🫁 MOCK OSCE · FCPS, MCPS, MD PAEDIATRICS ⏱ 10 min · RESPIRATORY · BRONCHIECTASIS

Bronchiectasis · Short Case

Candidate task: perform focused respiratory examination on a child with bronchiectasis.
Then discuss differential diagnosis, investigations, management & follow‑up.
Pre‑exam Protocol
⏤ · Wash, Warm, Introduce, Position, Expose, Approach ▾

Standard pre‑examination protocol – must be demonstrated:

🖐 Wash hands with sterilizing solution.
🔥 Warm hands and stethoscope.
👋 Introduce yourself to child & parent.
🧍 Position child: supine, sitting, then left lateral.
👕 Exposure — chest fully exposed, warm environment.
➡️ Approach from the right side.
✔ CPSP marker: Pre‑exam Protocol is observed and scored.
1. Clinical Examination (≈6 min)
02 General Look (Inspection from end of bed) ▾

Key observations – “Bronchiectasis” clues:

  • Posture: may be comfortable; no specific preference.
  • Respiratory effort: tachypnoea, use of accessory muscles (if extensive).
  • Chest shape: may be symmetrical or barrel‑shaped (if hyperinflated).
  • Colour: may be cyanosed (if severe / cor pulmonale).
  • Nutritional status: failure to thrive (chronic disease).
  • Clubbing: classically present (if chronic suppurative).
👁 Red flags: chronic productive cough + clubbing + coarse crackles → bronchiectasis.
03 Inspection (Respiratory Examination) ▾

Inspection findings in bronchiectasis:

Trachea Usually central (unless associated fibrosis).
Chest wall May be barrel‑shaped (if hyperinflation).
Respiratory movements Slightly reduced bilaterally (if extensive).
Apex beat Normal position (unless fibrotic shift).
Accessory muscles May be used if respiratory distress.
Scars / sinuses May indicate previous surgery / infection.
🔍 Key: clubbing + barrel‑shaped chest → chronic suppurative lung disease.
04 Palpation (Respiratory Examination) ▾

Palpation findings in bronchiectasis:

Tracheal position Central (unless fibrosis).
Chest expansion Slightly reduced bilaterally (if extensive).
Vocal fremitus Normal or slightly increased (if secretions).
Tactile fremitus Normal or increased.
Apex beat Normal position.
Tenderness Usually absent.
🖐 Key: vocal fremitus may be normal or increased due to secretions.
05 Percussion (Respiratory Examination) ▾

Percussion findings in bronchiectasis:

Percussion note May be normal or hyperresonant (if hyperinflation).
Upper border Not applicable.
Traube's space Tympanic (unless associated effusion).
Skodiac resonance Not a feature.
Grocco's triangle Not a feature.
Garland's triangle Not a feature.
👂 Key: percussion may be normal or hyperresonant.
06 Auscultation (Respiratory Examination) ▾

Auscultation findings in bronchiectasis:

Breath sounds May be vesicular with prolonged expiration.
Vocal resonance Normal or slightly increased.
Added sounds Coarse crackles (classic) — especially in dependent areas.
Wheeze May be present (if associated asthma / secretions).
Bronchophony Not a feature.
Pleural rub May be heard if associated pleurisy.
🩺 Key: coarse crackles that clear with coughing — characteristic of bronchiectasis.
07 General Physical Exam (Hands → Face → Chest → Abdomen → Limbs) ▾

Systematic GPE – identify aetiology & complications:

  • Hands: Clubbing (classic finding), cyanosis, pallor.
  • Face: cyanosis, sinus tenderness (sinusitis).
  • Chest: respiratory rate, accessory muscles, JVP (raised if cor pulmonale).
  • Abdomen: hepatomegaly (right heart failure), ascites.
  • Limbs: oedema (cor pulmonale), joint swelling (rheumatoid).
  • Back: kyphoscoliosis (restrictive component).
  • Skin: BCG scar, surgical scars, nasal polyps (cystic fibrosis).
📏 Anthropometry: weight, height, head circumference – plot growth.
08 Developmental Assessment & Associated Signs ▾

Assess developmental regression and associated features:

  • Motor milestones: delay / regression (chronic illness).
  • Speech: dysarthria, nasal speech (bulbar if neuromuscular).
  • Feeding: poor suck, dysphagia, aspiration.
  • Behaviour: irritability, fatigue.
  • Growth: failure to thrive (chronic infection, cystic fibrosis).
  • Respiratory: recurrent infections, clubbing, cyanosis.
🧠 Red flags: rapid progression, respiratory failure, cor pulmonale → ICU admission.

