Respiratory Medicine

366 Pages·2018·31.08 MB·English

by  Laura-Jane Smith, Jennifer Quint, Jeremy S Brown

eureka
Respiratory Medicine

eureka
Respiratory Medicine
Laura-Jane Smith MBBChir MRCP Jeremy S Brown MBBS MRCP DPhil
FHEA Professor of Respiratory Infection
Honorary Clinical Lecturer in Medical UCL Medical School
Education Honorary Consultant
UCL Medical School University College Hospital
Respiratory and Medical Registrar London, UK
North East London
London, UK
Jennifer Quint MRCP PhD MSc
Senior Lecturer in Epidemiology
London School of Hygiene & Tropical
Medicine
Honorary Consultant in Thoracic
Medicine
University College Hospital
London, UK
Series Editors
Janine Henderson MRCPsych Stephen Parker BSc MS DipMedEd
MClinEd FRCS
MB BS Programme Director Consultant Breast and General
Hull York Medical School Paediatric Surgeon
York, UK St Mary’s Hospital
Newport, UK
David Oliveira PhD FRCP
Professor of Renal Medicine
St George’s, University of London
London, UK
London • Philadelphia • New Delhi • Panama City
© 2015 JP Medical Ltd.
Published by JP Medical Ltd, 83 Victoria Street, London, SW1H 0HW, UK
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The rights of Laura-Jane Smith, Jennifer Quint and Jeremy Brown to be identified as the authors of this work
have been asserted by them in accordance with the Copyright, Designs and Patents Act 1988.
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Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative
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ISBN: 978-1-907816-72-7
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Publisher: Richard Furn
Development Editors: Thomas Fletcher, Paul Mayhew, Alison Whitehouse
Editorial Assistant: Sophie Woolven
Copy Editor: Kim Howell
Graphic narratives: James Pollitt
Cover design: Forbes Design
Page design: Designers Collective
v
eureka
Series Editors’ Foreword
Today’s medical students need to know a great deal to be effective as tomorrow’s doctors.
This knowledge includes core science and clinical skills, from understanding biochemical
pathways to communicating with patients. Modern medical school curricula integrate this
teaching, emphasising how learning in one area can support and reinforce another. At the
same time students must acquire sound clinical reasoning skills, working with complex
information to understand each individual’s unique medical problems.
The Eureka series is designed to cover all aspects of today’s medical curricula and reinforce
this integrated approach. Each book can be used from first year through to qualification.
Core biomedical principles are introduced but given relevant clinical context: the authors have
always asked themselves, ‘why does the aspiring clinician need to know this’?
Each clinical title in the series is grounded in the relevant core science, which is
introduced at the start of each book. Each core science title integrates and emphasises
clinical relevance throughout. Medical and surgical approaches are included to provide
a complete and integrated view of the patient management options available to the
clinician. Clinical insights highlight key facts and principles drawn from medical practice.
Cases featuring unique graphic narratives are presented with clear explanations that
show how experienced clinicians think, enabling students to develop their own clinical
reasoning and decision making. Clinical SBAs help with exam revision while Starter
Questions are a unique learning tool designed to stimulate interest in the subject.
Having biomedical principles and clinical applications together in one book will make
their connections more explicit and easier to remember. Alongside repeated exposure
to patients and practice of clinical and communication skills, we hope Eureka will equip
medical students for a lifetime of successful clinical practice.
Janine Henderson, David Oliveira, Stephen Parker
About the Series Editors
Janine Henderson is the MB BS undergraduate Programme Director at Hull York Medical
School (HYMS). After medical school at the University of Oxford and clinical training in
psychiatry, she combined her work as a consultant psychiatrist with postgraduate teaching
roles, moving to the new Hull York Medical School in 2004. She has a particular interest in
modern educational methods, curriculum design and clinical reasoning.
David Oliveira is Professor of Renal Medicine at St George’s, University of London (SGUL),
where he served as the MBBS Course Director between 2007 and 2013. Having trained
at Cambridge University and the Westminster Hospital he obtained a PhD in cellular
immunology and worked as a renal physician before being appointed as Foundation Chair of
Renal Medicine at SGUL.
Stephen Parker is a Consultant Breast & General Paediatric Surgeon at St Mary’s Hospital,
Isle of Wight. He trained at St George’s, University of London, and after service in the
Royal Navy was appointed as Consultant Surgeon at University Hospital Coventry. He has a
particular interest in e-learning and the use of multimedia platforms in medical education.

