Internal Medicine II

Module I

Dr. Rommel N. Tipones, MD, FPCCP, FPCP

TOP 10 LEADING CAUSES OF MORBIDITY IN THE PHILIPPINES

Diarrhea

Bronchitis/bronchiolitis

Pneumonia

Influenza

Hypertension

Tuberculosis

Diseases of the heart

Malaria

Measles

Chicken pox

CONDUCTING SYSTEM

From nasal cavity

and pharynx (upper
airways)

Larynx,

Trachea,

Main bronchi,

Distal bronchioles
(lower airways)

GAS-EXCHANGING
SYSTEM

Terminal
bronchioles,

Alveolar ducts and

Alveoli

TOP 10 LEADING CAUSES OF MORTALITY IN THE PHILIPPINES

Heart disease

Vascular system disease

Cancer

Road Accidents

Pneumonia

Tuberculosis

Dengue Fever

Chronic lower pulmonary diseases

Diabetes mellitus

Perinatal conditions

ANATOMY
STRUCTURES

APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION

INTRAPULMONARY
AIRWAYS

Bronchi

Membranous bronchioles

Respiratory
bronchioles/gas
exchange ducts

Venous blood drain into the azygos or hemiazygos veins,

pulmonary venules

The terminal bronchioles divide into 2-5 alveolar ducts,

each of which consists of 10-16 alveoli. Alveoli has 3 cell
types: Type I, the lining cell accounts for 95% of the
alveolar surface area. Type II cell produces surfactant, a
mixture of phospholipids, which maintains alveolar
stability. The macrophage acts as phagocytic defense vs
infection

The adult respiratory

system contains approx.
300 million alveoli. The
surface area of the
alveolo-capillary
membrane available for
02-C02
exchange
is
approximately 70-85m2

ANATOMIC DEAD SPACE

Upper
extrapulmonary
airways

Cartilaginous
intrapulmonary airways

RESPIRATORY BRONCHIOLE ALVEOLAR DUCT SYSTEM

Do not contribute to the anatomic dead space

One third of the alveolar volume

Space where fresh air ventilation enters during inspiration

AIRWAY RESISTANCE

TERMINAL
UNIT

RESPIRATORY

Alveolar ducts (100)

Alveoli (2000)

Minimal airway diameter at the terminal bronchioles (0.5

mm)

150,000 units

Large airways maintain partial constriction due to

bronchomotor tone

0.02 ml

Acinus (10 12 TRUs)

Mostly in upper airways and bronchi

CILIA

Half of the epithelial cells at all airway generations down

to the bronchioles

6 um long, 0.3 um wide

9 +2 axonemal structure/ motile

Move the superficial liquid lining layer toward the pharynx

GLANDS

Submucosa of the bronchi

Secrete water, mucins into the lumen

Release modulated by neurotransmitters/ inflammatory

mediators

GOBLET CELLS

Mucin-secreting epithelial cells

Decrease peripherally

Disappear at the terminal bronchioles

OTHER CELLS IN THE AIRWAYS

TYPE II CELLS

Basal cells

Small, cuboidal

Lymphocytes

Outnumber type I cells (15% vs 8%)

Smooth muscle cells

Synthesis, secretion and repair

Mast cells

Intracellular lamellar bodies

Internalize and recycle surfactant lipids and proteins

TERMINAL AIRWAYS

Partially ciliated low cuboidal

Interspersed with Clara cells

CLARA CELLS

Source of apoproteins

Synthesis, storage and secretion of lipids, proteins and

glycoproteins

Progenitors of ciliated cells. goblet cells, and new Clara

cells

BRONCHIAL CIRCULATION

Arteries from the aorta or upper intercostal arteries (hilum)

Blood supply to the trachea, bronchi, pulmonary vessels,

visceral pleura

TYPE I CELLS

Large, flattened

Accounts for 90 to 95% of the alveolar surface area of the

peripheral lung

Provide a large, thin cellular barrier for gas exchange

AIR SPACE MACROPHAGES AND LYMPHATICS

Superficial plexus of lymphatics

Deep plexus of lymphatics

Regional pulmonary lymph nodes

Extrapulmonary lymph nodes around the primary bronchia

and trachea

APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION

PHYSIOLOGY

During systole, deoxygenated blood returning from the bodys

cells is pumped from the right ventricle through the arterial
pulmonary circulation to the alveolar capillaries. CO2 diffuses
from the capillary blood across alveolo-capillary membrane and
enters the alveolar air. Simultaneously, O2 from inspired atm. air
in the alveolus crosses the alv.cap. membrane and enters the
pulmonary capillary blood

