Respiratory examination, basic investigations and therapeutics Dr Felix Woodhead Consultant...

Respiratory examination, basic investigations and therapeuticsDr Felix Woodhead

Consultant Respiratory Physician

Examination

• General appearance– Smoker

– BMI

– Tattoos etc

– Other diseases (RA etc)

• Clubbing and Lymph nodes

• Trachea, apex etc (mediastinal shift)

• Scars

• Unilateral vs bilateral

Examination –Unilateral changes• crackles:

– Pneumonia– localised bronchiectasis– ‘LRTI’

• Bronchial breathing– consolidation, – severe fibrosis, – anterior chest

• Wheeze: localised stricture (never heard!)• Reduced air entry

– Collapse– effusion

Examination –Bilateral changes

• Wheeze (obstructive disease)– Asthma

– COPD

– Bronchiectasis

• Crackles– Pulmonary oedema: moist

– Bronhiectasis: moist, pt coughing

– Interstitial disease: Velcro, ‘hair-on-end’

Investigations

• Physiology– Peak flow meter

– Spirometry

– ‘Full lung function’• Spirometry

• Lung Volumes

• Gas transfer

• Radiology– PA CXR

– CT (spiral vs HRCT)

Spirometry and PFTs

Spirometry• Measure Volume (bellows) or Flow (turbine), derive one from

the other

• FEV1 and FVC

• FEV1 /FVC ratio cutoff 70%

• Calculate it yourself!

• <70% = obstructive

– quantify by FEV1 % predicted

• ≥70% = NORMAL or restrictive– quantify by FVC % predicted

• Graph allows assessment of blow technique

• Better assessed by Flow/volume loop

Typical graphs

Other components of PFTs

• Static lung volumes– He dilution

– Body plethysmography

– TLC & RV

– ↑ in obstructive lung disease (esp emphysema)

– ↓ in restrictive disease

• Gas transfer– TLco ≡ DLco

– Kco = TLco/VA

– ↓ in alveolar/interstitial damage (emphysema & ILD)

Restrictive Defect

• “Small lungs” vs “Wheezy lungs” (obstructive)

• Intrinsic lung disease – abnormal radiology

– ↓TLco

• Extrathoracic restriction – normal radiology

– normal TLco

– ? ↑Kco (↓VA → TLco/VA ↑)

Extrathoracic Restriction• Soft tissues

– Obesity

– BMI not weight

• Muscles

– Diaphragm > intercostals

– Orthopnoea

– Sitting/lying FVC

• Thoracic cage

– Scoliosis > kyphosis

• Pleural thickening

Respiratory TherapeuticsDr Felix Woodhead

Consultant Respiratory Physician

Airways

Delivery methods

• Nebulisers

• Inhalers– Aerosol

– Dry powder

– Proprietary types

DrugsBronchodilators

β2 agonists

• Short-acting– Salbutamol

– Terbutaline

• Long-acting– Salmeterol

– Formoterol

Antimuscarinics

• Short-acting– ipratropium

• Long-acting– tiotropium

Steroids

• Beclomethasone

• Budesonide

• Fluticasone

• Small- particle BCZ

Combined agents

• Seretide (Purple)– =serevent (salmeterol) + flixotide (fluticasone)

– Evohaler (MDI) or accuhaler (DPI)

• Symbicort– Oxis (formoterol) + pulmicort (budesonide)

– Turbohaler (DPI)

– SMART regime

Systemic agents

Asthma

• β2 agonists

– Paediatrics

– Occ IV

• Theophyllines– IV

– Oral sustained release

• leukotriene-receptor antagonists– Monteleukast/zafirleukast

• Omalizumab

Antibiotics

Gram positive infections

• Penicillins– Amoxicillin

– Co-amoxiclav

– Piperacillin/tazobactam

• Macrolides– Erythromycin

– Clarithromycin

– Azithromycin

Gram negative infections

• Quinolones– Ciprofloxacin

– Moxifloxacin

• Aminoglycosides– Gentamicin

– Tobramycin

– Amikacin

Prophylactic antibiotics

• Oral– Azithromycin

– Others

• Nebulised– Aminoglycosides

– Colistin

Immunosuppressants

Steroid

• Prednisolone– Dose

– weaning

• Hydrocortisone

• (Dexamethasone)

• Methylprednisolone

Azathioprine

• Dosing– 1 mg/kg/day first 1/12 with weekly FBC/LFTs

– 2 mg/kg/day thereafter. Bloods every 6/52

• TPMG– Thiopurine methyltransferase

– Reduce dose if low expression

– Avoid Aza if absent levels

Methotrexate

• Widely used outside respiratory

• Generally avoided because of potential pulmonary toxicity

• ?useful in eg sarcoid