JoshuaChambers

Module5OSCEdocumentConsultationskills:Informationaboutthestation:

• 11-minutestation• Introduction• SSSICERAV–Signpost,summariseandscreen• Ideas,concernsandexpectations• Recognise,acknowledge,validate• HAVEASTRUCTURE!• Havesomekeyphrasesasbackups!

Introduction:• Washhands• Introduce• Highmynameis______.I'ma______medicalstudentfromtheUEA.AndI'vebeen

totalktoyoutodayisthatokay?• NameandDOB• Explainstructure• ‘Thisconsultationwilljustinvolvemeaskingaboutyoursymptomsandthenafew

questionsaboutyourpastmedicalhistory,lifestyleandanymedicationsthatyou’reon,doesthatsoundokay?’

• Areyoucomfortableformetobegin?• Openquestion:‘sowhathasbroughtyouintoday?’

Presentingcomplaint:• Cough-duration,severity,timeoftheday• Wheeze–(askthepatienttoclarifywhattheymeanbywheeze)• Sputum–colour,consistency,volume• Haemoptysis–howmuch,howoften?• Breathlessness–timing,exacerbatingandrelivingfactors,EXERCISETOLERANCE.• Chestpain–SOCRATES

SAWTEM:• “JusttocheckthatIhaven’tmissedanything,I’mjustgoingtoaskyousomegeneral

questionsaboutyourhealth”• AskaboutOrtho/Rhemoquestion:“Haveyougoanyachesorpainsinyour

joints?”PMHx:

• Openquestionaboutanyothermedicalcondition• Askabout:• Atopy• Asthma• Childhoodinfections

FHx:• Anyconditionswhichruninthefamily?• ‘specificallyanylungconditionswhichruninthefamily’• ‘Justaquestionweaskeveryoneisthereahistoryoflungcancer?’

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SHx:• Smoking

o 1packyear=20cigaretteso Howmany?o Forhowlong

• Alcoholo Amounto “Whatisyourdrinkofchoice?”

• Occupationo exposuretoasbestoso zookeepero coalminers

• House/Livingarrangementso House/bungalowo Aloneorwithfamily/supporto Adjustmentsathomeo Okaywithstairs?

• Petso chlamydiapsittacio allergenso birdfancierslung

• Anyforeigntravel?o PE/DVT/TB

• Anyuseofrecreationaldrugs• IMPACTONQOL-GOODTORAV

DHx:• ALLERGIES• Iftime,askaboutOTCandherbal• Inhalers?–whatcolour?Howdotheytakeit?• Bronchoconstriction:betablockers,opioids,NSAIDs• DrycoughwithACEinhibitors• Lungfibrosis/parenchymaldiseasewithcytotoxics,DMARDs• ThePILL?–iffemale(DVT/PE)• Amiodaroneandnitrofurantoin(pleuraleffusion,fibrosis)

Commonconditionsthatcouldcomeup?• Asthma• COPDandwithexacerbation• Pneumonia• PE• Lungcancer• Bronchiectasis• Pneumothorax

Respiratoryexamination:Introduction:

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• WASHHANDS• Introduceyourself• ConfirmpatientsnameandDOB• ‘I'vebeenaskedbythedoctortodoarespiratoryexaminationonyoutodayisthat

okay?Thisexaminationwillconsistofmehavingageneralinspection,thenhavingalookatyourhandsmouthandchestandthenhavingalistentoyourchest.Isthatokay?’

• Askthepatienttoadequatelyexposethemselves• Positionthepatientat45degrees

Inspection:JVP(Increasedheightorwaveform)/APEXBEAT/oralcandsis/legsperipheraloedema/Practiseeverything/cricosternaldistance/FLAPPINGTREMMOR/havinganydifficultieswithbreathing?Infectioninmouth/CommentonrespiratoryGeneralexamination:

• Commentonthegeneralwell-beingofthepatientandthepresenceofanyaidsaroundthebedsidee.g“oxygen,sputumpots,inhalers”

• Isthispatientinrespiratorydistress?canthepttalkinfullsentences?

• Symptomsofrespiratorydistress:“There’sno…”• nasalflaring,mouthbreathing,subcostal/intercostalmusclerecession,usesof

accessorymuscles(trapeziusandsternocleidomastoid)Hands:

• Lookingatthehandsforanyclubbing,tarstaining,cyanosisandatremor• Cockthewristsback–lookforCO2retentiontremor• Checkpulseandresprate

o Normalrespiratoryrate-12-20o Tachyponoea-greaterthan20o Bradyponoea-lessthan12

• Offertotakeabloodpressure• ‘ifIhadmoretimeIwouldideallytakeabloodpressure’

Eyes:• CouldIjustpulltheskinofyoureyedown?• Anaemia• Jaundice

Mouth:• Oralcandidiasis,centralcyanosis• Pursedlipbreathing

Neck:• Isthetracheacentral?• Cricosternaldistance(3-4fingers)

• Cricosternaldistancejugularnotchtocricoid–ifobstructivelungdiseasethedistancewillbesmallerifhyperinflationispresent3fingerdistance

• JVPandhepatojugularreflux• Askforabdopain–lookupforthis• Lookawayat45degrees

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• PressdownonstomachLymphNodes:

• Submental,submandibular,preauricular,postauricular,occipital,anteriorandposteriorcervicalchainandsupraclaviclar

Legs:

