Resp Flashcards
What does SOB indicate (resp)?
signs may include nasal flaring, pursed lips, use of accessory muscles, intercostal muscle recession and the tripod position (sitting or standing leaning forward and supporting the upper body with hands on knees or other surfaces).
Possible underlying diagnoses in an OSCE could include asthma, pulmonary oedema, pulmonary fibrosis, lung cancer and COPD. The inability to speak in full sentences is an indicator of significant shortness of breath
Cough indications
productive cough: pneumonia, bronchiectasis, COPD and CF.
dry cough may: asthma or interstitial lung disease
Wheeze indications
a continuous, coarse, whistling sound produced in the respiratory airways during breathing. Wheeze is often associated with asthma, COPD and bronchiectasis.
Stridor indications
high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways.
Stridor has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic)
Oedema indications (resp)
typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites) and is often associated with right ventricular failure. Pulmonary oedema often occurs secondary to left ventricular failure
Cachexia indications
ongoing muscle loss that is not entirely reversed with nutritional supplementation. Cachexia is commonly associated with underlying malignancy (e.g. lung cancer) and other end-stage respiratory diseases (e.g. COPD).
Medical paraphernalia of resp disease
Oxygen delivery devices: note the type of oxygen device (e.g. Venturi mask, non-rebreathing mask, nasal cannulae) and the current flow rate of oxygen (e.g. 2L, 4L, 10L, 15L). Look for other forms of respiratory support such as CPAP or BiPAP.
Sputum pot: note the volume and colour of the contents (e.g. COPD/bronchiectasis).
Other medical equipment: ECG leads, medications (e.g. inhalers/nebulisers in asthma/COPD), catheters (note volume/colour of urine) and intravenous access.
Cigarettes or vaping equipment: smoking is a significant risk factor for lung cancer and chronic lung disease (e.g. COPD).
Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time.
Fluid balance: fluid balance charts will give an indication of the patient’s current fluid status which may be relevant if a patient appears fluid overloaded or dehydrated.
Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications
Tar staining of hands (resp)
caused by smoking, a significant risk factor for respiratory disease (e.g. COPD, lung cancer)
Skin changes in hands
bruising and thinning of the skin can be associated with long-term steroid use (e.g. asthma, COPD, interstitial lung disease)
Joint swelling or deformity
may be associated with rheumatoid arthritis which has several extra-articular manifestations that affect the respiratory system (e.g. pleural effusions/pulmonary fibrosis)
Resp causes of finger clubbing
lung cancer
ILD
CF
bronchiectasis
Fine tremor
Ask the patient to hold out their hands in an outstretched position and observe for a fine tremor which is typically associated with beta-2-agonist use (e.g. salbutamol).
Asterixis (flapping tremor)
= type of negative myoclonus characterised by irregular lapses of posture causing a flapping motion of the hands.
most likely underlying cause is CO2 retention in conditions that result in type 2 respiratory failure (e.g. COPD). Other causes of asterixis include uraemia and hepatic encephalopathy
Hand temperature
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion.
Excessively warm and sweaty hands can be associated with CO2 retention
Pulse abnormalities
Bounding pulse: can be associated with underlying CO2 retention (e.g. type 2 respiratory failure).
Pulsus paradoxus: pulse wave volume decreases significantly during the inspiratory phase. This is a late sign of cardiac tamponade, severe acute asthma and severe exacerbations of COPD (therefore it is unlikely to be relevant to most OSCE scenarios)
Resp rate abnormalities
In healthy adults, the respiratory rate should be between 12-20 breaths per minute.
A respiratory rate of fewer than 12 breaths per minute is referred to as bradypnoea (e.g. opiate overdose).
A respiratory rate of more than 20 breaths per minute is referred to as tachypnoea (e.g. acute asthma)
Plethoric complexion
a congested red-faced appearance associated with polycythaemia (e.g. COPD) and CO2 retention (e.g. type 2 respiratory failure).
