1. Respiratory Examination Slides of Dr JM Nel Department Critical Care Dr Scarpa Schoeman – Dept Internal Medicine

2. Respiratory Examination 1. Positioning of the 1. Positioning of the patient patient 2. General Appearance 2. General Appearance 3. The hands 3. The hands 4. The face 4. The face 5. The trachea 5. The trachea 6. The chest 6. The chest 7. The heart 7. The heart 8. The abdomen 8. The abdomen 9. Other 9. Other

3. Positioning of the patient Undress to waist Undress to waist Sitting position Sitting position Acutely ill Acutely ill –Lying down

4. General appearance 1. Dyspnoea 1. Dyspnoea –Signs of dyspnoea at rest –RR: 16- 25/min 2. Cyanosis 2. Cyanosis –Central cyanosis: tongue 3. Cough character 3. Cough character

5. General appearance 4. Sputum 4. Sputum –Colour/volume/type –Hemoptysis 5. Stridor 5. Stridor –Loudest on inspiration 6. Hoarseness 6. Hoarseness

6. The hands 1. Clubbing 1. Clubbing –P51-Table 4.9

7. The hands Clubbing Clubbing –Cardiovascular  Congenital cyanotic heart disease  Infective endocarditis –Respiratory (80% the cause)  Lung carcinoma  Chronic pulmonary suppuration  Idiopathic lung fibrosis  Cystic fibrosis  Asbestosis  Pleural mesothelioma –Gastrointestinal  Cirrhosis  Inflammatory bowel disease  Coeliac disease COPD/TB does not give clubbing COPD/TB does not give clubbing

8. The hands HPO  Periosteal inflammation  Clubbing marked  Distal end of long bones,wrists,metacarpal,metatarsal bones, knees, ankles  Swelling/Tenderness

9. The hands 2. Staining 2. Staining –Cigarette smoking 3. Wasting and 3. Wasting and weakness weakness –Wasting small muscles –Weakness abduction –Infiltration of brachial plexus by lung CA

10. The hands 4. Pulse rate 4. Pulse rate –Pulse rate –Pulsus paradoxus  Systolic BP drop > 10mmHg 5. Flapping 5. Flapping tremor(Asterixis) tremor(Asterixis) –Dorsiflex hands –CO2 retention (COPD)

11. The face 1. Horner’s syndrome 1. Horner’s syndrome –Constricted pupil –Partial ptosis –Loss of sweating –Apical lung tumour –Compression of sympathetic nerves

12. The face 2. Skin changes 2. Skin changes –Connective tissue diseases

13. The face 3. URTI 3. URTI –Look inside mouth 4. Sinuses 4. Sinuses –Look inside mouth 5. SVC obstruction 5. SVC obstruction –Facial plethora or cyanosis

14. The trachea Position Position Tracheal tug Tracheal tug –COPD

15. The chest Inspection Inspection Palpation Palpation Percussion Percussion Auscultation Auscultation

16. The chest: Inspection 1. Shape and 1. Shape and symmetry of chest symmetry of chest shape shape –Barrel- shaped chest –Pigeon chest –Funnel chest –Harrison’s sulcus –Kyphosis, scoliosis, kyphoscoliosis –Lesions of chest wall –Movement of chest wall

17. The chest: Inspection Barrel- shaped chest Barrel- shaped chest –Increased AP diameter –Severe asthma/COPD –Normal elderly people

18. The chest: Inspection Pigeon chest(pectus carinatum) Pigeon chest(pectus carinatum) –Outward bowing sternum/costal cartilages –Chronic childhood resp infectons –Rickets Funnel chest(pectus excavatum) Funnel chest(pectus excavatum) –Developmental defect –Depression lower end of sternum –Severe: decreased lung capacity

19. The chest: Inspection Harrison’s sulcus Harrison’s sulcus –Linear depression lower ribs just above costal margins –Severe asthma in childhood –Rickets

20. The chest: Inspection Kyphosis, scoliosis, kyphoscoliosis Kyphosis, scoliosis, kyphoscoliosis –Severe: reduced lung capacity

21. The chest: Inspection Lesions of chest wall Lesions of chest wall –Scars  Previous surgery  Previous ICD –Radiotherapy  Erythema –Subcutaneous emphysema –Prominent veins  SVC obstruction

22. The chest: Inspection Movement of chest wall Movement of chest wall –Expansion  Upper lobes –From behind –Look down at clavicles  Lower lobes –From behind –Unilateral  Localized fibrosis, consolidation, collapse, pleural effusion –Bilateral  COPD, diffuse pulmonary fibrosis

23. The chest: Inspection Movement of chest wall Movement of chest wall –Asymmetry –Paradoxical inward movement abdomen during inspiration  Diaphragm paralysis

24. The chest: Palpation 1. Chest expansion 1. Chest expansion –Thumbs move symmetrical 5cm on inspiration –Lower lobe  From back –Upper lobe  From front

