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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2935_Библиотеки_им_академика_М_И_Перельмана
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Smoking and the Lung256
https://t.me/med1917
If the patient does not want to, or is not ready to quit, advise them where
•
they can get help if they change their mind in the future.
e health benefits of smoking cessation are listed in Table 17.2.
•
Table 17.2 Benefits of stopping smoking.
TIME AFTER
STOPPING
SMOKING HEALTH BENEFITS
20 minutes • Blood pressure and heart rate return to normal.
8 hours • Nicotine levels reduced by 90%.
• Carbon monoxide levels reduce by 75%.
48 hours • Carbon monoxide eliminated from body.
• Lungs start to clear mucus and debris.
• Nicotine eliminated from the body.
• Ability to taste and smell improved.
72 hours • Patients report breathing is easier
• Subjective energy levels increase.
2–12 weeks • Reduced rate of respiratory infections.
• Symptoms of coughing and shortness of breath improve.
• Physical appearance improves.
• Reduced severity of asthma attacks.
3–9 months • Symptoms of chronic bronchitis improve.
• Risk of duodenal or gastric ulcer falls.
• Lung function improvement for patients with mild/
moderate COPD.
1 year • An ex smoker previously smoking 20/day will have saved in
excess of £3000.
5 years • Excess risk of myocardial infarction halves.
• Decline in lung function equals that of a never-smoker.
10 years • Risk of lung cancer falls to 50% of the risk of a smoker.
• Risk of myocardial infarction falls to that of a never-smoker.
7. SMOKING CESSATION COUNSELLING
Support from stop smoking services can be delivered by:
•
• Group sessions.
• Drop-in sessions.
• Telephone consultations.
Respiratory Medicine
• Individual appointments with a specialist stop smoking practitioner.
e quit rate at 1 year after smoking cessation intervention is 15%, compared
•
to 4% of people who stop unaided.
Smoking and the Lung
https://t.me/med1917
MICRO-print
Quitting smoking is a difficult process: 85% of smokers who try to quit
relapse within a week. Smokers go through 7 stages or psychological
processes of quitting.
1. Pre-contemplation: Smoking is not considered a problem to the
patient.
2. Contemplation: The patient starts to consider quitting.
3. Preparation: The patient wants to quit and starts planning a quit
date.
4. Action: The patient stops smoking.
5. Maintenance: The patient continues to avoid smoking.
6. Termination: The patient no longer craves tobacco.
7. Relapse: Most commonly smokers progress to this stage; it usually
takes at least 4 attempts to quit.
8. NICOTINE REPLACEMENT THERAPY (NRT)
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A combination of NRT with counselling increases quit rates to
•
25%
• NRT is designed to minimise the effects of nicotine withdrawal.
• It can be prescribed, and most are available as over-the-counter medica-
tions; there are multiple preparations available.
• Most preparations are taken for 8–12 weeks.
Long-acting preparations such as patches can be used in combination with
•
rapid-acting preparations:
• Patches
• Chewing gum
• Sublingual tablets
• Lozenges
• Inhalator
• Nasal spray.
9. OTHER SUPPORTIVE PHARMACOTHERAPY
Bupropion (Zyban):
•
• Counteracts nicotine withdrawal symptoms by inhibiting dopamine,
serotonin and noradrenaline uptake, thus increasing the levels in the
brain.
• It has shown to lead to a 30% quit rate at 12 months when combined
with counselling.
Varenicline (Champix):
•
• Binds to and has a partial agonist effect to the a4b2-nicotine acetylcho-
line receptors, thus lessening the symptoms of withdrawal and reducing
the rewarding effects of smoking.
• 22% quit rate at 12 months.
.
Respiratory Medicine
Smoking and the Lung258
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Both bupropion and varenicline are prescription-only medicines and should
•
only be prescribed in patients with a firm quit date and with counselling
arranged for ongoing follow-up.
ese drugs can cause behavioural disturbance, especially with regards to
•
suicidal ideation, and should therefore be used with extreme caution in
adolescents.
MICRO-facts
Risk vs Reward: Contraindications of Smoking Cessation Medication
Varenicline:
Do not use in patients with a history of depression or serious neuro-
•
psychiatric conditions; safety has not been established in this patient
group.
Increases risk of depression, suicidal ideation and completed
•
suicide.
Any patient reporting neuro-psychiatric symptoms should have
•
the drug stopped permanently.
Seizures due to the drug reported. Use with caution in patients with a
•
history of seizure or seizure disorders.
Increased risk cardiovascular events and cardiovascular-related death.