During expiration, CO2 is exhaled from the lungs. Oxygenated

blood travels to the left side of the heart and is pumped from the
ventricle into the arterial circulation to the cells of the body, where
cellular respiration occurs

RESPIRATORY FAILURE

FUNCTIONS

Diffusion of O 2 and CO2

Adequate provision of fresh air to the alveoli (VENTILATION)

Adequate circulation (PERFUSION)

Adequate movement of gas between alveoli and pulmonary

capillaries (DIFFUSION)

Appropriate contact between alveolar gas and pulmonary

capillary blood(VENTILATION-PERFUSION matching)

Repeated 12 to 16 times per minute

Has a tidal volume of 500 mL

Has a portion (30%) which does not reach the alveoli (anatomic
dead space)

Has the remaining 70% reaching the alveolar zone

Inability of the lung to meet the metabolic

the body.

Failure of tissue oxygenation and/or

Failure of CO2 homeostasis

demands of

Clinical definition:

PaO2 <60 mmHg while breathing air, or

PaCO2 >50 mmHg

PHYSIOLOGY OF RESPIRATION

During inspiration, as these muscles contract, the thorax

expands. Intrathoracic pressure decreases, drawing air into the
tracheobronchial tree into the alveoli and expanding the lungs.
Gas exchange takes place in the alveoli

After inspiratory effort stops, the expiratory phase begins. The

chest wall and the lungs recoil, the diaphragm relaxes and rises
passively, air flows outward and the chest and abdomen return to
their resting positions

During inspiration, air enters the upper airway, travels through the
lower airways until it reaches the alveoli. Each alveolus is
surrounded by multiple capillaries

Ventilation is the movement of atmospheric air into and out of the

lungs. Ventilation consists of 2 components: alveolar ventilation
and dead space ventilation. Alveolar ventilation is also known as
effective ventilation because it is that portion of inspired air that
actually reaches the alveoli and participates in gas exchange.
Dead space ventilation, also known as ineffective or wasted
ventilation, is that amount of inspired air that does not participate
in gas exchange. The normal dead space ventilation (inspired air
that does not reach the alveoli-includes all the conducting
airways) in an adult individual is approximately 150CC.

APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION

APPROACH TO PATIENT WITH

RESPIRATORY DISEASE

SYMPTOMS

ABNORMALITY ON A CHEST RADIOGRAPH

HISTORY OF SYMPTOMS

Common

Dyspnea/ Shortness of breath

Acute (mins to
days)
Airways

Subacute (days
to weeks)

Smoking cessation

COPD and cancer

Second hand exposure

Inhaled agents

Asbestos, silica dusts pneumoconiosis

Molds, animal proteins hypersensitivity pneumonitis

Dust mites, pet dander,

exacerbation of asthma

Exposure to infectious agents/contact with infected

individuals

Chronic

Exacerbation of
airway disease

Exacerbations
remissions

Lung
parenchyma

Slow infection or
inflammation

COPD

Pleural space

Neuromuscular
disease

CILD

Pulmonary
vasculature

Chronic
disease

Chronic
disease

cardiac

Coexisting illness

AIDS

Previous treatments

Family history

allergens

PHYSICAL EXAMINATION
cardiac

Cough

May indicate the presence of lung disease

Sputum often suggests airway disease

Chronic cough
o

Asthma

Chronic
Disease

Gastroesophageal Reflux Disease

Postnasal drip

Pulmonary Tuberculosis

Obstructive

cockroach

Inspection

Palpation

Percussion

Auscultation

Extrapulmonary manifestations

Meticulous

Enlarged lymph nodes

Mentation

Signs pointing to smoking

Clubbing

Extrapulmonary findings

Pulmonary

Less common

Hemoptysis
Airways

Lung Parenchyma

Vasculature

Inflammatory
bronchitis
bronchiectasis
cystic fibrosis
neoplastic tumors
Localized
pneumonia
lung abscess
tubercolsis
aspergillosis
Diffuse
Pulmonary thromboembolic
disease
Arteriovenous malformations

