OSCE Papers - Resp

GOLD Guidelines

I:

• Mmrc (Dyspnea scale 0-4) + CAT (COPD questionaire)

Outcome measures:

• O2 Levels, auscultation, sputum, BORG, CAT, 6MWT

O:

• Bronchodilators indicated

• NB = Pulmonary rehab, education, smoking cessation

Symptoms:

• Dyspnea, sputum, repeated lung infections

Pulm. Rehab NB because:

• Dyspnea DOWN

• Exercise Tolerace UP

• Hospital Time DOWN

• Anxiety DOWN

Influence:

• Give O2 in distress - hypoxaemia kills faster than hypercapnia!

General Guidelines for COPD Diagnosis + management

GINA Guidelines

Main Treatment:

• Inhalers

• 80% of patients have bad technique = poor symptom control = more exacerbations

• Smoking cessation NB

• Avoid allergies + smoke + stress

Exercise?:

• Can participate w medical management with SPO2 93-95%

Risk factors for exacerbations:

• SABA Overuse

• Chronic Sinus Problems

• Obeisity

• Psychological issues - Anxiety/depression

Pathophysiology:

• Chronic inflammation of airways

• Bronchoconstriction + bronchospasm + mucus hypersecretions + airway wall thickening

Guidelines for Athsma

Usmani et al. 2018 - Inhaler tech. for COPD/ Athsma

P:

• Systematic Review - 123 Studies

I/C:

• Correct inhaler technique

• Vs. poor technique

O:

Inhaler technique mastery = 

• + Adherance

• + QOL

• + Clinical Outcomes

Poor technique:

• + Exacerbations

Study on inhaler technique

Lee et al. 2017

P:

• Systematic Review - 9 Studies

I/C:

• PEP/OPEP vs. ACBT, PD, AD, Exercise

O:

• Sputum clearance + QOL + Exacerbations measured

• Techniques of equal effectiveness

• Greater fatigue with PEP/ OPEP

Limitations:

• Short term outcomes only

Bronchiectasis - Review for best ACT’s

ERS Bronchiectasis Guidelines 2017

O:

• 2x per day ACT’s = Sputum volume, QOl and exercise capacity UP

best management:

• NB = Pulmonary rehab - increases capacity + QOL, dyspnea DOWN

• use bronchodilator before chest physio exercises

Bronchiectasis - Guidelines for best management

Chen et al. 2022

P:

• Cochrane review

• 8 RCTs

I/C:

• Compare different ACTs on pneumonia = ACT, FET, thoracic expansion, PEP

• Compared to No physio

O:

• ACT’s have little to no effect on survivial rates for patients with pneumonia vs standard care

• Little change in hospital stay time

• No change in antibiotic use or fever

• Didn’t measure sputum, or dyspnea levels as outcome measure

Limitations:

• Outcome measures limited,

• Low quality evidence for any particular treatment

Paper on Physio for Pneumonia

Nice Guidelines for CF 2017

O:

• Review with MDT every 3-6 months

• ACTs down to individuals ability + preference

• Exercise = NB for lung function + fitness

• O2 Therapy + NIV good

• Preventing cross infection = NB

Guidelines for Cystic Fibrosis

McIlwayne et al. 2019

• Systematic Review - 28 papers

• Included CF of all stages

I/C:

• PEP (Mostly mask) vs PD, percussion, ACBT, AD, OPEP, exercise

O:

• Lung function + sputum volume + exacerbations all measured

• Equal across techniques

Limitations:

• Evidence quality varied 

• Lack of blinding

Study on ACT’s for Cystic Fibrosis

Belli et al. 2021

P:

• Narrative Review of 77 sources - COPD, CF + post-op

I/C:

• To assess the best ACT

• Details the physiological mechanism for each ACT

O:

• No one ACT is superior! + Adherance = best success

• Patient directed choice in ACT is superior

• Combined ACTs have best outcomes

Amounts?:

• PD (manual) 20-30 mins 2-3x per day

• ACBT + AD 20-30 mins 2-3x per day

• PEP: 10-15 mins 1-2x per day

• OPEP 20 mins 2-3x per day

Limitations:

• Heterogenous Studies

• No standardised protocol for ACTs

General paper for ACBT use, can also be best used with what populations.

