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If you ever experience any of the symptoms, see our Respiratory Specialist.

When you have asthma, your airways are swollen, inflamed and overly sensitive. Asthma symptom include wheezing, cough, chest tightness and breathlessness. During an attack, your airways become even more swollen and the muscles around the airways tighten. This leads to the worsening of symptoms.

It is important to know what triggers your asthma and how to avoid it. Triggers may vary for different people. Examples of triggers:

  • House dust mite
  • Pollens
  • Mould
  • Foods: like peanuts, dairy products, seafood
  • Animals
  • Vigorous exercise like running
  • Infections like cold
  • Emotional stress and excitement
  • Pollution like cigarrete smoke, car exhaust, ozone
  • Occupational dusts like plastics, grains, wood, metals
  • Drugs like aspirin, ibuprofen
  • Household products like paint, bleach

There are two main types of medication: Controllers and Relievers. Controllers are used to control airways inflammation and hence prevent asthma attacks. It should be used daily. Relievers are used when needed to relax the airway muscles and keep them open. Frequent use of reliever more than twice a week is a sign of uncontrolled asthma.

Asthma Control

Asthma is a variable disease. You may experience difference in symptoms at different times of the day or year. Exposure to triggers may make your asthma worse. It is important to adjust the medications when your asthma is worse or better. Asthma attacks can be prevented very effectively by preventive medicine. How to control asthma?

  • Recognise your triggers and try to avoid them as much as possible.
  • Recognise the signs of worsening asthma so that you can take appropriate action. If you experience ore symptoms than usual, increase medication.
  • Understand the role of medications.
  • Visit your doctor regularly and review your Asthma Action Plan.

Worried about Asthma?
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Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) kills nearly three million people each year. About 600 million people around the world are affected by COPD. In the Asia Pacific region, it is estimated that over 56 million people suffer from moderate to severe form of this disease. COPD is currently the fourth leading cause of death in the world and it is expected to be the third by 2020. The COPD burden is projected to increase in coming decades because of continued exposure to COPD risk factors and aging of population. It is an important public health challenge that is both preventable and treatable.

COPD is a debilitating disease which affects the lungs and airways, causing airflow obstruction which is not reversible. It includes two sub-conditions: chronic bronchitis and emphysema. A COPD patient may have one or both of these conditions.

COPD patients differ from asthmatic patients as they usually are heavy smokers with a long smoking history, onset after age 40 years, symptoms progressive over time and not associated with allergies.

Cigarette smoking is the main risk factor. The genetic risk factor is severe hereditary deficiency of alpha-1 antitrypsin. However, this is relevant to a small part of the world’s population. Exposure to other types of tobacco like pipe, cigar and marijuana can cause COPD. Occupational exposures including organic and inorganic dusts, chemical agents and fumes are also risk factors. Indoor air pollution from biomass and coal cooking and heating in poor ventilated dwellings is an important risk factor. High levels of urban air pollution are harmful.
How COPD affects the lungs and airways:
The muscles around the airways constrict and more mucus is produced in the airways leading to blockage.
Air sacs:
The air sacs walls break down, leaving less surface area for exchange of carbon dioxide and oxygen. The air sac wall also loses elasticity causing air trapping.
The combination of these two factors causes air to be trapped in the lungs so carbon dioxide is not completely exhaled. This leaves less room for oxygen to be inhaled. The patients become increasingly breathless and unable to perform physical activity and other activities of daily living.
Symptoms of COPD:

  • Breathlessness
  • Chronic cough
  • Wheezing
  • Chest tightness
  • Sputum production

In the early stage, COPD can be asymptomatic until more than 50% of function is decreased, the patient will start to experience the shortness of breath.


COPD should be considered in any patient who has dyspnoea, chronic cough or sputum production, and/or history of exposure to risk factors for the disease. Spirometry is required to make the diagnosis in this clinical context.

Additional Investigations for diagnosis and assessment of severity include:

  • Chest x-ray to exclude other diagnoses. Changes associated with COPD include signs of hyperinflation.
  • CT scan thorax is not routinely done. It can exclude other diagnosis like bronchiectasis. It would show the emphysematous changes and distribution in COPD.
  • Lung volumes and diffusion capacity. COPD patients exhibit gas trapping from early stages of the disease. As the airflow limitation worsens, the total lung capacity increased. These measurements help to characterize the severity of COPD. Measurement of diffusion capacity provides the functional impact of COPD.
  • Oximetry and arterial blood gas are used to evaluate the oxygen saturation and need for supplemental oxygen therapy.

