Introduction to Respiratory 2023 PDF

Introduction to respiratory and respiratory investigations Lauren Peters  Introduction to respiratory history and examination Aims Cover common respiratory conditions Apply relevant investigations to the common conditions ...

Introduction to respiratory and respiratory investigations Lauren Peters  Introduction to respiratory history and examination Aims Cover common respiratory conditions Apply relevant investigations to the common conditions  3rd biggest cause of death Lung cancer Big increase over 1 in 5 people effected Chronic obstructive winter pulmonary disease (COPD) Burden of respirator Asthma: £ 3 Billion COPD: £1.9 billion All: £11 billion to the NHS y disease Mortality rates higher in disadvantaged groups Higher incidence of smoking, air pollution, poor housing, occupational hazards Anatomy and physiology Anatomy and physiology of the respiratory system  Common symptoms & Signs Upper respiratory tract Cyanosis of the lips/earlobes/fingertips Rhinorrhoea (Cyan: blue = deoxygenated blood) Nasal congestion Sore throat Crackles Lower respiratory tract Wet vs dry Breathlessness Coarse Haemoptysis Cough Bronchial breathing Productive/Dry Hollow sound Nocturnal Wheeze Wheeze Inspiratory (Stridor) Expiratory  Diagnostic clues Is it asthma? Variable, wheeze, nocturnal cough, triggers, atopy, low peak flow Is it COPD? Slowly progressive, smoking, low peak flow Is it a pneumothorax? pleuritic pain, quiet breath sounds, CXR findings Is it a PE? Risk factors (immobility, malignancy, previous PE/DVT), pleurisy, haemoptysis Swollen leg  Diagnostic clues Is it heart failure? Swollen ankles, orthopnoea, crackles, JVP Is it pneumonia? Fever, rigors, pleurisy, productive cough Bronchial breathing, crackles, CXR - consolidation Is it cancer? Smoking, weight loss, PMH (?secondary cancer) Is it interstitial lung disease? Occupational exposure, hobbies, drugs, crackles, dry cough  Diagnostic clues Sore throat/Rhinorrhoea: Upper respiratory tract infection (URTI) Stridor: Obstruction Who are these people?  Ockham’s Razor and Hickam’s Dictum… Ockham’s razor: Theory that the simplest explanation is the correct one! Hickam’s dictum: ‘A patient can have as many diseases as they damn well please!’ Remember that many things might be going on at once, patients often have many co-morbidities! Respiratory sounds patfyz.medic.upjs.sk/ simulatorvzorky /Respiratory auscultation.htm Respiratory Investigations Bloodwork: CT scan: Anaemia, infection, eosinophilia, BNP, calcium, thyroid, ?d-dimer, cultures PE, cancer, fibrosis, complex Peak flow: infections Asthma Sleep studies/overnight Spirometry: oximetry: COPD, asthma, fibrosis Obstructive sleep apnoea Chest X-Ray (CXR): ABG: Infection, fibrosis, cancer, collapse Hypoxia, COPD, Asthma Common respiratory conditions With associated investigations Asthma Common, atopic patient Chronic inflammation of the airways Hyper-responsive and reversible Inflammatory cells infiltrate the airways Smooth muscle hypertrophy Hyper = big/thickened Thickening of the airway Trigger by pollution, occupational exposure, allergens, bacteria and viruses, cold air Asthma history Risk factors Key history points Wheeze Smoking Have they ever been hospitalised/ITU Family history admission Childhood infections Have they required steroids/rescue pack Pollution Nocturnal cough Prematurity Worse at night Occupation (chemicals, dusts, spores) Worse at work/better on holiday Atopy Risks of exacerbations Eczema Poor inhaler technique Hayfever Continued triggers Illness Smoking (active vs passive) Viral/Bacteria Asthma signs & investigations Wheeze Peak flow BD (Twice a day) Dry cough Unless infected Know their best and calculate predicted Breathless Bloods Usually acutely IgE, eosinophils Progressive while unwell Responsive to treatment (usually) Spirometry Obstructive Not speaking in full sentences (acute) CXR Hypoxia and cyanosis in life threating exacerbations Sputum sample Summary Asthma management (Not acute) Peak flow diary Inhalers See control B2 agonist [salbutamol]: Relief (BLUE) (SABA) Steroid: preventer (BROWN) (ICS) Stop smoking/vaping Long acting B2 agonist (LABA) Combo Avoid/limit triggers Fostair (LABA/ICS) Vaccinations Symbicort (LABA/ICS) Flu CHECK inhaler technique! Covid Always use spacer where possible! Discharge checklist! Tablets if poor control Annual review Leukotriene antagonists, theophylline, steroids Asthma phenotypes BTS/SIGN Asthma guidelines  Consider triggers – allergies and occupation Principles of Consider concordance and inhaler technique https://www.youtube.com/watch?v=b asthma DHEEV0M62Y Control inflammation Inhaled steroids manageme Long acting B2 agonists (ICS/LABA inhalers) nt Leukotriene receptor antagonists Theophyllines Long acting anticholinergics (tiotropium) Nebulisers  Used in asthma and COPD What do put Salbutamol 2.5mg Ipratropium 500 micrograms Saline nebs in a neb? Used for certain antibiotics in CF/bronchiectasis Colomycin, gentamicin Don’t forget the spacer! 10 puffs in spacer is same as a neb No need for patients to buy the expensive machine! Advanced treatment IgE-driven disease Anti IgE (omalizumab) Eosinophil-driven disease Anti IL-5 (mepolizumab…) Anti IL – 4 alpha subunit Bronchial thermoplasty Asthma discharge 14 things to remember Peak flow Common Peak flow in and out of the lungs Used to monitor asthma control Can guide assessment of asthma exacerbation severity  Record standing up Deep breath in, form seal, short sharp breath out Peak Best of three attempts flow Record twice a day Patients usually know their usual PEFR Can predict based on height Acute asthma severity:  Emphysema & Chronic bronchitis 3 months productive cough for 2 years 2nd commonest admission cause to hospital COPD Over a million GP appointments a year Irreversible airways disease Smoking: > 80% cause What are the main problems with COPD? Breathlessness and disability Exacerbations Admissions to hospital Respiratory failure Death COPD history Breathless Associated features Progressive Temperatures MRC scale Headaches 1-on exercise Drowsy 5-house bound Recurrent admissions Try to quantify Chronic cough Ask about change volume and colour COPD: Signs and investigations Breathless CXR Wheezy Spirometry FEV1/FVC