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Respiratory Notes

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Respiratory Notes

  1. 1. RESPIRATORY MEDICINE 1. Topics 2. OSCE scenarios A B C Asthma Bronchiectasis PCP/HIV COPD Interstitial lung disease Lung Cancer Sarcoid PE Sleep apnoea Pleural effusion Pneumonia Pneumothorax Resp. failure – ABG profiles TB URTIs ASTHMA: Definition: Common chronic inflammatory disease of the airways characterised by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Signs and Symptoms: SYMPTOMS SIGNS Intermittent dyspnoea Tachypnoea Wheeze Audible wheeze Cough (often nocturnal) Hyperinflated chest Sputum Hyperresonant percussion Precipitating factors Emotion, cold, allergens etc Diminished air entry Diurnal variation Investigations: • FBC, U&E, CRP • ABG: / Pa02 and PaCO2 • Monitor PEF: >20% diurnal variation on 3 or more days per week (chronic asthma) • Spirometry: Obstructive changes (FEV1/FVC;  RV) • Bronchodilator reversibility (>15% improvement in FEV1) • Allergen skin prick tests: identify triggers • Aspergillus serology • CXR – hyperinflation: CXR > 6 anterior ribs
  2. 2. Management: ACUTE: 1. Assess severity: – Severe Attack - Can’t finish sentences; HR >110 bpm; RR > PEF 33 - 50% predicted – Life-threatening Attack - Silent chest; cyanosis; bradycardia; exhaustion; PEF <33% predicted; confusion; feeble respiratory effort 2. Sit patient up 3. High-dose O2 in 100% via non-rebreathing bag 4. Salbutamol 5mg + ipatropium bromide 0.5mg nebulised with O2 5. Hydrocortisone 100mg IV or prednisolone 40-50mg PO or both 6. Consider Magnesium sulphate 7. CXR Safe to discharge? • Stable on discharge meds for 24hrs • Inhaler technique checked • Peak flow rate > 75% predicted • Own PEF meter and management plan • GP appointment within a 1/52 CHRONIC: BTS Guidelines (just know this) • Step 1: Occasional short-acting inhaled ß2-agonist as required for symptom relief. (Salbutamol) • Step 2: Add standard-dose inhaled steroid. (Beclometasone) • Step 3: Add long-acting ß2-agonist (Salmeterol). If benefit but still inadequate control, increase steroid dose • Step 4: consider trials of: beclometasone up to 1000 μg/12h; modified-release oral theophylline; modified-release oral ß2-agonist. • Step 5: Add regular oral prednisolone. Refer to asthma clinic COPD: Definition: Common progressive disorder characterised by airway obstruction (FEV1 < 80% predicted; FEV1/FVC < 0.7) with little or no reversibility. “Umbrella term for emphysema and chronic bronchitis” • Emphysema – defined histologically as enlarged airspaces distal to terminal bronchioles with destruction of alveolar walls. • Bronchitis defined clinically as cough, sputum production on most days for 3/12 of 2 successive years.