Treatment and management

  • Smoking cessation
    • Lung function naturally declines as a person gets older. However the decline is accelerated when a person smokes. It is important to quit smoking to slow down the process of lung function decline.
  • Bronchodilators
    • These open up the airways. They make them less short of breath, reduce severe episodes requiring hospitalisation, will improve on the quality of life.
    • The short acting bronchodilators are used as reliever medication for quick relief from acute symptoms of COPD.
    • Long acting bronchodilators are used daily for maintenance treatment in moderate to severe COPD
    • These are either anticholinergics or beta2 agonists. They work through different pathways to open up the airways.
  • Antibiotics for infective exacerbations
  • Mucolytic
  • Anti-inflammatory medicines during exacerbations
  • Long term oxygen therapy
  • Pulmonary rehabilitation
  • Vaccinations

Breathlessness does not only limit the physical activity but may have an emotional impact. They may feel frustrated, lonely and depressed as they cannot keep up with the social activities and hence reduce interactions with family and friends. As they get worse, they may even need help with simple daily tasks. Their quality of life would be affected.

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Bronchitis is an inflammation of the air passages that extend from windpipe into the lungs. This may be caused by a virus, bacteria, smoking or the inhalation of chemical pollutants or dust. When the cells of the bronchial-lining tissue are irritated beyond a certain point, the tiny hairs (cilia) within them, which normally trap and eliminate pollutants stop functioning. As a result, they become clogged by debris and the irritation increases. In response, secretion of mucus is increased resulting in cough and if severe enough shortness of breath.

Bronchitis comes in two forms: acute (less than 6 weeks) or chronic (recurring frequently for more than two years):

  • Acute Bronchitis
  • This is responsible for the hacking cough and phlegm production that accompany an upper respiratory tract infection. In most cases, it is viral in origin, sometimes it is caused by bacteria. The mucosal area will return to normal after several days unless there is an underlying lung problem. The presence of fever, chills, muscle ache and chest pain suggest a more serious infection like pneumonia. Chest x-ray should be ordered.
  • Chronic Bronchitis
  • Chronic bronchitis is defined as excessive mucus secretion in the bronchi presenting with a chronic or recurrent mucus-producing cough that lasts three or more months and recurs year after year. Chronic bronchitis may result from a series of attack of acute bronchitis, or it may evolve gradually because of heavy smoking or inhalation of polluted air. When the mucus producing layer of the bronchial lining has thickened, narrowing the airways to the point where breathing becomes increasingly more difficult. When the cilia cannot sweep the air clean of foreign irritants, the air passages become more vulnerable to infection. This results in further tissue damage. Unlike acute bronchitis, chronic bronchitis is an ongoing, serious disease.
  • Symptoms
    • Persistent cough
    • Productive cough
    • Shortness of breath
    • Wheezing
    • Fever
  • Investigations
    • Chest x-ray
    • Blood test example blood count
    • Sputum test
    • Lung Function test

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Pneumonia is an infection in one or both lungs. It can be caused by bacteria, viruses, fungi or parasites. Bacterial pneumonia is the most common type in adults. Pneumonia causes inflammation in the air sacs in your lungs, which are called alveoli. The alveoli fill with fluid or pus, making it difficult to breathe. Pneumonia symptoms can be mild to life-threatening. The most common symptoms of pneumonia include:

  • Coughing that may produce phlegm
  • Fever, sweating, and chills
  • Shortness of breath
  • Chest pain
  • Haemoptysis

Other symptoms can vary according to the cause and severity of the infection, as well as the age and general health of the individual.

Pneumonia may be classified by:
  • The organisms:
    • Bacterial pneumonia
    • Viral pneumonia
    • Mycoplasma pneumonia
    • Fungal pneumonia
  • Where it is acquired
    • Hospital-acquired pneumonia (HAP): This type of bacterial pneumonia is acquired during a hospital stay. It can be more serious than other types, because the bacteria involved may be more resistant to antibiotics.
    • Community-acquired pneumonia (CAP): This refers to pneumonia that is acquired outside of a medical or institutional setting.
  • How it is acquired
    • Aspiration pneumonia: This type of pneumonia occurs when you inhale bacteria into your lungs from food, drink, or saliva. This type is more likely to occur if you have a swallowing problem or if you become too sedated from the use of medications, alcohol, or some types of illicit drugs.
    • Ventilator-associated pneumonia (VAP): When people who are using a ventilator get pneumonia, it is called VAP.
  • Anyone can get pneumonia, but certain people are at higher risk:
    • Infants from birth to age 2 years, and individuals ages 65 years or older
    • People who have had a stroke, have problems swallowing, or are bedridden
    • People with weakened immune systems because of disease or use of medications such as steroids or certain cancer drugs
    • People who smoke, misuse certain types of illicit drugs, or drink excessive amounts of alcohol
    • People with certain chronic medical conditions such as asthma, bronchiectasis, fibrosis, diabetes, or heart failure


