Why does this patient have respiratory failure?
The problem could be at any level:
Previous hot cases with this sort of theme to them can be found below.
The standard introduction
Ask examiners about turning up the lights
The physical examination
The details of this section can be seen in the opposite column.
The obs and investigations
The Physical Examination in Brief Detail
Ask the examiners to sit the patient up
Ask the examiners about any language barriers
Ask examiners to lay the patient flat.
Sit the patient back up again
One should point out before going any further that the patient being examined may be prone. This is an entirely different kettle of fish, and calls for a different approach.
The routine is also relevant.
One should also ask to look at the pressure-volume loops.
Special attention should be paid to the behaviour of the ICCs.
If there is a constant vigorous air leak, one should prepare for a vigorous discussion of bronchopleural fistula.
The content of these drains could be informative, especially if one notices blood or chyle.
A CVVHDF or SLEDD process may be in progress. The savvy candidate may wish to ask the following questions:
The patient you are examining may have some sort of extra gadget hooked up. If ECMO is in progress, one may wish to ask about the following parameters:
The presence of extracorporeal circuits may act as a marker of severity. One must have failed conventional ventilation to move on to ECMO.
If IABP counterpulsation is in progress, it raises additional questions. One may wish to ask the examiners whether one may be able to switch it to 1:2, to assess the efficacy of augmentation.
Intracranial pressure monitoring may point to the central nervous system as a cause of the respiratory failure. Has the patient lost their medulla? Or have they had severe neurogenic pulmonary oedema following an SAH?
The respiratory failure patient may have a plethora of additional devices around them. These may include the following:
The presence of such toys is a splendid gift, as it all but delivers the case into the hands of the candidate.
Ideally, one should get the patient sitting up to 30-45°.
This may not be possible. However, one should still ask for it.
The patient should be exposed from the waist up.
The candidate can then stand back and look for anything externally obvious:
Performing the GCS should be the first step, unless you notice that a neuromuscular junction blocker is among the infusions. The level of consciousness then determines how you go about examining the rest of the patient.
A traditionalist, who is examining Mr Bloggs, would approach the GCS in the following manner:
One has just performed a GCS assessment; one is still holding the hands.Now, time to look at them more closely.
First, one should spent a second assessing whther they are warm or cold.
Then, one can focus on the nails. Nail signs are numerous and deserve their own page.
In brief, the nail signs one could look for are as follows:
A candidate examining the respiratory failure patient needs to dwell on the clubbed digits. The examiners must appreciate the fact that clubbing has been found, and that the candidate is very excited about it.
Then, one should note the presence of any sort of characteristic deformities, eg:
Next comes the pulse.
Tone of the upper limbs
Perform a gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows. This is not the primary focus of the respiratory failure examination, but one should keep in mind that the respiratory failure may be due to some sort of myopathy or neuromuscular disorder, which may reflect in a decreased tone.
In the consciosu patient, it may be possible to assess asterixis by asking the patient to hold both their arms up with the wrists dorsiflexed. This may be useful if hypercapnea is suspected.
Examine the cubital fossa for
One should then palpate the axillary lymph nodes.
Palpate the neck:
A sophisticated and detailed cranial nerve examination is desirable; however, the limitations of the respiratory failure hot case force one to truncate this part of the examination.
Thus, after looking for Horner's syndrome in the eyes, one should focus on the lower cranial nerves (those involved with speech and swallowing):
This sign, associated with stroke and with an apical lung tumour, is composed of the following features:
It is a classical med-school sign. If it is present, and you miss it, your examiners will be very disappointed.
The Yankeur sucker is used to probe the posterior pharynx, on both sides. A gag reaction should result from this.
This collectively tests CN X and IX.
While on the subject of CN X, one may test the cough reflex by suctioning the trachea.
This tests CN X.
This is also a convenient time to ask about the volume and character of the secretions.
The conscious patient is asked to protrude their tongue, and move it from side to side.
This tests CN XII.
The uvula deviates away from the lesion.
