Respiratory examination, basic investigations and therapeutics

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

2. Examination • General appearance • Smoker • BMI • Tattoos etc • Other diseases (RA etc) • Clubbing and Lymph nodes • Trachea, apex etc (mediastinal shift) • Scars • Unilateral vs bilateral

3. 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

4. Examination –Bilateral changes • Wheeze (obstructive disease) • Asthma • COPD • Bronchiectasis • Crackles • Pulmonary oedema: moist • Bronhiectasis: moist, pt coughing • Interstitial disease: Velcro, ‘hair-on-end’

5. Investigations • Physiology • Peak flow meter • Spirometry • ‘Full lung function’ • Spirometry • Lung Volumes • Gas transfer • Radiology • PA CXR • CT (spiral vs HRCT)

6. Spirometry and PFTs

7. 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

8. Typical graphs

9. 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)

10. Restrictive Defect • “Small lungs” vs “Wheezy lungs” (obstructive) • Intrinsic lung disease • abnormal radiology • ↓TLco • Extrathoracic restriction • normal radiology • normal TLco • ? ↑Kco (↓VA → TLco/VA ↑)

11. Extrathoracic Restriction • Soft tissues • Obesity • BMI not weight • Muscles • Diaphragm > intercostals • Orthopnoea • Sitting/lying FVC • Thoracic cage • Scoliosis > kyphosis • Pleural thickening

12. Respiratory Therapeutics Dr Felix Woodhead Consultant Respiratory Physician

13. Airways

14. Delivery methods • Nebulisers • Inhalers • Aerosol • Dry powder • Proprietary types

15. Drugs Bronchodilators

16. β2 agonists • Short-acting • Salbutamol • Terbutaline • Long-acting • Salmeterol • Formoterol

17. Antimuscarinics • Short-acting • ipratropium • Long-acting • tiotropium

18. Steroids • Beclomethasone • Budesonide • Fluticasone • Small- particle BCZ

19. Combined agents • Seretide (Purple) • =serevent (salmeterol) + flixotide (fluticasone) • Evohaler (MDI) or accuhaler (DPI) • Symbicort • Oxis (formoterol) + pulmicort (budesonide) • Turbohaler (DPI) • SMART regime

20. Systemic agents

21. Asthma • β2 agonists • Paediatrics • Occ IV • Theophyllines • IV • Oral sustained release • leukotriene-receptor antagonists • Monteleukast/zafirleukast • Omalizumab

22. Antibiotics

23. Gram positive infections • Penicillins • Amoxicillin • Co-amoxiclav • Piperacillin/tazobactam • Macrolides • Erythromycin • Clarithromycin • Azithromycin

24. Gram negative infections • Quinolones • Ciprofloxacin • Moxifloxacin • Aminoglycosides • Gentamicin • Tobramycin • Amikacin

25. Prophylactic antibiotics • Oral • Azithromycin • Others • Nebulised • Aminoglycosides • Colistin

26. Immunosuppressants

27. Steroid • Prednisolone • Dose • weaning • Hydrocortisone • (Dexamethasone) • Methylprednisolone

28. 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

29. Methotrexate • Widely used outside respiratory • Generally avoided because of potential pulmonary toxicity • ?useful in eg sarcoid