OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Respiratory Medicine Published and forthcoming Oxford Handbooks Oxford Handbook for the Foundation Oxford Handbook of Genetics Programme 4e Oxford Handbook of G enitourinary Oxford Handbook of Acute Medicine, HIV and AIDS 2e Medicine 3e Oxford Handbook of Geriatric Oxford Handbook of Anaesthesia 3e Medicine 2e Oxford Handbook of Applied Dental Oxford Handbook of Infectious Sciences Diseases and Microbiology Oxford Handbook of Cardiology 2e Oxford Handbook of Key Clinical Oxford Handbook of Clinical and Evidence Laboratory Investigation 3e Oxford Handbook of Medical Oxford Handbook of Clinical Dermatology Dentistry 5e Oxford Handbook of Medical Imaging Oxford Handbook of Clinical Oxford Handbook of Medical Diagnosis 2e Sciences 2e Oxford Handbook of Clinical Oxford Handbook of Medical Statistics Examination and Practical Skills 2e Oxford Handbook of Neonatology Oxford Handbook of Clinical Oxford Handbook of Nephrology and Haematology 3e Hypertension 2e Oxford Handbook of Clinical Oxford Handbook of Neurology 2e Immunology and Allergy 3e Oxford Handbook of Nutrition and Oxford Handbook of Clinical Medicine – Dietetics 2e Mini Edition 8e Oxford Handbook of Obstetrics and Oxford Handbook of Clinical Gynaecology 3e Medicine 9e Oxford Handbook of Occupational Oxford Handbook of Clinical Pathology Health 2e Oxford Handbook of Clinical Oxford Handbook of Oncology 3e Pharmacy 2e Oxford Handbook of Oxford Handbook of Clinical Ophthalmology 2e Rehabilitation 2e Oxford Handbook of Oral and Oxford Handbook of Clinical Maxillofacial Surgery Specialties 9e Oxford Handbook of Orthopaedics Oxford Handbook of Clinical and Trauma Surgery 4e Oxford Handbook of Paediatrics 2e Oxford Handbook of Complementary Oxford Handbook of Pain Management Medicine Oxford Handbook of Palliative Care 2e Oxford Handbook of Critical Care 3e Oxford Handbook of Practical Drug Oxford Handbook of Dental Therapy 2e Patient Care Oxford Handbook of Pre-Hospital Care Oxford Handbook of Dialysis 3e Oxford Handbook of Psychiatry 3e Oxford Handbook of Emergency Oxford Handbook of Public Health Medicine 4e Practice 3e Oxford Handbook of Endocrinology Oxford Handbook of Reproductive and Diabetes 3e Medicine & Family Planning 2e Oxford Handbook of ENT and Head Oxford Handbook of Respiratory and Neck Surgery 2e Medicine 3e Oxford Handbook of Epidemiology Oxford Handbook of Rheumatology 3e for Clinicians Oxford Handbook of Sport and Oxford Handbook of Expedition and Exercise Medicine 2e Wilderness Medicine Handbook of Surgical Consent Oxford Handbook of Forensic Medicine Oxford Handbook of Tropical Oxford Handbook of Gastroenterology Medicine 4e & Hepatology 2e Oxford Handbook of Urology 3e Oxford Handbook of General Practice 4e Oxford Handbook of Respiratory Medicine Third Edition Stephen Chapman Consultant and Senior Lecturer in Respiratory Medicine, Oxford University Hospitals, Oxford Grace Robinson Consultant in Respiratory Medicine, Royal Berkshire Hospital, Reading John Stradling Professor of Respiratory Medicine, University of Oxford, Oxford Sophie West Consultant in Respiratory Medicine, Freeman Hospital, Newcastle John Wrightson Specialist Registrar, Respiratory Medicine, Oxford Rotation, Oxford 1 3 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 204 The moral rights of the authors have been asserted First Edition published in 2005 Second Edition published in 2009 Third Edition published in 204 Impression:  All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 98 Madison Avenue, New York, NY 006, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2049303 ISBN 978–0–9–870386–0 Printed in China by C&C Offset Printing Co. Ltd Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding. Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work. v Forewords I’m always full of awe for the Herculean efforts of the authors when asked to write a foreword to a book. The long hours that the authors of the Oxford Handbook of Respiratory Medicine put into the first edition, published in 2005, have been compensated by the book’s clear value and popularity. Since 2005, research has increased our understanding of respiratory dis- ease, particularly in the areas of airway disease, lung cancer and interstitial lung disease. Large robust clinical trials have also informed our clinical prac- tice, and there have been subsequent modifications in national and interna- tional guidelines to reflect these. Our practice on the respiratory ward and clinic has been influenced as a result. Nationally the burden of respiratory disease is being increasingly recog- nised. The government responses to the harmful effects of cigarette smoke, currently focused on banning smoking in cars carrying children, and con- sidering plain packaging for cigarettes, highlight the ongoing prominence of smoking in respiratory health. This third edition reflects many of these updates and changes, and is therefore a reliable and useful information source. The same authors across the three editions bring consistency (and reflects admirable stamina); and the need to keep it ‘user friendly’ for the respiratory trainee has been recog- nised and a new author has been added to provide a trainee’s perspective. Ian Pavord MA DM FRCP Professor of Respiratory Medicine NDM Research Building University of Oxford This respiratory medicine handbook provides reliable and up-to-date information for the respiratory trainee. Its format is designed so that infor- mation is easily accessible and practical, with useful tips for investigation and management in the outpatient clinic and the ward. It summarizes the most recent guidelines from the British Thoracic Society when applicable in each chapter, along with a detailed discussion of each condition, perti- nent research and common practice. As such, it could be used as a learning resource when preparing for the MRCP Speciality Certificate Examination in Respiratory Medicine, or other respiratory assessments. The practical procedures section is particularly useful, with step-by-step ‘how to’ guides for all procedures encountered by the trainee, such as pleural aspiration, chest drains, thoracoscopy, and bronchoscopy. Dr Adam Hill Consultant Respiratory Physician and Honorary Reader Royal Infirmary of Edinburgh Specialist Advisory Committee Chair Respiratory Associate PG Dean SE Scotland (Quality Management) vi Prefaces This Handbook of Respiratory Medicine has been written largely by special- ist registrars, for specialist registrars. Three of the four authors, Stephen Chapman, Grace Robinson, and Sophie West, are specialist registrars on the Oxford rotation and John Stradling is Professor of Respiratory Medicine in Oxford. It is in a format that the authors would like to have had when they started their specialist registrar training. However, we hope that any health worker or student with an interest in respiratory medicine will find this text a rapid and useful reference source. The layout of the book tries to fulfil the requirement to be able to look up a topic quickly when the clinical need arises, but also to provide a bit more insight into the more difficult areas. Therefore, the chapters are of necessity different in style and reflect the authors’ own views on how to best approach and understand an area. The handbook is divided into five sections: clinical presentations and approaches to symptoms and problems; the clinical conditions themselves; supportive information; procedures; and useful appendices (also on the inside covers), containing more technical and reference information. We hope you find it helpful. Feedback on errors and omissions would be much appreciated. Please post your comments via the OUP website: M http://www.oup.com/uk/medicine/handbooks. June 2005 The second edition of this book has allowed us to make several improve- ments in response to readers’ suggestions. We have changed the order of chapters within each section to alphabetical and improved the index, to make the contents more rapidly accessible. We have added new content such as more detailed radiology, pandemic influenza, and pulmonary com- plications of sickle cell disease. In addition, we have updated