Chest pain/ Pleurisy

Pleuritic

Accentuated by respiratory motion

Neoplasms/inflammation involving pleura

Parenchymal disorders extending to the pleura

ADDITIONAL HISTORIC INFORMATION/RISK FACTORS

Smoking

Current and past

Cigarettes

Number of years

Intensity

APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION

DIAGNOSTIC MODALITIES IN
PULMONOLOGY

Imaging studies

Techniques for acquiring specimens

Direct visualization

Pulmonary function testing

Ancillary procedures

ROUTINE RADIOGRAPHY

Posteroanterior and Lateral

Lateral decubitus

Apicolordotic

Anteroposterior

BASICC APPROACH TO RADIOGRAPHY

Background

Survey

Identify

Compare

Conclude

COMPARISON OF CXR FINDINGS IN ATELECTASIS,

PNEUMONIA, & PLEURAL EFFUSION
ATELECTASIS

PNEUMONIA

PLEURAL
EFFUSION

Margins sharply
defined & linear

Margins indistinct
unless
disease
strictly lobar or

Increases opacity
of
involved
hemithorax; at bases

Segmental

Often layers when

placed on decubitus
position

Tends to occur at
outer third of lung
Areas of lung
adjacent
to
atelectatic
regions
may be hyperlucent

Distribution tends
to be patchy rather
than linear

COMPUTED TOMOGRAPHY

May mimic pleural

thickening

Tends to respect
lobar & segmental
boundaries

Cross-sectional images

Better tissue density

Accurate size

Hilar and mediastinal disease

Pulmonary nodule assessment

Conventional CT

Helical CT

CT angiography

High-resolution CT (HRCT), multi-slice

Virtual bronchoscopy

APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION


MAGNETIC RESONANCE IMAGING

Bronchoscopy

VATS

Thoracotomy

Mediastinoscopy/Mediastinotomy

Percutaneous needle aspiration

Thoracentesis

Bronchoscopy

Rigid/flexible

Relies on energy generated by tissue when

Oral/nasal

Placed in strong magnetic field

Washing

MRI resolution limited to 3-4 mm

Brushing

Susceptible to motion

Biopsy

Superior in studying blood vessels & different soft tissues esp at

hilum & mediastinum

Bronchoalveolar lavage

Transbronchial biopsy

SCINTIGRAPHIC IMAGING

Radioactive isotopes

Ventilation-perfusion scanning

Albumin
macroaggregates
labeled with technenium 99

Inhaled radiolabeled xenon

gas

Video-Assisted Thoracoscopic Surgery (VATS)

Thoracotomy

Mediastinoscopy and Mediastinotomy

SPUTUM COLLECTION

Spontaneous expectoration; sputum induction

Adequate specimen: PMNs > 25/LPF; SECs < 10/LPF

Grams staining and culture

POSITRON EMISSION TOMOGRAPHIC SCANNING

Mycobacteria or fungi

(PET SCAN)

Viruses

Pneumocystis carinii

Cytologic staining

Polymerase chain reaction amplification

DNA probes

Identify malignant lesions

Increased uptake and metabolism of

glucose

F-fluoro-2-deoxyglucose (FDG)

PULMONARY ANGIOGRAPHY

Pulmonary artery

Pulmonary embolism

ENDOBRONCHIAL PATHOLOGY ON BRONCHOSCOPY

Filling defect

Tumors

Cutoff

Granulomas

Pulmonary AVMs

Sites of bleeding

Arterial invasion by neoplasm

Bronchitis

Being replaced by CT Angiography

Foreign bodies

Treatment

ULTRASOUND

Uses sonar

Limited use; doesnt pass through bone or air-filled spaces

Used to quantify pleural effusion and to guide percutaneous

needle aspiration of accessible masses/fluid

OBTAINING BIOLOGIC SPECIMENS

Laser therapy

Cryotherapy

Electrocautery

Stent placement

Therapeutic uses of bronchoscopy

Remove retained secretions/mucus plugs

Remove foreign bodies

Remove abnormal endobronchial tissue

Perform difficult intubation

BLOOD GASES

Assessment of oxygenation capacity

Assessment of oxygen pressure to guide therapy

Assessment of respiratory adequacy
Assessment of acid-base balance

Sputum Collection

Percutaneous needle aspiration

Thoracentesis

APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION


Arterial Sampling Sites

The illustration to the left shows

the location of the most commonly
used arterial sampling sites. These
include the radial artery, brachial
artery, and femoral artery. Of these
three articles, the radial artery
(lying in the wrist area on the
thumb side) is the preferred
sampling site owing to 3 primary
factors: 1) it is easy to access, 2) it
is a superficial artery (it is easier to
palpate, stabilize, and puncture a
superficial artery rather than a
deeper on) and 3) it has collateral blood flow.
If damage to the radial artery occurs or if it becomes obstructed,
the ulnar artery will supply blood to the tissues normally supplied
by the radial artery