•
Use with caution if history is suggestive of arteriopathy.
Bupropion:
Lowers the seizure threshold, is contraindicated in patients at
•
risk of developing seizures. Previous seizures are an absolute
contraindication.
Contraindicated in patients with history of anorexia nervosa or buli-
•
mia. Medication can cause significant weight loss.
MICRO-print
Electronic nicotine delivery system or e-cigarettes are increasingly
•
being used by smokers to quit.
They are widely used and have been shown to aid quitting of tobacco
•
compared to placebo.
Their use has generated controversy:
•
The long-term impact on health is uncertain.
•
There is concern that they could be used to attract a new gen-
•
eration into smoking and nicotine addiction.
However, the majority consensus is that these products carry far less
•
Respiratory Medicine
risk than tobacco.
Part
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Questions and Answers
II
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18
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Questions and
Answers
Questions
CHAPTER1: CLINICAL ASSESSMENT
EMQ: Lung function test
1. Asbestosis 6. Drug-induced pulmonary fibrosis
2. Asthma 7. Farmer’s lung
3. Bronchiectasis 8. Idiopathic pulmonary fibrosis
4. Coal workers pneumoconiosis 9. Normal lung function
5. COPD 10. Pigeon fanciers lung
Question 1
You are the junior doctor on the respiratory ward and have been asked to review
the spirometry results of a 45-year-old woman. She has a history of rheumatoid
arthritis and takes a number of anti-rheumatic drugs. e results show:
RESULTS
FEV1 (% predicted) 70
FVC (% predicted) 52
/FVC 88%
FEV
1
What is the most likely cause given the results and clinical information?
Question 2
You are the junior doctor on the respiratory ward and have been asked to review
the spirometry results of a 22-year-old student. He has been complaining of
shortness of breath and a cough that wakes him from sleep. Spirometry was performed then repeated after administration of salbutamol. e results are shown
below:
DOI: 10.1201/9781315113937-20
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RESULTS 1 RESULTS 2
FEV1 (% predicted) 45 85
FVC (% predicted) 70 90
/FVC 55 90
FEV
1
What is the most likely cause given the results and clinical information?
Question 3
You are the junior doctor on the respiratory ward and have been asked to review
the spirometry results of a 67-year-old man. He is an ex-miner and has smoked
for most of his life. Spirometry was performed then repeated after administration of salbutamol. e results are shown below:
RESULTS 1 RESULTS 2
FEV1 (% predicted) 40 42
FVC (% predicted) 65 68
/FVC 55 56
FEV
1
What is the most likely cause given the results and clinical information?
SBAs
Question 1
1) Acute kidney injury
2) Asthma
3) COPD
4) Opiate overdose
5) Pulmonary embolism
You are the junior doctor in the ED and are asked to see a 45-year-old woman
who was admitted short of breath. You take an ABG, the results of which are
shown below:
pH (NR: 7.35–7.45) 7.51
(NR: 11–13 kPa) 7.8 kPa
PaO
2
(NR: 4.7–6.0 kPa) 3.9 kPa
PaCO
2
(NR: 24–30 mmol/L) 21 mmol/L
HCO
3
Questions and Answers
RESULTS
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What is the most likely diagnosis?
Question 2
1) Asthma
2) COPD
3) Diabetic ketoacidosis
4) Pulmonary embolism
5) Salicylate overdose
You are the junior doctor in the ED and are asked to see a 73-year-old man with
shortness of breath. You take an ABG, the results of which are shown below:
RESULTS
pH (NR: 7.35–7.45) 7.27
(NR: 11–13 kPa) 6.0
PaO
2
(NR: 4.7–6.0 kPa) 8.1
PaCO
2
(NR: 24–30 mmol/L) 32
HCO
3
What is the most likely diagnosis?
CHAPTER2: RESPIRATORY INFECTION
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EMQ 1:
1) Ciprofloxacin 6) Meropenem
2) Co-amoxiclav 7) Oral amoxicillin
3) Co-amoxiclav and intercostal drain 8) Oseltamivir
4) Doxycycline 9) Piperacillin/tazobactam
5) Co-amoxiclav and clarithromycin IV 10) Rest and paracetamol
For each of the following questions, please choose the most appropriate treatment. Each option may be used once, more than once, or not at all.
1. A 72-year-old female is admitted to hospital with a 3-day history of cough
productive of purulent sputum, confusion and dyspnoea. Her observation chart
records hypoxia, tachypnoea with a respiratory rate of 32 and hypotension with
a blood pressure of 88/.48 On auscultation of the chest, there are crackles
at the left base with decreased chest expansion. e chest X-ray demonstrates
consolidation at the left lower zone.