vii
Preface
Respiratory diseases are both common and varied, and include chronic inflammatory
conditions, malignancy and infectious diseases. A sound understanding of the common
respiratory diseases is essential for all clinicians.
Eureka Respiratory Medicine provides the key skills to succeed in treating respiratory
conditions: the ability to take a good history, interpret examination findings, integrate
investigation results and apply these to the management of patients.
The book is structured to make it easy to find information in practice and during
revision, and is highly illustrated to aid understanding of key concepts. Chapter 1
provides the core respiratory anatomy, physiology and immunology that are essential for
an understanding of respiratory disorders. Chapter 2 outlines the clinical approach to
patients, i.e. how to make sense of symptoms and signs, and the range of investigations
and management options available to the clinician. The subsequent chapters describe the
important respiratory diseases. Each chapter is introduced by one or more detailed cases
that show how patients present, how clinicians think through the diagnosis and how
they decide which investigations to perform. Chapter 11 gives concise information on
respiratory emergencies and Chapter 12 explores important but often overlooked aspects
of caring for patients with respiratory disease. Finally, a chapter of SBA questions with
detailed answers is provided to aid revision.
We hope Eureka Respiratory Medicine provides students with all of the tools they
require to become successful clinicians in the future.
Laura-Jane Smith, Jennifer Quint, Jeremy Brown
April 2015
About the Authors
Laura-Jane Smith is a Respiratory Registrar and Honorary Clinical Lecturer in Medical
Education at University College London. She has been involved in clinical teaching
throughout her career and pursued this interest further by taking a year out of training as
a teaching fellow to complete a Postgraduate Certificate in Medical Education.
Jennifer Quint is a Senior Lecturer in Epidemiology at the London School of Hygiene and
Tropical Medicine and a Consultant in Thoracic Medicine at University College London
Hospital. She has extensive experience in teaching undergraduates and postgraduates and
is a Fellow of the Higher Education Academy.
Jeremy Brown is a Consultant in Respiratory Medicine with 25 years’ experience of
teaching medical students, for the past 12 years at the University College of London
Medical School. As well as lecturing and examining finals, he holds a weekly bedside
teaching session which emphasises the importance of clinical skills.
viii
Contents
Series Editor’s Foreword v Allergic bronchopulmonary aspergillosis 165
About the Series Editors v Other causes of irreversible airways
Preface vii obstruction 165
About the Authors vii
Glossary x
Chapter 4 Interstitial lung disease
Acknowledgements xii
Introduction 167
Case 3 Progressive shortness of breath 168
Chapter 1 First principles
Case 4 Cough and painful shin rash 171
Overview of the respiratory system 1
Pulmonary fibrosis 172
Development of the respiratory system 3
Hypersensitivity pneumonitis 176
Anatomy of the respiratory tract 5
Sarcoidosis 178
Ventilation and respiration 23
Pneumoconiosis 181
Control of ventilation 36
Rare types of interstitial lung disease
Acid–base balance 38
and lung infiltrations 182
Pulmonary circulation 40
Lung immunity and inflammation 42
Chapter 5 S leep and ventilatory
disorders
Chapter 2 Clinical essentials
Introduction 185
Introduction 61
Case 5 Falling asleep at work 186
Epidemiology and patient demographics 61
Obstructive sleep apnoea 188
Common symptoms and how to take
a history 62 Obesity hypoventilation syndrome 192
Common signs and how to examine Chest wall and neuromuscular disorders 192
the patient 77 Other causes of sleep-disordered
Investigations 95 breathing 193
Management options 123
Chapter 6 Pleural disease
Chapter 3 Airways disease
Introduction 195
Introduction 143 Case 6 Progressive breathlessness over
a month 195
Case 1 Recurrent cough and wheeze 144