Surrogate marker for risks of other common lifethreatening illnesses, e.g. lung cancer

Predictive of mortality

Spirometry and the Lung Volumes and Subdivisions

NORMAL ARTERIAL BLOOD GAS VALUES

pH :

7.35 7.45

pO2:

80 100 mmHg

pCO2:

35 45 mmHg

HCO3:

22 26 meq/L

SaO2:

97 100% (SAT)

CONTRAINDICATIONS FOR ARTERIAL PUNCTURE

Anticoagulant therapy

History of a clotting disorder (haemophilia)

History of arterial spasms following previous punctures

Severe peripheral vascular disease

Abnormal or infectious skin processes at or near the puncture

sites

Arterial grafts

PULSE OXIMETRY

Alternative method to assess oxygenation

Calculates oxygen saturation (not PaO2 )

An arterial PO2 of 60 mmHg corresponds to an SaO2 = 90%

Helium dilution method

Helium is diluted by gas present in lungs

Very little helium is absorbed into the pulmonary

circulation

May underestimate the actual volume

Body plethysmography

Patients sits in sealed body box

Closed mouthpiece

Measures pressure changes

Spirometry and the Lung Volumes and Subdivisions

Graphical Representations of Spirometry

Measures

SPIROMETRY

Measures rate at which lung volume is changing as a function of

time during breathing maneuvers

Simply put: measures lung volume and airflow from fully inflated
lungs

INDICATIONS

To evaluate symptoms, signs or abnormal laboratory tests

To measure the effect of disease on pulmonary function

To screen persons at risk of having lung disease

To assess preoperative risk

To assess prognosis

FVC

To assess health status before enrollment in strenuous

physical activity programs

FEV1

FEV1/FVC

NEED

Measurement of Volume

Measurement of Air Flow

Essential in separating obstructive from restrictive lung

diseases

PEFR/ Peak Flow/MEF

Necessary to judge response to therapy

FEF25-75, FEF50, FEF75

Necessary in plotting the course and prognosis of many

lung diseases

Inspiratory counterparts

MVV

APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION


Parameters are expressed as actual values and their % predicted

Measurement of Gas Exchange

AbN spirometry antedates onset of dyspnea by at least 10 years.

Once with SOB. AO is already significant: Early Detection Needed

Arterial blood gases

Alveolar-arterial gradient: A-a gardient

[ (713 x FiO2) pCO2/0.8)] paO2

Less than 15 mm Hg
Pulse oximetry
Diffusing Capacity (DLCO)

DISTURBANCES IN RESPIRATORY FUNCTION

Ventilatory function
Pulmonary function
Gas exchange

Patients of Abnormal Ventilatory Function

Obstructive

Decreased expiratory flow rates

Decreased FEV1/FVC ratio

Normal or increased TLC

RV is elevated
Restrictive

Decreased TLC

Parenchyma vs extraparencymal

SMOKING CESSATION
HEALTH HAZARDS OF SMOKING
WHAT IS THE MAGNITUDE OF THE PROBLEM?

Obstructive

Asthma
Chronic obstructive
emphysema)
Bronchiectasis
Cystic fibrosis
Bronchiolitis

lung

disease

(chronic

bronchitis,

Restrictive/Parenchymal

Sarcoidosis
Idiopathic pulmonary fibraosis
Pneumoconiosis
Drug-or radiation-induced interstitial lung disease

Restrictive/Extraparencymal

Neuromuscular

Diaphragmatic weakness/paralysis

Myasthenia gravis

Guillain-Barr syndrome

Muscular dystrophies

Cervical spine injury

Chest wall

Kyphoscoliosis

Obesity

Ankylosing spondylitis

Locally....

43% of adult males and 8% of females smoke

63% of male physicians and 37% of female physicians

smoke

38% of the respondents said they smoke in front of their

patients

Only 59% advised patients on the ill effects of smoking

Tobacco smoke contains more than 7000 toxic chemicals.

