Respiratory examination, basic investigations and therapeutics Dr Felix Woodhead Consultant...
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![Page 1: Respiratory examination, basic investigations and therapeutics Dr Felix Woodhead Consultant Respiratory Physician.](https://reader034.fdocuments.net/reader034/viewer/2022042702/56649d6e5503460f94a4ec5b/html5/thumbnails/1.jpg)
Respiratory examination, basic investigations and therapeuticsDr 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!
• <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
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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 > intercostals
– Orthopnoea
– Sitting/lying FVC
• Thoracic cage
– Scoliosis > kyphosis
• Pleural thickening
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Respiratory TherapeuticsDr 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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DrugsBronchodilators
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β2 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
• β2 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