Structured examination of the Respiratory System
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This is the structured approach to a full examination of the respiratory system as would be expected in an OSCE
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Structured examination of the Respiratory System
- 1. Respiratory Examination Jonathan Downham Advanced Nurse Practitioner 2008 www.criticalcarepractitioner.co.uk
- 4. Respiratory Examination • Physical Examination – Initial impression – Audible cough – Sputum sample – Wheeze – Stridor – Hoarseness – Dyspnoea – TPR www.criticalcarepractitioner.co.uk
- 5. Respiratory Examination • Hands and Pulse – Perfusion – Peripheral cyanosis – Tremor – Flap • CO2 retention – Finger clubbing • Pulmonary hypertension, interstitial lung disease, lung cancer – Pulse www.criticalcarepractitioner.co.uk
- 6. Respiratory Examination • Face and Neck – Central cyanosis – Neck veins – Lymphadenopathy – Trachea – Crepitus – Neck muscles – Pursed lips www.criticalcarepractitioner.co.uk
- 8. Respiratory Examination • The Chest – Inspection – Palpation – Percussion – Auscultation www.criticalcarepractitioner.co.uk
- 9. Respiratory Examination • Inspection – Shape – Scars – Lesions – Resp rate – Resp depth – Abnormal respiratory movements – Asymmetry of movement www.criticalcarepractitioner.co.uk
- 10. Respiratory Examination Pectus carinatum Pectus excavatum May prevent complete expiration of air from the lungs and thus may restrict air exchange considerably. Base lung capacity is decreased Chest wall www.criticalcarepractitioner.co.uk
- 11. Respiratory Examination • Chest expansion www.criticalcarepractitioner.co.uk
- 13. Respiratory Examination • Percussion – Illicit resonance • Tactile vocal fremitis – Compare both sides – Map out abnormal area www.criticalcarepractitioner.co.uk
- 14. Respiratory Examination 2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx producing hammer effect Entire movement comes from wrist www.criticalcarepractitioner.co.uk
- 16. Respiratory Examination Percussion Impaired(dull)resonance obtained – – Aerated lung tissue is separated from the chest wall e.g. fluid, pleural thickening – Lung tissue is airless e.g. consolidation, collapse, fibrosis “stony dullness”- pleural effusion Hyperresonance - pneumothorax www.criticalcarepractitioner.co.uk
- 17. Respiratory Examination • Auscultation technique – Diaphragm of stethoscope – Mouth open – Breathing deeply and fairly rapidly – Systematic approach over several areas, comparing both sides – Repeat asking patient to say “9,9,9” for vocal resonance – Whispering pectoriloquy • A whispering pectoriloquy is the increase in vocal resonance, to the extent that when a patient whispers, his voice may be heard clearly with a stethoscope on his chest over an area of lung consolidation. www.criticalcarepractitioner.co.uk
- 18. Respiratory Examination • Auscultation – Breath sounds – Added sounds – Vocal sounds (vocal resonance) www.criticalcarepractitioner.co.uk Basic Lung Sounds:http://www.stethographics.com/main/physiology_ls_introduction.html
- 19. Respiratory Examination • Vesicular breath sounds – Vibrations of the vocal cords caused by turbulent flow through the larynx – Transmitted along trachea, bronchi to chest wall – Rustling quality – Inspiration continuous with expiration – Intensity increases during inspiration & fades rapidly during first 1/3rd expiration Jonathan Downham 2010 Basic Lung Sounds:http://www.stethographics.com/main/physiology_ls_introduction.html http://www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm
- 20. Respiratory Examination • Bronchial breathing – “blowing” inspiratory & expiratory sounds – Expiratory phase as long as inspiration – Distinct pause between phases – High-pitched e.g. consolidation – Low-pitched e.g. fibrosis www.criticalcarepractitioner.co.uk Basic Lung Sounds:http://www.stethographics.com/main/physiology_ls_introduction.html
- 21. Respiratory Examination Diminished breath sounds Conduction limited by – Airflow limitation e.g. diffusely – asthma, emphysema localised – tumour, collapse – Something separating chest wall from lung e.g. effusion, fibrosis www.criticalcarepractitioner.co.uk
- 22. Respiratory Examination • Added sounds – Wheeze – Crepitations (crackles) – Pleural sounds www.criticalcarepractitioner.co.uk
- 23. Respiratory Examination • Wheeze – Due to passage of air through narrowed bronchus e.g. bronchospasm, mucosal oedema – Musical quality – High or low pitched – Usually expiratory – Expiration prolonged www.criticalcarepractitioner.co.uk
- 24. Respiratory Examination • Crepitations/crepitations – Inspiratory noises, usually 2nd half – Non-musical – Due to explosive reopening of peripheral small airways during inspiration which have become occluded during expiration www.criticalcarepractitioner.co.uk