and enhanced topics where there have been new guidelines and relevant publications. The overall aim of the book, to provide a rapid and comprehensive resource for all those involved in respiratory medicine, has remained paramount. October 2008 The third edition has allowed us to review and update all the existing chap- ters and include new clinical guidelines and significant research. New sec- tions on thoracic ultrasound and indwelling pleural catheters reflect changes in routine clinical practice since the previous editions. There are also new chapters on safe sedation and cardiopulmonary exercise testing. We wel- come the contribution of our new co-author, John Wrightson, who has helped maintain the specialist registrar perspective. September 203 vii Acknowledgements We would like to offer our grateful thanks to the following friends and col- leagues for their reviewing and advice on various sections of this book. First edition Dr Nicholas Bates, Dr Lesley Bennett, Dr Rachel Bennett, Dr Malcolm Benson, Dr Penny Bradbury, Mrs Debbie Buttar, Dr James Calvert, Dr Jane Collier, Dr Graham Collins, Dr Chris Conlon, Dr Chris Davies, Dr Helen Davies, Dr Rob Davies, Dr Thearina de Beer, Mrs Joan Douglass, Dr Rachael Evans, Dr Fergus Gleeson, Dr Maxine Hardinge, Dr Ling Pei Ho, Dr Andrew Jeffreys, Dr Nick Maskell, Dr Phil Mason, Dr Kim McAnaulty, Dr Fiona McCann, Dr Sarah Menzies, Dr Annabel Nickol, Dr Jayne Norcliffe, Dr Jeremy Parr, Mrs Lisa Priestley, Dr Naj Rahman, Dr Catherine Richardson, Mrs Jo Riley, Dr Peter Sebire, Mrs Gerry Slade, Dr Mark Slade, Dr S Rolf Smith, Dr Catherine Swales, Dr Denis Talbot, Dr David Taylor, Dr Catherine Thomas, Dr Estée Török, Dr David Waine, Dr Chris Wathen, Dr John Wiggins, and Dr Eleanor Wood. Second edition: additional acknowledgements Dr Luke Howard, Dr Clare Jeffries, Dr Stuart Mucklow, Dr Andrew Stanton, and Mrs Jan Turner-Wilson. Dr Fergus Gleeson and Dr Rachel Benamore provided considerable help with the radiology section. Third edition: acknowledgements Dr Henry Bettinson, Mr Peter Close, Dr Helen Davies, Mrs Julia De Soyza, Dr Prosenjit Dutta, Dr Rachael Evans, Dr Julia Fuller, Dr Helmy Haja-Mydin, Dr Bernard Higgins, Dr Ling-Pei Ho, Dr Rachel Hoyles, Ms Elaina Jamieson, Dr Alastair Moore, Dr Ben Prudon, Dr Naj Rahman, Mrs Jo Riley, Professor John Simpson, Dr Catherine Thomas, Mrs Jan Turner-Wilson, Dr Ann Ward. viii Contents Symbols and abbreviations xii Part  Clinical presentations—approaches to problems  Breathlessness  3 2 Chest pain  7 3 Chronic cough and a normal CXR   4 Critically ill patient with respiratory disease  2 5 Diffuse alveolar haemorrhage  27 6 Diffuse lung disease  3 7 Haemoptysis  43 8 Pleural effusion  49 9 Post-operative breathlessness  6 0 Pregnancy and breathlessness  65  Preoperative assessment  69 2 Pulmonary disease in the immunocompromised (non-HIV)  73 3 Pulmonary disease in the immunocompromised (HIV)  83 4 Sleep and ventilation  89 5 Unexplained ventilatory failure  95 Part 2 Clinical conditions 6 Acute respiratory distress syndrome  05 7 Asbestos and the lung   8 Asthma  25 9 Bronchiectasis  53 CONTENTS SYMBOLS AND ABBREVIATIONS ix 20 Bronchiolitis  63 2 Chronic obstructive pulmonary disease (COPD) 69 22 Connective tissue disease and the lung  89 23 Cor pulmonale  205 24 Cystic fibrosis  209 25 Eosinophilic lung disease  23 26 Extreme environments—flying, altitude, diving  239 27 Gastrointestinal disease and the lung  247 28 Hypersensitivity pneumonitis  253 29 Hyperventilation syndrome  259 30 Idiopathic interstitial pneumonias  265 3 Lung cancer  283 32 Lung transplantation  39 33 Mediastinal abnormalities  33 34 Paediatric lung disorders pertinent to adult patients  339 35 Pleural effusion  343 36 Pneumoconioses  36 37 Pneumothorax  37 38 Pulmonary hypertension  383 39 Pulmonary thromboembolic disease  397 40 Respiratory infection—bacterial  47 4 Respiratory infection—fungal  46 42 Respiratory infection—mycobacterial  485 43 Respiratory infection—parasitic  523 44 Respiratory infection—viral  529 45 Sarcoidosis  549 46 Sickle cell disease—pulmonary complications  565