History of the illness and physical examination are important. Listening to your lungs with a stethoscope may reveal abnormal sounds, such as crackling. A chest x-ray will be ordered. Typically, pneumonia can be diagnosed with the physical exam and the chest x-ray. But depending on the severity of your symptoms and your risk of complications, one or more of the following tests may be ordered:

  • Full blood count. This test can confirm an infection, but it may not be able to identify what is causing it.
  • Sputum culture. This sample from your lungs may identify the organism.
  • Secretions for Respiratory viral or pneumonia multiplex PCR.
  • A urine test which may identify the bacteria Streptococcus pneumonia and Legionella pneumophila.
  • A CT scan thorax. This test provides a clearer and more detailed picture of your lungs.
  • A fluid sample from the pleural space if there is pleural effusion.
  • A bronchoscopy. This test looks into the airways in your lungs. It does this using a camera on the end of a flexible tube that is gently guided down your throat and into your lungs. Samples of fluid aspirated will be sent for tests.


Antibiotic, antiviral, and antifungal drugs are used to treat pneumonia, depending on the specific cause of the condition. Most cases of bacterial pneumonia can be treated at home with oral antibiotics, and most people respond to the antibiotics in one to three days. If your symptoms are very severe or you have other health problems, you may need to be hospitalized. At the hospital, heart rate, temperature, blood pressure, oxygen saturation and breathing will be monitored. Treatment may include:

  • Intravenous antibiotics. The antibiotics are injected into your vein.
  • Chest Physiotherapy. The therapist helps you to clear your phlegm and teach you or help you to perform breathing exercises to maximize your oxygenation.
  • Oxygen therapy. This treatment helps maintain the oxygen level in your bloodstream. You may receive oxygen through a nasal tube or a face mask. If your case is extreme, you may need a ventilator (a machine that supports breathing).

Most people respond to treatment and recover from pneumonia. However, for some people, pneumonia can worsen chronic conditions or cause complications. Like your treatment, your recovery time will depend on the type of pneumonia you have, how severe it is, and your general health.A younger person may feel back to normal in a week after treatment. Others may take longer to recover and may have lingering fatigue. If your symptoms are severe, your recovery may take several weeks. If you have certain health problems already, pneumonia could make them worse. These conditions include congestive heart failure and emphysema. For certain people, pneumonia increases their risk of having a heart attack. Pneumonia may cause complications, especially in people with weakened immune systems or chronic diseases such as diabetes. Complications can include:

  • Bacteraemia
    • Bacteria from the pneumonia infection may spread to your bloodstream. This can lead to dangerously low blood pressure, septic shock, and in some cases, organ failure.
  • Lung abscesses
    • These are cavities in the lungs that contain pus.
  • Impaired breathing
    • You may have trouble getting enough oxygen when you breathe. You may need to use a ventilator.
  • Acute respiratory distress syndrome
    • This is a severe form of respiratory failure. It is a medical emergency.
  • Pleural effusion
    • If your pneumonia is not treated, you may develop fluid around your lungs in your pleura. The pleura are thin membranes that line the outside of your lungs and the inside of your rib cage. The fluid may become infected and need to be drained.
  • Death
Pneumonia vaccine

The first line of defence against pneumonia is to get vaccinated. There are two pneumonia vaccines, which can help protect against bacterial pneumonia. Pneumonia can often be a complication of the flu, so be sure to also get an annual flu shot. The pneumonia vaccines would not prevent all pneumonia. But if you are vaccinated, you are likely to have a milder and shorter illness, and a lower risk of complications. Two types of pneumonia vaccines are available:
Prevnar 13: This vaccine is effective against 13 types of pneumococcal bacteria. Pneumovax 23: This vaccine is effective against 23 types of pneumococcal bacteria.

Other prevention tips:

In addition to vaccination, there are other things you can to avoid pneumonia:

  • If you smoke, try to quit. Smoking makes you more susceptible to respiratory infections, especially pneumonia.
  • Wash your hands regularly with soap and water.
  • Cover your coughs and sneezes, and dispose of used tissues promptly.
  • Maintain a healthy lifestyle to strengthen your immune system. Get enough rest, eat a healthy diet, and get regular exercise.

