Respiratory Assessment Flashcards
Important elements of physical Respiratory assessment are…
Inspection
Palpation
Percussion
Auscultation
Surface Anatomy/Landmarks
Anatomical Landmarks
Identifying Landmarks
Lobe Position - Anterior
Lobe Position - Posterior
Lobe Position - Left Lateral
Lobe Position - Right Lateral
Before physical examination clinicians must…
Explain their intentions and the examinations they wish to carry out.
Gain consent from the patient to carry out examinations.
Ensure the setting is appropriate/private, chaperones present if required, patient positioned comfortably.
History taking should include…
Signs & Symptoms
Risk Factors (eg. Smoking)
Pain
Timescale (duration)
Ensure there is a review of systems
Cardiovascular (CVS)
Respiratory (RS)
Gastrointestinal/Urinary (GI/GU)
Musculoskeletal (MSK)
Neurological (Neuro)
Inspection of the face & neck should include…
JACCO - Jaundice, Anaemia, Clubbing, Cyanosis, Oedema.
Trachea
Jugular Veins (distention?)
Accessory muscle use
Pallor
Cyanosis
Inspection of the Chest will include…
Shape of the chest
Symmetry
Scars
Audible sounds
Rate of breathing
Sputum production
Retraction/accessory muscle use
Examples of chest shapes
Inspection of the hands will include…
Cyanosis
Asterixis (tremor/flapping of the hand when the wrist is extended)
Tar staining
Skin turgor
Clubbing
Oedema
Causes of Clubbing include…
Congenital Heart Disease
Bacterial Endocarditis
Cirrhosis
Lung Disease
Chronic Infections
Inflammatory Bowel Disease
Palpation of the chest will include & identify…
Lumps/lesions
Skin temp./moisture
Chest expansion & symmetry
Identify areas of tenderness/deformity
Tactile Fremitus (Intensity of vibration palpated on chest wall)
Anterior palpation/fremitus sites
Posterior palpation/fremitus sites
Percussion identifies…
Normal sound - Resonance
Abnormal sounds - Dull, Tympany & Hyperresonance
Useful identifying areas that are solid, fluid or air filled
‘Poor mans ultrasound!’
Percussion technique…
Hyperextend the middle finger of one hand & place the distal interphalangeal joint against the chest.
With the end of the opposite middle finger, and brisk movement of the wrist, strike the joint of the finger that is pressed against the chest.
Anterior locations for Percussion/Auscultation
Posterior locations for Percussion/Auscultation
Method of Auscultation
Listen over all lobes
Listen to at least 1 respiration on each region
Use the diaphragm of the Stethoscope
Note Intensity, Quality & Added sounds
Auscultation Tips!!
Where possible, do not listen through clothing.
Ask the patient to take deep breaths through the mouth whilst auscultating.
Ask the patient to cough a few times - helping to clear secretions.
If you hear added breath sounds, try to determine where in the cycle it is heard, eg. expiratory wheeze on exhalation.
Sounds created in the larger airways…
Sounds from the trachea & main, lobar & segmental bronchi are transmitted throught the rest of the lungs.
Air transmits sound POORLY
Fluid transmits sound WELL
Respiratory noises include…
Stridor
Bronchial
Vesicular
Rales/Crackles
Wheeze
Crackles
Rhonchi
Pleural Rub
Normal Tracheal Respiration
Normal over the trachea and main bronchi, they are wide so air movement is fast.
Inspiration & expiration are equal, there may be a small gap inbetween.
Normal breath sounds
Heard over the rest of the lungs/chest wall.
Inspiration is louder.
Expiration is quieter and shorter.
No gap between.
Absent/Reduced breath sounds
Compare to other side of chest!
Generalised decreased airflow (hypoventilation).
Localised decreased airflow (mucus plug).
Air in lung (emphysema).
Increased distance between lung & stethoscope (effusion, pneumothorax, obesity).
Bronchial breathing
Normal heard over the trachea, but abnormal if heard in the rest of the lungs.
Louder & harsher
Inspiration followed by equal/longer expiration.
May be a short gap between.
Indicates consolidation (dense lung).
Crackles
Fine or Coarse.
Snapping open of small airways.
Air bubbling through fluid.
Predominantly inspiratory.
Normal if they clear with a cough.
Wheeze
Narrowed, partially obstructed airways.
Lower airway obstruction.
Predominantly expiratory.
Short=mild.
