Fishman Pulmonary Diseases Pdf

[Akinlolu Watters]

Firstpublished in 1980, Fishman's Pulmonary Diseases & Disorders is the classic reference through which pulmonary physicians have gained a commanding look at the diagnosis and treatment of pulmonary diseases and disorders. Edited by the world's foremost authorities, Fishman's Pulmonary Diseases & Disorders covers exactly what you need to know about lung diseases and their management, including sleep-disordered breathing, COPD, emphysema, and lung cancer, as well as new technological advances and imaging techniques.

This unparalleled two-volume resource begins with a compelling overview of up-to-date clinical perspectives, along with the scientific basis of lung function health and disease. It then provides turnkey information on everything from respiratory disease signs and symptoms, to obstructive lung diseases, occupational and environmental disorders, and specific respiratory conditions such as infections diseases of the lungs and acute respiratory failure.

The respiratory tract is a primary interface of our bodies with the outside world. It comes into contact with 14 000 litres of air during a 40 hour working week and physical activity can increase ventilation 12-fold.1 The quality of the air we breathe therefore has major implications for the health of the respiratory tract. Although approximately 25% of our time is spent in the workplace, this environment is more likely to be the cause of exposure-related respiratory problems because, generally, air quality will be poorer at work than in the domestic environment.2

Air contaminants may be dusts, gases, vapours or fumes. Any part of the respiratory tract can be adversely affected by poor air quality, from the nose to the alveoli. The site affected within the respiratory tract depends on the integrity of defense mechanisms and the properties of the air contaminants (Figure 1). Other determinants include individual susceptibility and the intensity and duration of the exposure.

Inhalation of a strong irritant, such as that caused by an industrial accident, may injure the respiratory tract causing acute symptoms of shortness of breath, cough and chest tightness, potentially requiring emergency medical care. The extent of injury will depend on the type and dose of exposure and may lead to prolonged symptoms due to the development of irritant induced lung disease.2 Usually there will be a clear history of high level exposure at the time of onset of symptoms.

Exposures that typically affect the upper respiratory tract tend to be large particle dusts (>10 m in diameter) and highly water soluble gases such as ammonia and chlorine.1 Exposure of the upper respiratory tract to airborne irritants will cause nonspecific symptoms such as cough, nasal irritation and congestion. These unpleasant symptoms will encourage individuals to remove themselves from the exposure thereby providing protection.

Rhinitis may be allergic or nonallergic.4 Symptoms include sneezing, rhinorrhoea, nasal obstruction and itching of the nose, eyes and palate. If symptoms are due to an allergic mechanism (IgE mediated) there is generally a temporal association with exposure to the allergen. Sneezing occurs immediately, such as when emptying a vacuum cleaner bag or on entering a room with a cat, then nasal discharge followed by nasal obstruction over a few hours. Domestic exposures associated with perennial allergic rhinitis include house dust mite and pets. Occupational allergic rhinitis is defined as rhinitis directly attributable to a specific substance encountered in the work environment caused by IgE mediated sensitisation.5 Occupational exposures associated with allergic rhinitis include animal allergens (research laboratory workers, veterinarians), grain and flour dust (bakers, flour mill workers) and plant allergens (gardeners, farmers).

There is a clear association between occupational allergic rhinitis and asthma, therefore all workers with work related rhinitis should be assessed for the presence of asthma.6 The diagnosis of occupational allergic rhinitis should be considered a sentinel workplace health event and alert the employer that further control is required.5

Irritant rhinitis may be difficult to clinically differentiate from allergic rhinitis. In the office environment irritants may be in the form of volatile organic compounds from new paint, office furniture and cleaning products or emitted from malfunctioning appliances such as photocopiers. In the industrial setting, irritant exposures are likely to be more obvious such as welding fumes or wood dust.

