Chest & Respiratory Medicine

Pulmonology is the internal medicine specialty concerned with diseases of the lungs, pleura, mediastinum, and airways. Surgical chest conditions (thoracic surgery) constitute a separate field; pulmonology manages the medical side and refers to surgery when indicated.

The most common reasons patients visit our department:

• Cough lasting more than two weeks — dry or productive
• Shortness of breath — on exertion or at rest
• Wheezing or chest tightness — particularly at night or in the early morning
• Recurrent upper or lower respiratory tract infections
• Lung cancer screening requests in adults with a smoking history
• Night-time snoring, excessive daytime sleepiness, witnessed apnoea
• Coughing up blood (haemoptysis) — requires urgent assessment
• Lung monitoring following occupational exposure (dust, chemicals, asbestos)

Respiratory symptoms frequently overlap with presentations from other specialties — cardiology, ENT, and allergy. Distinguishing a cardiac cause of breathlessness from an upper airway cause of wheeze is critical for early diagnosis; for this reason our department conducts joint assessments with cardiology and ENT when clinically indicated.

Asthma is a condition characterised by chronic airway inflammation and variable airflow obstruction. Distinguishing between acute episodes and the interval period shapes the treatment plan.

Diagnostic assessment includes:

• Clinical history (attack pattern, triggers, family history)
• Spirometry (FEV1, FEV1/FVC) and bronchodilator reversibility testing
• Peak expiratory flow (PEF) monitoring — particularly relevant in occupational asthma
• Allergy history and referral for allergy testing where appropriate
• Comorbidity screening (rhinitis, GORD, obesity)

Principles of acute episode management:

A mild-to-moderate episode can often be managed at home with a short-acting bronchodilator (SABA) and, if necessary, oral corticosteroids. A severe episode requires hospital attendance. Cyanosis, breathlessness severe enough to prevent speech, oxygen saturation below 92%, and tachycardia are criteria for emergency referral. Our recommendation: every patient with asthma should have a written action plan setting out when to increase medication and when to go to A&E — documented in advance.

Inhaler technique: More than 50% of asthma treatment success depends on correct inhaler technique. We review inhaler technique at every outpatient appointment; many patients fail to benefit adequately from treatment simply because they have used their inhaler incorrectly for years. A spacer device is our standard recommendation for children and adults with hand tremor.

Allergic component: Seasonal triggers (pollen), house dust mite, pets, mould, cold air, and exercise all provoke asthma episodes. Identifying triggers is as valuable as medication itself. Indoor modifications — mattress covers, humidity control, rules around pet contact — are part of the treatment plan.

Chronic Obstructive Pulmonary Disease (COPD) is a condition caused by prolonged exposure to tobacco smoke and other harmful particles, characterised by irreversible airflow limitation. Its key distinction from asthma: the FEV1/FVC ratio remains persistently reduced after bronchodilator administration.

Diagnostic framework:

• Smoking history: Pack-year calculation (packs per day × years smoked). A history of 20+ pack-years represents a significant risk threshold.
• Spirometry: Post-bronchodilator FEV1/FVC < 0.70 is consistent with COPD. Staging is based on FEV1 percentage (GOLD grades 1–4).
• Symptom scoring: CAT (COPD Assessment Test) or mMRC dyspnoea scale. Symptom burden can vary considerably between patients sharing the same FEV1 value.
• Exacerbation history: Number of deteriorations and hospitalisations in the past 12 months.
• Comorbidities: Cardiovascular disease, osteoporosis, depression, and muscle-mass loss are closely associated with COPD.

Stepwise pharmacological therapy:

Treatment is stratified according to symptom burden and exacerbation risk, in line with GOLD guidelines:

• Long-acting bronchodilator (LAMA or LABA) monotherapy — for low-risk symptomatic patients
• LABA + LAMA combination — when symptom control is inadequate
• Triple therapy (LABA + LAMA + ICS) — for patients with high exacerbation burden and eosinophilia

Inhaler technique capability, comorbidities, and cost are all considered when selecting treatment.

Oxygen therapy: In patients with a resting arterial oxygen tension (PaO2) persistently below 55 mmHg, or oxygen saturation consistently below 88%, long-term oxygen therapy (LTOT) is the only intervention proven to extend survival. Eligibility is assessed via arterial blood gas analysis; oxygen is initiated on the basis of confirmed clinical indication, not for symptomatic comfort.

Smoking cessation: The single most effective intervention to slow disease progression in COPD is stopping smoking. No medication produces a comparable effect. Smoking status is addressed at every consultation without exception.

Pneumonia is an infectious inflammation of the lung parenchyma. The distinction between community-acquired pneumonia (developing outside hospital) and hospital-acquired pneumonia directly determines treatment choice.

