Chapter 11
Chest medicine
HOW TO . . . Treat influenza-like illness in older people
HOW TO . . . Manage the patient with pneumonia who fails to respond to treatment
Vaccinating against pneumonia and influenza
Aspiration pneumonia/pneumonitis
Asthma and COPD: drug treatment
HOW TO . . . Improve drug delivery in asthma or COPD
The ageing lung
Most of the functional impairment of the lungs that is seen in older people is due to disease, often smoking-related. Intrinsic ageing leads only to mild functional deterioration. The respiratory system has a capacity well in excess of that required for normal activity, so intrinsic ageing:
• Does not lead to symptoms in the non-smoker without respiratory disease, although reduced physical activity can lead to a reduction in physical fitness
• In those with respiratory disease (e.g. emphysema) will cause progressively worsening symptoms with age, even if the disease itself remains stable
• In acute disease, e.g. pneumonia, may cause earlier decompensation or a more severe presentation
Specific respiratory changes
Seen in healthy older people are similar to those seen in mild chronic obstructive pulmonary disease and include:
• ↓ elastic recoil causing small airways to collapse at low lung volumes and ↑ residual volume
• ↑ chest wall stiffness, due to:
• Degenerative change in intercostal, intervertebral, and costovertebral joints
• Osteoporosis and kyphoscoliosis
• Weaker respiratory muscles that may have lower endurance
• Reduced gas exchange and ↑ ventilation–perfusion (V/Q) mismatch, due to collapse of peripheral airways while perfusion remains intact
• Impaired chemoreceptor function, leading to lessened ventilatory response to ↓ PaO2 or ↑ PaCO2
• Impaired microbial defence mechanisms. Less effective mucociliary clearance and less sensitive cough reflex
Observed consequences of these changes
These include:
• ↑ susceptibility to infection (underventilation of, and inability to clear sputum from, dependent lung zones)
• Lower maximum minute ventilation (weaker musculature acting against a stiffer chest)
• An approximately linear fall in PaO2 with age (~0.3%/year). Since alveolar oxygen tension remains stable, the alveolar–arterial (A–a) oxygen gradient rises
• Reduced exercise capacity. However, oxygen consumption and cardiac output decline in proportion to lung function, so the lungs are rarely the limiting factor in exercise performance
Breathlessness in older people is often multifactorial
• Chronic breathlessness in an individual may be the result of, e.g. ↓ fitness, obesity, an inefficient gait (osteoarthritis or stroke), kyphosis, previous lung damage (e.g. apical fibrosis due to tuberculosis (TB)), and intrinsic ageing. In this example, note that only one of the factors is specific to the lung
• In the acutely breathless patient, pathologies commonly coexist, e.g. infection, fast AF, and heart failure. The classic treatment triad of digoxin, furosemide, and amoxicillin is not a sign of diagnostic indecision but is often entirely appropriate treatment
Respiratory infections
Cough with or without sputum, shortness of breath, fever, or chest pain are a very common presentation in older patients. It is very important to try to distinguish which part of the airway is primarily affected because this implies completely different pathogens, prognoses, and treatment strategies. Try to avoid aggregating all such patients together using the imprecise term ‘chest infection’.
Upper respiratory tract infections
These are caused by viruses, e.g. rhinovirus, respiratory syncytial virus, influenza, and parainfluenza. Symptoms include nasal discharge and congestion, fever, and sore throat. These may extend to the lower tract and then include cough, wheeze, sputum production, or worsening of existing cardiopulmonary disease.
With ↑ age:
• Upper respiratory tract infection becomes less frequent, but more severe
• The risk of complications ↑. These include:
• Lower tract infection such as bronchitis or pneumonia, which may be bacterial or viral
• Extrapulmonary manifestations such as falls, immobility, and delirium
• Post-infection weakness, fatigue, and anorexia are more severe and prolonged, maybe lasting several weeks
• Frequency of hospital admission and death ↑ substantially
Acute bronchitis
Occurs with inflammation of the bronchial tree, with little or no involvement of lung parenchyma (which is pneumonia). Is more common in those with chronic airways disease (see 
‘Asthma and COPD: assessment’, pp. 340–341).
Compared with pneumonia, bronchitis:
• Has fewer systemic features and a better prognosis
• Has no chest symptoms and signs, e.g. pleuritic pain or crepitations, but may have prominent cough and wheeze
• Can be managed less aggressively, with more reliance on supportive treatment and bronchodilators than antibiotics. Often viral in origin; if an antibacterial is thought appropriate, give amoxicillin to cover Streptococcus pneumoniae (erythromycin or clarithromycin if penicillin-sensitive)
Influenza
This is the most serious viral respiratory tract infection in older patients and is often a severe, systemic illness with pulmonary bacterial superinfection (Staphylococcus aureus, Haemophilus influenzae, S. pneumoniae). It occurs most commonly in December–February. Antigenic shifts result in periodic pandemics.
Presentation is similar in young and old, i.e. rapid onset of fever (rigors, chills), myalgia, headache, and fatigue, with variable degrees of prostration. Compared with less threatening viruses such as rhinovirus:
• Nausea, vomiting, diarrhoea, high fever, rigors, and ocular symptoms (e.g. photophobia) are more common
Less common serious complications include myocarditis and meningoencephalitis. Mild meningism is common and, if combined with other sinister features (e.g. altered conscious level), is an indication for CSF sampling.
Diagnosis is usually based on combining clinical assessment with epidemiological data, particularly current influenza incidence. Some other viruses can cause an identical clinical syndrome, and serological test results are not immediately available. Thus, an initial assessment cannot produce an absolutely confident microbiological diagnosis. The syndrome may therefore most precisely be labelled ‘influenza-like illness’.
Positive virological diagnosis in the context of ↑ community incidence or a care home outbreak is helpful by prompting vigorous attempts to reduce transmission of infection.
Reducing viral transmission
All >65yr olds in the UK are offered yearly influenza immunization. Mass outbreaks of respiratory viral infection are common in care homes and hospitals. They can occur at any time of the year but are most common from autumn to spring. Viruses are spread by aerosol or hand-to-hand contact (sometimes indirect, via fomites such as cutlery or drinking vessels).
During an outbreak
• Reduce transfers of healthy patients into, or symptomatic patients out of, the affected area
• Reduce staff movement across work areas (especially applicable to short-term staff who may work in many clinical areas in a short time)
• Care for symptomatic patients in single rooms, or in ward bays with similarly infected patients
• Exclude visitors with respiratory or viral symptoms from the ward
• Ensure that care staff have been immunized against influenza
• Ensure that scrupulous hand-washing procedures are followed
• Consider using face masks for staff caring for symptomatic patients
HOW TO . . . Treat influenza-like illness in older people
The following guidance is generic and should be tailored to the patient, their illness, and their care environment. If the highest-quality care cannot be provided, then a prompt step-up of care should be arranged. This may include hospital admission.
