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Respiratory Examination

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Respiratory Examination Clinical Examination Guide Respiratory Examination Components of the examination • Introduction and general inspection • Hands • Neck • Face • Anterior Chest - close inspection, palpation, chest expansion, vocal fremitus/resonance, percussion, auscultation • Posterior Chest - close inspection, palpation, chest expansion, vocal fremitus/resonance, percussion, auscultation • Sacrum and Ankles • Conclusion Surface markings for Chest Examination • Each lung extends 3cm above the clavicle (apex) • Anterior borders of lungs are closest at the sternal angle – 2nd costal cartilage (cc) • Left: Moves away from the midline at the 4th cc • Right: Moves away from the midline at the 6th cc • Both cross the midclavicular line at the 8th cc • Both cross the midaxillary line at the 10th cc • Pleura have the same surface markings as the lungs but reach further down to the 12th cc Introduction • Introduce yourself, confirm patient ID • Explain examination and gain consent, position patient at 45o and expose chest. Ask if they are in any pain • Gel hands and clean stethoscope Document Owner: Clinical Skills/LK Last Updated: March 2018 General Inspection • General inspection: Overall condition / colour / shape of the chest, scars • Breathing: Observe if talking in full sentences / rate / pattern / noise / cough / pursed lips / use of accessory muscles / Arms forward in a tripod position splinting the chest / • Surroundings: Look for O2 masks / nasal prongs / walking aids / portable O2 tank / inhalers / nebuliser / cigarettes / nicotine replacements / sputum pot Hands • Inspect nails for clubbing - assess for loss of angle of the nail bed AND increased nail bed fluctuation. May be increased nail curvature and bulk of distal tissues in later stages. • Inspect skin for general colour and tar staining • Ask patient to extend arms and abduct fingers, assess for fine finger tremor associate with salbutamol use. • In suspected CO2 retention ask the patient to hold hands outstretched with wrists dorsiflexed for 30sec to assess for asterixis • Note any signs of recent ABGs test at the wrists • Assess pulse, respiratory rate, BP and O2 Saturation Course flapping tremor (asterixis) from CO2 retention in respiratory failure (caused by failure of parietal mechanisms to maintain posture, so there are many underlying causes). Neck • Examine for scars over trachea and larynx • Warn the patient before using index and ring finger • Palpate for enlarged cervical lymph nodes (see to palpate for tracheal deviation by putting index ENT examination guide) finger and ring fingers on sterno-clavicular joints • Ask patient to turn head to left whilst you look and use your middle finger to GENTLY assess if across the sternocleidomastoid for the JVP. If trachea is in the midline visible pulsation, measure the vertical distance from the manubriosternal angle. • To differentiate JVP from arterial pulse consider Suprasternal Notch the following: • JVP disappears when occluding venous return at Sternoclavicular Joints base of the neck • JVP is not palpable Tracheal Deviation: Pulled towards a fibrotic, collapsed, surgically removed lung, pushed away from tension pneumothorax, large pleural effusion Face • Inspect eyes for conjunctival pallor (anaemia), Horner’s Syndrome: miosis (small pupil), partial ptosis miosis and, ptosis (Horner’s syndrome) (drooping eyelid) and anhidroisis (reduced sweating) • Palpate face with back of your hand for anhidrosis ALL ON THE SAME SIDE OF FACE. It is a sign of (Horner’s syndrome) impaired sympathetic innervation to the face, which • Inspect under the tongue for central cyanosis may be caused by obstruction to the sympathetic chain at apex of the lung Page 2 of 4 Anterior Chest Inspection • Inspect for scars and shape e.g. barrel, pectus carinatum, pectus excavatum. “Barrel shaped” where anteroposterior diameter is greater than lateral diameter is associated with lung hyperinflation Kyphosis and scoliosis reduce ventilator capacity Pectus Carinatum (pigeon chest) – developmental deformity with prominent sternum and often indrawing of ribs causing horizontal grooves (Harrison sulci). Caused by hyperinflation at young age e.g. through longstanding, poorly controlled childhood asthma, but also in rickets and osteomalacia Pectus Excavatum (funnel chest) – developmental deformity with depression at bottom of the sternum. Normally minimal impact on ventilation, cosmetic only. • Inspect movement on breathing: look for symmetry of expansion, use of accessory muscles Accessory muscles: Sternocleidomastoid, Scalenus Anterior, Pectoralis Major and Minor, Serratus Anterior, Latissimus Dorsi (and others) Palpation • Palpate chest wall for tenderness • Assess for upper and lower rib cage expansion using both hands in bucket and pump handle positions. - Place hands bilaterally on upper chest either side of sternum. Ask patient to take deep breath in and observe the motion of your hands (pump handle) - Reposition hands firmly either side gripping lower rib cage with thumbs meeting in midline, but not touching patient’s chest. Ask patient to take deep breath in and observe the gap between your thumbs (bucket handle). In Pump Handle - lateral view as sternum goes in and out normal expansion, there will be a 5cm gap with movement of the 2-6 ribs at costovertebral joints between inspiration and expiration. Bucket Handle – anterior view as lower ribs go up and - Observe closely for bilateral expansion without down at the sides added signs (see later) Anatomical Images: Moore and Dalley, Clinically Orientated Anatomy 6e Vocal frematis / Vocal resonance • Assess tactile vocal fremitus with ulnar border of your hand. The feeling of resonance of the breath is a buzz on your hand which should be symmetrical. • Place lateral border, horizontally of your hand in the chest wall while the patient says “99” * with each move of your hand • Alternate each side of chest at the following levels: - 1 above clavicle - 2 above 4th IC (nipple in man) - 1 below 4th IC - 2 laterally Page 3 of 4 • Assess Vocal Resonance (Bronchophony) using the same approach of asking the patient “99” to repeat the sound “99”, auscultate with the diaphragm of the stethoscope across all areas of the chest bilaterally. • In a normal examination, you will hear muffled sounds in all areas It is not necessary to perform vocal resonance AND vocal fremitus. Percussion and Auscultation • Percuss the same areas as above, and in addition, percuss the clavicles directly. You are listening for the pitch, loudness and symmetry of the percussion note. • Auscultate the areas with the diaphragm of the stethoscope whilst asking the patient to breathe through their mouth each time you move the stethoscope. If you mirror this, you will not make them uncomfortable. You are listening for the quality and symmetry of the breath sounds. Posterior Chest With the patient sitting forward and hands brought into their chest • Inspect for scoliosis, scars • Palpate for tenderness • Check for upper and lower chest rib cage expansion as before. This is more difficult, but is assessing for lower lobe inflation Working systematically, alternating either side of these chest examine at the apices and 3 levels in lower lung fields for: • Tactile vocal frematis / vocal resonance • Percussion • Auscultation Sacrum and Ankles • Assess for sacral oedema at the base of the spine if the patient has been lying in bed, of ankle oedema if the patient is ambulatory. • To do this, firmly press the skin with your index finger and hold for 1-2 seconds. On removal of your finger, an indent on the patient’s skin suggests oedema. Conclusion • Thank the patient, ask them to get dressed, report/record findings • Consider cardiovascular examination and peak flow measurement Page 4 of 4 .
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