SHORTNESS OF BREATH (DYSPNOEA)
Dyspnoea, or breathlessness can be due to problems with your lungs, or heart. There are often clues that suggest a respiratory cause in the history such as breathlessness that occurs with exercise, or an associated cough or wheeze.
Early assessment and treatment are vital. There are many simple investigations which can help determine the cause of breathlessness and its severity. Some of these are listed below and all are available at our Respiratory West rooms.
· Spirometry with or without bronchodilator. This is a simple test of breathing that can be done at time of consultation
· More complex lung function using a body plethysmograph
· Measures of exercise capacity such as a six minute walk test
· Aridol challenge to determine if asthma is present and / or safety to scuba dive
· ECG and echocardiogram (ultrasound of the heart) either at rest or on exercise
· Measurement of arterial blood gases to see how well the lungs are exchanging oxygen and removing carbon dioxide
Occasionally more complex procedures are required including a bronchoscopy (where we look down in the airways of the lungs with a special camera) or a coronary angiogram to look at the coronary arteries which supply blood to the heart muscle itself. These need to be performed in hospital but usually as a day procedure.
Cough is a common symptom, which in most cases is self limiting. It is usually a normal body response to either an infection or irritation of the vocal cords and / or upper airways and almost always goes away by itself after a few days.
Occasionally a cough might persist or become so severe as to interfere with normal functioning. Rarely, the development of a cough is a signal that something more serious might be present.
The most common causes of a persistent cough are listed below:
· Following an infection
· Due to rhinosinusitis (inflammation of nose and / or sinuses)
· Asthma (in these situations the cough is often but NOT ALWAYS accompanied by a wheeze)
· Gastro-oesophageal reflux disease (indigestion, heart burn)
· Vocal cord irritation which may be due to any of the conditions above
Less common causes of cough include:
· Lung cancer
· Unusual Infections including Tuberculosis
Anyone who has had a cough for a few weeks or who has a severe cough that is interfering with their lives should have a chest x-ray to ensure that a serious disease is not present. Anyone who coughs up blood should see their doctor urgently.
If a cough persists even if the chest x-ray is normal, then it may be appropriate to seek referral to a respiratory physician (specialist in lung diseases). The respiratory physician is likely to organise some tests including tests looking at your lung function, tests whether asthma or reflux disease is present and occasionally more involved testing such as a CT scan or bronchoscopy (where a small tube with a camera on it is passed into the airways under sedation) is required.
All causes of cough are treatable and the treatment depends on what cause is found.
Bronchiectasis is defined by abnormally dilated and floppy airways. As a result patients with bronchiectasis notice symptoms including cough with sputum production as the damaged airways are generally more inflamed producing increased amount of secretions which isn't removed efficiently by the floppy airways. The floppy airways collapse during breathing making it difficult for air to be expelled resulting in shortness of breathe. Complications from bronchiectasis include recurrent infections and pneumonia, bleeding and coughing blood and in more severe cases respiratory failure.
Bronchiectasis is usually suspected when people suffer from the symptoms as described above. A CT scan of the lungs demonstrating the dilated airways then diagnoses it. Other tests are then required to assess complications such as breathing and blood tests.
There are many causes of bronchiectasis that need to be tested for. Treatment includes managing underlying causes of bronchiectasis as well the problematic symptoms often with antibiotics, inhaled medications and other tablets.
Treatment should be started early to avoid complications.
INTERSTITIAL LUNG DISEASE
Interstitial lung disease (ILD) is lung disease affecting the supporting structure of the lungs (interstitium) and often involves the small airspaces (alveoli) as well. ILD comprises a very large number of different specific disease entities all with different treatments and outcomes.
Commoner forms of ILD include Idiopathic Pulmonary Fibrosis (IPF) often affecting patients beyond their sixth decade of life. It is often difficult to treat and is an area of respiratory medicine where much research is being undertaken. Other common types of ILD include allergic type reactions to inhaled particles known as Hypersensitivity Pneumonitis, damage to lungs by inhaled fibres including asbestos causing asbestosis and sarcoidosis a type of ILD of no known cause.
Symptoms include progressive breathlessness on exertion and cough, which is usually dry. Complications include respiratory failure and sometimes heart failure. ILD is suspected when patients have compatible symptoms and diagnosis is confirmed with x-rays, CT scans of the chest and often lung biopsy. The severity is assessed with special breathing and exercise tests while underlying causes and complications require investigation with a number of other tests including blood tests.
