Respiratory Examination

Related Subjects: |Cardiology Examination |Cardiology History Taking |Respiratory Examination |Gastroenterology Examination

End of bed - quickly inspect surroundings

• Patient sitting at 45 degrees in bed with chest exposed (treat females discretely)
• Is patient on supplementary oxygen - Nasal specs, venturi mask, NIV
• Packet of cigarettes, patient smell of smoking,Inhaler, sputum pot and contents

Patient appearance

• Cyanosed (> 5g/dl of deoxygenated Hb)
• Plethora - polycythaemia, SVC obstruction
• Anaemia or Jaundiced (e.g. liver metastases from lung ca)

Habitus

• Obese ( Hypoventilation, Obstructive sleep apnoea)
• Cushingoid (steroid treatment/Cushing's disease/Paraneoplastic)
• Thin, cachexia - malignancy, end-stage COPD, pulmonary fibrosis
• Tall and thin - Primary pneumothorax, Marfan's syndrome
• Smell of cigarettes, Unkempt, emaciated - ? TB, Alcoholism
• Hoarse voice - Recurrent laryngeal nerve palsy from bronchogenic carcinoma
• Kyphosis and/or scoliosis (Ankylosing spondylitis -apical lung fibrosis)

Breathing pattern

• Respiratory rate - normal 12-15/minute
• Hypoventilating - obese, sedated, COPD "Blue bloater"
• Cheyne-stokes: alternating fast and slow seen in those with very poor prognosis, preterminal
• Increased respiratory rate
• Intercostal indrawing of ribs suggests increased effort
• Prolonged expiratory phase - COPD, Asthma
• Normal but increased rate - PE, LVF, Panic attack
• Pursed lips - seen in emphysema as the patient maintains a positive airway pressure to prevent small airway collapse
• Tripod position - sitting forwards with both arms fixed enables more efficient use of accessory muscles

Hands

• Warm with finger pulses, peripheral cyanosis - CO2 retention
• Clubbed and tender wrists (HPOA*) - lung malignancy or suppuration or idiopathic pulmonary fibrosis
• Nicotine staining
• Wasting - Pancoast tumour, cachexia, ageing, motor neuron disease

Clubbing

• Bulbous swelling of terminal phalanges with loss of angle of nail bed
• Aetiology unsure ? circulating prostaglandins
• Associated with Hypertrophic pulmonary osteoarthropathy- onion skin like bone formation at the wrist associated with clubbing

Causes of Clubbing

• Malignancy - Lung cancer, Mesothelioma
• Infection - Lung abscess, Empyema, Bronchiectasis
• Cryptogenic fibrosing alveolitis
• Cryptogenic organizing pneumonia
• Endocarditis
• Atrial myxoma
• Congenital cyanotic cardiac disease
• Cirrhosis
• Congenital (AD)
• Inflammatory bowel disease

Pulse

• Bounding - CO2 retention
• Irregularly irregular - Atrial fibrillation
• Tachycardia - fever, distress, arrhythmia

JVP elevated

• Right heart failure due to lung disease - Cor pulmonale
• Congestive cardiac failure
• Fixed and elevated - Superior vena caval obstruction -malignancy

Face appearance

• Jaundiced sclera - ? liver malignancy
• Conjunctiva - pale and anaemic or pink and suffused with SVC obstruction
• Horner's syndrome -? Pancoast tumour

Chest Examination

Inspection

• Expose chest in the exam or request to. Allow the female patient to cover up when done. Ensure patient comfortable. Are both sides of the chest moving well? If one side moves less most often it has the pathology.
• Chest Scars - Thoracotomy (look front and back and side), Thoracoplasty, Plaster or gauze covering recent pleural tap, Phrenic nerve crush scar in supraclavicular fossa used previously for TB, Midline sternotomy scar - CABG, Valve replacement or both, Tattoos markings from the previous radiotherapy
• Chest wall appearance - Pectus excavatum, ankylosing spondylitis, kyphoscoliosis

Palpation

• Gripping chest with both hands and thumbs in the midline and see do both sides moving equally with respiration
• Check trachea central using forefinger and sliding index and ring fingers gently on either side to ensure same space
• Place hands across chest thumbs touching and make sure that both sides move the same with inspiration. Reduced movement on one side suggests pathology on that same side.
• Tactile fremitus "99"
• Axillary and supraclavicular lymph nodes if suspect a malignant process

Percussion

• Percuss rib spaces each side front and back comparing left and right side. Make sure that your technique is good. Don't forget over lung apices as well as percussion over clavicles and axillae.
• Dullness suggests underlying a lack of underlying aerated lung e.g. consolidation, collapse or fibrosis.
• Resonance seen with emphysema or even more so with pneumothorax.
• Stony dull suggests underlying fluid within the pleural space. Determine its upper margin

Auscultation with diaphragm of stethoscope

• Ask the patient to cough first to remove any phlegm that can add noises to the auscultatory findings
• Ask the patient to breathe through an open mouth as less resistance pathway and more air shifted and so more to hear
• Normal breathing pattern expiration more prolonged than inspiration 2:1
• Reduced air entry suggests pathology - collapse, consolidation, fibrosis, pleural thickening or hypoventilation if bilateral

Breath sounds

• Vesicular - Normal breath sounds and are soft and low pitch with a more blowy quality.
• Bronchial breath - harsh high pitch and equal duration inspiratory and expiratory phases. Sounds like listening over one's trachea. They are abnormal when heard on the chest surface. They usually suggest consolidation.
• Vocal resonance "99" and is increased over consolidation to the point that one gets "whispering pectriloquy"
• Reduced breath sounds: Hypoventilation, pleural effusion, pneumothorax

Added sounds

• Pleural rub: fine crackling noise with respiration
• Rhonchi/Wheeze suggests asthma or COPD
• Fine crepitations "crackles" or rales can suggest pulmonary oedema, resolving consolidation or infection or pulmonary fibrosis
• Coarser crackles heard with Bronchiectasis or cystic fibrosis

Extras

• Ask if you can measure the patient's PEFR (ensure you can do this properly)
• Look at observations chart for O2 sats and temperature and respiratory rate