COPD physical examination and management

COPD physical examination and managementCreated OnMay 29, 2020Last Updated OnMay 30, 2020byadmin You are here: Main Clinical Examination COPD physical examination and management < All Topics Table of Contents General examination: Vital signs Temperature of __ (febrile/afebrile) Pulse rate of tachycardia/bradycardia/pulsus paraadoxus (rate,rhythm,volume) Respiratory rate of tachypnea Blood pressure __ (normotensive? Hypotensive if severe) SpO2 <95 % Observation Assess the level of consciousness – Indicate the severity Note whether patient can speak in words/phrases/sentences/couldn’t speak Dyspnea, count respiratory rate Observe for any signs of distress Pleuritic chest pain Respiratory distress Diaphoresis Cyanosis Current oxygen therapy – Nasal prongs/ Simple face mask/ High flow mask/ Venturi mask, Bipap/cpap machine, connected to oxygen (how many litre/min) Bedside – Inhalers, medications (Can be a COPD patient) Eye Pallor Face Cushingnoid face **Refer to common signs** Blue bloater Pink puffer Central cyanosis Plethoric (secondary polycythemia) Cachexia/skeletal muscle wasting Neck Raised JVP (cor pulmonale) Hands Peripheral cyanosis Fine tremor (excessive use salbutamol) Finger clubbing Tobacco staining Pulsus paradoxus Mouth Oral candidiasis (steroids, immunocompromised) Central cyanosis Abdomen Check for inguinal hernia Leg Pedal oedema – cor pulmonale Systemic examination:   Acute COPD Inspection Normal Palpation Normal Percussion Normal Auscultation Rhonchi, wheeze Chronic COPD Inspection Chest deformity: barrel chest Increased AP diameter Decreased chest movement Use of accessory muscles (scalene, sternomastoid) Laboured breathing or respiratory distress Inspiratory & expiratory wheezing Thin build Palpation Tracheal central, trachea tug Apex beat absent Chest expansion reduced bilaterally Vocal fremitus reduced Percussion Hyperresonant Auscultation Reduced air entry Vesicular with prolonged expiration Rhonchi, wheeze, crepitation Sign of hyperinflated lungs Tracheal tug, reduced cricoid sternum distance, increase trachea-sternum distance Barrel chest (increased AP diameter) Lost of cardiac & liver dullness When to suspect: In any patient who has dyspnea, chronic cough or sputum production AND/OR A history of exposure to risk factors for the disease Diagnosis: By Spirometry The presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus COPD Post Bronchodilator test: post short-acting inhaled β2-agonists, inhaled anticholinergics or combined <12% to differentiate from asthma *FEV1 should be measured 10-15 minutes after a short-acting beta 2-agonist or 30-45 minutes after a short-acting anticholinergic or a combination *Both FVC and FEV1 should be the largest value obtained from any of 3 technically satisfactory curves and the FVC and FEV1 values in these three curves should vary by no more than 5% or 150ml, whichever is greater. Classification of severity: Based on post-bronchodilator FEV 1 Stage I: mild FEV1/FVC < 0.70 FEV1 ≥ 80% predicted Stage II: moderate FEV1/FVC < 0.70 50%   FEV1 < 80% predicted Stage III: severe FEV1/FVC < 0.70 30%   FEV1 < 50% predicted Stage III: very severe FEV1/FVC < 0.70 FEV1 < 30% predicted Investigation: Assessment of Symptoms (mMRC and CAT) Modified British Medical Research Council Questionnaires (mMRC) COPD Assessment Test (CAT)   Spirometric Assessment Assessment of Exacerbation Risk Exacerbation of COPD is an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations (dyspnea, cough, and/or sputum production) and leads to a change in medication (Number of exacerbations within the previous 12 months; if ≥2/year  frequent exacerbation)   Additional investigations: Imaging just to rule out alternative diagnosis: Pneumothorax- thin visceral line & no bronchovascular marking Pulmonary embolism- increase vascularity Hyperinflation (>6 anterior ribs above diaphragm in mid clavicular line) Flattened diaphragm on the lateral chest film Increased in the volume of retrosternal air space Hyperlucency of the lungs Rapid tapering (decrease) of the vascular markings Oximetry and Arterial Blood Gas Measurement Oximetry if FEV1 < 35% ABG if SaO2< 92% Management of Stable COPD Oxygen Therapy Long-term oxygen therapy; facemask or nasal cannulae For patients with chronic respiratory failure Long-term continuous therapy (> 15 hours per day) Complication: syncope   GOLD CLASSIFICATION FOR COPD 2019 ≥2 moderate exacerbations or ≥1 leading to hospitalization GROUP C     LAMA GROUP D   LAMA or LAMA + LABA or ICS + LABA   *Consider if highly symptomatic Eg. CAT>20 **Consider if eos > 300 0 or 1 moderate exacerbation (not leading to hospitalization) GROUP A   A Bronchodilator GROUP B   LABA/LAMA mMRC 0-1, CAT <10 mMRC≥2, CAT≥10 GROUP A: less symptom low risk GROUP B: more symptom low risk GROUP C: less symptom high risk GROUP D: more symptom high risk Differential diagnosis: Asthma Onset early in life (often childhood) Symptoms vary widely from day to day Symptoms worse at night/early morning Allergy, rhinitis, and/or eczema also present (atopy triad) Family history of asthma   COPD VERSUS ASTHMA COPD ASTHMA Presentation Onset in mid life Symptoms slowly progressive Onset early in life(childhood) Symptoms varies day to day...

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