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Respiratory Examination Scheme

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Respiratory Examination 1. General inspection (end of the bed!) Patient - colour (cyanosis) and appearance - smokers face - conscious level – carbon dioxide retention and narcosis - ? accessory muscle use - dyspnoeic, gasping for breath, sitting forward to support respiration - ? cachexia - Audible breath sounds such as wheeze or stridor - Ask patient to cough – type? Around the bed - oxygen mask etc. - nebuliser or inhalers - monitoring - cigarettes - sputum pot – mucoid, purulent, pink/frothy, haemoptysis? 2. Hands - Clubbing (Bronchial carcinoma, chronic suppurative lung disease – bronchiectasis, lung abscess, empyema; pulmonary fibrosis; cryptogenic organising pneumonia; pleural and mediastinal tumours) - Peripheral cyanosis - Tar staining - Small muscle wasting - (rheumatoid hands) - Wrist tenderness – hypertrophic pulmonary osteoarthropathy - ASTERIXIS (respiratory/renal/hepatic failure) 3. Radial pulse and respiratory rhythm - Radial pulse rate and character – e.g. bounding pulse of carbon dioxide retention - Respiratory rate (12-14) ° Increased - pneumonia, anxiety, metabolic acidosis, pleuritic pain (shallow breathing) ° Decreased – narcotic overdose, hypoventilation associated with cerebral or respiratory disease - Respiratory rhythm ° Cheyne-Stokes – deeper successive breaths until maximum is attained when apnoea occurs and cycle repeats 4. Blood Pressure - Presence of arterial paradox - >15mmHg decrease in systolic pressure on inspiration. Associated with severe airway obstruction such as acute asthma 5. Face and eyes - Polycythaemic facies - Conjunctival anaemia - Horners syndrome signs, e.g. ptosis, myosis, anhydrosis - Hoarseness of voice (RLN) 6. Mouth - Central cyanosis 7. JVP - Non palpable, two waves, upper height determined, obliterated by gentle pressure, hepatojugular reflux - Height ° Increased • Heart failure/cor-pulmonale – congestion • Pulmonary embolus • Pericardial effusion • Pulmonary embolus • Tension pneumothorax • SVC obstruction – tumour (non pulsatile) ° Decreased • Hypovolaemia 8. Neck palpation - Trachea central (distance to each sternocleidomastoid) ° Pulled – collapsed lung, fibrosis ° Pushed – pleural effusion, pneumothorax - Cricosternal distance - Tracheal tug - Cervical lymphadenopathy examination 9. Chest Inspection - Chest shape ° Kyphosis ° Scoliosis ° Pectus excavatum ° Pectus carinatum ° Barrel shaped (COPD) - Chest movements – symmetrical. Diminished movement on one side indicates disease on that side - Intercostal recession – in-drawing of intercostals and tracheal tug on inspiration indicates airway obstruction and non-compliant lung - Accessory muscles use – neck muscles - Scars – thoracotomy scar, old TB surgery scars - Dilated veins - Visible masses - Radiation marks 10. Apex beat - Position of apex beat assessed as an indicator of mediastinal shift. - RV heave palpated as indicator of potential cor-pulmonale 11. Chest Palpation - Chest expansion assessment – should be in excess of 5cm at level of nipple ° Reduced: consolidation, effusion, pneumonectomy, lobe collapse, pneumothorax - Assess symmetry of expansion - Tactile vocal fremitus (if indicated) ° Increased – consolidated lung ° Diminished – air, fluid or thickened pleura separates lung from chest wall 12. Chest Percussion - Percuss at several levels including in the axilla and clavicles (compare like with like) ° Resonant – normal lung ° Dull – solid lung (consolidation) or pleural thickening ° Stony dull – fluid (pleural effusion) ° Hyper-resonant – hyperinflated lung such as emphysema or pneumothorax 13. Auscultation (breathing with mouth open) - Breath sounds ° Vesicular breathing – less harsh, attenuated low frequencies, inspiratory and expiratory phases continuous ° Bronchial breathing (consolidation and upper level of pleural effusion) – harsh, gap between inspiratory and expiratory phases ° Diminished – thickened pleura, air or fluid separates lung from chest wall - Vocal resonance – enhanced over consolidated lung - Whispering pectoriloquy – soft whisper only heard through consolidated lung 14. Auscultation: added sounds - Crackles Inspiratory sounds of airways opening. Coarser the crackle the larger the obstructed airway, and later in inspiration the more distal the obstruction. ° Pulmonary oedema – fine ° Pulmonary fibrosis – fine, late ° Pneumonic consolidation ° Bronchiectasis – coarse and biphasic ° Chronic bronchitis - Wheeze Vibration of airway wall as air passes an airway narrowed to the point of closure. Lower the pitch, the larger the airway ° High pitched polyphonic – multiple distal airways as in asthma ° Low pitched monophonic – single larger airway e.g. tumour, foreign body - Stridor Monophonic inspiratory wheeze from a narrowed airway out of the thorax – usually trachea - Pleural rub ? inflamed pleural surfaces rubbing – but can be heard with effusion 15. Posterior chest – as above, including: - Inspection - ?scars, ?deformity - Palpation - ? sacral oedema 16. Abdomen - Palpation ° hepatomegaly or splenomegaly as signs of right heart failure ° metastasic disease 17. Legs - Inspection ° Swelling ° Cyanosis ° Toe clubbing - Palpation ° ? pitting ankle oedema 18. Additional tests - Basic observations: Blood pressure, temperature, respiratory rate - Oxygen saturation - Peak expiratory flow rate - Arterial blood gas - Sputum pot examination .
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    Respiratory Examination Intro (WIIPPPPE) o Wash your hands o Introduce yourself o Identity of patient – confirm o Permission (consent and explain examination) o Pain? o Position at 45° o Privacy o Expose chest fully General Inspection o Surroundings . Monitoring: pulse oximeter ECG monitoring . Treatments: oxygen therapy (method of delivery, rate, SATs, humidified, venturi) Inhalers Blue (reliever, short-acting B2 agonist e.g. salbutamol) Brown (preventer, corticosteroids e.g. beclometasone) Spiriva (tiotropium bromide, COPD patients) Nebulisers (driven by oxygen?) NIV IV infusions Chest drains Creon (capsules for CF patients with exocrine pancreatic insufficiency) . Paraphernalia: Ensures food and drink sputum pots Cigarettes/ nicotine patches/ gum o Patient . Well or unwell? . Alert and orientated or drowsy and confused? . Comfortable at rest or in pain? . Body habitus? Cachectic or obese? . Signs of respiratory distress: Dyspnoea/ tachypnoea Tripod posture Use of accessory muscles Pursed lip breathing Flared nostrils, intercostal/ subcostal recession, tracheal tug (children) . Chest shape . Breathing pattern . Added breath sounds? Stridor, audible wheeze? . Colour? Pale and shocked or peripherally cyanosed? . Obvious scars o Ask patient to cough . Listen to nature of cough – dry or productive? Hands o Inspect . Clubbing – perform Shamoroth’s window test and consider respiratory causes: Abscess of lung Bronchiectasis Cancer of the lung (not SCLC)/ Cystic fibrosis Empyema Fibrosis . Cigarette tar staining (not nicotine!) . Peripheral cyanosis . Wasting of small muscles of hand Especially dorsal interossei and thenar eminence Can be caused by a C8/T1 lesion e.g. Pancoast’s tumour . Hand signs of rheumatological conditions or steroid use o Palpate: . Pulse . RR Normally 12-16 breaths per minute Component of CURB-65 .