- 25. Respiratory Examination www.criticalcarepractitioner.co.uk Abnormal Sound Description Condition Crackles (rales) Short, discrete, popping or crackling sounds Pulmonary oedema Pneumonia Atelectasis Bronchiectasis Wheezes High pitched, squeaking, whistling sounds. Asthma Bronchospasm Pleural friction rub Creaking, leathery, loud, dry, course sounds Pleurisy Pleural effusion
- 26. Respiratory Examination • Pleural Rub – Creaking noise – Movement of visceral pleura over parietal pleura – Surfaces roughened by exudate – 2 separate phases at end inspiration and early expiration www.criticalcarepractitioner.co.uk
- 27. Respiratory Examination • Vocal sounds – Vocal resonance – Increased when voice sounds are louder and more distinct e.g. consolidation – Reduced when transmission impeded e.g. effusion, collapse www.criticalcarepractitioner.co.uk Basic Lung Sounds:http://www.stethographics.com/main/physiology_ls_introduction.html
- 28. Respiratory Examination • Information from auscultation – Type and amplitude of breath sounds – Type of added sounds and their location – Quality and amplitude of conducted sounds www.criticalcarepractitioner.co.uk
- 29. Respiratory Examination • Other physical signs – Peak flow – Oedema – Pulsatile liver Jonathan Downham 2010
- 30. Respiratory Examination • Interpretation of findings – Breath sounds locally reduced or absent over pleural effusion, thickened pleura, collapsed area – Breath sounds diffusely reduced in emphysema, asthma – Rhonchi heard in asthma, COPD – Crepitations may be widespread in COPD, LVF – Crepitations localised in area of consolidation – Pleural rub in pleurisy www.criticalcarepractitioner.co.uk Basic Lung Sounds:http://www.stethographics.com/main/physiology_ls_introduction.html
- 31. Respiratory Examination Pleural effusion • reduced tactile vocal fremitus • reduced chest expansion • stony dull • reduced air entry • no added sounds • reduced vocal resonance Consolidation • increased tactile vocal fremitus • reduced expansion • dull percussion • bronchial breathing • coarse creps • increased vocal resonance • whispering pectoriloquy Interpretation of findings www.criticalcarepractitioner.co.uk
- 32. Interpretation of findings Pneumothorax • deviated trachea • reduced tactile vocal fremitus • hyper-resonance • reduced air entry • reduced vocal resonance Collapse • deviated trachea • reduced tactile vocal fremitus • dull percussion • reduced air entry • +/- creps www.criticalcarepractitioner.co.uk
- 33. Respiratory Examination • Summary of examination – Note patients appearance and demeanour – Observe rate and pattern – Examine the hands – Measure the BP – Examine neck/JVP – Inspect chest – Trachea and apex beat – Percuss front and back – Auscultate front and back www.criticalcarepractitioner.co.uk
- 34. Respiratory Examination • Common Problems- Asthma. – Baseline control • Usual exercise tolerance • Frequency of attacks • Best Peak expiratory flow rate • Usual precipitating factors • Medication • Usual response to therapy • Previous hospital/ITU admissions • Symptoms suggestive of poor baseline control www.criticalcarepractitioner.co.uk
- 35. Respiratory Examination • Common Problems – Asthma – Drug History • Do they have a nebuliser at home? • Do they use a bronchodilator? • Do they take theophylline or aminophylline? (bronchodilators). • Do they take steroids? • Are they on medication which aggravates the symptoms... Beta blockers, aspirin. • Demonstrate inhaler technique. www.criticalcarepractitioner.co.uk
- 36. Respiratory Examination • Common Problems – Chronic Obstructive Pulmonary Disease (COPD) – Detailed history • Time course • Treatment given and effects • Any hospital admissions in the last year • Baseline function • Chronically deteriorating exercise tolerance. • Quantify normal amounts of sputum www.criticalcarepractitioner.co.uk
- 37. Respiratory Examination • Common Problems – Chronic Obstructive Pulmonary Disease (COPD) – Past Medical History – Drug History – Social History – Review of systems. www.criticalcarepractitioner.co.uk
- 38. Respiratory Examination • Common Problems – Chest Infection – History • Cough • Sputum Production • Dyspnoea • Wheeze • Pleuritic chest pain • Fever. – Drug History. www.criticalcarepractitioner.co.uk
Editor's Notes
- Initial impression Audible cough Sputum sample Wheeze Stridor Hoarseness Dyspnoea TPR
- Perfusion Warm, cool, clammy? Peripheral cyanosis If cyanosed check for central cyanosis. Tremor Could be caused by nebuliser therapy Flap CO2 retention Finger clubbing Pulmonary hypertension, interstitial lung disease, lung cancer Pulse
- Central cyanosis In patients with a normal Hb central cyanosis occurs with sats less than 90% Neck veins Maybe distended/check JVP Lymphadenopathy Feel for nodes in neck....will be covered later. Trachea Is it central Crepitus Surgical emphysema Neck muscles Use of accessory muscles Pursed lips
- Place two fingers on either side of the trachea and judge the distance between the fingers and the sternomastoid tendons.
