Breathe Easy: Understanding Respiratory Diseases an interview with Respiratory Physician- Dr Thomas Altree
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I'd like to let you know that Aussie Mediator is sponsored by OPC Health, an Australian supplier of prosthetics, orthotics, clinic equipment, compression garments, rehabilitation devices for doctors, physiotherapists, orthotists, podiatrists and hand therapists. If you'd like to know what OPC Health offers, visit opchealth.com.au and view their range online. Every breath we take is something we often take for granted until it becomes difficult.

Respiratory conditions affect millions of people worldwide, spanning from common ailments like asthma and COPD to life-threatening diseases such as pulmonary fibrosis and lung cancer. With environmental pollutants on the rise, the ongoing impact of smoking and the increasing prevalence of a chronic lung disease, the burden of respiratory illness is only growing. In fact, chronic respiratory diseases rank among the leading causes of morbidity or mortality globally, making them a critical area of focus for medical practitioners.

To help us navigate this vast and vital field, we're joined by Dr. Tom Altree, a specialist in respiratory and sleep medicine. Dr. Altree is a consultant at the Quindesville Hospital and sees patients in private practice at Breathe SA, and he serves as a senior research fellow at the Flinders University. In addition to his clinical expertise, he leads the Quindesville Hospital Respiratory Clinicals Trials Unit, where he investigates cutting-edge treatments for lung conditions, including COPD and pulmonary fibrosis.

Stay tuned as we explore his expert insights on diagnosing and managing respiratory conditions. G'day and welcome to Aussie Med Ed, the Aussie-style medical podcast. Our pragmatic and relaxed medical podcast designed for medical students and general practitioners, where we explore relevant and practical medical topics with expert specialists. Hosted by myself, Gavin Nyman, an orthopaedic surgeon, this podcast provides insightful discussions to a hunch of clinical knowledge without unnecessary jargon.

I'd like to start the podcast by acknowledging the Kaurna people as the traditional custodians of the land on which this podcast is produced. I'd like to pay my respects to the elders both past, present and emerging.

and recognising their ongoing connection to land, waters and culture. I'd like to say that this podcast is for educational purposes only and does not constitute medical advice. Always refer to clinical guidelines and consult a qualified healthcare professional before making medical decisions. It's my pleasure now to interview Dr Tom Aldry. Tom's joining us now on Aussie Media to talk to us about respiratory conditions. Tom, thank you very much for coming on board. It's great to have you here. My pleasure. Thanks for having me.

No worries. How common are respiratory conditions in society and around the world? It's about as big as you can get, Gavin. It's an enormous topic. Around the world, respiratory conditions contribute to a huge amount of disease burden. Just in Australia, just looking at chronic obstructive pulmonary disease in itself, over 600,000 Australians have COPD. That's about two and a half percent of the population. And that

That disease contributes to a huge amount of disease burden. And one of the problems around the world is that here in Australia, we see a condition like that. It's mostly related to smoking.

But things like smoke from bushfires, from pollution, from cooking also contribute to lung diseases. So anything that we breathe in can damage our lungs. And all the time, the lungs are exposed to the environment, which is a unique thing about them. Yeah, the thought came to mind was that the actual dryer, we actually clean out the lint filter. That's what's probably hitting our lungs every day.

All the time. Yep. And our macrophages are going to work trying to break all that stuff up. But if it's the wrong thing that's coming into our lungs, that can cause disease. Yeah. Our lungs are susceptible to all of the different things that are in the air.

And I was hoping it might be getting a bit better, hopefully reducing incidence of smoking. But I presume the pollutants in the air are getting greater as well. And that's also causing issues as well. That's true. In Australia, smoking rates are reducing, which has been a fantastic thing to see over the last few years. But rates of chronic obstructive pulmonary disease and rates of respiratory disease around the world are not reducing. They're going up.

And that is related to aging populations, exposure to inhaled pathogens. And now, of course, there's vaping as well. So even though in Australia we see the smoking rates going down, the vaping rates are increasing, especially in young people. And that is troubling. We don't really know what the full effect of that is going to be in the long term, but it's a worrying thing to see. Right.

Where do we start? How do we think about classifying these lung diseases? We classify lung diseases really based on what the pattern looks like on spirometry, so on lung function testing, and we break it down into obstructive or restrictive conditions.

Now, that doesn't cover the whole of respiratory medicine because, of course, you've got other conditions like vascular conditions, pulmonary emboli, pulmonary hypertension, infective disorders and cancers. But thinking about lung diseases in terms of obstructive or restrictive is a good way to go about it. With obstructive disorders...