  3. 3. Emphysema Bronchitis Signs and Symptoms: SYMPTOMS SIGNS Cough Resp. distress – Tachypnoea Use of accessory muscles Nasal flaring Sputum – white and frothy Hyperinflation Dyspnoea Hyperresonant Wheeze Quiet breath sounds Wheeze Cyanosis
  4. 4. Investigations: FBC ABG – PaO2  +/- hypercapnia Spirometry – obstructive (FEV1<80%, FEV1/FVC<0.7)  TLC,  RV. CXR – hyperventilation, flat diaphragms, Large central pulmonary vasculature ECG – RAH + RVH (right axis deviation) Blood cults. Sputum cults. Management: ACUTE: Look for cause – infection, pneummthorax 1. Controlled oxygen thx – start at 24 – 28% (aim for PaO2>8.0kPa + rise in PaCO2<1.5kPa 2. Nebulized bronchodilators – Salbutamol + Ipatropium 3. Steriods – IV hydrocortisone + PO prednisolone 4. Broad spectrum Abx to cover S. pneumonia, H. influenza and M. catarrhalis. E.g. amoxicillin & trimethoprim, doxycycline or cefuroxime NO RESPONSE Repeat nebs and consider aminophylline STILL NO RESPONSE Consider nasal intermittent positive pressure NIPPV if RR>30 or pH<7.35 Or consider intubation + ventilation if pH<7.26 and rising PaCO2 CHRONIC/STABLE: Life style advice – smoking cessation, exercise, dietary advice, vaccines etc MILD = FEV1 50-80% of predicted Antimuscarinic – Ipratropium bromide or B2 agonist Salbutamol PRN MODERATE = 30-49% of precicted Regular anticholinergic – Ipratropium bromide/tiotropium (long acting) +/- long acting B2 agonist Salmeterol + inhaled corticosteroids – beclomethasone (NB// Seretide – combines corticosteroid + LABA) SEVERE = FEV1<30% of predicted LABA + inhaled corticosteroid + anticholingeric Consider PO prednisolone trial EXTRA: Consider long term oxygen therapy (LTOT) if:
  5. 5. Clinically stable non-smokers PaO2 <7.3kPA satble on two separate occasions Or if PaO2 7.3-8.0 kPa + pulmonary hypertension + cor pulmonale TUBERCULOSIS: Definition:  Common infectious disease caused by a variety of strains of Mycobacterium, most commonly Mycobacterium tuberculosis and Mycobacterium Bovis, spread by airborne transmission  Worldwide epidemic - 1/3 of the world’s population is thought to be infected with M. tuberculosis  Accounted for 1.8 millions deaths worldwide in 2007, with 13 millions chronic/active cases in existence Pathogenesis & Progression: TB = granulomatous inflammatory condition TB  pulmonary alveoli and invade and replicate in alveolar macrophages They are then taken up by dendritic cells and can spread to lymph node  GHON COMPLEX T and B lymphocytes, macrophage and fibroblasts all aggregate and surround the infected macrophages to form a granuloma (granuloma is formed to prevent spread) Abnormal cell death at the centre  caseous necrosis. Can remain dormant or be reactivated and spread 10 TB (pulmonary)  20 TB (post 10 ) – result of reactivation  Progressive TB 75% cases active cases termed pulmonary TB 25% active cases can move from lungs to other sites e.g. upper airways and gut Disseminated TB = mammillary TB Primary TB (10 ) First contact with Bacillus Initial lesion in the parenchyma and subpleural space Involvement of draining hilar lymph nodes Leads to formation of the GHON COMPLEX Usually asymptomatic and most cases heal by scar formation
  6. 6. Secondary TB (20 ) Result of activation of latent 10 TB. GHON COMPLEX  ASSMAN FOCUS Signs and Symptoms: Investigations: Latent TB – Mantoux test if +ve consider interferon gamma testing Active TB – CXR = Consolidation, cavitation, fibrosis + calcification esp. in the apices. If CXR suggestive take sputum samples. At least 3 sputum samples (one in morning) and send for acid fast bacilli (consider bronchoscopy and lavage – obtain samples) Active non-pulmonary TB – find relevant clinical sample and send for cultures + CXR to exclude co-existing pulmonary TB Management: START WITHOUT CULTURE RESULTS! Test colour vision – ishihara plates and stress COMPLIANCE – consider direct observed thx. Initial phase - 8 weeks Continuation phase – further 16 weeks (24/52 on R & I in total)
