Conditions and Services
Dr Dakin sees patients with all aspects of respiratory disease. Some of the most common conditions, and the services offered, are described below.
Cough
Coughing is a very common problem, but requires investigation if persistent. The NHS advises taking medical advice, from your GP or elsewhere, if you have a cough which fails to improve after three weeks, particularly if you are coughing blood.
Coughing is a feature of many viral chest infections, in which case it usually settles in time. However, in other cases it may be a sign of more serious lung disease. When severe, coughing may be extremely distressing, to the point of causing sleep disturbance, bladder problems and vomiting.
In most cases, coughing is caused by treatable conditions, including asthma, persistent chest infection or gastro-oesophageal reflux. Many people suffer for years with coughing, often in the belief that nothing can be done. However, even the worst cases of coughing can usually gain significant improvement after assessment and treatment.
In some cases, coughing may be caused by more serious underlying lung disease, such as cancer or tuberculosis. Understandably, this sometimes makes people fearful to seek advice. Nonetheless, the sooner a condition is identified, the better the outlook is likely to be. In the great majority of cases, the underlying cause is benign.
Shortness of breath
Shortness of breath has many causes, usually relating to the lungs, but sometimes caused by problems with the heart, anaemia or muscle weakness, amongst other possibilities.
If the onset is rapid, for example over hours, then help should be sought from the emergency services, as urgent hospital admission may be required.
Often, shortness of breath may arise gradually, over weeks and months. As the lungs are the most frequent cause, a respiratory clinic is the best first-stop for evaluation. Common pulmonary causes include asthma, COPD, pulmonary fibrosis, and pulmonary embolism.
Measurement of pulmonary function is key to investigation. As Dr Dakin runs the lung function lab at the Nuffield, he is in a strong position to arrange investigation of this condition. In many cases, it may be possible to perform the necessary blowing tests in clinic, during the initial consultation. A CT scan of the lungs may also be required. A CT scan is like an x-ray, but gives a far greater level of detail.
If you are worried that you may have a problem with your lungs you can self-refer for lung function testing, without the need for a consultant appointment or a GP referral, by calling Dr Dakin’s PA using the contact details.
Asthma
Asthma management has moved on dramatically within the last 10 years as our understanding of this complex condition has progressed.
The first step of asthma management is to confirm the diagnosis, as not all who carry a diagnosis of asthma actually have asthma. For those with asthma, it is then necessary to characterise the subtype, along with any factors which may destabilise your condition. Such factors may include allergy, exercise, recurrent infection, gastro-oesophageal reflux, sinusitis and sleep apnoea, amongst others.
The assessments routinely performed include measurement of exhaled nitric oxide (FENO), bronchodilator responsiveness, allergy testing as well as a full clinical assessment including your previous respiratory history, clinical examination and review of previous x-rays.
Some people, with more difficult asthma, may require further investigation such as a CT scan, lung function or evaluation of suspected reflux, sinusitis, sleep apnoea or other exacerbating factors.
The great majority of people with asthma can achieve good control of their condition, once the above have been optimised. For those whose asthma remains poorly-controlled, despite optimal therapy, there are now powerful “biological” therapies, which may be transformational for those with severe uncontrolled asthma. These biological therapies alter the way that the immune system responds, by blocking specific pathways of inflammation eg interleukin 5. Biological therapies are provided by the NHS, from certain regional referral centres. Dr Dakin has strong links with the tertiary Portsmouth asthma service, to which he has so far referred approximately fifty patients, to access biological treatment.
COPD
Chronic obstructive pulmonary disease is a combination of bronchitis and / or emphysema, caused by smoking. People with COPD may experience shortness of breath and sputum production. COPD is a highly variable condition, which may be mild with few symptoms or severe, to the point of needing supplemental oxygen. Ordinarily, it does not become significantly worse after smoking cessation.
The mainstay of therapy for those with COPD is inhaled treatment, with a combination of bronchodilators ± inhaled steroids.
Bronchodilators are medicines which relax the muscles within the walls of the airways, opening them to improve airflow and relieving the sensation of breathlessness. Inhaled steroids help to treat inflammation and the underlying disease process of COPD.
However, most recent evidence suggests that whilst inhaled steroids may be of great benefit to some patients with COPD, they carry unnecessary side-effects for others. Assessment is required to target this treatment to those most likely to benefit.
The assessments which we perform include measurement of exhaled nitric oxide (FENO), bronchodilator responsiveness and blood tests, as well as a full clinical assessment including your previous respiratory history, examination and review of existing x-rays and any further scans which may be needed.
On the basis of these findings, therapy can be tailored. If necessary, additional treatments may be considered, such as lung volume reduction, surgical interventions, oxygen, biological therapy (anti-interleukin 5), non-invasive ventilation, help with smoking cessation and pulmonary rehab.
