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With years of experience and backed by state-of-the-art technology, Jane Yap Chest Medical Clinic is dedicated to helping you be your best self

Bronchoscopy

Diagnostics bronchoscopy
Transbronchial lung biopsy under fluoroscopy
Bronchoalveolar lavage

What is bronchoscopy?

Bronchoscopy is the examination of the airways that allows the doctor to inspect the trachea and bronchi (main airway passages) with a fibreoptic instrument called a bronchoscope.

This allows us to examine the patient's airways for abnormalities such as foreign bodies, bleeding, tumours, or inflammation. Specimens from brushing, biopsy and lavage will be taken and send for the relevant tests. Occasionally we need the help of fluoroscopy to guide us to the area concern for taking these samples.
The procedure usually is done as a day procedure under local anaesthesia and sedation. The patient is aware but drowsy. You will need to fast for at least 6 hours before the procedure which is usually done in the endoscopy centre in the hospital. You will be discharged on the same day.

Before the procedure, a local anaesthetic is given to numb the throat and nose followed by sedation given through a vein. On the average the whole procedure will take half an hour. During this procedure, the blood pressure, heart rate and oxygen saturation will be monitored. After the procedure you will be monitored for 4 hours in the day surgery room. Once fully awake you be allowed to eat and drink. You will be reviewed before discharge.

A chest x-ray is needed to exclude air leak if transbronchial biopsy is carried out. Otherwise bronchoscopy is usually safe. There may be some bleeding after the biopsy and hence your phlegm may be blood stained. Very rarely there is dyspnoea from laryngeal oedema, laryngospasm and bronchospasm.

Full sleep study (home/hospital)
Assessment and management of sleep disorders

Obstructive Sleep Apnoea (OSA) is most common in middle-aged men and postmenopausal women. It is a breathing disorder that affects people during sleep, usually without their knowing. Normally during sleep, the muscles which control the tongue and soft palate hold the upper airway open.

If these muscles relax, the airway becomes narrower, often causing snoring and breathing difficulties. If they relax too much the airway can become completely blocked. This obstruction is aggravated if the tonsils are enlarged. The most common symptom is loud snoring. They stop breathing in between the snores, repeatedly during sleep. These disruptions deprive the person of sleep and oxygen. They feel tired during the day, may fall asleep at work, while driving the car, while reading or watching television. They are often irritable. More serious consequences include depression, hypertension, heart condition, sexual problems, memory lapses and morning headaches.

Sleep apnoea is diagnosed by a Sleep Study. It is a very simple, safe and painless procedure. Various leads are attached to your skin to record what is happening when you sleep, like chest movement, heart rate, oxygen saturation, airflow and brain waves.

Treatment includes:

Weight loss in the obese person
Avoid sedative and alcohol
CPAP (Continuous Positive Airway Pressure) is the most effective non-surgical treatment. It uses a small mask that fits over the nose or both nose and mouth. It produces a steady light air flow under a small pressure which prevents airway collapse. This allows normal breathing during sleep.
Surgical treatment for OSA needs to be individualised to address the anatomical areas of obstruction
- Nasal obstruction
  - Septoplasty
  - Turbinate surgery
- Pharyngeal obstruction
  - Tonsillectomy
  - Uvulopalatopharyngoplasty
Oral appliance which shifts lower jaw forward to open the bite slightly and hence the airway

Spirometry
Flow volume loop
Lung volume
Diffusion study
Pulse oximetry and arterial blood gas
Fractional Exhaled Nitric Oxide test (FENO)
Exercise Challenge Test
Methacholine challenge Test

They include tests that measure lung size and air flow, such as spirometry and lung volume tests. Other tests measure how well gases such as oxygen get in and out of your blood. These tests include pulse oximetry and arterial blood gas tests. Another pulmonary function test, called fractional exhaled nitric oxide (FeNO), measures nitric oxide, which is a marker for inflammation in the lungs. You may have one or more of these tests to diagnose lung and airway diseases, compare your lung function to expected levels of function, monitor if your disease is stable or worsening, and see if your treatment is working.

