Lung Health  

In Hong Kong, Lung Cancer was the most common cancer in men and the third commonest cancer in women. Lung cancer was also the leading cause of death from cancer in men and women. In the early stages, lung cancer usually has no noticeable symptoms. Hence, most patients are diagnosed at an advanced, and thus non-curable disease stage. Survival time of lung cancer patient decreases significantly with progression of disease. It is therefore crucial to detect lung cancer early, before symptoms occur and while curable therapy is still achievable.

Tobacco smoking, including second-hand smoke, is the most important risk factor for lung cancer. Screening is often considered for individuals with a significant history of heavy smoking. However, screening with chest X-ray or sputum cytology did not reduce lung cancer mortality. An important American landmark study* showed that screening with Low Dose CT Thorax (LDCT) in specified high risk population could reduce mortality 20% when compared using Chest X ray as screening tool.

 
 
 
Lung Function Test
 
The Procedure
The Test measures the amount and speed of air that could be inhaled into and exhaled from the Respiratory system (nose, larynx, trachea, bronchus and lung alveoli) pressure changes, volume of air inspired, expired or remained in the lungs during breathing, and alveoli gas exchange function. The test will not cause any pain but may cause some feeling dizzy or mild shortness of breath.
 
Clinical Applications
The Test could detect airway obstruction, lung restriction or gas diffusion defects. It may diagnose abnormalities in patient’s lung function, natures of abnormalities/defect, causes of shortness of breath, site of pathology, severity of illness. It could monitor the clinical course and predict the prognosis, assess the treatment response and help with pre-operative assessment.  
   
1. Spirometry  

Spirometry is the most commonly ordered lung function test. It could be used to differentiate “Obstructive” and “Restrictive” lung defect. It is useful to assess the severity of airway diseases, treatment response, lung function impairment, cause of shortness of breath, occupation related lung problems and surgical risk.

 
   
2. Bronchodilator/Reversibility Test  

Bronchodilator/Reversibility Test is performed when obstructive defect is found in the baseline spirometry. Bronchodilator will be given to the patient and spirometry will be repeated. This test is useful to demonstrate the reversibility of airway obstruction.

 
   
3. Lung Volume Examination  

Lung Volume Examination is useful to differentiate Restrictive lung defect from Obstructive lung defect. Total Lung Volume and Residual Lung Volume are two important components of this test. Lung volume is typically raised in patients with emphysema.。

 
   
Reference : Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology 28 (Supplement 4): iv1–iv21, 2017 doi:10.1093/annonc/mdx222  
 
 
Conclusion
If one has airway diseases (Asthma or COPD), unexplained chronic cough, chest tightness or wheezing, then one should consider lung function test. Comprehensive Lung function test is also an essential risk assessment modality prior to lung resection.
 
Remarks:
This is general information only and the list of complications is not exhaustive. Other unforeseen complications may occasionally occur. In special patient groups, the actual risk may be different. For further information please contact your doctor. Evangel Hospital reserves the right to amend this leaflet without prior notice. We welcome suggestions or enquiries on the information provided in this leaflet. Please contact our ward nurses so that we could follow up and make improvement.
 
 
 
 
 
 
Lung Health Awareness Program & Lung Cancer Screening

Both lung cancer and chronic obstructive pulmonary disease (COPD) share similar risk factors (tobacco use and secondhand smoke in common). In addition, COPD is associated with an increased risk of lung cancer. LDCT for lung cancer screening may also identify previously undiagnosed COPD. Thus, both Lung cancer and COPD are common and potential lethal smoking related health hazards in Hong Kong.

Screening means testing for a disease when there are no symptoms of that disease. Doctor recommend a screening test to find a disease early, when treatment may work better in that person. Hence not everyone will get benefit from screening program. Our Lung Health Awareness Program targets at Lung Cancer and COPD screening in smoking population.