Community-acquired pneumonia — clinical approach:

• Fever, cough, sputum, pleuritic chest pain, shortness of breath
• In older patients, the classic presentation may be replaced by confusion, general malaise, and loss of appetite
• A chest X-ray supports the diagnosis; clinical suspicion is not excluded by a negative film
• Identifying a causative organism is not always necessary; empirical treatment is sufficient in most cases

Treatment decisions are guided by the following questions:

1. Can the patient be treated at home, or is hospital admission required?
2. What is the patient's age, comorbidity profile, and recent antibiotic history?
3. What are the current local resistance patterns?

Hospital referral criteria (CURB-65 score):

• Confusion
• Urea > 7 mmol/L (BUN > 19 mg/dL)
• Respiratory rate ≥ 30/min
• Blood pressure (systolic < 90 or diastolic ≤ 60)
• 65 years of age or over

Each criterion scores 1 point. A score of 0–1 supports home treatment; 2 suggests close monitoring or admission; 3 or more warrants hospital admission. This scoring tool is not a mechanical rule — it must be interpreted alongside the full clinical picture.

High-risk groups: Pneumonia follows a more severe course in adults aged over 65, those with underlying COPD or heart failure, and immunocompromised patients. Pneumococcal and influenza vaccines are our standard recommendation for these groups; vaccination status is reviewed at every autumn appointment.

Recovery: Patients treated at home can expect symptoms to begin improving within 48–72 hours. If fever persists, breathlessness worsens, or the patient is unable to maintain adequate fluid intake, the follow-up appointment is brought forward. Radiological resolution typically lags behind clinical improvement; a follow-up chest X-ray is requested when clinically indicated, not routinely.

Lung cancer is most often diagnosed at a locally advanced or metastatic stage. Because five-year survival is significantly higher when caught at an early stage, screening programmes are critically important.

Low-dose thoracic CT (LDCT) screening — who is eligible?

Internationally accepted screening criteria:

• Age 50–80 years
• A smoking history of 20 or more pack-years
• Currently smoking, or having stopped within the past 15 years

Patients who meet all three criteria are candidates for annual low-dose CT screening. Routine CT screening is not recommended for those who do not meet these criteria; the risks of unnecessary radiation exposure and false-positive findings outweigh the benefits.

Interpreting screening results:

• Lung-RADS 1–2 (negative or benign): Continue annual screening
• Lung-RADS 3 (probably benign): Follow-up CT in 6 months
• Lung-RADS 4 (suspicious): Short-interval CT, PET-CT, or referral for biopsy

Not every nodule found on a screening CT is cancer; more than 95% of nodules are benign. Our role is to accurately filter which nodules warrant further investigation.

Biopsy referral: The biopsy method for a suspicious nodule depends on its location. Central lesions are approached via bronchoscopy; peripheral lesions via CT-guided transthoracic needle biopsy; mediastinal lymph node involvement via EBUS (endobronchial ultrasound-guided biopsy). Referral to a specialist centre is arranged for these procedures.

Approach to patients who smoke: A screening CT is an opportunity to motivate smoking cessation. A "clear CT" result should not reassure the patient into complacency — it should be framed as "a reason to stop". Smoking status is reviewed at every visit; smoking cessation support programmes, nicotine replacement therapy, and pharmacotherapy where appropriate (varenicline, bupropion) are offered.

Obstructive sleep apnoea syndrome (OSAS) is characterised by repeated upper airway collapse during sleep, causing oxygen desaturation and disrupted sleep architecture. It is a common condition that remains largely undiagnosed.

Signs that raise clinical suspicion:

• Loud, irregular snoring at night
• Witnessed apnoea — breathing pauses observed by a bed partner
• Excessive daytime sleepiness, difficulty concentrating, waking unrefreshed
• Morning headache, frequent nocturnal urination
• Treatment-resistant hypertension
• Large neck circumference, obesity

Polysomnography (sleep study): The gold standard for diagnosis. The patient is monitored overnight in a sleep laboratory with electrodes attached; the apnoea–hypopnoea index (AHI) is calculated.

• AHI 5–15: mild OSAS
• AHI 15–30: moderate OSAS
• AHI > 30: severe OSAS

Our department does not have an in-house polysomnography facility; patients are referred to a partner sleep laboratory and we review the report together.

CPAP therapy: The first-line treatment for moderate-to-severe OSAS. Continuous Positive Airway Pressure keeps the upper airway open during sleep, preventing apnoeic episodes and oxygen desaturation. Pressure titration is tailored to the individual patient.

CPAP adherence is the most critical factor: Treatment success depends directly on consistent device use. The first one to three months are an adaptation period — mask discomfort, dry mouth, and a sense of claustrophobia are common complaints. At follow-up appointments, adherence data (hours of use, leak rate, residual AHI) is downloaded from the device memory; if problems are identified, mask type, pressure settings, or humidifier settings are adjusted accordingly.

Alternative treatments: For mild OSAS, anatomically correctable causes, or patients who cannot tolerate CPAP, options include a mandibular advancement device (oral appliance), a weight loss programme, positional therapy (supine avoidance), and — in selected anatomical cases — ENT referral for upper airway surgery. Where upper airway obstruction is suspected, joint assessment with the Nis Clinic ENT department is arranged.