• Do not underestimate the disease. Mortality and morbidity ↑ exponentially with age and frailty
• Give excellent supportive and symptomatic care. Its effectiveness should not be underestimated
• Fluids. Reduced intake and ↑ losses (fever) lead to volume depletion and end-organ dysfunction. Encourage frequent oral fluid, and suspend any diuretic treatment. Consider early initiation of s/c or iv fluids if a vicious spiral of dehydration and poor intake seems likely to ensue
• Nutrition. Encourage high-calorie, high-protein drinks or solids. If the illness is especially severe, prolonged, or complicated, or if the patient is especially frail or malnourished, consider a period of NG feeding. Involve a dietician early
• Paracetamol. If fever, discomfort, or pain occur
• Maintain mobility. Bed rest may sentence the patient to death or dependency. Carers may need clear, firm advice about this
• Identify and treat complications promptly
• Carers may need information about important warning signs and the need to seek prompt medical advice
• Perform regular observations of BP, pulse, and temperature where possible
• Common serious complications include delirium, 2° bacterial infection, bronchospasm, pressure sores, and circulatory collapse
• Antiviral agents (the neuraminidase inhibitors zanamivir and oseltamivir) may reduce both the severity and duration of influenza
• They are indicated in patients with severe symptoms if they are pregnant, >65 years, or with certain comorbidities (especially if hospitalized)
Further reading
National Institute for Health and Care Excellence (2009). Amantadine, oseltamivir and zanamivir for the treatment of influenza. Technology appraisal guidance TA168. 
http://www.nice.org.uk/ta168.
Pneumonia
Pneumonia
• This is a syndrome of acute respiratory infection with shadowing on CXR
• May be lobar, bronchial, or mixed pattern
• Symptoms may be mild and are often non-organ-specific, e.g. fever, malaise
• Common presenting scenarios include cough (often unproductive), delirium, reduced conscious level, lethargy, anorexia, falls, immobility, and dizziness. Rarely patients can present with shock, coma, and adult respiratory distress syndrome (ARDS)
• Chest pain, dyspnoea, and high fever are less common than in younger people. Signs may be minimal:
• The patient may be well or unwell. Assess severity using the CURB criteria (see ‘Characteristics of severe pneumonia: the CURB-65 score’, p. 322)
• Fever is often absent, but vasodilatation is common
• Tachypnoea is a sensitive sign, as is at least moderate hypoxaemia (≤95% on air) on oximetry
• Tests often guide management:
• Chest radiograph may reveal only minimal infective infiltrate. Also look for malignancy, effusion, or heart failure
• Blood cultures should be sent, but sputum culture is rarely useful, unless TB is suspected
• White cell count may be raised, normal, or even depressed
• CRP is often normal early in the illness
• U, C+E guide fluid management. Kidney impairment is a sign of poor prognosis
• Arterial blood gas (ABG) sampling is not usually necessary, unless oxygen saturations are <90%; oximetry is much better tolerated and usually sufficient to guide oxygen therapy
• Organisms vary depending on the clinical setting in which pneumonia occurs (see Table 11.1)
• Often no causative organism is identified
• Pneumococcus is common in all settings, including hospital
• Viral pneumonia, especially influenza, is under-recognized and is the second most common cause of community-acquired pneumonia
• Legionella and Mycoplasma pneumonias are uncommon. Mycoplasma is much more frequent during epidemics, occurring every 3 years or so
• Unusual organisms are more common in frail patients, in higher-dependency environments, and in those who have recently received courses of antibiotics. Organisms include Gram negatives (which colonize the oropharynx) and anaerobes (a result of aspiration of gut contents). MRSA pneumonia can occur in hospital or community. Health care-associated pneumonias can occur after discharge
Table 11.1 Pneumonia pathogens in various care settings (in approximate order of frequency)
| Community-acquired | Care home-acquired | Hospital-acquired |
| S. pneumoniae (>30% of cases) | S. pneumoniae (>30% of cases) | Gram-negative aerobic bacilli, e.g. Klebsiella, Pseudomonas aeruginosa |
| Viral, e.g. influenza, parainfluenza, respiratory syncytial virus | Viral, e.g. influenza, parainfluenza, respiratory syncytial virus | Anaerobes, e.g. Bacteroides, especially in those at risk of aspiration, e.g. immobility, swallowing difficulty, prolonged recumbency, or impaired conscious level |
| H. influenzae | Gram-negative aerobic bacilli, e.g. Klebsiella, P. aeruginosa | S. aureus (including MRSA) |
| Gram-negative aerobic bacilli, e.g. Klebsiella, P. aeruginosa | H. influenzae | S. pneumoniae and H. influenzae. NB. These may be the most common pathogens—in non-acute settings, e.g. rehabilitation wards—in the well, less frail patient |
| Legionella pneumophila. Mycoplasma pneumoniae if epidemic | Anaerobes, e.g. Bacteroides, Clostridium. Especially in those at risk of aspiration, e.g. immobility, swallowing difficulty, prolonged recumbency, or impaired conscious level | Viral, e.g. influenza, parainfluenza, respiratory syncytial virus |
| Other, e.g. TB | Other, e.g. TB | |
| Following influenza, think of 2° bacterial infection, especially with S. pneumoniae (most common), H. influenzae, or S. aureus | Following influenza, think of 2° bacterial infection, especially with S. pneumoniae (most common), H. influenzae, or S. aureus |
Pneumonia: treatment
Multifactorial treatment should be started promptly. Ideally, antimicrobials should be administered within 1h, alongside the following:
• Assess and optimize fluid volume status; give po, sc, or iv fluid as appropriate. Concurrent heart failure is common, but volume depletion more so
• If there is subjective dyspnoea or moderate/severe hypoxaemia, then supplement oxygen, titrating the inspired oxygen concentration upwards to achieve arterial oxygen saturations of 94–98% (see ‘Oxygen therapy’, pp. 346–347). For lesser degrees of hypoxaemia, it is not necessary to subject patients to claustrophobic, uncomfortable oxygen masks—simply monitoring saturations may be sufficient
• Exercise caution in COPD and other conditions that predispose to carbon dioxide (CO2) retention. Target saturations of 88–92%. Observe the patient closely, both clinically and with serial ABG sampling
• Avoid the use of nasal specs acutely; if ventilatory drive is poor, inspired oxygen concentrations are very uncontrolled
• Encourage mobility. If immobile, sit upright in bed, and sit out in a chair
• Request physiotherapy if there is a poor cough or lobar/lung collapse
• Use saline nebulizers to loosen secretions which are difficult to expectorate, and bronchodilator nebulizers when wheeze suggests associated bronchoconstriction
• Minimize the risk of thromboembolism, unless contraindicated, through prophylactic heparin and early mobilization
• Assess pressure sore risk and act accordingly (see ‘Pressure sores’, pp. 504–505)
• If dyspnoea, anxiety, or pain is very distressing, consider opiates. Side effects include respiratory depression, sedation, and delirium, so begin with small doses and assess effect
• Anticipate possible deterioration, and judge in advance the appropriate levels of intervention. Would renal dialysis, ventilation, and/or cardiopulmonary resuscitation be effective and appropriate? (see ‘Diagnosing dying and estimating when treatment is without hope’, p. 666.)
• Keep the family informed. Where possible, enlist their help, e.g. in encouraging eating and drinking
Characteristics of severe pneumonia: the CURB-65 score
Five key criteria (acronym ‘CURB-65’) determine prognosis and can help guide location of treatment:
• Blood pressure (<90 systolic and/or ≤60mmHg diastolic)
The score has a six-point scale (0–5 adverse prognostic features):
• 0 or 1: low risk of death (0–3%)
• 2: intermediate risk of death (13%)
• 3, 4, or 5: severe pneumonia, with high risk of death (score 3: mortality 17%; score 4: mortality 41%; score 5: mortality 57%)
A five-point scale using only four criteria (CRB-65; urea excluded) can be applied outside hospital and also discriminates effectively between good and poor prognoses (e.g. mortality score 1: 5%; score 3: 33%).