• Bilateraloedema–corpulmonale• Unilateraloedema–DVT

Inspection:CHEST:• ‘lookingatthechestanteriorlyandposteriorforanyscars,swelling(sternotomyand

thoracotomy),deformities(e,gpectusexcavatumorpectuscarinatum,kyphosisorscoliosis)’

• Chestwalldeformitieso Pectusexcavatum-sternumisdepressedinrelationtotheribs,o Pectuscarinatum-sternumismoreprominenttotheribso Barrelchest–emphysema/COPD

Palpation:Chestexpansion:

• Anteriorposteriordirection-placebothhandsonthepectoralregionandaskthepatienttotakeadeepbreath-chestshouldexpandsymmetrically

• Laterally-gripthechestbetweenbothhandsandaskthepatienttotakeadeepbreathwhilstobservingmovementofthethumbs

Apexbeat:• shouldbeinthe5thintercostalspaceatthemidclavicularline

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• Displacementoftheapexusuallysuggestcardiomegalybutrespiratoryconditionswhichmaycausetheapextobecomedisplacedinclude:Pulmonaryfibrosis,bronchiectasis,pleuraleffusions,pneumothoraxes

Percussion:• Clavicle,midclavicularline,betweentheribs• 4anterioallyand2laterallyEACH

Auscultation:• Askthepatienttobreathinandout–listen4anteriorandposteriorand2laterally

(Midaxillary)FOREACHside.• Listenfordiminishedbreathsounds• Bronchialbreathing• Addedsoundssuchaswheezes,stridororcrackles,orpleuralrubs

Vocalresonance:• Askthepatienttosay99• Increasedinfibrosis,consolidation,collapse

Summary:• Onexaminationofthispatient..• Oninspection..• Onpalpation…• Onauscultation• Clearvesicularbreathsounds• IfIhadmoretimeIwould:

o Doafullcardiovascularexamo LookatCXRo Dothefront/backo BedsidePeakflowo Lookatobschart

Commonconditionsyoumightget:• Chestwalldeformity

o kyphoscoliosis,pectusexcavatum• Post-surgerywithobviousthoracotomyscar• Bronchialbreathingispresentabovetheoedema(Becausethelunghasclumped

together)

SummaryofexaminationfindingsanddiseaseBreathsounds Indicates

Normalvesicularbreathing NormallungsBronchialbreathing Thisisfoundwherelungtissueisreplacedbyuniformlyconducting

tissue.Thisincludes:ConsolidationFibrosisCollapse(withpatentbronchus)

Absentbreathsounds PEPulmonaryeffusionPneumothorax

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Whisperingpectoriloquy ConsolidationCollapsewithpatentbronchus

Vocalresonance Consolidation–increasedPE–decreasedPulmonaryeffusion–decreasedPneumothorax–decreased

Crackles Fine–PulmonaryfibrosisandheartfailureCourse–infectionandbronchiectasis

Wheeze AsthmaCOPD

Pleuralrub Inflamedpleura,infection,PE,fracture

ConditionsrelatingtotheirexaminationfindingsCondition General Face/neck Inspection Palpation Percussion AuscultationPneumonia SOB,

fever,tachycardia,cyanosisandhypotension

Flushedorpale

Tachypneic,laboured,reducedexpansion

Tracheanormal

Dull CoursecrackleswithbronchialbreathingandVRandWPincreased.?PleuralrubProminent,mostly,inlowerlobes.

Pleuraleffusion Accessorymuscles,labouredbreathing,looksill

Reducedonside

Tracheaawayiflarge

Stonydull Absentbreathsounds.?Bronchialattopofeffusion.VRreduced

Pneumothorax SOB,pain

?Surgicalemphysema

Reducedexpansiononthatside

Trachealdeviationopposite

Hyper-resonant

Absentornobreathsounds,VRdecreased

Collapse SOB,Tachycardia

Reducedexpansion

Tracheatowardsiflarge

Dull Absentorreduced.?Crackesorwheeze.VFdecreased

ILD ClubbingCyanosis

Clubbing Reducedexpansion

Tracheanormal

Normal Finecrackles?Bronchialbreathing

COPD SOB,oxygen

Accessorymuscles,cyanosisWtloss

Barrelchest Tracheanormal

Normal,hyperresonant

Reducedairentry,(polyphonic)wheeze

Asthma ?SOB Labouredbreathing,shortsentences,accessorymuscles

Hyper-inflationofchest

Tracheanormal

Normal Wheeze

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PulmonaryEmbolism

Inpain,cyanosis

SOB,pleuriticpain,signsofDVT,raisedJVP

SOB Normal Normal Absentorreducedbreathingandpleuralrub

Bronchiectasis Reducedexpansion

Reducedpercussion

ReducedairentryCrackleswhichchangewithcoughing

PercussionnoteType Detectedover

Resonant NormallungHyperresonant PneumothoraxDull Pulmonaryconsolidation

PulmonarycollapseSeverepulmonaryfibrosis

Stonydull(Anythingliquid) PleuraleffusionHemothorax

CausesofdiminishedvesicularbreathingReducedconduction

ObesityPluraleffusionorthickeningPneumothorax

ReducedairflowGeneralised.COPDLocalised.Collapsedlungduetooccludinglungcancer

CausesofcracklesPhaseofinspiration Cause

Early Smallairwaydisease,bronchiolitisMiddle PulmonaryoedemaLate Pulmonaryfibrosis(Fine)

Pulmonaryoedema(Medium)BronchialsecretionsinCOPD,pneumonia,lungabscess,tubercularlungcavities(coarse)

Biphasic Bronchiectasis(Also,pulmonaryoedema,ILD,PF,COPD,Pneumonia)

CausesofbronchialbreathsoundsCommon

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Lungconsolidation(Pneumonia)Uncommon

LocalisedpulmonaryfibrosisPleuraleffusionCollapsedlungwheretheunderlyingmajorbronchussoundsareobvious(Oftenpartialcollapse)

Spirometryprocedureandinterpretation:• GooverPFTquizlet• Gooverthepaperdocumentinfolderwiththison

Whatismeasured?• Totalvolumeofairforciblyexpiredafterafullinspiration.(FVC)• Volumeofairthepatientisabletoexpireinthefirstsecondofaforcedexpiration.

