COPD Examination
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
- Use of accessory muscles - sternocleido mastoid, pec minor
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
- 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 Chronic bronchitis
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%