Antimicrobials
Refer to local guidelines, reflecting pathogen sensitivities and drug costs.
Community or care home settings
• Amoxicillin po is usually effective (vs S. pneumoniae and H. influenzae). Erythromycin or clarithromycin if penicillin-allergic
• Add clarithromycin (or erythromycin which has more gastric side effects) if there are features of atypical pneumonia, there is a Mycoplasma epidemic, or the patient may have had influenza
• Co-amoxiclav po has added activity against some Gram-negatives and S. aureus, and may be more effective in the frail patient or where aspiration is likely
• Ciprofloxacin alone should be used rarely—it has Gram-negative activity but is less effective against S. pneumoniae, an important pathogen in most settings. If an antimicrobial is sought that will cover both chest and urinary sepsis, a better choice may be co-amoxiclav or trimethoprim
• iv antibiotics are only necessary if the patient is very unwell (CURB-65 score of 3 or above). Examples include co-administration of co-amoxiclav and clarithromycin. If you suspect MRSA pneumonia, add vancomycin. Convert to oral therapy and change broad- to narrower-spectrum drugs when the patient’s condition improves and/or culture results are known, to minimize complications, e.g. CDAD (see ‘Clostridium difficile-associated diarrhoea’, pp. 614–615). Often, only 48h or less of broad-spectrum iv therapy is needed
Hospital-acquired infection
This presents a difficult dilemma. Hospitalized patients, especially those who are more frail and have spent longer in hospital, are prone to Gram-negative and anaerobic pulmonary infections. However, they are also susceptible to the adverse effects (especially diarrhoea) of broad-spectrum antimicrobials.
A hierarchical approach is sensible, considering likely pathogens and illness severity, guided by local protocols:
• In the less frail patient who remains well, begin amoxicillin alone, co-amoxiclav, or a combination of amoxicillin and a quinolone (all po). Broaden the spectrum only if the patient deteriorates or culture results suggest that the likely pathogen is insensitive
• If a patient is at high risk of Gram-negative infection (frail, dependency, prolonged stay, invasive procedures, aspiration risk), begin with iv piperacillin/tazobactam (or equivalent). Narrow the antimicrobial spectrum when the patient’s condition improves and/or a pathogen is identified
• If the patient has received multiple courses of treatment, seek microbiology advice
• In all cases, take blood cultures, and monitor the patient carefully
HOW TO . . . Manage the patient with pneumonia who fails to respond to treatment
Is the diagnosis correct?
• Consider other chest pathology such as heart failure, PE, pleural effusion, empyema, cancer, or cryptogenic organizing pneumonia. Extrathoracic pathology mimicking pneumonia includes acidosis (tachypnoea) and biliary or pancreatic pathology
• Review the history, examination, and investigations
• Consider admission to hospital and further tests
Is there a complication?
• For example, effusion, empyema, heart failure, silent MI, or PE
Is the antibiotic being taken regularly and in adequate dose?
• Is adherence a problem? Could a friend or relative help prompt tablet-taking, or would a Multiple Dosing System help?
• Syrups may be swallowed more easily than tablets
• If swallowing remains ineffective, or drug absorption in doubt (e.g. vomiting), then consider iv/im therapy
Is the organism resistant?
• Consider a change in antimicrobial, taking into account likely pathogens and their known sensitivities
• Consider atypical infection; send urine for Legionella antigen test, especially if the patient is immunocompromised or if a patient appears disproportionately unwell. Remember MRSA pneumonia, especially in those known to be previously colonized
Could other elements of care be more effective?
• For example, fluid balance, oxygenation, nutrition, posture, and chest PT. Would this be more effectively delivered on ITU/high dependency unit (HDU)?
Is this an end-of-life situation?
• Is treatment to extend life now inappropriate, the failure to respond a sign that the diagnosis is of ‘dying’ (see ‘Diagnosing dying and estimating when treatment is without hope’, p. 666)? If the patient cannot tell you their wishes, determine their likely views by discussing with family and friends, a decision informed by your judgement of where in their life trajectory your patient sits
• In determining prognosis, consider comorbidity—is this an abrupt, potentially reversible illness in an otherwise fit person, or a further lurch downhill for a patient with multiorgan failure? Not for nothing is pneumonia referred to as ‘the old man’s friend’, sometimes bringing to a brisk and welcome end a period of irrevocable decline and suffering
Further reading
British Thoracic Society. Guidelines. https://www.brit-thoracic.org.uk/standards-of-care/guidelines/.
Vaccinating against pneumonia and influenza
Vaccine delivery
• Both vaccines should be offered simultaneously in October or early November to all aged >65 years, especially:
• Those with comorbidity, e.g. heart failure, COPD, diabetes
• Pneumococcal vaccination is given once, whereas influenza vaccination should occur annually
• Reliable delivery of these vaccinations depends upon effective information management systems in GP, and substantial efforts by patients, carers, district nurses, and 1° care nurses
• A common reason to have missed immunization is to have been a long-term inpatient (e.g. undergoing rehabilitation) during the autumn immunization period. Hospitals should ensure that these inpatients are immunized
• Vaccinating health-care workers, especially those working in long-term care settings, reduces the spread of infection, and therefore death due to influenza, among patients
Pneumococcal vaccine
• Pneumococcal polysaccharide vaccine (PPV) is effective against 65% of serotypes
• Immunity remains for at least 5 years, perhaps for life
• Bacteraemia is reduced by at least 50%. The effect on incidence of pneumonia itself is less clear
Influenza vaccine
• The trivalent vaccine is prepared from currently prevalent serotypes
• Immunity develops in <2 weeks, and it is therefore useful during epidemics
• Immunity remains for up to 8 months
• The risk of pneumonia, hospitalization, or death due to influenza is reduced by over half
Post-exposure antiviral prophylaxis
• Pharmacological prophylaxis of influenza is currently recommended when an unimmunized, high-risk group adult (e.g. care home resident) has had close contact with a person with influenza-like illness during a period when flu is prevalent1
• Treatment with neuraminidase inhibitors must be initiated promptly (within 24h)
• Consider why immunization was not performed. Is it too late to administer this year (this contact may not have ‘flu, but the next one might)? If not, then optimize the chances of immunization next year
Pulmonary fibrosis
This common problem is much underdiagnosed in older people due to a combination of under-investigation and overlap of clinical signs with common pathologies such as heart failure.
Consider when breathlessness coexists with profuse fine chest crepitations, with or without clubbing, or is slow to recover from apparently minor respiratory infection. On CXR, there may be bilateral pulmonary shadowing indistinguishable from pulmonary oedema, but with little supporting evidence (e.g. normal heart size, absent Kerley B lines).
Causes
• Idiopathic. The most common type in older people, known as usual interstitial pneumonia
• Connective tissue disease, e.g. rheumatoid arthritis (most common), systemic lupus erythematosus (SLE), sarcoidosis. Lung involvement is sometimes the first manifestation of the multisystem disease
• Drugs, e.g. amiodarone, nitrofurantoin rarely
• Occupational exposure, e.g. asbestos, silica
• If localized, consider TB, bronchiectasis, and radiotherapy
Tests
• The diagnosis is usually confirmed by high-resolution CT scanning, which can also help distinguish subgroups likely to respond to immunosuppressive treatment
• Respiratory function tests may be useful (a restrictive picture with ↓ transfer factor is usual) but typically adds little in the frail older person
• Consider referral to a respiratory physician to confirm diagnosis and guidance on management
Prognosis
This is very variable—about a third are clinically stable, a third improve, and a third deteriorate at rates that vary greatly between individuals. Some can live with pulmonary fibrosis for years without significant functional impairment.
