Breathlessness – Royal College of Physicians Evening Update Feb 2018

Dr Klaus Witte – Consultant Cardiologist in Leeds. The origin of symptoms in heart failure – replacing dogma with data

“Are you breathless” is a ridiculous question because it is subjective depending on the answerer and the asker… A better question is about exercise tolerance.

Absolute 1 year mortality for heart failure has fallen from 44% in 1987 to around 8% now (based on heart failure trials).

Loop diuretics, oxygen and opiates do not improve mortality.

ACEi, bisoprolol and CRT improve symptoms and exercise tolerance with decreasing effect along that line.

Exercise tolerance is closely related to mortality in HF – and that is why it is such a big deal.

Klaus showed data which indicates that whilst heart failure starts with the heart, further down the deterioration is due to other causes.

For example, muscle wasting and abnormal muscle (abnormal mitochondria) is associated with heart failure. Abnormal mitochondria complex 1 –> abnormal metabolic milieu –> poorer capacity for exercise. Furthermore skeletal muscle ergoceptors stimulate more ventilation for the same amount of work. This is further simulated by sympathetic over-activation.

Backing this up, training does improve QoL and helps symptoms, although it doesn’t improve heart function nor improve mortality.

The lungs are also abnormal in patients with heart failure – there is respiratory muscle weakness in CHF patients. There is also increased airways resistance (Witte et al 2002) and bronchodilators reduces the symptoms. Furthermore, dead space ventilation is increased, as frequency is increased making respiration less efficient.

Exercise training is very useful – not because it improves the heart, but improves the patient’s general capacity for work and exercise. Good examples of this can be seen nationally in Belgium & Germany.

Dr Graham Burns – How to manage patients with difficult asthma

Only 5% of patients achieve guideline-defined control (as defined by GINA – Global Initiative for Asthma) (Rabe et al 2000).

Key theme for Graham is “Get the basics right”! He started with the BTS SIGN guidelines and NICE guidelines.

The diagnosis – the cardinal symptoms is the variability of the airway obstruction. He takes a careful history – symptoms should be worth in the night and morning, in response to exercise, cold air, beta-blockers; childhood symptoms; variability in symptoms. Then obtain objective confirmation where spirometry is better than peak flow (and normal results when well does not preclude the diagnosis). The confirmation hinges on proving variability over time. Lastly, you shouldn’t need exhaled NO routinely which the NICE guidelines seem to focus on.

Screen Shot 2018-02-20 at 19.12.46.png
Ref – BTS SIGN Asthma – http://www.sign.ac.uk/assets/qrg153.pdf

Then for treatment, BTS algorithm  is useful – key here is starting inhaled corticosteroid early as the basis for treatment:

Screen Shot 2018-02-20 at 19.13.20.png
Ref – BTS SIGN Asthma – http://www.sign.ac.uk/assets/qrg153.pdf

With regards to which combination inhaler to use, Graham recommends whatever the patient can actually take – otherwise he thinks the differences are minimal:

Screen Shot 2018-02-20 at 19.18.30.png
Ref – https://www.healthinfo.org.nz/patientinfo/Funded%20Inhalers%20in%20NZ%20CCN.pdf

After that, education is key – as well as checking inhaler technique.

Dr Philip Reid – Lung cancer- common presentations and management

Depressing stats: 2nd commonest cancer – biggest cancer killer – 5 year survival of 8.7%. 44,500 new cases each year in UK (~5000 in Scotland).

How does it present?

  1. Incidental on a CT scan / XR for another reason
  2. Local symptom – chronic cough, haemoptysis
  3. Systemic symptoms – tiredness, sweats etc
  4. Invasive symptoms – chest wall pain, hoarse voice
  5. Metastatic symptoms – liver, bone, adrenal, lymph node

Phil proceeded to show some really interested chest x-ray cases including one on cancer mimics like vasculitis.

He also talked about when to use CT-PET – in early stage disease, where it may be curable. False positives can come from inflammation or infection. There are also false negatives in hyperglycaemia.

Then talked about the many different options for getting a tissue diagnosis from more to less invasive.

 

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