This tests CN X and IX.
The airway is worth spending some time on.
Specific clues will be grossly obvious: eg. the dual lumen tube with one lumen clamped, or the endobronchial blocker, or the flanged tracheostomy tube.
It would also be worthwhile to note whether the cuff pilot balloon is well inflated. A tracheostomy patient with the cuff deflated may be able to speak, and is likely ready for decannulation.
Important questions to ask at this stage would be the character and quantity of secretions, and how long the patient has been intubated.
One puts both their hands on the chest to assess the symmetry of chest expansion.
One might wish to percuss the chest.
Changes in percussion resonance may be worth commenting on.
Not everybody does this in their day-to-day practice, and in hot case practice scenarios consultants who are not college examiners tend to either scoff at this practice, or attribute to it an undue emphasis. Theoretically, percussion is a part of the physical examination and should not be forgotten, but it is a low-yield investigation and one may wish to omit it if one were asked to focus on another system.
One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible.
The money is in the bases.
This, if done thoroughly in a patient on a mandatory mode, may be somewhat laborious (there may only be 12 breaths per minute, and one needs a breath for every change in stethoscope bell position).
The cardiac examination is a part of the respiratory assessment.
The clever candidate will make a big show of palpating both the apex and the right sternal edge.
One should auscultate in the following sequence:
The various clicks and murmurs one encounters are discussed elsewhere.
For this, one should ask to lay the patient flat.
The pelvic content would have been palpated during the abdominal exmaination. The more important part of this examination is the groin.
At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.
Observation and palpation of the pelvis:
Examination of the lines
Examination of the genitals and rectum
Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.
One should ask to remove TEDs and compression stockings.
The feet would have already been palpated to assess their temperature, and to look for pitting oedema.
Observation of the feet
One should look specifically for changes suggestive of chronic diabetic foot disease, or chronically poor vascular supply.
Palpation of the feet
This should consist of palpating the dorsalis pedis and posterior tibial pulse.
One should test the Babinsky bilaterally.
One should attempt to assess clonus in both feet.
Now is the time to properly start the neurological examination of this patient.
In the context of the respiratory failure hot case, one is looking for the following features:
Power of the muscle groups may be tested in the following sequence:
The patient has spent most of this time flat and supine. Time to sit them back up again.
Power of the upper muscle groups may be tested in the following sequence:
Ask to see the obs chart. If it is not allowed, ask for the following:
One may also wish do demonstrate an interest in the trends of any sort of advanced haemodynamic monitoring, eg. cardiac index as measured by PAC or PiCCO
One may wish to ask for the following information:
One needs to show an interest in the following labs:
One should always ask for the following:
You sometimes want to see the following:
"Mr Bloggs' respiratory failure is multifactorial."
"Contributing factors include [insert a list of respiration-impairing aetiologies]."
"I have come to this conclusion on the basis of the following findings: [insert clinical findings here]"
"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"
"The current management issues are as follows: [a brief list of management priorities]"
"I would approach the management of this respiratory failure in the following manner: [list of management strategies; it helps to organise this into an A,B,C,D,E approach if one has a complex multisystem problem to manage]"
"My approach to ventilation in this setting would consist of the following strategies:[describe how you would change the ventilator settings]"
”This is a complex case and I’m not certain of the diagnosis."
"I note the following organ dysfunctions which may be contributing to the respiratory failure: [list contributing organ problems]."
"I have identified clinical findings which support this hypothesis: namely, [insert list of findings]." "Thus, the possible aetiologies responsible for this respiratory failure could include [list of differentials]"
"In order to discriminate between these differentials, I would like to perform the following investigations: [list of investigations]"
"Furthermore, I would like to enlist the help of the following specialties [insert list of consults], for whom I will have the following specific requests/questions: [what questions will you ask these specialist teams]"
"In the absence of a clear diagnosis, my ventlation strategy would consist of the following techniques: [demonstrate to the examiners that you would be able to ventilate this patient safely in the absence of a clear diagnosis]"