Respiratory OSCE Station

By Jemima Robinson

ST4 Respiratory

Derriford Hospital

Objectives

• Common signs

• Common conditions that present

• Investigations

• Management

Respiratory Examination

• Inspection

• Palpation

• Percussion

• Auscultation

Round the Bed

Hands

• Clubbing

• Cyanosis

CO2 Retention Flap

• Tar Staining

Causes of finger clubbing

• Lung: bronchial carcinoma, pulmonary fibrosis

• Inherited: rare

• Gastrointestinal: inflammatory bowel disease, cirrhosis, hepatocellular carcinoma

• Heart: infective endocarditis, congenital heart disease

• Thyroid: Grave’s disease

• Idiopathic

Breathing Pattern

• Count respiratory rate

• Tachypnoea

• Pursed lipped breathing

• Use of accessory muscles

Cough

• Do first as part of inspection

• Dry Cough – Pulmonary fibrosis

– Pleural effusion

• Purulent cough/productive – Bronchiectasis/CF

– Pneumonia

Chest Shape

• Kyphosis

• Scoliosis

• Hyperinflated

• Chest Wall deformity

Scars • Midline Sternotomy

– CABG – Lung Transplant

• Thoracotomy – Lobectomy – cancer, abscess – Pneumonectomy – Lung Transplant – Oesophagectomy

• VATs – Pleural effusion/empyema – Lung Biopsy – Lung Cancer

• Chest drain/pleural aspiration sites

Tracheal Position

• Away

– Effusion

– Air

• Towards

– Collapse – cancer/consolidation

Cervical Lymphadenopathy

• Examine from behind

• Don’t play the piano

• Causes: – Lung Cancer – Head/neck cancer – Lymphoma – Glandular fever – TB

Chest Expansion

• Causes of Reduced:

Percussion

• Stony dull

– Effusion

• Dull

– Consolidation

– Collapse

• Hyperreasonant

– Air (pneumothorax)

Dull lung base • Consolidation

– Bronchial breathing – Crackles

• Collapse – Trachea deviation towards side of collapse – Reduced breath sounds

• Pleural thickening – Normal tactile vocal fremitus

• Raised hemidiaphragm

Crackles

• Coarse Expiratory – Consolidation

– (Bronchiectasis)

• Inspiratory – Pulmonary oedema

• Fine end inspiratory – Pulmonary fibrosis

Other Signs

• Wheeze – COPD – Bronchiectasis/lung cancer

• Bronchial Breathing

– consolidation

• Vocal fremitus

– Increased: consolidation – Reduced: effusion

Pleural Effusion • Signs

– Reduced expansion – Trachea away from effusion – Stony dull percussion note – Absent tactile vocal fremitus – Reduced air entry and breath sounds

• Signs to identify cause – Cancer: clubbing and lymphadenopathy – CCF: Raised JVP – Chronic liver disease: spider naevi, leuconychia – Chronic renal failure: AV fistula – Connective tissue disease: rheumatoid hands

Pleural Effusion • CXR

• Pleural Aspiration – Ultrasound guidance

– Protein – LDH – pH – if < 7.2 consistent with empyema

• Transudate (protein <30g/L)

– CCF – Chronic renal failure – Chronic liver failure

• Exudate (protein >30g/L) – Malignancy – primary or secondary – Infection – Infarction – Inflammation: RA and SLE

Pleural Effusion Treatment

• Transudate

– Treat the cause

• Exudate

– Pleural fluid cytology

– May need CT thorax

– Intercostal drainage may be appropriate

– Consider pleurodesis

Pneumonia • Signs

– Tachypnoea – Reduced expansion and increased tactile vocal fremitus – Dull percussion note – Focal coarse crackles, increased vocal resonance and bronchial breathing

• Investigations – CXR: consolidation (air bronchograms), abscess and effusion – Bloods: WBC, CRP, urea, atypical serology – Urinary pneumococcal and legionella antigens – Sputum cultures

• CURB-65

– Confusion – Urea > 7 – Respiratory Rate > 30 – BP systolic < 90mmHg – Age > 65

Pneumonia • Management

– Oxygen – Antibiotics – Consider immunosuppressed patients – Consider ITU referral

