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Respiratory OSCE Station

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Respiratory OSCE Station

  1. 1. Respiratory OSCE Station By Jemima Robinson ST4 Respiratory Derriford Hospital
  2. 2. Objectives • Common signs • Common conditions that present • Investigations • Management
  3. 3. Respiratory Examination • Inspection • Palpation • Percussion • Auscultation
  4. 4. Round the Bed
  5. 5. Hands • Clubbing • Cyanosis CO2 Retention Flap • Tar Staining
  6. 6. 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
  7. 7. Breathing Pattern • Count respiratory rate • Tachypnoea • Pursed lipped breathing • Use of accessory muscles
  8. 8. Cough • Do first as part of inspection • Dry Cough – Pulmonary fibrosis – Pleural effusion • Purulent cough/productive – Bronchiectasis/CF – Pneumonia
  9. 9. Chest Shape • Kyphosis • Scoliosis • Hyperinflated • Chest Wall deformity
  10. 10. 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
  11. 11. Tracheal Position • Away – Effusion – Air • Towards – Collapse – cancer/consolidation
  12. 12. Cervical Lymphadenopathy • Examine from behind • Don’t play the piano • Causes: – Lung Cancer – Head/neck cancer – Lymphoma – Glandular fever – TB
  13. 13. Chest Expansion • Causes of Reduced:
  14. 14. Percussion • Stony dull – Effusion • Dull – Consolidation – Collapse • Hyperreasonant – Air (pneumothorax)
  15. 15. 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
  16. 16. Crackles • Coarse Expiratory – Consolidation – (Bronchiectasis) • Inspiratory – Pulmonary oedema • Fine end inspiratory – Pulmonary fibrosis
  17. 17. Other Signs • Wheeze – COPD – Bronchiectasis/lung cancer • Bronchial Breathing – consolidation • Vocal fremitus – Increased: consolidation – Reduced: effusion
  18. 18. 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
  19. 19. 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
  20. 20. Pleural Effusion Treatment • Transudate – Treat the cause • Exudate – Pleural fluid cytology – May need CT thorax – Intercostal drainage may be appropriate – Consider pleurodesis
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. Causes of Pulmonary Fibrosis • Apical – TB – Radiation – Ankylosing Spondylitis/ABPA – Sarcoidosis – Histoplasmosis – Extrinsic allergic alveolitis • Basal – Usual interstitial pneumonitis – Asbestosis – Connective tissue diseases – Aspiration
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. Any Questions?
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