(FEV1)• FEV1/FVCratioexpressedasapercentage• Maximumflowachievedfromaforcedexpiration.(PEF)

Indications:

• Abnormalitypresent?• Assessmentofseverity• Serialmeasurements• OccupationalMedicineorEpidemiologicalstudies• Research

Normalvaluesdependupon:

• Age• Sex• Height• Ethnicorigin

Limitationstoflowvolumeloop

• Notspecific• Sensitivity

Whattocheckbeforewedospirometrywithpatients:

• Height,sex,age• Inhalers,whendidyoulastusethem• Shouldn’tbedoingitonpeoplewhohavehadanMIinthepastweek• Thoracicsurgeryinthepast12weeks• Haven’thadapneumothoraxinthepast2weeks• ‘Haveyoubeenaninpatient’• ‘Haveyouhadanyoperationsinthepastfewmonths?’• Otherconditions• Smoker?

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• ExplainthenatureandpurposeofthetestMeasurements:

• RVC’s(Relaxedvitalcapacity)–x3• FEV1/FCV–3withgoodtechnique

o 2withina100mlofeachotherBadtechnique:

• Co-ordination• Noleakage• Nocoughing• Nottakingfullbreathin• Gentle–givingaslowblow(misdiagnosedfalsepositiveslookslikeCOPD)• Earlytermination(Lessthan6sec)underestimateFVC,sofalsenegatives

FEV1%predicted:• >80mild• 50-79moderate• 30-49severe• <30verysevere

Obstruction:• ‘Scooping’onthegraph

CalculatingspirometryintheOSCE?

• Youwillbegivensomedatafromapatient(FEV1,FVC,possiblyacoupleofFlow/volumeloopsorvolume/timecurves)

• Youwillneedtocalculatethepatient’sFEV1/FVCratiousingacalculator(calculatorprovided!)

• Youwillneedtofindthepatient’spredictedFEV1onatable• Youwillthenneedtocalculatethepatient’spredictedFEV1%• FEV1/PredictedFEV1• Thensuggestadiagnosis–probablyCOPD• DescribeseveritybasedonNICEguidelines

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LearnCOPDseverity:

Describingspirometry:PRACTISETHIS

• Demographic–e.g.age• Quality–e.g.slowstart,takinganextrabreath• Numberofblows• FEV1(%predicted)• FVC(%predicted)• FEV1/FVC• Preandpostdilator• Commentoncurves–e.g.shape,anyanomalies• Diagnosis–e.g.restrictiveorobstructive• Lookatquality

o Ifpatienttooslowblowingout–scooponinspirationo Ortakinganextrabreath

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• DEFINEFEV1andFVC• Asthma

o Diurnal–morethan20%differenceatdifferenttimeso Peakflow

Flowvolumeloops:

• Thesearegraphsconstructedfrommaximalexpiratoryandinspiratorymanoeuvresperformedonaspirometer.

• Theloopismadeupoftwohalves,aboveistheflowoutofairfromthemouthandbelowistheflowofairintothemouth.

• Theshapeoftheloopcanidentifythetypeanddistributionofairwayobstruction.• Whenlookingatthese,lookforthenormalflowvolumeloop–withthetriangle

expiratorycurve,slowingdownoncetotalrespiratoryvolumeisreached.There’sasemi-circularinspiratorycurve

• AnydeviationfromtheshapeofA=pathology• TheFEV1=*• ReducedFEV1anywayindicatesobstructiveairwaysdisease.

Inrestrictivedisease:

• Maximumflowrateisreduced• Totalvolumeexhaledisreduced• Becauseofincreasedlungrecoil–flowrateishighduringthelaterpartofexpiration

Extraphysiologicaldetail:• Inrestrictivedisease(suchaspulmonaryfibrosis,ILD,neuromuscularproblemsor

chestandspinedeformities)there’sarestrictiontolungexpansion.Thereforethere’sareductioninthevitalcapacityinthelungs,resultinginareductioninFVC

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• Moreover,asthere’sreducedcomplianceandelasticitythere’sALSOareductionintheFEV1

Inobstructivedisease:• Flowrateislowinrelationtolungvolume• Expirationendsprematurelybecauseofearlyairwaysclosure“Scoopedout

appearance”afterthepoint.Extraphysiologicaldetail:

• Inobstructivedisease(COPD,Asthma,CF,bronchiectasis)there’saresistancetoexpiratoryflow.ThismakesitdifficulttoachieveagoodFEV1

• Thismakestheratiolower,commoninrespiratorydiseaseThegraphsshow:

• A=Normal• B=Restrictivedefect(Phrenicpalsy)• C=Volumedependantobstruction(Asthma)• D=Dependantobstruction(Severeemphysema)• E=Rigidobstruction(Trachealstenosis)

Volumetimegraphs:

• Inanobstructivepicture,thecurvedoesn’tplateau.Youhavetothinkaboutratios–

ifitdoesn’tplateauthenFEV1willbemuchlowerthanFCV,givingarestrictive<70%picture.