- Shape Barrel chest, pectus carinatum (pigeon chest), pectus excavatum (funnel chest). ON NEXT SLIDE Scars Lesions Resp rate Resp depth Abnormal respiratory movements Pursed lips, accessory muscles, abdominal etc. Asymmetry of movement Previous tb causing upper lobe fibrosis, kyphoscoliosis
- Primary objective is to assess symmetry Place hands around lateral chest wall Approximate thumbs in the midline NOT RESTING ON THE CHEST Ask patient to take a deep breath Observe displacement of thumbs from the midline.
- Illicit resonance Tactile vocal fremitis Place the hand on the chest wall and ask the patient to make a resonant sound e.g. Say ‘ninety nine’ Increased over areas of consolidation Decreased over areas of effusion or pneumothorax VERY HARD TO JUDGE Compare both sides Map out abnormal area
- Place your left hand on patients chest with fingers slightly separated Press the middle finger of your left hand firmly against the chest, aligned with the underlying ribs over the area to be percussed. Strike the centre of the middle phalanx of your left middle finger with the tip of your right middle finger, using a loose swinging movement of the wrist and not the forearm. Remove the percussing finger
- Wheeze Due to passage of air through narrowed bronchus e.g. bronchospasm, mucosal oedema causing continuous oscillation of opposing airway walls. Musical quality High or low pitched Usually expiratory Tend to be louder on expiration because airways normally dilate during inspiration and narrow on expiration Expiration prolonged Important to distinguish between wheeze and stridor which is heard on inspiration.
- Crepitations Inspiratory noises, usually 2nd half Non-musical Due to explosive reopening of peripheral small airways during inspiration which have become occluded during expiration
- Inhaler Technique Scoring Prepares Device (e.g. Shakes inhaler) 1 Exhales fully 1 activates and inhales 1 holds breath for several seconds 1
- Common Problems – Chronic Obstructive Pulmonary Disease (COPD) Detailed history In an acute exacerbation patients usually present following a cold with deterioration of dyspnoea in association with a productive cough and discoloured sputum. Time course Treatment given and effects Any hospital admissions in the last year Baseline function How far can you walk? Can you climb one flight of stairs easily? Chronic bronchitis History of cough, productive of sputum on most days, for 3 consecutive months, for at least 2 years. Emphysema is a pathological diagnosis of dilatation and destruction of the lungs distal to the terminal bronchioles
- Past Medical History Previous admissions to hospital with acute exacerbations of COPD Other smoking related illnesses (ischeamic heart disease, peripheral vascular disease, strokes, hypertension) Other causes of lung disease (occupational exposure to dust, previous TB) Asthma Drug History Bronchodilators Home oxygen Who initiated and on what evidence How many hours per day is it being used LTOT should be used for greater than 15 hours per day and its aim is to prevent cor pulmonale Caused by increase in blood pressure in the pulmonary artery which leads to enlargement and subsequent failure of the right side of the heart. Theophyliine.. Have levels been measured Steroids Inhaler technique Social History Consider all aspects of daily living Need to stop smoking!!
- Cough Duration, productive or dry Sputum Production Quantity, colour, recent changes Dyspnoea Quantitative account of exercise tolerance at baseline and during the illness Wheeze Pleuritic chest pain Common feature of pneumonia- be aware of pulmonary embolus Fever. If symptoms are prolonged , recurrent or associated with weight loss consider the possibility of an underlying malignancy especially if they are a smoker.