COPD Examination

Before you start some definitions

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

• 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

Inspection

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

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

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

Auscultation

• 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

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 shadow 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.

CBC

• Hct normal in emphysema, increased in CB

PFTs

• 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%

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