What we see on the lung function testing on spirometry, and that's where you breathe into the spirometer as hard as you can, and we look at how much air comes out in that first second, compare that to how much air comes out completely,

If that ratio is less than 0.7, then that's what we call an obstructive disorder. The main obstructive disorders are asthma, chronic obstructive pulmonary disease, bronchiectasis and cystic fibrosis.

On the other end of the scale, if there is a disorder which is reducing the lung volume, that is a restrictive disorder. And so we'll see in restrictive disorders that the FVC, the forced vital capacity, that's how much air you can breathe out completely, will be reduced. And if we want to confirm the restrictive disorder, then the next step is to do full lung

lung volume testing, and that will confirm if there's a restrictive disorder. And there's a lot of different diseases that cause restrictive disorders, such as interstitial lung diseases. So I like to break those restrictive disorders down into pulmonary or extrapulmonary disorders. So extrapulmonary are things like chest wall deformities, kyphosis, kyphoscoliosis,

neuromuscular diseases. These can all cause restriction or intrathoracic or true kind of respiratory restrictive disorders that are affecting the lung interstitium and they're the interstitial lung diseases. And there's a lot of those. And we can go into that in more detail if you'd like to, but that's a big topic. Okay. Would people present the same way, whether it's restrictive or obstructive, or they have different variations in sentimentology?

No, there's a variety in the ways that people present with respiratory diseases. I mean, breathlessness is the common presentation and breathlessness can be caused, as you know, by a whole host of different diseases and they're not all necessarily respiratory diseases.

But cough, weight loss, wheeze, exercise intolerance or pain in the chest as well are all symptoms that may be due to one of those disorders of the lungs. So one of the things I really like about respiratory medicine is that it covers a huge range of types of diseases. There's an enormous amount of diseases.

variety in what we do. We've got genetic diseases, infective, malignant diseases that have been caused by smoking, diseases that have been caused by environmental exposures, occupational exposures. There's a huge amount of variety there. So that kind of keeps it interesting to me. And it also means that people can present in a huge variety of ways.

So generally, how would you work someone up? I usually like to think of presentations as an acute presentation versus a chronic one or something that presents to A&E versus something that presents to your clinic. Do you think of it that way as well and does that help guide you?

Yeah, absolutely. And of course, respiratory conditions can be life-threatening conditions. A in ABC, Dr. ABC is airway and B is breathing. So the lungs, when there's an acute problem, it's really acute and you've got to act fast. And that means that a lot of those diseases are dealt with acutely by paramedics, emergency doctors, intensive care unit doctors. And

And so really, in my day-to-day work, I'm seeing more of the chronic presentation of these diseases, although we do get the emergencies that occur on the ward as well.

as well, like a pneumothorax needs a chest tube put in straight away. Really, if I'm in the clinic and somebody is coming in, I start the history very broadly. I listen to what their presenting complaint is and try and from that get an idea about, say, if they're breathless, is this breathlessness an acute problem? Is this a chronic problem? What makes it worse?

and what are the comorbidities and if they've got any other history of respiratory disease. And then from that, I start to narrow my history taking down based on what they've told me. So if it sounds like this is someone who's had chronic breathlessness for years and they've been smoking for a long time,

then that's probably going to be one of those obstructive diseases. Or if they're a smoker for a long time, it's probably going to be something like chronic obstructive pulmonary disease. Whereas if they happen to be

a stone cutter or they've been working in an industry where they've had a lot of asbestos exposure, then I'm going to be thinking about interstitial lung disease. So it really depends on a broad history and an occupational history and an environmental exposure history and a respiratory history is very important. Then we move on to the physical examination and

Now, once again, it's really guided by their history because there are so many different disorders. And when I'm talking to medical students about the physical examination, I tell them there are a lot of signs that you can see peripherally. Like you start off examining the patient just in general. You're looking in the corner. Is there an oxygen cylinder? Is there a sputum jar? Is there all that kind of thing?

You move on to their hands and then to their head and their neck. And there are a lot of signs to see there, especially if they're someone who's got a connective tissue disorder or something like that, causing interstitial lung disease.

But you want to move through that really quickly because really the money is in the chest. So when I'm talking to medical students, I say really try and get to the chest quickly because the chest examination can take up three or four minutes in an OSCE situation. And there's a lot to do there. So you really want to get there quickly and quickly.

The other thing I say to medical students is to get out there and practice as much as you can on each other. Go and see patients with signs because there are a lot of different presentations that you will see different signs in the respiratory examination, be it consolidation or pleural effusion or a malignancy or a pneumothorax or something like that.

I still remember it from my medical school days many years ago. Has it changed much at all? No, the examination hasn't changed much at all. What's really changed is the quality of imaging that we can get. Once you've moved on from history and examination and you're thinking about your investigations to do, the quality of imaging has changed a lot. But yeah, in the physical examination, it's...

