Respiratory Examination

Basheer Khassawneh, MD,FCCP

Associate Professor of Medicine Pulmonary and Critical Care and Sleep Medicine King Abdullah University Hospital JUST

Try to be safe.
Wash

hands before and after

Water and soap Alcohol based gel

Use

mask and gown when asked

First Impression count so.

Introduce yourself
Know you patient
Coat ID card

Shake hands

Tell patient what you intend to do and gain consent. Start to give a running commentary of what you are doing

Cultural issues

Exposure and Position

Adequate exposure of chest

Privacy Men: no shirt Women: cultural issues and cover the breasts

Position
Anterior exam: supine Posterior: sitting upright

Eye of an Eagle

Observe around the patient

Oxygen Inhalers Sputum container

On the patient
Drips Oxygen masks Nebulizer CPAP

General inspection

Color- obvious cyanosis

Does she/he look ill?

Signs of respiratory distress

Muscle wasting- cachexia Presence of cough

General inspection
From foot of the bed

Ask the patient Take two deep breaths please

Stridor Audible wheeze Chest movements

Is it asymmetrical?

RESPIRATORY RATE

Assess when the patient is at rest and calm Try to not let the patient realize you are counting the respiration Check respiratory rate with your peripheral vision watching for each breath.

RESPIRATION

How to measure
observe rise and fall of chest

Count for 30 seconds Normal respiration:

12 to 20 per minute

Patterns Of Respiration

Bradypnea: rate under 12: coma, medications, deep sleep Tachypnea: rate over 20: anxiety, heart or lung disease, pain Cheyne-Stokes: drugs, CNS damage Kussmaul: rapid, deep, labored: metabolic acidosis

Moving onto the Hands

Can

I have a look at your hands, please

Clubbing Peripheral cyanosis Nicotine stain on fingers Resting tremor Thin, paper like skin Muscle wasting Flapping tremor

Digital Clubbing

Pulmonary

Cardiovascular GI

Bronchiectasis Idiopathic lung fibrosis Chronic lung infection Cystic fibrosis Lung abscess Lung cancer

Cyanotic congenital heart disease Infective endocarditis Cirrhosis of liver Inflammatory bowel disease

Digital Clubbing

Cyanosis

A bluish or purplish tinge to the skin and mucous membranes Presence of 5 g/dL of deoxygenated hemoglobin in the capillaries Peripheral
Fingernails and tips

Central
Mouth

Look at the face .

Eyes
Horners syndrome
Myosis Ptosis

Anemia

Lips/ tongue/mouth Central cyanosis Pursed lip breathing

Examination of the Chest

Surface anatomy Anterior examination Posterior examination Exam steps

Inspection Palpation Percussion Auscultation

Surface Anatomy

SURFACE ANATOMY OF THE CHEST

Where are the Lungs?

The lungs extend from 4cm above the first rib to the 6 th rib

Where are the lungs?

Where are the lungs?

Laterally the lungs extend to the 8TH rib

All three lobes are accessible

Inspecting the chest

Scarsprevious chest drains Thoracotomy (look around back) Prominent veins

Superior vena cava syndrome

Chest Inspection

Chest shape Barrel chest

increased AP diameter- hyperinflation

Pigeon chest- pectus carinatum

outward bowing of sternum and costal cartilages

Funnel chest- pectus excavatum

Kyphosis- forward curvature of spine Scoliosis lateral curvature of spine

Palpation

Trachea- is it central? Chest expansion Tactile vocal fremitus

Superficial palpation

PALPATION Tracheal Position

It should be midline It may be lateral

Pulled to other side
Pneumothorax Pleural effusion

Pulled to the same side

Collapsed lung Post pneumonectomy

PALPATION - Thoracic Expansion

Placing the palms of the hands symmetrically on either side of the chest wall with the thumbs pointing towards the midline Ask the patient Could you please take a deep breath in? and feel whether the fingers move apart symmetrically The thumbs should separate by 5cm

Tactile Vocal Fremitus

Chest wall vibrations from speech (patient says "ninety-nine or ) Compare both sides

Decreased fremitus

Increased fremitus

Pneumothorax Collapsed lung Pleural effusion ) Scarred, thickened pleura

In pneumonia (consolidation)

Tactile Fremitus

Tactile Fremitus

Percussion

Dont forget clavicles and apices Move across in a systematic fashion Note the resonance of percussion note Decreased to dull Normal Hyperresonant to tympanic Note the level of note change

Percussion

Percussion

Hyper-resonant

Dull

Normal

Tactile Fremitus

Auscultation

Ask patient to breathe in and out of mouth Breath sounds

Vesicular Bronchial Broncho-vesicular

Added sounds Wheezes Crackles Pleural rubs

Note where these are occurring Vocal resonance

AUSCULTATION

Technique
Diaphragm Vs. Bell !!! Move from side to side

Breath Sounds

Vesicular
Heard over most of the lung (periphery) Sound of air moving in small airways and alveoli Continuous from inspiration to expiration Inspiration > Expiration Low pitched and soft

Breath Sounds

Bronchial
Higher pitched Expiration > Inspiration Gap between inspiration and expiration Heard normal over the trachea Abnormal elsewhere

Consolidation

AUSCULTATION FEATURES

Breath sounds are softer or diminished

Air around the lung (pneumothorax) Fluid around the lung (pleural effusion) Obese or has pleural thickening or scarring Moving less air (severe chronic obstructive lung disease or asthma)

AUSCULTATION FEATURES

Vocal resonance
Transmission of patient's voice The auditory equivalent of tactile fremitus

Whispered pectoriloquy
A whisper is clear to the stethoscope

Egophony
Patient says EEE and stethoscope hears AAA Similar to increased tactile fremitus

AUSCULTATION ABNORMALITIES

Crackles
Inspiratory sound Water in the alveoli (heart failure) Pus in the alveoli (pneumonia) Scarring (pulmonary fibrosis)

AUSCULTATION ABNORMALITIES

Wheezes
High pitched Continuous whistles Usually in expiration Sign of asthma or COPD

AUSCULTATION ABNORMALITIES

Rhonchi
Low pitched, snore-like Heard in inspiration and expiration Originate in larger airways Secretions in the airways

Friction rub
Dry, leathery sound Heard in inspiration and expiration It is a sign of inflammation of the pleura

Reading list

http://www.conntutorials.com/video.html