Shen et al. 2020

P:

• 8 RCTs - all stages of COPD

I/C:

• Measured sputum prod., cough + lung function during ACBT from 1-4 weeks

• Vs. AD, PD

O:

• ACBT improves sputum prod. + cough efficiency in COPD (short term)

• ACBT + PD together = effective

Limitations:

• Small sample

• No meta analysis

• Heterogeinity between studies

Paper of effects of ACBT for COPD

Birk et al. 2017

P:

• 20 new trachyostomy patients (Geriatric)

I/C:

• Cold air nebuliser vs heated + humidified

• 8 hours per day at 37 deg.

O:

• Less suctioning needed

• + better cilia beat frequency

Limitations:

• Patient sample not random

• No blinding

• Small sample

Paper for heating and hudification of O2

Burge et al. 2024

P:

• Systematic Review N=73 RCTs (COPD, athsma, interstitial lung diseases)

I/C:

• Pursed lip breathing + Diaphramatic breathing vs standard care

• Yoga breathing also better than standard, not as effective as pursed lip

O:

• Dyspnea -, MMRC score - , QOL +

Limitations:

• Heterogenous studies

• Lack of blinding in those studies

Paper supporting Pursed lip breathing/ Diaphramatic breathing

Dowman et al. 2021

P:

• 21 studies - Cochrane review

I/C:

• Pulmonary rehab for 3-48 weeks

• Vs no PR

O:

• 6MWT up

• Dyspnea down

• QOL up

Limitations:

• Low grade evidence used

Restrictive Lung disease paper + relevant coditions

ITS Position statement for IPF 2018

I:

• Used 6MWT to assess function

O:

• Pulmonary rehab + HEP = NB

• education on pacing + energy conservation important

• O2 Assessment = NB

• Must treat dysfunctional breathing

• MDT needed for ongoing treatment

Pulmonary fibrosis guidelines-esque for ongoing treatment + assessment

ITS LTOT Guidelines 2015

P:

• SPO2 of </=92% should be reffered

• Indicated for chronic hypoxaemia

• PO2 <7.3 or

• PO2: <8 with pulmonary hypertension, oedema or polycythaemia

O:

• Can use for 15-24 hours per day

• Reccomended starting dose 1L/min 

Guidelines for use of long term oxygen therapy

BTS (2013) - Guidelines on pulmonary rehab in adults

I/C:

• Effectiveness of Pulm. rehab in COPD, Bronchiectasis, IPF, Dyspnea, Asthma

• Min. 2x supervised sessions per week + min. 12 total

• Progressive RT + Aerobic training

O:

• Exercise capacity UP

• Dyspnea DOWN

• Wellbeing UP

Trad vs remote:

• Traditional GOLD standard in person centre PR didn't have substantially higher outcomes, can consider hybrid and remote as needed

Effectiveness of Pulmonary Rehab in Adults - Guidelines

Booth + Johnson 2019

P:

• Narrative Review - Cochrane

• 87 Sources

• Advanced resp. diseases, COPD, Cancer

I/C:

• Pulmonary rehab

O:

• Pulm. rehab = best evidence for Dyspnea -, QOL +, Lung function+

• Hand Held fan = moderate evidence

• CBT + Breath retraining = moderate

• NB = Stop spiral of disability!

Limitations:

Mixed evidence quality

Study of Pulm. Rehab effectiveness on dyspnea + What conditions

Zhong et al. 2021

P:

• P= 291 - RCT - post esophagectomy

I/C:

• ACBT on post op days 1-3

• vs. Deep breathing + manual percussions

O:

• Length of stay DOWN, comfort UP, Airway clearance UP

Limitations:

• Only measured short term outcomes

• One location only

ACBT use post operatively - Paper

NHS Abdominal surgery advice 2021

I:

• Out of Bed ASAP

O:

• Sit out of bed 6-8 hours per day

• Regular walks/ walking

• Circulatory exercises (Ankle pumps)

• Roll out of bed DON'T sit up

• 3x per day - exercises - knee slides, pelvic tilts etc.

Post operative guidelines-esque

Windfield et al. 2014

P

• Cochrane Review - 15 studies

I/C:

• Oscillation, PEP, CPAP, NIV

• vs. Standard care

O:

• Oscillation PEP and NIV all reduced RR + LOS

• No clear best approach

Prioritise:

• Movement through play

• Easy to remember techniques + carer instructions

Limitations:

• Heterogenous

• Low evidence quality

Paediatric management - Paper