  7. 7. R - Rifampicin I - Isoniazid P -Pyrazinamide E - Ethambutol SIDE EFFECTS: MUST KNOW R I P EXTRA –  ETHAMBUTOL - (EYE) Optic neuritis – 1st sign = colour vision damage  RIFAMPICIN - Red/orange discolouration of tears and urine + inactivation of the OCP + flu-like syndrome  ISONIAZID - Neuropathy, agranulocytosis ( WCC – mainly neutrophils)  PYRAZINAMIDE – Arthalgia (CI = Acute gout or porphyria) PE: Definition: • Thrombus usually formed in systemic veins embolized into the pulmonary arterial system. • 90% of cases arise from DVT. DVT present in 70% of patients with proven PE. • Silent PE present in 50% of patients with proximal DVT Signs and Symptoms: • Small PE: SYMPTOMS SIGNS Unexplained dyspnoea Tachypnoea Pleuritic chest pain Pleural rub Haemoptysis Crackles • Massive PE: SYMPTOMS SIGNS Sudden collapse Tachycardia Severe central chest pain Hypotension Peripheral shutdown ALL = HEPATITS (small  AST OK, if  bilirubin STOP thx)
  8. 8. Raised JVP (prominent A wave) Investigations: • Well’s Score to assess probability: o <2 = low probability o 2-6 = moderate probability o >6 = high probability • CTPA • V/Q scan • Duplex US with compression (for DVT) • Pulmonary angiography • ECG: S1Q3T3 • CXR • ABG: Decreased pO2 and pCO2 • D-dimer Management: • Admit • Non-massive: o IV LMW heparin (until INR = 2-3 for 2 consecutive days), o Warfarin continued for 6 months • Massive: o Thrombolysis o Unfractionated heparin
  9. 9. o Warfarin min. 6 months PLEURAL EFFUSION – EXUDATES VS TRANSUDATES: Definition: • Excessive accumulation of fluid in the pleural space. • Divided into two types depending on their protein concentration: o Transudate effusion < 30g/L o Exudate effusion > 30g/L • Pleural fluid: Serous fluid produced by normal pleura, contained within the cavity to aid lung function. Signs and Symptoms: • Asymptomatic OR:
  10. 10. SYMPTOMS SIGNS Dyspnoea Signs of associated disease Pleuritic chest pain – sharp & localised Investigations: • CXR: Management: • Drainage < 2L/24h • Pleurodesis - if recurrent • Thorascopic talc pleurodesis • Surgery PNEUMONIA: Definition: • Defined as the inflammation of lung parenchyma, usually as a result of infection. • It is a clinically acute illness typically presenting with cough, purulent sputum and fever. • Both physical signs and radiological changes are consistent with consolidation of the lungs. • Classification: o CAP vs. HAP o Lobar vs. Interstitial o Typical vs. Atypical
  11. 11. • CAP: Pneumonia presenting in the community or within 48 hours of attending hospital. Mainly caused by bacteria, although can also be caused by viruses. • HAP: Acute pneumonia presenting 48hrs or more after admission to hospital. Occurs in up to 5% of all admissions. Ventilator Associated pneumonia is a subset of HAP and has a mortality of between 50-60%. • CAP organisms: o TYPICAL  Streptococcus pneumonia, Haemophilus influenzae, Moraxella influenzae, Staphylococcus aureus o ATYPICALS  Mycoplasma pneumonia, Legionella pneumophilia (Legionnaires), Chlamydia species, Pneumocystis jiroveci o VIRAL  RSV (especially in 2<yrs and elderly, risk of secondary bacterial infection) • HAP organisms: o 20% - Staphlococcus aureus o 60%- Pseudomonas aeruginosa, Acinetobacter spp, E. coli. o 20%- Other plus respiratory viruses in the immunosuppressed Signs and Symptoms: SYMPTOMS SIGNS Fever Temp. up to 39.5 °C Pleuritic chest pain Rigors, Malaise, Anorexia Dry cough progressing to a rusty- sputum producing cough Purulent sputum Rapid shallow breathing Reduced O2 Sats CVS: Tachycardia, hypotensive, cyanosis Resp: Dyspnoea, tachypnoea, signs of consolidation (reduced expansion, dull percussion note, increased resonance, bronchial breathing, pleural rub) Investigations: • CXR: Chest X-ray will show consolidation. Imaging can lag behind clinical presentations. Similarly, consolidation can remain despite resolution of symptoms
