Respiratory System Physical Examination Ishraq Elshamli Respiratory Unit Tripoli Medical Center

Preparation for Examination Privacy : warm, well-lighted, quiet room. Wash your hands Introduce yourself to the patient. Seek permission for the examination and be polite to the patient. “Stop me at any time if it becomes uncomfortable or I cause you any discomfort

Introduction While seated or standing, the patient should be exposed to the waist OR uncovered intermittently. Teach the patient how to breathe deeply and quietly, slowly inhaling and exhaling through an open mouth

Physical Examination

Physical Examination Initial impression Stand back, to the right hand side of the patient : General appearance : Thin, Pink puffer, cachexia. Obese, blue bloater, cushinoid features Cyanosis Features of SVCO

Physical Examination (Initial Impression) SOB? Using accessory muscles of respiration Pursed lips Prolonged expiratory phase ?COPD Count Respiratory rate Normal adult, 12 - 20 breaths/min regular and unlabored. Tachypnea is an adult RR> 24 breaths/min. Bradypnea is an adult RR< 10 breaths/min.

Physical Examination (Initial Impression) Audible cough : is it dry/ productive. Is there a sputum pot? If so, look in it. Wheeze Stridor Hoarseness

Note the intercostals retractions (especially at the base of the neck,) and the position of the hands (a position known as 'tripodding.')

Tri-Pod Position : In patients with emphysema

Pink Puffer

Blue Bloater

Around the bed Inhalers. Oxygen. CPAP machine (Obstructive sleep apnoea). Sputum Pots.

Oximeter

Provides controlled Oxygen therapy Venturi mask : Provides controlled Oxygen therapy 24%, 28%, 35%, 60%

Ventolin Inhaler (mdi) Metered dose inhaler Foradil (Formetrol) Powder inhaler

Pulmicort and Oxis turbohaler Seretide diskhaler Metered dose inhalers(mdi) e.g. Becloforte (Beclomethasone), Ventolin (Salbutamol) Combivent(Salbutamol+ipratropium bromide)

Hands and Pulse Perfusion Nicotine staining Peripheral cyanosis Bruising/ thin skin: steroid therapy Clubbing - lung cancer, bronchiectasis, CF, lung abscess/empyema), pulmonary fibrosis, mesothelioma, (HPOA).

Examination of the hands Tremor (fine ? Β2 agonist) Flapping tremor (CO2 retention) . Other conditions: e.g. Yellow Nails/ RA hands/ Scleroderma/ Wasting of the intrinsic muscles of the hands (cachexia/ pancoast tumour) Pulse

Finger clubbing

Flapping tremor

Pulse Pulse: palpate rate, rhythm, character. Tachycardia: e.g. AF associated with pulmonary disease. Tachycardia associated with beta 2 agonists (nebulised salbutamol)

Face and Neck Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips

Face Horner’s Syndrome (MEAP! Myosis, enophthalmos, anhydrosis, ptosis). Central Cyanosis (4g of Hb has to be deoxygenated). Acneform eruptions associated with immunosuppressive therapy. Cushingoid appearance with long-term steroid use .

Acneform eruptions

Pursed lip breathing Improves ventilation. Releases trapped air. Keeps the airways open longer and decreases the work of breathing Prolongs exhalation to slow the breathing rate Relieves shortness of breath

The Neck Position of the trachea Lymph node enlargement (tuberculosis, lymphoma, malignancy, sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar􀃆previous ventilation in COPD etc. Central line scars Scar from LN biopsy JVP - ? right sided heart failure (cor pulmonale as a result of chronic lung disease)

Tracheostomy Scar Thyroidectomy Scar

Chest Traditional Sequence Inspection. Palpation. Percussion. Auscultation.

