Respiratory Medicine Overview (PDF) - Smoking Causes & Treatments

**[OVERVIEW OF ADULT RESPIRATORY MEDICINE]** 45♂ **Cough**, **Wheeze**, *[no previous]* hx 2 courses **ABX** and **Steroids**  Lost crown in sleep 5 months earlier ED + 6 months, unwell Rt sided chest pain Lots of fluid build up in the lungs -- Abscess in the pleural cavity...

**[OVERVIEW OF ADULT RESPIRATORY MEDICINE]** 45♂ **Cough**, **Wheeze**, *[no previous]* hx 2 courses **ABX** and **Steroids**  Lost crown in sleep 5 months earlier ED + 6 months, unwell Rt sided chest pain Lots of fluid build up in the lungs -- Abscess in the pleural cavity He recovered well **[SMOKING]** *[Every year]* over **100,000** **Smokers** in **UK Die** from **Smoking** **Related** **Causes** *[Half of all]* **Regular Smokers** will *[eventually]* be **Killed** by their **Addiction** **[DEATHS CAUSED BY SMOKING-RELATED DISEASES]** **Lung Cancer** is the *[most]* *[common]* **Smoking-Related Cause** of **Death** *[followed]* by **Heart Disease** and **COPD^1^** **Smoking** *[caused]* **121,700** out of **644,000** **Deaths** in the **UK** in **1995^1^** **[SMOKING AND DISEASE]** - **90%** of **Deaths** from **Lung Cancer** - **80%** of **Deaths** from **Emphysema** and **Chronic Bronchitis** (COPD) - **17%** of **Deaths** from **Cardiac Disease** **[ONE IN THREE CANCER DEATHS CAN BE ATTRIBUTED TO SMOKING]** - **Arsenic** -- Car Batteries - **Acetaldehyde** -- Carcinogenic Chemical Compund - **Ammonia** --*[Used to make]* **Fertilizers** and **Cleaning Products** - **Acetone** -- **Nail** **Varnish** **Remover** - **Butadine** -- *[used]* in *[manufacturing]* **Synthetic Rubber** - **Benzene** -- is a **Petrol Additive** and is a *known* **Carcingogen** - **Formaldehyde** -- **Carcinogen** *[used in preserving]* **Dead Bodies** - **Toluene** -- *[used in]* **Pain Thinners**, and **Permanent Markers** - **Methylamine**- *[Used]* in **Breaking Bad** as a part of the *[process to create]* **Methamphetamine** - **Berillium** - **Cadmium** - **Chromium** -- *[all used in]* **Battery** **Manufacturing**. - **Polonium 210 and Lead 210** -- *[build]* up in the **Lungs** and **Stick** to the **TAR** **Coating** the **Bronchioles** - **Polycyclic aromatic hydrocarbons** -- **Genotoxic** *[causes]* **Cell Mutations** **[SMOKING AND DENTAL HEALTH]** - **Bad** **Breath** - *[Increased]* **Risk** of **Periodontal Disease** - *[Increased]* **Plaque** - **Discolouration** of **Teeth** - *[Delayed]* **Healing** **Post** **Dental** **Procedures** - **Oral Cancers** **[5 A'S]** **Ask** --- **Systematically** **Identify** all **Tobacco** *[users at every]* *[visit]* **Advise** --- *[Strongly]* urge all **Tobacco** *[users]* to **quit**\ **Assess** --- **Determine** **Willingness** to make a **quit** **attempt**\ **Assist** --- *[Aid]* the **Patient** in *[quitting]* (provide counseling and medication)\ **Arrange** --- *[Ensure]* **followup** **contact** **[PASSIVE SMOKING]** **Major Studies** *[have shown that]* Passive Smoking is a cause of: - **Lung** **Cancer** - **Heart** **Disease** - **Respiratory** **Disease** in **childhood** - **Cot death** - **Middle ear disease** - **Asthma** **[Smoking Cessation -- NICE guidance]** Key Components - **5 A's** -*[ask]* *[about]* **Smoking** in *[all admissions]* at **First Available Opportunity** - **Advise** of **Smoking Ban** in **Hospital Environments** - **NRT** on first contact **[NICE guidance]** **People** *[who are]* **Unwilling** or **Not Ready To Stop** - *[offered]* a **Harm‑Reduction** **Approach** - *[Are advised]* *[about]* **using** **Nicotine‑Containing Products** and *[supported]* to *[obtain]* **licensed nicotine‑containing products.** - *[Suggest]* which **approaches** to *[stopping]* **Smoking** *[might b]*e Most Suitable **[Smoking Cessation -- NICE guidance]** - In **Smokers** *[who do not want]* to **quit** - *[Offering]* use of **Nicotine Replacement** patients **2x More Likely To Quit In Future** - *[May help]* with **Nicotine** **Withdrawal** in hospital - *[Does]* the **Hospital Ban Work**? **[Smoking Cessation - treatment]** - **E Cigarettes** *[containing]* **Nicotine** **[Medication]** - **Varenicline** - **Cytisine** - **Combined** **NRT** - In patients - **Bedside Counseling** ASAP with **Behavioral Support** - *[Advise]* all **Staff** *[who]* **Smoke** to **stop**. *[Ensure]* **systems** are in *[place for]* **Staff** who **Smoke** to *[receive]* **Advice** and **guidance** on *[how to stop]* - Continued support into the community **[PHE -- Independent expert review Aug 2015]** - *[Current]* **Best Estimate** is that **E-Cigarettes** are around **95% Less Harmful Than Smoking** - *[Nearly]* **Half The Population** (44.8%) don't *[realize]* **E-Cigarettes** are ***[much less