Treatment
• Treat or remove any underlying cause, e.g. drugs
• A minority respond slowly (over weeks) to immunosuppression (e.g. prednisolone and azathioprine or pirfenidone). Ensure bone protection with calcium, vitamin D, and bisphosphonates
• Home oxygen therapy is often useful
• Give opiates for distressing dyspnoea
• In those in whom dyspnoea progresses, consider end-of-life issues, including treatment limitation, and a change of focus from life-extending measures to a purely palliative approach
Rib fractures
• Often a result of falls or even minimal bony stress such as coughing in a person with osteoporosis
• Consider the possible contribution of alcohol, which causes both falls and osteoporosis
Diagnosis
Rib fractures should be diagnosed clinically.
• Point tenderness and crepitus are often found
• Pressure over the sternum may provoke the pain in a lateral rib
• CXR, even with multiple projections, may miss the fracture but is useful in excluding early complications such as pneumo- or haemothorax
• Radioisotope bone scans are very sensitive but not specific (hot spots are often found without clinical fracture), so they are rarely indicated
Management
Rib fractures heal without specific treatment. The major problem is pain, which commonly leads to voluntary splinting of the injured area. There is hypoventilation and a failure to clear secretions, and 2° pulmonary infection can occur.
• The patient should be encouraged to breathe deeply and to cough. Supporting the injured area when coughing, using a small pillow, minimizes pain. Strapping of the affected area is no longer done, as it ↑ complication rates
• Regular analgesia should include paracetamol, plus a weak opiate in most cases. A short course of NSAIDs with gastric protection may be helpful
• Anticipate and treat complications (usually infection) promptly
• In cases of severe pain (e.g. multiple fractures), consider strong opiates or intercostal/paravertebral blocks. Involve the local pain team
• Surgical repair is an option, e.g. for flail chest, multiple fractures
The patient is often reassured with a diagnosis and explanation that the injury itself is not severe and will heal without immobilization, and that coughing will prevent complications, not cause further damage.
Pleural effusions
A frequent (clinical or radiological) finding, sometimes incidental. Common causes are heart failure, post-pneumonia, PE, and malignancy (especially lung 1°, mesothelioma, leukaemia, lymphoma, and metastatic adenocarcinoma (ovary, stomach)).
The differential diagnosis is wide, but narrowed when the results of CXR and pleural fluid aspiration are known (see Table 11.2).
Pleural aspiration (diagnostic and therapeutic) is now mainly done under ultrasound guidance by a clinician with appropriate competencies.
Light’s criteria is used to differentiate fluid type.
Exudate is likely if one of the following is present:
• Effusion protein:serum protein ratio >0.5
• Effusion lactate dehydrogenase (LDH):serum LDH ratio >0.6
• Effusion LDH level > two-thirds the upper limit of the laboratory’s reference range of serum LDH
Table 11.2 Differentiating cause by fluid type
| Transudate | Exudate |
| Heart failure | Malignancy |
| Hepatic cirrhosis | Infection, including TB |
| Hypoproteinaemia, e.g. malabsorption, sepsis | Gastrointestinal causes, e.g. pancreatitis |
| Nephrotic syndrome | Multisystem disorders, e.g. rheumatoid |
| (Exudative causes if low serum protein) | (Heart failure after diuresis) |
• Empyema, malignancy, and TB produce exudates with low pH (<7.2), low glucose (<3.3mmol/L), but high LDH
• Transudates are usually not due to focal lung pathology and so usually affect both lungs. Unilateral effusions due to transudates occasionally do occur, more commonly on the right side
• Effusions due to heart failure are typically bilateral, with cardiomegaly; they can be unilateral, but usually a tiny contralateral effusion is seen, manifesting as blunting of the costophrenic angle; if the angle remains sharp, other causes are more likely
• A massive unilateral effusion is usually due to malignancy
• A uniformly bloodstained effusion is usually due to infection, embolism, malignancy, or trauma
Chronic effusions
• If bilateral transudates, should be treated as for heart failure
• If the diagnosis is not clear after CXR and aspiration, consider CT chest and/or chest physician referral
• For large, recurrent effusions, consider chest physician referral for continuous outpatient external fluid drainage via a semi-permanent intrapleural catheter or pleurodesis
• Frail patients may not tolerate, or desire, the more invasive tests. In this case, consider:
• Repeated aspiration, combining diagnostic with therapeutic taps and sending larger volumes of fluid for cytology and acid-fast bacilli culture
• ‘Watching and waiting’, with regular clinical review
• A trial of diuretics, especially if the effusion is a transudate
Further reading
Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972; 77: 507–13.
Pulmonary embolism
PE is common yet, as ‘the great pretender’ (of other pathology), is under-diagnosed and underreported on death certificates. It commonly coexists with, and is confused with, other lung disease, e.g. pneumonia, heart failure, and COPD—and is a common cause of deterioration in such patients.
Presentation
The classic symptom triad of pain, dyspnoea, and haemoptysis is seen less commonly in older people.
Common presentations include:
• Brief paroxysm(s) of breathlessness, or tachypnoea
• Collapse, cardiac arrest, syncope, presyncope, or hypotension
• Pulmonary hypertension and right heart failure, presenting as chronic unexplained breathlessness
• Puzzling signs, e.g. fever, wheeze, resistant heart failure, arrhythmia, confusion, or functional decline
Investigations
Determining the likelihood of PE rests on combining clinical judgement (the product of history, examination, and immediately available tests such as CXR) with appropriate imaging such as V/Q scan or CT pulmonary angiography (CTPA). The common clinical features of PE—tachypnoea, tachycardia, and modest degrees of hypoxaemia—are common in ill older people, so clinical judgement alone is rarely enough.
Moreover, a confident diagnosis is essential because in older people:
• The risk of anticoagulation is higher
• The risk of a missed diagnosis is higher (less physiological reserve)
Possible PE in older people should be investigated in the usual way, with the choice of tests guided by local facilities and expertise. The following issues are especially relevant:
• In a patient without known lung disease, the combination of breathlessness and a CXR showing clear lung fields strongly suggests PE. Further test(s) (V/Q or CTPA) are indicated. Ensure adequate hydration prior, to minimize the risk of contrast nephropathy
• CXR abnormalities may be minor (atelectasis, raised hemidiaphragm, small effusions) or major (usually reflecting comorbid conditions, rather than PE itself). Classical wedge shadows or unilateral oligaemia are rare
• PE in the absence of lower limb DVT is common (10–20% of cases), so do not be put off by an absence of clinical signs of the leg or a negative Doppler ultrasound
• D-dimer can be a useful screening test to rule out PE, but because many older people have coexisting conditions, e.g. infection, false positives are very common (i.e. sensitivity high, specificity low)
• ABGs have some value in diagnosis, but the common abnormalities (low PaO2, low PaCO2, and ↑ A–a oxygen gradient) are neither sensitive nor specific
• In healthy older people, an ↑ A–a gradient is common
• In older people following PE, a normal A–a gradient is seen in >10%
• Echocardiogram may be normal following PE. However, in a patient with a high clinical probability, typical features of PE on echocardiogram may provide sufficient diagnostic confidence to permit anticoagulation without further imaging
• In the patient with unexplained right heart failure, consider PE—obtain an ECG and echocardiogram (ask for PA pressures) and request imaging that details the lung parenchyma (high-resolution CT: pulmonary fibrosis?) and the vasculature (CTPA: PE?)