  12. 12. Lobar Pneumonia: Focal area of consolidation. This can be difficult to differentiate from pulmonary oedema and fluid accumulation Try to spot air bronchiograms. These can be hard to spot but they are essentially round black areas surrounded by white consolidation (representing consolidation surrounding bronchioles). • Oxygen saturation (ABGs) • ECG? • Blood tests (FBC, U+Es, LFTs, CRP, blood cultures, tailor to presentation) • Sputum (microscopy and culture) • Check urine antigen for legionella in severe cases Management: • Oxygen (prevent respiratory failure O2< kpa) • IV fluids (hypotensive, dehydrated, hypovolemic shock) • Analgesia (eg. Paracetamol) • Antibiotics (empirical then adjust to results of cultures)
  13. 13. • Check for progression/ complications • F/U at 6 weeks (repeat CXR) • CURB65 to assess severity: o Confusion (abbreviated mental test <8) o Urea (> 7mmol/L) o Respiratory Rate (>30/min) o Blood pressure (systolic< 90, diastolic< 60) o 65 yrs and above • 0-1 = Mild • 2 = Moderate • 3-5 = Severe • 0-1 treat as an outpatient, 2 consider a short stay in hospital or watch very closely as an outpatient 3-5 requires hospitalization possibly ITU • MILD/MODERATE o Amoxicillin or Clarithromycin • SEVERE o Cefuroxime plus clarithromycin o Benzylpencillin plus clarithromycin o Clarithromycin plus rifampicin for Legionnaires • This treatment is empirical until organism sensitivities can be elicited • Prevention: o Vaccination and pencillin prophylaxis in those at high risk (HIV, Cystic fibrosis, lymphomas, leukaemias, cytotoxic drugs and corticosteroids) o Hand washing and VAP precautions o Hyperchlorination of water and heating (prevent legionaires) o Stop smoking (mucocillary paralysis etc…) PNEUMOTHORAX: Definition: • A collection of air in the pleural cavity between the lung and the chest wall. • Tension pneumothorax: A breach in the lung surface acts as a valve, allowing air into the cavity but not out. • Causes: o Spontaneous - thin young men o Trauma o Iatrogenic
  14. 14. o Secondary to e.g. Asthma; COPD; pneumonia; lung abcess; carcinoma; cystic fibrosis Signs and Symptoms: SYMPTOMS SIGNS None Reduced chest expansion Sudden onset dyspnoea Hyper-resonant percussion Pleuritic chest pain Reduced Breath sounds If 2˚ to asthma/COPD – sudden deterioration Tension Pneumothorax: SIGNS Deviated trachea and apex away from pneumothorax Hypotension Distended neck veins Respiratory distress Tachycardia Investigation: • If a tension pneumothorax is suspected, no tests as immediate treatment required • Otherwise, expiratory CXR to confirm • Dark area devoid of lung markings, peripheral to edge of collapsed lung • ABG if patient is dyspnoeic or has chronic lung disease.
  15. 15. Management: BRONCHIECTASIS: Definition: • “Abnormal and permanently dilated airways” • Classification: OBSTRUCTIVE* LOWER respiratory tract • Aetiology: the airways become dilated secondary to a chronic, destructive (hence irreversible), inflammatory process. • Causes: o Congenital: Cystic fibrosis, Primary ciliary dyskinesia o Acquired: Post-infective bronchial damage. Major organisms: H. influenza; Strep. Pneumoniae; Staph. Aureus; Pseudomonas aeruginosa; Klebsiella o Mechanical bronchial obstruction. Extrinsic ( tumour, lymph nodes) or Intrinsic (foreign body) Signs and Symptoms:
  16. 16. SYMPTOMS SIGNS Persistent cough Copious purulent sputum Frequent production of green sputum SOB Intermittent haemoptysis Clubbing Coarse inspiratory crepitations Wheeze Investigations: • CXR: Cystic shadows, thickened bronchial walls. Can be normal • CT: Dilated cygnet-ring appearance airways. Use to assess extent and severity. • Sputum culture essential for treatment • Spirometry: obstructive pattern. Assess reversibility Management: • Postural drainage: BD • Abx: ciprofloxacin 500mg 2x; o Flucloxacillin 500mg per 6 hours in cases of Staph. Aureus. • (Bronchodilators) • (Anti-inflammatory agents e.g steroids) INTERSTITIAL LUNG DISEASE: Definition: • A group of lung diseases affecting the interstitium (the tissue and space around the air sacs of the lungs). i.e alveolar epithelium, pulmonary capillary endothelium, basement membrane, perivascular and perilymphatic tissues. • Are classified as a restrictive lung disease • Prolonged ILD may result in pulmonary fibrosis, but this is not always the case.
