27-10-22 – Examination of the Respiratory System Flashcards
Learning outcomes
- To demonstrate an understanding of the process of respiratory examination
- To detect signs of respiratory pathology on clinical examination
- To relate clinical signs to underlying pathology
- Use history & examination findings to direct appropriate treatment / investigations
What are the 5 (6) steps of the respiratory examination?
- 5 (6) Steps of the respiratory examination:
1) Introduction & explanation
2) Inspection
3) Palpation
4) Percussion (a new skill for respiratory)
5) Auscultation
6) (+/- tactile vocal fremitus and vocal resonance)
What are the 8 steps in the introduction of the respiratory examination?
- 8 steps in the introduction of the respiratory examination:
1) Ensure adequate hygiene of hands/stethoscope
2) Introduce self
3) Confirm patient’s name and DOB
4) Ask patient if in any discomfort
5) Explain the procedure
6) Seek permission to examine the respiratory system - consent
7) Position patient appropriately (at 45 degrees) with chest adequately exposed
8) Ensure the patient has privacy
What 6 things do we ask/do during general inspection?
- Things do we ask/do during general inspection:
1) Does the patient look unwell? Cachectic (weakness and wasting of the body due to severe chronic illness)? In pain?
2) Use of accessory muscles / work of breathing?
3) Look around the patient
* Do they have methods of administering medication, such as a nebuliser or inhaler?
* Nebulisers breaks down medication down into smaller inhalable particles
4) Look at the patient
* Can check for erythema nodosum
5) Listen (audible stridor, hoarseness, pattern of speech – can patient talk in complete sentences?)
6) If any pathological signs, think:
* What is the underlying cause?
* How does this relate to history?
* Does it increase the likelihood of respiratory pathology?
What is erythema nodosum?
What is it caused by?
What is stridor? When can it be heard? What does it indicate?
- Erythema nodosum is inflammation of fat under skin causing raised red tender lumps that are painful with pressure
- Caused by streptococcal infections
- Stridor is a loud, harsh, high pitched respiratory sound
- It can usually be heard on inspiration
- Stridor is indicative of an upper airway obstruction
What are the first 3 stages of close inspection and palpation?
What 7 things are we looking for when examining the hands?
What 4 things might we also measure when counting respiratory rate?
What 3 things are we checking for when inspecting face, eyes, mouth, and pharynx?
- First 3 stages of close inspection and palpation:
1) Examine hands
* Inspect and palpate for:
* Warmth
* Venodilation
* Flapping tremor
* Fine tremor
* Nail clubbing
* Tar staining
* Radial pulse (assess rate and rhythm)
2) Count respiratory rate
* At this point, can also check:
* Oxygen saturation with pulse oximeter (normal is 95-100, but those with COPD can walk around with less than this, but for young people, hypoxia can be significant)
* Pulse
* Temperature (pyrexia is >38 degrees and can indicate infection)
* Would also measure blood pressure here
3) Inspect face, eyes, mouth, and pharynx
* Checking for:
* Central cyanosis – blue discolouration of body and mucous membranes
* ‘Ruddy’ complexion polycythaemia – elevated haemoglobin that causes red skin, especially in the face, hands, and feet
* Horner’s syndrome – eye drooping, pupillary constriction, and lack of sweating on affected side
What are 5 different respiratory causes of clubbing?
- 5 different respiratory causes of clubbing:
1) Bronchial carcinoma - Bronchogenic carcinoma is any type or subtype of lung cancer
2) Mesothelioma - lung cancer caused by asbestos exposure
3) Chronic suppurative lung disease - a range of lung diseases characterised by chronic productive cough, compromised airway clearance and poor long-term health:
- Bronchiectasis - widening of bronchioles
- Lung abscess - liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection
- Empyema - air sacs in the lungs (alveoli) are damaged
4) Pulmonary Fibrosis
5) Cystic Fibrosis
What is the cause of ‘Ruddy’ complexion polycythaemia?
What does it present with?
What is Horner’s syndrome caused by?
How can this damage be caused?
What are 3 clinical features of Horner’s syndrome?
What might Horner’s syndrome indicate?
- ‘Ruddy’ complexion polycythaemia is caused by elevated haemoglobin levels as body tries to compensate for hypoxia
- Causes red skin, especially in the face, hands, and feet
- Horner’s syndrome is caused by damage to sympathetic trunk or Stellate ganglion (C7-T1)
- This damage can be caused by a Pancoast tumour, which is a tumour at the apex of the lungs
- 3 clinical features of Horner’s syndrome:
1) Unilateral miosis – constricted pupil on affected side
2) Partial ptosis – drooping for the eye lid
3) Loss of sweating on same side (facial anhidrosis) - Horner’s syndrome indicate may indicate serious pathology
What is a fine tremor?
