--- module: 015-02 language: en chapter: 15 title: "Obstructive, Restrictive, Vascular, Infectious, and Neoplastic Lung Disease" module_title: "Respiratory phenotypes, progression mechanisms, and treatment selection" source_sha256: e780d7dff20e8b556d35b8d39b236d1ba4d9d37ea4161dd0da9dc35af3f15efe --- # Respiratory phenotypes, progression, and treatment selection ## Asthma beyond episodic bronchospasm ### Type two inflammation: eosinophils, immunoglobulin E ### Neutrophilic, mixed, and paucigranulocytic patterns ### Phenotype guides steroids and biological therapy ### Remodelling: epithelial injury, muscle, matrix #### Variable obstruction can become partly fixed ### Breathless despite controlled airway inflammation #### Dysfunctional breathing, obesity, reflux, deconditioning ### Intubation risk: lost tone, worsened trapping ## Chronic obstructive disease as traits ### Emphysema, small airways, mucus, exacerbation, frailty ### Spirometry confirms physiology, not burden ### Dynamic hyperinflation cuts inspiratory capacity #### Bronchodilation improves exercise despite modest spirometry ### Inhaled corticosteroid: fewer exacerbations, more pneumonia #### Guided by exacerbations, eosinophils, asthma overlap ### Rehabilitation breaks the dyspnoea and inactivity cycle ## Bronchiectasis and microbial ecology ### Mucus, cilia, immunity, aspiration, microbial community ### Repeated broad antibiotics select resistance ### Stable sputum baseline, exacerbation comparison ### Macrolides: antimicrobial and immunomodulatory effect #### Check repolarisation, hearing, resistance, mycobacteria ### Treat the driver, not only the infection ## Interstitial disease and progressive fibrosis ### Inflammation, fibrosis, granuloma, exposure, or vessels ### Ground-glass opacity is non-specific #### Filling, thickening, inflammation, haemorrhage, oedema ### Traction and distortion mean established change ### Vital capacity stable when emphysema offsets restriction ### Progression across symptoms, physiology, or imaging ### Ask tasks, materials, ventilation, protection, hobbies ## Pulmonary vascular classification ### Pre-capillary: resistance without left-sided pressure ### Post-capillary follows left-heart pressure ### Lung disease and hypoxia constrict and reduce bed ### Chronic thromboembolic obstruction, then microvascular change ### Echocardiography estimates, catheterisation measures ### Vasodilators can harm left-heart or lung disease ### Embolism risk: pressure, right-heart function, biomarkers ## Infection, pleura, and source control ### Infection plus parenchymal response, imaging may lag ### Microbiology when severity or resistance changes therapy ### Detection is not causation: colonisation, shedding ### Aspiration site follows position and anatomy #### Chemical pneumonitis can settle with support ### Pleural infection: invasion, acidity, loculation #### Undrained space keeps sepsis despite susceptibility ### Tuberculosis joins individual and public health ## Lung cancer and treatment reserve ### Staging plus molecular and immune profiling ### Obtain enough tissue for histology and biomarkers ### The easiest lesion may set the highest stage ### Resectability: predicted function, exercise, cardiac risk ### Checkpoint therapy can inflame lung and organs ### New dyspnoea needs a broad differential ## Synthesis and longitudinal review ### Name the compartment and dominant physiological defect ### Cause or exposure, activity, structural reversibility ### Exacerbation risk and systemic consequence ### One broad label makes treatment imprecise ### Track symptoms, function, gas exchange, burden ### Keep rapid access for sudden deterioration ## Multimorbidity and valued outcomes ### One improved measurement may not restore function ### Anaemia, heart failure, weakness still limit exercise ### Undernutrition, depression, disturbed sleep as well ### Walking improves through peripheral muscle efficiency #### Breathing technique and reduced anxiety help ### Judge activities, exacerbations, admissions, medication burden ## Oxygen and exacerbation review ### Oxygen follows stable-state hypoxaemia and criteria ### Symptoms alone do not justify long-term oxygen ### Exacerbation oxygen reassessed after recovery ### Walking or sleep desaturation made explicit ### Safety, flame, portability, flow, humidification ### Look for a new process, not variation #### Infection, missed doses, technique, allergen, smoke #### Heart failure, embolism, or pneumothorax ### Sputum colour alone is not bacterial infection ### Rebuild the model when response fails