• In the patient who does not respond to treatment for chest infection, heart failure, or acute exacerbation of COPD, consider whether PE may be responsible
Treatment
Anticoagulation
Standard treatment is low-molecular-weight heparin (e.g. dalteparin, enoxaparin), followed by warfarin, with a goal for INR of 2–3. DOACs (e.g. apixaban, dabigatran) are also recommended and achieve full anticoagulation after the first dose. Once the possibility of PE is raised, it is essential to treat with treatment-dose low-molecular-weight heparin pending investigation results, unless there are particular treatment risks.
To minimize bleeding risk:
• Anticoagulate with caution. Check baseline clotting
• Beware the older patient with mild anaemia/low MCV—do they have occult blood loss?
• In the very frail, sick, unstable patient in whom oral anticoagulation would present significant risk, consider a period of anticoagulation with low-molecular-weight heparin. Start an oral agent when clinical stability returns
Thrombolysis
Consider thrombolysing, balancing risks and benefits, where there is life-threatening PE manifesting as acute right heart strain and systemic hypotension. Both risk and benefit ↑ with age, so age itself is not a contraindication.
Inferior vena cava filter
An IVC filter can be inserted under local anaesthesia by an interventional radiologist. Follow-up should be arranged to consider timing for removal.
Indications include:
• Strong contraindication to anticoagulation, e.g.:
• A high risk of bleeding, e.g. newly diagnosed peptic ulcer or very recent haemorrhagic stroke
• Massive thromboembolism with contraindication to thrombolyis
• Ongoing thromboembolism despite anticoagulation
• Embolism from a septic focus
Aspiration pneumonia/pneumonitis
The involuntary entry of extrinsic material into the pulmonary airways. This is a common problem, ranging from subclinical micro-aspiration of oropharyngeal mucus to major inhalation of gastric contents.
Risk factors
• Gastro-oesophageal disorders leading to reflux
• Impaired conscious level, including seizures
• Previous aspiration or non-aspiration pneumonia
• Clinically assisted nutrition—either NG or gastrostomy
Diagnosis
Commonly, the occurrence of pneumonia in a patient with risk factor(s) suggests the diagnosis.
CXR may show consolidation in dependent lung zones, e.g. right lower lobe, although any zone may be affected.
Treatment
• The role of antibiotics is debated. Much of the radiographic response may be chemical pneumonitis, i.e. inflammatory reaction to caustic gastric contents, rather than infective pneumonia
• The choice of antibiotics is also contentious. Many cases respond well to amoxicillin or co-amoxiclav, but consider broad-spectrum iv antibiotics to cover Gram-negatives and anaerobes in:
• Where aspiration has been major
• If possible, treat the underlying cause. If risk factors persist (e.g. impaired swallow or continual seizures), consider a ‘nil by mouth’ order until they are addressed
• Where the swallow may be impaired, perform a formal swallowing assessment (see ‘HOW TO . . . Manage swallow after stroke’, p. 187) and manage according to the results
• Consider anticholinergics to dry secretions
• In advanced dementia, it is often appropriate to accept the risk of aspiration. Insertion of a gastrostomy (commonly a PEG) risks medicalizing the final months while achieving nothing—aspiration is common in patients with a PEG
• It is often cruel and futile to deny a dying patient food that he or she may enjoy, even if the risk of aspiration and a life-shortening pneumonia exists. ‘Nil by mouth’ orders are usually inappropriate in end-of-life situations. Instead consider using thickened fluids, pureed diet, supervised feeding, and avoiding eating in a recumbent position, with straws or feeder cups
Chronic cough
A common problem, with causes ranging from the trivial to the sinister. Even where the underlying cause is benign, chronic cough can be both distressing and disabling.
Causes
• Asthma. Cough is a common presenting symptom in older people
• Post-nasal drip can be due to sinusitis or chronic rhinitis. Frequently allergic in origin, but in older people, symptoms are often not seasonal
• Drugs, e.g. ACE inhibitors (may take weeks or months to develop), β-blockers (leading to bronchospasm)
• Persistent benign cough following upper respiratory tract infection. May persist for 2–3 months
• Chronic pulmonary pathology, e.g. COPD, TB, bronchiectasis
• Heart failure, with high pulmonary pressures
• Thoracic malignancy, either 1° or 2°
Investigation
Consider both tests and trials of treatment. Their pace and extent depend on the differential diagnosis following careful history and examination. Consider the following tests:
• Spirometry, with assessment of response to bronchodilators
• Monitoring of PEFR, looking for morning drops suggesting asthma
• Sputum microscopy and culture are unlikely to be helpful
Next, consider a trial of treatment for the most likely cause, e.g.:
• Bronchodilators (and inhaled steroids) for possible asthma
• Assess the effect of treatment of possible chronic rhinitis with:
• Nasal corticosteroids. Probably the treatment of choice, e.g. beclometasone, budesonide
• Decongestants. Should be used in short courses only (since rebound phenomenon)
• Antihistamines. Most useful for obvious allergic rhinitis. Can be topical spray or tablet. Should be used with caution; select those with fewer anticholinergics properties, e.g. cetirizine or loratadine
In all cases, trials of treatment need to be prolonged (≥8 weeks).
Treatment
This is of the underlying cause. Where this cannot be treated effectively (e.g. advanced malignancy), specific treatments aimed at reducing cough may be of benefit. These include opiates such as codeine or morphine. Simple cough linctus may be useful for irritating dry cough following an upper respiratory tract infection.
Lung cancers
The most common cause of cancer deaths, and largely a disease of older people.
• Symptoms may be non-specific (e.g. fatigue, weight loss), or else pulmonary in origin but attributed to existing non-malignant pathology (e.g. dyspnoea in a patient with COPD)
• Have a high index of suspicion and a low threshold for further investigation. Have an even higher degree of suspicion in older smokers presenting with pneumonia
Sinister features in those presenting with pneumonia include:
• Haemoptysis, especially if significant, e.g. with persistent blood clots
• Regional or generalized symptoms of cancer (e.g. hoarse voice, weight loss)
• Cough and consolidation without obvious infective symptoms (e.g. fever)
• Symptoms that continue to be troublesome despite antibiotics
If sinister features are present, it is unacceptable to wait (up to 6 weeks) before repeating a CXR to confirm resolution. Refer promptly for urgent specialist assessment, and consider CT scanning, bronchoscopy, or lung biopsy.
Treatment
• Treatment has improved and is now more effective, both in extending life and in palliating symptoms. Therefore, ‘benign neglect’, i.e. simply observing an older person with probable lung cancer, is now only rarely acceptable. It may be appropriate, for example, in cases of extreme frailty or severe cognitive impairment
• Older people with probable lung cancer remain under-investigated and undertreated:
• Tests such as bronchoscopy and a histopathological diagnosis are less commonly obtained. This makes palliative treatment and prognostication difficult
• Treatment such as surgery or chemotherapy are less commonly considered or administered. To an extent, this reflects appropriate decision-making based on functional status
• Treatment decisions should be made by expert MDTs that consider the patient’s functional status, comorbidities, and cancer characteristics
► Refer all patients with suspected or confirmed lung cancer for a specialist opinion.
