Respiratory

Question 1

What makes up a respiratory examination

Answer 1

General inspection & closer observation of hands
Checking respiratory rate
Assess position of trachea
Palpate apex beat
Percussion
Auscultation
Vocal resonance

Question 2

General inspection of Pts body

Answer 2

Any chest deformity or scars?

Cyanosis: bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).

Shortness of breath: signs may include nasal flaring, pursed lips. Asthma, lung cancer and COPD. The inability to speak in full sentences is an indicator of significant shortness of breath.

Cough: a productive cough can be associated with several respiratory pathologies including pneumonia, bronchiectasis, COPD and CF. A dry cough may suggest a diagnosis of asthma or interstitial lung disease.

Wheeze: a continuous, coarse, whistling sound produced in the respiratory airways during breathing. Wheeze is often associated with asthma, COPD and bronchiectasis.

Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage/chronic disease) or poor perfusion (e.g. congestive cardiac failure). It should be noted that healthy individuals may have a pale complexion that mimics pallor.

Oedema: 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.

Conjunctival pallor: suggestive of underlying anaemia. Ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva.

Question 3

Hands

Answer 3

Colour: cyanosis of the hands may suggest underlying hypoxaemia.

Tar staining: caused by smoking, a significant risk factor for respiratory disease (e.g. COPD, lung cancer).

Skin changes: 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).

Finger clubbing - lung cancer, interstitial lung disease, cystic fibrosis and bronchiectasis.

Temp - Cool hands may suggest poor peripheral perfusion. Excessively warm and sweaty hands can be associated with CO2 retention.

Question 4

Chest wall deformities

Answer 4

Asymmetry

Pectus excavatum

Pectus carinatum

Hyperexpansion (a.k.a. ‘barrel chest’)

Question 5

Asymmetry

Answer 5

Typically associated with pneumonectomy (e.g. lung cancer) and thoracoplasty (e.g. tuberculosis).

Question 6

Pectus excavatum

Answer 6

A caved-in or sunken appearance of the chest.

Question 7

Pectus carinatum

Answer 7

Protrusion of the sternum and ribs.

Question 8

Hyperexpansion (a.k.a. ‘barrel chest’):

Answer 8

Chest wall appears wider and taller than normal. Associated with chronic lung diseases such as asthma and COPD.

Question 9

Respiratory rate:

Answer 9

Whilst still palpating the radial pulse (but no longer counting it), assess the patient’s respiratory rate (palpation of the radial pulse at this stage purely to avoid making the patient aware you are directly observing their breathing, as this can itself alter the respiratory rate).

Note any asymmetries in the expiratory and inspiratory phases of respiration (e.g. the expiratory phase is often prolonged in asthma exacerbations and in patients with COPD).

Question 10

Normal respiratory rate

Answer 10

In healthy adults, the respiratory rate should be between 12-20 breaths per minute.

Question 11

Abnormal respiratory rate

Answer 11

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).

Question 12

Assess position of trachea

Answer 12

Ensure patient’s neck musculature is relaxed by asking them to position their chin slightly downwards.
Dip your index finger into the thorax beside the trachea.
Gently apply side pressure to locate the border of the trachea.
Compare this space to the other side of the trachea using the same process.

Question 13

Why assess position of trachea

Answer 13

A difference in the amount of space between the sides suggests the presence of tracheal deviation
Should be central in healthy individuals
The trachea deviates away from tension pneumothorax and large pleural effusions.
The trachea deviates towards lobar collapse and pneumonectomy.

Question 14

Assess Chest expansion

Answer 14

Place your hands on the patient’s chest, inferior to the nipples.
Wrap your fingers around either side of the chest.
Bring your thumbs together in the midline, so that they touch.
Ask the patient to take a deep breath in.
Observe the movement of your thumbs (in healthy individuals they should move symmetrically upwards/outwards during inspiration and symmetrically downwards/inwards during expiration).

Question 15

Abnormal chest expansion

Answer 15

Reduced movement of one of your thumbs indicates reduced chest expansion on that side.

Symmetrical - pulmonary fibrosis reduces lung elasticity, restricting overall chest expansion.
Asymmetrical - pneumothorax, pneumonia and pleural effusion would all cause ipsilateral reduced chest expansion.

Question 16

Percussion

Answer 16

Place your non-dominant hand on the patient’s chest wall.
Position your middle finger over the area you want to percuss, firmly pressed against the chest wall.
With your dominant hand’s middle finger, strike the middle phalanx of your non-dominant hand’s middle finger using a swinging movement of the wrist.
The striking finger should be removed quickly, otherwise, you may muffle the resulting percussion note.

Question 17

Where to percuss

Answer 17

Supraclavicular region: lung apices, Infraclavicular region, Chest wall: percuss over 3-4 locations bilaterally, Axilla

Question 18

Meaning of percussion sounds

Answer 18

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).

Question 19

Auscultation of the chest

Answer 19

Ask the patient to relax and breathe deeply in and out through their mouth (prolonged deep breathing should, however, be avoided).
Position the diaphragm of the stethoscope over each of the relevant locations on the chest wall to ensure all lung regions have been assessed and listen to the breathing sounds during inspiration and expiration. Assess the quality and volume of breath sounds and note any added sounds.
Auscultate each side of the chest at each location to allow for direct comparison and increased sensitivity at detecting local abnormalities.

Question 20

Normal breath sounds

Answer 20

Vesicular: the normal quality of breath sounds in healthy individuals.

Question 21

Bronchovesicular

Answer 21

These are heard over the 1st and 2nd intercostal spaces and the interscapular area. The inspiratory and expiratory phases are roughly equal in length. They reflect a mixture of the pitch of the bronchial breath sounds heard near the trachea and the alveoli with the vesicular sound.

Question 22

Bronchial

Answer 22

These are normally heard over the manubrium. Expiratory phase is greater than inspiratory. The expiratory pitch is high and intensity is loud. Hollow, tubular sounds that are lower pitched.
Heard in consolidation.

Question 23

Tracheal

Answer 23

These sound are heard directly over the trachea. Inspiratory phase equals the expiratory phase. The sound is very loud and the pitch very high.

Question 24

Volume of breath sounds

Answer 24

Quiet breath sounds: suggest reduced air entry into that region of the lung (e.g pleural effusion, pneumothorax).

Question 25

Abnormal breath sounds

Answer 25

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.

Question 26

Vocal resonance

Answer 26

Ask Pt to say “99” repeatedly at the same volume and in the same tone.
Auscultate all major regions of the anterior chest wall, comparing each side at each location with the opposite side of the stethoscope to cancel out heart beating sounds.

Question 27

Abnormal vocal resonance:

Answer 27

Increased volume over an area suggests increased tissue density (e.g. consolidation, tumour, lobar collapse).
Decreased volume over an area suggests the presence of fluid or air outside of the lung (e.g. pleural effusion, pneumothorax).
The presence of increased tissue density or fluid affects the volume at which the patient’s speech is transmitted to the diaphragm of the stethoscope.