Remember Always describe the chest in terms of anterior and posterior. Describe the lungs as zones not lobes i.e. Upper/ middle/ lower zones

Anterior View Posterior View

Left Lateral View Right Lateral View

Inspection Inspection is performed to: Scars : pneumonectomy ,lobectomy Chest drains , thoracocentesis. Radiation tattoo’s (previous radiotherapy). Shape or Chest wall deformity – pectus excavatum / carinatum(pigeon chested), Barrel chest (Hyper-inflated), Kyphosis, Scoliosis. Resp rate, depth& Mode of breathing.

Inspection Movements . Equal symmetry or reduced on one side? Respiratory effort, intercostal indrawing or use of accessory muscle .

Kyphosis: Causes the patient to bend forward. X-Ray shows curvature of the spine.

Pectus excavatum: Congenital posterior displacement of lower sternum. The x-ray shows a concave appearance of the lower sternum.

Barrel chest : In chronic lung hyperinflation (e.g.Asthma, COAD) Due to increased AP diameter of the chest.

Scoliosis Is an increased lateral curvature of the spine . (i.e. Like the shape of the Letter “S”).

Intercostal retraction

ANTERIOR EXAM Palpation Trachea: palpate for tracheal position midline or deviated Rt or Lt

Position of the Trachea

A Apex Beat

Chest expansion Place your palms on the patient’s chest with your thumbs parallel to each other near the midline OR lightly pinch the skin between your thumbs Ask the patient to take a deep breath , observe for bilateral expansion

Tactile Vocal fremitus Place the ulnar side of your hand on the patient’s chest . Instruct the patient to say “44” each time they feel your hand on their back. Comment on the tvf increased or decreased

Percussion

Percussion technique Place left hand on chest wall, palm downwards with fingers separated 2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx producing hammer effect Entire movement comes from wrist

Percussion Technique Compare like with like

Percussion Do not forget the apices of the lungs Compare both sides Impaired(dull)resonance obtained – Lung tissue is airless e.g. consolidation, collapse, fibrosis Hyper resonant = pneumothorax/ COPD Stony Dull = Pleural effusion

Percussion

Auscultation

Auscultation technique Diaphragm of stethoscope covers a larger surface than the bell Breath deeply with Mouth open Systematic approach over several areas, comparing both sides listen to one complete respiration Repeat asking patient to say “9,9,9” for vocal resonance Whispering pectoriloquy

Auscultation The auscultatory assessment includes breath sounds audible or not . Character of breath sounds. Abnormal sounds or added sounds. Examination of the sounds produced by the spoken voice. Use a zigzag approach, comparing the finding at Each point with the corresponding point on the Opposite hemithorax.

Auscultation Breath sounds Added sounds Vocal sounds (vocal resonance)

Vesicular – Normal, Or Diminished localised or diffuse expiration inspiration Vesicular – Normal, Or Diminished localised or diffuse inspiration expiration inspiration expiration Vesicular with prolonged expiration Bronchial Breathing

Vesicular breath sounds Vibrations of the vocal cords caused by turbulent flow through the larynx Transmitted along trachea, bronchi to chest wall Rustling quality Inspiration continuous with expiration Intensity increases during inspiration & fades during first 1/3rd expiration

Diminished breath sounds Conduction limited by Airflow limitation e.g. diffusely – asthma, emphysema localised – tumour, collapse Something separating chest wall from lung e.g. effusion, fibrosis

Bronchial breathing “blowing” inspiratory & expiratory sounds Expiratory phase as long as inspiration Distinct pause between phases High-pitched e.g. consolidation Low-pitched e.g. fibrosis

Added sounds Rhonchi (wheeze) Crepitations (crackles) Pleural sounds

Rhonchi Due to passage of air through narrowed bronchus e.g. bronchospasm, mucosal oedema Musical quality High or low pitched Usually expiratory Expiration prolonged

Crepitations Inspiratory noises, usually 2nd half Non-musical Due to explosive reopening of peripheral small airways during inspiration which have become occluded during expiration