• However,withrestrictive,thecurveisjustasmallerversionthannormal.That’swhytheratioremainsthesame.

• Rememberrestrictivedefectsincludeintrathoracicandextrathoracicrestrictions

Peakflowprocedureandinterpretation:Peakflow:Intro:

• Washhands• Introduceself• ConfirmpatientsnameandDOB

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• ‘I’vebeenaskedtoassessyourpeakflowisthatokaywithyou?Explanation:

• Checkpatientsunderstandingofthecondition• ExplainwhymeasuringtheirPEFRisimportantasaguidetohowwell-controlled

theirasthmais• ExplaintothepatientthattheyshouldbecheckingtheirPEFRregularly,particularly

iftheirasthmaisworsethanusual• Thepeakflowmeasuresthemaximumspeedofexpiration(howfastyoucanblow

outalltheairinyourlungs)• Todothisyouwillhavetoblowashardandasfastasyoucanintoatube.

Demographicstoreceive:

• Weight• Height• Ethnicity

Thingstoconsider?

• Havetheyjusttakenaninhaler?• Havetheyjustsmoked?• Havetheyjustdonestrenuousexercise?• Havetheyjusthasabigmeal?

StepsofthePEFRmeasurement:

• DescribethestepsinPEFRmeasurement• Connectacleanmouthpiece• Ensurethemarkerissetto0• Standorsitupright• Holdthemeterhorizontallyandensuretheyarenottouchingthedial• Takeasdeepabreathinasyoucanandholdit• Placethemouthpieceinyourmouthandformastightasealaspossiblearoundit

withyourlips• Breathoutashardandasfastasyoucan(measuresthefirstpuffsotheydonot

needtoexpirefully)• Observeandrecordthereading• Repeat3-4timesandrecordthehighestreading• Notedowntherecordinginadiaryforcomparison• Afterdescribingtheprocesstothepatient,youshouldshowthepatienthowto

performthemeasurement–dothisbymeasuringyourownPEFR• ASKTHEPATIENT,ISTHISALLCLEAR,DOYOUHAVEANYQUESTIONS?REPEATTO

MEBACK• Oncethetechniquehasbeendemonstratedasthepatienttoshowyouhowthey

wouldperformthemeasurementbythemselves.• Makesuretheyaredoingitcorrectlyandresolveanymistakestheymaybemaking

Postprocedure:

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• Askthepatientiftheyhaveanyquestionsorconcerns• Disposeofthemouthpiece• Thankthepatient

Describeorplotagraph:

• Diurnalvariation• Morningdipping• Betterthroughouttheday• ORrecoverfromanasthmaattack,anditgraduallygettingbetter• Orpostbronchodilator–morethan20%difference

Advancedrespiratorytestinterpretation:• Lookatpaperdocforthis

Transferfactor:• Transferfactor(TLCO)isdefinedastheamountofcarbonmonoxidetransferred/min

–correctedfortheconcentrationgradientofCOacrossthealveolarcapillarymembrane.

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Whenistransferfactorreduced?• Feweralveolarcapillaries• V/Qmismatches• Reducedaccessiblelungvolumes

Testing:• Gastransferisarelativelysensitivebutnon-specifictest• Itisusefulfordetectingearlydiseaseinlungparenchyma• Transfercoefficient,therefore,isabettertest.• Transfercoefficient(KCO)iscorrectedforlungvolumesandisusefulat

distinguishingcausesoflowTLCOduetolossoflungvolume.• TLCOandKCOarealwayslowinemphysemaandfibrosingalveolitis• TLCOislowbutKCOisnormalinpleuraleffusionsandconsolidation.

Conditionsthataffectthetransferfactor

DecreasedTF IncreasedTFPulmonarycauses Emphysema,lossoflung

tissueanddiffuseinfiltration

PulmonaryHaemorrhage

Cardiovascularcauses Lowcardiacoutput,pulmonaryoedema

Thyrotoxicosis

Othercauses Anaemia Polycythaemia

ABGprocedure:Introduction:

• Washhands• Introduceyourself• ConfirmpatientsnameandDOB• ‘I'vebeenaskedbythedoctortotakeabloodsamplefromyourarteriestodayis

thatokay?’• Explainprocedure• ‘Theprocedurewillinvolvemeputtingasmallneedleintoanarteryintoyourwrist

togetabloodsample.Itshouldn’tbetoouncomfortablebutifyou’dlikemetostopatanypointpleaseletmeknow’

Tocheckfor:• Contraindications

o Clottingdisorders“Anyproblemsinthepast?”o Onanyanticoagulants/warfarin

• Isthepatientonair?o Inspiredair-oxygensats/pao2-aretheyonconstantoxygen?