Lung cancer
Lung cancer causes more deaths than any other cancer in the UK, with approximately 10% of cases occurring in non-smokers. However, lung cancer may be curable, if identified early. It is important to seek medical advice for a persistent cough, particularly if expectorating blood or associated with loss of weight or appetite.
The NHS provides a good service for those with suspected cancer, with a target that all those who are referred for evaluation should complete the necessary investigations within 31 days and start treatment within 62 days. Sometimes though, this may seem a long time to wait, when faced with such grave concern. Within the private sector, it may be possible to complete investigations within 2 weeks and start treatment within 3 weeks.
Investigations are likely to include a CT scan and biopsy. A biopsy procedure involves taking a small sample of tissue for examination under the microscope, in a pathology lab. A biopsy may either be performed endoscopically, from within the airway, or by passing a fine needle through the chest wall, under local anaesthetic. Dr Dakin regularly performs the endoscopic procedures of bronchoscopy and endobronchial ultrasound (EBUS), for investigation of lung cancer and other conditions. The procedures are performed under sedation and local anaesthetic, to numb the airways and reduce coughing. Private sector procedures are performed at the Royal Surrey Hospital.
For early-stage lung cancer, surgery offers the best chance of cure, with survival rates in the range of 60–90%. Surgery may also have a role for more advanced cancer in carefully selected cases. In no case is any stone left unturned in trying to find a solution which may offer cure.
For more advanced lung cancer, other treatments have a greater role than surgery, including chemotherapy, radiotherapy or novel “targeted” therapies, which are selected according to underlying molecular mutations which may be detected in tissue obtained at biopsy. The treatments for more advanced cancer may not bring cure but may give significant survival prolongation, particularly in the case of the targeted therapies. Dr Dakin is a core member of the lung cancer multi-disciplinary team at the Royal Surrey, as well as having close connections with leading experts in the private sector.
See also: lung cancer screening.
Lung nodules
Pulmonary nodules are a common incidental finding on CT scans, particularly in those aged fifty and over, but may arise at any age. The great majority of these are benign, but some are not. Sometimes, nodules are found on CT scans performed to investigate respiratory symptoms, such as coughing or shortness of breath. Not uncommonly, nodules are identified on CT scans performed for some other reason, possibly for investigation of cardiac or other issues. Nodules themselves rarely cause symptoms, so are usually an incidental finding, unrelated to the original reason for performing the CT scan.
When nodules are identified, risk stratification is required, according to the background of the patient and the features of the nodule. In most cases, the best approach is to keep the nodule under surveillance for 1–2 years. If the nodule remains unchanged after a period of observation, then no further action is required. When nodules are larger or have more worrying features, up-front investigation may be required, such as biopsy to obtain a tissue sample.
Pulmonary fibrosis / Interstitial lung disease
Fibrosis means scarring. Pulmonary fibrosis refers to scarring of the lungs. Fibrosis often begins as some kind of interstitial lung disease (ILD), of which there are many different causes including exposure to occupational dusts (eg asbestos, coal), certain drugs (eg Amiodarone, Methotrexate, Nitrofurantoin) and exposure to certain moulds or allergens (eg birds, haybarns, dry rot).
Interstitial lung disease may also occur in association with other medical or rheumatological conditions, for example rheumatoid arthritis, lupus and sarcoidosis.
In many cases, there is no identifiable cause of fibrosis. In this situation the condition is called idiopathic pulmonary fibrosis, idiopathic meaning “of no cause.”
Investigation includes a CT scan, lung function tests and various blood tests, looking for any underlying cause. In selected cases, bronchoscopy may be helpful, to take washings from the lungs (broncho-alveolar lavage), which can give useful information about the nature of the inflammatory response within the lungs.
Not all interstitial lung diseases progress to fibrosis, particularly if an offending exposure eg mould or drug is withdrawn at an early stage. Other interstitial diseases such as sarcoidosis tend to resolve on their own without treatment and without lasting damage to the lungs.
In other cases, treatment may be beneficial, in slowing or preventing further irreversible scarring of the lungs. Careful management of pulmonary fibrosis is always required, as it is difficult to treat and the drugs themselves are not without side effects. Nonetheless, great advances have been made over the last ten years, and all such cases should be assessed by a specialist with an interest in the condition, as the benefits of treatment may be significant.
Dr Dakin managed a large interstitial clinic when in post in Portsmouth, where he set up various aspects of the service including access to novel treatments and investigation. He maintains a keen interest in these conditions. More recently, he set up a regular joint discussion forum between the Royal Surrey Hospital and the world-leading centre at the Royal Brompton Hospital.
Pulmonary embolism
Pulmonary embolism refers to a disease in which abnormal blood clots pass into the arteries of the lungs, having travelled through the circulation from a site of origin elsewhere in the body, usually the legs. Often, symptoms arise as soon as the clot reaches the lungs, typically with chest pain and shortness of breath. Classically, the chest pain is worse on inspiration. In a minority of cases, smaller blood clots may be asymptomatic and unsuspected at the time of occurrence, but repeated clots may cause cumulative damage, with progressive shortness of breath over a period of months.
