Respiratory Examination

Question 1

What are the stages of a respiratory examination?

Answer 1

Intro

Inspection

Palpation

Percussion

Auscultation

Completion

Question 2

What is involved in the intro of a resp exam?

Answer 2

Wash your hands
• Introduction, identification and consent
• General inspection of the bed area e.g. inhalers, nebuliser, oxygen mask, sputum pot
• General observation of the patient (colour, breathing, comfort, position, purse-lipped breathing in COPD, nutritional state (obesity may suggest obstructive sleep apnoea, Pickwickianism))

Question 3

What is involved in the inspection stage of a resp exam?

Answer 3

Inspect the hands for clubbing, tar staining and wasting of the intrinsic muscles (T1 nerve invasion by an apical lung cancer)
• Look for tremor (flapping asterixis in respiratory failure, fine with beta-agonists e.g. salbutamol)
• Assess pulse rate, rhythm and character (e.g. bounding in CO2 retention) whilst simultaneously assessing respiratory rate, rhythm, pattern and effort.
• Note the presence of pulsus paradoxus (an exaggeration of the normal decrease in blood pressure during inspiration). The ‘paradox’ is that you can detect beats on auscultation of the heart during inspiration that cannot be palpated at the radial artery due to a fall in blood pressure. Pulsus paradoxus is seen in severe obstructive airways disease and cardiac tamponade.
• Check the blood pressure.
• Check for raised JVP, suggesting cor pulmonale. A raised non-pulsatile JVP may be seen in superior vena cava (SVC) obstruction due to a lung cancer, in which case there will be oedema of the face and neck.
• Look for respiratory disease in the eyes:
o Horner’s syndrome
o Chemosis (conjunctival oedema may be seen with hypercapnia 2° to COPD)
• Look for respiratory disease in the face and mouth:
o Facial swelling is seen in SVC obstruction
o Dental caries (may cause lung abscess by inhalation of debris)
o Central cyanosis
• Expose the chest and inspect for:
o Shape
▪ Barrel chest (hyper inflated in emphysema)
▪ Severe kyphoscoliosis
▪ Severe pectus excavatum (funnel chest)
▪ Pectus carinatum (pigeon chest) +/- Harrison’s sulci
o Symmetry
o Scars
o Muscle wasting
o Chest versus abdominal (diaphragmatic) breathing
o Use of accessory muscles
o Recession (more common in children, but can be seen in adults with partial laryngeal/tracheal obstruction)

Question 4

What is involved in the palpation stage of the resp exam?

Answer 4

Check trachea and apex beat for deviation. Deviation occurs toward the side of the pathology with pulmonary fibrosis or collapse, but away from the pathology with a tension pneumothorax or massive effusion.
• Assess chest expansion (normal = 3-5cm; abnormal

Question 5

What is involved in the percussion stage of the resp exam?

Answer 5

Starting at the apices, percuss from side to side anteriorly. Consider the surface marking of the lungs and their fissures whilst percussing. Ensure that you have percussed every lobe (including the right middle lobe).

Question 6

What is involved in the auscultation stage of the resp exam?

Answer 6

• Starting at the apices, auscultate from side to side anteriorly and laterally with open mouthed breathing (clavicle to 6th rib, mid-clavicular line; Axilla to 8th rib, mid-axillary line). Again, recall the surface markings of the lungs and their lobes whilst auscultating. Note the presence of:
o Vesicular (normal) breath sounds
o Bronchial breathing
o Rhonchi (wheezes)
o Crackles / crepitations
o Pleural rub
o Assess for any change in these sounds after coughing (crepitations due to secretions will alter after coughing whereas those in fibrotic conditions won’t)
• Assess vocal resonance (say “ninety-nine” whilst auscultating with the stethoscope). (This technique allows discrimination between dullness to percussion from pleural effusion and that from consolidation. Voice sounds, which are created in the larynx, are transmitted more effectively across an area of consolidation. Transmission is reduced across a pleural effusion or pneumothorax.)
• If you suspect an area of consolidation, perform whispering pectoriloquy (whisper “twotwo-two”). (Whispers are transmitted more loudly across an area of consolidation.)

Question 7

How do we complete the resp exam?

Answer 7

Repeat inspection, palpation, percussion, and auscultation (spine of scapula to 11th rib) on the back with the patient sitting forward

Palpate the cervical lymph nodes.
• Palpate the ankles for oedema.
• Check sputum pot (volume, consistency, colour, odour, any haemoptysis)
• Assess peak flow (state that you would do this in the OSCE)
• Thank the patient and request them to redress.
• Wash your hands