Respiratory examination, basic investigations and therapeutics Dr 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 FEV 1 and FVC FEV 1 /FVC ratio cutoff 70% Calculate it yourself! <70% = obstructive –quantify by FEV 1 % 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/V A –↓ 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 (↓V A → TLco/V A ↑)

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

Respiratory Therapeutics Dr Felix Woodhead Consultant Respiratory Physician

Airways

Delivery methods Nebulisers Inhalers –Aerosol –Dry powder –Proprietary types

Drugs Bronchodilators

β 2 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 β 2 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