You know, it's exactly what it would have said in the textbooks 30, 40, 50 years ago. You look at a general inspection and you go and look at the hands, clubbing, connective tissue disorders. Is there asterixis, which in reality, you're not going to see that a lot, but you look for it. Hypertrophic pulmonary osteoarthropathy. All those things are in the textbook that you might see once or twice in your career. You move on to the head. You look for Horner's syndrome, a sign of apical lung tumour.

Have a look in the back of the throat, try and look at the tonsils. Is there any central cyanosis? See if the trachea is midline JVP, as you said, and then you move into the chest. But I really try and get through all of that stuff really quickly in an exam situation because really the chest is where the findings usually are.

I've got to put my hand up and be honest and say, I have always been a bit critical of the percussion technique. I thought it was more of a way of learning how to do tonal sign properly. But is percussion really useful? When I was learning as a medical student, I never found it that useful, but I presume it must be. You can definitely discern differences.

So what are we doing when we're percussing? We're trying to transmit a sound back to us. So if you've got a smoker with chronic obstructive pulmonary disease, bad emphysema, and they're very hyperinflated,

then that percussion is going to be really resonant because they're full of air. If you've got someone with a pleural effusion or consolidation, then that percussion is going to be dull. Now, of course, medicine is much more sophisticated than tapping on somebody's back. So we're going to move on. We're not going to just rely on percussion. But it adds one piece of information to an overall picture of what's going on.

Excellent. And then when you're doing auscultation, what are the particular things? I used to be able to hear bronchial breathing. I think you described it to me when we were discussing it before as being like Darth Vader, some noises coming from the chest. Yeah. If you want to hear bronchial breathing, just watch Star Wars.

Yeah, Darth Vader, he's got bronchial breathing all the time. If Darth Vader turned up with pneumonia, you wouldn't be able to tell because he's bronchial breathing anyway. Really what you're listening for in auscultation is, are there breath sounds that you can hear throughout all the zones of the chest? Because if there aren't, then...

For some reason, air isn't getting to that part of the lung. That may be cause of a pneumothorax. That might be cause of a pleural effusion. The breath sounds really come with training. The more lungs you listen to, the more your appreciation is of what a normal breath sound is versus what is an abnormal breath sound.

So something like pneumonia or consolidation, you'll get bronchial breathing. In something like a pleural effusion, you will have reduced breath sounds in that area, but then you can do vocal resonance and that will be dull as opposed to an area of consolidation where it will be increased. So it's a bit like if you jump under the water in a pool and you try and

yell out to your mate down the end of the pool, you can't hear that sound or they can't hear that sound very well. But if you get your mate to put their ear down to the end of a table, a wooden table, and then you knock on the table down the other end, they'll hear that really well. So that's sound being transmitted through consolidation or pneumonia. It sounds gets transmitted through solids really well. So all of those different components to the examination add their piece.

And once you can put that together at the end of the examination, depending on what you heard with percussion, auscultation, vocal resonance, that helps you to really have a good idea about what's going on in the lungs. I'd like to let you know that Aussie Med Ed is supported by HealthShare. HealthShare is a digital health company that provides solutions for patients, GPs and specialists across Australia.

Two of HealthShare's products are Better Consult, a pre-consultation questionnaire that allows GPs to know a patient's agenda before the consult begins, as well as HealthShare's Specialist Referrals Directory, a specialist in the allied health directory helping GPs find the right specialist.

What about coughs and different types of coughs, different types of shortness of breath, and also where there's blood in the sputum as well? Do those things make a difference to your diagnosis as well? Absolutely. Blood in the sputum is a red flag sign. And to me, blood in the sputum is lung cancer until proven otherwise. Now, there's a lot of other reasons why there'll be haemoptysis. And most of the time, it doesn't end up being caused by a

lung cancer, but that is one of those really important signs that has to be investigated very thoroughly. Answering the question about cough or different types of breathlessness, yeah, absolutely. So cough is an extremely common symptom and a lot of patients that I see have chronic coughs

Chronic cough is one of those conditions that can represent a serious underlying abnormality like a lung cancer. It may represent true pulmonary disease. People with asthma can get cough, but often we work up the patient and it's hard to find the cause of the cough.

So that is a cause of symptom burden out there in the community that is hard to diagnose and can be hard to manage, although there are new types of medications that are coming through the research trials that are directed towards people with chronic cough, and they look quite promising. So how do you proceed? You've got the person who presents with their shortness of breath, their coughing,

You've done a thorough examination and you've assessed them. Where do you go to from there? Normally, imaging will be the next step. It depends on what you've found so far. If you think there's a connective tissue disorder, for example, and that causes a lot of lung disease, then I'd be doing autoimmune blood tests in addition to imaging. But usually, imaging is the next step.

