.

Andrew

What is organic-dust toxic syndrome?

Two weeks ago, for five days, the National Centre for Farmer Health, which is based in Hamilton and affiliated with Deakin University, ran a five day Agricultural Health and Medicine course.

I spoke on the first day of the course about respiratory disease affecting farmers. There were two aspects of the talk I considered to be blog-worthy.

The first is ‘Organic dust toxic syndrome’ (ODTS). This is an entity about which I was entirely naïve until I began to practice in the Western District and read about occupational hazard facing farmers.

Organic dusts are those inhalable particles that arise from grains, and also from animal dung when it is dried and crushed – for example, under foot in a stock yard on a dry day. They contain multiple potentially hazardous compounds, but perhaps the most significant (and most prevalent) is endotoxin. This fragment of gram negative bacteria is thought to be very significant in inducing immune system inflammatory response, and a key mediator of illness in life-threatening gram negative sepsis.

Farmers, grain workers, swine handlers (enclosed livestock environments are particularly hazardous) may inhale this substance. If they do, then it can act in the airways to induce an acute inflammatory response. The resultant illness – ODTS – is ‘flu like’ and, I am sure, often misdiagnosed as such. The key is that there will usually be a history of massive exposure to inhaled organic dusts; for example, a particularly dry and busy day at the stockyards or silo with a lot of dust in the air. If many workers had the same exposure then many of them will likely to be sick at the same time. It resolves, like the flu, over several days but will recur after similar repeated exposure.

A good description of ODTS, along with a comparison of the less common ‘Farmers Lung’, is found on the University of Missouri website. I am concerned that this entity is common, but often misdiagnosed as viral illness or pneumonia, and remains therefore as a hidden, significant occupational hazard for agricultural workers. Those of us who provide care to such workers – particularly GPs – need to be aware of it and ask the appropriate occupational questions.

The second thing I wanted to share was the following graph from the Sustainable Farm Families research.

This research used the Piko6 device as a sort of spirometer (it measures FEV1/FEV6 rather than FEV1 over FVC) to obtain lung function measures from farmers. If the ratio was below 75% then it was reported as 'poor' lung function. Note the discrepancy between dairy farmers and other farmers - with five to seven percent more farmers in cropping, cattle and sheep ventures having ‘low’ lung function when compared with dairy farmers. This needs to be teased out further, but does lend one to suspect that there are less respiratory toxins in dairy farms than in other farming environments in our district.

Andrew

Now practicing at our new rooms at 2/14 Crouch Street, South Mt Gambier

After some time our desire to have our own practice in Mt Gambier has reached fruition and we commence consulting and lung function testing there on Wednesday 10 March.

We identified that our patients in the Mt Gambier region were keen to have Dr Bradbeer consult on a more regular basis and in Mt Gambier. We are also keen to provide a service to our patients reflective of that which they receive in our practice at Lonsdale Street in Hamilton.

We are currently consulting and performing lung function testing on Wednesdays, from 10am to 4pm and over the next few months expect to secure the services of another physician who will also consult at the Crouch Street South practice. Further to this, we are taking steps to have a nurse in attendance for consulting; we will keep you updated on the progress of this service.

To make appointments, please continue to contact our Hamilton office on 1800 184 828. Until we increase our hours at the new practice, Crouch Street South will only be contactable by phone on Wednesdays from 10am to 4pm.

Payments can be made during our office hours on Wednesdays or posted to PO Box 573 Hamilton Vic 3300. To ensure we receive the payment please do not leave at any other location.

There are 4 car parks at the back of the premises which are clearly identified as Regional Respiratory Medicine.

If you have any questions relating to the new practice please phone us and we will gladly take your inquiry.

Maureen

Doctors advice to smokers

I was prompted to write this blog for a couple of reasons.
The first was Heather and I had been discussing the role of spirometry for all smokers over 45 years old. This can show signs of early COPD and be a powerful incentive to quit. A few years ago now I worked as a quit facilitator and in the courses a peak flow meter and norms for their age were used as a means to show smokers the damage they were doing.

The second was that in the news this week Barack Obama latest medical was made public (apparently the public has a right to this normally confidential information as the status of his health may affect the way he governs). One of the pieces of advice that has given to the leader of the USA by his doctor was to quit smoking (it was a little know fact that he smoked).

A study by the Centre for Behavioural Research in Cancer that was prepared for Quit Victoria looked at Doctors advise to their patients about smoking: 2004.

Previously research has demonstrated that advice from health professional, even during brief interventions can be effective in encouraging quitting smoking.

Since the introduction of guidelines under the five A's model (Ask, Assess, Advise, Assist and Arrange) it was reported that advice to stop smoking increased from 11% to 37% (between 1990-1998).

The 2004 report looked at the experiences of smokers and those who had recently quit who had visited the Gp in the last 12 months; whether their doctor asked about their smoking behaviours and if so whether they were given advice to quit and if on receiving this advice it was associated with attempts to quit and motivation to quit.

The results showed that 73% of Victorian adults, who were either current smokers or who had quit within the past 12 months, were asked by their GP whether they smoked. Smokers aged between 30-49 years (75%) and those who smoked 15 cigarettes or more per day were most likely to be given advice on ways to quit smoking by their GP.

Respondents were most likely to be recommended to cut down their smoking (57%) and also given information regarding the use of NRT (30%), followed by other advice (21%). Advice to call the quit line was given to only 13% of respondents.

The respondents that received advice were more motivated to quit with over half reporting they were seriously considering quitting in the next 6 months, compared with those who had not received advice.

It is evident smokers are being asked about their smoking status and that advice from a GP has a demonstrated impact on making at least one quit attempt and increased motivated to quit smoking. It will be interesting to see what impact Obama's doctors recommendation will have on his smoking status.

Jessica