Non-small cell carcinoma (squamous cell, adeno-, and large cell carcinoma)
• Surgery may lead to cure if:
• There is adequate pulmonary function (arbitrarily, FEV1 ≥1.5L)
• There is no distant spread (but >50% of cancers have spread at presentation)
• The patient is relatively well with good functional status and no serious comorbidity
• Surgical procedures are high-risk, but the condition is always fatal without treatment, so the patient’s view is critical
• Radiotherapy. When surgery is not feasible, either because of the nature of disease or the fitness of the patient, then radiotherapy may be used either palliatively (to control symptoms), neoadjuvantly (to reduce tumour volume and sometimes to convert a non-operable tumour into an operable one), or occasionally curatively
• Molecular characterization of tumour tissue enables tailored treatment. Chemotherapy, molecularly targeted therapy, and/or immunotherapy can be useful
Small cell carcinoma
• Relatively more common in older people: >20% of cases
• Most cases are advanced at presentation
• Most patients are treated with combination chemo- and radiotherapy. Frail patients are unlikely to tolerate aggressive treatment and it risks reducing the quality of the brief life that remains. Therefore, regimens are tailored to the patient, determined by structured assessment of performance status. In general, frail patients undergo fewer, but similar, therapy cycles, compared to the more robust
• Prophylactic cranial irradiation ↓ the incidence of brain metastases and prolongs survival in patients with limited disease
• Very advanced disease is managed supportively or with chemotherapy alone
• Surgery is seldom useful because tumours are rarely localized at presentation
Palliative interventions
• Radiotherapy for superior mediastinal obstruction, bronchial obstruction, chest pain, haemoptysis, or painful bony metastases. This is generally well tolerated, although ~10% develop radiation pneumonitis weeks after treatment, and it is on average more severe in older people
• Aspiration of pleural effusion for breathlessness
• Endobronchial therapy (e.g. stenting, diathermy)
Tuberculosis: presentation
• Incidence of TB is much higher, especially in the very old and certain immigrant populations
• Outcomes, including mortality, are much less good
• TB is most commonly due to reactivation of previous disease, the 1° infection having been asymptomatic or unrecognized. In the early twentieth century, 1° infection of young adults was common. By the mid-late twentieth century, 1° infection in younger people had diminished. When this cohort reaches old age, TB reactivation will be much less common
• Reactivation (post-1° disease) occurs due to ↓ immunity, itself due to intrinsic ageing, disease (e.g. diabetes mellitus, renal failure), malnutrition (e.g. chronic alcohol excess), or drugs (e.g. steroids)
• A few patients develop new infection from open cases. Care home residents are most vulnerable, infection passing from fellow residents or from care home staff
• Consider HIV infection when TB diagnosed
Presentation
Pulmonary disease
• Sometimes similar to that in younger people, i.e. cough, sputum, fatigue, weight loss, and anorexia
• Night sweats, fevers, and pulmonary symptoms may be less common
• May present as pneumonia that fails to resolve or as an incidental finding suggested on CXR
Extrapulmonary disease
Most (>75%) presentations are pulmonary, but extrapulmonary cases are relatively more common in older people, e.g.:
• Miliary. Diffuse, overwhelming infection with fever, weight loss, and hepatosplenomegaly. Pancytopenia can occur
• Urogenital and renal. May affect any part of the renal tract. Sterile pyuria, haematuria, abdominal or back pain, genital sinuses, or pelvic masses may occur, or disease may be asymptomatic
• Meningeal. Consider this in the very frail, malnourished, or immunosuppressed patient with non-specific cerebral signs (e.g. confusion, dementia-like syndrome, headache, or reduced conscious level). Meningism may be absent, and the CSF virtually acellular
• Skeletal. Bone infection most commonly affects the spine (usually thoracic or lumbar), presenting as pain and tenderness. TB arthritis usually affects large weight-bearing joints
• Other, e.g. lymph nodes, intestine
Sequelae of previous treatment
Lung collapse therapy was used widely in the treatment of pulmonary TB in the 1930–50s. Procedures included therapeutic pneumothorax, thoracoplasty, and plombage (expanding the extrapleural space with artificial materials). Sequelae include empyema, sinus formation, bronchopleural fistulae, and ventilatory failure. TB pyogenic or fungal organisms may be isolated. Early specialist input is essential.
Tuberculosis: investigation
Chest X-ray
Changes are more variable than in younger people and may mimic other benign or malignant disease (e.g. bacterial pneumonia, cancer).
• Usually upper zone infiltrates with cavities, but more common features in older people include mid-/lower zone infiltrates, and miliary (diffuse nodular) and bilateral changes
• Healed old disease is usually seen, i.e. calcified hilar nodes, a peripheral 1° complex, pleural thickening, and diffuse apical fibrosis and calcification
• Pleural effusions are common
• Rare changes include mass lesions or isolated lymphadenopathy
• The CXR may be normal, e.g. occasionally in miliary or endobronchial disease. If clinical suspicion persists, repeat at an interval
Sputum for microscopy and culture
The standard method of confirming TB:
• Conventionally, three early morning sputum specimens are obtained and stained by acid fast staining (e.g. Ziehl–Neelsen). The quality and persistence of the microscopist is important, as the scanty organisms can be easily missed on cursory examination
• If a patient cannot expectorate, obtain ‘induced sputum’ through PT or nebulized normal saline (rarely nebulized hypertonic saline). If this fails, or clinical suspicion is high despite negative smear and culture, consider bronchoscopy with washings
Other tests
• Raised ESR and CRP are usual
• FBC. Mild (normocytic) anaemia and reduced white cell count are more common in older people. Lymphocytosis or pancytopenia can occur
• Obtain three early morning urine specimens in case of possible genitourinary infection
• Tissue sampling. Where possible, sample tissue, e.g. lymph node, pleura, bone marrow. Send samples to both microbiology (microscopy and culture) and histology. Typical histological features of caseous necrosis with granuloma formation (with or without acid-fast bacilli) support strongly the diagnosis of TB
• Polymerase chain reaction (PCR) testing on smear-positive sputum can identify the type of Mycobacterium and help guide appropriate antimicrobial therapy
• Tuberculin skin testing (Mantoux test) is used to diagnose latent TB and is done in high-risk individuals where treatment would be considered. Tuberculin purified protein derivative (PPD) is injected in a standardized manner, and the reaction assessed quantitatively. Previous bacille Calmette–Guérin (BCG) vaccination can cause a reaction, but this usually reduces over about a decade. Age can reduce the immunological response to tuberculin, and the test and its interpretation are best done by specialist clinicians
• Interferon γ release assay is a newer type of blood test for TB that is becoming more widely available and is used to help diagnose latent TB
Tuberculosis: treatment
Given the complexities of treatment, specialist referral is mandatory. This is a notifiable disease, and public health local authorities will investigate contacts, especially in the care home setting. Respiratory isolation precautions are necessary for patients with pulmonary TB treated in hospital.
