Asthma symptoms include coughing, wheezing, a tight feeling in the chest and trouble breathing. Asthma occurs when the main breathing tubes of your lungs are over-sensitive and react to things that don’t affect other people. As a result of this they become swollen and narrow.

If your asthma is not getting better with standard treatment (preventer and reliever inhalers) or if you are having more asthma attacks than you or your doctor are comfortable with, you may be referred to a specialist.

In most cases you’ll be asked to give a complete medical history and will also be examined by the doctor. Sometimes other conditions can appear like asthma or complicate asthma, so you may be asked to have some tests to help in the diagnosis.

Tests looking for severity and complicating features of asthma include: chest X-ray, spirometry and CT chest.

Treatment

This includes taking medicines as well as changing some lifestyle factors. A peak flow meter can be used to keep a watch on your asthma and help with plans to prevent attacks. Stopping smoking is very important as is learning to recognise what brings an asthma attack on.

Asthma is treated with inhaled medicines. There are two types:

1. a preventer medicine is taken every day. It soothes the irritated breathing tubes and prevents worsening of asthma, “asthma attacks”.
2. a reliever treats the asthma attacks. It relaxes the tightened muscles around the breathing tubes.

For more information on asthma see Asthma New Zealand website.

This term is used to describe lung disease where the breathing tubes become blocked and the surrounding tissue and air sacs inside the lungs become damaged. COPD includes conditions such as emphysema, chronic bronchitis and chronic asthma. COPD is a long term and sometimes fatal disease that can be managed and slowed down. Smoking is the main cause of emphysema and chronic bronchitis.

Chronic bronchitis is an inflammation of the main breathing tubes (bronchi) in the lungs, which results in the production of excess mucous (phlegm) and a reduction in the amount of airflow in and out of the lungs. In the early stages of chronic bronchitis, a cough usually occurs in the morning. As the disease progresses, coughing persists throughout the day. There is often associated shortness of breath and an increased rate of chest infections.

Emphysema is the gradual destruction of the air sacs (alveoli) in the lungs. The alveoli are unable to completely relax. As they become larger they are not as good at transporting oxygen to the blood. Emphysema cannot be cured, but can be managed through medication and lifestyle changes.

Investigations

You may have some of the following tests before or after your clinic appointment:

• chest X-ray
• spirometry
• lung function tests
• CT chest

The specialist will decide if you need any of these tests, depending on your symptoms and examination findings.

Treatment

There are ways to manage COPD. The first and most important is to stop smoking if this applies to you. There are exercises and dietary changes that can help maintain and improve fitness. Medications include inhalers, although they are not used for everyone. If you have COPD it is a good idea to have the flu vaccination every year.

For more information on COPD Australian Lung Foundation

This is when abnormal malignant cells divide and grow in an uncontrolled fashion in the lung tissue. The effect of this is to destroy normal lung tissue and block off the breathing tubes. There are several types of lung cancer. The most common cause is cigarette smoke; however exposure to asbestos, marijuana smoke and a number of other chemicals can also increase your risk of developing cancer.

Common signs and symptoms

• a cough that gets worse with time
• coughing up blood
• chest pain
• loss of appetite and weight
• tiredness
• repeated doses of, or not improving, bronchitis or pneumonia.

Diagnosis

To diagnose lung cancer your doctor will look at your medical and smoking history. You will also have a physical examination. This is usually followed by a number of tests. The aim of the tests is to confirm the diagnosis and find out what type of cancer it is which usually involves obtaining some cells to look at under the microscope. Test you are likely to have include:

• chest X-ray. This is the first test that may raise the question of a lung cancer. It is usually followed by other tests to confirm the diagnosis
• CT scans with or without fine needle aspirate
• bronchoscopy

Treatment

Once lung cancer is diagnosed, a process known as staging determines the extent of the disease. Knowing the type and stage of cancer means the doctor can plan your treatment.

Different treatment options include:

• surgery. The type of surgery depends on the size and type of cancer
• radiotherapy is a form of high energy radiation (X-ray) that kills cancer cells
• chemotherapy is the use of drugs aimed at killing cancer cells.

The aim of treatment is to keep the person as well as possible even if the cancer cannot be cured.

If you have a lung cancer there will be ongoing follow up with specialists and nurses throughout treatment and afterwards.

For more information about lung cancer see Cancer Society NZ - Lung cancer; Australian Lung Foundation

Bronchiectasis comes from the Greek words Bronckos (airway) and ektasis (widening). Damage to the airways in bronchiectasis causes them to become damaged and enlarged. Mucous or sputum is not cleared easily from the lungs allowing infection to occur which then leads to further damage to the airways.

In bronchiectasis the damage can be widespread affecting both lungs, or localised to a single focal area. Symptoms vary considerably with a good number of patients feeling well most of the time. Symptoms include cough, bad breath and coughing up blood (this may indicate infection).

Causes of bronchiectasis:

• Viral infections in childhood such as measles and whooping cough
• Pneumonia or severe viral infections in adulthood
• Inhalation of foreign bodies into the breathing tubes
• Aspiration of the stomach contents occurring with reflux (heartburn)
• People can be born with this condition
• Often no recognisable cause is found

Chronic cough is a common and distressing symptom which is defined as a cough lasting more than 8 weeks.  It is surprisingly common.

Cough is a defensive reflex with elements of voluntary control which, if persistent, may signal a problem in the respiratory system.

