PACES respiratory station: common cases and how to present them
The PACES respiratory encounter: a reliable routine, the common cases (fibrosis, bronchiectasis, effusion, COPD, lung cancer, post-TB), what each chest scar means and how to present.
The short answer
- The respiratory encounter is the second half of Station 1, after the communication encounter: up to 6 minutes to examine, then at least 4 minutes of questions.
- The common cases are interstitial lung disease, bronchiectasis, cystic fibrosis, pleural effusion, COPD, lung cancer, post-TB lung disease and previous lung surgery or transplant.
- The bedside clues often give the answer: oxygen, inhalers, a sputum pot, transplant medication, and scars you only find if you look under the arm and at the back.
- Don’t stop at the sign: an effusion or a collapse may be the clue to an underlying lung cancer.
A 6-minute routine
- Introduce, consent and position the patient at 45°.
- Bedside clues and general inspection: oxygen, inhalers and nebulisers, sputum pot, breathlessness, accessory muscle use, cachexia, chest shape and radiotherapy marks.
- Scars: look under the arms and at the back for thoracotomy, VATS port and chest drain scars. With permission, look gently beneath the bra line; a pen torch helps with faded scars.
- Hands: clubbing, tar staining, wasting of the small hand muscles, flapping tremor, rheumatoid or sclerodermatous changes.
- Face and neck: cyanosis, Horner's syndrome, the JVP, lymph nodes, trachea.
- Chest, front then back: expansion, percussion, auscultation and vocal resonance.
- Finish: ankle oedema, and offer to check oxygen saturations and peak flow.
Common cases
| Case | Key signs | Clues and points to raise |
|---|---|---|
| Interstitial lung disease | Clubbing, reduced expansion, fine end-inspiratory "Velcro" crackles at the bases that don't change with coughing | Look for the cause: rheumatoid hands, sclerodactyly, an irregular pulse (amiodarone). High-resolution CT, lung function with transfer factor, ILD MDT; antifibrotics for fibrotic disease |
| Bronchiectasis | Clubbing, coarse crackles that may change with coughing, wheeze, sputum pot | Causes: post-infective or post-TB, immunodeficiency, ABPA, CF, primary ciliary dyskinesia. HRCT (signet ring sign), sputum culture (Pseudomonas), airway clearance |
| Cystic fibrosis or primary ciliary dyskinesia | Young patient, clubbing, coarse crackles, low weight; a port, gastrostomy or glucose sensor (CF); dextrocardia (Kartagener syndrome) | Multisystem disease; CFTR modulators; specialist centre care |
| Pleural effusion | Reduced expansion, stony dull percussion, reduced breath sounds and vocal resonance; a large effusion pushes the trachea away | Transudate or exudate, and could it be malignancy or infection? Ultrasound-guided aspiration, Light's criteria |
| COPD | Hyperexpanded chest, pursed-lip breathing, quiet breath sounds, prolonged expiration, wheeze, nicotine staining | Clubbing is not a feature of uncomplicated COPD: if present, look for bronchiectasis, cancer or fibrosis. Spirometry, inhalers, rehabilitation, long-term oxygen criteria |
| Lung cancer | Cachexia, clubbing, nodes, an effusion or collapse; Horner's syndrome and hand wasting (Pancoast tumour); signs of SVC obstruction | CT chest and upper abdomen, tissue diagnosis, PET-CT for staging, lung cancer MDT |
| Post-TB lung disease | Upper-zone crackles or bronchial breathing, volume loss with tracheal shift, sometimes thoracoplasty | Aspergilloma, reactivation and cancer if there is new haemoptysis or weight loss |
| Consolidation | Dullness, bronchial breathing, increased vocal resonance | Pneumonia; if it doesn't resolve, consider an obstructing cancer |
Scars and what they tell you
| Scar | What it usually means |
|---|---|
| Posterolateral thoracotomy | A route, not a diagnosis: usually lobectomy or pneumonectomy for cancer. A trachea pulled towards the scar with dullness and absent breath sounds suggests pneumonectomy |
| Lateral or anterolateral thoracotomy with transplant medication | Single-lung transplant: breath sounds differ between the native and transplanted lungs |
| Bilateral anterolateral ("clamshell") | Bilateral lung transplant; the chest may sound nearly normal. Look for immunosuppression effects |
| Several small port scars | VATS: biopsy, lobectomy, bullectomy or pleurodesis. Small scars don't mean minor surgery |
| Small scar in the "safe triangle" | Previous chest drain: pneumothorax, effusion or empyema |
| Radiotherapy tattoos and skin change | Previous breast, lung or lymphoma treatment; look for recurrence or radiation fibrosis |
Distinguishing the dull chest
- Effusion: stony dull, reduced breath sounds and reduced vocal resonance; trachea central or pushed away.
- Pneumonectomy or lobar collapse: dull with reduced or absent breath sounds, and the trachea pulled towards the affected side.
- Consolidation: dull with bronchial breathing and increased vocal resonance.
Likely viva topics
- Light's criteria: an effusion is an exudate if the pleural fluid to serum protein ratio is above 0.5, the LDH ratio is above 0.6, or pleural fluid LDH is above two-thirds of the upper limit of normal for serum.
- Pleural infection: fluid pH of 7.2 or below, or pus, means drainage rather than repeated taps.
- COPD: long-term oxygen criteria (PaO₂ below 7.3 kPa, or 7.3–8.0 kPa with polycythaemia, pulmonary hypertension or oedema), rehabilitation, inhaler escalation.
- ILD: HRCT patterns, transfer factor, the ILD MDT and antifibrotics.
- Bronchiectasis: causes, Pseudomonas, airway clearance and long-term macrolides for frequent exacerbations.
Common pitfalls
- Calling coarse crackles fine, or the reverse.
- Forgetting the trachea, which separates effusion from collapse or pneumonectomy.
- Missing a thoracotomy or VATS scar under the arm or behind the patient.
- Stopping at the sign without asking what caused it.
Sources
Frequently asked questions
What are the common respiratory cases in PACES?
Interstitial lung disease, bronchiectasis, cystic fibrosis, pleural effusion, COPD, lung cancer, post-TB lung disease and previous lung surgery or transplant (lobectomy, pneumonectomy, single or bilateral lung transplant).
How do you tell fine from coarse crackles?
Fine crackles are high-pitched, late-inspiratory and do not clear with coughing, typical of pulmonary fibrosis. Coarse crackles are lower-pitched and may change with coughing, typical of bronchiectasis.
What does a clamshell scar mean in PACES?
A bilateral anterolateral (clamshell) scar most often means a bilateral lung transplant. The chest may sound nearly normal, so look for signs of immunosuppression and the original disease.
Is clubbing a feature of COPD?
No. Clubbing is not a feature of uncomplicated COPD. If a patient with COPD has clubbing, look for bronchiectasis, lung cancer or pulmonary fibrosis.
Where is the respiratory station in PACES?
The respiratory examination is the second encounter at Station 1, following a 10-minute communication encounter.
Written by The Ace PACES team. Exam facts are taken from the Federation of the Royal Colleges of Physicians’ published PACES guidance, linked in the sources above. This guide supports exam preparation and is not a clinical guideline.
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