Worried about Pneumonia?
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Tuberculosis (TB) is one of the oldest diseases known to humanity, dating back to ancient Egypt. TB kills nearly 3 million people each year. It is caused by infection with Mycobacterium Tuberculosis. TB usually attacks the lungs, causing pulmonary TB. The cells of the immune system fight back but usually cannot kill all of the germs. The germs can cause holes in the lungs. TB can also affect the lymph nodes, pleura, kidneys, joints and in fact any parts of the body. TB is spread by inhalation of droplets when people with active TB disease cough, sneeze, talk, sing or spit. However prolonged exposure is required before you are infected. Family members and colleagues are at greatest risk of infection. One third of the world are currently infected with TB. Most people infected never become infectious or sick because their immune system walls off the TB germs. Only 5-10 percent of TB – infected people become sick. People with weakened immune system have a much greater chance of becoming sick with TB. For examples HIV positive people infected with TB have more than a 30 times greater risk. Symptoms of TB includes coughing, blood stained sputum, weight loss, fever and night sweats. Left untreated, 50 percent will die within 5 years and most others will be seriously debilitated. To confirm the sickness, a chest x-ray will be taken and if suggestive, the sputum is sent for examination under a microscope and culture. If they are positive, you have infectious TB which can spread to your close contacts. TB is usually treated on an outpatient basis. You have to take a combination of medicines (rifampicin, isoniazid, ethambutol, pyrazinamide, streptomycin) for a total of 6 to 9 months. Most of these are tablets or capsules. Some may need injections for the first two months. The medicines for TB are generally safe. However, some patients may experience certain side effects like giddiness, skin rashes, nausea and jaundice. Treatment is long as TB germs are hard to kill. You will start to feel better after the first few weeks. You must take your medicine until the full course is finished to be completely cured. If you do not finish the course, the TB germs that remain in the body will grow and you will fall sick again. This time, it may become resistant to the medicines that you have been taking. You will now need to take different kinds of medicines. These new medicines must be taken for a longer period of time and usually have more side effects. When you become sick again, you could also spread your drug resistant TB germs to your family and loved ones

Screening for latent tuberculosis

When you are tested positive for latent TB, it means you have inactive TB germs in your body. You do not have any symptoms, your Mantoux test or IGRA test is positive and chest x-ray is normal. Being infected means you do not have tuberculosis disease. However, you may be in danger of getting TB disease at some time in your life. Although the TB germs are inactive, they are still alive and may break down the walls, multiply and damage your lungs and or other body parts. If you take preventive medicine, the germs will be killed. Usually isoniazid is prescribed daily for six months, alternatively rifampicin is given for 4 months.

Lung Cancer

Lung Cancer is one of the leading causes of cancer deaths in Singapore. Lung cancer is the number 2 killer in males and 3rd in females in Singapore. Men have a 3 times higher risk of lung cancer than women. Among the 3 major ethnic groups, the Chinese have the highest risk. Between 2010 and 2014, there was an average of 1370 people in Singapore diagnosed with lung cancer yearly. Most persons diagnosed with lung cancer are older than 40 years of age. Usually there is no symptoms in the early stage. When the disease is advanced, one may complain of:

  • Chronic cough
  • Changes in chronic cough or smoker’s cough
  • Coughing up blood
  • Shortness of breath
  • Chest pain
  • Wheezing
  • Hoarseness
  • Recurrent chest infection
  • Enlarged lymph nodes

There are two types of lung cancer:

  • Small cell lung cancer: It occurs almost exclusively in heavy smokers and is less common than non-small cell lung cancer. It makes up 10-15% of the cases.
  • Non-small cell lung cancer: This is an umbrella term for several types of lung cancers that behave in a similar way. This includes squamous cell carcinoma, adenocarcinoma and large cell carcinoma.

Cigarette smoking is the main cause of lung cancer. The risk of lung cancer developing in a smoker is 15-25 times more than a non-smoker. The risk is greater with increasing number of years of smoking and with higher number of cigarettes smoked per day. Pipe, cigar and marijuana smoking also increase the risk of lung cancer. Breathing in cigarette smoke (second hand smoke) can increase the risk by about 30%. Exposure to certain workplace chemicals such as asbestos, coal gas, chromium, nickel, arsenic chloride, radon and mustard gas also increase risk of lung cancer. Despite the strong association of smoking with lung cancer, it has also been recognised that more than one quarter of the cases in Singapore occur in people who have never smoked or have prior smoke exposure.

  • Imaging tests
  • An X-ray image of the lungs may reveal an abnormal mass. A CT Scan can reveal small lesions.

  • Sputum cytology
  • Examination of the sputum under microscope may reveal cancer cells.

