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 .