• Temperatureo canaffectdissociationcurve

• Alan’stesto Tocheckforulnaarteryperfusiono Toensureadequatebloodsupplytothehand

Preparation:

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Getequipment:• Gloves• Syringepack• Alcohol• Cottonwool• Sharpsbin

Questionstoask:• Whichisthepreferredarm?• Placethewristinhyperextension• Locatetheradialartery• Offeranaesthetic(2%lidocainesubcut)

Procedure:• Palpateradialartery• Cleanskin• Letthepatientknowyouareabouttoproceedandtoexpectasharpscratch.• Pullbackplungerto0.7(1.5ml)toallowroomforthebloodtofillit• Inserttheneedleat30degreestotheskinatthepointofmaximumpulsationof

theradialartery.• Advancetheneedleuntilarterialbloodflushesintothesyringe.Thearterialpressure

willcausethebloodtofillthesyringe.• Removetheneedle/syringeplacingtheneedleintothebung.Pressfirmlyoverthe

puncturesitewiththegauzetohaltthebleeding.(5secondsthenletthepatientdoit)

• PushoutanyairwithinitandShaketomixanticoagulantsPostprocedure:

• Labelthesamplewiththepatient’sname,DOB,hospitalnumberandinspiredoxygenandsendforanalysis

• Removeyourglovesanddisposethemintheclinicalwastebin.• Disposeofallofthestuffintherelevantbins• Washyourhandsandthankthepatient.

ABGinterpretation:

1. Onairoronoxygen2. Lookatoxygen–type1/2respiratoryfailure?Below8kPa3. LookatthepH,AcidemiaorAlkalemia?4. LookatthePCO2,Isithigh?Thatwouldbeanacidosis.Isitlow?Alkalosis?Ifit

correspondstowhatisinstepone–youknowitsduetorespiratoryabnormality,ifitdoesn’tcorrespond–iepHof7.47andaCO2innormalranges–it’sprobablymetabolic

5. Lookatthebicarb.Isthebicarbhighorlow?Highbicarb–alkalosis.Low–acidosis.6. THINKwhatisoppositetothepH?IftheCO2agreeswiththepHandthebicarbis

opposingthepHitsuggestscompensation7. Ifyouhaveconflictingresultsbetweenametabolicorrespiratoryprimary–lookat

theO2.IftheO2islowitdoesindicatethatthere’srespiratoryfailure…Therefore..leadingyoutobelieveit’sarespiratoryprimary.

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Noteoncompensation:

• Compensationisanopposingmechanism• Thebodyneverovercompensates,topushittheotherside• Compensationmaybecompleteorincomplete.Thus,ifit’scompleteitthepHmay

stillbeinnormalranges.Ifit’sincompletethepHwillbeoutsidenormalranges.Type1RespiratoryFailure=paO2<8kPawithnormal/lowpaCO2Type2RespiratoryFailure=paO2<8kPawithhighpaCO2>6.5kPaSteps ResultsFirstlookatthepH <7.35=Acidosis

>7.45=Alkalosis

NextlookatpaCO2-Isitinkeepingwithabove?

pH<7.35andpaCO2>6.0=RespiratoryacidosispH>7.45andpaCO2<4.5=Respiratoryalkalosis

IfpaCO2notinkeepingwithpHthenlikelyitsgoingtobemetabolic

pH<7.35andHCO3-<22=Metabolicacidosis

pH>7.45andHCO3->28=Metabolicalkalosis

Lookforcompensation Respiratorycompensationmayoccurearlywhereasmetaboliccompensationoccursinchronicdisease

InterpretationofABGs–valuestobearinmind

HC03 <21mmoles 21–29mmoles >29mmolesPaC02>6kPa

Respiratory+metabolicacidosis

Respiratoryacidosis Metabolicalkalosis+respiratoryacidosis

PaC024.5–6kPa

Metabolicacidosis Normal Metabolicalkalosis

PaC02<4.4kPa

Metabolicacidosis+respiratoryalkalosis

Respiratoryalkalosis Metabolic+respiratoryalkalosis

Pastandsfor“Pressureintheartery”

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Generalcausesofrespiratoryfailure:Type1:

• It’scausedbyaloworhighV/Qmismatch• LowV/Qcauses:whereareasoflungareperfusedwithdeoxygenatedbloodbynot

ventilatedwithoxygen• HighV/Qcauses:Whereareasofthelungareperfusedwithdeoxygenatedbloodbut

arenitbeingventilated.• ThereasonCO2isnormal,isbecausethenormalpartsofthelungarefreetoblood

offmoreCO2thannormalType2:

• Causedbyalveolarhyperventilation• Thismeansthatoxygencannotgetintothealveoliandcarbondioxidecannotget

out• COPD,restrictivelungdiseaseorneuromusculardiseasecausethis

Oxygentherapy,practicalstuff,prescribingandtypesofmask:FiO2:

• FiO2=fractionofinspiredoxygen• Roomairis21%FiO2• Highflowmaskscangive60%FiO2• CanbehardtotellifPO2isappropriatelyhighforFiO2andwhetheroxygenationis

impaired• Ruleofthumb:ExpectedPO2=FiO2%-10• Example:patientonFiO240%(facemask).ABGshowsPO2of18.8kPa(normal

>10kPa)• IMPAIREDOXYGENATION

TargetsatsforCOPDandnormalpatient:TargetsaturationsforT1/T2respiratoryfailure?

• TypeIIRespiratoryFailure:o 88-92%targetsats.o VenturiessentialinTypeII

• TypeIRespiratoryFailure:o 94-98%targetsatso Assesssatsatleast6hourly

Uncontrolled(variable)performancesystems:Theoxygensuppliedtothepatientwillbeofvariableconcentrationdependingontheflowofoxygenandthepatient’sbreathingpattern.

• ThisiswhenO2requiredtoraisetheSaO2above92%• NoconcernsthehighO2willsupresstheventilatorydrive.

