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Lecture 2: 06/02/2022 Presented by: Jessica Lancaster Respiratory Examination SURGICAL SOCIETY JUNIOR ANATOMY SERIES | CPA LECTURE SERIESContents 1) Structure of Respiratory Examination 2) Pathological Examination Findings 3) Anatomy Top Tips 4) X-Ray Interpretation 5) Questions S U R G S O C J A S | C P A L E C T U R E S E R I E S Structure of Respiratory Examination Position General Inspection Palpation and Exposure Auscultation Percussion and Lymph Nodes Tactile vocal fremitus S U R G S O C J A S | C P A L E C T U R E S E R I E S • Wash your hands Introduction •your name and rolef with "Introduce yourself to the patient and examination"e consent for the • Confirm the patient's name and date of birth • Briefly explain the examination • Obtain Informed consent • Pain S U R G S O C J A S | C P A L E C T U R E S E R I E SInspection • Tachypnoea • Cough distress on inspection from the end of• Cyanosis the bed? • Use of accessory muscles • Audible wheeze • Nasal flaring • Sweating • Tripod S U R G S O C J A S | C P A L E C T U R E S E R I E SGeneral Report respiratory rate in Inspection breaths per minute: "Assess the patient's respiratory rate"RR <12 Bradypnoea RR 12-20 Normal RR >20 Tachypnoea S U R G S O C J A S | C P A L E C T U R E S E R I E SPalpation The Trachea should be located equidistant between the "Palpate the Patient's trachea" clavicular heads as it is a midline structure. Tracheal deviation arises due to unequal intrathoracic pressure. S U R G S O C J A S | C P A L E C T U R E S E R I E SPalpation- Trachea Causes of tracheal deviation away fromive pleural the lesion effusion •Tension pneumothorax •Chest expansion S U R G S O C J A S | C P A L E C T U R E S E R I E SPalpation- Trachea •Upper lobe collapse the lesiontracheal deviation towards •Upper lobe fibrosis •Pneumonectomy S U R G S O C J A S | C P A L E C T U R E S E R I E S Normal chest expansion Palpation should be 4-5 cm and "Assess chest expansion anteriorly/ symmetrical. posteriorly" Expansion should take off at the same time bilaterally. S U R G S O C J A S | C P A L E C T U R E S E R I E SPalpation- Chest Expansion Causes of unilateral decrease in chest• Pneumothorax expansion • Pleural effusion • Collapsed lung • Consolidation S U R G S O C J A S | C P A L E C T U R E S E R I E SPalpation- Chest Expansion • Asthma expansion symmetrical decrease in chest • COPD • Fibrosis • Rib Fracture S U R G S O C J A S | C P A L E C T U R E S E R I E SPercussion Describe the percussion sound over healthy lung tissue: "Percuss the chest anteriorly/ posteriorly" • Resonant • Loud • Low pitched S U R G S O C J A S | C P A L E C T U R E S E R I E SPercussion "Percuss the chest anteriorly" S U R G S O C J A S | C P A L E C T U R E S E R I E SPercussion "Percuss the chest posteriorly" S U R G S O C J A S | C P A L E C T U R E S E R I E SPercussion Due to excess air: Causes of hyper-resonant percussion • Pneumothorax • COPD • Acute Asthma • Hollow bowels S U R G S O C J A S | C P A L E C T U R E S E R I E S Anything that fills the lungs Percussion that isn't air! Causes of hypo-resonant percussion Dull: • Bone • Tumour • Consolidation • Collapse • Normal liver S U R G S O C J A S | C P A L E C T U R E S E R I E SPercussion Anything that fills the lungs that isn't air! Causes of hypo-resonant percussion Stoney dull: • Pleural effusion • Haemothorax S U R G S O C J A S | C P A L E C T U R E S E R I E S Bronchial Breathing: Auscultation • Loud and high-pitched "Auscultate the chest anteriorly/ posteriorly" • Equal Inspiratory and expiratory phase • Pause between inspiration and expiration • Heard over the trachea S U R G S O C J A S | C P A L E C T U R E S E R I E S Vesicular breathing: Auscultation "Auscultate the chest • Lower-pitched rustling sounds anteriorly/ posteriorly" • Longer inspiratory phase • No