Resp Flashcards
What are the key stages of the respiratory exam
Intro (WIPERQQ)
Inspection
Hands (IPA)
Neck
Face
Chest (IPPA)
Back (IPPA)
Legs
Further examinations
What are the clinical signs you are looking for in the initial inspection of the resp exam (9)
Age
Cyanosis: bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
Shortness of breath: signs may include nasal flaring, pursed lips, use of accessory muscles, intercostal muscle recession and the tripod position (sitting or standing leaning forward and supporting the upper body with hands on knees or other surfaces). The inability to speak in full sentences is an indicator of significant shortness of breath.
Cough
Wheeze: often associated with asthma, COPD and bronchiectasis.
Stridor
Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage/chronic disease) or poor perfusion (e.g. congestive cardiac failure). It should be noted that healthy individuals may have a pale complexion that mimics pallor.
Oedema
Cachexia: ongoing muscle loss that is not entirely reversed with nutritional supplementation. Cachexia is commonly associated with underlying malignancy (e.g. lung cancer) and other end-stage respiratory diseases (e.g. COPD).
What do different types of cough suggest
a productive cough can be associated with several respiratory pathologies including pneumonia, bronchiectasis, COPD and CF. A dry cough may suggest a diagnosis of asthma or interstitial lung disease.
What is stridor and what could it indicate
a high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways. Stridor has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic).
Why is age an important clinical observation in a resp exam
Age: the patient’s approximate age is helpful when considering the most likely underlying pathology, with younger patients more likely to have diagnoses such as asthma or cystic fibrosis (CF) and older patients more likely to have chronic obstructive pulmonary disease (COPD), interstitial lung disease or malignancy.
Why is age an important clinical observation in a resp exam
Age: the patient’s approximate age is helpful when considering the most likely underlying pathology, with younger patients more likely to have diagnoses such as asthma or cystic fibrosis (CF) and older patients more likely to have chronic obstructive pulmonary disease (COPD), interstitial lung disease or malignancy.
What objects should you look for around the bed at the beginning of a resp exam and what is the importance of each? (8)
Oxygen delivery devices: note the type of oxygen device (e.g. Venturi mask, non-rebreathing mask, nasal cannulae) and the current flow rate of oxygen (e.g. 2L, 4L, 10L, 15L). Look for other forms of respiratory support such as CPAP or BiPAP.
Sputum pot: note the volume and colour of the contents (e.g. COPD/bronchiectasis).
Other medical equipment: ECG leads, medications (e.g. inhalers/nebulisers in asthma/COPD), catheters (note volume/colour of urine) and intravenous access.
Cigarettes or vaping equipment: smoking is a significant risk factor for lung cancer and chronic lung disease (e.g. COPD).
Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time.
Fluid balance: fluid balance charts will give an indication of the patient’s current fluid status which may be relevant if a patient appears fluid overloaded or dehydrated.
Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.
What observations are you looking for on the hands in the resp exam
Colour
Tar staining: caused by smoking, a significant risk factor for respiratory disease (e.g. COPD, lung cancer).
Skin changes: bruising and thinning of the skin can be associated with long-term steroid use (e.g. asthma, COPD, interstitial lung disease).
Joint swelling or deformity: may be associated with rheumatoid arthritis which has several extra-articular manifestations that affect the respiratory system (e.g. pleural effusions/pulmonary fibrosis).
Tremors
What is finger clubbing likely to indicate in the OSCE respiratory exam (4)
lung cancer,
interstitial lung disease,
cystic fibrosis
bronchiectasis.
What tremors do you look for in the resp exam
fine tremor:
Ask the patient to hold out their hands in an outstretched position and observe for a fine tremor which is typically associated with beta-2-agonist use (e.g. salbutamol).
Asterixis (also known as ‘flapping tremor’) is a type of negative myoclonus characterised by irregular lapses of posture causing a flapping motion of the hands. In the context of a respiratory examination, the most likely underlying cause is CO2 retention in conditions that result in type 2 respiratory failure (e.g. COPD). Other causes of asterixis include uraemia and hepatic encephalopathy.
How do you check for asterixis
Whilst the patient still has their hands stretched outwards, ask them to cock their hands backwards at the wrist joint and hold the position for 30 seconds.
In the context of a respiratory examination, the most likely underlying cause is CO2 retention in conditions that result in type 2 respiratory failure (e.g. COPD). Other causes of asterixis include uraemia and hepatic encephalopathy.
What do you palpate on patients’ hands during the resp exam
Temperature
Heart rate
Respiratory rate
What should a patient’s hands’ temperature be like in the resp exam
What do abnormal results suggest
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion.
Excessively warm and sweaty hands can be associated with CO2 retention.
What types of abnormal pulse are most relevant in the resp OSCE exam (2)
Bounding pulse: can be associated with underlying CO2 retention (e.g. type 2 respiratory failure).
Pulsus paradoxus: pulse wave volume decreases significantly during the inspiratory phase. This is a late sign of cardiac tamponade, severe acute asthma and severe exacerbations of COPD (therefore it is unlikely to be relevant to most OSCE scenarios).
What is the normal range for respiratory rate?
What if it is outside this
In healthy adults, the respiratory rate should be between 12-20 breaths per minute.
A respiratory rate of fewer than 12 breaths per minute is referred to as bradypnoea (e.g. opiate overdose).
A respiratory rate of more than 20 breaths per minute is referred to as tachypnoea (e.g. acute asthma).
Note any asymmetries in the expiratory and inspiratory phases of respiration (e.g. the expiratory phase is often prolonged in asthma exacerbations and in patients with COPD).
How do you measure the JVP
- Position the patient in a semi-recumbent position (at 45°).
- Ask the patient to turn their head slightly to the left.
- Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The IJV has a double waveform pulsation, which helps to differentiate it from the pulsation of the external carotid artery.
- Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm).
Give Respiratory causes of a raised JVP
A raised JVP indicates the presence of venous hypertension. Respiratory causes of a raised JVP include:
Pulmonary hypertension: causes right-sided heart failure, often occurring due to COPD or interstitial lung disease.
There are several other causes of a raised JVP that relate to the cardiovascular system (e.g. congestive heart failure, tricuspid regurgitation and constrictive pericarditis).