Pulmonary disease is treated for a total of 6 months:
• Usually 6 months of rifampicin and isoniazid, with pyrazinamide and ethambutol for the first 2 months only
• Longer-treatment periods may be needed for extrapulmonary disease
In older people:
• Drug resistance is rare, as most infections are recurrences of 1° disease, contracted decades ago
• Failures of treatment are usually due to poor adherence. Combination drug preparations may improve this
• Side effects are more common, including ocular toxicity from ethambutol (reduce dose in renal impairment) and hepatitis from isoniazid. Close monitoring is important
• Atypical mycobacteria, e.g. Mycobacterium avium intracellulare or kansasii, can occur in those with structural lung disease such as bronchiectasis. This requires even broader and more prolonged courses of antibiotics, but isolation is not required as it does not spread from person to person
Asthma and COPD: assessment
Presentation
Asthma and COPD (see Table 11.3) in older people:
• Are both diseases characterized by airflow obstruction
• Commonly coexist, e.g. in the childhood asthmatic who has smoked
• May be both mimicked by other common diseases, e.g. cancer, PE, heart failure
• May present late—older people are less aware of hypoxaemia, breathlessness, or bronchoconstriction, or may interpret it as ‘normal’ ageing
• Are under-diagnosed and undertreated, especially in older people
Asthma
• May present in old age as true ‘late-onset asthma’. There are also ↑ numbers of people who have grown old with their asthma
• In older people, cough may dominate, symptoms fluctuate less, triggers (e.g. cold, smoke, allergens) are less frequent, and the association with hay fever or eczema is less strong
• Nocturnal cough or dyspnoea, including paroxysmal nocturnal dyspnoea, may be caused by asthma
• NSAIDs and β-blockers (oral or ocular) may worsen bronchoconstriction
COPD
• Is much more common in older age, the consequence of intrinsic ageing and progressive disease
• Is caused by environmental exposure, usually to tobacco smoke, in genetically susceptible people. Significant disease can develop in those who have not smoked for years, as acquired lung damage depends more on ‘total pack years’ smoked, rather than duration alone
• Symptoms are usually more chronic and slowly progressive, without significant variability
• If bronchitis is significant, there is a productive cough
• Fatigue and sleep disturbance are common. Daytime somnolence suggests ventilatory failure
• There may be associated anaemia of chronic disease, osteoporosis, malnutrition, and depression
Investigations
• Pulse oximetry will determine the presence and degree of hypoxaemia. In moderately or severely hypoxaemic patients (oxygen saturation <92%), consider ABGs to determine whether long-term oxygen therapy (LTOT) may be of benefit (see ‘Oxygen therapy’, pp. 346–347) and, in the acutely unwell, to guide oxygen administration
• CXR, ECG, and FBC will help to exclude other pathology, e.g. anaemia, dysrhythmia
• α-1 antitrypsin should be considered in atypical cases
• PEFR, measured regularly (bd–qds) for up to 2 weeks, helps determine whether variable airways obstruction (asthma) exists. Variability of ≥20% is significant. Older people may find using PEFR meters and charting the results difficult. Ask them to demonstrate the technique, reading the device, and charting in clinic
• Spirometry. Obtain at least FEV1 and forced vital capacity (FVC). An FEV1:FVC ratio of <0.7 suggests obstruction
• Older people often have difficulty performing pulmonary function tests; an experienced technician in a respiratory laboratory will help provide accurate results
• Assessments for bronchodilator responsiveness using inhaled bronchodilators are now considered less helpful, as they are poorly predictive of the response to treatment and do not distinguish reliably between asthma and COPD. However, airflow obstruction that completely and repeatedly resolves after bronchodilator administration does exclude COPD
• Assessments for steroid responsiveness can be helpful in distinguishing between asthma and COPD (response is greater in asthma than COPD, although there is overlap). Perform spirometry before and after steroids (either 2 weeks of prednisolone 30mg od or 6 weeks of inhaled beclometasone 400 micrograms bd)
• Some patients show improvement in FVC or functional status (walking distance or speed) despite no significant change in FEV1
Table 11.3 Distinguishing asthma from COPD
| Asthma | COPD |
| Modest degree of fixed airways obstruction (this is uncommon in younger people) | Greater degree of airways obstruction |
| Significant or full reversibility | No, or only minimal, reversibility |
| ≥20% variability in PEFR | <20% variability in PEFR |
| Greater age | |
| Significant smoking history |
Asthma and COPD: drug treatment
In general, treatment principles are similar to those in younger people and are described in detail in British Thoracic Society guidelines. However, some differences and some similarities benefit from emphasis.
Bronchodilators
• Older people perceive symptoms less reliably, so where there is evidence of variable airways obstruction, give bronchodilators regularly, rather than as required
• These include short-acting β2-agonists (SABA), short-acting muscarinic antagonists (SAMA), long-acting β2-agonists (LABA), and long-acting muscarinic antagonists (LAMA)
• Protocols exist for up-titration of these, starting with short-acting agents, then adding in the long-acting agents in a stepwise fashion
• In older age, response to antimuscarinics, e.g. ipratropium, tiotropium, may be better than to β-agonists, e.g. salbutamol
• High-dose β-agonists, e.g. from nebulizers, may cause tremor, tachycardia, or rate-related angina. Nebulizers may not be required—try higher inhaled doses via a spacer or long-acting agents
• Antimuscarinic bronchodilators uncommonly cause side effects such as dry mouth or blurred vision, more often with higher (nebulized) doses and with long-acting preparations. Acute glaucoma is a rare, but important, complication—reduce ocular exposure by nebulizing via a mouthpiece, rather than a face mask
Corticosteroids
• Inhaled corticosteroids have a role in the protocols
• Long-term oral steroids are rarely beneficial
• In those receiving regular courses of oral steroids for acute exacerbations, give osteoporosis prophylactic treatment. Inhaled steroids alone probably do not cause osteoporosis
Theophylline
• Toxicity is common in older people. Plasma levels are ↑ by febrile illness, heart failure, and drugs, e.g. erythromycin/ciprofloxacin. Serious side effects, e.g. convulsions, may be the first sign of toxicity
• Check levels when titrating the dose. Most of the therapeutic effect is seen at the lower end of the therapeutic range, so target this first
• Before introducing oral theophylline, optimize inhaled bronchodilator and steroid therapy, including the use of long-acting and higher-dose preparations, if necessary
Other
• Influenza and pneumococcal vaccine should be given
• Exercise extreme caution in the use of respiratory depressants, e.g. benzodiazepines or opiates. In general:
• In acutely unwell patients with CO2 retention, stop them, reintroducing only if withdrawal effects occur
• In stable patients with or without CO2 retention, withdraw or reduce them where possible
• In severe end-stage COPD, if dyspnoea or cough are distressing and cannot be otherwise relieved, consider giving opiates. Give small doses initially, but ↑ as needed to relieve distress, even if respiratory function deteriorates. Explain the rationale to staff, relatives, and the patient, if appropriate
HOW TO . . . Improve drug delivery in asthma or COPD
• The traditional metered-dose inhaler alone is rarely adequate, due to difficulties in coordinating device activation and the onset of inhalation
• Adding a large-volume spacer device reduces the need to coordinate activation with inhalation, improving drug delivery and reducing side effects (e.g. oral thrush). Spacers are generally better tolerated by older patients who do not tend to attach the same social stigma as youngsters
• Breath-activated devices provide an alternative to the metered-dose inhaler, although lung volumes may not be adequate to activate the device. They vary widely in design, and patients vary greatly in the ability to use them
• Assess and advise on the technique regularly, involving both hospital and community teams (doctor, nurse, and pharmacist), as well as the family and other carers
• Nebulizers are rarely required. A metered-dose inhaler via a large-volume spacer device is usually just as effective. Patients in whom nebulized drugs are being considered should be referred for specialist assessment
• Where adherence is an issue, e.g. in a person with dementia living alone:
• Give long-acting preparations where possible
• Once-daily inhaled steroid is better than none
• Supervise the taking of medication as often as possible, but accept that for pulmonary drugs, taking medications irregularly is probably better than taking them not at all
• Rarely, inhaled drugs are administered too frequently by cognitively impaired people. This very rarely causes side effects, but relatives may need reassurance that this is the case
• Occasionally, oral β-agonists are useful in patients in whom all inhaled preparations have been unsuccessful
Further reading
British Thoracic Society. Guidelines. https://www.brit-thoracic.org.uk/standards-of-care/guidelines/.
