Examination of the respiratory system

Question 1

Learning outcomes

Answer 1

 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

Question 2

Discuss the basic structure of the examination of the resp system

Answer 2

– Introduction & explanation
– Inspection
– Palpation
– Percussion (a new skill for respiratory) – Auscultation

Question 3

Discuss the general inspection part of the examination of the resp system

Answer 3

 Does the patient look unwell? Cachectic? In pain?
 Use of accessory muscles / work of breathing
 Look around the patient
 Look at the patient
 Listen (audible stridor, hoarseness, pattern of speech)
 If any pathological signs, think:
– What is the underlying cause?
– How does this relate to history?
– Does it increase the likelihood of respiratory pathology?

Question 4

What is stridor

Answer 4

 Stridor

• Loud, harsh, high pitched respiratory sound - Usually on inspiration
• Upper airway obstruction

Question 5

Discuss Close Inspection and Palpation in examination of the resp system

Answer 5

•
Close Inspection and Palpation
Examine hands - inspect
palpate for warmth and venodilation
flapping tremor and fine tremor palpate radial pulse (rate and rhythm)
Count respiratory rate
Inspect face, eyes, mouth and pharynx

Question 6

What are the resp causes of clubbing?

Answer 6

 Bronchial carcinoma
 Mesothelioma
 Chronic suppurative lung disease:
– Bronchiectasis 
– Lung abscess 
– Empyema
 Pulmonary Fibrosis
 Cystic Fibrosis

Question 7

Discuss Horner’s syndrome

Answer 7

 Damage to cervical sympathetic nerves

 Clinicalfeatures
– Unilateral miosis
– Partial ptosis
– Loss of sweating on same side (facial anhidrosis)

 May indicate serious pathology

Question 8

Discuss tremors of the hands

Answer 8

 Fine tremor
– Excessive use of B-agonists

 Flapping tremor
– Severe ventilatory failure with CO2 retention
– Hold hands outstretched
– Wrists cocked-back
– Look for a jerky, flapping tremor – Associated confusion

Question 9

Discuss close inspection of the chest/neck in examination of the resp system

Answer 9

 Scars – cardiac surgery, thoracotomy, chest drain scars
 Pattern of breathing
 Shape of chest
– Symmetry
– Deformity (kyphoscoliosis / pectus excavatum) – Increase in A-P diameter (‘barrel shaped’)
 Prominent veins on chest wall – SVC obstruction
 JVP

Question 10

Discuss the palpation of the neck and chest in examination of the resp system

Answer 10

 Lymphnodes
– Examine carefully
For cervical lymphadenopathy
– Be systematic
– Don’t rush
- With patient sat forwards

Question 11

Discuss palpation of the chest in examination of the resp system

Answer 11

 Subcutaneous(‘surgical’)emphysema(ifappropriate)
– Crackling sensation
– Air in subcutaneous tissues
– May be diffuse chest, neck, face swelling
- Consider trauma / underlying pneumothorax (“a collection of air in the pleural cavity, between lung and chest wall, resulting in collapse of lung on affected side”)
 Palpate for rib fractures if appropriate (e.g. history of chest trauma)

Question 12

Discuss palpation of the NECK + chest in examination of the resp system

Answer 12

 Mediastinal position
– Tracheal position
 Suprasternal notch
 Rightmiddlefinger2cm superior to notch
 Gentlypressdownand back
 Palpatespacetoeither side
 Shouldbecentral
– Cardiac apex (apex beat)
- Assess for right ventricular heave

 Chestexpansion
– Anterior and posterior
(posterior when sitting forwards)
– Ask patient to breathe deeply
– Thumbs should move apart equally

Question 13

Discuss percussion

Answer 13

 Anterior, posterior and lateral chest
 Use middle finger / left hand
 Apply firmly to patient’s chest
 Strike it’s middle phalanx with
the middle finger of right hand
 Percuss over intercostal spaces
 However percuss clavicles directly
 Compare left and right
 Listen to note produced

Question 14

Discuss tactile vocal fremitus

Answer 14

 Usepalm/ulnarborderofhand
 Say“99”
 Feelforvibration
 Increasedfremitus-consolidationorfibrosis
 Decreasedfremitus-pleuraleffusion,pneumothoraxorcollapse

Question 15

Discuss auscultation

Answer 15

 Use bell or diaphragm of stethoscope (usually bell apices and diaphragm rest)
 Ask patient to breathe deeply in and out through mouth
 Listen through full inspiration and full expiration
 Compare side to side – anterior, posterior and lateral (similar to percussion sites)
 Listen for breath sounds and added sounds

Whilst listening ask yourself:
• Are breath sounds present?
• Are they vesicular in nature?
• Are breath sounds equal on both sides?
• Are there any bronchial breath sounds?
• Are there any added sounds such as crackles, wheezes or
pleural rubs?

Question 16

Discuss breath sounds in auscultation

Answer 16

 Normal = Vesicular

• Intensityofsoundsrelatestoairflow
• Inspiration longer than expiration
• Low pitched, quiet, heard over most of lung fields
• No gap between inspiration and expiration (however is after expiration)

Diminished vesicular breath sounds
• Whennormallungdisplacedbyair, e.g:
 Obesity
 Pleural effusion
 Pneumothorax*
 Collapse
 Hyperinflation – emphysema - in COPD
*Pneumothorax can be primary spontaneous in healthy people (typically young men); secondary associated with underlying lung disease, traumatic or iatrogenic

 Bronchial breath sounds (abnormal)
 Noise originates from larger airways
 When damage to small airways / alveoli
 Harsh in nature
 Gap between inspiration and expiration
 Expiratory component dominates
 Find in consolidation – when alveoli and small airways fill with dense material (e.g. with pneumonia, infection on top of pleural effusion) or fibrosis

Question 17

Discuss crackles in auscultation

Answer 17

 Crackles (formerly known as rales or crepitations)
 High-pitched, discontinuous sounds
 Similar to the sound produced by rubbing your hair between your
fingers
 Causes:
Pulmonary oedema / pulmonary fibrosis / bronchial secretions / COPD / pneumonia / lung abscess / TB / bronchiolitis / bronchiectasis
 Fine late crackles feature of Cryptogenic Fibrosing Alveolitis

Question 18

Discuss pleural rub in auscultation

Answer 18

• Pleuralrub
 May be associated with pleuritic pain (sharp on inspiration / coughing)
 Like “creaking leather”
 Low pitched
 Causes:
PE / pneumonia / vasculitis

Question 19

Discuss wheeze in auscultation

Answer 19

 Wheeze
 Continuous oscillation of opposing airway walls  Musical quality, high pitch
 Implies airway (small) narrowing
 Louder in expiration
 Causes
Generalised – Asthma / COPD Localised – lung tumour
N.B ‘Silent chest’ in severe airways obstruction

Question 20

Discuss vocal resonance

Answer 20

 If area of dullness on percussion (i.e. not in the “normal”)
 Either tactile vocal fremitus or vocal resonance – no need to do both
 Use stethoscope, ask patient to say “one, one, one”
 Compare with the other side. Assess quality and amplitude
 Ask patient to whisper “one, one, one”. Whispering is not heard over a normal lung but in consolidation the sound is transmitted.
 Increased resonance consolidation or fibrosis
 Decreased resonance pleural effusion, pneumothorax or collapse (i.e. can interpret as per tactile vocal fremitus)

Question 21

Discuss tertiary areas to consider in examination of the resp system

Answer 21

 Ankleoedema
 Sputumpot
 Observation chart – Pulse, BP, Temp, Oxygen saturation
 Peakflow
 Spirometry
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?