Target
● 55 to 80 years old
● Current smokers or people who have ever smoked

 
 
 
Lung Health Awareness Program

● Respiratory physician assessment
● Low dose CT thorax exam
     - effective in detecting lung cancer
● Lung function test
     - diagnosing & assessing the severity of COPD
● Chest X-ray
● Pulse Oximetry
● Investigation Report

 
 
 
Lung Cancer Screening

● Respiratory physician assessment
● Low dose CT thorax exam
     - effective in detecting lung cancer
● Chest X-ray
● Pulse Oximetry

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

肺癌篩查新知

 
     
 

毫無疑問吸煙是肺癌的主要原因,但肺癌絕不僅僅是吸煙者的疾病。全球男性的吸煙率逐漸下降,但女性的吸煙率保持穩定或下降速度較慢[1]。然而,前吸煙者在戒煙後25年內仍處於肺癌高風險中[2]。此外,從不吸煙者肺癌的患病率也在逐漸上升:在英國和美國,大約20%的肺癌發生在從不吸煙的人身上,這個數字在一些亞洲國家高達約為53%[3]。肺癌死亡的性別分佈也發生了全球變化,許多國家的女性死亡率大多在上升[4]。綜合所有因素,未來幾十年肺癌患者的數量可能仍然很大。

與大多數癌症相比,肺癌的預後很差,這主要是大部分病例在晚期才被發現,病人到了那時可選擇的治療方案將會有限。由於大多數人難以將持續咳嗽、呼吸急促和肺部反復感染等症狀識別為肺癌的症狀[5],因此許多人僅在癌症發展到治療選擇有限且預後不良的階段,才向醫護人員求診 [6]。大約只有20%的肺癌患者在肺癌第一期被診斷出來,此時他們五年的存活率仍能在68-92% 之間,相比之下,超過 40% 的肺癌病人在第四期時才被檢測到,此時他們五年的存活率已降至低於10%。

因此,如果能在肺癌的早期階段就診斷出來,便能顯著減少肺癌死亡人數。能實現這種目標的最有效方法是使用低輻射量胸腔電腦掃描(LDCT)進行針對性篩查。一項名為 NELSON的大型醫學研究[7]表明,對目前和以前的重度吸煙者進行 LDCT 篩查,可以使肺癌的早期診斷發生顯著的階段轉變。在這項試驗中,篩查組(使用LDCT)868 例死亡中有 18.4% 是由於肺癌,而對照組 860 例死亡中有 24.4% 是由於肺癌。這相當於十年內男性肺癌死亡率降低了24%,亦發現當中女性肺癌死亡率降低了33%。這些重要發現使世界各地的專家確信以LDCT作肺癌篩查,可降低肺癌死亡率的說法是無可爭議的[8-10]

目前的肺癌篩查建議是對特定年齡範圍內的當前或以前的重度吸煙者進行LDCT 篩查[11,12]。 然而,醫學專家越來越認識到吸煙狀況不足以識別所有肺癌高危群組。例如,在台灣,53%的肺癌死亡發生在從不吸煙的群組中[13]。在中國內地,39.7%至48%的肺癌發生在非吸煙者中[15,16]。並且專家越來越多認識到諸如家族史、接觸烹飪油煙和接觸環境致癌物等風險因素也與肺癌有關[14]

對於使用LDCT作肺癌篩查,主要風險是電腦掃描所引起的輻射暴露和假陽性結果導致的誤診。但隨機臨床試驗的累積數據顯示,LDCT 篩查的輻射暴露風險是可以接受甚或微不足道[17]。如果在高質量標準下進行,LDCT 篩查不會導致大量假陽性結果或後續不必要的程序或治療[18]

有針對性的篩查計劃可以幫助具有明確風險因素(例如吸煙狀況和年齡)的人士; 然而,風險因素較少但卻出現肺癌症狀的人士也需要盡快求診,以便醫護能盡快安排診斷以排查肺癌。

 

