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RESPIRATORY EXAMINATION Anya Olsen and Olivia Owen 1 RESPIRATORY EXAM • Introduction • Inspection • Palpation • Percussion • Auscultation • The back and other areas • Summary and offer additional tests 2 INTRODUCTION • Hand hygiene/PPE • Introduce self • Name and role • Confirm patient identity • Name and DOB • Explain examination • Gain consent • Position the patient (45 degrees) • Obtain adequate exposure (chest) • Ask about pain 3WHAT DOWE LOOK FOR IN GENERAL INSPECTION? 4 GENERAL INSPECTION • Patient’s bedside • Inhalers, nebulisers , sputum pot, oxygen delivery devices, cigarettes/vapes, mobility aids,other medical equipment • Patient • Cyanosis,SOB,cough,wheeze,stridor,pallor,oedema,cachexia,use of accessory muscles Pick 3 or 4 and learn these then you can use these every time. Nebulisers – asthma, COPD Sputum pot – if present comment on colour, is blood present, thickness and quantity Red due to blood: PE, lung cancer, pneumonia, Tb Pink: Heart failure Clear: viral infection, allergies, COPD Frothy: heart failure and COPD Green/brown ‘purulent’: infection, brown in CF Black: smoking SOB – look for nasal flaring, pursed lips, accessory muscle use, tripod position (leaning forward with hands and knees on the examination couch). Common in respiratory conditions for example asthma, COPD, pulmonary oedema (heart failure), fibrosis, lung cancer Cough – pneumonia, COPD, asthma, lung cancer, CF, bronchiectasis, ILD 5Pallor – pale complexion: anemia/poor perfusion/hypovolemia Cachexia – muscle loss usually due to malignancy or advanced COPD Wheeze – whistling sound on expiration, causes include asthma, COPD, heart failure Stridor – (high pitched noise on inspiration) due to upper airway obstruction 5 WHAT HAND SIGNS DOWE LOOK FOR IN RESPIRATORY EXAMINATION? • And what do they mean? 6 HANDS (1) • Inspect • Pallor • Peripheral cyanosis • Tar staining • Joint swelling – does anyone know why? • Clubbing 7HAND SIGNS Clubbing can indicate lung cancer,pulmonary fibrosis,chronic Joint swelling due to rheumatoid arthritis diseases forming pus (cystic fibrosis,lung abscess,empyema) can be associated with respiratory manifestations e.g.pleural effusion Peripheral cyanosidue to Tar stainindue to hypoxaemia can be due to asthma, smoking increases risk of COPD, lung cancer,most lung diseases COPD,pneumothorax etc. Peripheral cyanosis can be due to basically all respiratory issues https://www.verywellhealth.com/what-is-clubbing-2249079 https://www.hopkinsarthritis.org/arthritis -info/rheumatoid-arthritis/ra -symptoms/ https://www.physio-pedia.com/Cyanosis https://biology.stackexchange.com/questions/36493/how -does-a-smokers-finger-or- mustache -get-yellowish-by-nicotine 8 HANDS (2) • Palpation • Assess temperature (include arms) • Measure right radial pulse (rate and rhythm) • Calculate resp rate (same time as radial pulse) • Look for fine tremor and flapping tremor • What is the difference between fine and flapping tremor? Resp rate should be 12-20 Bradypnea - Opiate OD Tachypnea - PE - Acute asthma 9HANDANDARM SIGNS Flapping tremor is due to severe ventilatory Fine tremor due to beta-2-agonist overuse (salbutamol) failure with hypercapnia ( CO2 retention ),This can be due to a stroke,decreased ventilation in situations such as sepsis or something as common as COPD.It could be due to gas exchange problems such as PE or emphysema Temperatur–ecool hands suggests poor peripheral perfusion. Warm and sweaty hands could be CO2 retention https://twitter.com/wblmd/status/1010588800647680000?lang=gl https://mstrust.org.uk/a-z/tremor https://runningmagazine.ca/sections/training/whats -the-ideal-temperature-for- running/ 10 NECK • Inspect JVP • Feel for trachea • Is it central? • Why might it not be central? 