Device Image Flowrates(FiO2)

ConcofOxygenthatcan

bedelivered

Examplesofuse

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Nasalcannulae

1-6L/min

approx24-50%

SimpleFaceMaskAlsoreferredtoas:• MCMask• MediumConcentration

Mask• MaryCatterallMask• HudsonMask

6-10L/min

Flowratemust

beatleast5

L/mintoavoidCO2re-

breathing

approx40-60%

ReservoirMask(NonRe-breathingMask)

• Deliverthehighestflowoxygentosomeoneinhospital

• Reallysickpatients• 15L–MAXoxygen

10-15LminReservoir

mustbefilledcorrectlybefore

administration

approx60-90%

Short-termuseTraumaEmergencyCriticalillnessPostcardiac/respiratoryarrest

Controlled(fixed)performancesystemsWillgiveanaccurateconcentrationofoxygentothepatientregardlessofthepatientsbreathingpatternandflowofoxygen(providingtheminimumsuggestedflowrateasshownontheVenturivalveisused)

• ControlledusewithextraO2isrequired.• However,it’sCONTROLLEDasventilationrequiresthehypoxicdrive• ThereforePaO2mustnotgoabove8kpa(BasicallyoutofT2respiratoryfailure)

VenturiMasks• O2isdirectedthrough

anarrownozzleandexitsatspeed.

• Thisdrawsinairanddilutestheoxygen

• ItmixesairandO2atthesameratioregardlessofflow

Asper

instructiononVenturivalve

24-60%

Patientsatriskofhypercapnicrespiratoryfailure(egCOPD)

TracheostomyMask

OxygenMUSTbehumidified

24-70%

Patientswithtracheostomyorlaryngectomy

Oxygentherapy:

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OxygentherapyreviewTypeofoxygentherapy Aims IndicationsLTOT–Longtermoxygentherapy PatientNEEDSoxygen

LongtermhypoxiaAtleast15hoursIdeally18-20Toreducelongtermcomplicationsofchronichypoxiasuchascorpulmonale(LTOT)

PaO2lessthen7.3(Hypoxicinastablestate)Lessthan7.3Kpaon2occasions,3weeksapartwhenstableOR7.3-8IF…Secondarypolycythaemia,nocturnalhypoxemiaandcorpulmonaleNOTinacuteexacerbationABGinoutpatients,lessthan7.3–doagainin2weeks,confirmandthenstartLTOT

Ambulatoryoxygentherapy AllpatientsonLTOTExercisedesaturation

ExercisedesaturationIeatrest–O294-95%...butifyoudoa6minwalktestitdropssuddenlyNEEDtodemonstratethepatientsgetbenefitwithoxygenMakethepatientwalk,without,withplaceboandwithoxygen–supposedtogiveambulatoryoxygen

SBOT:Shortburstoxygentherapy SevereSOBandunresponsivetoothermeasuresThus,theirPaO2isfineallthetimebuttheyfeelREALLYbreathlessPlaceboornot–itkeepspeopleawayfromhospital

Oxygenalertcard:

• ThisshouldbegiventoallpatientswithapreviousHxofhypercapnia/respiratoryfailure

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Prescription:• Oxygenshouldbeprescribedonthedesignatedsectionofthedrugcharttoachievea

targetoxygensaturationof94-98%formostacutelyillpatientsor88-92%forthoseatriskofhypercapnicrespiratoryfailure.

• Forsomepatientsitmaybeappropriatetospecifyadifferenttargetrange.• Alloxygenshouldbeprescribedexceptinanemergency(peri-arrestorcriticallyill)when

itshouldbestartedimmediatelyusingamaskwithreservoirbagat15L/minanddocumentedlaterinthepatientsrecord.

CXRandCTreportsChestX-ray:

• First–READTHESCENARIO.Thiswillgiveyouclues• Demographics:–Name–DOB–DateTaken–View(AP/PA/lateral)–“Thisisa

plainfilmchestradiograph,PAview,takenof………..,DOB10/06/1941.Itwastakenon15/11/2014…”

• BrieflyrunthroughqualityofCXR(RIPE)o Inclusion/Exposure–bothcostophrenicangles,bothapiceso Rotation–symmetryofclavicleso Inspiration–5-7anteriorribso Penetration–seethoracicvertebraethroughheart

• WorkthroughrestoftheCXR:o A-Airwaysincludingthehilao B-Bonesandsofttissueo C-Cardiacsilhouette,sizeandmediastinumo D-Diaphragm,costophrenicanglesandhemidiaphragmso E-Effusionsandpleurao F-Lung'fields‘

• Checkpleuraandlungedgeforpleuraleffusionandpneumothorax• Lines,drainsetc..E.g.chestdrain,centralline• KerleyBlines=Pulmonaryoedema

o Usuallyfoundatthelungbases• Anyforeignbodies,ECGleads,endotrachealtubes,pacemakers• STATETHEOBVIOUSFINDINGS

Extras:• Opacity=white

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• Hypo(dark)/hyper(white)density• LateralCXR–drawthehorizontalandtransversefissuresofthelung–knowthe

surfacemanagementHowtodescribealesion?

