COPD Examination

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Before you start some definitions[edit]

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]

  • 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

Inspection[edit]

  • Look for cyanosis
    • Central - look at lips, oral mucosa and tongue
    • Peripheral - nails, hands and feet
  • Look at fingers for cigarette tar stains and clubbing of fingernails
  • 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]

  • 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]

  • 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]

  • 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]

Differences between emphysema and chronic bronchitis on exam[edit]

Inspection[edit]

  • emphysema: pink puffer (SOB and tachypnea), hyperinflation, SOBOE, respiratory distress
  • chronic bronchitis: blue bloater, cyanotic, peripheral edema (RVF), mild SOB post cough

Percussion[edit]

  • emphysema: hyperresonant, decreased diaphragmatic excursion
  • chronic bronchitis: normal

Auscultation[edit]

  • emphysema: decreased breath sounds, no egophony
  • chronic bronchitis: crackles and wheezes

CXR[edit]

  • 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]

  • both have decreased PaO2 and increased PaCO2 (retainers) (low pH) but chronic bronchitis is worse than emphysema.

CBC[edit]

  • Hct normal in emphysema, increased in CB

PFTs[edit]

  • 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%

Other OSCE modules[edit]