2. A 62-year-old male with a history of emphysema and type 2 diabetes mel-
litus sees his GP with a 4-day history of dry cough and shortness of breath
proceeded by a sore throat. He has had several episodes of rigor at home. One
Questions and Answers
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week ago he visited his grandchildren, who were suffering from symptoms of a
“nasty cold”. His GP notes his temperature to be 38.10C and sends him for a
chest X-ray, which is normal.
3. A 92-year-old male is admitted from a nursing home with sudden onset over a
day of breathlessness and cough productive of purulent sputum. He was noted
to be vomiting the night before. His medical history includes a right middle
cerebral artery territory stroke 2 years ago which has left him with residual leftsided weakness. On auscultation of his chest he has crepitations at the right
base with reduced chest expansion. His chest X-ray shows consolidation at the
right lower zone. e nurse mentions to you that the patient seemed to cough
more when he was eating his lunch.
EMQ 2:
Options:
1) Haemophilus influenzae 6) Mycoplasma pneumoniae
2) Influenza A 7) Respiratory syncytial virus (RSV)
3) Influenza C 8) Staphylococcus aureus
4) Legionella pneumophilia 9) Staphylococcus epidermis
5) Mycobacterium tuberculosis 10) Streptococcus pneumoniae
For each of the following questions please select the organism or virus that you
think is the single most likely cause of the patient’s symptoms. Each option may
be used once, more than once, or not at all.
1) A 58-year-old man presents with a history of high fever
present over 24 hrs. He has developed a productive cough, chest pain and
severe dyspnoea. On examination he appears unkempt with poor personal
hygiene, smells strongly of alcohol and is cyanosed. ere is dullness on percussion and bronchial breathing bilaterally, as well as a heart murmur. His
chest X-ray shows bilateral multi-lobar consolidation and cavitation. He has
no fixed abode and is currently in receipt of a regular methadone script.
2) A 35-year-old man presents to his GP with a worsening cough and chest pain
that have developed over the past 10 days. He also reports a headache, sore throat
and general malaise. On examination he has a fever 38.7oC and generalised
rhonchi with wheeze. ere has been an unusual number of previously fit, young
people turning up to surgery with similar symptoms over the last few months.
3) A 42-year-old woman presents with a gradual onset of fever, chills, a dry cough
and general muscle pains over the last 3 days. On examination she seems generally unwell, is unstable on her feet and on auscultation there is bronchial
Questions and Answers
breathing at both lung bases. She has just returned from a business conference,
other attendees have reported similar symptoms.
40.6oC and chills
()
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SBAs respiratory infections:
For the following clinical scenarios please select the single most appropriate
initial management:
Question 1
A 67 -year-old woman presents with a productive cough and shortness of
breath. Her vital signs are as follows: pulse 120 bpm, respiratory rate 32 per
minute, BP 120 / 95 and a temperature of 38..5°C On auscultation she has
dullness to percussion and bronchial breathing at the right base.
1) Send home with no treatment
2) Prescribe a course of amoxicillin and get her GP to review in a week.
3) Insert a cannula into the second intercostal space mid-clavicular line.
4) Admit to hospital and start fluids and antibiotics.
5) Ask for a senior review and reserve a bed in ITU.
Question 2
A 6-year-old girl is brought into A&E. She looks very unwell, with a temperature of 39.4C , and is having difficulty breathing. She sits leaning forward with
her mouth open, drooling, and she has a soft high-pitched stridor. Her parents
say that she started complaining of a sore throat and developed a temperature
about 6 hours previously.
1) Look in her eyes, ears and back of throat, to determine site of infection.
2) Insert a cannula and start IV antibiotics.
3) Give oral dexamethasone, oral prednisolone and nebulised budesonide.
4) Give oral dexamethasone, oral prednisolone and nebulised adrenaline.
5) Call an anaesthetist and senior paediatrician, to assess in Resus and facilitate
rapid intubation of the patient.
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Question 3
An 18-year-old female presents with shortness of breath, fever and cough
productive of purulent sputum. Her symptoms are getting worse despite her
GP starting a course of amoxicillin. She is normally fit and well. She has
consolidation on her chest X-ray and you make a diagnosis of CAP. You have
noticed an unusually high number of younger patients with pneumonia this
year.
What is the most likely causative organism?
1. Haemophilus influenzae
2. Legionella pneumophilia
3. Mycoplasma pneumonia
4. Staphylococcus aureus
5. Streptococcus pneumoniae
Questions and Answers
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