These chemicals can cause disease, whether tobacco is

chewed or inhaled
Benzene (petrol additive)
A colourless cyclic hydrocarbon obtained from coal and
petroleum, used as a solvent in fuel and in chemical
manufacture - and contained in cigarette smoke. It is a known
carcinogen and is associated with leukaemia.
Formaldehyde (embalming fluid)
A colourless liquid, highly poisonous, used to preserve dead
bodies - also found in cigarette smoke. Known to cause cancer,
respiratory, skin and gastrointestinal problems.
Ammonia (toilet cleaner)
Used as a flavouring, frees nicotine from tobacco turning it into a
gas, found in dry cleaning fluids.
Acetone (nail polish remover)
Fragrant volatile liquid ketone, used as a solvent, for example,
nail polish remover - found in cigarette smoke.
Tar
Particulate matter drawn into lungs when you inhale on a
lighted cigarette. Once inhaled, smoke condenses and about 70
per cent of the tar in the smoke is deposited in the smoker's
lungs.

Diffusion of Oxygen and Carbon Dioxide

Ventilation & Perfusion Matching

There are 1.1 billion smokers worldwide - about 1/3 of

the global population aged 15 years and older.

WHAT IS IN A CIGARETTE?

Disturbance in Gas Exchange

Globally....

APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION


Nicotine (insecticide/addictive drug)
One of the most addictive substances known to man, a
powerful and fast-acting medical and non-medical poison. This
is the chemical which causes addiction.
Carbon Monoxide (CO) (car exhaust fumes)
An odourless, tasteless and poisonous gas, rapidly fatal in
large amounts - it's the same gas that comes out of car
exhausts and is the main gas in cigarette smoke, formed when
the cigarette is lit. Others you may recognize are :
Arsenic (rat poison), Hydrogen Cyanide (gas chamber poison)

TABACCO RELATED DISEASES

WHAT IS THE HARMFUL EFFECTS OF SMOKING?

Tobacco has been shown to cause about 40 life-threatening

diseases.
Smoking kills 10 Filipinos every hour

TABACCO ADVERTISING

Makes smoking socially acceptable

Influences smokers to smoke more
Influences non-smokers to start smoking
Discourages smokers from giving up

SMOKING IS ADDICTIVE

Tobacco is a drug. It is addictive, which means it is difficult to

stop using it, even when one wants to stop.
Once you become physically addicted to the nicotine in
tobacco, you only feel comfortable when it is in your body.
Nicotine acts on certain receptors in the brain, releasing
hormones and neurotransmitters, including dopamine,
norepinephrine and serotonin, vasopressin, and betaendorphine.
The smoker feels pleasure, reduced tension, appetite
suppression, and enhanced performance.
The smokers brain gets accustomed to a certain level of
nicotine and tolerance develops. Eventually, the brain
becomes dependent on nicotine to produce even normal levels
of dopamine.
Higher levels of nicotine become necessary to produce the
same effects that lower doses used to produce, causing the
smoker to smoke even more.
Overnight, nicotine dissipates in the body, the smokers craving
returns, and the cycle starts over.
While people begin using tobacco and other substances to feel
high, they end up using them so they wont feel low.
Highly controlled or compulsive pattern of drug use
Smokers are driven by the bodys need to smoke
Mood altering effects of tobacco
Smokers report that it in increases their feeling of well-being
and keeps them relaxed
Drugs function as a reinforcer
Once youve smoked one cigarette youll want to smoke
another
Withdrawal syndrome
When people stop smoking, a consistent pattern of withdrawal
follows. The following are typical signs and symptoms that can
be observed within 24 hours of not smoking:

Sleep disturbances

Craving

Increased appetite

Decreased heart rate

Restlessness

Anxiety

PRACTICAL TIPS and FEASIBLE OPTIONS

LIMITATIONS

Reliant on predominantly foreign data

Discussion of details of counseling and behavior modification

entails a significantly greater amount of time than what is
allotted

WHY BOTHER?