Horner’s syndrome
Ptosis, miosis, enophthalmos, anhydrosis
when sympathetic trunk is damaged by pathology eg. pancoast tumour affecting lung apex
Oral candidiasis
a fungal infection commonly associated with steroid inhaler use (due to local immunosuppression). It is characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa
Axillary thoracotomy scar
between the posterior border of the pectoralis major and anterior border of latissimus dorsi muscles, through the 4th or 5th intercostal space.
used for the insertion of chest drains
Posterolateral thoracotomy scar
between the scapula and mid-spinal line, extending laterally to the anterior axillary line.
used for lobectomy, pneumonectomy and oesophageal surgery.
Radiotherapy-associated skin changes
may be present in patients who have been treated for lung cancer. Clinical features can include xerosis (dry skin), scale, hyperkeratosis (thickened skin), depigmentation and telangiectasia.
Asymmetrical chest
pneumonectomy (lung cancer)
thoracoplasty (TB)
Barrel chest
= hyperexpansion
chest wall appears wider and taller than normal
chronic lung disease ie asthma or COPD
Causes of tracheal deviation
The trachea deviates away from tension pneumothorax and large pleural effusions.
The trachea deviates towards lobar collapse and pneumonectomy.
Palpation of the trachea can be uncomfortable, so warn the patient and apply a gentle technique
Cricosternal distance
= distance between inferior border of cricoid cartilage and suprasternal notch
healthy: 3-4 fingers (of patient)
distance fewer than 3 fingers = lung hyperinflation (asthma, COPD)
Displaced apex beat in resp exam
Right ventricular hypertrophy (e.g. pulmonary hypertension, COPD, interstitial lung disease)
Large pleural effusion
Tension pneumothorax
Causes of reduced chest expansion
Symmetrical: pulmonary fibrosis reduces lung elasticity, restricting overall chest expansion.
Asymmetrical: pneumothorax, pneumonia and pleural effusion would all cause ipsilateral reduced chest expansion.
Areas to percuss
Supraclavicular region: lung apices
Infraclavicular region
Chest wall: percuss over 3-4 locations bilaterally
Axilla
Types of percussion note
Resonant: a normal finding
Dullness: suggests increased tissue density (e.g. cardiac dullness, consolidation, tumour, lobar collapse).
Stony dullness: typically caused by an underlying pleural effusion.
Hyper-resonance: the opposite of dullness, suggestive of decreased tissue density (e.g. pneumothorax).
Abnormal tactile vocal fremitus
Increased vibration over an area suggests increased tissue density (e.g. consolidation, tumour, lobar collapse).
Decreased vibration over an area suggests the presence of fluid or air outside of the lung (e.g. pleural effusion, pneumothorax)
Breath sounds
Vesicular: the normal quality of breath sounds in healthy individuals.
Bronchial: harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal and there is a pause between. This type of breath sound is associated with consolidation
Quiet breath sounds: suggest reduced air entry into that region of the lung (e.g pleural effusion, pneumothorax).
When presenting your findings, state ‘reduced breath sounds’, rather than ‘reduced air entry’
Added breath sounds
Wheeze: a continuous, coarse, whistling sound produced in the respiratory airways during breathing. Wheeze is often associated with asthma, COPD and bronchiectasis.
Stridor: a high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways. Stridor has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic).
Coarse crackles: discontinuous, brief, popping lung sounds typically associated with pneumonia, bronchiectasis and pulmonary oedema.
Fine end-inspiratory crackles: often described as sounding similar to the noise generated when separating velcro. Fine end-inspiratory crackles are associated with pulmonary fibrosis.
Resp causes of lymphadenopathy
Lung cancer with metastases
Tuberculosis
Sarcoidosis
Final steps in resp exam
(lymph nodes)
Sacral and pedal oedema (CHF)
DVT (e.g. swelling, increased temperature, erythema, visible superficial veins) as the patient may have shortness of breath secondary to pulmonary embolism.
Erythema nodosum (sarcoid)
To complete resp exam
Take full history
?cardio/abdo exam
Check oxygen saturation (SpO2) and provide supplemental oxygen if indicated.
Check other vital signs including temperature and blood pressure.
Take a sputum sample.
Perform peak flow assessment if relevant (e.g. asthma)
Request a chest X-ray (if abnormalities were noted on examination)
Take an arterial blood gas if indicated (also see ABG interpretation)
Perform a full cardiovascular examination if indicated (e.g. cor pulmonale)