  • Tissues samples

A sample of abnormal cells may be removed in a procedure called biopsy. This can be performed in the following ways:

  • Bronchoscopy:
    The abnormal areas of the lung will be examined using a lighted tube that is passed down the throat and into the airway.
  • Mediastinoscopy:
    An incision is made at the base of neck and surgical tools inserted behind breastbone to take samples from lymph nodes.
  • Percutaneous needle biopsy:
    The radiologist uses CT images to guide a needle through your chest and into a suspicious nodule to collect cells.
  • Lymph node biopsy:
    The cells can be sampled from enlarged peripheral lymph nodes.


Once your lung cancer is diagnosed, the extent of the cancer will be determined. This will help to decide the most appropriate treatment. Staging tests may include imaging procedures such as MRI brain, PET and bone scans.


You will be advised on a treatment regimen based on a number of factors such as your overall health, the type and stage of cancer and your own preferences. Treatment options include surgery, chemotherapy, radiation, targeted drug therapy, immunotherapy and palliative care.

  • Surgery

The surgeon will remove the cancer and a margin of healthy tissue. Procedures:

  • Wedge resection: a small section that contains the tumour along with a margin of healthy tissue is removed.
  • Lobectomy: the entire lobe is removed.
  • Pneumonectomy: an entire lung is removed.


Chemotherapy uses drugs to kill cancer cells. One or more drugs may be administered through your vein in your arm or taken orally. A combination of drugs is given in a series of treatment over a period of weeks or months, with breaks in between. It is used as first line treatment or as an additional treatment after surgery.

Radiation therapy

This uses high-powered energy beams to kill cancer cells. Radiation can be directed at the cancer area from outside your body (external beam radiation) or it can be put inside needles, seeds or catheters and placed inside the body near the cancer (brachytherapy). It can be used alone or along with other treatments. It can be used to lessen the side effect of lung cancer.

Targeted drug therapy

These are newer cancer treatment that target specific abnormalities in cancer cells. This can be used for advanced and recurrent non-small cell lung cancer that has not been helped by chemotherapy.


Immunotherapy is a relatively new treatment option for a variety of cancers, including lung cancer. Immunotherapy helps the body's existing immune system recognize and attack cancer cells. People who have certain types of non-small cell lung cancer (NSCLC) are typical recipients of immunotherapy. Often, immunotherapy is given to people whose cancer has returned after treatment. Sometimes, however, immunotherapy is a primary treatment and is often coupled with chemotherapy. Unfortunately, doctors are not yet able to predict which people will benefit from immunotherapy.
There are a few different types of immunotherapy for fighting lung cancer. These include:

  • Immune checkpoint inhibitors
  • Adoptive T cell therapy
  • Therapeutic vaccines

The different types of therapies offer alternative ways for the body to attack cancer cells. There is still a need for further research into how effective these treatments are, who benefits most from their use, and their overall safety.

  • Supportive (palliative) care

This means that you will receive treatment to cease the symptoms and to make you more comfortable. There will not be treatment that aim at stopping the cancer.

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Lung nodules

Lung nodules are described as "spots" that are 3 centimetres (1.5 inches) in diameter or less. These nodules are often referred as coin lesions. Lesions larger than 3 cm are referred as lung masses which are more likely to be cancerous. Lung nodules usually need to be at least one centimetre in size before they can be seen on a chest x-ray, whereas nodules as small as one to two millimetres may sometimes be seen on a CT scan Factors such as a history of smoking, what the nodule looks like (for example, if calcifications are present), and more can may help in assessing whether the nodule is malignant or benign. Diagnosis usually includes a CT scan or other studies, but a biopsy is needed to make a conclusive diagnosis. Treatments will vary depending on the specific cause of the nodule.At least 60 percent of lung nodules overall—are not cancerous and that if a nodule is lung cancer there is still a good chance that it can be cured. A nodule, by definition, is less than three centimetres in diameter, and at this size, many lung cancers are curable. Yet even for lung cancers that are larger, the treatment and survival rates for lung cancer have improved significantly in just the past few years. At the current time, there are more former smokers and never smokers who develop lung cancer, than people who smoke. Anyone who has lungs can get lung cancer, and in fact, lung cancer has been significantly increasing among one group: young, never-smoking women.
Symptoms Most lung nodules do not cause any symptoms and are found “accidentally” or "incidentally" when a chest x-ray is done for some other reason. If symptoms are present, they may include a cough, coughing up blood, wheezing, shortness of breath (often vague at first and only with activity), or respiratory infections if the nodule(s) is located near a major airway.
Causes Lung nodules can be either benign (non-cancerous) or malignant (cancer). The most common causes overall include granulomas (clumps of inflamed tissue due to an infection or inflammation) and hamartomas (benign lung tumours). The most common cause of malignant lung nodules includes lung cancer or cancers from other regions of the body that have spread to the lungs (metastatic cancer). Recent research suggests that even when a lung nodule is found in a person who might be expected to have lung metastases, only half of the nodules were metastases when biopsied. Up to 25 percent, rather, were a second primary lung cancer.
Nodules can be broken down into a few major categories.