Most pulmonary emboli cause immediate and distressing symptoms, often prompting attendance at an Emergency Department. The diagnosis is usually made on a CT scan, performed after an injection of contrast medium, which allows visualisation of the blood vessels within the lungs. Blood-thinning treatment is effective and lifesaving.
Although the benefit of blood-thinning treatment is undoubted, there is often a debate about the optimal duration of treatment. Lifelong blood-thinning treatment reduces the risk of recurrence, at the expense of a very small risk of spontaneous haemorrhage or prolonged bleeding following injury.
Sleep apnoea
Sleep apnoea is a common condition, something like a severe form of snoring, in which the upper airway closes off intermittently during sleep. Sufferers are usually unaware of this during their sleep, but awake in the morning feeling unrefreshed, as the repetitive airway closure disrupts the quality of sleep. People with sleep apnoea may feel excessively sleepy throughout the day, often to the point that they fall asleep unintentionally, throughout the daytime or evening.
The only way to find out if you have sleep apnoea is to undergo a multi-channel, overnight respiratory sleep study. This involves fitting various monitoring equipment in the clinic, which you can then take home and wear during sleep. The equipment monitors your breathing, heart and oxygen level overnight. Although home sleep-trackers, such as wrist-watch devices, may provide useful information, such data are not enough to make a robust diagnosis of sleep apnoea.
CPAP is the standard treatment for sleep apnoea. CPAP works by having a flow generator (fan device) connected through a tube to a face-mask, applied to the nose ± mouth during sleep.
Although the thought of wearing a face-mask during sleep may initially seem unappealing, CPAP treatment is highly successful and transformational for many who suffer with obstructive sleep apnoea.
The application of gentle positive pressure to the upper airway during sleep prevents the repetitive closures of the airway which occur in sufferers of sleep apnoea. By maintaining airway patency overnight, the restorative quality of sleep is re-established. Most people take to CPAP extremely well and after a few nights of usage, would not be without the treatment.
Once on treatment, many people regain a level of energy long-gone. As the treatment is available free to all on the NHS, some people who have a new diagnosis of sleep apnoea transfer to the NHS to access treatment. Others self-fund the treatment, to start as quickly as possible.
Dr Dakin is one of a small number of accredited Somnologists in the UK, having passed the European examination of the European Sleep Research Society, of which he is a member.
Lung cancer screening
For smokers, the best way to avoid lung cancer is to quit smoking. However, it takes at least 15 years for the risk of lung cancer in an ex-smoker to fall to that of a non-smoker, whilst the effect of cigarette smoke works its way out of your system. Alternatively, you may be a current smoker planning to stop. In either case, regular CT scans may detect lung cancer at an early stage, when it may still be curable.
Screening for lung cancer has a useful role for those who remain at increased risk of lung cancer, to pick up any worrying nodules at an early stage.
Lung cancer screening is offered to current or recent ex-smokers in some countries including the US. A lung cancer screening programme is now being rolled out across the UK, but has not yet started running in all areas.
Screening involves undergoing a regular CT scan every two years, to detect early stage cancer, usually for 15 years from the time of quitting smoking. This is proven to reduce the death rate from lung cancer in those who are at high risk.
If you have a suspicious nodule, it can be further evaluated by more detailed scans and / or a biopsy as needed. It is very likely that private medical insurers would cover the cost of further investigation (though usually not the initial screening). Alternatively, the NHS would cover the cost of further investigation.
Oxygen
Oxygen may be helpful for people with all kinds of respiratory conditions, but particularly COPD and pulmonary fibrosis, which have the potential to progress to “respiratory failure.” Respiratory failure refers to a situation where the lungs are able to provide some oxygenation of the blood, but not enough to maintain a completely healthy physiological environment for organ function.
Some people may have a blood oxygen level which is normal at rest, but falls on activity. In these situations, the use of supplemental oxygen may significantly increase the distance subjects are able to walk. Portable oxygen may be used either from a small portable cylinder or from a portable oxygen concentrator, which may bring a wide range of activities back within reach, like gardening, gentle exercise or going out.
Portable oxygen concentrators are light enough to carry around in a small rucksack or a highly portable trolley. Concentrators provide a constant stream of oxygen by enriching room air, so never run out of gas, unlike portable cylinders. Portable concentrators run on battery power and provide up to 6 hours of oxygen or more without re-charging, or all day if you are able to re-charge at some point.
Portable oxygen concentrators have revolutionised the lives of many people with respiratory impairment, allowing them to travel the world including cruises or even trips to altitude.
If your oxygen levels are found to fall during exercise, it may be helpful to perform a walking test whilst you are using oxygen supplementation. If oxygen supplementation improves your walking distance or breathing, we can assist you to purchase a concentrator from a supplier, as a medical certificate is required.