11JVPANDTRACHEA Deviation of the tracheais most commonly due to a tension Raised JVP is due to venous hypertension.Pulmonary pneumothorax.Other causes can be hypertension due to COPD or interstitial lung disease large mediastinal mass,lobectomy, atelectasis,fibrosis,large pleural effusion can cause this. Trachea deviates towards Trachea deviates away from Atelectasis Tension pneumothorax Fibrosis Large pleural effusion Pneumonectomy/lobectomy https://www.youtube.com/watch?v=CaCmCw9NVEY https://www.youtube.com/watch?v=XpIGWDCWntc 12 FACE • Inspection:eyes • Horner's syndrome,pallor • What is Horner's syndrome? • Inspection:face • Polycythaemia • Inspection:mouth • Central cyanosis,oral candidiasis What is the significance of these findings in the context of respiratory examination? 13FACIAL SIGNS Horner's syndrome this is caused by an apical tumour of Oral candidiasis is a fungal Ruddy face (red) due to infection commonly associated the lung (Pancoast polycythemia (high RBC) secondary with steroid inhaler use tumour) compressing the to COPD sympathetic chain causing miosis, anhidrosis, enopthalmos and ptosis ipsilateral to the tumour https://www.britannica.com/science/thrush -medicine https://www.physio-pedia.com/Horner%27s_Syndrome https://www.altmeyers.org/en/dermatology/polycythaemia -vera-120797 14 CHEST - INSPECTION • Scars • Symmetry • Pectus excavatum • Pectus carinatum • Flail chest • Hyper-expansion 15INSPECTION OF CHEST - FINDINGS Pectus carinatum Pectus excavatum Barrel chest/hyper -expansion is associated Both are due to defects in costal cartilage with COPD https://en.wikipedia.org/wiki/Pectus_excavatum https://healthjade.com/pectus-carinatum/ https://www.ice99.com/health/3580387.html https://simpleosce.com/examinations/core/respiratory -examination.php 16 CHEST – PALPATION • Apex beat • Heaves • Chest expansion • Trachea (if you forgot before!) Apex – should be mid clavicular line 5th intercostal space Displaced can be due to cardiomegaly, large pleural effusion, right sided tension pneumothorax Heaves – a respiratory cause is cor pulmonale 17CHEST EXPANSION Chest expansion How: ask the patient to breatheALL the way out.Wrap your hands around the patient’s chest and ask them to take a deep breath in. Keep your fingers in contact with the chest wall laterally but keep thumbs off the chest wall Normal chest expansion: tumbs move apart form each other equally on both sides Abnormalities – reduced expansion Lung collapse Pneumonia Pnemonectomy /lobectomy Pneumothorax https://geekymedics.com/respiratory-examination-2/ 18 CHEST – PERCUSSION • Lung apices • Infraclavicular • Chest wall (3 -4 locations) • Axilla Apex – should be mid clavicular line 5th intercostal space Displaced can be due to cardiomegaly, large pleural effusion, right sided tension pneumothorax Heaves – a respiratory cause is cor pulmonale 19 PATTERN OF PERCUSSION AND AUSCULTATION Anterior Posterior Above clavicle On clavicle (for percussion– percuss straight onto clavicle) Chest wall and axilla Later on the back… around scapulae – get your patient to hug a pillow!! 20PERCUSSION FINDINGS Stony dullness Generally due to an Resonant (normal) underlying pleural effusion This case is a right sided pleural effusion,note the meniscus sign Dullness Hyper resonance Due to increased tissue Suggests a decrease in density e.g.cardiac tissue density such as a dullness,consolidation pneumothorax e.g.,pneumonia, tumour, lobar collapse This Xray shows a left sided pneumothorax. In this case there is right Note the lack of lung lower zone dullness due markings and deviation of to lobar pneumonia trachea to the right Resonant – sound travels better through air Dullness – you can't shout through increased density like a pillow https://radiopaedia.org/cases/normal-frontal-chest-x-ray?lang=us https://radiopaedia.org/cases/pleural-effusion-7 https://medschool.co/tests/chest-xray/pneumonia https://fpnotebook.com/lung/rad/chstxryinpnmthrx.htm 21 VOCAL FREMITUS/RESONANCE When percussion is dull how can we differentiate what it is? Vocal fremitu– getting the patient to say 99 and feeling for vibrations Vocal resonanc– get the patient to say 1 -1-1 whilst listening to the chest On percussion - dull On percussion - stony Due to increased tissue dullness density e.g.cardiac