Who needs respiratory medicine?
Patients with a wide array of conditions, with symptoms such as cough or shortness of breath for example, will benefit from the services provided by Circle's respiratory medicine department. This article will look at the diagnostic process, including the tests that are available and it will discuss three of the conditions themselves and the various treatment options.
The diagnostic process
At your first consultation, the consultant will seek to establish as clear as possible an understanding of your condition by taking a history of how long you have had your symptoms and their precise nature. The consultant will also focus on your particular hopes, needs and expectations.
Breathlessness can be a symptom of hereditary diseases affecting the lungs (such as cystic fibrosis), exposure to toxins (tobacco smoke, asbestos, exhaust fumes and polluted air, etc.). It can be caused by infectious agents or by autoimmune conditions, such as pulmonary fibrosis or pulmonary hypertension. As well as this, diseases of the heart, rather than the lungs, can give rise to breathlessness and so this has to be investigated as a possible cause.
A general physical exam will also aid diagnosis. Your consultant will check your blood pressure, temperature, heart rate and rhythm, respiratory rate and oxygen saturation levels. Your lung sounds will be listened to with a stethoscope and the movement of your chest wall will be examined.
You may be asked to do some breathing tests, to assess the size of the lungs and airways, and to see how effective they are at getting oxygen from the air into your blood stream.
Skin tests for allergies can be performed if allergy is considered a possible cause of your breathlessness.
Diagnostic imaging in the form of a chest X-ray or CT scan may be undertaken.
An electrocardiogram (ECG) may be arranged.
Blood tests for anaemia, thyroid, liver and kidney function, allergy and heart problems may also be performed.
An exercise tolerance test measuring cardiopulmonary activity is an important diagnostic tool to help establish whether the breathlessness is originating in the heart or the lungs.
If you are suspected of having obstructive sleep apnoea (OSA) - in which your breathing can be repeatedly interrupted during the night - you may be asked to undergo an overnight study at home. You will be attached to a machine called a pulse oximeter, which evaluates the levels of oxygen in your blood. If necessary, you may need a more detailed study with measurement of your air flow, chest movement, snoring and heart rate. If a clear diagnosis of OSA hasn't been reached following the sleep study, you may be offered a trial of treatment with a CPAP mask (which will be explained in a later section of this article); if CPAP helps, this confirms OSA as your likely diagnosis.
The Circle Health service
One of the great advantages of being referred to Circle is that, where diagnostic tests are concerned, it is a one-stop shop. Following initial assessment by your consultant, if you require any of the tests mentioned above, they can all be performed at the Treatment Centre and the results are generally available on the day. This speeds up the diagnostic process and eliminates the need for multiple attendances before treatment can begin.
Conditions and treatments
Whilst conditions such as COPD and asthma can be well managed in the community and primary care service, some cases are more complex and a firm diagnosis and treatment plan may still need to be made. Circle has the facilities and expertise to assist with this. Three of the many conditions that are treated at Circle will now be described.
Chronic obstructive pulmonary disease (COPD)
COPD is an umbrella term for lung diseases such as emphysema and chronic bronchitis. It involves breathlessness and a productive cough which are constantly present in varying degrees but which can become particularly bad during an acute exacerbation. Treatment includes the use of bronchodilators, a type of drug designed to open up your airways and assist breathing. Steroid inhalers are also prescribed to reduce inflammation and swelling, particularly during flare ups. If you get a lot of sputum, you may require mucolytic medicine to thin it and make it easier to cough up.
If low levels of oxygen are detected in your blood, oxygen can be helpful in COPD as in other conditions causing breathlessness. This can be delivered by way of a small, portable cylinder (called ambulatory oxygen) if oxygen levels fall due to exertion. If the fall in oxidised blood occurs at rest, oxygen therapy may be offered on a long term basis at home. However, if your blood oxygen levels are normal, additional oxygen will not help with breathlessness.
For patients with COPD, pulmonary rehabilitation is a helpful programme promoting physical exercise and giving general advice about improving lung health. Breathing techniques and body positioning to aid recovery from an episode of breathlessness are also taught in these programmes.
In an asthma attack, certain triggers will cause the muscles around the airways to tighten, thereby narrowing the passages. The lining of the airways becomes inflamed and this causes sputum to build up, further narrowing the passages and making it more difficult to breathe. This can be caused by a number of things, such as allergy to pollen or animal fur, reaction to substances such as dust, tobacco smoke or spray cleaners or to air pollutants from traffic, etc. It can also be brought on by physical exertion, strong emotions or sometimes in the wake of a cold.
Two types of inhalers are commonly used to treat asthma: "preventer inhalers", designed to stop asthmatic symptoms from occurring in the first place and "reliever inhalers", for treatment during an attack.
In particularly severe cases of asthma (estimated to be less than 5% of all cases), patients may require a multi-disciplinary approach and consideration of biological therapies.
Obstructive sleep apnoea (OSA)
OSA occurs when your throat muscles relax, causing your throat to close, so that you stop breathing for ten or more seconds until your brain registers this and starts you breathing again. This may happen repeatedly during the night. When you wake, you may well have no memory of this interrupted breathing but you will be more tired during the day as you will not have been refreshed by a good night's sleep. When OSA is suspected, patients are referred for sleep studies, as outlined above, to establish a firm diagnosis.
The treatment for OSA depends on the cause. If your lower jaw is found to be malaligned, a mandibular repositioning device may be prescribed to bring it forward and help keep your airway open. In most cases, however, the treatment of choice is continuous positive airway pressure (CPAP), which is delivered by a machine which pumps air through a mask. You put this on at night and it keeps your airway open while you sleep. It is a very effective treatment for OSA but it does require perseverance and your consultant and his team will be happy to discuss any queries or concerns you have about using it. Circle also runs a self-help group for non-invasive ventilation systems such as CPAP, so that patients can exchange experiences and help one another to get the most benefit from it.
One further service that is available at Circle Health for people with sleep difficulties is a treatment for insomnia involving cognitive behaviour therapy (CBT).