Smoking is the single most important cause of preventable

mortality and morbidity

Smoking cessation is beneficial

Smoking cessation is not impossible

Smoking cessation programs can be implemented in all levels

of health care

Smoking cessation program is mandatory

SMOKING IS A MEDICAL ILLNESS

Nicotine dependence
Nicotine addiction
Stronger addiction than to narcotics
Must be treated as a chronic illness

APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION


SMOKING IS THE SINGLE MOST IMPORTANT
PREVENTABLE MORTALITY and MORBIDITY

CAUSE

OF

Bans on tobacco advertising and promotion

Policies designed to prevent smoking in public spaces

or workplaces

Pharmacological therapies to help smokers to quit

Attributable to tobacco smoking

7090% of lung cancer

5680% of chronic respiratory diseases

22% of cardiovascular diseases

A reduction in the prevalence of tobacco smoking would be the

single most effective preventive health measure

80% of the worlds 1.1 billion smokers live in low income

countries

By 2030, seven out of every 10 deaths from smoking will occur

in low income countries

P46 B in health care cost & productivity losses

SMOKING CESSATION PROGRAMS ARE MANDATORY

Republic Act No. 9211- An Act regulating the packaging, use,
sale, distribution and advertisement of tobacco products and for
other purposes

Sec.33.c. National Smoking Cessation Program- A

National Smoking Cessation Program shall be
undertaken with the approval of the IAC-Tobacco.

Sec.33.h. Withdrawal Clinics- The DOH shall establish

smoking withdrawal clinics to provide counselling
regarding
the
hazardous
health
effects
of
tobacco/cigarette smoking and to rehabilitate smokers
from the hazardous effects of such products

SMOKING CESSATION IS BENEFICIAL

A reduction of 15% is seen in the RR of all-cause mortality in

heavy smokers subjected to intensive clinical cessation
interventions.

The risk of lung cancer is 30% to 50% lower than that of

continuing smokers after 10 years of abstinence.

IS IT FEASIBLE?

To integrate intensive smoking cessation interventions in the

usual clinical setting?

Limited time

Limited resources

Limited motivation

Yes!

Different levels of intervention

Minimal time and resources needed

Even the seemingly brief and trivial interventions are

still beneficial

Set the stage for more intensive intervention

Motivation of both the patient AND the health care provider is

important

THEORETICAL FRAMEWORK
SMOKING CESSATION IS NOT IMPOSSIBLE

Simple advice from a physician to stop smoking improves

smoking cessation rates (odds ratio [OR], 1.74; 95% confidence
interval [CI], 1.482.05).

High intensity counselling of greater than 10 minutes can

increase six month quitting rates to 22 percent when added to
any quitting method, cold turkey or NRT

Drug treatments result in better smoking cessation rates than

placebo.

Treatments, alone or in combination, improve cessation rates

over placebo after 6 months (OR, 1.77; 95% CI, 1.661.88).

Typical Long-term quit rates

Models for chronic illness and behaviour modification

Measures that could increase compliance

ADHERE TO LONG TERM TREATMENT

Increasing the effectiveness of adherence interventions may

have a far greater impact on the health of the population than
any improvement in the specific medical treatments.

Stages of Change Model

Describes how people modify a problem behavior or

acquire a positive behavior

Theoretical basis for developing effective interventions

to promote health behavior change

Conceptualizes change as a phenomena occurring over time,

not a single event

Change progresses over a series of

5 stages:

SMOKING CESSATION PROGRAMS CAN BE IMPLEMENTED IN ALL

LEVELS OF HEALTH CARE

Measures to reduce tobacco supply are difficult to implement

Interventions to reduce the demand for tobacco

Higher tobacco taxes

Antismoking education

Pre-contemplation

Contemplation

Preparation

Action

Maintenance

10

APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION


Pre-contemplation

People are not intending to take action in the near future (6

months)

May be uninformed/under-informed or tried to change but failed

Is not seriously considering stopping smoking.

Contemplation

People intend to change in within the next 6 months

Are more aware of pros of changing but also acutely aware of

cons

Social support from clinicians in the form of

encouragement, assistance

Skills training/problem solving (cessation/abstinence

techniques)

Pharmacotherapy, such as nicotine-replacement,

e.g., patches, gum

SMOKING CESSATION AT THE INDIVIDUAL LEVEL

More feasible and may be the only option in most settings

Balance of pros and cons can cause ambivalence and state of

chronic contemplation or behavioral procrastination

Maximize the potential of providing intervention at each clinic

visit

Employ measures to enhance adherence to treatment

Is seriously considering stopping within 3 to 6 months.