  • Infections: Infectious causes of nodules may include bacterial infections such as tuberculosis and other mycobacterial infections, fungal infections such as histoplasmosis, blastomycosis, aspergillosis, and coccidiomycosis, and parasitic infections such as ascariasis (roundworms), echinococcus (hydatid cysts), and paragonimous (liver flukes). When the immune system "walls off" areas of infection it often forms granulomas.
  • Inflammation: Conditions such as rheumatoid arthritis, sarcoidosis, and Wegener's granulomatosis, as well as pneumoconioses such as silicosis can also lead to granulomas.
  • Benign tumours: Benign lung tumours such as hamartomas (the most common benign lung tumour), bronchial adenomas, fibromas, blastomas, neurofibromas, and haemangiomas. can show up as a nodule in the lungs on x-ray.
  • Malignant tumours: Cancers that may appear as a nodule includes lung cancer, lymphomas, sarcomas, and carcinoid tumours (neuroendocrine tumours).
  • Metastases: Lung nodules may also be due to metastases from other cancers such as breast cancer, colon cancer, bladder cancer, and prostate cancer. When a nodule is due to a metastasis from another cancer, there are often multiple lung nodules present.
  • Other benign nodules: Pulmonary infarctions (areas of lung tissue that have lost their blood supply), blood vessel abnormalities (AV malformations), atelectasis (collapse of part of a lung), pulmonary fibrosis, and amyloidosis are all other possible causes of a lung nodule.


The first thing is to obtain any previous x-rays you may have had and compare them. If the nodule or nodules have been present for a long time, further tests may not be needed. If the nodule is new or there are no prior x-rays to compare, further workup may be needed.

If a nodule is found on a chest x-ray, the first step is usually to do a CT scan of your chest. The history as well as any risk factors for any type of lung nodules. For example, if there is a recent travel history, a fungal infection may be likely, whereas if you have smoked, a malignant tumour may be more likely. Characteristics of the tumour as seen on your CT scan will also be evaluated.

A PET scan is sometimes helpful in further defining a nodule. Unlike CT scans which are "structural" tests, a PET scan is a "functional test." A CT scan can find lesions in the lungs but does not give a measure of what is happening in a nodule. With a PET scan, a small amount of radioactive sugar is injected into the blood stream. Actively growing tumours take up more of the sugar which lights up on the examination. This can be helpful in distinguishing a growing tumour from a scar tissue as a growing tumour will take up more of the sugar. This is especially helpful for those who have had previous chest radiation, lung infections, or surgery which may result in scar tissue.

If a nodule does not appear to be growing or has characteristics of a benign tumour, (has "low probability" of being cancer) a "wait and watch" approach may sometimes be taken, with a CT scan repeated after a certain period of time. Single solitary nodules that have remained unchanged for a period of two or more years do not generally need any further workup.

Biopsy of Pulmonary Nodules

Unfortunately, a lung biopsy is often needed to know for sure what is causing a nodule. Thankfully, newer and less invasive methods of sampling tissue are now often available. Depending on the location of the nodule, a fine needle biopsy may be done. The biopsy can be done as part of a bronchoscopy or a CT guided through the chest wall. At times an open biopsy may be needed. Even when this is the case, newer techniques, such as video-assisted thoracoscopic surgery (VATS) can often be done instead of a thoracotomy.

Benign vs. Malignant Nodules

Overall, the likelihood that a lung nodule is cancer is 40 percent, but the risk of a lung nodule being cancerous varies considerably depending on several factors. In people less than 35 years of age, the chance that a lung nodule is cancer is less than one percent, whereas half of lung nodules in people over age 50 are malignant (cancerous).