It is very important the type of ILD is correctly diagnosed as treatment is very different between the different types and specialist consultation is generally recommended. This is particularly important with recent breakthroughs in treatments for IPF in particular. Our team includes specialist radiologists, pathologists and our clinical nurse specialist who are part of our multidisciplinary team who assist in treating this complicated group of disorders.
Tuberculosis (TB) is a disease caused by infection with the TB bacteria (germ). It is caught by breathing the bacteria into the lungs. TB is usually not highly contagious, but the infection is caught simply by breathing the same air as someone with the disease in his or her lungs. Although TB is uncommon in Australia, it has not been eradicated as many people believe, and is still a very large health problem in other parts of the world.
TB infection can remain dormant in a person's lungs for years, and in this situation the person remains well and cannot give the infection to anyone else. However, it can occasionally be important to diagnose and treat this dormant infection so as to prevent TB disease in the future. TB infection is usually diagnosed with a Mantoux skin test.
Most people who are infected with TB do not develop disease. When the infection does cause disease (tuberculosis), it most commonly involves the lung, but can also involve many other parts of the body. It is often a slow and initially mild illness, but if left untreated can be very serious. The disease is diagnosed by growing the bacteria (germ) from samples taken from the affected area e.g. a phlegm sample.
Treatment is with specialised antibiotics, and is highly effective. Because TB is an unusual disease in Australia, and can be complicated, it should always be treated by a doctor who specialises in TB. People with TB are usually also helped by specialist community nurses, who assist with the supply of medication and ensure the treatment is completed satisfactorily. With this help, cure rates are better than 95%.
NON-TUBERCULOSIS MYCROBACTERIAL LUNG INFECTION (MAC LUNG DISEASE)
There are many bacteria that are in the same family as tuberculosis (called Mycobacteria) that can cause lung disease, but are different from tuberculosis (TB). These are called Non-tuberculous Mycobacteria (NTM) and are often also called "atypical TB".
The commonest NTM in Australia is Mycobacterium intracellulare, also called Mycobacterium avium complex, or MAC for short. This is still quite uncommon, but the number of people affected by it is increasing for unclear reasons. Disease caused by MAC is now more common than TB.
MAC most often causes lung disease in middle-aged to elderly people, more commonly females. It is not caught from someone else, and, unlike TB, is not contagious. The germ is breathed in from the environment, and why it causes disease in some and not others is not clear. Most people with MAC disease do not have a problem with their immune system.
The infection can cause damaged airways and scarring on the lungs, and lead to bronchiectasis. Symptoms include cough, phlegm production, night sweats, weight loss and lethargy. These usually develop very slowly, and sometimes the disease can develop over years before being diagnosed.
Treatment is with specialised antibiotics, which are given over a prolonged period. This can be difficult for the patient, and requires the expertise of a doctor specialising in the disease. However, the treatment is often effective in stopping symptoms and any further damage to the lungs.
Sarcoidosis is a disease mainly affecting the lungs and the lymph nodes (glands) next to the lungs. It causes a specific type of inflammation (granulomas) that can lead to enlargement of the glands and damage to lung tissue, especially scarring in the upper parts of the lungs.
The cause of sarcoidosis is not known. It is not started by an infection, vaccination, chemicals or exposure to something at work. The body's immune system starts over working and the resulting inflammation causes damage to tissues.
It often starts in early adult life, and affects both men and women. In the lungs it can cause cough and shortness of breath. It often affects other parts of the body, especially glands in the neck, eyes, skin and liver.
Most people with sarcoidosis have very mild or no symptoms at all. It is not uncommonly found by accident on an x-ray. Very often patients with sarcoidosis have no significant problem (symptoms, x-ray changes or damage to other organs), and monitoring the disease to make sure about this is all that is required.
In a small proportion (less than 30%) of patients with sarcoidosis, treatment is required. This is usually because the symptoms are bad enough or there is evidence that the disease is causing increasing damage. The diagnosis usually requires a CT scan of the chest, lung function tests, blood tests and occasionally a biopsy of the lung. Treatment is with medication to stop the inflammation, most often prednisolone. It needs to be done by a specialist physician to make sure that it is effective and side effects are minimized.
Very rarely sarcoidosis causes serious illness and treatment is difficult, but for nearly all patients it causes no trouble at all or is responsive to treatment lasting for 3 - 24 months and with minimal long-term consequences.