參考文獻:
1. International Agency for Research on Cancer. 2020. World cancer report: Cancer research for cancer prevention. Lyon: IARC
2. J Natl Cancer Inst 2018, 110(11): 1201-07
3. Eur J Cancer2017, 84: 55-59
4. Transl Lung Cancer Res 2015, 4(4): 327-38
5. Lung Cancer Europe. 2019. IV LuCE report on lung cancer: early diagnosis and screening challenges in lung cancer. Bern: LuCE
6. United Kingdom Lung Cancer Coalition. 2020. Early diagnosis matters: making the case for the early and rapid diagnosis of lung cancer. London: UKLCC
7. N Engl J Med 2020, 382(6): 503-13
8. N Engl J Med 2020, 382(22): 2164-66
9. Respirology2020, 25(Suppl 2): 5-23
10. N Engl J Med 2020,382(6): 572-73
11. The Canadian Taskforce for Preventive Health Care. Recommendations on screening for lung cancer. Can Med Assoc J 2016, 188(6): 425
12. Screening for Lung Cancer: US Preventive Services Task Force recommendation statement. JAMA 2021, 325(10): 962-70
13. J Thorac Oncol 2021, 16(3): S58
14. Clin Lung Cancer. (2018) 19:E539–50.
15. Transl Lung Cancer Res 2018, 7(4): 450-63
16. Clin Cancer Res 2009, 15(18): 5626-45
17. J Thorac Oncol 2021,16(1): 37-53
18. N Engl J Med2020, 382(22): 2164-66

(文:鄺國柱醫生 呼吸系統科專科)

 
     
     
     
     
 
 
 
 
 
 
 
 

慢性呼吸道病人該如何應對疫情

 
     
 

新冠肺炎席捲全球,數以萬計人死於疫症。而根據中華流行病學雜誌官網,研究檢視截至2月11日的4萬多宗中國確診病例,發現心血管疾病患者最可能死於新冠肺炎併發症(致死率為10.5%),而慢性呼吸道疾病患者致死率為6.3%。之後中外學者再確認慢性阻塞性肺病(COPD)患者是受新冠肺炎(COVID-19)影響最嚴重的群組之一。

慢阻肺病是一種會危害生命的漸進性肺病,而吸煙就是其最重要的病因。科學家發現吸煙的人(current smoking)以及慢阻肺病人的肺細胞中血管緊張素轉換酶II受體(Angiotensin Converting Enzyme II ,ACE-2 receptor)水平升高,而新冠病毒正是透過這個受體(ACE-2 receptor)進入宿主細胞並引起感染。而前吸煙者(former smoker)的ACE-2水平則與從未吸煙者相似。

國際慢阻肺病權威( Global Initiative for Chronic Obstructive Lung Disease/GOLD ,The National Institute for Health and Care Excellence/NICE) 迅速發表了指引:要向慢阻肺患者解釋說明,他們會患上嚴重新冠肺炎的風險是較高。病人首要任務就是繼續服用常規吸入和口服藥物,以盡可能穩定其病情。少數慢阻肺病的患者亦會使用吸入式類固醇(ICS),幸好現時沒有證據顯示ICS治療會增加感染新冠狀病毒的風險。雖然有一些證據顯示使用ICS可能會令慢阻肺病人增加肺炎(非新冠)的風險,但不要將這種風險延伸作為改變在新冠疫情下使用ICS的原則。往常醫生或會處方口服類固醇和/或抗生素給某些慢阻肺病人作緊急自我治療之用(self management action plan),但是由於慢阻肺病發作和新冠肺炎的症狀甚為相似(咳嗽,發燒,疲勞和呼吸急促),所以現在慢阻肺病人不應自行評估及用藥(口服類固醇和/或抗生素),及需要從速求醫。