Long=severe.
Can be localised or generalised.
Stridor
Higher pitched sound.
Upper airway obstruction.
Usually inspiratory.
Croup, Epiglottis, Burns, FB, Tumour.
Often easily audible at the mouth.
DANGEROUS.
Pleural Friction Rub
2 inflamed pleural layers rubbing together.
‘Creaking like old leather.’
Inflammation spread from underlying lobe.
Heard during inspiration & expiration.
Often dominant during expiration.
Often localised, eg. PE, Pneumonia.
Alternative terminology
Normal breath sounds-Tracheal, Vesicular
Crackles-Crepitations(JRCALC), Creps, Rales
Wheeze-Rhoncus, Rhonchi
Breath sounds associated with conditions
Pneumothorax-Decreased/Absent
Consolidation-Bronchial, Crackles
Pneumonia-Bronchial/Decreased, Crackles & ?Wheeze
Pleural Effusion-Decreased/Absent
Asthma-Prolonged expiration, ?Decreased, Wheeze
Pulmonary Oedema-Decreased, Crackles, ?Wheeze
Emphysema-Decreased air entry, Prolonged expiration
Special tests during Respiratory assessment include…
Broncophony:
- normal - soft & muffled
- abnormal - louder & clearer
Egophony:
- normal - prolonged ‘eeee’
- abnormal - ‘e’ changes to ‘a’
Whispered Pectoriloquy:
- normal - whisper is muffled
- abnormal - whisper is clearer
Tactile Fremitus
Respiratory RED FLAGS
++ respiratory effort
unable to speak
wheeze/silent chest
stridor
RR <10
RR >29
reduced/absent breath sounds
reduced SaO2
PF <33% expected
etCO2 <45mmHg
HR100+ or <40
arrythmias
pallor/cyanosis
respiratory exhaustion
reduced BP
confusion/combative behaviour
decreasing LOC/GCS
Pneumothorax
S&S:
- sudden ons DIB
- unilateral pleuritic pain
- tachycardia/tachypnoea
- ? unequal chest wall movement
PN: ? hyper-resonant over affected area
Ausc: ? reduced sounds over affected area
Misc:
- TVF
- ? reduced/absent sounds
- ? tracheal deviation
Consolidation/Pneumonia
S&S:
- dyspneoa
- pyrexial
- cough (sputum)
- pleuritic pain/myalgia
- tachycardia
PN: dull over airless area
Ausc:
- bronchial over affected area
- late inspiratory crackles
Misc: TVF increased over affected area
Indicator scores: Community Acquired Pneumonia(CAP)
new onset confusion +1 point
RR >30 +1 point
systolic BP <90mmHg & diastolic <60mmHg +1 point
pt age >65 +1 point
A+E mandatory if score >2
Pleural Effusion
S&S:
- ? tracheal deviation in large unilateral effusion
- S&S of underlying cause
PN: dull/flat over fluid
Ausc:
- decreased/absent
- ? bronchial near top of large effusion
Misc:
- TVF decreased/absent
- may increase near top of large effusion
Asthma
S&S:
- dyspnoea
- cough
- unable to complete sentences
PN: resonant/hyper-resonant
Ausc: expiratory wheezes/crackles
Misc: assess RR, PF, HR to differentiate between acute, severe & moderate
Chronic Bronchitis
S&S:
- chronic productive cough
- SOB
- cyanosis
PN: resonant
Ausc:
- coarse crackles on insp/exp
- possible wheezes/rhonchi
Misc:
- Hx suggestive
- Low SpO2
- TVF normal
COPD
S&S:
- SOB
- exacerbation of previously stable condition
- accessory muscle use
PN: diffusely hyper-resonant
Ausc:
- decreased/absent
- possible crackles, wheezes & rhonchi
Misc:
- TVF decreased
- measure capnography and SpO2
Risk factors for PE
Malignancy
Immobilisation
Obesity
Recent surgery
Recent trauma
Hx of DVT/PE
Pregnancy
OCP
Limb fracture
Indicator scores - PE
PRF?
Document:
- air entry on each side
- quality
- added sounds
- location
simple diagrams work well
Note:
- obvious distress
- position & use of accessory muscles
- RR, depth, & adequacy(perfusion/cyanosis)
- expansion symmetry
- trachea
- presence or absence of:
added breath sounds
percussion and palpation findings
pain or bony tenderness & signs of injury
location of any abnormality