The textbooks will say do a chest x-ray. And if you're ordering a chest x-ray, you always need to make sure they're doing a lateral as well as a PA. But in reality, nowadays, for most of the cases where we're ordering chest imaging, we'll be doing a CT scan of some sort.

And there used to be these HRCTs, high resolution CTs that you would want to do for interstitial lung diseases. HRCT really is a higher resolution, but you don't get as many cuts or you didn't get as many cuts. Doing something like an HRCT wouldn't be appropriate if someone's got lung nodules because you might miss the nodules in between the cuts.

Nowadays, the quality of the scanners is so high that you essentially get that high resolution from the old school HRCT with your standard CT scan.

And then if you need to define vascular structures, then you would add contrast into the mix. And the timing of the contrast is important. CT technicians are good at timing that contrast if you're looking for something like a pulmonary embolus. So in most cases, imaging is the next step.

And in almost all cases that I see, I'll be ordering a full set of lung function tests as well. And we're very lucky at the hospital that I work at, the Queen Elizabeth, we've got an excellent lung function lab.

Lung function is one of those things that it can be hard to access for all doctors all around the country. There's a lot of variability in the quality of lung function testing that is out there. But if you've got access to a proper accredited lung function lab, getting quality lung function is really the recommendation because it's very helpful and can tell you a lot about what's going on in the lungs.

Perhaps just outline what happens to the patient when they come in for those. Yeah, so there's three main components to full lung function testing. So that's spirometry, which we talked about earlier, lung volume testing, and diffusing capacity. So spirometry, as we mentioned, is that one where you blow into the machine as hard as you can for as long as you can, and you repeat that two or three times. And

And then the lung function technician will get you to inhale a bronchodilator and they'll repeat that again. So that will show if there's any reversibility in bronchoconstriction and that helps us to diagnose asthma.

The next component is the lung volume testing. And that's done by sitting in a box in the lung function lab that looks a little bit like an old telephone booth. And that box has got a known volume. And then we know the volume of the person by their height and weight. So we can tell how much air is displaced when they go into the box. And we get them to do some breathing techniques. And that tells us a lot about

how much air is in the chest, but not only what their total lung capacity is, but different breakdowns of that. And I'm sure if you think back to medical school, you remember that graph where there was tidal breathing while I'm going up and down and I'm going to breathe all the way in to the total lung capacity and then all the way out down to residual volume. And there were all of these capacities that you were supposed to remember for exams.

They matter a lot. And I get my medical students to memorize all of that when they're on the wards with me because those different breakdowns of the lung volumes are very important. If you've got something like chronic obstructive pulmonary disease, where the smoke has destroyed the elastic tissue in your lungs and your lungs have lost that elasticity and they've become hyperinflated,

then you've got a lot of air stuck in your lungs, but it's really hard to get it in and out. So your functional residual capacity, which is the air left in your lungs after the end of a normal breath, becomes a lot higher. And that means that you're breathing with a lot of air in your chest, which is really inefficient. And that makes the work of breathing really hard. And if you exert yourself,

You can't get all of your air out before you need to take another breath in. So it gets worse and worse. That's called dynamic hyperinflation. So that's something that we can see on lung volume testing. That third component of lung function testing is diffusing capacity or gas transfer.

And that really is a measure of how well oxygen is getting from the alveolus across the alveolar membrane into the blood vessels and how well carbon dioxide is getting from the blood vessels out into the alveoli and then breathing that back out. And that test will be impaired in many lung diseases, but especially interstitial lung disease.

And how do you do that test? Do you need to do an arterial line to monitor that? No, it involves breathing in a small amount of carbon monoxide, not anywhere near enough that it would ever cause any problems. And this is a really common test that we do. We would do it

20 times in a day at the Queen Elizabeth Lung Function Lab. But by breathing in that small amount of a known gas, that allows us, there's a lot of stuff that goes on in the background, but that allows you to tell how well gas is transferring across that membrane. So it sounds like someone's there for a few hours having these tests done. Yeah, if you're going to do that full set of lung function testing, it'll take about one hour.

We don't do all three every time, but if we do all three, as we often do, it'll take about an hour. And that will tell you whether it's obstructive or restrictive as a main... Based on that ratio of the air that goes out in a second versus the air that goes out completely, that'll tell us if it's obstructive. Those other tests are really adding to the amount of information that we've got. And we use those tests to monitor lung disease over time as well.