Generally due to an dullness,consolidation, underlying pleural tumour, lobar collapse effusion Vocal fremitus Vocal fremitus When it is increased Fluid of air outside of the tissue density you will lung will decrease the feel and hear increased vibration and vibration over the area sound.Think about trying to yell whilst underwater 22 Increased vocal fremitus/ resonance Decreased vocal fremitus/ resonance Atelectasis Pleural effusion Pneumonia Pneumothorax Malignancy (consolidation) If you shout under water you can’t be heard so if there is pleural effusion you can’t hear anything 23 CHEST - AUSCULTATION • Ask patient to take deep breaths in and out thromouth each time you place your stethoscope down • Use the bell in the apex and diaphragm over the rest of the chest to listen to breathing sounds • Go from left to righcompare • (on the back remember get them to hug a pillow!!) 24 HOWTO DESCRIBE BREATH SOUNDS Quality Added sounds • Vesicular– normal • Wheeze – continuous,coarse,whistling sound.This is often associated with asthma,COPD,bronchiectasis • Bronchial – harsh sounding, inspiration and expiration equal with pause in • Stridor – high pitched breath sounds due to turbulent between.Associated with consolidation flow as a result of narrowed upper airways.This can be due to inhaled foreign body (acute) and subglottic stenosis (chronic) Volume • Coarse crackles – brief,popping sounds generally associated with pneumonia,pulmonary oedema • Quiet – suggest reduced air entry e.g. and bronchiectasis pneumothorax,pleural effusion • Fine end -inspiratory crackles – sound like velcro and • Present this as reduced breath sounds are associated with pulmonary fibrosis 25 BACK • Inspection • Palpation • Chest expansion • Percussion • Auscultation • Lymph nodes • Sacral oedema 26BACK FINDINGS Sacral oedema due to right heart failure,fluid overload (hypoalbuminemia) Lymphadenopathy Can be caused by infection, inflammatory disorders (lupus, rheumatoid arthritis), malignancy , medications (allopurinol, atenolol,cephalosporins,penicillin, phenytoin),or they can be benign Cervical LN palpation - No spider fingers - Use pads of fingers and circular motions - Palpate all of the areas - Submental – submandibular – tonsillar/parotid (behind angle of mandible) – pre- auricular – post-auricular – occipital – anterior and posterior cervical – supraclavicular (ask patient to bring ear to shoulder) https://link.springer.com/chapter/10.1007/978 -3-319-52423-8_17 https://www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2020/06/Paediatric - guidelines-Lymphadenopathyand-lymphadenitis.pdf 27 LEGS • Inspection/palpation • Ankle oedema • Inspect the calves for swelling,redness,tenderness • What are we looking for here? • Erythema nodosum • What disease is associated with this? 28LEG SIGNS Pedal/ankle oedema is Erythema nodosum this kind of due to right heart failure rash can be associated Check the calves!! with sarcoidosis Swelling,increased temperature,redness and pain can all indicate a DVT.The patient may be SOB due to a pulmonary embolism too https://en.wikipedia.org/wiki/Edema https://www.nhs.uk/conditions/deep-vein-thrombosis-dvt/ https://www.pcds.org.uk/clinical-guidance/erythema -nodusum 29 OTHER AREAS • Look in any sputum pot if available • Ask for/examine any observation chart • Offer peak flow and spirometry if indicated 30 TO COMPLETE THE EXAMINATION • Explain the examination is over and thank the patient • Allow the patient to re -dress • Dispose of PPE and wash your hands • Summarise your findings (1 minutes) 31 EXAMPLE SUMMARY Today I did a respiratory examination on XXX who is XX years old. On general inspection,there was no oxygen,inhalers or nebulisers around the patient and looking at the patient there was no accessory muscle use,cyanosis or cachexia.On peripheral inspection there were no signs of respiratory disease such as pallor,peripheral cyanosis or fine/flapping tremor.In the face there was no conjunctival pallor,Horner's syndrome or evidence of polycythemia.The JVP was