Pleural Rub Creaking noise Movement of visceral pleura over parietal pleura Surfaces roughened by exudate 2 separate phases at end inspiration and early expiration

Vocal sounds Vocal resonance Increased when voice sounds are louder and more distinct e.g. consolidation Reduced when transmission impeded e.g. effusion, collapse

Information from auscultation Type and amplitude of breath sounds Type of added sounds and their location Quality and amplitude of conducted sounds

Whisper pectoriloquy With your stethoscope the over area of possible pathology, have the patient whisper the phrase ‘one-two-three’. Listen to hear if the sound is distorted. Confirm that a similar change is absent over the identicallocation on the contralateral chest.

Egophony With your stethoscope over the area of possible pathology, have the patient vocalize the vowel ‘EEEE’.Listen for the sound to be distorted into the sound ‘AHHH’. Confirm that a similar change is absent over the identical location on the contralateral chest.

I would like to complete my examination by Reviewing the temperature and blood pressure. Examine for features of cor pulmonale. (Inspect the JVP / look for peripheral oedema / other signs of right heart failure). Check the patient’s peak flow and forced expiratory time.

Forced expiratory time Instruct the patient to: take in as deep breath in as deep as you can and then hold it. Then, breathe out as forcefully and as quickly as possible. Or blow as hard as you can until all the air has emptied from your lungs.

If you can’t empty your lungs in 6 seconds, this suggests a degree of obstruction i.e. COPD.

Finishing off the examination At this stage say to the patient “Thank-you, you may sit back now” And to cover them up with the blanket

Interpretation of findings Breath sounds locally reduced or absent over pleural effusion, thickened pleura, collapsed area Breath sounds diffusely reduced in emphysema, asthma Rhonchi heard in asthma, COPD Crepitations may be widespread in COPD, LVF Crepitations localised in area of consolidation Pleural rub in pleurisy

Interpretation of findings Pleural effusion reduced tactile vocal fremitus reduced chest expansion stony dull reduced air entry no added sounds reduced vocal resonance Consolidation increased tactile vocal fremitus reduced expansion dull percussion bronchial breathing coarse creps increased vocal resonance whispering pectoriloquy

Interpretation of findings Pneumothorax deviated trachea reduced tactile vocal fremitus hyper-resonance reduced air entry reduced vocal resonance Collapse deviated trachea reduced tactile vocal fremitus dull percussion reduced air entry +/- creps

Pleural effusion

pneumothorax

A candidate was asked to examine the respiratory system EXAMPLE: A candidate was asked to examine the respiratory system

Examiner observations: A reasonable method. She did commence examination of the chest from the posterior aspect. The findings: The patient was breathless at rest. Was using oxygen via nasal prongs. There were no peripheral signs . The chest was normal apart from bilateral basal crepitations.

What is your Diagnosis: Fibrosing alveolitis. What are other causes of bilateral basal crepitations : Heart failure. Brocnhiectasis. Atypical pneumonia JVP sputum pots or inhalers

Patient re-examined: General Examination: The patient was propped up in bed suggesting dyspnoea. The face was flushed flaring of the alae nasi O/E No clubbing but the peripheries were warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear lobe with no predominant waveform . Causes of Dyspnea A pink puffer The patient had respiratory distress cor pulmonale or heart failure

On examination of the chest: Barrel shaped . There was little movement of the chest wall with respiration being predominantly abdominal. Respiratory rate was 26 per minute. The apex beat was difficult to palpate Respiratory movements were equal on the two sided vocal fremitus unremarkable

Percussion not showed increased resonance with diminished cardiac and liver dullness Breath sounds were vesicular There were a few crepitations at both bases but they were mostly mid-inspiratory and cleared with coughing Heart sounds were soft

COPD Respiratory failure Cor pulmonale Diagnosis COPD Respiratory failure Cor pulmonale

This case demonstrate: A methodical examination . Evaluation of the findings at each step. Makes diagnosis much easier.

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