接受長期氧氣(long term home oxygen therapy)或動態氧氣(ambulatory oxygen therapy)治療的慢阻肺病患者,不要純因憂慮疫情而自行調整氧氣用法或流量。慢阻肺病人要做的是適時戴口罩,定期洗手和清潔設備(儲霧器和峰值流量計),絕對不能與他人共享吸入器和其他設備。在家中接受無創通氣(non-invasive ventilation)的患者要在通風良好的房間內使用無創通氣;而其他家庭成員此時應盡可能遠離。仍在吸煙的慢阻肺患者應下定決心戒煙。

另一方面,哮喘患者較幸運,現在沒有證據顯示他們會較容易感染新冠病毒,至於新冠病毒是否會引起哮喘發作則尚待觀察。對於哮喘患者來說,保持肺部健康的最佳方法就是按照規定定期服用吸入式類固醇和其他常規藥物。哮喘病權威(如Global Initiative for Asthma/GINA; British Thoracic Society/BTS) 強烈建議哮喘患者應繼續使用吸入式類固醇(ICS)或吸入式類固醇/長效氣管舒長藥(ICS / LABA)組合。如果哮喘患者出現急性發作,醫生仍會在有需要時使用口服類固醇的。至於長期需要口服類固醇治療的患者:他們在疫情下仍應繼續按規定劑量服用,因為如果此類特別病人突然停止使用口服類固醇,大有可能令哮喘病失控。因哮喘病而接受生物療法(biological therapies)的患者也不應停止使用生物製劑,因為沒有證據表明它們會抑制病人免疫力。

新冠病毒感染可令人出現類似於哮喘發作的症狀(例如咳嗽和呼吸急促),但哮喘發作本身不會令病人發燒,失去味覺或嗅覺的。相反,這些症狀更可能是新冠病毒感染而不是哮喘發作。其實無論是慢阻肺或哮喘患者,如果他們能時常保持最佳的病情控制,那麼他們因急性發作要去急症室的機會自然減少,這樣實際上是減少了他們接觸新冠病毒的機會。

筆者對患有慢性呼吸道疾病人士有以下的生活小貼士

第一,戴口罩是防疫政策重中之重,但戴上口罩後就要避免大活動量。如果口罩濕了,就應盡快更換。

第二,慢阻肺病人戴上口罩後,要留心自己有無出現血液中二氧化碳量過高病徵:異常疲勞、頭痛、頭暈、氣促、面紅、無法集中精神。有的話,盡快除開口罩。

第三,戴上口罩後不要怕麻煩,有痰就要咳清。

第四,如果閣下無法親身去覆診,就一定要請家人代去配藥。貿然停藥可能引起病發。

第五,如果你出現發作現象,就要去求診。任何延醫絕對有可能危害你的健康。

第六,對塵蟎過敏的人士用較高溫的水去洗床單被鋪,可以減低過敏,又可減低受新型冠狀病毒感染。

第七,尚未接種今年「流感疫苗」或「肺炎球菌疫苗」,最好盡快接種。

第八,患有慢性呼吸道疾病的病人也要留意自己的精神狀態 [如焦慮、恐慌及抑鬱等等],極端情緒也會影響本身呼吸道疾病的控制

 

(文:鄺國柱醫生 呼吸系統科專科)

 
     
     
     
     
 
 
 
 
 
 
 
 

新型冠狀病毒肺炎

 
     
 

從2019年12月以來,中國發現了多例新型冠狀病毒感染,而世界衛生組織於2020年2月11號正式為這病定名COVID-19。這種新型冠狀病毒(2019-nCoV)與SARSr-CoV和MERSr-CoV有明顯區別,研究顯示與蝙蝠SARS冠狀病毒(bat-SL-CoVZC45)同源性達85%以上。至今共發現多種傳播病毒的途徑:主要經「呼吸道飛沫」和「密切接觸」。在相對封閉的環境中長時間暴露於高濃度氣溶膠情況下存在經「氣溶膠」傳播的可能。由於在病人糞便及尿中可分離到新型冠狀病毒,應注意糞便及尿對環境污染造成氣溶膠或接觸傳播。

 