  17. 17. Causes: • Inhaled substances – inorganic (e.g. asbestosis) or organic (e.g. Hypersensitivity pneumonitis) • Drug induced e.g. statins, methotrexate, amiodarone • Connective tissue disease • Infection e.g. Atypical pneumonia or TB • Idiopathic – Sarcoid or IPF • Malignancy - Lymphangitic carcinomatosis Signs and Symptoms: • Pneumoconiosis: SYMPTOMS SIGNS SOB End inspiratory crackles Cough Wheeze Fever Occur hours after antigen exposure. • Pulmonary fibrosis: SYMPTOMS SIGNS Progressive breathlessness as disease becomes more severe Progressive cyanosis Resp. failure Pulmonary hypotension Cor pulmonale Gross finger clubbing (2/3 patients) Fine bilateral end-inspiratory crackles Investgations: • Restrictive pulmonary spirometry with decreased DLCO. • Decreased VC and TLC • FVC and FEV1 decreased to similar degree therefore FEV1/FVC normal or even raised. • CXR: o Pneumoconiosis: upper zone fibrosis and/or honeycomb lung. o Pulmonary fibrosis: shows irregular reticulonodular shadowing
  18. 18. • CT: o Pulmonary fibrosis: Typically ground glass opacification – best seen at the bases. Honeycomb lung in severe cases – represents cystic air spaces which are dilated and thickened terminal bronchioles. Management: • Depends on type. • Pneumoconioses/Hypersensitivity pneumonites: Remove source of allergen. Damage present is irreversible. SARCOIDOSIS: Definition: • A multisystem non-caseating granulomatous disorder • Granuloma: An organised collection of macrophages • Unknown aetiology • Can affect almost any organ. 90% cases lung Signs and Symptoms: SYMPTOMS SIGNS None Erythema nodosum Cough & exertional breathlessness Superficial lymphadenopathy Respiratory & constitutional symptoms Restrictive pattern of spirometry due to decreased lung compliance and gas exchange Arthralgia Clear chest auscultation Ocular symptoms Investigations: • Lymphopenia • LFTs • Hypercalcaemia (increased formation of calcitriol by macrophages) • Hypercalciuria • Raised serum ACE • CXR: symmetrical BHL, paratracheal nodes • FEV1/FVC • Biopsy (non caseating granuloma) • Bronchoscopy: cobblestone
  19. 19. Management: • If acute illness, NSAIDS • If severe, steroids • Most have spontaneous remission • If hypercalcaemia, pulmonary impairment, renal impairment, uveitis then PREDNISOLONE • Strong sunlight avoidance • Poor prognosis: afrocaribbean, >40, symptoms more than 6 months, more than 3 organs, lupus pernio. Use methotrexate, azathioprine. Single lung transplant • Overall mortality is low and reflects cardiac involvement or pulmonary fibrosis.