Spirometry measures the rate of air flow and estimates lung size.
- A spirometer measures how much air you inhale, how much you exhale and how quickly you exhale.
Lung volume tests are the most accurate way to measure how much air your lungs can hold.
- These can be measured by nitrogen washout technique or a body plethysmography technique. These can help us assess restrictive lung disease from lung fibrosis, respiratory muscle weakness or chest wall deformity like kyphosis and scoliosis.
Lung diffusion capacity assesses how well oxygen gets into the blood from the air you breathe and carbon dioxide gets removed from the blood.
- For this test, you will breathe in and out through a tube for several minutes without having to breathe intensely. You also may need to have blood drawn to measure the level of haemoglobin in your blood. This test is useful for lung fibrosis and COPD.
Pulse oximetry estimates oxygen levels in your blood.
- For this test, a probe will be placed on your finger or another skin surface such as your ear. It causes no pain and has few or no risks.
Arterial blood gas tests directly measure the levels of gases, such as oxygen and carbon dioxide, in your blood.
- A spirometer measures how much air you inhale, how much you exhale and how quickly you exhale.
Spirometry measures the rate of air flow and estimates lung size.
- Arterial blood gas tests are usually performed in a hospital, but may be done in a doctor’s office. For this test, blood will be taken from an artery, usually in the wrist where your pulse is measured. You may feel brief pain when the needle is inserted or when a tube attached to the needle fills with blood.
Fractional Exhaled nitric oxide Test
- An exhaled nitric oxide test can help with the diagnosis and treatment of asthma. It measures the level of nitric oxide gas in an exhaled sample of your breath. This sample is collected by having you breathe into the mouthpiece of a machine that performs the measurement. Nitric oxide is produced throughout the body, including in the lungs, to fight inflammation and relax tight muscles. High levels of exhaled nitric oxide in your breath can mean that your airways are inflamed — one sign of asthma.
- Nitric oxide testing is also done to help predict whether or not steroid medications, which decrease inflammation, are likely to be helpful for your asthma. If you've already been diagnosed with asthma and treated with one of the steroid medications, your doctor may use an exhaled nitric oxide test during office visits to help determine whether your asthma is under control.
- To do this test, you'll be seated. You will put in a mouthpiece attached to a tube that leads to an electronic measurement device. Next, you'll breathe in for two or three seconds until your lungs are filled with air. You will then exhale steadily so that the air flows out of your lungs at a steady rate. You will be watching a computer monitor that registers how much you're breathing out so that you can maintain a steady exhalation. The entire test generally takes five minutes or less.
- Results

Higher than normal levels of exhaled nitric oxide generally mean your airways are inflamed — a sign of asthma.

Levels under about 20 parts per billion in children and under about 25 parts per billion in adults are considered normal.
More than 35 parts per billion in children and 50 parts per billion in adults may signal airway inflammation caused by asthma.

Nitric oxide test results can vary widely from person to person. When interpreting test results, your doctor will consider a number of other factors. These may include:

Your asthma signs and symptoms
Past nitric oxide test results
Results of other tests, such as peak flow tests or spirometry tests
Medications you take
Whether you have a cold or the flu
Whether you have hay fever or other allergies
Whether or not you smoke
Your age

Exercise challenge test
- A test that enables your doctor to observe and assess symptoms is an exercise challenge. You will run on a treadmill or use other stationary exercise equipment that increases your breathing rate. This exercise needs to be intense enough to trigger the symptoms you've experienced. Spirometry tests before and after the challenge can provide evidence of exercise-induced bronchoconstriction, EIA (asthma)
Methacholine challenge test
- o This lung function test for asthma is more commonly used in adults than in children. It might be performed if your symptoms and screening spirometry do not clearly or convincingly establish a diagnosis of asthma. Methacholine is an agent that, when inhaled, causes the airways to contract and narrow if asthma is present. During this test, you inhale increasing amounts of methacholine aerosol mist before and after spirometry. The methacholine test is considered positive, meaning asthma is present, if the lung function drops by at least 20%. A bronchodilator is always given at the end of the test to reverse the effects of the methacholine.

Influenza Vaccine

Seasonal influenza is characterized by a sudden onset of high fever, tiredness, sore throat, muscle or body aches. Flu symptoms can make people so exhausted and unwell that they have to stay in bed. Flu spreads easily by the infected droplets caused by coughing, sneezing or talking.

The virus can also be spread by hands contaminated with the virus. You can stop flu spreading by frequent hand washing, resting at home, and using tissues and masks as well as immunisation. Vaccination is the most effective way to prevent infection and protect against the consequences of flu. In general, vaccination is given annually. This vaccination is recommended for:

Persons aged 65 years and above
Young children aged 6 to 59 months
Pregnant women
Persons with chronic medical diseases (heart, lung, kidney, diabetes, liver, blood, and neurological diseases)
Immunosuppressed persons
Persons staying in long term care facilities
Healthcare workers
Travellers

Pneumococcal Vaccine

Globally close to 900000 adults die from Pneumococcal Disease (PD) every year. In Singapore, the mean annual hospitalisation rate for PD is 10.9 per 100,000 with Pneumococcal Pneumonia as the predominant type followed by Pneumococcal Septicaemia (Bacterial infection of the blood) and Pneumococcal meningitis (inflammation of the membranes that cover the brain and the spinal cord). This rate increases significantly to 56.4 per 100,000 amongst patients aged above 65. The risk of serious infection increases with age as the body’s ability to fight disease declines. If you have:

COPD (Chronic Obstructive Pulmonary Disease), your risk of contracting PD is 15.7 – 18 .0 times
Asthma, you risk of contracting PD is 1.9 – 3.1 times
Diabetes, your risk of contracting PD is 4.2 – 5.0 times
Chronic cardiovascular (heart) disease, your risk of contracting PD 6.5 – 7.4 times

There are two pneumococcal vaccinations: Prevenar 13 and Pnemovax 23. They are recommended for:

Healthy persons aged 65 years and above
Adults with chronic (Lung, Heart, Kidney, Liver and Diabetes) illnesses
Persons with cochlear implants or cerebrospinal fluid leaks
Persons with anatomic or functional asplenia
Immunocompromised patients

Management of patients in general ward, high dependency ward and intensive care unit

CT guided percutaneous lung biopsy

This procedure uses CT scan to guide the needle biopsy of the lung lesion. This is carried out at the radiological department. The area will be cleaned and the radiologist will give you a local anaesthetic injection to numb the skin and soft tissue over the area in question. Using the biopsy needle, the radiologist will remove tiny pieces of tissue

from the lesion and send for the relevant tests. You will stay in the day surgery and discharged 4 hours after biopsy and chest x-ray confirmation that there is no air leak. The biopsy area may be tender or sore for one to two days. You may cough out blood but this is usually minimal and self-limiting.

Pleural biopsy

This is a procedure to remove a sample of the tissue lining the lungs and the inside of the chest wall to check for disease (like cancer) or infection (like tuberculosis). The procedure is done under ultrasound guidance. A local anaesthetic injection is given to numb the skin before a small cut is made and Trucut needle inserted. Samples are sent for the relevant tests.

Possible complications: of pleural biopsy: pneumothorax, introduction of infection to the pleural cavity which can lead to empyema, bleeding which is usually minor and self-limiting, (but if intercostal artery is damaged could be disastrous) and puncturing the lungs.

Thoracentesis (chest tap) is a procedure to remove fluid or air from around the lungs. A needle is put through the chest wall into the pleural space. The pleural space is the thin gap between the pleura of the lung and of the inner chest wall. The fluid or air is aspirated.
A chest tube (flexible plastic tube) can help drain air, blood, or fluid from the space surrounding your lungs, called the pleural space. Chest tube insertion is also referred to as chest tube thoracostomy. After local anaesthesia, a small cut is made and the tube is inserted between the ribs into the pleural space. The tube may be connected to a machine to help with the drainage. The tube is removed after the fluid or air is removed and lung expanded.

Both are carried out under ultrasound guidance. Both are diagnostic and therapeutic. Possible complications are bleeding, infection and lung injury.

Long term oxygen therapy

Long-term oxygen therapy (LTOT) is the treatment proven to improve survival in chronic obstructive pulmonary disease (COPD) patients with chronic respiratory failure. It also appears to reduce the number of hospitalizations, increase effort capacity, and improve health-related quality of life.

Oxygen therapy delivers an extra supply of oxygen into the body that can help improve symptoms of COPD. Not everyone with COPD needs oxygen therapy, but it is part of the treatment plan. It is prescribed according to a set of guidelines

Oxygen can be given at no more than 28% (via venturi mask, 4 L/minute) or no more than 2 L/minute (via nasal prongs) and aim for oxygen saturation 88-92% for patients with a history of COPD until arterial blood gases (ABGs) have been checked. We can get the supply of oxygen from tank or concentrator. Both can be small enough to allow ambulatory oxygen therapy.

Smoking cessation therapy

Smoking cessation is the process of discontinuing tobacco smoking. Tobacco smoke contains nicotine, which is addictive. Nicotine withdrawal makes the process of quitting often very prolonged and difficult. Each cigarette contains over 4000 types of chemicals, with at least 50 are cancer causing.

