Comment: Corresponding to the ideal referral letter
Philip Ind
pp 4-4
All GPs write referral letters and all consultants write replies (and referrals to other specialists). These letters represent day-to-day but important interactions that guide the crucial steps between the first patient contact and access to scarce, expensive and worrying (to the patient) hospital care. While they are vital in terms of patient care, the letters are also a potential two-way educational opportunity. Little attention is paid to this in training but, not surprisingly, much has been written about these communications and what we each expect from them.
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Palliating dyspnoea in end-stage respiratory disease
Fiona Hicks
pp 5-8
Dyspnoea, defined as an uncomfortable awareness of breathing, is a common symptom in end-stage respiratory disease. As a subjective sensation, dyspnoea often has physical, psychological, social and spiritual dimensions which form the patient’s experience, akin to the concept of ‘total pain’ coined by Cicely Saunders in the early days of the hospice movement. The pathophysiology underlying the sensation of dyspnoea remains incompletely understood and treatment is often non-specific. Effective palliation often remains elusive.
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Bronchoscopy
Jonathan I Ferguson and William S Walker
pp 9-12
Historically, rigid bronchoscopy was the only method of directly visualising the endobronchial tree and of operating or biopsing endoluminally. Flexible fibreoptic bronchoscopy has revolutionised the diagnosis and management of pulmonary diseases. Although the vast majority of endoscopic procedures are now performed with flexible bronchoscopes, there is still a well defined role for rigid bronchoscopy. Flexible bronchoscopy allows a broad spectrum of specialists to perform bronchoscopy; however, rigid bronchoscopy is still performed mainly by thoracic surgeons.
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The prevention of acute viral bronchiolitis
Warren Lenney
pp 13-15
In 1955, investigators in the USA cultured a new virus from nasal secretions in young chimpanzees with severe coryzal symptoms. They named it the chimpanzee coryza agent (CAA). In the following year CAA-like viruses were recovered from two children with severe respiratory illnesses in Baltimore. In a follow-up study of 106 infants with bronchiolitis or pneumonia, the same virus was isolated in 57% of cases. Because the virus caused cell fusion and formed syncytia in cell cultures, it was renamed respiratory syncytial virus (RSV).
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Bronchodilator therapy in chronic obstructive pulmonary disease
Stephen Iles and Christopher Swinburn
pp 16-19
Chronic obstructive pulmonary disease (COPD) is a common cause of morbidity and mortality. Many patients have moderate to severe disease at presentation. Bronchodilators remain the mainstay of treatment therapy. Which drugs to use, in what dose and by which means of delivery, are important choices to make for each patient. With the growing use of spirometers in primary care, these questions can be logically addressed in accordance with recent guidelines. This article attempts to summarise our approach to the selection of bronchodilator therapy in COPD.
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Chronic cough
Robert G Stirling and Kian Fan Chung
pp 20-23
Cough is a reflex and volitional protective mechanism of the upper airways causing expulsion of air at high velocity, enabling fluid and particulates to be dislodged and expelled from upper and lower airways. However, many conditions can accentuate the cough reflex, leading to persistence of this symptom – which is among the most common causes for presentation to the general practitioner. Chronic cough is said to exist when cough persists for more than three weeks.
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