Asthma and COPD: non-drug treatment
• Smoking cessation should be advised, except in the very advanced or terminal phase where it may lack benefit and be unkind. Consider referring for support and/or nicotine replacement therapy
• Exercise is beneficial, sometimes available as part of a pulmonary rehabilitation scheme. Elements should include aerobic and strength-based exercises, as well as specific breathing exercises
• Pulmonary rehabilitation is as effective as inhaler therapy and should be a key part of treatment. It is a complex intervention tailored to the individual, with exercise, behavioural, and educational components. Individual action plans can be followed by older people, facilitating self-management and early intervention
• Weight reduction is beneficial in the obese. However, weight commonly falls in advanced disease as the work of breathing exceeds calorific intake, and nutritional supplements may be needed
• Comorbidities, including depression, are common and should be treated aggressively
• Social and practical interventions. A comprehensive multidisciplinary assessment may be warranted. Provide appropriate mobility aids, e.g. electric wheelchairs, stairlifts, and alarm systems, e.g. pendant alarms. Treat social isolation
Assisted ventilation
• Consider this in cases of respiratory acidosis, delirium, exhaustion, or deteriorating respiratory function despite full treatment. Hypercapnia, rather than hypoxaemia, is usually the key contributor to delirium; sedation is likely to worsen ventilation and precipitate coma
• For some patients with acute-on-chronic deterioration, ventilation will be futile and inappropriate. Make such a decision after considering:
• The nature of the chronic illness and recent deterioration
• The presence of reversible factors
• The patient’s current physiological status
• The views of the patient or others who represent them
• If in doubt, request guidance from the ITU team
• Non-invasive ventilation (NIV), e.g. nasal intermittent positive pressure ventilation, provides an acceptable alternative to invasive ventilation (usually endotracheal intubation). NIV is often well tolerated, can be delivered on specialist or high-dependency wards, and provides a modest level of ventilatory support that can be weaned promptly as the patient recovers
Palliative interventions
• Reassure—many patients are frequently terrified. Assure them that their symptoms of suffocation can, and will be, treated. Consider advance care planning
• Positioning—sit up, day and night
• Involve the palliative care team. Their advice and support are often valuable and can continue into the community if discharge occurs
Oxygen therapy
• Oxygen is a drug—it has clear indications and common and important side effects. Precision and care in prescribing maximizes benefit and reduces harm
• Controlled oxygen therapy targeted to pulse oximetry (94–98% for most, 88–92% for those at risk of type 2 respiratory failure)
• In older people, dyspnoea may be more frequently accepted, leading to underprescribing
• However, indiscriminate prescribing, particularly the use of high-concentration oxygen, risks respiratory depression and CO2 narcosis. This is common in older people with COPD
High-concentration oxygen therapy
• Previously used in emergency situations (15L/min via a non-rebreathe bag); this is rarely required to achieve the target saturations of 94–98%.
• Hyperoxaemia can be harmful (it can cause vasoconstriction and depressed respiratory drive)
Oxygen delivery systems
Supply patients with an administration device applicable to their circumstances which should be prescribed on the drug chart.
Constant performance oxygen delivery systems (e.g. Venturi mask) provide a stable concentration of inspired oxygen (FiO2) (24%, 28%, 35%, etc.) for a range of ventilation rates. These must always be used for hypoventilating patients with elevated PaCO2.
Variable performance oxygen delivery systems—the FiO2 varies. The system delivers oxygen at a given rate which mixes with room air at rates dependent on ventilation. Systems include:
• Nasal cannulae. Often better tolerated by patients and allow them to eat and talk. With oxygen flows of 1–2L/min, FiO2 is usually low (<28%) but can approach 30% if the patient hypoventilates
• Simple face mask, e.g. Hudson. Provides variable FiO2 up to 40%
• Non-rebreathing mask with a reservoir bag. Provides variable FiO2 of up to 60%
Long-term oxygen therapy
This improves prognosis in severe COPD and in moderate COPD with features of cor pulmonale. To reduce pulmonary hypertension, arterial pO2 should be raised to above 8kPa for at least 15h each day. FiO2 of 24–28% usually achieves this. Respiratory depression is very rarely a problem in patients with stable respiratory failure who receive low oxygen concentrations.
Specific criteria must be met before prescribing LTOT. Measure ABGs twice, on air, at least 3 weeks apart and at least 4 weeks after an acute exacerbation.
Criteria include:
• PaO2 7.3–8.0kPa in COPD with complications such as peripheral oedema, evidence of pulmonary hypertension, or polycythaemia
• PaO2 <7.3kPa in COPD without the complications already listed
Intermittent oxygen therapy (IOT)
This is useful for a variety of cardiorespiratory conditions, e.g. COPD, advanced heart failure, lung cancer. It relieves distress and improves exercise tolerance and mobility. Low concentrations (24–28%) can achieve significant symptomatic benefit. Prognosis is unaltered.
Oxygen gas supply
Oxygen concentrators are costly to purchase, but running costs are low. They are cost-effective when needing low-flow oxygen for prolonged periods (≥8h per day). Oxygen is piped to convenient position(s) in the home and usually administered via nasal cannulae. Urgent installations can usually be arranged within 24h.
Oxygen bottles are useful for:
• Patients on LTOT via an oxygen concentrator who wish to leave their home for short periods
• Patients needing oxygen as required, who do not meet the LTOT criteria
• Patients who are likely to have a short-term need for continuous oxygen, e.g. for end-of-life palliation, for whom installation of an oxygen concentrator may not be worthwhile
A small oxygen cylinder (300L, lasting 2h) is available which is convenient for wheelchair excursions or travel in a car.
► Smokers should stop smoking before beginning oxygen therapy. The risk of burns and household fires is substantially ↑.
Asbestos-related disease
The period between asbestos exposure and overt (or covert) disease is usually long, often over 20 years. Almost all new cases are in older people because asbestos exposure is so carefully regulated now. The exposure may not be clearly recollected by the patient, but always consider in high-risk occupations, including building, dock work, and heavy engineering. Confirming the diagnosis is important because compensation may be due if disease can confidently be shown to have arisen as a consequence of asbestos exposure. If the diagnosis could not be confirmed during life, then post-mortem confirmation may lead to compensation payments to relatives.
Pleural plaques
Discrete areas of thickening of the pleura that often calcify. Benign. A marker of asbestos exposure, but of no further clinical significance. Compensation for this is not universally available.
Asbestosis
Progressive fibrosis, clinically and radiographically similar to idiopathic pulmonary fibrosis. Usually due to prolonged and substantial occupational exposure.
Mesothelioma
A malignant, incurable tumour of the pleura, presenting as cough, chest pain, effusion, or dyspnoea. Very poor prognosis; few survive over 2 years. Treatment is nearly always palliative; the tumour is not resectable and is relatively insensitive to chemotherapy or radiotherapy. Asbestos exposure may have been only transient.
Bronchial carcinoma
There appears to be a synergistic effect between asbestos and tobacco.
1 National Institute for Health and Care Excellence (2008). Oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza. Technology appraisal guidance TA158. https://www.nice.org.uk/guidance/ta158
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