Other factors that raise or lower the risk that a lung nodule is cancer include:
  • Size: Larger nodules are more likely to be cancerous than smaller ones.
  • Smoking: Current and former smokers are more likely to have cancerous lung nodules than never smokers.
  • Occupation: Some occupational exposures raise the likelihood that a nodule is cancer.
  • Medical history: Having a history of cancer increases the chance that a nodule could be malignant.
  • Family history: Those who have nodules and a family history of lung cancer are more likely to have cancerous nodules than those without a family history.
  • Symptoms: The chance that a nodule is lung cancer is greater if other signs or symptoms of lung cancer are present.
  • Shape/appearance of the nodule: Smooth, round nodules are more likely to be benign, whereas “spiculated” nodules, or those with irregular or lobular borders are more likely to be cancerous.
  • Solid/non-solid: Nodules that are part solid rather than solid are more likely to be cancerous
  • Growth: Cancerous lung nodules tend to grow fairly rapidly with an average doubling time of about four months, while benign nodules tend to remain the same size over time.
  • Calcification: Lung nodules that are calcified are more likely to be benign.
  • Cavitation: Nodules described as “cavitary,” meaning that the interior part of the nodule appears darker on x-rays, are more likely to be benign.
  • Ground glass nodules: Nodules that are described as having a ground glass appearance are often a challenge and can be either benign or malignant. Due to this difficulty, a biopsy of these lesions is usually needed.
  • The number of nodules: Those who have multiple lung nodules are more likely to have cancer than those who have a solitary or only a few pulmonary nodules. The most common cause of multiple lung nodules is metastatic cancer from the breast, prostate, colon, or bladder (though many tumours can metastasize to the lungs).
  • Location of the nodules: Lobules located in the right or left lower lobes or the right middle lobe of the lung are less likely to be cancerous than those located in the left or right upper lobes.
  • Ethnicity and geographic location: If there is a travel history or a long stay overseas, a lung nodule may be benign. For example, recent studies have found that lung nodules due to schistosomiasis, a parasitic infection, are fairly common in Africans. Likewise, nodules related to fungal infections, such as coccidiomycosis.

Indeterminate Lung Nodules

The number of lung nodules that are read by radiologists as "indeterminate" has increased with the advent of lung cancer screening. Hearing that the nodule or nodules are indeterminate can be confusing. Unfortunately, there are times when it is impossible on imaging tests alone to know whether a nodule is malignant—even after considering all of the factors above. In order to answer this question, a biopsy must be done.

Lung Cancer Screening

Lung cancer screening in appropriate people has been found to decrease the mortality rate from lung cancer by 20 percent. But as with any screening test, there is the risk of false positives, and it's common to find nodules on CT screening. But finding nodules does not always mean cancer. In fact, studies thus far estimate that only around five percent of nodules found on a first lung CT screening are cancerous.


The treatment of lung nodules varies widely depending upon the cause, whether they are related to infections, inflammation, cancer, or other conditions. Most benign lung nodules, especially those that are present and have not changed over a period of a few years, can be left alone.

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Chronic Cough

Cough is an important mechanism that allows us to clear the airway of secretion and foreign material. However this is also a means of spreading infection. Chronic cough is troublesome. It may have complications like insomnia, muscle pain and rib fracture. You should consult a doctor especially when it persists longer than 3 weeks.
Acute cough is most frequently due to the common cold, sinusitis, allergic rhinitis, exacerbations of asthma and COPD. Although less common, it can also be associated with serious conditions like pneumonia and heart failure.
Chronic cough can result from a single cause or a combination of two or more conditions. The most common causes of chronic cough among non-smokers are post nasal drip syndrome (PNDS), asthma and gastroesophageal reflux disease (GERD).
A person with PNDS usually has a feeling of something dripping down his throat. He tends to experience a need to clear his throat, nasal congestion, nasal discharge or hoarseness. He would have had a recent cold or suffer from allergic rhinitis, acute or chronic sinusitis.
Asthma must be considered in all with a chronic cough even when there is no other characteristic symptoms like wheezing.
GERD is caused when contents from the stomach flow back (reflux) into the gullet. It is not easy to make the diagnosis as more than half of them is unaware of the reflux. They may not have the typical symptoms like heartburn, sour sensation or regurgitation.

Some other causes of chronic cough:
  • Lung cancer
  • Smoker’s Cough
  • Tuberculosis
  • COPD
  • Pulmonary fibrosis
  • Drug induced cough like certain group of anti-hypertensive medicine
  • Habitual and Psychogenic cough

Basic investigations may include:
  • Chest X-ray
  • CT Scan thorax
  • Lung function tests
  • Nitric oxide test
  • ENT (Ear, nose, throat) examination
  • Gastroscopy (examination of gullet and stomach)

Treatment depends on the diagnosis.
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Shortness of Breath

This is a feeling of insufficient air in the lung, unable to take deep breath or having breath stuck in the chest. Some describe it as chest tightness or suffocation. This feeling may be due to serious underlying conditions and should not be ignored.

Common causes:
  • Asthma
  • COPD
  • Bronchitis
  • Heart conditions (heart failure, valvular disease, angina, arrthymia)
  • Physical deconditioning
  • Gastroesophageal reflux disease
  • Anaemia
  • Anxiety
  • Obesity

Less common causes:
  • Pneumothorax
  • Pulmonary embolism
  • Pulmonary hypertension
  • Pleural effusion
  • Interstitial lung disease

History is of particular importance when determining the cause. The onset, character, duration, periodicity and severity of the symptoms are all important factors.