Dysfunctional behaviour of the larynx is an important and underappreciated cause of recurrent respiratory symptoms and may be triggered by exposure to respiratory irritants and strong odours, such as perfumes. Unfortunately, there is a lack of consensus regarding the terminology and diagnostic features of this condition. Vocal cord dysfunction (VCD) is probably the most well known form of nonorganic laryngeal dysfunction, especially to respiratory physicians. Often VCD may masquerade with symptoms suggestive of asthma; it may also co-exist with asthma. Symptoms are due to inappropriate vocal cord motion causing partial airway obstruction, especially during inspiration.7 Typical symptoms of VCD are recurrent episodes of dyspnoea, sensation of inspiratory limitation, throat tightness and cough. Frequently, episodes have a rapid onset and resolution.8 Work-associated irritable larynx syndrome describes recurrent laryngeal symptoms associated with a specific workplace trigger.8

Occupational asthma is the development of new onset asthma (or the recurrence of asthma) due to an exposure specific to a workplace.9 Occupational asthma is the most common occupational lung disease in developed countries. It is estimated that 15% of all adult onset asthma is due to workplace factors; contributing substantially to the burden of asthma in the general community.10

Hypersensitivity pneumonitis (HP, or extrinsic allergic alveolitis) is a complex syndrome caused by an immunological reaction to an inhaled agent.2 Acute HP may present with fevers, chills, malaise, cough and shortness of breath; mimicking an infective process. Symptoms of acute HP generally subside within hours or a few days of removal from the exposure. Chronic HP may present with features of pulmonary fibrosis such as dyspnoea. Identification of this condition requires a high level of suspicion and a careful exposure history. Some industries and exposure associated with HP include:4

Workplace and environmental exposures may exacerbate pre-existing respiratory disease. Asthma is a common condition that is influenced by environmental exposures. It has been estimated that work exposures worsen asthma control in 21% of adults with asthma.12 Factors include irritants, exercise, cold or dry environments and emotional stress. The identification and management of these factors will assist in achieving asthma control. All patients with asthma should be questioned regarding symptom triggers and their domestic and work environments.

To identify whether a respiratory problem may be due to an exposure, clinicians need to have a high index of suspicion and take an occupational and environmental history (Table 2, 3). If a patient presents with new onset respiratory symptoms it is useful to ask about recent changes in their environment, such as whether they have a new pet at home or if they have commenced a new job. It is also useful to ask whether symptoms improve when away from an exposure. Symptoms of recent onset occupational asthma may improve over a weekend but are more likely to improve over a week or when on holidays. Longstanding or severe occupational asthma may not improve until many months after removal of the cause, if at all.

Investigation of patients with respiratory problems should include spirometry and a chest X-ray, which is available to most general practitioners. These preliminary tests will not rule out many conditions and more specialised investigations such as bronchial provocation testing or a chest computed tomography (CT) scan may be necessary. Referral to a respiratory physician will assist in the performance of appropriate further investigations and establishing a diagnosis. If the condition is work related, then involvement of a respiratory or occupational physician is needed to consider factors such as the effect of the causative exposure on other workers, how to control the exposure at the workplace and appropriate use of personal protective equipment. The role of pre-employment screening is controversial and therefore an experienced clinician should supervise these assessments.

Nearly all respiratory diseases can be caused or exacerbated by environmental exposures. The identification and control of relevant exposures has the potential to improve clinical outcomes and protect others from the development of respiratory disease. Clinicians should regularly take an occupational and environmental history to identify possible exposures associated with breathing problems.

A $3 million gift from University of Pennsylvania alumnus Jay Fishman, and his wife, Randy, will support comprehensive at-home respiratory care for adult Penn Medicine patients with chronic respiratory insufficiency due to neurological, muscular, skeletal or chronic respiratory diseases, including amyotrophic lateral sclerosis (ALS), a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord.

Penn Medicine is partnering with The ALS Association to have the program recognized as an ALS Association-approved program in pulmonary care. Such a designation would be a first for a specific medical practice within the broad ALS clinical arena. The intent of the program is to deliver the benefits of rapidly emerging new technologies and related data to physicians caring for patients whose breathing is compromised.

Working in close collaboration with neurologists who staff the Penn Comprehensive ALS Center and the Penn Muscular Dystrophy Association Clinic, the physicians who lead the Home Assisted Ventilation Program will coordinate the efforts of a wide array of multidisciplinary specialists, including respiratory therapy, speech therapy, gastrointestinal medicine and surgery, nutrition, physical therapy and rehabilitation medicine. The Fishman Program will also focus on medical education, providing a one-year advanced fellowship training program in the care of adults who need home-assisted ventilation.

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