So in addition to the bloods and doing either an x-ray or preferably a CT scan, as well as these lung function tests, what other investigations may you do as a respiratory physician? There's a whole lot of other ones. We have an ultrasound machine with us in the clinic, which we use to have a look at the lungs. And that's especially handy if someone's got a pleural effusion.

because that can allow us to see what the shape of that effusion is, what the size of that effusion is, and if it's amenable to us being able to drain it, for example.

We will often do arterial blood gases on patients. And that tells us a huge amount of information about oxygenation, how high the carbon dioxide is, the bicarbonate and the pH. And really, that's a useful test in those patients who have CO2 retention. So it'll tell us if there's respiratory failure, chronic or acute. And that's something that we will do often on the wards in our patients with

respiratory failure from various different causes. The oxygen saturations are very helpful, but it doesn't tell us anything about the carbon dioxide. And the carbon dioxide is a marker of ventilation.

Someone is not ventilating properly, then their CO2 is going to be going up and that's deadly. And so if someone's got true acute CO2 retention, something needs to be done about that quickly, depending on the cause. And often we'll use non-invasive ventilation on the ward, BiPAP machines to assist the ventilation, to help that lung expand and get the CO2 out. But you really need the arterial blood gas to know what those blood gases are doing.

And those people who are retaining CO2 are the blue bloaters. Is that correct? You can be a CO2 retainer and be a pink puffer as well. That kind of old blue bloater phenotype is more to do with overweight, obese people with COPD who have a more of a chronic bronchitis type phenotype.

This concept of phenotypes is something that we're appreciating more and more in respiratory disease, that although there are overlying umbrella terms like COPD or like asthma,

There are a lot of traits within those diseases that are targetable with different treatments and different phenotypes. So asthma, for example, I know you've done a topic on asthma in the past, but that's a classic one where there's these different traits where now there are new monoclonal antibody therapies that can be targeted towards the type of

over-sensitive immune reaction that's going on that's causing asthma in some people, but not all. So it's actually been a fantastic thing over the last few years to have some of these new drugs coming on board. And that's helped our understanding that all of these diseases really have subcategories and those subcategories are important because they guide treatment. It's still an area that has got a long way to go. Our understanding of

specific genes that might convey more of a susceptibility to smoking is really in its infancy, I think. You get those people who smoke and smoke for their whole life and they don't seem to get any problems from it.

And then other people are exquisitely susceptible to cigarette smoking. And there's a genetic basis to that, like in alpha-1 antitrypsin disease, for example, where those people will be very prone to developing

emphysema in the upper lobes, especially if they smoke. The smoking seems to do something that really drives the damage that's going on. Yeah, genetics is just like in many other kind of subspecialties of medicine. Genetics plays a huge role and our understanding is not great at the moment, but it's improving and it will guide treatment.

So if we look at the main classifications, the obstructive lung disease versus restrictive, from my reading and my trying to understand it all, it looked like there was this purely asthma and COPD and maybe bronchiectasis as obstructive lung disease. And the restrictive seemed to be a list as long as your arm of different causes.

Perhaps you could outline a bit more about that and actually expand upon that. Oh, that's complicated. And I scratched my head about the list of interstitial lung disease diagnoses myself. The list is long, but they're also not as common. So those obstructive diseases are diseases that we see a lot more in practice and anybody will see a lot more in practice. But

But if we dive into those restrictive disorders, so the interstitial lung disorders, I think about it in terms of connective tissue disorders, environmental or occupational exposures, drug-induced causes, idiopathic

So for many of them and for many severe conditions, just like idiopathic pulmonary fibrosis, there's no obvious cause to that, but they get quite a severe disease phenotype. And then once you've got those categories, then you've got a whole lot of different conditions under each of those categories. So for connective tissue-related interstitial lung disease, for example,

rheumatoid arthritis, ankylosing spondylitis, Sjogren's, a whole host of those different extertial disorders can all be associated with interstitial lung

lung disease. And we work very collaboratively with our rheumatology colleagues because there's so much overlap between rheumatological connective tissue disorders and lung diseases. Going back to what I was saying earlier about history taking, those environmental and occupational related incisional lung diseases are important not to miss. There can be

avenues for compensation for people who have had occupational exposures, who have developed severe lung disease.

Sometimes there'll be some kind of allergic cause that they're still having an exposure to. So you see that in people like bird keepers who can develop a hypersensitivity pneumonitis, and that can be a deadly disease. And it can also be hard to convince some people to stop the exposure. If that's their reason for being, keeping their parrots or something, that can be tough.