At the initial assessment for cough we need to elicit any alarm symptoms that may indicate a serious underlying cause and identify  whether there is a specific disease present that is associated with chronic cough.  Non specific cough suppressant therapy offers little benefit in managing persistent cough.

Alarm symptoms include:

• Coughing blood
• Smoking history
• Hoarseness
• Recurrent infection
• Abnormal CXR

 A comprehensive history, examination and appropriate investigations will identify the cause in 95% of people.

A chest X-ray is normally undertaken to check the chest wall, lungs and heart. A chest X-ray is often the first test used to determine the reason for shortness of breath, persistent cough, chest pain or injury. Although you may think of an X-ray as a picture of bones, a trained observer can also see air spaces, like the lungs (which look black) and fluid (which looks white).

Women should always advise their doctor if they are or think they may be pregnant before an X-ray is undertaken. When having a chest X-ray you are exposed to a very small amount of radiation.

What to expect?

You will have all metal objects removed from your body. You will be asked to remain still in a specific position and hold your breath on command. There are staff present, but they will not necessarily remain in the room, but will speak with you via an intercom system and will be viewing the procedure constantly through a windowed control room.

With CT you can see much more detail than with a normal X-ray. Using an X-ray beam, which is sent through the body from different angles, creates a CT image and by using a complicated mathematical process a computer is able to produce an image. This allows cross-sectional images of the body without cutting it open. The CT is used to view all body structures but especially soft tissue such as body organs (heart, lungs, liver etc.).

What to expect?

You will have all metal objects removed from your body. You will lie down on a narrow padded moveable table that will be slid into the scanner, through a circular opening.

You will feel nothing while the scan is in progress, but some people can feel slightly claustrophobic or closed in, whilst inside the scanner. You will be asked to remain still and hold your breath on command. There are staff present, but they will not necessarily remain in the room, but will speak with you via an intercom system and will be viewing the procedure constantly through a windowed control room, from where they will run the scanner.

Some procedures will require Contrast medium. Contrast medium is a substance that makes the image of the CT clearer. Contrast medium can be given by mouth, or by injection into the bloodstream.

The scan time will vary depending on the type of examination required, but as a rule it will take around 30 minutes.

Depending on what is seen on the CT scan an additional test can be done where a fine needle is inserted into your chest into the cancer and some cells sucked up into the needle. This is done while taking pictures with the CT scanner to guide the doctor as to where to place the needle. Local anaesthetic is put into your skin and muscles so that the test is not overly painful. A specialist doctor does this.

A tiny camera attached to a long tube is inserted through your nose or mouth and passed down through the airways into your lungs. This allows the surgeon to make a diagnosis either by seeing directly what is causing the problem or by taking a small tissue (biopsy) or lung secretion sample.

Service types: Lung function tests (Spirometry | Peak flow meter).

You may be required to undergo lung function tests to find out how much air moves in and out of the lungs as you breathe.

These include:

1. peak flow meters
2. spirometry
3. detailed lung function test
4. exercise tests
5. bronchial provocation tests

Sometimes lung function tests are done before and after taking a medication known as a bronchodilator (reliever medication such as Ventolin) to open your airways.

1. Peak flow meter

This is a small hand-held tube that can measure what is happening in your breathing tubes. People often have one at home and you can measure your peak flow by blowing into it as hard and fast as possible. Comparisons in recordings are often used as part of an asthma management plan.

2. Spirometry

Spirometry is an inexpensive test which measures the speed at which your lungs can be filled and emptied with air. This in turn can be used to diagnose your breathing problems and also to monitor the effectiveness of your treatment.

I will perform this for you at your initial consultation.

3. Detailed lung function tests

These are performed by the lung function laboratory. These include spirometric volumes, total lung volumes and the ability of oxygen to diffuse into the blood through the walls of the small air sacs (alveoli) in the lungs. This can be low in patients with emphysema, lung fibrosis and pulmonary hypertension.

4. Exercise tests

These are also performed by the lung function laboratory. Patients may be exercised on a bicycle or a treadmill and are performed when extra information is required.

5. Bronchial provocation tests

These are tests for asthma. There are several different types used to help decide if a patient has asthma.

This is a test performed on your breath whilst breathing out,  If these levels are high (>30ppb) this may mean that you have asthma.  If these levels are elevated whilst you are taking inhaled steroids this may suggest that control of your asthma is not optimal.

This is a method of extracting cells from your breathing tract. Hypertonic (very salty) water is nebulised for about 5 minutes which usually causes individuals to cough and to produce some mucus from their lower airways.

We can use these specimens to test for unusual infections (e.g. pulmonary tuberculosis) or to find out what inflammatory cells are present. A finding of >3% eosinophils suggests  asthma whereas greater than 60% neutrophils is likely to indicate bacterial infection.

This test can be very helpful in determining the nature of your chronic cough or your recurrent episodes of bronchitis or asthma.

This is similar to a blood test but instead of a needle going into a vein it is inserted briefly into a small artery in your wrist. A small amount of blood is taken and sent to the laboratory for information about the oxygenation of your blood and other gases.

Blood gas measurements may also be used if you have known respiratory, metabolic or kidney disease, especially if you have severe difficulty breathing. Many conditions can cause a blood gas imbalance and while the blood gas tests do not identify the exact cause of the imbalance they will point to either a respiratory or metabolic problem.

It is also used to assess the requirement for home oxygen in patients with very severe emphysema