25. The chest: Palpation 2. Apex beat 2. Apex beat –Displacement  Towards side of lesion –Collapse lower lobe –Localized fibrosis  Away from lesion –Pleural effusion –Tension pneumothorax –Impalpable  COPD: hyperinflation

26. The chest: Palpation 3. Vocal fremitus 3. Vocal fremitus –Palm of hand –“99” –Differences –Increased: Consolidation –Same as vocal resonance 4. Ribs 4. Ribs –Localized pain  Trauma, metastases, prolonged coughing

27. The chest: Percussion

28. 1. Symmetrical 1. Symmetrical –Ant/Post/Lat –Supraclavicular fossa over lung apex –Clavicle with finger

29. The chest: Percussion

30. 2. Interpretation 2. Interpretation –Resonant  Normal –Dull  Solid structure (liver)  Consolidation –Stony dull  Fluid- filled area (pleural effusion) –Hyperresonant  Over hollow structures –Bowel, pneumothorax

31. The chest: Percussion 3. Liver dullness 3. Liver dullness –Upper level  5 th / 6 th rib MCL  If lower: hyperinflation 4. Cardiac dullness 4. Cardiac dullness –Decreased  COPD  Asthma

32. The chest: Auscultation 1. Breath sounds 1. Breath sounds 2. Vocal resonance 2. Vocal resonance

33. The chest: Auscultation 1. Breath sounds 1. Breath sounds –General –Quality of breath sounds –Intensity of breath sounds –Added sounds

34. The chest: Auscultation(Breath sounds) General General –Diaphragm of stethoscope –Compare sides –Axilla –Bell of stethoscope above clavicles  Lung apices

35. The chest: Auscultation(Breath sounds) Quality of breath sounds p125 Quality of breath sounds p125 –Normal breath sounds (vesicular) –Bronchial breath sounds –Amphoric breath sounds

36. The chest: Auscultation(Breath sounds) Normal breath sounds (vesicular) Normal breath sounds (vesicular) –Most of chest –Breath through mouth –Inspiration  Longer and louder than expiration –No gap between inspiration and expiration

37. The chest: Auscultation(Breath sounds) Bronchial breathing Bronchial breathing –Hollow, blowing sound –Audible in expiration –Gap between inspiration and expiration –Expiration  Higher intensity than inspiratory –Normal posteriorly over upper chest –CONSOLIDATION

38. The chest: Auscultation(Breath sounds) Amphoric breathing Amphoric breathing –Exaggerated bronchial quality –Very hollow (blowing over bottle) –LARGE CAVITY

39. The chest: Auscultation(Breath sounds) Intensity of breath sounds Intensity of breath sounds –Normal or reduced –Reduced  COPD  Pleural effusion  Pneumothorax  Pneumonia  Large neoplasm  Pulmonary collapse

40. The chest: Auscultation(Breath sounds) Added sounds Added sounds –Continuous sounds (wheezes) –Interrupted sounds (crackles)

41. The chest: Auscultation(Breath sounds) Continuous sounds (wheezes) Continuous sounds (wheezes) –Musical –Inspiration +/- expiration –Airway narrowing –High pitched  Smaller bronchi  Asthma –Low pitched  Larger bronchi  COPD –Monophonic  Localized  Bronhial obstruction (Lung CA) –Stridor  Louder over trachea  Inspiratory

42. The chest: Auscultation(Breath sounds) Interrupted sounds Interrupted sounds (crackles) (crackles) –Non-musical –Early inspiratory  Small airway disease  COPD  Medium coarseness –Late/pan-inspiratory  Disease in alveoli  Fine –Pulmonary fibrosis  Medium –LV failure  Coarse –Bronchiectasis –Retention of secretions

43. The chest: Auscultation(Breath sounds) Pleural friction rub Pleural friction rub  Thickened pleural surfaces rub together  Grating sound  Causes –Pleurisy  Secondary to pulmonary infarction –Pneumonia –Malignant involvement of pleura –Spontaneous pneumothorax

44. The chest: Auscultation 2. Vocal resonance 2. Vocal resonance –Auscultation while patient speaks –Ability of lung to transmit sounds –Normal –Consolidation  Can hear “99”  Aegophony –Bee becomes bay  Whispering pectoriloquy –Can hear when whispers

45. The chest: Signs

49. Hyperinflation Hyperinflation –Increased AP diameter –Trageal tug –Apex not palpable –Hyperressonant percussion –Liver displaced downwards –No cardiac dullness –Soft heart sounds

50. The Heart Measure JVP Measure JVP –Increased in RV failure Listen to P2 Listen to P2 –Loud in pulmonary hypertension

51. The Abdomen Liver examination Liver examination –Displaced downward in hyperinflation –Enlarged in metastases (Lung CA)

52. Other Pemberton’s sign Pemberton’s sign –Lift arms over head one minute –SVC obstruction  Facial plethora  Cyanosis  Inspiratory stridor  Non-pulsatile elevation of JVP

53. Other Feet Feet –Oedema  Cor pulmonale –DVT  PE