Case 7 Sudden onset of breathlessness 197
Case 2 Worsening breathlessness in a
70-year-old smoker 145 Pleural effusions 199
Large airways obstruction 148 Pneumothorax 203
Asthma 150 Benign pleural thickening 206
Chronic obstructive pulmonary disease 157
ix
Contents
Chapter 7 Malignancy Chapter 10 Circulatory disorders
Introduction 209 Introduction 285
Case 8 Breathlessness and weight loss 210 Case 13 Four days of chest pain
on breathing 286
Case 9 Chest pain and breathlessness 212
Case 14 Leg swelling in a patient
Primary lung cancer 214
with COPD 288
Mesothelioma 225
Lung metastasis 228 Pulmonary embolism 290
Carcinoid and other lung tumours 230 Pulmonary hypertension 293
Pulmonary vasculitis 296
Arteriovenous malformation 298
Chapter 8 Lung infections
Introduction 233
Chapter 11 Respiratory
Case 10 Three days of cough and fever 235 emergencies
Case 11 Three months of cough and fever 237
Introduction 301
Microbiology of the respiratory tract 239 Case 15 Massive pulmonary embolism 301
Upper respiratory tract infection,
Case 16 Type 2 respiratory failure 303
tracheitis and bronchitis 247
Bronchiolitis 248 Case 17 Acute severe asthma 305
Community-acquired pneumonia 249 Case 18 Acute respiratory distress
Hospital- and ventilator-acquired syndrome 306
pneumonia 256
Case 19 Stridor 308
Pneumonia in the immunocompromised
patient 257 Case 20 Major haemoptysis 309
HIV infection 260 Case 21 Tension pneumothorax 311
Parapneumonic effusions and empyema 261
Subacute lung infections and lung abscess 263
Tuberculosis 264 Chapter 12 Integrated care
Non-tuberculous mycobacteria 270
Introduction 313
Case 22 Poorly controlled asthma 314
Chapter 9 B ronchiectasis and
Case 23 Repeated admissions for COPD 316
cystic fibrosis
End-stage respiratory disease 317
Introduction 273
Disease prevention 319
Case 12 Chronic cough with sputum
Pregnancy and respiratory disease 320
production 273
Non-cystic fibrosis bronchiectasis 275
Chapter 13 Self-assessment
Cystic fibrosis 280
SBA questions 323
SBA answers 334
Index 343
x
Glossary
A−a alveolar−arterial ERV expiratory reserve volume
A1AT α-antitrypsin ESR erythrocyte sedimentation rate
1
ABG arterial blood gas EUS endoscopic ultrasound
ABPA allergic bronchopulmonary aspergillosis FDG fluorodeoxyglucose
AC adenylyl cyclase FEV forced expiratory volume (in 1 s)
1
ACE angiotensin-converting enzyme Fio2 fractional concentration of oxygen in
ACh acetylcholine inspired air
ACTH adrenocorticotropic hormone FRC functional residual capacity
ANCA anti–neutrophil cytoplasmic antibody FVC forced vital capacity
BALT bronchus-associated lymphoid tissue GOLD Global Initiative for Chronic Obstructive
BCG bacille Calmette–Guérin Lung Disease
GP general practitioner
cAMP cyclic AMP GPA granulomatosis with polyangiitis
Cao2 oxygen-carrying capacity of arterial Gs G protein
blood
CAP community-acquired pneumonia HAP hospital-acquired pneumonia
CFA cryptogenic fibrosing alveolitis HP hypersensitivity pneumonitis
CFTR cystic fibrosis transmembrane HSCT haematopoietic stem cell transplant
conductance regulator
CMV cytomegalovirus IC inspiratory capacity
COPD chronic obstructive pulmonary disease ICS inhaled corticosteroid
CPAP continuous positive airway pressure Ig immunoglobulin
CPE complicated parapneumonic effusion IL interleukin
CT computerised tomography ILD interstitial lung disease
CTPA computerised tomography pulmonary INR international normalised ratio
angiography IPF idiopathic pulmonary fibrosis
Cvo2 oxygen-carrying capacity of venous IRV inspiratory reserve volume
blood
K transfer coefficient of the lung for
CO
Do oxygen delivery to tissues carbon monoxide
2
DPLD diffuse parenchymal lung disease
2,3-DPG 2,3-diphosphglycerate LABA long-acting b agonist
2
DVLA Driver and Vehicle Licensing Agency LAMA long-acting muscarinic anticholinergic
LDH lactate dehydrogenase
EBUS endobronchial ultrasound LLL left lower lobe
ECG electrocardiogram LMWH low-molecular-weight heparin
EGFR epidermal growth factor receptor LUL left upper lobe
EPGA eosinophilic granulomatosis with
polyangiitis MRC Medical Research Council
MRI magnetic resonance imaging