How prevalent are they?
What 2 things can cause a fine tremor?
How do we check for a flapping tremor (asterixis)?
What 3 things can flapping tremors be associated with?
- Fine tremors are barely noticeable
- Fine tremors can be quite common, and can be benign
- 2 things can cause a fine tremor:
1) Alcohol
2) Excessive B-agonist use e.g from inhalers - To test for a flapping tremor (asterixis), we ask the patient to hold hands outstretched and cock their wrists back
- This will lead to a jerky, flapping tremor
- 3 things flapping tremor can be associated with:
1) Severe ventilatory failure with CO2 retention
2) Liver disease
3) Confusion
What 5 things do we look at during close inspection of chest / neck?
- 5 things we look at during close inspection of chest / neck:
1) Scars
* Cardiac surgery, thoracotomy, chest drain scars
2) Pattern of breathing
3) Shape of chest
* Symmetry
* Deformity (kyphoscoliosis / pectus excavatum) – could affect lung expansion/capacity
* Increase in A-P (anterior-posterior) diameter (‘barrel shaped’)
4) Prominent veins on chest wall
* Can indicated SVC obstruction
* Distended, obvious veins across the chest can be associated with malignancy, as tumour growth presses on SVC
5) Jugular venous pulse
* Visibility can indicate increased venous pressure on the right side
What 5 steps are part of the palpation of the neck and chest?
- Steps are part of the palpation of the neck and chest:
1) Palpation of face/neck lymph nodes
2) Palpation of chest for Subcutaneous (‘surgical’) emphysema (if appropriate)
3) Palpate for rib fractures if appropriate (e.g. history of chest trauma)
4) Mediastinal positioning (trachea position, apex beat, assess for right ventricular heave)
5) Assessment/palpation of chest expansion
Palpation of the neck and chest.
What do we palpate first in palpation of the neck and chest?
How do we examine the lymph nodes?
How is the patient sat during this?
What order do we palpate the lymph nodes of the face/neck (6)?
- During palpation of the neck and chest, we first palpate the lymph nodes
- When examining the lymph nodes, we have to examine carefully, systematically and not rush the examination
- During this, the patient is sat forwards
- Order of lymph node palpation in the face/neck:
1) Pre-auricular
2) Posterior auricular
3) Submandibular
4) Submental
5) Cervical chain
6) Occipital
How do we palpate for subcutaneous (‘surgical’) emphysema?
What may be present with subcutaneous emphysema?
What does subcutaneous emphysema indicate?
What 3 things might cause subcutaneous emphysema?
What do we palpate for next?
- To palpate for subcutaneous (‘surgical’) emphysema, we can touch the overlying skin, which will make a crackling sound (like rice krispies) if surgical emphysema is present
- With subcutaneous emphysema, there may also be diffuse chest, neck, and face swelling
- Subcutaneous emphysema indicates that there is air in the subcutaneous tissues
- 3 things that might cause subcutaneous emphysema:
1) Trauma
2) Surgical trauma
3) Underlying pneumothorax - We then palpate for rib fractures if appropriate (e.g. history of chest trauma)
What 3 things do we assess during assessment of mediastinal positioning?
- 3 things we assess during assessment of mediastinal positioning:
1) Tracheal position
* Suprasternal notch
* Right middle finger 2cm superior to notch
* Gently press down and back
* Palpate space to either side
* Should be central
2) Cardiac apex (apex beat)
* 5th intercostal space
3) Assess for right ventricular heave
* Place arm perpendicular to the chest and see how high it is raised
* Excessive raising indicates right ventricular hypertrophy
What 3 conditions cause displacement of trachea towards the lesion?
What 2 conditions cause displacement of trachea away from the lesion?
What 1 condition causes other displacement of the trachea?
What is the difference between a tension and non-tension pneumothorax?
Which one is a life-threatening emergency?
- 3 conditions cause displacement of trachea towards the lesion (decreased pressure can pull trachea towards):
1) Lobar collapse
2) Pneumonectomy
* a type of surgery to remove one of your lungs because of cancer, trauma, or some other condition
3) Pulmonary fibrosis
- 2 conditions cause displacement of trachea away from the lesion (increased pressure can push trachea away):
1) Large pleura effusion
* Build-up of excess fluid between the layers of the pleura outside the lungs
* Called ‘water on lungs’
2) Tension pneumothorax
- 1 condition causes other displacement of the trachea:
1) Mediastinal masses
- In a Tension pneumothorax, air can only move in and not out (1-way valve), leading to an increase in pressure, causing lung collapse
- In a non-tension pneumothorax, air can move in and out
- Tension pneumothoraxes are a life-threatening emergency; presents with severe symptoms/signs of respiratory distress
How do we assess chest expansion?