根據目前的流行病學資料,新冠肺炎的潛伏期為1至14天,多是3-7天。病人在潛伏期(即未出現病徵前)也可傳染他人。多數(約88%)患者最終會發熱,但只有44%病人在發病初期會發熱。而約68%病人有咳嗽(乾咳為主),亦有少數患者有鼻塞、流涕、咽痛、肌痛和腹瀉(3-4%)等症狀。部份兒童及新生兒病例徵狀並不典型,表現為嘔吐、腹瀉等消化症狀或僅表現為精神弱、呼吸急速。而重型病例多在7日後出現呼吸困難和/或低氧症,嚴重者可能快速進展為急性呼吸窘迫綜合症和多器官功能衰竭。從目前的病例情況看,多數患者預後是良好,兒童病例症狀相對較輕。而內地學者檢視了44672宗確診病例後,發現心血管疾病患者最可能死於新冠肺炎併發症(致死率為10.5%),其次是糖尿病(7.3%)、慢性呼吸道疾病(6.3%,但論文中沒有詳列那種肺病)和高血壓患者(6.0%)。截至2020年3月9號,國內新冠肺炎的整體死亡率約為3.86%。

 

如果面對懷疑個案,醫生會在病人鼻咽拭子、痰或其他下呼吸道分泌物作病源學檢查(RT-PCR &/or NGS)。在病人的血液或糞便中也可檢測出新型冠狀病毒核酸。新型冠狀病毒的IgM抗體多在發病後3-5天出現,而IgG抗體滴度於恢復期較急性期有4倍或更高增加。病人早期的胸腔電腦掃描呈現多發小斑片影及間質改變,以肺外帶明顯,後期發展為雙肺多發磨玻璃影,嚴重者可出現肺實變,但胸腔積液則較少見。但不是每一位確診病人的胸部電腦掃描都會顯示出肺炎的,所以應稱確診病人為新型冠狀病毒感染較科學化。

 

治療新型冠狀病毒感染方案由緊密監察病人維生指標開始、能及早發現病人是否出現併發症或惡化。由於未有專治新型病毒的藥物,所以現時是以支援治療為主調:使用氧氣、抗生素、靜脈輸液、機械通氣、甚至體外膜氧合(即人工肺)。現在醫生已不會像當年SARS,向每一個患者常規性地使用高劑量類固醇,專家多建議考慮使用Kaletra (Lopinavir/Ritonavir)、Interferons、Ribavirin、Chloroquine 等,而各地亦正研究 Remdesivir的效用中。而內地亦制訂了使用康復者血槳治療重型及危重型COVID-19的方案。

 

市民則應主動採取多項預防措施,才能避免接觸新型冠狀病毒:不應前往疫區(現在日韓及某些歐洲國家的疫情急轉直下中)、推遲不必要的外遊計劃、經常保持雙手清潔、在公眾場所(尤其是公共交通工具中)正確佩戴合適口罩、減少社交接觸(特別是避免多人飯聚,多使用視像會議),並常常保持個人清潔衛生。除了要保持室內空氣流通外,要特別注意廁所及去水渠衛生,定期注水入U型聚水器。

 

新冠肺炎疫情亦容易引發市民焦慮、恐慌及其他精神困擾徵狀,所以大家同時要注意自己的精神健康。最後想呼籲大家尊重大自然,人類要學習與萬物和諧共存,祝願大家身心靈安康。

 

(文:鄺國柱醫生 呼吸系統科專科)

 
     
     
     
     
 
 
 
 
 
 
 
 
Healthy Tips
 
 
 
 
 
 
 
 
If you have any one of following symptoms suspicious of lung cancer, please consult your doctor promptly for further investigation and management.

● Persistent or worsening cough
● Blood stained sputum
● Unexplained chest or shoulder pain
● Unexplained shortness of breath
● Unexplained loss of appetite & weight
● Recurrent chest infection

 
 
 
 
[*Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening. N Engl J Med 2011;365:395-409.]
 
 
 
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