not raised and trachea central. On inspection of the chest there was no scars,deformities or pulsations. The apex beat was in the 5 intercostal space,mid-clavicular line which is normal.There were no heaves and chest expansion was equal bilaterally,both anterior and posteriorly. On percussion,lung fields were resonant throughout and on auscultation the breath sounds were vesicular,with no added sounds.There was no ankle or sacral oedema and the calves were soft and non-tender.The observation chart shows….Additional spirometry,CXR,ABG,cardiovascular examination.)putum sample,peak flow, 32 WHAT FINDING IS MOST LIKELY INA PATIENT WITH COPD? • A.Fine tremor • B.Hyper expansion/barrel chest • C.Oralcandidiasis • D. Heaves • E.Dullness on percussion B A. Fine tremor – beta 2 agonist overuse. Possible but unlikely C. due to inhaler steroid use, again possible but not the most likely D. Heaves – could develop due to COPD causing cor pulmonale E. Like to be pneumonia or a tumour 33 WHAT FINDING IS MOST LIKELY INA PATIENT WITH COPD? • A.Fine tremor • B.Hyper expansion/barrel chest • C.Oralcandidiasis • D. Heaves • E.Dullness on percussion B A. Fine tremor – beta 2 agonist overuse. Possible but unlikely C. due to inhaler steroid use, again possible but not the most likely D. Heaves – could develop due to COPD causing cor pulmonale E. Like to be pneumonia or a tumour 34 WHICH ONE OF THESE OPTIONS WOULD MOST LIKELY INDICATE A PLEURAL EFFUSION? • A.Stony dullness with increased vocal fremitus/resonance • B.Dullness with decreased vocal fremitus/resonance • C.Hyper resonance • D. Stony dullness with decreased vocal fremitus/resonance • E.Dullness with increased vocal fremitus/resonance A. Stony dullness would be coupled with decreased vocal fremitus/resonance B Dullness would be coupled with increased vocal fremitus/resonance C. hyper resonance in pneumothorax D. Correct answer E. This would happen in a consolidation such as pneumonia or tumour 35 WHICH ONE OF THESE OPTIONS WOULD MOST LIKELY INDICATE A PLEURAL EFFUSION? • A.Stony dullness with increased vocal fremitus/resonance • B.Dullness with decreased vocal fremitus/resonance • C.Hyper resonance • D. Stony dullness with decreased vocal fremitus/resonance • E.Dullness with increased vocal fremitus/resonance A. Stony dullness would be coupled with decreased vocal fremitus/resonance B Dullness would be coupled with increased vocal fremitus/resonance C. hyper resonance in pneumothorax D. Correct answer E. This would happen in a consolidation such as pneumonia or tumour 36 55Y/O M PRESENTSTO GP NOTICING HIS RIGHT EYE DROOPINGAND HE'S NOTICED HE'S NOT SWEATING ONTHE RIGHT SIDE. HE HAS ALSO BEEN GETTING INCREASINGLY SOB.WHAT ISTHE MOST LIKELY DIAGNOSIS? • A.COPD • B.Idiopathic pulmonary fibrosis • C.Pancoast tumour (apex of lung) • D. Pleural effusion • E.Mesothelioma A. no PMH mentioned, possible but doesn’t explain the eye and lack of sweat B. would likely hear inspiratory crackles on examination, likely to present with cough and weight loss C. correct answer D, wouldn’t explain other symptoms E. no history of asbestos use 37 55Y/O M PRESENTSTO GP NOTICING HIS RIGHT EYE DROOPINGAND HE'S NOTICED HE'S NOT SWEATING ONTHE RIGHT SIDE. HE HAS ALSO BEEN GETTING INCREASINGLY SOB.WHAT ISTHE MOST LIKELY DIAGNOSIS? • A.COPD • B.Idiopathic pulmonary fibrosis • C.Pancoast tumour (apex of lung) • D. Pleural effusion • E.Mesothelioma A. no PMH mentioned, possible but doesn’t explain the eye and lack of sweat B. would likely hear inspiratory crackles on examination, likely to present with cough and weight loss C. correct answer D, wouldn’t explain other symptoms E. no history of asbestos use 38 DIFFERENTIAL DIAGNOSIS FOR 72 -YEAR -OLD MAN WITH CHRONIC SOB.ON EXAMINATIONTHERE ISA DRY COUGHAND FINE END INSPIRATORY CRACKLES, THE REMAINDER OFTHE EXAMINATION IS NORMAL. Heart rate 82 Respiratory rate 17 Blood pressure 145/89 Saturations 94% Temperature 36.9 A. Asthma B. COPD C.Idiopathic pulmonary fibrosis D. Heart failure E. Community -acquired pneumonia C – fibrosis Fine crackles Asthma and COPD wouldn’t cause crackles HF and CAP would cause coarse crackles 39 DIFFERENTIAL DIAGNOSIS FOR 72 -YEAR -OLD MAN WITH CHRONIC SOB.ON EXAMINATIONTHERE ISA DRY COUGHAND FINE END INSPIRATORY CRACKLES, THE REMAINDER OFTHE EXAMINATION IS NORMAL. Heart rate 82 Respiratory rate 17 Blood pressure 145/89 Saturations 94% Temperature 36.9 A. Asthma B. COPD C.Idiopathic pulmonary fibrosis D. Heart failure E. Community -acquired pneumonia C – fibrosis Fine crackles Asthma and COPD wouldn’t cause crackles HF and CAP would cause coarse crackles 40WHAT SIGNSWOULD BE PRESENT? 