Lung cancer
COPD
Heart Disease
Stroke
Cancers;
- Mouth (5X the risk)
- Throat (5X the risk)
- Larynx (10X the risk)
- Pharynx (2-5X the risk)
- Oesophagus (2-5X the risk)
- Stomach (2X the risk)
- Pancreas (4X the risk)
- Kidney
- Bladder
Other diseases
- Cataracts (40% higher)
- Tooth decay
- Gum disease
Women diseases
- Cervical and breast cancer
- Painful and irregular menstruation
- Decreased egg count
- Early menopause
- Intrauterine growth in pregnancy
- Miscarriage (20% risk)
- Still birth
- Ectopic pregnancy
- Foetal and infant mortality rates 25-56% among smoker
Male problems
- Erectile dysfunction, impotence
- Infertility due to lower sperm count, abnormal sperm shape and motility, reduced volume of ejaculation

How smoking harms your loved ones:

Lung cancer (20-30%)
Heart Disease (25-30%)
Asthma (40-60%)
Stroke (as high as 82%)

Respiratory infections
Middle ear infections
Asthma
Chronic bronchitis
Sudden Infant Death Syndrome

Health
Physical
Emotional
Social
Financial

Misconception of smoking as a stress-relief tool, in fact nicotine withdrawal leads to stress and irritability
Smoking as a companion: boredom and post meal habit
Fear of withdrawal: nicotine replacement therapy can alleviate symptoms
Lack of confidence and quit resources
Peer pressure
Fear of weight gain especially for females

Cold Turkey
- Picks a date and stop completely
- Highest success rate
- Recommended as the first try
Gradual reduction
- Reduce number of cigarettes smoked per day until stops completely, day 7 as recommended
Delaying
- Delay the time at which you start smoking until stop completely on day 7 as recommended
Nicotine replacement therapy
- When used in conjunction with quit therapy, NRT is 4 times more effective for long term quitting
- Each form should be used in decreasing amount until you can do without it
- Types: inhaler, patch, gum, lozenges
Bupropion hydrochloride
- It does not contain nicotine but effective in reducing withdrawal symptoms and urge to smoke.
- Start therapy while smoking as steady state blood level is reached at about a week.
- Continue for 7-12 weeks
- Dosing should begin at 150 mg/day for first 3 days followed by 300 mg/day
Avoid smoker friends temporarily
Avoid places associated with smoking such as pubs and bars
Frequent places where smoking is banned
Take up alternative activities to relieve stress
Break smoking out of habit by replacement method like brushing teeth after meal instead of a smoke, low calorie snacks in the mouth instead of cigarette
Cravings
Tiredness
Lack of concentration
Headaches
Insomnia
Stomach upset
More cough and cold
Irritability

Pulmonary rehabilitation programme

Regular exercise is important for everyone. For patient with COPD, it is especially important to exercise. The benefits of exercise includes:

Decreases breathlessness
Boosts energy and decrease fatigue
Improves well-being and mood
Helps to keep your muscles and bones in good condition
Reduces the likelihood of admission
Improves sleep

It is important to make a life-long commitment to exercise as benefits are quickly lost if you do not maintain a regular exercise programme.

Walking is the best form of exercise for patients with lung disease. It is recommended to walk at least 7000 steps each day. Other forms of exercise include swimming, cycling and weight training are helpful.

Simple exercise guidelines:
How often?

Aim for at least 5 days a week
Schedule it at the same time each day
Choose a time when you have the most energy
Do not exercise after a meal

How long?

Start by walking for a short time like 10 minutes and gradually build up to 30 minutes
Take regular rests if breathless or tired, allowing time to recover and then start walking again
Set target like:
- How long
- Which place to reach
- How many steps

How intense?

Walk at an intensity that causes moderate breathlessness
Do not talk while walking, save energy for the walk

What are the suitable places?

Walk on firm level ground
Parks, shopping centre (if weather is hot, wet, windy or humid but do not be distracted by the shops)
Vary the walking venue
Wear comfortable clothing and shoes suitable for walking

In a pulmonary rehabilitation programme, people with chronic lung diseases undergo a supervised exercise training programme. This takes place in the hospital outpatient setting. The programme is patient tailored. It includes:

Exercise training
Respiratory and chest physiotherapy techniques
Psychosocial support

Pulmonary rehabilitation has the following benefits:

Improvement in quality of life: dyspnoea, fatigue, emotions and patient control over disease
Improvement in maximal exercise capacity, endurance time and walking distance
Reduction in anxiety, depression and improvement in psychological well-being
Reduction in exertion and overall dyspnoea
Reduction in acute exacerbation and hospitalisation

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Saturday	09:00 - 13:00
Sunday	Closed

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Our Services

With years of experience and backed by state-of-the-art technology, Jane Yap Chest Medical Clinic is dedicated to helping you be your best self

Bronchoscopy

Sleep Studies

Lung Function Testing

Vaccination

Management of patients in general ward, high dependency ward and intensive care unit

CT guided percutaneous lung biopsy

Pleural biopsy

Chest tap and chest tube drainage

Long term oxygen therapy

Smoking cessation therapy

Pulmonary rehabilitation programme

Working Time

Request Form

Emergency Case

Our Services

With years of experience and backed by state-of-the-art technology, Jane Yap Chest Medical Clinic is dedicated to helping you be your best self

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