The Young Medics

Great to have so many young medics from Taiwan in the clinic.  Lots of sharing.  Very enthusiastic bunch.  They are on a study tour and will be visiting the Orang Asli camps.  

Happy learning and Happy holiday!

Managing Shortness of Breath

Managing shortness of breath in patients with COPD, Interstitial Lung Diseases, Bronchiectasis. 

Live recording of hybrid meeting at 15 Clarke Street on 2nd December 2023. Apologies for technical problems during ZOOM recording.  Recording is much longer and contains the same slides as the above presentation. 

Lung Bulla

 Smokers may have shortness of breath because of chronic obstructive pulmonary disease or COPD.  The development of lung bullae in a smoker's emphysematous lungs may worsen breathlessness.  

Shuttle Walk Test vs 6 Minute Walk Test

My clinic has a corridor of only 15 meters. Need to find out the most appropriate walk test to evaluate the functional capacity of a person. This is what I found out.

The 6-minute walk test (6MWT) and the shuttle walk test (SWT) are both exercise tests that can be used to measure an individual's exercise tolerance and functional capacity. However, there are some key differences between the two tests.

Test protocol: The 6MWT involves walking as far as possible for 6 minutes along a flat, straight, and unobstructed corridor, usually 30 meters long. In contrast, the SWT involves walking back and forth along a shorter distance, usually 10-15 meters, for a set period of time, such as 1-3 minutes.

Turnarounds: In the 6MWT, the participant turns around at the end of the 30-meter corridor and continues walking in the opposite direction. In the SWT, the participant turns around at the end of the shorter distance and walks back in the opposite direction.

Pace: In the 6MWT, the participant can choose their own pace and may slow down or stop if needed, while in the SWT, the pace is set by a pre-recorded audio signal that gradually increases the speed of walking.

Performance measures: The primary outcome measure in the 6MWT is the total distance walked in meters in 6 minutes. In the SWT, the primary outcome measure is the number of shuttles completed in the set time period.

Clinical use: The 6MWT is commonly used in clinical settings to assess exercise tolerance and functional capacity in individuals with chronic lung diseases, heart failure, and other conditions that affect exercise capacity. The SWT is commonly used to evaluate exercise capacity in individuals with chronic obstructive pulmonary disease (COPD) and peripheral artery disease.

In summary, both the 6MWT and the SWT can be used to assess exercise tolerance and functional capacity, but they have different test protocols, primary outcome measures, and clinical uses. It's important to use the appropriate test for the individual and condition being evaluated.

More details on how to perform the SWT:

The Shuttle Walk Test (SWT) is a modified version of the 6-minute walk test, which involves walking back and forth between two markers that are set at a shorter distance. Here are the general steps to perform the Shuttle Walk Test:

• Set up the test area: The test area should be a flat and unobstructed corridor or hallway that is 10-15 meters long. Two markers should be set at each end of the corridor, spaced 9-10 meters apart.
• Measure vital signs: Measure the participant's vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation, before the test.
• Warm-up: The participant should warm up by walking at an easy pace for a few minutes.
• Test instructions: Explain the test instructions and demonstrate the walking pattern to the participant.
• Audio signal: Start the audio signal or use a stopwatch to keep track of the time. The audio signal should gradually increase the walking speed every minute or every 2 minutes.
• Walking pattern: The participant should start walking from one marker to the other marker and back, and should touch the marker or turn around at each end. The walking speed should be set by the audio signal, and the participant should try to keep up with the speed as long as possible.
• Test completion: The test is completed when the participant can no longer keep up with the audio signal or when they have completed the required number of shuttles. Record the number of shuttles completed and the time taken to complete the test.
• Measure vital signs: Measure the participant's vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation, after the test.
• Cool-down: The participant should cool down by walking at an easy pace for a few minutes.

Breathing Well is a choice.

To live we need to be able to breathe.  Breathing is natural and automatic.  Breathing well however is a choice because we need to exercise the respiratory muscles and also treat any underlying disease that causes airflow obstruction or impairment of gas exchange.  

There is a saying that goes; "when you can't breathe, nothing else matters".  How true!  

Get Well message

 This Get Well message was made using Canva.  Several steps involved.  First to choose the background picture.  Selected a picture with many fruits as fruits are usually given when visiting ill persons.  Second comes the message and choosing the fonts and colours to go with it.  Then needed to frame the words with some added  transparency.  The signature came with a new tool just available in Canva.  Finally took some time to select an appropriate bible verse to go with the message.  Chose John 14:21.  Hope you like it!

Managing Cough and Excessive Phlegm

 I have taken the liberty to split up the long virtual workshop on Managing Cough and Excessive Phlegm into several smaller video segments.  The segments contain information on how to perform home chest physiotherapy.  These videos are suitable for patients having chronic bronchitis, COPD, bronchiectasis, cystic fibrosis, lung infection etc.  

Heart failure with preserved ejection fraction.

This is an interesting topic. The ejection fraction is a measurement of left heart function obtained during echocardiography. The question is how does the heart fail when the measured EF is normal? 

Heart failure is an important cause of shortness of breath which has to be differentiated from lung causes of shortness of breath.  Often the distinction between the two conditions is not obvious clinically without further investigations. Relevant investigations include ECG, NT proBNP (blood test), echocardiography, chest x-ray and coronary angiography.  

Heart failure with preserved ejection fraction is a type of heart failure with normal or near normal ejection fraction and objective evidence of diastolic dysfunction.  

More than half of heart failure patients have heart failure with a maintained ejection fraction. The illness primarily affects the elderly, accounting for 4.9 percent of the population over the age of 60. It appears to be more common in women, and it is projected to become more widespread as people live longer. 