  20. 20. 2. OSCE a) Respiratory history b) Respiratory exam c) Presenting a chest x-ray d) Inhaler technique/PEAK flow e) Explaining a procedure such as a chest drain a) Respiratory History: Key things to remember SOCRATES if pain = Pleuritic or cardiac Associated symptoms = Wheeze SOB Cough – character + productive Phlegm – colour and volume or blood? Night sweats Weight loss PND – wake up gasping Systemic symptoms Travel history If female – COCP? b) Respiratory exam Notes The Set-up Washes hands Introduces themselves to the patient Asks what the patient prefers to be called by Explains the examination and gets permission Assesses pain status of the patient Exposes patient from the waist up Repositions patient to 45 End of the bed Checks for signs of breathlessness/wheeze/stridor/distress Checks whether the patient can speak in full sentences without breathing in between Checks surroundings for CPAP, oxygen tubing, peak flow meter, sputum pots, nebulisers, inhalers, cigarettes Hands Checks for temperature (warm in CO2 retention, cold with
  21. 21. peripheral vasoconstriction or heart failure) Checks for tar staining (nicotine does no stain) Checks for peripheral cyanosis (poor perfusion to peripheries due to peripheral vascular disease, Reynaud’s phenomenon or vasoconstriction eg. in the cold) Checks for clubbing (respiratory causes are most commonly lung cancer, interstitial lung disease (importantly asbestositis) and suppurative lung diseases such as abscess, empyema, bronchiectasis. NOT COPD/asthma) Checks for fine tremor (caused by beta-agonists such as salbutamol) Checks for CO2 retention flap (late sign of CO2 retention) Arms Measurer radial pulse (Rate, rhythm and character. Bounding pulse present in CO2 retention) Measures respiratory rate subtly while taking pulse Face Checks eyes for anemia (pale conjunctiva) Checks eyes for Horner’s syndrome (compression of the sympathetic chain in the chest cavity interrupts sympathetic supply causing ptosis [relaxed superior tarsal muscle], anhydrosis and meiosis) Checks face for lupus pernio (purple swelling of sarcoid granuloma) Checks lips and tongue for central cyanosis (seen in severe pneumonia, COPD and pulmonary embolism) Neck Checks the JVP (raised in states of pulmonary hypertension and/or right-sided heart failure such as cor pulmonale, superior vena cava obstruction, cardiac tamponade, constrictive pericarditis and restrictive cardiomyopathy) Palpates the submental, submandibular, pre-auricular, post-auricular, cervical chain, supraclavicular, occipital and axillary lymph nodes Inspecting the Chest Checks for scars (such as a sternotomy or thoracotomy) Check for assymmetrical expansion (indicates lung disease on that side) Checks for visible veins (sign of superior vena cava obstruction) Checks for pectus excavatum (normal variant whereby sternum is depressed into the chest) Checks for pectus carinatum (abnormal deformity with chest wall protruding outwards caused by increased respiratory effort in childhood when bones are still malleable, eg. asthma) Checks for barrel chest (rounded thorax caused by hyperinflation, a
  22. 22. marker of smoking related lung disease) Checks for spinal deformities such as scoliosis or kyphosis Checks for the use of accessory muscles Palpating the Chest Palpates for tracheal deviation (deviated towards collapsed lung or localised fibrosis, deviated away from pneumothorax and large pleural effusion) Assesses chest expansion (unilateral reduction in expansion caused by pneumothorax, pleural effusion, pneumonia and collapsed lung) Assesses the tactile vocal fremitus by asking the patient to say “99” while feeling at 3 places each side of the chest using the ulnar edge of the hand (Increased over areas of consolidation eg. pulmonary edema, inflammatory exudate, blood or pus. Increased over areas of pleural effusion or pneumothorax as the filled pleaural space acts as a barrier to sound) Percussing the Chest Percusses the clavicle (without the flat hand) Percusses 3 areas of the lung on each side (Resonant=normal lung. Dullness=areas of increased density such as consolidation (eg. pneumonia), collapse, alveolar fluid, pleural thickening, fibrosis, peripheral abscess or neoplasm. Stony dullness=the unique extreme dullness heard over a pleural effusion. Hyper-resonant=areas of reduced density emphysema, pneumothorax, COPD) Auscultation of the Chest Asks patient to take deep breaths in through the mouth when stethoscope is placed on the chest Auscultates both sides of the chest (Normal “vesicular” sounds are produced by the large airways and then changed as they come through the normal small airways. Reduced sound is caused by an effusion, tumor, pneumothorax. Bronchial breathing occurs when consolidation, lung absesses and dense fibrosis cause the sound from the bronchi and larynx to be better transmitted to the chest wall and therefore sounds like breath sounds at the trachea. Added sounds include: 1) Wheeze is a whistling caused by a narrowed airways heard best in expiration. A polyphonic wheeze occurs in asthma as many airways are constricted. A monophonic wheeze occurs when a single airway is narrowed eg. foreign body or carcinoma. 