Physical examination may also provide important clues.
  • Tachycardia (rapid pulse) may accompany anaemia, heart failure, and pulmonary embolism.
  • Distention of the jugular veins and peripheral oedema may be consistent with heart failure.
  • Cardiac murmurs may suggest underlying valvular disorders.
  • Decreased breath sounds and wheezing may indicate COPD.
  • Pulse oximetry will give an idea of the oxygen saturation.
  • Neurological examination to exclude muscle weakness.

Investigations may include the following:

  • Chest X-ray
  • CT Scan thorax
  • ECG
  • Full blood count
  • Metabolic Panels
  • Spirometry tests and other lung function tests
  • Echocardiogram (ultrasound of heart to assess the valves and function)
  • Treadmill test (Exercise stress test that allows us to assess the response of your heart to the increased workload and demand for blood during exercise)

Treatment depends on the identified cause.

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Pleural diseases

The pleura is a large, thin sheet of tissue that wraps around the outside of your lungs and lines the inside of your chest cavity. Between the layers of the pleura is a very thin space. Normally it is filled with a small amount of fluid. The fluid helps the two layers of the pleura glide smoothly past each other as your lungs breathe air in and out.

Disorders of the pleura include:

  • Pleurisy
    • Inflammation of the pleura that causes sharp pain with breathing
    • This is caused by viral or bacterial infection.
  • Pleural effusion
    • Excess fluid in the pleural space
    • This may be blood stained, pus, serous fluid
    • Causes: Bacterial infection, tuberculosis, malignancy, inflammation, excessive volume from heart failure, kidney or liver disorder, low protein state, perforation of thoracic organs (chylothorax, oesophageal rupture)
  • Pneumothorax
    • Build-up of air or gas in the pleural space
    • Causes: traumatic, iatrogenic or spontaneous.
    • A tension pneumothorax is a particular type of pneumothorax where the air may enter (though a defect of the chest wall, lung, or airways) on inspiration, but cannot exit on expiration. Each breath increases the amount of trapped air in the chest cavity, leading to further lung compression. This is often an urgent situation and may progress to a medical emergency if there is compromise of the venous return to the heart causing hypotension and rarely shock.
  • Haemothorax
    • Build-up of blood in the pleural space
    • Chest injury is the most common cause

A tension pneumothorax is a particular type of pneumothorax where the air may enter (though a defect of the chest wall, lung, or airways) on inspiration, but cannot exit on expiration. Each breath increases the amount of trapped air in the chest cavity, leading to further lung compression. This is often an urgent situation and may progress to a medical emergency if there is compromise of the venous return to the heart causing hypotension and rarely shock.
Other pleural diseases:

  • Pleural calcified fibrous pseudotumor
  • Pleural plaques: discrete fibrous or partially calcified thickened area which can be seen on X-rays of individuals exposed to asbestos. Although pleural plaques are themselves asymptomatic, in some patients this develops into pleural thickening.
  • Pleural endometriosis
  • • Pleural tumours may be benign (i.e. solitary fibromas) or malignant in nature. Pleural Mesothelioma is a type of malignant cancer associated with asbestos exposure.
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Haemoptysis means you cough out blood or blood streaked sputum. This has to be differentiated from blood that is vomited or which comes from the nose. It refers specifically to blood coming from the lower airways. It can be in varying amounts ranging from blood staining sputum to coughing out fresh blood in large amounts. You should consult a doctor as soon as possible.

Causes of Haemoptysis:
  • Sinusitis
  • Pharyngitis
  • Tuberculosis
  • Lung cancer
  • Bronchiectasis
  • Lung abscess
  • Pneumonia
  • Heart conditions like heart failure, mitral stenosis
  • Pulmonary embolism
  • Pulmonary haemorrhage syndromes. These are rare causes
  • Alveolar haemorrhage. Usually associated with systemic conditions such as connective tissue disease
  • Bleeding disorders such as low platelet count
  • Trauma
  • Foreign body in the airway


If the haemoptysis is large, you will likely be admitted to hospital and the necessary investigations will be performed there. If the amount of blood is small, you may be investigated as an outpatient. The following may be done:

  • Chest X-ray
  • CT Scan thorax
  • Sputum for TB tests
  • Bronchoscopy
  • ENT (ear, nose throat) examination
  • Platelet count
  • Bleeding Profile

This depends on the cause of haemoptysis identified.

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