pause between inspiration and expiration • Heard all over the rest of the lung fields S U R G S O C J A S | C P A L E C T U R E S E R I E S When heard outside their Auscultation normal territory, due to When are bronchial breath sounds increased transmission of sound pathological? to the surface of the chest. • Consolidation • Pleural effusion • Pulmonary fibrosis • Collapsed lung S U R G S O C J A S | C P A L E C T U R E S E R I E S Wheeze- High pitched sound due to Auscultation airway narrowing, loudest on expiration. Examples of added breath sounds: Stridor- High pitched sound due to upper airway obstruction. poppingsounds from air being forcedus through a fluid, pus or mucus filled airway. late inspiration originating from small airways Coarse crackles- Heard in early inspiration originating from large airways S U R G S O C J A S | C P A L E C T U R E S E R I E ST actile Vocal Palpable vibrations as a result Fremitus of sound transmitting through "Assess for tactile vocal fremitus lung tissue anteriorly/ posteriorly" Healthy lung tissue: Vibration should be symmetrical S U R G S O C J A S | C P A L E C T U R E S E R I E ST actile Vocal Arises due to increased Fremitus density: Causes of increased tactile vocal fremitus • Consolidation pneumonia • Tumour • Lobe collapse S U R G S O C J A S | C P A L E C T U R E S E R I E ST actile Vocal Due to decrease in density: Fremitus • COPD fremitusf decreased tactile vocal Increase in distance between lungs and chest wall: • Pleural effusion • Pneumothorax S U R G S O C J A S | C P A L E C T U R E S E R I E S Using the pads of the fingers Lymph Nodes in a circular motion palpate "Palpate the patient's lymph nodes" across all the cervical lymph node groups. Note: • Size • Mobility • Tenderness • Consistency S U R G S O C J A S | C P A L E C T U R E S E R I E SLymph Nodes Causes of Lymphadenopathy • Infection • Inflammation • Malignancy • Medication • Benign idiopathic S U R G S O C J A S | C P A L E C T U R E S E R I E S Describe the surface markings of: Horizontal Lungs Pleura and Oblique Fissures S U R G S O C J A S | C P A L E C T U R E S E R I E SS U R G S O C J A S | C P A L E C T U R E S E R I E SChest X-rays A Systematic Approach • Airway • Breathing • Circulation • Diaphragm • Everything else! S U R G S O C J A S | C P A L E C T U R E S E R I E S X-rays either pass freely through the body or are variably attenuated by anatomical structures. The more dense the tissue, the more X-rays are attenuated. For example, X-rays are attenuated more by bone than by lung parenchyma. S U R G S O C J A S | C P A L E C T U R E S E R I E SCardiac The aortic arch is the first structure on the left mediastinum. The left pulmonary artery can be seen branching throughout the lung. The left border of the heart is made of the left atrium and left ventricle. S U R G S O C J A S | C P A L E C T U R E S E R I E SCardiac The edge of the superior vena cava can be seen superiorly. The right border of the heart is made up solely by the right atrium. Why does the right ventricle not have a border on this chest film? S U R G S O C J A S | C P A L E C T U R E S E R I E SCardiac Why does the right ventricle not have a border on this chest film? The right ventricle sits anteriorly so does not have border on PA chest film. S U R G S O C J A S | C P A L E C T U R E S E R I E SX-ray 1: What pathology is shown in the following chest X-ray? S U R G S O C J A S | C P A L E C T U R E S E R I E S COPD Chest hyper-expansion In healthy patients the diaphragm is intersected by the 5th to 7th anterior ribs in the mid-clavicular line. Flattened hemidiaphragm is a more reliable indication of hyper- expansion S U R G S O C J A S | C P A L E C T U R E S E R I E S COPD continued Bullae Bullae are permanent air filled pockets in the lung parenchyma and are at least 1cm in diameter with a poorly defined wall. S