So yeah, there's a whole range of different causes there. But like anything in medicine, if you've got an idea about the classification, then it's a lot easier to recall all of those different

diseases. I remember being on a general medicine ward round once and the general medicine physician said to me, Tom, give me 10 signs of thyrotoxicosis. And I kind of stood there scratching my head and maybe I came up with one or two, but

But I really went home and I thought about that. And if you've got a system in your head, if you've got neurological signs, cardiac signs, optic signs, then under those headings, then you've got a whole lot of the signs of thyrotoxicosis, for example. And that's just an example that...

that applies to every aspect of medicine. That's one of the other things I really drum into students that I have is to try and develop systems of classification allows you to recall things a lot better.

It's a perfect sedge way for those who want to look at my other podcast on the rule of threes as a way of subdividing things up and using that as a basis for it. Remembering that things are two, threes, fours apart. Yeah, glad we're on the same wavelength. I think it's a good way of remembering things rather than trying to just be haphazard when you're trying to bring things up.

Once you know the diagnosis, I presume it affects both the treatment options and helps you determine prognosis for the scenarios. There are so many different respiratory diseases that the treatments are...

wide and varied. If you think about that breakdown of infectious causes, malignant causes, environmental, smoking-related causes, and that's just a few of the different kind of conditions that can cause respiratory diseases, then the treatments for all of those things

are very different. And one of the reasons that I got into respiratory medicine was that aside from the variety that you get, it's quite a hands-on specialty as well. We do quite a lot of procedures. So we do bronchoscopies.

And in bronchoscopies, that's getting more and more advanced. So in the case of things like lung tumors, if they're affecting the central airways, we've got techniques to burn them away and laser them away and sometimes put in stents.

We do a lot of diagnostic work with bronchoscopy as well. We can sample the lymph nodes or if there are peripheral tumors, we can get out to them and use ultrasound on the end of the scope to see where we are in the airway and make sure that we're biopsying the right area.

If we've got patients with pleural diseases as well, putting in things like chest tubes to relieve the pleural effusion, and sometimes they're long-dwelling chest tubes. That's a more complicated type of chest tube that we put in. There's quite a lot of hands-on therapies that we do, and that really drew me towards respiratory medicine. But

Really, because there are so many diseases, there are so many different types of treatments. The mainstay of treatments in diseases of the airways, like chronic obstructive pulmonary disease and asthma, are inhaled therapies. And that's usually a mixture of anti-muscarinic beta agonists and inhaled corticosteroids, depending on the severity of the disease.

For the interstitial lung disease types of disorders, the mainstay of that is steroids. But the other kind of important way to think about many of those interstitial lung diseases is that they often develop with an inflammatory process. And then over time, that inflammatory process becomes fibrotic.

And so if you can treat it in that inflammatory window, and that may be years or it may be shorter than that, then often it's a lot more responsive to therapy than down the track when it progresses to a more fibrotic type of therapy.

disease. So even though you've got so many different types of interstitial lung diseases, many of them follow that pattern from inflammatory to fibrotic over time. And depending on the disease, we've got different types of medications to try and target that inflammatory period. And there's a big overlap with the medications that are used in rheumatology, like all of those infusions with monoclonal antibodies.

But then as we get towards that fibrotic stage, that's when treatment becomes difficult.

There are antifibrotic drugs, but at the moment, the ones that are available don't tend to turn the disease around. They tend to slow the progression of the disease. But there are some promising antifibrotic therapies coming through the clinical trial stage, and we're a site for a few of those big international multi-centre trials at the Queen Elizabeth, where these antifibrotic

drugs seem to be improving lung function over 26 to 52 weeks. We're hoping that they are actually breaking down some of that fibrosis, but that's still early stages. So you're using lung function tests to work out how well someone responds to the treatment.

Where does the role of classifying obstructive type conditions into the GOLD classification come into it? That's pretty much just used in chronic obstructive pulmonary disease. Yeah, so we've got these kind of GOLD classes of spirometry impairment. And GOLD is the Global Obstructive Lung Disease Group. So that's a group of international experts who have come together to develop guidelines.

And those guidelines break down the severity of COPD into their different gold categories. And we also use how breathless somebody is and how frequently they're having a COPD exacerbation to help determine the gold stage. And that will help us to decide which inhaler to start or which inhaler to step up to or which other types of treatments to change over to.

And there are classifications for asthma as well. There are breakdowns for interstitial lung disease. But yeah, for anybody wanting to learn about COPD management, the gold guidelines are a fantastic resource. They're very thorough. So there are similar systems used for the other diseases as a way of deciding what sort of treatment options you're going to use or assessing how well they respond as well. So it's not just using the absolute numbers or anything.

