1. OSCE Revision Respiratory Mark Woodhead Honorary Clinical Professor of Respiratory Medicine

2. BREATHLESSNESS Respiratory

3. BREATHLESSNESS Respiratory Cardiac Haematological Neurological Psychiatric

4. BREATHLESSNESS Pattern Age / duration Precipitants and relievers Severity Associated symptoms Exacerbations

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

6. 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

7. BREATHLESSNESS Precipitants and relievers Worse in summer – asthma Worse in winter – most things! Animals, specific irritants – asthma Occupation – specific sensitiser (asthma) or just effort? Risks for PVTE Effort – most causes

8. BREATHLESSNESS Severity At rest (talking) Effort – how much, distance, stairs ADLs Work Exacerbations – frequency, times in hospital, ever ICU

9. BREATHLESSNESS Associated symptoms Sputum > 3/12 of year, in consecutive years – COPD, bronchiectasis, asthma Large volume sputum – bronchiectasis Haemoptysis – bronchiectasis, cancer, PVTE Anorexia and weight loss – cancer Ankle swelling – not asthma, cardiac, cor pulmonale Unilateral leg swelling – PVTE Fever, rigors, purulent sputum – pneumonia Pleuritic chest pain – pneumonia, PVTE, pneumothorax

10. BREATHLESSNESS Exacerbations Yes – asthma, COPD, bronchiectasis Frequency and severity…..

11. CHEST PAIN Respiratory

12. CHEST PAIN Respiratory Cardiac Musculoskeletal Gastrointestinal

13. CHEST PAIN Site Central – most things Lateral – pneumonia, PVTE, pneumothorax, musculoskeletal Radiation – arm – cardiac - back – most things

14. CHEST PAIN Type / precipitants Constant / intermittent Effort related – cardiac Pleuritic – pneumonia, PVTE, pneumothorax, musculoskeletal Movement eg arm – musculoskeletal Meals - GI

15. BRONCHODILATOR THERAPY Concepts of Prevention and Relief regular vs as required use red/brown inhalersBlue vs SABA LABA, (LABA – formoterol) corticosteroid, anti-muscarinic, combinations

16. BRONCHODILATOR THERAPY MDI Take off cap Shake Breathe out Device to mouth Full breath in and activate as breathing Hold breath for few seconds Repeat Steroid – rinse / gargle afterwards

17. 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

18. EXAMINATION

19. EXAMINATION - PNEUMONECTOMY Affected side Thoracotomy scar Reduced movement / expansion Dull to percussion VF up or down Reduced breath sounds Mediastinum towards the affected side (trachea, apex beat) Differential pleural effusion – mediastinum away from affected side

20. EXAMINATION COPD/ASTHMA Cyanosis (COPD)Raised respiratory rate Tremor – asterixis if CO2 retention (COPD) - fine - B-agonist Signs of air trapping due to airway narrowing: reduced cricosternal distance increased A-P diameter of chest (‘barrel’) reduced or lost lateral chest expansion paradoxical lower chest movement reduced / absent cardiac dullness on percussion reduced breath sounds (often mainly apical) Wheeze, insp, exp, but may be absent Sputum pot (COPD, bronchiectasis) Inhalers, Peak Flow meter by the bed

21. EXAMINATION PULMONARY FIBROSIS Finger clubbing (50%) Cyanosis (if severe) Raised respiratory rate Reduced chest expansion (‘restriction’) Persistent, bi-basal, fine, late inspiratory crackles

22. SPIROMETRY Restriction – FEV1 and FVC reduced in parallel ratio normal or increased FEV1 65% predicted FVC 67% Ratio 80% Restriction – alveolar disease eg pulmonary fibrosis chest wall disease eg kyphoscoliosis, muscle weakness, obesity

23. SPIROMETRY Obstruction – FEV1 reduced more than FVC ratio less than 70% FEV1 65% predicted FVC 80% Ratio 64% Obstruction – airway diseases eg asthma, COPD, bronchiectasis

24. BLOOD GASES Always look at pH first normal means normal or compensation has occurred PO 2 cannot be interpreted without FiO 2

25. BLOOD GASES Type I respiratory failure low PO 2 only (PCO 2 normal or low and pH normal) Type II respiratory failure low PO 2 and high PCO 2 pH may be normal (compensated – HCO 3 will be raised) or reduced

26. BLOOD GASES FiO 2 0.6 pH7.37 pO 2 10.3 pCO 2 3.1 HCO 3 25 CO 2 + H 2 O  H + + HCO 3

27. BLOOD GASES FiO 2 0.6 pH7.47 pO 2 10.3 pCO 2 3.1 HCO 3 25

28. BLOOD GASES FiO 2 0.28 pH7.37 pO 2 10.3 pCO 2 8.4 HCO 3 35

29. BLOOD GASES FiO 2 0.6 pH7.31 pO 2 10.3 pCO 2 8.4 HCO 3 24

30. BLOOD GASES FiO 2 0.6 pH7.31 pO 2 10.3 pCO 2 8.4 HCO 3 15