COPD Examination
Appearance
Before you start some definitions
[edit | edit source]Emphysema - dilation and destruction of air spaces distal to bronchioles
Chronic bronchitis - airway narrowing and mucous production
- chronic cough
And now a stepwise approach to the OSCE examination
1. Knock on the door, walk in and introduce yourself. Wash hands and make sure the patient is comfortable then begin the examination.
General
[edit | edit source]- ABCs
- as a general rule, if the patient can talk to you their airway and breathing are okay
- LOC
- Pulse rate
- Respiratory rate, rhythm and depth
- Effort of breathing
- Use of accessory muscles - sternocleido mastoid, pec minor
- arms braced on knees or table
- speaking in full sentences
- Pursing of lips
- Nasal flaring
- Paradoxical abdominal breathing
- Sweating
- Tracheal tug
- Use of accessory muscles - sternocleido mastoid, pec minor
Inspection
[edit | edit source]- Look for cyanosis
- Central - look at lips, oral mucosa and tongue
- Peripheral - nails, hands and feet
- Look at fingers for cigarette tar stains
- Shape of chest
- Chest wall deformities or trauma
- Asymmetries of shape or movement
- Barrel chest has increased AP diameter - common in COPD
- Look for intercostal, subcostal and supraclavicular indrawing
Palpation
[edit | edit source]- Feel for tracheal position and presence of a downward tug
- Feel for range and symmetry of movement on inspiration - decreased range with hyperinflated lungs of COPD
- Feel for tactile fremitus - decreased in COPD
Percussion
[edit | edit source]- Percuss anterior and posterior, comparing left to right - hyperresonance with COPD
- Estimate diaphragmatic excursion by noting the difference in the level of dullness on percussion with inspiration and expiration - normal is 5-6cm, but is decreased with hyperinflated lungs of COPD
Auscultation
[edit | edit source]- listen to each of the five lung lobes and compare findings between sides
- Air entry - decreased in COPD
- Adventitious sounds
- wheezes, crackles, other
- generalized versus localized
- loud vs soft
Make diagnoses
[edit | edit source]Differences between emphysema and chronic bronchitis on exam
[edit | edit source]Inspection
[edit | edit source]- emphysema: pink puffer (SOB and tachypnea), hyperinflation, SOBOE, respiratory distress
- chronic bronchitis: blue bloater, cyanotic, peripheral edema (RVF), mild SOB post cough
Percussion
[edit | edit source]- emphysema: hyperresonant, decreased diaphragmatic excursion
- chronic bronchitis: normal
Auscultation
[edit | edit source]- emphysema: decreased breath sounds, no egophony
- chronic bronchitis: crackles and wheezes
CXR
[edit | edit source]- hyperinflated lungs with flattened diaphragms
- retrosternal airspace
- heart shadow long and narrow or enlarged if RVF/cor pulmonale
- may see bullae with emphysema
ABGs
[edit | edit source]- both have decreased PaO2 and increased PaCO2 (retainers) (low pH) but chronic bronchitis is worse than emphysema.
CBC
[edit | edit source]- Hct normal in emphysema, increased in Chronic bronchitis
PFTs
[edit | edit source]- Emphysema
- TLC increased (barrel chest)
- RV increased
- VC decreased
- FEV1 < 50%
- DLCO decreased (because alveoli destroyed)
- Chronic bronchitis
- TLC normal
- RV slightly increased
- VC slightly decreased
- FEV1 < 50%
- DLCO slightly decreased or normal
- cor pulmonale if FEV1 < 25%