• Whereisit• Howbigisit?(Tennisball,5pcoin,10pcoin)• Whatisit’sshape?• Boarderwellorpoorlydemarcated?• DESCRIBEwhatitlookslike–fluffy,homogenous,heterogenous?)• Presenceofanairfluidlevel?• Awhitefluffyzonearoundalesionisoftensclerotic

Howtodescribeanopacity:

• Whereisit?• Whatzoneisit?• Doesitcoveranyboarders?(Indicatingalobe)• DESCRIBEWHATYOUSEE,fluffy,homogenous,hetrogenous…etc..

Commonpathologiestocomeup(Knowthemanagementofthese!)

• Pneumonia:consolidation,airbronchograms,identifylobes,parapneumoniaeffusion

• PleuralEffusions:bluntingofcostophrenicangle,homogenouswhiteout,mediastinalshiftaway

• Pneumothorax:mediastinalshifttowards(unlesstension),pleuralline,lossoflungmarkings

• Pulmonaryoedema:batwingappearance,septallines,venoushypertension,smallbilateralpleuraleffusions

• Collapse:mediastinalshifttowards,increaseddensitywithoutairbronchograms,identifylobes

• Fibrosis–thisisclassifiedasupper,middleorlowerzones–andcanbespreadoutallaround…Itgivesthoseweirdlinedappearances..

• KNOWWHERETHEFISSURESAREBOTHONAPANDLATERALThingstoconsiderfortheOSCE:

• Atfirst,untiltoldto,don’tbespecific!Say“Opacity”insteadofconsolidation• Insteadof“Cavity”say“Lesion”,asthisislessspecific.• USEZONESinsteadoflobes• ALWAYScheckifit’sAP/PA• AlwaysrelateCXRtotheclinicalpicture…• InbonesREALLYLOOKFOR#orchunkmissing-becauseoftentheremaybea

pneumothorax!• Forany?consolidation-look

Specificsforcollapse:(+generalcollapsefindings)

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• Upperlobecollapse–subtlebecausethelowerlobecompensateso Oftendemarcatedbythehorizontalfissureo Thelungbecomessmallero Mediastinalshiftoccurso Diaphragmgoesupo Tofindoutwherethecollapseis–lookforshady/hazyshadowingandthisindicatesasto

whereitis.o Canyouseethroughtheheart?Ifnot?Leftlowerlobecollapseo Looktoseeifthehilahasmovedupordowno Veillikeappearancehereiscommon

• Leftlowerlobecollapseo Tocardiacleftboarders‘Sailsign’o Canlooklikecardiomegaly

• Leftupperlobecollapseo Vaillikeopacityo Also,retentionoftheheartboarder

• Rightupperlobecollapseo Somethingdodgeisgoingonupinthatcornerasthelungfoldsinonitselfo AlthoughthisCANlooklikeabronchogeniccarcinoma

• Rightmiddlelobecollapse:o Oftenamassorevenaverywelldefined,sharptrianglejuttingoutofthemediastinum

• Rightlowerlobecollapse:o Quiteaclearsailsortontherightsidecoveringthecosto-diaphragmaticangle.

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Prescribing(oxygen),inhalersandnebulisers:Inhalers:Typesofinhaler:

• Nebulisero Drivinggaso Forathomeuseo Onlyforuseinpatientswho’sbreathingissolabouredthatcoordination

wouldbeimpossibleo Mostclinicalscenariosuseaspacerinstead.

• Metereddoseinhalero Pressurisedincanister

• Drypowderinhalero Inspirationo Notgoodwithpeoplewhoworkinwetdampenvironments

Techniquedependingontype:

• DPI=quickanddeepfromthestart• MDI/aerosol=Breatheinslowlyandsteadily• Mostinhalersarequickanddeep.

TakinganMDI:

• Checktheexp.Date• Checkthecapsoff• Checkforanyforeignbodies• Shake• Breathout• Sealaroundcap• Pressdownonce• Slowandsteady• Holdbreathandwaitfor10seconds

MDIwithspacer:• Same• Breatheout• Pressit• 4-5tidalbreaths–slowandgentle• (Reducesoralthrushasitdoesn’thitthemouthasfast)

Whyarespacerssogood?

• Co-ordinationo Delayininspirationo Itgivesusalittletimetogetitallin

• Lessoropharyngealdeposition• Improvedlungdelivery

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CPAPandBiPAP:TypeofpatientwithCPAP:Type1

• OSAo Stentingopentheupperairways

• Pulmonaryoedemao Shorttermthingtoenablethemedicalmanagementtokickin(Ie

diuretics/nitrites)• Pneumonias

o Affectingpressuregradiento Can’tventilateo HIGHFLOW(oxygen)ratherthansomethingtosplintthemopen

TypeofpatientonBIPAP:Type2

• COPD• Patientsintype1thatgettired,andunderventilate• Bronchiectasis• Chestwallissues

o Abnormalventilation• Obesity

o Fat• Neuromuscularconditions• Headinjuries/opiates/postsurgery

Inhalertechniqueandinformationgiving:Introduction:

• Introduceyourself.• Washhands.• Confirmpatientdetails–name/DOB• Checkpatient’sunderstandingoftheirinhaler–allowingyoutotailoryour

explanationtothepatient’slevelofknowledge.Explanation:

• Explainwhattheinhalerdeviceis• Youhavebeenstartedon….(nameofinhaler)…foryourasthma/COPD“–Showthe

patienttheinhalerdeviceExplainingdifferenttypesofinhaler:Preventer:

• Forexample,ICSbeclomethasone(Brown)• (Name of inhaler) is a preventer – it helps to reduce the swelling in the airways and

stopping them from being so sensitive. You use this to lower the risk of severe attacks. I would like you to inhale …(x puff(s))…(x time(s) a day)…everyday. It’s really important that you don’t miss doses, as regular use is key to keeping your asthma/COPD under control” – Remind the patient to rinse mouth after use if the inhaler contains a steroid due to risk of oral candidiasis.