U R G S O C J A S | C P A L E C T U R E S E R I E SX-ray 2: What pathology is shown in the following chest X-ray? S U R G S O C J A S | C P A L E C T U R E S E R I E S Left sided pleural effusion • The left lower zone is uniformly white • At the top of this white area there is a meniscus sign • The left heart border, costophrenic angle and hemidiaphragm are obscured S U R G S O C J A S | C P A L E C T U R E S E R I E SX-ray 3: What pathology is shown in the following chest X-ray? S U R G S O C J A S | C P A L E C T U R E S E R I E S Left sided pneumothorax • Visible pleural edge • Lung markings not seen peripheral to this line • Rib fracture S U R G S O C J A S | C P A L E C T U R E S E R I E SX-ray 4: What pathology is shown in the following chest X-ray? S U R G S O C J A S | C P A L E C T U R E S E R I E S Left middle zone consolidation • White middle zone • Air bronchograms The patient is febrile and has a productive cough Pneumonia S U R G S O C J A S | C P A L E C T U R E S E R I E SX-ray 5: What pathology is shown in the following chest X- ray? S U R G S O C J A S | C P A L E C T U R E S E R I E S Cardiomegaly Patient demonstrates severe cardiomegaly. Previous mitral valve repair can be seen. S U R G S O C J A S | C P A L E C T U R E S E R I E S Question 1: An 18 year old male presents to A&E with dyspnoea and right sided pleuritic chest pain. The symptoms started two hours prior while the patient was playing football. On examination the patient has: • Reduced chest expansion on the right • Hyper-resonant percussion note on the right • Decreased breath sounds on the right • Decreased fremitus on the right What is the most likely diagnosis? S U R G S O C J A S | C P A L E C T U R E S E R I E S Right sided Pneumothorax An 18 year old male presents to A&E with dyspnoea and right sided pleuritic chest pain. The symptoms started two hours prior while the patient was playing football. On examination the patient has: • Reduced chest expansion on the right • Hyper-resonant percussion note on the right • Decreased breath sounds on the right • Decreased fremitus on the right What is the most likely diagnosis? S U R G S O C J A S | C P A L E C T U R E S E R I E S Question 2: A 72 year-old woman presents with slowly increasing dyspnoea over the past 2 months and left sided chest pain. Her dyspnoea is exacerbated when she lies flat. On examination: • Reduced chest expansion on the left • Stoney dull percussion note over the lower left lung field • Bronchial breath sounds heard over lower left lung field • Decreased tactile vocal fremitus over lower left lung field S U R G S O C J A S | C P A L E C T U R E S E R I E S Left sided pleural effusion A 72 year-old woman presents with slowly increasing dyspnoea over the past 2 months and left sided chest pain. Her dyspnoea is exacerbated when she lies flat. On examination: • Reduced chest expansion on the left • Stoney dull percussion note over the lower left lung field • Bronchial breath sounds heard over lower left lung field • Decreased tactile vocal fremitus over lower left lung field S U R G S O C J A S | C P A L E C T U R E S E R I E S Question 3: What are the surface markings of the horizontal fissure? S U R G S O C J A S | C P A L E C T U R E S E R I E S Question 3: What are the surface markings of the horizontal fissure? Its surface markings are from the level of the right fourth costal cartilage laterally along the 4th rib to a junction with the oblique fissure at approximately the midaxillary line in the fifth intercostal space. It divides the right lung above the oblique fissure into the right superior and right middle lobe S U R G S O C J A S | C P A L E C T U R E S E R I E S Jessica Lancaster jl2719@ic.ac.uk JAS Leads CPA Lead: Mohamad Abou-Eid (ma2219@ic.ac.uk) Phase 1a Lead: Sree Kanakala (sk1821@ic.ac.uk) Phase 1b Lead: Ananya Jain (aj620@ic.ac.uk) Feedback