• Common Organisms (community)

– Streptococcus pneumoniae 50% – Mycoplasma pneumoniae 6% – Haemophilus influenzae

• Causes of Consolidation

– Tumour – Pulmonary embolism – infarction – Vasculitis – churg strauss

Bronchiectasis • Signs

– Cachexia and tachypnoea – Clubbing – Mixed crackles that alter with coughing – Occasional squeaks and wheeze – Sputum +++

• Investigations – Sputum culture – CXR – High resolution CT thorax

• Treatment

– Physiotherapy – Prompt antibiotic thearpy – Bronchodilators

Pulmonary Fibrosis • Signs

– Clubbing, central cyanosis and tachypnoea – Fine end inspiratory crackles – No sputum

• Investigations

– CXR – Lung function tests: Restrictive pattern, Low TLC, Low KCO – High resolution CT – Lung biopsy

• Treatment – Immunosuppression, eg. Steroids and azathioprine – Single lung transplant – Beware:- Unilateral fine crackles and contralateral thoracotomy

scar with normal breath sounds

Causes of Pulmonary Fibrosis

• Apical – TB – Radiation – Ankylosing Spondylitis/ABPA – Sarcoidosis – Histoplasmosis – Extrinsic allergic alveolitis

• Basal – Usual interstitial pneumonitis – Asbestosis – Connective tissue diseases – Aspiration

COPD

• Signs – CO2 retention flap, bounding pulse and tar-stained fingers

– Tracheal tug/accessory muscles working

– Hyper-expanded

– Percussion note resonant

– Expiratory wheeze and reduced breath sounds

• Investigations – CXR: hyperexpanded

– Spirometry: low FEV1, FEV1/FVC <0.7 obstructive, low TLCO

COPD discussion • Treatment

– Smoking cessation – GOLD guidelines:

• Mild (FEV1 > 80%)– beta agonists • Moderate (FEV1 < 60%) – tiotropium plus beta agonists • Severe (FEV1 <40%) – above plus inhaled corticosteroids

– Pulmonary rehabilitation – Surgical options

• Bullectomy • Lung reduction surgery • Lung transplant

– Long-term Oxygen Therapy • PaO2 on air < 7.3KPa • Need 2-4L/min for at least 15 hours a day

Old TB • Signs

– Chest deformity and absent ribs – Reduced expansion – Dull percussion but present tactile vocal fremitus – Crackles and bronchial breathing

• Old treatment techniques

– Plombage: polystyrene balls into thoracic cavity – Phrenic nerve crush: diaphragm paralysis – Thoracoplasty: rib removal; lung nor resected – Apical lobectomy

• Current treatment

– Isoniazid, rifampicin and pyrazinamide (RIFATER) – Ethambutol

Lung Cancer • Signs

– Cachectic – Clubbing and tar-stained fingers – Lymphadenopathy – Tracheal deviation – Reduced expansion – Percussion note dull – Auscultation:

• Crackles and bronchial breathing (consolidation/collapse) • Reduced breath sounds and vocal resonance (effusion)

• Other signs – Superior vena cava obstruction – Recurrent laryngeal nerve palsy – Horner’s sign

Lung Cancer • Investigations

– CXR – CT thorax – Bronchoscopy for biopsy – Lung function tests – Bloods: Including LFTs, calcium, Hb

• Treatment

– NSCLC • Surgery: lobectomy or pneumonectomy • Radiotherapy • Chemotherapy

– SCLC • Chemotherapy

Cystic Fibrosis • Signs

– Small statue, clubbed, tachypnoeic, sputum +++ – Hyperinflated with reduced chest expansion – Coarse crackles and wheeze

• Look for portacath or hickmann line/scar

• Genetics

– Autosomal recessive chromosome 7q – Commonest defect Δ 508 (70%)

• Treatment – Physiotherapy – Mucolytics – Prompt antibiotics – Pancreatic supplements – Lung transplant

If you get stuck! • Say what you hear

• Don’t make up a diagnosis

• Look for bedside clues

• Common respiratory investigations:

– CXR – CT thorax/high resolution CT thorax – Lung function tests – obstructive or restrictive – Peak flow – asthma only – Sputum culture

Any Questions?