harmful]*** than **smoking** - There is **No Evidence** so far that **E-Cigarettes** are *[acting]* as a **Route** *[into]* **Smoking** for **Children** or **Non-Smokers** **[BTS 2016]** - *[No]* **Serious Adverse Events** in **RCT** and **Prospective Studies** - *[No standard]* **e cig** - *[No]* **Long Term Effect** studies - 34% studies had conflict of interest! **Diacetyl** (sweetener, previously used in popcorn) in 75% - **Popcorn Lung** (OB)in exposed workers **[E CIGARETTES]** **2015** - 2.6 million adults **2024** - 5.6 million adults **53%** were former smokers **[Cochrane review Nov 22]** - 78 studies, over 22,000 people - More likely to stop smoking at least 6/12 cf NRT - 8-12/100 might stop cf 6/100\ **2023** -- estimated that 15% of 11--15-year-olds vaping 17 year old **24th FEB 2020** **[17 Year Old 24th Feb 2020]** - **Catered** at a **Chinese Wedding** *[one week before]* - Viral **URTI** **symptoms** - **Acute type 1 resp failure (LOW OXYGEN Levels in his blood)** **[TRANSFERRED TO WYTHENSHAWE 5 DAYS LATER ]** - *[3 months later]* **Repatriated** to **Local Hospital** - **Critical Myoneuropathy** - **Prednisolone** and **Ursodeoxycholic** **Acid** for *[secondary]* **Sclerosing Cholangitis** - **Morphine**, **Diazepam**, **Clonidine** - **EVALI** (e-cigarette or vaping product use associated lung injury) - **OP physio** and **OT**, **Zimmer** **Frame** **[EVALI]** *[Frist]* **Recognised Summer** 2019 **2/3 male** **Acute** **Lung** **Injury** **Mechanical** **Ventilation** in about **25%** in one series **ECMO** **Rare** **2.4% mortality** in **2800** **Patients** admitted **[CXR June 2020]** **[RESPIRATORY HISTORY ]** **[Symptoms]** - **Variability** - **Exacerbation** **rate** - **Functional Status** **[SH]** - **SMOKING** - **OCCUPATIONAL -- Asbestos** *[working in]* **Construction** - **ACCOMMODATION** and *[those who share]* it **[IMPORTANT ASPECTS OF EXAMINATION]** **[General Appearance]** - **Communication --** Can they get out a sentence - **Breathing** **pattern -- Neck** and **Belly** *[getting]* **involved** - **BMI** **Standard observations** - **RR** - **O2 sat** - **HR** - **BP** **[Gas Exchange] -** *[How]* **o2** [from] the **Mouth** *[getting to the]* **Organs** of the **Body** **['NORMAL LUNG']** White bits are blood vessels **[EMPHYSEMA]** Vessels and alveoli are damaged or gone [ **BRONCHIECTASIS**] Too Big Airways [**PULMONARY FIBROSIS-** *Looks lik*]e **Honeycombing** *[lots]* of **Scaring [ ]** **[PULMONARY EMBOLUS] -- normal CTPA**  **[PULMONARY EMBOLUS]** **Blood Clots** *[causing]* **Low Oxygen** and **Restricting** **Blood Flow** **[Respiratory failure -- PO2 \< 8Kpa on air]** **Type 1** - Normal CO2 **Type 2** - CO2 \> 6 Kpa (cant get rid of the CO2 in the body) **[DIFFERENTIAL DIAGNOSIS]** **[TYPE 1]** **[ACUTE]** - **Pneumonia** **Covid 19 - PE** - **Asthma** - **ALI/ARDS** (**Acute Injury** to the **Lung** *[like the]* **Big Vaper**) - **Pulmonary oedema** - **Chest trauma** **[CHRONIC]** - **Pulmonary** **Fibrosis** - **Emphysema** - **Pulmonary** **Hypertension** **[TYPE 2]** -- *[important]* to be **aware** *[maybe]* **Sensitive** to **Oxygen** - **COPD** - **Asthma** - **Bronchiectasis** - **Decompensated Obstructive sleep apnoea**/**Obesity** **Hypoventilation** (OSA/OHS) - **Pulmonary Oedema** - **Neuromuscular** - **Thoracic Cage** **Abnormalities** - **Drugs -- Morphine** and **Heroin** OD Because some of these individuals who have **Breathing Issues** are so *[used to having]* **High Levels** of **Co2**, it can actually be dangerous to give them **High Doses** of **Oxygen** *[as their]* **Brain** *[can sometimes shut off.]* Don't get **O2** **Saturation** above **96%** whoever they may be. [ ] **[FLOW VOLUME LOOPS]** 70% is *[considered]* **Airway Obstruction** -- Harder to get rid of the CO2 in the body **[ASTHMA]** **Definition** - *[No]* **Gold Standard** *[but must have]* **Symptoms** and **Variable Airflow Obstruction** - *[Related]* to **airway inflammation** **Initial diagnosis based on;** - *[Careful]* **Assessment** of **Symptoms** - *[Measuring]* **Airflow Obstruction** **COPD** -- an **Umbrella Term** covering the "**IRREVERSIBLE**" aspect of **CHRONIC BRONCHITIS**, **EMPHYSEMA** and **ASTHMA** **[NICE recommendations: Diagnosis ]** *[Consider]* a *[Diagnosis]* of **COPD** in: - *[Patients]* over **35** - *[Who are]* **Smokers** or **EX-SMOKERS** - *[With]* **symptoms** - **Exertional Breathlessness** - **Chronic Cough** - *[Regular]* **Sputum Production** - **Frequent Winter** '**Bronchitis'** - **Wheeze** And *[no]* **Clinical Features** of **ASTHMA** **[COPD severity -- FEV1 post bronchodilator]** - **Mild ≥** 80% (must be symptomatic) - **Moderate** 50-79% pred - **Severe** 30-49% pred - **Very Severe** \