41 WHAT SIGNSWOULD BE PRESENT? Hyperresonance on percussion Tracheal deviation to the right Lack of breath sounds on the left Breathlessness – increased RR,decreased sats Unequal expansion Left sided tension pneumothorax 42WHAT SIGNSWOULD BE PRESENT? 43 WHAT SIGNSWOULD BE PRESENT? Dullness to percussion on the left side Decreased vocal fremitus and resonance Lack of breath sounds Coarse crackles Breathlessness – increased Unequal expansion RR,decreased sats Left sided large pleural effusion 44 WHAT SIGNSWOULD BE PRESENT? Pneumonia LUL 45 WHAT SIGNSWOULD BE PRESENT? Bronchial breathing on SOB auscultation of left upper zone Cyanosis Coarse crackles (central/peripheral) Cervical lymphadenopathy Reduced breath sounds Reduced expansion Dullness to percuss on left tachycardia upper zone Pneumonia LUL 46 EXPLAININGA CONDITION • Explain a condition in simple terms • Introduce yourself • Build rapport (quick hx) • Ask why they’ve come in • Find out what they know about the condition • Discuss what you’ e going to talk about 47 EXPLAININGASTHMA Normal anatomy/physiology •body absorbs the oxygen in the air into our blood which gets used to give oxygen to cells which they need to work What is the disease • Asthma is a lon-germ condition where the smaller tubes narrow,this makes it more difficult to breathe hence why you can feel SOB, less oxygen gets absorbed in to blood, you breathe faster to try and compensate. It can be triggered by things like cold air, exercise and allergies Problems/complications • SOB, wheezing, acute asthma Management • Aim to have no symptoms.We will give you an inhaler which helps to relax and widen your breathing tubes,this will make it easier to breathe 48 INHALERTECHNIQUE • Test your inhaler • Shake the canister, remove the cap, press the canister down to check it works • Getting ready • Take the cap off, check nothing in mouthpiece, shake the inhaler then sit or stand up straight, tilt chin up • Breathe out until lungs empty then put lips around inhaler make a tight seal • Start to breathe in slowly and press canister once • Continue to breathe in slowly until your lungs feel full • Remove mouthpiece from your mouth, don’t breathe out, keep your lips closed, hold your breath for 10 seconds • https://oscestop.education/communication/inhaterhnique/ 49 PEAK FLOWTECHNIQUE • new mouth piece on the peak flow meter back to 0 and insert • Sit up straight and hold the meter at the sides (not obstructing the counter) • Take a deep breath all the way in • Wrap your mouth around the mouth piece making a tight seal • Blow out as hard and fast as you can • Make a note of the reading and repeat 2 more times • Take the best reading https://www.asthma.org.uk /advice/manage-your-asthma/peak-flow/ 50 RECOMMENDED RESOURCES • Geeky medics notes and videos • Respiratory exam: https://geekymedics.com/respiratory -examination -2/ • Oxygen delivery devices: https://oxfordmedicaleducation.com/prescribin-delivery/ • OSCE Stop • Respiratory exam: https://oscestop.com/Respiratory_exam.pdf 51 SOURCES https://geekymedics.com/respiratory -examination -2/ https://medschool.co/exam/resp We do not own any of the imagesthey have solely been used to demonstrate the conditions spoken about 52 FEEDBACK FORMS • We would be very grateful if you can fill out the feedback form (link in chat/ email from MedAll) • Slides and certificates of attendance will be made available on completion of the feedback form 53
