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Auscultation 4 Post-Acute COVID-19 Exercise & Rehabilitation (PACER) Project Cardiovascular and Pulmonary Examination By: Morgan Johanson, PT, MSPT, Board Certified Cardiovascular and Pulmonary Specialist Disclaimer • This course is intended for educational purposes and does not replace mentorship or consultation with more experienced cardiopulmonary colleagues. • This content is current at time of dissemination, however, realize that evidence and science on COVID19 is revolving rapidly and information is subject to change. Introduction and Disclosures • Morgan Johanson has no conflicts of interest or financial gains to disclose for this continuing education course • Course faculty: Morgan Johanson, PT, MSPT, Board Certified Cardiovascular and Pulmonary Specialist – President of Good Heart Education, a continuing education company providing live and online Cardiovascular and Pulmonary Therapy and Rehabilitation training and mentoring services for Physical Therapist studying for the ABPTS Cardiovascular and Pulmonary Specialty (CCS) Examination. – Adjunct Faculty Member, University of Toledo, Ohio – Practicing at Grand Traverse Pavilions SNF in Traverse City, MI – Professional Development Chair, CVP Section of the APTA Disclosures • Any pictures contained in the course that are not owned by Morgan Johanson were obtained via Google internet search engine and are references on the corresponding slide. Morgan Johanson does not claim ownership or rights to this material, it is being used for education purposes only and will not be reprinted or copied (so you will not see the pictures in your handout) Patient Interview • Relevant social history: smoking, alcohol, drug use, lifestyle, support mechanisms – COVID-19 patients – important to find out if they had cardiac involvement during the acute phase • Home environment assessment • Prior level of function • Occupational history • Home exercise program – Access to exercise equipment • Nutritional intake Specific Questions to Ask Patients with COVID-19 • Explain their disease course to date – Were they hospitalized, were they admitted to the ICU-for how long, were they intubated-for how long, what was total length of stay? • Did they have cardiovascular complications? • Did they have neurologic complications? • Do they feel SOB at rest or with activity? • If they are on supplemental O2, do they know their oxygen prescription? Is it different at rest versus during activity? (you will need to have this, usually in order sets for SNF/HH but OP may need to request this from MD, if you’re finding that their resting prescription doesn’t adequately cover them during activity you will need to request prescription to be updated from MD- do this as soon as possible) • What do they think their biggest deficit is? Systems Review • Cognitive Status • Cardiovascular and pulmonary system • Musculoskeletal system – Evidence shows patients with COVID-19 have weakness (might be UE>LE) • Neurologic system Patients• Integumentary with COVID system-19 who had prolonged ICU stay with or without intubation might have lingering cognitive deficits, important to screen for this! Cardiovascular and Pulmonary Chest Examination 4 components 1. Inspection/observation 2. Palpation 3. Auscultation 4. Mediate Percussion Inspection • General appearance • Facial expression • Evaluation of the neck • Evaluation of the chest wall – Resting and dynamic breathing pattern • Phonation and cough • Appearance of Extremities: clubbing, skin temperature, hair growth, edema Patient’s with COVID-19 who had prolonged hospitalization and were put in prone positioning, might have skin breakdown on their bony prominences, important to screen for this! General Appearance • Level of consciousness • Body type • Posture and Positioning • Skin tone • Equipment used in monitoring the patient Facial Expression • Work of breathing • Fatigue Anecdotal reports indicate that fatigue levels are high in patients with COVID-19 Image: UCSD Practical Guide to Clinical despite severity of Medicine disease Evaluation of the Neck • Jugular venous distention • Hypertrophy of accessory muscles • Prominent clavicles Images: EMSBasics.com Evaluation of the Chest Wall Symmetry • Kyphosis • Incisions • Scoliosis • Scar tissue Images: Mayoclinic.org Configuration • Congenital birth defects – Pectus excavatum – Pectus carinatum • Increased AP diameter (barrel shaped) Image: ResearchGate.net Resting and Dynamic Breathing Pattern • Inspiration: expiration ratio • Chest wall motion • Muscle recruitment – Inhalation: diaphragm and bilateral intercostals – Relaxed exhalation: none, relaxation of diaphragm and intercostals – Forced exhalation: abdominals • Abnormal breathing patterns Patients with COVID-19 will likely have tachypnea! Phonation and Cough • Phonation • Secretions • Cough: – Amount – 4 phases – Consistency • Inspiration – Color • Glottis closure – Odor • Compression phase – Frequency • Expulsion – Time of day **Mechanical ventilation can damage the epiglottis and/or vocal folds COVID-19 recommendations: do not assess cough in patients with possible or active COVID-19 infection as this will aerosolize the virus and could increase exposure to the PT! Appearance of Extremities • Peripheral edema • Digital clubbing • Cyanosis Image: medlibes.com Image: GrepMed.com Image: eMedicineHealth.com Color of Extremities •Hemisiderosis: venous stasis •Rubor: arterial insufficiency Image: Image: quizlet.com WoundCareAdvisor.com Palpation • Tracheal Position • Chest Motion • Diaphragm motion • Fremitus • Chest wall pain • Pulses Tracheal Deviation –Shifts caused by disproportionate intrathoracic pressures or lung volumes –Shifts toward affected side when pressure or volume is decreased •Lobectomy, pneumonectomy, atelectasis –Shifts toward unaffected side when pressure is increased •Pneumothorax, pleural effusion, tumor Image: NurseKey.com Chest Wall Motion • Performed segmentally to assess movement of upper, middle and lower lobes during resting and deep breathing • Assess symmetry, respiratory muscle recruitment, timing of movement, and amount of movement • Allow hands to move with the patient’s chest wall Image: Semanitcscholar.org Diaphragm Motion •Palpate the abdomen below xiphoid process •Measuring chest wall excursion –Circumferentially below xiphoid process –Circumferentially at axillary line –Normal excursion •2-3 inches (Hillegass) • 4-7 cm (Reddy) Images: Semanitcscholar.org Fremitus • Normal: vibration will be uniform throughout the chest wall – Patient repeats word “99” • Pronounced vibration produced by presence of secretions in the airways • Decreased vibration produced by presence of fluid in the airway Image: UCSD Practical Guide to Clinical Medicine Pulses • Assessment tool for arterial occlusion • Skin temperature can indicate tissue perfusion • Note quality and compare to the other side • Patients with diabetes and peripheral arterial disease can have diminished pulses Patient’s with COVID-19 and cardiac involvement, might have had arrhythmias Image: Medical during their hospitalization, are they still Dictionary –The Free at rest or with activity? Dictionary.com Auscultation •Technique –Optimally done with patient in sitting position –Listen to breath sounds over bare skin –Anterior to posterior, superior to inferior and from right to left sides of the chest (listen for asymmetry) –At least 1 breath cycle over each bronchopulmonary segment –Have the patient breathe in and out through the mouth –First listen with quiet respiration, if breath sound is diminished or absent and cue the patient to take a deep breath Breath Sounds • 2 types – Normal • Bronchial • Bronchovesicular • Vesicular – Adventitious • Continuous – high pitched (Wheezes ) – low pitched (Rhonchi) – Stridor Image: Quizlet.com • Discontinuous (Crackles ) • Pleural Rub Auscultation Findings in COVID-19 • Mild disease – Clear breath sounds – As disease progresses might hear fine crackles and bronchial breath sounds • Severe disease – Coarse crackles and diffuse rhonchi YouTube. Sounds of Coronavirus (COVID 19) – Lung Sounds. https://www.youtube.com/watch?v=3Kkp6ZM35As Voice Transmission Tests • Egophony –Patient says “E” out loud –Positive finding = sound auscultated is “A” • Bronchophony –Patient says “99” out loud –Positive finding = sound heard very loudly via auscultation • Whispering pectoriloquy –Patient whispers –Positive finding = whispered words are heard clearly via auscultation Egophony may be present in Image: UCSD Practical Guide to Clinical patients with COVID-19 over the Medicine areas of consolidation in the lungs! Auscultation of the Heart • 5 areas where heart sounds are heard best – Aortic – Right 2nd intercostal space – Pulmonic – Left 2nd intercostal space – Erb’s Point- Left 3rd intercostal space – Tricuspid – Left 4th intercostal space – Mitral – Left 5th intercostal space Image: MedicalStudy.com Heart Sounds • Determine rate and rhythm • Normal – S1 and S2 • Abnormal – S3 and S4 (Gallops) Images: UCSD Practical Guide to Clinical Medicine Splits • S1 • S2 Image: Stanford Medicine25.Stanford.edu Pericardial Rub • Rubbing sound due to friction of the visceral and parietal layers of pericardium • Sounds like a creak with the normal heart sounds in the background • Occurs due to pericarditis and cardiac tamponade (fluid accumulation around the heart) Murmurs • Types – Systolic – Diastolic • Causes (acronym: spasm) – Stenosis – Partial obstruction – Aneurysm – Mitral Valve regurgitation Mediate Percussion • Place your finger on the intercostal space and tap on it with your other
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