OSCE Revision

Respiratory

Mark WoodheadHonorary Clinical Professor of Respiratory Medicine

BREATHLESSNESS

• Respiratory

BREATHLESSNESS

• Respiratory• Cardiac• Haematological• Neurological• Psychiatric

BREATHLESSNESS

PatternAge / durationPrecipitants and relieversSeverityAssociated symptomsExacerbations

BREATHLESSNESS

Pattern

Diurnal variation (asthma)Sleep disturbance (asthma)Nocturnal worsening (most causes!)Orthopnoea (LVF, COPD, Obesity…)Paroxysmal nocturnal dyspnoea (LVF)

BREATHLESSNESS

Age / duration

Age < 30 - asthma, bronchiectasis, psychological (COPD unlikely)

Age > 50 - COPD, (asthma), cardiac

Present since childhood asthma (bronchiectasis)

Present only since 40s - COPD

Recent onset – pneumonia, PVTE, pneumothorax

Non-smoker – asthma, Smoker – (asthma) or COPD

BREATHLESSNESS

Precipitants and relievers

Worse in summer – asthmaWorse in winter – most things!

Animals, specific irritants – asthma

Occupation – specific sensitiser (asthma) or just effort?

Risks for PVTE

Effort – most causes

BREATHLESSNESS

Severity

At rest (talking)Effort – how much, distance, stairs ADLsWork

Exacerbations – frequency, times in hospital, ever ICU

BREATHLESSNESS

Associated symptomsSputum > 3/12 of year, in consecutive years – COPD, bronchiectasis, asthmaLarge volume sputum – bronchiectasisHaemoptysis – bronchiectasis, cancer, PVTEAnorexia and weight loss – cancerAnkle swelling – not asthma, cardiac, cor pulmonaleUnilateral leg swelling – PVTEFever, rigors, purulent sputum – pneumoniaPleuritic chest pain – pneumonia, PVTE, pneumothorax

BREATHLESSNESS

Exacerbations

Yes – asthma, COPD, bronchiectasisFrequency and severity…..

CHEST PAIN

• Respiratory

CHEST PAIN

• Respiratory• Cardiac• Musculoskeletal• Gastrointestinal

CHEST PAIN

Site

Central – most thingsLateral – pneumonia, PVTE, pneumothorax, musculoskeletalRadiation – arm – cardiac - back – most things

CHEST PAIN

Type / precipitants

Constant / intermittentEffort related – cardiacPleuritic – pneumonia, PVTE, pneumothorax, musculoskeletalMovement eg arm – musculoskeletalMeals - GI

BRONCHODILATOR THERAPY

Concepts of Prevention and Relief regular vs as required usered/brown inhalers Blue vs

SABALABA, (LABA – formoterol)corticosteroid, anti-muscarinic, combinations

BRONCHODILATOR THERAPY

MDI

Take off capShakeBreathe outDevice to mouthFull breath in and activate as breathingHold breath for few secondsRepeatSteroid – rinse / gargle afterwards

LONG TERM CORTICOSTEROID THERAPY

Benefits – disease control

Harms – dose and duration

Short term – hunger, dyspepsia, insomnia, acne

Long term – weight gain, hypertension, diabetes, pneumonia osteoporosis, skin thinning, cataracts

Balance benefit vs harm, aim for lowest effective dose

EXAMINATION

EXAMINATION - PNEUMONECTOMY

Affected side

Thoracotomy scarReduced movement / expansionDull to percussionVF up or downReduced breath sounds

Mediastinum towards the affected side (trachea, apex beat)

Differential pleural effusion – mediastinum away from affected side

EXAMINATION COPD/ASTHMACyanosis (COPD) Raised respiratory rateTremor – asterixis if CO2 retention (COPD)

- fine - B-agonist

Signs of air trapping due to airway narrowing:reduced cricosternal distanceincreased A-P diameter of chest (‘barrel’)reduced or lost lateral chest expansionparadoxical lower chest movementreduced / absent cardiac dullness on percussionreduced breath sounds (often mainly apical)

Wheeze, insp, exp, but may be absentSputum pot (COPD, bronchiectasis)Inhalers, Peak Flow meter by the bed

EXAMINATION PULMONARY FIBROSIS

Finger clubbing (50%)

Cyanosis (if severe)

Raised respiratory rate

Reduced chest expansion (‘restriction’)

Persistent, bi-basal, fine, late inspiratory crackles

SPIROMETRY

Restriction – FEV1 and FVC reduced in parallelratio normal or increased

FEV1 65% predictedFVC 67%Ratio 80%

Restriction – alveolar disease eg pulmonary fibrosischest wall disease eg kyphoscoliosis, muscle weakness, obesity

SPIROMETRY

Obstruction – FEV1 reduced more than FVC ratio less than 70%

FEV1 65% predictedFVC 80%Ratio 64%

Obstruction – airway diseases eg asthma, COPD, bronchiectasis

BLOOD GASES

Always look at pH first

normal means normal or compensation has occurred

PO2 cannot be interpreted without FiO2

BLOOD GASES

Type I respiratory failure

low PO2 only (PCO2 normal or low and pH normal)

Type II respiratory failure

low PO2 and high PCO2

pH may be normal (compensated – HCO3 will be raised) or reduced

BLOOD GASES

FiO2 0.6

pH 7.37pO2 10.3pCO2 3.1HCO3 25

CO2 + H2O H+ + HCO3

BLOOD GASES

FiO2 0.6

pH 7.47pO2 10.3pCO2 3.1HCO3 25

BLOOD GASES

FiO2 0.28

pH 7.37pO2 10.3pCO2 8.4HCO3 35

BLOOD GASES

FiO2 0.6

pH 7.31pO2 10.3pCO2 8.4HCO3 24

BLOOD GASES

FiO2 0.6

pH 7.31pO2 10.3pCO2 8.4HCO3 15