Examination of the Respiratory System Flashcards
Outline the basic structure of a respiratory examination
- Introduction and explanation
- Inspection
- Palpatation
- Percussion
- Auscultation
What should you look for during a general inspection?
- 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, hoarsness, pattern of speach)
- 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 would be used in more serious conditions a nebuliser or an inhaler?
A nebuliser
What is stridor?
- Loud, harsh, high pitched respiratory sound
- Usually on inspiration
- Upper airway obstruction
What is erythema nodosum?
Swollen areas of fat under skin. Typically on shins. Red/purple discolouration.
Associated with pneumonia, sarcoid, tb and IBS.
What should you do upon close inspection and palpatation?
- Examine hands - inspect
palpate for warmth and venodilation, flapping tremour and fine tremour, palpate radial pulse (rate and rhythm) - Count respiratory rate
- Inspect face, eyes, mouth and pharynx
Where can you see central cyanosis?
- Lips
- Tongue
What are the respiratory causes of clubbing?
- Bronchial carcinoma
- Mesothelioma
- Chronic suppurative lung disease
Bronchiectasis
Lung abcess
Empyema - Pulmonary fibrosis
- Cystic fibrosis
What is mesothelioma?
Cancer of the lining of the lungs (often linked to asbestos exposure)
What does a ‘ruddy’ complexion
Acutely low oxygen (due to increased levels of haemoglobin.
What is high haemoglobin called?
Polycythaemia
What are the clinical features of horner’s syndrome?
- Unilateral miosis
- Partial ptosis
- Loss of sweating on same side (facial anhidrosis)
What does a fine tremor indicate?
Excessive use of B-agonists
What is a flapping tremor?
- Severe ventilatory failure with CO2 retention
- Hold hands outstreched
- Wrists cocked-back
- Look for a jerky, flapping tremor
- Associated confusion
What should you look at when inspecting the chest and neck closely?
- Scars - cardiac surgery, thoracotomy, chest drain scars
- Pattern of breathing
- Shape of chest
Symmetry
Deformity (kyphoscliosis / pectus excavatum)
Increase in A-P diameter (‘barrel shaped’) - Prominant veins on chest wall (SVC obstruction)
- JVP
What is pectus excavatum?
Structural deformity of the anterior thoracic wall in which the sternum and rib cage are shaped abnormally. This produces a caved-in or sunken appearance of the chest.
Affects lung function
What can SVC obstruction appear like?
Visible vein distribution on chest
What are the lymph nodes which need to be palpated during the respiratory examination?
- Postauricular
- Preauricular
- Occipital
- Periparotid
- Tonsillar
- Posterior cervical
- Supraclavicular
- Submental
- Anterior cervical
- Submandibular
What should you look for when palpating the chest?
- Subcutaneous (‘surgical’) emphysema (if appropriate)
- Palpate for rib fractures if appropriate (e.g history of chest trauma)
What is subcutaneous emphysema?
- Air in subcutaneous tissues
- Crackiling sensation under skin
- May be diffuse chest, neck, face swelling
- Consider trauma / pneumothorax
What is pneumothorax?
A collection of air in the pleural cavity, between lung and chest wall, resulting in collapse of lung on affected side.
What should be palpated/checked on the neck and chest?
- Tracheal position
- Cardiac apex
- Assessment for right ventricular heave
How should the trachea be palpated?
- On suprasternal notch
- Right middle finger 2cm superior to notch
- Gently press down and back
- Palpate spce to either side
- Should be central
What conditions result in displacement of the trachea towards the lesion?
- Lobar collapse
- Pneumonectomy
- Pulmonary fibrosis
What conditions result in displacement of the trachea away from the lesion?
- Large pleural effusion
- Tension pneumothorax
When palpating the chest how can you tell the lungs are expanding equally?
The thumbs should move apart equally
How should you percuss the chest?
- Percuss 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
What does a resonant note indicate when percussing the chest?
Air / normal lung
What does a dull sound indicate when percussing the chest?
- Collapse
- Consolidation
- Fibrosis
(liquid or solid)
What does a hyper resonant sound indicate when percussing the chest?
- Emphysema
- Large bullae
- Pneumothorax
What does a ‘stoney’ or very dull percussion note indicate?
Pleural effusion or haemothorax
What is tactile vocal fremitus?
- Vibration felt on the patient’s chest during low frequency vocalization.
- Done using palm / ulnar border of the hand
- Say ‘99/11’ / low frq noise
What does increased fremitus indicate?
- Consolidation or fibrosis
What does decreased fremitus indicate?
- Pleural effusion, pneumothorax or collapse
What does auscultation involcve in a respiratory examination?
- Use bell or diaphragm
- 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
What questions should you ask whilst listening to the chest?
- Are any 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?
What should normal vesicular breath sounds sound like?
- Inspiration longer and expiration
- Low pitched, quiet, heard over most of lung fields
- No gap between inspiration and expiration
What can cause diminished vesicular breath sounds?
- When lung is displaced by air e.g: Obesity Pleural effusion Pneumothorax Collapse Hyperinflation - emphysema - in COPD
What are bronchial breath sounds (abnormal)?
- Noise which 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 pneumonia, infection on top of pleural effusion) or fibrosis
What can fine late crackles indicate?
Cryptogenic fibrosing alveolitis
What can cause crackles?
- Pulmonary oedema
- Pulmonary fibrosis
- Bronchial secretions
- COPD
- Pneumonia
- Lung abcess
- TB
- Bronchiolitis
- Bronchiectasis
What does pleural rub sound like?
low pitched, like ‘creaking leather’
What can cause pleural rub?
- PE
- Pneumonia
- Vasculitis
May be associated with pleuritic pain (sharp on inspiration / coughing)
What can cause ‘wheeze’?
- Continous oscillation of opposing airway walls
- Implies airway (small) narrowing
- Generalised caused by asthma and COPD
- Localised is caused by a lung tumour.
What does a ‘wheeze’ sound like?
- Musical quality, high pitched
- Louder in expiration
What is the difference between tactile vocal resonance and tactile vocal fremitus?
- Fremitus - feeling vibrations with hands
- Resonance - listening with stethoscope
Where should you examine lymph nodes from?
The back
What additional areas can you look at at the end of the respiratory exam
- Ankle oedema
- Sputum pot
- Observation chart - pulse, BP, Temp, O2 saturation
- Peak flow
- Spirometry
What can a spirometer be useful for diagnosing?
Confiriming COPD or diagnosing asthma
What information about the patient do you need to consider when assessing the peak flow?
Age and height