No, it's not the absolute numbers. It's disease specific, but those absolute numbers, we monitor disease and we see if there's disease progression or disease improvement based on their lung function testing over time.

Right. So for the end-stage type disease, you've tried to take away the pathogen that's caused it, and you're trying to treat the acute flare-ups in the inflammatory stages. But for the end-stage, it's the fibrotic lung and the restrictive condition or the end-stage obstructive disorders. What are the actual fallback options? I was looking at the literature, and it looked like the actual final outcome was a lung transplant, which didn't sound that

readily available or easily accessible. Lung transplant is not to be taken lightly. It's an enormous procedure and there's a very

large amount of workup that needs to be done before someone will be deemed eligible to have a lung transplant. It is offered in many cases. You've got to be robust enough to deal with the surgery because it's a pretty big operation. And at the moment, that surgery is not done in Adelaide. So you've got to travel interstate. So that brings its challenges. You've got to stay interstate

in that hospital and then near the hospital for at least a few weeks after the procedure before coming back. And then like any other transplant, there's immunosuppressive therapies you've got to be on lifelong afterwards. It's a very big step, but can be a fantastic treatment in the right patients.

That said, there are a lot of other treatments that we use. So just getting back to chronic obstructive pulmonary disease, in those very hyperinflated patients that I was talking about before, there are some new devices called endobronchial valves.

And these are very small one-way valves that are inserted into the airways of a lobe of the lung that happens to be particularly hyperinflated or particularly affected by emphysema and is essentially not functioning anymore. And what those valves do is that they lead to that part of the lung collapsing.

So no more air goes to that part of the lung anymore. It all goes off to the other parts of the lungs, which are better functioning parts of the lung. So this is a less invasive way to get the same outcome as the old procedures where the cardiothoracic surgeon would do lung volume reduction, where they take out the upper lobe or both upper lobes. That surgery really isn't done very much anymore, but we

we can get the same functional outcome bronchoscopically. Wow.

So that's a pretty cool procedure that's come on in the last five, six, seven or so years. Would you use that also for someone who has recurrent billi bursting and causing pneumothoraces and things? Yeah, absolutely. Spot on. Yep. It's a treatment for recurrent pneumothorax. You can stop the air going to the part of the lung where the air leak is and collapse that down and

And then often you go in and you take out the valves down the track a few weeks later once that pleura has had a chance to heal. So that's the other good thing about them is that they can be taken out if you need to.

So that's one kind of additional therapy for chronic obstructive pulmonary disease. Pulmonary rehabilitation is a really important part of managing people with lung disease. And that's kind of a dedicated course of exercise and strength and conditioning run by our physiotherapy colleagues. And there's pulmonary rehabilitation programs offered through all of the major hospitals in South Australia. And that really helps with

people with lung disease's overall condition and their ability to deal with their breathlessness. That's key.

A lot of these diseases are diseases of multi-morbidity. So it's common that people with respiratory disease will have heart disease. They'll be sarcopenic. They'll be osteoporotic. So all of those things have to be managed as well. And as disease gets more severe and symptoms get worse, then we really need to focus on those symptoms.

Hypoxia and breathlessness is a key problem. And so sometimes oxygen therapy in the home is given. And that might be just when someone needs it for exertion, going down to the shops. It might be just used at nighttime, a during sleep, or it might be that someone needs oxygen therapy all day. Okay.

In some people, their ventilation is impaired, and so they need to use a kind of a type of CPAP device at home called BiPAP, bi-level positive airway pressure, which helps aid their ventilation, which is often worse during sleep when all of the muscles are less effective during sleep.

So there's a whole range of different adjunctive therapies that we can offer that become more and more relevant as disease severity goes on. Thinking about what you've just been saying, the two questions come to mind is, I presume respiratory function, even without all these other factors, deteriorates with age.

And also when you look at the young sports person or particularly the free divers who can hold their breath for a very long time, obviously even someone who is fit, just training to improve your lung capacity must have some benefits for longevity later on in life. Is this something that we all should be doing, going through some sort of respiratory training ourselves throughout our lives so we're ready for it as we get older? Yes. I've got some bad news for you, Gavin. We've both peaked.

In terms of our lung function, we both peaked years ago. Lung function or total lung capacity really hits its peak in our early to mid-20s, and then it's all downhill from there. We slowly lose a little bit of lung function every year from there on.