Reliever:• Forexample,Salbutamol(Blue)

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• (Name of inhaler) is a reliever. This is useful to help relieve immediate wheezing/asthma attacks. It works by relaxing the airways so that you can breathe more easily. You shouldn’t need this more than 3 times a week if your asthma is well controlled. Ask your GP for a review if you are using this more frequently. I would like you to inhale (x puff(s)) when you feel short of breath.

SMART/MARTtherapy:• (Symbicort Maintenance and Reliever Therapy)regime

“Symbicort is used as both a preventer and a reliever. You need to use this regularly …(x puff(s))…twice a day to prevent symptoms and …(x puff(s))…each time you have an attack.” – Remind the patient to rinse mouth after use due to risk of oral candidiasis.

ASKTHEPATIENTTOSUMMARISEKEYPOINTSBACKTOYOUDemonstration:1.Preparetheinhaler–Takeoffthelid/ShakeifMDI/Insertcapsuleifhandihaler2.Loadthedose–pressbuttontopuncturecapsuleifhandihaler/pressleveronceifaccuhaler/twistbottomifturbohaler3.Breatheoutgentlyasfarasiscomfortable.4.Tightlyseallipsaroundthemouthpiece.5.Breathein:

• Drypowderinhalers(DPI)needstobebreathedinquickanddeep• Metereddoseinhalers(MDI)needstobebreathedinslowanddeep• Softmistinhalers(SMI)needstobebreathedinslowanddeep

6.Removeinhalerfrommouth,holdbreathforaslongasiscomfortable.7.Repeatprocedureasdirected.Observeandassess:

• Askthepatienttocarryouttheprocedurethemselveswhilstyouobserve• Mostpatientswillrequiretweaking.• Pointoutthepositives…“youaredoingX&Yverywell“…thenintroduceroomfor

improvement…”butdoingA&Bmayhelpyourinhalersworkmoreeffectivelyforyou“

• DEMONSTRATE>OBSERVE>FINETUNE>REPEATASNECESSARYSpacerdevises:

• Spacersareusedtoimprovedrugdepositiontothelungsinpatientswhocannotmastertheiraerosolinhalertechnique.Theyareusefulinreducingsideeffectsofhighdoseinhaledcorticosteroidsbyreducingtheamountofdrugswallowedandabsorbedintothebody.CommonlyusedspacersareVolumaticandAeroChamber.

1.Prepareinhaler(shakeaerosolinhaler).2.Attachinhalermouthpiecetothespacerdevice.3.Breatheoutgentlyasfarasiscomfortable.4.Lipssealaroundthespacermouthpiece.5.Release1doseintothespacerdevice.6.Breatheinandoutthroughthespacermouthpieceseveraltimes.7.Administerseconddoseifneededandfinish.

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• Thespacerdeviceshouldbewashedwithdetergent(washingupliquidisfine)onceamonthandleavetoair-dry.Itshouldneverbewipeddryasthiscancausestaticwithinthedeviceanddrugparticleswillsticktosidesofthespacerasaresult.Spacersshouldbereplacedatleastonceayear.

Closingtheconsultation:

• Askifthepatienthasanyquestionsorconcerns–ensureyouaddressthese• Provideinformationleafletifavailable.• Advisethepatienttogetintouchshouldtheyhaveanymorequestionsorconcerns.• Thankpatient.• Washhands.

SleepstudiesTypes:

• Overnightpulseoximetry• Limitedpolysomnography• Fullpolysomnography• Actigraphy

CXR:

• Lookforairbronchograms• Lookforonething,lookforsomethingelse• Bilaterallymphadenopathycausedbylymphoma• Pleuralplaques–asbestosis• Multiplelungmetsinbothlungs

o Renalo Melanomao Ovarian

• FULLWHITEOUT:pleuraleffusion(butlookfortrachea)pneumonectomyandfulllongcollapse(Inacavity–fillswithfluid)

• Surgicalemphysema–lookup–looksstreakfromtheoutside• Leftlowerlobecollapse–CTindicatedasit’smostcommonlycausedbyatuourof

theleftlowerbronchus• Pneuothorax• COLLAPSE:CTindiated,orbronchoscopylookforcause(Mucousplug,tumouretc..)• Tumourinlungapex–candamagephrenicnerveandcausediaphragmisraised• Welldefinedpneumoniawithinalobe–lobar/roundpneumonia• Smallandfairlywelldefined–CANCER–goforCTand/orbiopsy• TRAUMA–Pneumohaemothorax(Orhydropneumothorax)becausetheairpushes

downtheeffusion• Ifwhiteopacitywithnomeniscus–think,infectionconsolidation• Middlewhiteopacitythatlookslikemiddlelobeconsolidationisacavitywith

infectionandairfluidlevel• CANgetsailsignwithrightlowerlobecollapse–lookforheartboarderunderthe

effusion!!Ifwelldefined

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• LOOKFORNGtubegoingintotheleftlung• Don’tcommentoncardiomegaly–AP• IFTRIAGNLEOPACITYFROMRIGHTHEARTBOARDER–middlelobeconsolidationor

collapse• Theringshadowsinbronchiectasisarebronchioles