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
 * 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

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 Chronic bronchitis

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%