📋 Case Presentation – (fill in during exam)

I have examined _____, _____ years old who is conscious and cooperative, having _____ built and a cannula in his _____ arm. He is _____ (pink / cyanosed) in room air with _____ (no / signs of) respiratory distress or dysmorphism.

His respiration is _____ (abdominothoracic / thoracic) with a rate of _____ per minute.

Inspection: Chest is _____ (normal in shape / barrel‑shaped). There are no scars, prominent veins or Harrison sulcus. He has _____ (no mediastinal shifting / mediastinal shift) as evident by _____ (central trachea / tracheal shift). Apex beat is in _____ ICS about _____ cms lateral to midclavicular line.

Palpation: Superficial palpation reveals no tenderness. My findings are bilateral in the form of slightly reduced chest expansion and normal vocal fremitus.

Percussion: Normal / Hyperresonant percussion note bilaterally.

Auscultation: Vesicular breathing with coarse crackles bilaterally (more prominent in dependent areas) and normal vocal resonance.

Back: Back is normal in shape with no visible deformity and similar findings are found in the infrascapular areas.

He is _____ (afebrile / febrile), Pulse is _____ beats/min, regular in rhythm and normal in volume and character, BCG scar mark is _____ (present / absent), throat is normal.

There is no evidence of cyanosis, clubbing, lymphadenopathy, rash and oral ulcers.

I would like to know his height and weight.
I want to see his chest X-ray.

2. Viva Discussion (≈4 min)
09 Viva · Differential, Investigations, Management, Follow‑up ▾
🔹 Differential Diagnosis

• Bronchiectasis – cystic fibrosis, PCD, post‑infective
• Cystic fibrosis – sweat chloride, pancreatic insufficiency
• Primary ciliary dyskinesia (Kartagener's) – situs inversus, sinusitis
• Immunodeficiency – recurrent infections
• Foreign body aspiration – focal bronchiectasis
• Tuberculosis – post‑TB bronchiectasis
• Allergic bronchopulmonary aspergillosis – asthma, eosinophilia
• Alpha‑1 antitrypsin deficiency – emphysema + bronchiectasis
• Connective tissue disorders – rheumatoid, SLE

🔹 Investigations – Diagnosis

• Chest X-ray – tram‑tracking, crowding, cystic spaces
• High‑resolution CT (HRCT) – gold standard; shows bronchial dilatation
• Sputum culture & sensitivity – identify organisms
• Complete blood count, CRP, ESR – infection / inflammation
• Pulmonary function tests – obstructive pattern
• Bronchoscopy – if foreign body / localized disease

🔹 Investigations – Aetiology

• Sweat chloride test – cystic fibrosis
• Immunoglobulin levels (IgG, IgA, IgM, IgE) – immunodeficiency
• Ciliary biopsy / saccharin test – PCD
• Mantoux test / gastric aspirate – TB
• Alpha‑1 antitrypsin levels – deficiency
• Autoantibodies (ANA, RF) – collagen vascular
• Aspergillus precipitins / IgE – ABPA

🔹 Investigations – Exclude / Complications

• Pulmonary function tests (VC, MIP) – respiratory failure
• Autonomic function – BP/HR monitoring
• Swallow study – aspiration risk
• DVT prophylaxis – Doppler if immobile
• ECG / echocardiography – cor pulmonale

🔹 Management – Across Organ Systems

Respiratory

Chest physiotherapy (postural drainage, percussion), bronchodilators, mucolytics. Oxygen if hypoxic.

Antimicrobial

Antibiotics for exacerbations (culture‑guided), prophylactic antibiotics (if recurrent).

Medical

Immunoglobulins (if deficiency), anti‑inflammatory (if ABPA / CF).

Surgical

Lobectomy (if localized disease), lung transplantation (if end‑stage).

Nutrition

High‑calorie feeds (chronic illness), pancreatic enzymes (if CF).

Multidisciplinary

Respiratory therapy, dietitian, physiotherapy, social work.

📈 Prognosis

  • Localized bronchiectasis: good with surgery.
  • Cystic fibrosis: progressive; median survival improving.
  • PCD: better prognosis than CF.
  • Post‑infective: good with early treatment.
  • Cor pulmonale: poor prognosis.

📋 Follow‑up Schedule

  • Stable: 3‑6 monthly review.
  • Exacerbations: daily until improvement.
  • Annual: sputum culture, lung function, X‑ray.
  • CF: multidisciplinary follow‑up monthly.
💡 Examiner expectation: logical differential (CF, PCD, immunodeficiency), systematic investigation (HRCT, sweat test), and management plan with physiotherapy, antibiotics, and follow‑up. Know coarse crackles and clubbing for bronchiectasis.
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Mock OSCE · Bronchiectasis · Based on Wyne‑Harris, Nelson & CPSP curriculum