And if you're smoking, then that rate of loss is a lot higher. But if you stop smoking, then your rate of loss goes back to the normal rate that it would have been for anybody else. We don't really gain lung function from exercise, unfortunately. What we've got is what we've got. What we can improve is the efficiency with which we use oxygen. So that's really related to muscle adaptations and exercise.

cardiovascular adaptations to exercise. But it all just comes down to that old adage, use it or lose it. And that's why pulmonary rehabilitation is so important in our patients because there's this downward spiral that if you become deconditioned, then it's so much harder to get back to that level of fitness that you had beforehand. So we really encourage our patients and we've got systems of support in place to maintain that

exercise and activity in later life. In the end, it's all about getting oxygen to your blood. And erythropoietin could actually improve your red blood cells and improve your blood carrying capacity. Has that got a role to play in any of these chronic lung diseases as well?

We often see in people with chronic lung diseases that they develop polycythemia because of the chronic hypoxia. So they've already, often in many cases, they've already had that kind of adaptation that you see with altitude. We don't have good evidence that adding in something like erythropoiesin or giving a blood transfusion unless they've got anemia actually helps a lot.

Yeah, it's interesting to see what happens with the adaptations of the red blood cell to an environment where there's low oxygen. Yeah, that makes sense. Obviously, if they're reducing oxygen, then they'll actually increase their own EPO to help.

All right, Tom, speaking about these respiratory illnesses and conditions, you mentioned the involvement of other teams. Obviously, you've talked about physiotherapists in rehab for maintaining lung capacity. Do you involve a multidisciplinary team in your assessments of these patients at all? And does that have a role to play in respiratory conditions?

Yeah, the multidisciplinary team is used mostly in the context of lung cancer. That would be the respiratory condition where the MD really plays a pivotal role in

And we hold a lung cancer MDT weekly across both the Royal Adelaide and the Queen Elizabeth Hospital. And it really improves the quality of care, bringing all of those specialists into the one room. And there are so many different examples that I can think of where

The decisions that have been made about treatment or about further investigations have changed based on having everybody there together. So for respiratory lung cancer MDTs, we'll often have a mixture of respiratory physicians, cardiothoracic surgeons, medical oncologists, radiation oncologists.

and radiologists. And then in our particular MDT, we're very lucky that we've also got nuclear medicine and pathologists in the room. And the pathologists are able to show us the cells from the biopsies. So it's a very comprehensive MDT and it's a very effective MDT.

Because the respiratory diseases are diseases of multi-morbidity and they affect so many aspects of life, it's really important to involve patients.

different different clinicians in the care of our patients so we've got a fantastic nurse-led outreach team who follow up on many of our clinic patients especially the ones on oxygen our physiotherapy team are fantastic and you know it just it really improves the quality of care that our patients receive by having all of those different people involved

Is there anything else you think we should cover when we're looking at these respiratory conditions? Is there anything we've perhaps missed out for the medical students that you might want to remember when assessing a person with a respiratory condition? Yeah, I guess one of the things is that these respiratory conditions, because they're often associated with other conditions or they can be caused by other conditions, it's important to try and keep in mind the varying impacts that those conditions may have.

on the person overall and on the lungs. So for example, in ankylosing spondylitis or other rheumatological conditions, you might see that someone's developed an interstitial type process from their connective tissue disorder,

But they can also have extra thoracic changes that can affect respiratory function, like chest wall deformities or a stiff vertebra that you can get in ankylosing spondylitis, for example. Just keep in mind that more than one thing might be affecting respiratory function. It's a great sort of thought to have for an OSCE where it's more than one area you need to look at as well. And also for the GP who's assessing the patient too.

Where do you think things are heading for the future in this scenario? It sounds like it's progressed a lot over the years. I think a lot of the improvements in the near future are related to our improving understanding of the immune function in lung diseases. So immune function affects inflammatory processes in all of the different lung diseases that are out there. And so a lot of the clinical trials show

now are looking at monoclonal antibodies targeted to particular types of inflammatory cells or particular interleukins in a whole range of different respiratory diseases. So we've got trials of anti-interleukin monoclonal antibodies in chronic obstructive pulmonary disease, in asthma, in interstitial lung diseases at the moment.

And it's meant that we've had to really get our heads around immunology. I thought that after my physician exams, I wouldn't really need to worry about all that kind of stuff anymore. But the way things are going, it's becoming more and more relevant again for us. So I think looking to the future, the next five or 10 years, that's the big thing that's going to change in respiratory medicine. Pretty impressive stuff. So look, I really thank you very much for your time today, Tom. It's great having you on board on Lossie MedEd. Really appreciate your help.

Thanks for asking me to come and talk about respiratory conditions. I'm very happy to do so. Brilliant. Thank you very much. I'd like to remind you that all the information presented today is just one opinion and there are numerous ways to treat all medical conditions. It's just general advice and may vary depending upon the region in which you are practising or being treated. The information may not be appropriate for your situation or health condition and you should always seek the advice from your health professionals in the area in which you live.

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