Respiratory Examination

Introduction

• Wash hands

• Introduce yourself

• Confirm patient details – name / DOB

• Explain the examination

• Gain consent

• Ask the patient to sit at 45 degrees

• Adequate exposure

• Chaperone ??

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General inspection

• Treatments: Oxygen, Inhalers, Nebulisers, sputum pots

• Breathlessness

• Scars

• Chest Wall – abnormalities or asymmetry

• Cachexia – thin patient with muscle wasting (malignancy, CF, COPD)

• Cough – Productive (bronchiectasis/COPD if older, CF if younger) or dry (Asthma if younger, ILD if older)

• Wheeze – Asthma, COPD, bronchiectasis

• Stridor – Upper Airway Obstruction

• Use of accessory muscles

• Pain or discomfort

Cachexia

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Hands

• Tar staining on fingers (or nicotine patches on body)- smoker – increased risk of COPD / lung cancer

• Clubbing – lung cancer / interstitial lung disease / bronchiectasis

• Koilonychia - Anaemia

• Peripheral cyanosis – bluish discolouration of nails – O2 saturation <85%

• Assess temperature– ↓ temperature suggests peripheral vasoconstriction / poor perfusion

• Fine tremor– can be a side effect of beta 2 agonist use (e.g. salbutamol)

• Flapping tremor– CO2 retention – type 2 respiratory failure – e.g. COPD

• Palpate pulse– rate and rhythm and Assess respiratory rate– normal adult range = 12-20 breaths per minute

Clubbing

Koilonychia

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Head/Neck

• Conjunctival pallor - ask patient to lower an eyelid to allow inspection – anaemia is associated with pallor

• Sclera of eyes

• Horner’s syndrome – ptosis / constricted pupil (miosis)

• Mouth – oral candida from inhaler

• Signs of dehydration

• Central cyanosis

• Odour

• JVP - a raised JVP may indicate pulmonary hypertension /

• fluid overload

• Feel the lymph and cervical nodes – Tender – infection, non-tender - malignancy

Lymph nodes to check:

• Anterior and posterior triangles

• Supraclavicular region

• Axillary region

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Thorax

Ask patient to remove top

Inspection

• Scars

• Skin changes – may indicate recent or previous radiotherapy – erythema / thickened skin

• Asymmetry – major surgery:

• Pneumonectomy (usually for cancer)

• Thoracoplasty (rib removed / previously used to treat tuberculosis)

• Deformities – barrel chest (COPD) / pectus excavatum and carinatum

• Accessory breathing

• Rashes

Palpation

• Tracheal Position “I’m going to feel for your windpipe”

1. A difference in the amount of space between the sides suggests deviation

2. The trachea deviates away from pneumothorax and large pleural effusions

3. The trachea deviates towards lobar collapse and pneumonectomy 

4. Palpation of the trachea can be uncomfortable, so warn the patient and apply a gentle technique

• Apex Beat – mediastinal shift --> 5th intercostal space, mid-clavicular line

• Chest expansion - Reduced --> lung collapse/pneumonia

Percussion (comparing side to side)

• Supraclavicular (lung apices)

• Infraclavicular

• Chest wall (3-4 locations bilaterally)

• Axilla

Types of percussion note

• Resonant– this is a normal finding

• Dullness– this suggests increased tissue density – consolidation / fluid / tumour / collapse

• Stony dullness– this suggests the presence of a pleural effusion

• Hyper-resonance– the opposite of dullness, suggestive of decreased tissue density – e.g. pneumothorax

Auscultation

Ask the patient to take deep breaths in and out through their mouth.

• 4-6 on front

• 2-4 on side

• 8-10 on back

Vocal resonance:

• Ask patient to say “99” repeatedly and auscultate the chest again

• Increased volume over an area suggests increased tissue density (especially if there is a dull percussion note over the same area) – consolidation / tumour / lobar collapse

• Decreased volume over an area (especially if there is an associated dull percussion note) suggests fluid outside of the lung (pleural effusion)

Tactile Fremitus:

• Ask the person to say “99” - vibration increased over solid tissue

Accessory muscles

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Assess the posterior chest

• Repeat inspection, chest expansion, percussion and auscultation on the posterior aspect of the chest.

• Spend more time assessing the posterior aspect of the chest as this is where you are likely to find clinical signs.

• Examine the sacrum for oedema (fluid overload in cor pulmonale)

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Examine the legs

• Pitting oedema (fluid overload in cor pulmonale)

• Assess the calves for signs of deep vein thrombosis

• Inspect for evidence of erythema nodosum (associated with sarcoidosis)

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Further assessments and investigations

• Check oxygen saturation

• Provide supplementary oxygen if indicated

• Perform peak flow assessment (if asthmatic)

• PFT’s

• Request a chest x-ray – if abnormalities were noted on examination

• Take an arterial blood gas if indicated (See ABG analysis)

• Perform a full cardiovascular examination if indicated

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Added Sounds

Wheeze

• Localised narrowing within the airway

• Usually in expiration

Stridor

• Large airway narrowing = harsh sounds

• Occurs in inspiration and expiration

Coarse crackles

• Fluid or secretions in large bronchi

• Cleared or altered by coughing

• Pneumonia

Fine crackles

• Forceful opening of closed airways

• Chronic bronchitis and bronchiectasis

• Cardiac failure, fibrosis and pneumonia

Pleural rub

• Creaking noise = inflamed surfaces rubbing together

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Questions:

1. Give three causes of chronic cough

2. What colour sputum would suggest an infective cause?

3. What are 3 respiratory causes of clubbing?

4. Give 2 features of a severe asthma attack

5. Give a respiratory related cause of Horners syndrome

6. Give 2 causes of tracheal deviation

7. Name 2 conditions which would cause fine crackles

8. What are the 2 main categories of pleural effusion?

9. What are the accessory muscles of breathing?

10. Describe the percussion note/breath sounds/vocal resonance in pneumonia

11. What is a flapping tremor? What is the respiratory significance?

12. Give 4 causes of haemoptysis