2) Crackles (also called crepitations or rales) are caused by “popping open” of collapsed alveoli as air enters them. Fine crackles occur in small airways late in inspiration and are caused by fluid, infection or fibrosis usually at the lung bases. Coarse crackles sound like rice krispies and are in the larger airways caused by infection or fluid. 3) Pleural rub occurs in both expiration and inspiration due to inflamed surfaces of the pleura
  23. 23. rubbing together in pneumonia and pulmonary embolism with infarction.) Assesses vocal resonance Assesses vocal pectoriloquy (whispering sound instead of “99”. If still loud, then consolidation is likely) Back Inspects the patient’s back Palpates the patient’s back Percusses the patient’s back Auscultates the patient’s back Finishing off (SOAP) Sends off a Sputum pot Checks Oxygen saturation Checks for Ankle edema Measures Peak flow Asks if patient would like help getting dressed c) Presenting a chest x-ray DO NOT TOUCH THE FILM!!!!!! Identify film NAME DOB DATE OF FILM TYPE (AP/PA) Quality of film: R – rotation = position of clavicle heads I – inspiration > 6 anterior ribs = hyperinflation P – penetration = see thoracic spine through heart E – exposure F – framing L – lines or anything else Then state the most striking abnormality. Now Begin by looking at: • Trachea – central or displaced? • Towards lesion = Collapse • Away from lesion = Tension
  24. 24. • Mediastinum – widened? • Aneurysm • Unfolded aorta • LN enlargement – TB/ Sarcoidosis/ Lymphoma • Hila = L usually higher than R & compare shape and density • Enlarged – Pulmonary artery HTN • Calcified – Post TB/ Silicosis • Heart = CTR – 50% (hard to assess in AP film) – can you see the R and L heart borders • Diaphragm = Costophrenic angles – blunt or defined? • Look for stomach bubble/ raised hemi-diaphragm IF NOTHING SEEN – KEY AREAS: 1. Behind the heart 2. Pleura 3. Apices 4. Below diaphragms 5. Bones Finally summarise your findings, mentioning the important negatives and the stating the most consistent diagnosis. d) Inhaler technique WIPER Introduce and explain purpose of interview Check understanding of Asthma and rationale behind inhaler therapy 1. Stand up sit up straight before using inhaler 2. Remove cap and shake inhaler 3. Hold canister vertical for delivery of drug 4. Hold canister with middle finger and thumb 5. Put mouthpiece in mouth at start of inspiration 6. Inhalation should be slow and deep 7. Press canister down with index finger 8. Hold breath for 10 seconds
  25. 25. 9. Wait about 30 seconds before administering the next dose 10. Close cap Offer Spacer if still difficult. Same rules just breath normally through spacer Spacer not dishwasher safe, just simply rinse and leave to dry. If steroid inhaler advise to do just before teeth – good mouth hygiene indicated Offer leaflet and a follow up to answer questions they might have later on. Rotahaler Capsule administration of drug Twist to release drug – inhale simultaneously Hold breath for 10 s Other inhalers Easi-breath (teeth bite mouthpiece inhaler), Accuhaler (metered dosing) e) Explaining a procedure such as a chest drain Key to all explaining stations is to have a proforma that can be applied to all of them and avoid jargon. They are checking your communication not your knowledge. WIPER Emphasis on explaining why here – that want to discuss proposed action and answer any of their questions. Say that this is a chance for them to ask you anything so feel free to interrupt me. Then establish their knowledge base and what they want to know? Background – reasons for doing procedure etc Before – if there is any prep needed ie fasting etc During – on the day what to expect After – Can they leave straight after/ drive/operate machinery etc also will they need a friend or family member to pick them up Risks and benefits Results – when will they receive them and how Any questions? Ask them to repeat back what you have said and then offer leaflet and another chance to chat if they would like NB// if this is a consent station bare in mind you must also offer alternatives and risks if patient choses not to have procedure.

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