Prompt referral to appropriate specialized clinics or groups

IMPROVING ADHERENCE (WHO)

Preparation

People intend to take action in the immediate future (1 month)

Have a plan of action, have taken preparatory steps

Is seriously considering stopping within the next week to month,

and has already made changes such as cutting back.

May be recruited for programs

Patient-tailored interventions are required

Action

There is no single intervention strategy, or package of

strategies that has been shown to be effective across
all patients, conditions and settings. Consequently,
interventions that target adherence must be tailored to
the particular illness-related demands experienced by
the patient. To accomplish this, health systems and
providers need to develop means of accurately
assessing not only adherence, but also those factors
that influence it.

People have made overt modifications in lifestyle (past 6

months)

Not all behavior is action; must be proven to have benefits

Has recently stopped smoking (within last 6 months).

ASK, ADVISE, ASSESS, ASSIST, and ARRANGE model

Vigilance against relapse is critical

Model based on outcomes from six major

clinical trials of physician-delivered smoking
intervention conducted in the late 1980s

INDIVIDUAL INTERVENTION

Maintenance

People are working to prevent relapse

Less tempted to relapse, more confidence that change can

continue

Has quit for at least 6 months, but may still

be vulnerable to a relapse up to 1 year.

Advocacy

Interventions are most effective if they are attuned to specific

stages of change

Entails a thorough understanding of which stage a particular

patient is in

Interventions can be tailored according a patients needs

Intervention will be more efficient (in the face of limited time and
resources)

Ask, Advise, Assess, Assist, Arrange: Key Elements

Ask

Advise

Minimal Advice: As your physician, I must advise

you that smoking is bad for your health, and it
would be important for you to stop.

Augmented Advice: Because of your (__________)

condition, it is particularly important for you to stop. If
you stop now, (briefly educate patient about basic
health benefits from quitting).

Assess

Minimal Assessment: Ask every tobacco user if

he/she is willing to make a quit attempt at this time.

Augmented Assessment: Assess characteristics of

smoking history and patterns.

GENERAL GUIDELINES

Clinicians should document the tobacco-use status of

every patient.

Clinicians should assess the readiness to quit of patients

who use tobacco and assist those who wish to quit in
setting a quit date.

Patients using tobacco should be provided with at least one of

the effective brief cessation interventions that are available.

In general, more intense interventions are more effective than

less intense interventions in producing long-term tobacco
abstinence, reflecting the dose-response relationship between
the intervention and its outcome.

One or more of the three treatment elements identified as being

particularly effective should be included in smoking-cessation
treatment:

Screen for smoking status at every visit or

admission.

Amount smoked.

Quit history.

Stage of Change

Nicotine Addiction: Fagerstrom Test for

nicotine dependence

Assist/Counsel

Minimal Assistance: Provide self-help materials;

assess interest in quitting; assess interest in and
appropriateness of pharmacological aids.

Augmented Assistance: Provide brief 5 to 7 minute

patient-centered counselling.

Arrange Follow-up Support

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APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION


Minimal Follow-up Support: Arrange for single
follow-up contact by visit or by telephone in about 2
weeks; provide referral to a smoking counselor or
group.

Extended Follow-up Support: Establish quit smoking

contract with quit date. Arrange three or more follow-up
contacts by visit or by telephone.

PHARMACOLOGIC INTERVENTIONS

Drugs address the physiologic component of nicotine addiction

by decreasing withdrawal symptoms and urges

Timing of their use coincides with the period where the severity
of withdrawal symptoms and relapse is greatest

Not expected to work in unmotivated or unwilling patients

The impact in a study of nicotine patch and nicotine nasal spray

used with minimal behavioural intervention in a non-specialized
setting was smaller in magnitude.

The choice of therapy should be individualized based on a

number of factors

FOR THE BUST CLINICIAN

Pre-contemplation

Educate patient

Correct misconceptions

Past experience

Encourage patient to consider quitting

Patient and/or physician preference

Potential agent side effects

Contemplation

Emphasize benefits, reassure on side-effects

Motivate the patient

Tip the balance, pros outweigh cons

Each piece typically contains 2 or 4 mg of nicotine

Convince patient to quit, strengthen the intention

Appropriate dosage depending on the smoking habits of the

user

Preparation

Assist the patient

May also address oral fixation

Help patient gain confidence in overcoming temptations

Instructions for use:

Refer to specialized programs

Gum is first chewed until it is soft and a tingly sensation

and/or peppery taste is noticed

Support the patient

Pressed between the cheek and gums (parking)

