Archive:COPD Examination

Before you start some definitions

Emphysema - dilation and destruction of air spaces distal to bronchioles

Chronic bronchitis - airway narrowing and mucous production

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.

2. General

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

3. Inspection

Look for cyanosis
- Central - look at lips, oral mucosa and tongue
- Peripheral - nails, hands and feet
Look at fingers for nicotine 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

4. Palpation

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

5. Percussion

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

6. Auscultation

7. Make diagnoses

Differences between emphysema and chronic bronchitis on exam:

Inspection
- emphysema: pink puffer (SOB and tachypnea), hyperinflation, SOBOE, respiratory distress
- chronic bronchitis: blue bloater, cyanotic, peripheral edema (RVF), mild SOB post cough
Percussion
- emphysema: hyperresonant, decreased diaphragmatic excursion
- chronic bronchitis: normal
Auscultation
- emphysema: decreased breath sounds, no egophony
- chronic bronchitis: crackles and wheezes

CXR:
- hyperinflated lungs with flattened diaphragms
- retrosternal airspace
- heart sahdow long and narrow or enlarged if RVF/cor pulmonale
- may see bullae with emphysema

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

Other OSCE modules