Link to this interesting article which I have read:

Heart failure with preserved ejection fraction | Radiology Reference Article | Radiopaedia.org

Feger, J., Worsley, C. Heart failure with preserved ejection fraction. Reference article, Radiopaedia.org. (accessed on 24 Mar 2022) https://doi.org/10.53347/rID-93980

Tracheostomy for Ventilated Patient

Doctors struggle to accurately predict which patients will require prolonged mechanical ventilation.  Doctors need a clear understanding of the nature and typical course of chronic critical illness.

Communication about chronic critical illness should begin before its onset and, ideally, as early as the initiation of mechanical ventilation (or even at decision-making about whether to initiate ventilation).  Doctors should inform not only of the risk of death in the ICU, but also the chance the patient might survive but remain dependent on the ventilator and other intensive therapies for a prolonged period. 

These initial discussions allow a longer time for doctors to “cultivate prognostic awareness” i.e. the capacity to understand prognosis and the likely illness trajectory and help patients and families prepare psychologically and practically for further developments.

Based on the available evidence, routine placement of tracheostomy prior to day 10 of mechanical ventilation is not indicated. General consensus is that a tracheostomy should be placed after day 10 if the patient is likely to require more than a few additional days of ventilation i.e. the patient will neither be liberated from the ventilator nor die in the near future i.e. the patient is chronically critically ill.

Benefits of tracheostomy include:

Improved patient comfort

Easier oral care and suctioning

Reduced need for sedation or analgesia

Reduced accidental extubation

Improved weaning from mechanical ventilation

Easier facilitation of rehabilitation

Earlier communication and oral nutrition

Facilitated transfer to lower level of care

Early Complications:

Bleeding

Air leak causing subcutaneous emphysema, pneumothorax, pneumomediastinum

 

Damage to the swallowing tube (esophagus)

 

Injury to the nerve of the vocal cords (recurrent laryngeal nerve)

 

Tracheostomy tube can be blocked by blood clots, mucus, or pressure of the airway walls.

Late Complications:

Accidental removal of the tracheostomy tube

 

Infection in the trachea and around the tracheostomy tube

 

Trachea may be damaged by pressure from the tube resulting in bacterial infections and scar tissue formation

Delayed Complications:

Thinning of the trachea from the tube rubbing against it (tracheomalacia)

B Lines in Lung Ultrasound

Lung ultrasound has come in vogue during the COVID pandemic.  LUS is simple to perform and can be readily done at the bedside.  LUS performed well, together with a proper clinical history and physical examination, can help clinicians reach a diagnosis quickly before needing to perform more extensive investigations like HRCT scans of the lungs.

Indentification of B line artifacts in the lungs can mean pulmonary oedema (heart failure), interstitial syndrome (interstitial lung disease), infections (viruses or bacteria) and ARDS (acute respiratory distress syndrome).

LUS is a useful screening tool at the bedside in ward or emergency room.  The ultrasound machine can also be used to scan other organs of the body (heart, blood vessels, liver, kidneys, etc) at the same sitting providing more useful clinical information.

Blue Bloaters

Blue bloaters is the name used to describe COPD (chronic obstructive pulmonary disease) patients who are overweight, puffed up, having difficulty breathing, lacking oxygen (hence the blue, cyanotic discolouration) and have leg swelling due to right heart faillure.  COPD is mainly caused by cigarette smoking.

These patients are hypoxic with low oxygen saturation and some with carbon dioxide retention.  The brain adapts and is reliant on the low oxygen in the blood to drive breathing.  As such, an overdose of oxygen, removing the hypoxic drive, will make them worse leading ultimately to deeper respiratory failure, carbon dioxide narcosis, respiratory arrest and death. 

Therefore, it is very important for caregivers to know exactly how much oxygen (litres per minute) to give to these COPD patients.  Some of these patients may only need to maintain their SpO2 at only 90% to 93% as they are used to these low oxygen to drive ventilation and to "blow out" the carbon dioxide. 

Please consult your doctor for medical advice and not to give too much oxygen to these COPD patients.  Arterial blood gas analysis is required to make a proper diagnosis for these patients. 

Plain Chest Xray

 A CT scan of the lungs will give better definitions than a plain chest x-ray.  However, CT scans are more expensive, needs an appointment and person will receive more radiation. 

Long COVID lung complications

 

These uncommon lung complications present with dry cough and shortness of breath on exertion. 

Six Warning Signs of Lung Diseases

Video created to bring awareness of important symptoms of lung diseases.  Also helps listeners to take note of certain details regarding each symptom.  Detail descriptions of various symptoms will help the doctor zoom in and focus on certain diseases of the lungs and their differential diagnosis. 

30th Anniversary of Leong Chest Clinic

Leong Chest Clinic began operation in 1991 at 178 Jalan Pasir Puteh, 31650 Ipoh. At that time, I had a choice of either locating the practice at Jalan Leong Sin Nam or Pasir Puteh Road.  I decided to take Pasir Puteh Road as the shophouse at Jalan Leong Sin Nam was already rented out to a fellow colleague.  

I had been in public medical service for 10 years and my last post was as head of the Chest Unit in Ipoh General Hospital (Hospital Raja Permaisuri Bainun, Ipoh).  I am indeed very proud of my 10 years of service in the public sector as it gave me a very rich experience in serving the needy.  I also had a great time teaching the young doctors and nurses. 

Pictures are from a video taken during the opening ceremony.  

We had a gala time with family friends. The food was from the First Restaurant, our usual food caterer.  Sad to say some of these dear friends are no longer with us.  One advice to everyone is to take photos of people and places at every opportunity as these photos will bring back sweet memories of days gone by.   

 A big thank you to all for the flowers and well wishes.