How do we assess this posteriorly?
Ideally, what are we looking to happen during this test?
- Chest expansion can be assessed by placing our hands across the patient and watching how far apart our thumbs move as the patient takes a deep breath
- Posteriorly, chest expansion should be assessed when the patient is sitting up
- During this test, we want to see unilateral chest expansion, with our thumbs moving away an equal distance on each side
How do we percuss?
What 4 areas do we percuss on different sides?
What structures make a:
* Resonant percussion note (1)
* Hyper resonant percussion note (3)
* Dull percussion note (3)
* ‘Stony’ or very dull percussion note (2)
What do we do if there is a dull percussive note when there shouldn’t be?
- To percuss we apply the left hand firmly to patient’s chest, and strike it’s middle phalanx with the middle finger of right hand
- Areas we percuss on both sides (left, right, anterior, posterior):
1) Supraclavicular areas
2) Onto clavicle directly
3) Anterior, posterior, and lateral chest
4) Intercostal spaces - We listen to the notes produced and compare the different sides
- We can percuss the lung through intercostal spaces, which should be resonant, since they are filled with air
- When we press directly over the clavicle/heart/liver, it won’t resonate, and instead will make a dull sound
- Structures that make a:
1) Resonant percussion note (1)
* Normal lung
2) Hyper resonant percussion note (3)
* Emphysema
* Pneumothorax
* Large bullae
* A bulla is defined as an air space in the lung measuring more than one centimetre in diameter in the distended state.
* The term giant bulla is used for bullae that occupy at least 30 percent of a hemithorax
3) Dull percussion note (3)
* Collapse
* Consolidation
* Fibrosis
4) ‘Stony’ or very dull percussion note (2)
* Pleural effusion
* Haemothorax – collection of blood in pleural cavity
- if there is a dull percussive note when there shouldn’t be, we need to check tactile vocal fremitus now or vocal resonance after auscultation – see end
When do we use tactile vocal fremitus?
What are the 3 steps of tactile vocal fremitus?
What are 2 reasons for increased fremitus?
What are 3 reasons for decreased fremitus?
- If there is a dull percussive note when there shouldn’t be, we need to check tactile vocal fremitus now or vocal resonance after auscultation – see end
- 3 steps of tactile vocal fremitus:
1) Use palm / ulnar border of hand through different intercostal spaces
2) Get patient to say “99”
3) Feel for vibration - different conditions of the lung will alter the vibration felt - 2 reasons for increased fremitus:
1) Consolidation
2) Fibrosis - 3 reasons for decreased fremitus:
1) Pleural effusion
2) Pneumothorax
3) Collapse
Where can vesicular breath sounds be heard?
What 4 ways do vesicular (normal) breath sounds present?
- Vesicular breath sounds be sound over most of both of the lungs
- 4 ways vesicular (normal) breath sounds present:
1) Intensity of sounds relates to airflow
2) Inspiration longer than expiration
3) Low pitched, quiet, heard over most of lung fields
4) No gap between inspiration and expiration (however, there is after expiration)
When do bronchial breath sounds (abnormal) occur?
Where do they originate from?
Where can they be heart?
What are 3 characteristics of bronchial breath sounds?
What are 2 situations when bronchial breath sounds occur?
- Bronchial breath sounds (abnormal) occur when there is damage to small airways/alveoli
- They originate from the larger airways
- Bronchial breath sounds can be heard over the manubrium (and similar sounds can be heard over trachea, as it’s a large airway, but this isn’t part of the examination)
- 3 characteristics of bronchial breath sounds:
1) Harsh in nature
2) Gap between inspiration and expiration
3) Expiratory component dominates (normally meant to be inspiration dominating) - Bronchial breath sounds can due to consolidation – when alveoli and small airways fill with dense material (e.g. with pneumonia, infection on top of pleural effusion) or fibrosis
What can if often be easier to do regarding examination of different sides?
What are 4 other tests we may run in other areas?
What should we try do with our findings?
- It can often be easier to do the full exam for one side, then do all of it for the other side, so we aren’t constantly switching back and forth
- 4 other tests we may run in other areas:
1) Ankle oedema
2) Sputum pot (sputum sample)
3) Peak flow
* Peak flow is a simple measurement of how quickly you can blow air out of your lungs.
* It’s often used to help diagnose and monitor asthma
4) Spirometry
* Spirometry is the most common of the pulmonary function tests.
* It measures lung function, specifically the amount and/or speed of air that can be inhaled and exhaled
- Try to make sense of findings – if mucky green sputum and fever is there an infective cause, for example pneumonia, leading onto signs of consolidation?
