Respiratory examination, basic investigations and therapeutics

1
Respiratory examination, basic investigations and
therapeutics

• Dr Felix Woodhead
• Consultant Respiratory Physician

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Examination

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

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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

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Examination Bilateral changes

• Wheeze (obstructive disease)
• Asthma
• COPD
• Bronchiectasis
• Crackles
• Pulmonary oedema moist
• Bronhiectasis moist, pt coughing
• Interstitial disease Velcro, hair-on-end

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Investigations

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

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Spirometry and PFTs
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Spirometry

• Measure Volume (bellows) or Flow (turbine),
  derive one from the other
• FEV1 and FVC
• FEV1 /FVC ratio cutoff 70
• Calculate it yourself!
• lt70 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

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Typical graphs
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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)

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Restrictive Defect

• Small lungs vs Wheezy lungs (obstructive)
• Intrinsic lung disease
• abnormal radiology
• ?TLco
• Extrathoracic restriction
• normal radiology
• normal TLco
• ? ?Kco (?VA ? TLco/VA ?)

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Extrathoracic Restriction

• Soft tissues
• Obesity
• BMI not weight
• Muscles
• Diaphragm gt intercostals
• Orthopnoea
• Sitting/lying FVC
• Thoracic cage
• Scoliosis gt kyphosis
• Pleural thickening

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Respiratory Therapeutics

• Dr Felix Woodhead
• Consultant Respiratory Physician

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Airways
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Delivery methods

• Nebulisers
• Inhalers
• Aerosol
• Dry powder
• Proprietary types

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Drugs

• Bronchodilators

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ß2 agonists

• Short-acting
• Salbutamol
• Terbutaline
• Long-acting
• Salmeterol
• Formoterol

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Antimuscarinics

• Short-acting
• ipratropium
• Long-acting
• tiotropium

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Steroids

• Beclomethasone
• Budesonide
• Fluticasone
• Small- particle BCZ

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Combined agents

• Seretide (Purple)
• serevent (salmeterol) flixotide (fluticasone)
• Evohaler (MDI) or accuhaler (DPI)
• Symbicort
• Oxis (formoterol) pulmicort (budesonide)
• Turbohaler (DPI)
• SMART regime

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Systemic agents
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Asthma

• ß2 agonists
• Paediatrics
• Occ IV
• Theophyllines
• IV
• Oral sustained release
• leukotriene-receptor antagonists
• Monteleukast/zafirleukast
• Omalizumab

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Antibiotics
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Gram positive infections

• Penicillins
• Amoxicillin
• Co-amoxiclav
• Piperacillin/tazobactam
• Macrolides
• Erythromycin
• Clarithromycin
• Azithromycin

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Gram negative infections

• Quinolones
• Ciprofloxacin
• Moxifloxacin
• Aminoglycosides
• Gentamicin
• Tobramycin
• Amikacin

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Prophylactic antibiotics

• Oral
• Azithromycin
• Others
• Nebulised
• Aminoglycosides
• Colistin

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Immunosuppressants
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Steroid

• Prednisolone
• Dose
• weaning
• Hydrocortisone
• (Dexamethasone)
• Methylprednisolone

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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

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Methotrexate

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