Address withdrawal symptoms

Give medications

When the tingly sensation stops, the gum is chewed

again, and then pinched between the cheek and gums
in a different place in the mouth

Commend the patient on his efforts

WOF relapse

Continued until the gum is depleted of nicotine (about

30 minutes)

Action

Nicotine Gum

Maintenance

Commend the patient on the accomplishment

Involve the patient on the advocacy

Work at sustaining abstinence

FOR THE BUSY CLINICIAN AND THE PATIENT WHO IS READY

TO QUIT

S et a quit date. Not even a single puff after

The total recommended dose is 10 to 12 pieces of gum daily for

13 months.

After 3 months, a gradual withdrawal from gum use is

recommended, with completion of treatment within 6 months

Hiccups, perceived constriction of the throat muscles, gum

disease

Varenicline

Blocks nicotine from activating alpha4beta2 nicotinic receptors,

which in turn prevents dopamine stimulation in the brain.

Should a patient decide to smoke while using this drug, there is

no nicotine "feel good" rush, and the smoking experience is flat;
dull.

Six clinical trials involving 3659 chronic cigarette smokers were

used as a basis for the effectiveness of Varenicline as a therapy
for smoking cessation.

Five of the trials were randomized, placebo-controlled studies,

and showed that Varenicline was more effective than a placebo
to help people quit smoking.

Urge to smoke after a meal, etc., urges usually pass

after a few minutes

Sold as 0.5 mg and 1 mg tablets

Titrating the dose from 0.5 mg every day for 3 days to 0.5 mg
twice daily for 4 days to 1 mg twice daily is recommended

Smoking settings: bars, parties, etc.

Not recommended for use by children, those under 18 years

old, pregnant or breastfeeding women

Smoking settings, cues: stress, coffee, alcohol, etc.

Relaxation techniques for stress; Exercise; do other

things when bored

Nausea, headache, difficulty sleeping, and abnormal dreams,

change in taste, vomiting, abdominal pain, flatulence, and
constipation

Post-marketing reports

the quit date. Sign contract.

T ell friends, family, co-workers of plans to quit.

A nticipate challenges to planned quit

attempt. Find new habits.

R emove tobacco products from your

environment. Reward yourself.

FOR THE BUSY CLINICIAN AND THEPATIENT WHO WILL DEAL

WITH TEMPTATIONS

Delay

Escape

Avoid

Distract

suicidal ideation

occasional suicidal behaviour

erratic behaviour

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APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION

Unknown whether the psychiatric symptoms are related to the

drug or to nicotine withdrawal symptoms

INTERVENTIONS FOR IMPROVING ADHERENCE

Socioeconomic-related factors

() High treatment cost

(+) Higher education levels, older age

cial assistance

Health care team/health system-related factors

() Unavailability for follow up or lost to follow up

(+) Access to free NRT; more frequent contact with

physicians and pharmacists

Pharmacist mobilization ; access to free NRT; frequent

follow-up interviews

Condition-related factors

() Daily cigarette consumption; expired CO, plasma

nicotine and cotinine levels; Fagerstrom Tolerance
Questionnaire (FTQ) scores ; greater tobacco
dependence ; psychiatric comorbidities; depression;
failure to stop or reduce smoking during treatment

Education on use of medications; supportive psychiatric

consultation

Therapy-related factors

(+) Attendance at behavioural intervention sessions

NRT; antidepressant therapy; education on use of

medications; adherence education; assistance with
weight
reduction;
continuous
monitoring
and
reassessment of treatment; monitoring adherence

Patient-related factors

() Weight gain

(+) Motivation; good relationship between patient and

physician

Adjunctive
psychosocial
treatment;
behavioural
intervention; assistance with weight reduction; good
patientphysician relationship

SUMMARY

There is an acute need to establish a form of smoking cessation

program in all health care settings

We should apply the general principles of approach to chronic

illness and adherence to long term treatment in the
management of patients who wish to stop smoking

Strong evidence support the benefit of various modalities

employed in management of nicotine dependence

Integration of aspects of smoking cessation interventions in

usual clinical practice is possible

Brief clinic interventions, referral to specialized programs and

pharmocotherapy should be offered to patients who are
smokers
~END~

That in all things, God may be glorified

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APPROACH TO PATIENT WITH RESPIRATORY DISEASE and SMOKING CESSATION