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
- 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